Archive | December, 2011

seizures and tongue lacs

30 Dec

QUESTION:

–my patient had some sort of ‘episode’, story is unclear
–does their tongue lac tell me anything? was this a seizure?

PUBMED BIOPSY (not a ton out there):
STUDY 1: “Value of tongue biting in the diagnosis of seizures”
–study of 106 patients admitted to epilepsy unit + 45 patients with syncope
–small sample size, but interesting

–8/106 seizure patients had a tongue lac: all on the side
–1/45 syncope patients had a tongue lac: at the tip.

–sensitivity of 24% and a specificity of 99% for the diagnosis of generalized tonic-clonic seizures.
Lateral tongue biting was 100% specific to grand mal seizures.

STUDY 2: The diagnostic value of oral lacerations and incontinence during convulsive “seizures“.

–84 patients on EEG
–trying to tell seizure from pseudoseizure (a.k.a. psychogenic non-epileptic seizure, or PNES)

oral lacs: (p=0.01)

  • seizure: 26% (17/66) —14 side of tongue, 1 tip of tongue, 2 cheek, 3 lip
  • not a seizure: 0% (0/18)
  • sensitivity 26%, specificity 100%

Incontinence: (p = 0.09)

  • seizure: 23% (15/66)
  • not a seizure: 6% (1/18) –!!! (now that’s commitment)
  • sensitivity 23%, specificity 94%

BOTTOM LINE:
side-of-tongue lac is near 100% specific for seizure, not very sensitive
–if the story fits, and you bit the side of your tongue and/or pissed yourself, you probably earned a seizure workup

Reference(s): tongue biting, oral lacs and incontinence, picture

PE and the ECG

29 Dec

STUDY:
–retrospective chart review, 130 patients with diagnosed PEs, 140 controls with negative CTPAs
–checked 15 different ECG parameters between the groups, to see if people with PEs had particular ECG findings that normals didn’t

NOTABLE NUMBERS:
Sinus tachycardia (found in 39% of PE group vs. 24% of control group, P <0.01)
S1 Q3 T3 pattern (12% vs. 3%, P <0.01)
–atrial tachyarrhythmias (15% vs. 4%, P <0.005)
–Q wave in lead III (40% vs. 26%, P <0.02)
–Q3 T3 pattern (8% vs. 1%, P <0.02)

NICE RECAP:
–“We conclude that 1) standard 12-lead ECG findings can increase the pretest probability of pulmonary embolism before performing CT pulmonary angiography; and that 2) the ECG findings have relatively low likelihood ratios to have clinical use.”

Reference(s): study, picture

orthostatic vital signs in the ED: not so useful

28 Dec

THEORY:
–normally, standing leads to a small fall in systolic BP (5 to 10 mmHg), an increase in diastolic BP (5 to 10 mmHg) and a compensatory increase in pulse rate (10 to 25 beats per minute)

–traditional criteria for orthostatic hypotension

  • > 20 mmHg decreased SBP
  • > 10 mmHg decreased DBP
  • Symptoms of cerebral hypoperfusion
–also seen:
  • >20 increased HR

NOT TOO USEFUL:
–study of 132 random, presumed euvolemic ED patients
–took lying & standing vitals
–HR range was from decreases 5.0 to increases 39.4 beats per minute
–SBP range was decreases 20 to increases 25.7 mm Hg
–DBP range was decreases 6.4 to increases 24.9 mm Hg
43% had “positive” orthostatic vital signs according to currently accepted values
TO REITERATE:
–43% of likely euvolemic random ED patients had +orthostatic vitals by numbers
–43% suspected false positive, essentially
–probably not a useful test, this orthostatic vital signs thing
  

audio podcast: the knee

22 Dec

INAUGURAL PODCAST!
–trying something here, taking the audio from one of our excellent resident lectures, and posting it up as an audio file/podcast for everyone to enjoy
–if you missed this conference, need a refresher, or just want something to put in your ipod for your next workout or for the drive home, here it is!
–the goal is to make this a semi-regular thing; haven’t decided yet how frequent

THIS MONTH:
THE KNEE: ORTHOPEDIC INJURIES & ED MANAGEMENT
–tough to imagine an ortho lecture being good without pictures, but actually some good talking points if you stick with it. give it a listen. feedback is appreciated.

download link

Lecture by E. Hawkins.

ethylene glycol ingestion and Wood’s lamp-ing urine

21 Dec

NICE IDEA:
–most antifreeze (which contains ethylene glycol) has fluorescein added to it

–fluorescein should light up with a Wood’s lamp (=blacklight = UV)
–can you light up a patient’s face (to see if they drank some) and/or urine (to see if they’re peeing it out) to help your diagnosis?

NOT THAT USEFUL, SADLY:
STUDY 1: 60 docs in 2 groups; 150 urine specimens, all of which were fluorescent by flow cytometry
–Group 1 reported fluorescence in 80.7% of urine specimens
–group 2 reported fluorescence in 69.3%
–Interrater agreement was poor (72.5%)

STUDY 2: 2 docs, 27-30 urine specimens; shown sequentially or together on a test tube rack
–sequential: sensitivity 35%, specificity 75%, accuracy 48% for detecting florescein
–grouped:  sensitivity 42%, specificity 66%, accuracy 50%

BOTTOM LINE:
urine fluorescence for ethylene glycol ingestion, nice idea, not too clinically useful
not very sensitive, specific, or accurate
–we suck at eyeballing fluorescence, apparently
–stick with anion/osmol gaps, clinical judgement, etc.

Reference(s): study 1, study 2, another study that agrees, picture

Dexamethasone Instead of Prednisone for Acute Asthma

20 Dec

EMERGENCY MEDICINE NEWS:

–this month’s journal had a nice breakdown of a couple articles about using dex instead of prednisone to treat asthma exacerbations. head over there for details, its a decent read
10-SECOND VERSION:
corticosteroids (with bronchodilators) help avoid admission & ED relapse in acute asthma exacerbations
–dexamethasone has longer half-life (days) than prednisone (hours)
dex 0.6mg/kg daily (x 2 days) vs. prednisone 1mg/kg daily (x 5 days)
adult size: dex 16mg/day vs. pred 60mg/day

–limited studies, but generally dex was same or slightly better
–dex is probably ok alternative to pred

Reference(s): emergency medicine news: article, uptodate.com: prednisone, dexamethasone, picture

heliox for acute asthma

19 Dec
COCHRANE REVIEW:
–10 small RCT’s (7 adults, 3 children), 544 acute asthma patients comparing inhaled heliox vs placebo (O2, air) in addition to standard treatment found no difference in PFT’s or admission to hospital (1)
–However, in subgroup of patients with severe baseline pulmonary function, heliox did improve PFT so may be some benefit to use in patients w/severe airway obstruction
PEARLS:
–Should be considered after 1st (albuterol, Duoneb, steroid) and 2nd (mag, terbutaline, epi) line therapies fail and patient still has some reserve
–“Heliox-driven albuterol nebulization may be considered for patients who have life- threatening exacerbation or who remain in severe exacerbation after intensive conventional adjunctive therapy” (2)
–Since generally given in mixtures of 70:30 (helium:O2) CANNOT use in patients who are hypoxemic (i.e. need 50% FiO2)
–If the patient needs to be intubated, INTUBATE!
Submitted by F. DiFranco.
Reference(s): (1) i.Rodrigo GJ, Pollack CV, Rodrigo C, Rowe BH. Heliox for non-intubated acute asthma patients. Cochrane Database of Systematic Reviews 2006, Issue 4; (2) Cincinnati Children’s Hospital Medical Center. Evidence-based care guideline for management of acute asthma exacerbation in children. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; INFO@GUIDELINES.GOV 2011, picture