Podcast # 392: Maggot Therapy

Author: Jared Scott, MD

Educational Pearls:

  • Interest started as it was noticed soldiers who had wounds infected with maggots had better outcomes than those without maggots
  • Studies have shown that wound care with maggots is essentially equivalent to traditional therapy with oxygen, antibiotics, and debridement
  • Maggots debride the wound with proteolytic enzymes, sterilize the wound, and stimulate wound healing

References:

Sherman RA. Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. J Diabetes Sci Technol. 2009 Mar 1;3(2):336-44. Review. PubMed PMID: 20144365; PubMed Central PMCID: PMC2771513.

Baer WS. The treatment of chronic osteomyelitis with the maggot (larva of the blow fly) J Bone & Joint Surg. 1931;13:438–475.  DOI: 10.1007/s11999-010-1416-3

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

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Podcast # 391: Necrotizing Fasciitis

Author: Peter Bakes, MD

Educational Pearls:

 

  • Necrotizing fasciitis is an infection of the deep soft tissues with destruction of the muscle fascia and overlying fat
  • Think of it if pain is out of proportion to your exam
  • Polymicrobial and Clostridium species typically cause condition in susceptible individuals (immunocompromised, diabetics, obese, penetrating injury)
  • Group A strep typically is less specific and can cause necrotizing infections in otherwise healthy individuals
  • Treatment is typically rapid surgical debridement in addition to broad spectrum antibiotics in addition to clindamycin

 

References:

Breyre A, Frazee BW. Skin and Soft Tissue Infections in the Emergency Department. Emerg Med Clin North Am. 2018 Nov;36(4):723-750. doi: 10.1016/j.emc.2018.06.005. Review. PubMed PMID: 30297001.

Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 7;377(23):2253-2265. doi: 10.1056/NEJMra1600673. Review. PubMed PMID: 29211672.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

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Podcast # 390: Haloperidol for Pain

Author: Gretchen Hinson, MD

Educational Pearls:

  • Reasonable approach of haloperidol 10 mg IM (or 5 mg IV) for pain relief in opioid-dependent patients; can repeat once.
  • Chronic opioid use results in hyperalgesia and a narrow therapeutic window in the long-term so alternatives are essential.
  • Consider the risk of QTc prolongation with haloperidol, particularly if the patient is on other drugs that may do so.

Editor’s note: Interested in more alternatives to opioids? Check out the Colorado ACEP Opioid Prescribing & Treatment Guidelines and the impact these have had in Colorado

References:

http://ercast.libsyn.com/haloperidol-for-analgesia

Ramirez R, Stalcup P, Croft B, Darracq MA. Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. Am J Emerg Med. 2017 Aug;35(8):1118-1120. doi: 10.1016/j.ajem.2017.03.015. Epub 2017 Mar 12. PubMed PMID: 28320545.

Seidel S, Aigner M, Ossege M, Pernicka E, Wildner B, Sycha T. Antipsychotics for acute and chronic pain in adults. Cochrane Database Syst Rev. 2013 Aug 29;(8):CD004844. doi: 10.1002/14651858.CD004844.pub3. Review. PubMed PMID: 23990266.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD.

Podcast #389: BRUE

Author:  Sarah Normandin, MD.

Educational Pearls:

  • BRUE (Brief Resolved Unexplained Event) replaces what was previously called ALTE.
  • BRUE describes an event in a child less than one year of age with one or more of the following:
    • cyanosis or pallor
    • absent, decreased, or irregular breathing
    • decreased or increased tone
    • altered responsiveness
  • These must be sudden, brief, and now resolved and without an alternative explanation after a history and physical exam
  • Low risk patients can be safely discharged with reassurance
  • Low risk criteria must all be present:
    • Age over 60 days old
    • >32 weeks gestational age at birth and adjusted gestational age > 45 weeks)
    • No CPR was performed (by a trained medical professional)
    • First event
    • Duration less than 1 minute of event
  • Patients who satisfy above criteria can be considered low risk and may be discharged after minimal/no workup

 

References:

Tieder JS, Bonkowsky JL, Etzel RA, et al. Clinical Practice Guideline: Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics. 2016:137(5):e20160591. Pediatrics. 2016 Aug;138(2). pii: e20161488. doi: 10.1542/peds.2016-1488. PubMed PMID: 27474017.

 

Summary by Travis Barlock, MS4    |   Edited by Erik Verzemnieks, MD

Podcast #388: Antibiotics for Appendicitis

Author:  Aaron Lessen, MD

Educational Pearls:

  • 5-year follow up study on antibiotic treatment for uncomplicated appendicitis showed 39.1% recurrence rate requiring appendectomy by 5 years
  • Nearly 60% chance then of preventing an appendectomy by using antibiotics only for uncomplicated appendicitis

 

Editor’s note: not surprisingly, complications were much higher in the group receiving surgery, which reiterates why an antibiotic-only approach is attractive for the right patient population

References:

Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Mecklin JP, Sand J, Virtanen J, Jartti A, Grönroos JM. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018 Sep 25;320(12):1259-1265. doi: 10.1001/jama.2018.13201. PubMed PMID: 30264120.

Summary by Travis Barlock, MS4    |   Edited by Erik Verzemnieks, MD

Podcast #387: Fluoroquinolones are Perfectly Safe?

Author:  Don Stader, MD

Educational Pearls:

  • Fluoroquinolones can cause connective tissue disruption leading not only to tendon rupture but also aortic dissection.
  • Retrospective study from Taiwan showed over a 2x higher rate of dissection when exposed to fluoroquinolones (1.6% vs 0.6%).
  • Remember to think about aortic dissection when you have a patient with chest pain that travels and/or involves neurologic symptoms.
  • Try to use fluoroquinolones when no other appropriate antibiotic exists as they have significant other side effects as well.

 

Editor’s note:  In July 2018, the FDA required strengthening of warning labels on fluoroquinolones about the risks of mental health effects and hypoglycemia

References:

Lee CC, Lee MG, Hsieh R, Porta L, Lee WC, Lee SH, Chang SS. Oral Fluoroquinolone and the Risk of Aortic Dissection. J Am Coll Cardiol. 2018 Sep 18;72(12):1369-1378. doi: 10.1016/j.jacc.2018.06.067. PubMed PMID: 30213330.

Khaliq Y, Zhanel GG. Fluoroquinolone-associated tendinopathy: a critical review of the literature. Clin Infect Dis. 2003 Jun 1;36(11):1404-10. Epub 2003 May 20. Review. PubMed PMID: 12766835.

https://www.fda.gov/downloads/Drugs/DrugSafety/UCM612834.pdf

 

Summary by Travis Barlock, MS4    |   Edited by Erik Verzemnieks, MD

Podcast #386: Respecting Transgender Patients

Author:  Kasey Champion, MD

Educational Pearls:

  • Transgender populations are frequent victims of discrimination in healthcare.
  • Ask transgender patients what their preferred pronoun is.
  • It is sometimes important to ask about transition status (i.e. on hormones, surgery).

References:

Chisolm-Straker M, Willging C, Daul AD, McNamara S, Sante SC, Shattuck DG 2nd, Crandall CS. Transgender and Gender-Nonconforming Patients in the Emergency Department: What Physicians Know, Think, and Do. Ann Emerg Med. 2018 Feb;71(2):183-188.e1. doi: 10.1016/j.annemergmed.2017.09.042. Epub 2017 Nov 3. PubMed PMID: 29103796.

Summary by Travis Barlock, MS4    |   Edited by Erik Verzemnieks, MD

Podcast #385: Probiotics

Author:  John Winkler, MD

Educational Pearls:

  • Probiotics are bacteria that are ingested to promote gut health but recent research casts doubt on their effectiveness.
  • Recent study suggests that most probiotics that are ingested are killed by stomach acid. Those that remain are not very healthy and are outcompeted by the normal gut flora.
  • Probiotics should not be given as a one-size-fits-all treatment.

 

References:

Zmora N, Zilberman-Schapira G, Suez J, Mor U, Dori-Bachash M, Bashiardes S, Kotler E, Zur M, Regev-Lehavi D, Brik RB, Federici S, Cohen Y, Linevsky R, Rothschild D, Moor AE, Ben-Moshe S, Harmelin A, Itzkovitz S, Maharshak N, Shibolet O, Shapiro H, Pevsner-Fischer M, Sharon I, Halpern Z, Segal E, Elinav E. Personalized Gut Mucosal Colonization Resistance to Empiric Probiotics Is Associated with Unique Host and Microbiome Features. Cell. 2018 Sep 6;174(6):1388-1405.e21. doi: 10.1016/j.cell.2018.08.041. PubMed PMID: 30193112.

Podcast #384: Don’t stab a PTA?

Author:  Don Stader, MD

Educational Pearls:

  • Recent study suggests we may not need to drain uncomplicated peritonsillar abscesses.
  • Patients who received medical therapy alone had no difference in complications and failure compared to those who received surgical drainage plus medical therapy.
  • Medical therapy in study was ceftriaxone, clindamycin, and dexamethasone.
  • Medical therapy was also associated with fewer opioid prescriptions, sore days, and days off from work.

 

References:

Battaglia A, Burchette R, Hussman J, Silver MA, Martin P, Bernstein P. Comparison of Medical Therapy Alone to Medical Therapy with Surgical Treatment of Peritonsillar Abscess. Otolaryngol Head Neck Surg. 2018 Feb;158(2):280-286. doi: 10.1177/0194599817739277. Epub 2017 Nov 7. PubMed PMID: 29110574.

Categories ENT

Podcast #383: Prehospital Tubes

Author:  Sam Killian, MD

Educational Pearls:

  • Two high-quality randomized control trials published in 2018 demonstrated no difference in mortality or neurologic outcomes when using a supraglottic airway compared to endotracheal intubation in out of hospital cardiac arrest
  • These two trials enrolled over a combined 12000 patients
  • Supraglottic airways have a higher success rate than intubations

 

References:

Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):779-791. doi: 10.1001/jama.2018.11597. PubMed PMID: 30167701

Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):769-778. doi: 10.1001/jama.2018.7044. PubMed PMID: 30167699.