Clinical you say?

Thanks to Journal Watch for this article:

Clinical Signs Accurately Identify Pneumonia, Study Suggests

by Jennifer Garcia

Four clinical variables — the presence of fever, elevated pulse rate, crackles on auscultation, and low oxygen saturation — can help identify patients with pneumonia in the primary care setting, according to new data.

"[T]he four variables identified by this analysis are easily measured clinical signs," write Michael Moore, BM BS, MRCP, FRCGP, from the University of Southampton, Aldermoor Health Centre, United Kingdom, and colleagues.

"If antibiotic prescribing was restricted to people who had one or more of these signs, it could substantially reduce antibiotic prescribing for this condition," the authors write in an article published online November 22 in the European Respiratory Journal.

For the prospective cohort study, the researchers evaluated 28,883 patients between 2009 and 2013 who presented to their primary care provider with symptoms of acute cough attributed to a lower respiratory tract infection

Among the 720 patients radiographed within the first week after their initial consultation, 16% (115/720) were diagnosed as having definite or probable pneumonia.

The researchers noted specific independent predictors of radiograph-confirmed pneumonia among this cohort, including temperature 37.8°C or higher (risk ratio [RR], 2.65; 95% confidence interval [CI], 1.46 - 4.81), pulse rate 100/minute or higher (RR, 1.90; 95% CI, 1.12 - 3.24), crackles on auscultation (RR, 1.82; 95% CI, 1.12 - 2.97), and oxygen saturation below 95% (RR, 1.73; 95% CI, 0.98 - 3.06).

Overall, 86.1% (99/115) of patients with pneumonia exhibited at least one of these clinical signs. In contrast, other factors, including presenting symptoms, age, sex, smoking history, and past medical history, provided no predictive information for a pneumonia diagnosis.

The authors note that previous studies have found fever, crackles, and elevated pulse rate to be predictors for the presence of pneumonia. However, unlike the current best diagnostic model, the presence of a runny nose was not found to be significant in the present study. In contrast, the addition of pulse oximetry has demonstrated clinical utility in previous retrospective studies in the primary care setting.

The researchers acknowledge limitations to the study, primarily that thoracic radiographs were only obtained in a small sample of the full cohort and that those patients selected for radiography were more ill and at higher risk for pneumonia. This may have resulted in fewer reported cases of radiograph-confirmed pneumonia in the cohort as a whole, and as well as overemphasis of the importance of the four clinical signs as positive predictors of pneumonia.

Given this limitation, the study authors caution that, although pulse oximetry may have a role in the diagnosis of pneumonia, further studies that include comprehensive assessment, including thoracic radiographs, will be required.

Funding for this study was provided through a grant from the National Institute for Health Research. The authors have disclosed no relevant financial relationships.

Eur Respir J. Published online November 22, 2017. Full text

Webucation 30/8/17

Webucation this time comes from subjects encompassing departmental ethos, paediatric and adult trauma, ECG dilemmas and even TED talk skills. As always credit to the original content creators. Do visit their sites.

• What really happens to a SAH?
• Pseudo lung point on U/S
• Bouncing kids and their injuries
• Don't kill your audience with bulletpoints
• STEMI or not STEMI... that is the question
• Is it ever too late to trauma activate?

• Nurse led codes
• What if your child had an arrest (this is a "must hear")

The last 2 links are worth the listen on your way home or on a jog. They describe and portend resuscitation at its best when elements align. Both talks show what can be if we get the heady mix of training, tech and guts right.

Age-ism in d-dimers

This is something that has been a bug bear of many a physician for years. Your gestalt and experience downtrodden by a slightly raised d-dimer that should not have been sent in the first place. Here's a reason why you should have that leeway.


Original article via Medscape.com:

Pulmonary Embolism Guidelines Released by ACP

Beth Skwarecki

September 28, 2015

New pulmonary embolism guidelines suggest that computed tomography (CT) imaging and plasma D-dimer testing are overused in patients suspected of having a pulmonary embolism, and may do more harm than good. The American College of Physicians (ACP) published the guidelines online September 29 in the Annals of Internal Medicine.

Plasma D-dimer tests are more appropriate for those at intermediate risk for a pulmonary embolism, and no testing may be necessary for some patients at low risk.

"Although the use of [computed tomography] for the evaluation of patients with suspected [pulmonary embolism] is increasing in the inpatient, outpatient, and [emergency department] settings, no evidence indicates that this increased use has led to improved patient outcomes," write Ali S. Raja, MD, vice chair, Department of Emergency Medicine, Massachusetts General Hospital, Boston, and colleagues from the ACP's Clinical Guidelines Committee. Potential harms of unnecessary imaging include increased costs, radiation exposure, and follow-up for incidental findings.

Instead, the authors recommend using either the Wells or Geneva rules to choose tests based on a patient's risk for pulmonary embolism.

If the patient is at low risk, clinicians should use the eight Pulmonary Embolism Rule-Out Criteria (PERC); if a patient meets all eight criteria, the risks of testing are greater than the risk for embolism, and no testing is needed. "By avoiding D-dimer testing in these low-risk patients, physicians can avoid false-positive D-dimer results and subsequent CT, which is unnecessary. Of note, the PERC should not be applied to patients at intermediate or high risk for [pulmonary embolism]," they write.

For patients at intermediate risk, or for those at low risk who do not meet all of the rule-out criteria, the authors recommend a high-sensitivity plasma D-dimer test as the initial test. In patients older than 50 years, the authors recommend using an age-adjusted threshold (age × 10 ng/mL, rather than a blanket 500 ng/mL) because normal D-dimer levels increase with age. Patients with a D-dimer level below the age-adjusted cutoff should not receive any imaging studies. Patients with elevated D-dimer levels should then receive imaging.

Patients at high risk should skip the D-dimer test and proceed to CT pulmonary angiography, because a negative D-dimer test will not eliminate the need for imaging in these patients. Clinicians should only obtain ventilation-perfusion scans in patients with a contraindication to CT pulmonary angiography or if CT pulmonary angiography is unavailable.

The new guidelines are being released as a Best Practice Advice statement, meant to guide but not replace clinicians' judgement, based on a nonsystematic literature review.

One author reports that he chairs the Test-Writing Committee for the secure examination of the American Board of Internal Medicine. Another reports that he chaired the Quality and Performance Committee of the American College of Emergency Physicians, in which capacity he helped to develop performance measures of appropriate use of computed tomography for pulmonary embolism. The other authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online September 29, 2015.

Webucation 26/7/15

Web musings from around the globe this round include pointers on trauma, paeds, cardio and a good rundown on the ever challenging asthmatic.

• Choose life, choose minimal radiology - Gathering momentum to return to clinical judgement
• The crashing asthmatic - Avoid the crash for Dr your patients sake. Excellent talk
• Taking the lead - A great learning case from Steve Smith himself
• South of California? - Emergucate's imaging case of the week is a peninsula.
• Those little necks - ERCast discusses paediatric C-spine clearance

• Archaic trauma life support - Basic course indeed

The last link is a notion supported by our group as well. It is essential to know the basics of trauma resuscitation and how teams work in that arena. It just shouldn't be termed "Advanced" in this day and age.

Webucation 16/2/15

This edition of web wisdom comes from the domains not just land based radiology and paediatrics but also a gem of a myth-buster from the air. Soeaking of air, LITFL does quick work on something familiar. Pls credit the original content creators when able.

• Did you spot it before clicking ? - Be honest!

• Imaging case of the week - Think laterally man

• Algorithm for knee - Why not we say.

• PTX time for change? - All this tension over a cannula.

• Sports name - What eponymous sport is the answer?

• Paeds inguinal hernia - its not just the old men who get this.

Your lungs will no explode - Aeromed myth busting finally

The last link is another great piece of dogma lysing which is all too common these days with the advent of sensible, pragmatic studies which are permeating our profession. Long may it continue.

Webucation 17/1/15

This edition of web wisdom brings you weird and wonderful and in rainbow colours as well. Be sure to credit the original content creators.

• Cough CXR? - Sometimes even bad things come in three's.
• That's a big tummy - Think you know your kid abdo xrays? Try this one.
• Ventilation in severe asthma - Can you get out of this difficult position in the future?
• Blue vomiting? - Cos who knows when this will show up...
• Dont i+d that paronychia - That's no moon, its a whitlow!
• Bronchiolitis 2015 - Finally a simplification we were all waiting for.
• Anti-CT top 10 - Ban pan scan man.

The last link provides yet another example of how the world is collectively wisening up to the dangers of irradiation and importance of wholistic care.

Bronchiolitis revamp

This article is from Medscape Emergency Medicine Briefs:

AAP Releases New Guidelines on Management of Bronchiolitis CME/CE

News/CME Author: Laurie Barclay, MD

CME/CE Released: 11/19/2014 ; Valid for credit through 11/19/2015

CLINICAL CONTEXT

On the basis of recent evidence, the American Academy of Pediatrics (AAP) has revised its 2006 clinical practice guideline on diagnosis and management of bronchiolitis in otherwise healthy children 1 to 23 months old. Each practice statement includes the underlying level of evidence, benefit-harm relationship, and level of recommendation.

Bronchiolitis is commonly caused by viral lower respiratory tract infection and is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, resulting in increased mucus production. Typical signs and symptoms initially include rhinitis and cough, sometimes followed by tachypnea, wheezing, rales, use of accessory muscles of respiration, and/or nasal flaring.

STUDY SYNOPSIS AND PERSPECTIVE

Management of bronchiolitis in children 1 to 23 months old no longer requires testing for specific viruses or a trial dose of a bronchodilator, according to new guidelines issued by the AAP and published online October 27 in Pediatrics.

According to a comprehensive evidence review, the new AAP guideline on diagnosing, treating, and preventing bronchiolitis updates the previous recommendations published in 2006. It targets pediatricians, family physicians, emergency medicine specialists, hospitalists, nurse practitioners, and physician assistants who care for children.

Bronchiolitis is the most common cause of hospitalization among infants younger than 1 year. The new guideline emphasizes that only supportive care, including oxygen and hydration, is strongly recommended for young children with bronchiolitis.

"Bronchiolitis is a disorder commonly caused by viral lower respiratory tract infection in infants," write Shawn L. Ralston, MD, FAAP, and colleagues from the AAP. "Bronchiolitis is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, and increased mucus production. Signs and symptoms typically begin with rhinitis and cough, which may progress to tachypnea, wheezing, rales, use of accessory muscles, and/or nasal flaring."

Changes from the 2006 guideline are that testing for specific viruses is no longer needed, because multiple viruses may cause bronchiolitis. Routine radiographic or laboratory studies are also unnecessary, and clinicians should diagnose bronchiolitis and assess its severity on the basis of history and physical examination.

The AAP also no longer recommends a trial dose of a bronchodilator, such as albuterol or salbutamol, because evidence to date shows that bronchodilators are ineffective in changing the course of bronchiolitis (evidence quality: B, strong recommendation). In addition, in accordance with a policy statement published in July by the AAP, the new guideline updates recommendations for use of palivizumab to prevent respiratory syncytial virus (RSV) infections: Otherwise-healthy infants with gestational age of 29 weeks or older should not receive palivizumab, but during the first year of life, infants with hemodynamically significant heart disease or chronic lung disease of prematurity should receive palivizumab (maximum of 5 monthly doses, 15 mg/kg per dose, during the RSV season).

Other recommendations are that when making decisions about the assessment and management of bronchiolitis in children, clinicians should evaluate risk factors for severe disease, such as age younger than 12 weeks, prematurity, underlying cardiopulmonary disease, or immunodeficiency. Finally, clinicians should not give epinephrine to infants and children diagnosed with bronchiolitis, nor should these children receive chest physiotherapy.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online October 27, 2014. Full text

STUDY HIGHLIGHTS

• A new recommendation is that a diagnosis of bronchiolitis no longer requires testing for specific viruses, because multiple viruses may cause bronchiolitis.
• Clinicians should diagnose bronchiolitis and determine its severity on the basis of history and physical examination.
• Routine radiographic or laboratory studies are unnecessary.
• When considering the evaluation and management of bronchiolitis in young children, clinicians should assess risk factors for severe disease, such as age younger than 12 weeks, prematurity, underlying cardiopulmonary disease, or immunodeficiency.
• A new recommendation is that management of bronchiolitis no longer requires a trial dose of a bronchodilator, because available evidence shows that bronchodilators do not change the course of bronchiolitis (evidence quality: B, strong recommendation).
• Only supportive care, including oxygen and hydration, is strongly recommended for young children with bronchiolitis.
• Otherwise-healthy infants with a gestational age of 29 weeks or older should not receive palivizumab to prevent RSV infections.
• However, during the first year of life, infants with hemodynamically significant heart disease or chronic lung disease of prematurity should receive palivizumab (maximum of 5 monthly doses, 15 mg/kg per dose, during the RSV season).
• Infants and children diagnosed with bronchiolitis should not receive epinephrine or chest physiotherapy.
• Infants with a diagnosis of bronchiolitis in the emergency department should not receive nebulized hypertonic saline.
• However, infants and children hospitalized for bronchiolitis may receive nebulized hypertonic saline.
• Clinicians may choose not to use continuous pulse oximetry for infants and children diagnosed with bronchiolitis.
• Infants and children with bronchiolitis should not receive antibiotics unless there is a concomitant bacterial infection, or a strong suspicion of such an infection.
• Infants with a diagnosis of bronchiolitis who cannot maintain oral hydration should receive nasogastric or intravenous fluids.
• All people should use alcohol-based rubs for hand decontamination when caring for children with bronchiolitis, or hand-washing with soap and water when alcohol-based rubs are not available.
• Clinicians should encourage exclusive breastfeeding for at least 6 months to reduce the morbidity of respiratory tract infections.
• When evaluating a child for bronchiolitis, clinicians should counsel caregivers about exposing the infant or child to environmental tobacco smoke and should also provide counseling on smoking cessation.
• Clinicians and nurses should educate personnel and family members on evidence-based diagnosis, treatment, and prevention in bronchiolitis.

CLINICAL IMPLICATIONS

• A new recommendation in the updated AAP guideline for bronchiolitis is that a diagnosis of bronchiolitis no longer requires testing for specific viruses, because multiple viruses may cause bronchiolitis.
• Another new recommendation in the updated AAP guideline is that management of bronchiolitis no longer requires a trial dose of a bronchodilator, because available evidence shows that bronchodilators do not change the course of bronchiolitis.

SEMS 2014: Ang Shiang Hu - Managing life threatening asthma

Our own Dr Ang Shiang Hu on managing a challenging condition in the ED.



The slides are here:

SEMS 2014: Ang Shiang Hu - Life threatening asthma from Rahul Goswami

Webucation 22/4/14

We have just finished a great EM conference here in Singapore and we will bring you the videos and slides in the coming few weeks to months. Stay tuned!

Internet intuition this time comes from the realms of paeds, anaesthetics and some cardio thrown in. Always support the content providers.

• Drain that kid - Good morsel on how big the drain should be in kids. Don't be cruel indeed!
• Altitude vs attitude hypoxia - Andy buck delivers a great opinion on the contrast between aviation and EM.
• Pre-oxing - the Rebel gives us a great summary of pe-ox techniques and its evidence. A must read for every intubator.
• Sign,sign, everywhere-a-pediatric-vital-sign - A wonderful insight as to whether we're treating kids or "kidding" ourselves. Also a great homage to the metal group Tesla!
• OPD the leaks! - a new way of handling large air leaks you say?
• Heartbreak diagnosis - This morsel educates us on the ills and chills of myocarditis. A scary condition in our experience. The few that we have diagnosed (albeit later rather than sooner) have eventuated in poor outcomes and transplant lists. Respect this condition and treat shocked children EARLY!

Trochar to chest!

Interesting new device demonstrated here by a video by Prof Larry Mellick.
Lots of different ways around the world to treat this type of pathology eh?

We're all guilty!

We've all done it in our careers. To be fair most of  us correct our mistakes. Some learn through good mentors, some learn through reading the papers, some even learn it off TV.
The truth is that we should be wary of the greater picture of antibiotic resistance and ineffectual remedies which do not target the pathology.
Here's a great article and the links below are for people who have access.
Do the right thing folks.

Medscape link
NIH link

Over-prescribing of Antibiotics and Imaging in the Management of Uncomplicated URIs in Emergency Departments

K Tom Xu, Daniel Roberts, Irvin Sulapas, Omar Martinez, Justin Berk, John Baldwin

Abstract

Background Unnecessary use of resources for common illnesses has substantial effect on patient care and costs. Evidence-based guidelines do not recommend antibiotics or imaging for uncomplicated upper respiratory infections (URIs). The objective of the current study was to examine medical care providers' compliance with guidelines in treating uncomplicated URIs in emergency departments (EDs) in the US.

Methods Nationally representative data from the NHAMCS 2007 and 2008 were used. Uncomplicated URIs were identified through ICD-9 codes of nasopharyngitis, laryngitis, bronchitis, URI not otherwise specified and influenza involving upper respiratory tract. Exclusion criteria were concurrent comorbidities, follow-up visits, and age < 18 or >64 years. Most frequently prescribed classes of antibiotics were identified. Multivariate analyses were conducted to identify the factors associated with the prescribing of antibiotics and use of imaging studies.

Results In 2007 and 2008, there were 2.2 million adult uncomplicated URI visits without any other concurrent diagnoses in EDs in the US. Approximately 52% were given antibiotic prescriptions, over one-third of which were macrolides, and nearly half of the visits performed imaging studies. About 51% had a diagnosis of bronchitis, 35% URI NOS, 9% nasopharyngitis, laryngitis or influenza, and 4% multiple URI diagnoses. The diagnosis of bronchitis, fever at presentation, older ages, male gender, longer waiting time, and metropolitan areas were associated with a greater likelihood of prescribing antibiotics or imaging studies, controlling for confounding factors.

Conclusion Despite the recommendations and campaign efforts by the CDC and many medical associations, the prescribing of antibiotics in treating uncomplicated URIs in the EDs remains prevalent. Furthermore, overutilization of imaging studies is prevalent. Changes at levels of health care system and hospitals are needed to avoid unnecessary resource utilization. In addition, further patient education about antibiotic use in the community may greatly facilitate the transition out of an antibiotic-dependent consumer culture.

Webucation 19/5

Been away for a few weeks on a course. The web has been active though and here's more than a few good articles to ponder over.

• How-marriage-works-in-medicine - interesting read for those in and around wedlock and even more interesting for those not "locked"
• Ringer's ain't great...again. - not as much volume expansion as you once thought
• FOOSH again - excellent revision on a not so common wrist injury from Emergucate
• PTX aspiration - great video by NEJM on needle aspiration of pneumothorax of you have not seen one before.
• Don't ignore naughty parts! - the trauma pro talks about not ignoring stuff down below
• Macrolides and CCBs - do they interact and cause shock?
• LUL collapse - we agree that its probably the hardest collapse to see on CXR
• Microbiology pearls - truly one of the best write-ups we have seen recently. What every hospital doc should know about those pesky microbes and what really happens. We cannot recommend this link enough.

Vampire lung

A 33 year old lady with pleuritic chest pain for 3 days comes in and this is her CXR.
What is the major abnormality and what is its significance?