Üst gastrointestinal sistem kanamaları acil servis başvurularının önemli nedenlerinden birini oluşturuyor. Endoskopik tedavi yöntemlerindeki ilerlemeler ve yaygın kullanılan medikal tedavi alternatifleri, ne yazık ki bu önemli sağlık sorununda mortalite rakamlarında ciddi bir düşüşe neden olamadı. Bu yazıda üst GİS kanamalarına acil serviste uygulanabilecek tedavi alternatiflerinden, mortaliteye etki eden faktörler ekseninde bahsetmeye çalışacağım.
ÖNEMLİ NOT: Aşağıdaki metinde, konuyla ilgili yazının yayınlanma tarihinde güncel literatürde olan ve yazarın dikkatini çeken önemli noktalara yer verilmiştir. Yazı, herhangi bir makale veya kılavuzun birebir çevirisi olmayıp yazarın yorumlarını içermektedir ve sağlık profesyonellerine yöneliktir. Tıp sürekli gelişen ve değişen bir alandır; tıbbi uygulamalarınızda güncel literatürü esas almanız tavsiye edilir.
Teknolojideki tüm gelişmelere karşın, tıbbın son 50 yılında değiştiremediği oranlardan biri de akut üst gastrointestinal sistem kanamalarında %10larda seyreden mortalite rakamları. Son 50 yılda hayatımızın çoğunu değiştiren yenilikler, elbette GİS kanama yönetimini de değiştirdi. Artık karnındaki geniş laparotomi skarının nedenini sorduğumuz hastalar bizlere, mide kanaması geçirdiklerini söylemiyorlar (yoksa söylüyorlar mı?). Mortalite rakamlarını değiştirmese de uygulanan farklı tekniklerin ve tedavi yaklaşımlarının bu değişikliklerde payı büyük: Endoskopik tedavi yöntemleri ve bu yöntemlere ulaşılabilirlikteki hız, içinde proton pompa inhibitörlerinin başı çektiği geniş bir ilaç yelpazesi..
Rockall skorunun parametreleri ise aşağıda yer alıyor. Rockall skoru endoskopiyle ilgili bir puanlamaya da sahip. Mayıs 2013’te AJEM’de yayınlanan bir makalede bu skorlama sistemleri karşılaştırılmış, makalede karşılaştırılan üç skorlamadan biri de preendoskopik Rockall skoru (çok kaba bir ifadeyle genişletilmiş vital bulgular desek de olur). Bu nedenle şimdilik “sıfır” olan Blatchford skoruna inanmak, skorlama sistemlerinden acil tıpçılara faydası dokunacak tek şey gibi duruyor.
Endoskopi öncesi uygulamayı sevdiğimiz ilaç grubunu oluşturuyor. 2010 yılında yapılmış olan bir Cochrane derlemesi 2223 hastalık, 6 randomize kontrollü çalışmanın sonuçlarını ele alıyor. Bu sonuçlara göre proton pompa inhibitörlerinin endoskopi öncesi kullanımları:
- Mortalite üzerine etkili değil [OR 1.12, %95GA (0.72-1.73)
- Yeniden kanama üzerine etkili değil [OR 0.81, %95GA(0.61-1.09)]
- Cerrahiye gidişi etkilemiyor [OR 0.96, %95GA (0.68-1.35)].
- Kanama açısından yüksek riskli lezyon görülme olasılığını azaltıyor [OR 0.67, %95GA (0.54-0.84)]
- Tekrarlayan endoskopi gereksinimini azaltıyor [OR 0.68, %95GA (0.50-0.93)]
Somatostatin analogları, özellikle özefagus varis kanamalarında sıklıkla tercih ediliyor. Varis kanamalarının bildiğiniz gibi, tüm üst GİS kanamaların küçük bir bölümünü temsil etmesine karşın (%6) mortalitesi oldukça yüksek. Derlemeye alınan çalışmalarda heterojenite olmakla birlikte, oktreotid uygulamasının mortaliteye etkisi gösterilememiş. Bununla birlikte varise bağlı ve varis dışı üst GİS kanamalarda rekürrent kanamayı azaltıyor, transfüzyon ihtiyacını azaltıyor.
Faydası gösterilememiş durumda.
- Hemorajik şokta, şoka yönelik tedavi uygulanmalıdır (sıvı resusitasyonu, kan replasmanı, end-organ perfüzyon belirteçleri…)
- Hasta anstabilse, endoskopi resusitasyonu takiben “hemen” uygulanmalıdır
- Proton pompa inhibitörleri ve oktreotidin, üst GİS kanama yönetimine sınırlı katkısı vardır. Her iki ilaç da mortalite üzerine etkili olmamakla birlikte, transfüzyon ve ek girişim ihtiyacını azaltabilirler.
- Endoskopik yöntemlerle sonlandırılamayan üst GİS kanamalarda öncelikle anjiyoembolizasyon, sonra cerrahi düşünülmelidir.
- Traneksamik asitle ilgili ciddi bir literatür boşluğu bulunmaktadır.
Kaynaklar ve İlave Okuma:
Blatchford O ve ark. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet. 2000;356:1318-21.
Stanley AJ ve ark. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet 2009;373:42-7.
Wang CH ve ark. A prospective comparison of 3 scoring systems in upper gastrointestinal bleeding. Am J Emerg Med 2013;31:775-8.
Sreedharan A ve ark. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev 2010;(7):CD005415.
Lau JY ve ark. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 2007;356:1631-40.
Khuroo MS ve ark. Treatment with proton pump inhibitors in acute non-variceal upper gastrointestinal bleeding: A meta-analysis. J Gastro Hepato 2005;20:11–25.
CG141 Acute upper GI bleeding: NICE guideline http://guidance.nice.org.uk/CG141/NICEGuidance/pdf/English
Gøtzsche PC ve ark. Somatostatin analogues for acute bleeding oesophageal varices. Cochrane Database Syst Rev. 2008;(3):CD000193.
Gluud LL ve ark. Tranexamic acid for upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2012;(1):CD006640.
Il dolore toracico è una motivazione d’accesso frequente in Pronto Soccorso. Grossolanamente, qualora si sospetti che possa essere di origine ischemica, il percorso diagnostico è sintetizzato nella figura 1. La definizione di paziente ad alto rischio è tratta dalle linee guida AHA sul dolore toracico a basso rischio. Il test da sforzo (nello studio in [...]
Twice recently, I’ve been privy to patient complaints about emergency department “misdiagnoses” when patients have gone to follow up appointments with their physicians.
One case involved a young girl who had a rash. The rash was preceded by a low grade fever in the days prior, began on the chest and spread outward, and had the classic appearance of a viral exanthem. The girl’s parents weren’t happy with that diagnosis. They believed that the girl was suffering from an allergic reaction and that she needed antihistamines and steroids. The doctor explained that the rash was not an allergic-type rash and that she didn’t appear to be ingesting anything that could have caused an allergic reaction. The family left unhappy. The following day, the nurse manager gets a phone call from the patient’s irate mother. During a follow up appointment the following day, the patient’s pediatrician stated that the rash was “absolutely” an allergic reaction and immediately started the patient on Benadryl and prednisone. Oh, and the patient also had an ear infection that the emergency physician missed, so she was started on amoxicillin as well. The money quote for that call was “What type of doctors do you have working in your hospital, anyway?”
Of course, the natural course of an exanthem is that it will go away after a couple of days. So right after the patient starts taking the medications for her “allergic reaction,” her rash will get better which will reinforce the “post hoc ergo propter hoc” logical fallacy. Of course, the patient could have been given magic beans and eye of newt and she would have had the same outcome (perhaps with a little bit of an added sour stomach from the eye of newt), but it doesn’t matter because according to the pediatrician, the emergency physician misdiagnosed the cause of the rash. Of course if the patient happened to have a reaction to the amoxicillin, then the logical conclusion would be that the delay in treatment by the emergency physician caused the allergic reaction to get worse. So regardless of the outcome, the emergency physician comes out looking like a bad doctor.
Another case involved a patient with a severe headache. He was seen by his primary care physician and diagnosed with sinusitis. The following day, the headache had not improved on Augmentin and nasal steroids, so the patient came to the emergency department. Because it was a new-onset severe headache in a patient who never had headaches before, the emergency physician ordered a CT scan of the head. After some Imitrex and some Compazine, the headache resolved. The CT scan showed no abnormalities – including absolutely clear sinuses. Based on this, the emergency physician told the patient that he probably was suffering from migraines that he could stop taking the Augmentin and nasal steroids because the sinuses were normal on the CT scan.
Two days later, the patient returned to the emergency department in person so that he could loudly tell the registration clerks that they better watch that “dangerous doctor” working back there. A nurse intervened and the patient told her that his primary care doctor told him the emergency physician was absolutely wrong and that sinus infections absolutely can occur even without any abnormalities on CT scan, and that he needed to finish the antibiotics and keep taking the steroids — which he had thrown away after his emergency department visit. His next stop was allegedly to a lawyer’s office to look into suing the hospital.
It doesn’t matter that the medical literature shows that antibiotics and nasal steroids are ineffective as treatment for acute sinusitis. It doesn’t matter that the acute sinusitis resolved with migraine medications. It doesn’t matter that the sinuses were normal on CT scan. It only mattered that the patient’s physician was able to explain away the care rendered in the emergency department as being incompetent in a forum where the emergency physician was not present to defend himself from the criticisms.
These cases aren’t intended to illustrate that emergency physicians are always right.
Rather, they are intended to show how, even when the opinions are wrong, there is a tendency to believe that the last opinion is the correct one.
They are also intended to show how behavior by subsequent treating physicians can anger patients and potentially lead to lawsuits.
In fact, one of these scenarios upset the emergency physician so much that there was an ethics complaint made to the hospital administration. I’d like to be a fly on the wall at that meeting.
This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.
These are the times when I think: THEY DO NOT PAY ME ENOUGH. We should be making triple what we do. If the public saw what we really deal with on a regular basis they would be shocked:
Every disgusting thing that comes out of the human body has to be cleaned up by somebody and that person is a nurse.
From the smell of c diff to GI bleed to homeless feet to beer and cigarettes, we deal with it. Day after day. j
The worst thingl I ever smelled was burning flesh. A doctor decided to removed some kind of skin growths in our ER (totally inappropriate).
Sorry this is a digusting blog entry, but it is the reality of what we do and Lord knows I'm all about being real. ...
Here's a question for you: What do you use to get rid of bad smells? We use coffee grounds.
Tombstones, checkmarks, and bundles, oh my!
Psychiatric Predictive Value of the Voice Message
Had voice messages existed in the past, there would be a Budhist riddle to the effect of “what is the sound of one man conversing?”. For most of us, the answer to this riddle would be “awkward”. Human communication relies on feedback and cues from an audience. Sustained solo communication just feels weird.
Health budgets are about to be squeezed like the bowels of a patient being disimpacted. To extrapolate the analogy further, the likely result coming out of both patient and cuts will be the same. Each challenge requires innovative solutions, and here our friend the voice message comes into its own.
Most normal human beings will sound awkward when leaving a voice message. However, those with narcisstic personality disorders and other such ailments are more likely to enjoy auto- monologue. The voice message is an acceptable situation to assess these personal traits. The patient believes they are being given a task, however the exercise is an assessment of how comfortable a patient is talking to themselves.
Should the patient leave a perfect voice message they should be further tested for psychopathy. In this way the voice message may be used as a screening test.
Broome Docs: The Lactate “Debate” with Dr Seth Trueger
EMCrit's response to Marik & Bellomo
Here's a little bit on the sepsis bundle as a pay-for-performance quality measure from Surviving Sepsis (overview)
Issue 3 (Vol. 25) of Emergency Medicine Australasia published online on 13 June 2013
Although 45% of Australians have private health insurance and 41% of inpatient care is delivered in private settings, only 6% of ED visits occur in private hospitals. In this first ever descriptive study of patient characteristics in Australian private EDs, Fitzgerald and colleagues analysed routinely collected data aggregated from 83,279 patients presenting across four participating EDs for a one year period, and compared this with public ED datasets. Variability in private ED data systems limited the range of data that could be combined as well as detailed comparisons. Nonetheless, attendance patterns by day of week and time of day were similar to public EDs. However the acuity of public ED patients was more likely to be in triage categories 1 and 2. There were similar arrival methods to public and private EDs, but self-referral was higher for public ED patients. The proportion of patients staying less than 4 hours was slightly higher in private EDs and mean LOS was, on average, 30 minutes shorter across all triage categories in private EDs, however hospital admission rates were higher from private EDs. The most significant difference was patient’s health insurance status, with only 14% of public ED patients having some form of insurance, compared with 79% of patients in private EDs. Private hospital EDs have a significant role in the Australian emergency health system, although data systems are required that enable a nationally consistent dataset, aligned to data elements routinely collected in public EDs, to allow comparative benchmarking and whole of system analyses to inform evidence-based public policy
Inter-hospital transfers of critically ill patients delay access to definitive care and are associated with increased ICU and hospital LOS and higher mortality rates. Visser et al, describe a data linkage study of Adult Retrieval Victoria and ICU datasets to determine factors related to ICU mortality in transferred critically ill patients over a one year period. Advanced patient age, cardiac conditions, lower mean arterial blood pressure and tachycardia on completion of retrieval were associated with increased ICU mortality in the study cohort. These findings support the need for clinician awareness of retrieval patients being at greatest risk and optimised cardiac support for these patients.
Distal forearm fracture is a painful injury that is a common paediatric ED presentation. Early reduction enables best outcomes and if this can be achieved in the ED, costly hospital admission can be avoided. This multicentre survey by Schofield et al, from the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network, evaluated current clinical practices for procedural sedation and analgesia (PSA) and reduction of forearm fracture in children. Ketamine and nitrous oxide were the most frequently used PSA agents, with guidelines for use of these agents available in almost all PREDICT sites. Most physicians would reduce fractures up to 25o angulation, with higher displacement referred to theatre. Better definitions on cut-off points for fracture reduction in the ED, standardised practice guidelines for specific PSA agents, and improved access to image intensifiers in EDs are recommended
Demography is destiny (#FOAMed)
The increasing numbers of older patients presenting with acute exacerbations of chronic illness and complex geriatric syndromes pose significant challenges to the practice of emergency medicine in Australasia. This perspective, from Arendts and Lowthian, calls for a proactive approach to geriatric emergency medicine practice, research, education and policy development. There are several areas where ED processes can be improved, including quality of geriatric clinical care in the ED, up-skilling the emergency physician workforce in areas of geriatric medicine and introduction of evidence-based models and systems of care that better meet the needs of older patients. However, the greatest gains in addressing this issue are likely to be achieved outside the ED. As such, a framework for research and policy development is proposed to improve care for older people with less hospital occupancy through strategies that avoid ED attendances, reduce hospital admissions from ED, improve ED clinical care for common geriatric presentations and avoid ineffective or futile treatment at times of critical illness
Bleeding in early pregnancy is a common ED presentation and vaginal examination is traditionally considered ‘essential’ for diagnostic assessment. In this prospective randomised control trial of stable patients presenting with first trimester bleeding, Johnstone demonstrates that vaginal examination does not improve diagnostic accuracy and is unlikely to inform management or disposition of the patient. Not only is this physical examination unpleasant and invasive for the patient, this study challenges clinical convention with evidence that the examination does not contribute any additional diagnostic information. Decisions on operative or conservative management of early pregnancy bleeding are much better based on ultrasound performed within a day of presentation. As such vaginal examination should no longer be required for routine assessment of patients with early pregnancy bleeding.
Case Presentation by Dr. Jeff Cloyd
CHIEF COMPLAINT: “My right eye hurts”
HISTORY OF PRESENTING ILLNESS:
53-year-old female presents to the ARC complaining of pain in her right eye over last 24 hours. She began to notice some redness in the right eye during the day yesterday, but as the evening wore on last night she noticed a sharp pain in her right eye and worsening redness. She has not noticed any clear or purulent discharge from the eye. She states she has always had some sinus congestion providing a sensation of pressure behind both eyes, but this feels no worse today. She states the pain seems to be worse when she looks into bright lights, and gets better when she goes into dark places. She is not noticing pain when moving her eyes. She does report that she has had some decreased vision in the right eye when compared with the left. She never had anything like this before and denies trauma to this eye. She has not had any medications for her eye pain.
REVIEW OF SYSTEMS:
Constitutional: No fevers, chills, sweating, or hot flashes
Eyes: Eye pain with decreased vision
ENT: No rhinorrhea, sore throat
CV: No palpitations
Respiratory: No cough
GI: No nausea, vomiting, diarrhea
PAST MEDICAL, FAMILY, AND/OR SOCIAL HISTORY:
PMH: Negative for glaucoma, rheumatoid arthritis, or sarcoidosis
FH: Negative for glaucoma, rheumatoid arthritis, or sarcoidosis
SH: Pt lives at home. Pt denies tobacco and illicit drug use. Pt denies alcohol use.
EXAMINATION OF ORGAN SYSTEMS/BODY AREAS:
VS: Heart rate 84, blood pressure 140/78, respiratory rate 18, temperature 36.3 orally
Constitutional: Well-developed, well-nourished, patient is alert and oriented x3. She is seen moving her head comfortably in all directions, cooperative and interactive on exam.
Eyes: Extra-ocular movements are intact in all directions without pain. Pupils are equal at 3 mm, and reactive to light. Bilateral pupils are symmetric. Patient has erythema of the conjunctiva of the right eye worse immediately adjacent to the iris and improving distally. When light is shined in the right eye the patient experiences pain in the same; when light is shined in the left eye, she reports pain in the right eye. She has no pain relief with proparacaine instillation. Pressures in the bilateral eyes averaged 14 mmHg. No fluorescein uptake is appreciated in bilateral corneas. Slit-lamp examination reveals no cell or flare in the anterior chamber of the bilateral eyes. Visual acuity is 20/50 in the affected eye and 20/25 in the unaffected eye. No swelling of the soft tissues appreciated peri-orbitally bilaterally.
Nose: No rhinorrhea, mucous membranes are pink and moist. No mucosal edema
Mouth: No erythema or exudates in the posterior pharynx, tonsillar lymph nodes are not enlarged.
Neck: Supple, no meningismus, no anterior cervical lymphadenopathy.
Skin: No rash, no diaphoresis.
Neurological: No facial asymmetry/droop. Patient is able to shake hands with expected strength and is moving all of her extremities spontaneously. Sensation is appreciated as normal in all extremities. No aphasia or dysarthria, tongue protrudes midline. Normal gait.
Question #1: What is the most appropriate treatment for this patient’s diagnosis?
a) Oral Cefalexin
b) Timolol drops
c) Warm compresses
d) Intravenous Ampicillin-sulbactam
e) Homatropine drops
f) Bacitracin ophthalmic ointment
g) Prednisolone acetate ophthalmic suspension
Question #2: Iritis, unlike acute angle-closure glaucoma, is not an immediately vision-threatening disease. However, these patients do require rapid Ophthalmology follow-up (ideally within 24 hours). This patient was seen late in the evening in the ARC, but an appointment was made for the patient the following morning at the Ophthalmology clinic. Which investigative study might be considered prior to this patient’s discharge?
e) Chest xray
Question #3: During your next shift in the ARC one week later this patient presents with a chief complaint of “foreign body in left eye”. She reports that her right eye symptoms have almost completely resolved. However, she reports that she has been keeping her eye drops in her desk drawer…. the same drawer in which she also keeps her super glue. One hour prior to arrival she placed three or four drops of what she thought was Pred-forte into her left eye but immediately noticed that her eyelids were sticking together. After realizing her mistake she attempted to flush her eyes with water but presents now for evaluation.
On exam you remove some pieces of hardened glue from the conjunctiva. The palpebral conjunctiva appears to be adhered to the sclera in the upper, outer quadrant and fluoroscein staining reveals a generalized uptake over the entire surface of the cornea. In addition to removing any large pieces and flushing the patient’s eye with water, which medication will you provide this patient?
b) Erythromycin ophthalmic
d) Normal saline ophthalmic
e) Reading glasses
Filed under: Question of the Week
Do you spend more than $2000 per year on self-education?
If so, this affects you...
This single-center study performed in Philadelphia gives results similar to prior work in the same vein. 23 attending physicians and 21 residents were surveyed regarding estimates of cost of care for 102 of their patients discharged from the Emergency Physician. Each estimate for the total cost of care was compared with the actual final charges billed to the patient or their insurance carrier.
Median estimated charge: $1,268
Median actual charge: $2,175
There was no difference between attending and resident performance.
Not an encouraging result – particularly as patients are likely going to be burdened with ever-increasing portions of their healthcare costs, and we ought to be able to communicate with them the cost of care as part of shared decision-making in the Emergency Department.
"Emergency physicians’ knowledge of the total charges of medical care"
Acute uncomplicated cystitis is becoming more difficult to treat in the setting of increasing antimicrobial resistance. In the 2010 IDSA Guideline, as summarized in a PV Card on Cystitis and Pyelonephritis in Women, nitrofurantoin is now listed as the first-line choice, surpassing ciprofloxacin and sulfamethoxazole/trimethoprim from the previous iteration.
For tested E. Coli strains at my institution in 2012, the susceptibility to common agents is as follows:
- Ciprofloxacin 61%
- Levofloxacin 72%
- Sulfamethoxazole/trimethoprim 69%
- Nitrofurantoin 97%
The reality of resistance hits close to home for me and may be similar in your institutions.
Why not just prescribe 5 days nitrofurantoin for all patients with acute uncomplicated cystitis?
- The American Geriatrics Society’s Beers Criteria for Potentially Inappropriate Use in Older Adults recommends against using nitrofurantoin in this age group.
- Nitrofurantoin is contraindicated in patients with creatinine clearance < 60 mL/min.
Let’s tackle each of these concerns.
- Darrell Hulisz, PharmD explores the reason for nitrofurantoin’s inclusion in the Beers Criteria in a recent Medscape article. He concludes
“It is generally accepted that nitrofurantoin may be ineffective for UTIs in the elderly because age-related declines in renal function result in subtherapeutic concentrations in the urinary tract. However, the recommendation to avoid the drug in the elderly is not because it causes nephrotoxicity. Although not well-documented, it is plausible that the risk for other toxicities from nitrofurantoin, such as pulmonary fibrosis, would increase secondary to drug accumulation.”
- Is it really true that nitrofurantoin is not effective when CrCl drops below 60 mL/min?
- When nitrofurantoin was originally FDA-approved in 1988, the CrCl lower limit was 40 mL/min. It was changed to 60 mL/min in 2003 with little explanation. The contraindication seems to be based on a few studies from the 1950s and 1960s addressing urinary recovery of this drug in patients with various degrees of renal function. 
- A retrospective chart review of 356 patients (mostly older adults) was conducted in 2009 that assessed the efficacy and safety of nitrofurantoin in patients with renal impairment. The study concluded that nitrofurantoin cure rates for UTI and adverse events were similar between those with and those without renal impairment. 
- In a cohort of 21,317 women, nitrofurantoin treatment was not associated with a higher risk of ineffectiveness in women with UTI and moderate renal impairment (30-50 ml/min/1.73 m2). However, the authors did find a significant association between renal impairment (1.73 m2) and pulmonary adverse events leading to hospitalization (HR 4.1, 95% CI 1.31-13.09). 
- Concern exists for an associated increased risk for serious adverse reactions in patients with renal impairment.
- Pulmonary toxicity, hepatotoxicity, and hemolytic anemia are rather rare occurrences, and are often linked to prolonged treatments (6 months or longer). 
- Published cases of peripheral neuropathy associated with nitrofurantoin in patients with renal insufficiency have occurred most often with treatments lasting beyond the 5-day period recommended by the IDSA. 
While both recent studies had some important limitations, they still suggest that patients with an estimated creatinine clearance >40 mL/min are probably ok to receive a 5-day course of nitrofurantoin. This is different from the current 60 mL/min mark stated in the Beers Criteria and Macrobid package insert. Cure rates and adverse reactions are similar to patients with normal renal function.
- M. Oplinger, and C.O. Andrews, "Nitrofurantoin contraindication in patients with a creatinine clearance below 60 mL/min: looking for the evidence.", The Annals of pharmacotherapy, 2013. http://www.ncbi.nlm.nih.gov/pubmed/23341159
- A. Bains, D. Buna, and N.A. Hoag, "A retrospective review assessing the efficacy and safety of nitrofurantoin in renal impairment", Canadian Pharmacists Journal, vol. 142, pp. 248-252, 2009. http://dx.doi.org/10.3821/1913-701X-142.5.248
- A.F.J. Geerts, W.L. Eppenga, R. Heerdink, H.J. Derijks, M.J.P. Wensing, T.C.G. Egberts, and P.A.G.M. De Smet, "Ineffectiveness and adverse events of nitrofurantoin in women with urinary tract infection and renal impairment in primary care.", European journal of clinical pharmacology, 2013. http://www.ncbi.nlm.nih.gov/pubmed/23660771
- D.R. Guay, "An update on the role of nitrofurans in the management of urinary tract infections.", Drugs, 2001. http://www.ncbi.nlm.nih.gov/pubmed/11293646
I have tired of treating my ultrasound exam of a patient as separate from my physical exam. In the emergency department and ICU where I practice, ultrasound is much more than an adjunct, it is an integral part of my evaluation of the patient.
The JAMA series on Rational Clinical Examination has taught us that each physical exam maneuver needs to be evaluated with an evidenced-based assessment, that includes sensitivity and specificity. We have learned through the series that many specific exams are near worthless, while others provide some value though far less than we may have been led to believe during our medical school and residency training.
The knowledge of the fall failings of the traditional physical exam, and the near universal availability of bedside ultrasound has changed the physical exam fundamentally and forever. Many previous exam maneuvers such as palpating ventricular heave or PMI, are distant markers of what you fundamentally care about which is cardiac function. With ultrasound that gives you direct visualization of structures, ventricular function can be directly interpreted even by novice registrars.
In the United States, Medicare billing requires a certain number of physical exam bullets fore a specific level of billing which prompts physicians to continue performing useless physical exam maneuvers on patients, or even worse document that they performed them without actually doing so. While unethical, this grows out of a frustration with documentation requirements that do not fit with our current knowledge and practice of medicine. it is also unethical for Medicare to subject the patient to fruitless parts of the physical without any benefit to their care.
What I have become a strong advocate for, is incorporating my ultrasound findings directly into my physical exam documentation. Assessments made by ultrasound should be viewed as tests answering questions, and should documented accordingly.
Below I shown an example comprehensive physical exam of a patient presenting with shortness of breath, who has decompensated heart failure. I have highlighted the items included based on ultrasound.
Vital Signs: BP 128/68 | Pulse 111 | Temp 37.7 °C (Oral) | Resp 24 | Wt 118.8 kg | SpO2 89% on room air.
Constitutional: Mild respiratory distress. Does not appear toxic.
Eyes: White and quiet. PERRL (R 3~2 | 3~2 L).
ENMT: Moist oral mucosa. No tonsilar exudates or hypertrophy. No swelling or erythema of posterior oropharynx.
Respiratory: Increased effort. Rales bilaterally. Sliding lung signs present bilaterally. Approximately 12 B-lines bilaterally. No significant pleural effusion.
Cardiovascular: Regular tachycardic rhythm. Soft S3 heard with no murmur. No pericardial effusion. Dilated cardiac structure. Moderately decreased cardiac function. Proximal thoracic aorta 20mm. No significant aortic valve or mitral valve stenosis. E-point septal separation is 12mm.
Gastrointestinal: Soft. No tenderness to palpation. No intraperitoneal free fluid. Maximum abdominal aorta diameter 2.9 cm. IVC diameter 2.4cm with no respiratory variation. Bladder decompressed with Foley catheter balloon in place.
Genitourinary: Foley catheter in place.
Neurologic: No deficits of cranial nerves. Strength and sensation normal in bilateral upper and lower extremities.
Musculoskeletal: Moving all extremities freely. No swelling or erythema of legs. Normal graded compression of bilateral common femoral vein and popliteal vein.
Skin: Warm and dry. No rashes or mottling.
Psychiatric: Fully oriented. Anxious but interacting appropriately for situation.
I would be glad to hear your feedback. Contact me if your are interest in joining me in my lobbying efforts of ACEP, ABIM, and most importantly CMS.
Wie jedes Jahr findet Mitte Juni die MedArt Basel statt. Eine der besten Fortbildungsveranstaltunge, die ich kenneEtwas ganz besonderes ist die MedArt App, welche kostenfrei aus dem itunes Store geladen werden kann. Es sind alle Vorträge aufgespielt und es sollen demnächst auch die Videoaufnahmen der Vorträge eingespielt werden. Wirklich eine exzellente Fortbildungsmöglichkeit!
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Thematisch passende Beiträge
Das Manuskript, das ich Ihnen hier vorstellen möchte, ist mir primär bei der Literatursuche “durch die Lappen” gegangen. Danke an Dr. M. Baumgärtel, der sich seit Jahren bei uns mit der Thematik des Volumenmanagements beschäftigt!
Wie mache ich Volumenmanagement bei Patienten, die nach einer Reanimation eine therapeutische milde Hypothermie erhalten und einen kardiogenen Schock aufweisen? Sie werden natürlich sagen, das ist eine klinische Entscheidung oder ich steuere das Volumen anhand des zentralen Venendrucks. Insbesondere die letztgenannte Argumentation ist schwierig zu halten, zumal in zahlreichen Studien keine Korrelation zwischen intravaskulärem Volumen und ZVD gezeigt werden könnte. In Resuscitation ist eine sehr interessante und auch elegante Studie erschienen:
Eine Arbeitsgruppe um Adler et al. beschäftigte sich mit der Frage, inwieweit der Einsatz eines mit dem PICCO-System gesteuerten Protokolls zu einem besseren Volumenmanagement gegenüber der “Standardtherapie” bei oben genannten Patienten führt. Ein Volumenmanagement, das sich an volumetrische Parametern (ELWI, GEDI) und Parametern, die von der Analyse des invasiv gemessenen Blutdrucks abgeleitet wird, ausgerichtet ist, führt zu einer signifikant niedrigeren Rate an akutem Nierenversagen. Auffällig ist hierbei, dass über 1000mL mehr Volumen innerhalb der ersten 6 Stunden bei der Verumgruppe appliziert wurde.
Hier ist das Protokoll kurz dargestellt:
Ein Leserbrief zu diesem Artikel thematisiert noch die Problematik der Verwendung von kolloidalen Lösungen. Diese sind in der Studie zugelassen worden. Exakte Daten über die Häufigkeit der Anwendung sind leider im Manuskript nicht genannt.
Zusammenfassend ist diese Studie hochinteressant, zeigt sich doch nach der Meilenstein-Studie von Rivers et al. erneut, dass ein strukturiertes Vorgehen mit einem STandard und klug gewählten Messparametern zu einer Verbesserung einer Hochrisikogruppe von Patienten führt.
Copyright © 2013 by DGINA e.V.
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The use of this feed on other websites breaches copyright. If this content is not in your news reader, it makes the page you are viewing an infringement of the copyright. Digital Fingerprint: 678345985D53467G45367I56478N35782A
Thematisch passende Beiträge
I am finishing up residency after 5 years, and finally took the time to visit the Hennepin Medical History Museum. It is truly a fascinating place where you can see the evolution of medicine literally before your own eyes. I was particularly intrigued by the iron lung which was the mainstay of polio treatment, and the role Australian-borne nurse Sister Kenny played, when she eventually settled in Minneapolis.
Deaths from Carbon Monoxide: WCNC in Charlotte, N.C. reports that on June 8, 11-year-old Jeffrey Williams died of carbon monoxide poisoning in the same Boone N.C. motel room where an elderly couple had died nearly 2 months before. On April 16, Shirley Mae Jenkins, 72, and her husband Daryl, 73, were found dead in the room. Laboratory tests available on June 1 revealed that both victims had carboxyhemoglobin levels > 60%. Apparently these results were not passed on to police and fire officials. The source of the carbon monoxide was traced to a faulty indoor pool water heater.
Ethylene glycol poisoning: On her blog at wired.com, Deborah Blum writes about the medical oncologist at M.D. Anderson Hospital in Houston who is accused of poisoning her colleague/lover using coffee spiked with ethylene glycol. In the post, Blum also reviews other recent episodes of ethylene glycol poisoning.
Speaking of toxic alcohols: ABC News in Australia reports that a 21-year-old man in Brisbane died after drinking home-made grappa contaminated with methanol.
Must-read of the week: ion.com has a truly fabulous collection featuring images of bottles and ads from the days when cocaine and heroin were available over-the-counter in products claiming to cure toothache, cough, hay fever, and other ailments.
Confessions of a novice PHARM co-author: I am guilty of blogging negligence for not posting this sooner. I had an asynchronous conversation with Scott Weingart on Airway Checklist real world implementation …
This was about 2 weeks ago and he recorded an audio response to me at that time which was gold and thanks to his permission, it has to be shared!
We were discussing how feedback on checklist implementations included lists being too long and how in crash situations some choose to not use a checklist however this is when it might be even more critical to get things right but it cannot take 5 minutes to check things. Scott talks about the <60 second version of the EMCrit checklist.
Since then I have read through Atul Gawande’s “The Checklist Manifesto” twice (a must read).
A few things stick out in my mind:
Checklists protect against “faulty memory and distraction”, however “people can lull themselves into skipping steps [which] … don’t always matter … until one day it [does].”
“Good checklists are remarkably brief, usually just a few lines on a page in big easy to ready type”, “not vague, not too long” and “treat the people using the tools as smart professionals”, “do not spell out every single step … otherwise it turns people’s brains off rather than turn them on”: “checklists cannot fly a plane.”
“Good checklists are precise, efficient … easy to use even in most difficult situations”. They “provide reminders of only the most critical and important steps, ones that even skilled professionals [under duress] could miss”, they “help experts remember how to manage a complex process, can make priorities clearer, prompt people to function better as a team.”
The brief reminder headings of the Airway Checklist is printed on the kit dump:
- —Pause team briefing—-
- Risks (HOp)
- Fail plan
The actual Airway Checklist might be on a laminated card with a small picture of the equipment kit dump on the reverse of the card.
- PreOx: O2 by 2 sources 3 ways (reOx deN2ate apOx)
- Resources: other MDs including anesthesia, RNs, RTs
- Meds: induce, paralyze, facilitated, pressors, post intub sed/analg
- Position: ear2notch face|| HoB30 RevTrend BedHeight ELM HeadElev JawThrust
- —Pause team briefing—- situation, task, intent, concerns, calibrate
- Approach: best first attempt
- Risks (HOp): avoid hypotension, hypoxia, hypoventilation, PPE
- Fail plan: no more than 3 attempts if SpO2>92%, change things to address difficulty, reoxygenation plan, surgical airway triggers
- Roles: watch SpO2, waveform, BP, intubation assistant, timer/recorder, lifeguard
The long version below is for training or for the rare/occasional intubator as a quick reminder
20 seconds TASKS CHECKLIST
- Reoxygenation to >>95%
- Denitrogenation with FiO2 100% for 3 min TV or 8 VC breaths (NRB >>15lpm)
- Apneic oxygenation with nasal cannula at 15LPM with nasopharyngeal patency
- other ED docs
- PHARM MD by phone
- receiving MD by phone
- Pressor/Fluid bolus
- Premedications (blunt catecholamine surge etc like fentanyl etc.)
- Post intubation sedation/analgesia
- Ear to sternal notch (i.e. ramped in bariatric)
- Face plane parallel to ceiling
- Head of bed 30 degrees
- Reverse trendelenburg in bariatric, 3rd trimester pregnancy, spine immobilized
- Height of bed compared to intubator
(b) Intubation assistant
- External laryngeal manipulation of thyroid held after bimanual laryngoscopy
- Head elevation
- Jaw thrust
- Collar plan
- Bougie assist, post intubation assist/confirmation etc
40 seconds COMMUNICATIONS CHECKLIST – pause for team briefing that includes the situation, task, intent, concerns/questions
- See Search and Rescue Briefings which I heard via a comment by Clint Kalan on the EMCrit Intubation Checklist.
1) What is the planned APPROACH
- Assess airway, look in mouth, dentures, neck mobility, ability to be positioned
- Definitive airway (oral or nasal endotracheal intubation)
- Best optimized first attempt (methodical suction epiglottoscopy, laryngeal exposure and tube delivery)
- Best modality chosen as determined by speed, familiarity, anticipated difficulty in anatomy, pathology, cooperativeness (RSI or facilitated or crash) and physiology
2) Are there any anticipated RISKS (HOpP) and what would be the plan
- hypoventilation in low pH severe metabolic acidosis
3) What is the FAILURE PLAN in event of airway miss?
- E.g. no more than three attempts at definitive airway if SpO2 >92%
- Each attempt MUST change things to address difficulty of the previous airway misses, consider change intubators
- Reoxygenation goal to >>95% with #1 optimized BMV (2 person, OAW,NPAs, positioned, >>15lpm, PEEP) and #2 supraglottic airway if GCS low enough
- Cricothyroidotomy if oral route fail or improbable for success and failure of reoxygenation
4) Are all present aware of each others names and ROLES?
- Assign a pulse ox watcher (SpO2 alarm at 92% and waveform quality watch for early perfusion loss)
- Assign a BP watcher (q1-2min BP, alarm if MAP<70)
- Assign a recorder and timer, lifeguard
- Intubation assistant
Filed under: Aeromedical retrieval, airway, Emergency anaesthesia, Emergency medicine and critical care, FOAMEd, Online critical airway training Tagged: airway, checklist, emcrit, FOAMed, intubation, Kit Dump, PHARM
From the UK, Dr Olusegun Olusanya and Dr James Day discuss recent literature based around the October 2012 edition of the Journal of the Intensive Care Society (JICS).
The articles mentioned are found at the following link: JICS October 2012
Many thanks to Segun (@iceman_ex) and James for involving ICN with sharing this JICS Cast.
An 87 year old presented with increasing throat pain 7 hours after choking on a fish bone.
The X-Ray was reported as normal by the junior doctor on over night. The patient was kept in over-night for symptomatic relief.
Next day the X-Ray was reported by the radiologist and the retropharyngeal gas was noted. No fish bone was seen. (He also has pretty spectacular osteophytes which can be distracting)
The presumed puncture into the retropharyngeal space can lead to life threatening mediastinitis.
The patient was transferred to a hospital with ENT cover for nil by mouth, pharyngoscopy, oesophogoscopy (to look for foerign bodies), IV antibiotics and observation.
Here’s my two cents on the trial
Goodacre, Steve, Judith Cohen, Mike Bradburn, Alasdair Gray, Jonathan Benger, and Timothy Coats. “Intravenous or Nebulised Magnesium Sulphate Versus Standard Therapy for Severe Acute Asthma (3Mg Trial): a Double-Blind, Randomised Controlled Trial.” The Lancet Respiratory Medicine 1, no. 4 (June 2013): 293–300. doi:10.1016/S2213-2600(13)70070-5.
- UK publicly funded
- 34 EDs involved in the UK
- acute severe asthma (remember it’s not that hard to get into that category)
- specifically excluded those with life threatening features
- centrally randomised and reasonable description of blinding
- each pack had nebs and an infusion
- IV Mag (2g) v 3 Mg Nebs v placebo
- all dummys so it looked like everyone gets the same
- treated as per SIGN and BTS guidelines, though I didn’t see details of how many salbutamol nebs they got etc…
- two primary outcomes
- hospital admission either at the time or within 7 days or
- a change in breathlessness on a VAS
- Big trial – 1000 folk, average age 35 or so. This is important as a trial this size is unlikely to be equaled.
- about 75% admitted, no one died in the ED. 2 died overall (not sure why)
- powered to detect a 10% difference in admission rates and there was only about an 6% difference favouring IV Mag. This didn’t reach stat significance of course.
- Neb Mag didn’t seem to do much of anything
- 7 of 1000 needed intubation emphasising how “severe” acute severe asthma is
- Standard treatment with beta agonists and steroids was awesome as you can see in the placebo group.
- to be honest this is hardly surprising. I’ve rarely, if ever, seen magnesium work like a magic drug. I’ve always given it cause it’s benign (which this trial reinforces) and there was some support for its use. That was enough for me. It’s hardly surprising that the trial was negative but I suspect the small improvement that is there is real but is just that – small.
- having never used nebulised Mag, I’m now not about to start.
A 79 year old previously well female presents with loss of consciousness, having been found unresponsive by her daughter who saw her well one hour previously.
Examination reveals a GCS of E1V2M3 = 6 and reactive pupils with no lateralising signs. She is hypertensive. A VBG reveals a normal glucose and sodium and a pCO2 of 60 mmHg (7.9 kPa).
The emergency physician’s plan is to intubate and get a CT scan of her brain. This is explained to the daughter.
A no-brainer? You’d think so.
A consistent issue that recurs during discussions with UK emergency medicine colleagues is that of having to rely on anaesthesia and/or ICU colleagues for intubation of their patients in the ED. The pain comes not from disagreeing about who does the procedure or what drugs to use, but rather on the decision to intubate.
The refusal to intubate can stall or halt a resuscitation plan, delay care, result in risky transfers to the imaging suite, and even deny potential outcome-improving therapy (for example post-ROSC cooling). It can undermine team leadership and disrupt the team dynamic.
There are often different ways to ‘skin a cat’ and it is frequently helpful to invite the opinion of other critical care specialists. However, it is clear from multiple discussions with frustrated EM colleagues that the decision not to intubate is often influenced by non-clinical factors, most often ICU bed availability. Other times, it appears to be that the ‘gatekeeper’ to airway care (and to ICU beds) does not share the same appreciation of the clinical issues at stake. Examples here include the self-fulfilling pessimism post-ROSC based on inappropriate assignment of predictive value to neurological signs, and the assumption of non-treatable pathology in elderly patients presenting with coma.
The obvious solution to this is that the responsibility for managing the ‘A’ of ABC should not be delegated to non-emergency medicine personnel. Sadly, this is not achievable 24/7 in all UK departments right now for a number of awkward reasons.
So what’s a team leader to do when faced with a colleague’s refusal to intubate? The best approach would be to gently and politely persuade them to change their mind by stating some clinical facts that enable a shared mental model and agreed management plan, and to ensure the most senior available physicians are participating in the discussion.
Sometimes that fails. What next? Here’s a suggestion. This is slightly tongue-in-cheek but take away from it what you will.
It is imperative that the individual declining intubation appreciates the gravity of his or her decision. They must not be under the impression that they’ve done you (and the patient) a favour by giving their opinion after an ‘airway consult’. They have declined a resuscitative intervention requested by the emergency medicine team leader and should appreciate the consequences of this decision and the need to document it as such.
Perhaps say something along the lines of:
And here’s the form. It is provocative, cheeky, and in no way should really be used in its current form:
“Decolonizing” New ICU Patients Reduces Bloodstream Infections: NEJM In humankind’s battle against bacteria, the ICU is the front line. And with MRSA infection rates doubling in the past 5 years, and the more recent and scary spread of lethal pan-resistant Enterobacteriae, lately the bugs have won a few rounds. The problem isn’t just catching a deadly [... read more]
The post Decontaminate all incoming ICU patients to reduce infections, says RCT (NEJM) appeared first on PulmCCM.
Date: June 16, 2013
Title: Ultra Spinal Tap
Case Scenario: A 66YO man presents with a 48hr history of fever, lethargy and headache. No significant past medical history. On physical examination he has a temperature of 38.8C, GCS 15, stiff neck on flexion and no rash. Urinalysis and CXR are normal. Laboratory testing reports an elevated WBC with a left shift. You decide he needs a LP to check for meningitis.
Question: Can ultrasound be used to improve successful LP attempts?
Background: The following procedures may decrease the risk of post-LP headache. Listen to SGEM#34: This is Spinal Tap for all the details.
- Small-gauge atraumatic needles
- Reinsertion of the stylet prior to the removal of the spinal needle
- Mobilization of patients after completing the LP
Reference: Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis. Shaikh F et al. BMJ 2013;346:f1720 doi: 10.1136/bmj.f1720
- Population: 14 studies (n=1334)
- Intervention: U/S assisted LPs (5 studies) and epidurals (9 studies)
- Control: Unassisted
- Outcome: Reduction of failed attempts
- Failed procedures 12 studies (n=1234) 79% RRR (95% CI: 57-90) NN 16 (95% CI: 12-25)
- Traumatic Procedures 5 studies (n=?) 73% RRR (95% CI: 33-89) NN 17 (95% CI: 11-44)
Authors Conclusion: “Ultrasound imaging can reduce the risk of failed or traumatic lumbar punctures and epidural catheterizations, as well as the number of needle insertions and redirections. Ultrasound may be a useful adjunct for these procedures.”
BEEM Comments: There was no blinding for the patients. This might effect subjective outcomes such as post-LP headaches. It would be easy to do a sham ultrasound. However, the lack of blinding should not effect objectives outcomes such as failed or traumatic attempts.
Only 5 of 14 studies were done for LPs with the rest for epidurals. Half of the patients in the studies were obstetrical patients. All the physicians involved were ultrasound ‘keeners”. These things weaken the external validity of the results to the emergency department setting.
BEEM Bottom Line: There needs to be an adequately powered blinded RCT of ED doctors on consecutive ED patients in need of an LP showing a difference in patient oriented outcomes. Until then we suggest maximizing the methods proven to improve LP technique before we start adding unproven modalities (Straus et al).
Case Resolution: You successfully perform the LP without an ultrasound and send off the CSF to the lab for analysis to rule out meningitis.
KEENER KONTEST: The hoser who won last week was Constant Coolsma from the Netherlands. He knew that Tim Horton was a Canadian ice hockey defence man who later founded a coffee house/doughnut shop named after him.
Be sure to listen to this weeks podcast for another chance to a cool skeptical prize. Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.
Follow the SGEM on twitter @TheSGEM and like TheSGEM on Facebook.
Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Have a great Father’s Day and talk with you next week.
Acute Psychosis Associated with Recreational Use of Benzofuran 6-(2-Aminopropyl)Benzofuran (6-APB) and Cannabis. Chan WL et al. J Med Toxicol 2013 Jun 4 [Epub ahead of print]
6-APB is a structural analogue of MDA that has characteristics of both phenethylamines and amphetamines. It is not yet scheduled or regulated in the United States. On June 10 2013, 6-APB was listed as a “Temporary Class Drug” in the United Kingdom, a move that outlawed its sale or import.
This case report describes a 21-year-old man who was brought to the emergency department after ingesting 6-APB and smoking marijuana. He was agitated and paranoid, stating that the emergency staff was “trying to read his mind”. He had multiple forearm lacerations from self-inflicted razor blade wounds. Interestingly, the remainder of his physical examination was unremarkable. There were no other manifestations of the sympathomimetic toxidrome. The patient continued to exhibit paranoia and agitation, treated with diazepam, throughout his 5-day hospital course. After transfer to a psychiatric hospital, his psychotic manifestations resolved and he was discharged 8 days after presenting to the emergency department.
Toxicological testing of the patient’s urine revealed 6-APB (2,000 ng/ml) along with cannabinoids and a metabolite of the synthetic sannabinoid JWH-122. There were also small amounts of amphetamine, chloroquine, ketamine metabolite, and ephedrine.
In their discussion, the authors make the following points:
- 6-APB is a triple monoamine reuptake inhibitor.
- 6-APB is a potent agonist at the 5-HT2C receptor, a property that has been associated with developement of anxiety.
- Some users on discussion forums such as Erowid report feelings of anxiety for up to 5 days after exposure to 6-APB.
- 6-APB can produce severe and prolonged neuropsychiatric manifestations.
- Patients who have used 6-APB and present with neuropsychiatric symptoms should be considered for prolonged observation.