The last blog entry for 2012 asks you, the reading audience, which article is your favorite? Which one impacted your daily practice the most? Which one did you hate the most? Please post in your comments below.
For example, I know the article that has changed my practice the most was the one on the IDSA (Infectious Disease Society of America) inaugral August 2012 pediatric pneumonia guidelines for vaccinated children.
My favorite article was the Dr. Citron suggested right chest pain MI predictivity article, and the article I found most "scary" was the Dr. Fuller suggested concussion guidelines.
As always, thanks for all the past suggestions and commentary.
Linwood Watson, MD Rex Express Care Blog Director
Saturday, December 29, 2012
Friday, December 28, 2012
New Tamiflu Guidelines for Children Less than One Year Old
http://www.medscape.com/viewarticle/776564?src=nl_newsalert
Well, flu season is here in all its challenging glory. While most phyisicians are aware, especially after the 2010 swine flu outbreak, of the risk of secondary bacterial pneumonia in certain age groups, mainly children less than 5 years old, one caveat has been that Tamiflu has not been aproved for children less than 1 year old.
Recently-12/21/12 in fact- the FDA approved Tamiflu for children less than 1 year old. Now, if you have a sick child, say a 9 month old, presenting in the initial 48 hours of influenza, you can write for the dosing. A few pearls from the short, but helpful, article:
-Remind parents Tamiflu only shortens the flu, it does not "cure" the flu. As such, parents must still brace themselves for a few evenings of 103 degree fussiness.
-The main clinical focus of Tamiflu use in this age group is for children, less than 6 months old, who have much higher rates of flu complications, like bacterial pneumonia. For our practices, this would be the 4month to 6month age group.
- I highly suggest perusing the article before writing a script, but note that the dose is 3mg/kg po bid for 5 days. A key issue here is that the pharmacist will have to give a different dispenser than the one that currently comes with the standard pediatric solution of Tamiflu that is 6mg/ml in concentration.
-As a real world practical issue, in a child between 4 months and 1 year old who has the flu in our clinic and is not dehydrated or in respiratory distress, I would humbly suggest that one still obtain a chest x-ray. This allows confirmation that the child has not already developed a "full blown" bacterial appearing pneumonia (lobar consolidation and not the standard "perhilar pneumonitis") and helps to cofirm that the child does not also require concomitant antibiotics (see the previous blog on pediatric pneumonia guidelines for vaccinated children). Also, especially if a child gets worse and returns to urgent care or the Rex ER, it allows a baseline to be present. Make no mistake, I am all for limiting prediatric radiation exposure, but this population and the flu are a lethal mix.
-My final tip is a reminder to take a full 30 seconds to 1 minute, and watch the child breath and take a full respiratory rate timing at the bedside, and document it in your note! The close, meticulous observation allow a better clinical picture for you and it conveys concern to the parent.
-Again, review the article BEFORE writing your first prescription, and be sure to give clear signs of worsening in your discharge instructions to the parents to guide them properly.
Well, flu season is here in all its challenging glory. While most phyisicians are aware, especially after the 2010 swine flu outbreak, of the risk of secondary bacterial pneumonia in certain age groups, mainly children less than 5 years old, one caveat has been that Tamiflu has not been aproved for children less than 1 year old.
Recently-12/21/12 in fact- the FDA approved Tamiflu for children less than 1 year old. Now, if you have a sick child, say a 9 month old, presenting in the initial 48 hours of influenza, you can write for the dosing. A few pearls from the short, but helpful, article:
-Remind parents Tamiflu only shortens the flu, it does not "cure" the flu. As such, parents must still brace themselves for a few evenings of 103 degree fussiness.
-The main clinical focus of Tamiflu use in this age group is for children, less than 6 months old, who have much higher rates of flu complications, like bacterial pneumonia. For our practices, this would be the 4month to 6month age group.
- I highly suggest perusing the article before writing a script, but note that the dose is 3mg/kg po bid for 5 days. A key issue here is that the pharmacist will have to give a different dispenser than the one that currently comes with the standard pediatric solution of Tamiflu that is 6mg/ml in concentration.
-As a real world practical issue, in a child between 4 months and 1 year old who has the flu in our clinic and is not dehydrated or in respiratory distress, I would humbly suggest that one still obtain a chest x-ray. This allows confirmation that the child has not already developed a "full blown" bacterial appearing pneumonia (lobar consolidation and not the standard "perhilar pneumonitis") and helps to cofirm that the child does not also require concomitant antibiotics (see the previous blog on pediatric pneumonia guidelines for vaccinated children). Also, especially if a child gets worse and returns to urgent care or the Rex ER, it allows a baseline to be present. Make no mistake, I am all for limiting prediatric radiation exposure, but this population and the flu are a lethal mix.
-My final tip is a reminder to take a full 30 seconds to 1 minute, and watch the child breath and take a full respiratory rate timing at the bedside, and document it in your note! The close, meticulous observation allow a better clinical picture for you and it conveys concern to the parent.
-Again, review the article BEFORE writing your first prescription, and be sure to give clear signs of worsening in your discharge instructions to the parents to guide them properly.
Wednesday, November 28, 2012
An Ounce of Prevention Is Worth a Pound of Cure
Many of our express care physicians receive the "JUCM", or Journal of Urgent Care Medicine,and the November 2012 issue had an excellent summary article in the "health law" section on malpractice reminders (page 33 in the scroll magazine below, if accessible).
http://www.jucm.com/magazine/members.php?issue=/magazine/issues/2012/1112/
The article written by a MD/JD had several tidbits to keep you from getting complacent in the everyday drone of mucus and aches.
1. Remember, in "drug seekers with recurrent back pain"-stay vigilant for the rare but catastrophic spinal epidural abscess. Per the article fewer than 10% of spinal epidural abscesses present with the textbook triad of back pain, fever, and focal neurological deficits, but if you do see fever and back pain, strongly consider emergent imaging in the ER. As always a thorough neurologic exam is crucial, even with routine back pain.
2. Yes, the "lab book" is the bane of our existence, but consider reminder #3- "failure to inform a patient about an abnormal test is a red flag issue." I think the biggest landmine here is when a chest x-ray to rule out pneumonia shows a nodule, or when the radiologist thinks it is pneumonia, but suggests "repeat x-ray in 6 weeks to confirm clearing." In these cases I strongly suggest, getting a copy of the CD, and writing in the discharge instructions to have a repeat xray in 6-8 weeks to confirm clearing. With a smoker, I would even go so far as writing, "to ensure no tumor is present" in the discharge instructions, which clearly and hopefully unequivocally conveys to the patient the gravitas of the situation.
3.The article has the solid perspective, " Urgent care is a very high risk environment-even higher than the emergency department. It is high risk because everyone, including the patients, thinks it is low risk and we can all be lured into a false sense of complacency. Remember, "(think) Worst First!"
4.If your discharge diagnosis is a diagnosis that may come back to haunt you, such as headache, chest pain, et al, then be very thorough in documenting your reasoning and pertinent positives and negatives. For example, go back to spring 2012 and review the blog article on "When to Refrain with Chest Pain" for some crucial pertinent negatives.
5.Minor head injuries in patients on coumadin are by defintion not minor.
6 Here is a classic, " The same patient presenting more than twice with the same complaint needs to be conclusively figured out/admitted on the third visit." I always try to adhere to a "3 strikes and you are out policy"- the ER comes on strike 3. Every "bounceback" exponentially increases your liability and appearance of ignorance to a jury. Refer and move on. It is hard to "save the world" when embroiled in a major, years long, malpractice battle, so again, move on.
7. Read the notes of others before discharging a patient. Pay close attention to the ED summary note with vitals, as it is easy for the nurses to type in a vital sign wrong- and that typo could make you look incompetent. I have seen legion times a mistyped temperature of 95, or a respiratory rate of 56. You may ignore it since you can see the patient, but it needs to be corrected, as that temperature of 95 will doom you when that elderly patient with what you "think" is manageable pyelonephritis goes home, becomes septic overnight, and dies the next day. Then, the lawyer is suddenly reminding you that hypothermia can signal advanced sepsis....and then we have a major problem. Also read the nurses "chief complaint section" to ensure his/her documentation is not contradicting yours-and write out the resolution. As the article states, you don't want your note to say "mild headache", but the nurse triage note to say, "worst headache of my life." You may state in your medical decision making, " nurse triage note reviewed, discussed with patient directly how severe headache was- patient stated 6/10, and was "throbbing" but "not worst of life." Overlooked discrepancies can hurt you immensely!
Never forget, as a medical provider in today's world you are one thing- a target.
http://www.jucm.com/magazine/members.php?issue=/magazine/issues/2012/1112/
The article written by a MD/JD had several tidbits to keep you from getting complacent in the everyday drone of mucus and aches.
1. Remember, in "drug seekers with recurrent back pain"-stay vigilant for the rare but catastrophic spinal epidural abscess. Per the article fewer than 10% of spinal epidural abscesses present with the textbook triad of back pain, fever, and focal neurological deficits, but if you do see fever and back pain, strongly consider emergent imaging in the ER. As always a thorough neurologic exam is crucial, even with routine back pain.
2. Yes, the "lab book" is the bane of our existence, but consider reminder #3- "failure to inform a patient about an abnormal test is a red flag issue." I think the biggest landmine here is when a chest x-ray to rule out pneumonia shows a nodule, or when the radiologist thinks it is pneumonia, but suggests "repeat x-ray in 6 weeks to confirm clearing." In these cases I strongly suggest, getting a copy of the CD, and writing in the discharge instructions to have a repeat xray in 6-8 weeks to confirm clearing. With a smoker, I would even go so far as writing, "to ensure no tumor is present" in the discharge instructions, which clearly and hopefully unequivocally conveys to the patient the gravitas of the situation.
3.The article has the solid perspective, " Urgent care is a very high risk environment-even higher than the emergency department. It is high risk because everyone, including the patients, thinks it is low risk and we can all be lured into a false sense of complacency. Remember, "(think) Worst First!"
4.If your discharge diagnosis is a diagnosis that may come back to haunt you, such as headache, chest pain, et al, then be very thorough in documenting your reasoning and pertinent positives and negatives. For example, go back to spring 2012 and review the blog article on "When to Refrain with Chest Pain" for some crucial pertinent negatives.
5.Minor head injuries in patients on coumadin are by defintion not minor.
6 Here is a classic, " The same patient presenting more than twice with the same complaint needs to be conclusively figured out/admitted on the third visit." I always try to adhere to a "3 strikes and you are out policy"- the ER comes on strike 3. Every "bounceback" exponentially increases your liability and appearance of ignorance to a jury. Refer and move on. It is hard to "save the world" when embroiled in a major, years long, malpractice battle, so again, move on.
7. Read the notes of others before discharging a patient. Pay close attention to the ED summary note with vitals, as it is easy for the nurses to type in a vital sign wrong- and that typo could make you look incompetent. I have seen legion times a mistyped temperature of 95, or a respiratory rate of 56. You may ignore it since you can see the patient, but it needs to be corrected, as that temperature of 95 will doom you when that elderly patient with what you "think" is manageable pyelonephritis goes home, becomes septic overnight, and dies the next day. Then, the lawyer is suddenly reminding you that hypothermia can signal advanced sepsis....and then we have a major problem. Also read the nurses "chief complaint section" to ensure his/her documentation is not contradicting yours-and write out the resolution. As the article states, you don't want your note to say "mild headache", but the nurse triage note to say, "worst headache of my life." You may state in your medical decision making, " nurse triage note reviewed, discussed with patient directly how severe headache was- patient stated 6/10, and was "throbbing" but "not worst of life." Overlooked discrepancies can hurt you immensely!
Never forget, as a medical provider in today's world you are one thing- a target.
Wednesday, November 14, 2012
Ring the Bell for Steroids!
http://www.neurology.org/content/early/2012/11/07/WNL.0b013e318275978c.abstract
Above is a current nice meta analysis abstract from the American Academy of Neurology summarizing that for Bell's palsy, the treatment of choice definitively should include steroids, and at best, antivirals should be an adjunct. I lack access to the full article, but being a meta analysis I assume one set dose and period of steroids was not agreed upon. A rough survey of older texts though seems to avoid the "Medrol Dose Pak" in favor of higher, constant doses to battle Bells. While there is some literature disagreement, most authorities concur that no steroid taper is required for 5 days of therapy, and I have seen quotes ranging from 7 to 9 days before a taper is required. A few other tips:
1. Again, this 2012 analysis emphasizes steroids for Bells. As the abstract states, antivirals can be used, but the proven benefit is modest- 7% at best.
2. DOCUMENT in your note how long the patient has noted symptoms, as most bad outcomes are linked to patients presenting over 3 days from symptom appearance. As such, a lack of response to therapy (ie- a patient saying "you horrible provider, you have not cured me yet!") is often due to late presentation-not your improper therapy.
3. Make it clear in your discharge instructions for diabetics about hypergylcemia issues, including the need for primary care follow up for possible monitoring, before you embark on the steroids. Ditto for history of severe/bleeding GI ulcers.
4. In a busy clinic it is easy to do, but recall- per my recollection- that this "Bells/steroids emphasis" is different from zoster/shingles, where the focus is more on prompt antivirals. Per my reading there is less conclusive data on the benefits of steroids in zoster, including post herpetic neuralgia. Please comment if you know of a renewed or newly proven emphasis on steroids for zoster.
5. DON'T FORGET THE EYE! In Bell's palsy people wil sleep and the eye cannot/will not completely shut. Without the constant stream of germ diluting eye secretions from the tear ducts, people with poor eye management in Bells have had devastasting corneal ulcers. Give written instructions to use sterile saline ad lib during the day and at night to "tape" the eyelid shut with paper tape. Eye irritation or discomfort should prompt an ophthalmology evaluation.
6. For what it's worth, I usually go with Prednisone 50mg tablets, one a day with food for 5 days, no taper. Do you all have any other "favorite" regimens?
7. Lastly, infectious disease specialists rant about considering Lyme disease in a patient with Bells palsy. While I see no problem with documenting a tick exposure history, I would kindly refer one to the legion articles in the past on this blog about the limits and pitfalls of Lyme testing. As I often say, "any fool can ordrer a test- the medical skill comes in proper interpretation."
Above is a current nice meta analysis abstract from the American Academy of Neurology summarizing that for Bell's palsy, the treatment of choice definitively should include steroids, and at best, antivirals should be an adjunct. I lack access to the full article, but being a meta analysis I assume one set dose and period of steroids was not agreed upon. A rough survey of older texts though seems to avoid the "Medrol Dose Pak" in favor of higher, constant doses to battle Bells. While there is some literature disagreement, most authorities concur that no steroid taper is required for 5 days of therapy, and I have seen quotes ranging from 7 to 9 days before a taper is required. A few other tips:
1. Again, this 2012 analysis emphasizes steroids for Bells. As the abstract states, antivirals can be used, but the proven benefit is modest- 7% at best.
2. DOCUMENT in your note how long the patient has noted symptoms, as most bad outcomes are linked to patients presenting over 3 days from symptom appearance. As such, a lack of response to therapy (ie- a patient saying "you horrible provider, you have not cured me yet!") is often due to late presentation-not your improper therapy.
3. Make it clear in your discharge instructions for diabetics about hypergylcemia issues, including the need for primary care follow up for possible monitoring, before you embark on the steroids. Ditto for history of severe/bleeding GI ulcers.
4. In a busy clinic it is easy to do, but recall- per my recollection- that this "Bells/steroids emphasis" is different from zoster/shingles, where the focus is more on prompt antivirals. Per my reading there is less conclusive data on the benefits of steroids in zoster, including post herpetic neuralgia. Please comment if you know of a renewed or newly proven emphasis on steroids for zoster.
5. DON'T FORGET THE EYE! In Bell's palsy people wil sleep and the eye cannot/will not completely shut. Without the constant stream of germ diluting eye secretions from the tear ducts, people with poor eye management in Bells have had devastasting corneal ulcers. Give written instructions to use sterile saline ad lib during the day and at night to "tape" the eyelid shut with paper tape. Eye irritation or discomfort should prompt an ophthalmology evaluation.
6. For what it's worth, I usually go with Prednisone 50mg tablets, one a day with food for 5 days, no taper. Do you all have any other "favorite" regimens?
7. Lastly, infectious disease specialists rant about considering Lyme disease in a patient with Bells palsy. While I see no problem with documenting a tick exposure history, I would kindly refer one to the legion articles in the past on this blog about the limits and pitfalls of Lyme testing. As I often say, "any fool can ordrer a test- the medical skill comes in proper interpretation."
Wednesday, October 24, 2012
Don't let the Bedbugs Bite...
http://www.aafp.org/afp/2012/1001/p653.html
The American Family Physician magazine recently had a concise summary of bedbug diagnosis and treatment. A few caveats that I thought were worth mentioning:
1 The article has a nice picture depicting the full range of sizes and appearances of bedbugs across the bug's lifespan (nymphs, etc). While none of us are entomologists, knowing the general appearance is helpful. If you cannot access the AFP article, check out the life cycle pictures on the below linked Wikipedia article.
http://en.wikipedia.org/wiki/Bed_bug
2. People worry about eradication of bedbugs that have latched onto travel items, like backpacks and luggage. Note in the ending table it suggests either 2 hrs of heat over 120F, or 5 days of freezing. While bedbugs are hardy in a normal room environment, they are very temperature sensitive. For travel item decontamination, one easy tip in the North Carolina summers is to leave luggage, travel items, etc. in your car trunk for one afternoon, as temperatures are well over 120F. Alternatively, placing items in the freezer should help also-but note the time difference of 5 days.
3. Perhaps I did not read enough or was misled when I read about bedbugs as they re-emerged in the early 2000s, but I was under the clinical impression that most of the bites were papule or wheal like. However, as the article mentions, the appearance of bedbug bites can run the "maculopapular" gamut. A typical red flag, per the article, is the "breakfast, lunch, dinner" linear pattern of bites, but clinically I have also seen that with scabies clumping along an elastic waistband, or chiggers hitting a sockline.
4. Lastly, in true "academic" non real world fashion the article cites that no treatment has been shown effective, so give reassurance and tell the patient to wait a week or two. Good luck with that strategy. People who are told of a bedbug diagnosis would rather drink cyanide than do nothing. If you are leery of topical or po steroids, I have heard many dermatologists recommend topical, over the counter Sarna lotion for 20-30 minutes of relief from the itch.
What varied appearances have you seen of suspected bedbugs? Papules? Scabbed macules?
Any favorite medicines for the itch?
Any tips to calm the hysteria?
The American Family Physician magazine recently had a concise summary of bedbug diagnosis and treatment. A few caveats that I thought were worth mentioning:
1 The article has a nice picture depicting the full range of sizes and appearances of bedbugs across the bug's lifespan (nymphs, etc). While none of us are entomologists, knowing the general appearance is helpful. If you cannot access the AFP article, check out the life cycle pictures on the below linked Wikipedia article.
http://en.wikipedia.org/wiki/Bed_bug
2. People worry about eradication of bedbugs that have latched onto travel items, like backpacks and luggage. Note in the ending table it suggests either 2 hrs of heat over 120F, or 5 days of freezing. While bedbugs are hardy in a normal room environment, they are very temperature sensitive. For travel item decontamination, one easy tip in the North Carolina summers is to leave luggage, travel items, etc. in your car trunk for one afternoon, as temperatures are well over 120F. Alternatively, placing items in the freezer should help also-but note the time difference of 5 days.
3. Perhaps I did not read enough or was misled when I read about bedbugs as they re-emerged in the early 2000s, but I was under the clinical impression that most of the bites were papule or wheal like. However, as the article mentions, the appearance of bedbug bites can run the "maculopapular" gamut. A typical red flag, per the article, is the "breakfast, lunch, dinner" linear pattern of bites, but clinically I have also seen that with scabies clumping along an elastic waistband, or chiggers hitting a sockline.
4. Lastly, in true "academic" non real world fashion the article cites that no treatment has been shown effective, so give reassurance and tell the patient to wait a week or two. Good luck with that strategy. People who are told of a bedbug diagnosis would rather drink cyanide than do nothing. If you are leery of topical or po steroids, I have heard many dermatologists recommend topical, over the counter Sarna lotion for 20-30 minutes of relief from the itch.
What varied appearances have you seen of suspected bedbugs? Papules? Scabbed macules?
Any favorite medicines for the itch?
Any tips to calm the hysteria?
Tuesday, October 2, 2012
Your "Gut"- You know When to Hold 'Em, and When to Fold 'Em
http://www.bmj.com/content/345/bmj.e6144
Above is a free article that summarizes what many practicing clinicians have long (literally) felt: sometimes you just have to "go" with your intuition. The article essentially validates that these "gut" impressions, especially for pediatrics, are accurate.
A few quick points:
- Yes, the article is from Europe where the malpractice climate may be different, but it still has a solid number of patients.
- Newer/less experienced providers still "have" a gut feeling, it is just that the "newbies" often lack the ability to clinically correlate it into a diagnosis. This finding is important. Heed your "gut" regardless of your experience level, and take correct action/referral.
-While I am staunchly against "fever phobia" the article revalidates the finding that for every degree over 102 F, your chance of an occult "deep" infection (pneumonia, uti/pyelonephritis, sepsis) increases. Specifically, the article states that 1 out of every 20 children with a documented fever over 40C/104F end up with a documented "significant" bacterial issue.
-Once again, the article is a firm reminder of the importance in children to document their immunization status. The decrease-thanks to immunization- in invasive forms of Streptococcus pneumoniae has been impressive over the years. As such, as previous blog articles have outlined, the days of "rocephinizing febrile kids for 2-3 days until the labs are normal" are fading. Converesely, unvaccinated kids, from an urgent care perspective, with high fever may be more needing of ER evaluation.
-Lastly, note that the "gut" impression is majorly composed of a global, "stepping back" and looking at the patient and observing! Sometimes it is best to just unclothe the child, step back 3 or 4 feet, and watch for the "eternity" of 30 seconds to a minute. This tactic displays thoroughness to parents and often yields important clincal information.
GO WITH YOUR GUT- IT USUALLY IS RIGHT!
Above is a free article that summarizes what many practicing clinicians have long (literally) felt: sometimes you just have to "go" with your intuition. The article essentially validates that these "gut" impressions, especially for pediatrics, are accurate.
A few quick points:
- Yes, the article is from Europe where the malpractice climate may be different, but it still has a solid number of patients.
- Newer/less experienced providers still "have" a gut feeling, it is just that the "newbies" often lack the ability to clinically correlate it into a diagnosis. This finding is important. Heed your "gut" regardless of your experience level, and take correct action/referral.
-While I am staunchly against "fever phobia" the article revalidates the finding that for every degree over 102 F, your chance of an occult "deep" infection (pneumonia, uti/pyelonephritis, sepsis) increases. Specifically, the article states that 1 out of every 20 children with a documented fever over 40C/104F end up with a documented "significant" bacterial issue.
-Once again, the article is a firm reminder of the importance in children to document their immunization status. The decrease-thanks to immunization- in invasive forms of Streptococcus pneumoniae has been impressive over the years. As such, as previous blog articles have outlined, the days of "rocephinizing febrile kids for 2-3 days until the labs are normal" are fading. Converesely, unvaccinated kids, from an urgent care perspective, with high fever may be more needing of ER evaluation.
-Lastly, note that the "gut" impression is majorly composed of a global, "stepping back" and looking at the patient and observing! Sometimes it is best to just unclothe the child, step back 3 or 4 feet, and watch for the "eternity" of 30 seconds to a minute. This tactic displays thoroughness to parents and often yields important clincal information.
GO WITH YOUR GUT- IT USUALLY IS RIGHT!
Friday, September 7, 2012
Can we concuss the lawyers' noggins?
http://www.nejm.org/doi/pdf/10.1056/NEJMcp064645
A hat tip to Dr. Fuller for an excellent summary article in the New England Journal of Medicine on concussions. While slightly dated at 2007, I have not seen an updated NEJM article on this topic. Please correct me if my search was myopic. For those of you who dislike the NEJM, I do encourage the summary "clinical practice" articles, as they have more a "real world", non-academic, "in the trenches" utility for practitioners like ourselves.
The article can speak for itself, but I would offer the following caveats:
- Special focus should be on Table 1, and be sure to read ALL of the footnotes! Note that the New Orleans criteria has higher sensitivity (in other words, you are less likely to miss an important CT abnormality or a lesion needing neurosurgery) than the Canadian CT Head Rule.
-Note that the Canadian rule excluded children under 16, and as such is invalid for pediatrics.
-Remember that these are screening tests, so the sensitivity should be HIGH, but the specificity should be very LOW. As such, note that even when these rules are met and a CT is performed, a significant issue is present only 5% of the time.
-Woe to all who work in the Express Care New Year's Day. Be very aware that the rules do not apply to intoxicated patients, and remember that if the injury occurred while intoxicated your history is very compromised, to put it nicely.
-The article mentions that the old habit of "waking a person up in the middle of the night" to check on lethargy has not been established. However, if one is concerned enough to ask the family to do this, then one should likely consider going on and getting the CT. Reminds one of the old maxim, "if you think a patient may need intubation, then you probably should have intubated 5 minutes ago."
- In the real world, note that the New Orleans criteria says that if someone has a head injury and is over 60, then since one criteria is met (age over 60), that warrants a CT scan. That is a lot of CT scans (and probably a lot of AMA forms), but that is the price of making the lawyers happy with 99% sensitivity.
Lastly, I think the major reminder here is to be sure to give the patient clear, WRITTEN DISCHARGE INSTRUCTIONS that explains the major symptoms to watch for and the need for urgent emergency room evaluation via 911 or someone else driving. No clinical imaging rule is 100%. The best combo is a well applied, prudent clinical rule and clear, written discharge instructions.
Again, the article is a classic, and please comment below, link, or email me if someone has newer criteria.
A hat tip to Dr. Fuller for an excellent summary article in the New England Journal of Medicine on concussions. While slightly dated at 2007, I have not seen an updated NEJM article on this topic. Please correct me if my search was myopic. For those of you who dislike the NEJM, I do encourage the summary "clinical practice" articles, as they have more a "real world", non-academic, "in the trenches" utility for practitioners like ourselves.
The article can speak for itself, but I would offer the following caveats:
- Special focus should be on Table 1, and be sure to read ALL of the footnotes! Note that the New Orleans criteria has higher sensitivity (in other words, you are less likely to miss an important CT abnormality or a lesion needing neurosurgery) than the Canadian CT Head Rule.
-Note that the Canadian rule excluded children under 16, and as such is invalid for pediatrics.
-Remember that these are screening tests, so the sensitivity should be HIGH, but the specificity should be very LOW. As such, note that even when these rules are met and a CT is performed, a significant issue is present only 5% of the time.
-Woe to all who work in the Express Care New Year's Day. Be very aware that the rules do not apply to intoxicated patients, and remember that if the injury occurred while intoxicated your history is very compromised, to put it nicely.
-The article mentions that the old habit of "waking a person up in the middle of the night" to check on lethargy has not been established. However, if one is concerned enough to ask the family to do this, then one should likely consider going on and getting the CT. Reminds one of the old maxim, "if you think a patient may need intubation, then you probably should have intubated 5 minutes ago."
- In the real world, note that the New Orleans criteria says that if someone has a head injury and is over 60, then since one criteria is met (age over 60), that warrants a CT scan. That is a lot of CT scans (and probably a lot of AMA forms), but that is the price of making the lawyers happy with 99% sensitivity.
Lastly, I think the major reminder here is to be sure to give the patient clear, WRITTEN DISCHARGE INSTRUCTIONS that explains the major symptoms to watch for and the need for urgent emergency room evaluation via 911 or someone else driving. No clinical imaging rule is 100%. The best combo is a well applied, prudent clinical rule and clear, written discharge instructions.
Again, the article is a classic, and please comment below, link, or email me if someone has newer criteria.
"Dogma" is "Am God" Spelled Backwards...
http://www.sciencedirect.com/science/article/pii/S1551714412002030
http://www.nejm.org/doi/full/10.1056/NEJMoa1203378
I will round out this series of Spring/Summer 2012 tick articles with 2 new articles that are a solid reminder of the unclear understanding of tick zoonoses. Please review the 2 earlier blog summary articles on Lyme disease and the other summary article on RMSF and Ehrlichiosis.
Note that the Lyme article was very clearly against persistent/long term, chronic anitbiotic treament for Lyme disease, especially the pseudo-entity of chronic Lyme disease. Most of the strong recommendations were based on expert opinion from the Infectious Disease Society of America, the IDSA. In fact, as readers of the license suspensions in the NC Medical Board newsletter, The Forum, may recall, a few years ago a physician north of Charlotte had his license questioned (and I believe revoked) for chronic ceftriaxone and IV antibiotic therapy for Lyme cases.
Well, as radio host Paul Harvey says, "and then there's the rest of the story". The Medscape referenced first article now questions some of the studies that originally doubted the repeat antibiotic therapy.
I am a believer in science and standing upon the newest and best research as basis for one's therapeutic decisions. However, I cite the Lyme article above to emphasize just how tenuous and evolving the current understanding of Lyme disease is, even when one removes the often confounding variables of vague symptoms and disability compensation payments.
Given that the current understading of Lyme and its treatment options are evolving, and as the previous article mentions the risk of false positive IgM antibodies YEARS after an exposure, I encourage all providers to be very selective in their diagonosis and treatment of Lyme issues, with a paramount focus on proper non urgent care follow up, monitoring, and a written discharge plan in the patient's discharge instructions. I think one can safely say that trying to fully deal with Lyme and its legion issues from an urgent care setting is akin to going to a gunfight with a knife...you lack the continuity to properly monitor and deal with the outcomes.
The second article is another reminder of how little we know about ticks. In this NEJM article, 2 suspected cases of Ehrlichiosis (including the 'trademark' elevated LFTs, thrombocytopenia, and leukopenia) did not improve on doxycycline. Subsequent analysis showed a novel phlebovirus, now dubbed the "Heartland virus", to be the culprit.
In summary, I am reminded of what a grizzled old professor told me my last week of medical school, "Keep reading and stay flexible, because 1/2 of what we have taught you will be wrong in 5 years. The problem is we don't know yet which half....."
Protect yourself with a full awareness of the pros and cons of ordering labs, being leery of false positives and false negatives, and realizing when a situation is best dealt with in a traditional family medicine/internal medicine setting that has continuity, discussion, and better referral ability.
http://www.nejm.org/doi/full/10.1056/NEJMoa1203378
I will round out this series of Spring/Summer 2012 tick articles with 2 new articles that are a solid reminder of the unclear understanding of tick zoonoses. Please review the 2 earlier blog summary articles on Lyme disease and the other summary article on RMSF and Ehrlichiosis.
Note that the Lyme article was very clearly against persistent/long term, chronic anitbiotic treament for Lyme disease, especially the pseudo-entity of chronic Lyme disease. Most of the strong recommendations were based on expert opinion from the Infectious Disease Society of America, the IDSA. In fact, as readers of the license suspensions in the NC Medical Board newsletter, The Forum, may recall, a few years ago a physician north of Charlotte had his license questioned (and I believe revoked) for chronic ceftriaxone and IV antibiotic therapy for Lyme cases.
Well, as radio host Paul Harvey says, "and then there's the rest of the story". The Medscape referenced first article now questions some of the studies that originally doubted the repeat antibiotic therapy.
I am a believer in science and standing upon the newest and best research as basis for one's therapeutic decisions. However, I cite the Lyme article above to emphasize just how tenuous and evolving the current understanding of Lyme disease is, even when one removes the often confounding variables of vague symptoms and disability compensation payments.
Given that the current understading of Lyme and its treatment options are evolving, and as the previous article mentions the risk of false positive IgM antibodies YEARS after an exposure, I encourage all providers to be very selective in their diagonosis and treatment of Lyme issues, with a paramount focus on proper non urgent care follow up, monitoring, and a written discharge plan in the patient's discharge instructions. I think one can safely say that trying to fully deal with Lyme and its legion issues from an urgent care setting is akin to going to a gunfight with a knife...you lack the continuity to properly monitor and deal with the outcomes.
The second article is another reminder of how little we know about ticks. In this NEJM article, 2 suspected cases of Ehrlichiosis (including the 'trademark' elevated LFTs, thrombocytopenia, and leukopenia) did not improve on doxycycline. Subsequent analysis showed a novel phlebovirus, now dubbed the "Heartland virus", to be the culprit.
In summary, I am reminded of what a grizzled old professor told me my last week of medical school, "Keep reading and stay flexible, because 1/2 of what we have taught you will be wrong in 5 years. The problem is we don't know yet which half....."
Protect yourself with a full awareness of the pros and cons of ordering labs, being leery of false positives and false negatives, and realizing when a situation is best dealt with in a traditional family medicine/internal medicine setting that has continuity, discussion, and better referral ability.
Saturday, August 11, 2012
Going, Going, "Gon"orrhea Options Dwindling
http://www.cdc.gov/nchhstp/newsroom/docs/2012/GonorrheaTreatmentGuidelinesFactSheet8-9-2012.pdf
A few days ago the CDC sent out a notice informing providers that due to increasing resistance, cefexime (Suprax) is no longer the first line of therapy for gonorrhea. Many of you all will recall not too long ago
the fluoroquinolones lost favor as therapy due to resistance. As such, the current mainstay of suspected gonorrhea is ceftriaxone (Rocephin) injected.
Please remember that due to high coinfection rates, if you clinically suspect gonorrhea enough to treat for it, you should "assume" coinfection with chlamydia, and also prescribe zithromax or doxycycline. Depending on the study you cite, as many as 20-40% of people who are positive for gonorrhea will also test positive for chlamydia. So, thinking of one should lead to the other.
Of course, don't forget these are all notifiable diseases once the labs return. Use the standard health department report form and fax it to 919-250-3945. The most crucial item to fill out on the form is to be sure to tell the health department if the patient was treated.
This change will impact many of our express cares, as many providers liked Suprax as a "non shot" alternative to rocephin. The CDC article admits an ultra low chance of resistance, but when a "standard of care", precedent setting group like the CDC changes its first line therapy, all providers should be aware, since a second line treatment should include documentation as to why the first line was not used.
A few days ago the CDC sent out a notice informing providers that due to increasing resistance, cefexime (Suprax) is no longer the first line of therapy for gonorrhea. Many of you all will recall not too long ago
the fluoroquinolones lost favor as therapy due to resistance. As such, the current mainstay of suspected gonorrhea is ceftriaxone (Rocephin) injected.
Please remember that due to high coinfection rates, if you clinically suspect gonorrhea enough to treat for it, you should "assume" coinfection with chlamydia, and also prescribe zithromax or doxycycline. Depending on the study you cite, as many as 20-40% of people who are positive for gonorrhea will also test positive for chlamydia. So, thinking of one should lead to the other.
Of course, don't forget these are all notifiable diseases once the labs return. Use the standard health department report form and fax it to 919-250-3945. The most crucial item to fill out on the form is to be sure to tell the health department if the patient was treated.
This change will impact many of our express cares, as many providers liked Suprax as a "non shot" alternative to rocephin. The CDC article admits an ultra low chance of resistance, but when a "standard of care", precedent setting group like the CDC changes its first line therapy, all providers should be aware, since a second line treatment should include documentation as to why the first line was not used.
Wednesday, August 8, 2012
One "gal" you don't want to date....
http://www.medscape.com/viewarticle/768306?src=mp&spon=38
Major thanks to Sara Hubbell, nurse practitioner, for I suspect the most succinct summary of this emerging disease that will bring dangerous anaphylaxis to our doorsteps.
When anaphylaxis comes our way and we quickly scamper around with our medicines and 911 calls, we often try to question the alarmed patient about the "usual suspects" pine nuts, pineapple, shrimp, and the like. Note though that a new and rather novel entity, involving tick bites (mainly the Lone Star tick), anaphylaxis and red meat exposure has emerged. By red meat, this includes beef, pork, lamb, and venison. Most patients maintain a tolerance (no reation to)chicken, turkey and fish.
The presumed mechanism of action is thought to start with a Lone Star tick bite. The tick bite triggers production of IgE antibodies to the carbohydrate galactose-alpha-1,3-galactose, known thankfully as the shorter, "alpha-gal".
Sadly for the patient, the "alpha-gal" moiety is a common item in mammalian meat glycoproteins and glycolipids. As such, from the initial tick bite the patient becomes anaphylactic to red meats. As the case studies mention, the allergists can order an antibody test for IgE alpha-gal, which is usually elevated.
https://www.google.com/search?q=lone+star+tick&hl=en&prmd=imvns&tbm=isch&tbo=u&source=univ&sa=X&ei=46siUJPHNsaQ2QXepoHQCQ&ved=0CFgQsAQ&biw=1024&bih=585
Some crux urgent care points (the above link is to pictures of the Lone Star tick for all you wannabe entomologists):
- The alpha-gal anaphylaxis usually occurs 3-6 hours after eating the red meat, which is a bit delayed compared to the usual anaphylaxis reactions where the triggering event is mostly within the last 15-60 minutes.
- The alpha-gal anaphylaxis carries all the pitfalls of usual anaphylaxis, such as hypotension, syncope and hives. The treament is the same, with the mainstay being epinephrine.
- Because many allergists also will do an allergy panel to specific meats, the alpha-gal workup is best done by an allergist/immunologist. From an urgent care standpoint, it may help to remind the patient as they go to the ER to be sure to fill their epinephrine precription and consider an allergist workup. Parents also would appreciate this advice at a scary time.
Again the article is very concise. It is worth the Medscape registration if you have not done so previously, and the cases are enlightening.
The cynical side of me says this is actually a government made vector unleased on the public to combat the obesity epidemic (making red meat have the potential to kill you), but then again I know the fast food lobby is much too strong in Washington DC to have allowed that to happen.....
Comments are welcome....
Major thanks to Sara Hubbell, nurse practitioner, for I suspect the most succinct summary of this emerging disease that will bring dangerous anaphylaxis to our doorsteps.
When anaphylaxis comes our way and we quickly scamper around with our medicines and 911 calls, we often try to question the alarmed patient about the "usual suspects" pine nuts, pineapple, shrimp, and the like. Note though that a new and rather novel entity, involving tick bites (mainly the Lone Star tick), anaphylaxis and red meat exposure has emerged. By red meat, this includes beef, pork, lamb, and venison. Most patients maintain a tolerance (no reation to)chicken, turkey and fish.
The presumed mechanism of action is thought to start with a Lone Star tick bite. The tick bite triggers production of IgE antibodies to the carbohydrate galactose-alpha-1,3-galactose, known thankfully as the shorter, "alpha-gal".
Sadly for the patient, the "alpha-gal" moiety is a common item in mammalian meat glycoproteins and glycolipids. As such, from the initial tick bite the patient becomes anaphylactic to red meats. As the case studies mention, the allergists can order an antibody test for IgE alpha-gal, which is usually elevated.
https://www.google.com/search?q=lone+star+tick&hl=en&prmd=imvns&tbm=isch&tbo=u&source=univ&sa=X&ei=46siUJPHNsaQ2QXepoHQCQ&ved=0CFgQsAQ&biw=1024&bih=585
Some crux urgent care points (the above link is to pictures of the Lone Star tick for all you wannabe entomologists):
- The alpha-gal anaphylaxis usually occurs 3-6 hours after eating the red meat, which is a bit delayed compared to the usual anaphylaxis reactions where the triggering event is mostly within the last 15-60 minutes.
- The alpha-gal anaphylaxis carries all the pitfalls of usual anaphylaxis, such as hypotension, syncope and hives. The treament is the same, with the mainstay being epinephrine.
- Because many allergists also will do an allergy panel to specific meats, the alpha-gal workup is best done by an allergist/immunologist. From an urgent care standpoint, it may help to remind the patient as they go to the ER to be sure to fill their epinephrine precription and consider an allergist workup. Parents also would appreciate this advice at a scary time.
Again the article is very concise. It is worth the Medscape registration if you have not done so previously, and the cases are enlightening.
The cynical side of me says this is actually a government made vector unleased on the public to combat the obesity epidemic (making red meat have the potential to kill you), but then again I know the fast food lobby is much too strong in Washington DC to have allowed that to happen.....
Comments are welcome....
Wednesday, July 11, 2012
You May Be Surprised-When to Refrain with Chest Pain
http://www.medscape.com/viewarticle/766543
Like the previous blog entry, you may need to sign into Medscape to view this article.
Above is a very current (7/5/12) article on what signs and symptoms truly lead to adverse outcomes (death, MI, urgent need/revisit for revascularization) within 6 months of a medical evaluation. Thanks to Dr. Citron for the excellent article which very much applies to our practice.
One more preface note, the author, Amal Mattu, MD, is a prolific medical writer on common ER pitfalls. While in my humble opinion, not to the level of Dr. Gregory Henry in "Bouncebacks", Dr. Mattu definitely focuses and has pithy wisdom on items that "can trip doctors up." If you like this article I suggest an Amazon book/Kindle search on his name. Of note, Mattu has an "urgent care pitfall" book that will be published October 2012.
The jist of the article is that "classic" MI signs, sternal pressure going into the left jaw and neck, etc. may not be so classic. This prospective study of 796 patients in an inner city in England intensively tracked what signs and symptoms were most correlated actual MIs (true cardiac disease). Per the article, CORRECT signs that most point to cardiac disease include:
-Pain radiating to the RIGHT arm or shoulder (odds ratio(OR) 2.23)
-Pain going to BOTH shoulders (OR 2.69)
-Vomiting (OR 3.50)
-Central Location of chest pain- (OR 3.29)
-Clinician observed Diaphoresis (OR 5.18). For the record, patient reported diapohoresis (but not observed) did correlate to MI but not as highly as clincian observed diaphoresis.
I can do no better than parpaphrase the 3 take home points at the end of the article, which are:
1. While this study and the mentioned studies can provide guidance, note that obviously NO sign or symptom can fully stratify a patient to "no risk". Use the findings as guidance-not gospel.
2. If you are taking the "plunge" and sending a patient home with chest pain, document as many of the "low" risk features as possible in your chart to display your medical reasoning and increase your defensibility. The article mentions pleuritic chest pain, positional chest pain, sharp pain, pain reproduced by palpation, and pain not associated with exertion. To be devil's advocate though, recall that pleuritic chest pain may then open you up to pulmonary embolism (I threw that in for you, Dr. Wood).
3.The most important predictors of acute coronary syndrome and MI appear to be: chest pain that radiates (especially bilaterally or to the right side), associated diaphoresis, associated vomiting, and pain on exertion. The article suggests asking and documenting these 4 items for all chest pain patients, and to really refrain from sending people with these traits home with the usual "pleurisy", "costocondritis", or "GERD" diagnosis.
Thanks again to Dr. Citron for the useful article. Let me hear some comments on your opinion of the "right shoulder" phenomenon.
Like the previous blog entry, you may need to sign into Medscape to view this article.
Above is a very current (7/5/12) article on what signs and symptoms truly lead to adverse outcomes (death, MI, urgent need/revisit for revascularization) within 6 months of a medical evaluation. Thanks to Dr. Citron for the excellent article which very much applies to our practice.
One more preface note, the author, Amal Mattu, MD, is a prolific medical writer on common ER pitfalls. While in my humble opinion, not to the level of Dr. Gregory Henry in "Bouncebacks", Dr. Mattu definitely focuses and has pithy wisdom on items that "can trip doctors up." If you like this article I suggest an Amazon book/Kindle search on his name. Of note, Mattu has an "urgent care pitfall" book that will be published October 2012.
The jist of the article is that "classic" MI signs, sternal pressure going into the left jaw and neck, etc. may not be so classic. This prospective study of 796 patients in an inner city in England intensively tracked what signs and symptoms were most correlated actual MIs (true cardiac disease). Per the article, CORRECT signs that most point to cardiac disease include:
-Pain radiating to the RIGHT arm or shoulder (odds ratio(OR) 2.23)
-Pain going to BOTH shoulders (OR 2.69)
-Vomiting (OR 3.50)
-Central Location of chest pain- (OR 3.29)
-Clinician observed Diaphoresis (OR 5.18). For the record, patient reported diapohoresis (but not observed) did correlate to MI but not as highly as clincian observed diaphoresis.
I can do no better than parpaphrase the 3 take home points at the end of the article, which are:
1. While this study and the mentioned studies can provide guidance, note that obviously NO sign or symptom can fully stratify a patient to "no risk". Use the findings as guidance-not gospel.
2. If you are taking the "plunge" and sending a patient home with chest pain, document as many of the "low" risk features as possible in your chart to display your medical reasoning and increase your defensibility. The article mentions pleuritic chest pain, positional chest pain, sharp pain, pain reproduced by palpation, and pain not associated with exertion. To be devil's advocate though, recall that pleuritic chest pain may then open you up to pulmonary embolism (I threw that in for you, Dr. Wood).
3.The most important predictors of acute coronary syndrome and MI appear to be: chest pain that radiates (especially bilaterally or to the right side), associated diaphoresis, associated vomiting, and pain on exertion. The article suggests asking and documenting these 4 items for all chest pain patients, and to really refrain from sending people with these traits home with the usual "pleurisy", "costocondritis", or "GERD" diagnosis.
Thanks again to Dr. Citron for the useful article. Let me hear some comments on your opinion of the "right shoulder" phenomenon.
Monday, July 9, 2012
Dog Days and Bug Bites and Swimming Issues
http://reference.medscape.com/features/slideshow/bug-bites?src=nl_slide
Above is an interesting and picture laden summary of several bug bite lesions. A few quick reminders that were spurred by the pictures:
1. When confronted with an "odd" rash" or fever, don't forget to document any travel history. While a full workup for say, malaria, would be best started in the emergency room ( better lab access to a "thick" blood smear, easier blood culture attainability), it is important to maintain your clincial suspicions.
2. Make no mistake,I am amazed by the number of "red bugs" or chigger bites in this region. Explain to patients that because the chiggers may have been residing on one clump of grass or brush, it is not unusual for only one person in the outdoor party to be affected, even when doing similar activities, such as hiking together.
3. For all our patients enjoying ocean and lake activities (and for those taking board recertifications!) don't forget the difference between "swimmers itch" and "seabathers eruption". The itch is when non-human schistomsomes (often from birds and small mammals) invade the EXPOSED skin. As such, the "itch" is on non swimsuit covered areas, such as arms and legs. Usually the swimmer's itch is freshwater. In contrast, the seabathers eruption is from 2 saltwater animals, and get "caught" under swim clothing. So, people return from their beach trip with an itchy rash that affects only areas UNDER their clothing. Both respond to topical/systemic itch relief. Note that the swimmer's itch is a different schistosome from the human parsitic schistosomes that infect the bladder and other sites from exposure in areas like the Nile in Africa.
Please note you may need to "become" a Medscape member to access the article. The Medscape feed is useful though.
Above is an interesting and picture laden summary of several bug bite lesions. A few quick reminders that were spurred by the pictures:
1. When confronted with an "odd" rash" or fever, don't forget to document any travel history. While a full workup for say, malaria, would be best started in the emergency room ( better lab access to a "thick" blood smear, easier blood culture attainability), it is important to maintain your clincial suspicions.
2. Make no mistake,I am amazed by the number of "red bugs" or chigger bites in this region. Explain to patients that because the chiggers may have been residing on one clump of grass or brush, it is not unusual for only one person in the outdoor party to be affected, even when doing similar activities, such as hiking together.
3. For all our patients enjoying ocean and lake activities (and for those taking board recertifications!) don't forget the difference between "swimmers itch" and "seabathers eruption". The itch is when non-human schistomsomes (often from birds and small mammals) invade the EXPOSED skin. As such, the "itch" is on non swimsuit covered areas, such as arms and legs. Usually the swimmer's itch is freshwater. In contrast, the seabathers eruption is from 2 saltwater animals, and get "caught" under swim clothing. So, people return from their beach trip with an itchy rash that affects only areas UNDER their clothing. Both respond to topical/systemic itch relief. Note that the swimmer's itch is a different schistosome from the human parsitic schistosomes that infect the bladder and other sites from exposure in areas like the Nile in Africa.
Please note you may need to "become" a Medscape member to access the article. The Medscape feed is useful though.
Friday, June 22, 2012
Lies, Lyme, and Labs- Tips for Lyme Disease
Diagnosis and Management of Lyme Disease - June 1, 2012 - American Family Physician
The article above is a solid summary of the current Lyme disease diagnosis and management principles. Here are a few pearls that caught my eye in this article.
1. As an ultra quick review, recall that typical Lyme has 3 stages. Stage 1 is early localized and includes erythema migrans and viral/flu like illness (fatigue, malaise, fever, chills, myalgia, headache). Obviously, most of our patients will present at this stage. Stage 2 is "early disseminated" Lyme, where the organism spreads to other organ systems from the tick bite site. Manifestations include cardiac (AV block, especially 3rd degree AV block), dermatologic (multiple, disseminated lesions of erythema migrans), musculoskeletal (arthralgias), and neurologic (facial nerve palsy, meningitis, encephalitis). Stage 3 includes arthritis and chronic neurologic issues, such as peripheral neuropathy.
2. Make sure to note the differentiation that the Stage 3 arthritis, which can occur months to years after a tick bite, is distinct from recently named, but not clinically validated, entities of "post Lyme disease syndrome" which is more of an unproven fatigue issue, and "chronic Lyme disease", which is currently a broad term of chronic patient issues that may or may not have Lyme disease.
3. Of vital importance to the Express Care physician in reassuring hysteric patients is that of all the tick diseases, Lyme is probably the hardest to transmit from tick to humans. The tick must bite, attach, feed until engorgement, then vomit the Lyme organism into the human bloodstream. The Borrelia bacterium actually lives in the midgut of the tick, and it must move via emesis into the tick salivary glands. Hence 2 vital items to document are how long the tick may have been attached (as Lyme usually takes 36 hrs of attachment to be transmitted), and whether the tick was engorged.
4.Symptoms of Stage 1 Lyme have been documented anywhere from days 3-30 after a bite, but the typical is 1-2 weeks after a tick bite.
5. As many as 80% of patients do develop the erythema migrans rash. Note that technically erythema migrans is a circular UNIFORM erythematous lesion with a range of 5cm to 70 cm. The CDC actually lists to diagnose erythema migrans an erythematous macule or papule at least 5 cm in size, with or without central clearing. In fact, only 19% of erythema migrans rashes develop the "ultra classic" bulls-eye rash. Patient and physicians can easily over focus on the central clearing, or lack thereof. The key is a red macule or papule at the bite 5cm or more.
6.Recall that the preferred indirect lab method by the CDC is the 2 step method where if the initial ELISA is positive, then a confirmatory Western blot assay be done. However, as the article displays in Table 3, the sensitivity in early localized Lyme with the 2-tier testing is still low, down to 17% sensitivity for acute phase early localized Lyme.
7. False postive labs also run rampant, as the IgM (surprisingly) and the IgG antibodies can remain in the serum for years even after (a resolved) infection. As such, the "usual aches and fatigue" can be mistakenly attributed to Lyme disease.
8. Treatment of early localized Lyme can be accomplished with doxycycline, amoxicillin, cefuroxime, and even azithromycin (which makes me wonder why Lyme has not been eradicated f rom the American population like smallpox has from the human population..just kidding).
Again, these were just a few of the useful Lyme reminders in this article. Check it out when you get a chance, and please add any additional observations below. Linwood
The article above is a solid summary of the current Lyme disease diagnosis and management principles. Here are a few pearls that caught my eye in this article.
1. As an ultra quick review, recall that typical Lyme has 3 stages. Stage 1 is early localized and includes erythema migrans and viral/flu like illness (fatigue, malaise, fever, chills, myalgia, headache). Obviously, most of our patients will present at this stage. Stage 2 is "early disseminated" Lyme, where the organism spreads to other organ systems from the tick bite site. Manifestations include cardiac (AV block, especially 3rd degree AV block), dermatologic (multiple, disseminated lesions of erythema migrans), musculoskeletal (arthralgias), and neurologic (facial nerve palsy, meningitis, encephalitis). Stage 3 includes arthritis and chronic neurologic issues, such as peripheral neuropathy.
2. Make sure to note the differentiation that the Stage 3 arthritis, which can occur months to years after a tick bite, is distinct from recently named, but not clinically validated, entities of "post Lyme disease syndrome" which is more of an unproven fatigue issue, and "chronic Lyme disease", which is currently a broad term of chronic patient issues that may or may not have Lyme disease.
3. Of vital importance to the Express Care physician in reassuring hysteric patients is that of all the tick diseases, Lyme is probably the hardest to transmit from tick to humans. The tick must bite, attach, feed until engorgement, then vomit the Lyme organism into the human bloodstream. The Borrelia bacterium actually lives in the midgut of the tick, and it must move via emesis into the tick salivary glands. Hence 2 vital items to document are how long the tick may have been attached (as Lyme usually takes 36 hrs of attachment to be transmitted), and whether the tick was engorged.
4.Symptoms of Stage 1 Lyme have been documented anywhere from days 3-30 after a bite, but the typical is 1-2 weeks after a tick bite.
5. As many as 80% of patients do develop the erythema migrans rash. Note that technically erythema migrans is a circular UNIFORM erythematous lesion with a range of 5cm to 70 cm. The CDC actually lists to diagnose erythema migrans an erythematous macule or papule at least 5 cm in size, with or without central clearing. In fact, only 19% of erythema migrans rashes develop the "ultra classic" bulls-eye rash. Patient and physicians can easily over focus on the central clearing, or lack thereof. The key is a red macule or papule at the bite 5cm or more.
6.Recall that the preferred indirect lab method by the CDC is the 2 step method where if the initial ELISA is positive, then a confirmatory Western blot assay be done. However, as the article displays in Table 3, the sensitivity in early localized Lyme with the 2-tier testing is still low, down to 17% sensitivity for acute phase early localized Lyme.
7. False postive labs also run rampant, as the IgM (surprisingly) and the IgG antibodies can remain in the serum for years even after (a resolved) infection. As such, the "usual aches and fatigue" can be mistakenly attributed to Lyme disease.
8. Treatment of early localized Lyme can be accomplished with doxycycline, amoxicillin, cefuroxime, and even azithromycin (which makes me wonder why Lyme has not been eradicated f rom the American population like smallpox has from the human population..just kidding).
Again, these were just a few of the useful Lyme reminders in this article. Check it out when you get a chance, and please add any additional observations below. Linwood
Sunday, June 3, 2012
TIme to Get Ticked Off...
http://www.cdc.gov/mmwr/PDF/rr/rr5504.pdf
Thanks to the above link from Dr. Fuller for an excellent summary of Rocky Mountain Spotted Fever and Ehrlichiosis. The article is slightly dated at 2006, but it still forms a bedrock of knowledge that will serve any urgent care clinician well. I wanted to highlight a few interesting points:
1. As the graphs show, North Carolina typically leads the nation in RMSF. For some reason, past CDC reviews typically list us or Oklahoma as the usual top getters. Most patients focus on Lyme, but again, the main, proven enemy in this state is RMSF.
2. On page 8, the article cites the useful tip that one should not assume that in the event of a family outbreak of illness, that the disease is not a tick borne disease and instead the fever is likely a viral illness. The literature is peppered with well confirmed "group outbreaks" of tick borne disease among golfing communities, families on camping trips, or a family pet leading to family wide tick disease.
3. Most people present on day 2-3 of a suspected tick bite or disease. Most cases of RMSF that have a rash first develop the rash on days 2-4, so keep in mind you could be confronting " Rocky Mountain Spotless Fever". The rash usually starts on the ankles, wrists and forearms. As such, I often document in a febrile patient "normal wrists and ankles" to show I was looking for tick disease/rash.
4. Useful lab hints at the clinical diagnosis of RMSF ehrlichiosis are leukopenia, thrombocytopenia, mild hyponatremia, and mildly elevated hepatic transaminases. So, a CBC and CMP may augment your CLINICAL suspicion.....but note the lab titers should not, as even the earliest IgM does not start to rise until day 7.
5. If you or someone else orders titers, the article mentions that titers can be elevated up to 3.5 years after infection. As such, it is easy to generate false alarm in a febrile illness you are investigating, since suddenly you have a "positive lab", but you are actually being misled by an old finding of elevated titers.
6. The article bluntly says on page 12, " doxycycline is the drug of choice for treatment of all tick disease in children and adults." THE END. The article further explains that the 1960s studies showing tooth staining in children less than 7 involved multiple, extended courses of doxycycline for otitis media. As such, a comparatively short (7-10 day) course of doxycycline should not harm the teeth of any child, regardless of age. The American Academy of Pediatrics Committee on Infectious Diseases revised its guidelines in 1997 to say that doxycyline is the drug of choice for presumed or confirmed RMSF and ehrlichial infections in children of ANY age. I would use this CDC, standard of care paper as your reference in any legal accusations or conversations with parents on tooth stain risks. Remember you will get the call after the parent fills the prescription and reads the mandatory included drug summary and side effect pamphlet.
Again, I highly encourage all to peruse the article. You will be a better beacon of knowledge for it!
Thanks to the above link from Dr. Fuller for an excellent summary of Rocky Mountain Spotted Fever and Ehrlichiosis. The article is slightly dated at 2006, but it still forms a bedrock of knowledge that will serve any urgent care clinician well. I wanted to highlight a few interesting points:
1. As the graphs show, North Carolina typically leads the nation in RMSF. For some reason, past CDC reviews typically list us or Oklahoma as the usual top getters. Most patients focus on Lyme, but again, the main, proven enemy in this state is RMSF.
2. On page 8, the article cites the useful tip that one should not assume that in the event of a family outbreak of illness, that the disease is not a tick borne disease and instead the fever is likely a viral illness. The literature is peppered with well confirmed "group outbreaks" of tick borne disease among golfing communities, families on camping trips, or a family pet leading to family wide tick disease.
3. Most people present on day 2-3 of a suspected tick bite or disease. Most cases of RMSF that have a rash first develop the rash on days 2-4, so keep in mind you could be confronting " Rocky Mountain Spotless Fever". The rash usually starts on the ankles, wrists and forearms. As such, I often document in a febrile patient "normal wrists and ankles" to show I was looking for tick disease/rash.
4. Useful lab hints at the clinical diagnosis of RMSF ehrlichiosis are leukopenia, thrombocytopenia, mild hyponatremia, and mildly elevated hepatic transaminases. So, a CBC and CMP may augment your CLINICAL suspicion.....but note the lab titers should not, as even the earliest IgM does not start to rise until day 7.
5. If you or someone else orders titers, the article mentions that titers can be elevated up to 3.5 years after infection. As such, it is easy to generate false alarm in a febrile illness you are investigating, since suddenly you have a "positive lab", but you are actually being misled by an old finding of elevated titers.
6. The article bluntly says on page 12, " doxycycline is the drug of choice for treatment of all tick disease in children and adults." THE END. The article further explains that the 1960s studies showing tooth staining in children less than 7 involved multiple, extended courses of doxycycline for otitis media. As such, a comparatively short (7-10 day) course of doxycycline should not harm the teeth of any child, regardless of age. The American Academy of Pediatrics Committee on Infectious Diseases revised its guidelines in 1997 to say that doxycyline is the drug of choice for presumed or confirmed RMSF and ehrlichial infections in children of ANY age. I would use this CDC, standard of care paper as your reference in any legal accusations or conversations with parents on tooth stain risks. Remember you will get the call after the parent fills the prescription and reads the mandatory included drug summary and side effect pamphlet.
Again, I highly encourage all to peruse the article. You will be a better beacon of knowledge for it!
Wednesday, May 16, 2012
"My throat is STILL sore..."
http://www.jabfm.org/content/22/6/663.full
No doubt, sore throat is a common issue in the express cares. What is the consensus though, when the throat culture returns only to show "Beta- hemolytic strep, not Group A or C?" Note that these letters refer to Lancefield groups of streoptococcal bacteria, and include Groups A,B,C,F and G, all of which are beta-hemolytic streptococci on blood agar mediums.
To shed some light on this issue, I linked the above 2009 article. Some interesting points from this as well as the UptoDate article following are:
http://www.uptodate.com/contents/group-c-and-group-g-streptococcal-infection?source=search_result&search=pharyngitis+treatment&selectedTitle=7%7E150
1. Groups C and G streptococcus have NOT been associated with formal cardiac rheumatic fever or post-streptococcal glomerulonephritis. However, these bacteria have been implicated in internal infections including actual (non immunologic) endocarditis, septic arthiritis, and UTIs, and as such have some pathogenic risks in certain organs.
2. Groups C and G are almost uniformly susceptible to penicillin. However, there is common resistance to macolides. As such, this may be the cause of patient callbacks of "my throat is killing me" despite a negative rapid strep test and no response to Zithromax.
3. Per the UptoDate article, treating these infections with antibiotics can be accomplished in 5 days. As mentioned above, due to no associated immunologic induced rheumatic fever or glomerulonephritis, the standard 10 days of therapy for sore throat does not have to include these isolates. Of course, Group A strep throat infections do need the usual 10 days of penicillin.
4. The real "$64,000 dollar question" that both articles above and the literature in general seem to skirt is whether or not treatment with antibiotics of non-group A streptococcal throat infections leads to faster clinical improvement. The UptoDate article says treatment IS appropriate, but the actual efficacy is still debated.
5. In the first cited article there is a good review of the often used Centor criteria that can allow presumptive treatment despite a negative rapid strep. Please note that the more rigid Infectious Disease Society of America (IDSA) disagrees with most primary care physician groups (like the AAFP) on the validity of antibotic treament based solely on the Centor criteria. These criteria are fever (over 99.5F), palpable cervical lymph nodes, exudates in the pharynx, headache, and absence of cough. Sensitivity when all 5 of these are present approaches 80%.
6. One practical pearl, don't forget when confronted with pediatric fever, headache, and sore throat, with POSTERIOR cervical lymph nodes, be sure to consider mononucleosis in your differential. Plus, recall that aside from the typical mid-late adolescent, the NEXT most common group for mono is toddlers and early elementary school children (recall it is saliva transmitted-which includes not just kissing but sharing beverages/"juice boxes").
Comment below on whether or not anecdotally you see that antibiotics help or hasten recovery from non- Group A beta-hemolytic pharyngitis infections. What is your stance? I realize that again, the literature varies so you may base your practice on a different study or study reliability/methodology. The more views the better, so comment...when you are going through the pending labs and a throat culture comes back NON Group A beta hemolytic strep, do you call in antibiotics?
No doubt, sore throat is a common issue in the express cares. What is the consensus though, when the throat culture returns only to show "Beta- hemolytic strep, not Group A or C?" Note that these letters refer to Lancefield groups of streoptococcal bacteria, and include Groups A,B,C,F and G, all of which are beta-hemolytic streptococci on blood agar mediums.
To shed some light on this issue, I linked the above 2009 article. Some interesting points from this as well as the UptoDate article following are:
http://www.uptodate.com/contents/group-c-and-group-g-streptococcal-infection?source=search_result&search=pharyngitis+treatment&selectedTitle=7%7E150
1. Groups C and G streptococcus have NOT been associated with formal cardiac rheumatic fever or post-streptococcal glomerulonephritis. However, these bacteria have been implicated in internal infections including actual (non immunologic) endocarditis, septic arthiritis, and UTIs, and as such have some pathogenic risks in certain organs.
2. Groups C and G are almost uniformly susceptible to penicillin. However, there is common resistance to macolides. As such, this may be the cause of patient callbacks of "my throat is killing me" despite a negative rapid strep test and no response to Zithromax.
3. Per the UptoDate article, treating these infections with antibiotics can be accomplished in 5 days. As mentioned above, due to no associated immunologic induced rheumatic fever or glomerulonephritis, the standard 10 days of therapy for sore throat does not have to include these isolates. Of course, Group A strep throat infections do need the usual 10 days of penicillin.
4. The real "$64,000 dollar question" that both articles above and the literature in general seem to skirt is whether or not treatment with antibiotics of non-group A streptococcal throat infections leads to faster clinical improvement. The UptoDate article says treatment IS appropriate, but the actual efficacy is still debated.
5. In the first cited article there is a good review of the often used Centor criteria that can allow presumptive treatment despite a negative rapid strep. Please note that the more rigid Infectious Disease Society of America (IDSA) disagrees with most primary care physician groups (like the AAFP) on the validity of antibotic treament based solely on the Centor criteria. These criteria are fever (over 99.5F), palpable cervical lymph nodes, exudates in the pharynx, headache, and absence of cough. Sensitivity when all 5 of these are present approaches 80%.
6. One practical pearl, don't forget when confronted with pediatric fever, headache, and sore throat, with POSTERIOR cervical lymph nodes, be sure to consider mononucleosis in your differential. Plus, recall that aside from the typical mid-late adolescent, the NEXT most common group for mono is toddlers and early elementary school children (recall it is saliva transmitted-which includes not just kissing but sharing beverages/"juice boxes").
Comment below on whether or not anecdotally you see that antibiotics help or hasten recovery from non- Group A beta-hemolytic pharyngitis infections. What is your stance? I realize that again, the literature varies so you may base your practice on a different study or study reliability/methodology. The more views the better, so comment...when you are going through the pending labs and a throat culture comes back NON Group A beta hemolytic strep, do you call in antibiotics?
Wednesday, April 25, 2012
You Gave Me the Finger!
Common Finger Fractures and Dislocations - April 15, 2012 - American Family Physician
Spring greetings to all. Of course, spring means more spring sports, and that means hand injuries in our express cares. I linked up to a very informative and succinct hand injury summary. Please read the article, as I promise you will be a better healthcare provider because of it...and that is the highest compliment I can give an article. Here are some quick highlights that I thought really stood out:
1. Be sure to counsel and remind patients with distal phalanx (tuft) fractures that these fractures are routinely complicated by hyperesthesia, pain and numbness for up to SIX months post injury. This counseling will likely prevent patient worry, doubt, and unneeded callbacks.
2. For mallet fractures (forced flexion at the DIP joint producing a bone fragment at the dorsal surface of the proximal part of the distal phalanx..whew, say that 3 times fast), recall that the clinical result is a DIP that cannot be extended. For these, 2 caveats. First, splint in full extension for EIGHT, not 6, weeks. Document and remind patients that the extension/splint MUST never be taken off in this period, because if you remove the splint, you "break the healing"and essentially reset the healing clock back to zero. Second, for these mallet FRACTURES, once you splint in full extension, REPEAT an x-ray with the splint to document and ensure congruity between the fractured piece and the distal phalanx.
3. Conversely, for the jersey fingers (forced extension at the DIP joint producing a bone fragment at the VOLAR surface of the proximal distal phalanx), along with the fracture you have clinically an inability to flex the DIP. Note that these volar surface DIP issues also involve damage to the flexor digitorum profundus tendon. Take home point- unlike the dorsal DIP mallet finger/fractures, it is very important to have these jersey fingers sent to orthopedics/hand specialists, due to tendon retraction risk.
4. Feel free to comment below, but I was always told in my training that in your exam, be sure to ISOLATE, each joint individually, say on the edge of a table, to avoid "tendon and collateral cheating" to ensure each DIP/PIP/MCP is fully evaluated. From the edge of the table, flex and extend each joint individually, with the other joints fully at rest. Don't forget to check active and passive ROM.
5. One last reminder-we are all human and as such we forget things. Hence, when reviewing this or any other hand article, don't be shy or ashamed to open up and have the old Netter/ Grants atlas at your side. Often, these anatomy reviews really help your mind correlate the injury mechanism with the x-rays and the possible complications.
Please email me if you cannot access the article, and I will gladly let you borrow my AAFP password. Review the article though- you will be glad you did!
Spring greetings to all. Of course, spring means more spring sports, and that means hand injuries in our express cares. I linked up to a very informative and succinct hand injury summary. Please read the article, as I promise you will be a better healthcare provider because of it...and that is the highest compliment I can give an article. Here are some quick highlights that I thought really stood out:
1. Be sure to counsel and remind patients with distal phalanx (tuft) fractures that these fractures are routinely complicated by hyperesthesia, pain and numbness for up to SIX months post injury. This counseling will likely prevent patient worry, doubt, and unneeded callbacks.
2. For mallet fractures (forced flexion at the DIP joint producing a bone fragment at the dorsal surface of the proximal part of the distal phalanx..whew, say that 3 times fast), recall that the clinical result is a DIP that cannot be extended. For these, 2 caveats. First, splint in full extension for EIGHT, not 6, weeks. Document and remind patients that the extension/splint MUST never be taken off in this period, because if you remove the splint, you "break the healing"and essentially reset the healing clock back to zero. Second, for these mallet FRACTURES, once you splint in full extension, REPEAT an x-ray with the splint to document and ensure congruity between the fractured piece and the distal phalanx.
3. Conversely, for the jersey fingers (forced extension at the DIP joint producing a bone fragment at the VOLAR surface of the proximal distal phalanx), along with the fracture you have clinically an inability to flex the DIP. Note that these volar surface DIP issues also involve damage to the flexor digitorum profundus tendon. Take home point- unlike the dorsal DIP mallet finger/fractures, it is very important to have these jersey fingers sent to orthopedics/hand specialists, due to tendon retraction risk.
4. Feel free to comment below, but I was always told in my training that in your exam, be sure to ISOLATE, each joint individually, say on the edge of a table, to avoid "tendon and collateral cheating" to ensure each DIP/PIP/MCP is fully evaluated. From the edge of the table, flex and extend each joint individually, with the other joints fully at rest. Don't forget to check active and passive ROM.
5. One last reminder-we are all human and as such we forget things. Hence, when reviewing this or any other hand article, don't be shy or ashamed to open up and have the old Netter/ Grants atlas at your side. Often, these anatomy reviews really help your mind correlate the injury mechanism with the x-rays and the possible complications.
Please email me if you cannot access the article, and I will gladly let you borrow my AAFP password. Review the article though- you will be glad you did!
Sunday, April 8, 2012
Pediatric Pneumonia Tips
http://www.medscape.org/viewarticle/749312
http://www.medscape.com/viewarticle/752596
Recently in August 2011, the Infectious Disease Society of America (IDSA) composed its first ever expert opinion guidelines on pediatric community acquired pneumonia (CAP). We all have been well versed in this group's adult community acquired pneumonia guidelines (the usual Levaquin or the combo of Rocephin and Zithromax), but little guidance has been given for pediatrics.
Please note that for all you evidence based medicine fans (Is that an oxymoron?) the IDSA admits to a relative paucity of studies in the area of pediatric community acquired pneumonia. After all, it is hard to get a randomized trial going, let alone a meta-analysis, of kids with respiratory distress and pneumonia. Still, a broad ranged panel of 13 experts sifted through the data and came up with the guidelines above. Both of the Medscape articles are summary articles, while the end IDSA link is the full 52 page document for all you OCD providers (like myself and Dr. Chao).
Here is a rough sumary, but I do encourage people to check out the fairly succinct first link above- #749312.
Point 1: For preschool and school aged children who have been previously healthy and IMMUNIZED, the recommended first line agent is (believe it or not) amoxicillin. The ID experts cite the extreme success of the previous Prevnar 7, and now the newer Prevnar 13, against the real "bad boy" resistant Strep. pneumoniae that previously wreaked havoc on pediatric workups. REMEMBER- immunization is crucial to this guideline!
Point 2: Don't forget macrolides (good ol' "Vitamin Z"-Zithromax) for MAINLY school aged children who have clinical histories consistent with atypical pneumonia.
Point 3: Don't forget antivirals for confirmed pneumonia with flu-like histories.
Point 4: The IDSA guidelines bluntly suggest for all children with suspected pneumonia aged 3-6 months old, hospitalization should be done. The experts cite the vulnerability of this age group to encapsulated bacteria like Strep pneumoniae, and the lack of full immunization at this age.
Point 5: For amoxicillin failures, don't forget CA-MRSA as a potential pathogen. I would be interested in comments on this matter, as the IDSA always suggests CA-MRSA pneumonia needs vancomycin, but does anyone know if Bactrim has the needed respiratory/lung penetration to treat lung infections? Just food for thought...
Lastly, we all realize the challenge with pediatric guidelines is not the credibility of the science per se, but instead getting the parents on board. Still, I hope this update lets you practice with more confidence and awareness.
Here is the full IDSA paper:
http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2011%20CAP%20in%20Children.pdf
http://www.medscape.com/viewarticle/752596
Recently in August 2011, the Infectious Disease Society of America (IDSA) composed its first ever expert opinion guidelines on pediatric community acquired pneumonia (CAP). We all have been well versed in this group's adult community acquired pneumonia guidelines (the usual Levaquin or the combo of Rocephin and Zithromax), but little guidance has been given for pediatrics.
Please note that for all you evidence based medicine fans (Is that an oxymoron?) the IDSA admits to a relative paucity of studies in the area of pediatric community acquired pneumonia. After all, it is hard to get a randomized trial going, let alone a meta-analysis, of kids with respiratory distress and pneumonia. Still, a broad ranged panel of 13 experts sifted through the data and came up with the guidelines above. Both of the Medscape articles are summary articles, while the end IDSA link is the full 52 page document for all you OCD providers (like myself and Dr. Chao).
Here is a rough sumary, but I do encourage people to check out the fairly succinct first link above- #749312.
Point 1: For preschool and school aged children who have been previously healthy and IMMUNIZED, the recommended first line agent is (believe it or not) amoxicillin. The ID experts cite the extreme success of the previous Prevnar 7, and now the newer Prevnar 13, against the real "bad boy" resistant Strep. pneumoniae that previously wreaked havoc on pediatric workups. REMEMBER- immunization is crucial to this guideline!
Point 2: Don't forget macrolides (good ol' "Vitamin Z"-Zithromax) for MAINLY school aged children who have clinical histories consistent with atypical pneumonia.
Point 3: Don't forget antivirals for confirmed pneumonia with flu-like histories.
Point 4: The IDSA guidelines bluntly suggest for all children with suspected pneumonia aged 3-6 months old, hospitalization should be done. The experts cite the vulnerability of this age group to encapsulated bacteria like Strep pneumoniae, and the lack of full immunization at this age.
Point 5: For amoxicillin failures, don't forget CA-MRSA as a potential pathogen. I would be interested in comments on this matter, as the IDSA always suggests CA-MRSA pneumonia needs vancomycin, but does anyone know if Bactrim has the needed respiratory/lung penetration to treat lung infections? Just food for thought...
Lastly, we all realize the challenge with pediatric guidelines is not the credibility of the science per se, but instead getting the parents on board. Still, I hope this update lets you practice with more confidence and awareness.
Here is the full IDSA paper:
http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2011%20CAP%20in%20Children.pdf
Saturday, March 24, 2012
Anaphylaxis Reminders and Pearls
http://www.aafp.org/afp/2011/1115/p1111.html
I linked the above article, but it is through the American Family Physician website and may be restricted. AAFP members can log in and find it in the AFP list, but for others who want a full text, the end of the report has the full article listing, which may be available via the Rex library.
Regardless, this was an excellent and current overview article on anaphylaxis. Below were some instructive pearls:
1. Recall the risk of anaphylaxis is doubled in patients with mild asthma and tripled in severe asthma.
2. 1-20% of anaphylaxis cases suffer the dreaded "biphasic reaction" where symtpoms recur later, despite initial treatment. Most commonly, this "second wave" is within 8hrs, but can occur up to 24-72 hours post exposure (yikes!). Hence, this is why many people recommend a brief ER visit/monitoring as well as po steroids afterwards for a few days. From various ER referrals and call backs, I have seen ER docs observe patients anywhere from 2-12 hours, with admits usually only occuring after blatant and refractory hypotension. Please chime in on your observations, either direct (via ER work) or indirect (via patient call backs) of ER holding periods.
3. The #1 anaphylaxis imposter/mimic is a vasovagal event.
4. The #1 medicine is always epinephrine. I sense that ER's seem to "frown on", or "take pride" in not having to give epinephrine, but being in a suburban location, the #1 priority is to avoid intubation. The article, with regards to possibly being leery of epinephrine in older people with possible or confirmed coronary artery disease, flatly states, "while there are no controlled studies that have weighed the risk, at this time, best evidence shows that benefits (of epinephrine) outweigh the risk."
5. Recall and remind nurses the BEST epinephrine route is IM, not subcutaneous. All the clinics should have adult Epi-Pens and Epi-Pen Jrs. The Jr. pens are for children less than 30kg. The article specifically says the PREFERRED method is Epi-Pens, due to several cases of misjudging the dose when drawn hurriedly from a vial of epinephrine.
6 .Reminder of Epi-Pen points- it is injected through the pants and hold for 10 seconds.
7. THE most crucial point of all from the AFP article was to remember that although H1 receptor blockers help the patient "look" and "feel" better- via less cutaneous erythema and less pruritus-they yield no benefit in improving hypotension or lessening upper airway obstruction!!!
Thanks for reading, I look forward to comments, and check in frequently for new authors and discussions!
Linwood
Full article citation- A Review of "Anaphylaxis Recognition and Management", American Family Physician. November 15, 2011. Vol 84. No. 10.
I linked the above article, but it is through the American Family Physician website and may be restricted. AAFP members can log in and find it in the AFP list, but for others who want a full text, the end of the report has the full article listing, which may be available via the Rex library.
Regardless, this was an excellent and current overview article on anaphylaxis. Below were some instructive pearls:
1. Recall the risk of anaphylaxis is doubled in patients with mild asthma and tripled in severe asthma.
2. 1-20% of anaphylaxis cases suffer the dreaded "biphasic reaction" where symtpoms recur later, despite initial treatment. Most commonly, this "second wave" is within 8hrs, but can occur up to 24-72 hours post exposure (yikes!). Hence, this is why many people recommend a brief ER visit/monitoring as well as po steroids afterwards for a few days. From various ER referrals and call backs, I have seen ER docs observe patients anywhere from 2-12 hours, with admits usually only occuring after blatant and refractory hypotension. Please chime in on your observations, either direct (via ER work) or indirect (via patient call backs) of ER holding periods.
3. The #1 anaphylaxis imposter/mimic is a vasovagal event.
4. The #1 medicine is always epinephrine. I sense that ER's seem to "frown on", or "take pride" in not having to give epinephrine, but being in a suburban location, the #1 priority is to avoid intubation. The article, with regards to possibly being leery of epinephrine in older people with possible or confirmed coronary artery disease, flatly states, "while there are no controlled studies that have weighed the risk, at this time, best evidence shows that benefits (of epinephrine) outweigh the risk."
5. Recall and remind nurses the BEST epinephrine route is IM, not subcutaneous. All the clinics should have adult Epi-Pens and Epi-Pen Jrs. The Jr. pens are for children less than 30kg. The article specifically says the PREFERRED method is Epi-Pens, due to several cases of misjudging the dose when drawn hurriedly from a vial of epinephrine.
6 .Reminder of Epi-Pen points- it is injected through the pants and hold for 10 seconds.
7. THE most crucial point of all from the AFP article was to remember that although H1 receptor blockers help the patient "look" and "feel" better- via less cutaneous erythema and less pruritus-they yield no benefit in improving hypotension or lessening upper airway obstruction!!!
Thanks for reading, I look forward to comments, and check in frequently for new authors and discussions!
Linwood
Full article citation- A Review of "Anaphylaxis Recognition and Management", American Family Physician. November 15, 2011. Vol 84. No. 10.
Friday, March 9, 2012
Welcome to the Rex Express Care blog!
Hello -
This is the first test post on Express Knowledge. This is a place where we can share news, information, stories, etc. relating to urgent care and Rex Express Care.
We can include links, like this one to the Rex Express Care Wait Times meters.
We can also drop in a photo like this:
Or we could even drop in a video, like this:
This is the first test post on Express Knowledge. This is a place where we can share news, information, stories, etc. relating to urgent care and Rex Express Care.
We can include links, like this one to the Rex Express Care Wait Times meters.
We can also drop in a photo like this:
And other users can add comments below...
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