ASX HTN

"My BP went from 160 to 170. Should I take an extra dose of my clonidine? or my metoprolol? or my enalapril?"

"No. You should stop checking your BP unless you have symptoms."

"Which should I take then?"

"911."

Tweet of the Day: Now What?

@justanerdoc airway mgt or trauma resus, you pick.

— Klint W. Kloepping (@KlintWKloepping) April 20, 2013

White Whale

There he is.

I've been trying to find this paper for a while, finally was able to. I saw Judd Hollander quote it in a grand rounds as PGY2:

Costochondritis. A prospective analysis in an emergency department setting.


This might be the coolest chest pain study ever done.

Rheumatologists evaluated 122 consecutive ED patients with chest pain at the Cabrini ED in 1991-2, and used the American College of Rheumatology criteria for diagnosing costochondritis.

Costochondritis was identified by digital palpation, applying enough pressure to induce partial blanching of the examining finger (=4 kg/cm2), over the costochondral and costostemaljoints (CCSJ), as previously reported. Patients were asked if such a maneuver: (1) caused no pain, (2) caused a pain different from original chest pain, or (3) caused a pain similar to the original one. Patients were considered to have CC if the answer was (2) or (3). The rest was used as a control group. Not included in this study were patients whose chest pain was associated with recent trauma, surgery, infection, fever, or malignancy.

Punchline:
6% of patients with costochondritis diagnosed by Rheumatologists in the ED = acute MI.

That's right. One out of every 17 patients who was diagnosed by a Rheumatologist, using the ACR costochondritis diagnostic criteria were having a heart attack.

Not ACS. Not positive stress. Biomarker-positive my-o-cardial in-farct.*

Judd Hollander's conclusion was: don't ever use the word costochondritis. If a resident uses it, send them home for the day because they did a bad job.

One big question remains:

How hard were these Rheumatologists pushing?**

For features from the HPI that make ACS more likely, see Salim Rezaie's great summary in Academic Life in EM.

A great question came up:

@mdaware @mgkatz036 Who has ever seen a Rheum in an ED, and why were they seeing CP pts?
— Cynic (@Apathetic_Cynic) March 29, 2013

(Perhaps that's why Cabrini closed?)

On a historical note, I find it interesting that the authors included this line in their discussion:

One of the most interesting observations in  this study was the low frequency ofAMI in the CC group,  which was four times lower than in the control group, in spite of having similar risk factors for CAD,  based on age, history of smoking, and hypertension.

That thinking on working up chest pain is (in hindsight) now outdated. See this great discussion on ERCAST.

Basically, the "risk factors for CAD" are just that: risk factors for developing CAD, which is a very different question than: does this patient with chest pain have ACS?

The way I think about it: traditional risk factors don't differentiate between which patients in the ED with chest pain have ACS; rather, the Framingham risks tell us which patients will end up in the ED with ACS at some point in the future. 

*plasma CK-MB. It was the early 1990s. 

**Actually we know: about 4 kg/cm2, "enough pressure to induce partial blanching of the examining finger"

Tools of the Trade

"What do you carry with you on shift?" 

This question has come up a few times, so I figured I'd put it down in one place:

Breast pocket:
2 pens
Sharpie (industrial) for marking landmarks (#13; eg cric, LP, and paracentesis)
scalpel

Rear pocket:
2 sheets of paper, folded in quarters for signout, notes, etc.
iPhone (not pictured, because it's taking the picture)

Waistband:
Trauma shears: most useful ED tool

ID:
mini-LED (like these)
retractable reel clip

Desk:
stethoscope; still useful in a handful of situations, mostly wheezing, reiki, and leading into questions about smoking

Shift bag:
head lamp (AA battery powered) for things like finger & scalp lacs
big clamp
meconium aspirator & swivel adaptor for messy airways
extra guaiac cards & developer
3-way stop cocks -- poorly stocked in my ED, can come in handy (here, here, here, here, here, here)

Glossary Term: Not Looking So Hot...

crackophrenia (noun):

(1) the state or condition of being crazy from smoking crack cocaine

(2) the morphotype of the same

The patient has crackophrenia hair.

Credit to: David Lehrfeld

Special thanks to Scott Goldberg

Don't forget to check out the other glossary entries!

RSA A-OK

The patient has neck & face tattoos

With all due respect to Darren Braude (who is both smarter and significantly more qualified than me!) I'm admittedly not a huge fan of RSA -- rapid sequence airway. The concept is simple: give RSI meds (sedative + paralytic), place EGA* to preoxygenate, then intubate. The main concern I have is that you are taking patients who already think there might be an issue in oxygenating, and paralyzing them. Not much of a safety net.

However, the main reason I don't like RSA isn't because RSA is terrible or wrong but because the patients who need RSA are sick, tricky patients and all paths are fraught with danger.

There's been an twitter discussion over the past day or so between Nicholas Chrimes, Minh Le Cong, myself, and few others (Pik Mukherji, Alexander Sammel, Taylor, Brent May, Alan Grayson, Crystal Upshaw, Chris Edwards, Valerio Pisano, Kath Woolfield... sorry if I missed anyone!). And sometimes 140 characters (plus all the @tags taking up space) just isn't enough.

The main discussion skeptic of RSA here is Nicholas Chrimes, who asks:

Why not just try to intubate these patients? If they desat or the airway is unexpectedly difficult, then place an EGA and reoxygenate.

To me, the patient who needs RSA is the patient who you need to intubate now (no time for awake or AFOI or OR), and while you can preoxygenate, that preoxygenation is tenuous. This is admittedly a very, very small group of patients (smaller than the small group of patients who require DSI).

And I want to be very specific: I mean the patient who is preoxygenated to 100% on NIV for 3 minutes with 10 of PEEP and by the time the spatula hits the glossus, the sat is 85%. Doesn't happen much but when it does, no one is happy.

I think that the best thing you can do with this patient is slip in an LMA, reoxygenate, then intubate via the LMA. Dr. Chrimes disagrees, for a few reasons.

First, he contends that an attempt at ETI is just as fast as LMA placement. I disagree. I think that in the time it takes me to get the blade in the mouth, I could already have the LMA in place and start reoxygenating. I haven't done a formal lit search on this but in addition to my experience, there is at least one paper that at least suggests it (PMID 22796543**).

Next, Dr. Chrimes suggests that the goal is airway protection from aspiration, not oxygenation. Aspiration is very bad, but I think one of the lessons from NAP4 is that desaturation kills in the ED, aspiration kills in the OR.

As Minh suggests, in these patients the risk of aspiration is low but the risk of critical desaturation is very real and the consequences are dire. The goal here isn't to leave an LMA in place. It's to bridge the patient to a protected airway without critically desaturating. The patient who critically desaturates injures their brain and/or arrests. Which is bad.

“It's not about plastic in the trachea, it's about oxygen in the lungs." (Rich Levitan)

Sure, there is a risk for aspiration. But if the patient is desaturating precipitously, then the risk for hypoxia is much higher than it usually is. Here RSA is used to avoid hypoxia -- which you know will be a problem, while aspiration only might be a problem.

I don't think the answer is necessarily clear. But to me, this seems like the least dangerous path in a very dangerous patient.

UPDATE March 8, 2013:

As the twitter argument conversation continues, something I realized I forgot to include:

Part of Nic's contention is that ETI is just as fast as LMA placement. Again, I disagree. In fact, to me, part of the reason RSA makes so much sense here is that while you may not have enough time to intubate the patient before a critical desaturation, you very well might have time to slip in an LMA. After rexoygenating, you can then intubate through the LMA, which should also take less time than a laryngoscopy & tube placement attempt.

Basically, you're breaking up your intubation attempt with the LMA, and adding a chance for the patient to catch their breath.

Plus, attempting to intubate via an LMA has an added benefit: if you need to bag the patient back up, the time it takes to abandon your attempt and start ventilating is very short -- certainly shorter than backing out from an attempt at ETI and going back to bagging. And, now you're LM bagging, which is often better than FM bagging.

Lastly, Scott Weingart chimed in:

@nicholaschrimes @mdaware @rfdsdoc @socalexmd @ercowboy best place for rsa imho is solely met acidosis pt you want to bag thru ap period

— Scott Weingart (@emcrit) March 8, 2013

*Extra glottic airway, such as a laryngeal mask or King-LT. I happen to prefer LMAs -- and I know that technically LMA is a brand name but I don't want to keep typing "laryngeal mask"

**I happen to have been a subject in this study

ACEP Chooses Wisely

Kudos to ACEP for joining the Choosing Wisely campaign! I think this is a big step forward in helping reign in unnecessary care, which not only will help our patients but also happens to save money. Note that helping patients is the priority here; saving money is nice added benefit (and will help keep other people's noses out of our professional business).

As explained briefly on The Central Line:

“Choosing Wisely” is part of a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation to help physicians be better stewards of finite health care resources. The campaign encourages medical specialty organizations to identify five tests or procedures commonly used in their field, the necessity of which should be questioned and discussed by patients and physicians.

ACEP had considered joining 3 times before, but was concerned that and most recently had declined to join in the summer of 2012. Some concerns expressed by then-ACEP president David Seaberg include:

Many of these patients have been sent in with expressed instructions from the family physician to have this or that test ordered 

It is simply not possible for emergency physicians to talk about reducing ‘unnecessary’ testing without including messages about the need for medical liability reform.

it very well may assure that emergency physicians will not receive reimbursement for the five identified procedures or tests.

Although those concerns are not unwarranted (mostly the latter 2), I think they are generally outweighed by the benefits. As I explained in a reply on the EP Monthly re-post of the same essay by Dr. Seaberg:

Choosing Wisely is gaining national recognition for its patient-centered approach to decreasing unnecessary care. This is one major way we -- as professionals -- can decide what is appropriate for our patients. Parsimony is coming. If we don't take the lead then others will decide how we should care for our patients. As a specialty, we can define our standard of care so groups like CMS don't have to.