CMD Journal Club
Published on Nov 30, 2021
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PRESENTATION OUTLINE
What can we learn from 2021?
- Concussion management is giving me a headache
- COVID-19 broke my heart
- Give me a break!
- Back pain- just deal with it!
Photo by Jeremy Bishop
Concussion management is giving me a headache
Photo by Ben Hershey
Recovery- what do you advise?
- Cognitive rest? How long?
- Avoid screen time? Until when?
- Can they return to play? When?
Cognitive rest- 2011, 2013- rest needed, screens bad (not actually studied)
2015- prolonged rest may be harmful, worsens symptoms
Decrease in executivbe functioning means poor performance early on.
Gradual return to play recommended 2011-2018; so complicated!
2015- prolonged rest may be harmful, worsens symptoms
Decrease in executivbe functioning means poor performance early on.
Gradual return to play recommended 2011-2018; so complicated!
Photo by Anthony Tran
Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial
JAMA Pediatr. 2021 Nov 1;175(11):1124-1131.
Why do we care about screen time?
U.S. teens spend up to 7 hours each day looking at some form of computer screen.
TV screens are known to be a migraine trigger.
Eye strain and light stimulation are probably not best for kids who need cognitive rest.
Does Screen Time Worsen Concussion Symptoms?
This was a RCT including 125 children with concussion in the ED, who were randomized to abstain from screen time or use screens ad lib for the first 48 hours after the ED visit.
Discharge instructions were otherwise identical
U.S. teens spend up to 7 hours each day looking at some form of computer screen.
TV screens are known to be a migraine trigger.
Eye strain and light stimulation are probably not best for kids who need cognitive rest.
Does Screen Time Worsen Concussion Symptoms?
This was a RCT including 125 children with concussion in the ED, who were randomized to abstain from screen time or use screens ad lib for the first 48 hours after the ED visit.
Discharge instructions were otherwise identical
Photo by Rodion Kutsaev
Conclusion: Children with concussion recovered almost 5 days faster with limits on screen time in the first 48 hours after injury.
Results: Abstainers used screens less (130 min/d screen time) and recovered in a median 3.5 days vs screen users (630 min/d screen time), with recovery at a median 8 days; p=0.03.
Implications: Exposure to digital screens right after concussion prolongs recovery.
Implications: Exposure to digital screens right after concussion prolongs recovery.
Photo by Josh Hild
Will this change your practice?
Limit screens in first few days; limit longer if screens cause worsening symptoms.
Photo by Jonnelle Yankovich
Does exercise extend recovery time?
Photo by MSC U15 Green
A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mTBI
Acad Emerg Med. 2021 Jan 22.
This was a randomized controlled trial conducted in three Canadian EDs.
Adult (18-64 years) ED patients with an mTBI sustained within the preceding 48 hours
The intervention group received discharge instructions prescribing 30 minutes of daily light exercise, and the control group was given standard mTBI instructions advising gradual return to exercise following symptom resolution.
The primary outcome was the proportion of patients with PCS at 30 days
Adult (18-64 years) ED patients with an mTBI sustained within the preceding 48 hours
The intervention group received discharge instructions prescribing 30 minutes of daily light exercise, and the control group was given standard mTBI instructions advising gradual return to exercise following symptom resolution.
The primary outcome was the proportion of patients with PCS at 30 days
Photo by gurana
There were no differences in recovery or health care utilization outcomes.
Results suggest that early light exercise may be encouraged as tolerated at ED discharge following mTBI, but this guidance is not sufficient to prevent PCS.
Photo by Arek Adeoye
Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial
JAMA Pediatr. 2019 Feb 4.
Kids?
This was a multicenter RCT of 103 teenage athletes (13-18) with sports-related concussion who were randomized to either placebo (mild stretching exercises) or aerobic exercise to just below the threshold of concussion symptoms, each for 20 minutes a day. Both groups started around 5 days after concussion.
This was a multicenter RCT of 103 teenage athletes (13-18) with sports-related concussion who were randomized to either placebo (mild stretching exercises) or aerobic exercise to just below the threshold of concussion symptoms, each for 20 minutes a day. Both groups started around 5 days after concussion.
Photo by Rosie Sun
Conclusion: Light aerobic activity that doesn’t evoke concussion symptoms speeds recovery vs rest.
Patients in the exercise group recovered 4 days faster than placebo (13 vs 17 days). There was a non-significant trend to fewer patients with prolonged, delayed recovery (> 30 days) in the exercise group as well, 2 patients; placebo group, 7 patients (p = 0.08). This is yet another paradigm change for concussion. Doing light aerobic exercise actually hastens recovery.
Photo by Jeremy Bishop
Will this change your practice?
Adults- light exercise doesn't hurt, may not help
Kids- light exercise may help, after a few days
All- avoid overexertion
Kids- light exercise may help, after a few days
All- avoid overexertion
Photo by Jonnelle Yankovich
COVID-19 broke my heart
Photo by Fusion Medical Animation
Can I recognize myocarditis?
- How does it present?
- What signs and symptoms will clue me in to the possible diagnosis?
- When should I LOOK for it?
DDX: LOOK for it with:
COVID
Lyme
Influenza
EBV
HSV
Parvovirus
Mycoplasma
Staph/strep
Non-infectious:
ETOH
CO
Antibiotics (penicillins, cephalosporins, sulfonamides)
Diuretics (thiazide, loop)
Lithium
Systemic disorders:
Celiac disease
Collagen-vascular diseases
Inflammatory bowel disease (Crohn disease, ulcerative colitis)
Kawasaki disease
Sarcoidosis
Thyrotoxicosis
COVID
Lyme
Influenza
EBV
HSV
Parvovirus
Mycoplasma
Staph/strep
Non-infectious:
ETOH
CO
Antibiotics (penicillins, cephalosporins, sulfonamides)
Diuretics (thiazide, loop)
Lithium
Systemic disorders:
Celiac disease
Collagen-vascular diseases
Inflammatory bowel disease (Crohn disease, ulcerative colitis)
Kawasaki disease
Sarcoidosis
Thyrotoxicosis
Photo by camilo jimenez
Diagnosis and Management of Myocarditis: An EB Review for the EM Clinician
J Emerg Med. 2021 Sep;61(3):222-233.
A summary of the background, pathophysiology, diagnosis, and management of myocarditis, with a focus on emergency clinicians.
Photo by vestman
Adults
- Preceeding viral prodrome
- Dyspnea
- Chest pain
- Tachypnea, tachycardia
- Suspected ACS or heart failure without typical risk factors
- ACS with recent infection
Myocarditis occurs when inflammation of the heart musculature causes cardiac dysfunction.
Symptoms may range from mild to severe and are often preceded by a viral prodrome.
Laboratory assessment and an electrocardiogram can be helpful for the diagnosis, but echocardiography is needed.
Workup: ED workup includes ECG, laboratory tests (elevated ESR, CRP, troponin, BNP), and CXR. Point-of-care ultrasound is most useful to identify cardiac dysfunction in the ED. Cardiac MRI, catherization, and endomyocardial biopsy usually occur after admission.
Symptoms may range from mild to severe and are often preceded by a viral prodrome.
Laboratory assessment and an electrocardiogram can be helpful for the diagnosis, but echocardiography is needed.
Workup: ED workup includes ECG, laboratory tests (elevated ESR, CRP, troponin, BNP), and CXR. Point-of-care ultrasound is most useful to identify cardiac dysfunction in the ED. Cardiac MRI, catherization, and endomyocardial biopsy usually occur after admission.
Photo by Ashkan Forouzani
Conclusion: Myocarditis is associated with significant morbidity and mortality, but it can be tricky to diagnose if you don’t suspect it.
Management: These patients require admission.
50% of patients will fully recover, 30% will decompensate, and 20% will require transplant.
ED treatment focuses on management of acute heart failure.
NSAIDs should be avoided, as they may worsen mortality. Specific therapies vary based on etiology; IVIG is controversial, and immunosuppressants and steroids can be used for giant cell or eosinophilic myocarditis.
50% of patients will fully recover, 30% will decompensate, and 20% will require transplant.
ED treatment focuses on management of acute heart failure.
NSAIDs should be avoided, as they may worsen mortality. Specific therapies vary based on etiology; IVIG is controversial, and immunosuppressants and steroids can be used for giant cell or eosinophilic myocarditis.
Photo by euthman
Your patient w/COVID has possible myocarditis. What will you see on the ECG?
Studies have shown that up to 90% of critically ill COVID-19 patients demonstrate at least one ECG abnormality
These abnormalities are associated with increased risk of in-hospital mortality and the need for mechanical ventilation.
ECG abnormalities may be caused by, “cytokine storm, hypoxic injury, electrolyte abnormalities, plaque rupture, coronary spasm, microthrombi, or direct endothelial or myocardial injury.”
These abnormalities are associated with increased risk of in-hospital mortality and the need for mechanical ventilation.
ECG abnormalities may be caused by, “cytokine storm, hypoxic injury, electrolyte abnormalities, plaque rupture, coronary spasm, microthrombi, or direct endothelial or myocardial injury.”
Photo by osseous
Electrocardiographic manifestations of COVID-19
Am J Emerg Med. 2021 Mar;41:96-103.
A literature review of PubMed and Google Scholar databases was performed for articles up to October 23, 2020, using the keywords ‘COVID’ OR ‘SARS-CoV-2’ OR ‘coronavirus’ OR ‘SARS’ AND ‘ECG’ OR ‘EKG’ OR ‘electrocardiogram’ for this narrative review.
The initial literature search revealed over 200 articles, with the majority of these articles consisting of case reports.
The initial literature search revealed over 200 articles, with the majority of these articles consisting of case reports.
Photo by Alesa Dam
ECG manifestations of COVID-19
- SVTs- sinus tach, afib = poor outcome
- Malignant ventricular dysrhythmias- monomorphic VTach
- Morphologic changes- ST segment elevation/depression, T wave inversion, pathologic Q waves
- RV strain (RAD, prominent R in V1 & V2, ST dep/T wave inv leads II, III, aVF and V1 to V4.)- think PE or multi-lobar PNA
- Bradycardia, AV block- less common
SVTs most common and d/t hypovolemia, hypoperfusion, hypoxia, fever, pain, anxiety.
Malignant ventricular dysrhythmias are the result of QT-prolonging medications, metabolic abnormalities, and myocardial inflammation.
Malignant ventricular dysrhythmias are the result of QT-prolonging medications, metabolic abnormalities, and myocardial inflammation.
Photo by zen
Untitled Slide
Afib w/rapid vent response
What about myocarditis in children?
Diagnosis and Management of Myocarditis in Children
Circulation. Jul 2021;144:e123–e135
A Scientific Statement From the American Heart Association
This detailed review article from the AHA comes down to this: the scientific community needs to focus on a standardized definition for diagnosis of pediatric myocarditis, and then design rigorous trials to assess for therapeutic benefits of multiple treatment options. Until then, this article offers the best summary of what we do know.
Diagnosis and Management of Myocarditis in Children
Circulation. 2021 Jul 7;CIR0000000000001001.
This detailed review article from the AHA comes down to this: the scientific community needs to focus on a standardized definition for diagnosis of pediatric myocarditis, and then design rigorous trials to assess for therapeutic benefits of multiple treatment options. Until then, this article offers the best summary of what we do know.
Diagnosis and Management of Myocarditis in Children
Circulation. 2021 Jul 7;CIR0000000000001001.
Photo by nicandres
Presenting history
- Preceeding viral prodrome ~40-70%
- Arrhythmias ~10-45%
- Syncope ~4-10%
- Sudden Cardiac death ~ inestimable
Etiology: May be infectious (most likely viral, including SARS-CoV-2) or non-infectious (autoimmune, hypersensitivity, medication-induced, toxin-mediated)
Photo by Ryoji Iwata
How do kids present?
- Fatigue ~25-70%
- SOB ~35-70%
- Fever ~ 30-60%
- N/V/ABD pain ~ 30-50%
- Rhinorrhea ~ 40-45%
- Chest pain ~24-42%
- Dyspnea ~22-25%
- Cough 17-44%
- Palpitations~16%
- Diarrhea ~8%
Clinical characteristics at presentation:
Heterogenous and non-specific.
Heterogenous and non-specific.
Photo by Jeremy Bishop
Exam findings in kids
- Tachypnea ~50-60%
- Tachycardia ~30-60%
- Hepatomegaly ~ 20-50%
- Respiratory distress ~20-47%
- Murmur or gallop~20-25%
- Diminished pulses ~16-20%
- Edema ~7%
- Cyanosis ~2%
Signs at presentation
Diagnosis: Don’t be fooled by a normal WBC, ESR, or CRP.
ECG might show anything from sinus tachycardia to ischemic changes; heart block to tachyarrhythmias of supraventricular or ventricular origin.
Disposition: For any suspicion of myocarditis, admit for arrhythmia monitoring.
Diagnosis: Don’t be fooled by a normal WBC, ESR, or CRP.
ECG might show anything from sinus tachycardia to ischemic changes; heart block to tachyarrhythmias of supraventricular or ventricular origin.
Disposition: For any suspicion of myocarditis, admit for arrhythmia monitoring.
Photo by Jeremy Bishop
While pediatric myocarditis is not common, it can be deadly. A high level of suspicion and a conservative approach to management is prudent.
The presentation of myocarditis in children is heterogenous.
If you suspect it, respect it – these kids are at high risk for arrhythmia and decompensation.
An injured myocardium can still remodel slowly and become myopathic later in life. In the largest follow-up of biopsy-proven and presumed myocarditis in children, Foerster et al57 showed that 46% to 48% of patients had persistent echocardiographic systolic dysfunction, 6% to 7% died, and 17% to 19% required transplantation over a 3-year period. It is possible that in some patients with idiopathic DCM presenting in adulthood, its origin could have been undiagnosed childhood myocarditis.
If you suspect it, respect it – these kids are at high risk for arrhythmia and decompensation.
An injured myocardium can still remodel slowly and become myopathic later in life. In the largest follow-up of biopsy-proven and presumed myocarditis in children, Foerster et al57 showed that 46% to 48% of patients had persistent echocardiographic systolic dysfunction, 6% to 7% died, and 17% to 19% required transplantation over a 3-year period. It is possible that in some patients with idiopathic DCM presenting in adulthood, its origin could have been undiagnosed childhood myocarditis.
Photo by Sophia Müller
Will this change your practice?
Remember:
If it's not on your differential, you will miss the diagnosis 100% of the time. Review this article!
Have you thought about possible myocarditis with every COVID, influenza, or Lyme you diagnose?
Have you asked the right questions?
Have you performed a thorough physical exam?
If it's not on your differential, you will miss the diagnosis 100% of the time. Review this article!
Have you thought about possible myocarditis with every COVID, influenza, or Lyme you diagnose?
Have you asked the right questions?
Have you performed a thorough physical exam?
Photo by Jonnelle Yankovich
Clinically Suspected Myocarditis Temporally Related to COVID-19 Vaccination in Adolescents and Young Adults
Originally published 6 Dec 2021 https://doi.org/10.1161/CIRCULATIONAHA.121.056583
Using data from 26 pediatric medical centers across the United States and Canada, the researchers reviewed the medical records of 139 patients younger than 21 with suspected myocarditis within 1 month of receiving a COVID-19 vaccination.
Photo by Markus Grossalber
Key Observations
- Male 90%
- 91% after 2nd dose
- 2 days to symptoms
- CP 99%, fever 30%, SOB 27%
- RX: NSAIDs, IVIG, Steroids, colchicine
- 26 were admitted to ICU
- 2 needed inotropic/vasoactive support
- No one died nor required ECMO
- Median admission time- 2 days
Most cases of suspected COVID-19 vaccine-related myocarditis in people younger than 21 are mild and resolve quickly
Photo by Jeremy Bishop
What about return to play?
- When can athletes safely return to play after COVID?
- How common is silent myocarditis?
- Does it even matter?
A lot of papers over the past year.
More research is needed.
According to autopsy studies, myocarditis is associated with sudden cardiac death, especially with exercise.
The risk of sudden death may not correlate with the severity of myocardial inflammation, and sudden death has been observed even with normal systolic function after myocarditis.
More research is needed.
According to autopsy studies, myocarditis is associated with sudden cardiac death, especially with exercise.
The risk of sudden death may not correlate with the severity of myocardial inflammation, and sudden death has been observed even with normal systolic function after myocarditis.
Photo by August Phlieger
Prevalence of Clinical and Subclinical Myocarditis in Competitive Athletes w/ Recent SARS-CoV-2 Infection
JAMA Cardiol. 2021 Sep 1;6(9):1078-1087
We know COVID-19 may cause myocarditis in some patients. But what about patients with mild symptoms or no symptoms of COVID-19 infection? And what about athletes? Is it safe for them to return to competitive play after a mild bout of COVID-19? Could they still have myocarditis with no symptoms of dyspnea and a normal ECG, troponin i, and echocardiogram?
Prevalence of Clinical and Subclinical Myocarditis in Competitive Athletes w/ Recent SARS-CoV-2 Infection
JAMA Cardiol. 2021 Sep 1;6(9):1078-1087
Prevalence of Clinical and Subclinical Myocarditis in Competitive Athletes w/ Recent SARS-CoV-2 Infection
JAMA Cardiol. 2021 Sep 1;6(9):1078-1087
Photo by Instant Vantage
Findings
- The prevalence on CMR of myocarditis is 1% to 3% in athletes following positive COVID-19 test results
- The absence of symptoms in athletes with myocarditis is not necessarily reassuring
- It is unclear if abnormalities on CMR after COVID-19 represent markers for increased risk of sudden death
The absence of symptoms in athletes with myocarditis is not necessarily reassuring, because more than 50% of affected individuals in an autopsy series of proven myocarditis in athletes were asymptomatic prior to death.
As vaccinations proceed and individuals with COVID-19 become less frequent and/or ill, we can anticipate that the pretest probability of finding signs of myocarditis will become lower with time. Screening will result in a higher number of false-positive and misleading results.
The more practical and more widely available approach of testing with ECG, echocardiography, and serum troponin.
As vaccinations proceed and individuals with COVID-19 become less frequent and/or ill, we can anticipate that the pretest probability of finding signs of myocarditis will become lower with time. Screening will result in a higher number of false-positive and misleading results.
The more practical and more widely available approach of testing with ECG, echocardiography, and serum troponin.
Photo by cw_anderson
So now I have a sports PE. The patient had COVID-19. What do I do?
Return to Play for Athletes After COVID-19 Infection: The Fog Begins to Clear
https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/cli...
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Photo by Abigail Keenan
Untitled Slide
RTP algorithm
Untitled Slide
AHA 14 element screening
Summary
- ALL: AHA 14 element screening
- Already back to sports w/o sxs, normal PE- Clear
- Mild or Moderate COVID, w/sxs, abnormal PE or ECG- cardiology
- Moderate, no sxs, normal PE AND normal ECG; gradual RTP
- ASX or Mild COVID, no sxs, normal PE- may clear fully, ECG optional
Photo by Jeremy Bishop
Will this change your practice?
Remember:
If it's not on your differential, you will miss the diagnosis 100% of the time. Review this article!
Have you thought about possible myocarditis with every COVID, influenza, or Lyme you diagnose?
Have you asked the right questions?
Have you performed a thorough physical exam?
If it's not on your differential, you will miss the diagnosis 100% of the time. Review this article!
Have you thought about possible myocarditis with every COVID, influenza, or Lyme you diagnose?
Have you asked the right questions?
Have you performed a thorough physical exam?
Photo by Jonnelle Yankovich
Give me a break!
Do NSAIDs impair healing?
Photo by Richard Masoner / Cyclelicious
Do Nonsteroidal Anti-Inflammatory or COX-2 Inhibitor Drugs Increase the Nonunion or Delayed Union Rates After Fracture Surgery?: A Propensity-Score-Matched Study.
J Bone Joint Surg Am. 2021 Aug 4;103(15):1402-1410
retrospective registry-based case series study of 8,693 adult patients with upper or lower extremity fractures who were treated with any surgical intervention at the fracture site between 01/1998 and 12/2018.
the primary outcome was set as a diagnosis of “non-union” or “delayed union” at 6 to 48 months. Secondary outcome was defined as reoperation for nonunion/ delayed union.
the primary outcome was set as a diagnosis of “non-union” or “delayed union” at 6 to 48 months. Secondary outcome was defined as reoperation for nonunion/ delayed union.
Photo by Oregon State University
There was no short-term impact of NSAIDs/COX-2 inhibitors on long-bone fracture healing BUT using NSAIDs >3 weeks was associated with higher rates of non-union or delayed union
NSAID users had a significantly lower hazard of non-union compared with matched nonusers (HR 0.69 [0.48 to 0.98], 95% confidence interval), but there was no significant difference in any other matched comparison.
COX-2 inhibitors showed no significant difference among the groups with respect to medication duration.
This suggests that patients who felt more pain (and thus may have used medications longer than 3 weeks) may have been more susceptible to non-union or delayed union. It does indicate that perhaps duration of medication prescribing could be a red flag to providers that care for these patients rather than type of medication.
COX-2 inhibitors showed no significant difference among the groups with respect to medication duration.
This suggests that patients who felt more pain (and thus may have used medications longer than 3 weeks) may have been more susceptible to non-union or delayed union. It does indicate that perhaps duration of medication prescribing could be a red flag to providers that care for these patients rather than type of medication.
Photo by Dean Hochman
Will this change your practice?
Photo by Jonnelle Yankovich
Does this need a cast?
Does this need a cast?
Does this need a cast?
Torus (buckle) fractures are the most common fractures of the wrist in children, involving the distal radius and/or ulna bone.
They typically occur in children up to age 14, usually after a low energy fall. FOOSH
The flexibility of immature bone in children enables force to be absorbed as with the “crumple zone” of a car: crushing—or buckling—as it is injured.
Torus fractures result in a mild deformity without a break in the bone surface, and pain is the main clinical feature.
They typically occur in children up to age 14, usually after a low energy fall. FOOSH
The flexibility of immature bone in children enables force to be absorbed as with the “crumple zone” of a car: crushing—or buckling—as it is injured.
Torus fractures result in a mild deformity without a break in the bone surface, and pain is the main clinical feature.
What level of immobilization is necessary for treatment of torus (buckle) fractures of the distal radius in children?
BMJ 2021;372:m4862
Cochrane review included nine RCTs comprising 695 patients in studies comparing removable splints with rigid casts and 237 patients in studies comparing bandages with rigid casts.
A larger trial is underway in the UK and is due to report out in late 2021, called the FORCE trial.
A larger trial is underway in the UK and is due to report out in late 2021, called the FORCE trial.
Photo by Towfiqu barbhuiya
Findings
- Pain scores were similar with a splint or bandage vs cast, no adverse events
- Most children with torus fractures of the distal radius fully recover in 6 weeks in simple splint
- Splint immobilization and immediate discharge are recommended
- No need for follow-up
Overall, pain scores in these studies were similar with a splint or bandage vs cast, and no adverse events were noted.
The available evidence demonstrated no difference in pain, function or serious events between the different interventions used.
Editor’s comments:
The quality of evidence for rigid cast immobilization of torus wrist fractures is poor. Instead, these patients can safely be managed with either a removable splint or a bandage and no need for follow-up.
In the meantime, parents don’t seem to like the alternative of “no treatment.” A soft bandage or splint tends to be better received. In my practice setting, we now use a removable velcro wrist splint for these children. It provides immobilization, seems to improve pain, and families seem to like that it can be removed to allow hand-washing and bathing.
The available evidence demonstrated no difference in pain, function or serious events between the different interventions used.
Editor’s comments:
The quality of evidence for rigid cast immobilization of torus wrist fractures is poor. Instead, these patients can safely be managed with either a removable splint or a bandage and no need for follow-up.
In the meantime, parents don’t seem to like the alternative of “no treatment.” A soft bandage or splint tends to be better received. In my practice setting, we now use a removable velcro wrist splint for these children. It provides immobilization, seems to improve pain, and families seem to like that it can be removed to allow hand-washing and bathing.
Photo by Jeremy Bishop
Will this change your practice?
Photo by Jonnelle Yankovich
Do you Xray this?
Management and Outcomes of Children With Nursemaid's Elbow
Ann Emerg Med. 2021 Feb;77(2):154-162.
This was a retrospective review of 45 pediatric EDs over 9 years that identified 88,466 patients with a diagnosis of nursemaid’s elbow.
Photo by mliu92
with a Nursemaid's Elbow
Missed fractures are rare
Missed fractures, defined as upper extremity fracture detected within 1 week of the original encounter, were extremely rare: 247 cases (0.3%).
However, 28.5% of initial visits had an x-ray performed.
This indicates that we could likely perform radiography less often.
Nursemaid’s occurred most often in children 1-3 years of age, 85.3% of cases.
Risk factors for missed fracture
- Older than 6 yrs
- Had Xray on initial visit
- Received ibuprofen or acetaminopen at initial visit
Photo by Oleksandr Koval
Will this change your practice?
Photo by Jonnelle Yankovich
The effectiveness of intradermal sterile water injection for low back pain in the emergency department: A prospective, randomized controlled study
The American Journal of Emergency Medicine Vol 42, April 2021, p 103-109
This was a prospective RCT with 112 patients equally split into 2 groups; everyone received an IV NSAID, but the intervention group received the ISWI.
Photo by Erda Estremera
Untitled Slide
They used a 26-gauge, 0.5 inch insulin syringe to inject 0.1cc sterile water in a square pattern (each side was 3cm) around the area of maximal pain. Each injection created a small skin wheal, similar to a TB skin test.
For acute non-specific low back pain (LBP), intradermal sterile water injection (ISWI) + IV NSAID reduced pain and improved patient satisfaction vs IV NSAID alone.
At 10 min post-ISWI, the patient's pain was significantly improved, and the pain relief persisted for 24 hours (still statistically significant).
Interestingly, the authors note that this procedure has been shown effective for other painful conditions of the back, such as kidney stones and LBP from labor.
Finally, the authors state that other studies have shown less reduction in pain if the procedure was performed with sterile saline!
As for ED patient satisfaction? The ISWI group was highly satisfied 88% of the time, compared to the control group, which was highly satisfied only 16% of the time.
Interestingly, the authors note that this procedure has been shown effective for other painful conditions of the back, such as kidney stones and LBP from labor.
Finally, the authors state that other studies have shown less reduction in pain if the procedure was performed with sterile saline!
As for ED patient satisfaction? The ISWI group was highly satisfied 88% of the time, compared to the control group, which was highly satisfied only 16% of the time.
Photo by Lee Jeffs
Will this change your practice?
After reading this article, I feel like I don't actually understand anything about pain.
This is a potentially practice-changing paper for me.
This is an essentially risk-free intervention (with the exception of brief pain) with potential significant benefit
This is a potentially practice-changing paper for me.
This is an essentially risk-free intervention (with the exception of brief pain) with potential significant benefit
Photo by Jonnelle Yankovich
