Back to pain being the 5th vital sign, or so this study may have us believe. This study included an independent investigator essentially sneaking into the patient room to tell half the patients that “the treatment of pain is very important and be sure to tell the staff when you have pain.”
77.6% of the control vs 88.8% of the intervention group reported being provided with the above “pain advice” and the intervention group had an absolute and relative increase in satisfaction of 6.3% vs 14.2%, respectively. 91.3% of patients who were “very satisfied” had received this advice vs 76.3% of patients who were not “very satisfied” having received “pain advice.”
I think that ultimately, the aforementioned increase in patient satisfaction goes with giving clear instructions, and being clear with your projected management and expectations. I imagine that having a third party (such as Dr McDreamy) come over and say, “the treatment of pain is very important and be sure to tell the staff when you have pain,” will undoubtedly boost patient satisfaction. Likewise, I also question if it buys a bit (too much?) into “pain is the 5th vital sign” that got us into our current opiate frenzy in the first place. Regardless, there is potential for this to be a useful word choice in the quest for improved Press Ganey scores.
It’s a generally accepted FOAM principle that packing an abscess is of no benefit, but now we can add one more reason onto why we should not do this:
An impressively high rate of recurrence!
In this study of 272 patients with roughly 83% of patients having the unpleasant packing experience (!!) the adjusted OR for recurrence: 4.64. (coincidentally, there was also an 83% 1 week follow up and 71% follow up at either 1 or 3 months). Overall recurrence rate was about 28% within 3 months. The only two variables associated with a recurrence? A prior abscess within the last 2 months, and a prior abscess within the last 3-6 months.
So… Not HIV status, not the presence of diabetes… Nope. Just the lack of the providers FOAM knowledge base about wound packing will bump up your likelihood of recurrence. Perhaps they had larger abscesses, but given that abscess size and amount of erythema was not significantly correlated with recurrence, I doubt it.
Per the authors: “The reasons for this latter observation is unclear; however, other studies have shown that this practice may not improve outcomes and can lead to increased pain… Interestingly, packing was associated with increased recurrence, warranting further investigation of this practice.”
Or we could just stop doing it altogether. Cant you just see a late night TV ad? If you’ve had an abscess packed, then had another one within three months, call us now! You may be entitled to a settlement! Operators are standing by!
We are just going to cut to the chase on this one.
“No study reported digital necrosis or gangrene attributable to epinephrine, either in healthy patients or in patients with risk for poor peripheral circulation. In total, at least 2797 digital nerve blocks with epinephrine have been performed without any complications… Epinephrine 1:100,000-200,000 (5-10 μg/mL) is safe to use in digital nerve blocks in healthy patients. Physiological studies show epinephrine-induced vasoconstriction to be transient. There are no reported cases of epinephrine-induced harm to patients with risk for poor peripheral circulation despite a theoretical risk of harmful epinephrine-induced vasoconstriction. A lack of reported complications suggests that the risk of epinephrine-induced vasoconstriction to digits may be overstated.”
When I was a teenager, two friends & I worked for the Parks & Recreation Department in our town. We did things like manage the softball & baseball fields, water town greens, cut grass, etc. Both of my friends, every summer, managed to get some ugly cases of poison ivy. I always remember one of them requiring “the long course” of steroids because “it always came back with only a few days of prednisone.”
This has always sort of stuck with me since I started practicing. Poison Ivy & the like are generally the only time I will write for a steroid taper. I recently reviewed the evidence, and low and behold, found this:
This study compared long taper vs short term fixed dosing for patients greater than 14 years old with “severe” cases of poison ivy defined as having a clear exposure, a rash consistent with poison ivy, PLUS one of the following: 1) rash >20% of body surface area 2) rash on hands, feet, face, or genitals, or 3) involvement of two or more body areas. 27 patients were allocated to the short treatment arm (5 days of 40mg prednisone), and 28 patients allocated to a long taper (30mg x 2 days, 20mg x 2 days, 10mg x 2 days, 5mg x 4 days). One patient in the short treatment arm discontinued treatment due to weight gain, while 3 in the long term taper were lost to follow up and 2 discontinued treatment due to improvement of rash.
While not statistically significant, the mean time to improvement favored the long taper (2.93 days vs 4.42 days), as did mean time to resolution (11.7 days vs 14.63 days), and rate of side effects (3 vs 0). The rate of seeking additional medication to use was statistically significant, favoring long taper treatment with 5 patients using additional meds, vs 15 patients in the short course treatment arm (22.7% vs 55.6%). In the short course, these additional medications ranged from an additional oral steroid prescription in 11 cases (vs 2 additional steroid prescriptions for the long course), as well as calamine lotion, antihistamines, topical hydrocortisone, and other OTC lotions. The NNT with longer tapers to avoid having to take additional medications– 3.
My thoughts: If you’re going to get poison ivy, isn’t it usually on your hands or involve more than 2 body areas? Based on their definition of “severe,” the authors essentially recommend to give oral steroids to the majority of patients with poison ivy who present to the ED. While this seems odd on first glance, then again, almost half of the patients in the short course of steroids bounced back and required an additional oral steroid prescription, so the authors are probably on to something. The numbers are small, but compelling enough that unless patients really put up a fight about having steroids, I would just give them a tapered dose. If they are adamant about only having as short a course as possible, giving them two prescriptions with the second being the taper would seem reasonable.
Oh, and if you’re looking for preventative therapy, Tecnu has the most efficacy (70% protection after exposure), with Goop and Dial being the most cost effective ($0.07 per ounce for both vs $1.25 for Tecnu, with protection after exposure rates of 62% and 56% respectively), though results were not statistically significant from each other, but were statistically significant above placebo.
Happy & Safe Fourth.
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.
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.
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!
Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the fourth 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.
Despite the national attention narcotic misuse has received recently, there is scant evidence on the effect of a statewide prescription monitoring program within the ED. Sadly, evidence shows class II, III, IV, V analgesic prescription rates from ED providers increased from 2001-2010, while nonopioid analgesia prescriptions remained stable. I would be curious to see if prescriber habits have changed since the recent onslaught of naroctic overdoses in the media, especially since 49 of the 50 states have a state-wide prescription monitoring program. Have we written for fewer tablets per prescription? Say, from 20 to 12 tabs? Are we writing for less oxycodone and more NSAIDs (or for more hydrocodone or Tramadol rather than percocet) after implementation of a statewide database? Are we even using the tools at our disposal? If not, then why not? Are we too busy? Too burned out? Just want to “get the patient out of the ED?” Just don’t care? Don’t want conflict? Is there an difference between MDs, PAs, and NPs? What about level of experience? Does type of workplace (urgent care, office, ED) matter? Do we think we can actually spot the addict – because multiple studies show we suck at it.
In New York state, all urgent care centers, ambulatory surgery centers, private practices, dental offices, and clinics are required to check the database if writing for 5 days of narcotics. Sadly, ED’s are not required to do this. NY actually makes it easy – while providers must register, they can designate another person to check the database. I’ve heard of urgent care centers having the triage nurse checking the database before they see the provider. Sadly, I’ve seen colleagues write for “a few days” to get the patient through “until their pain doctor sees them in 2 days” – despite this being a known red flag for substance abuse.
All providers are in a unique position – the patient that has an extensive database history also needs your help. Rather than be confrontational, we can sit down, explain you are concerned about their recent prescription pattern, and would like to offer them help if they feel as though they need it. If they decline, I still refer them to detox on their discharge papers.
So, I would like to see if providers are changing practice since implementation of a statewide prescription monitoring database, and if not, then why. There is hope, interventions show we can change (though durability is a separate issue). As a provider, if you are not interested in checking the database for every prescription you write, consider moving to Missouri, the only state without a database, also known as America’s drug store.
ACEP opioid policy: www.acep.org/content.aspx?id=88197
Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the third 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
Lets cut straight to the evidence on this one: 95 uncomplicated lacerations of the hand (full thickness <2 cm; without tendon, joint, fracture, or nerve complications) who would normally require sutures were enrolled to suturing or conservative treatment. Essentially, there was no difference in the assessment of cosmetic appearance 3 months after treatment by independent blinded doctors on the visual analogue scale. The mean time to resume normal activities was the same in both groups. Patients treated conservatively had less pain and treatment time was significantly shorter by 14 minutes on average.
Now, have you ever see a laceration come back for suture removal and wonder, “Why did they put so many sutures in this thing?” Brian Lin has a great post on his website about this here, and has started, what I’ve begun to call, a Lac Lookbook. Unfortunately, the referenced study is only on hand lacerations and I can not find any literature to support the 2cm cutoff on other parts of the body. I would love to see a published article on provider and parent assessment of repair 2-3 months after the initial visit for lacerations all over the body and initiate a pediatric Lac Lookbook. This would be the Holy Grail to show parents- “look, exactly what your child has and what to expect.” This is a great way to save time, actually show parents an estimate of what to expect, save supplies, a repeat visit, and in some cases, a papoose and/or ketamine.