Tricks of the Trade: Ten Common Complaints

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Tricks of the Trade Ten Common Complaints

• Joe Lex, MD, FAAEM
• Temple University
• School of Medicine
• Philadelphia, PA

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Sometimes shunted aside
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but Im an optimist
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Ten Common Complaints

• 1) I got something in my eye.
• 2) My nose is bleeding.
• 3) I got hit in the mouth.
• 4) I cut my hand.
• 5) A stray dog bit me.

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Ten Common Complaints

• 6) I think I broke something.
• 7) I stepped on a nail.
• 8) My back is killing me.
• 9) I must have strep throat.
• 10) My bronchitis is back.

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Which topic do you want?

• Eye
• Nose
• Mouth
• Hand
• Dog

• Break
• Nail
• Back
• Strep
• Bronchitis

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I got something in my eye
Eye
8
I got something in my eye
Eye
9
I got something in my eye
Eye
10
I got something in my eye

• History
• Pain, tearing, foreign-body sensation
• Light sensitivity w/ blepharospasm
• History of trauma or extended contact lens wear

Eye
11
I got something in my eye

• Physical
• Bulbar conjunctival injection
• If palpebral, think conjunctivitis
• Visual acuity should be normal
• Fluorescein cobalt blue or Woods light dye
  uptake where corneal epithelial cells damaged

Eye
12
Pearls

• Use pinhole if patient forgot glasses

Eye
13
Corneal Abrasion
Eye
14
Retained Foreign Body
Eye
15
Positive Seidels Perforation
Eye
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Pearls

• Topical anesthetic helps exam
• Cycloplegic 20 - 30 minutes before exam can ease
  spasm
• If no slit lamp, use Woods lamp with fluorescein
• Poor mans slit lamp fluorescent ceiling lights

Eye
17
Poor Mans Slit Lamp
Eye
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Beware the Dendrite!
Eye
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Pearls

• Evert eyelid to look for foreign bodies
• Fluorescein can permanently stain soft contact
  lenses
• Tetanus check status, update as needed

Eye
Ostler HB. JAMA 1988 260 553.
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Tetanus and Eyes

• 38 cases reported between 1847 (sic) and 1993
• 33 involved perforated globe
• None were in patients with simple corneal
  abrasions

Eye
Benson WH. J Emerg Med 11677, 1993
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Topical Anesthetic

• Prolonged use causes secondary keratitis,
  compromises healing

Eye
22
Proparacaine vs. Tetracaine

• Proparacaine Ophthaine
• Less irritating
• Onset 20 sec
• Lasts 10 - 15 min
• 15 / bottle

• Tetracaine Pontocaine
• Stings a lot
• Onset 1 min
• Lasts 15 - 20 min

Eye
Both 0.5 solution
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Irrigation

• Use neutral solution
• Use urine dipstick to check pH
• Oxygen tubing nasal prongs over bridge of nose

Eye
24
Patch vs. No Patch

• Six studies
• Pain no difference in 4, patching worse in 2
• Complications no difference
• Recommendation let patient decide which feels
  better

Eye
Flynn CA. J Fam Pract 1998 Oct47(4) 264-70
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Antibiotic Eyedrops

• Routine use controversial
• Several available, no advantage
• Sulfacetamide (8 / 15cc) Sulamyd Bleph-10
  (21 / 5cc)
• Trimethoprim / polymyxin B (14 / 10cc)
  Polytrim (34 / 10cc)

Eye
26
Antibiotic Eyedrops

• Tobramycin (8) Tobrex (35)
• Gentamicin (10) Garamycin (25)
• Norfloxacin Chibroxin (25)
• Ciprofloxacin Ciloxan (41)
• All costs for 5 cc bottle

Eye
27
Which Antibiotic Drop?

• Slowest healing tobramycin, gentamicin
• Worst cornea effect tobramycin, gentamicin
• No significant difference between control
  solution and any active drop

Eye
Stern GA. Arch Ophthalmol 101(4)644, 1983
28
Pearls

• Scratch from contact lens use antibiotics
• Infection, ulcers common
• Cover Gram-negatives, especially pseudomonas
• Avoid neomycin (Neosporin) many people allergic

Eye
29
NSAID Eyedrops

• Decrease cyclooxygenase activity ? lower
  prostaglandin precursor ? less prostaglandin
  synthesis
• NSAID soft contact may give symptomatic relief,
  preserve binocular vision

Eye
Salz JJ. J Refract Corneal Surg 1994 Nov-Dec
10(6) 640-6
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NSAID Eyedrops

• Diclofenac Voltaren (48/5ml)
• Ketorolac 0.5 Acular (45)

Eye
9 / ml 270 / ounce 2160 / cup 9000 /
liter 37,854 / gallon
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Cycloplegics / Mydriatics

• Cycloplegic paralyzes ciliary muscles that adjust
  lens shape
• Relieves photophobia, pain
• Mydriatic causes pupil to dilate
• Can cause acute narrow angle closure

Eye
32
Cycloplegics / Mydriatics

• Homatropine
• Mydriasis 10 - 30 minutes
• Cycloplegia 30 - 90 minutes
• Lasts up to 48 hours
• Useful for patient with dark iris

• Cyclopentolate (Cyclogyl)
• Mydriasis 30 - 60 minutes
• Cycloplegia 25 - 75 minutes
• Lasts up to 24 hours

Eye
33
What Works Best?

• 401 patients with corneal abrasions
• Lubrication vs. homatrapine vs. NSAID drops vs.
  homatropine plus NSAID drops
• All outcomes no difference among any groups

Eye
Carley F. J Accid Emerg Med 18(4)273,2001
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And by the way

• Gutta gt drop
• Guttae gtt drops
• Theres no such thing as gtts
• Another name for eye medicines collyrium (Gr.
  ????????, eye-salve)
• Half-life of eye drops 20 minutes

Eye
36
My nose wont stop bleeding
Nose
37
My nose wont stop bleeding
Nose
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My nose wont stop bleeding

• Bimodal incidence age peaks 2-10 years and 50-80
  years
• Cold months, dry cold climates
• Some drugs predispose, make treatment difficult
• Aspirin, NSAIDs, warfarin, heparin, ticlopidine,
  clopidogrel, dipyridamole

Nose
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Other Predisposing Factors
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My nose wont stop bleeding

• Acute hemorrhage from nostril, nasal cavity, or
  nasopharynx
• gt90 of patients can be treated by non-ENT
  physician
• Anterior Kiesselbach plexus
• Posterior below posterior half of inferior
  turbinate / nasal cavity roof

Nose
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Anterior Bleed
Nose
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Posterior Bleed
Nose
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Pincher
Nose
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Pincher

• Immediate direct pressure
• Four tongue depressors
• One-inch tape
• Double wrapped at one end

Nose
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Not Effective
Nose
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What About Icepacks?

• Nasal blood flow measured by laser Doppler
  flowmeter
• Forehead ice pack no change or slight increase
  in nasal flow
• Intraoral ice pack nasal flow reduced average of
  23 in 56 of patients

Nose
Porter M. Acta Otolaryngol (Stockh) 111(6)1122,
1991
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Other Equipment
Nose
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Other Equipment
Nose
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Vasoconstriction

• Have patient blow nose decreases local
  fibrinolysis, removes clots
• Vasoconstrictor reduces bleeding
• Local anesthetic reduces pain of exam and packing
• Classic cocaine 4 or 10
• Now XAP, LET

Nose
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Vasoconstriction

• Unroll cotton ball (pledget) until 10 - 12
• Soak in XAP / LET
• Wring near-dry
• Gently insert with bayonet forceps
• Leave for 10-15 minutes

Nose
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Chemical Cautery
Nose
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Chemical Cautery

• Roll tip of silver nitrate stick over mucosa
  until gray eschar forms
• If both sides cauterized, can cause necrosis or
  perforation
• Should be performed only after bleeding controlled

Nose
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Vaseline Gauze
Nose
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Vaseline Gauze

• Grasp gauze 6 inches from end, place it as far
  back as possible but with free end protruding
  from nose
• If you push the end in first, it will dangle in
  the oropharynx and choke your patient
• Press onto floor of nasopharynx

Nose
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Vaseline Gauze

• Grasp ribbon 4-5 inches from nasal alae, bring
  second strip into nose and press downward
• Layer gauze from inferior to superior until naris
  completely packed
• Both ends of ribbon protrude from naris and
  secured with tape

Nose
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Compressed Sponge

• Trim Merocel foam to fit snugly through naris,
  place it along nasal cavity floor
• Once wet with blood or saline, it expands to fill
  nasal cavity and tamponade bleeding

Nose
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Absorbable Sponges

• Oxidized regenerated cellulose
• Oxicel sponge-like material
• Surgicel gauze mesh
• Absorbable gelatin sponge
• Gelfoam
• Pack liquefaction by 2nd or 3rd day, gone by one
  week in two-thirds

Nose
Fanous NJ. Otolaryngol 9(6)462, December 1980
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Nose
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Posterior Balloon
Nose
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After Packing

• Observe for at least an hour
• Have patient do a walkaround to be certain
  bleeding has stopped
• Mustache dressing to catch seepage

Nose
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Coagulation Studies?

• 140 patients admitted for epistaxis
• PT / PTT performed in 86
• Abnormalities identified in 8.3
• All were taking warfarin
• Two patients abnormal platelets
• Both with previously diagnosed myelodysplasia

Nose
Thaha MA. J Laryngol Otol 114(1)38, 2000
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Follow-Up

• Prophylactic antibiotics
• Risk of sinusitis
• Risk of toxic shock syndrome
• Amoxicillin 250 500 mg PO tid until packing
  removed
• Remove non-absorbable nasal pack after 48 72
  hours

Nose
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Pitfalls of Nosebleed

• Failure to apply pressure for 10 minutes or more
• Failure to pack nose properly
• Failure to do walk around
• Failure to give antibiotic
• Failure to stop aspirin therapy

Nose
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Nose Trauma
Nose
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Nose Trauma
Nose
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Before After
Nose
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Who Needs X-rays?

• 75 patients with nasal trauma seen by ENT
• 89 x-rayed, 61 had fractures
• Treatment based solely on clinical examination in
  every patient
• Management not influenced by x-ray findings

Nose
Sharp JF. J Roy Soc Med 87(3)153, March 1994
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Pitfalls of Trauma Nosebleed

• Failure to identify and treat septal hematoma
• Persistent bleed after trauma failure to rule
  out CSF leak

Nose
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Saddle Nose Deformity
Nose
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I got hit in the mouth.
Mouth
71
I got hit in the mouth.

• Chipped tooth
• Avulsed tooth 5,000,000 / year
• Tongue laceration
• Antibiotics

Mouth
72
I chipped a tooth.

• Tooth enamel, dentin, pulp
• Crown above gum line
• Root below
• 32 permanent

Mouth
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Ellis Classification
Enamel
Dentin
Pulp
Mouth
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Ellis Classification

• Ellis I cosmetic
• Ellis II dentin covered with calcium hydroxide
• Ellis III pulpectomy vs. immediate bonding
• Drop of blood ? exposed pulp

Mouth
Medford HM. Ann Emerg Med 1983 12(6) 364-6
75
I got a tooth knocked out
Mouth
76
I got a tooth knocked out
Mouth
77
I got a tooth knocked out

• Rinse with water do not scrub
• Hold gently by crown, not root
• In cooperative adult, can gently put back in
  socket
• Transport tooth in saline, milk, saliva, Hanks
  solution
• Dry tooth will damage in minutes

Mouth
78
I got a tooth knocked out

• Child, uncooperative adult tooth saver
  solution
• Loosened, pushed in, broken teeth avoid eating
  or drinking
• Tooth broken in pieces retrieve parts and
  transport in suggested solutions as above

Mouth
79
I got a tooth knocked out

• 90 of replantations performed within 30 minutes
  are successful
• If wait 2 hours, falls to 5
• Insert slowly into socket, hold pressure for 10
  to 15 minutes
• If forced abruptly, will be extruded
• Consult dentist

Mouth
Lind GL. Anesth Analg 61(5)469, May 1982
80
I got a tooth knocked out

• Stabilization with arch bars and wires for two
  weeks
• If primary (baby) tooth, no long-term problems
  anticipated
• Primary tooth blue-white
• Permanent tooth yellow-white
• No reimplantation if primary

Mouth
81
I got smacked in the mouth

• Remove debris, especially tooth or denture
  fragments
• Irrigate copiously
• Avoid radical debridement
• Can close up to 24o after injury
• Penicillin (or erythromycin) for through and
  through, but no studies

Mouth
Potter BC. Amer Fam Phys 18(5)96,1978
82
I got smacked in the mouth

• Tongue cuts rarely need stitches

Mouth
Potter BC. Amer Fam Phys 18(5)96,1978
83
I got smacked in the mouth

• Cheek / lip cuts close to prevent food entrapment

Mouth

• Frenulum cut let heal on own

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Piercings
Mouth
85
I cut my hand
86
I cut my hand

• Hand injuries 5.5 of ER visits
• Male to female 1.7 to 1
• 60 are age 16 to 32
• Lacerations gt60
• Fractures gt10
• Most frequent distal phalanx long finger

Hand
Frazier WH. J Amer Coll Emerg Phys 7(7)265,
1978
87
Prophylactic antibiotics

• 105 clean hand wounds
• Treat within six hours of injury
• 5-days placebo vs. QID cephalexin (250mg, 500mg)
• Placebo 2 infections require antibiotic
• Low-dose cephalexin 2 infections
• High-dose cephalexin 2 infections

Hand
Worlock P. Br J Clin Pract 39(10)290, 1980
88
Prophylactic antibiotics

• Haughey, R.E., et al, Ann Emerg Med 10(4)187,
  April 1981
• Grossman, J.A. et al, JAMA 245(10)1055, March
  13, 1981
• Roberts, A.H.N., et al, J Hand Surg 10B(3)370,
  October 1985
• Suprock, M.D., et al, J Hand Surg (Am)
  15A(5)761, September 1990

No improvement
Hand
89
Irrigation Solution

• 100 cytotoxic
• 1 povidone iodine
• 3 hydrogen peroxide
• Bactericidal, not cytotoxic
• 0.001 povidone-iodine
• Irrigated with 1 povidone-iodine significantly
  weaker than wounds in other groups

Hand
Lineaweaver W. Arch Surg 120(3)267, March 1985
90
How much is 0.001?

• Betadine Solution 10 iodine povidone
• 0.001 1 cc in 10 liters

Hand
10 liters
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What if I soak the wound?

• 1 povidone-iodine for 10 minutes no change in
  bacteria count
• Normal saline solution for 10 minutes increased
  bacterial load

Hand
Lammers RL. Ann Emerg Med. 1990 Jun19(6)709-14
92
Tap water irrigation?

• Valente JH. Ann Emerg Med 41(5)609, May 2003
• Riyat MS. J Accid Emerg Med 14(3)165, May 1997
• Angeras MH. Eur J Surg 158(6-7)347, June-July
  1992
• Worrall GJ. Can Fam Physician 331185 1987

Hand
93
No stitches?

• 95 simple hand lacerations
• Less than 2 cm in length
• No bites or punctures, diabetes, anticoagulant,
  chronic steroid
• Tap water clean, ointment
• No difference in
• cosmetic appearance at 3 months
• interval to return to normal activities

Hand
Quinn J. Br Med J 3251, August 10, 2002
94
No stitches?

• Treatment time 19 vs. 5 minutes
• Mean pain score during treatment 31 vs. 13 (100
  point VAS)
• Infection
• One sutured wound
• None managed conservatively

Hand
Quinn J. Br Med J 3251, August 10, 2002
95
Hand bites

• Bad reputation, large referral bias
• Less than 1/3 present in 12 hours
• Human strep and staph, polymicrobial
• Dog and cat pasteurella common
• Cephalosporin, PRP recommended
• If appropriate, penicillin to cover pasteurella

Hand
Peeples E. J Trauma 20(5)383, 1980
96
A stray dog bit me
Dog
97
How common is rabies?

• Human rabies in US 1980 to 1996
• 32 deaths (2 per year)
• Foreign country exposure 11
• Foreign dog bite 6
• No history animal exposure 25
• Domestic bat bite 1
• Incubation 53-150 days

Dog
Noah DL. Ann Intern Med 128(11)922, June 1, 1998
98
Who should be treated?

• Immediate treatment after skunk, raccoon, bat,
  fox, woodchuck bite
• No treatment after exposure involving livestock,
  rodent (gerbil, squirrel, hamster, guinea pig,
  rat, mouse, chipmunk), or lagomorph (rabbit or
  hare)

Dog
Morb Mortal Week Rept 401, 1991
99
How to avoid treatment

• Healthy domestic dog, cat, or ferret observe for
  10 days
• If animal stray or unwanted observe for 10 days
  or euthanize
• Unprovoked attack more likely to indicate rabid
  animal
• Currently vaccinated dog, cat, or ferret unlikely
  to become infected

Dog
Morb Mortal Week Rept January 08, 1999 /
481-21
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But I cant suture them

• 88 dog, 45 cat, 12 human bites
• Head/neck 57, arm 36, leg 6
• Mean length 2.5 cm
• Mean width 4.8 mm
• Deep structure involvement 12
• After primary closure 5.5 infection rate (8
  patients)

Dog
Chen E. Acad Emerg Med. 2000 Feb7(2)157-61
102
Dont they get infected?

• 769 dog bite victims 2.1 with infection at
  follow-up
• Predictors for infection
• Wound depth
• Wound requiring debridement
• Female sex (victim, not dog)

Dog
Dire DJ. Acad Emerg Med. 1994 May-Jun1(3)258-66
.
103
Dont they all need antibiotics?

• Estimated cumulative risk of infection 16
• Relative risk if given antibiotics 0.56 (95 CI
  0.38 to 0.82)
• Number needed to treat to prevent one infection
  14
• Cost / benefit unknown

Dog
Cummings P. Ann Emerg Med 1994 Mar23(3)535-40
104
Dont they all need antibiotics?

• Same as prior study, but eliminate the study with
  a 60 infection rate
• Infection rate 9
• 3.8 would benefit from antibiotic
• Number needed to treat 26
• If you treat 100 dog bite victims at 20 each,
  you can prevent 3.8 infections at a cost of 526
  each.

Dog
Callaham M. Ann Emerg Med 1994 Mar23(3)577-9
105
Dont they all need antibiotics?

• But recommended antibiotic is amoxicillin /
  clavulanate
• If you treat 100 dog-bite victims at 120 per
  prescription you will prevent 3.8 infections at a
  cost of 3160 each

106
Other studies no difference

• Elenbaas RM. Ann Emerg Med. 1982
  May11(5)248-51
• Boenning DA. Am J Emerg Med. 1983
  Jul1(1)17-21
• Rosen RA. Am J Emerg Med. 1985 Jan3(1)19-23
• Callaham M. Ann Emerg Med. 1980 Aug9(8)410-4

Dog
107
The final word

• There is no evidence that the use of prophylactic
  antibiotics is effective for cat or dog bites.
• There is evidence that the use of antibiotic
  prophylactic after bites of the hand reduces
  infection but confirmatory research is required.

Dog
Cochrane Database Syst Rev. 20012CD001738
108
Take a Break
10 minutes
109
Take a Break
9 minutes
110
Take a Break
8 minutes
111
Take a Break
7 minutes
112
Take a Break
6 minutes
113
Take a Break
5 minutes
114
Take a Break
4 minutes
115
Take a Break
3 minutes
116
Take a Break
2 minutes
117
Take a Break
1 minute
118
I think I broke something

• Ankle
• Knee
• Collarbone

Break
119
I think I broke something

• Ankle
• Knee
• Collarbone

Break
120
I think I broke something
Break
121
I think I broke something
Break
122
I twisted my ankle

• Less than 15 of ankle x-rays are positive for
  fracture
• Ottawa Ankle Rules safely rule out fracture
  without x-ray
• Mechanism twist, blunt, fall
• Not if 18 years or younger

Ankle
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125
Ottawa Ankle Guidelines

• To assess ability to bear weight, have patient
  take four steps
• Two transfers to injured ankle patient passes
  test
• 27 studies with 15,581 patients
• False-negative rate 0.3
• Sensitivity 97.6

Ankle
Bachmann LM. BMJ 2003 Feb 22326(7386)417.
126
Whaddaya mean, no x-ray?

• Malpractice potential insignificant
• Patient expectation radiograph
• Doctor perception high fracture rate
• Communicate with patient
• Do thorough exam
• Explain chip treated same as sprain
• Save time and money

Ankle
Anis AH. Ann Emerg Med 26422, 1995
127
Warn about the swelling!!
Ankle
128
Mobilize early vs. immobilize?

• Two days elastic wrap then air stirrup vs. 10
  days splint / crutches

Ankle
Eiff MP. Am J Sports Med 22(1)83, 1994
129
Mobilize early vs. immobilize?

• Meta-analysis 22 trials, 2700 patients
• Immobilized more long-term impaired range of
  motion (RR 1.64)
• Functional management more satisfied with care,
  less pain
• No differences in stability or recurrence
• Conclusion immobility no benefit

Ankle
Kerkhoffs GMMJ. Arch Orthop Trauma Surg
121(8)462,2001
130
Sprain ankle Ace wrap?

• Elastic wrap 3-5 days vs. nothing
• Scoring system
• Subjective pain, function
• Objective swelling, mobility, and pain on
  passive movement
• No difference in any category

Ankle
Linde F. Scand J Rehab Med 16(4)177, 1984
131
Ibuprofen vs. placebo

• 68 patients with acute ankle sprain
• Placebo vs. ibuprofen 2400 mg / d
• Ankle swelling no effect
• Additional analgesia no effect
• Ice-sprays, icebags, cold water no influence on
  swelling

Ankle
Fredberg U. Am J Sports Med. 1989
Jul-Aug17(4)564-6.
132
COX-II for acute injury

• Celecoxib 400 mg/d vs. ibuprofen 2400 mg/d vs.
  placebo
• Pain relieve with celecoxib better than placebo,
  same as ibuprofen
• Celecoxib 4.05 / day
• Ibuprofen 2400 mg 1.06 / day

Ankle
Ekman EF. Am J Orthop. 2002 Aug31(8)445-51.
133
How much ibuprofen to use?

• Ceiling dose for analgesia
• 200 to 400 mg/dose, 1200 mg/day
• Laska EM. Clin Pharmacol Ther 1986 401-7
• Seymour RA. Br J Oral Maxillofac Surg
  199634110-114
• Winter L. Oral Surg Oral Med Oral Path
  197845159-166

Ankle
134
Ottawa knee rules

• After blunt knee trauma, x-ray if
• Older than 55 years
• Tender at head of fibula
• Isolated tenderness of patella
• Unable to flex knee to 90o
• Unable to bear weight for 4 steps immediately
  after injury and in ED

Knee
Stiell IG. JAMA 2782075, 1997.
135
Clavicle strap vs. sling
Clavicle
136
Clavicle strap vs. sling

• 20 figure-of-eight vs. 20 sling
• 4 straps swollen blue arm
• 1 strap axillary skin breakdown
• Long-term follow-up all achieved full, painless
  range of motion

Clavicle
McCandless DN. Practitioner 223(1334)266,
August 1979
137
Clavicle strap vs. sling

• Fowler AW. J Bone Jt Surg
• 1962 B44440
• Andersen K. Acta Orthop Scand.
• 1987 Feb58(1)71-4.
• Stanley D. Injury.
• 1988 May19(3)162-4.
• Nordqvist A. J Orthop Trauma.
• 1998 Nov-Dec12(8)572-6.

Clavicle
138
I stepped on a nail.
Foot
139
I stepped on a nail.
Foot
140
I stepped on a nail.
Foot
141
I stepped on a nail.

• Highest risk
• Lowest risk
• Moderate risk

Foot
Patzakis MJ. West J Med 150(5)545, May 1989
142
I stepped on a nail.

• Soaking no benefit
• Coring no benefit
• Plantar puncture, especially high-risk patient,
  forefoot wound, through athletic shoe antibiotic
• High risk PVD, diabetes mellitus,
  immunocompromise

Foot
Pennycook A. J Roy Soc Med 87(10)581, October
1994
143
I stepped on a nail.

• Dilemma
• Foot osteomyelitis after puncture through
  sneaker Pseudomonas
• Treatment of choice 2nd generation
  fluoroquinolone
• Not approved for kids
• Short course safe used in CF

Foot
144
Referral bias?

• Survey 200 adult patients
• 88 remembered stepping on nails 156 times
• 79/156 saw physician
• 10 wounds infected (6.4)
• 9 infections reason for visit
• No one required gt one visit

Foot
Weber EJ. J Accid Emerg Med 13(4)274, July 1996
145
My back is killing me
Back
146
My back is killing me
Back
147
My back is killing me
Back
148
Back basics

• Initial assessment
• determine source of pain (many diseases refer
  pain to back)
• red flags indicating severe disease?
• which tests are needed
• treat pain

Back
149
Pain referred to back

• Kidney stones
• Pyelonephritis
• Pancreatitis
• Cholecystitis
• Peptic ulcer
• Abdominal aortic aneurysm

• Usually can be ruled out with history and
  physical
• Usually have other symptoms

Back
150
Red flags from AHCPR

• Fracture trauma, older patients
• Cancer constitutional symptoms worse at night,
  not better with rest weight loss smoking
  history
• Infection risks for spinal osteomyelitis or
  spinal epidural abscess (IV drug use, diabetes)

Back
AHCPR Publication No. 95-0643.
151
True emergency

• Cord compression / cauda equina
• Incontinence, leg weakness, neurologic deficit
• Cause fracture, cancer, infection
• Must be identified immediately
• Study of choice spine MRI

Back
AHCPR Publication No. 95-0643.
152
Root vs. Cord

• Nerve root
• Unilateral
• Sensory deficit in dermatome
• Decreased or absent deep tendon reflexes

• Central cord
• Bilateral
• Sensory deficit below level of compression
• Hyperreflexia / spastic paralysis
• Incontinence

Back
153
Foot is window to the back

• gt90 of disc herniation at L5 and S1
• L5 motor toe dorsiflexion
• L5 sensory dorsal foot, space between first and
  second toes
• L5 reflex cannot isolate
• S1 motor plantar flexion of toes
• S1 sensory lateral aspect of foot
• S1 reflex ankle jerk

Back
154
Resource utilization
Back
Cherkin DC. N Engl J Med 3391021, 1998
155
NSAID vs. Placebo

• Four studies show benefit
• Postacchini F. Neuro-orthopedics
  19886(1)28-35.
• Amlie E. Spine 198712(5)473-6.
• Basmajian JV. Spine 198914(4)438-9.
• Berry H. Ann Rheum Dis 198241129-132.

Back
156
NSAID vs. Acetaminophen

• None
• Zero
• Zip
• Nada
• Nothing
• Bupkis

Pre-2005
Back
157
NSAID vs. Acetaminophen

• 300 patients with acute musculoskeletal injury
  associated
• Acetaminophen (1g)
• Indomethacin (25mg)
• Diclofenac (25mg)
• Acetaminophen plus diclofenac

Back
Woo WW et al. Ann Emerg Med. 2005
Oct46(4)352-61.
158
NSAID vs. Acetaminophen

• At 2 hours and at 3 days
• no statistical difference in pain
• no clinical difference in pain
• Combination therapy associated with slightly
  higher adverse effect rate
• Therefore use APAP

Back
Woo WW et al. Ann Emerg Med. 2005
Oct46(4)352-61.
159
Muscle Relaxer vs. Placebo

• 9 RCTs 7 showed some benefit
• Benefit lasted 4 to 7 days only

Back
Muscle Relaxer vs. NSAID

• No comparative benefit
• No additive benefit
• Side effects in 30

HSTAT Clinical Guideline 14
160
Opioids vs. Placebo

• No studies

Opioids vs. NSAID
Back

• 3 RCTs 2 codeine, 1 oxycodone
• Codeine no difference
• Oxycodone better 1st 3 days only
• Return to work same in all groups

HSTAT Clinical Guideline 14
161
Treatment Analgesics

• Comparing NSAIDs cost only difference
• Tylenol w/ codeine GI side effects
• Guideline first agent should be inexpensive
  non-opioid analgesic (i.e., APAP, ibuprofen)
• If not effective, add opioid or muscle relaxant

Back
Deyo RA. Spine 212840, 1996
162
Treatment Bedrest

• Bed rest may slow recovery
• Early return to activity seems to work better
• Limit activity and give precautions but do not
  put patients to bed

Back
Allen C. Lancet 3541229, 1999
163
Treatment Physical Therapy

• Exercise and physical therapy studies
  conflicting
• Acute pain probably no benefit
• Chronic pain may help
• Manipulation no difference among spinal
  manipulation, physical therapy, and giving
  educational pamphlet on back care

Back
Bronfort G. J Manipulative Physiol Ther 19570,
1996
164
Treatment PENS TENS

• Percutaneous electrical nerve stimulation (PENS)
  therapy vs. transcutaneous electrical nerve
  stimulation (TENS)
• 91 of patients with chronic low back preferred
  PENS therapy
• More pain reduction, better sleep, less use of
  analgesics

Back
Ghoname EA. JAMA 281 818, 1999
165
Treatment Acupuncture

• No high-quality studies
• Whats your control group??
• Suggestion it may offer benefit

Back
Ernst E. Arch Intern Med 1582235, November 9,
1998
166
Treatment Calcitonin

• Elderly patients with vertebral compression
  fractures
• Good pain relief
• Many GI side effects
• Expensive 2cc 35

Back
Blau LA. Ann Pharmacother 37564, April 2003
167
Prevention Back Belts
Back
168
Prevention Back Belts

• OSHA / CDC-P study
• 6300 employees
• Back belts offered no protection against injury
• Biggest predictor of injury prior injury

Back
Wassell JT. JAMA 284(21)2727, 2000
169
I must have strep throat
Throat
170
Sore Throat

• Dysphagia difficulty swallowing
• Odynophagia painful swallowing
• Pharyngitis infection or irritation of pharynx

Throat
171
First

• make sure its not epiglottitis.

Throat
172
Some throat facts

• Rare in infants lt1 year old
• Uncommon lt2 years old
• Streptococcal pharyngitis peaks between ages 4 to
  7 years
• Seasonal variation winter disease

Throat
Denny FW. Pediatr Rev 15185, 1994.
173
Some throat facts

• Most common cause virus
• Rhinovirus and adenovirus majority
• Epstein-Barr, herpes simplex virus,
  influenzavirus, parainfluenzavirus, and
  coronavirus responsible for 5
• GABHS 15
• Peaks late winter / early spring
• Incubation 2 to 5 days

Throat
Middleton DB. Primary Care 23719, 1996.
174
Antibiotic use

• Large majority of adults with acute pharyngitis
  have self-limited illness
• Antibiotic treatment benefits only patients with
  GABHS infection
• Adults with sore throat Strep throat
  prevalence 5 15

Throat
Cooper RJ. Ann Emerg Med. June 200137711-719
175
Antibiotic use

• Offer appropriate analgesic, antipyretic, other
  supportive care
• Clinically screen adults with pharyngitis for
  Centor criteria
• Do not test or treat patients with zero or one
  they are unlikely to have GABHS

Throat
Cooper RJ. Ann Emerg Med. June 200137711-719
176
Centor Score

• history of fever
• tonsillar exudates
• no cough
• anterior cervical lymphadenitis
• 0-1 lt5 GABHS
• 2-3 5 30 GABHS
• 4 30 60 GABHS

Throat
177
Centor Score
Throat
178
Centor Score
Post-test probability of GABHS
179
Antibiotic use

• Rapid antigen if 2, 3, or 4 criteria antibiotic
  only if test
• Rapid antigen if 2 or 3 criteria antibiotic if
  test or 4 criteria
• Antibiotic if 3 or 4 criteria no rapid antigen
  testing

Throat
Cooper RJ. Ann Emerg Med. June 200137711-719
180
Antibiotic use

• Throat culture not recommended for routine
  primary evaluation of adult with sore throat or
  to confirm negative rapid antigen
• Preferred antibiotic for GABHS pharyngitis
  penicillin or erythromycin if penicillin-allergic

Throat
Cooper RJ. Ann Emerg Med. June 200137711-719
181
We prevent disease?

• 1 of 3000 untreated GABHS leads to acute
  rheumatic fever
• 1000 kids / 20 prevalence 200
• Strep screen 80 sensitive, 95 specific
• Treat 160, culture
• other 840

Throat
182
We prevent disease?

• Prevalence now 40/840 (5)
• Culture 95 sens, 95 specific
• NNT 798/38 21 cultures to find one positive
• 3,000 x 21 63,000 prevent one case ARF
• NNH 15

Throat
183
Mononucleosis

• Classic fever, lymphadenopathy, exudative
  pharyngitis, atypical lymphocytosis, splenomegaly
• Severe sore throat is common complaint
• Physical severe bilateral exudative tonsillitis
  / pharyngitis wet white leather

Throat
184
Mononucleosis

• Treatment supportive
• Ampicillin ? rash (transient EBV-induced
  antibodies against drug)
• Acyclovir has in vitro effects on EBV
  replication, but in vivo clinical studies have
  failed to show any clinically significant effect

Throat
185
Mononucleosis
Throat
186
Mononucleosis
Note petechiae!
Throat
Wet white leather
187
What about steroids?

• Many studies
• Heterogeneous populations
• Pain improves few hours earlier, not maintained
  over time
• Statistical significance, marginal clinical
  significance
• Not a standard of care

Throat
188
My bronchitis is back
Lungs
189
Acute Bronchitis

• More than 90 viral
• Account for 1/3 US antibiotic prescriptions
• Sputum color not predictive of bacterial
  infection
• Antibiotics prescribed 60 of visits
• Broad-spectrum antibiotic in 25

Lungs
Mainous AG. Arch Fam Med 5(2)79, February 1996
190
Useless Antibiotics?

• 28,000 doctor visits
• Bronchitis and URI accounted for 21 of
  prescriptions
• Rate of prescribing antibiotics
• Colds 51
• URI 52
• Bronchitis 66

Lungs
Gonzales R. JAMA 278(11)901, September 17, 1997
191
Possible Tiny Benefit??

• Meta-analysis of 8 RCTs
• 4 no benefit, 4 slight benefit
• Conclusion reduced cough and sputum production
  by about one half day in healthy patients
• Does not outweigh adverse effects of widespread
  antibiotic use

Lungs
Bent S. Am J Med 10762, July 1999
192
Beta-Agonists Do Help

• MDI albuterol vs. placebo
• Treatment persistent cough in 61 at 7 days
• Placebo 91
• No differences in productive cough or persistent
  night cough
• Addition of oral erythromycin did not
  significantly affect results

Lungs
Hueston WJ. J Fam Pract 39(5)437, November 1994
193
More Proof Against Antibiotics

• Adults placebo v. azithromycin
• No statistical or clinical differences between
  treatment groups
• No change in rate of improvement, return to usual
  activities, repeat physician visits, perceived
  adverse effects of medication

Lungs
Evans AT. Lancet 3591648, May 11, 2002
194
But Surely in Smokers

• 9 studies of 774 adults with acute bronchitis,
  49 smokers
• 4 showed no benefit to anyone
• 3 showed tiny benefit in smokers
• 1 showed tiny benefit to both
• 1 showed trend to improve among nonsmokers, not
  among smokers

Lungs
Linder JA. J Gen Intern Med 17230, 2002
195
How About Cough Medicine

• 15 randomized controlled trials
• Codeine, dextromethorphan, mucolytics,
  antihistamines
• Nine trials showed no effect of active treatment
• Six with benefits of questionable clinical
  relevance

Lungs
Schroeder K. Br Med J 3241, February 9, 2002
196
Expectations

• Interview 30 family physicians and 30 patients
  treated for bronchitis
• Physicians acknowledged that bronchitis is
  usually viral
• Patients felt they would not improve unless seen
  by physician

Lungs
Snell LM. J Fam Pract 51(12)1035, December 2002
197
Expectations

• All patients got a prescription
• 27/30 received antibiotic
• All physicians believed that patients expected
  antibiotic
• 3/4 felt pressured by patients
• Some felt pressured by employer, legal system, or
  insurers

Lungs
Snell LM. J Fam Pract 51(12)1035, December 2002
198
Education Is Key

• 212 bronchitis patients given prescription, told
  use only if worse
• Half got booklet on natural course of bronchitis,
  antibiotic advantages and disadvantages
• With book 42 took antibiotics
• No book 62 took antibiotics

Lungs
Macfarlane J. Br Med J 3241, January 12, 2002
199
How to Avoid Antibiotics

• Call it a chest cold

Lungs
200
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201
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