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EMERGENCY MEDICINE UPDATE

May 2013 1) Syncope is a pain and I will not rail on more about how much we hate it, although I am positive you have already seen the first word of this paragraph and skipped the rest of the paragraph. Here they say that folks without CHF who are under the age of 60 will have little risk of death in 30 days, so send them home. (AEM 19(5)488). Let us look a little closer at this study. First of all it was a retrospective study based on ICD 9 codes; although that shouldn't be much of an issue here, as syncope doesn't have many imitators. But it will miss those who syncopized and had a good reason- like hypoglycemia which wouldn't kill most people, but also v tach, and MI so we cannot know true mortality. However, if we go by their numbers- they had almost 24000 ED visits and found only 307 deaths within 30 days. Again, we cannot be sure that they found everyone who died but the mortality was about 1% which I believe is probably true. Now they found higher hazard ratios with DM, and CHF. However, the hazard ratio will be higher in the above 60 group simply because they have more of a preponderance of these illnesses. Basically you can

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probably send home the under sixty set if they have no EKG findings and no CHF. Above sixty, if they are really healthy- I still admit them if this is a first time event. TAKE HOME MESSAGE: exactly what I wrote in the last line 2) New usages for Superglue- I am sure Ken Iserson will have even more- but this article says- use it to anchor in IV linesthe IV will not be damaged by the glue nor by the agents to remove it like paraffin (but do not use acetone). There were no skin irritation problems and no bacterial growth underneath the glue (Anest Int Care 40(3)460). Add this to the list of new usages for glue which will also include temporary bracing of subluxed teeth and to anchor in avulsed nails (to keep the germinal matrix open- if you really need to do this) Yes this is a picture of someone who fell in to the bubble gum vat. And you will get a big star if you know the movie this

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comes from TAKE HOME MESSAGE: Use Hisotacryl for anchoring in those IVs. Works well for diarrhea too! 3) America is now being overrun with new drug issues- it used to be herion, then it was designer drugs and I am not saying that these have disappeared but now it is prescription drugs. Oh, I know you were shocked to find out that those 450,678 pills of Percocet that you prescribed for Mr. Handley for his renal colic fell into the hands of other law abiding folks but be carefulthe swallowing of whole fentanyl patches is now on the upswing. (JEM 42(5) 549). They saw 76 patients in their series

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and 80% of them required admission- nearly all to the ICU (of course we can not be sure of what criteria were used to decide that) We still do not know if Narcan is enough and what the duration of toxicity is, but it seems that this does work for a high. TAKE HOME MESSAGE: fentanyl patches can be swallowed for a high- think about that when patients keep running out of their patches. Five points too if you can pronounce the last name of the author of the paper Time for quotes- actually titles. Country music is very popular in the rural areas of the USA and is known for its twang-y rhythms, banjo and fiddle accompaniment and corny "blues "type titles to their songs. Let's look at some of these(all of them are real): Here's A Quarter--Call Someone Who Cares--Travis Tritt Fax Me
A Beer--Hank Williams, Jr. 4) Let's put this to rest. Penicillin allergies do not translate to

Cephalosporin allergies. What was thought to be a 10% cross reactivity is probably less than 1% and only with those cephalosporins that have an R1 chain- and even then- the allergy is to Amoxicillin or Ampicillin whom also have an R1 chain. Now I know you know which cephalosporins have an R1

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side chain, but I will repeat it here for the benefit of the one moron who forgot. They are Cefaclor, Cefadroxil. Ceftatrizine Cefpozil Cephalexin and Cephadrine. Now while you are praising the genius that decided that all cephalosporins should start with the prefix cephlet me remind you that those who use second and third generation cephalosporins are usually safe. (JEM 42(3)612) TAKE HOME MESSAGE: Most cephalosporins can be used in Penn allergic patients "How Can I
Miss You When You Won't Go Away"--Dan Hicks and the Hot Licks. David Frizell's "I'm Gonna Hire A Wino To Decorate Our Home" 5) I really do not know what to do with epidemiology studies- it is

kind of like philosophy class-at the end of the day what are you left with? In any case they crunched the studies and found that Amoxicillin in early pregnancy increases your risk

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for cleft lip. (Epidemiology 23(5)699) Maybe.

Probably is that R1 chain 6) Maybe this is just a problem in Israel, but I doubt it. We have been railing about (aren't I always railing about something? Well, you know there is a haloperidol shortage) catheter overuse that is finally now getting attention. There is pressure to reduce the amount of patients walking around with these awful contraptions, and in this study they found that in the hospital, the place were most catheters were inserted was the

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OR (makes sense to me, since urologists do this after every surgery) but the second most common place was the ED (although admittedly a lot less than the OR). (Inf Contr Hosp Epid 33(10)1057) Now I can hear for BPH you may want to screw in one of these things, but in my country all intubated patients must go up with an NGT and a catheter. True that it helps for measuring input and output, but that isn't necessary for all intubated patients. Does it help for COPD patients? Let's be a little more flexible and judge each case individually. TAKE HOME MESSAGE: Those who routinely insert catheters for admitted patients should themselves be catheterized I am not sure why I thought of this- but let's dedicate this to many UK readers who know what I am talking about- the sport of

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ferret legging- yes sticking this:

in your

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pants: 7) OK clinical quiz time. This old disease is making a comeback and is as angry as a ferret in your pants. If the disease progresses you can commonly see Higoumenakis sign (unilateral enlargement of the sternoclavicular joint), mulberry molars (extra cusps on the molars), Olympian brow (frontal bossing) and less commonly clutton joints (sterile

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effusions of major joints) saber shins (bowing of the tibia). I last saw this disease at Jacobi Hospital back in the eightieswant to guess what we are talking about? (Am Fam Phys 86(5)433) I Don't Know Whether To Kill Myself or Go Bowling . If I Can't Be
Number One In Your Life, Then Number Two On You.

8) I guess this information may help someone- birds are often pets (although who wants to deal with Q fever and psittacosisdon't you detest words that have a silent p? You should see a psychiatrist) and yes, you do have to know microbiology. Parakeet bites can inoculate salmonella and the ever popular Staph Aureaus- you will need Cipro and TMP/SMZ to cover them. They also have E coli. Cockatoos carry bacillus species and their bites will require clinda coverage. Parrots pass on Pasturella and Pseudomonas so consider Cipro and Augmentin. Conures require cipro. This information was passed on to me from a presentation at the International Virtual conference of Veterinary Medicine by Dr. Jesus- whom I do not know, but I am sure Father Greg does. (J Hand Surgery (am) 37 (9)1925) TAKE HOME MESSAGE: Bird bites are not innocuous and require serious antibiotics especially to the

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hand. Reminds me of a quote from sickie Jack Handey "why is the dove the symbol of peace? It should be the pillow- you get more feathers and do not have to deal with those nasty beaks" 9) Aren't too many articles about this subject, but I will just highlight the things you got to know. Scromboid poisoning is when someone eats a fish that has been improperly stored and contains high levels of histamine from bacterial degradation. As such, this is not a seafood allergy. While it is called scromboid poisoning since it was found originally in scrobmoids (which are tuna and mackerel) it can be seen in sardines and anchovies as well (although that is a little misleading since sardines can be different fish depending on which country you come from) . The symptoms are those of histamine release and this is usually treated well with anti histamines. The need for steroids or adrenalin is rare. However, the fish may smell normal (although it still smells like fish- yuck) and as histamine is heat stable- cooking freezing smoking or canning does not destroy the histamine. (CMAJ 184 (6) 674) TAKE HOME MESSAGE: Scromboid

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poisoning can be found in tuna and sardines and is not an allergy. Antihistamines are enough. The fish will have no signs of histamine excess. Mama Get A Hammer (There's A Fly On Daddy's
Head). I Still Miss You Baby, But My Aim's Gettin' Better 10) And yet another clinical quiz. Fever, red eye, hypopyon (pus in

the anterior chamber) and a macular lesion on the palm in a lady with mitral valve prolapse, obesity and hypertension.

(JACC 60(12)e21)

Kind of easy, no? I Wouldn't Take Her To A Dog Fight, Cause I'm Afraid She'd Win. I'm So Miserable
Without You; It's Like Having You Here. 11) I don't know when you will use this information- maybe to

treat a bird bite- but Tramadol can be used as a local anesthetic and aside from local irritation works just as well (J Cut Med Surgery 16(2)101) Maybe- the p values verus

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lidocaine were not significant but Tramadol is more expensive and true lidocaine allergies are rare. But I included this just in case you give this med IV and it infiltrates. However I would offer this caveat- diphenhydramine can also be used as an local anesthetic but it can also cause local necrosis which was only noted on a later bigger study.- we need a bigger study here too TAKE HOME MESSAGE: Tramadol can be used as a local anesthetic too. But why? My Head Hurts, My Feet Stink, And I Don't
Love You. My Wife Ran Off With My Best Friend and I Sure Do Miss Him 12) They did very well with just needling pilonidal abscesses and

then sending them home with antibiotics. They then returned much later for the elective procedure of removing the tract. True this was a small study but we have been trumpeting for a while the idea of just needling abscesses and not opening them. (Dis Colon Rectum 55(6)640) My question is- did they really need the antibiotics?? The abscesses were needled until dry. TAKE HOME MESSAGE: a Pilonidal abscess can also be needled and discharged for a definitive procedure later on. She
Got The Ring and I Got The Finger 13) A little twist on ultrasound for our geeks: ultrasound can break

up clots although the mechanism is not well understood. You


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can use ultrasound alone to break up a CVA clot, you can use it with glycoprotein IIb/IIa inhibitors or you can use TPA with it. I want to emphasize this is not ready for prime time yet but maybe safer than TPA because you may need lower dosages of TPA when you use ultrasound (Stroke 43:1706) TAKE HOME MESSAGE: ultrasound may be used to break up clots- with or without meds You're the Reason Our Kids Are So Ugly. 14) Hopefully Father Greg did not miss this article why oh why is it in the cardiology literature? Spirits- I am assuming that means whiskey and the like and not Casper the Ghost contains 20 ml of alcohol in the house bottles you get on the plane for outrageous process and 300 cc of alcohol if you buy the 750 ml bottle in the store. Wine bottles on the airplane contain 25 cc of alcohol and in the stores 100 cc of alcohol. Beer in the USA is about 5% alcohol so it contains on 18 ml. So you can drink 285 ml of beer to get as sauced as 120 ml of wine and 30 ml of spirits. Now there are 7 calories per ml in alcohol- you can do the math, but it doesn't look good.

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(AJC 110:761) I would enjoy Father's input on some of the finer wines available in Flint Michigan (actually I have hit up on Flint enough- let's hit up on the Day glo plaid jacket capital of the world- nearby Ypsilanti Michigan) including those tried and true favoritesThunderbird, Ripple and Sterno. Now while I think Risk Management Monthly is a great way to learn how to practice medicine in the ED and not in the courtroom, I want to point out that each issue ends with Father Greg's Wine of the

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Month. So I think EMU will match Father with the wino of the month: Here are three that were well known for their love of Chardonnay grown in from special vintage concord grapes

from Downtown Ypsilanti. Michigan

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Who are these guys? 15) We spoke about syncope above and now on to another favorite subject: Vertigo. There are two choices here- either its BPPV or its a stroke. But there is a third option and that is vestibular neuritis which is an inflammation of the vestibular nerve. They state in this article that it is missed 85% of the time (how do they know this? There is no gold standard) but there are some hints to it. VN is a single event with rotational vertigo. Vomiting occurs and it doesn't get better when you stand still. There is a loss of the vertibulo ocular reflex and there is usually nystagmus when they look forward. On the other side, stroke is when people can't walk at all (VN- they
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can balance while holding on to furniture) and they have hearing loss, neuro symptoms and a headache, as well as a positive head impulse test. VN doesn't recur and takes weeks to get over. Steroids do not help. (BMJ 345:e5809) TAKE HOMEMESSAAGE: Vestibular neuritis is not BPPV. But it isn't a stroke either. They get better on their own and steroids and maneuvers don't help. "Did I shave my legs for this?" "If the phone doesn't ring , you'll know its me" 16) I couldn't get this article because it is in a journal that only about 8.5 people in the whole world get, but they did list their myths about management of distal radial fractures. Firstly, that casting must include the elbow. Secondly early mobilization leads to better outcomes. And thirdly, good anatomic reduction leads to better function. All of these are false (Hand Clinics 28(2)127). This may be true- but it depends on the level of evidence and which radial fractures we are talking about (Galeazzi's are much different than buckle). However from my years of casing (casting?) the literature I will add my own comments. Casting above the elbow is definitely not necessary in many wrist fractures but

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that is probably related to the next point. The purpose in casting one joint up is to prevent usage of the tendons and musculature that are left free to move if the elbow isn't included. But that is dependant on whether early mobilization is necessary of not- and I believe giving as much function as possible does help fractures. Look at osteoporosis-we know exercise does help because it mobilizes calcium into the bones. And of course the question must be asked if you need to cast in the first place- buckles and greensticks probably do not need casting. However I agree with exact anatomic reduction not being crucial- kids can do well with a lot of displacement and most adults can do well as well providing that they have no healing problems and engage in physiotherapy. (No raising a wine glass to your mouth is not physiotherapy) TAKE HOME MESSSAGE: Distal radial fractures do not need exact anatomic reduction and long casts and early remobilization is bad. Or good. Or something." And there was Grandma, swingin' on the outhouse door without a shirt on" Baked my sweetie a pie but he left with a tart" "Don't want that floozy in my Jaccuzzi"

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17) This study looked at the use of low dose Droperidol for headaches and they have remarkable results- 73% had resolution or significant improvement in their headaches. The dosages averaged only 1.25 mg. None had cardiac arrhythmias; none ended up in black boxes however EPS symptoms were seen in some. (AJEM 30(7)1255). True this was retrospective but it was from a pharmacy data base so they can be sure the patients got the medicine. How they knew who got better is a different story and it doesn't look like they used a standard headache or pain scale. In addition I am tired of Americans whining about how unfair it is that they can't use Droperidol at will while many of us in the Third World (defined as any one over the George Washington Bridge heading West, and anyone beyond the Nassau Coliseum on the east) don't have this drug. But do not despair. A review in the CJEM says that this family does work, but the side effects are many. In truth, Haloperidal which every one has and is of the same family- probably works, but most of the research has been done on Droperidol, so it is hard to say. I use Haloperidol for headaches in my patients

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and most do well (some shake but I always assumed those were rum fits from drinking too much) (CJEM 13(2)96) TAKE HOME MESSAAGE: Butyrophenones are good treatment for headaches even at low doses. "Gave her my heart and a diamond and she clubbed me with a spade"" He's got a way with women and he just got away with mine" 18) This twelve year old Indian boy came to the ED with signs of brain death: a GCS of 3, intubated and absent corneal reflexes. This occurred after a snake bite which in India- home of the king cobra- is not a good idea. (ibid E1) But wait the kid woke up and went home neurologically intact- seems that is what you would expect from the neuro paralytic effects of the venom. I do not think brain death should be used as a measure of inability to be functional- many of our finest politicians have suffered from this malady and are serving faithfully tot his day. TAKE HOME MESSAGE: Is there one? "I just bought a car from the guy who stole my girl, but it don't run so I guess it was an even deal" "I wish I was a woman (so I could go out with a guy like me)"

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19) I don't care what a genius you are, and you probably are one if you read EMU- but even the best internist has never heard of Mondor's Disease. This is a superficial thrombophlebitis of the chest wall which is cordlike and usually goes from the breast to the axilla. Enoxaprin is given for a month, and a clotting workup is indicated. Predisposing factors include trauma, surgery infections, and excessive exercise. US does the diagnosis (ibid 30(7)1325) TAKE HOME MESSAGE: Mondor disease- superficial thrombosis of the chest wall,- requires a clotting workup. "I got the hungries for your love and I'm standing in your welfare line" 20) Biostatics is about as interesting as discussing quantum physics with Lady Gaga, but you got to know something. After all you want to grow up to be and strong and trash articles like Jerry Hoffman. So every once in a while we have to include these types of articles. You see odds ratio around a lot. An odds ratio is simple- how many people who smoke will get lung badness compared to how many people who don't. Risk ratio is how many smokers will actually get the lung badness. As you can see, Risk ratio tells us more about the

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group we want to know about. This article made a push for more expression of RCTs and cohort studies with relative risk and not odds, although you see odds ratios all the time (CMAJ 184(8)895). Now I would just like to add that absolute risk tells you more than ratios do because in small groups, the risk may be magnified. TAKE HOME MESSAGE: Risk ratio tells us

more than odds ratio 21) Don't you just love neonates? You know, those cute little creatures that just come out the oven all looking the same? Well, there are some changes as to dealing with these little adults if they need resuscitation that go beyond just APGAR and calling in the pediatricians. Temperature control,

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breathing and circulation have not changed. Assessment is importantthe baby's color is an unreliable parameter- it correlates poorly with saturations and there is considerable inter observer disagreement. So you would say- well, who says saturation is the way to go in assessment? And you would be correct it is normal for a newborn to have a depressed saturation which over a few minutes responds. Actually the heart rate is a better parameter. The article points out that babies are born naked and wet (a surprise- I didn't know this) and therefore should be kept warm as possible-they aren't real good at temperature modulation. However, if they are hypoxic and have low APGARS and the pH is less than seven, hypothermia seems to save lives. But this is for term babies. Preemies- we just do not know. Next. Suctioning out the meconium is no longer required. We do not give oxygen unless they fail to respond to air. If you do use oxygen- try to wean it fast. CPAP and surfactant can be used instead of intubation and the choice is yours- the guidelines allow both. Circulatory support- adrenalin via the ET is unreliable. Give it IV or IO.(J Paed and Chidl Helath

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48:735) Beer, wine and whiskey have no role in neo natal resuscitation, but that may be changing. Then again, maybe the baby itself needs changing. I cannot be quite sure why I thought of his quote know, but I'll use it "I love cooking with wine. Sometimes I even add it to the food "Julia Child, famous Chef. TAKE HOME MESSAGE: Neonatal resuscitation has changed- give air instead of oxygen- consider CPAP and hypothermia for selected cases. "One day when you swing that skillet my face ain't going to be there" 22) Toxicologist- hydoxyurea is used often for thrombophilia and for sickle cell anemia. It has been shown to be safe in infarcts. A case report about a two year that swallowed a35 day supply of this stuff said it was safe as the child had minor transient mylosuppression. (Ped Blood Cancer 59(1)170) TAKE HOME MESSAGE: Hydroxyurea is probably a benign overdose "Thanks to the cathouse , I am in the doghouse with you" This gun ain't loaded, but I am" 23) So there is this explorer in Africa and he hear hears drumming. The native accompanying him says "when drumming stops very bad" Suddenly the drumming stops.

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The explorer turns to the native aghast and says-"what next" The native calmly says "bass solo next" So let me beat a drum I have been beating for ever. The six hour rule for closing wounds is based on lousy if any evidence (Injury 43(11)1793) So if there is no evidence let me say what I think. I think it depends on the blood supply to the region (faces do well even after 24 hours) how dirty the wound is (although good debridement can accomplish a lot in any case) and the protoplasm of the patient- I do not think anyone would dispute that 36 hours may be OK for a healthy child whereas even 3 hours may be too long for an elderly diabetic. By the way, the above article and this article were both done at SUNY Downstate, so let me give a shout out to Dr. Silverman who works there and is a long time EMU subscriber TAKE HOME MESSAGE: Wound age is important but six hours is probably not. "Velcro arms, Teflon Heart" "When my love comes back from the ladies room will I be too old to care?" 24) We have said this before but this is from the home country so hooray for the red white and blue. Or at least the white and the blue. This Israeli study showed that honey does

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have an effect on nocturnal cough in children. (Peds 130(3)445). The problem here is that placebo did very well too- and in this case it was Silan date extract. However, since dates also make honey, we can say this is the placebo effect or we can say it was from the dates. Now Dr. Shapiro has told me in the past that it depends on what honey you use, and here they used eucalyptus, citrus or labiatae honey. Here is a congrats to the writers of the paper- Prof Kozer whom I know and is an EMU reader, and Hannah Efrat. TAKE HOME MESSAGE: Honey is effective for coughs. But so is placebo. If you use the right placebo?? "You done changed your name from Brown to Jones and my name from Brown to blue" 25) This makes sense. Obese folks needed higher doses of medicines because you need to reach a larger distribution in their bodies. There are guidelines for this and we are not following them (AJEM 30:2012). The concept is sound, but the paper is not terribly useful. These guidelines are for those who have a BMI greater than 40 which may be on the rise but is still not that common where I practice. Furthermore it was only for IV drugs and only studied Cipro (which I can't

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remember the last time I gave IV), cefazolin and cefepime.) The guidelines are also based on creatinine clearance which few of us compute. But say the creatinine clearance is normal: you would give 2 grams of cefazolin IV every eight hours, Cipro 750 po twice a day and 800 IV twice a day, and Cefepime 2 grams every eight in serious infections and every 12 in less so. TAKE HOME MEEASGE: Give those obese patients higher antibiotic dosages. Remains to be seen about other medications. Here is a picture of Nick Cole. Until he was released two years by the Philadelphia eagles, he had the biggest BMI in the NFL- a 58.

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Heck he isn't have as

scary as most mothers in law

"I
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changed her oil, she changed my life" 26) I thought this article had a lot of potential- but while we are on the subject of sports lot of potential usually means it didn't go anywhere. This article explored dignitary medicinethat is; you are part of the medical team accompanying officials abroad. Most of this is common sense- knowing local medical capabilities, packing a good medical kit, recognizing local terrain and evacuation possibilities , medicines available and not available in the country, food and water in rural areas without reliable supplies of either and a good knowledge base in EM (that part I liked). (AJEM 30:1274) There are sites for this including one for international SOS, but indeed we have discussed a similar issue 4 years ago- how to organize your hospital for a VIP admission. We are now featured on three sites-life in the fast lane, MD Anderson and EM Central- they may have search function to find this TAKE HOME MESSAGE: Dignitary medicine requires careful planning and a lot of potential. "I knew she really missed me when the ashtray flew past my head" 27) Time for letters: Hi Yosef

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Hope all is relatively quiet there at the moment. I suspect that the U.S. and Canadian medical students might be very interested in knowing that I just posted 8 new YouTube videos about the specialty selection process and residency/fellowship application process (including two on International Medical Graduates). Two are about D.O.s. These stem from the new (8th) edition of my book, "Getting Into a Residency: A Guide for Medical Students," that will be available in early May. Pass on this information; I'm sure they will be pleased. Best wishes, Yosef:
Ken

Well, that's from Ken Iserson. Ken, thanks for writing- and the information has been passed on
Thanks again for the excellent EMU. I wanted to make a comment about the pediatric article on abscesses (Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department) by Kessler. While I personally am unsure about the utility of packing, and have begun to do more loop drainage procedures, I don't think this study should be trusted to be good enough evidence to conclude that packing doesn't decrease morbidity. The following weaknesses in the study make any conclusions unclear:
Study was stopped early because they couldnt enroll enough patients. Only in age 1-25 (mostly teenagers)

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We dont know how many patients were not enrolled because the physician wanted to pack the abscess (selection bias) Their failure rates are exceptionally high (70% and 59%) No information on why some patients got antibiotics and which antibiotics. 18% of the patients (5/27) in the packing group werent included in the data analysis because of incomplete data or followup Criteria for all their outcomes were left up to the blinded physicians assessment but werent defined in the paper. Large confidence intervals could be missing a large effect size of treatment.

In summary, while there are some small studies that suggest that packing is painful and useless, I don't think this study should be used to support a specific approach. Just my opinion - most abscesses just need to be adequately drained to heal (but this study isnt' proof.) Thanks. Jeff Freeman MD

Jeff, that was excellent. I think that you may want to consider joining the EMU staff (currently consists of one guy, but we can find room for you). Truth be told, most abscesses will probably get better no matter what you do, and I always believe that doing less is better. But you are entirely correct, the evidence is lacking at least in this study. Unfortunately, the Kessler that wrote this article is not the one that is an EMU subscriber, but our Dr. Kessler is a prolific writer and one of articles that came out recently on TTP was excellent (JEM 43(3)538). We have spoken about TTP in the past but I will try to include
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it next month. Thanks for writing Jeff. And also a big thanks to Doron Dusanitzky for passing on more info on the convoluted mess of fever in kids. I beelver we are getting closer but And lastly, we would like to welcome a new site which will carry EMU. Presently, we are featured in Life in the Fast Lane and EM Central- now MD Anderson has picked us up as well. This is a real honor and I am pleased. Here are a few word s from them and please go up and visit their site. (I am sorry Knox, the picture did not copy and
paste) In 2010, MD Anderson created the first academic department of emergency medicine in a comprehensive cancer center. Knox H. Todd, MD, MPH, founding chair of the department, leads a dedicated group of physicians and researchers in promoting the development of oncologic emergency medicine as a distinct discipline. More than 22,000 patients annually receive care in MD Andersons 44-bed Emergency Center for a variety of acute oncologic emergencies. Department faculty have a broad range of research interests, including oncologic emergencies, pain treatment, health disparities, palliative care, and the role of obesity and diabetes in cancer. The Department of Emergency Medicine has established a new fellowship in Oncologic Emergency Medicine and we encourage international applicants. We are actively recruiting new clinical and research faculty, including a director for our ultrasound program. Links to these opportunities appear on our website: http://www.mdanderson.org/emergency-medicine . We are

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proud supporters of Yosef Leibmans Emergency Medicine Update. Current and past editions of EMU appear on the EMPainline website: http://empainline.org/emu . Congratulations, Yosef!
Knox H. Todd, MD, MPH Professor and Chair Department of Emergency Medicine MD Anderson Cancer Center 1400 Pressler St. FCT 13.5077 Houston, Texas 77030-3722 Office: 713 745 9911

28) Answer to number 2- The Mad adventures of Rabbi Jacob- which was and still is a pretty funny movie. And number 7 is of course tertiary syphilis- may have helped to mention saddle nose but that would have given it away. Do get yourself checked out for this before you read another EMU. And number 10 was easy it was an article in JACC so it had to do with cardiology- it was infective endocarditis- Staph Aureaus to be exact. The lesions is of course a Janeway lesion but these are rare

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(About 5%(NEJM368:1425) And the friends of Father in 14 were Dean Martin- a comedian who teamed up with Jerry Lewis in the sixties, Boris Yeltsin who was the Premier of Russia and Billy Carter who actually was a beer imbiber who was President Jimmy Carter's brother and was

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famous for embarrassing him with his red neck ways. He eventually fell from grace after taking money from our old pal Moamar Ghaddafi RIP.

EMU LOOKS AT: Tunnel Visions


A few months back we looked at some neuro cases, this month we are going to look at some eye cases. They are pretty basic but then again we do not see many eye cases and may not feel comfortable with them. The source for that essay is JFP 61(8)474.The first essay though will go into the Carpal Tunnel and look at CTS The source for that essay is BJHM 73(4)199. Carpal Tunnel Syndrome

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1) If you are not familiar with the anatomy, here it is.

This is a problem of entrapment of the median nerve. 2) I know that this conjures up thoughts of fibromyalgia, RSD, TMJ, Mitral Valve prolapse and all sorts of nebulous diseases that the modern day personality disorder patient has at 3 AM. However there is some rhyme and reason to this condition. The epidemiology of Carpal Tunnel Syndrome is that it is most common in females who have a smaller carpal tunnel and occurs mostly in patients between the ages of 45 and 65. This entrapment is caused by tendon thickening, synovitis, fluids, or lesions
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in that area which is more common as people get older. CTS seems to run in families. If you are pregnant, obese, or have rheumatoid arthritis you have more of a risk for CTS. M and alcoholism will also give these symptoms but here there is a nerve damage problem so the usual decompression things won't work. Power tool use and wrist fractures can also be causes. 3) Usually one sees parasthesia in the median nerve distribution. But there is pain as well. Pain is worse at night and when gripping objects for a long time. Pain improves when they shake their hands. Pain can radiate to the forearm and thumbs can get weak-leading to dropping objects. 4) So how do you diagnose this? Tinel's test and Phalen's test were the classic ways of diagnosis- the former is tapping on the area of the median nerve at the wrist and reproducing the parasthesia and the latter is flexing the wrist resulting in the same but these tests are pretty poor both the sensitivity and the specificity. EMG is probably the best test but it hurts; so use it only for cases that aren't clear. US and MRI should not

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be used routinely. They are best when there is suspicion of a space occupying lesion. 5) There are some other conditions that can look like this. Cervical radiculopathy, deQuervains, and Thumb OA round out the DDx of common mimickers. Cubital tunnel syndrome can also look

like this.

Of course, here in the cubital tunnel -

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the parasthesias will be different although there will be pain and parastesias in the hand. 6) Treatment: Steroid injections (easy to do- a little proximal to the wrist crease) are unlikely to do damage and these injections and cock up splints are effective. Physiotherapy can help to, but all of these work for only about two months. Surgery is the ultimate treatment and can be done under local, in the office and takes a few minutes. Oral steroids and oral NSAIDs do not work. There is now a mini release surgery which has a smaller incision. Endoscopic techniques also exist. Sensitivity in

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the area can be present for a few months after ward but usually resolves. Recurrences are rare. Treatment of the following tunnel

problem is more difficult. Eye Cases- Pain Here are the five cases- pretty basic but let's see how you do. A). 74 year old with left eye pain that stared when he turned off the light to take a nap. He has a headache, blurred vision, pain and nausea. There is corneal haziness and the eye is dilated and reacts poorly to light. B) A 20 year old guy wearing contacts during a game of volleyball. He sustained no trauma. He feels all of the sudden stinging in his right eye
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like having sand under the eyelid. Sunlight makes the pain worse. Flushing with water did not help. There is a gray spot on the cornea. What next? C) A 17 year old girl is brought in because of eye pain and vision loss in her right eye- she saw spots of light then she lost her vision. There is edema of disc margins on fundoscopic exam. D) This is a 31 year old lady with sarcoidosis- with a red eye and pain. OK, the sarcoid kind of makes it easy- but still what is this? There is no eye discharge. E) 21 year old co-ed with pain in the left eye. She of course wears contact lens. She feels like there is something in her eye and on exam you do see an opacity. 1) This is glaucoma and was precipitated by the eye trying to dilate this acute angle closure glaucoma and not open angle which is more chronic If you have a slit lamp- fine- you will see a shallow anterior chamber and increased ocular pressure. Give acetazolamide, mannitol, isosorbide and get him to the optho guy fast. Key here is in a patient who is elderly an vomiting- do ask about his vision so you do not miss this. If you have them, timolol or and pilocarpine drops will help

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2) This is a corneal abrasion or ulcer caused by the movement of the contact lens during the game. Contact lens can cause all sorts of infections, especially Staph and Pseudomonas. The exam is straight forward- you have all done it. They do not like aminoglycosides as they are toxic to the cornea (I confess I knew that for the ear, but not for the eye), but then recommend tobramycin if it is a contact lens problem because of the danger of it being Pseudomonas. Pain control: they still use cyclopentolate (and we have presented studies that this doesn't help), but I like Volatren drops- they do not dissolve the cornea. They say chronic use of local anesthetics is dangerous- recent evidence calls that into question. Patching is not done. I think that we all agree on that- it makes a nice warm milieu for bacteria to grow happily. 3) Get this lady an MRI she has optic neuritis. Kids more likely have no pain and have blurred vision in both eyes with this; adults have pain and only one eye affected. If you are good at fundoscopy you will see a papillitis and swelling of the optic disc, but this is only seen in one third of the patients. Light reflex will be sluggish. They will need IV steroids and it will take a few weeks to get vision back. 4)Uvietis is the obvious answer- but which one- anterior or posterior? We know uvieitis can be seen in all sorts of rheum disorders like Sjogrens syndrome, Kawasaki, JIA (formerly known as JIA) and TB, herpes and
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HIV. Visual exam reveals redness around the iris- not so much peripherally like in conjunctivitis. Anterior uvietis has pain and photophobia. Posterior has less pain but there can be floaters. Both have some visual loss. Here you wan to manage the disease that caused it and give steroid drops. 5) You may jump right onto the contact lens and say this is a bacterial keratitis. And indeed it is important to remember that conjunctivitis has no pain or vision changes and this does even though both have mucopurlent discharges. Now if I said the opacity had a branching pattern, now it is easier- Herpes keratitis. This is treated with antiviral eye drops or acyclovir by mouth. Bacterial keratitis usually does well with antibiotic eye drops, but if there are contact lens consider coverage for our old pal pseudomonas (I always wondered if this is a "pseudo"monas- what does the real monas look like?) with cipro drops or tobra drops- six to eight times a day.

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