#FOAMed Digest No. 4: Butter My Biscuit, Baby

Welcome back, to the brand new edition of the WUEMR FOAMed Digest. Get out your Tintinalli’s and strap in, because we’re going back to basics today. It’s all about the bread and butter. The things any PGY-2 setting off to an overnight Saturday shift in the Deuce should have down cold…yet us seniors still screw up on the daily.

FOAMed…ENGAGE!

Three Stars:

1. If my last shift at Children’s is any indication, the season is upon us – pharyngitis in every exam room. Casey Parker over at Broome Docs (a blog authored by EPs & GPs practicing in rural Australia), presents a magnificent summary of the data surrounding rapid strep swabs, antibiotic use for symptom relief, and antibiotic use for preventing secondary complications of strep. As always, be sure to check out the original literature for yourself. And don’t miss Minh Le Cong’s excellent counterpoint in the comments, which is also well-referenced.

2. What’s your record for most C-collars cleared in one shift? (When you hit double-digits, then we can talk.) The best tools in our arsenal for clearing C-spine in low-risk patients remain the Canadian C-spine and NEXUS instruments. But which one should you use? Do you even remember which criteria belong in each rule, or do you find yourself trying to apply the “Canadi-EXUS” criteria, like I do? Luckily for us, Alayna Hawling at BoringEM authored an excellent rundown and comparison – with a pretty flowchart!

3. As much as you want to start the fist-pumping and beer-chugging as soon as you drop that tube past the cords, your work with the intubated patient is not done, my friend! We’ve already touched on our persistently poor rates of achieving adequate analgesia & sedation in the intubated patient. Another part of quality post-intubation care is knowing what to do if your ventilated patient acutely decompensates. Check out Chris Cresswell’s summary of the DOTTS mnemonic over at EM Tutorials.

(EXTRA CREDIT: He also included a link to Scott Weingart’s notes regarding care of the crashing ventilated patient, which are well worth a look.)

Oldie But Goodie:

There’s been some e-mail discussion lately among our attendings regarding the best way to clean lacs prior to closure. Back in February, Ken Milne at the Skeptic’s Guide (along with Eve Purdy, a rockstar med student and creator of the excellent Manu et Corde blog) published a piece dedicated to breaking down the dogma of management of simple lacerations. Tap water vs sterile water, sterile gloves vs clean gloves, to sew or not to sew…it’s all covered here. Plus there’s links to other excellent FOAMed resources regarding wound care dogma.

F(FN)OAMed:

The good folks over at EB Medicine recently published a stem-to-stern guide to UTI diagnosis and management in the ED, all based on best available evidence. A bit lengthier than your average blog post, but incredibly high-yield and well worth your time. It’s a bit difficult for me to place a direct link here, but you can find it simply by logging into your account at EBMedicine, following the link to browse issues of Emergency Medicine Practice, and opening the July 2014 issue on UTI.
(As always, contact your friendly neighborhood Social Media Committee member if you need help obtaining access to EB Medicine resources.)

The Gunner Files:

1. Hard to get through a Deuce shift without breaking out the prochlorperazine at least once. We’ve all seen patients get jittery, agitated, or downright whacky following its use. Does Benadryl help? A PharmD expert at ALiEM has a good lit review of the topic.

2. Short and sweet: some diabetic medications are more likely to cause harmful hypoglycemia after overdose than others. Quick table-based rundown over at ALiEM.

3. It is asthma season, and you may find yourself in the worst-case-asthma-scenario of impending need for intubation. Check out this post from The Kings of County regarding care for the sick asthmatic, including intubation and mechanical ventilation issues.

4. FOAMed is taking the world by storm! Does the UK College of Emergency Medicine launching a dedicated FOAMed site mean it’s officially gone mainstream? Don’t worry – we were all into FOAMed before it was cool. But seriously, check out this vodcast on diagnostics in EM, and not feel quite so much increase in sphincter tone when Carpenter or Cohn pimp you on likelihood ratios or Bayesian analysis.

5. Another classic from the Skeptic’s Guide, this time addressing another oh-so-common ED complaint: renal colic. Fluids? Flomax? Any good evidence for either? In news that will surprise no one, Ken Milne is skeptical.

Never stop learning,

Sam Smith, PGY-3

A suspected case of Eczema Herpeticum

Your patient is a 2 y/o with a history of eczema who was brought in by his mother for a new rash x 1 day, associated with fever. The rash is pustular-appearing and in other places vesicular. It covers the arms, legs (including palms and soles), and trunk with relative sparing of the face. There are no oral lesions were noted. In the emergency department, the patient is febrile and tachycardic, but otherwise non-toxic appearing.

You are worried that he might have eczema herpeticum or a staph superinfection. You collect viral and bacterial swabs, and admit him to the pediatrics service. 

Question:

Should you start acyclovir right away, or is it okay to wait until the swab results come back?

Literature: 

Fortunately, an article in Pediatrics aimed at answering this very question. The study was a large, retrospective cohort study conducted between 2001-2010. This study included 1331 children age 2 mo to 17 yrs treated at 42 different centers for eczema herpeticum (identified by their primary discharge diagnosis). The primary objective of the study was to determine whether delayed acyclovir therapy was associated with increased LOS. Secondarily, the study examined the mortality rate (0%), the rate of ICU admission (3.8% ), co-existing bacterial infection (30.3%) and Staph bacteremia (~3.9%). Using multivariable linear regression models, the authors found that a delay in initiation of acyclovir was associated with an increased length of stay. Adjusted increase in LOS was 11% (95 % CI 3-20), 41% (95 % CI 19 - 67), and 98% (95% CI 60-145) for a delay in initiation by 1, 2, and 3-6 days respectively. These results were statistically significant (p <.001). The authors found no significant difference between the administration of acyclovir in IV vs. oral form. Given the above results, the authors concluded that “Patients clinically suspected of having eczema herpeticum should receive empiric therapy with acyclovir because there is a statistically significant time-dependent increase in LOS with every day of delaying in initiating acyclovir therapy". Adverse events from acyclovir therapy were not addressed.


Take Home:

1) If you are admitting a child because you are worried about eczema herpeticum, start acyclovir. Oral form is fine if kid can take it.

2) Send blood cultures and start antibiotics for co-existing Staph infection, especially if the kid is febrile because ~ 30% have co-existing Staph infection and ~4% are bacteremic.


Reference:

Aronson et. al. “Delayed Acyclovir and Outcomes of Children Hospitalized with Eczema Herpeticum.” Pediatrics 2011; 128; 1161.