Antibiotics for Strep Pharyngitis: The Pediatric Perspective

Around this time last year, a post on R.E.B.E.L. EM discussed the evidence surrounding the risks and benefits of antibiotics in Strep pharyngitis.  The general take-home was that it should not be done.

Since the article did not specifically discuss differences between children and adults, Brendan Fitzpatrick, one of our 4th year residents sent the article to Indi Trehan, who is boarded in both pediatric emergency medicine and infectious disease.  Thankfully, between saving babies in Malawi, writing grants and submitting papers, he crafted this response which he agreed to let us share on the blog:

 

>> Fitzpatrick, Brendan wrote:

Let me know what you think:

http://rebelem.com/patients-strep-throat-need-treated-antibiotics/

Brendan M. Fitzpatrick, MD
PGY-4, Division of Emergency Medicine
Washington University School of Medicine in St. Louis

 

> Trehan, Indi wrote:

Hey man,

I talked about this Strep throat thing with some (admittedly more biased and traditional) folks in ID. You're absolutely right, the incidence of ARF/RHD is going down and there is very little left in rich countries, but I don't think any of us are comfortable yet not treating this.

Some thoughts, going through the article from top to bottom:

Background - 10 million patients treated with antibiotics annually but less than 10% have Strep...

True, but this is 10 million adults and most places don't test them for Strep. One of the outcomes of that study was the re-emphasis on the importance of only testing people with symptoms (Centor score at least 2). In the three big children's hospitals I have worked in, this is standard of care -- we only treat those who have tested positive.

C. diff and allergic reactions

The rate of C. diff is extremely low in children -- for example we use clindamycin like candy. Otherwise healthy ambulatory kids who come in with a sore throat just don't get C. diff from the occasional course of antibiotics.

Yes, allergies are always a risk with antibiotics. Hence an additional reason to limit their usage by only testing and treating appropriately as above.

Argument #1

Agreed, reducing symptoms is uninteresting to most of us.

Argument #2

Agreed, suppurative complications are not why most of us treat.

Argument #3

I think this is probably a place where adult data doesn't apply to kids. The rate of RHD/RF reported in that military study in the 1950s is indeed quite low but that's because that was in military recruits. RHD/RF simply happens at much much lower rates in adults than kids -- it really is a disease that is almost entirely of 5-15 year olds, a few younger and a few older of course, but it doesn't surprise me at all to see only a 1-2% rate among what is probably 17-25 year olds.

But even aside from this fact, these studies from the 50's and 60's are all quite small and given the very low rate of these complications, a meta-analysis is in order in order to be able to have enough power to detect a difference. The Cochrane review on this subject does this meta-analysis for us -- see Analyses 4.1 and 4.2 which found that giving antibiotics reduced ARF -- RR 0.27 (95% CI 0.12-0.60). Giving penicillin specifically was also studied -- RR 0.27 (95% CI 0.14-0.50).

Need to treat 2 million patients in order to prevent a single case of RF...

This number is not exactly right. It is correct in its intention of pointing out that you need to treat a ton of people to prevent one complication, but the denominator is not correct since we really shouldn't be testing or treating adults and we shouldn't be treating those without a positive rapid test or culture. So if you limit the testing and treatment to the high risk population (i.e., children) and then only treat those who have a positive test, this 2 million number falls dramatically.

The point about hygiene as the real cause of the decrease in rates of ARF is exactly correct and I'm glad they are pointing this out. In the same way that polio's eradication in the US is just as much a result of improved hygiene as it is from vaccination, we still need to keep immunizing kids against polio due to the unpredictable risk of it flaring up in an outbreak at any time. (Admittedly, this analogy falls apart when comparing the almost-zero risk of complications due to vaccination when compared to the slightly higher risk of penicillin allergy.)

The thing with Group A Strep is that certain strains are rheumatogenic and far more likely to cause ARF. Which ones these are is quite unpredictable. There also seems to be certain people that are particularly susceptible because of their own genetic predisposition (this comes from twin studies and such). And of course who those people are is unknown with our limited genetic techniques.

When you put these together, sometimes you get the perfect storm of sporadic or widespread cases of ARF. So some fair number of kids will still get ARF/RHD and then there are also big outbreaks that arise periodically and unpredictably -- the most famous was in Utah in the 80's -- and so keeping the burden of this bacteria low and limiting its spread seem to be a worthwhile public health goal.

But overall, your point is well taken -- this is a disease with declining incidence and morbidity and we are getting close to the point of not needing to treat it in the US, with the caveats that the numbers derived from adults don't necessarily apply to children who have a much higher incidence of rheumatic complications and that those who will suffer these is relatively unpredictable, especially given the problem that kids are not the cleanest in the world and quickly spread bacteria around their house and day care centers and schools. Another small practical problem we have to remember is "standard of care" -- so if you don't test or treat a child with Strep throat who goes on to develop ARF/RHD and the community standard of care -- "what any reasonable practitioner would do" -- still says to test and treat, then you are up a creek when it comes to malpractice. But I do hope that when IDSA looks to update and revise their guideline (as they do every few years), they take a serious look at this changing epidemiology and decide to narrow their recommendations for treatment...

indi

I am Chris Miller, former Party Fowl, and this is How I Turkey Harder


·       Name: Chris Miller, MD
·       Location: Barnes Jewish Hospital, St. Louis Missouri
·       Current job(s): PGY-2, Emergency Medicine, Washington University in St. Louis
·       One word that best describes how you eat: Furiously
·       Current turkey style: Sara Lee, Honey Roasted, 2mm cuts

WHAT’S YOUR CURRENT SANDWICH SETUP?
I like to keep it simple.  I am very old-school when it comes to that.  On most occasions I find myself eating the sandwich as it was originally packaged.  On occasion, if I’m feeling spontaneous, you will catch me mixing it up a little bit (open face, fork & knife, double decker).

WHAT’S YOUR BEST TIME-SAVING TURKEY TIP?
Nail down your microwave times.  I can’t tell you how many times I see nurses, techs and even our own interns wasting too much time at the microwave.  It’s either still cold or scorching hot.  Some rookies will even remove the plastic wrap. 
Here’s a pro tip:
1.     Place sandwich on a paper towel (keep in plastic wrap)
2.     Microwave for 27 seconds
3.     Remove plastic wrap
4.     Add condiments & enjoy

WHAT’S YOUR BEST TIP REGARDING MEAT MANAGEMENT?
Not all sandwiches are created equal.  Most of the time you can spot the differences as you squat in front of the fridge making your selection.  Some sandwiches, I call them “the chosen ones,” seem to have more meat.  Select these at the beginning to save yourself some time and disappointment later.
Supplement your turkey with other healthy alternatives like reconstituted grape juice and pre-scored graham crackers.  If you are looking for extra protein consider dipping in peanut butter.

MAYONNAISE: LIGHT OR ORIGINAL?
I realize this is controversial.  I have even heard of people using mustard instead, but that goes against everything I stand for.  This question often depends on departmental availability.  Original mayonnaise tends to be more popular with the patients.  I often find myself reaching for the Light Hellmann’s.  It packs fewer calories, but still provides that powerful, smooth, creamy texture we all crave in a condiment.

WHAT’S THE BEST ADVICE YOU’VE EVER RECEIVED ABOUT EATING ED TURKEY?
I was nearly a full two years into my residency before I received a game-changing piece of advice.  Sam Smith, PGY-3 (The Czar of ED Turkey) told me that for nearly a year he had been doubling up on his meat.  Rather than wasting time to select the ideal sandwich at the fridge, simply grab any two sandwiches, unwrap, steal meat from one and apply to the other.  Then rewrap and microwave like nothing happened.  What to do with the extra bread is your call.  Double decker vs throwing away are two popular options.
Turkey brings people together and we should embrace that.  I think the former president said it best:
I have no desire to crow over anybody or to see anybody eating crow, figuratively or otherwise.  We should all get together and make a country in which everybody can eat turkey whenever he pleases.
                                                                                                       Harry S. Truman, 33rd President of the USA

WHO WOULD YOU LOVE FOR US TO TRACK DOWN TO ANSWER THESE SAME QUESTIONS?
1.     Sam Smith, MD PGY-3
2.     Chris Holthaus, MD Attending
3.     Emily Garibay, RN

How Do You "FOAM," Anyway?

Last fall, I had the honor and opportunity of delivering a lecture about FOAMed to my fellow residents and faculty during our Tuesday didactic conferences. During this lecture, I had about 40 minutes to try my best to give a broad overview of what FOAMed is, how it’s impacting our specialty, and how to incorporate it into one’s practice.

The lecture can be viewed on Vimeo here..

Today, I want to focus on a specific part of the lecture: “How do you ‘FOAM,’ anyway?” For those following along at home, it starts about 15 minutes in, and lasts for about 15 minutes.

In my experience – and I think this sentiment is shared by others – one of the major hurdles faced by those looking to jump in to the FOAMed world is information overload. The sheer number of blogs and podcasts has exploded in recent years and has reached the point of being overwhelming, as seen in this figure from a paper by Mike Cadogan and Brent Thoma chronicling the rise of the FOAM:

From Emerg Med J. 2014 Oct;31(e1):e76-7

For FOAMed to be used as a learning tool, especially for the EM physician in training, I think two important points must be kept in mind. First, learning can only occur in an environment in which there is a positive cognitive margin. Basically, when you have the time, energy, and focus to be able to sit down and really dive into something, retention is maximized. If the environment is not conducive to cognitive functioning – from fatigue, distraction, intoxication, what-have-you – true active learning from a FOAMed resource is going to be very difficult.

Second, while we are in general andragogical learners who want to seek out the information we want and need rather than having it all spoon-fed to us, it is exceptionally inefficient and difficult to wade out into the FOAM world and attempt to “pull in” everything of interest to you. Much more efficient and comprehensive to have everything that’s new “pushed” to you, for your perusal at a time in which you have a positive cognitive margin.

And this is where Chris Nickson’s chosen vernacular comes in. Replace “information overload” with “filter failure” in your lexicon. Particularly when you’re first starting out, you don’t want every new item posted from every FOAMed world pushed to your brain all at once. You need a way to improve the signal-to-noise ratio, to pare down the breadth of content to those things that are highest-yield to you.

Having gone through the painful process of trying to “pull” FOAMed information to me, and then subsequently being drowned in knowledge from filter failure after learning how to “push” information, I’d like to do what I can today to help my fellow EM learners ease their transition to “push” information and filtering.

How To Do It:

1. Familiarize yourself with RSS feeds. This is basically a piece of computer code that indexes all of the posts of a particular blog. They’re usually signified with the following icon:

In and of themselves, they’re useless. If you happened to click on one, your screen would be filled with incomprehensible programming code. BUT, if only there were a piece of software that knew what to do with them…

2. Learn how to use an RSS feed aggregator. This is a program into which you can upload RSS feeds for whatever blogs you want to follow, and then those posts from all of those blogs will be listed out for you in a chronological digest format. I prefer Feedly, which you can download here. It integrates into PC & Mac browsers, and I believe there are both Apple & Android apps for mobile devices. Adding blogs to Feedly is pretty simple; I go over it in the video, right at the 19-minute mark.

3. But how do I know which blogs to add? How do I know where to start? Well, this is what I’m going to try to help you with. There is actually another way to add blogs to your Feedly feed, and you can do it en masse. This is via an OPML file, which is just a file cataloging the RSS feeds from whichever blogs you want. Upload the OPML file to Feedly, and *BOOM* all of those blogs are instantly added. Here’s a couple screencaps showing you how to do this in Feedly.

Clicking your e-mail address in the bottom left corner will take you to the "Organize" screen.

Select the appropriate OPML file for import.

Can you feel the power?

There are a variety of options to view and organize posts from your chosen FOAMed resources.

I have created a set of OPML files to help you get started. The file names should be relatively self-explanatory. “Getting Started” includes just a few of the most popular and highest quality resources out there for those just dipping their toes in the FOAMed kiddie pool. “The Basics” adds a few more resources, and it goes up from there. The “Advanced Practice” file includes every blog on my Feedly, which is every active EM-relevant blog I know about. I’m sure I've missed a few, but it should be the lion’s share of what’s out there. You can download these at will and upload them to your Feedly.

I. Getting Started

II. The Basics

III. Intermediate Level

IV. Advanced Practice

If you load “Getting Started” but later want to see more, you can upload one of the other files. Only the new additions will be added to your feed; it won’t duplicate what you already have. Pretty neat.

5. Go get FOAMy! Remember: there’s no “right” or “wrong” way to do this. I still struggle with filter failure. Just remind yourself there’s no possible way to read everything. Find the things that look interesting to you, and bookmark those to read in detail later. Don’t be afraid to let some other things pass you by – if you stay active in the FOAMed Twitter world and keep up with high-quality FOAMed digests like those from Life in the Fast Lane and EM Curious, you’ll catch the most-important, highest-quality stuff. Hopefully the organization of the OPML files will help those of you just getting started, or those of you struggling with “push” information gathering and filter failure.

I’m always open to comments and questions! Feel free to comment here on the blog, or catch me on Twitter: @CSamSmithMD.

Never stop learning,

C. Sam Smith

FOAM Party, Part I: Abscess Diagnosis, at Faster than the Speed of Sound

Last month, as part of our regularly-scheduled Tuesday didactic conference, our residents participated in a Team-Based Learning exercise. This was not your typical TBL, as the purpose was to generate original FOAMed content. The residents, divided into teams, pored over a curated list of available FOAMed resources regarding a very bread-and-butter but still somewhat controversial topic in Emergency Medicine – abscess management. They critically appraised their most high-yield resource (utilizing the ALiEM AIR assessment tool as a blueprint), and delved into the primary literature as well. The teams worked together to generate their lists of “pearls” from each resource – the bits of information they found the most impactful. These pearls have been collated and edited to form the FOAM Party post below. This is Part 1 of a three-part series on diagnosis & management of abscesses. 
We hope this exemplifies the power of crowdsourcing and “swarm medicine” in generating FOAMed content. As always, your comments and feedback are appreciated! Enjoy!

Part 1, Diagnosis:

We all know what an abscess is – an accumulation of pus beneath the epidermal layers as a result of bacterial infection, usually with Staph or Strep spp [1]. It presents as a red, swollen, fluctuant, tender mass, possibly with active drainage of purulent material. Varying degrees of surrounding cellulitis and induration can be appreciated. Providers must determine the presence of an abscess – requiring incision & drainage (I&D) for treatment, versus cellulitis – treated with antibiotics alone.

Unfortunately, studies of abscess diagnosis indicate the issue is not always straightforward...


- A prospective, cross-sectional study of interrater reliability of exams of patients presenting to a pediatric ED with suspected skin or soft-tissue infection (SSTI) found only “fair” or “moderate” agreement (weighted k statistics ≈ 0.4) for diagnoses of lesions as abscesses and for determination of whether lesions required I&D [2]. Experience of the examining physicians did not impact this result.

- A similar study found “fair” or “moderate” agreement for assessment of purulent drainage, tenderness, and fluctuance, but no agreement was seen in assessment of induration (k = -0.08) [3]. For diagnosis of a lesion as an abscess, k = 0.39. For determination of whether a lesion required I&D, k = 0.44. Again, physician experience did not affect the results.


Our residents noted that they commonly use bedside ultrasound to help determine if there is a drainable abscess in indeterminate cases. Thus far, we feel the preponderance of published data favors the diagnostic utility of POCUS for SSTI:

- A study group led by Chao et al correlated ultrasound features of SSTI with clinical symptoms and lab values in 86 children believed to have SSTI [4]. They described four different stages of infection: 1) subcutaneous tissue thickening without disarray or pus accumulation, 2) disarray of subcutaneous tissue without pus accumulation, 3) disarray of subcutaneous tissues with pus accumulation, 4) disarray of subcutaneous tissues with frank abscess formation. Sonographic tissue disarray +/- pus accumulation was statistically significantly associated with longer duration of symptoms, high-grade fever, leukocytosis, and higher CRP levels.

Image credit: Sonoguide.com


- A prospective observational study by Squire et al compared the accuracy of clinical examination to ultrasound in differentiating cellulitis from abscess [5]. The composite reference standard used in this study was either the presence of pus on I&D or the resolution of symptoms on antibiotics alone if no I&D was performed. They showed that ultrasound was superior to clinical examination and physician judgment in sensitivity (98% vs 86%), specificity (88% vs 70%), PPV (93% vs 81%), and NPV (97% vs 77%). Of note, almost half of the patients who did not have I&D performed were lost to follow-up (25/51) – if even a small number of these ended up having an abscess, the diagnostic utility of POCUS would be significantly lower than the reported values.

- A prospective study of the impact of POCUS on management of SSTI without obvious signs of abscess was published in 2006 [6]. Examining physicians were asked to provide their pretest probability of need for an I&D and for presence of a visible fluid pocket. The results of the ultrasound examination changed the ED management plan in 56% of patients (95% CI 47% - 64%). Results of the ultrasound led to I&D being performed in 33 of 82 patients believed not to need drainage on initial exam (all of these I&D are reported as being positive for abscess). The ultrasound led to I&D not being performed in 16/44 patients initially believed to have needed it. These 16 patients did not return to the study hospital in the 72hr follow-up period of the study. Several other patients had further changes to their management plan including adjustment of incisional approach, need for specialist/surgical consult, and further imaging studies.

Image credit: Sonoguide.com


- The utility of POCUS for diagnosis of abscess in the pediatric population was examined by Sivitz et al in 2010 [7]. In this study, POCUS changed management plan after initial clinical assessment in 11/50 cases. Diagnostic utility was also assessed, with gold standard being positive I&D for pus or return visit within 1 week. POCUS demonstrated greater sensitivity than clinical exam (90% vs 75%) and similar specificity (83% vs 80%) in detecting abscess.

- Another prospective observational cohort study of pediatric patients with SSTI again tried to determine if results of POCUS had an effect on the treating physician’s management of the patient [8]. Compared with clinical exam, POCUS had increased sensitivity (97.5% vs 79%) and similar specificity (69% vs 67%). Unlike some earlier studies, these results affected clinical management in only a few cases.  Unfortunately there was no clearly-defined “gold standard” for abscess diagnosis or outcome measures, and there was no control group.
(See St. Emlyn’s excellent Journal Club assessment of this paper here.)

- The latest study to investigate the diagnostic utility of POCUS for SSTI in pediatric patients was published by Marin et al in 2013 [9]. In this study, the treating physician conducted a clinical exam and based his/her management accordingly. Completely separate from this, a study physician performed his/her own clinical exam, and then performed POCUS. These results were not known to the treating physician and did not affect management. The reference standard was positive I&D and follow-up at 2 days. This study did have a much larger sample size than prior studies, with over 700 lesions analyzed. Once again, there was only fair agreement in physicians’ clinical exams (k = 0.39). If both treating and study physicians’ exams agreed that the lesion in question was likely an abscess or likely not an abscess, then POCUS added nothing to the diagnostic utility of exam alone in terms of sensitivity, specificity, or accuracy. However, for lesions in which the clinical exam was uncertain, POCUS significantly improved sensitivity (78% vs 44%), along with PPV and NPV. The trend toward increased specificity for POCUS did not reach clinical significance.


Take-home:

- As a group, we feel our use of ultrasound in SSTI reflects the conclusions of the Marin study – probably unnecessary if the diagnosis is obvious, but potentially very helpful if you are uncertain.

- We feel there are additional benefits to ultrasound of these lesions, including improvement in planning I&D approach, identifying sensitive anatomic structures in proximity to the lesion, or potentially uncovering alternative diagnoses. The clinical applicability of these benefits have been described in the literature [10-12].

- We recognize the potential for overdiagnosis – of performing I&D on a lesion with an identifiable fluid pocket on ultrasound, but that may have otherwise improved on its own with conservative management +/- antibiotics had the POCUS imaging not been available. However, standard care at this point for a pus collection of any size is drainage, and until further study is done to delineate those lesions that may improve with medical management alone, we feel the identification of fluid collections indicating abscess is a useful application of POCUS.


Take this FOAM party on the road and check out these other excellent resources for ultrasound diagnosis of SSTI:

- Sonoguide on how to perform SSTI POCUS, with reference images.
- A video guide to SSTI POCUS can be found at EmergencyUltrasound Teaching.
- Summary and reference images from the PEM Fellows Blog.
- Further reference images at Sinai EM Ultrasound.
- Test your knowledge of soft-tissue POCUS on EM Sono.

Keep on FOAMing,
C. Sam Smith, PGY-3 (@CSamSmithMD)

References:

[1] Singer AJ, Talan DA. Management of Skin Abscesses in the Era of Methicillin-Resistant Staphylococcus aureus. N Engl J Med 2014;370:1039-47.
[2] Marin JR, Bilker W, Lautenbach E, Alpern ER. Reliability of clinical examinations for pediatric skin and soft-tissue infections. Pediatrics. 2010 Nov;126(5):925-30.
[3] Giovanni JE, Dowd MD, Kennedy C, Michael JG. Interexaminer agreement in physical examination for children with suspected soft tissue abscesses. Pediatr Emerg Care. 2011 Jun;27(6):475-8.
[4] Chao HC, Lin SJ, Huang YC, et al. Sonographic evaluation of cellulitis in children. J Ultrasound Med. 2000;19:743-749.
[5] Squire BT, Fox JC, Anderson C. ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections. Acad Emerg Med. 2005;12:601-606.
[6] Tayal VS, Hasan N, Norton HJ, Tomaszewski CA. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Acad Emerg Med 2006;13:384-8.
[7] Sivitz AB, Lam SH, Ramirez-Schrempp D, Valente JH, Nagdev AD. Effect of bedside ultrasound on management of pediatric soft-tissue infection.  J Emerg Med. 2010 Nov;39(5):637-43.
[8] Iverson K, Haritos D, Thomas R, Kannikeswaran N. The effect of bedside ultrasound on diagnosis and management of soft tissue infections in a pediatric ED. Am J Emerg Med 2012;30:1347-51.
[9] Marin JR, Dean AJ, Bilker WB, Panebianco NL, Brown NJ, Alpern ER. Emergency ultrasound-assisted examination of skin and soft tissue infections in the pediatric emergency department. Acad Emerg Med. 2013 Jun;20(6):545-53. doi: 10.1111/acem.12148.
[10] Cardinal E, Bureau NJ, Aubin B, et al. Role of ultrasound in musculoskeletal infections. Radiol Clin North Am. 2001;39:191-201.
[11] Craig JG. Infection: ultrasound-guided procedures. Radiol Clin North Am. 1999;37:669-678.
[12] Ramirez-Schrempp D, Dorfman DH, Baker WE, Liteplo AS. Ultrasound soft-tissue applications in the pediatric emergency department: to drain or not to drain? Pediatr Emerg Care. 2009 Jan;25(1):44-8.

#FOAMed digest No. 9: For the Visually Oriented


As was discussed in conference by Jason Wagner last week, and brought up by EM Curious in this tweet,

humans are visual learners and there is little substitute for an image when it comes to retention of information.   Therefore, the focus of this installment of the #FOAMed digest is on visually-oriented FOAMed resources - from static visual aids, to procedural videos or talks.  Since I think the same applies to Case-based learning (I know that I personally learn best from cases that I have seen or heard of), I've thrown some of that in too.

Visual aids: EMCurious has created some wonderful visual aids that allow you to navigate patient management, evidence based medicine and #FOAMed content. I particularly like these infographics on management of Afib with RVR in the emergency department or this infographic on vasopressors in septic shock.   For a simple visual algorithm (and cognitive aid) on managing the difficult airway, check out the vortex approach (I recommend watching the video as it explains the image). 

Ultrasound : It would be impossible to properly teach ultrasound without case examples and visual demonstrations.  There are some excellent online resources to enhance your ultrasound learning.  Laura Wallace (@labellalaura) recommended the Ohio State ultrasound website for tutorials on common US exams.  If you like a little entertainment with your ultrasound, check out the emc to learn about ultrasound findings and pathophysiology of both cardiac tamponade and PE.  For the combination of case-based learning and excellent videos, be sure to add the ultrasound of the week to your weekly to do list.  I particular liked this case of a patient with lung cancer and shortness of breath because it gave me good reminder to look at everything in the ultrasound image (sorry for the sort-of-spoiler alert). 

Procedures:  Much like my husband did when he fixed the dishwasher,  I have used YouTube when refreshing on a procedure before doing it in the ER.  I have also watched procedural videos in anticipation of having to do the procedure (such as this set of emcrit central line videos the night before my first TCC shift as an intern).  As far as #FOAMed procedural videos, EM Curious has a "procedures club" of videos for those less frequent but high-stress ED procedures, including ED thoracotomy , lateral canthotomy, and crichothyrotomy.  Our own PD, Jason Wagner, has made this video of simulated perimortem C-section. 

EM Basics & Board Review: The possibilities for this category are endless.  Here are a couple resources that may be helpful.  For case-based and visual learning, Northwestern has an excellent site for Orthopedics review, complete with case scenarios and excellent X-ray images.  For board review in general, see the EM Board review blog - here is a link to a rapid fire review you may want to watch before the inservice.  If flashcards are your thing,  here is a link to a flashcard host site for board review flashcards based in Rosen's shared by Boring EM.

On being human - Sometimes we need to be reminded that we are human and our patients are too.  To me, when it comes to medical error and mistakes, individual cases motivate me for change more than any jumbo jet analogy.  I think we all have some cases where we sat down to think about (or lay in bed awake at night wondering) what we could have done differently.  Here are talks, by both doctors and patient families, on mistakes that happen and what we can do better:
              The story of Elaine Bromiley
              Doctor's make mistakes - Can we Talk About That? 
              Transparency and Truth in Medical Errors

 Enjoy the tour,
Maia Dorsett, PGY-3 (@maiadorsett)

Expert Commentary: Troubleshooting Hypoxia on the Vent

In emergency medicine education, we tend to focus on establishing the airway but spend less time discussing the aftercare and managing the ventilator.  While we have spent more time on this recently, thanks to Brian Fuller and his research on the importance of low tidal volume ventilation in the ER (see EM Journal club summary and podcast from February 2014),  most of us are still more comfortable putting the ET tube in than managing the vent.

Luckily for us, here at WashU we have some EM-Critical Care wise guys who can teach us a thing or two, and today we share with you Brian Fuller's method for trouble-shooting hypoxia on the vent, forwarded to us by PGY-3 Brendan Fitzpatrick:

>>From: Fitzpatrick, Brendan
>>To: Fuller, Brian
>>Subject: vent desats

Dr. Fuller,

Good working with you last night. I was trying to recall how you broke down desats on the vent last night, but somewhere between little sleep and my kids' halloween parade, I've lost the finer points.

In all your free time, would you mind jotting down what you told me so I can review it?

thanks,

Brendan

 

>From: "Fuller, Brian"
>To: "Fitzpatrick, Brendan"
>Subject: RE: vent desats


For the purposes of acute deterioration (in the form of hypoxia) on the ventilator, we are gonna talk about two airway pressures: peak pressure and plateau pressure. As an aside, mean airway pressure is the average pressure over one cycle of inspiration and expiration. It is largely governed by PEEP and I:E ratio. It really governs oxygenation- higher it is, more you open up stiff alveoli in sick vented patients.


Peak pressure is the summation of pressure generated from: 1) tidal volume and compliance; 2) resistance and peak inspiratory flow; and 3) PEEP
 

Plateau pressure is a reflection of compliance. Think "how stiff the lungs are"; or "how much transalveolar stretch is occurring".
Compliance is ∆ volume/∆pressure. Specifically, tidal volume/(plateau pressure - PEEP)




So the first thing I do when somebody becomes acutely hypoxic on the ventilator is to look at their peak airway pressure:

1. If decreased: you have an air leak or the patient is hyperventilating/tugging hard and therefore pulling the airway pressures down. Air leak would be something like: bronchopleural fistula, the chest tube you just put in has a leak in the system, your ETT has migrated or cuff has a leak and air is escaping.

2. If increased: see above- this could either be primarily a compliance or resistance problem. So your next step is to look at the plateau pressure to figure out where the problem lies.

If no change in plateau, you therefore have a bigger difference between the peak pressure and the plateau pressure than existed before the hypoxic event. See above for what governs these pressures, so you can tell that this is therefore a resistance problem. Think: airway obstruction from bronchospasm, clogging of the ETT with secretions, kinking of the ETT.


If plateau pressure is also increased, you now have a situation where the peak and plateau pressures both increased. See above for what governs these pressures, so you can tell that this is therefore a compliance problem. Think: pulmonary edema, abdominal distention, pneumothorax, atelectasis, etc.

3. If no change: think "Something made my patient hypoxic but didn't change my airway pressures." Not a lot of stuff does that. Think: pulmonary embolism, PFO.

Sometimes it is difficult to figure out "Is the ventilator and my ventilator settings the problem, or is this a patient problem?" If you remove the patient from the ventilator, and therefore take that out of the equation, bag them and they get better, it is probably a ventilator problem. If you bag them and they stay bad, it is probably a patient problem.

Hope this helps. Hit me back with questions PRN.

Feel free to share with others.

Be good man.
B



For those of you who like pictures, here is a visual representation of the algorithm:

Want to do a little more reading or watching about this? Life in the Fast Lane had a nice review of Pulmonary Mechanics.  I recommend the second Eric Strong video on pulmonary pressures as a supplement to understanding the above material (and hell, it only takes 9 minutes to watch).

Expert Commentary by Brian Fuller
Visual aids by Maia Dorsett (@maiadorsett), PGY-3 
Expert inquiry, sharing skills and parenting by Brendan Fitzpatrick, PGY-3.

#FOAMed Digest No. 8: Thank You Sir, May I Have Another?

In the spirit of demonstrating how FOAM resources can reinforce resident curriculum, I thought for this installment of #FOAMed digest we would do something a little different and highlight FOAM resources that build on the topics and discussions from conference last week.  For those of you who didn't make it, the conference run down from last week:

             GI core content: esophagus and stomach
             Trauma Case Conference: Traumatic cardiac arrest in the blunt trauma patient 
                                                           Traumatic cerebrovascular injury
             Key papers in critical care
             Navigating the politics of innovation
                .... and a little on cognitive overload

For those of you who want to solidify and expand your knowledge,  you need not wait for tommorrow's review.  Here are some FOAM resources to help you do just that:

Disorders of the esophagus and stomach: Medical school taught you to memorize buzzwords and basics of management for disorders of the esophagus and stomach, but the FOAM world can expand
on this background and sometimes teach you to think critically about management decisions.  Here are some good FOAM resources on the Upper GI bleed:
              Who can I send home?  An oldie but goodie - a review from our own journal club on risk stratification for patients presenting with a GI bleed.
               Here is a critical review by EM Lyceum of upper GI bleed management including PPIs, octreotide in variceal bleeds, and conclusions from the good old NG lavage.  Some of things we do are really not that evidence-based.

Dr. Wessman's review of key article in critical care touched on GI also, recommending that we all read  this article published in NEJM, and reset our transfusion goal to 7 in the absence of massive hemorrhage.

And here is a link to the Scott Weingart video on Blakemore placement shown in conference. 

Traumatic Arrest:  Let's see if we can learn about things being done a little differently ... and prehospital -  Listen to this emcrit podcast  on management of a patient in traumatic arrest with Irish Road Racing doctor and RAGE team member, John Hinds.  Be sure to read the commentary, because there is an excellent discussion/debate bringing up important considerations for management of traumatic arrest.

Traumatic arrest patients usually do not need meds to facilitate intubation, but as an aside last week one of our trauma colleagues brought up whether we should be using ketamine instead of etomidate
Photo credit: http://inkrose98.deviantart.com/art/Car-Crash-2-254652116
when intubating trauma patients (especially hypotensive ones) in our ED.   I highly recommend this critical review posted last week by the SGEM about ketamine's undeserved bad reputation.  You might just make it your go-to in your next trauma patient even if you suspect intracranial pathology.


What blood products should we be giving to our patients?  A recent body of research from the THOR consortium (Traumatic Hemostasis and Oxygenation Research which includes St. Louis Children's Hospital PICU attending Phil Spinella), suggests whole blood.  Here is a link to the THOR website and articles of interest published by the consortium.

Last week during conference we asked the FOAMed world via twitter for input on CPR in traumatic arrest.  The response was largely negative.  Steve Carroll of @embasic mentioned potential use of REBOA.  For those of you unfamiliar with this device here is a description of the procedure and current evidence regarding its use from the Hennepin County site HQMeded.  If you are still interested, here is  an amazing story recounted on emcrit of prehospital REBOA use for a pelvic fracture. 

And finally... if you still have not watched Cliff Reid's talk on Making Things Happen on leading a resuscitation, do it now.  You will not regret it.

Traumatic vertebral artery injury: If you need a basic review of the talk given by our surgery colleagues, you can read the East Guidelines on Blunt Cerebrovascular Injury.  If you are wondering about the data on the sensitivity of CTA for detection of blunt cerebrovascular injury, you can listen to a podcast by the SGEM here.  Finally, our own blog took on the subject of whether vascular imaging is mandated in the presence of a cervical seatbelt sign, read what we had to say here 

Navigating the politics of innovation: When I think about what I like about FOAMed, it is that it is a a bottom --> up innovation.  As we learned from Dr. Andrew Knight's talk last week, one of the barriers to dissemination of innovation is top-down decision making with the expectation of bottom-up use.  This is important when thinking about how to effect culture change, but also useful when thinking about managing patient expectations.  I think two good reads on how to talk to patients regarding management decisions are this article in Wired about David Newman and the NNT as a method for data translation, and the "Ed in the ED" blog as a discussion forum on difficult patient conversations.

Wild Style, the epitome of quick-thinking-calm-under-pressure
... and a little on Cognitive Overload : I highly recommend this lecture from Air Force pararescuer Mike Lauria on enhancing cognition and critical decision making in acute care that was shared on the emcrit blog.   Take a Deep Breath.


Enjoy,
Maia Dorsett (@maiadorsett), PGY-3

@WUSTL_EM FOAMed Digest #7: Best of the Best of the Best Sir! ...With Honors

To build on my “Intro to FOAMed” lecture from Tuesday, I thought I would use the Digest this week to highlight some of the highest-quality resources out there for those of you just dipping your toes into the FOAMy goodness. You can’t go wrong adding these to your Feedly. Well-referenced, expert review, open discussion with prompt response – they’re really setting the bar for the FOAMed world.

And don’t worry – in the spirit of FOAMed the lecture and slides will be posted as soon as the video editing is done.

Now come on in, the water’s fine!

Three Stars:

1. Academic Life in EM (ALiEM) continues to be one of the paragons of the FOAMed community. Check out this “Diagnose on Sight” case from this week – don’t want to give it away, but you will see it time and time again during your Children’s shifts. Make note of the reference list and pre-publication review from a practicing clinician. Supremely high quality.

2. I must credit my inspiration for this FOAMed Digest – the LITFL Review from Life in the Fast Lane. Curated by some of the sharpest tacks around, it’s a great way to get familiar with the variety of resources out there. Lots of good stuff this time around, including links to Amal Mattu’s EKG video review of QT prolongation, the latest edition of FOAMCast (all about the spleen!), and the St. Emlyn’s view of the new NICE guidelines for managing acute heart failure.
EXTRA CREDIT: If you need help keeping up with the EM primary literature, the Research & Reviews in the Fastlane segment is a great place to start!

3. EM Lyceum takes the “flipped classroom” concept to the next level. Every month or so, they publish a series of clinical questions focused on a particular topic. This time, it was trauma. The point is to ponder those questions, discuss them in a group, and maybe even do your own research. The EM Lyceum group then publishes the best evidence-based answers they could find in an exceptionally well-referenced summary. Pearl from this month: Bust out the PCC for ICH on warfarin, but no good evidence for PCC in your “average” coagulopathic trauma patient.  





Oldie But Goodie:

This post isn’t actually that old, but it’s about older patients, so we’re gonna count it. On the heels of Dr. Galante’s lecture from last month, Ken Milne at the Skeptics’ Guide to Emergency Medicine takes on Chris Carpenter’s systematic review of ED tool to predict fall risk ingeriatric patients from this months Annals.
This is a can’t-miss episode, as it is the initial installment of the “Hot Off The Press” series. You can watch in real-time as the FOAMed and published-journal worlds start to merge. Each episode of this series will feature a critical analysis and interview with an author of a paper just published in Annals or CJEM. The audience (i.e., everyone) will have a chance to respond with their own post-publication peer review via social media outlets. The top responses will be featured in a future publication in each journal. Knowledge translation and crowdsourced feedback at the speed of social media!

F(FN)OAMed:

If you’re going to pick one podcast to listen to religiously, that podcast should probably be EM:RAP. This month, be sure to check out the segment on IV contrast myths.
Take-home points: Iodine is not an allergen. Seafood allergy does not increase risk of anaphylaxis to IV contrast any more than any other given allergy, although previous reaction to IV contrast or past history of atopy does increase risk. And most notably – premedication with steroids has not been shown to decrease the number of severe reactions.

The Gunner Files:

1. Check out Scott Weingart’s interview with Dr. John Hinds regarding his approach to the patient with blunt traumatic arrest.
In Dr. Hinds’ shop, before they do anything else they: 1) intubate, 2) perform bilateral finger thoracostamies, 3) place a pelvic binder, 4) reduce any gross long-bone deformities, 5) start uncrossmatched transfusion. Only then do they start a formalized assessment. Really interesting stuff.

2. Similar to the R&R from the Fastlane mentioned above, Ryan Radecki’s EM Lit of Note blog is another excellent version of a curated primary literature review. Here is his critical appraisal summary of a systematic review and meta-analysis comparing trauma “pan scan” with more selective imaging.

3. The most recent installment of the EM BASIC podcast is your panic-free look at what we know about Ebola – screening, clinical signs & symptoms, diagnosis, isolation, and treatment.

4. The ultimate skeptic, Rory Spiegel of EM Nerd, turns his nihilistic eye towards the cash cow of cardiac interventionalists everywhere – PCI. Turns out, there’s not a lot of evidence to support its use outside the realm of emergent intervention for STEMI.

5. In the most recent podcast on Emergency Medicine Cases, an EM sports medicine specialist and an orthopedic surgeon help you to avoid falling prey to the “Commonly Missed (Uncommon) Orthopedic Injuries.” Want to know how not to miss a DRUJ? Lisfranc? Perilunate? Tune in.


Never stop learning,


C. Sam Smith, PGY-3

Expert Commentary: ARISE and ED Sepsis Resuscitation

As we discussed on our last Paper Trail post, the results of the ARISE and ProCESS trials seem to indicate that the most meaningful interventions for a patient in severe sepsis/septic shock are early antibiotics & source control and aggressive resuscitation in an appropriately-monitored environment. 

At our shop, we're currently working on analyzing our own sepsis response data and designing new protocols. In these discussions, some have expressed concern over the potential for giving too much fluid to these patients. The concepts of "fluid responsiveness" and "fluid tolerance" are the subject of much debate in the FOAMed critical care world these days. 
(See the discussions between Drs. Marik and Weingart over at EMCrit for reference.)

Our own ED Critical Care guru, Dr. Christopher Holthaus, stepped up to the plate and offered his views on fluid resuscitation of septic patients in the ED:




"The fluid issue can be challenging. Although some studies suggest that an early restrictive fluid strategy potentially may bear a signal [toward improved outcomes], the preponderance of current ED-based RCTs involving patients with severe sepsis and septic shock will have up-front ED volumes of 4-6L and are showing the best mortalities to date (approx. 18%). [See comparative table below delineating up front/early fluid volumes PROCESS vs ARISE -- Ed.] 

"Although any patient is at risk for volume overload during a resuscitation, patients in these studies appear to have tolerated these volumes relatively well with low adverse events as far as acute pulmonary edema (< 0.02%). We know patients do worse if they are dry and get placed on pressors. Somewhere in between probably lies the truth. Perhaps better exact timing of fluid administration when the heart is truly volume-responsive (i.e., on the ascending portion of the Starling curve) will be the way to go. It remains to be seen, but this approach hypothetically may also show the same overall total volume in the end...     

"Nevertheless, perhaps in the meantime a more judicious rule of thumb is to discriminate "early vs. late" in the resuscitation, and to acknowledge that patients with distributive shock from sepsis generally have trouble maintaining intravascular volume and/or blood pressure during SIRS-related events. Unfortunately we don’t have any great immediate fixes for that yet besides giving volume (or pressors), treating the source, and supportive care. 

"Providers dealing with these patients early in their presentation (i.e., first 6-8 hours) are supported in administering total fluid volumes of 4-6 L (Rivers’ EGDT, PROCESS, ARISE). The RCT using an ED early restrictive fluid strategy for these patients does not exist yet. In current practice, most providers will bolus the first 1-2 L on presentation and perhaps another 500-1000 mL "PRN" based on various factors -- fluid tolerance, tachycardia, hypotension, urine output. The argument for a maintenance rate in these patients is supported by Figure S2 from the PROCESS trial [shown below - Ed.] which used maintenance rates of 250-500 mL/hr once a SBP > 100 or Shock Index < 0.8 were achieved with boluses. This point alone was perhaps one of the best contributions from PROCESS in regards to demonstrating a proven objective alternate fluid administration strategy which went beyond the original use of CVP for quantitative resuscitations. 

"Because the ED currently does not have a go-to gold standard outcome study for gauging volume responsiveness via dynamic changes in stroke volume in these patients, we are left with the fluid volume quantity and rates which stands as the current best available evidence (i.e., 4-6 L in first 6-8 hrs parsed between boluses and maintenance rates).

"In the end, of course one size does not fit all and clinical judgment individualized to the patient is always warranted."

Adopted from ARISE & ProCESS data by Holthaus CV.




Protocol for Standard Therapy arm of ProCESS trial (Supplmental Figure S2)


What do you think? Is fluid overload from ED resuscitation in the "early" phase of sepsis a legitimate concern? When do you pull the trigger and start pressors? Let us know what you think!


Submitted by Christopher V. Holthaus MD.
Copy editing C. Sam Smith, PGY-3.



FOAMed Digest #6 Update: The Paper Trail

Today, we'd like to introduce a new section to the Everyday EBM FOAMed Digest, which will be published as a standalone post. It may seem a bit counterintuitive, but each week we're going to draw your attention to some of the latest-and-greatest papers from the primary EM literature. Most of these will not be open-access, but we hope you can still access them via the medical library at your institution. A lot of the discussion in the FOAMed world centers around recently-published papers from EM journals. The EM trainee should view FOAMed as a tool to assist with understanding and analysis of this literature, as a forum for discussion and further discovery -- not as a replacement for reading the papers for his/her self. We'll provide you a very short summary here and link you to relevant FOAMed resources if applicable.




1) This week, it's impossible to hold any discussion of EM literature this week and not start with the ARISE trial. Hot on the heels of ProCESS, the results of this trial appear to confirm what resuscitationists have long suspected: in terms of sepsis care, you don't have to do a lot of s***, you just have to give a s*** (H/t Dr. Weingart).

Briefly, this multi-center RCT enrolled over 1600 patients from 51 hospitals (mostly in Australia & New Zealand) who presented to an ED with suspected infection, 2+ SIRS criteria, and refractory hypotension (low SBP after 1L IVF) and/or hypoperfusion (lactate >4). These patients were randomized to receive EGDT (as ensured by a dedicated sepsis response team) or "usual care," which allowed for treatment at the physicians' discretion except that ScvO2 measurement was not permitted within the first 6 hours of therapy. There was no difference in the primary outcome, mortality at 90 days.

Needless to say, this publication has got the FOAMed world all atwitter (pun intended).

- The best high-yield summary with all the relevant info can be found on The Bottom Line. Also includes links to other FOAM resources, and excellent tables comparing the Rivers trial to the "holy trinity" of modern sepsis studies -- ProCESS, ARISE, and ProMISe.
- EM Lit of Note also published a short piece.
- Scott Weingart of course has an excellent summary on his latest EMCrit podcast, which has the added bonus of including references to two other recently published papers. The TRISS trial from NEJM found no differences in clinical outcomes when using transfusion goals of 9 g/dL vs. 7 g/dL. A retrospective study by Ferrer et al published in Critical Care this month again demonstrates that delayed time to antibiotics for patients with severe sepsis/septic shock increases mortality in a near-linear fashion. (The Bottom Line summary of the Ferrer study here).
- The European Society of Intensive Care Medicine posted an interview and a presentation by the lead author of ARISE, Dr. Sandra Peake.


The ARISE trial is probably more than enough to keep you busy, but a few more items for your perusal:

2) The Dalai Lama of PE diagnosis in the ED, Dr. Jeffrey Kline, is back at it again, this time with a systematic review and meta-analysis of pregnant patients undergoing investigation for PE in the ED. Seventeen studies including over 25,000 patients were analyzed, and Dr. Kline's team found a lower rate of VTE among pregnant patients compared with nonpregnant patients, with a pooled risk ratio of 0.60 (95% CI 0.41-0.87). Dr. Kline cautions, "We do not interpret these data to indicate that pregnant patients have a lower risk of PE when compared to healthy nonpregnant patients. Instead, we believe that our data illustrate that clinicians order testing at a low test threshold among pregnant patients." Well worth a read.
- Our own Captain Cranium, Dr. Chris Carpenter provided a commentary to this piece, astutely summarizing the controversy of PE overdiagnosis.
- Sarah Sanders, a 4th year medical student (!) posted an excellent summary of this paper and other current research to the EM Curious blog.

3) While this next paper is perhaps not of the most relevance to the EM trainee, its publication should be a source of pride for all of us here at Wash U. The results from the Contraception CHOICE Project, conducted entirely here in St. Louis by the Washington University OB/Gyn Department, were published in the NEJM this week. Through private funding, the investigators were able to provide young women enrolling in the study their choice of birth control method, with special emphasis on Long-Acting Reversible Contraception (LARC) such as implants or IUDs. Without cost as a barrier, 72% of the women enrolled chose a LARC method. Women utilizing LARC methods reported unintended pregnancy at a far lower rate than the national average, especially for those age 15-19 years. Really great work.

Never stop learning,
Sam Smith, PGY-3

#FOAMed Digest No. 6: Ain't Nobody Got Time For That

Welcome back, FOAMheads! My apologies for the delay this week. I ended up being a bit busier than I expected, which not coincidentally brings me to the theme for today's entry.

Sometimes you have a lot on your plate and may not be able to set aside a large chunk of time to watch/listen to a 30-minute-plus podcast. But that doesn't mean you don't have time to get your learn on! This time around, we'll highlight some of the best FOAMed sources of short-and-sweet educational pearls. Easily digestible for the highly-distractible mind of the EM trainee.

There is no moment like the present -- let's get started!




Three Stars:

1. The Glasgow Coma Scale was first introduced 40 years ago. It's past time we started assessing it properly. "GCS 12" doesn't cut it any more. What are the deficits? How do you score for eye-opening if the patient's eyes are swollen shut from trauma? What does "abnormal flexion" even mean, anyway? Ian Miller at TheNursePath provides us an excellent infographic-style breakdown of the "new" GCS.

2. The EMS 12-Lead blog, edited by EMT-P and prehospital resuscitationist extraordinaire Tom Bouthillet, is an excellent resource of EKG cases. This week's case provides an excellent example of why a resuscitationist must always treat the patient, not the monitor. Review the EKG and develop your interpretation first, then read the conclusion.

3. I don't know that a FOAMed segment has ever been more appropriately titled. "Positively Painful Private Parts" is a four-part series published by Brad Sobolewski on his PEM Blog, focusing on the evaluation of acute testicular and scrotal pain. There is a pediatric focus, not surprising given the nature of the blog, but Dr. Sobolewski does include information on "adult" diagnoses like epididymitis as well. Each part is succinct and high yield.
Part 1: Focused H&P
Part 2: Testicular torsion
Part 3: Pathology of the appendix testis
Part 4: Epididymitis

Oldie But Goodie:

An excellent case from The Blunt Dissection, in which Dr. Chris Partyka lays out everything you need to know when you must intubate a crashing neonate.

F(FN)OAMed:

Via your EMRA membership, you now have access to all of the resources from the EMedHome website. Go to the site and explore for yourself the wealth of resources available -- everything from taped lectures from prior EM conferences, the EMCast podcast hosted by Amal Mattu, weekly clinical and radiology pearls, and other vodcasts and presentations.

This week, check out the clinical pearl describing some of the changes in the new 2014 AHA/ACC guidelines for management of patients with NSTEMI.  Ryan Radecki at EM Lit of Note also published his take on the new guidelines this week; well worth the quick read.

(As always, if you need help getting access to any of these resources, please contact your friendly neighborhood Social Media Committee member.)

The Gunner Files:

1. Reinforce the take-home points from the EM Lyceum piece on DKA management with this bullet-pointed breakdown by Adaira Landry on emDocs.

2. In case you've been off the grid for the past week, ebola is here. Triage and isolation protocols are coming to an ED near you any day now. Luckily for all of us Daniel Cabrera at the Mayo EM Blog published for your review the CDC infographic Algorithm for Evaluation of the Returned Traveler.

3. So the latest installment of the Skeptic's Guide to Emergency Medicine will take you about half an hour to listen to, but it's well worth the time. Drs. Milne and Swaninathan analyze the Ottawa Aggressive Protocol for ED cardioversion and discharge of patients presenting with AFib.
This piece really highlights the interconnectedness of the FOAMed world, as it references back to last week's FOAMCast on AFib (as seen in FOAMed Digest #5), and a recently-published research letter (containing data from the largest-ever study on this topic) in JAMA calling into question the safety of cardioverting AFib patients presenting with >12 hours of symptoms.
This research letter was analyzed in depth by Rob Orman on the latest episode of his ERCast.
We're all in this together, folks.

4. I don't want to think too hard about having a cricket or other insect lodged in my ear canal, but it is probably in our best interest to know what to do if we're presented with it. Mitchell Li at ALiEM has us covered. (Great tip for getting out plastic beads, too!)

5. When you do get a little extra time, don't miss the September installment of the Annals of Emergency Medicine podcast. Covered topics include pigtail catheters for pneumothorax, acute stroke care, age-adjusted D-dimer cutoffs, and the HINTS exam (authored by our very own Dr. Brian Cohn!) You can download the podcast directly here.
(And be sure to check out Cohn's paper!)

Never stop learning,
Sam Smith, PGY-3

#FOAMed Digest No.5: But This One Goes to 11

Time once again for your mid-week blast of FOAMy goodness from around the interwebs. There’s no particular subject today; instead we’re going to highlight some of the better podcasts/vodcasts that updated this week. Podcasts are great. They break up the monotony of reading (and the monotony of mundane things like laundry, grocery shopping, training for this damn marathon…). For the more distractible among us, they usually come in easily-digestible 20-30 minute morsels. They expose you to different presentation styles, and allow you to match a face and a voice with the big names in FOAMed. Most of them also feature written show notes with references as well, which allows you both to reinforce the things you learned while listening, and also to dig deeper into topics you’re interested in.

Fun for the whole family!

Three Stars:

1. I think FOAMcast, authored by residents and EM social media savants Jeremy Faust and Lauren Westafer, might be the first example of “metaFOAM.” They peruse the FOAM world for interesting recent posts, then integrate that information with relevant material from the most popular EM textbooks (i.e., “Rosenalli”), other relevant blogs/podcasts, primary literature, and even Rosh Review questions. This week they use a post from ALiEM on calcium channel blockers vs beta blockers for A-Fib as a jumping-off point for a discussion on ED management of A-Fib and A-Flutter. There’s links to vodcasts from Scott Weingart and Amal Mattu on narrow-complex tachydysrhythmias, and plenty of cited references from the primary literature (including one from our own Brian Cohn!). It’s good stuff.

2. Speaking of the Godfather of ED EKG, Dr. Mattu has two quick cases for you to ponder. Remember: T-wave inversion does not always mean cardiac ischemia!
Remember: Gotta think tox in a seemingly unprovoked wide complex tachycardia!

3. Steve Carroll at EM Basic provides an excellent analysis of the ED management of asymptomatic hypertension, including references to the relevant ACEP Clinical Policy document and other FOAMed resources.


Oldie But Goodie:

Chris Nickson, creator and administrator of Life in the Fast Lane, gave an excellent talk at the original SMACC conference in March 2013 with the confidence-inspiring title, “All Doctors are Jackasses.” Why are we jackasses? Because we don’t do enough to understand how we think and how we make decisions, and this leads us to make errors. Watch Nickson’s lecture and begin to understand how to remedy this situation.
(EXTRA CREDIT: Links in the show notes to the other SMACC talks in the “Mind of the Resuscitationist” plenary by Weingart, Cliff Reid, and Simon Carley.)

F(FN)OAMed:

By this point you guys all know how awesome EM:RAP is, but this week is particularly relevant because Herbert & Co. just released an “EM:RAP Mini” segment about the newly-published “Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis” trial in the New England Journal. For those of you that aren’t familiar, this was a study in which we participated, and our own Drs. Aubin and Griffey are authors on the paper! An excellent summary of this paper is found on the Emergency Medicine Ireland blog, with a link to download the EM:RAP Mini segment in the show notes.

The Gunner Files:

1. Time to synthesize the knowledge you gained about non-surgical management of pediatric appendicitis at Journal Club last month. Dr. Cohn is back with another excellent EMJClub podcast along with Drs. Trehan and Horst, summarizing the primary literature.

2. EMin5 is back at it with a review of the four types of shock, in a little over four minutes.

3. From the Maryland Critical Care Project, an excellent lecture from Neuro Critical Care and ED intensivist Dr. Wendy Chang describing the ED management of status epilepticus. She covers the gamut from first-line benzos to second-line AEDs and third-line agents for initiation of therapeutic coma.

4. The good people at the All NYC EM blog posted a lecture given during their conference day by the FOAMed superstar Dr. Haney Mallemat. He covers all the basics of ultrasound evaluation of pericardial effusion and tamponade, even ultrasound-guided pericardiocentesis.

5. In case you’re not familiar, US Air Force Pararescuemen, a.k.a. “PJs,” are the ultimate badasses. Just look at it this way: think becoming a SEAL is tough? PJ training has an even higher failure rate. But I digress.
Former PJ and critical care flight retrieval medic Mike Lauria is now in medical school, and is making a bit of a splash in the FOAMed community as an expert on training, thinking, and operating in high-stress environments. Scott Weingart recently interviewed him on EMCrit about the concept of “mental toughness,” how that translates from the combat realm to the ED, and how to incorporate it into physician training. Really interesting stuff.


That Others May Live,

Sam Smith, PGY-3

#FOAMed Digest No. 4: Butter My Biscuit, Baby

Welcome back, to the brand new edition of the WUEMR FOAMed Digest. Get out your Tintinalli’s and strap in, because we’re going back to basics today. It’s all about the bread and butter. The things any PGY-2 setting off to an overnight Saturday shift in the Deuce should have down cold…yet us seniors still screw up on the daily.

FOAMed…ENGAGE!

Three Stars:

1. If my last shift at Children’s is any indication, the season is upon us – pharyngitis in every exam room. Casey Parker over at Broome Docs (a blog authored by EPs & GPs practicing in rural Australia), presents a magnificent summary of the data surrounding rapid strep swabs, antibiotic use for symptom relief, and antibiotic use for preventing secondary complications of strep. As always, be sure to check out the original literature for yourself. And don’t miss Minh Le Cong’s excellent counterpoint in the comments, which is also well-referenced.

2. What’s your record for most C-collars cleared in one shift? (When you hit double-digits, then we can talk.) The best tools in our arsenal for clearing C-spine in low-risk patients remain the Canadian C-spine and NEXUS instruments. But which one should you use? Do you even remember which criteria belong in each rule, or do you find yourself trying to apply the “Canadi-EXUS” criteria, like I do? Luckily for us, Alayna Hawling at BoringEM authored an excellent rundown and comparison – with a pretty flowchart!

3. As much as you want to start the fist-pumping and beer-chugging as soon as you drop that tube past the cords, your work with the intubated patient is not done, my friend! We’ve already touched on our persistently poor rates of achieving adequate analgesia & sedation in the intubated patient. Another part of quality post-intubation care is knowing what to do if your ventilated patient acutely decompensates. Check out Chris Cresswell’s summary of the DOTTS mnemonic over at EM Tutorials.
(EXTRA CREDIT: He also included a link to Scott Weingart’s notes regarding care of the crashing ventilated patient, which are well worth a look.)

Oldie But Goodie:

There’s been some e-mail discussion lately among our attendings regarding the best way to clean lacs prior to closure. Back in February, Ken Milne at the Skeptic’s Guide (along with Eve Purdy, a rockstar med student and creator of the excellent Manu et Corde blog) published a piece dedicated to breaking down the dogma of management of simple lacerations. Tap water vs sterile water, sterile gloves vs clean gloves, to sew or not to sew…it’s all covered here. Plus there’s links to other excellent FOAMed resources regarding wound care dogma.

F(FN)OAMed:

The good folks over at EB Medicine recently published a stem-to-stern guide to UTI diagnosis and management in the ED, all based on best available evidence. A bit lengthier than your average blog post, but incredibly high-yield and well worth your time. It’s a bit difficult for me to place a direct link here, but you can find it simply by logging into your account at EBMedicine, following the link to browse issues of Emergency Medicine Practice, and opening the July 2014 issue on UTI.
(As always, contact your friendly neighborhood Social Media Committee member if you need help obtaining access to EB Medicine resources.)

The Gunner Files:

1. Hard to get through a Deuce shift without breaking out the prochlorperazine at least once. We’ve all seen patients get jittery, agitated, or downright whacky following its use. Does Benadryl help? A PharmD expert at ALiEM has a good lit review of the topic.

2. Short and sweet: some diabetic medications are more likely to cause harmful hypoglycemia after overdose than others. Quick table-based rundown over at ALiEM.

3. It is asthma season, and you may find yourself in the worst-case-asthma-scenario of impending need for intubation. Check out this post from The Kings of County regarding care for the sick asthmatic, including intubation and mechanical ventilation issues.

4. FOAMed is taking the world by storm! Does the UK College of Emergency Medicine launching a dedicated FOAMed site mean it’s officially gone mainstream? Don’t worry – we were all into FOAMed before it was cool. But seriously, check out this vodcast on diagnostics in EM, and not feel quite so much increase in sphincter tone when Carpenter or Cohn pimp you on likelihood ratios or Bayesian analysis.

5. Another classic from the Skeptic’s Guide, this time addressing another oh-so-common ED complaint: renal colic. Fluids? Flomax? Any good evidence for either? In news that will surprise no one, Ken Milne is skeptical.


Never stop learning,

Sam Smith, PGY-3

#FOAMed Digest No. 3: You Need Me On That Wall

Emergency Medicine physicians practice in a unique environment. We must synthesize plans for  diagnosis, management, and disposition while utilizing input from almost every subspecialty, and the ED is the ultimate proving ground for diagnostic tests and treatment modalities of every sort. Unsurprisingly, a fair deal of controversy and debate exists regarding the optimum management of patients. (For reference, see any Trauma Case Conference featuring Drs. Schuerer and Aubin.) The “best evidence” is often poor evidence. We in Emergency Medicine retain the rebellious spirit of our founders, and are always looking for new and innovative techniques. Some physicians are too quick to jump on the bandwagon, and others lag behind the curve when it comes to adopting new practices.

The selections this time around are not meant to tell you the best way to do things. The algorithms and practice patterns suggested are not universally adopted, written in textbooks, or taught as part of any standard curriculum. They are meant to promote thought, to prompt you to read the primary literature for yourself, to encourage you to seek the opinions of other experts on the subject, and to form your own conclusions. Hopefully they will inspire you to suggest new ideas to your seniors and attendings during your next shift – or even question ideas you think are unsound. Maybe, just maybe, they will even inspire a new research or QI project. FOAMed is by design perfectly adapted to assist you in this quest.

Ramblers, let’s get ramblin’.

Three Stars:

1. Ken Milne at the Skeptic’s Guide to Emergency Medicine pretty much sets the bar when it comes to FOAMed of the latest EBM topics. He asks his clinical questions in the PICO format, he applies a rigorous quality checklist when analyzing the available literature, and includes in his discussion other FOAMed experts (including on occasion our very own Chris R. Carpenter, a.k.a. “Captain Cranium”). This episode he turns his skeptical eye to a topic sure to generate heated discussions for years to come: tPA for stroke.

2. If there’s anyone that looms larger in the ED Critical Care world than Weingart, it’s Resuscitationist Extraordinaire Cliff Reid. His lecture from the SMACC Gold conference hit resuscitation dogma like an A-bomb, leaving irradiated bits of unfounded practice patterns strewn about the Outback countryside.
(EXTRA CREDIT: Reid’s talk from the original SMACC conference, “Making Things Happen,” should be required viewing for anyone wanting to be a Trauma Senior someday.)

3. If pediatric surgeons have come to accept ultrasound as a stand-alone diagnostic method for appendicitis, maybe there’s hope that someday ultrasound can also be used as a radiation-sparing technique for diagnosis of small bowel obstruction. Academic Life in EM has an excellent run-down of the technique and comparative research studies.
(EXTRA CREDIT: The book Evidence-Based Emergency Care, authored in part by our own Captain Cranium Chris R. Carpenter, has a chapter dedicated to the inferiority of plain films for SBO diagnosis. You can read it for free online via Becker Library.)

Oldie But Goodie:

I think here in a few more years this will reach “accepted standard practice” level, and maybe even “textbook” level, but it’s not there yet. It should be: there’s good evidence to show kayexelate doesn’t work, and may even cause harm. Let Weingart and the PaperChase fellows from EM:RAP give you the ammunition you need to stand up to any pesky floor seniors.

F(FN)OAMed:

In a very enlightening segment from this month’s EM:RAP, Rob Orman interviews a community ED practitioner, Dr. Cameron Berg, regarding his hospital’s new Accelerated Diagnostic Protocol for low-risk chest pain. While his exact algorithm hasn’t been externally validated and probably isn’t ready for prime-time at our shop, the evidence-based and pragmatic approach is certainly worth considering. And he provides links to almost all of his references in the show notes!

The Gunner Files:

1. The “Research & Reviews” segment on Life in the Fast Lane is worth checking out every week. A group of some of the brightest minds in the FOAMed world get together and spoon-feed us summaries some of the most relevant, practice-changing, or downright strangest papers in the EM literature.

2. Josh Farkas over at PulmCrit wrote an excellent piece laying out his argument for super-high-flow NC (think 30-45L!) as an acceptable method of preoxygenation before RSI. It’s also got a good rundown of apneic oxygenation using NC (which we all should be doing every time), and an enlightening counterpoint from the grand maester of ED Critical Care, Scott Weingart.

3. Pediatric EM expert Sean Fox provides an excellent summary of the neonatal ALTE on his blog Pediatric EM Morsels.

4. Two EM airway heavyweights, Rich Levitan and Reuben Strayer, slug it out in the ultimate Direct Laryngoscopy vs Video Laryngoscopy debate, posted to the Prehospital and Retrieval Medicine podcast hosted by Minh Le Cong.

5. All of us will be the bearer of the -07 phone at some point, and that means you better have your act together when discussing decision-making capacity. Bill Johnston, EMT-P and author of the excellent blog Prehospital Wisdom, shares his fundamentally sound and no-bullshit method for determining capacity in the field.

In the words of Ken Milne: “Meet ‘em, greet ‘em, treat ‘em, and street ‘em!”

Sam Smith, PGY-3

#FOAMed Digest No. 2: Breathless Love

Welcome back! Fresh new FOAMy goodness for you, this time with an emphasis on airway and pulmonary care. Let’s do it!

Three Stars:

1. No way around it: “Delayed Sequence Intubation” is the new hotness. If you want to be one of the cool kids, you better get on board. I’ll let the more graphically-minded folks at EMCurious lay it all out for you with a prototypical case. Don’t miss the links – more excellent FOAMed resources on DSI.
(And Weingart’s seminal paper on the subject is required reading at this point.)
(And, oh yeah, ketamine does NOT increase ICP. Let’s use these two systematic reviews 1 & 2 to stop the foolishness already.)

2. Someday you will need to perform a cricothyrotomy. Accept it as reality, and do everything you can to prepare for it. Start here, with Weingart’s lecture on the surgical airway delivered at the SMACC Gold conference last fall. This page from the EMCrit blog has compiled all sorts of great surgical airway resources from around the FOAMed world all in one spot, including can’t-miss stuff about the scalpel-finger-bougie technique and Weingart’s pre-intubation checklist. You should probably add it to your favorites list now.

3. Wouldn’t be a FOAMed Digest without getting a little off-topic, and Rick Body’s recent contributions over at St. Elmyn’s regarding ACS & “low-risk” chest pain in the ED are too good to pass up. Great post analyzing his recent paper, which concluded ED physicians simply aren’t capable of ruling out ACS in chest pain patients with an acceptable accuracy using only the clinical exam. Dr. Body also gives you a run-down of how to properly utilize high-sensitivity troponin in his talk from SMACC Gold.
(Link to Body's paper here.)

Oldie But Goodie:

By the end of our Ultrasound rotation, we can all diagnose pneumothorax with ultrasound at the bedside. It’s time to take it next-level. A-lines, B-lines, pneumonia vs edema…the experts at the Ultrasound Podcast help you figure it all out in a two-part 1 & 2 podcast.

F(FN)OAMed:

Sanjay Arora and Mike Menchine, hosts of the PaperChase segment on EM:RAP, summarize the current literature about how terrible we are at adequately sedating patients after RSI. Roc lasts longer than Sux – the patients won’t be able to tell us they need sedation!
(Links to relevant papers in the show notes.)

The Gunner Files:

1. Brett Sweeny at EMDocs provides an exhaustive review of FOAMed resources regarding permissive hypotension in trauma. Great lectures and podcasts from some of the brightest minds in EM & trauma surgery.

2. We’re seeing it already – asthma cases are starting to pile up over on the SLCH side. Luckiliy for you, Pediatric EM rockstar Andy Sloas just published an excellent podcast on the evaluation and management of asthma in the Peds ED.

3. Next time you’re consulting Ortho or Plastics for a hand injury, sound like you know what you’re talking about. The folks over at EMin5 hit you with the quick rundown on the neuro exam of the hand.

4. Last week, St. Elmyn’s helped the rooks get up to speed when it came to dealing with the dyspneic patient in the ED (and I bet the seniors learned a thing or two as well). This time, get your mind right when faced with a syncopal patient.

5. Who doesn’t love infographics? And if they actually help us learn something about managing septic patients, that’s just a bonus! Very well done by EMCurious, with embedded links to the relevant studies!

6. New podcast from R.E.B.E.L.EM, summarizing the results of a meta-analysis just published this month in Annals which concluded prehospital application of NIPPV in patients with severe respiratory distress regardless of cause reduced need for intubation (NNT 8) and in-hospital mortality (NNT 18). 
w00t prehospital medicine!
(Original pub here.)

That’s all, folks! Go get your learn on!

Sam Smith, PGY-3

#FOAMed Digest No. 1: Total Eclipse of the Heart

Welcome to the very first edition of the WUEMR FOAMed Digest! The Social Media Committee hopes with this segment to parse out from the overwhelming FOAMed universe a few of the most high-yield pieces of highest relevance to the general EM trainee. We hope to deliver this in an easily digestible format that you can realistically work through over a week – even if you’re stuck in an ICU.

Each post will contain several sections:

1. Three Stars: Three of the best-of-the-best from the FOAMed world published in the past week or so.

2. Oldie But Goodie: The FOAMed universe has been around long enough that there’s already a good number of very well-done and highly informative blog posts and podcasts.

3. Free (For Now) Open Access Med Ed: F(FN)OAMed for short. There are some great resources out there that are not free to the vast majority of EM practitioners but, due to your EMRA membership being graciously covered via the residency and MoCEP, you have access to them. Most notably, your EMRA membership allows you subscription to the EM:RAP podcast and the EB Medicine resources – EM Practice, EM Critical Care, etc. You should take advantage of this opportunity while you can, and this section will help you do so. (Contact your friendly local Social Media Committee member if you need help setting up your access.)

4. The Gunner Files: The Social Media Committee recognizes that, with this being Wash U and all, some of you will always be overachieving. So we’ll include a few extra selections for those of you that have a more insatiable FOAMed appetite.

Without further ado, let’s kick the tires and light the fires.
This week, “Total Eclipse of the Heart,” will focus on care of various cardiac conditions.

Three Stars:

1. Ever heard of Wellens’ Syndrome? If you have any hope of passing your boards one day, you should. Not mention that whole “you shouldn’t miss a critical EKG finding that portends certain doom” thing. Never fear, Salim Reazie, author of the excellent R.E.B.E.L.-EM blog, has you covered
(Don’t miss the links list at the bottom that highlights posts from other top-notch FOAMed resources!)

2. Syncope is one of those presenting complaints that really must be approached in a systematic manner. The grandmaster of EM EKG interpretation, Amal Mattu, reviews the differential while highlighting the characteristic EKG findings of a can’t-miss diagnosis.

3. Okay, so DKA isn’t exactly a “cardiac” condition – but the worst-case-scenario is still hemodynamic collapse, right? It counts. The EBM gurus over at Anand Swaminathan’s blog EMLyceum give you the latest & greatest when it comes to evidence-based care of DKA.

Oldie But Goodie:

So you’ve achieved the nigh-impossible – achieved sustained ROSC in an OHCA patient. Now what? The reigning American Idol of EM Critical Care, Scott Weingart, tells you what in an excellent two-part interview with one of the lead authors of the TTM trial, Stephen Bernard.

F(FN)OAM:

Worst-case scenario #137: Running ACLS on a patient brought in with PEA arrest. As CPR continues, the staff looks to you. “Uhhhhhh…more Epi?” Like all things resus, you need a systematic approach. The smart dudes over at EM:RAP, along with EM cardiology expert Amal Mattu, review a newly published paper that will help you do just that in the August 2014 edition.
PubMed link to the paper itself here.
(Once again, contact the Social Media Committee if you need helping subscribing to EM:RAP.)

The Gunner Files:

1. Excellent review article from the journal Emergency Medicine Australasia covering that bane of the overnight Deuce shift. No, not vaginal discharge – dental pain.

2. EMLyceum deals in pearls once again when addressing ocular emergencies.

3. Ryan Radecki over at EMLitofNote looks at a very interesting paper just published in JAMA regarding the use of pulse oximetry and dispo of bronchiolitis patients
(And as always, be sure to read the original paper for yourself!)

4. My FOAMed man-crush, Rory Spiegel of EMNerd, tackles the C-spine injury algorithm debate.

5. The Aussies over at St. Elmyn’s get you straightened out when dealing with the breathless patient in the ED. Incredibly high-yield for new ‘terns, but useful for docs of all ages.

Now get to FOAMing! 
As always, comments/concerns/criticisms are appreciated!



C. Sam Smith, PGY-3