Absorbable Sutures?

1490260878009.jpeg

By Adam Rhodes, MD

Edited by Nicholas Otts, MD

A Common Problem:

A 6-year-old male presents with a laceration on his face.  He screams, “no stitches,” and requires intranasal versed for sedation for the laceration repair.  Absorbable sutures would negate a difficult followup visit for suture removal. But what about the cosmetic outcome, the infection risk, and other complications such as dehiscence? Is there evidence to support the use of absorbable sutures versus non-absorbable sutures in this scenario?

surgical_gut_light_page_hero_2.png

A Small Dose of EBM:

The literature over the last decade strongly supports the use of absorbable sutures.

A randomized controlled trial of pediatric patients in 2004 (using a wound evaluation score and a validated visual analog scale during follow up visits) determined that there was no difference in cosmetic outcome, dehiscence, or infection (1).

A caveat - the study used plain gut, whereas most PEM providers use fast absorbing plain gut.

A-size-6-0-fast-absorbing-gut-suture-on-a-13mm-38ths-of-a-circle-cutting-needle.jpg

Thankfully,  a study in 2008 utilized fast absorbing gut with similar control trial structure (also using a visual analogue scale as well as parents and three blinded observers). It found no difference in infection, wound dehiscence, keloid formation, and parental satisfaction. (2)

My-Logo-4.png

Further, a meta-analysis of randomized controlled trials compared outcomes of absorbable versus non-absorbable sutures for skin closure in 2016. They concluded that absorbable sutures for skin closure were not inferior and recommended they be considered due to lower cost and time saving benefits. (3)

References:

1. Karounis H, et. al. A randomized controlled trial comparing long term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus non absorbable nylon sutures. Acad Emerg Med 2004 Jul;11(7):730-5.

2. Luck et. al. Cosmetic outcomes of absorbable versus non absorbable sutures in pediatric facial lacerations. Pediatric Emerg Care 2008 Mar;24(3):137-42.

3. Xu B. et. al. Absorbable versus Nonabsorbable Sutures for skin closure: A meta-analysis of randomized controlled trials. Ann Plastic Surgery 2016 May;76(5):598-606.

 

 

Torsion: Enter the Whirlpool

By Nicholas Otts, MD

Edited by Gal Altberg, MD and Abbas Husain, MD

A Common Problem:

11 year old male complaints of two episodes of testicular pain associated with nausea and vomiting, but in the emergency department the pain resolved. His testicular exam is non contributory. Ultrasound of his scrotum shows increased flow to left testicle. Torsion ruled out?

A Small Dose of EBM:

Testicular torsion has a bimodal distribution - initial peak during first year of life followed by the pubertal surge in adolescence; thus, torsion is primarily a PEM problem. Classically, ED residents are taught to evaluate torsion with an ultrasound, using power doppler to assess flow to involved testicle. If no or decreased flow compared to other side, there is a much higher concern for torsion.  

(http://paediatricem.blogspot.com/2015/05/testicular-torsion.html)

What about normal or even increased flow? Does that rule out torsion? What if pain has resolved. What about intermittent torsion?

(https://www.123rf.com/photo_3011933_two-almond-nuts-put-side-by-side-isolated-on-white-background.html)

Intermittent testicular torsion, in which the spermatic cord twists and spontaneously resolves, is often a harbinger of final torsion. It is a problem that needs surgical correction, and, thus a diagnosis that cannot be missed.

On ultrasound, however, it can look like other causes of testicular pain. With flow returned to the testicle, the subsequent inflammation can appear as increased flow on doppler, which can be mistaken for orchitis. Further, the epididymis, near the spermatic cord, is often inflamed with or without return of flow, appearing enlarged and hyperemic on ultrasound, leading one to possibly suspect epididymitis.

Enter the Whirlpool

Whirlpool sign on ultrasound is another marker of torsion, and is created by a twisting of the spermatic cord (1,2,3). A good retrospective study at Texas Children’s showed that in patients with a surgical diagnosis of intermittent torsion, the whirlpool sign on ultrasound is a significant marker and can help distinguish this from other causes of testicular pain when doppler is non-diagnostic (4).

So, the next time you suspect torsion, think about intermittent torsion and make sure the ultrasound evaluation includes a good examination of the spermatic cord.

(http://www.aium.org/soundWaves/article.aspx?aId=654&iId=20130808)

A good article with video of whirlpool sign:

http://dx.doi.org/10.1594/ecr2011/C-0965

References:

1. Vijayaraghavan SB. Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion. J Ultrasound Med 2006; 25:563-574

2. Baud C, Veyrac C, Couture C, Ferran JL. Spiral twist of the spermatic cord: a reliable sign of testicular torsion. Pediatr Radiol. 1998;28:950–954

3. Esposito F, Di Serafino M, Mercogliano C, Vitale V, Sgambati P, Vallone G. The “whirlpool sign”, a US finding in partial torsion of the spermatic cord: 4 cases. Journal of Ultrasound. 2014;17(4):313-315.

4. Munden MM, Williams J, et. al. Intermittent Testicular Torsion in the Pediatric Patient: Sonographic Indicators of a Difficult Diagnosis. American Journal of Roentgenology. 2013;201: 912-91

 

Hand, Foot, and...Lidocaine?

by Nicholas Otts, MD

Edited by Gal Altberg, MD

A Common Problem:

3 year old male presents w/ decreased oral intake associated w/ ulcerative and vesicular lesions in his mouth and irritability. Normal amount of wet diapers, no signs of dehydration on exam. Vesicular lesions on palms and soles as well.

(https://www.shutterstock.com/image-vector/hand-foot-mouth-disease-hfmd-illustration-265246085)

To give or not to give viscous lidocaine in an attempt to increase oral intake in a patient you do not wish to admit?

A Small Dose of EBM:

Treating pediatric viral stomatitis is a challenge. The primary goal is to avoid dehydration, and thus, admission for a primarily viral problem that will resolve with time. Oral medications commonly attempted in the ED include diphenyhydramine, coating agents (maalox), and viscous lidocaine (including combinations). For years, much of the EBM supporting either was case based and anecdotal. The desire to do something for these patients and their suffering parents is strong.

(http://njmommyblog.com/coxsackie-hand-foot-mouth-disease-signs-symptoms-survival/)

The most potentially toxic (1,2) but also potentially helpful medication is lidocaine.  Thankfully, a recent blinded, randomized, placebo-controlled trial examined this exact question (3).

In 2014, a trial out of Australia tested 2% viscous lidocaine against a placebo with improved oral intake after one hour as the primary outcome measure. The study had a good design and was powered appropriately.

In the end, however, the oral intake in both groups was not significantly different. Viscous lidocaine appeared to make no difference for all of the measured outcomes. Further, because viscous lidocaine has the most potential to cause harm out of the agents frequently used, it is a less than desirable choice.

(http://www.babyinfo.com.au/newborns-and-infants/understanding-hand-foot-and-mouth-disease)

Because  both the placebo and lidocaine groups in general showed significant improvement in oral intake as compared to the reported oral intake at home, it is suggested that simply the attention and instruction by the ED staff to the parents contributed significantly to the better outcomes.

This is a good trial, but there are some problems.  First, as pointed out by the famous NYC toxicologist Dr. Hoffman in a letter to the editor in response to the article (4), the trial did not account for pain at all as an outcome measure.  One can only use this trial to say that lidocaine did not improve oral intake, not that it does not relieve pain.

Further, the study only accounted for the first hour of oral intake post administration, and a longer term benefit of lidocaine was not assessed (but the timing was applicable to standard emergency department goals of disposition in these types of patients).

Bottom line: right now, due to potential for toxicity and no proven benefit in increasing oral intake, lidocaine may not be the best option for ulcerative lesions in the mouth. Good instruction to the parents and bringing attention to the issue of dehydration, however, may make all the difference.

References:

1. Hess GP, Walson PD. Seizures secondary to oral viscous lidocaine. Ann Emerg Med. 1988; 17(7) 725.

2. Questions and Answers: Reports of  rare, but potentially serious and potentially fatal adverse effect with the use of OTC benzocaine gels and liquids applied to gums or mouth. www.fda.gov/Drugs/DrugSafety/ucm250029.htm

3. Hopper SM, McCarthy M, Tancharoen C, et al. Topical Lidocaine to improve oral intake in children and painful infectious mouth ulcers: a blinded, randomized, placebo-controlled trial. Ann Emerg Med. 2014; 63: 292-299.

4. Hoffman R. Viscous Lidocaine Treatment for Painful Oral Infections in Children: Disappointingly Dismissive of Pediatric Pain. http://dx.doi.org/10.1016/j.annemergmed.2014.02.026

Concussions: Tough Love

by Nicholas Otts, MD

edited by Gal Altberg, MD

A Common Problem:

16 y F presents with headaches, nausea, cloudy mentation, and irritability a day after heading a ball during a soccer game. You diagnose a concussion. Parents want to know when she should start exercising again and when she can go back to school?                          

 Two female soccer players competing for the ball, aerial view.

(https://www.sciencenewsforstudents.org/article/soccer-watch-out-collisions)

A Small Dose of EBM:

Many physicians commonly advocate for both physical and mental rest following concussion, but the evidence for that practice is lacking.  Let’s break it down into two areas, PHYSICAL and MENTAL.

**PHYSICAL **

Evidence for physical rest post concussion is based on old small observational studies, animal models, and “expert consensus” opinions, which in the EBM world is the same thing as letting the patient’s Mother and Google decide what is best.

(http://stevedalepetworld.com/mother-knows-best/)

Evidence that does exist suggests aerobic physical activity is beneficial in the initial week post concussion.

A prospective, multicenter cohort study showed physical activity within a week (versus no physical activity) was associated with reduced risk of persistent postconcussive symptoms a month later (1). A prospective randomized control trial showed similar benefit (2). Further, another study suggested that patients that had prolonged symptoms a week after the initial event, aerobic physical activity improved symptoms and was beneficial to recovery (3).

(*Important caveat: these studies refer to aerobic physical activity that does not risk further head injury. This does not mean the patient can return to whatever exercise activity he or she wants.)


Thus, the tough love advice of getting the athlete back on the exercise bike (but off the football field) is probably the better approach than nurturing them on the couch with Netflix and pizza.

(https://www.theodysseyonline.com/10-shows-you-must-binge-watch-netflix)

**MENTAL**

The current approach is to suggest “mental rest,” until the patient has no further symptoms, which includes a prescription for staying home from school, avoid reading or writing, and “stimulating” video games.

The evidence for this approach is based on expert consensus and observational studies, which, again, is not ideal for clinical decision making (4,5,6).

1107_gsoccer1 01 1107_gsoccer1 01

(https://www.bethesdahbot.com/head-injury/sports-injuries/)

A prospective trial previously mentioned (2) actually suggested that cognitive rest lengthened duration of post concussive symptoms.

Bottom line, if you prescribe cognitive rest or cognitive activity as tolerated, the evidence so far will not back you either way.  But I think it reasonable to suggest that children attempt as much mental activity as they can tolerate without worsening symptoms. Thus, the tough love approach in this scenario may also be best.

References:

1 Grool AM, Aglipay M, Momoli F, et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA 2016; 316:2504.

2 Thomas DG, Apps JN, Hoffmann RG, et. al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics 2015; 135:213.

3 Leddy JJ, Kozlowski K, Donnelly JP, et al. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med 2010; 20:21.

4 Brown NJ, Mannix RC, O’Brien MJ, et. al. Effect of cognitive activity level on duration of post concussive symptoms. Pediatrics 2014; 133: e299.

5 Sady MD, Vaughan CG, Gioia GA. School and concussed youth: recommendations for concussion education and management. Phys Med Rehabil Clin N Am 2011; 22:701.

6 Howell D, Osternig L, Van Donkelaar P, et. al. Effects of concussion on attention and executive function in adolescents. Med Sci Spots Exerc 2013; 45: 1030.

 

Asthma: Nebulous Nebs and DexMex

by Nicholas Otts, MD

Edited by Gal Altberg, MD and Abbas Husain, MD

A Common Problem:

6 year old female with a PMHx of asthma presents to the ED with shortness of breath and wheezing.

What medications and routes have the best evidence?

A Small Dose of EBM:

NEBULOUS NEBS

There have been a wealth of studies that show a small benefit (or at least a non inferiority) with using a metered dose inhaler (MDI) with valved holding chamber (one-quarter to one-third puff/kg, minimum two puffs and maximum eight puffs per dose), versus nebulizer (.15 mg/kg, minimum 2.5 mg and maximum of 5mg per dose) for exacerbations requiring treatment.

A popular hypothesis as to why nebulizers are more nebulous with the administration of albuterol: much of the drug is lost to the surrounding environment before reaching the patient’s lungs, exacerbated by non-perfect use in the pediatric patient.

Studies below show either a non inferiority or a benefit to MDI including a decrease in hospital admission rate in those with a severe exacerbation, an improvement “severity” scores, and a decrease in length of stay in the ED (1,2,3).

That this benefit does not apply to adults further advances the theory that nebulous nebs lose some of the drug to the surrounding environment when not used perfectly (3).

Some of the advantages of using nebulized treatment include the simultaneous administration of oxygen and ipratropium bromide, as well as the ease of administration (vs. MDI) for a child in respiratory distress. Thus, when considering the best route of treatment, one must make a judgement call on the patient in front of them. If they can handle proper use of a metered dose inhaler, I think the evidence supports its use.

DEXMEX

I like to think of the prednisolone versus dexamethasone debate as TexMex versus traditional Mexican food. TexMex is less traditional but gets the job done with equal efficacy.

 

A non inferior (and better if you consider parent convenience) treatment for these patients would be a single dose of dexamethasone (.6mg/kg) in the ED versus additional days of prednisolone at home. (A traditional course of 2mg/kg/day for first day and then 1mg/kg/day for next 4 days.)

A randomized trial compared a single-dose oral dexamethasone (0.3mg/kg) versus multi dose prednisolone (1mg/kg/day) and found no difference in subsequent hospital admission rates or return visits to a health care professional (4). Why prescribe the longer course and risk the bitter taste, potential for vomiting, and decreased compliance?

Some would argue that this trial only compared dexamethasone  with three days of prednisolone and that we usually prescribe four additional days of steroids. To that I would site a meta analysis that showed no difference between a 3-5 day course of prednisolone (2mg/kg first day, 1mg/kg/day for subsequent 2-4 days) and dexamethasone given as a single intramuscular dose (0.3 to 1.7 mg/kg) or one to two daily oral doses (0.6mg/kg) (5).

I think time will prove that one dose is equivalent, and I think there is evidence to practice that way now (additional studies I have not cited in the adult world). If you are stuck on five days of steroids, a compromise solution would be one additional dose of dexamethasone the next day.  Some would say there is nothing wrong with DexMex twice, but I think once is enough.

________________________________________________________________

1 Castro-Rodriguez JA, Rodrigo GJ. Beta-agonists through metered-dose inhaler with valved holding chamber versus nebulizer for acute exacerbation of wheezing or asthma in children under 5 years of age: a systematic review with meta-analysis. J Pediatr. 2004; 145 (2): 172

2 Ploin D, Chapuis FR, et. all.High-dose albuterol by metered-dose inhaler plus a spacer device versus nebulization of preschool children with recurrent wheezing: A double-blind, randomized equivalence trial. Pediatrics. 2000; 106 (2 Pt 1): 311.

3 Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013

4 Cronin JJ, McCoy S, et.all. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Ann Emerg Med. 2016 May; 67 (5): 593-601. e3. Epub 2015 Oct 14.

5 Keeney GE, Gray MP, Morrison AK, et al. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics 2014; 133: 493.

Dehydration: A Future in POC Testing

SmallDosesCover.jpg

by Nicholas Otts, MD

Edited by Gal Altberg, MD and Abbas Husain, MD

A Common Problem:

9 month female presents to an ED with vomiting, diarrhea, and decreased PO intake at home.

Is this child dehydrated? What PE signs am I relying on? What urine or lab values matter?

A Small Dose of EBM:

A good systematic review suggested that the most useful individual physical exam findings for predicting 5% dehydration are abnormal capillary refill time, abnormal skin turgor, and abnormal respiratory pattern (1).  

However, a combination of PE findings is better than any of the above individual signs; also, this combination can include other common PE findings such as dry mucous membranes, sunken fontanelle, etc.

As for labs (BUN, BUN/Cr ratio, etc.), serum bicarbonate is best, but only as a tool to help you rule out dehydration (if greater than 15 or 17) (1,2,3).

Further, all urine values (specific gravity, ketones, output, etc.), which some use as POC testing, have been found to be not helpful (1,4).

A Brighter Future:

Since multiple studies have suggested a normal bicarb as a method of ruling out moderate dehydration (and thus, ruling out the need to establish an IV in a dehydrated patient), a brighter future may be found in POC testing in the EM. Yale did a recent study establishing significant cost savings of point of care (i-Stat) testing of serum electrolytes (including bicarb) vs. traditional lab work in pediatric patients with gastroenteritis (5). If this kind of technology becomes more widespread, PEM attendings may be able to avoid many IV placements in future patients with gastroenteritis.


An explanation.  Let’s tackle some research on the subject.

There is a wealth of research on pediatric dehydration, but few studies use a valid gold standard. The gold standard for dehydration is weight loss, but it is impossible to have an accurate weight change in a patient when we aren’t measuring their well weight just before they get sick.

Thus, good studies use a comparison of the rehydration weight to the acute weight as an estimation. (rehydration weight - acute weight) / rehydration weight.

There was a systematic review from JAMA in ‘04 of pediatric dehydration that used the above standard in its analysis. It identified studies from 1966-2003 on this topic (1603) and eliminated those that did not meet the above gold standard for analysis, among others. It created tables of the LR (likelihood ratios) all the common PE findings and lab values that could be used to assess dehydration (1).

Some bottom line numbers: abnormal cap refill time LR 4.1, 95% CI 1.7-9.8, abnormal skin turgor LR 2.5, 95% CI 1.5-4.2, and abnormal respiratory pattern LR 2.0, 95% CI 1.5-2.7) (1).

Labwork appears to have some value if grossly abnormal ( such as BUN/Cr > 45) but the bicarb was the only value that had good data (LR .18 to .22 for ruling out dehydation) (1,2,3)

Further, for those that like using a U/A to rule in or out the need for an IV placement, a prospective cohort study in ‘07 also used the above gold standard and looked specifically at urine studies--specific gravity, urine ketones, and output--and did not find predictive value for dehydration (4)

As always, there are limitations in every study, and even the gold standard used for analysis of dehydration (with the rehydration weight), is not ideal.  But it is helpful to create discussion from the current literature in those that will assess this kind of patient on every shift.

References:

1. Steiner M, DeWalt D, Byerley, J. Is this Child Dehydrated? JAMA,  June 9, 2004 - Vol 291, No.22

2. Vega RM, Avner JR. A prospective study of the usefulness of clinical and laboratory parameters for predicting percentage of dehydration in children.  Pediatric Emergency Care. 1997; 13:179-182.

3. Yilmaz K, Krabocuoglu M, Citak A, Uzel N. Evaluation of laboratory tests in deydrated children with acute gastroenteritis. J Paediatr Child Health. 2002; 38: 226-228.

4. Steiner, M, Nager A, Wang V. Urine Specific Gravity and Other Urinary Indices: Inaccurate Test for Dehydration. Pediatric Emergency Care, Vol 23, Number 5, May 2007

5. Whitney R, Santucci K, Hsiao A, Chen L. Cost effectiveness of point-of-care testing for dehydration in the pediatric ED. American Journal of Emergency Medicine 34 (2016) 1573-1575.

Welcome to Small Doses

Welcome to StatenIslandEM’s  new and improved PEM Blog, SMALL DOSES of EBM!

We seek to evaluate the best evidence based medicine in the PEM world that could change your practice.
 

Author:

Nicholas Otts, M.D.

PGY2 Emergency Medicine

Northwell Health - Staten Island University Hospital

 

Editors:

Gal Altberg, M.D.

Pediatric Emergency Medicine

Northwell Health - Staten Island University Hospital

 

Abbas Husain, M.D. FACEP

Associate Program Director

Department of Emergency Medicine

Northwell Health - Staten Island University Hospital