Appendicitis in Three Courses

Fearless chief Ted has organized the first of our Tuesday Night Journal Clubs (with apologies to Sheryl Crow). The goal of these meetings is to informally discuss several relevant and provocative papers on a certain topic of interest in EM. Particularly, we wanted to give attendees a foundation in the literature, and some ammunition when dealing with other services. We picked a dinner theme, with an appetizer, main course, and dessert.

Our appetizer came from the classic JAMA Rational Clinical Exam series, “Does This Patient Have Appendicitis?” (Wagner et al. JAMA Nov 20 1996, Vol 276, No. 19, PMID 8918857). Some interesting and quotable tidbits from this comprehensive review:

• RLQ pain had a positive likelihood ratio of about 8, and negative LR of between 0 and 0.28
• Rigidity wasn’t very sensitive, but had a positive LR of 3.8
• Migration of pain had a LR of 3.2
• Psoas sign, rebound, guarding, nausea, vomiting, fever and anorexia had relatively unimpressive positive and negative LR’s. Having ‘no similar pain previously’ gave a negative LR of 0.32.

The main course and desert follows below!

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Lyse and Statistics: GRACIA-2 vs. ASSENT-4

The first Journal Club of the year got off to a thunderous start (there was lightning and flooding, too, and an explosion a little bit later). Those who braved the elements participated in a discussion about thrombolysis before angioplasty for STEMI, centered on two papers with two different conclusions about its benefit.

The primary paper we covered was from the GRACIA-2 non-inferiority RCT, called Primary angioplasty vs. early routine post-fibrinolysis angioplasty for acute myocardial infarction with ST-segment elevation (from the European Heart Journal 2007 Vol. 28, p949-960).

Our secondary paper was from the ASSENT-4 RCT, called Primary verses tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute MI (from the Lancet 2006: Vol 367, p569-578).

MSCT for ACS: Good in Stressful Situations?

For the final journal club of the year, Ravi picked an article from Goldstein (and others)  entitled, “A Randomized Controlled Trial of Multi-Sliced Coronary Computed Tomography for Evaluation of Acute Chest Pain” (available from the Journal of the American College of Cardiology, 2007 Vol 49, No. 8, pp863-871).

It’s not the definitive, practice-changing study we’re waiting for, but it draws upon previous work (such as JAMA 2005; 293:2471-8) estabilishing multi-slice CT coronary angiography as effective in diagnosing occlusion, and attempts to compare the safety, efficacy and efficiency of MSCT against established protocols.

SAEM followup

Thanks to all who stopped by our Innovations inEM Education booth at SAEM these past few days. Your input and encouragement were appreciated! The abstract is now online and an MS-Word version of our informational pamphlet is available for download.  

 For those of you who wanted to discuss things further, my email is Nicholas.Genes /at/ mssm.edu.

Other EM journal club websites with analyses of articles:

• Washington University (archives)
• University of Michigan (archives)
• Emory (archives)
• East Virginia Medical School

If you know of more, please share! The idea of putting EM Journal Clubs online, for prompt bedside access, goes back a few years…

SAH Update: Are New CT Scanners Good Enough to Obviate the LP?

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…

Remedies for Intractable Hiccups

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…

Mad CAP Antics: Antibiotics Within 4 Hours

Jack tackled a controversial topic at this month’s Journal Club — what’s the evidence for giving antibiotics within four hours for CAP patients? It’s a good question, because how well we perform at this task is a big part of how our hospitals are measured. Ineed, pneumonia antibiotic timing is one of JCAHO’s Core Measures and there are only more such metrics down the road — so we’d like to think that our funding depends on rock-solid science and proven benefits.

Well…

As Jack noted, the 4-hr policy is based primarily on four papers,

1) Kahn et al, JAMA 1990 Oct 17 264(15) 1969-73 with comments 1995-6

2) McGarvey et al, Quality Review Bulletin April 13(4) 124-30

3) Meehan, Houck et al.  JAMA 1997 Dec 17 278(23) 2080-4 

4) Houck et al, Arch Intern Med. 2004; 164(6):637-644.

It’s this last paper we’re going to discuss — a retrospective study derived from a national sample of medicare patients with pneumonia.  

Undifferentiated Agitation in the ED: A new RCT

When I was preparing an M+M last fall, I came across this notable study called Management of Acute Undifferentiated Agitation in the ED: A Randomized Double-Blind Trial of Droperidol, Ziprasidone, and Midazolam . It’s by Martel et al (including Michelle Biros, who’s editor of Academic Emergency Medicine), and appeared in Academic Emergency Medicine in December 2005 (Vol 12, No 12, pp1167 — coincidentally, right after Dr. Richardson’s EMPATH study).

It’s a good study that we might otherwise overlook, because it came out on the eve of the ACEP guidelines for agitation management and thus, wasn’t included in that extensive lit review.

Dexamethasone in Benign Headaches

This week in journal club, Matt reviewed a nice little trial submitted by a group of Texans to the Canadian Journal of Emergency Medicine. They studied IV dexamethasone in preventing benign headache recurrence (Can J Emerg Med 2006;8(6):393-400, PDF) – something I had never tried, but apparently has been bouncing around the neurology and EM literature for 20 years.

It turns out that migraines may not be simply a vascular disorder, but rather an inflammatory disease. And, as Matt pointed out, it’s very difficult to diagnose migraines; it might be simpler for us ED folk to say headaches exist on a continuum between tension and migraine, and maybe ED patients with primary headache would benefit from a steroid.

Expirations: Does End-Tidal CO2 Monitoring Predict Adverse Respiratory Events In Sedation?

In the growing backlog of articles and journal club presentations I’d like to write up, I came across this publication which was presented a few months back — Does End-tidal Carbon Dioxide Monitoring Detect Respiratory Events Prior to Current Sedation Monitoring Practices? from Burton, Harrah, Germann and Dillon in Academic Emergency Medicine 2006; 13:500-504. My notes on the presentation have long since disappeared (I believe it was given by… Tim?) but my interest in the topic was rekindled after a recent M+M.