Colace and cerumen impaction

BOTTOM LINE (at the top):

--two randomized controlled trials below both comparing Cerumenex and Colace show that Colace is superior to Cerumenex.  And its cheaper!

PMID: 10969225

--Prospective, randomized, controlled, double-blind trial comparing Cerumenex and Colace. 

--50 Patients enrolled, 23 with cerumenex and 27 with colace.

--Groups were similar in age, sex, and proportion of completely obscured tympanic membranes at presentation (78%).

--ability to completely visualize the tympanic membrane was significantly greater after treatment with docusate sodium versus triethanolamine polypeptide (81% versus 35%; 95% confidence interval [CI], 22 to 71) particularly in children aged 5 or less (90% versus 0%; 95% CI 50 to 100).

PMID: 11132053

--Immediately after ceruminolytic instillation there was no difference between the 2 treatments.

--However, after 2 irrigations with normal saline, complete clearing was achieved in 82% of the docusate-treated patients and 35% of the triethanolamine-treated patients (95% confidence interval [CI], 22%-71%).

--In other words, every other patient treated with docusate instead of triethanolamine would have benefited (number needed to treat=2.13).

--Although this difference was markedly greater in children younger than 5 years (95% CI, 51%-100%), there were only 4 very young children who received triethanolamine.

--No adverse events were reported.

BOTTOM LINE(again):

--colace (docusate sodium) works; helps remove earwax

--it works better than ceruminex (triethanolamine polypeptide)

--no adverse events reported

Submitted by J. Gullo.

Reference(s): article 1, article 2, picture

Fleshing out the history of monoarthritis

Submitted by K. Sullivan.


Reference(s): aafp article

nerve block for occipital neuralgia

Submitted by K. Sullivan.

Reference(s): on the slide

the blown pupil

Submitted by E. Hawkins.

infection in the asplenic patient

Submitted by E. Hawkins.

Oral Naloxone for opioid associated constipation

NALOXONE:

--Oral administration of naloxone block enteric mu receptor

--but due to high first pass metabolism has low systemic effect. (2% systemic bioavailability taken orally)

SMALL STUDY DATA (N=22) 

--By day 6 of using naloxone compared to the control period, the mean number of days with laxation increased from 2.1 to 3.5 (P<0.01)

--the number of days with other laxative medication decreased from 6 to 3.8 (P<0.01).

--the mean naloxone dose in the naloxone period was 17.5 mg/day.

--some side effects: (yawning, sweating, shivering and abdominal cramps) lasting 30 min to 6 hrs.

--Recommend starting at 2 mg and titrating upward.

Submitted by K. Sullivan.

Reference(s): Pain. 2000 Jan;84(1):105-9. http://www.ncbi.nlm.nih.gov/pubmed/10601678, picture

vertigo and the head thrust test

QUICK RECAP:
--quick head movement toward defunct canal...
--patient loses the target, needs a "catch up" saccade to re-fixate


Submitted by. K. Sullivan.


Reference(s): bmj article

BiPAP in asthma

 

Submitted by E. Hawkins.


Reference(s): you just saw 'em

posterior and RV myocardial infarction

Submitted by E. Hawkins.

cervical radiculopathy

LIKELY CULPRITS:

--Disc herniation accounts for 20-25% of young pt’s cervical radiculopathy

--foraminal narrowing is the most common cause of elderly pt’s symptoms. 

--Risk factors are manual labor, smoking, and driving/operating vibrating equipment.

MRI IN ED? 

--As in lumbar radiculopathy, MRI is the appropriate test but should be limited to those symptomatic after 4-6 weeks of nonsurgical treatment given high frequency of abnormalities detected in asymptomatic adults.


Submitted by T. Boyd.

Reference(s): Carette et al. Cervical Radiculopathy. NEJM. 2005; 353:392-399. Malanga et al. Cervical Radiulopathy. Emedicine. picture

spinal epidural abscess: how good is our H&P?

Spinal epidural abscesses have variable presentations with:

• 70-90% having back pain
• (only) 60-70% having fever
• 33% having point tenderness to palpation
• 71% have an abnormal neuro exam
• 94% of these patients have an elevated ESR

IMAGING:
--MRI spine
--CT myelogram


BOTTOM LINE:
--symptoms for epidural abscess include fever, spine tenderness, back pain
--unfortunately, less patients show up with these than you'd think (or like to think)
--MRI or CT myelogram if suspicious
--good luck


Submitted by T. Boyd.

Reference(s): Tompkins et al. Spinal Epidural Abscess. J Emerg Med. 39:3; 2010.; picture

cardiac tamponade and electrical alternans

POSSIBLE EKG FINDINGS IN CARDIAC TAMPONADE:
--sinus tachycardia
--low voltage
--electrical alternans

ELECTRICAL ALTERNANS:

--beat to beat alternation in QRS appearance
--related to back & forth swinging motion of the heart in the pericardial fluid (thought this was a nice way of picturing it)


Reference(s): uptodate.com: cardiac tamponade; pendulum, EKG

tick removal: what works?

WHAT DOES NOT WORK (in inducing detachment):

--wheal of 1% lidocaine
--1% lido +epi
--1% chloroprocaine
--application of petroleum jelly
--fingernail polish
--70% isopropyl alcohol
--a hot kitchen match

WHAT DOES WORK:
--use of forceps or protected fingers

NICE IDEAS:

--grasp as close to the skin as possible with curved forceps, tweezers or protected fingers.

--Pull straight up with steady even pressure. If cement or mouthparts remain, then extract if that is practical.

--Disinfect bite site before and after tick removal.

--Do not squeeze, crush, or puncture the body of the tick, because its fluids (saliva, hemolymph, gut contents) may contain infectious organisms.


Submitted by J. Gullo.

Reference(s): lidocaine study, 5 common techniques article, aafp overview, emedicine overview, picture (CDC)

Forget about antivirals for Bell's palsy

RAGING HYPOTHETICAL:

--A guy comes in with a facial droop. You check for eyebrow raise and unequal smile and correctly identify this as a isolated peripheral VIIth nerve palsy. (Nice job not bothering the stoke fellow)

WHAT WILL YOU SEND THEM HOME WITH?

1) Eye protection

-patch to close at night and put some lacrilube in there. Artificial tears Q1 hour during the day

2) Antivirals?

-minimal extra efficacy when added to steroids vs. steroids alone, not statistically significant (looked at both valacyclovir and acyclovir)

-treating with antivirals alone was significantly worse than treating with steroid alone, and no better than placebo. (BMC Neuro 2011)

-consider adding antivirals in severe patients (only barely perceptible motion of face or complete paralysis)

3) Steroids

-Prednisolone (60 mg daily for five days, then tapered by 10 mg daily, for a total treatment length of 10 days) was studied in a large RCT.

-Patients treated with prednisolone in this RCT had a shorter return to recovery vs. those without steroid treatment.(Lancet 2008).

-An easy substitute would be Prednisone 60mg PO daily for 1 week.

10-SECOND RECAP:

--(whole) facial droop/paralysis, check eyebrows (upper face) & smile (lower face); if both involved, think 7th nerve/Bell's palsy

--eye protection/lube/tears

--antivirals not too useful, consider in severe palsy

--steroids hasten recovery; 7-10 day course prednisone.

Submitted by R. Morris.

Reference(s): Numthavaj, P. BMC Neurology 2011;  Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol. 2008 Nov;7(11):993-1000. Epub 2008 Oct 10; image

Ear lacerations

CAN YOU WIGGLE YOUR EARS?
--The musculature of the ear, if damaged, is of no significant importance
--Generous dual blood supply = heals well
--Need to cover exposed cartilage and minimize wound hematoma


WHEN TO REFER TO PLASTICS/ENT:

• Auricular hematoma
• Involvement of auditory canal
• If Humpty Dumpty is hard to identify:
• Large skin avulsion (>5mm)
• Large cartilage defects
• Severe crush injury
• Complete or near complete avulsion or amputation
• Obvious devitalization
       

IF YOU FIX IT:
--try regional nerve blocks or field blocks
--Avoid local anesthesia --> causes pain and distorts landmarks
--No good evidence to show the epinephrine causes ischemic necrosis

HEALS GREAT, LESS FILLING:
--The skin and underlying cartilage adhere to each other well, so that separate closure of cartilage is usually unnecessary
--only approximate cartilage separately from skin when the wound is extensive
--Apply pressure dressing to avoid hematoma formation

Submitted by J. Gullo.

Reference(s): emedicine.com: complex ear lacerations, picture 1, picture 2, picture 3

The Common Cold (lecture podcast)

THE EVIDENCE BEHIND OTC REMEDIES:

--another great lecture by one of our senior residents

--video available on iTunes U at the link below
--for those on the go, an audio version is posted also

--enjoy!


VIDEO: via iTunes U

AUDIO: download


Lecture by R. Morris.