Aktuelle FOAMed Infos rund um die klinische Notfallmedizin, Notfallmedizin und Intensivmedizin, auf den Spuren vom Skeptics Guide to emergency medicine

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Date: February 2nd, 2017

Reference: Bodkin et al. Effectiveness of glucagon in relieving esophageal foreign body impaction: a multicenter study. AJEM June of 2016

Guest Skeptic: : Meghan Groth (@EMpharmGirl) is an emergency medicine pharmacist. She has contributed to the Academic Life in Emergency Medicine (AliEM) and Emergency Medicine PharmD blogs, and is a member of the ALiEMU Capsules team.

Case: It’s the day after St. Patrick’s Day, and you have a 28-year-old man that presents to the emergency department with difficulty swallowing. He was enjoying a feast of corned beef and cabbage several hours prior to arrival when he said it felt like “something got stuck” in his throat. He does have a history of esophageal strictures, and this has happened to him before but he thought if he washed the food down with enough Guinness he wouldn’t have a problem. 

Background: Esophageal foreign body impaction (EFBI) is the most common foreign body impaction seen in emergency departments in the United States and accounts for about 75% of cases. Although estimates vary, the majority of foreign body impactions are meat boluses. In addition, the clinical presentation of these cases is complicated by the presence of baseline esophageal pathology, ranging anywhere from 30 to 90% (Weant and Weant, Eisen et al, Sodeman et al, Al-Haddad et al and Tibbling et al).

Current guidelines for the management of foreign body impaction include endoscopic treatment options like food extraction and advancement of the bolus into the stomach, pharmacologic interventions such as glucagon, and plain old observation or expectant management (Eisen et al).

Guidelines on the management of ingested foreign bodies state that glucagon may be used in the setting of food bolus impaction while endoscopic therapy is being coordinated due to the fact that it is relatively safe but its use shouldn’t delay definitive endoscopic removal (Eisen et al).

Glucagon exerts its effect by relaxing smooth muscle and lowering esophageal sphincter resting pressure (Christiansen et al). Glucagon monotherapy is frequently used to manage food bolus impaction despite having variable success rates (ranging from 9% to 38%) (Al-Haddad et al) and a financial cost.

Glucagon administration also has the potential to cause adverse effects such as hypersensitivity reactions, hypotension, nausea, vomiting, and dizziness (Eli Lilly and Company). 

Clinical Question: Is glucagon safe and effective for the management of esophageal foreign body impaction?

Reference: Bodkin et al. Effectiveness of glucagon in relieving esophageal foreign body impaction: a multicenter study. AJEM June of 2016

* Population: Any adult or pediatric patient with EFBI

* Intervention: Glucagon administration

* Comparison: Patients who did not receive glucagon for EFBI

* Outcome: Efficacy was defined as resolution of symptoms within 60 minutes after administration of glucagon. Patients who vomited within 60 minutes of receiving glucagon were considered not successful.

Authors’ Conclusions: Glucagon-related resolution occurred in 14.2% of patients and was not significantly different compared with those that did not receive glucagon (10.3%). Concomitant medication administration was associated with lower success. Overall, glucagon had a low success rate, was related to adverse effects, and does not offer advantages for treatment.

Quality Checklist for Observational Studies:

SGEM#164: Cuts like a Knife – But your might also need antibiotics for uncomplicated skin abscesses.

Podcast: lien!

Bienvenue à l’édition française du « Skeptics Guide to Emergency Medicine » , le guide des « sceptiques » en médecine d’urgence

Date: 21 décembre 2016

Titre: « Être à couteaux tirés avec l’abcès cutanée en y ajoutant un antibio!»

Pierre-Alexandre Leblanc, R3 – MU5

Cet épisode est la traduction du podcast #164 initialement fait en octobre 2016 par Ken Milnes et Chip Lange.  SGEM#164: Cuts Like a Knife – But you Might Also Need Antibiotics for Uncomplicated Skin Abscesses

 

Notre invité est Pierre-Alexandre LeBlanc, résident sénior du programme de médecine d’urgence spécialisée de l’Université Laval.

Je suis votre hôte Marcel Émond.

 

 

Cas: Un homme de 40 ans avec des antécédents de SARM se présente à votre urgence avec un érythème fluctuant au centre d’une masse, le tout compatible avec un abcès au niveau du membre supérieure gauche. Selon les ouïes dires de son ami médecin, l’incision et le drainage d’un abcès ne nécessiteraient pas un traitement supplémentaire avec un antibiotique. Il nie toute allergie et vous mentionne aucune complication dans le passé avec les médicaments sulfonylurés.

Contexte: Les abcès cutanés représentent une complainte fréquente au département d’urgence et nous avons déjà discuté de leur prise en charge dans le passé sur le blogue.

L’un des questionnements précédents était face à la décision de mettre ou ne pas mettre une mèche après l’incision et le drainage de l’abcès. Notre conclusion en 2012 était que le méchage de routine des abcès cutanés non-compliqués pouvait ne pas être nécessaire. (SGEM#13: Better Out than In).

 

Nous avons récemment vérifié si l’irrigation d’un abcès cutanée après l’incision et le drainage réduisait le besoin d’intervention supplémentaire. La conclusion de notre équipe de cette question fut que l’irrigation n’était probablement pas nécessaire. SGEM #156: Working at the Abscess Wash.

Un autre débat toujours d’actualité dans les dernières années était l’utilisation d’antibiotiques comme traitement de routine après l’incision et le drainage d’abcès. Nous avons également couvert le sujet dans un revue il y a presque dix ans maintenant par Hankin and Everett en 2007 sur le podcast SGEM#13. Il y avait alors peu d’évidences de qualité supportant cette pratique à ce moment.

Ils avaient dit : « Une étude clinique multicentrique, randomisée et contrôlée, à double aveugle, serait nécessaire pour supporter l’évidence.» La conclusion de notre équipe ne supportait donc pas le traitement de routine d’antibiotique dans les abcès cutanés non-compliqués, et ce même dans une ère de SARM.

Nous avons maintenant une étude clinique randomisée contrôlée à double aveugle utilisant un placébo pour répondre à cette question.

Question clinique:

Est-ce qu’un traitement de TMP/SMX offre un taux de guérison cliniquement supérieur à celui d’un placébo chez les patients se présentant à l’urgence pour un abcès cutané non compliqué et drainé?

L’article est :Talan et al. Trimethoprim–Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. NEJM March 2016

Quelle est la question PICO?

Population : Tous les patients âgées de 12 ans et plus se présentant au département d’urgence avec un abcès cutané apparu il y a moins d’une semaine et mesurant plus de 2 cm de diamètre (soit par les rebords indurés si la lésion est fluctuante ou soit par l’image échographique de la cavité si la lésion est non-fluctuante.

Exclusions : Pied diabétique; Suspicion ostéomyélite ou arthrite septique; Ulcère de pression ou ischémique; Morsure; Plaie avec corps étranger; infection d’un autre site/organe; utilisation de drogues intraveineuses avec fièvre dans le dernier mois; détention pénitencier; immunodéficience; fonction rénale réduite CrCl <50mL/min; condition cardiaque prédisposant à l’endocardite; allergie ou intolérance au TMP/SMX; prise de coumadin, phenytoin[...]

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Date: January 19th, 2017

Reference: Keh D et al. Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis: The HYPRESS Randomized clinical Trial. JAMA 2016.

Guest Skeptic: Salim Rezaie is a faculty physician at Greater San Antonio Emergency Physicians (GSEP) in San Antonio, Texas. He is the founder and creator of REBEL EM and REBEL Cast as well as the co-creator and co-founder of the Teaching Institute, a medical education startup company trying to change the world of medical education. 

Case: A 66-year-old female comes to the emergency department with fever and cough. She has a past medical history of diabetes mellitus, hypertension, and hyperlipidemia. Initial vital signs show a blood pressure of 154/87 mmHg, heart rate 132 beats per minute, respiratory rate 28 breaths per minute, oxygen saturation of 94% on room air, and an oral temperature of 101.9 degrees Fahrenheit (38.8C). You get two peripheral intravenous lines, place the patient on two litres of oxygen by nasal cannula, and hook them up to the cardiac monitor. You begin with a two litre normal saline bolus, Pan-culture your patient, and give empiric antibiotics for community acquired pneumonia (CAP), as this patient has no risk factors for nosocomial infections. A chest X-ray confirms your suspicion of CAP. Despite aggressive intravenous fluids and antibiotics the patient’s systolic blood pressure starts to trend down into the 140s, then the 120s. You remember reading about a recent study that talked about giving hydrocortisone early in the spectrum of sepsis, before the patient develops septic shock.

Background: We have covered sepsis a number of times on the SGEM.

* SGEM#44: Pause (Etomidate and Rapid Sequence Intubation in Sepsis)

* SGEM#69: Cry Me A River (Early Goal Directed Therapy) ProCESS Trial

* SGEM#90: Hunting High and Low (Best MAP for Sepsis Patients)

* SGEM#92: ARISE Up, ARISE Up (EGDT vs. Usual Care for Sepsis)

* SGEM#113: EGDT – ProMISe(s) ProMISe(s)

One thing we have not covered is the use of steroids in treating sepsis.

The Surviving Sepsis Campaign 2016 was just published updating the 2012 guidelines. The new guidelines continue to give a weak recommendation based on low quality evidence for the use of intravenous hydrocortisone at a dose of 200mg per day in patients with refractory septic shock (i.e. inadequate response to fluid resuscitation and vasopressor therapy).

There have been some changes in the definitions for sepsis and septic shock (Singer et al JAMA 2016. This is important to consider when looking at the study we are going to be reviewing today.

REBEL EM did a summary piece of the Singer et al paper entitled Sepsis 3.0. The overall summary points were:

* Sepsis = life-threatening organ dysfunction caused by a dysregulated host response to infection

* Septic Shock = Need for Vasopressors and Lactate >2 mmol/L

* Severe Sepsis is out

* SIRS is out and qSOFA/SOFA are in

Some of the other terms to know for this episode of the SGEM.

Aktuelle FOAMed Infos rund um die klinische Notfallmedizin, Notfallmedizin und Intensivmedizin, auf den Spuren vom Skeptics Guide to emergency medicine

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Date: November 29th, 2016

Guest Skeptic: Dr. Amy Cheng is an Emergency Physician, the Emergency Department Director of Quality Improvement and the Interim Medical Director of Quality and Patient Safety, at St. Michael’s Hospital in Toronto. She is also the National Co-Chair for Choosing Wisely Canada in Emergency Medicine.

This is another SGEM Xtra over the holiday season. There are a lot of top ten lists released at this time of year. The Canadian Association of Emergency Physicians (CAEP) published a top ten list in October of this year called Ten Things Physicians and Patients Should Question. I thought this would be a perfect time to review the list as an SGEM Xtra.

This initiative is part of the Choosing Wisely campaign that was launched in 2012 by the American Board of Internal Medicine (ABIM). We covered this campaign before on SGEM#15.

* “The goal of the campaign is to reduce waste in the health care system and avoid risks associated with unnecessary treatment. It calls upon leading medical specialty societies and other organizations to identify tests or procedures commonly used in their field whose necessity should be questioned and discussed with patients”. ABIM Choosing Wisely

There is a Canadian Version of the campaign called Choosing Wisely Canada. CAEP is part of this group and followed this process in selecting items to be on its list:

* CAEP established its Choosing Wisely Canada Top 10 (phase 1 and phase 2) recommendations by forming an Expert Working Group to generate an initial list of potentially overused tests, procedures, and treatments in emergency medicine that do not add value to care. CAEP subcommittee chairs were invited
 to provide further input to the initial list. The list of potential items was then sent to more than 100 selected emergency physicians to vote on the items based on: action-ability by emergency physicians, effectiveness, safety, economic burden, and frequency of use. The CAEP working group discussed the items with the highest votes, and the ten Choosing Wisely Canada recommendations were generated by consensus. The first five recommendations (items 1-5) were released in June 2015, and the second five recommendations (items 6-10) were released in October 2016.

The American College of Emergency Physicians (ACEP) also came out with a list of things physicians and patients should question in October 14, 2013 (1-5) and October 27, 2014 (6-10).

CAEP: Ten Things Physicians and Patients Should Question

Click on links for PDF copy of CAEP Choosing Wisely Canada in ENGLISH or FRENCH that include how the list was created all the references.

Listen to the SGEM podcast on iTunes to hear Dr. Amy Cheng explain each of these ten things physicians and patients should question.

Dr.

SGEMGlobal 150: Français – Du salin hypertonique pour le traumatisme crânien

SGEM#150: Hypertonic Saline for Traumatic Brain injury?

Podcast: lien!

Bienvenue à l’édition française du « Skeptics Guide to Emergency Medicine » , le guide des « sceptiques » en médecine d’urgence

Date: Le 18 avril, 2016

Titre:  « Du salin hypertonique pour le traumatisme crânien ? » Cet épisode est la traduction francaise du podcast #150 initialement publié le 24 mars 2016

Dr Chantal Guimont.Ph: J Bernier de Focus.

Cette traduction est faite avec Dr Marcel Émond, professeur agrégé à l’Université Laval et urgentologue à l’Enfant-Jésus du CHU de Québec et l’auteure principale de l’article: Dr. Elyse Pelletier. Elyse travaille au CIUSSS Chaudières-Appalaches hôpital Hôtel-Dieu de Lévis. Elle est chargée d’enseignement clinique.

Dr. Elyse Berger Pelletier

Cas: Un homme de 21 ans est debout au coin d’une rue quand il est frappé à la tête avec une baton de baseball. Il souffre d’un traumatisme crânio-cérébral (TCC) sévère. Il est amené dans la salle de traumatologie et semble avoir une blessure à la tête isolée. Il n’ouvre pas les yeux à la douleur, ne parle pas, et il retire aux stimuli douloureux. Son score de Glasgow est 6 et après intubation, sa pupille gauche réagit lentement et est à 5 mm, tandis que la droite est de 3 mm et réactive. Vous décidez de donner une solution hyperosmolaire pour son hypertension intra-crânienne présumée, alors qu’il est transporté au CT. Vous demandez un sac de mannitol, mais quelqu’un demande si une solution de salin hypertonique (SSH) sera plus efficace pour ce patient?

Contexte: Les traumatismes crânio-cérébraux (TCC) sévères sont associés à un taux élevé de morbidité et de mortalité. C’est une blessure fréquente vu au Canada (Turgeon et al and Zygun et al). Dans les cas graves, l’hypertension intra-crânienne (HTIC) peut se produire et générer des lésions cérébrales secondaires, via une pression de perfusion cérébrale diminué et l’ischémie. L’augmentation de la pression intra-crânienne (PIC) est fortement associée à la mortalité et aux résultats neurologiques défavorables (Giulioni and Ursino).

Plusieurs interventions ont été proposées pour contrôler la pression intra-crânienne:

– Drainage du liquide céphalorachidien (Bullock et al) – Un drain ventriculaire externe est inséré dans l’un des ventricules du cerveau pour drainer du liquide lorsque la pression augmente.

– Craniectomie décompressive (Bullock et al) – Un morceau de crâne est retiré pour permettre à l’œdème cérébral de prendre de l’espace et de réduire ainsi la PIC.

– Coma barbiturique (Guidelines) – Ceci est un traitement de dernière ligne lorsque toutes les autres thérapies médicales et chirurgicales ont échoué. Les barbituriques sont utilisés pour diminuer la PIC via certains mécanismes tels que l’abaissement du tonus vasculaire et du métabolisme cérébral. Malheureusement, les études sur les comas barbituriques ont toutes été faites dans les années 80, lorsque les soins standards étaient l’hyperventilation prolongée, la restriction de fluides et les stéroïdes.

 

Une intervention thérapeutique pour traiter l’augmentation de la PIC est l’utilisation de solutions hyperosmolaires. Le mannitol est une des solutions les plus fréquemment administrés et est la solution recommandée par les guides de pratique clinique (Guidelines). Le mannitol est considéré comme l’étalon d’or pour la thérapie hyperosmolaire dans le traitement de l’HTIC (Guidelines, Brown et al,  and Sakowitz et al).

Récemment, des solutions salines hypertoniques ont reçu le soutien dans le traitement de l’augmentation de l’ICP dans TBI en raison de leurs propriétés d’expansion du volume et de l’effet osmotique (Mattox et al).

Question clinique:

Quels sont les avantages cliniques et les inconvénients liés à l’utilisation d’une solution saline hypertonique par rapp[...]

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Date: December 14th, 2016

Reference: Plint et al. Management of Bronchiolitis in Community Hospitals in Ontario: a Multicentre Cohort Study. CJEM November 2016

Guest Skeptic: Dr. Chris Bond. Chris is an emergency physician and clinical lecturer at the University of Calgary. He is currently the host of CAEP Casts, which highlights educational innovations from emergency medicine residency programs across Canada. Chris also has his own #FOAMed blog called Standing on the Corner Minding My Own Business (SOCMOB).

Case: Parents present to your community emergency department with their 6-month-old daughter. She has had a cough, fever, and “noisy breathing” for the past 24 hours. She is otherwise healthy, having had a previously uncomplicated prenatal, delivery, and post-natal course. Her immunizations are up to date. There is no family history of atopy or asthma.

On exam she is febrile at 38.4 Celsius, pulse 150bpm, respiratory rate 50bpm, and an oxygen saturation of 93% on room air. You even manage to get a blood pressure, which is 78/48. She has a lot of clear nasal discharge and mildly increased work of breathing, with subcostal indrawing. Her cardiac exam is unremarkable, but there is diffuse wheezing throughout the lungs bilaterally, which the parents say has never happened before. The remainder of her exam is reassuring.

Background: It has been said that there are two seasons in North America… Bronchiolitis season and August. We know that bronchiolitis presents a significant burden of disease not only to patients and families, but the health-care system as well.

Although the vast majority of infants with bronchiolitis can be managed with supportive care at home, due to its high incidence, it is the number one reason for infants to be hospitalized (Njoo et al 2001, Langley et al 2003, Craig et al 2007 and Shay et al 1999).

Since bronchiolitis is a clinical diagnosis, there is no test, including viral testing and radiography, which rules it in or out (Schuh et al 2007).

Sadly, despite multiple guidelines (NICE, AAP, CPS), there has also been no “magic bullet” in terms of treatment.

Although there has been some benefit shown with inhaled hypertonic saline (Zhang et al 2015) and early research on combining nebulized epinephrine and systemic steroids is promising, there is concern about the ongoing use of unproven therapies such as beta-agonists, steroids alone and antibiotics.

Existing research has helped to quantify the bronchiolitis practice patterns of physicians in children’s hospitals. Plint et al, in 2004, found that Canadian pediatric emergency departments continued to use bronchodilators and steroids for children with bronchiolitis.

Since a number of these infants are seen in community hospital settings, the practice patterns of physicians in these envi...

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Date: November 2nd, 2016

Guest Skeptic: Dr. Sanjay Sharma is a professor of ophthalmology and epidemiology at Queen’s University in Kingston, Ontario, Canada. He has authored over 200 research articles and three books including the American Medical Association’s Evidence-Based to Value-Based Medicine. His research is in macular degeneration, health economics and medical education.

This is another SGEM Xtra and not a critical review. There are just so many great topics to cover as well as recent publications. Don’t panic…we will be back next time with a critical appraisal cutting the knowledge translation window down from over ten years to less than one year with the power of social media.

In this episode we talk to Dr. Sharma about his newly launched medical education project called MedSkl.com. Listen to the SGEM podcast on iTunes to hear his responses to the questions below.

Questions for Dr. Sanjay Sharma:

* What is the MedSkl.com?

* Were did you get the idea for MedSkl.com?

* What kind of content will you be providing?

* How are you making MedSkl.com part of the #FOAMed movement?

* Who is your target audience?

* What are the goals of Medskl.com?

* Who do you have providing the content?

* How do you control for quality?

* How many Universities have signed on?

* What kind of feedback have you received about MedSkl.com?

* How can people find out more about your project?

* Is there anything else you want to say about the MedSkl.com project?

MedSkl.com Summarized Into a Tweet: Medskl.com: complete curriculum in animation and video by 180+ leading faculty. Think Cecils meets Pixar. #FOAMed

The SGEM will be back next time with a critical review of a recent publication.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

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Date: November 21st, 2016

Reference: Eisenbrown et al. Which Febrile Children with Sickle Cell Disease Need a Chest X-Ray? AEM November 2016

Guest Skeptic: Dr. Corey Heitz is an associate professor of emergency medicine at the Virginia Tech Carilion School of Medicine in Roanoke Virginia. He is also the CME editor for Academic Emergency Medicine and the associate editor for emergency medicine simulation at the AAEM MedEdPORTAL.

Case: You are working in the Emergency Department on an overnight pediatric coverage shift. A worried mother brings her 2-year-old child in with a fever of 38.6C (that’s 101.5F). The female child’s medical history is significant for sickle cell disease. On exam, the child is uncomfortable appearing, tachycardic, tachypnic and febrile. Mom says the child has had a runny nose and a mild cough along with the fever.

Background: Children with sickle cell disease who develop fever are at higher risk of severe bacterial infection than children without sickle cell disease. The National Heart, Lung, and Blood Institute (NHLBI) suggest a routine workup that includes a CBC, blood cultures, and empiric antibiotics (NHLBI Expert Panel Report 2014).

One of the life-threatening infections for which these children are most at risk is acute chest syndrome (ACS). The NHLBI recommend a chest x-ray (CXR) for children with respiratory signs or symptoms (shortness of breath, tachypnea, cough, and/or rales).

Controversy exists as to whether the history and physical exam are sensitive enough to determine which febrile children need a CXR.

Clinical Question: Which febrile children with sickle cell disease presenting to the emergency department should get a CXR to help diagnose acute chest syndrome?

Reference: Eisenbrown et al. Which Febrile Children with Sickle Cell Disease Need a Chest X-Ray? AEM November 2016. 

* Population: Children age three months to 21 years with sickle cell disease presenting to one of two children’s emergency departments with a fever of 38.4C or greater.

* Intervention: Accuracy of white blood cell count, history and physical exam findings to rule-in or rule-out acute chest syndrome.

* Comparison: None

* Outcome:

* Primary Outcome: Presence of acute chest syndrome.

* Secondary Outcomes: Classification and regression tree (CART) analysis, sensitivity, specificity, positive and negative likelihood ratios of constellations of WBC, history/physical exam findings for acute chest syndrome.

The SGEM HOP episodes always have one of the authors on the show. Dr. David Brousseau is a Pediatric Emergency medicine physician at the Children’s Hospital of Wisconsin.

Author’s Conclusions: Children with SCD presenting to the ED with fever and shortness of breath, tachypnea, cough, rales, or chest pain should receive a CXR due to high ACS rates. A higher WBC count or history of ACS in a child without one of those symptoms may suggest the need for a CXR. Prospective validation of these criteria is needed.

Quality Checklist for Clinical Decision Tools:

* The study population included or focused on those in the ED. Yes

* The patients were representative of those with the problem. Yes

* All important predictor variables and outcomes were explicitly specified. Yes

* This is a prospective, multicenter study including a broad spectrum of patients and clini...