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: I&D Only or Add Antibiotics?

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Treating skin and soft tissue abscesses with antibiotics in addition to incision and drainage (I&D) resulted in significantly increased clinical cure rate (NNT = 14) and decreased incidence of new lesions (NNT = 10) compared to I&D alone.

Why does this matter?
Skin and soft tissue abscesses are a very common presenting complaint in the emergency department (ED) and outpatient clinics. For years, I&D was considered standard of care for simple abscesses, and the adjunctive use of systemic antibiotics was controversial. However, prior high-quality evidence for or against the use of systemic antibiotics in conjunction with I&D for abscess treatment was limited. Furthermore, abscesses due to MRSA have been increasing in prevalence, which could influence recurrence and treatment failure rate for abscesses after incision and drainage.

When in doubt, cut it out…and add antibiotics
This was a meta-analysis of four randomized controlled trials with a total of 2,406 participants comparing adjuvant antibiotics vs placebo in the treatment of abscesses after I&D. Studies were performed in the ED or outpatient clinics, and the antibiotics used were either trimethoprim-sulfamethoxazole or clindamycin. Almost half of abscesses were due to MRSA with prevalence of 49%.

Adjunctive antibiotic use reduced treatment failure (7.7% in antibiotic group vs 16.1% in placebo group, p=0.002) which corresponded to an odds ratio for clinical cure of 2.32, with NNT of 14 in favor of antibiotic use. In addition, there was decreased incidence of new lesions (6.2% in antibiotic group vs 15.3% in placebo group, p<0.001) with an odds ratio of 0.32 and NNT of 10. Adverse events occurred slightly more frequently in the antibiotic group (24.8% vs 22.2%, p=0.01), but most adverse events were mild and self-resolving consisting of gastrointestinal symptoms, rashes, drowsiness, or headache.

Another Spoonful
REBELEM also has a great summary on antibiotic use for abscesses: Reformation of an Antibiotic Nihilist

Systemic Antibiotics for the Treatment of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2019 Jan;73(1):8-16. doi: 10.1016/j.annemergmed.2018.02.011. Epub 2018 Mar 9.

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#2: Time to Take an Ax to the Wood’s Lamp?

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The overall sensitivity of the Wood’s lamp, compared to the gold standard slit lamp, to establish the diagnosis of common corneal and conjunctival abnormalities was found to be an abysmal 52%.

Why does this matter?
The Wood’s lamp has advantages: cheaper, quicker, and easier to store and use. However, let’s face it folks…if you have the resources in your emergency department to have a functioning slit lamp, then you need to be using it. Albeit a small study, the numbers made me super nervous about the ol’ Wood’s lamp.

It’s like not performing a rectal exam for a patient with dark, tarry stool; for the love…if you have a slit lamp, use it!
OK, I will get off of my soap box now. For a little background, the standard Wood’s lamp uses long-wave ultraviolet light with a magnification of 2-3 times. The slit lamp uses a magnification of 8-40 times. Thus, it makes sense that the slit lamp would catch more pathology than the Wood’s lamp, but just how much better is it? They performed this study in an ophthalmologist’s office. When a patient arrived with complaints centered on potential anterior chamber pathology, fluorescein was instilled into the affected eye; the ophthalmologist would examine the eye using the Wood’s lamp and record the results. Then the ophthalmologist would examine the eye using the slit lamp, and results were recorded. Here is what they found:

  • Wood’s lamp detected only 56% of the corneal abrasions.
  • Wood’s lamp detected only 50% of the corneal ulcers.
  • Wood’s lamp detected only 44% of corneal foreign bodies.
  • Non-herpetic and herpetic keratitis cases were also missed.

This study was small, with 73 adult patients participating and just one ophthalmologist performing the exams. The gold standard (slit lamp) was also one of the tests being studied, which increases risk of incorporation bias. Additionally, everyone may not have the luxury of having a slit lamp at their fingertips. However, the numbers of missed diagnoses that could have potential complications were high. No more excuses ladies and gentlemen. Dust off the chin rest and lenses and let’s get back to slit lamp business. The more you do it, the more natural it becomes. The extra time it takes is worth it for the patient. Good luck, and happy slit lamping!

Prospective study of the sensitivity of the Wood’s lamp for common eye abnormalities. Emerg Med J. 2019 Jan 10. pii: emermed-2018-208235. doi: 10.1136/emermed-2018-208235. [Epub ahead of print]

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#3: Clearing the Pediatric C-Spine

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This expert panel came up with a comprehensive algorithm to clear the c-spine in children with trauma.

Why does this matter?
It can be very challenging to clear the c-spine in children. PECARN did an important case-control that helped shape this algorithm. The goal is to identify all injuries yet clear children quickly out of the collar and minimize radiation exposure. Here is what these experts came up with.

Clearing kids’ c-spines
This was a group of experts, mostly pediatric orthopedic surgeons, who developed this based on 80% agreement of the committee members. Also represented were specialists in pediatric emergency, neurosurgery, trauma, and radiology. The key graphic from the article looked pretty pixelated. I remade it here exactly as they had it in the paper but with better graphic quality. Here is the algorithm. I have made a few comments at the end. Click here if you’d like this as a PDF.

Here are some of my thoughts.

  • Children with a broken neck who are alert (GCS 14-15) will hold their head oddly and won’t want to move their neck. You can clear them clinically if they hold their head normally, move their neck normally, are not tender on palpation, and are moving their arms and legs normally. This group agrees.
  • Plain x-ray (favoring just a lateral view) was the first-line imaging recommended in alert patients with an abnormal exam in this algorithm. This is debatable, which was acknowledged in the paper. At least a 2-view is standard, and many advocate for CT first-line given its higher sensitivity.
  • A study from 2017 at Vanderbilt found one-third of injuries would have been missed with x-ray alone. The sensitivity of x-ray was 51% for all injuries and just 62% for clinically significant injuries (as defined by NEXUS). That’s a little concerning.
  • This group did not recommend imaging based on mechanism of injury alone, apart from other clinical findings or concerns. The threshold for imaging should be low with axial load (i.e. diving), clothes-line, or high-risk MVC as the mechanism.
  • Children with abusive head trauma need c-spine MRI per this group.
  • The lower the GCS, the more they need a CT c-spine.
  • If children have severe injury to the chest, abdomen, or pelvis, the authors do not recommend clinical clearance.
  • There is debate over whether MRI is really necessary after a negative high-quality CT. The utility of flexion/extension films in that part of the algorithm is also debatable.
  • Keep in mind, much of this is based on expert opinion. Many of the recommendations are based on low-quality evidence. So, don’t take this as gospel.

Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. J Bone Joint Surg Am. 2019 Jan 2;101(1):e1. doi: 10.2106/JBJS.18.00217.

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#4: Reducing Post-Ketamine Cray-Cray

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Pretreatment with either midazolam or haloperidol prior to ketamine sedation markedly reduced the risk of recovery agitation but delayed recovery time by about 20-30 minutes.

Why does this matter?
Recovery agitation, a.k.a. emergence reaction, after sedation with ketamine can be frightening for patients. If you’ve seen it before, you’ll know it can be quite impressive. I have seen some whooping and hollerin’. Where I live, people sometimes say “holler,” which means – to yell very loudly, vociferate, shriek, call out. It can also mean a small valley between two hills, as in, “We live down in the holler.” Anyway, blunting this adverse effect might be good.

Preventing post-ketamine cray-cray
This was a multifactorial RCT comparing placebo, midazolam 0.05mg/kg IV, or haloperidol 5mg IV pretreatment to prevent recovery agitation after ketamine sedation in the ED. They enrolled 185 patients and found that on validated agitation scales, recovery agitation was significantly less. Both midazolam and haloperidol were 3 points lower than placebo on the agitation scale. The downside was that recovery was delayed: 18 minutes, placebo; 35 minutes, midazolam; 50 minutes, haloperidol. Despite the delay, it did not seem to impact clinician satisfaction with the overall sedation. Recovery agitation occurred in 64% of the placebo group, which seems a bit high. It occurred in only 25% of the midazolam patients and 20% of the haloperidol patients; relative risk reduction 61-69%. The guide to all things ketamine by Reuben Strayer found emergence reaction occurred in 10-20% of patients. However, I tend to think this study is credible since they measured it with the validated Pittsburgh Agitation Scale, whereas other studies have used visual analog scales or other non-validated scores to measure agitation. Clinically significant, disruptive behaviors occurred in 26.2% in the placebo group, and were also markedly reduced in the midazolam and haloperidol groups.

Another Spoonful
If you want a great read on the adverse effects of ketamine in adults, Reuben Strayer has the comprehensive guide.

Premedication With Midazolam or Haloperidol to Prevent Recovery Agitation in Adults Undergoing Procedural Sedation With Ketamine: A Randomized Double-Blind Clinical Trial. Ann Emerg Med. 2019 Jan 3. pii: S0196-0644(18)31465-3. doi: 10.1016/j.annemergmed.2018.11.016. [Epub ahead of print]

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