This is a talk I gave recently for our registrar teaching morning. Not the sexiest presentation (forgive the bullets) but hopefully will give you the basic, textbook level info a al foamcast style
Direct Download [60mb]
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Back in March 2014 I had the pleasure of speaking at SMACC Gold in Australia. The whole thing was great fun and I’m sure you’re all aware it’s going to Chicago in May 2015 so be sure to be there. Indeed Registration opens tonight (in the UK at least) so check it out!!!
Every talk from the conference is coming out via the SMACC podcast so make sure you subscribe.
As my talk is so predominantly visual, it really needs the slides for it to make sense so I’ve included the slideset here. I’ll hopefully record it as a podcast and stick it on this page and the podcast feed too.
For people interested in learning some more detailed neuroanatomy I’d strongly recommend headneckbrainspine.com
They’ve done what I’ve always wanted to do and have created scrolling, labelled radiology images that wonderfully demonstrate the anatomy in 3 dimensions. Really invaluable stuff.
Here’s a list of previous neuro related podcasts I’ve done:
And if you’re interested in working where I work as an ultrasound or education fellow then get in touch.
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If you’ve found your way to this blog at all then I’m sure you’ve heard of SMACC.
The programme for the next conference in Chicago 23-26th June 2015 has just been released. Be sure and check out the programme to get an idea of the quality experience you can expect. It’s great to see some names whose papers I’ve been reading for years but don’t exist on social media such as Paul Marik and Mervyn Singer. Also great to see one of the longest standing names in FOAMed, Mark Crislip making a couple of appearances.
A nice list of reflections from last year (ripped from Tim’s site)
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The 2014 meeting of IAEM was a great experience. For a country of 4.5 million with just over 70 emergency physicians we put on a pretty good show I think. I like to use “we” even though I had no part to play in organising the damn thing. Credit to David Menzies for leading the work.
There was almost a mini SMACC reunion with Rick Body, Mark Wilson, Weingart and John Hinds all in attendance and speaking. Through the premiere of Code Black I also managed to have dinner with Billy Mallon which was everything you would expect it to be.
I also got the chance to do my first stroke thrombolysis debate. I got into all this about 3 or 4 years ago when I first started listening to the abstracts and heard Jerry Hoffman on it. It was the first real topic to get me really excited about critical appraisal and reading the medical literature. If it turns out us skeptics are all wrong on tPA then at least I’ve gained a few skills along the way.
Below is my half of the debate. The pro side was delivered by a local stroke physician and I have to confess that I lost the debate. I must be doing something wrong if the emergency doc can lose a debate on stroke thrombolysis to a room of other emergency docs…
As with most short debates like this, it isn’t a deep and considered view of all the evidence, it’s as much about making the argument as anything else. Any feedback is of course welcomed. I’ve tried to include a reasonably comprehensive list of references at the bottom.
It’s probably worth noting that I work in a hospital that has a very enthusiastic stroke thrombolysis team (which as part of my job I have a small role in activating) and to give credit where it’s due they provide a great service with the quickest and best assessment in the ED you can imagine. It’s very rare in Ireland to get a consultant to the patient’s bedside within minutes of arrival but our stroke team does this well. We would do well to provide close to such a service for our trauma patients but that’s another story altogether…
The BMJ Pro Con Debate
The Ioannidis Paper
A decade of reversal
Prasad V, Vandross A, Toomey C, Cheung M, Rho J, Quinn S, et al. A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices. Mayo Clinic Proceedings. Elsevier; 2013 Aug;88(8):790–8. [Full Text]
The Lenzer paper on the problems with guidelines
Roger Shinton’s letter to the Lancet
Simon Thompson’s paper on heterogeneity in meta-analysis [H/T Dave Newman for this one]
The systematic review mentioned
Wardlaw JM, Murray V, Berge E, del Zoppo G, Sandercock P, Lindley RL, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet. 2012 Jun 23;379(9834):2364–72. [Full Text]
Jeff Mann’s break down of the NINDS patients revealing the baseline imbalance
- Intravenous desmoteplase in patients with acute ischaemic stroke selected by MRI perfusion-diffusion weighted imaging or perfusion CT (DIAS-2): a prospective, randomised, double-blind, placebo-controlled study. Lancet Neurology 2009 Feb.;8(2):141–150. PMCID 2730486
- Effects of alteplase beyond 3 h after stroke in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET): a placebo-controlled randomised trial. Lancet Neurology 2008 Apr.;7(4):299–309.PMID 18296121
- Randomised controlled trial of streptokinase, aspirin, and combination of both in treatment of acute ischaemic stroke. Multicentre Acute Stroke Trial–Italy (MAST-I) Group. The Lancet 1995 Dec.;346(8989):1509 -1514. PMID: 7491044
- Thrombolytic therapy with streptokinase in acute ischemic stroke. The Multicenter Acute Stroke Trial–Europe Study Group (MAST-E). N Engl J Med 1996 Jul.;335(3):145–150. PMID: 8657211
- Streptokinase for acute ischemic stroke with relationship to time of administration: Australian Streptokinase (ASK) Trial Study Group. JAMA 1996 Sep.;276(12):961–966. PMID: 8805730
- Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS (B) Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. JAMA 1999 Dec.;282(21):2019–2026. PMID: 10591384
- The rtPA (alteplase) 0- to 6-hour acute stroke trial, part A (A0276g) : results of a double-blind, placebo-controlled, multicenter study. Thromblytic therapy in acute ischemic stroke study investigators.(ATLANTIS A) Stroke 2000 Apr.;31(4):811–816. PMID 10753980
- Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (NINDS). N Engl J Med 1995 Dec.;333(24):1581–1587. PMID: 7477192
- Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 1995 Oct.;274(13):1017–1025.1. PMID: 7563451
- Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. The Lancet 1998 Oct.;352(9136):1245–1251. PMID: 9788453
- Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke (ECASS III). N Engl J Med 2008 Sep.;359(13):1317–1329. PMID: 18815396
- The IST-3 collaborative group. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet. 2012 May 23.PMID: 22632908
A few #FOAMed resources
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[Featured Image: Creative Commons, danielleellis55 on Flickr.]
First off here’s a video I recorded for the CEM FOAMed network on “approach to the injecting drug user“. Be sure to subscribe on iTunes and check out the site. There’s a podcast feed and a blog feed, so be sure to get both.
[Direct Download ]]
Injecting Drug User (IDUs) are frequent attenders at EDs for lots of reasons. While there is no doubt that there are a lot of social factors involved in these attendances, we can all too easily forget that these patients get really sick and often get left in the bottom of the queue of patients waiting to be seen. I think “the approach to the IDU” would make a great chapter for Rosen’s but it’s not in there yet. Harwood Nuss is the only one I’ve seen with a good chapter on it.
Complications of injection drug use
Hardwood-Nuss 5th edition p1398
I find this population of patients perhaps the most fascinating to treat. Generally ostracised by society in the way homeless people usually are. Usually undertriaged at the front door (“just another junkie”) I frequently find them in the waiting room with fairly dramatic vital signs. Without doubt injection drug use is usually not compatible with a stable and productive lifestyle and low grade criminality abounds. Certain aspects of the doctor patient relationship can be challenging here but they aren’t always drug seeking the way we expect they are.
And if your waiting room is anything like mine by the time they’ve waited 12 hrs to be seen then they’ve usually gone into withdrawal and it’s easy to blame all their symptoms and abnormal vital signs on withdrawal (even though their symptoms and abnormal vital signs all occurred prior to their withdrawal…)
All this to say that we approach them with so many cognitive biases and good old fashioned prejudices that it’s no wonder we fail to diagnose lots of the really interesting illnesses they bring with them.
Soft tissue infections
- Probably higher incidence of MRSA
- Most tentanus and wound botulism these days is associated with IDU
- Necrotising fascitis is a much higher risk
- Pyomyositis is a nice complication
- Arteriovenous malformations
- Pseudo aneurysm
- Here’s a quote “any mass over a vascular territory may actually be a pseudo aneurysm and should be approached with caution”
- I know a number of people with great stories of enthusiastic junior surgeons incising and draining these with impressive and unexpected results
- Associated abscess
- All 4 of the above in the same leg as I saw once…
- Those lovely cutaneous groin sinuses that descend to dear knows where.
- Mycotic aneurysms, typically with infectious endocarditis
- ‘Pocket shooting': injecting into the supraclvaicular space in the hope of finding a vessel. Can result in pneumo, haemo, hydropneumo and the wonderfully titled pyopneumothorax
- Dissolving tablets and injecting them can result in what I’ve heard called trash lung or talc lung. [Check out BroomeDocs podcast with @dreapadoirtas on this]
- This can cause granulomas in the pulmonary and even retinal vasculature (in fact looking at the retinas for talc might be better CXR or pulmonary function tests)
- Restrictive and obstructive dysfunction can occur. I suspect this is commoner than we suspect. I see a lot of IDUs with lowish sats and it gets blamed on something like COPD from smoking.
- Chronic pulmonary hypertension can result
- Osteomyelitis and septic arthritis can be local or haematogenous
- Commonest is vertebral osteomyelitis usually lumbar which may have associated disc it is with or without the even more emergent spinal epidural abscess
- Pain is often chronic (as has been in the cases I have seen)
- Don’t expect fever (unless you’re the admitting doctor in which case it can’t possibly be vertebral osteo without a fever…)
- Joint involvement is axial. Think sacroiliac, sternoclavicular, hip and pubic symphysis. (Mainly fibro cartilaginous joints if you’re into the anatomy of it all)
- This is really important as no one will consider septic arthritis in someone with tender central chest pain.
Central nervous system
- Meningitis both fungal and bacterial
- Various sites for epidural abscesses
- Brain abscesses
- CNS aspergillosis
- Cerebral murcomycosis (even when HIV negative)
- Headache, fever, cranial and motor deficits
- Apparently basal ganglia lesions on CT are the key
- Decreased acuity, eye pain
- White vitreal exudate on fundoscopy
Blood Born Viruses
- Hep C (almost ubiquitous amongst IDU. >80% in our population)
- Hep B (up to 80% become seropositive over lifetime)
- HIV (about 10% in our local population)
- (lifetime incidence of 5%)
- Classic signs are rare
- Mainly right sided
- A brief, febrile episode following injection when the solution is filtered through cotton balls
- No way to distinguish this in the ED from the other more serious occult causes of fever in the IDU
It might be easier is to think about common clinical presentations and then apply appropriate IDU pathologies
IDU with stroke
- Brain abscess
- Subdural empyema
- Mycotic aneurysms
- Good old fashioned stroke
- AV fistula
- Pseudo aneurysm
- And I suppose it could be just a hernia
- PE (esp in groin injectors)
- ACS (chronic inflammatory states like HIV lead to accelerated atherosclerosis. Never mind the cocaine use)
- Sternal joint osteomyelitis
- Brain abscess
- SAH (remember all the cocaine use that goes with the heroin)
- Complications of associated HIV
- And yes it could just be a migraine too i suppose…
- Epidural abscess
- Vertebral osteomyelitis
- And yes it could just be good old fashioned back pain too I suppose
- Cotton fever
- HIV related
- TB (a lot of these guys are homeless and in Dublin anyhow there are reasonably high rates of TB amongst the homeless)
- Haematological malignancy
- And yes I suppose it could just be a flu or the dreaded ‘viral illness’
Shortness of breath
- Talcosis or trash lung
- Chronic pulmonary hypertension
- Pneumothorax from trying to inject a neck vein
- Aspiration from their recent OD, GCS 3 episode
- And yes I suppose it could be a good old fashioned chest infection too
Cellulitis in IDU
- necrotising fasciitis
- Subcutaneous abscess
- And yes I suppose it could be a simple staph or strep cellulitis
- Nice EM News Post on the febrile IDU
- Hardwood-Nuss 5th edition p1398
- A paper from our place characterising our population
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Smith-Bindman R, Aubin C, Bailitz J, Bengiamin RN, Camargo CA Jr., Corbo J, et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. N Engl J Med. 2014 Sep 18;371(12):1100–10.
They managed to come up with the STONE trial as acronym for this one. [Study of Tomography Of Nephrolithiasis Evaluation]
This is big news for USS, as it’s an RCT of the use of ED US use. Ultrasound, of course, makes sense to lots of us who see the probe as some sort of prehensile extension of the human body able to go forth and grasp the diagnosis. Still it’s nice to have some data to help us better understand how it helps our practice.
Here’s the details as I read them.
- multi centre randomised trial. All good so far
- Randomisation could have been better described I thought
- 3 Groups
- ED performed US by an EP credentialed in US – unclear if these were US super users or just regular punters with basic level US skills
- Radiology perfromed US
- The first major concern is in the lack of blinding. Though it’s hard to see how you could blind this.
- the ultimate decisions on imaging and disposal after the randomised imaging were down to the EP looking after the pt. So people afer US could go on to have CT if this was felt to be needed
- Unclear if the EP looking after the doc was also looking after the patient
- 3 Primary outcomes (which is a tad naughty. The prmary outcome should of course be, primary I would have thought)
- “high-risk diagnoses with complications that could be re- lated to missed or delayed diagnoses”. The obvious one here might be a missed AAA for example. the missed pathology was pre defined and categorised by a number of the authors all independent of each other.
- cumulative radiation exposure (does imaging beget imaging)
- total costs (which I presume is for a different paper, as it’s not reported here)
- follow up was by repeated phone calls and a structured interview
- diagnostic accuracy was a secondary outcome but the gold standard here was the patient reporting stone passage or surgical removal. This is important as most people consider CT as the gold standard but as this is one of the modalities being assessed it would be “incorporation bias” to include CT in the gold standard
- screened 3700, took 2700
- 3-5% lost to follow up which may be a problem – is the reason they didn’t answer the phone at follow up due to the fact they were dead? The reassuring thing is that lost to follow up was similar between groups
- 40% in this trial had a prior history of stone
- most were youngish and the most of the time the doc had a >50% pre-test probability of stone. Which is common – stones are usually obvious and most CTs we do for stone are positive, at least in my experience anyhow
- only 8% were admitted from the ED. This is amazing to me as we admit almost all our query stones. Either because we can’t get a CT at 3am for a stone (let’s face it the priority is pain control not diagnosis here) or because we need to get them a urologist (who only have a weekday service in our place). Our admissions are short but still, it’s nice to see that it is more than possible to manage these as out patients in a less dysfunctional system than ours in Ireland.
- Primary outcomes
- the missed high risk diagnoses were tiny (you have to look in the supplementary appendix for this
- ED US – 6. One bowel obstruction but mainly people returning with infections
- Rad US – 3 – one missed ovarian torsion and the others infective
- CT – 2 – infective complicatons
- All of these were less than 1% and of course when the numbers are this tiny, there’s no statistical difference between them. Worth noting that the infective complications are going to be there no matter what you do, no imaging is going to be definitive for pyelo most of the time.
- There was significantly less radiation in both US groups. Which is hardly surprising. The excess radiaiton in the CT group was all due to the index CT and not lots of follow up CTs thankfully.
- One of the most interesting things to me was the accuracy of all 3 tests. Remember that the gold standard here was stone passage of surgery. All 3 tests had identical sens/spec. Sensitivity of 85% and spec of 50%.
- 40% of those in the ED US group went on to have a CT anyhow at the docs discretion. 27% of the rad group went on to have CT. Again, this is hardly surprising. People simply don’t trust US and most urologists want a CT, I know ours do. Despite the fact that even their guidelines suggest US as the investigation of choice if available.
- This is a great effort and a substantial trial. As we probably already knew, EP performed US appears safe and accurate when we pose a focused question. There will always be misses but the numbers here are tiny and are more clinical judgement related than imaging related.
- The issue will be dealing with the specialists who may not be able, or willing to deal with just the US. I don’t say that to be critical, there may be lots of good reasons to pursue further imaging, but there doesn’t seem to be much need for the young, uncomplicated, clinically typical stone.
Finally, the entire study protocol is available as a PDF of supplementary material on the NEJM site and is a fascinating insight into the background of putting together an RCT and the sheer volume of work required for it.
Want more renal ultrasound:
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