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Emergency and Urgent Care Livestream Course April 22-25, 2020 3/27/2020

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Emergency and Urgent Care Livestream Course April 22-25, 2020 3/27/2020 Emergency and Urgent Care Livestream Course April 22-25, 2020 3/27/2020 Day 4 - Saturday, April 25, 2020 - (Session times are based off the Eastern Time Zone) CME Credit 7:55 – 8:00 am Announcements – Alan Ehrlich, MD 8:00 – 9:00 am Interventions to Abandon in the ER & UC – Paul D. Simmons, MD, FAAFP; Mark A. Graber, 1.00 MD, MSHCE, FACEP 9:00 – 10:00 am Acute Abdominal Pain - Paul D. Simmons, MD, FAAFP 1.00 10:00 – 10:15 am Break 10:15 – 11:15 am Animal Bites and Stings – Paul D. Simmons, MD, FAAFP 1.00 11:15 am – 12:15 pm Assessment of the Acutely Ill Elderly Patient – Alan Ehrlich, MD 1.00 12:15 pm Course Adjourns Copyright© 2020 American Academy of Family Physicians. All rights reserved. Interventions to Abandon in the ER & UC Paul D Simmons, MD, FAAFP Mark A. Graber, MD, MSHCE, FACEP Disclosure It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME session. • Vu Kiet Tran, MD, MBA has disclosed a relationship with Elvium on the topic “Acute Pain Management”. All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. Learning Objectives 1. Discuss the evidence for avoiding the use of the tests or procedures identified by the AAFP list of Fifteen Things Physicians and Patients Should Question. 2. Identify additional medical strategies and practices that may have not added value for patients. 3. Educate patients and staff on the value and benefit of appropriate evidence-based diagnostic tests and procedures. Stop sending pregnant patients for V/Q scan Both chest CT and V/Q scanning are acceptable imaging options and involve acceptable radiation levels (Obstet Gynecol. 2011;118:718). The D-dimer is not a routine part of a chest pain workup! Stop doing them on everyone. 25% of CTs are false positive. Hutchinson BD et al. Overdiagnosis of pulmonary embolism by pulmonary CT angiography. AJR Am J Roentgenol 2015 Aug; 205:271. Syncope: Just like death except you get better. (Choosing Wisely, ACP, ACEP) (www.choosingwisely.org) Don’t do a head CT for patients with simple syncope. •Syncope requires either: −Both hemispheres to be knocked out −or the reticular activating system •Syncope is a brain perfusion/oxygenation problem. Any other reasons not to do CT scan besides cost, etc.? CTs cause Cancer •What we know about radiation: −Even a single brain CT in an infant can cause a learning disability. −1:500 women and 1:600 men will develop cancer as a result of an abdominal CT at age 20. −One study estimated that roughly 29,000 future cancers could be attributed to CT scans performed in the US in 2007 alone −(see UpToDate for the data on abd CT and future cancers) CT scan and radiation risks •Children/young adults: greater Cancer risk −tissues are more radiosensitive −more years of life to develop radiation induced cancer •Est. lifetime risk of cancer from one 64 slice Chest CT −20 y/o female = 1 in 142 −40 y/o female = 1 in 284 −60 y/o female = 1 in 466 −80 y/o female = 1 in 1338 Einstein AJ, et al. JAMA 2007; 298: 317-23. Careful with that oxygen, Eugene Oxygen seems harmful in MI if O2 >94% JAMA. 2010;303(21):2165. Air Versus Oxygen in ST-Segment Elevation Myocardial Infarction Circulation (http://circ.ahajournals.org/content/early/2015/05/22/CIRCULATIONAHA.114.014494) Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev 19 Dec 2016 Anything new on this front? Glad you asked! A new practice guideline. Should we use oxygen in any ill patient? Siemieniuk RAC et al. Oxygen therapy for acutely ill medical patients: A clinical practice guideline. BMJ 2018 Oct 24; 363:k4169. (https://doi.org/10.1136/bmj.k4169) Recommendations •Overall oxygen increased mortality •The upper limit for peripheral capillary oxyhemoglobin saturation (SpO2) should be ≤96% (strong recommendation). Moderate evidence suggests higher levels are associated with excess mortality. •For patients with acute myocardial infarction or stroke, oxygen should not be initiated when SpO2 is ≥93% (strong recommendation), as hyperoxia can be harmful; •Those at risk for hypercapnic respiratory failure should be maintained at lower targets (i.e., 88%–92%); •A few conditions, such as carbon monoxide poisoning or sickle cell crisis, warrant SpO2 targets approaching 100%. Stop using fluid for resuscitation of traumatic hemorrhage (sort of) Owattanapanich N et al. Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: A meta-analysis. Scand J Trauma Resusc Emerg Med 2018 Dec 17; 26:107. (https://doi.org/10.1186/s13049-018-0572-4) Initial Care of the Severely Injured Patient NEJM 2019, 380;8 Main Points from NEJM Review Essentially Verbatim •If active bleeding…. −Normotensive patients should receive no fluid resuscitation −Hypotensive patients should have fluid resuscitation withheld until systolic blood pressure approaches 80 mm Hg systolic −“[When get to] 80mm Hg careful, small-volume boluses of blood or plasma (250 to 500 ml) should be given to maintain systolic blood pressure between 80 and 90 mm Hg.” −Mortality RR 0.5-0.7. • There is definitely publication bias. Talk to your surgeon. Stop using steroids for acute urticaria. Barniol C et al. Levocetirizine and prednisone are not superior to levocetirizine alone for the treatment of acute urticaria: A randomized double-blind clinical trial. Ann Emerg Med 2017 May 3; [e-pub]. (http://dx.doi.org/10.1016/j.annemergmed.2017.03.006) What we already know: •Even 1 week of prednisone is enough to increase infectious complications, thromboembolic disease as well as falls and fractures (probably subclinical myopathy) Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ 2017;357:j1415. This study •100 patients with < 24 hours of hives randomized to levocetirizine 5mg or levocetirizine + prednisone 40 mg X 4 days. •Outcome was itch score and relapses No difference in any outcome. •No difference of itch score of zero at 2 days (62% vs. 76% favoring placebo). •Relapse after stopping meds 30% vs. 24% (again favoring placebo) •Recurrence: 12% vs. 14% (favoring steroids). UpToDate says to skip the steroids unless there is angioedema. Feel free to use diphenhydramine or hydroxyzine if desired and tolerated. Stop referring for thrombolysis in patients with a DVT. Enden T, Haig Y, Kløw NE, et al.; CaVenT Study Group. Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet. 2012; 379(9810):31–38. •Transfusion was 11.1% vs. 6.5% in the anticoagulation group •Pulmonary embolism was 17.9% vs. 11.4% •Vena cava filter placement was 34.8% vs. 15.6% •P<0.1 •Intracranial bleeding, length of hospital stay, and cost were also more favorable with standard treatment. Why would we try try this? Within 2 years many get post thrombotic syndrome. Vedantham S et al. Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis. N Engl J Med 2017 Dec 7; 377:2240. This paper: •691 patients with symptomatic proximal DVT •Yes or no pharmacomechanical thrombolysis •24 months no difference in postthrombotic syndrome 47% •Moderate-to-severe PTS occurred more often in the control group (24% vs. 18%), and severity of PTS was significantly greater in this group at all visits between 6 and 24 months. •However, quality-of-life measures were similar in both groups. •6 had major bleeding. •Yes, a bit less post-thrombotic syndrome (NNT 16) •But no difference in quality of life. •So…use only when there is phlegmasia (which is basically a compartment syndrome). •Consistent with Chest guidelines: Use only when there is impending gangrene. Stop using steroids for bronchitis Hay AD et al. Effect of oral prednisolone on symptom duration and severity in nonasthmatic adults with acute lower respiratory tract infection: A randomized clinical trial. JAMA 2017 Aug 22; 318:721. •Looked at patients with lower respiratory tract infection but no pneumonia (bronchitis) •401 adults, mean age, 47 [SD, 16.0] years −63% women −17% smokers −77% phlegm −70% shortness of breath −47% reported wheezing; (only 6% wheezing on exam) −46% chest pain −42% abnormal peak flow Patients with COPD or asthma or who “needed” antibiotics excluded. −Randomized to prednisolone 40 mg for 5 days or placebo and followed for 8 weeks. −No difference in moderate or bad cough at 5 days, symptom severity or peak flow. −But…only 6% were wheezing. PDS Stop Using Steroids for Wheezing in Preschool-Aged Children Scenario You’re seeing a four-year-old girl with one prior episode of wheezing in the ED. She’s given albuterol nebulizers and a dose of dexamethasone, and admitted for observation. The next day, she’s clinically better, needing a neb only every 4 hours. Another dose of dexamethasone is given and she’s discharged. Did the dexamethasone do anything to alter her course? Probably Not… A LOT of preschool children wheeze – but many of these are viral- induced, not asthma. Trials on the benefit of systemic steroids in preschool-aged kids with wheezing (and no diagnosis of asthma) have had MIXED or NEGATIVE results.
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