presented by Mel Herbert
edited by Veronica Vasquez

1. Can you trust your gut?
Ahbinav Chandra and colleagues looked at 10,145 patients over two years who had presented to multiple EDs with the complaint of chest pain. After a negative work-up (non-diagnostic ECG changes, normal initial biomarkers, and a non-MI impression) the EP had stratified each patient as non-cardiac, low risk, high risk, or unstable angina, based solely on their gut instinct.  How right were they?  Actually they were pretty good.  EPs judged 6% of the patients as “unstable angina”, 23.5% “high risk”, 44% “low risk”, and 26.3% as “non-cardiac”.  The adverse event rate at 30 days had an inverse relationship.  22% of the adverse events had occurred in the “unstable” patients and 10.2% in the high risk.  Combining unstable and high risk categories the EPs had predicted 29.% and the actual had been 32.2%.  Looking at the stats another way, the relative risk of an event for those labeled unstable was 10.2 times that of those labeled low risk.  The relative risk for those labeled high risk vs those labeled low risk was 4.7 times.  The bottom line is that your gestalt is an important factor in differentiating low risk and high risk patients suspected of acute coronary syndrome. 
Chandra A, et al, Acad Emerg Med, 2009;16(8):740-8.
{mospagebreak title=Cough/Cold Meds safe for kids?} 

2. Are Over the Counter Cough/Cold Meds safe for children under 4?
by Robert S. Hoffman MD
After three pediatric deaths related to OTC meds containing pseudoephedrine, the FDA changed the warning labels of meds containing this compound to “should not be used in children under 4 years of age.”  Were they right or overly cautious?  A study of children under 12 took place in 63 EDs involving 7,091 patients.  They found that 5.7% of all the visits were for adverse drug events.  Of that group, 64% were for children 2 to 5 years old.  66% of those were unsupervised ingestions.  93% did not require admission to the hospital.  The study data did not uncover any cases of adverse events occurring in patients taking the recommended dosages.  Critics of the study point out that the data was based on medical coding.  Moreover it contained poor poison control data and unpublished FDA data.  But did the study support the conclusion that these meds were unsafe to be given to children under 4?  Probably not.  But the result is that packaging now offers no dosing recommendations for this age group, only the warning.  Is this simply an FDA backlash on a class of drugs that have been used safely for decades?  Then again, no study has ever shown that these meds were beneficial in the first place.

{mospagebreak title=CT and Contrast: An overview}

3. CT and Contrast:  An overview
by Scott Melanson MD

Oral Contrast
Yes:  When opacification of the bowel is needed
    To show bowel wall thickness
No:  When there is a risk of vomiting and aspiration 

Indications for Oral Contrast:
-Bowel obstruction (optimal is IV + PO contrast)
-Appendicitis:  conventional wisdom dictates that IV contrast will show periappendiceal 
-Stranding and PO contrast will show dilated appendix, while no contrast shows appendicolith.  But two recent studies (300 and 296 patients) looking at non-contrast CT in appendicitis, demonstrated 96% and 99% sensitivity and specificity.

Indications for IV/Oral/Rectal Contrast:
Diverticulitis:  identifies bowel wall thickening and abscesses, but a recent study of rectal contrast alone got as good results as using all three.

IV Contrast:
Yes:  For enhanced visualization of solid organs and bowel wall
-To identify soft tissue inflammation and stranding
No:  Renal insufficiency
-Allergic to iodine, shell fish, etc.

Indications for IV Contrast
Yes:  Small tumors
No:  Trauma, most tumors, toxoplasmosis

Facial Infections:
Yes:  Orbital and perorbital abscesses
No:  Sinusitis

Yes:  Carotid or vertebral artery dissection

Yes:  Deep tissue abscess
-Necrotizing fasciitis (to identify planar involvement)

Yes:  Pulmonary embolism
No:  Pneumonia (w/o will identify air-space disease)

Yes:  Traumatic injuries or aneurysm
No:  Renal impairment

PE v. Dissection:  work with radiology

Yes:  If looking for hydronephrosis or delayed nephrogram
No:  To visualize stone

Yes:  IV contrast identifies bleeding, solid organ injury  (no oral contrast needed)

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