tag:blogger.com,1999:blog-69379531691374181782024-03-14T01:56:08.393-07:00Standing on the corner, minding my own business in the EREmergency medicine blog with a focus on dispelling myths and pseudoaxioms in medicine, as well as medical education.SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.comBlogger16125tag:blogger.com,1999:blog-6937953169137418178.post-83236306999168858512013-03-13T21:00:00.002-07:002013-03-13T21:00:26.140-07:00SOCMOB How To: Make Your Own End-Tidal CO2 Detector<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">Hey SOCMOBBERS,</span></span><br />
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">I have a new video on how to make your own end-tidal CO2 detector for a face mask or non-rebreather. Check it out <a href="http://socmob.org/2013/03/socmob-how-to-make-your-own-end-tidal-co2-detector/">here</a>.</span></span><br />
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<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">Cheers,</span></span><br />
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">Chris</span></span><br />
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">@SOCMOBEM</span></span>SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com5tag:blogger.com,1999:blog-6937953169137418178.post-3241859985115017122013-03-08T05:20:00.003-08:002013-03-08T05:20:33.036-08:00SOCMOB has moved!<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;">Hi all,</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;">SOCMOB has moved to Wordpress. Go to <a href="http://www.socmob.org/">www.socmob.org</a> to check out the new site, sign up for RSS feeds, tweets, etc.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;">All new content will now be appearing there.</span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;">Thanks for reading,</span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;">SOCMOBEM</span></span>SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com3tag:blogger.com,1999:blog-6937953169137418178.post-76875178769646717442013-02-27T08:12:00.000-08:002013-02-27T19:44:13.371-08:00NSAIDs part 2: The Ceiling Effect<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">Sorry readers. I've been slacking off on vacation in NYC, eating too much and blogging about food more than medicine. Tonight at dinner with Mr. EMCrit, Scott called me out a bit for insufficient content. Also, one of my readers has some rounds coming up soon, and needs to talk NSAIDs. With that in mind, here's part 2 of the NSAID saga.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">In <a href="http://www.socmob.blogspot.ca/2013/02/nsaids-part-1-which-one-is-best_3955.html" target="_blank">part 1 </a>on NSAIDs, we looked at NSAID equivalency for analgesia and the <b>myth that is ketorolac (Toradol). </b></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">Hat tip to readers Moshe<b> </b>and Elisha (@ETtube on twitter)<b> </b>for pointing out the concept of the <b>ceiling effect </b>with NSAIDs. I did not mention this in part 1, and will discuss it today.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">There's a great talk by Larry Raney on the Free Emergency Talks website that discusses NSAIDs and the ceiling effect. You can find it <a href="http://freeemergencytalks.net/2010/04/larry-raney-nsaids-rational-use/" target="_blank">here</a>. As an aside, the Free Emergency Talks website is run by Joe Lex, one of the great EM educators, and has a thousands of talks from any conference you can think of. </span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;"><b>What is the ceiling effect?</b></span><br />
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<span style="font-size: large;"><a href="http://3.bp.blogspot.com/-LEqKld3DVAM/URh0mBIZgXI/AAAAAAAAAFk/Hw53b-pMCzA/s1600/Belagio+Ceiling.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://3.bp.blogspot.com/-LEqKld3DVAM/URh0mBIZgXI/AAAAAAAAAFk/Hw53b-pMCzA/s1600/Belagio+Ceiling.jpg" height="212" width="320" /></a></span></div>
<span style="font-size: large;"><b><span style="font-family: Georgia,"Times New Roman",serif;">* Free sammich to the first reader who tells me where this ceiling is. </span></b><span style="font-family: Georgia,"Times New Roman",serif;">(Sammich will be good when it goes in the mail, but I can't guarantee quality on arrival. Might make it a cockroach and twinkie sammich to prevent spoilage.)</span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">The <b>ceiling effect</b> is the concept that<b> ther</b><b>e is a maximum level of analgesia that can be reached with a</b><b> dose of medication, and beyo</b><b>nd that do</b><b>se, </b><b>you get</b> <b>no</b><b> more</b><b> analgesia.</b> </span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">In addition, you continue to get<b> more side effects</b>. <b> That double sucks!</b></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">Tylenol and NSAIDs classically fall into the category of analgesics with a ceiling, while opiates have no ceiling. This is why we can bomb in loads of fentanyl or morphine, but you don't see us pounding patients with ibuprofen.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">If you look at the doses of NSAIDs listed in <a href="http://www.socmob.blogspot.ca/2013/02/nsaids-part-1-which-one-is-best_3955.html" target="_blank">part 1</a>, you'll see some pretty whopping doses. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">Aside from the <b>ceiling of anti-inflammatory dosing</b>, there is also the concept of a <b>secon</b><b>d ceiling for ac</b><b>ute pain</b>?</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;"><b>Two ceilings?</b> Yup, two ceilings.</span><br />
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<span style="font-size: large;"><b><span style="font-family: Georgia,"Times New Roman",serif;">The ceiling dose for acute pain with ibuprofen is 400 mg po.</span></b></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>The</b><b> hig</b><b>her ibuprofen dose</b><b> ceiling of 800 mg</b> I mentioned in part 1 is the anti-inflammatory ceiling of the NSAID and comes from the rheumatology literature. I apologize if I confused anyone with this. One key to understanding the NSAID literature is that it generally comes from 3 patient groups: <b>rh</b><b>eumato</b><b>logic disease, post-operative pain and dental pain</b>. The latter two are probably both representative of pain we see in ED patients, ie: acute, non-inflammatory pain.</span></span><span style="font-size: large;"><b><span style="font-family: Georgia,"Times New Roman",serif;"> </span></b></span><br />
<span style="font-size: large;"><b><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></b></span>
<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">This is the reason why meta-analyses of NSAID efficacy are a challenge; the indications, duration of therapy, dose, etc. are completely different. In some studies, you are looking at patients with chronic inflammatory conditions on long term therapy. These patients may need higher dose NSAIDs for their anti-inflammatory effects. In other studies, it is single dose or short-term NSAIDs where analgesic ceiling will be 400 mg.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">You can see how lumping all of these studies together in a review would misconstrue pretty much any endpoint.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;"><b>Let's now look at the two main studies supporting the 400 mg ceiling dose of ibuprofen and 10 mg ceiling dose of ketorolac. </b></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">In<b> </b>contrast to the usual scenario in which old research = bad research (or a <b>HSSP:</b><b> High School </b><b>Science Project</b>), there are papers from 1978 and 1986 looking at the ibuprofen ceiling effect. </span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=winter+ibuprofen+1978" target="_blank">The first</a>, by Winter et al. in 1978 looked at </span><span style="font-size: large;"><b><span style="font-family: Georgia,"Times New Roman",serif;">510 post oral surgery patients </span></b><span style="font-family: Georgia,"Times New Roman",serif;">who had 1 or more extractions, impactions and</span><b><span style="font-family: Georgia,"Times New Roman",serif;"> even a few with alveolectomies.</span></b><span style="font-family: Georgia,"Times New Roman",serif;"> That all sounds pretty painful! They compared <b>five treatments:</b></span><b><span style="font-family: Georgia,"Times New Roman",serif;"> ibuprofen 400 mg, ibuprofen 800 mg, </span></b><span style="font-family: Georgia,"Times New Roman",serif;">ASA 650 mg, Darvon 65 mg and placebo. <b>Both ibuprofen </b><b>groups ha</b><b>d similar reduction in pain scores</b><b> and were better than the other 3 treatment arms</b>. The study was done with pooled data from two separate dentists; in one group 400 mg ibuprofen seemed slightly more effective, while 800 mg seemed slightly more effective in the other. However, there are no data to support any statistically significant difference between ibuprofen groups in the article.</span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=1986+laska+ibuprofen" target="_blank">The second article</a>, by Laska et al. in 1986 was a double blind parallel group study with 200 patients post oral surgery compared doses of 400 mg , 600 mg and 800 mg of ibuprofen. There was <b>no evidence of a dose response efficacy difference between 400, 600 and 800 mg.</b></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">Considering that dental pain hurts like hell, I'm inclined to believe these studies are sufficiently representative of ED patients with most injuries. *As an aside, learn to do dental blocks, they are invaluable to patients.</span> <br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">With regards to <b>k</b><b>etorolac</b>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=staquet+ketorolac" target="_blank">th</a><a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=staquet+ketorolac" target="_blank">is double blind RCT from Staquet in 1989</a> compared <b>10 mg, 30 mg and 90 mg IM ketorolac </b></span><span style="font-size: large;"><b>with placebo in 128 patients with cancer pain</b>. Again, <b>no difference</b> was found between the 3 ketorolac dosing regimens, with all being much superior to placebo.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">Other similar studies have been done and show <b>10 mg is probably the ceiling dose of ketorolac both orally and parenterally. </b></span><span style="font-size: large;"><b> </b></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">In the next parts of the NSAID saga, we'll discuss side effects profiles of various NSAIDs, and NSAID hodgepodge such as effect on fracture healing, use in renal colic and more.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">Cheers,</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">SOCMOBEM </span><span style="font-size: large;"><b> </b></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;"><b>References: </b></span><br />
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<span style="font-size: large;">Winter et al. <span role="menubar"><a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=winter+ibuprofen+1978#" role="menuitem" title="Oral surgery, oral medicine, and oral pathology.">Oral Surg Oral Med Oral Pathol.</a></span> <span class="highlight">1978</span> Feb;45(2):159-66.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;">Laska et al. </span><span role="menubar" style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=1986+laska+ibuprofen#" role="menuitem" title="Clinical pharmacology and therapeutics.">Clin Pharmacol Ther.</a></span><span style="font-size: large;"> <span class="highlight">1986</span> Jul;40(1):1-7.</span><br />
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<span role="menubar" style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=staquet+ketorolac#" role="menuitem" title="Journal of clinical pharmacology.">Staquet MJ J Clin Pharmacol.</a></span><span style="font-size: large;"> 1989 Nov;29(11):1031-6. </span>SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com3tag:blogger.com,1999:blog-6937953169137418178.post-71838769618248697382013-02-14T10:23:00.001-08:002013-02-14T10:32:25.917-08:00Battle Preparation 2: The Buddy Shift<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>This is the 2nd part in the Battle Preparation series by SOCMOB guest blogger Damon Tedford.</b></span></span><br />
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">In <a href="http://www.socmob.blogspot.ca/2013/02/battle-preparation-getting-ready-for.html" target="_blank">part 1</a>, we looked at a <b>checklist of items</b> that new learners and staff should identify and examine prior to their first shift in a new ED. Today we will be looking at the<b> critical questions to ask on your buddy shifts</b> before venturing off alone in your new ED. These posts are most oriented to the level of senior residents who will become new staff physicians in the near future. However, the checklists will also be very beneficial to anyone entering a new department, including nurses, junior residents, respiratory therapists, etc. <b>The ability to find proper equipment is more important </b>than the proper strategy in dealing with a problem. <b>Amateurs discuss strategy, experts discuss logistics. </b></span></span><br />
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<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Important questions in this document include:</b></span></span><br />
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">- What radiology tests do I have access to, and at what times of day?</span></span><br />
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">- How do I set a patient up for outpatient antibiotic therapy?</span></span><br />
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">- Is there a crisis worker for psychiatric patients or do I see them first?</span></span><br />
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">- What are the expectations in our group for shift handover?</span></span><br />
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">and many more...<b><br /></b></span></span><br />
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<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">Let me use a story to<b> emphasize the importance of logistics versus strategy.</b> A few months ago on a CCU rotation, I was managing a chest pain patient in the ED. He had hyperacute T-waves on his ECG. It was about 2 AM, the ED was packed, and it would be about 45 minutes until he could get to the cath lab. In the meantime, he required management of his chest pain and a nitroglycerin infusion had been started at 10 mcg/min. His nurse was only intermittently in the room, so frequent titration of his nitro would have been impossible unless I knew how to do it myself. Fortunately, I had made sure to learn to use our IV pumps; thus I could quickly increase his nitro infusion independent of nursing staff requirements.</span></span><br />
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">This same concept applies to everything you do in the ER; from inserting a urinary catheter to preparing a patient for inter-department transport. <b>Self-reliance and total logistic knowledge of your environment is a must.</b> <b>Pretend you're an anesthetist</b>. <b>Have you ever seen an anesthetist who didn't set up his/her own pumps or draw up his/her own meds?</b></span></span><br />
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<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">Here is a<b> <a href="http://www.scribd.com/doc/125511039/SOCMOBEM-Emeregncy-Department-Orientation-Buddy-Shift-Questions-for-New-Staff-and-Trainees" target="_blank">link to part 2 of the Battle Preparation: Buddy Shift Questions</a></b></span></span><br />
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<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.scribd.com/doc/125511039/SOCMOBEM-Emeregncy-Department-Orientation-Buddy-Shift-Questions-for-New-Staff-and-Trainees" style="text-decoration: underline;" title="View SOCMOBEM: Emeregncy Department Orientation - Buddy Shift Questions for New Staff and Trainees on Scribd">SOCMOBEM: Emeregncy Department Orientation - Buddy Shift Questions for New Staff and Trainees</a> by </span></span> </div>
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><iframe class="scribd_iframe_embed" data-aspect-ratio="undefined" data-auto-height="false" frameborder="0" height="600" id="doc_44411" scrolling="no" src="http://www.scribd.com/embeds/125511039/content?start_page=1&view_mode=scroll" width="100%"></iframe></span></span>
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<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Cheers,</b></span></span><br />
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Damon Tedford (@DamonTedford), Chris Krause and Chris Bond (@SocmobEM) </b></span></span><br />
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<span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com0tag:blogger.com,1999:blog-6937953169137418178.post-55866112939673952202013-02-09T18:37:00.000-08:002013-02-10T20:04:14.173-08:00NSAIDs Part 1: Which one is best?<div class="separator" style="clear: both; text-align: center;">
<a href="http://1.bp.blogspot.com/-Y8VIpqg7xbk/URbwMB5lYII/AAAAAAAAAFA/XpjAlu2oExk/s1600/IheartNSAIDs.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="http://1.bp.blogspot.com/-Y8VIpqg7xbk/URbwMB5lYII/AAAAAAAAAFA/XpjAlu2oExk/s200/IheartNSAIDs.png" height="200" width="200" /></a></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">I
love NSAIDs! Yup, love ‘em!</span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">NSAIDs
</span></b><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">(Non-steroidal anti-inflammatory drugs)
are some of the best analgesics available, plus they’re generally over the
counter. Despite their daily use for decades, <b style="mso-bidi-font-weight: normal;">NSAIDs remain sorely misunderstood. </b>I know they’re not a
panacea, and they have some serious side effects in certain
populations. But for healthy patients without co-morbidities, they
are pretty awesome painkillers, with no addictive potential (that I’m aware
of). </span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Before we start,
perform a <b style="mso-bidi-font-weight: normal;">Gedanken experiment</b> if you
will. Not a true Gedanken Schrodinger’s Cat type experiment, but answer
the following questions in your mind.</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">1)
What is the best NSAID for analgesia?</span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">2)
Do oral or parenteral NSAIDs provide better pain relief?</span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Got your answers?
Good.</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Based on the
conversations among staff, residents and nurses in the ED, <b style="mso-bidi-font-weight: normal;">oral or</b> <b style="mso-bidi-font-weight: normal;">parenteral ketorolac
(AKA: IM Toradol) is the strongest/bestest/most fantastic/awesome NSAID out
there. </b></span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">WRONG!</span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">I know that regardless
of what I say from here on, some of you will stand by IM Toradol like a dying
loved one. That’s okay, I understand. It’s not your fault that you’ve
been brainwashed into thinking this way. Or maybe it’s anecdotal
experience from years of practice, and I’m just a young pup who doesn’t know
anything.</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Just
hear me out. </span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">What
is the best NSAID for analgesia?</span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">There
isn’t one</span></b><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">. </span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">They’re all the same
when dosed appropriately. I cannot say it better than Grant Innes did in <a href="http://www.ncbi.nlm.nih.gov/pubmed/15829391"><span style="mso-bidi-font-size: 12.0pt;">this 2005 review of ED pain medications.</span></a></span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span style="font-family: Arial; font-size: 18.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";">“Although some
agents have been advocated for specific indications (eg, indomethacin for
gout), <b style="mso-bidi-font-weight: normal;">there is no compelling evidence
that any one NSAID is superior to any other—for any indication</b>.
Consequently, NSAIDS should be selected based on convenience, cost, and
availability rather than on theoretical efficacy advantages.”</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Important to note are
the dosing regimes for each NSAID, as they are more than often used in the ED:</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Ibuprofen<b> up to</b> 800
mg QID </span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Naproxen <b>up to</b> 500 mg
TID </span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Ketorolac <b>up to</b> 10 mg
QID</span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Indomethacin <b>up to</b> 50
mg QID</span><br />
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";"><b>*Edit</b>: There is an important concept of <b>ceiling effect</b> with NSAIDs. I left this out here, and it is very important so we'll discuss it in part two of the NSAID saga. Thanks to reader @ETtube for pointing this out. </span><br />
<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";"><br /></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Other NSAID regimes
are also found in this paper, but these are the most common ones in North
America.</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";"> </span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">But
what about IM toradol? It always works for my patients.</span></b><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">
</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">I don't know but
maybe these<b style="mso-bidi-font-weight: normal;"> these guys </b>know the
answer.</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB"><a href="http://1.bp.blogspot.com/-uStFX9rZxec/URbyC7M4Y3I/AAAAAAAAAFM/sv2Z0XVQbEc/s1600/Mel-Herbert.jpeg"><span lang="EN-US" style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman"; mso-no-proof: yes; text-decoration: none; text-underline: none;"></span></a><a href="http://2.bp.blogspot.com/-gZPaXsr2q0A/URbyHJMr5_I/AAAAAAAAAFU/2gQdsPZd7_k/s1600/Arora.png"><span lang="EN-US" style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman"; mso-no-proof: yes; text-decoration: none; text-underline: none;"><br /></span></a></span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">That's right, <b style="mso-bidi-font-weight: normal;">Sanjay Arora and Mel Herbert from EM:RAP</b>
actually wrote a paper on this. 6 years ago!</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">I highly suggest you
take 10 minutes of your day to read t<a href="http://www.ncbi.nlm.nih.gov/pubmed/17391598"><span style="mso-bidi-font-size: 12.0pt;">his great article in CJEM in 2007. </span><span style="color: black; mso-bidi-font-size: 12.0pt;">The full text version is free as well.</span></a></span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Alternatively, I'll
summarize it here.</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";"><a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=1994+wright+ketorolac"><span style="mso-bidi-font-size: 12.0pt;">1994 Wright et al.</span></a>– Retrospective
analysis of data that was collected by prior prospective survey. </span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">800 mg ibuprofen po
vs. 60 mg ketorolac IM - <b style="mso-bidi-font-weight: normal;">NO DIFFERENCE</b>
in pain as rated by visual analogue scale (VAS)</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";"><a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=1995+turturro+ketorolac"><span style="mso-bidi-font-size: 12.0pt;">1995 Turturro et al. </span></a>– Prospective
DBRCT (Double blind randomized controlled trial). </span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">800 mg ibuprofen vs.
60 mg ketorolac IM - <b style="mso-bidi-font-weight: normal;">NO DIFFERENCE</b></span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";"><a href="http://www.ncbi.nlm.nih.gov/pubmed/9492131"><span style="mso-bidi-font-size: 12.0pt;">1998 Neighbor and Puntillo –</span></a> Prospective DBRCT. 800 mg
ibuprofen vs. 60 mg ketorolac IM. All patients had self-assessed
pain between 5-8/10 on VAS. </span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">NO
DIFFERENCE</span></b><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";"> </span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">*</span></b><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Funny
thing about this study is the author’s name is spelled as Neighbour with a “U”
in the text, but not in the references. Funny because the Canadian CJEM
autocorrect probably added the “U”. Maybe funny just to me.*</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">They also cite two
more trials comparing post-op pain with the same ibuprofen vs. ketorolac
dosing, but at this point, you get the picture.</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Finally, all of these
studies compared <b style="mso-bidi-font-weight: normal;">60 mg </b>of ketorolac
IM to 800 mg of ibuprofen. <b style="mso-bidi-font-weight: normal;">Who
actually gives 60 mg? </b> I've never seen it where I work, where 30 mg is
the standard dose. So, maybe ibuprofen is actually better than the 30 mg
of IM ketorolac that we give. </span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Some
of you may say, “I use the toradol for the placebo effect of an
injection. You can’t argue with that.” </span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Sorry,
someone studied that too.</span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";"><a href="http://www.ncbi.nlm.nih.gov/pubmed/10958124"><span style="mso-bidi-font-size: 12.0pt;">This study<b style="mso-bidi-font-weight: normal;"> </b>by Schwartz et
al.</span></a> was a prospective DBRCT<b style="mso-bidi-font-weight: normal;"> </b>in
which patients <b style="mso-bidi-font-weight: normal;">“were unknowingly given
800 mg oral ibuprofen in a flavoured drink and then given either a placebo IM
injection or a placebo pill.” </b>No patient really received any IM
medication in either group, and there was similarly no difference in the VAS
between the two groups. <b style="mso-bidi-font-weight: normal;">So IM for
placebo effect only also appears unwarranted</b>. </span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Also,
that study design is kick ass!</span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Treatment
bottom line: </span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">There
is no difference between NSAIDs when it comes to pain control. Just use
an adequate dose of whichever you choose. </span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">IM
ketorolac still has a role in vomiting patients or those unable to take po
meds, but don’t kid yourself that it’s a “stronger” medication. It’s not.</span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span style="font-family: Arial; font-size: 18.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";">Despite all of
this, I agree that some NSAIDs work better for certain people? Why is
this?</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span style="font-family: Arial; font-size: 18.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";">Watch for parts
2 and 3 of the NSAID discussion, where we'll talk about this and much
more. </span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">*Personal disclosure:
I use ibuprofen almost exclusively, but also use Naproxen, as the BID (can go
TID) dosing regimen generally means patients will be more compliant and
hopefully have better pain control for a greater duration. When we
discuss side effect profiles in the coming weeks, you'll see why I don't use
ketorolac.</span><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"> </span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Cheers,</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">SOCMOBEM</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">References:</span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Innes
GD, Zed PJ, <a href="http://www.ncbi.nlm.nih.gov/pubmed/15829391"><span style="mso-bidi-font-size: 12.0pt;">Emerg Med Clin North Am.</span></a> 2005
May;23(2):433-65, ix-x. </span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Arora
S, Wagner JG, Herbert M. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17391598"><span style="mso-bidi-font-size: 12.0pt;">CJEM.</span></a> 2007 Jan;9(1):30-2. </span></b><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">Schwartz
NA, et al. <a href="http://www.ncbi.nlm.nih.gov/pubmed/10958124"><span style="mso-bidi-font-size: 12.0pt;">Acad Emerg Med.</span></a> 2000 Aug;7(8):857-61. </span></b><span lang="EN-GB" style="font-family: Arial; font-size: 18.0pt; mso-bidi-font-family: "Times New Roman";">
</span><span style="font-family: Times; font-size: 10.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman";"></span></div>
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SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com7tag:blogger.com,1999:blog-6937953169137418178.post-47652900093162355682013-02-05T18:10:00.000-08:002013-02-14T10:35:56.306-08:00Battle Preparation: Getting Ready for Your First Shift in the ER<div class="MsoNormal">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://www.blogger.com/blogger.g?blogID=6937953169137418178" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"></a></div>
<span style="font-family: Arial; font-size: large;">Today is a first for the SOCMOB blog, as we have our
first <b>guest blogger.</b> <b>Damon
Tedford</b> is one of my fellow EM residents, and is also in his final year of
training. Combining his military
background with the works of Cliff Reid and Scott Weingart, Damon had the
fantastic idea of <b>creating a checklist</b>
to familiarize oneself with the ED prior to their first shift. This will be released in <b>two parts, a walk-about checklist today,
followed by a list of key questions later in the week. </b></span><br />
<br />
<span style="font-family: Arial; font-size: large;"><span style="font-size: large;">*For<span style="font-size: large;"> <span style="font-size: large;">part 2, <a href="http://www.socmob.blogspot.ca/2013/02/this-is-2nd-part-in-battle-preparation.html" target="_blank">click here</a>.</span></span></span><b> </b></span></div>
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<span style="font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: large;"><b><u><span style="font-family: Arial;">Battle Preparation: Getting Ready for Your First
Shift in the ER</span></u></b></span></div>
<span style="font-size: large;"><b>
</b></span><br />
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<span style="font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">As the end of residency approaches, I often hear of
the tumultuous emotional trajectory that awaits the recently certified ER doc.
"Plan for three months of fear. It slowly gets easier after
that." I expect some growing pains after shedding the training
wheels, but have we not figured out a better way of assisting physicians with
this transition? After all, it is a <b>yearly event.</b></span></div>
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<span style="font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">In the few places I have interviewed, it would seem
that buddy shifts are the norm for newcomers. Physicians are eased into
their working environment over a number of shifts with a local, experienced
physician. It is a great, but imperfect idea, as the value of the orientation
depends on the cases of the day and what your mentor thinks you need to know.
In addition to these shifts, I plan on adding a more active and ordered
approach, leaving less to chance.</span></div>
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<span style="font-size: large;"><br /></span></div>
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<span style="font-family: Arial; font-size: large;">Before my medical days, I trained as an army officer
in the Canadian Forces, and if anyone can do order, it's the army.
During those days, we were taught a regimented approach to mission
planning. We called the process
"Battle Procedure." Reconnaissance, or a <b>"Recce," is
a key component of Battle Procedure, so much so that all army leaders know the
axiom, “Time on recce is seldom wasted”. </b></span></div>
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<span style="font-size: large;"><br /></span></div>
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<span style="font-family: Arial; font-size: large;">During the planning stage, a commander will draft a recce
plan to identify factors that will waylay the mission (What equipment do I have
at my disposal? What aspects of the ground will impact my team? Where am I
vulnerable and how can I mitigate that risk?) These are some examples of
questions the leader seeks to answer during his recce. During the
recce, the leader walks the ground with a plan in mind. If this is impractical, he/she reviews
maps, satellite photography, or accounts from first-hand witnesses to get a
sense of the environment he/she will be operating. The commander then
completes a plan and shares it with the team. Together they may
"war-game" it, playing out each phase of the operation, identifying
oversights or unique aspects of the operational environment that necessitate
changes to how they have done business in the past.</span></div>
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<span style="font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">Battle Procedure is a deliberate process, and one I
have used to work through some complex problems. If the military analogy
does not work for you, have a listen to <a href="http://emcrit.org/podcasts/mind-resus-doc-logistics/" target="_blank">Scott Weingart's Podcast #49 - Mind ofthe Resus Doc: Logistics over Strategy.</a> It's one of my favorites and a
major inspiration for the checklists you will find below. </span></div>
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<span style="font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: large;"><a href="http://emcrit.org/podcasts/emcrit-intubation-checklist/" target="_blank"><span style="font-family: Arial;">EDIT: Also check out Scott's new intubation checklist podcast just released today. </span></a></span></div>
<span style="font-size: large;"><a href="http://emcrit.org/podcasts/emcrit-intubation-checklist/" target="_blank">
</a></span><br />
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<span style="font-size: large;"><a href="http://emcrit.org/podcasts/emcrit-intubation-checklist/" target="_blank"><span style="font-family: Arial;"><br /></span></a></span></div>
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<span style="font-family: Arial; font-size: large;">Here at SOCMOBEM, we have completed a recce plan for
the new ER physician, but this could easily be used by anyone new to the
department. Our goal is to ease the transition of new ER team members and
get them ready for peak performance on day one.</span></div>
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<span style="font-size: large;"><br /></span></div>
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://www.blogger.com/blogger.g?blogID=6937953169137418178" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"></a></div>
<span style="font-family: Arial; font-size: large;">Identifying the key tasks we could be called upon to
complete during our first shift, we have created a list of equipment for time
sensitive resuscitation tasks as well as those that are more regular but
routine. Finding the equipment before your first shift prevents loss of
valuable time and also improves department flow. However, the document is
more than a medical scavenger-hunt. </span></div>
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<a href="http://i643.photobucket.com/albums/uu156/MooglesC1/SOCMOBEM/SOCMOBChecklistPart1_zpsfc616035.png" target="_blank"><span style="font-size: large;"><br /></span></a>
<a href="http://i643.photobucket.com/albums/uu156/MooglesC1/SOCMOBEM/SOCMOBChecklistPart1_zpsfc616035.png" target="_blank"><span style="font-size: large;"></span></a><span style="font-size: large;"><a href="https://www.blogger.com/blogger.g?blogID=6937953169137418178" target="_blank">Click here or on docume<span style="font-size: large;">nt for full size ch<span style="font-size: large;">ec</span>klist.</span></a></span><br />
<span style="font-size: large;"><br /></span>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://i643.photobucket.com/albums/uu156/MooglesC1/SOCMOBEM/SOCMOBChecklistPart1_zpsfc616035.png" target="_blank"><span style="font-size: large;"><img border="0" src="http://2.bp.blogspot.com/-WtkZevmB1Dg/URG1shQeBcI/AAAAAAAAAEk/Bin-3ujfE2A/s1600/Screen+shot+2013-02-05+at+7.48.53+PM.png" height="457" width="640" /></span></a></div>
<br />
<a href="http://www.scribd.com/doc/124095489/SOCMOB-ER-Orientation-Checklist-for-New-Staff-and-Trainees" target="_blank"><span style="font-size: large;">Download the file here</span></a><span style="font-size: large;">.</span>
<span style="font-size: large;"><br /></span></div>
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<span style="font-family: Arial; font-size: large;"></span><span style="font-size: large;"><b><span style="font-family: Arial;">While
checking off items, ask yourself: </span></b></span></div>
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<span style="font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">What is the state of repair of the equipment? </span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">Are there shortages of essential items within the
procedure bundles that I will need to complete the task? </span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">Would I be able to set up this ventilator alone?</span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">How do I see a resuscitation playing out here?</span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">Does equipment location make sense?</span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">Where could things potentially go wrong for my team and
what could I do about it? </span></div>
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<span style="font-size: large;"><b><span style="font-family: Arial;">You get the idea.</span></b></span></div>
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<span style="font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">With a fresh set of eyes, we may identify
opportunities to improve patient care and efficiency. <b>A word of caution: no one likes a
know-it-all. </b>Unless patient safety is an issue, <b>save the
recommendations</b> for an appropriate time and venue and deliver those suggestions
tactfully. </span></div>
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<span style="font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">The second document will contain a list of questions
that will guide the conversation between mentor and new ER physician.
Perhaps it could be done over a coffee. Some examples of these
questions include: </span></div>
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<span style="font-size: large;"><br /></span></div>
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<span style="font-family: Arial; font-size: large;">What services are available after hours?</span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">How do we handle mass casualties? </span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">Do we have a massive transfusion protocol?</span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">Where can I find this and other protocols? </span></div>
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<span style="font-size: large;"><br /></span></div>
<span style="font-size: large;"><b>
</b></span><br />
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<span style="font-family: Arial; font-size: large;"><a href="http://www.socmob.blogspot.ca/2013/02/this-is-2nd-part-in-battle-preparation.html" target="_blank"><b><span style="font-size: large;">C<span style="font-size: large;">lick here <span style="font-size: large;">for <span style="font-size: large;">P</span>a<span style="font-size: large;">rt 2: Buddy Shift Questions.</span></span></span></span></b></a></span> </div>
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<span style="font-size: large;"><br /></span></div>
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<span style="font-family: Arial; font-size: large;">We hope these posts help those who find themselves in
a new emergency department. If you have suggestions, let us know.
Peer review is key to improvement. </span></div>
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<span style="font-size: large;"><br /></span></div>
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<span style="font-family: Arial; font-size: large;">Cheers,</span></div>
<div class="MsoNormal">
<span style="font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: large;">Damon</span></div>
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<span style="font-size: large;"><br /></span></div>
SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com2tag:blogger.com,1999:blog-6937953169137418178.post-42679069358783393052013-01-24T12:27:00.000-08:002013-02-03T10:35:29.214-08:00New Surviving Sepsis Guidelines 2012: WTF?<span style="font-size: large;">Hey all, this is just <span style="font-size: large;">a short snippet<span style="font-size: large;">, not a full blog post. <span style="font-size: large;">As the 2012 Survi<span style="font-size: large;">vi<span style="font-size: large;">ng Sepsis Guidelines were just release<span style="font-size: large;">d<span style="font-size: large;">, I<span style="font-size: large;">'m just making a few <span style="font-size: large;">comments an<span style="font-size: large;">d directing you to Scott Weingart's gr<span style="font-size: large;">eat podcast on <span style="font-size: large;">the guidelines.<span style="font-size: large;"> </span></span></span></span></span></span></span></span></span></span></span></span></span> </span><br />
<br />
<span style="font-size: large;">Everyone who takes care of emergent/critical care sepsis patients needs to take 18 minutes of their life and go listen to Scott Weingart's new Practical Evidence podcast on the 2012 Surviving Sepsis guidelines <a href="http://practicalevidence.org/surviving-sepsis-campaign-guidelines-2012/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+FOAMEM+%28FOAM+RSS%29" target="_blank">here</a>.</span><br />
<br />
<span style="font-size: large;">The whole document is 60 some pages, but the <b>big highlights</b> for me are:</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>Good:</b></span><br />
<br />
<span style="font-size: large;"><b>1)Lactate clearance now included</b> as measure of tissue perfusion - But there is also some BAD with this one (see below).</span><br />
<br />
<span style="font-size: large;"><b>2)Norepinephrine is 1st choice vasopressor</b> for all patients.</span><br />
<br />
<span style="font-size: large;"><b>3)Epinephrine</b> as 2nd vasopressor, followed by vasopressin (new does 0.03 units/min)</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>4)Dopamine pretty much gone - Yay!</b></span><br />
<br />
<span style="font-size: large;"><b>5)Protective lung ventilation strategies for sepsis induced ARDS </b></span><span style="font-size: large;"><br /></span><br />
<br />
<span style="font-size: large;"><b>Bad:</b></span><br />
<br />
<span style="font-size: large;"><b>1)Still recommending use of CVP goal of 8-12 mmHg to guide fluid therapy. </b>Haven't we beaten this dead horse enough. <a href="http://www.socmob.blogspot.ca/2012/10/why-should-we-insert-cvcs.html" target="_blank">See here</a></span><br />
<br />
<span style="font-size: large;"><b>2)Still recommends SCvO2 to monitor tissue perfusion. This is fine if you have a CVL, but they do not make mention of lactate clearance being non-inferior to SCvO2. </b>Also discussed in previous post on CVL (linked above).</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>3)Recommends delaying antibiotics up to 45 mins to give BCx. Uh, isn't time to antibiotics our #1 goal? </b></span><br />
<br />
<span style="font-size: large;"><b>4)No recommendation for U/S of IVC, but still recommend static markers (HR/BP) to guide fluid responsiveness.</b></span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;">Scott does a great job of going over all of this and more in his podcast. A summary of the guidelines is also found there.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Cheers,</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">@SocmobEM</span><br />
<span style="font-size: large;"><br /></span>SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com0tag:blogger.com,1999:blog-6937953169137418178.post-38151852688926345252013-01-24T10:59:00.002-08:002013-02-03T10:36:10.725-08:00Thiamine Before Glucose will not cause Wernicke's Encephalopathy<span style="font-size: large;"><b>If there's one area of medicine that suffers from more dogma than any other, it's toxicology. </b></span><br />
<br />
<span style="font-size: large;">I'm not razzing tox, <b>I love tox</b>. But <b>management in toxicology usually = throw kitchen sink at patient</b>, followed by a case report that concludes the last intervention done just prior to the patient improving is a new treatment for that toxicity. One of the biggest researchers I've published with once told me, "I don't do case reports, that's not real evidence based medicine".</span><br />
<span style="font-size: large;"><br /></span><span style="font-size: large;">Over the next few weeks we're going debunk a few of the best tox myths.</span><br />
<br />
<span style="font-size: large;">Before we get into myth #1, if you do not know about Leon Gussow's blog at<a href="http://www.thepoisonreview.com/" target="_blank"> The Poison Review, you should check it out here.</a></span><br />
<span style="font-size: large;"><br /></span>
<br />
<span style="font-size: large;">The other day, a fellow EM resident asked me about one of my favorite toxicology related myths.<b> </b></span><br />
<br />
<span style="font-size: large;"><b>Will giving glucose before thiamine cause acute development or worsening of Wernicke's encephalopathy?</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Like most medical dogma, this teaching can be traced back to case reports/series and a few animal studies. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22104258" target="_blank">This article</a> from Schabelman and Kuo in JEM 2012 reviews the literature on this topic, and concludes that while <b>prolonged (at least >24 hours and usually longer) administration of glucose without thiamine may worsen Wernicke's</b>, there is no evidence for the near instantaneous development of Wernicke's that we are taught in medical school. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Reading some of the studies that form the basis of this concept is <b>both enlightening and entertaining.</b> One of the two studies that forms the basis of the Thiamine teaching comes from <a href="http://pubget.com/paper/5908887/Occurrence_of_acute_Wernicke_s_encephalopathy_during_prolonged_starvation_for_the_treatment_of_obesity" target="_blank">Drenick et al. in the NEJM, 1966. </a></span><br />
<br />
<span style="font-size: large;">In this case report, a morbidly obese man (180 cm, 335 lbs.) was<b> starved for just under two months</b> (Feb.25 to April 20th), on a <b>500 calorie per day</b> diet with <b>no vitamin supplementation.</b> They measured daily thiamine in the urine and found it to be absent by 30 days. There were 4 others originally in the study who also had absent thiamine by 30 days. </span><br />
<br />
<span style="font-size: large;">The obese male developed nausea and required withdrawal from the study on April 20th, at which point <b>they re-fed him with only glucose and orange juice for 13 days! </b>Over that period, he developed worsening symptoms of Wernicke's encephalopathy, and <b>upon administration of thiamine, his symptoms resolve over a period of days. </b></span><br />
<br />
<span style="font-size: large;">The study that is most often cited regarding this myth<a href="http://pubget.com/paper/7319764/Acute_Wernickes_encephalopathy_precipitated_by_glucose_loading" target="_blank"> is a 1981 article by Watson et al.</a> This case series looked at <b>4 patients</b> <b>who were given</b> <b>between 24 hours and 5 days of glucose</b> without thiamine and developed partial/complete Wernicke's. These resolved either partially or fully with the administration of thiamine. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Finally, you may want to read this <b>1952 study by Phillips et al, if only to see what a crazy study design and lack of ethics looks like.</b> The study design here could be called random case series, observational study or <b>high school science project</b>. They looked at 9 alcoholic patients with 6th nerve palsies other Wernicke's symptoms (presumably, as this was pre-CT head era, these patients may have had chronic SDH for all we know) and then fed them glucose only diets for days. After a few days of getting worse, they'd start supplementing various quantities of thiamine, and some patients improved.</span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b>Bottom line: Giving glucose prior to thiamine will not precipitate an acute Wernicke's encephalopathy. Prolonged administration (at least > 24 hours) of glucose only diets</b> <b>may worsen symptoms, but can then be reversed by giving thiamine.</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Over the next few weeks, the site will be moving, so please bear with me.</span><br />
<br />
<span style="font-size: large;">Also, as there is so much great FOAM mythbusting going on out there, you may start to notice more short posts that collate already great FOAM resources.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Finally, there may be some guest bloggers coming on board in the near future, so you can look forward to an increased volume of posts here at SOCMOB.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Cheers,</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">@SocmobEM</span><br />
<br />
<span style="font-size: large;"><b>References:</b></span><br />
<span style="font-size: large;"><br /></span>
<br />
<div class="cit">
<span style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/22104258#" role="button" title="The Journal of emergency medicine.">Schabelman E, Kuo D. J Emerg Med.</a> 2012 Apr;42(4):488-94. doi: 10.1016/j.jemermed.2011.05.076. Epub 2011 Nov 21.</span><br />
<br />
<span style="font-size: large;"><span class="citation">Drenick et al. N Engl J Med 1966; 274:937-939</span></span> <br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Watson AJ, Walker JF, Tomkin GH, Finn MM, Keogh JA. Acute Wernickes encephalopathy precipitated by glucose loading. Ir J Med Sci 1981;150:301–3.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Phillips GB, Victor M, Adams RD, Davidson CS. A study of the nutritional defect in Wernicke’s syndrome; the effect of a purified diet, thiamine, and other vitamins on the clinical manifestations. J Clin Invest 1952;31:859–71.</span></div>
<h1>
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SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com2tag:blogger.com,1999:blog-6937953169137418178.post-48885013721307614202013-01-16T19:15:00.000-08:002013-01-16T21:29:36.460-08:00How to make your own Cricothyrotomy Trainer<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>Who has done a cricothyrotomy</b>?</span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b>Who thinks they would be comfortable doing a cric if asked? Without having a code brown first?</b></span> <br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Though I have done a few tracheostomies (only three on live people), I've never done a cric on anyone. Furthermore, when it's time to cric, we need to be ready. Unfortunately, we can't practice on our fellow residents, cadavers are hard to come by, and industry made cric training devices are hundreds of dollars to purchase. <b>How are we going to be ready to cric without any practice?</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">While there are many great videos out there showing how to perform a cric, they are usually performed on cadavers/simulators, which most of us do not have routine access to. In particular, Scott Weingart from EMCrit has a great quick n<span style="font-size: large;">' dirty cric video<span style="font-size: large;"> which can be found <a href="http://www.youtube.com/watch?v=54lG3nFi8eY" target="_blank">here</a>.<span style="font-size: large;"><br /></span></span></span></span><br />
<br />
<span style="font-size: large;">Whi<span style="font-size: large;">le Scott's vid<span style="font-size: large;">eo is awesome,</span></span> there aren't any videos on how to make your own cric trainer, so I thought it would be nice to fill that gap. Below you'll find a video I've made showing the steps for <b>making your own cric trainer</b>. </span><br />
<span style="font-size: large;"> </span><br />
<span style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/15488062" target="_blank"><span style="font-size: large;">T</span>his</a> 2004 Anesthesiology article provides the basis for making the cric trainer. In this article, Varaday et al. compared use of a cric trainer made from a few standard operating room supplies (AKA Homemade) to expensive commercially available cric trainers. 20 anesthesia trainees practiced on the homemade device, while a second group of 20 trainees practiced on the commercial devices.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">The study concluded, "trainees found the homemade model a useful substitute for practice of percutaneous techniques and teaching" and "both models were rated well, with similar scores. The homemade model is an easily assembled alternative to more expensive models"</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">The advantage of this cric trainer is being inexpensive, reusable and pretty realistic. I think the greatest value of this trainer will be for those who are required to teach cric's, especially for large numbers of residents/students. One set of ventilator tubing provides enough practice "trachea" for a large number (eg. > 10-20) of cric trainers, and the remaining materials are easily accessible. </span><br />
<br />
<span style="font-size: large;">If you are an individual resident/student looking to practice your skills, you'll just have to politely ask an anesthetist/OR staff to give you a few supplies. If you tell them the purpose of it, I doubt they'll have much problem with it.</span><br />
<span style="font-size: large;"><br /></span>
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-size: large;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-size: large;"></span></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-size: large;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.youtube.com/embed/5-SJL9zq5eM?feature=player_embedded' frameborder='0'></iframe></span></div>
<a href="http://www.youtube.com/watch?v=5-SJL9zq5eM&feature=youtu.be" target="_blank"><span style="font-size: large;"><br /></span></a>
<span style="font-size: large;"><span style="font-size: large;"><a href="http://www.youtube.com/watch?v=5-SJL9zq5eM&feature=youtu.be" target="_blank">Click the YouTube link if above video isn't working</a></span></span><br />
<span style="font-size: large;"></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Having now performed a few real life tracheostomies, I think this trainer is actually very good, and approximates the real thing quite well considering how easy and inexpensive it is to make. </span><br />
<br />
<span style="font-size: large;">You'll notice I made a few modifications from the trainer used in the article:</span><br />
<span style="font-size: large;">1 - If you only have single thickness vent tubing, reinforce the tubing and the skin with 2-3 pieces of iv tape. I find this definitely mimics reality a little better with regard to the difficulty of cutting the skin and trachea.</span><br />
<span style="font-size: large;">2 - I don't completely cover the trainer with tape as they do in the article. I find this is not totally necessary and allows you to rotate your vent tubing more easily to make a "fresh" trachea.</span><br />
<span style="font-size: large;">3 - I have not attached a bag here to act as lungs, but if you have an O2 source and jet insufflation equipment, attaching an old bag from the anesthesia cart will add to the realism.</span><br />
<span style="font-size: large;"></span><br />
<span style="font-size: large;"></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">That's all for today, watch for some upcoming toxicology myths that I'll be busting over the next few weeks.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">P.S. I know today's blog was again a detour from busting up pseudoaxioms and dogma. Overall
the SOCMOB blog will continue to focus on dispelling medical myths, but I'll also
be incorporating more procedure videos, rants and interesting cases as well. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Happy cric-ing,</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">@SOCMOBEM </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>References:</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/15488062#" role="button" title="Anaesthesia.">Varaday SS et al. Anaesthesia.</a> 2004 Oct;59(10):1012-5.</span>SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com3tag:blogger.com,1999:blog-6937953169137418178.post-17350909935854031202013-01-13T12:37:00.001-08:002013-01-16T19:39:41.822-08:00Drinking the PPI Hate-O-Rade<span style="font-size: large;">Hi all, sorry about the extended hiatus. I was away after Christmas for about 12 days and have been getting back in the swing of things over the past week. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Since the break, one great new blog that has popped up on the FOAMed landscape is the boringem blog, started by Brent Thoma, one of the other ER residents in Saskatoon. You can check it out <a href="http://boringem.com/" target="_blank">here</a>.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Also, look for a new blog section for med ed. videos in the near future. I'll start it out with a cardiology parody I made back as a med student. Watch for a How To video on making a homemade cricothyrotomy trainer soon.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Onto the blog.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Proton pump inhibitors (PPIs) have been taking a beating in the FOAM arena lately, with a large portion of the credit going to David Newman of <a href="http://www.smartem.org/podcasts/upper-gi-bleed-ppi" target="_blank">SmartEM</a> and t<a href="http://www.thennt.com/nnt/proton-pump-inhibitors-for-acute-upper-gi-bleeding/" target="_blank">heNNT</a>. Just before Christmas, <a href="http://thesgem.com/2012/12/sgem-16-ho-ho-hold-the-ppi/" target="_blank">theSGEM blog </a>did an excellent blog post and podcast on this topic as well. The links above will allow you to review the common misconceptions surrounding PPIs, as well as the evidence to support this. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Briefly, PPIs have been thought of as a panacea over the past decade, with the 80 and 8 bolus + infusion protocol thought of as the cure for all UGIBs. Unfortunately, this <a href="http://www.ncbi.nlm.nih.gov/pubmed/20614440" target="_blank">2010 Cochrane systematic review </a>on PPIs for UGIB showed no reduction in mortality at 30 days, nor did it show any reduction in rebleed rates or requirement for surgery at 30 days. Transfusion requirements and hospital LOS could not be analyzed, but there is no good, reproducible evidence that these outcomes are improved either. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">At this point, it seems pretty obvious that I'm not too keen on the empiric use of PPIs for UGIB. Unfortunately, there's one reason we will not win this battle with gastroenterologists any time soon. <b>Need for endoscopic intervention</b>. This RCT by <a href="http://www.ncbi.nlm.nih.gov/pubmed/17442905" target="_blank">Lau et al.</a> showed that despite no reduction in other significant outcomes, there was a decreased need for endoscopic therapy (28% vs. 19%, p <0.007). </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">As ER physicians, we do not admit or scope our UGIB patients. We resuscitate, stabilize and refer for endoscopy. Despite the fact that there is no change in major outcomes (eg. mortality, rebleeding and surgery), a faster endoscopy requiring less intervention remains a significant outcome for the physician performing it. For that reason, I find it difficult to believe this battle will be won by ER physicians any time in the near future. I would love to be proven wrong. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">My question to readers is if you have discussed this with your GI docs, and what reasoning they are using for the PPI infusions? Please post in the comments if you have.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">However, I think it remains important for med students, residents and nurses to understand that the PPI infusion is not the most critical intervention in the course of the UGIB patient. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>Bottom Line:</b> <b>PPIs do not reduce 30 day mortality, rebleed rates or surgery requirements at 30 days. However, because of reduced need for endoscopic intervention and the prolonged period required for knowledge translation, their empiric use will continue for the foreseeable future.</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Cheers,</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">SOCMOBEM</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">References:</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/20614440">Cochrane Database Syst</a> Rev. 2010 Jul 7;7:CD005415. Review. PubMed PMID: 20614440</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/17442905" role="button" target="_blank" title="The New England journal of medicine.">N Engl J Med.</a><a href="http://www.ncbi.nlm.nih.gov/pubmed/17442905" target="_blank"> </a>2007 Apr 19;356(16):1631-40.</span>SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com2tag:blogger.com,1999:blog-6937953169137418178.post-43527488355579809962012-12-24T22:53:00.002-08:002013-01-16T19:39:41.829-08:00Choosing your Battles: My Christmas Pearl of 2012<div class="separator" style="clear: both; text-align: center;">
<a href="http://4.bp.blogspot.com/-KVwztBkJPks/UNoaAEqqXfI/AAAAAAAAAD8/dGFDeBf8gUo/s1600/Pick-your-battles3.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="298" src="http://4.bp.blogspot.com/-KVwztBkJPks/UNoaAEqqXfI/AAAAAAAAAD8/dGFDeBf8gUo/s400/Pick-your-battles3.jpg" width="400" /></a></div>
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">This blog post isn't about EBM or getting my hate on about antiquated dogma; it is about a useful pearl that I think can benefit all of my like-minded, avant-garde, #FOAMed friends out there. In particular, this is a piece of advice that the "young whippersnapper" types like myself should pay attention to. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Last week while at Tintinalli Rounds with one of my preceptors, we covered tons of material and talked EBM galore. It was a nerd alert to the extreme. While we were ranting about how "ridiculous" it is to give gravol to pediatric patients with gastro, and that ondansetron is the evidence based pediatric panacea, we paused for a serious discussion. As residents soon to enter practice, he gave us this advice.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">"Choose your battles"</span><br />
<br />
<span style="font-size: large;">Having only graduated from residency a few years ago, this preceptor moved from a highly respected pediatric EM fellowship program to a pediatric EM department in its relative infancy. Upon arrival, he did what most of us would do in the same situation. He wanted change. And he didn't want a bit of change, he wanted a revolution. There was room for improvement everywhere, with everything. </span><br />
<br />
<span style="font-size: large;">However, he quickly realized that enthusiasm only goes so far, and knowledge translation can be <span style="font-size: large;">a bitch</span>. </span><br />
<br />
<span style="font-size: large;">Rather than revolutionize a new department and effectively ostracize himself in the process, he chose the battles that he wanted to fight. Every time he saw something in need of change, he asked himself, "is this a battle I want to fight?" </span><br />
<br />
<span style="font-size: large;">Ondansetron for pediatric gastroenteritis was a battle he wanted to fight, and there were a couple of others as well. By limiting himself to a few battles, he could effectively stimulate change, while keeping his new colleagues from beating him senseless.</span><br />
<span style="font-size: large;">(O<span style="font-size: large;">h<span style="font-size: large;"> fine</span></span>, I keep mentioning the peds gastro t<span style="font-size: large;">hing</span> so head over to <a href="http://www.thennt.com/ondansetron-for-pediatric-gastroenteritis/" target="_blank">theNNT</a> for a summary of this if you're interested.) </span><br />
<br />
<span style="font-size: large;">He also made the point that while some of us are up to
date and evidence based, that knowledge will never supplant the 20 years
of experience that our older colleagues have. Rules and scores allow
junior physicians to "catch up faster", effectively giving us some of
the gestalt that thousands of hours of ER medicine have traditionally
provided. So despite all of your book knowledge, respect your seniors/colleagues.</span><br />
<span style="font-size: large;">Another form of choosing your battles is what to do as learners desiring to challenge the status quo.</span><br />
<br />
<span style="font-size: large;">Here's a twitter conversation I saw today</span><br />
<span style="font-size: large;"><br /></span>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://1.bp.blogspot.com/-SQVpHTj8fU4/UNlNUN0aYeI/AAAAAAAAADs/-m8U1LaSLig/s1600/Screen+shot+2012-12-25+at+12.53.28+AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://1.bp.blogspot.com/-SQVpHTj8fU4/UNlNUN0aYeI/AAAAAAAAADs/-m8U1LaSLig/s1600/Screen+shot+2012-12-25+at+12.53.28+AM.png" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-size: large;"></span></div>
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">The context here is that PPIs are not the miracle UGIB treatment that we once thought, and that Lauren, a FOAM loving medical student, tried unsuccessfully to convince someone (I'm guessing an attending) of this. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">This is another form of choosing our battles. As junior learners/staff, we need to diplomatically approach these topics, and be selective as to how often we question the methods of our seniors. Nobody likes the learner (or colleague for that matter) who contradicts everything. I know I have probably been that annoying resident in the past, and thus ask myself "is this really worth it" before choosing a battle. Furthermore, if circumstances (eg. busy shift, non receptive preceptor) indicate I am about to run into a stone wall, sometimes it's better to just "abort mission" and try again at a better time/place.</span><br />
<br />
<span style="font-size: large;">For what it's worth, I think Lauren picked a great battle here, and her follow-up tweet to this is impressively mature. This is an excellent example of the attitude FOAM advocates should have, so take note.</span><br />
<span style="font-size: large;"><br /></span>
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-size: large;"><a href="http://3.bp.blogspot.com/-pRKKXwr6RJw/UNlFVLGjGRI/AAAAAAAAADM/Jm1n-7euo4I/s1600/Screen+shot+2012-12-25+at+12.19.39+AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://3.bp.blogspot.com/-pRKKXwr6RJw/UNlFVLGjGRI/AAAAAAAAADM/Jm1n-7euo4I/s1600/Screen+shot+2012-12-25+at+12.19.39+AM.png" /></a></span></div>
<span style="font-size: large;"><br /></span>
<br />
<span style="font-size: large;">To summarize, being young and enthusiastic about medical education, EBM and FOAM is awesome. But regardless of your medical profession (EMT, nurse, resident, etc.), if
you are keen and on the FOAM bandwagon, you will be saying some crazy
sounding things. If you are in a position to effect change, fantastic, but this is another situation where less may be more, and choosing your battles wisely is a lesson for us all.</span><br />
<br />
<span style="font-size: large;">It's been Christmas Day for 30 minutes now, so put in the Die Hard (or whatever your favorite Christmas movie is), and <b>do not stand on the corner minding your own business</b>. Bruce Willis was just minding his own business at Nakatomi Plaza and look what happened.</span><br />
<span style="font-size: large;"><br /></span>
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-size: large;"><a href="http://3.bp.blogspot.com/-sW7VCEOM__Y/UNlKQ1G8DiI/AAAAAAAAADc/W9kNYPP84cA/s1600/diehard-cookies.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://3.bp.blogspot.com/-sW7VCEOM__Y/UNlKQ1G8DiI/AAAAAAAAADc/W9kNYPP84cA/s1600/diehard-cookies.jpg" /></a></span></div>
<span style="font-size: large;"><br /></span>
<br />
<span style="font-size: large;">With that, I wish you all Happy Holidays (whatever you may celebrate) and a great 2013. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">SOCMOBEM</span>SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com3tag:blogger.com,1999:blog-6937953169137418178.post-32640074580449219992012-12-08T03:45:00.002-08:002013-01-16T19:39:41.826-08:00Evidence Based Laceration Repair<span style="font-size: large;">First, a huge thanks to everyone who has been visiting the site, tweeting and spreading the #FOAMed love. FOAM is all about word of mouth, and having others spread the word drives me to put up more posts. Second, if you have comments or suggestions to improve the blog, questions for me, or myths you'd like to see busted, please tweet or email. I'm always looking for new ideas. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Also, a shout out to a new podcast I've found recently. The SGEM (Skeptics Guide to Emergency Medicine) podcast is based out of Ontario, Canada, and takes a similar approach to topics as I do. Episode 9 covers some of the wound management myths I'm about to deal with, and a few others I've left out. It can be found on iTunes or on their website <a href="http://thesgem.com/">http://thesgem.com/</a></span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b>Onto the blog.</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Case: A 25 year old female presents to the ED with a 3 cm laceration to the dorsum of her forearm. It is superficial, entering only the hypodermis. It is easily approximated, not over a joint, and under no tension. Before reading on, mentally go through the steps of how you would manage this wound. (eg. cleaning, prepping, suture material, dressing) Got it? Read on.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">No procedure in medicine contains as many ancient, dogmatic teachings as laceration repair. Considering this is something we do and teach every day, it's critical that we have an evidence based approach.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">In this post, I will present the thinking that goes through my head as I prepare to close a wound.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>NB. </b>Throughout this post, we are talking about uncomplicated lacerations/wounds ie: no fracture, foreign body, tendon injury, bone injury, joint injury, immunosuppression, anti-coagulation, etc. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">The reason behind all of the laceration repair dogma can be summarized in one word, <b>infection</b>. </span><br />
<br />
<span style="font-size: large;">We've all seen someone prepare a simple cut as if it were an open abdomen in the OR. Why? Not so long ago, surgeons began using sterile technique in the OR; this was critical for reducing post-op infection rates. Naturally, that meticulous preparation was then passed down to ED physicians as lore. </span><br />
<br />
<span style="font-size: large;">But lets think about this for a minute. There are millions of lacerations every year, and we see a miniscule number of them in the ED. The rest are managed at home with water, some paper towel and maybe a band-aid. That's certainly not sterile technique. So why aren't our departments overrun with wound infections from people who cut themselves and didn't waste 4 green huck towels, a bottle of chlorhexidine, a sterile kidney basin, and countless other tools? Because clean wounds rarely get infected. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Preparing wounds with sterile technique and meticulous detail is not only unnecessary from an infectious standpoint, it's time consuming. As a medical student and resident, laceration repair is great. It's fun, you get to work with your hands, sit down, take a mental break. Overall, as a presenting complaint, laceration is about as good as it gets. As I get closer to the realm of being a staff physician, I view lacerations differently, in much the same way as I look at insertion of lines and tubes (see previous blogs). Properly repairing a laceration remains the most important element, but efficiency and managing department flow are also critical. Furthermore, I don't want to waste my patient's time by having them unnecessarily return to the ED for follow-up, suture removal, or complications of the procedure.</span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b>Onto the pseudoaxioms.</b></span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b>1)Wounds must be cleaned with fancy solutions. NO!</b></span><br />
<br />
<span style="font-size: large;"><b><img height="150" id="il_fi" src="http://www.medhelp.org/drug_images/BAX00481.JPG" style="padding-bottom: 8px; padding-right: 8px; padding-top: 8px;" width="200" /> VS. </b><b><img height="209" id="il_fi" src="http://cfnewsads.thomasnet.com/images/large/014/14057.jpg" style="padding-bottom: 8px; padding-right: 8px; padding-top: 8px;" width="320" /> </b></span><br />
<br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">We usually clean lacerations with tap water at home, so why do we need sterile water/saline or chlorhexidine in the ED? </span><br />
<br />
<span style="font-size: large;">Thankfully, this has been studied.</span><br />
<br />
<span style="font-size: large;"><b>First, forget antiseptics. </b>There is little, if any evidence that chlorhexidine or other antiseptics reduce rates of infection. Conversely, chlorhexidine and povidone-iodine solutions are more likely damage normal cells and slow healing. <b>These are skin cleansers, for external use only.</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>So the real choice is between tap water and sterile saline/water.</b></span><br />
<span style="font-size: large;"><a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003861.pub2/otherversions" target="_blank"><br /></a></span>
<span style="font-size: large;"><a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003861.pub2/otherversions" target="_blank">This Cochrane Review</a> last updated in 2010 included 11 quasi-randomized studies, 3 of which were RCTs. In adults, <b>tap water is at least as good, if not better, than sterile saline</b> for preventing infectious complications. In children, there was similarly no difference between tap water and sterile saline. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">I think my favorite part of this review is the authors conclu<span style="font-size: large;">sion</span> that there is no evidence that cleansing a wound is better than not cleansing it. Now that would be a kick ass RCT! Even if it passed ethics, I think you'd need a used car salesman to consent the patients for the no cleansing group.</span><br />
<br />
<span style="font-size: large;"><a href="http://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CDIQFjAA&url=http%3A%2F%2Fwww.siumed.edu%2Fsurgery%2Femergency_medicine%2Fimages%2Fpdf%2FTap%2520Water%2520Article%2520-%2520Sept%252008.pdf&ei=GgTDUPriA-K5ywHk3IGoDg&usg=AFQjCNEzGz8R3D8iV7Hbe-5Y4dyAwGFifA&sig2=EE3Key68gWtQIzIOXYP0kw&bvm=bv.1354675689,d.aWc" target="_blank">This prospective RCT</a> done in 2007 also compared sterile saline <span style="font-size: large;">with</span> tap water. Though the study had several problems, one thing it made clear was the<b> cost savings </b>of using tap water in place of sterile saline, a syringe and splash guard would be ~$65.6 million annually in the U.S. That's huge!</span><br />
<br />
<span style="font-size: large;">Disclaimer: If you don't have a clean tap water source, this likely doesn't apply, but you could still be using boiled and cooled distilled water in place of the more expensive alternatives. </span><br />
<br />
<span style="font-size: large;">When I clean a wound in the ED, especially if it's an upper
extremitiy, I will anesthetize, walk the patient over to the sink, and
wash their hand under running water for a few minutes. The volume difference is huge, and it takes virtually no time at all. </span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b>Bottom line: Tap water is just as good, if not better than sterile saline for irrigating simple wounds in the ED.</b></span><br />
<br />
<span style="font-size: large;"><b>2)Glove selection</b></span><br />
<br />
<span style="font-size: large;"><b><img height="320" id="il_fi" src="http://freemarketlovingcommie.files.wordpress.com/2010/05/latex-gloves-296x405.jpg" style="padding-bottom: 8px; padding-right: 8px; padding-top: 8px;" width="233" /> </b></span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;">After I've cleaned my patient's hand in tap water, should I grab some sterile gloves to sew them up? Maybe the patients love to see me snap on those fancy gloves that come from their own, individually sealed bag.</span><br />
<br />
<span style="font-size: large;"><b>Bottom Line: Clean gloves are just fine.</b> </span><br />
<span style="font-size: large;">The best data on this comes from a <a href="http://www.ncbi.nlm.nih.gov/pubmed/14985664" target="_blank">2004 study by Perelman et al. in Annals of EM. </a>This Canadian study was a prospective RCT, and looked at 816 patients over the age of 1 year with simple lacerations. They found the <b>infection rate for sterile vs non-sterile gloves was 6.1% and 4.4%,</b> respectively with<b> no significant statistical difference.</b> </span><br />
<br />
<span style="font-size: large;">Again, the cost difference between using sterile and non-sterile gloves is massive when we consider how often they are used on a daily basis. </span><br />
<br />
<span style="font-size: large;">I will admit that in cases that require a significant amount of suturing or I want an optimal cosmetic result, (eg. facial lacs) I will use sterile gloves because they provide a much better feel than the non-sterile ones. Go ahead and call me a hypocrite. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>3)All lacerations must be sutured using non-absorbable suture.</b></span><br />
<br />
<span style="font-size: large;">First, there is evidence that not all lacerations < 2 cm even require suturing in the first place. But let's say that we do decide to close this laceration, how will we do it?</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Who asks for prolene, ethilon or another non-absorbable suture when they repair lacerations? What about vicryl rapide, fast chromic gut or another absorbable suture? Does anyone ask for glue?</span><br />
<br />
<span style="font-size: large;">Has anyone heard this: Don't use absorbable sutures or glue, they'll get a nasty scar! </span><br />
<br />
<span style="font-size: large;"><b>Let's look at the evidence.</b></span><br />
<br />
<span style="font-size: large;">First let's take the scenario of the 3 year old child with a non-gaping facial laceration after running into a coffee table. I'm sure many of us have gone through the joy of anesthetizing this child and suturing them while a nurse holds them in a death grip. All the while, the parents are looking on horrified and never wanting to return to the hospital. </span><br />
<br />
<span style="font-size: large;"> <img height="328" id="il_fi" src="http://daniandjen.files.wordpress.com/2012/06/11483_1_alberta-childrens-hospital_1000.jpg" style="padding-bottom: 8px; padding-right: 8px; padding-top: 8px;" width="640" /></span><br />
<br />
<span style="font-size: large;">While rotating through the Alberta Children's Hospital (AKA Lego-land with an ICU), I was exposed to all the awesome ways of repairing lacs in kids. The children would have topical maxilene or lidocaine applied at triage and we would sometimes give intranasal midazolam as well. Suffice it to say, this place is pretty much heaven as far as peds EM is concerned, and laceration repair was all happiness and roses. Unfortunately, most of our EDs do not have these luxuries, but we do have one awesome thing. <b>Glue!</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Again we have some Canadians to thank for this <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003326/abstract?systemMessage=Wiley+Online+Library+will+be+disrupted+on+15+December+from+10%3A00-12%3A00+GMT+%2805%3A00-07%3A00+EST%29+for+essential+maintenance" target="_blank">Cochrane Review</a> looking at tissue adhesives vs. standard wound closure for laceration repair. Eleven studies compared a tissue adhesive with standard wound closure.
<b>No significant difference was found for cosmesis at any time point
examined.</b> As would be expected, <b>pain scores and procedure time significantly favoured tissue adhesives</b>. However, there was a <b>statistically significant increased rate of wound dehiscence</b> <b>favouring standard wound care</b>, with a<b> NNH of 40. </b> </span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b>But what about gaping lacerations where glue won't work?</b></span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;">Traditionally we are taught to always use non-absorbable sutures, as they are stronger, less prone to infection, etc. Having been sutured up several times as a child, I recall fearing the return visit for suture removal even more than the initial visit to get sewn up. When <span style="font-size: large;"><span style="font-size: large;">a child is</span></span> bleeding everywhere, the pain <span style="font-size: large;">is</span> bearable, but pulling out the scissors and forceps in front of a completely well child <span style="font-size: large;">creates</span> un<span style="font-size: large;">necessary fear.</span></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>Can we avoid this return visit without compromising cosmesis? Yes.</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/15231459" target="_blank">This 2004 paper</a> by Karounis et al. looked at pediatric patients (0 to 18 years) with traumatic lacerations. It showed <b>no differences in early or late cosmesis, wound dehiscence or need for scar revision</b> when comparing absorbable and non-absorbable suture. In fact, all of the outcomes showed a trend toward benefit in the absorbable suture group. (I know, trends don't mean squat in EBM)</span><br />
<span style="font-size: large;">The main weakness of this study was the extremely high loss to follow-up of<b> </b>34%<span style="font-size: large;">. However, this is a very common weakness of <span style="font-size: large;">laceration repair studies, and getting good <span style="font-size: large;">follow-up in these types of studie<span style="font-size: large;">s seems impossible.</span></span></span></span></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/18347489" target="_blank">Another study from 2008</a> looked at fast absorbing catgut suture vs. nylon in 88 pediatric patients. Again there were no differences in cosmesis, infection rate, dehiscence, keloid formation or parental satisfaction. This paper also s<span style="font-size: large;">uffered</span> from a lack of follow-up (though it was equal in both groups).</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>Bottom Line: For non-gaping lacerations, glue is where it's at. For gaping lacerations in children, absorbable suture is at least as good as non-absorbable. </b></span><br />
<span style="font-size: large;"><b>The savings on patient/parental trauma and time are huge. </b></span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;">Note: Although I didn't cover staples, they are <span style="font-size: large;">likely</span> as good as sutures for repairing scalp lacerations. There are small studies comparing them, but no large RCTs.</span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b>4)After closing the wound you should apply a topical antibiotic such as polysporin/neosporin.</b></span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;">This one may be my biggest peeve of all, as somehow the marketing of topical antibiotics that are primarily effective against Gram -ve bacteria has resulted in physicians regularly recommending these to patients. For this, we have to go to the Dermatology literature. This peeve comes from doing 6 weeks of dermatology electives, several of which were spent with someone who only did patch testing for contact dermatitis.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">It is true that a clean, moist, covered wound will heal faster than an uncovered, dirty wound. However, all of the dermatology literature points toward non-antibiotic containing petroleum based lubricants being equally efficacious to neomycin (Neosporin), bacitracin and polymixin B (both in Polysporin) containing ones. Furthermore, neomycin is the number one contact allergen in patch testing at a whopping 11% of the U.S. population. Bacitracin is not far behind at 8% of the population. </span><br />
<span style="font-size: large;">Fortunately Neosporin is no longer sold in Canada, but it is the bane of American dermatologists. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>Bottom Line: Use Vaseline, Aquaphor or other petrolatum based gel for wounds, and stop creating allergies.</b></span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b>Summary:</b></span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b>1)Tap water is as good as sterile saline</b></span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b>2)Clean gloves are fine</b></span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b>3)Glue and absorbable sutures provide the same cosmetic results as non-absorbable ones, particularly for facial lacerations.</b></span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;"><b>4)Use non-antibiotic, petrolatum based gels to cover wounds, not poly/neosporin.</b></span><br />
<span style="font-size: large;"><b><br /></b></span>
<span style="font-size: large;">You now have all the evidence you need to manage simple lacerations in 5-10 minutes, without putting your patients at<b> </b>increased risk of infection, giving them an ugly scar, or causing a contact dermatitis.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Until next time, I'll be getting up in people's faces, <span style="font-size: large;">not minding my own business. </span> I'm way less likely to get stabbed that way. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Happy sewing.</span><br />
<br />
<span style="font-size: large;">SOCMOBEM</span><br />
<br />
<br />
<span style="font-size: large;"><b>References:</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>Cleaning Wounds:</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database
of Systematic Reviews 2008, Issue 1. Art. No.: CD003861. DOI:
10.1002/14651858.CD003861.pub2. </span><br />
<br />
<span style="font-size: large;">Moscati RM <span class="st">et al. Acad Emerg Med 2007; 14:404–410</span></span><br />
<br />
<span style="font-size: large;"><b><span class="st">Gloves:</span></b></span><br />
<br />
<div class="cit">
<span style="font-size: large;">Perelman VS et al. Ann Emerg Med. <span class="highlight">2004</span> Mar;43(3):362-70.</span></div>
<div class="cit">
</div>
<div class="cit">
<span style="font-size: large;"><b>Suture and glue:</b></span></div>
<div class="cit">
</div>
<div class="cit">
<span style="font-size: large;">Farion KJ, Russell KF, Osmond MH, Hartling L, Klassen TP, Durec T,
Vandermeer B. Tissue adhesives for traumatic lacerations in children
and adults. Cochrane Database of Systematic Reviews 2002, Issue 3. Art.
No.: CD003326. DOI: 10.1002/14651858.CD003326. </span></div>
<div class="cit">
</div>
<div class="cit">
<span style="font-size: large;">Karounis H et al.
A Randomized, Controlled Trial Comparing Long-term Cosmetic Outcomes of
Traumatic Pediatric Lacerations Repaired with Absorbable Plain Gut
Versus Nonabsorbable Nylon Sutures <i>Acad Emerg Med</i> July 2004; 730-735 </span></div>
<div class="cit">
<span style="font-size: large;"><br /></span></div>
<div class="cit">
<span style="font-size: large;">Luck RP et al. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18347489#" role="button" title="Pediatric emergency care.">Pediatr Emerg Care.</a> 2008 Mar;24(3):137-42.</span></div>
<div class="cit">
</div>
<div class="cit">
</div>
<br />
<span style="font-size: large;"><span class="st"> </span> </span><br />
<span style="font-size: large;"><br /></span>SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com7tag:blogger.com,1999:blog-6937953169137418178.post-57566363180238656332012-11-23T19:12:00.000-08:002013-01-16T19:39:41.839-08:00The Gaco Cycle (No educational content)<span style="font-size: large;">Two weeks ago, some of the EM residents and I were in Las Vegas for the Essentials of EM conference. It was a great time, with many highlights, one of which was the first night of drinking with Damjan, AKA the Serbian teddy bear. Damjan's (pronounced Dam-yin) mission was to get blind drunk ASAP after getting off the plane, so he proceeded to get 4 double tremclad-cokes (actually bourbon, but they tasted like paint thinner) in our first half hour at the Cosmopolitan.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">At this point he decided it was time to play some poker, so we headed over to Planet Hollywood. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">What happened next is best shown in diagram form.</span><br />
<br />
<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://3.bp.blogspot.com/-bbPe7RaKTYs/ULAedsWfu_I/AAAAAAAAACI/srzvONWxzzY/s1600/Slide1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://3.bp.blogspot.com/-bbPe7RaKTYs/ULAedsWfu_I/AAAAAAAAACI/srzvONWxzzY/s1600/Slide1.jpg" height="480" width="640" /></a> </div>
<br />
<span style="font-size: large;">Two hands and 10 minutes later, we were done.</span><br />
<span style="font-size: large;">In this variation of the Krebs cycle, 8 bourbon in leads to 2 cry as the product. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Next trip maybe we'll get to Gacolysis or Oxidative Damjanalation. </span><br />
<br />SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com1tag:blogger.com,1999:blog-6937953169137418178.post-56672560227687749882012-11-15T11:16:00.000-08:002013-01-16T19:39:41.836-08:00All about chest tubes<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Of all the interventions we perform, chest tube insertion is one of the most dangerous, complicated and misunderstood. Today I'll discuss not only the myths, but also some unfortunate realities that we must understand when we undertake this procedure.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>Myth # 1</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>Bigger is better</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">I'm pretty sure we've all been told, partially thanks to ATLS, that we better put a 36 or 40 French chest tube in during trauma, otherwise the blood will clog up the tube and drainage will cease. Wrong, wrong, wrong!</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><a href="http://journals.lww.com/jtrauma/Abstract/2012/02000/Does_size_matter__A_prospective_analysis_of_28_32.16.aspx" target="_blank">This</a> <b>prospective, non randomized</b> trial of trauma patients over a 3 year period from 2007-2010 compared <b>small (28-32 French) with large (36-40 French) </b>chest tubes. The <b>operator chose tube size</b>, and sicker patients got bigger tubes (More ISS >25, GCS <8, sBP <90, (all p<0.01) for large chest tube group) However, there was no difference in thoracic trauma pathology between the two groups (eg. flail chest, pulmonary contusions, PTX, pneumomediastinum, etc.)</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Overall, there was <b>no difference in the rate of complications</b> between the two groups. This includes pneumonia, empyema and retained hemothorax. Further, there was no difference in interventions required for retained hemothorax (Additional chest tube insertion, intrapleural throombolysis, IR guided catheter insertion, VATS and thoracotomy) </span><br />
<span style="font-size: large;">When <b>adjusted for ISS, GCS and sBP, there was still no difference</b> between the two groups, with respect to complication rates or interventions for retained hemothorax. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">When<b> pneumothoraces were analyzed separately</b>, there was <b>no difference</b> in rate of complications or requirement for further intervention in this group either.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">The second hypothesis of this study was that bigger tubes are more painful, and a visual analogue scale was used to rate patient pain. There was <b>no difference in VAS scores</b> between the small and large chest tube groups.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>Bottom Line: Any tube that is at least 28 French is suitable for draining a chest. </b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Although it might not hurt less than a larger tube, it may still pass through the intercostal space a little more easily, so go ahead with those smaller tubes. The logical next question is: Are tubes smaller than 28 French adequate? That remains to be studied.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>Myth #2</b></span><br />
<span style="font-size: large;"><b><br /></b><b>Directing the chest tube. ie: Up for air, down for blood.</b></span>
<br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">Every medical student/resident is asked this question repeatedly throughout their training. "Where would you put the tube for a hemothorax? What about a pneumothorax?" The answers is always posterobasal for fluid and apical for air, right? </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">2 things about this myth. First, once the tube gets inside the chest, our ability to direct it is poor. Second, as long as you are in the pleural space, you'll be fine. It is a closed system and you have suction. The fluid will drain regardless. You may still have complications, but it's not because you put the tube in the apex of a hemothorax.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">More important than directing the chest tube is ensuring it's in the pleural space, not advancing when you meet resistance and not causing any other complications. </span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;">There is a BestBets on this topic which can be found <a href="http://bestbets.org/bets/bet.php?id=752" target="_blank">here</a>. There really isn't great data on this, so it is more of a physics myth than anything else.</span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>Truth #1</b></span><br />
<span style="font-size: large;"><br /></span>
<span style="font-size: large;"><b>Complications of chest tubes</b> - <b>This is not a myth, this is for real.</b></span><br />
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<span style="font-size: large;">This is one critical point for all of us, but especially for residents inserting chest tubes.</span><br />
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<span style="font-size: large;">The morbidity associated with chest tube insertions is astronomical! About 25-30% of chest tube insertions have a complication, regardless of who inserts them. A <a href="http://journals.lww.com/jtrauma/Abstract/2012/09000/Development_of_posttraumatic_empyema_in_patients.35.aspx" target="_blank">2012 AAST study</a> looking at post-traumatic empyema rates in major trauma centers is 27%. That is crazy.</span><br />
<span style="font-size: large;">However, as an EM resident, I was disappointed to read this article that <b>suggests EM residents may be the worst of all</b>. Really it's only a trend toward significance, and a retrospective study, but I'm still a bit sad to read it. </span><br />
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<span style="font-size: large;"><b>We have to do something to get these rates of complications down. </b></span><br />
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<span style="font-size: large;">Use of antibiotic prophylaxis when inserting chest tubes is a topic of controversy. EAST (The Eastern Association for the Surgery of Trauma) published a <a href="http://www.east.org/resources/treatment-guidelines/tube-thoracostomy-for-traumatic-hemopneumothorax-prophylactic-antibiotic-use" target="_blank">guideline</a> in 2000 suggesting antibiotic prophylaxis for chest tube insertion. More recently, <a href="http://www.ncbi.nlm.nih.gov/pubmed/22396050" target="_blank">this meta-analysis</a> reviewing antibiotic prophylaxis was published in 2012. </span><br />
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<span style="font-size: large;">For <b>penetrating trauma,</b> I would say that at least a single dose of antibiotic (1st gen cephalosporin) should be given at the time of insertion, if time and resources allow. This results in reduced rates of empyema and pneumonia, which in turn affects hospital and ICU LOS. </span><br />
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<span style="font-size: large;">For <b>blunt trauma</b>, which is the majority of what we see in Canada, no statistically significant reduction in infectious complications was found, and you may choose to withhold antibiotics in this group.</span><br />
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<span style="font-size: large;">In all cases, <b>duration of therapy is controversial. </b>It appears that short term (single dose or 24 hours) is equally effective as prolonged antibiotics (until time of chest tube removal). </span><br />
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<span style="font-size: large;"><b>Bottom line:</b> Our rates of post-chest tube complications (empyema and pneumonia) are ridiculously high, even in major trauma centers. A single dose of cefazolin at the time of chest tube insertion is a pretty benign intervention, and in my opinion warranted, particularly in penetrating trauma.</span><br />
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<span style="font-size: large;">I'm curious who is giving antibiotics and if so, is it single dose, 24 hours, or longer?</span><br />
<span style="font-size: large;"><b><br /></b><b>Summary:</b></span>
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<span style="font-size: large;">1)Any chest tube at least 28 French is suitable for traumatic hemo/pneumothorax.</span><br />
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<span style="font-size: large;">2)Get the tube in the pleural space but direction doesn't matter.</span><br />
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<span style="font-size: large;">3)Complications of chest tubes are exceedingly high. Give a single dose of peri-procedure antibiotics (particularly in penetrating trauma) and use sterile technique.</span><br />
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<span style="font-size: large;">Until next time, I'll be standing on the corner, mindin' my own business. </span><br />
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<span style="font-size: large;">Cheers,</span><br />
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<span style="font-size: large;">@SOCMOBEM</span><br />
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<span style="font-size: large;">References and some chest tube links from people much more intelligent than me:</span><br />
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<span style="font-size: large;"><a href="http://lifeinthefastlane.com/2011/04/own-the-chest-tube/" target="_blank">Own the chest tube</a> with Chris Nickson at Life in the Fast Lane</span><br />
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<span style="font-size: large;">Michael McGonigal's <a href="http://regionstraumapro.com/" target="_blank">Trauma Professionals Blog</a> has some great videos and posts about chest tubes as well.</span><br />
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<span style="font-size: large;">Eastern Association of Surgeons for Trauma (EAST) Guidelines for Hemothorax and Occult PTX can be found <a href="http://www.east.org/resources/treatment-guidelines/hemothorax-and-occult-pneumothorax%2c-management-of" target="_blank">here</a>. </span><br />
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<span style="font-size: large;">EAST Guideline on antibiotic prophylaxis for tube thoracostomy can be found for free <a href="http://www.east.org/resources/treatment-guidelines/tube-thoracostomy-for-traumatic-hemopneumothorax-prophylactic-antibiotic-use" target="_blank">here.</a><a href="https://www.blogger.com/blogger.g?blogID=6937953169137418178"> </a></span><br />
<span style="font-size: large;">This is the reference. <a href="http://www.google.com/url?sa=t&source=web&cd=2&ved=0CEEQFjAB&url=http%3A%2F%2Fjournals.lww.com%2Fjtrauma%2Ffulltext%2F2000%2F04000%2Fthe_east_practice_management_guidelines_for.28.aspx&ei=HjwDTvOKOaK10AGWmeSMDg&usg=AFQjCNGCO_1v06UYArKUUpR7WBidzHct_Q">J Trauma. 48(4): 758-759, April 2000.</a></span><br />
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<span style="font-size: large;">2012 Meta-analysis for antibiotic prophylaxis</span><br />
<span style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/22139619" target="_blank">Bosman A, de Jong MB, Debeij J, van den Broek PJ, Schipper IB. </a><a href="https://www.blogger.com/blogger.g?blogID=6937953169137418178" role="button" title="The British journal of surgery.">Br J Surg.</a> 2012 Apr;99(4):506-13</span><br />
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<span style="font-size: large;">Chest tubes: Does Size Matter</span><br />
<span style="font-size: large;"><a href="http://journals.lww.com/jtrauma/Abstract/2012/02000/Does_size_matter__A_prospective_analysis_of_28_32.16.aspx" target="_blank">Inaba, K et al. J Trauma 72(2):422-427, 2012. </a></span><br />
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<span style="font-size: large;">Post-traumatic chest tube empyema rates</span><br />
<span style="font-size: large;"><a href="http://journals.lww.com/jtrauma/Abstract/2012/09000/Development_of_posttraumatic_empyema_in_patients.35.aspx" target="_blank">J Trauma 73(3):752-757, 2012.</a></span>SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com0tag:blogger.com,1999:blog-6937953169137418178.post-44794457864284388822012-10-21T15:21:00.001-07:002013-01-16T19:39:41.831-08:00Why should we insert CVCs?<span style="font-size: large;"><span style="font-size: large;">WHY SHOU<span style="font-size: large;">LD WE INSERT CVCs?</span></span></span><br />
<span style="font-size: large;"><span style="font-size: large;"><span style="font-size: large;"> </span></span><br />CVCs/CVLs are found in many, if not all critically ill ICU patients. Why? </span>
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<span style="font-size: large;">To monitor central venous pressure and fluid responsiveness? To measure markers of perfusion? To provide fluid resuscitation?</span><br />
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<span style="font-size: large;">Let's discuss some common myths surrounding the uses of CVCs.</span><br />
<span style="font-size: large;"><br />A good place to start is a list of indications for insertion of central lines. Take UpToDate as an example. They list 5 indications for CVC insertion:</span>
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<span style="font-size: large;"><br /><b>1)Hemodynamic monitoring including central venous pressure (CVP), central venous oxygen saturation (SCvO2) or for insertion of a pulmonary arterial catheter.</b></span>
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<span style="font-size: large;"><br />2)For infusion of irritants (eg. vasopressors, TPN, chemotherapy)</span>
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<span style="font-size: large;"><br />3)Transvenous cardiac pacing</span>
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<span style="font-size: large;"><br />4)Plasmapheresis, apheresis, hemodialysis or CRRT</span>
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<span style="font-size: large;"><b><br /></b><b>5)Poor peripheral venous access</b></span>
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<span style="font-size: large;"><br />I would say this list is consistent with the common teaching of today. While none of these is 100% wrong, there are many problems with indications 1 and 5 on this list. By the end of this post, hopefully you'll agree with me that CVCs are primarily for 3 things: </span>
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<span style="font-size: large;">Infusion of irritants, transvenous pacing, and pheresis/HD/CRRT.</span><br />
<span style="font-size: large;"><br />Let's look at #1 first.</span>
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<span style="font-size: large;"><br />There is no dispute that you can measure a CVP using a CVC. But what is the value of that number in predicting volume status or guiding fluid resuscitation? </span>
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<span style="font-size: large;"><br /><b>Nothing, zero, nada!</b></span><br />
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<span style="font-size: large;">You might as well pick a random number out of your head and assign it to your patient's CVP, as it will be just as useful in guiding your resuscitative efforts. The best review article on this subject comes from Paul Marik's Tale of Seven Mares in an issue of <a href="http://journal.publications.chestnet.org/article.aspx?articleid=1085950" target="_blank">Chest, 2008</a>. (All articles cited below) In this meta-analysis, 24 studies (803 patients) were included, with patients primarily in ICU and OR settings. </span><br />
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<span style="font-size: large;"><b>3 questions were asked:</b> </span>
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<span style="font-size: large;"><b>1)What is the relationship between CVP and blood volume? </b></span><br />
<span style="font-size: large;"><b>Terrible.</b> Of the 5 studies that looked at this outcome, the pooled correlation coefficient was <b>0.16</b> (95% CI, 0.03 to 0.28)</span><br />
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<span style="font-size: large;"><b><span id="scm6MainContent_lblClientName">2)What is the ability of CVP to predict fluid responsiveness?</span></b></span></div>
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<span id="scm6MainContent_lblDoi" style="font-size: large;"><b>Also terrible. "</b></span><span id="scm6MainContent_lblDoi" style="font-size: large;">The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index (reported in 10 studies) was <b>0.18</b> (95% CI, 0.08 to 0.28)."</span><br />
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<span id="scm6MainContent_lblDoi" style="font-size: large;"><b>3)What is the ability of a change in CVP (Delta CVP) to predict fluid responsiveness?</b> </span></div>
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<span id="scm6MainContent_lblDoi" style="font-size: large;"><b>Still brutal.</b> </span><span id="scm6MainContent_lblDoi" style="font-size: large;">"The pooled correlation between DeltaCVP and change in stroke index/cardiac index (reported in seven studies) was <b>0.11 </b>(95% CI, 0.01 to 0.21). </span></div>
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<span id="scm6MainContent_lblDoi" style="font-size: large;">The baseline CVP (reported in 11 studies) was 8.7 +/- 2.3 mm Hg in the responders, as compared to 9.7 +/- 2.2 mm Hg in nonresponders (not significant; p = 0.3)." </span></div>
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<span id="scm6MainContent_lblDoi" style="font-size: large;">A picture is worth a thousand words: Predictive value of CVP for volume responsiveness.</span></div>
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-size: large;"><a href="http://3.bp.blogspot.com/-1kUPOq_Wg54/UIR0Av9vreI/AAAAAAAAABw/6-PMfI9EAjM/s1600/Screen+shot+2012-10-21+at+4.18.26+PM.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="293" src="http://3.bp.blogspot.com/-1kUPOq_Wg54/UIR0Av9vreI/AAAAAAAAABw/6-PMfI9EAjM/s1600/Screen+shot+2012-10-21+at+4.18.26+PM.png" width="400" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span id="scm6MainContent_lblClientName" style="font-size: large;"><i>CHEST</i>.<span class="ppub"><span class="year">2008</span></span>;134(1):172-178.</span></td></tr>
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<span style="font-size: large;">A word about the stats: The correlation coefficient (r) is a measurement of
the strength and direction of the relationship between two variables,
and is measured between 0 and 1. A coefficient of 1 would mean the CVP
is perfectly predictive of the blood volume, while a coefficient of 0 means there is no association between the two variables. Generally, a coefficient of <0.5 means a weak association, while >0.8 is a strong association. </span><br />
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<span style="font-size: large;">Thus, the ability of CVP to predict volume status/volume responsiveness is <b>beyond poor</b>. As an aside, the article is called the Tale of Seven Mares because the only study
that has shown CVP to be predictive of fluid responsiveness was an
animal study done in seven standing horses. So now when you are asked to go hook up that CVP tracing, you can say "I don't recall seeing a horse in that ICU bed." If you're a staff you can say that, med students and residents might want to be a little more careful.</span><br />
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<span style="font-size: large;">So what does CVP actually measure? It measures right atrial pressure. So you could justify hooking up the CVP probe by saying you wanted to check if the patient had elevated right sided pressures for some reason (eg. PE, RV infarction, TR). But if you really wanted to do that, slapping on the ultrasound probe and looking at the RV is much faster and less invasive.</span></div>
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<span style="font-size: large;"><b>How about the central venous O2 saturation? That's good isn't it?</b></span></div>
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<span style="font-size: large;">The ScvO2 is a fine measurement, but at least in the case of septic shock, we have a non-inferior, less invasive alternative in the form of lactate clearance. </span></div>
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<span style="font-size: large;">This comes from a <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2918907/" target="_blank">JAMA 2010</a> article, in which 300 patients with severe sepsis/septic shock (as per the 2001 Rivers Early Goal Directed Therapy (EGDT) criteria) were treated. One group of 150 patients was resuscitated to the EGDT endpoints for CVP, MAP and ScvO2, while the other group was resuscitated using CVP, MAP and a lactate clearance of 10% in the first 6 hours. There was no in-hospital mortality difference between groups, and it was concluded that lactate clearance was non-inferior to ScvO2. </span></div>
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<span style="font-size: large;"><b>Let's now look at the 5th indication for CVC insertion, fluid resuscitation.</b></span></div>
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<span style="font-size: large;">CVC insertion is not a benign procedure, nor is it a rapidly performed procedure, especially in inexperienced hands. Over a one week period last month, I witnessed four carotid punctures when residents were attempting to insert IJs. </span></div>
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<span style="font-size: large;">There is now a much safer, faster method for fluid resuscitation.</span></div>
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<span style="font-size: large;"><a href="http://2.bp.blogspot.com/-j8NuhmZcngE/UIM_rWW6IKI/AAAAAAAAAA4/DQsTdR-yVJU/s1600/EZ-IO.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://2.bp.blogspot.com/-j8NuhmZcngE/UIM_rWW6IKI/AAAAAAAAAA4/DQsTdR-yVJU/s1600/EZ-IO.jpg" width="295" /></a></span></div>
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<span style="font-size: large;">Intraosseous access (EZ-IO) pictured above.</span></div>
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<span style="font-size: large;">Intraosseous access has traditionally been used more commonly in pediatric populations, but now is making it's way into adult resuscitative algorithms as well. It is faster and requires less operator skill than establishing a peripheral iv. More importantly, when a pressure bag (or blood pressure cuff) is used, the flow rates are just as good as CVCs.</span></div>
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<tr><td style="text-align: center;"><span style="font-size: large;"><a href="http://4.bp.blogspot.com/-2xr16oLUW9w/UIQpbAZ5ncI/AAAAAAAAABI/n8Dhpc9bjBw/s1600/EMJScreenshot.png" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="238" src="http://4.bp.blogspot.com/-2xr16oLUW9w/UIQpbAZ5ncI/AAAAAAAAABI/n8Dhpc9bjBw/s1600/EMJScreenshot.png" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span id="article-slug-jnl-abbr" style="font-size: large;"><abbr class="slug-jnl-abbrev" title="Emergency Medicine Journal">Emerg Med J</abbr>
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<span class="slug-pub-date" itemprop="datePublished">2011;</span><span class="slug-vol">28<span class="cit-sep cit-sep-after-article-vol">:</span></span><span class="slug-pages">201-202</span></span></td></tr>
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<tr><td style="text-align: center;"><span style="font-size: large;"><a href="http://1.bp.blogspot.com/-AkZHj5Hfrkk/UIQr9fDqdzI/AAAAAAAAABY/h61Tij7xKtM/s1600/IntJEmergMedScreenshot.png" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="180" src="http://1.bp.blogspot.com/-AkZHj5Hfrkk/UIQr9fDqdzI/AAAAAAAAABY/h61Tij7xKtM/s1600/IntJEmergMedScreenshot.png" style="cursor: move;" width="320" /></a></span></td></tr>
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<span class="citation-abbreviation" style="font-size: large;">Int J Emerg Med. </span><span class="citation-publication-date" style="font-size: large;">2009 September; </span><span class="citation-volume" style="font-size: large;">2</span><span class="citation-issue" style="font-size: large;">(3)</span><span class="citation-flpages" style="font-size: large;">: 155–160. </span></div>
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<span style="font-size: large;">These two tables are from 2 different papers, but are conveniently labeled as Table 2 and Table 3.<span style="font-size: large;"> </span>The first table shows flow rates of standard peripheral and central iv catheters, with and without pressure bags. </span></div>
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<span style="font-size: large;">The second table shows IO flow rates in sick human patients in Singapore. You can see the<span style="font-size: large;"> </span>flow rates with a pressure bag compare to a<span style="font-size: large;"> </span>20 gauge peripheral iv infusion rate, and also <span style="font-size: large;"></span>compare favorably with CVC infusion rates.</span><span class="citation-abbreviation" style="font-size: large;"><span style="font-size: large;"> </span>In many of these patients, they had both a <span style="font-size: large;"></span>tibial and humerus IO placed for resuscitation. </span><br />
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<span style="font-size: large;"><map id="logo-imagemap" name="logo-imagemap"><area alt="springer.com" coords="2,57,108,73" href="http://www.springer.com" shape="rect" target="pmc_ext"></area><area alt="This journal" coords="111,56,203,72" href="http://www.springer.com/12245" shape="rect" target="pmc_ext"></area><area alt="Toc Alerts" coords="208,57,289,73" href="http://www.springer.com/springeralerts/toc-alphabetical" shape="rect" target="pmc_ext"></area><area alt="Submit Online" coords="293,56,393,72" href="http://www.editorialmanager.com/ijem/" shape="rect" target="pmc_ext"></area><area alt="Open Choice" coords="401,56,497,73" href="http://www.springer.com/openchoice" shape="rect" target="pmc_ext"></area></map></span>
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<span class="citation-abbreviation" style="font-size: large;"><b>NB.</b> The humerus IO generally allows much faster infusion rates than the tibia, despite what this small study shows.</span></div>
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<span style="font-size: large;"><b>Some pearls regarding IO access:</b></span></div>
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<span style="font-size: large;">1)In order to achieve the most rapid infusion volumes with the least patient discomfort, after establishing IO access, give<b> 40 mg of lidocaine (eg. 2 cc of 2%) mixed into a 10 cc NS flush syringe</b>. Do this before starting your infusion. In healthy patients, the cardiac effects of this are minimal.</span></div>
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<span style="font-size: large;">2)<b>Any medication</b> that can be given IV, can be given IO. </span></div>
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<span style="font-size: large;"> </span></div>
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<span style="font-size: large;">3)In an urgent ED situation, IO is your friend. Use one, use two, you could put in ten before someone established a central line. Once you have volume resuscitated them somewhat, establish a peripheral IV.</span></div>
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<span style="font-size: large;"><b>One more CVC related myth = Infectious complication rates</b></span></div>
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<span style="font-size: large;">I've always been taught that femoral lines are BAD! The groin is dirty, so infectious complication rates must be higher, right? Aren't DVT rates higher too?</span></div>
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<span style="font-size: large;"><b>NO!</b></span><br />
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<span style="font-size: large;">Again we have Paul Marik to thank for this one, as he decided to undertake a meta-analysis looking at these questions. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22809915" target="_blank">This study</a> included 2 RCTs and 8 cohort studies and looked at approximately 3200 femorals, 3200 subclavians and just under 11000 IJs. The total number of catheter days was 113000.</span></div>
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<span style="font-size: large;">The bottom line from this analysis is that there is <b>no significant difference in catheter related bloodstream infections with any of the three sites.</b> </span></div>
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<span style="font-size: large;">The analysis also suggests no difference in the rate of DVT, however, this was not an outcome declared at the start of the trial, and there was significant heterogeneity between studies. </span></div>
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<span style="font-size: large;"><b>My overall take on CVCs</b></span></div>
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<span style="font-size: large;">1)<b>CVCs have one MAJOR role: Infusion of irritants </b>- ie: pressors, inotropes, TPN, chemo</span></div>
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<span style="font-size: large;">They are also needed for transvenous pacers and other therapies in the ICU setting (eg. HD, CRRT)</span></div>
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<span style="font-size: large;">2)<b>It's time to take another look at EGDT</b>. Not only is the CVP an inaccurate measurement, it is a potentially dangerous one. Attaching a CVP tracing may deter you from giving volume when it is needed, or may stimulate you to give volume when the tank is full and your patient needs vasopressors.</span></div>
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<span style="font-size: large;">Furthermore, the ScvO2 can be effectively replaced with serial lactate measurements as markers of tissue perfusion. Lactate going down = good. Lactate going up = really bad.</span></div>
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<span style="font-size: large;">3)<b>If you want to put in a femoral line, go ahead.</b> I'm still going to stick with IJs and subclavians, except in codes/crash lines, but fems are defensible. In all cases,<b> strict sterile technique.</b></span></div>
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<span style="font-size: large;">4)<b>IOs kick ass.</b> They're fast, well-tolerated by patients, require limited operator skill, and can provide big volumes of fluid if you put on a pressure bag. Plus, power tools are fun.</span></div>
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<span style="font-size: large;">Disclaimer: The Rivers study was a landmark study and monumental achievement. As with any EBM, it is only a matter of time before we start to assess the individual interventions that comprised EGDT, and see which ones (fluids and antibiotics) were more valuable than others (CVP).</span></div>
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<span style="font-size: large;">Until next time, I'll just be standing on the corner, minding my own business.</span></div>
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<span style="font-size: large;">Cheers,</span></div>
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<span style="font-size: large;">SOCMOB</span></div>
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<span style="font-size: large;">References: </span></div>
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<span style="font-size: large;">Original Rivers EGDT article</span></div>
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<span style="font-size: large;"><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa010307" role="button" target="_blank" title="The New England journal of medicine.">Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M;<span style="font-size: large;"> </span>N Engl J Med.</a><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa010307" target="_blank"> 2001 Nov<span style="font-size: large;"> </span>8;345(19):1368-77. </a></span> </div>
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<span style="font-size: large;">CVP for fluid responsiveness</span></div>
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<span style="font-size: large;"><a href="http://journal.publications.chestnet.org/article.aspx?articleid=1085950" target="_blank"><span class="highlight">Marik PE</span></a><a href="http://journal.publications.chestnet.org/article.aspx?articleid=1085950" target="_blank">, Baram M, Vahid B. </a><a href="https://www.blogger.com/blogger.g?blogID=6937953169137418178" role="button" title="Chest.">Chest.</a> 2008 Jul;134(1):172-8.</span></div>
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<span style="font-size: large;">Lactate clearance </span></div>
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<span style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2918907/" target="_blank">Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA. JAMA. 2010 Feb 24; 303(8): 739-746. </a></span></div>
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<span style="font-size: large;"><a href="http://emj.bmj.com/content/early/2010/06/25/emj.2009.083485" target="_blank">Reddick
AD, Ronald J, Morrison WG. Emerg Med J
2011;28:201-202 </a></span></div>
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<span style="font-size: large;">Review of CVC related infections</span></div>
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<span style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/22809915" target="_blank"><span class="highlight">Marik PE</span></a><a href="https://www.blogger.com/blogger.g?blogID=6937953169137418178">, Flemmer M, Harrison W. </a><a href="https://www.blogger.com/blogger.g?blogID=6937953169137418178" role="button" title="Critical care medicine.">Crit Care Med.</a> 2012 Aug;40(8):2479-85. </span></div>
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<span style="font-size: large;">IO+IV papers</span></div>
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<span style="font-size: large;"><map id="logo-imagemap" name="logo-imagemap"><area alt="springer.com" coords="2,57,108,73" href="http://www.springer.com" shape="rect" target="pmc_ext"></area><area alt="This journal" coords="111,56,203,72" href="http://www.springer.com/12245" shape="rect" target="pmc_ext"></area><area alt="Toc Alerts" coords="208,57,289,73" href="http://www.springer.com/springeralerts/toc-alphabetical" shape="rect" target="pmc_ext"></area><area alt="Submit Online" coords="293,56,393,72" href="http://www.editorialmanager.com/ijem/" shape="rect" target="pmc_ext"></area><area alt="Open Choice" coords="401,56,497,73" href="http://www.springer.com/openchoice" shape="rect" target="pmc_ext"></area></map></span>
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<span style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760700/" target="_blank">Adeline Su-Yin Ngo</a><a href="https://www.blogger.com/blogger.g?blogID=6937953169137418178">, Jen Jen Oh, Yuming Chen, David Yong, Marcus Eng Hock Ong</a></span></div>
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<span style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760700/" target="_blank"><span class="citation-abbreviation">Int J Emerg Med. </span><span class="citation-publication-date">2009 September; </span><span class="citation-volume">2</span><span class="citation-issue">(3)</span><span class="citation-flpages">: 155–160. </span></a></span></div>
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SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com1tag:blogger.com,1999:blog-6937953169137418178.post-18626503180913256492012-10-12T22:19:00.001-07:002013-01-16T19:39:41.824-08:00Welcome to SOCMOB!<div class="separator" style="clear: both;">
<span style="font-size: large;">T<span style="font-size: large;">HE INTRO</span></span></div>
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<span style="font-size: large;">"You're not going to use lidocaine with epi for that ring block, are you?"</span></div>
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<span style="font-size: large;">"Whoa, that potassium is 7, go get some Kayexalate."</span></div>
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<span style="font-size: large;">"Calcium in a digoxin overdose, you'll kill them!"</span></div>
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<span style="font-size: large;">Do any of the above sound familiar to you? I hope so!</span></div>
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<span style="font-size: large;">I'll venture to guess that many of you have heard injecting the "fingers, toes, ears, nose or hose" with epinephrine will cause your patient's bits to start falling off. Or that Kayexalate will "exchange that potassium" and fix hyperkalemia. And if you give an amp of calcium to a dig toxic patient, their heart will turn to stone!</span></div>
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<span style="font-size: large;">What is this all about? </span></div>
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<span style="font-size: large;"><a href="http://2.bp.blogspot.com/-kuuLljlh9u8/UHjlFMlofJI/AAAAAAAAAAg/N1oH0Kxj4-s/s1600/dogma.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="http://2.bp.blogspot.com/-kuuLljlh9u8/UHjlFMlofJI/AAAAAAAAAAg/N1oH0Kxj4-s/s1600/dogma.jpg" style="cursor: move;" /></a></span></div>
<span style="font-size: large;"><a href="http://3.bp.blogspot.com/-OgIUYVOJHMg/UHjlFzUZ7sI/AAAAAAAAAAo/b9K8YX_zHO8/s1600/stethoscope.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="http://3.bp.blogspot.com/-OgIUYVOJHMg/UHjlFzUZ7sI/AAAAAAAAAAo/b9K8YX_zHO8/s1600/stethoscope.jpg" /></a> </span><br />
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<span style="font-size: large;">David Newman of <a href="http://www.thennt.com/" target="_blank">the NNT</a> and <a href="http://smartem.org/" target="_blank">SMART EM</a> fame said it best in <a href="http://www.annemergmed.com/article/S0196-0644%2807%2900732-9/fulltext" target="_blank">this</a> article from Annals of EM in 2007:</span></div>
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<span style="font-size: large;">"<span id="hotword"><span id="hotword" name="hotword" style="color: #333333; cursor: default;">Although axioms are universally accepted principles or rules, pseudoaxioms, like pseudoscience, are false principles or rules often handed down from generation to generation of medical providers and<br />accepted without serious challenge or investigation."</span></span></span></div>
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<span style="font-size: large;">As medical trainees, whether we are nurses, paramedics, residents, or any other health care provider, we are bombarded with information at every opportunity. Often, it is the simple question, "Why?", that befuddles us or our preceptors the most. We often respond with correct, evidence based answers. But just as often, we give answers like "that is how we've always done it" or "Rosen's, Tintinalli's or (insert other textbook) says so? It is at times like these that we must go back and look at why humans, and not computers, practice medicine. </span></div>
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<span style="font-size: large;">Medicine is a field based in Science, and prides itself on the powers of observation, logic and reasoning. Over thousands of years, observation has served us extremely well, but in the past few decades, there has truly been a paradigm shift. Evidence based medicine. More recently, Free Open Access Medical Education or Med-ucation (FOAM) has spread like wildfire, and we are able to share information in real time, across the globe. Rather than wait months or years for an NEJM article to be published and disseminated across the country, we can now tweet critical appraisals of articles that came out yesterday. </span></div>
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<span style="font-size: large;">Combining EBM and FOAM, medicine is in a golden era, not because of the superior technologies and techniques we have available, but because we can instantly re-examine the evidence for a particular topic through an online search. Just tweet it to a friend, and the discussion begins.</span></div>
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<span style="font-size: large;">Let's take a look at the pseudoaxioms mentioned above. Since it's an intro blog, I've chosen three that have been reviewed beautifully by some of the super-geniuses in the EM world. </span></div>
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<span style="font-size: large;">First, the purported dangers of injecting epinephrine into digits. </span></div>
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<span style="font-size: large;">This was still (and maybe still is) published in Toronto Notes when I began medical school in 2006. For Canadian med students/residents, Toronto Notes is kind of like a bible for our end of medical school licensing exam. In addition to the paper linked <a href="http://www.annemergmed.com/article/S0196-0644%2807%2900732-9/fulltext" target="_blank">above</a>, David Newman gave an amazing lecture on pseudoaxioms for USC Grand Rounds in Nov. 2011. It can be found in the itunes store if you search "USC Emergency Medicine." </span></div>
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<span style="font-size: large;">Bottom line: Don't put your finger in hot boric acid! A common theme that arises from papers advocating against the use of epinephrine was the surgeons sending their patients home with instructions to keep their wounds clean by immersing them in "hot boric acid". Sometimes, the patients were still partially or fully anesthetized, and thus could not feel the temperature or severity of the burns being caused by the acid. </span></div>
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<span style="font-size: large;">In his lecture, Dr. Newman also covers some other great ED myths including; septal hematomas, treatment of strep throat and others. Well worth a listen.</span></div>
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<span style="font-size: large;">Second up is the use of Kayexalate or sodium polystyrene sulfonate for treatment of acute hyperkalemia. There is a brilliant podcast over at the <a href="http://emcrit.org/misc/is-kayexalate-useless/" target="_blank">emcrit</a> site that is a must-listen for anyone who has ever used Kayexalate. Have a listen, then do yourself a favor and look up the two 1961 NEJM references and have a read. Great stuff!</span></div>
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<span style="font-size: large;">Bottom line: Kayexalate is no more effective than placebo in reducing potassium for treatment of acute hyperkalemia. The drug was approved by the FDA in 1958, yet it was 3 years before a study was required to be done on it. <a href="http://www.ncbi.nlm.nih.gov/pubmed/13700297" target="_blank">This study</a> is a must read, as it contained 10 patients, 5 of whom received sorbitol+resin, 3 received sorbitol only and 2 received sorbitol+resin as an enema. The sorbitol only group had a non-statistically greater reduction in serum potassium (6.3 to 4.6) than the sorbitol+resin group (6.6 to 5.2). They state "sorbitol alone is as effective as a combination of resin and sorbitol in
removing potassium, or more so. However, sorbitol alone necessitated a
greater volume of debilitating diarrhea. In <span style="font-family: inherit;">either case the predictability of the fall in serum potassium was impressive.</span>" A second study supporting the use of Kayexalate was in the same issue of NEJM, and was an uncontrolled, 32 patient trial with NO CONTROL GROUP. Yup, times have changed.</span></div>
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<span style="font-size: large;">Recently, there have been multiple case reports of intestinal ischemia/colonic necrosis with Kayexalate, one of which can be found <a href="http://www.ncbi.nlm.nih.gov/pubmed/19373153" target="_blank">here</a>. Safety and effectiveness are reviewed by Sterns et al. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20167700" target="_blank">here</a>. So when I show up with my K of 8, no Kayexalate for me please.</span></div>
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<span style="font-size: large;">Finally, digoxin toxicity. As a cardiac poison that's been in use for hundreds of years, the literature on this is a lot of fun to read. There are countless articles that start with sentences like "Over the past year I have seen four cases of poisoning with foxglove", which is how articles were written back in the day. Along with this body of mostly observational literature comes many conclusions based on case reports, including the concept of the "stone heart". This refers to cardiac arrest precipitated by giving calcium to hyperkalemic patients. Amit Maini of <a href="http://www.edtcc.com/" target="_blank">ED Trauma Critical Care</a> does a great job of reviewing this <a href="http://www.edtcc.com/blog/2012/1/13/myth-buster-episode-4-the-case-of-the-stone-heart.html" target="_blank">here</a>.</span></div>
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<span style="font-size: large;">Bottom line: Calcium is unlikely to cause any harm in acute digoxin toxicity, and even less likely in chronic toxicity.</span></div>
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<span style="font-size: large;">Inspired by the great reviews above, I'll do my best to analyze other medical dogma, and separate the axioms from the pseudoaxioms.</span></div>
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<span style="font-size: large;">Please send me your questions, comments and ideas for future topics using the contact page, comments or on twitter @socmobem</span></div>
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<span style="font-size: large;">Cheers!</span></div>
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SOCMOBEMhttp://www.blogger.com/profile/05640822357520212905noreply@blogger.com0