Sinai EM Journal Club

This month’s journal club presentation began with what I believe was a discussion of blood clots in Cro-Mags before touching upon late 19th century versions of CPR, the landmark closed-chest cardiac massage paper, and eventually, a comparison of ROSC (return of spontaneous circulation) in real patients vs. as seen on television. Chad then led the group in a discussion of a new meta-analysis by Xin Li et al appearing in a recent issue of Resuscitation (2006: Vol 70, pp31-36) on the topic of CPR with and without thrombolytics.

Read more »

This month in Journal Club, we continued our theme of prognostication papers as Corey reviewed two recent ones from Latha G. Stead’s group at Mayo.  One paper ran last year and is called “Initial Emergency Department Blood Pressure as Predictor of Survival After Acute Ischemic Stroke” (Neurology 2005, 65:1179:1183). The second paper is called “Impact of Acute Blood Pressure Variability on Ischemic Stroke Outcome” (Neurology 2006:66:1878-1881).

This is something I frankly hadn’t spent much time thinking about — all the emphasis in stroke guidelines and tPA admin has been about getting BP down into a safe range, not worrying about whose BP is too low. But the big result from the first paper was that a diastolic of < 70 mmHg, a systolic less than 155, or an MAP of less than 100 mmHg was associated with higher mortality at 90 days than those with higher BPs (even after adjusting for age, gender, NIHSS score, etc). The worst relative risk (RR) was for a diastolic less than 70; RR = 2.2 in that case, which the authors find is actually worse than the RR of having a diastolic over 105 (RR=1.9… How about that).    Read more »

We continue to make our way through the recent pain management papers, once again turning to the August Annals (Vol 48, No 2). Chang, Gallagher et al. strike back with a second analgesia piece in this issue — from now on, Montefiore will be simply be known as the House of Pain. The paper’s called Safety and Efficacy of Hydromorphone as an Analgesic Alternative to Morphine in Acute Pain: An RCT (if you’re logged into the Sinai library, full text is here). It’s full of provocative hypotheses, good study technique, and fun historical trivia… more below!

Read more »

I wanted to highlight the NEJM’s new (well, 6 months old) internet feature, Videos In Clinical Medicine. You ought to be able to access these videos after logging into the Sinai library (with MSSM-ID and life number) and then heading over the NEJM’s recent videos page.

Many of the videos feature the work of Gary Setnik, MD, an early figure in EM. The most recent one (from Oct 26th, Vol 355, No. 17) is on basic laceration repair – so maybe it’s something you can show to your beleaguered 4th year med student while you’re busy with other things. Other videos may be more relevant to us, including thoracentesis, LP, A-line placement, and knee arthrocentesis. The videos can also be downloaded in formats for Palm OS, Windows, and iPod.

Clinicalcases.org, a very useful collection of links, videos, simulators and more, also has a page full of procedure video links, as well as some physical exam videos that may be worth brushing up on.  

If you’re aware of any other good online resources like this, let me know or share ‘em with Ted, who’s compiled a list of his own.

I’m finally getting around to the some of the good articles on ED pain management that appeared this summer. The first was in the August 2006 Annals of EM, an article by Gallagher, Esses et al. entitled, “Randomized Control Trial of Morphine in Acute Abdominal Pain.” The authors tested the oft-repeated dictum that morphine affects diagnostic accuracy, measuring pain on a 0-100mm visual scale in a prospective double-blind random trial, giving 0.1 mg / kg of IV Morphine sulfate or placebo (ouch!) with an endpoint of “diagnostic accuracy” (ie, comparing the provisional diagnosis made by an emergency physician in 15 minutes after the agent is given, vs. diagnosis at six or more weeks of followup.)

They randomized 78 patients into the morphine arm, 73 into the placebo group. After fifteen minutes, the patients who got morphine changed their pain rating from 98 to 65, on average, whereas the placebo group went from 99 to 97. Diagnostic discordance occurred 11 times in each group, meaning that accuracy wasn’t affected by analgesia.

The dictum to avoid analgesia in abdominal pain dates to a 1921 proclamation by Sir Zachary Cope — a good example of emminence-based medicine. Maybe this warning was appropriate in the age before antibiotics and CT scanners, but we now have eleven trials in the last twenty years showing that Cope doesn’t cut it. Read more »

Drs. Nelson, Baumlin and Basavaraju wrote up an interesting case that was featured in the Correspondence section of the September 2006 Annals of Emergency Medicine (Vol. 48, No. 3, pp339-340). The letter was titled, Sonographic Diagnosis of Axillary Artery Aneurysm Presenting As Painful Axillary Mass and features some vivid photos. The summary is excerpted below:

Although the assessment of abdominal aortic aneurysms has long been a standard indication for bedside ultrasound, this case represents a previously unreported presentation (possible abscess) of a rare condition (axillary artery aneurysm). In this case, rapid assessment using bedside ultrasonography was able to unequivocally exclude abscess from the differential diagnosis, and allow the proper consultants to become involved earlier in the course of the ED visit. Furthermore, identification of the axillary artery aneurysm led to obtaining a computed tomography scan which revealed a larger and potentially lethal aortic aneurysm. Although it is unlikely that an emergency physician would have attempted to incise and drain a pulsatile “abscess,” it is useful to distinguish a mass impinging on a vessel from a mass which is a vessel.

Incidentally, the letter to Annals immediately following this one is from a former classmate. It is indeed a small EM world.

Given our recent guest speaker and spirited discussion, I thought it would be worthwhile to discuss a review from the September ‘06 Annals: the Use of Noninvasive Ventilation in ED Patients with Acute Cardiogenic Pulmonary Edema. We know ACEP will soon be publishing a new clinical policy on heart failure, it’ll be interesting to see how their interpretation of the literature squares with that of Collins et al.

And, even though we’ve all seen these masks in action, it’s probably worth repeating that CPAP is continuous positive airway pressure, regardless of inspiration or expiration. CPAP has been shown to reduce the work of breathing and decrease LV afterload, while maintaining cardiac index.

Noninvasive positive pressure support — sold under the trade name BiPAP – works similarly, but with less positive pressure during exhalation; it’s inspiratory pressure support plus PEEP (this variant called C-Flex kind of demonstrates it, but with an exhalation pression of zero). In theory, BiPAP should reduce the work of breathing even more than CPAP, and physiologically would seem to be of more benefit in obstruction airway disease (asthma, COPD).

For a more in-depth review of the mechanisms, indications and contraindications, check out this eMedicine article. For a practical guide with some key citations, see EMCrit.org. Basically, both CPAP and BiPAP work in part by raising intrathoracic pressure, which decreases preload AND afterload (which probably benefits patients with cardiac dysfunction). Neither therapy is definitive for cardiogenic pulmonary edema; they’re temporizing measures while your nitrates and diuretics kick in.

Previous studies have shown that CPAP decreases intubation rates in patients with acute cardiogenic pulmonary edema (ACPE). A systemic review in 1998 bolstered the claim, but that review included trials with non-ED patients.

The first big BiPAP study (Mehta, 1997) showed an increase in respiratory function and hemodynamic improvement compared to CPAP, but similar rates of mortality in hospital, and similar intubation rates. Plus, notably, the BiPAP patients experienced more MI! (it’s worth noting that that arm of the study received, by chance more patients complaining of substernal chest pain, and a 2004 study comparing CPAP and BiPAP showed no difference in MI).

Since then, many small trials between CPAP and BiPAP suggested no difference between these noninvasive ventilatory modes compared to standard-of-care, which other studies suggested a decrease in intubation and mortality. But this paper is the first systematic review of CPAP and BiPAP in ED ACPE patients.

Read more »

Dinali did a stellar job this month at Journal Club; not only was her talk thought-provoking and clinically relevant, but I learned more about the history of of our world’s 8th most abundant element than I would have ever thought possible.

This month’s JC was primarily about Davey and Teubner’s AEM paper on using Magnesium sulfate as an adjunct to “usual care” for rate control in atrial fibrillation (AEM Vol 45, No 4, April ‘05, p347-353). We also touched upon some data from an all-Greek study in the Int’l Journal of Cardiology on Mg alone vs diltiazem alone in A-fib (Chilidakis, IJC 79 2001 p287-291). Read more »

This week’s New Yorker (our program’s most widely-read non-EM journal) has a fun article about Jones fractures and fifth metatarsal avulsions. Apparently, the latter are exceedingly common on Martha’s Vinyard in the summer. And there’s just one orthopedist on that island, to see all of them. There’s more below, but a more scholarly review of mifth metatarsal fractures and avulsions can be found at Wheeless’ Orthopedic Dictionary, online. They’ve got Xrays and differentials and more than Tintinalli, so check it out.   Read more »

Ah, the first Conference of the academic year. The new faces, with their bubbling enthisasm, suddenly confronted with the annual reading of the policies & procedures manual… why, it’s enough to give anyone a headache and photophobia. Which is why it’s so timely that we review meningitis, with a focus on some physical exam skills that can (but may not) help guide your diagnosis.

Tim reviewed a paper by Thomas et al out of Yale, published in Clinical Infectious Diseases (2002;Vol 35 July 1, pp46-52) called “The Diagnostic Accuracy of Kernig’s Sign, Bruzinski’s Sign, and Nuchal Rigidity in Adults with Suspected Meningitis.” Here’s his CAT sheet. Read more »