一起來討論journal article: "Imaging strategies for detection of urgent conditions in patients with acute abdominal pain"

這篇BMJ的文章滿有意思的，一共收了從六個醫院急診的1021個病人，每個都做plain radiographs, ultrasonography, and CT，table 2裡看到clinical diagnosis alone的sensitivity跟其他個別的diagnostic test是幾乎一樣的(statistically and clinically)，不過要注意的是這裡是要detect "urgent" etiology。雖然他們有稍加敘述如何用panel的來定義，覺得還是不夠詳細和精確。

他們花了很多的工夫給每個acute abdomen需要imaging的病人做了這三樣檢查，可惜的是沒對examiner和interpreter做好的standardization。很多的ultrasound & CT是在沒有supervision的情形下做檢查和判讀的，結果就是significantly lower sensitivity... 很有趣的是他們也有想到不要只針對全部的abdominal pain來做分析，於是在strategy 10 & 11就有比較；更有趣的是這樣的結果和CT alone是相近的，於是乎American College of Radiology guideline似乎就不是很有力了…

另外是對於這樣hierarchical的結構，也許是可以考慮multilevel的分析方式，當然只有六個醫院沒法做太詳細的分析，可是我覺得至少要用empirical Bayes的方法來分析… 再來是一個小東西，figure3的ROC space小弟覺得有點名不正言不順，since這裡的diagnostic是binary的，沒有任何的cutoff可以用，不認為是否可以仍然以ROC命名…

先野人獻曝一下，希望大家不吝提出高見… 下週我們的journal club也會討論，到時再來跟大家分享結果。

BMJ的網站做得很不錯，還有一堆空間給reader來做rapid response...

ED grand round 11/13/09

Again, I join the Hopkins weekly grand round today. Along with the residents candidate interviewing to day, many attending physicians join the meeting today, which made the meeting more interesting. Just again share my note with everybody who might be interested.

Today the topic is Sedation

Pharmacology

Importance of ETCO2:

CO2 decrease before O2 (more sensitive and earlier)

Brady = hypoxia
Tachy = hypercapnia until proven otherwise
Hypoxia sequence (EtCO2 down, SpO2 down, then Bradycardia)
Cyanosis: happens when SpO2 <>

Advocate the usage of Propofol
Propofol 20+% hypotension, bolus only otherwise redistribute propofol
infusion syndrome lactic acidosis

(Hopkins have yet started the usage of Propofol in ED, but will be soon.)

One person does procedure one does sedation (will be policy)

This is not new to me. At my visit in U of Alberta, I realized that's a two man procedure. When can we really start to do EM @ TW sophisticated like this?

Fasting rule 8hr solid food 4 breast milk 2 clear liquid (policy)

www.Hopkinsinteractive.org (everyone needs to have certificate)

will share more information after I visit the web

Midazolam peak in 2-5min whoch might be the reason over
Mike never use that to sedate unless intubated already

(quite different from the practice @ CGMH back in TW)
Diazepam is quicker than mid (oral is opposite) he thinks safer drop blood pressure

Barbitals
Methohexital barbituate peds like but not great for RSI though it's
quick onset and offset
Pentobarbital longer
Thiopental longer and quick safe

Etomidate is better (widely used drug for RSI in US)

Choral hydrate oldest great for peds slow onset last hrs t1/2 10hrs

Etomidate has myoclonus effect, however some say transient. adrenal
insufficiency is owing to prolonged use. NEJM article (for randomized trial)
Propofol has musclelysis (do we have this term?)

Ketamine in peds iv im (the reason why ppl loves it)

Nitrous oxide for dentist (in his rotation)

Single vs mixed drug use debate eg ketofol

Hopkins RN or not creditential personnel can't give deep sedation agents

High risk pt want to involve anesthesia
Previous problem
Extreme of age
Sleep apnea
Obesity
Pregnancy
Multiple trauma
Substance abuse

ASA category
Evaluate
Discharge plan

Cuff20-50% should be greater than arm circum

Paradoxical motion
SpO2 -30 = PaO2

Head position picture shoulder should be higher (different airway structure)

Sequence of getting Epi or atrop depends on availability (brady get epi first then atropin in peds)

Add bicarbonate in local (1:9 in lidocaine)

Simulation room:
same situation like ACLS different from TW: give compliment before criticize

Meningitis:
Nuchal rigidity only has 30% sensitivity
Burski sign even worse
the head rotation test has 93% sen, of course, not specific
chemoprophylactis done throughly in there
steroid need to be given
worry about the Listeria for >50, immunocompromised, etc. give ampicillin
RBC found in non-traumatic tap, worry about HSV. tap before given acyclovir

Chairman chat again panel type
Synco-pe

again they use the interactive remote answer card
www.turningtechnologies.com

http://www.turningtechnologies.com/professionalaudienceresponse/audienceresponsesolutions/
Head or facial trauma hints the duration or severity of cause of syncope
Open discussion is interesting but need the culture to do that
TnI for risk stratification

Interesting research forum today

Research forum is the monthly dialogue we have here in GTPCI at Hopkins. Students are asked to either share their research dilemma or initiate discussion the might be helpful for their project in this forum. Today a surgeon shared the project that makes him able to jump up to wear his shoes every morning about the decision that physicians or surgeons make for the resection of liver metastasis from colorectal cancer.

It's interesting because this surgeon, although very passionate, is a sort of 'typical' surgeon. By saying that implies the stereotype of surgeon is confident but sometime arrogant. Today he just keeps giving the example that he operated a 35 year-old having 4 kids man, who has been told by another doc "to have a cruise". Obviously there's some gap between the society of surgeon and medical oncologist. How physicians make decision is going to be his main research question. But since he who's also in the panel of expert to make the guideline thinks the consensus now is 'arbitrary', seems the director's suggestion: go make the guideline more solid by doing some outcome analysis is very wise. However, this 'typical' surgeon seemed not able to pick up his idea but still trying to defend himself...

Very interesting research forum today...