Emergency Medicine in the NEJM

You know, I like the new New England Journal of Medicine web design, but some of their recent EM-related reviews and summaries have driven me crazy.

Let’s start with Acute Pulmonary Embolism, which I view as a pretty good emergency medicine topic. We’re obviously not the only physicians who evaluate patients for pulmonary embolism, but we’re pretty much the only ones that evaluate outpatients for them. Maybe it’s just specialty pride (and lack of understanding of the Italian health care system), but it seems strange to have a review on “Acute Pulmonary Embolism” written by physicians who hail from the “Internal and Cardiovascular Medicine and Stroke Unit” in Italy. (Especially when Harvard itself has its own PE expert, Chris Kabrhel.)

A couple things rub me the wrong way (and luckily, the comments to the journal say similar things):

  • There’s no mention of the PERC rule. The authors presume anyone who is short of breath without any other identifiable cause should get a D-Dimer, which, based on the number of short of breath patients I have, would increase my CT angiograms exponentially. (In a patient with pre-test probability less than 15%, the PERC can get your patient down to a <2% risk of PE.)
  • It’s surprising to me that there’s discussion of the data on thrombolysis and thrombectomy but that no high-quality data exists in favor of anticoagulation. Sure, there’s ethical issues (“it’s the standard of care”), but I think it’s at least worth mentioning.
  • Finally, fondaparinux is thrown into the treatment mix prominently (“subcutaneous low-molecular-weight heparin or fondaparinux or intravenous unfractionated heparin”) and I’m not completely sure why. Perhaps it’s used much more in Europe than in the US (I have never ordered it here in my community hospital in New York). Also concerning is the fact that the lead author, Giancarlo Agnelli, was both advisor/consultant and member of the Speaker’s Bureau of GlaxoSmithKline, maker of fondaparinux. This is not mentioned in his disclosures.

Next up is Emergency Treatment of Asthma, which, even more than PE, is the bread and butter of Emergency Medicine. Again, it’s not written by an emergency physician, but by Dr. Lazarus from UCSF’s Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute. Just seems a bit strange that “Emergency Treatment of Asthma” is written by a pulmonologist, when their population bias is probably either the intubated asthmatic or the outpatient asthmatic, but not the range of “acute asthma” we see in the ED.

  • First is FEV1/peak flow. I know some of my colleagues like to use this for their asthmatics, but I personally don’t. I find that I can typically see which way my asthmatics are going just by listening to them, looking at them, and speaking to them. That is: clinically.
  • Second is the workup:

    Laboratory and imaging studies should be performed selectively, to assess patients for impending respiratory failure (e.g., by measuring the partial pressure of arterial carbon dioxide [PaCO2]), suspected pneumonia (e.g., by obtaining a complete blood count or a chest radiograph), or certain coexisting conditions such as heart disease (e.g., by obtaining an electrocardiogram).

    Where to start: who is still getting ABGs on these patients for hypercapnia? Obviously in the intubated asthmatic, or the asthmatic who looks like they’re tiring out or getting sleepy, but an arterial stick is nowhere near my list of priorities for a tight asthmatic. Next up: the chest x-ray. I typically only get it when the patient is not improving (“maybe it’s not asthma”) or the story is concerning for pneumonia. I won’t even mention getting a CBC to evaluate for suspected pneumonia.)

  • I can’t even believe this is really in the table in the New England Journal of Medicine, but it actually suggests that we should be measuring for pulsus paradoxicus to determine who’s a severe asthmatic. If someone could explain this to me, I’d really like to understand its usefulness.
  • I’m also unsure as to why inhaled steroids are recommended in this article, when the Cochrane Review did not find any benefit to these (and the Cochrane review includes the cited paper).
  • Next, the paper recommends reassessing the patient after an hour of treatment. In my severe asthmatics, this would get many of them intubated.
  • Finally, IV magnesium is discussed as an area of uncertainty, but I will typically give it to any severe asthmatic. In subgroup analysis of severe asthmatics, it was beneficial at preventing admission. I find I’m typically throwing the kitchen sink at the bad asthmatic (including BiPAP, occasionally terbutaline) to prevent them from getting intubated.
  • In summary: New England Journal of Medicine: either cover the diseases emergency physicians see adequately, or I’ll just keep reading our own journals instead.

  1. #1 by Dr. J - December 11th, 2010 at 16:53

    On the one hand I am a little surprised and dismayed that diagnoses that are central to emergency medicine are not reviewed by emergency doctors. On the other hand the NEJM reviews are usually far more ‘expert opinion’ than factual. The fact that these 2 are so poorly done and done by non-emergency doctors allows me the privilege to totally ignore the articles without any concern what-so-ever that I have failed to recognize something relevant to the standard of care for asthma or PE in the ED.

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