August 2015 REBELCast

17 Aug
August 17, 2015

August 2015 REBELCastWelcome to the August 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics. First topic: renal colic. Renal colic is a commonly seen condition encountered in emergency departments and the use of medical expulsive therapy (MET) is commonly recommended by our urology colleagues. Proponents of MET in the treatment of ureteric colic advocate for them due to their potential ability to increase stone passage, reduce pain medication use, and reduce urologic interventions. Second topic: pediatric weights. In pediatric resuscitations many of use the Broselow tape to predict weights for dosing of medications.  With the increasing weights in pediatric patients seen in developed countries around the world, does the commonly used Broselow tape accurately predict weights?   So with that introduction today we are going to specifically tackle:

Topic #1: MET for Renal Colic
Topic #2: Use of the Broselow Tape to Estimate Pediatric Weights

August 2015 REBELCast Podcast

Click here for Direct Download of Podcast

Topic #1: MET for Renal Colic

  • Question #1: In renal colic, does MET facilitate an increase in the rate of stone passage?
  • Article #1: Pickard R et al. Medical expulsive therapy in adults with urteric colic: a multicenter, randomized, placebo-controlled trial. Lancet 2015. (25998582)
  • Background #1: Ureteric (renal) colic is a common, painful condition encountered in the Emergency Department (ED). Sustained contraction of smooth muscle in the ureter as a kidney stone passes the length of the ureter leads to pain. The majority of stones will pass spontaneously (i.e. without urologic intervention). For over a decade, calcium channel blockers (i.e. nifedipine) and, more commonly, alpha adrenoreceptor antagonists (i.e. tamsulosin) have been employed in the treatment of ureteric colic for their potential ability to increase stone passage, reduce pain medication use and reduce urologic interventions. The physiologic basis for treatment with these agents is that they reduce spasm. The use of these medications was based on poor methodologic studies and meta-analyses of these flawed studies. A number of randomized trials performed over the last 6 years have not been as supportive. However, these studies were small and had flaws of their own. The question of whether medical expulsion therapy (MET) is beneficial remains.
  • What They Did #1:
    • Randomized 1136 patients to one of three arms: placebo, once daily nifedipine (30 mg) or once daily tamsulosin (400 mcg).
    • Multicenter, double-blind, placebo controlled
  • Bottom Line #1: MET does not appear to facilitate the passage of kidney stones and should not empirically be used in most patients with ureteric colic. This paper is strong evidence that we should not use tamsulosin or nifedipine in the vast majority of renal colic patients.

Topic #2: Use of the Broselow Tape to Estimate Pediatric Weights

  • Question #2: In the era of epidemic obesity in children, is the Broselow Tape (BT) still a reliable tool to estimate the weight of children?
  • Article #2: Milne WK et al. Ontario children have outgrown the Broselow tape. CJEM 2012; 14(1): 25-30. (22417954)
  • Background #2: In pediatric emergencies and resuscitation it is important to have an accurate estimate of a child’s weight. Many including myself, use the Broselow Tape (BT), which was developed in the late 1980s, to help with drug dosages and equipment size.   More than 30 years later the World Health Organization referred to obesity as a global pandemic. In Canada research has shown that the rates of obesity and overweight children has more than doubled in recent decades with more than one in three children considered overweight or obese. In light of the increasing obesity rates, the BT may actually underestimate children’s weight and more importantly has not been revalidated in light of the childhood obesity epidemic.
  • What They Did #2:
    • Prospective observation cohort study including 6,361 children in Ontario, Canada.
    • Compared actual weights vs. weight estimates using BT (2002A)
  • Bottom Line #2: The Broselow tape remains a good estimate of weight in pediatric patients, but it is just that, an estimate. With the growing population of overweight and obese children, there is a very real chance the BT will underestimate the actual weight. This has the potential for clinical consequences, such as under dosing of medications and using equipment that is too small.

For More Details of the above Studies Checkout the August 2015 REBELCast Show Notes

For more on what others thought on these topics checkout:

MET for Renal Colic

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

Bibliography

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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of R.E.B.E.L. EM
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