Lido+Epi and other pseudoaxioms

[bulgethetwine]

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I was reading an article in Annals tonight and the accompanying editorial about lidocaine + epinepherine as a local anesthetic in digital blocks. In short summary, they contend that concerns for using epi added to lidocaine when anesthetizing digits is really an unfounded concern based on the prevailing literature. The authors refer to this as a "pseudoaxiom": A long-held belief in medical practice that really has no evidence to support it.

The authors of the editorial offer up another pseudoaxiom, the belief that administering analgesia to patients with surgical abdomens diminishes the clinical exam. (Most in EM would agree that this issue has long since been settled, but even as recently as last week, a surgical resident was upset that I had given the 32 year old with RLQ pain 4mg of morphine prior to his consult).

Alas, this thread is neither about the lido-epi debate or morphine prior to exam. Instead, can any of you think of any other "pseudoaxioms" in your clinical practice?

 

[ditch doctor]

"Sterile" technique in simple lacs and abscesses... been told by countless attendings at different hospitals that studies exist which show no difference whatsoever in outcome between sterile and non-sterile. Although, I have to admit, I still do it... and probably will as an attending....

 

[Dr.Evil1]

I don't know if it is a pseudoaxiom but the concerns about administering IV dye to people who have shellfish, fish or "iodine" allergy is just wrong. First of all you can't be allergic to iodine since it is a basic element and necessary for thyroid function. Second the above allergies are usually due to a protein found either in the shellfish or the iodine scrub. Third, most of the time "allergy" to contrast dye is actually an anaphylactoid reaction rather than a true antibody mediated allergy.

BTW As you may know there is ionic as well as non-ionic (less likely to cause anaphylactoid response) IV dyes. Both of them contain iodine.

 

[edinOH]

I too follow the clean gloves vs. sterile gloves theory on lac repair. No difference in infection rate. Why waste the sterile gloves?

I've proven time and again that beta blockade in patients with cocaine related chest pain is perfectly safe. I can't count the number of times in residency and now in practice where the patient sweared up and down and all over that they have never even seen cocaine let alone ever used the stuff when they are in the department with chest pain, tachycardia, hypertension et al and of course their screen comes back positive.

Haven't killed one yet with the theoretical "unopposed alfa".

Anyone else seen different?

 

[roja]

I was reading an article in Annals tonight and the accompanying editorial about lidocaine + epinepherine as a local anesthetic in digital blocks. In short summary, they contend that concerns for using epi added to lidocaine when anesthetizing digits is really an unfounded concern based on the prevailing literature. The authors refer to this as a "pseudoaxiom": A long-held belief in medical practice that really has no evidence to support it.

The authors of the editorial offer up another pseudoaxiom, the belief that administering analgesia to patients with surgical abdomens diminishes the clinical exam. (Most in EM would agree that this issue has long since been settled, but even as recently as last week, a surgical resident was upset that I had given the 32 year old with RLQ pain 4mg of morphine prior to his consult).

Alas, this thread is neither about the lido-epi debate or morphine prior to exam. Instead, can any of you think of any other "pseudoaxioms" in your clinical practice?

I knew there was only one person who would use "pseudoaxiams" in an article. 😎

There are many others. I will dive into the lecture I have seen and dig them up. No morphine in belly pain, antibiotics for strep throat in adults, placebo effect....

I am sure there are more....

 

[NKMU]

How about no numbing eye drops for corneal abrasions? Didn't they talk about that in a recent EMRap or EMAbstracts?

 

[Jeff698]

Although, I have to admit, I still do it... and probably will as an attending....

I do too, but only because they have a better fit and allow me to feel like I have better control. Plus, my patient's seem to like it.

Take care,
Jeff

 

[kungfufishing]

I just use this old pair of Wells Lamont work gloves, nice and broke in, give me great feedback and I figure when I pull them out of my back pocket and the patient sees all the blood, sawdust, roofing tar, and dermabond built up on em they are put at ease as I must be more experienced than I look.

 

[nocallaochicas]

how about precipitating Wernicke-Korsakoff by giving sugar before thiamine?

psuedoaxiom, old-wives tale?

 

[corpsmanUP]

Here are a few that I can think of.

Lidocaine for pre-intubation

CT before LP

Intubation for asthma should never be done and causes the physician caring for that patient to be stricken down with glaring stares and must therefore be labeled a loser for life!!! 😛 (I must be one hec of a loser as I have already had 2 astmatics who got hypercarbic and dropped before I could even summon the bipap Gods).

Bicarb to buffer lidocaine- sorry...I just don't really care since I am not a pediatrician. I have enough trouble finding the lidocaine.

Adenosine will cause wide complex to deteriorate to asytole! I have been using this stuff when I wasn't sure it was wide or aberant for a long time.

My favorite of all......don't give oxygen to COPDers because you will terminate their hypoxic drive to breath. There is ample evidence to support that there is no such monster as a hypoxic drive, and that you can safely deliver oxygen to a COPDer when needed. I just love it when the nurse comes in and asks me if I want a NC instead of a facemask in the COPDer who is gray and awaiting the BiPAP!!

 

[kungfufishing]

There is a small amount of evidence that lidocaine may be beneficial and not much to suggest it isnt. I actually just looked into this topic and after researching it decided to keep doing it until there was better evidence that it was really voodoo or was harmful. There is some more recent stuff using remifentanil for this purpose that is interesting, in that it is ultrashort acting.

Buffering lidocaine does make at least some difference and might make patients happier about their ED visit which in turn might improve their satisfaction with the job we do.

There are quite a few papers describing the limited utility of the DRE in trauma patients - even when it is "positive" i.e. blood it is often falsely positive. I still do it, but think it is a little ridiculous when other services who subsequently see the patient want to repeat it as part of "their" exam. Especially in light of all the patient movement it involves, never mind adding insult to injury.

 

[basementbeast]

lido for ICP: keep in mind that *if* it is helpful that it takes some minutes....so in the true crash intubation if it is given immediately before your sedative/paralytic that it will probably not have time to work...

 

[docB]

How about not giving morphine to chole pain? I've heard the sphincter of Odi stuff is wrong or at least not clinically significant.

 

[f_w]

BTW As you may know there is ionic as well as non-ionic (less likely to cause anaphylactoid response) IV dyes. Both of them contain iodine.

The risk of allergic/anaphylactoid reactions is IDENTICAL for ionic, non-ionic, high osmolar, low-osmolar and iso-osmolar contrast.

but:
- The risk of contrast induced nephropathy is considerably lower for low-osmolar/iso-osmolar than high-osmolar contrast agents
- The risk of nonspecific vomiting (through the rapid osmolality shift induced by ionic high-osmolar agents) is lower.
- If low-osmolar extravasates, nothing bad happens. If ionic high-osmolar extravasates you can slosh of the skin (if you are lucky) or the forearm (if your patient is unlucky).

 

[southerndoc]

The risk of allergic/anaphylactoid reactions is IDENTICAL for ionic, non-ionic, high osmolar, low-osmolar and iso-osmolar contrast.

Can you cite a source for this? This goes against what I have read and what our radiology colleagues are telling us.

 

[southerndoc]

Anyone else seen different?

I've only seen paradoxical hypertension associated with labetalol use (3:1 beta:alpha). If you give a beta blocker and the blood pressure goes up, always suspect cocaine ingestion.

I know of one case who became severely hypertensive (240+ systolic) after administration of metoprolol. He had a major SAH shortly thereafter, became unresponsive, and died. Urine tox was positive for cocaine. Which triggered the hypertensive episode and bursting of a pre-existing aneurysm? Who knows.

 

[bulgethetwine]

How about not giving morphine to chole pain? I've heard the sphincter of Odi stuff is wrong or at least not clinically significant.

I think morphine is okay. It's meperidine (I thought) that caused the Sphincter of Oddi stuff 😕

Could be wrong. Irregardless, I think this could be a pseudoaxiom, too...

BTT

 

[docB]

I think morphine is okay. It's meperidine (I thought) that caused the Sphincter of Oddi stuff 😕

Could be wrong. Irregardless, I think this could be a pseudoaxiom, too...

BTT

I think you've got it backwards (but since we trying to debunk the issue that may not be a bad thing🙂). I often see the sphincter of Odi thing used as a reason FOR using Demerol instead of morphine. For example, one radiology group I work with won't do a HIDA on anyone who has had morphine within 6 hours. They demand that those patients be on Demerol. Now I don't know anything about the rads lit or the mechanics of preforming/interpreting HIDAs but I have head that the MS doesn't cause clinical problems like increased pain by spasming the sphincter.

 

[corpsmanUP]

It's the morphine that theortically causes the sphincter of odi spasm. It's the meperidine that theoretically does not. The data regarding this is nothing but propaganda and rhetoric. Meperidine is not even used in my old ED. The surgeons are onboard with our data and agree.

At our last trauma conference we had a joint surgery/EM presentation with a debate on the issues of the utility of CXR, FAST, and DRE on every trauma patient.

The argument from the EM side of the house was that DRE's provide little other than sphincter tone, and that CXR's read by rads docs still showed missed pneumos routinely and that clinical exam should drive the CXR being ordered. The FAST is obviously a terrible test to perform on every trauma patient unless they are truly hemodynamically unstable. It's nice to practice but it's unbelievably rare to see any abnormalities in stable seeming patients.

 

[f_w]

Can you cite a source for this? This goes against what I have read and what our radiology colleagues are telling us.

I should re-phrase that: The risk of death due to contrast reactions is identical between the two groups. The risk of severe adverse effects is approx 75% lower.

e.g.
http://www.ncbi.nlm.nih.gov/sites/e...med.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

 

[f_w]

Now I don't know anything about the rads lit or the mechanics of preforming/interpreting HIDAs but I have head that the MS doesn't cause clinical problems like increased pain by spasming the sphincter.

The test is standardized for the use of morphine, that's all. It is not about hurting the patient, it is about not being able to tell whether the common duct is open.

 

[southerndoc]

I should re-phrase that: The risk of death due to contrast reactions is identical between the two groups. The risk of severe adverse effects is approx 75% lower.

e.g.
http://www.ncbi.nlm.nih.gov/sites/e...med.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

Right. That's what our radiologists state. However, they've told us that the rate of death is somewhat lower, but it is still a significant number of deaths. The rate of reactions is considerably less with non-ionic contrast agents.

 

[f_w]

Right. That's what our radiologists state. However, they've told us that the rate of death is somewhat lower, but it is still a significant number of deaths. The rate of reactions is considerably less with non-ionic contrast agents.

I am more worried about the 3% contrast induced nephropathy than the 1ppm death by anaphylaxis. Knock on wood, haven't killed anyone yet.

 

[FISKUS]

Recently attended a lecture about procedural sedation, the doc spoke alot about ketamine.

1 - there is no good research to support that ketamine is of any benefit in the treatment of asthma. There are several studys thet show that is has no real effect on overall outcomes.

2 -Ketamine and ICP effects - again, this myth is based on some really bad research from the 70s. No neurologic deteriation has ever been attributed to ketamine use in a head injury.

3 - The actual sedative and analgesic effects on the agitated CHI pt will far outweigh the very theoretical ICP and BP effects. About the only contrindication in CHI is focal neuro deficits or blown pupil

4 - The significance of Emergence Phenomona is way overblown. It is easily treated with low dose benzos

 

[f_w]

Yeah, 'Special K' for everyone !👍

(millions of cows can't be wrong)

 

[Jeff698]

Yeah, 'Special K' for everyone !👍

(millions of cows can't be wrong)

a big hell yeah from me on this.

I love this drug.

Used it several hours ago with great success. 👍

Take care,
Jeff

 

[VentdependenT]

I've only seen paradoxical hypertension associated with labetalol use (3:1 beta:alpha). If you give a beta blocker and the blood pressure goes up, always suspect cocaine ingestion.

I know of one case who became severely hypertensive (240+ systolic) after administration of metoprolol. He had a major SAH shortly thereafter, became unresponsive, and died. Urine tox was positive for cocaine. Which triggered the hypertensive episode and bursting of a pre-existing aneurysm? Who knows.

Its 7:1. Not trying to be a jerk about it. But labetolol is basically just a non-specific beta-blocker with a whiff of alpha.

BB's for cocaine toxicity are ok as long as you are prepared to treat the BP as well. NTG or Nicardipine would be my titratable drugs of choice. In fact Nicardipine alone will take care of everything.

 

[VentdependenT]

ketamine doesn't do jack squat for asthma. If anything it'll cause you to have to admit your patient for hallucinations and generalized "creepiness."

 

[southerndoc]

Its 7:1. Not trying to be a jerk about it. But labetolol is basically just a non-specific beta-blocker with a whiff of alpha.

BB's for cocaine toxicity are ok as long as you are prepared to treat the BP as well. NTG or Nicardipine would be my titratable drugs of choice. In fact Nicardipine alone will take care of everything.

Sorry, you're right. It's 7:1 with IV administration; 3:1 with oral administration.

 

[grb137]

Bicarb to buffer lidocaine- sorry...I just don't really care since I am not a pediatrician. I have enough trouble finding the lidocaine.

So buffering lidocaine doesn't reduce the pain of infiltration... because you don't care? Because you are not a pediatrician? Because you don't know where your medical supplies are kept?

😕

 

[quinsy]

Great thread.

Since I am an intern and have little time to read these 'seminal articles' you speak of, I have a question for you on pseudoaxioms.

I recently heard that the whole cross-reactivity between cephalosporins and penicillins, instead of being 30% or whatever we were taught in med school, is actually zero and there is no cross-reactivity. Is that true? I know someone here must know this.

Also, I guess we should differentiate between pseudoaxioms and things that we do that might work but have no evidence base (vs. things that we are taught as gospel which are actually proven false). I heard that cricoid pressure to prevent aspiration has no evidence base, but I don't think anyone's going to stop holding cricoid pressure. Am I right?

 

[missmod]

How about trauma patients who come in with possibly urethral injury (blood on meatus, etc)...? I don't know if there is literature that exists, but I see people put foleys in them all the time, even though you're not supposed to bc you might damage the urethra.

 

[RockfordWF]

I do too, but only because they have a better fit and allow me to feel like I have better control. Plus, my patient's seem to like it.

Take care,
Jeff

Also, the Biogel sterile gloves are thicker and less prone to needle sticks.

 

[Lukin]

I too follow the clean gloves vs. sterile gloves theory on lac repair. No difference in infection rate. Why waste the sterile gloves?

I've proven time and again that beta blockade in patients with cocaine related chest pain is perfectly safe. I can't count the number of times in residency and now in practice where the patient sweared up and down and all over that they have never even seen cocaine let alone ever used the stuff when they are in the department with chest pain, tachycardia, hypertension et al and of course their screen comes back positive.

Haven't killed one yet with the theoretical "unopposed alfa".

Anyone else seen different?

Funny you should mention this
2 nights ago I had a lady with thyrotoxicosis from Graves and I gave her propranolol. Turns out she was also doing some cocaine (she says she is an undercover agent).
didn't kill her, in fact she felt much better.
I had this conversation with my attending
unopposed alpha my ass

 

[Lukin]

how about not using antimotility agents for infections diarrhea
I heard some internal med resident say this earlier this year

I think this was based off of research done on guinea pigs in the 60's

 

[kungfufishing]

How about trauma patients who come in with possibly urethral injury (blood on meatus, etc)...? I don't know if there is literature that exists, but I see people put foleys in them all the time, even though you're not supposed to bc you might damage the urethra.

actually there is a pretty recent article or two regarding exactly this subject that suggests we probably arent doing any more damage and to go ahead and put the foley in. I dont remember where I saw it, I'd guess J Trauma.

 

[corpsmanUP]

So buffering lidocaine doesn't reduce the pain of infiltration... because you don't care? Because you are not a pediatrician? Because you don't know where your medical supplies are kept?

😕

Didn't mean to sound harsh! 😳 Just in the scheme of things, I think the small amount of pain that is produced from local anesthesia is about on the scale of starting an IV...maybe not even that painful. And we don't anesthetize IV sites in our ED I assure you. I do use the technique in the Peds/ED though because it makes the attendings happy. And my other point was that it takes long enough to track down the lido, not to add on the confusion of the bicarb (often times they bring you the amps from the crash cart instead of the vial!!)

Funny thing: I was in the Peds ED one day and was debating with a peds attending the reason for the bicarb. So we did our own blinded study on each other and injected .5cc of lido both with and without bicarb and neither of us could tell the difference in the pain.

 

[Dr. Will]

I recently heard that the whole cross-reactivity between cephalosporins and penicillins, instead of being 30% or whatever we were taught in med school, is actually zero and there is no cross-reactivity. Is that true? I know someone here must know this.

I had this very discussion with one of my attendings the other day. He stated it's about 10% cross-reactivity. He will still prescribe a cephalosporin if the reaction to pcn was just a rash, but if it was in anyway anaphylaxis in nature, he won't take that 10% chance. Most of the patients don't know what their reaction to the drug is, so I usually just look for an alternative. Although, there is a resident in our program doing some research on "true pcn allergies." I'm not entirely sure of all the details.

 

[FISKUS]

They cant protect their airway because their gag reflex is absent.

Have you ever watched a sword swallower? ( or Deep Throat)

 

[bulgethetwine]

I had this very discussion with one of my attendings the other day. He stated it's about 10% cross-reactivity. He will still prescribe a cephalosporin if the reaction to pcn was just a rash, but if it was in anyway anaphylaxis in nature, he won't take that 10% chance. Most of the patients don't know what their reaction to the drug is, so I usually just look for an alternative. Although, there is a resident in our program doing some research on "true pcn allergies." I'm not entirely sure of all the details.

.

The number I am familiar with is also 10% ... but it has been my understanding that his applies to the 1st and (possible) 2nd gen cephs. Once you're talking 3rd gen and above the rate drops to 1-3%. I'll try and dig up the data and post it.

I think this is relevant since many hospitals utilize Rocephin as the "big gun" in combo with something else, as well as the fact that rocephin is half of the broad-spectrum coverage typically started for rule out meningitis.

 

[ditch doctor]

Didn't mean to sound harsh! 😳 Just in the scheme of things, I think the small amount of pain that is produced from local anesthesia is about on the scale of starting an IV...maybe not even that painful. And we don't anesthetize IV sites in our ED I assure you. I do use the technique in the Peds/ED though because it makes the attendings happy. And my other point was that it takes long enough to track down the lido, not to add on the confusion of the bicarb (often times they bring you the amps from the crash cart instead of the vial!!)

Funny thing: I was in the Peds ED one day and was debating with a peds attending the reason for the bicarb. So we did our own blinded study on each other and injected .5cc of lido both with and without bicarb and neither of us could tell the difference in the pain.

did the same "study"... I couldn't tell the difference between the two.... what we found out was that the speed of injection more than anything that hurt. The traditional super quick "wheal" hurt like a bitch, but if you did one super slow, it didn't really hurt at all... I'm convinced... ever since I started doing my LP's with a ridiculously slow wheal I don't get as much of the dreaded jump-cry-tachylordia-please-hold-still-arch-your-back as much....

 

[RailroadMan]

Isn't it funny that we follow all of these "pseudoaxioms" of epi in the finger, etc., but most don't even use bicarb to buffer their lidocaine when it's literature proven to help pain...🙁

 

[waterski232002]

.

The number I am familiar with is also 10% ... but it has been my understanding that his applies to the 1st and (possible) 2nd gen cephs. Once you're talking 3rd gen and above the rate drops to 1-3%. I'll try and dig up the data and post it.

I think this is relevant since many hospitals utilize Rocephin as the "big gun" in combo with something else, as well as the fact that rocephin is half of the broad-spectrum coverage typically started for rule out meningitis.

Here you go... enjoy.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1070890

http://mediwire.skyscape.com/main/Default.aspx?P=Content&ArticleID=171444

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=7697478&dopt=Citation

 

[bulgethetwine]

Isn't it funny that we follow all of these "pseudoaxioms" of epi in the finger, etc., but most don't even use bicarb to buffer their lidocaine when it's literature proven to help pain...🙁

Let's pretend they're not pseudoaxioms, and they're truth:

Giving epi to finger: ischemia, necrosis, lost finger
Not buffering lido: Hurts a little more



This is why it actually isn't so "funny". Focus on the big things, not the minutiae.

 

[roja]

The epi with lido is total bubcuss in my mind. I mean, really, what is the half life of lidocaine? 2 hours, if you are really generous?


And have you ever seen a Bierr Block? http://www.nda.ox.ac.uk/wfsa/html/u01/u01_003.htm



Okay, I'm being punchy because I am tired, but although not a major deal in the grand scheme of things, it violates my educational tendencies... Ie, we probably shouldn't be reinforcing fallacies....