Topics in this EM Quick Hits podcast

Natalie May on Kawasaki disease clues to diagnosis (1:25)

Justin Morgenstern on suturing dog bites: the evidence (7:52)

Anand Swaminathan on BVM prior to laryngoscopy (11:51)

Michelle Klaiman on anticraving medications for alcohol use disorder  (18:39)

Howard Ovens on managing ED violence with compassionate care (24:31)

 

Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Natalie May, Justin Morgenstern, Anand Swaminathan and Michelle Klaiman, edited by Anton Helman

Cite this podcast as: Helman, A. May, N. Morgenstern, Swaminathan, A. Klaiman, M. Ovens, H. EM Quick Hits 3 – Kawasaki Disease Clues to Diagnosis, Suturing Dog Bites: The Evidence, BVM Prior to Laryngoscopy, Anticraving Medications for Alcohol Use Disorder and Managing ED Violence Humanely. Emergency Medicine Cases. March, 2019. https://emergencymedicinecases.com/em-quick-hits-march-2019/Accessed [date].

Kawasaki Disease clues to diagnosis

  • Know the diagnostic criteria and ask yourself – could this be Kawasaki disease or incomplete Kawasaki Disease
  • Consider Kawasaki disease particularly in children re-presenting with fever or with fever for more than five days: specifically document the diagnostic criteria and their presence or absence, especially if discharging these patients
  • In children who present with cardiac ischemia or dysrhythmia, consider Kawawaki as the inciting cause
  • For the stable patient with a suspected diagnosis of Kawasaki disease, refer for coronary artery echocardiogram and consideration of prompt IV immunoglobulin +/- high dose ASA.

  1. Anderson, M. S., J. K. Todd, et al. (2005). Delayed Diagnosis of Kawasaki Syndrome: An Analysis of the Problem. Pediatrics 115(4): 428-433.
  2. Baumer, J., S. Love, et al. (2009). Salicylate for the treatment of Kawasaki disease in children [review]. Cochrane Database of Systematic Reviews(4).
  3. Burns, J. C., H. Shike, et al. (1996). Sequelae of Kawasaki disease in adolescents and young adults. Journal of the American College of Cardiology 28(1): 253-257.
  4. Furusho, K., T. Kamiya, et al. (1991). Intravenous γ-Globulin for Kawasaki Disease. Pediatrics International 33(6): 799-804.
  5. Kato, H., T. Sugimura, et al. (1996). Long-term Consequences of Kawasaki Disease: A 10- to 21-Year Follow-up Study of 594 Patients. Circulation 94(6): 1379-1385.
  6. Newburger, J. W., M. Takahashi, et al. (2004). Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease. Circulation 110(17): 2747-2771.

 

Suturing dog bites: the evidence

  • Routinely suturing dog bites does not seem to cause an increased rate of infection, but this is only based on two small RCTs
  • Based on one of the RCTs, suturing may result in better cosmetic outcomes

  1. Maimaris C, Quinton DN. Dog-bite lacerations: a controlled trial of primary wound closure. Archives of Emergency Medicine. 5(3):156-61. 1988.
  2. Paschos NK, Makris EA, Gantsos A, Georgoulis AD. Primary closure versus non-closure of dog bite wounds. A randomised controlled trial. Injury. 2014; 45(1):237-240.
  3. First10EM on dog bites

 

BVM before laryngoscopy – a possible modification to RSI

  • Positive pressure breaths can improve physiologic shunting by recruiting atelectatic portions of the lung that are not involved in gas exchange and increase the patient’s oxygen reserve prior to intubation.

  • A recent ICU study published in the NEJM questions the core principle of RSI of no BMV after induction.

  • Adding BMV (with a PEEP valve, ventilating at 10 breaths/minute, with the smallest tidal volume to generate chest rise by specifically trained operators) after induction and before laryngoscopy, led to an improvement in the lowest O2 sat during intubation – a 4.7% adjusted difference and, more importantly, a lower incidence of critical hypoxemia (defined as a sat < 80%, in the BMV group 10.9% vs 22.8%), without any increase in clinically apparent aspiration.

  1. Casey JD et al. Bag-Mask Ventilation During Tracheal Intubation of Critically Ill Adults. NEJM 2019.

  2. PulmCrit: Is Pure RSI a Failed Paradigm in Critical Illness? The Primacy of Pressure

 

Anti-craving medications for alcohol use disorder

  • Alcohol is the most commonly abused substance worldwide.
  • Less than 9% of patients with alcohol use disorder are offered anti-craving medications.
  • Emergency physicians should consider prescribing anti-craving medication for patients with alcohol use disorder.
  • Based on Cochrane Reviews, Naltrexone 50mg daily is first line for alcohol use disorder with a NNT of 12 for a return to heavy drinking and 20 for any drinking. The alternative, is Acamprosate 333 mg 2 tabs tid for patients with advanced liver disease.

  1. Core IM: 5 Pearls on Treatment of Alcohol Use Disorder, November 7, 2018. https://www.clinicalcorrelations.org/2018/11/07/core-im-5-pearls-on-treatment-of-alcohol-use-disorder
  2. Jonas DE, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014 May;311(18):1889-900.
  3. Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: a review. JAMA, 320(8), 815-824.
  4. Rösner S, et al. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2010.
  5. Rosner S, et al. Acamprosate for alcohol dependence. Cochrane Database Syst Rev. 2010.
  6. Spithoff S, Turner S, Gomes T, Martins D, Singh S. First-line medications for alcohol use disorders among public drug plan beneficiaries in Ontario. Can Fam Physician. 2017;63(5):e277-e283.

 

ED violence, staff safety and compassionate care

  • Many ED patients come from marginalized groups. Many will have had experiences since childhood with staff and institutions that either are unconcerned with their welfare and needs, or openly abusive and discriminatory. People in power, especially in uniforms, rules they can’t understand, all can be triggering and evoke defensive or angry reactions.
  • A 1995 Lancet study – a “Trial of Compassionate Care” – randomized homeless patients in the ED to be approached by a trained volunteer (who were encouraged to get to know the patients, engage them in conversation and offer snacks or other comforts) vs no trained volunteer. They tracked the frequency of repeat visits between the control and the treatment arm. Patients who were approached by a trained volunteer made 1/3 less visits over the next month than those that did not.
  • Rather than a “zero tolerance” slogan, we need a thoughtful suite of approaches including ED design, properly trained security staff, clear policies and procedures to safely effect physical and chemical restraint, clear processes for incident reporting and review, administrative accountability for safety and security and a reliance more on individualized care plans and “patient watches” rather than banning patients from the ED.

For a deep dive into this topic  – Waiting to Be Seen Part 1 and Part 2 on Zero-tolerance Policies in the ED

  1. SREMI – The Schwartz/Reisman Emergency Medicine Institute. Dr Howard Ovens Professorial Address. YouTube. 2014 Nov 7. Available from: https://www.youtube.com/watch?v=_iTahFV2nt0. Accessed 2019 Jan 26.
  2. Redelmeier DA, Molin JP, Tibshirani RJ. A randomized trial of compassionate care for the homeless in an emergency department. Lancet. 1995;345(8958):1131-1134.

None of the authors have any conflicts of interest to declare