Journal Feed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: Systemic Lupus – Spoon-Feed Version

Spoon Feed
Systemic lupus erythematosus is an autoimmune disorder with several manifestations that are tricky to diagnose and several disease manifestations that may lead to emergency care.

Why does this matter?
SLE is common. You will see these patients in the ED. Here are the common dangerous presentations and the medications and side effects you need to know.

Lupus – late 16th century: from Latin, literally ‘wolf’

Clinical Manifestations

  • The most common are in the table. The name lupus comes from the malar rash, which apparently made the face appear “wolf-like” to some tortured soul.

  • Any combination of 4 in the table is adequate for diagnosis.

  • African-American women are disproportionately affected.

  • Common and concerning ED presentations include: severe hematologic manifestations, shortness of breath, PE, chest pain, neurologic or neuropsychiatric manifestations, rapid decline in renal function, or fever.

  • Notable severe manifestations of SLE: lupus nephritis, alveolar hemorrhage, or CNS vasculitis all need treatment with high-dose steroids and immunosuppressive medications.

From cited article. Any 4 to make the diagnosis

From cited article. Any 4 to make the diagnosis

Pregnancy

  • Flares may occur during pregnancy.

  • DVT/PE risk is greater.

  • Preeclampsia and HELLP are more common.

Treatment

  • Glucocorticoids, antimalarial agents, non-steroidal anti-inflammatory drugs, immunosuppressive agents, and B cell–targeting biologics are the mainstays.

  • Hydroxychloroquine is the most commonly used drug.

  • Common medications are in the table. I needed to remind myself of the adverse effects of most of these drugs and found this column helpful. I need to point out three things.

    • Beware azathioprine (6-MP) and allopurinol together. This can cause profound myelosuppression. Xanthine oxidase helps break down 6-MP and is inhibited by allopurinol.

    • Allopurinol can also increase cyclosporine levels.

    • Know the tacrolimus-hyperkalemia association. Imagine a board question about drugs that increase potassium that lists spironolactone, lisinopril, tacrolimus, and mycophenylate. It’s not mycophenylate (…another point for you!).

  • Fever may indicate opportunistic infection and should usually receive broad-spectrum antibiotic coverage.

From cited article.

From cited article.

Disposition

  • Most SLE management is outpatient and is out-of-sight, out-of-mind for us in the ED.

  • Hospitalization is usually needed in patients with severe thrombocytopenia, rapidly progressive kidney disease, pneumonitis or pulmonary hemorrhage, severe cardiac or neurological disease manifestations, or fever.

Source
Systemic Lupus Erythematosus. Ann Intern Med. 2020 Jun 2;172(11):ITC81-ITC96. doi: 10.7326/AITC202006020.

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#2: Maybe Ondansetron Rx Does Reduce Bouncebacks in Kids

Spoon Feed
In this retrospective study, an ondansetron prescription was associated with decreased 72-hour return visit rates for children with vomiting or acute gastroenteritis and did not appear to mask any alternative diagnosis.

Why does this matter?
Ondansetron is a commonly prescribed medication for children presenting to the ED with vomiting. This study addresses whether an outpatient prescription at discharge affects rates of return to the ED for this group of patients. Previous smaller studies did not show reduction in ED bouncebacks with ondansetron. What does this massive study show?

Stay home…with ondansetron
This was a retrospective cohort study of pediatric patients aged 6 months to 18 years old who presented to an ED or urgent care with discharge diagnosis of gastroenteritis or vomiting. A total of 82,139 patients were included, of which 7.9% received an IV fluid bolus, 55.1% received ondansetron in the ED, and 13.4% received a prescription for ondansetron at discharge. Within a 72-hour period, 3851 patients (4.7%) returned to the ED. Receiving a prescription for ondansetron significantly reduced the odds of a return visit (adjusted OR 0.84). Factors that increased odds of a return visit included younger age, receiving intravenous fluids or ondansetron at the index visit, and having a radiologic study performed at the index visit. A prescription for ondansetron did not increase the risk of patients’ returning with an alternative diagnosis (e.g appendicitis or intussusception).

Source
Ondansetron Prescription Is Associated With Reduced Return Visits to the Pediatric Emergency Department for Children With Gastroenteritis. Ann Emerg Med. 2020 May 26. pii: S0196-0644(20)30262-6. doi: 10.1016/j.annemergmed.2020.04.012. [Epub ahead of print]

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#3: Geriatric Rib Fractures – Spirometry or Pain Control for Dispo?

Spoon Feed
Bedside spirometry measurements, specifically the FEV1, can help predict outcomes for geriatric patients with isolated rib fractures and may be used to make decisions about admission and discharge. Pain control did not correlate with pulmonary function or predict discharge home.

Why does this matter?
Rib fractures are associated with significant morbidity and mortality in the geriatric population, and a recent algorithm developed by the Western Trauma Association recommends admitting most patients older than 65 with two or more rib fractures to a monitored setting. However, much of this correlation is likely related to concomitant injuries, and the evidence for geriatric patients with isolated rib fractures is limited. Multiple studies have suggested that pulmonary function tests such as incentive spirometry or FVC can help predict outcomes, but what role do these tests have for geriatric patients with isolated rib fractures? Will trauma surgery want to do spirometry and recommend early discharge in some cases, even from the ED?

Spirometry for geriatric rib fractures…like a breath of fresh air
This was a prospective observational study of 86 patients evaluating FVC, FEV1, NIF, pain level, and grip strength as predictors of outcome in patients ≥ 60 years of age with three or more isolated rib fractures. Complications such as pneumonia (2), unplanned ICU admission (3), and intubation (1) were rare. FVC, FEV1, and grip strength on day one predicted discharge to home, and both FEV1 and pain level on day one moderately correlated with the length of stay (LOS).

After adjusting for confounders, the FEV1 on day one was a significant predictor of both LOS and discharge home with a 3% increase in the odds of discharge home for every percent increase in FEV1 percent predicted (p=0.023). The only other predictor of home discharge that reached significance was younger age (p<0.001). Almost all patients with FEV1 greater than 60% of predicted were discharged home with a short LOS. For each patient, FVC, FEV1, and NIF did not change significantly over three days even though there was improvement in pain.

Interestingly, pain score had little impact on the potential for discharge home and was not associated with respiratory volumes, although improving pain was associated with shorter LOS.

 Source
Spirometry Not Pain Level Predicts Outcomes in Geriatric Patients with Isolated Rib Fractures. J Trauma Acute Care Surg. 2020 May 26. doi: 10.1097/TA.0000000000002795. [Epub ahead of print]

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