BP in Sepsis, Abx for COPD, and Fever in SSD

We had our last Journal Club on September 17, and it was great.  Much great discussion.

First Article:
http://www.ncbi.nlm.nih.gov/pubmed/22923662
Efficacy of antibiotic therapy for acute exacerbations of mild to moderate chronic obstructive pulmonary disease.
Bottom Line: Antibiotics may be useful in mild to moderate COPD exacerbations; whereas we already know it's beneficial (mortality benefit) in severe COPD.  Gerenalizability is limited by choice of antibiotics, and infrequent use of steroids.

Second Article:
http://www.ncbi.nlm.nih.gov/pubmed/24635770
High versus low blood-pressure target in patients with septic shock.
Bottom Line: This is a good one that was overshadowed by the Process Trial.  No benefit for MAP goal of 85 vs 65.  However, in patient's with hypertension, the high target group required less renal replacement therapy.  So, you may consider a higher target in those with chronic hypertension, but no strong, compelling evidence to do so.  Also, probably doesn't matter in the ED.

Third Article:
http://www.ncbi.nlm.nih.gov/pubmed/23669523
Bacteremia risk and outpatient management of febrile patients with sickle cell disease.
Bottom Line: In pediatric patients with good follow up, it is safe to discharge a febrile sickle cell patient after a shot of ceftriaxone - less than 1% of these patients had bacteremia.  I think the key here is that this was Boston Children's, and they all had good follow up.  So, if that's your scenario, discharge away (unless they look ill, of course).  Great comment from one of our community docs - "I've never gone home and thought dang, I wish I wouldn't have given that rocephin."

Monomorophic Ventricular Tachycardia Algorithm

Posted via http://www.emdocs.net/amiodarone-vs-procainamide-stable-vt/. 

Procainamide vs Amiodarone for Ventricular Tachycardia

...or you could just shock him...

I sent the following to Dr. Mattu:

How I Navigate Online Emergency Medicine Resources

This may seem a bit cryptic without actually hearing me give the lecture, but you get the idea...

EM Resources from bcooper876

Choosing Wisely Campaign

Last October, ACEP joined ABIM's "Choosing Wisely" campaign.  5 measures were agreed upon.  They're pretty soft, but it's a start:

Aggressive BP Management in Patients with ICH

Check out my guest post at EMDocs.net here: http://www.emdocs.net/aggressive-bp-management-patients-ich/

Bottom Line:
Early BP reduction in ICH is safe and probably efficacious, although the data doesn’t definitively say so yet.  The AHA still recommends “modest” reduction if SBP>180 or MAP>130 to a goal of 160/90 or MAP of 110, but the ATACH results may prompt a change in the guidelines…we shall see.  Also worth noting, the ADAPT trial confirms that perihematoma blood flow is maintained even in those with aggressive BP lowering.  So, if you’re feeling rather aggressive, lower away!  BP lowering will not harm your patient with ICH, and may help.

Bugs & Drugs - Antibiotic QuickCard

Antibiotic selection has been identified as a potential weak spot for our residents. So, I created the below table to serve as a quick reference while on shift. My hope is to condense it to the size of a badge (front and back) so that it can be worn on one's badge holder.  Please note the disclaimer below.  This has not been peer reviewed yet.  References are listed below.

Source		Bugs	Drugs	Comments
PNA	CAP	S. pneumonia, H. influenza, Moraxella Atypicals - Mycoplasma, Chlamydia, Legionella	OP - azithro x 5d OR doxy 100mg bid x 7d IP - ceftriaxone 1g + azithro 500mg	consider moxifloxacin for comorbidities (i.e COPD, DM, CHF)
	HCAP	PsA, MRSA, E. Coli, Acinetobacter, Serratia	IP - vanc 20mg/kg + pip/tazo 4.5g + azithro 500mg	Pen allergic - substitute aztreonam or cefepime for pip/tazo

Mini Intern Bootcamp

Every July, a countless number of bright-eyed Emergency Medicine interns will exit their 4th year slumber and wake up to a sobering shower of utter confusion. I know this because I remember well the day I forgot 4 years of medical education. It wasn't that long ago for me. Allow me to introduce a project that may ease the interns’ hemorrhage of medical knowledge. You may think of it as tranexamic acid for the traumatized and bleeding intern – it just may reduce your interns’ ED mortality rate.

Small Bowel Obstruction

55M c h/o colon ca p/w abd pain x 3d.  Rebound on exam.  3/6/9 Rule: small bowel dilated if > 3 cm, large bowel if > 6 cm, cecum if > 9 cm.

Amal Mattu's ECG Case of the Week: April 28, 2014

52 Articles 2014

Here's my attempt at 52 articles in 52 weeks.  Our residency will be reading all of these over the next year.  Disclaimer: subject to change.

Airway	Preoxygenation and prevention of desaturation during emergency airway management.	Weingart SD	2012	Ann Emerg Med	PubMed
Airway	The importance of first pass success when performing orotracheal intubation in the emergency department.	Sakles JC	2013	Acad Emerg Med	PubMed
Airway	Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices?	Burton JH	2006	Acad Emerg Med	PubMed

Brugada Type II

30M w/o PMH p/w intermittent CP and dizziness w/o syncope x 1 year.

NOAC Reversal

Ok, we all know warfarin sucks.  Patients hate it because it has to be monitored, and if they eat too many collard greens or you prescribe bactrim or cipro they're going to bleed and die.  Invariably, we've all had the patient with hematuria and an INR of 10, but totally stable and with a normal hematocrit.  You consult "the chart" on uptodate and end up more confused.  So, you make something up...um...let's stop taking the warfarin for the next two days, and decrease your dose from 5 mg to 4 mg...and, um...here's 2.5 mg of vitamin K...now, go check in at your coumadin clinic...

Phlegmasia Cerulea Dolens

Sudden onset painful leg that became swollen within 15 minutes.

Osteomyelitis

53M s/p TMA p/w new ulcer.  Elevated inflammatory markers and clear cortical involvement on XR (although not called by radiology); MR confirmed oseteo.  Findings suggestive of OM on radiography include cortical erosion, periosteal reaction, mixed lucency, and sclerosis; but may not be evident for up to 2 weeks into the infection.

Lane's Top Ten

I can't claim credit for this, but Lane Blankenship recently gave his Senior Grand Rounds, and it was excellent!  Here are his top ten articles:

Free Air

60M w/o PMH p/w sudden onset abd pain several hours earlier, rigid abd, found to have free air on upright.  Perfed dudenoal ulcer found on ex-lap.

Spine Sign

40F c h/o CHF p/w SOB and productive cough.  Radiology report made no mention of focal consolidation.  The vertebral bodies should become more lucent the more inferior they are, but you can clearly see they become more opaque in this lateral view - a finding called "the spine sign."  This is consistent with a focal consolidation.

Transfusion Strategies in UGIB

Villanueva C, et al.  Transfusion Strategies for Acute Upper Gastrointestinal Bleeding.  2013 Jan 3;368(1):11-21.
Recently, I presented the landmark article for promoting a restrictive transfusion strategy in upper GI bleeding (UGIB) at our journal club.  I spent a fair amount of time researching the background to this study.  Suffice it to say, there's been a lot of nerds manufacturing non-evidenced based guidelines for decades regarding this issue.  They usually met in Italy, so I can understand the draw to convene.  This study aimed to set the record straight on transfusion strategy for undifferentiated UGIB.

Wellens' Syndrome

60M c exertional CP x 2 weeks, biphasic t's and STE; 95% prox LAD on LHC.

Complete Heart Block

83M c CP, new RBB and CHB, STD in anterolateral leads and TWI in inf, HR36; taken for PPM following day.

LITFL -- ALiEM -- EM Lit Of Note -- emDocs -- EMCrit