Improving Outcomes, Improving Throughput, Mythbusting, Twelve Trials of Christmas!

The 12th Day of Christmas- #FOAM to what effect?

Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the last of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done.  I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM.  Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

From Chris Nickson & Mike Cadogan: “Scientific research in the clinical sciences is essentially worthless unless it alters patient outcomes.  Social media and FOAM have the potential to play a major role in knowledge translation.”

While I whole heartedly agree that FOAM spreads the knowledge, what is our rate of provider penetration?  Why are we not using it?  What if we make LITFL the department homepage?  Once someone has tried Twitter (or any other FOAM resource), do they continue to use it? Do residency programs that have an active twitter presence produce attendings that continue to use #FOAM 2 years after completing residency?  What about 5 or 10 years out?  What about their midlevels?

I’d like to poll various ED providers on whether or not they actively use #FOAM, and then quiz them on various topics to see if they attain standard of care.  This could be across a variety of things like sterile technique for suturing, use of kayexalate, and use of narcotics in acute headaches.  We could then ask questions more trendy in #FOAM such as use of DSI, use of regional anesthesia, and RUSH protocol. Hell, we could also see if it affects outcomes and patient satisfaction.

Ultimately, I would suspect that the rate of FOAM use is low, and those that use it more frequently would be more likely to use cutting edge treatments like DSI, regional anesthesia, and not use narcs for headaches. But hey, I’m a bit biased.

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Improving Outcomes, Improving Throughput, Twelve Trials of Christmas!

Day 11 of Christmas: Telepsychiatry For All!

Welcome to the Twelve Trials of Christmas series on EMinFocus!  This is the eleventh of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM.  Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

This is not so much a trial as something that needs to be done.  For anyone that works at an ED that has a psychiatry unit, you have likely seen wait times in excess of 24 hours regularly “waiting for a bed.” You’ve likely not checked in on that dispositioned psych hold all shift as well.  All of this creates an unsafe environment for patients both of psych and non-psych ilk, and to some extent, ED staff.

Enter, telepsychiatry.  This has actually been piloted, and found the agreement between the psychiatrists about disposition with a face-to-face assessment was 84% vs 86% with telemedicine.  There were no significant differences for disposition recommendation, strength of recommendation, diagnosis, the HCR-20 dangerousness scale, or suicide scale.

Telepsychiatry has been used in critical access hospitals, demonstrating mean and median times to consult were reduced from 16 hours and 14 hours respectively, to 5.4 hours 2.5 hours, with similar reductions in length of stay and door-to-consult times.

We could set up a tiered system of having a crisis counselor do the intake, much like we usually do, followed by immediate psychiatry evaluation, rather than holding them in the ED until the morning to see the patient.  We could also immediately initiate medication on the patient to decrease their LOS as an inpatient.  With residency fill rates approaching 100% (98, 99, and 96% in the last 3 years – better than anesthesia or radiology!), and with more total positions than orthopaedics, neurology, dermatology, radiology, or ob-gyn, we could easily decrease ED wait times for psych eval, and likely decrease LOS as an inpatient by, conservatively, 12 hours if we could start them on meds in the ED.

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Critical Care, Improving Outcomes, Neurology, Twelve Trials of Christmas!

Day Ten of Christmas: Keppra Post-Arrest.

Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the tenth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM. Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

Even after a successful initial resuscitation of a cardiopulmonary arrest, there is then significant concern for the patients neurological outcome.  Sure, there is the  hypothermia protocol, but is there any other neuroprotective drugs that we may be able to trial post arrest to try and improve neuro outcomes?

Let’s first say this: we’re talking about mouse studies, so it’s a leap of faith.  However, levetiracetam is quite safe, and really, what harm, post arrest, could a few doses of Keppra for the first 72 hours really do?  In mouse models, its been shown to have neuroprotective effects in experimental stroke, ICH, and neurotrauma.  ( 1 , 2 )

There was a study published in March 2014 in regards to anti-epileptics (phenytoin, levetiracetam, valproate, clonazepam, propofol, midazolam), which showed no measurable difference when administered to patients post-arrest.  However, in this study, patients were already placed in the ICU and the requirement was to be placed on continuous EEG monitoring within 12 hours of hospital presentation.  If the EEG was positive, they were enrolled in the study, and initiated on some anti-epileptic (being on propofol post intubation, apparently allowed them into the protocol under the propofol group).  Essentially, this study is useless to the ED and should not stray us from doing a good study to begin Levetiracetam as early as possible in cardiac arrests.  We know that the later we attempt to reverse status epilepticus, the more difficult a time we will have(and here, they didn’t attempt for HOURS!), so why not make a good attempt at giving arrests the best possible outcome with an easy study?  Hang a bag of Levetiracetam vs a bag of saline on all arrests, those that survive, compare neurologic outcomes.  This is an easy one to pass through the IRB – cant hurt, may do a world of help.

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Improving Outcomes, Improving Throughput, Twelve Trials of Christmas!

Day 9 of Christmas: Midlevel EM Sono Training

Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the ninth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM. Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

Simply put, for traumatic injuries, nerve blocks are the best source of pain control. If your only option of providing pain control for a femur fracture is to make the patient limp from your favorite opiate or giving tylenol, you have failed as a provider to keep up with current trends and literature. EM is all about having options in your toolbox.

Why are we not using nerve blocks? Can we train mid-levels to do these safely to provide a higher level of care and provide more job satisfaction?

I have seen patients with rib fractures go to observation for pain control and have been stonewalled in attempts to perform a block, either by myself or in consultation with anesthesia. This is despite evidence showing that nerve blocks work wonderfully during the EDs attempt at initial pain control, and with even better when a catheter is placed for continuous infusion. Nerve blocks for rib fractures also decrease mortality.  In case you were wondering, lidoderm patches wont work.

So, can we perform an ED based study showing mid-levels can safely use ED ultrasound for blocks? We can already safely do sono guided liver biopsies, soft tissue foreign bodies, hip injections, transrectal prostate biopsies, and we can even be remotely guided for lung sono. Its time for an ED study demonstrating we can safely do this in the ED.

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Improving Throughput, Twelve Trials of Christmas!

Day 8 of Christmas- Dexamethasone for Allergic Reactions

Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the eighth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM. Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

We’ve seen that two dose dexamethasone is as effective for pediatric asthma exacerbations as prednisone. In fact, there are fewer missed school days for children and adults return to work sooner with two days of decadron rather than 5 days of prednisone with similar relapse rates.  There is decent evidence here and here that a single intramuscular dose of dexamethasone for young asthmatics (<8 yrs, mean age 36 months) is sufficient.  To wit, 40% of children missed >30% of the oral prednisone dose vs receiving all of the IM dexamethasone dose despite parental efforts, with 70% of parents in both the oral prednisone and the IM dexamethasone group would choose IM dexamethasone to treat their child’s next asthma exacerbation.

With all of this information, why not apply it to allergic reactions? We know that biphasic reactions are rare and rarely life threatening. One or two doses of decadron plus an epiPen to go with over the counter diphenhydramine for mild breakthrough pruritis should likely do the trick. Easy trial to do, yet amazingly no literature for dexamethasone in allergic reactions.

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Critical Care, Improving Outcomes, Improving Throughput, Mythbusting, Pulmonary, Twelve Trials of Christmas!

Day 7 of Christmas- NAC for COPD.

Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the seventh of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM. Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

The next ED study I would like to see is Nacetylcysteine (NAC) for COPD.  Initially, the BRONCHUS trial in 2005 looked at 523 patients using once daily 600mg NAC for prevention of flares and mproving FEV1. They found no benefit.  Two studies in the last two years have looked at twice daily dosing of NAC, finding decreased exacerbations, and a third showing NAC potentiated the bronchodilatory effect of ipratropium.

 

Given the above, a trial of NAC in the ED may provide some benefit in helping patients get over the initial hump, and perhaps, lead to an early discharge. (Perhaps akin to early systemic steroids in addition to the patients inhaled steroid regimen during exacerbations).  At the least, it may cause pulmonology to reconsider giving NAC to their patients on the outside world and help it come standard of care.

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Improving Outcomes, Mythbusting, Pulmonary, Twelve Trials of Christmas!

Day six of Christmas – curing the bronchitis!

Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the sixth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM. Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

Essentially, there are about 4 things to do for a cough.  Dextromethorphan (robitussin), anything with Benadryl/codeine/phenergan/hydrocodone, tessalon, and honey.  For pediatrics at least, honey seems to be the preferred method for parents and seems work better than Dextromethorphan and Benadryl in head to head trials.  I’ve yet to find data on Tessalon, Phenergan, or codeine suggesting it is useful for a cough when compared to placebo.  I’d like to add another medication to the toolkit for an intractable cough: nebulized lidocaine.

The studies are not of the best quality, but here is what I can find:

– 21 patients with obstructive, restrictive, or infective disease who received 10-20mg of nebulized lidocaine Q4-6hrs seemed to improve and/or resolve the cough when compared to standard of care (hycodan, Robitussin).

– A case series of 3 pts treated with a single dose 10mg lidocaine and 5mg bupivacaine (both nebulized) and had no recurrence of cough.

– A case series of 3 patients with a chronic cough secondary to lung cancer treated with higher doses of nebulized lidocaine  (up to 400mg!) along  with 2-5mg albuterol.  Resolution of cough persisted for >1week in all patients.

– A case report of a pediatric patient treated with 30mg nebulized lidocaine for a cough refractory to cough suppressants, beta agonists, steroids, and antibiotics.  The cough completely resolved.

 

There are multiple studies looking at nebulized lidocaine for endoscopy and laryngoscopy, but no reports of systemic toxicity from nebulized lidocaine as there appears to be less systemic uptake when administered via nebulizer.  So, it appears safe in that regard.   The asthma literature is a mixed bag, as some say it cause harm during asthma exacerbations as it may decrease FEV, but others show benefit.  However, for COPD flares, it appears beneficial.


For those hacking coughs that truly feel bad for, I’d love to see an ED trial of nebulized lidocaine as a one time dose – or even perhaps in an observation unit for your COPD’ers / pneumonia/bronchitis patients.  Easy trial to perform, and one that would significantly improve patient satisfaction – and perhaps then something other than a z-pack would get credit for improving the cough!  

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