EMU Monthly – April 2007

1)   Nicolau Syndrome.  Anyone ever hear of this?  It is a rare syndrome where you give an injection and you get immediate pain followed by erythema, then finally necrosis.  This is scary and fortunately rare but the reason I bring it to your attention is two fold.  Firstly, it is associated with injectable NSAIDS, which are quite popular in Israel. (See British Journal of Dermatology, Feb 2004 for another case report of this after Diclofenac injection) We have in the past discussed that these medications given IM do not work much faster than po (IM-10- 20 minutes, PO 1 hr, Micromedex) and in addition, studies have shown pain for up to three weeks at the site of injection.  When you consider that these medications given IM can cause both Nicolau syndrome and a focalized pain syndrome, than maybe you will think twice about using them.  Also, we are trying to get away from IM injections, and we have reported in the past that if you give injections in the buttocks you rarely get to the muscle.  It is thought that subcutaneous injections are a risk for this syndrome. (J Ortho Surg 1 Apr 06).  Just as a reminder, dextrose under the skin can cause the same thing (Ann Emrg Med Sept 06)

2)   We just heard an excellent lecture about pain at the convention, but if you ask folks with abdominal pain if they had pain 98% said yes.  But if you waited until they asked for pain relief, only 1/3 would ask for it. ( J Emrg Nurs Aug 06)  The point is that you should consider asking the patient instead of waiting for them to ask for it.   Many emergency departments document pain level upon presentation, but fail to document pain relief (see EMU , Mar 07).  While we are discussing pain, if you still use ethyl vinyl chloride for inserting IV s, it does not work ( Clin Peds Sept 06)

3)   I am not asking you to be a whiz at reading articles- few of us are, and most of us give up when it comes to area under the curves and odds ratios.  But what I am asking you to do is to be very careful about industry supported studies.  They often suffer from the following tricks: They often use dosages that are not used in practice, they often do not do head to head comparisons with their competition, when they do do head to head comparisons they use sub optimal dosages of the competitors drug, and they often dredge the data that is negative in order to find some surrogate marker or subgroup where there was superiority.( Neurol 8 Aug 06)

4)    As well, be careful about self-serving articles.  J trauma, Aug 06 seems to believe that even minor injuries treated at trauma centers do better and heal better then at non trauma centers.  Many confounders here and I won’t go in to them, but there is a point for Israel here.  Emergency physicians do not get too involved in trauma cases, and it is a shame.  Our treatment differs little from theirs, and outcomes should be similar but of course, no one has ever studied it.

5)   Hard to say about past penicillin allergies.  In this study, they tested patients with a claim of Penn allergy. First they did a skin test, then an oral challenge, and 72/75 patients showed no reaction.  They concluded that history of allergy, type of reaction, and time since last reaction shows little relation to true penicillin allergy.  (Ann Allergy Asthma Immuno Aug 06).  Of course, too few patients here, but could help in a pinch.

6)   In 2004 the CLOT BUST trial showed that using ultrasound augmentation with TPA dissolved clots more effectively than TPA alone in stroke. However, will it work in worse strokes where TPA doesn’t even do well?  The surrogate marker for a bad stroke is hyperglycemia, and seems, that ultrasound will not help much here as well- they did just as poorly  (Neuro 22 Aug 06)

7)   We know that antibiotics make E Col 0157: H7 worse.  Or do they? Seems most antibiotics truly do, but quinolones and fosfomycin may be beneficial.  Need more studies- keep your eyes open (Alimen Pharm Ther 1 Sep 06)

8)    Two pointers from the critical care literature.  Seems erythropoietin can lower the amount of blood that is needed for transfusions in the first 42 days of treatment.  (CCM Sept 06)  Also, we reported on many articles on the past on lactic acidosis in prolonged treatment of kids with propofol.  They have started to see it in adult head injured patients (ibid) Question is- is this due to the propofol or the massive cathecholamine burst from a head injury?

9)   Been a long time since we discussed this, but worth repeating.  If you need to anticoagulate someone using oral agents, it will take five days, and will not go any faster with 10mg than with 5mg of coumadin (AJC 15 Aug 06).  We are speaking about an INR of at least 2.  However,  Ann Int Med , 6 May 03 reported the opposite. That is, that 10mg does get to therapeutic levels faster (difference of 1.4 days). Both studies were tiny, so nothing to conclude yet.

10)                  This is scary.  In this study from Laos, substandard drugs (“counterfeit”) are used.  That means for example, that the Augmentin they are given by relief agencies may have very little Augmentin in it.  (Lancet Inf Dis Aug 06).  However, a look at an article from the J AM Pharm Assoc in 2001 shows that some of these drugs make their way back to other markets such as the USA. Careful on Internet purchases!!

11)                  I ain’t perfect.  I missed this article in Peds (118(34) 2006) that the height of temperature and WBC elevation did not help differentiate between viral etiologies and serious bacterial ones.  Problem was that they were only able to document 40 infections out of 103 kids.  Fortunately I found the article quoted in the BMJ 26 Aug 06 and in the same issue, there is an unrelated article where  they repeat that giving Lasix (Fusid) will give your ARF patient ototoxcity, and will not save him from dialysis.  In essence it does not help.

12)                  Kids get diarrhea a lot.  Who needs a culture?  Who needs antibiotics?  Who should definitely not have antibiotics?  I can not answer any of these questions, but at least in one children’s hospital, 50% of the kids coming with diarrhea had positive cultures. What was interesting was that they saw a lot of more rotavirus, C. Difficle, and E Coli 0157:H7 than Shigella and Salmonella.  (CID 1 Oct 06).  Now I know you can not say for sure that this data is reproducible for all emergency departments, but it gives one pause about using antibiotics for diarrhea-with these pathogens it could be the wrong decision.

13)                  Date rape is still a danger and while Rohyphnol is no longer too available in the States, it is around in Israel.  Other Benzos and Ketamine are also popular. There are now two kits to check a beverage to see if they were spiked,and this study checked how they did.  They checked Ketamine, Valium, GHB , Temazepam, and Rohyphnol in Pepsi Max, water, Stella Artois beer, and Bacardi Breezer.  I won’t bore you with the numbers, but the one with the better specificity, called Drink Guard has very poor sensitivity, and poor kappas, and it has trouble with detection in water.  Drink Detective has good kappas, but sensitivity and specificity that miss a least 1 in four.  What makes this worse is that most of the testing someone will do is in the dark and perhaps intoxicated, so expect the results to be even worse  (Addiction Oct 06)

14)                  As bad as soft palate lacerations look, leave them alone, unless they are through and through (that is go out to the skin) or if they are flaps.  Most heal well, and carotid or neuro damage is rare.  (Oto Head Neck Surg Sept 06)

15)                  Do not treat those spontaneous pneumothoraces with a chest tube.  This state of the art article says if it is a first time event then observation and aspiration if necessary are indicated.  The second time- talc sclerosis under video assisted thorascopic surgery. (Eur Resp J.  Sept 06) We see a lot of these in Israel and I think our patients would be pleased not to have chest tubes.

16)                  Mortality statistics show that having T wave inversions in an ACS is not so bad.  ST depression is (19% death in four years). You knew that.  LBBB is also bad (36%) You should have known that as well.  How about RBBB?  Better than LBBB, but still bad  (23%). Did you know that? You should have. (QJM Sept 06)

17)                  I include this article because we are expected to know how deliver a baby.  One of the complications is shoulder dystocia, where the shoulder of the baby gets “stuck” against the ramus of the mother, and if it is not released, the baby can suffer demise.  Furthermore, brachial plexus injuries can occur.  Guidelines include fundal pressure, the McRoberts technique, where the woman lifts up her knees to her chest, and turning the baby or lifting up the free arm of the baby and bringing it out, freeing up more room  (see the internet for how to perform these).  Symphysectomy is the old treatment, but it is treacherous.  The problem is that despite these maneuvers, the rate of brachial plexus injuries has not fallen.  (AJOG Sept 06)

18)                  Ultrasound is a very important tool in emergency medicine and you too can learn how to check a hip joint to see if we are speaking about transient synovitis or a septic joint.  (PEC Aug 06).  This article was another quality effort by Itai Shavit from Rambam.  Problem is that large joint effusions can be either disease, and no effusion brings in the specter of osteomyelitis or an effusion of transient synovitis that the operator did not see.  You still need to coordinate this test with a clinical picture.

19)                   Can you see any reason to give a PPI together with a H2 blocker?  PPIs work to suppress acid production when the pump is working, which is when you eat, but work poorly when the pump is not working.  So give your PPI before 30 minutes before breakfast (not with your H2 – it will decrease the absorption of the PPI) or give half a dose morning and evening.  H2 blockers suppress acid production all the time, so give it for nighttime symptoms, but remember, tolerance does develop.  ( Prescribers Newsletter Mar 07)

EMU LOOKS AT: Thrombocytosis

 

This essay will be short due to the amount of abstracts this month. We often are befuddled by a platelet count which is high on an incidental blood test. We present some pointers based on an article from Dr. Schafer in the Cleveland Clinic Journal of Medicine  73(8) Aug 06

 

1)    By far the most common cause is reactive, meaning that diseases such as blood loss, infection or inflammation can cause the platelet count to go up as a result of acute phase reactants.  What is interesting is that exercise can cause a thrombocytosis as well.  Now some reactive cases can be sustained, like in asplenia, anemia, and chronic infectious or inflammatory disease.

2)    Second cause is a defect in stem cells, what we call a myeloprolifertative disorder.  Here is where trouble can develop.  These people have a risk of both bleeding and clotting, with more danger of bleeding when the count is higher. Some problems include DVT, PE, BuddChiari, arterial thrombosis, other abdominal thromboses, placental and digital ischemia.  Also GI bleeding, hemoptysis, GU bleeding and epistaxis.

3)    How do you tell which is which?  Reactive has a reason that is clinically apparent.  All these complications mentioned above are unusual in reactive.  There is no splenomegaly.  Blood smear is normal

4)    Treatment- in reactive- treat the underlying disease.  In Myloproliferative,  you will find few excellent treatments

5)    Plasmapharesis works really well and is indicated for those having acute ischemia.  But it is a transient effect, and there is a problem of rebound.

6)    Alkylating agents cause leukemia, do not use them

7)    Hydoxyurea is the standard, but it can cause ischemic leg ulceration

8)    Anagrlide works to, but has numerous adverse effects and can cause myelofibrosis.

9)    Interferon works, but the side effect profile makes it almost impossible to take. However, it is not teratogenic.

10)  And now to the one, which you would think, would make the most sense- aspirin.  Firstly, be careful if you are going to use the other agents, you may increase the risk of bleeding.  Secondly, there is still a controversy if this works and how much it works- the p values are definitely not impressive.  I personally would not use it for reactive thrombocytosis.  They do not recommend it for low risk myloproliferative patients either.

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