Archive | March, 2014

PPIs for upper GI Bleeds?

31 Mar

some NNT recap (check the links below)

NO BENEFIT (prior to endoscopy):

  • no difference in
    • death,
    • needing surgery,
    • preventing repeat bleeding

 

  • there was a 14% reduction in endoscopic hemostasis in the PPI group (NNT=7)

But the clinically important outcomes for upper GIB, PPI’s don’t seem to do much.

 

ON THE OTHER HAND:

  • in Asian population studies, there did seem to be some benefit, but not in European/Western populations
    • No difference in:
      • death,
      • blood transfusions
      • shorter hospital stay

 

    • 6.6% were helped by preventing rebleeding
    • 3.2% were helped by avoiding a surgical intervention
    • 10% were helped by avoiding repeat endoscopy

 

Interesting food for thought.

 
References: NNT endoscopy; NNT asian population; picture

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Laryngeal Trauma

28 Mar

QUICK HITS:

second most common cause of death from head and neck trauma

Mortality from injuries directly associated with the laryngeal trauma:  2%-15%

 

signs and symptoms of blunt laryngeal trauma,

  • neck or facial crepitus (from subcut emphysema)
  • Hamman’s sign – crunching sign over precordium from mediastinal air
  • dysphonia,
  • hemoptysis,
  • hematoma,
  • dysphagia,
  • cartilaginous step-offs
  • pneumothorax
  • stridor

 

initially stable-appearing airway may progress quickly to obstruction secondary to swelling 

 

stick with the ABC’s first: if signs of respiratory distress/compromise, go get an airway first.

 

beware of false passages

 

Awake fiberoptic intubation is preferred 

 

Laryngeal mask airways are contraindicated, as they can not only complete the airway obstruction but may also ventilate air through the mucosal defects in the larynx out into the neck.

 

If necessary, formal tracheotomy is preferable to cricothyrotomy, as the latter may further injure the laryngotracheal complex. 

 

DIAGNOSTICS:

  • if possible, endoscopic examination before radiographic examination (ideally nasopharyngoscope or bronch)
  • Examination is best performed with the patient in the upright position if possible
  • CT scan of the neck with contrast, with fine cuts of the larynx. 

 

TREATMENT:

  • AIRWAY if needed
  • most should be admitted for observation 24–48 h with serial exams
  • 8–10 mg of IV dexamethasone q8hr or methylprednisolone 250 mg IV q4hr  (for 24 hr)
  • IV antibiotics for mixed upper aerodigestive tract flora (for known mucosal tears or initial empiric tx)

 

Submitted by Heather Reed-Day.

 

References: Brett T. Comer, Thomas J. Gal Recognition and Management of the Spectrum of Acute Laryngeal Trauma; The Journal of Emergency MedicineVolume 43, Issue 5November 2012Pages e289-e293; picture.

Ischemic colitis in marathon runners

27 Mar

QUICK PEARLS:

the GI system is put under stress during both training and the actual race.  GI complaints include:

  • abdominal cramping,
  • rectal incontinence,
  • gastrointestinal bleeding.

 

most extreme manifestation of this: ischemic colitis.

  • reported incidence of occult blood: ranges from 8–85% (great)
  • As many as 16% of runners in one study reported having bloody diarrhea on at least one occasion after a race or hard run
  • incidence of ischemic colitis in endurance athletes is not known.  

 

  • can be from upper or lower GI sources.
  • Endoscopy of subjects after a race has found a high rate of gastritis

 

delay from onset of symptoms to presentation ranged from 8-24 h.

 

WHY DOES IT OCCUR?

extreme manifestation of the common phenomenon of exercise-induced decrease in mesenteric blood flow.

Some have compared this pattern of ischemia to a shock state

unclear if this is…due to decreased perfusion or if a repetitive trauma may contribute to the development of right-sided colonic ischemia. 

 

 

TREATMENT:

  • fluid resuscitation,
  • pain control,
  • antiemetics as needed. 
  • Bowel rest
  • Nasogastric lavage should be considered, as hemorrhagic gastritis is another possibility. (editor’s note: I have gone away as much as possible from NG tubes in these patients, given its limited utility and that its one of the more painful procedures)  

Most patients will have  complete resolution of their symptoms with no further interventions. 

 

Submitted by Heather Reed-Day.

 

References:  Leon D. Sanchez, Jason A. Tracy, David Berkoff, Ivan Pedrosa. Ischemic colitis in marathon runners: A case-based review. The Journal of Emergency MedicineVolume 30, Issue 3April 2006Pages 321-326.; picture

 

Anaphylaxis: pearls

25 Mar

Some highlights from a good article by Dr. James Roberts over at EM News:

 

FINDINGS IN ANAPHYLAXIS (many are probably less than you thought):

  • generalized erythema 66%
  • pruritis 56%
  • urticaria 50%
  • dyspnea 43%
  • angioedema 40%
  • wheeze 35%
  • laryngeal edema 25%
  • bronchospasm 18%
  • syncope/dizziness 15%
  • BP <90 mmHg 9%

 

good evidence for epinephrine in anaphylaxis

IM better than SC; “important to avoid the use of IV epi in all but the most egregious cases” (if you do go IV, 1:10,000 concentration, and slowly–60-90 sec diluted in saline)

“no report of problems or worse outcome when epinephrine was used…in patients with cardiac history” (anaphylaxis is bad anyways)

not much evidence for pre-medication with glucocorticoids or H1/H2-blockers preventing anaphylactoid reactions to contrast media (“Such premedication will likely persist.”)

for anaphylaxis treatment, “I see no downside to giving glucocorticoids or antihistamines…but the first drug chosen should always be epinephrine.”

reminder: standard dose is 0.3mg (1:1000 concentration) IM

 

References: EMN article; picture

 

neurogenic pulmonary edema

24 Mar

QUICK PEARLS:

WHAT IS IT?

increase in pulmonary interstitial & alveolar fluid, developing rapidly after acute CNS injury (e.g. seizure, trauma, cerebral hemorrhage)

shares characteristics of ARDS (acute respiratory distress syndrome)

 

SYMPTOMS/FINDINGS include:

  • dyspnea
  • mild hemoptysis (maybe)
  • tachypnea
  • tachycardia
  • basilar rales/pulmonary edema
  • normal heart size

 

PATHOPHYS?

“remains incompletely understood” (awesome)

usually associated with elevated ICP, but elevated ICP is not necessary to have neurogenic pulm edema

theories include:

  • medulla oblongata mediated – sympathetic surge
  • pulmonary venoconstriction
  • increased pulm capillary permeability, by secondary mediators (e.g. histamine, bradykinin) or microvascular injury from high pressure surge

,

INTERESTING TIDBITS:

  • alpha adrenergic blockage (e.g. phentolamine) can prevent NPE (animal models).  so can spinal cord transection at/above C7, & denervation of sympathetic fibers to lungs.

 

TREATMENT:

supportive care (ABC’s)

treat the underlying disorder

majority resolve in 2-3 days

data for meds (e.g. phentolamine) is limited, and NPE should resolve anyways, so hard to read into results — proceed with caution

supportive care (ABC’s)

 

References: uptodate.com: neurogenic pulmonary edema; picture

surgical airway tips

21 Mar

nice video up on EMCrit by Dr. Levitan on the surgical airway, worth a watch.

 

Some quick takeaways from the video:

Hardest part is making the decision to cut; decide quickly/early

Laryngeal handshake (use whole hand rather than just 1 finger to feel your landmarks)

Sternal stabilization (rest your hand on the sternum, rather than hanging free in the air)

Cords to carina = 11cm (remember, its shorter than you’d normally push an ETT from above)

 

Not from the video, but good advice:

Stash a scalpel (know where one is at all times. if you need to tape one somewhere, that’s an option, too).

References: EMCrit post; picture

tramadol efficacy?

20 Mar

mythbuster article by Dr. Klauer in January’s ACEP Now.  covers a few topics, but here’s one highlight

 

TRAMADOL: Not the best analgesic

meta-analysis, 1197 patients (age range, 16-46 years) 

patients with dental pain s/p molar extraction

Pain relief was superior to placebo (P < or = .0001) for all treatments.

Pain relief provided by tramadol/ APAP was superior to that of tramadol or APAP alone

 

order of efficacy (at eight hours):

  • ibuprofen 400mg,
  • tramadol/APAP 75/650,
  • APAP 650,
  • tramadol 75,
  • placebo

 

onset of pain relief

  • tramadol/APAP (75 mg/650 mg) – 17 min
  • APAP 650 mg – 18 min
  • ibuprofen 400 mg – 34 min
  • tramadol 75 mg – 51 min
  • placebo – 66 min

on a brief pubmed search, there seem to be a number of maxillofacial articles that have NSAIDs (diclofenac, tramadol) more effective than tramadol as well.  food for thought.

 

References: ACEP Now article; original article; diclofenac vs.; tramadol vs; picture