Journal Feed Weekly Wrap-up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: Are Bullet Fragments Causing Lead Poisoning?

Spoon Feed
Patients with retained bullet fragments (RBF) are at risk for toxic lead levels and should probably be screened for the first year after ballistic injury.

Why does this matter?
Most of the time, it is not recommended to remove bullet fragments. This review noted the following exceptions: “joints, CSF, or the globe of the eye…impingement on a nerve or a nerve root, and bullets lying within the lumen of a vessel, resulting in a risk of ischemia or embolization, should be removed.” The CDC recommends lead levels in children be <5 μg/dL. Above this, children may have renal problems, hypertension, and adverse cognitive effects. In fact, there is no “safe” lead level, especially in children or pregnant women. Does leaving lead in other anatomic locations leach into the tissues and cause levels to rise?

Led by lead levels
This was a meta-analysis of 12 studies. They found that patients with retained bullet fragments (RBF) had elevated lead levels 5.47 μg/dL higher than controls; and the more RBF, the higher the level. Higher levels were also associated with bone fractures. The median lead level was 9 μg/dL. The authors recommend quarterly serial blood lead levels if RBF are present for a period of one year. If levels are rising, the RBF should be removed – assuming it can be done safely. This is a game-changer for me. I have always considered lead absorption to be so minimal as to obviate any concern. And for most, that’s still true. But for some, lead absorption may be unusually high. I plan to recommend patients with RBF follow up and have lead levels checked.

Lead toxicity from retained bullet fragments: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2019 Sep;87(3):707-716. doi: 10.1097/TA.0000000000002287.

Open in Read by QxMD

#2: How to Work Up TASER Shocks

Spoon Feed
Patients who have been shocked with a conducted energy device (i.e. TASER) need a careful exam to rule out injury from the electrical probe and to screen for trauma from muscular contraction, fall, etc. If none, no ECG, monitoring, or lab evaluation is indicated.

Why does this matter?
Conducted energy weapons, such as TASERs, give a jolt of 50,000 volts. That seems like a lot. The question is, do we need to do a medical workup after a weapon like this has been used on a patient?

A stunning review
This was a review of the literature on conducted energy weapons to answer these questions.

  1. Do these patients need cardiac monitoring, ECG, or troponin measurement after a shock under 15 seconds? If a patient is awake, alert, and had a <15 second shock, there is no indication for ECG, prolonged cardiac monitoring, or measurement of troponin.

  2. What about checking other labs? There have been no studies that found electrolyte abnormalities. Some have found clinically insignificant elevations of lactate and CK. So, the answer is no.

  3. Anything to be done with a shock in “drive stun” or touch stun mode (directly applied to person)? No, it may cause minor skin irritation or small burns at the contact sites that do not require intervention.

  4. What about when the probe is fired at a patient (“probe mode”)? This is where most of the problems arise. The probe may cause eye injury, vascular puncture, or nerve injury. In addition, spinal compression fracture or other soft tissue injury from forceful muscle contractions or fall with blunt trauma occurs rarely, 0.5% in real world use.

Emergency Department Evaluation After Conducted Energy Weapon Use: Review of the Literature for the Clinician. J Emerg Med. 2019 Sep 6. pii: S0736-4679(19)30553-0. doi: 10.1016/j.jemermed.2019.06.037. [Epub ahead of print]

#3: Managing Massive Hemoptysis

Spoon Feed
Massive hemoptysis is a life-threatening emergency. Here are the top ten tips to give our patients the best shot at survival.

Why does this matter?
I am sure that everyone who reads this already knows the feeling you get when you see a patient with massive hemoptysis. It’s one of the leading causes of provider Code Browns in the world. Therefore, here are some tips from a couple of pulmonologists to guide you after you change scrubs.

Top Ten Ways to Help Massive Hemoptysis Patients

  1. Always consider epistaxis and hematemesis as other sources of bleeding.

  2. Up to 80% of malignancy-related massive hemoptysis have an episode of sentinel bleeding.

  3. The lungs have a dual blood supply (pulmonary arteries and bronchial arteries) with ~90% of cases of massive hemoptysis stemming from the bronchial vasculature.

  4. CT is very effective in localizing bleeding from the bronchial arteries; CXR is about 46%.

  5. Put the bad lung down toward the bed.

  6. Avoid nasotracheal intubation (tube doesn’t go as far and the size is usually smaller).

  7. Use a single-lumen ETT ≥ 8.5mm (allows for some larger bronchoscopes); dual-channel may sound better but it is too small.

  8. You should mainstem the good lung if you are able to lateralize it; however, be aware that the take off of the RUL is at high-risk of occlusion.

  9. Management options include flexible bronchoscopy, rigid bronchoscopy, IR guided bronchial artery embolization (BAE), or surgery.

  10. BAE has an initial success rate of 70-99%; however, risk of re-bleed is high: 58% at 30 days.

Managing Massive Hemoptysis. Chest. 2019 Jul 30. pii: S0012-3692(19)31386-8. doi:10.1016/j.chest.2019.07.012. [Epub ahead of print]

Open in Read by QxMD


Leave a Reply

Your email address will not be published. Required fields are marked *