Archive | October, 2013

kidney injury from IV contrast?

31 Oct

MAYBE NOT…

Nice review in October’s EM News by Dr. James Roberts

Click through for the whole read, but here are some PEARLS:

 

No specific treatment once contrast nephropathy happens.   Same plan as any cause of acute kidney necrosis: fluid/electrolyte balance.

 

typical definition of contrast nephropathy: increased serum creatinine of 0.5mg/dL, or >25% increase above baseline in 2-3 days

…”clinical significance of these minor elevations is likely minimal”

 

in one study: 773 patients got contrast CT, no one needed dialysis

 

in people with previously normal kidneys (Cr < 1.5 mg/dL, or GFR>60 ml/min):  incidence of AKI in contrast and non-contrast exposed patients were similar

 

results are conflicting RE: AKI protective pre-treatments (e.g. N-acetylcysteine, bicarb, saline hydration).  IV fluid is probably the most available and intuitive method to try (before, during, & after).

 

pathogenesis unclear, some type of acute tubular necrosis (ATN)?  

 

BOTTOM LINE:

“It would appear reasonable to eschew the use of contrast material for CT scans whenever possible, but the use of IV contrast material is not as detrimental to kidney function as previously thought.”

 

References: EMN article; picture

Advertisements

handy website: shoulderdislocation.net

30 Oct

the shoulderdislocation.net site has some nice anatomy pics and some pics/videos of a handful of reduction techniques (scapular manipulation, Cunningham, etc). 

Check it out, some useful tips and refreshers for your next reduction!

 

ONE PARTICULARLY HANDY TIP (from the site):

tell the patient to shrug their shoulders, chest out.

brings the scapulae together, better position (like in scapular manipulation) for the shoulder to reduce

 

References: site (pic from site)

best way to flavor oral contrast?

29 Oct

Fun to consider, nice for your patients drinking contrast for CTs.

 

1997 study:

Kool-Aid with Gastrograffin got a mean palatability score of 8.2 (out of 10, 10 = “like a lot”)

 

2009 EM study:

mean (SD) taste scores

  • Tropical Punch Kool-Aid 44 (20),
  • orange juice 40 (20)
  • lemonade 37 (21),
  • water 12 (5)

 

Sort of related food for thought: GI Study on polyethylene glycol bowel prep

sugar-free Menthol candy improved palatability scores:

  • candy drop users 3.9 (out of 5, 5=”tasty”), SD 0.7
  • controls 2.8, SD 1.2
  • Side effects were similar except for nausea (24.5% candy drops vs 44% controls; P = .04).

 

BOTTOM LINE:

find something flavorful to mix with the oral contrast: nicer for patients, maybe less nausea.

Kool-Aid seemed to get some higher taste scores, if you have it handy.

 

References:  1997 study; 2009 study; menthol/bowel prep study; picture

abscess packing after I & D?

28 Oct

2013 Peds Surg article:

N = 85, (43 packing, 42 non-packing)

excluded: diabetic/immunosuppressed, perianal or pilonidal, post-op abscess

everyone got I&D, 7 days oral abx (puts a damper on this data, a bit) warm soaks

two groups were not statistically different with respect to

  • recurrent abscesses (one in each group),
  • MRSA incidence (81.4% PG/85.7% NPG)

 

FROM AN OLD POST:

–prospective, randomized, single-blinded trial, N =48

  • no significant difference in need for a second intervention at the 48-hour follow-up
    • packed (4 of 23 subjects)
    • nonpacked (5 of 25 subjects)
    • (p = 0.72 (NOT SO GOOD))
  • higher pain scores immediately postprocedure in packed group and at 48 hours postprocedure
  • greater use of ibuprofen and oxycodone/acetaminophen in packed group 

 

PERIANAL ABSCESSES:
–“designed to show that perianal abscess may be safely treated by incision and drainage alone” vs. I&D + packing
–50 patients were recruited (7 lost to follow-up); 20 in the packing and 23 in the nonpacking arm

  • Mean healing times were similar ( P = 0.214).
  • The rate of abscess recurrence was similar ( P = 0.61).
  • Postoperative fistula rates were similar ( P = 0.38).
  • Pain scores at the first dressing change were similar ( P = 0.296).
  • Although pain scores appeared much reduced in the nonpacking arm, this did not attain statistical significance

 

BOTTOM LINE:

limited data out there on packing abscesses
–packing doesn’t seem to improve healing or reduce recurrence in limited studies, some with Abx
–packing might hurt more
might be ok NOT to pack abscess after I&D, but limited size studies limit the statistical significance.  small data is suggestive, though.

 

Reference(s): peds surg article;   ; previous post on abscess packing; picture

Perimortem C-section

25 Oct

great post from this year at St. Emlyn’s blog:

 

Click through for the entire post, worth a quick read, (and old post has a great video review, too) but here are some highlights:

 

You do NOT have time to open a textbook, phone a friend, wait for peds/OB (though you should stat page ’em), etc.  

 

ALLOCATE:

  • someone to run the adult code,
  • someone to resus the baby,
  • someone (you) to do the peri-mortem C-sxn

 

in a pinch: the “Thoracotomy tray has retractors, scissors and clamps which together with a scalpel is all that you will need.”

 

“What feels slow for you is probably fine. Do it right first time without removing anyone’s fingers.”

 

midline vertical incision from pubis to umbilicus”

“If the placenta is in the way, you will just have to cut through it.”

Deliver the head, body should follow. Cut the cord, hand the baby off. Deliver placenta.

 

“Use the greatest simulator known to mankind – the Human Brain”

 

Be prepared.

 

References: St. Emlyn post; old video post; picture

 

stethoscope as hearing aid

24 Oct

Ever taken an entire medical history shouting at your hard of hearing patient (and the rest of the ED)?

Next time, try the reverse stethoscope trick: 

Put your stethoscope in the patient’s ears (preferably after cleaning the earpieces)

Talk (don’t shout) into the diaphragm.  

 

There you go. 

 

References: medscape article & picture

dermabond to patch a leak

23 Oct

nice trick from an old Academic Life in Emergency Medicine post:

dermabond/tissue adhesive to seal a patch

to keep it dry (and dry faster), high-flow nasal cannula

might help with other leaking sites (e.g. dialysis puncture), too

File it away for your next quick-fix patch.

References: ALiEM post (& picture); old post