Common ER Myths Debunked

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Dr Peter E. Sokolove

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Commonemergencymedicinemythsdebunked

July 8, 2010

By Doug Brunk

SAN DIEGO (EGMN) Is it a myth or a fact that atropine must always begiven when using ketamine for procedural sedation in children?

Thats a myth, Dr. Peter E. Sokolove said during the annual meeting of theCalifornia chapter of the American College of Emergency Physicians.Hypersalivation with ketamine is infrequent and can be managed withsuctioning or atropine, said Dr. Sokolove, vice chair for education andresidency program director in the department ofemergencymedicine at theUniversity of California, Davis Health System. Atropine is not routinelyrequired when using ketamine for sedation in children.

The weight of the evidence comes from a prospective observational study of1,090 children who received dissociative sedation at Loma Linda (Calif.)University Medical Center and Childrens Hospital (Acad. Emerg. Med.2008;15:314-8). The researchers used a 100-mm visual analog scale tomeasure hypersalivation, with zero being the lowest rate, and recorded thefrequency of airway complications.

Of the 1,090 sedations, 947 (87%) did not require atropine and the majority of patients (92%) had a score ofzero on the visual analog scale. Only 12 (1.3%) had a visual analog score of greater than 50 mm, and 4.2%required some form of intervention, usually suctioning. One patient (0.11%) required brief desaturation fromhypersalivation,

Dr. Sokolove went on to dispel several othermythscommon in emergencymedicine:

Myth: Buckle fractures of the distal radius must be treated with a cast for several weeks. Onerandomized trial of 39 children (most aged 5-10 years) in the United Kingdom found that buckle fractures of thedistal radius are safely treated in a soft bandage (J. Pediatr. Orthop. 2005;25:322-5). The researchersrandomized the children to a soft bandage or to a case for 4 weeks. The soft bandage consisted of orthopedicwool, cotton crepe, and tape.

At 4 weeks, children in the soft-bandage group reported less pain overall, had a shorter duration of injury, anddisplayed significantly better range of motion (162 degrees vs. 126 degrees in the cast group).

In a separate study, Canadian researchers randomized 113 children (aged 6 -15 years) with wrist bucklefractures to either a cast or a plaster volar splint for 3 weeks (Pediatrics 2006;117:691-7). Children in the volarsplint group were instructed to remove the splint as desired for activities of daily living such as bathing, butwere asked to refrain from contact sports.

The researchers followed the children via weekly telephone calls for 4 weeks and assessed their physicalfunction using the Activities Scale for Kids, a self-report measure (www.activitiesscaleforkids.com).

Children in the splint group had better Activities Scale for Kids scores at 2 weeks, compared with theircounterparts in the cast group. They also reported less difficulty bathing, had no increase in pain, and had novisits to the emergency department for splint problems (11% of children in the cast group visited the ED for castproblems). Buckle fractures of the distal radius may have a better outcome when treated with a soft bandageinstead of a cast, Dr. Sokolove commented. A removable plaster splint is a reasonable alternative to a cast.From a practical standpoint, it really depends on the patient and his or her level of activity, and the parentslevel of anxiety.


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Myth: Mist therapy is a useful first-line treatment for children with croup in the ED. In a trial of 71children (aged 3 months to 6 years) who presented with moderate croup, researchers randomized the childrento receive the mist stick (humidified oxygen) or nothing. All patients received dexamethasone. Racemicepinephrine or budesonide was administered at the physicians discretion (Acad. Emerg. Med. 2002;9:873-9).

Over a period of 2 hours, there were no differences between the two groups in croup score, oxygen saturation,heart rate, or respiratory rate. The mist made zero difference for these patients, Dr. Sokolove said.

In a separate study, Canadian researchers randomized 142 children (aged 3 months to 10 years) with moderateto severe croup to receive 30 minutes of treatment with blow-by mist, controlled delivery of 40% humidity, ordelivery of 100% humidity with 6.2 mcm particles (JAMA 2006;295:1274-80).

No significant differences were observed among the three groups at 30 minutes or 60 minutes in terms of croupscore, oxygen saturation, heart rate, respiratory rate, use of steroids, or rate of hospital admission. This doesnttell us about kids with mild croup, Dr. Sokolove noted. Maybe it does work for those kids; it doesnt hurt to try.

Myth: Pelvic ultrasounds will be inadequate unless the patient has a full bladder. In a 1-month study of206 consecutive patients, Dr. Beryl R. Benacerraf of the department of obstetrics and gynecology atMassachusetts General Hospital, Boston, and her associates found that transvaginal ultrasound alone wassufficient to detect findings in 172 patients (83.5%), transvaginal and transabdominal scans through an emptybladder were required for 31 patients (15%), and only 3 patients (1.5%) required a full bladder to visualize one

ovary each (J. Ultrasound Med. 2000;19:237-41).

Overfilling [the bladder] can give false positives and false negatives, Dr. Sokolove added. And of course, itsmore uncomfortable. Pelvic ultrasounds rarely require a full bladder.

Myth: Response to antacids and nitroglycerin can help with the diagnosis of acute coronarysyndromes. A review of published articles on the topic discussed one small study of 46 patients with acutemyocardial infarction (Emerg. Med. J. 2003;20:170-1). Nearly half of the patients (45%) had pain consistent withindigestion, and use of antacids relieved pain in 29% of cases. That is the same number we see for placebo inall sorts of pain trials, Dr. Sokolove said. About 30% of patients in pain trials get better with placebo.

In a later prospective study of 664 patients who presented to the ED with chest pain, researchers used an 11-point numeric descriptive scale for pain after the initial dose of nitroglycerin (Ann. Emerg. Med. 2005;45:581-5).

They defined cardiac-related pain as chest pain in a patient discharged with a diagnosis of myocardial infarctionor with coronary artery disease based on a positive diagnostic test.

Cardiac-related etiology was identified in 122 patients (18%). In the overall patient population, 125 (19%)patients had no change in pain, 206 (31%) patients had minimal reduction, 145 (22%) patients had moderatereduction, and 188 (28%) patients had significant or complete reduction in pain. The researchers detected nosignificant difference in any subgroup of numeric descriptive scale response to sublingual nitroglycerinadministration in patients with and without a diagnosis of cardiac chest pain.

Your response to antacids and nitroglycerin does not predict ischemic chest pain, Dr. Sokolove said. Thesemedications are treatments, not diagnostic tools. Thats the key point.

Dr. Sokolove said that he had no relevant financial conflicts to disclose.

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Common ER Myths Debunked