Archive | February, 2013

what’s important in PE? location, location, location

28 Feb

nice post from PulmCCM.org: “Forget “embolic burden” of pulmonary embolism: location is everything”

 

HIGHLIGHTS:

multicenter study out of Europe, 579 patients with acute symptomatic PE

Emboli were:

  • central in 60%,
  • lobar in 25%,
  • distal in 15%,
  • saddle in 13.5%,
  • subsegmental in 4.8%,

bilateral in 77%

Overall, 5.9% died and 4.5% had clinical deterioration (10.4% combined)

In hemodynamically stable patients

  • central PE was an independent predictor (HR 8.3, 1.0 to 67) of death or deterioration; 8.4% died or had clinical deterioration,
  • lobar PE was nearly so (HR 7.57, 0.95 to 60); 7.8% died or had clinical deterioration,
  • distal PE was associated with lower risk (HR 0.12, 0.01 to 0.97); 2.6% died or had clinical deterioration,

overall burden of PE was not associated with worse outcome

 

BOTTOM LINE:

central or lobar PE’s are bad, distal PE’s not so much.

total clot burden seems to matter less than location of the clot

 

References: post; picture

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ketorolac for migraine?

26 Feb

REVIEW ARTICLE (click through for the details):

8 trials were included, involving over 321 (141 KET) patients.

looked at pain scores at 60 minutes

 

 

THEIR CONCLUSIONS:

KET results in similar pain relief

less potentially addictive than meperidine

more effective than sumatriptan

however, it may not be as effective as metoclopramide/phenothiazine agents.

 

ED BOTTOM LINE:

nice that an NSAID has some evidence for success (Naproxen for home has been done, also)

fine if its a clear migraine, probably a bit ballsy if a bleed is in your headache differential

 

References: review article; picture

hold the PPI in GI Bleed?

25 Feb

interesting post from the Skeptic’s Guide to EM:

BASIC QUESTION:

Does the use of PPIs (e.g. 80mg pantoprazole IV bolus followed by an 8mg/hr drip) prior to endoscopy in acute upper GI bleeds change patient oriented outcomes?

 

 

10-SECOND TAKEAWAY:

bleeding usually from peptic ulcer

seemed reasonable and has been common practice to lower the gastric acid

 

Mortality (six trials n=2223) NO DIFFERENCE

Rebleeding (five trials n=2,121) NO DIFFERENCE

Surgery (five trials n=2,165) NO DIFFERENCE

Active bleed at scope (four trials n=1,332) 8.6% PPI vs. 11.7% placebo

 

“Applying a costly treatment that does not seem to positively effect clinically important end points like mortality, need for surgery or re-bleeding does not seem wise.  Proton pump inhibitors may be required but this data does not support the routine use of them before endoscopy.”

 

References: post; picture

know your slang: xanabars

22 Feb

keeping it simple for friday:

 

XANABAR

 

slang term for a Xanax (alprazolam, the street benzodiazepine of choice) bar

looks like a bar (duh), comes in a scored string-of-pearls line of breakable doses.

 

typical bar is 2 mg total, meaning each fragment is 0.5 mg

 

and now you know.

 

References: dr. google; “the street”; picture

treating GI bleeding in cirrhotics

21 Feb

nice NNT breakdown in February’s EPmonthly

10-SECOND TAKEAWAY:

prophylactic antibiotics for cirrhotic GI bleeders:

  • NNT (to prevent 1 infection) = 4
  • NNT (to prevent 1 death) = 22
  • WHY:
    • cirrhotics have impaired immune function and increased bowel translocation of bacteria
    • give antibiotics during bleeding event to help prevent infections

 

octreotide (somatostatin analogue) for variceal bleeding:

  • NNT: no benefit

 

References: epmonthly article; picture

failed airway algorithm

20 Feb

cribbed right from the emcrit blog post on the Shock Trauma Center Failed Airway Algorithm

check it out. sums up what we usually do. 

personally, i’m a bougie fan. lately, been giving more consideration to using the LMA as a rescue airway for a difficult intubation. take a look, form your own favorites.

BOTTOM LINE:

have a plan A, plan B, and plan C (at least).

 

References: emcrit post

neonatal therapeutic hypothermia

19 Feb

journal of pediatrics article commentary on hypothermia for neonatal encephalopathy

Not as prime-time as with adults, but there’s hypothermia being looked at for the tiny kiddos, too.

 

BOTTOM LINE CONCLUSION:

“Based on the available data and the significant knowledge gaps, the expert panel suggested that although hypothermia is unequivocally a promising therapy for HIE, a substantial proportion of infants still die or are left with disability despite treatment…”

 

For those interested, a quick hits look at the studies that article referenced:

study 1:

  • 218 infants
  • 73/110 (66%) conventional care died or had severe disability at 18 months
  • 59/108 (55%) assigned head cooling died or had severe disability at 18 months
  • (odds ratio 0.61; 95% CI 0.34-1.09, p=0.1).

study 2:

  • 205 infants.
  • Death or moderate or severe disability occurred in
    • 45 of 102 infants (44 percent) in the hypothermia group
    • 64 of 103 infants (62 percent) in the control group
  • (risk ratio, 0.72; 95 percent confidence interval, 0.54 to 0.95; P=0.01)

study 3:

  • 163 underwent intensive care with cooling, 162 underwent intensive care alone.
  • cooled group, 42 infants died and 32 survived but had severe neurodevelopmental disability,
  • noncooled group, 44 infants died and 42 had severe disability
  • (relative risk for either outcome, 0.86; 95% confidence interval [CI], 0.68 to 1.07; P=0.17)

study4:

  • 111 infants were evaluated at 18 to 21 months (53 in thehypothermia group and 58 in the normothermia group).
  • The rates of death or severe disability were
    • 51% in the hypothermia group
    • 83% in the normothermia group
  • (P=.001; odds ratio: 0.21 [95% confidence interval [CI]: 0.09-0.54]; number needed to treat: 4 [95% CI: 3-9])

study5:

  • 100 and 94 infants in the selective head cooling and control group, respectively
  • the combined outcome of death and severe disability
    • selective head cooling 31%
    • control groups 49%
  • (OR: 0.47; 95% CI: 0.26-0.84; P=.01)

study 6:

  • died or had a major sensorineural disability at 2 years
    • 55 of 107 infants (51.4%) in the hypothermia group
    • 67 of 101 infants (66.3%) in the control group
  • (risk ratio, 0.77 [95% confidence interval, 0.62-0.98]; P = .03).

 

Submitted by H. Reed-Day.

 

References: pediatrics article; referenced studies linked above; picture