Sinai EM Journal Club

At our last Journal Club, Tom presented a 2005 paper from JEM on new CT scanners in the evaluation of SAH. The paper was called Subarachnoid Hemorrhage Diagnosis By Computed Tomography and Lumbar Puncture: Are Fifth Generation CT Scanners Better at Identifying SAH? by Boesiger and Shiber, and it appears in Journal of Emergency Medicine (2005: Vol. 29, No. 1 pp23-27).

The article is motivated by the fact that 1% of headache patients in the ED have SAH. Most are traumatic, but those that aren’t are usually from Circle-of-Willis aneurysm ruptures, which often kill or disable otherwise healthy people. EM physicians hate that sort of unsettling risk, and the situation is further complicated by the 20-50% of SAHers who present with a sentinel bleed. So there’s a real opportunity to help some potentially moribund patients —  but if you ask most interns, they’ll say they’re shoving too many needles into the backs of people who probably just needed some exedrin.

Maybe we can change our practice, based on recent upgrades in CT scanner technology. These authors were the first to look at the new scanners with an eye toward sensitivity in SAH diagnosis. More below…

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Lynn was telling me about a case she saw this year – if I recall, it was a young man who developed uncontrollable hiccuping after an inguinal hernia repair. I don’t know what happened to the guy, but I saw my first hiccuping patient shortly thereafter. As I surf the web, I keep coming across remedies for this unusual but vexing complaint:

• Methylcellulose (to expand the stomach) 
• NG Tube (to decompress the stomach)
• An implantable vagal nerve stimulator
• Pressing on the ears while drinking through a straw
• Digital rectal massage (also reported in Annals of EM)
• Chlorpromazine 25-50mg IV (the only FDA-approved agent for intractable hiccups)

Our anesthesia colleagues have looked at this issue, as hiccuping in the OR is a pressing concern. Unfortunately, a systematic review (Kranke, Eur J Anaesthesiol 2003 Mar;20(3):239-44) turned up lots of anecdotes, but only one (inconclusive) RCT:

A large variety of interventions have been proposed for the treatment of hiccup during anaesthesia and sedation. However, perioperative treatment is still based on empirical findings and no treatment is ‘evidence-based’. Thus, no valid recommendations for the treatment of hiccup can be derived. Uncontrolled observations are inadequate to establish treatment efficacy.

More drug suggestions below, along with some background on hiccups…

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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.