Andy Neill

EM Reg/Resident based near Dublin. Former anatomy lecturer, theology student and occasional musician @andyneill | + Andy Neill | Contact
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About Andy Neill

EM Reg/Resident based near Dublin. Former anatomy lecturer, theology student and occasional musician @andyneill | + Andy Neill | Contact

Approach to the IDU in the ED from the CFN

[Featured Image: Creative Commons, danielleellis55 on Flickr.]

First off here’s a video I recorded for the CEM FOAMed network on “approach to the injecting drug user“. Be sure to subscribe on iTunes and check out the site. There’s a podcast feed and a blog feed, so be sure to get both.

CEM FOAMed widget

[Direct Download ]]

 

Injecting Drug User (IDUs) are frequent attenders at EDs for lots of reasons. While there is no doubt that there are a lot of social factors involved in these attendances, we can all too easily forget that these patients get really sick and often get left in the bottom of the queue of patients waiting to be seen. I think “the approach to the IDU” would make a great chapter for Rosen’s but it’s not in there yet. Harwood Nuss is the only one I’ve seen with a good chapter on it.

Complications of injection drug use

Hardwood-Nuss 5th edition p1398

I find this population of patients perhaps the most fascinating to treat. Generally ostracised by society in the way homeless people usually are.  Usually undertriaged at the front door (“just another junkie”) I frequently find them in the waiting room with fairly dramatic vital signs. Without doubt injection drug use is usually not compatible with a stable and productive lifestyle and low grade criminality abounds. Certain aspects of the doctor patient relationship can be challenging here but they aren’t always drug seeking the way we expect they are.

And if your waiting room is anything like mine by the time they’ve waited 12 hrs to be seen then they’ve usually gone into withdrawal and it’s easy to blame all their symptoms and abnormal vital signs on withdrawal (even though their symptoms and abnormal vital signs all occurred prior to their withdrawal…)

All this to say that we approach them with so many cognitive biases and good old fashioned prejudices that it’s no wonder we fail to diagnose lots of the really interesting illnesses they bring with them.

Soft tissue infections

  • Probably higher incidence of MRSA
  • Most tentanus and wound botulism these days is associated with IDU
  • Necrotising fascitis is a much higher risk
  • Pyomyositis is a nice complication

Vascular

  • DVT
  • Arteriovenous malformations
  • Pseudo aneurysm
    • Here’s a quote “any mass over a vascular territory may actually be a pseudo aneurysm and should be approached with caution”
    • I know a number of people with great stories of enthusiastic junior surgeons incising and draining these with impressive and unexpected results
  • Associated abscess
  • All 4 of the above in the same leg as I saw once…
  • Those lovely cutaneous groin sinuses that descend to dear knows where.
  • Mycotic aneurysms, typically with infectious endocarditis

 Pulmonary

  • ‘Pocket shooting': injecting into the supraclvaicular space in the hope of finding a vessel. Can result in pneumo, haemo, hydropneumo and the wonderfully titled pyopneumothorax
  • Dissolving tablets and injecting them can result in what I’ve heard called trash lung or talc lung. [Check out BroomeDocs podcast with @dreapadoirtas on this]
    • This can cause granulomas in the pulmonary and even retinal vasculature (in fact looking at the retinas for talc might be better CXR or pulmonary function tests)
    • Restrictive and obstructive dysfunction can occur. I suspect this is commoner than we suspect. I see a lot of IDUs with lowish sats and it gets blamed on something like COPD from smoking.
    • Chronic pulmonary hypertension can result

 Skeletal

  • Osteomyelitis and septic arthritis can be local or haematogenous
  • Commonest is vertebral osteomyelitis usually lumbar which may have associated disc it is with or without the even more emergent spinal epidural abscess
    • Pain is often chronic (as has been in the cases I have seen)
    • Don’t expect fever (unless you’re the admitting doctor in which case it can’t possibly be vertebral osteo without a fever…)
  • Joint involvement is axial. Think sacroiliac, sternoclavicular, hip and pubic symphysis. (Mainly fibro cartilaginous joints if you’re into the anatomy of it all)
    • This is really important as no one will consider septic arthritis in someone with tender central chest pain.

Central nervous system

  • Meningitis both fungal and bacterial
  • Various sites for epidural abscesses
  • Brain abscesses
  • CNS aspergillosis
  • Cerebral murcomycosis (even when HIV negative)
    • Headache, fever, cranial and motor deficits
    • Apparently basal ganglia lesions on CT are the key

 Fungal endophthalmitis

  • Decreased acuity, eye pain
  • White vitreal exudate on fundoscopy

Blood Born Viruses

  • Hep C (almost ubiquitous amongst IDU. >80% in our population)
  • Hep B (up to 80% become seropositive over lifetime)
  • HIV (about 10% in our local population)

Endocarditis

  • (lifetime incidence of 5%)
  • Classic signs are rare
  • Mainly right sided

Cotton fever

  • A brief, febrile episode following injection when the solution is filtered through cotton balls
  • No way to distinguish this in the ED from the other more serious occult causes of fever in the IDU

It might be easier is to think about common clinical presentations and then apply appropriate IDU pathologies

IDU with stroke

  • Brain abscess
  • Subdural empyema
  • Botulism
  • Mycotic aneurysms
  • Good old fashioned stroke

Groin pain

  • Abscess
  • AV fistula
  • DVT
  • Pseudo aneurysm
  • And I suppose it could be just a hernia

Chest pain

  • Pneumonia
  • PE (esp in groin injectors)
  • ACS (chronic inflammatory states like HIV lead to accelerated atherosclerosis. Never mind the cocaine use)
  • Sternal joint osteomyelitis

Headache

  • Brain abscess
  • Meningitis
  • SAH (remember all the cocaine use that goes with the heroin)
  • Complications of associated HIV
    • Toxoplasmosis
    • Lymphoma
  • And yes it could just be a migraine too i suppose…

 Back pain

  • Epidural abscess
  • Discitis
  • Vertebral osteomyelitis
  • And yes it could just be good old fashioned back pain too I suppose

Fever

  • Endocarditis
  • Meningitis
  • Osteomyelitis
  • Cotton fever
  • HIV related
  • TB (a lot of these guys are homeless and in Dublin anyhow there are reasonably high rates of TB amongst the homeless)
  • Haematological malignancy
  • And yes I suppose it could just be a flu or the dreaded ‘viral illness’

Shortness of breath

  • PE
  • Talcosis or trash lung
  • Chronic pulmonary hypertension
  • Pneumothorax from trying to inject a neck vein
  • Aspiration from their recent OD, GCS 3 episode
  • And yes I suppose it could be a good old fashioned chest infection too

Cellulitis in IDU

  • necrotising fasciitis
  • Pyomyositis
  • Subcutaneous abscess
  • And yes I suppose it could be a simple staph or strep cellulitis

 

References/FOAMed Resources:

  •  Nice EM News Post on the febrile IDU
  • Hardwood-Nuss 5th edition p1398
  • A paper from our place characterising our population

RCT of ED Renal Ultrasound for renal colic

The Trial

Smith-Bindman R, Aubin C, Bailitz J, Bengiamin RN, Camargo CA Jr., Corbo J, et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. N Engl J Med. 2014 Sep 18;371(12):1100–10. 

They managed to come up with the STONE trial as acronym for this one. [Study of Tomography Of Nephrolithiasis Evaluation]

This is big news for USS, as it’s an RCT of the use of ED US use. Ultrasound, of course, makes sense to lots of us who see the probe as some sort of prehensile extension of the human body able to go forth and grasp the diagnosis. Still it’s nice to have some data to help us better understand how it helps our practice.

Here’s the details as I read them.

METHODS

  • multi centre randomised trial. All good so far
  • Randomisation could have been better described I thought
  • 3 Groups
    • ED performed US by an EP credentialed in US – unclear if these were US super users or just regular punters with basic level US skills
    • Radiology perfromed US
    • CT
  • The first major concern is in the lack of blinding. Though it’s hard to see how you could blind this.
  • the ultimate decisions on imaging and disposal after the randomised imaging were down to the EP looking after the pt. So people afer US could go on to have CT if this was felt to be needed
  • Unclear if the EP looking after the doc was also looking after the patient
  • 3 Primary outcomes (which is a tad naughty. The prmary outcome should of course be, primary I would have thought)
    • “high-risk diagnoses with complications that could be re- lated to missed or delayed diagnoses”. The obvious one here might be a missed AAA for example. the missed pathology was pre defined and categorised by a number of the authors all independent of each other.
    • cumulative radiation exposure (does imaging beget imaging)
    • total costs (which I presume is for a different paper, as it’s not reported here)
  • follow up was by repeated phone calls and a structured interview
  • diagnostic accuracy was a secondary outcome but the gold standard here was the patient reporting stone passage or surgical removal. This is important as most people consider CT as the gold standard but as this is one of the modalities being assessed it would be “incorporation bias”  to include CT in the gold standard

RESULTS

  • screened 3700, took 2700
  • 3-5% lost to follow up which may be a problem – is the reason they didn’t answer the phone at follow up due to the fact they were dead? The reassuring thing is that lost to follow up was similar between groups
  • 40% in this trial had a prior history of stone
  • most were youngish and the most of the time the doc had a >50% pre-test probability of stone. Which is common – stones are usually obvious and most CTs we do for stone are positive, at least in my experience anyhow
  • only 8% were admitted from the ED. This is amazing to me as we admit almost all our query stones. Either because we can’t get a CT at 3am for a stone (let’s face it the priority is pain control not diagnosis here) or because we need to get them a urologist (who only have a weekday service in our place). Our admissions are short but still, it’s nice to see that it is more than possible to manage these as out patients in a less dysfunctional system than ours in Ireland.
  • Primary outcomes
    • the missed high risk diagnoses were tiny (you have to look in the supplementary appendix for this
      • ED US – 6. One bowel obstruction but mainly people returning with infections
      • Rad US – 3  – one missed ovarian torsion and the others infective
      • CT – 2 – infective complicatons
      • All of these were less than 1% and of course when the numbers are this tiny, there’s no statistical difference between them. Worth noting that the infective complications are going to be there no matter what you do, no imaging is going to be definitive for pyelo most of the time.
  • There was significantly less radiation in both US groups. Which is hardly surprising. The excess radiaiton in the CT group was all due to the index CT and not lots of follow up CTs thankfully.
  • One of the most interesting things to me was the accuracy of all 3 tests. Remember that the gold standard here was stone passage of surgery. All 3 tests had identical sens/spec. Sensitivity of 85% and spec of 50%.
  • 40% of those in the ED US group went on to have a CT anyhow at the docs discretion. 27% of the rad group went on to have CT. Again, this is hardly surprising. People simply don’t trust US and most urologists want a CT, I know ours do. Despite the fact that even their guidelines suggest US as the investigation of choice if available.

THOUGHTS

  • This is a great effort and a substantial trial. As we probably already knew, EP performed US appears safe and accurate when we pose a focused question. There will always be misses but the numbers here are tiny and are more clinical judgement related than imaging related.
  • The issue will be dealing with the specialists who may not be able, or willing to deal with just the US. I don’t say that to be critical, there may be lots of good reasons to pursue further imaging, but there doesn’t seem to be much need for the young, uncomplicated, clinically typical stone.

Finally, the entire study protocol is available as a PDF of supplementary material on the NEJM site and is a fascinating insight into the background of putting together an RCT and the sheer volume of work required for it.

Want more renal ultrasound:

Exit Block: What it is and why it’s dangerous.

This a great video from the college on the significance of exit block and the effects it’s having on our patients and staff. This, along with the recruitment crisis is, I think the biggest issue facing emergency medicine in both Ireland and the UK.

Well worth a watch.

[H/T Simon Carley for the orignial tweet where i saw this]

Recent controversies in sepsis

Below is a recent talk I prepared for a teaching meeting for the ICU and ED staff. Unfortunately I was still on my train when I was due to give it so here it is online instead.


References:

  • Annane D. Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock. JAMA. 2013 Nov 6;310(17):1809.
  • Brown SGA. Fluid resuscitation for people with sepsis. BMJ (Clinical research ed). BMJ Publishing Group Ltd; 2014 Jul 22;349(jul22 16):g4611–1.
  • SMACC Podcast: Myburgh: Fluid Resuscitation: Which, When and How Much?
  • EMCrit Podcast: Marik: Fluids in Sepsis
  • EMCrit Podcast: Angus on Process
  • Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008 Jul;134(1):172-8. doi: 10.1378/chest.07-2331. Review. PubMedPMID: 18628220.
  • Marik PE. Iatrogenic salt water drowning and the hazards of a high central venous pressure. 2014 Jun 24;:1–9. [free pdf]
  • Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368–77.
  • Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA. Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial. JAMA. 2010 Feb 24;303(8):739–46.
  • Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis Campaign Guidelines Committee2012. Crit Care Med.2013 Feb;41(2):580-637. doi: 10.1097/CCM.0b013e31827e83af. PubMed PMID: 23353941.
  • The ProCESS Investigators. A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med. 2014 Mar 18;:140325070040003.
  • Kaukonen K-M, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality Related to Severe Sepsis and Septic Shock Among Critically Ill Patients in Australia and New Zealand, 2000-2012. JAMA. American Medical Association; 2014 Apr 2;311(13):1308–16.
  • Marik PE. Early Management of Severe Sepsis. Chest. American College of Chest Physicians; 2014 Jun 1;145(6):1407–18.

CEM FOAMed network

CFN Logo

The College of Emergency Medicine is the body responsible for training all the wonderful UK emergency medicine trainees and represents the speciality in the UK. The trainees in Ireland do the UK exams so the specialties in both countries have a fairly close relationship.

The college’s main online educational presence in recent years has been the ENLIGHTENme platform. There’s been some good stuff on there but it’s behind a log in and not immediately accessible in the way FOAMed resources have been.

With the rise of FOAMed and it’s influence on education of emergency physicians, it’s only natural that the college would want to embrace the idea.

Simon Laing (of the HEFT EM Podcast) is the college lead for this and he has been involved in recruiting people from the different regions of the UK and Ireland to provide FOAMed resources. Ultimately the goal is to ‘map’ the college curriculum. Somewhat similar to my own little anatomy project but on a much broader scale.

The UK exams for emergency medicine are a different beast to the Aus/NZ ones so it’s a natural that there’ll be a need for some more specifically directed resources.

The CEM FOAMed Network (rejoicing in the acronym CFN) is a project in development. The website is in the pipeline and the introductory podcast is now live on iTunes.

Please check it out and look out for more FOAMed resources in the near future.

Conflicts

  • I am the regional lead for Ireland for the project
  • The college was kind enough to provide me some small amount of funds for a microphone.