Bridge over Diagnosis!

With a more than impressive nod to Simon and Garfunkel, this ballad from James McCormack is a stirring tribute to sensible healthcare, contextualising each patient and treating guidelines as what they are - GUIDE LINES.

You can see his other videos here.

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.

Webucation 8/12/14

Webucation took a break due to some holidays but is back with pearls from radiology, cardiology and paeds philosophy. As always pls credit the content creators.

• Imaging-case-of-the-week-108 - Emergucate gives us an intriguing wrist xray
• Peg normality? - Test your C-spine skills
• Panning in Oz - The trauma pro quotes a new Oz study about the much debated pan scan - will you do the right thing?
• AF blockade - Are you a B or C person in fibrillating patients?
• Nice or NOT Nice - Ali G is "all up in da face of" da NICE guideline. Booyakasha!
• Appendicitis clinical decision rules - Are you part of the intellectually destitute?

The last link resonates with a lot of older physicians and docs who still practice without blood tests or CT scanners (some through no choice of their own). We think the community will be fine so long as agree that we need guides, not rules.

SEMS 2014 - Ng Kee Chong: What is permissible in a critically injured child?

A/Prof Ng Kee Chong is the esteemed head of the only tertiary paediatric emergency department in Singapore. He discusses the modern techniques of adult trauma resuscitation and then gives an in-depth analysis of which of those principles can be realistically applied to the critically injured child.




His slides are below:

A/Prof Ng Kee Chong - What is permissible in paediatric trauma from Rahul Goswami

SEMS 2014: Eric Tin - Medicolegal case studies

Eric Tin is a lawyer with Donaldson & Burkinshaw and also with the Medical Protection Society. He goes into some valuable learning points of some cases which the society has been involved in.





Slides are here:

SEMS 2014 - MPS case studies from Rahul Goswami

SEMS 2014: Edmund Kronenburg - A lawyer's perspective

Edmund Kronenburg is a Singaporean lawyer who specialises in medical disputes. he has graced our conference before and does so again with insights into why doctors get into medico-legal trouble. This is a great talk for all levels of providers.

Slides are here:

SEMS 2014: Edmund Kronenburg from Rahul Goswami

SEMS 2104: Marcus Ong - PAROS outcomes

A/Prof Marcus Ong gives us the in depth analyses of this much vaunted co-operative study.




The slides are here:

Marcus Ong - PAROS outcomes from Rahul Goswami

2014 ED drug poster

We've updated out ED infusion guidelines for 2014. Added a few more common drugs and also an intranasal one. Feel free to use but always clear with your institution first. Feedback most welcome.

You can get more of such items and links at our "Useful guides" page.

JW's top stories of 2013

Journal watch's Ron Walls has a lovely list of the best articles of 2013. His post is shown below unedited.

December 27, 2013 Emergency Medicine Editors' Choice: Top Stories of 2013 Ron M. Walls, MD, FRCPC, FAAEM A perspective on the most important research in the field from the past year

This has been an exciting year for us, as we embraced a broader collaboration with our colleagues in the NEJM Group and changed our name to NEJM Journal Watch Emergency Medicine. We remain devoted to providing clinicians with the information they need to give their patients the best care — and, as part of NEJM Group, we are now poised to do that better than ever. We are constantly exploring new ways to provide you with richer content, enhanced graphics, and a more useful, convenient website, all intended to make our information and guidance timely, relevant, and succinct. As in past years, we have selected for you the studies we feel most important to your practice, summarized these, and provided insightful and directive comments to help you put the knowledge into a clinical perspective. As we do each year, this month we feature the 10 summaries from 2013 that we feel are most important for you to be aware of, to think about, and to discuss with others. You may want to navigate back to the original studies, or simply to review these summaries again to refresh your memory. The year brought new clarity to compression-only CPR, rapid blood pressure control during acute intracranial hemorrhage, and the endlessly distracting etomidate in sepsis argument. Iconoclastic studies challenged the Wells and modified Geneva scores for acute pulmonary embolism, and the Alvarado score for appendicitis. And, of course, there was more. Our Emergency Medicine Top Stories of 2013 are Is Intensive Blood Pressure Lowering Beneficial in Acute Intracerebral Hemorrhage? More Information on Thrombolysis Benefits for Ischemic Stroke Steroid-Pressor Cocktail for In-Hospital Cardiac Arrest? Etomidate Does Not Increase Mortality in Intubated Septic Patients Meta-Analysis Finds Ultrasound Guidance Superior to Landmark Technique for Central Venous Catheter Placement CPR: Compression-Only Wins the Long Race Acetylcysteine for Prevention of Contrast-Induced Nephropathy Pretest Probability for PE: Structured Scoring System or Clinical Judgment? Poor Performance of an Appendicitis Decision Rule Volume of Crystalloid During Massive Transfusion Is Associated with Increased Mortality

Choose wisely... reader discretion advised - some of you may say DUH

The ACEP board of directors approved the following 5 Choosing Wisely recommendations for patients seen in the emergency department:

1. For patients with minor head injury who are deemed to be at low risk for skull fractures or hemorrhage, based on validated decision rules, clinicians should avoid head computed tomography scans. The majority of minor head injuries do not result in brain hemorrhage.
2. For stable patients who can urinate on their own, clinicians should avoid placing indwelling urinary catheters for either urine output monitoring or patient or staff convenience.
3. For patients likely to benefit from palliative and hospice care services, clinicians should not delay in engaging such services when available. Early referral from the emergency department can improve quality, as well as quantity, of life.
4. For patients with uncomplicated skin and soft tissue abscesses successfully treated with incision and drainage, clinicians should provide adequate medical follow-up but avoid antibiotics and wound cultures.
5. For children with mild to moderate, uncomplicated dehydration, clinicians should avoid giving intravenous fluids before a trial of oral rehydration therapy.

The Eagles simplify medicine

James McCormack combining a few of my favourite things: Simplification, understanding perspective and The Eagles.

Watch his other videos here. Highly recommend the Gotye guidelines video.

Its SAD what you know.. or you thought you knew

Abstract

Background The SADPERSONS Scale is commonly used as a screening tool for suicide risk in those who have self-harmed. It is also used to determine psychiatric treatment needs in those presenting to emergency departments. To date, there have been relatively few studies exploring the utility of SADPERSONS in this context.

Objectives To determine whether the SADPERSONS Scale accurately predicts psychiatric hospital admission, psychiatric aftercare and repetition of self-harm at presentation to the emergency department following self-harm.

Methods SADPERSONS scores were recorded for 126 consecutive admissions to a general hospital emergency department. Clinical management outcomes following assessment were recorded, including psychiatric hospital admission, community psychiatric aftercare and repetition of self-harm in the following 6 months.

Results Psychiatric hospital admission was required in five cases (4.0%) and community psychiatric aftercare in 70 (55.5%). 31 patients (24.6%) repeated self-harm. While the specificity of the SADPERSONS scores was greater than 90% for all outcomes, sensitivity for admission was only 2.0%, for community aftercare was 5.8% and for repetition of self-harm in the following 6 months was just 6.6%.

Conclusions For the purposes of suicide prevention, a low false negative rate is essential. SADPERSONS failed to identify the majority of those either requiring psychiatric admission or community psychiatric aftercare, or to predict repetition of self-harm. The scale should not be used to screen self-harm patients presenting to general hospitals. Greater emphasis should be placed on clinical assessment which takes account of the individual and dynamic nature of risk assessment.

Direct link is here.

Just goes to show that what is comon practice in one time, could be meaningless in another time. Whats surprising is the time it took to traverse those 2 extremes! Just like THIS article states!

Oxygen is harmful - you just didn't know it

Changing practice is plain hard. Many of us cling to what we've been taught in medical school - what the professors said and what the textbooks teach must be true. Just like fluid therapy, which we all learnt somewhere, all ill patients should get a drip - right? According to Professor John Myburgh at SMACC 2013, fluids are given by junior staff with brownian motion like randomness, and they have all the potential to cause morbidity and mortality downstream. Similarly, supplemental oxygen, which is slapped onto almost all patients in the resus room , has the potential to cause harm, and we don't even think twice about it.

Now, hypoxia is bad, so oxygen therapy is a given in that situation. But, HYPERoxia may just be as harmful. The article below gives a great review of the historical evidence on oxygen therapy in critically ill patients:

Cornet AD, Kooter AJ, Peters MJ, Smulders YM. The potential harm of oxygen therapy in medical emergencies. Critical Care 2013;17(2):313.

The evidence is rather overwhelming against hyperoxia. Did you know, giving too much oxygen may be detrimental in:

• AMI patients
• acute stroke patients
• septic patients
• cardiac arrest patients
• COPD patients

Which is pretty much the majority of the resus cases we see day to day, of whom all would get some form of supplemental oxygen. Do NOTE that while the totality of evidence suggests harm, there is no high quality evidence (i.e. RCTs) to prove that hyperoxia is really harmful. Conversely, there is also no high quality evidence to suggest the opposite; that hyperoxia will result in improved outcomes. The reviewers in the above article note this, and point out that guidelines advocating oxygen use acknowledge the paucity of data to guide oxygen recommendations, and most of it is based on expert opinion.

How do we then rationalise oxygen use? IMO, titrate oxygen use to SpO2, targeting 88-92% for patients with COPD, 94-98% for everyone else, and not letting the SpO2 reach 100% (which may mean PaO2 in the hundreds). The BTS guidelines (see below) lays it out pretty nicely:

O'Driscoll BR, Howard LS, Davison AG, British Thoracic Society. BTS guideline for emergency oxygen use in adult patients. Thorax 2008, Oct;63 Suppl 6:vi1-68.

In summary, next time, when you're on shift looking after that critical patient, remember to check the oxygen requirements for each patient, and use supplemental O2 wisely.

CDC field triage

The CDC has updated its field triage recommendations and they can be found here: Update article
A quick summary of recommendations is shown below for those interested in Disaster Med.

Diagnostic Imaging Pathways

When deciding on the best radiological investigation it is nice to have a flowchart on which to base your decision-making process. The Diagnostic Imaging Pathways project is a constantly reviewed, literature-based website that fits this bill.

The website is developed in Perth, Western Australia but has universal applicability, and includes pathways appropriate for emergency medicine. Best of all, it's free!

The site can be found here

The NaCl debate

The human race markedly improves with civilised discussion, questioning and research. The recent critical care study regarding overuse of Normal Saline was reported by one of our authors here. That's not the whole story though. Ryan Radecki from EMLITOFNOTE does a good breakdown (crediting another in the process also) and its well worth a read.

JAMA editors let us down

Gotye medical rant

Hilarious and intellectually satisfying at the same time. Kudos to James McCormack for this.

Management of Penetrating Neck Trauma

Forget about ATLS & Zone I, II, III...
Just see if the platysma is breached;
a.  If hemodynamically unstable = Operative Mx
b.  If hemodynamically stable = CT angio kiv non-operative mx

Read - http://tinyurl.com/bux96gv

Dengue high alert!

It is dengue season alright here on the equator. A huge spike in cases over the last month has prompted the authorities to not only step up mosquito eradication drives but hospitals also have been bracing themselves for more than a fare share of dengue shock syndrome.
Good guidelines have been sent out by health authorities and here's an edited and condensed version for those who need to brush up or are new to dengue:

Dengue haemorrhagic fever guide

Remember to watch the platelet counts daily and look out for subtle signs of shock and bleeding.

A headache to diagnose

It is sometimes difficult to ascertain what is a benign history and what is not. Here is a great read to revise the different forms of presentations of headaches.

NICE headache guideline