Keeping Up! - by Vanderbilt Emergency Medicine

 Update 15, July 22, 2010

   ...What do you think about opt-out HIV testing in the ED?

 Is opt-out HIV testing effective in the ED? Could a single question identify drug abuse 100 percent of the time? Are antibiotics needed after incision and drainage in the MRSA era? Is there adequate evidence to do CPR prior to defibrillation? What is the ideal dose for pediatric cardioversion? Do arrest victims do better if witnessed by EMS? Are you really seeing more kidney stones in kids, or is it just your imagination? Is it safe to combine olanzapine and a benzodiazepine? Need tips on incorporating simulation to teach your trainees? Does an ED sepsis protocol improve time to antibiotics?  Find out all these answers in this Emergency Medicine Update! (This is a random photo of some budding patriots in Yorktown, VA.)

Update 14, July 8, 2010

   ...  There are several key take home facts you won't want to practice without in this update.

 What is the risk of bacterial meningitis after complex febrile seizure? Why does TMP/SMX cause hyperkalemia in older patients? Should referring hospitals CT traumatized children or just send them to the trauma center ASAP? So your ED patient is a little delirious, does it matter? Are labs drawn from a child's 24 gauge IV reliable? What is the compiled evidence for or against tissue glue? What is the chance of bleed after 6 hours in a child with minor head injury? If you hold cricoid pressure and can't see the glottis, what's your next move? Could we start using cosyntropin for post-dural puncture headache? What are the optimal pre and post-shock pauses for v-fib? Find out all these answers in this Emergency Medicine Update!

 Opposing View on CRASH-2

   ...  Dr. Bryan Cotton did not share our rosy opinion of CRASH-2 last week.

Bryan A. Cotton, MD, MPH, Associate Professor of Surgery at The University of Texas Health Science Center at Houston, Department of Surgery and The Center for Translational Injury Research did not share our rosy assessment of tranexamic acid and it's role in trauma patients.  He raises some excellent points that you need to consider about this drug.  Here are his comments.  "I wanted to let you know that I enjoy the Keeping Up site and think you guys are doing a fantastic job.  However, I wanted to take an opposing view to the positive evaluation you gave to the CRASH-2 trial.  Let me start by saying that I think the concept of anti-fibrinolytics is a cool one and very fascinating and I think we should consider whether it has a place in our massive transfusion protocols.  That being said, it would be interesting if the authors of this study had evaluated the drug in patients who actually had 'traumatic hemorrhage.'  I, and my colleagues here in Houston, were not surprised to see that such a drug would not have any effect on the number of units transfused in such a general population.  Perhaps they have a sub-analysis in the works on patients arriving in shock.  Consider also their approach to randomization - letting physicians leave out those who they think must get the intervention and those the doc believed should not get the intervention.  As well, in a drug that was supposed to decrease bleeding, (1) 50% of the patients did not get ANY blood, (2) the rate of transfusion was the same between groups = 6 units, and (3) only 48% had any surgery.  More interesting is that here is a trauma paper without any mention that I can find of ISS, base deficit, or lactate.  As well, the majority of patients enrolled were not hypotensive (using 90 as a cut off), not tachycardic (using 110 as a cut off), had a GCS of 13-15 and were not,  from what I can tell, in shock.  Now, yes, this is a HUGE study, but this shouldn't dismiss the major issues with this RCT.   However, the most important part of the study is this: we're talking about a 0.7% absolute reduction in 'death due to bleeding.'  Zero POINT seven.  This translates into number needed to treat of 132."  Our opinion was that this massive study showed fairly impressive overall mortality benefit, and this drug has promise.  But, these serious limitations deserve mentioning.  Also, the NNT in the podcast and written summary should read 66 for overall mortality benefit, and this has been corrected in the written version (please pardon the error).  What do you think?  Comment on this article.

Update 13, June 24, 2010

   ...  Should we be the "pain police" and check state monitoring databases when we write controlled substance prescriptions?

 Should ED docs be the "pain police?" Have you heard of the new drug, tranexamic acid, that may save the lives of trauma patients? Which is better, high-dose IV or low-dose oral steroids for COPD? Do newer button batteries need to be removed from the esophagus in under two hours? What's the truth about frequent flyers in the ED? Does it make a difference whether you start anticoagulation in the ED for PE? How long is your pediatric patient going to have post-concussive symptoms? What is the expert consensus on coronary CTA? Do infants need treatment for pain during lumbar puncture? Which is better and safer for ED sedation, ketamine or propofol? Find out all these answers in this Emergency Medicine Update!