Antibiotics for Mandible Fractures?

Clinical Scenario:

You’re working a busy Saturday overnight, and the traumas are rolling in. You’ve just finished packaging up your patient with an abdominal GSW for the OR, and they’re bringing back a new patient before the stretcher is even flipped over. He’s a 25 year-old male, presenting to the ED after being in an altercation with some friends of friends. He was hit in the face during the fistfight. He is complaining of left-sided jaw pain and facial swelling. He is able to open his jaw to a reasonable degree, but uncomfortably. There is no apparent intra-oral injury. CT max/face shows multiple minimally-displaced fractures of the left mandibular ramus and paramental region.

Luckily for you the ENT consult resident is still in the department from seeing your last patient with a complicated ear lac. She evaluates the patient with her senior and looks over the images. The patient will need surgical repair, but is OK for discharge with close pre-op follow-up next week. They recommend mouthwash, nasal spray, analgesia, and antibiotics.

Clinical question:

When are prophylactic antibiotics indicated in mandibular fractures, and how effective are they are preventing infection?

3D CT recon of minimally-displaced mandible fractures. Image from MD Consult.

Steroids for Acute Chest Syndrome?

Clinical Scenario:

A 41 year-old male with a history of well-controlled sickle cell disease and a remote history of CVA and Acute Chest Syndrome (ACS) presents to the ED with three days of left sided chest, shoulder, and flank pain. The pain was subacute in onset, was not pleuritic, was worse with movement, and was not improved with NSAIDs. He also complained of a dry cough but reported no fevers. He had an oxygen saturation of 88% on room air, but his vital signs were otherwise normal. His physical exam demonstrated clear lungs and pain with palpation of his left shoulder and left anterior chest wall. His EKG showed stable borderline LVH. Labs were notable for a negative troponin and Hgb of 5.8, and a left basilar airspace opacity on lateral chest X-ray. He was given IV fluids, morphine, and IV ceftriaxone & azithromycin to cover for Community-Acquired PNA (CAP) triggering Acute Chest Syndrome.

Clinical Question:

Do steroids have a role in treatment of Acute Chest Syndrome?

Plain CXR showing patchy infiltrates of acute chest syndrome. Image credit from AccessMedicine.

EKG challenge #2 Resolution - Sometimes You are Anxious because You are Going to Die

We'd like to start by thanking everyone who participated in the EKG challenge.  Without further ado, the case conclusion:

It's an early Sunday morning and it hasn't gotten that busy yet.  You decide to go to the cafeteria and get some breakfast.  As you sit down to start shoveling in the Western Hash Browns, a patient pops up the board.  It is a a male in his 30's with a chief complaint of "chest pain".   You click your name on, but figure you have time to eat a few bites before going in the room when the patient care tech who wheeled him back comes and tells you "hey, that guy doesn't look so good".

When you walk in the room you are faced with a diaphoretic young, slightly overweight male who complains of 7/10 left-sided chest pain.  It has been going on since yesterday and he states, "I thought it was my anxiety acting up but it didn't go away."  He has a HR of 90 and a blood pressure of 115/80.

The tech wheels in the EKG machine and obtains the following EKG:

EKG #1

Looking at EKG #1 you are concerned about cardiac ischemia because of ST elevation in V3 associated with a hyperacute T wave and suggestion of ST depression in the inferior leads.  After promptly telling your attending about the patient, ordering some labs and pain control you walk back in the room to check on him. The guy at this point looks decidedly peakish.  You decide, as you should, to obtain a repeat EKG:

EKG #2

You notice that the ST elevation has become more severe in the anterior leads and the ST depression deeper on the inferior leads.  In addition to ST segment changes, the patient has developed a new RBBB. The rhythm is still sinus - but the complex has gotten wide and the R waves tall in V1.  In fact, the patient has a RBBB and a LAFB (which you can tell because there is a RBBB with left axis deviation).  Concerned that these changes represent acute MI in this ill-appearing patient, you activate the cath lab ... 

@WUSTL_EM FOAMed Digest #7: Best of the Best of the Best Sir! ...With Honors

To build on my “Intro to FOAMed” lecture from Tuesday, I thought I would use the Digest this week to highlight some of the highest-quality resources out there for those of you just dipping your toes into the FOAMy goodness. You can’t go wrong adding these to your Feedly. Well-referenced, expert review, open discussion with prompt response – they’re really setting the bar for the FOAMed world.

And don’t worry – in the spirit of FOAMed the lecture and slides will be posted as soon as the video editing is done.

Now come on in, the water’s fine!

Three Stars:

1. Academic Life in EM (ALiEM) continues to be one of the paragons of the FOAMed community. Check out this “Diagnose on Sight” case from this week – don’t want to give it away, but you will see it time and time again during your Children’s shifts. Make note of the reference list and pre-publication review from a practicing clinician. Supremely high quality.

2. I must credit my inspiration for this FOAMed Digest – the LITFL Review from Life in the Fast Lane. Curated by some of the sharpest tacks around, it’s a great way to get familiar with the variety of resources out there. Lots of good stuff this time around, including links to Amal Mattu’s EKG video review of QT prolongation, the latest edition of FOAMCast (all about the spleen!), and the St. Emlyn’s view of the new NICE guidelines for managing acute heart failure.

EXTRA CREDIT: If you need help keeping up with the EM primary literature, the Research & Reviews in the Fastlane segment is a great place to start!

3. EM Lyceum takes the “flipped classroom” concept to the next level. Every month or so, they publish a series of clinical questions focused on a particular topic. This time, it was trauma. The point is to ponder those questions, discuss them in a group, and maybe even do your own research. The EM Lyceum group then publishes the best evidence-based answers they could find in an exceptionally well-referenced summary. Pearl from this month: Bust out the PCC for ICH on warfarin, but no good evidence for PCC in your “average” coagulopathic trauma patient.  

A Simple Community-Acquired Pneumonia? -- Appropriate Antibiotic Choice in the Era of Strep Pneumo Resistance

Clinical Scenario:  

You are taking care of a middle-aged female who presents to the ER from home with fevers/chills, shortness of breath, and cough that has gotten progressively worse over the last two days. She has not been in the hospital within the last 3 months and does not have other HCAP risk factors. You decide to get a CXR which identifies a patchy left lower lobe airspace opacity and tiny left pleural effusion consistent with pneumonia. 

Clinical Question: 

With the increasing resistance of Strep pneumo to macrolides, should we consider changing outpatient CAP empiric treatment to a fluoroquinolone? Keep in mind, that here in Saint Louis, Strep pneumo is sensitive to erythromycin 54% of the time at BJH and 43% of the time at SLCH according to current antibiogram data.

EKG challenge #2 - "I've got really bad anxiety"

It's an early Sunday morning and it hasn't gotten that busy yet.  You decide to go to the cafeteria and get some breakfast.  As you sit down to start shoveling in the Western Hash Browns, a patient pops up the board.  It is a a male in his 30's with a chief complaint of "chest pain".   You click your name on, but figure you have time to eat a few bites before going in the room when the patient care tech who wheeled him back comes and tells you "hey, that guy doesn't look so good".

When you walk in the room you are faced with a diaphoretic young, slightly overweight male who complains of 7/10 left-sided chest pain.  It has been going on since yesterday and he states, "I thought it was my anxiety acting up but it didn't go away."  He has a HR of 90 and a blood pressure of 115/80.

The tech wheels in the EKG machine and obtains the following EKG:

After promptly telling your attending about the patient, ordering some labs and pain control you walk back in the room to check on your patient. The guy at this point looks decidedly peakish.  You decide, as you should, to obtain a repeat EKG:

 Interpret the EKGs.  What do you think is going on?  What would you do next?

See the case conclusion HERE.

Sour Milk: Antibiotic Coverage For a Breast Abscess

Clinical scenario:  

Your patient is a middle-aged female who was brought in from home for altered mental status.  As EMS is moving her over to the stretcher, they say: "this lady has some kind of infection on her breast ... I saw it when I went to do her EKG".  The patient is febrile to 39.3, tachycardic in the 120’s, but maintaining a blood pressure of 150’s/80’s.  She has a large, right- sided breast abscess with some spontaneous drainage.  Clearly, this patient has severe sepsis and she needs IVF, antibiotics, and source control.

Clinical Question:  

What is the most appropriate antibiotic choice for coverage of a breast abscess?  Obviously, the patient needs an I&D, but in the meantime, what typically is growing in there?  Should anaerobic coverage be routine?

Expert Commentary: ARISE and ED Sepsis Resuscitation

As we discussed on our last Paper Trail post, the results of the ARISE and ProCESS trials seem to indicate that the most meaningful interventions for a patient in severe sepsis/septic shock are early antibiotics & source control and aggressive resuscitation in an appropriately-monitored environment. 

At our shop, we're currently working on analyzing our own sepsis response data and designing new protocols. In these discussions, some have expressed concern over the potential for giving too much fluid to these patients. The concepts of "fluid responsiveness" and "fluid tolerance" are the subject of much debate in the FOAMed critical care world these days. 
(See the discussions between Drs. Marik and Weingart over at EMCrit for reference.)

Our own ED Critical Care guru, Dr. Christopher Holthaus, stepped up to the plate and offered his views on fluid resuscitation of septic patients in the ED:

FOAMed Digest #6 Update: The Paper Trail

Today, we'd like to introduce a new section to the Everyday EBM FOAMed Digest, which will be published as a standalone post. It may seem a bit counterintuitive, but each week we're going to draw your attention to some of the latest-and-greatest papers from the primary EM literature. Most of these will not be open-access, but we hope you can still access them via the medical library at your institution. A lot of the discussion in the FOAMed world centers around recently-published papers from EM journals. The EM trainee should view FOAMed as a tool to assist with understanding and analysis of this literature, as a forum for discussion and further discovery -- not as a replacement for reading the papers for his/her self. We'll provide you a very short summary here and link you to relevant FOAMed resources if applicable.

EKG Challenge #1 - Unresponsive and Bradycardic - Case Conclusion

We'd like to start by thanking everyone who participated in the EKG challenge.  Without further ado, the case conclusion:

You are working in TCC when EMS arrives, bagging an unresponsive elderly-appearing female.   They report that they were called to a nursing home for unresponsiveness, and found the patient on the floor.  On their arrival, she was minimally responsive to noxious stimuli and had a heart rate of 36 on the monitor.  She received atropine 0.5 mg x 3 prehospital with minimal response.   Her blood pressure is 80/60.  To identify if there is heart block, you get an EKG demonstrating marked sinus bradycardia with a 1^st degree AV block and possible ST elevation in the inferior and precordial leads (see below):

Beyond tPA: Does Thrombectomy offer any Clinical Benefit in the Treatment of Acute Ischemic Stroke?

Your patient is a middle-aged female with multiple comorbidities who presents with sudden onset of right-sided weakness and difficulty speaking x 1 hour. Her head CT demonstrates a hyperdense left MCA. On exam, she is found to have a dense right hemiparesis, neglect and aphasia, for an NIHSS of 17. The team decides to administer tPA. An hour later, her exam is not improved. The neurology stroke team is very concerned, and wants to wheel the patient off to the neurointerventional suite for a thrombectomy.

Clinical Question:

How effective is thrombectomy in the treatment of acute ischemic stroke?

Unresponsive and Bradycardic - EKG challenge #1

An elderly lady is brought in by EMS minimally responsive.  The only VS that  you have are a blood pressure of 80/60, HR of 36, and a oxygen saturation of 100% on NRB. She received atropine 0.5 mg x 3 in the  field with no effect. You obtain the EKG above. Interpret the EKG. What are your diagnostic considerations?  What other information do you want?  What are you doing to stabilize the patient?

See case conclusion HERE

#FOAMed Digest No. 6: Ain't Nobody Got Time For That

Welcome back, FOAMheads! My apologies for the delay this week. I ended up being a bit busier than I expected, which not coincidentally brings me to the theme for today's entry.

Sometimes you have a lot on your plate and may not be able to set aside a large chunk of time to watch/listen to a 30-minute-plus podcast. But that doesn't mean you don't have time to get your learn on! This time around, we'll highlight some of the best FOAMed sources of short-and-sweet educational pearls. Easily digestible for the highly-distractible mind of the EM trainee.

There is no moment like the present -- let's get started!

...And We All Fall Down... Eventually : Nonpharmacologic pain management for hip fractures in the elderly?

Your patient is an elderly male with history of dementia and multiple medical comorbidities who is sent to the emergency department after a fall from standing. He complains of left hip pain and his X-rays demonstrate a comminuted intertrochanteric left hip fracture. Since the elderly and demented constitute an at-risk population for inadequate analgesia as well as increased risk of fall, respiratory depression and delirium from polypharmacy, you wonder what nonpharmacologic pain control interventions may supplement your pain control management for this patient?

Clinical question: 

Are nonpharmacologic pain control interventions effective in treating pain associated with hip fracture? Do nonpharmacologic pain control interventions reduce the need for opiates in patients with hip fracture?

The Literature: 

Several studies have examined the efficacy of skin traction (foam boot connected to weight via pulley) versus position of comfort (pillow support) for pain relief in patients with various hip fractures. In two randomized studies, skin traction showed no benefit over pillow support:
The first study, published in 2001, was a randomized study enrolling 100 participants. They compared skin traction with a 5lb weight versus pillow support. The authors found that patients who were treated with pillow support required less pain medication and reported statistically significantly lower pain scores prior to surgery (after overnight stay awaiting operative intervention) than their traction treated counterparts (p 0.04). They had an average reduction of pain score of 2.82 points versus a reduction of 1.76 points. The average age of patients in the study was 78 and nearly half had intertrochanteric hip fractures (other half were femoral neck fractures). The study was limited in that they excluded demented patients in their study as they were felt unable to demonstrate adequate understanding of the pain scale and reliably report pain scores.
The second study, released in 2010, included 108 patients randomized to either weighted traction, unweighted traction apparatus or pillow support. Similarly, they observed no difference in pain control between pillow and weighted traction. However, unweighted traction had a statistically significant improvement in pain control compared to the other two. They attributed this to a placebo effect as it provided no actual support of the fracture fragments and did not restrict movement.
Neither study reported negative outcomes associated with pillow treatment, however both observed minor negative outcomes with skin traction either weighted or unweighted. These included blistering, pressure sores and neurapraxia.

Take home: 

- At least two studies demonstrate no improvement in pain control by employing skin traction over pillow support. 
- Moreover, while the pillow group had no reported negative outcomes related to treatment, the skin traction groups in both studies reported wounds, blistering, nerve compression, and pain with application of the treatment. 
- In this population with advanced age, comorbid illness, and potentially limited ability to sense or communicate discomfort with a boot, these minor problems could develop important long term sequelae.
- My treatment plan for the next elderly hip fracture: Pillow support + adequate pharmacologic analgesia + consideration for local nerve blocks. 

References:
1) Rosen, JE et al, “Efficacy of preoperative skin traction in hip fracture patients: a prospective, randomized study,” 2001. Journal of Orthopedic Trauma. Vol. 15(2) 81-85.
2) Sayqi, B et al, “Skin traction and placebo effect in the preoperative pain control in patients with collum and intertrochanteric femur fractures.” 2010 Bulletin of the NYU Hospital for Joint Diseases. Vol. 68(1) 15 - 17.


Contributed by Sara Manning, PGY-3