Articles of the month (November 2015)

A monthly collection of the most interesting emergency medical literature I have encountered.

Here is this month’s summary of my favorite reads from the medical literature…

Bronchiolitis – it will take your breath away

Willwerth BM, Harper MB, Greenes DS. Identifying hospitalized infants who have bronchiolitis and are at high risk for apnea. Ann Emerg Med. 2006;48:(4)441-7. PMID: 16997681

Its that time of year. Some children are beginning to hold their breath in anticipation of Christmas. Or, maybe that was an apneic spell from bronchiolitis? Which children are at risk? This is a retrospective cohort of 691 children less than 6 months old who were admitted to the hospital for bronchiolitis looking at risk factors associated with apnea. The authors found that full term babies less than 1 month old, preterm babies less than 48 weeks post-conception, and babies whose caregivers had already witnessed an apnea spell were at higher risk for further apnea spells. Overall 19 (2.5% 95%CI 1.7-4.3) children had apnea spells while admitted, and all 19 met one of the criteria above.

Bottom line: 2.5% is relatively low risk, but breathing is relatively important. I would have the pediatricians review the kids that fall into these categories.

More bronchiolitis and the need for oxygen

Cunningham S, Rodriguez A, Adams T. Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. Lancet (London, England). 386(9998):1041-8. 2015. PMID: 26382998

This is a multi-center, randomized, controlled trial of children aged 6 weeks to 12 months admitted to hospital with bronchiolitis. This children were either placed on a standard sat probe or one that was altered so that a sat of 90% would display as 94%. Staff were instructed to provide oxygen to any child with a sat less than 94%. (94% seems like a pretty high target. I am more interested in whether we should be starting oxygen at say 92% or 88% or even lower.) I think they chose a pretty poor primary outcome: time to resolution of cough. For what it’s worth, it was equivalent, but did we really think oxygen could cure cough? Some secondary outcomes were also not affected, but none capture why I give oxygen. Oxygen is given when children are approaching the steep portion of the oxygen-hemoglobin dissociation curve to prevent precipitous drops, desaturations, and bad outcomes. The authors do report no change in ‘adverse events’, but if you look at the supplement, respiratory adverse events were things like cough and otitis media. Although I believe we probably over-treat bronchiolitis, this is another in a slew of papers that fails to actually prove that it is safe to withhold oxygen or discharge patients with low oxygen saturations.

Bottom line: Oxygen saturation is still an important parameter to monitor in bronchiolitis. We don’t know the ideal saturation to target.  

Children inhaling salt water – no, not drowning, but bronchiolitis treatment

Silver AH, Esteban-Cruciani N, Azzarone G. 3% Hypertonic Saline Versus Normal Saline in Inpatient Bronchiolitis: A Randomized Controlled Trial. Pediatrics. 2015. PMID: 26553190

This is a randomized, double-blind, controlled trial from a single pediatric hospital comparing 4 ml of either 3% saline or 0.9% saline nebulized every 4 hours in 227 children under 12 months old with bronchiolitis. There was no difference in any of the many outcomes they measured, including length of stay, ICU admission, readmission, and objective respiratory findings. Of course, it’s possible that normal saline is more therapeutic than no treatment – but, come on, you know that nothing works in bronchiolitis.

Bottom line: No treatments work in bronchiolitis. Do you think we will ever come to terms with that?

It might just be the season, but it seems like I am obsessed with wheezing kids

Cronin JJ, McCoy S, Kennedy U. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Annals of emergency medicine. 2015. PMID: 26460983

I have covered dexamethasone versus prednisone for asthma before, but here is another RCT. In 245 pediatric patients (aged 2-16) with asthma, they compared a single dose of dexamethasone (0.3mg/kg) to prednisolone (1mg/kg) for 3 days. Their primary outcome was a PRAM score on day 4 and there was no difference between the two.

Bottom line: I will continue using the easier single dose dexamethasone over prednisone.

More shots fired in the continuing Roc versus Sux RSI battle

Tran DT, Newton EK, Mount VA, Lee JS, Wells GA, Perry JJ. Rocuronium versus succinylcholine for rapid sequence induction intubation. The Cochrane database of systematic reviews. 10:CD002788. 2015. PMID: 26512948

This one is going to ruffle a few feathers. Let’s start with the author’s conclusions: “Succinylcholine created superior intubation conditions to rocuronium in achieving excellent and clinically acceptable intubating conditions.” This is a cochrane review that includes 50 trials covering 4151 patients. For “excellent intubating conditions” succinylcholine was superior to rocuronium (RR 0.86 95%CI 0.81-0.92). The problem with this conclusion is the significant heterogeneity in the included studies. For me, the biggest concern is varying doses. In fact, the authors even conclude that if you use 1.2mg/kg of rocuronium (the appropriate dose for RSI) there was no difference between roc and sux. Unfortunately, they make the erroneous conclusion that sux is still better because it has a shorter duration of paralysis. In emergent airways, short paralysis is not a good thing.

Bottom line: Ignore the conclusions, rocuronium at a proper dose (1.2mg/kg) is a great paralytic for RSI.

One of my favorite myths to rant about – and apparently some very smart people out there agree with me

Swaminathan A, Otterness K, Milne K, Rezaie S. The Safety of Topical Anesthetics in the Treatment of Corneal Abrasions: A Review. The Journal of emergency medicine. 49(5):810-5. 2015. 26281814

I spoke about topical anesthetics for corneal abrasions at rounds earlier this year. (My handout from that talk can be found here.) This is a systematic review looking at the same topic. They identify 2 emergency department studies and 4 ophthalmology studies (after a procedure called photorefractive keratectomy – essentially a iatrogenic corneal abrasion) that prospectively evaluated the use of topical anesthetics for corneal abrasions.  All the studies were small. Topical anesthetics resulted in no complications. Overall, topical anesthetics appear to be effective, with clinically and statistically significant pain score reduction in 5 of 6 studies.

Bottom line: Treat your patient’s pain. A short course of topical anesthetic is probably safe and almost certainly effective for corneal abrasions.

Acute HIV – a diagnosis I am probably missing

Rosenberg ES, Caliendo AM, Walker BD. Acute HIV infection among patients tested for mononucleosis. The New England journal of medicine. 340(12):969. 1999. PMID: 10094651 [free full text]

Early HIV infection presents as a mononucleosis-like infection, making it very difficult to diagnose. Although I generally dislike using the emergency department for public health screening, if HIV is not diagnosed during this initial stage, many years may pass before it is diagnosed, not only hurting the patient, but also putting their many contacts at risk. This is a letter to the editor describing a study where they retrospectively took all blood samples that were sent for epstein barr virus at Massachusetts General Hospital and tested them for HIV RNA. They found that 1.2% (7/563) has an acute HIV infection and another 0.8% (4/563) had chronic HIV.

Bottom line: This is well above the threshold for screening for HIV. Perhaps monospot and HIV testing should be paired?

1 more: Non specific viral illness or acute HIV?

Pincus JM, Crosby SS, Losina E, King ER, LaBelle C, Freedberg KA. Acute human immunodeficiency virus infection in patients presenting to an urban urgent care center. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 37(12):1699-704. 2003. PMID: 14689354 [free full text]

Sticking with the same topic, these authors tested all patients presenting with viral symptoms and 1 or more HIV risk factors at their urban urgent care centre for HIV. (They were very broad with their HIV risk factors: any sexual contact, any injection drug use, any crack use, or any alcohol use in the last 2 months.) Of the 499 patients included, 5 (1.0%) were diagnosed with an acute HIV infection and another 6 (1.2%) were diagnosed with chronic HIV. They did not have any false positives.

Bottom line: Depending on your work environment, it may be worth screening for HIV in patients with viral illnesses.

It’s all about that aVL

Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. The American journal of emergency medicine. 2015. PMID: 26542793

Is that Inferior ST elevation indicative of STEMI? Or is it pericarditis? aVL might hold the key. This is a retrospective look at 3 different groups. Of 154 patients with a final diagnosis of inferior STEMI, all 154 had some degree of ST depression in aVL. Of the 49 patients with pericarditis, 49 had some degree of inferior ST elevation, but none had any ST depression in aVL. There was a third cohort with subtle inferior ST elevation (less than 1mm) but confirmed vessel occlusion on cath. Of these 54 patients, 49 had ST depression in aVL. The authors conclude that ST depression is highly sensitive for inferior STEMI and specific for pericarditis.

Bottom line: I will certainly look at aVL, but would love to see this repeated prospectively

If you want to read more about this and see some example ECGs, check out the blog post by senior author Dr Steve Smith:


Cold – the pure green coffee (ask Dr. Oz) of the brain

Andrews PJ, Sinclair HL, Rodriguez A. Hypothermia for Intracranial Hypertension after Traumatic Brain Injury. The New England journal of medicine. 2015. PMID: 26444221 [free full text]

Another in the cold brain is not healthy brain category. This is a multicentre, randomized controlled trial of 387 adult patients (out of 2498 screened patients) with traumatic brain injury and persistently elevated ICP after sedation, elevation of the head of the bed, and mechanical ventilation. They were randomized to either get or not get hypothermia (target between 32 and 35 degrees Celsius for 48 hours.) The trial was stopped early for harm. Their primary outcome (neuro status based on the extended Glasgow outcome scale) was worse in the hypothermia group (OR 1.53 95%CI 1.02-2.30). Mortality was also worse (OR 1.45 95%CI 1.01-2.10). The biggest problem with the study was that they included patients up to 10 days after injury, which could just be too late for the magical power of cold to work.

However, I don’t think we should find this too surprising. Hypothermia has been tried for many conditions, including TBI, in the past with limited success. The general failure of hypothermia is one of the reasons to remain highly skeptical of those two small, biased trials that indicated that it worked in cardiac arrest. It may be reasonable to continue using hypothermia for the time being, but if anyone gets around to actually repeating the hypothermia versus placebo trial in cardiac arrest, we shouldn’t be surprised if it turns out to have no effect.

Bottom line: No hypothermia for trauma

Dual antiplatelets for stroke/TIA?

Wang Y, Pan Y, Zhao X. Clopidogrel With Aspirin in Acute Minor Stroke or Transient Ischemic Attack (CHANCE) Trial: One-Year Outcomes. Circulation. 132(1):40-6. 2015. PMID: 25957224

This is one of those trials that will get talked about, but I worry we will over apply the results. This is a large multicenter randomized trial in which 5170 Chinese patients with high risk TIA or minor CVA were randomized to either clopidogrel 75mg daily for 3 months plus aspirin 75 mg daily for 21 days or aspirin 75 mg daily for 3 months. The primary outcome of stroke at 1 year occurred in 10.6% of the combo group as compared to 14.0% of the aspirin alone group (hazard ratio, 0.78; 95% confidence interval, 0.65-0.93; P=0.006). Bleeding was the same in both groups. I think there are a few important caveats. First, you should question the generalizability of these results to your patients unless you work in China, because the rates of smoking in China are unlike those anywhere else in the world. Second, it is unlikely that the combination of ASA and clopidogrel has the same bleeding rates as ASA alone. That doesn’t fit well with previous studies or general experience. This should remind us that RCTs are usually not well designed to identify harms and will often over estimate the benefit to harm ratio.

Bottom line: I would not be changing my practice to include dual antiplatelet therapy based on this study alone.

Great ultrasound tip – try using both probes for IUP

Tabbut M, Harper D, Gramer D, Jones R. High-frequency linear transducer improves detection of an intrauterine pregnancy in first trimester ultrasound. The American Journal of Emergency Medicine. Article in Press. PMID:

Traditionally, we are taught to use a curvilinear abdominal probe when performing transabdominal ultrasound to detect first trimester pregnancy. This study looked at adding the high frequency linear transducer after failure to identify IUP with the standard transducer. Of 81 initial scans, 27 patients did not have an IUP visualised with the curvilinear probe. Of those, 9 (33%) were found to have an IUP by using the linear probe.

Bottom line: It’s probably worth trying the linear probe if you can’t see an IUP with the curvilinear.

Cricoid pressure: the evidence?

Algie CM, Mahar RK, Tan HB, Wilson G, Mahar PD, Wasiak J. Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation. The Cochrane database of systematic reviews. 11:CD011656. 2015. PMID: 26578526

This is a Cochrane review designed to look for any RCT evidence of the value of cricoid pressure in either emergent or elective airways. The review really says nothing of value, because there is no evidence to review. So why include it? Because sometimes it’s important to know that there is no evidence to review. If anyone ever gets too dogmatic on either side of the cricoid pressure debate, they should probably be ignored.

Bottom line: There is no evidence supporting the use of cricoid pressure. I abandoned it a long time ago, but I would be happy to see an RCT done to confirm or contradict my current practice.  

Sex is better than flomax!

Doluoglu OG, Demirbas A, Kilinc MF. Can Sexual Intercourse Be an Alternative Therapy for Distal Ureteral Stones? A Prospective, Randomized, Controlled Study. Urology. 86(1):19-24. 2015. PMID: 26142575

By now, everyone should know that tamsulosin does not help patients with kidney stones, but that doesn’t mean we should give up on our patients. Is there anything else we can do to help? In this randomized, controlled study 75 adult patients with nephrolithiasis were randomized to either 1) being asked to have sex at least 3-4 times a week, 2) tamsulosin 0.4mg a day, or 3) usual care. There were no placebos (although if you can come up with a placebo version of sex I want to hear about it.) The mean time to stone expulsion was only 10 days (95%CI 4.2-15.8 days) in the sex group, versus 16.6 (95%CI 8.1-25.1 days) with tamsulosin and 18 (95%CI 15.5-23.5 days) with usual care (p=0.0001). I foresee a large number of men looking for medical notes explaining this therapy to their wives. Perhaps there may even be a few malingerers without stones looking to get this prescription?

Bottom line: Sex is good

When is dementia not dementia?

Djukic M, Wedekind D, Franz A, Gremke M, Nau R. Frequency of dementia syndromes with a potentially treatable cause in geriatric in-patients: analysis of a 1-year interval. European archives of psychiatry and clinical neuroscience. 265(5):429-38. 2015. PMID: 25716929

Dementia is a horrible diagnosis that we can’t do anything about. But is it always? In this retrospective review of patients admitted to hospital with dementia, the authors searched for reversible causes. Of the patients previously diagnosed with dementia, the authors were able identify a potentially reversible cause in 23%. Of the newly diagnosed dementia, 31% had potentially reversible causes. The common reversible causes included low B12, depression, alcoholism, and normal pressure hydrocephalus. I wouldn’t hang my hat on any of the numbers, given the retrospective nature of the trial, but this should serve as a reminder that we might be able to help some of these patients. If you can reverse dementia, that is a true save.

Bottom line: Some dementia is reversible. These causes should be searched for.

Dikembe Mutombo is wagging his finger – Block!

Riddell M, Ospina M, Holroyd-Leduc JM. Use of Femoral Nerve Blocks to Manage Hip Fracture Pain among Older Adults in the Emergency Department: A Systematic Review. CJEM. 2015. PMID: 26354332

My appraisal may be biased because I love nerve blocks, especially when I can do them with an ultrasound. This is a systematic review of randomized control trials asking the question: does the use of a femoral nerve block reduce pain, opioid use, delirium, or improve function in adults over 65 with an acute hip fracture. They found 7 RCTs covering a total of 224 patients – so the studies were small. Also, only one trial was placebo controlled. The remainder compared the nerve block to opioids. The authors appropriately did not perform a meta-analysis, as the studies were heterogenous, so a single numerical summary is not possible. The best summary is that the nerve block group consistently had both statistically and clinically significant reduction in their pain scores as compared to placebo, used less opioid, and had fewer complications.

Bottom line: Nerve blocks work great for hip fractures. We should be using these.

From Dikembe Mutombo to Mark Spitz

Browne KM, Murphy O, Clover AJ. Should we advise patients with sutures not to swim? BMJ (Clinical research ed.). 348:g3171. 2014. PMID: 24859900

I always find it a little frustrating when my non-medical friends ask me questions about medicine that seem really simple, but that I honestly can’t answer. What exactly did I learn in all those years of school? The most recent question was: “when can I started swimming again after getting stitches?” This is a review, if you can call a search that unearthed only a single case report a review, trying to answer that question. Yes, apparently in the entire medical literature there is a single reported case of a wound infection that occurred after swimming – and that was in a hospital rehab pool which is probably more likely to be colonized with strange bugs than your average swimming pool. The authors try to shape this into a practical answer, but I think the best answer we can give is “we don’t know”. Early showering after surgery has been shown to be safe, so maybe you could extrapolate from that.

Bottom line: There is much in medicine that we simply don’t know

Which is more important: rinsing your dishes before they go in the dishwasher, or rinsing out the inside of an abscess?

Chinnock B, Hendey GW. Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success. Annals of emergency medicine. 2015. PMID: 26416494

I was never taught to irrigate abscesses in residency. It was only this year that I discovered that this has been suggested by numerous guidelines. But not so fast. This is a non-blinded RCT of 209 patients with cutaneous abscesses randomized to irrigation or no irrigation. There was no difference in the need for further treatment (I&D, antibiotic change, or admission) at 30 days between the 2 groups (15% vs 13%). Unfortunately a huge number of these patients were put on antibiotics (91% in the irrigation and 73% in the no irrigation group), which we know are unnecessary in most abscesses, but contaminate the results here.

Bottom line: This wasn’t common practice where I trained and we never saw many bouncebacks. I won’t start irrigating abscesses based on this.

Should the Bee Gees pause for a breath (at 30:2)?

Nichol G, Leroux B, Wang H. Trial of Continuous or Interrupted Chest Compressions during CPR. The New England journal of medicine. 2015. PMID: 26550795 [free full text]

“Well, you can tell by the way I use my walk, I’m a woman’s man. No time to talk… Ah,ha,ha,ha, stayin’ alive”. This is a large randomized controlled trial of 23,711 adult patients with out of hospital cardiac arrest comparing the standard 30:2 ratio of chest compressions to rescue breaths, to continuous chest compressions at 100/min with 10 asynchronous breaths a minute. The primary outcome of survival to hospital discharge was identical, 9.0% in the continuous chest compression group and 9.7% in the 30:2 group. Neurologically intact survival was 7.0% and 7.7% respectively. The biggest issue with the data is that everyone got extremely high quality CPR, and the compression fraction was almost identical in both groups, so it would have been difficult to demonstrate any difference.

Bottom line: Personally, I like continuous compressions with asynchronous breaths more, but this trial supports whatever you are comfortable with as long as you are doing high quality CPR.

A quick and easy rule out blood test for aortic dissection? Get real

Asha SE, Miers JW. A Systematic Review and Meta-analysis of D-dimer as a Rule-out Test for Suspected Acute Aortic Dissection. Annals of emergency medicine. 66(4):368-78. 2015. PMID: pubmed

This is a systematic review and meta-analysis looking to determine the diagnostic accuracy of D-dimer as a rule out test of aortic dissection. In total they found 5 studies including a total of 1600 patients. My first point of concern is that 1035 of those patients came from a single study, which could potentially dominate a meta-analysis, and that study was not designed to test the accuracy of D-dimer. In fact, the study enrolled 1455 patients, but only 1035 were counted in this meta-analysis, because the other patients never even had a D-dimer drawn. The results they present are pretty impressive, with a pooled sensitivity of 98% (95%CI 96-100%), specificity of 42% (95%CI 39-45%), negative likelihood ratio of 0.05 and positive likelihood ratio of 2.11. However, I would be very careful interpreting those results. Not only are the majority of the patients from a registry where D-dimer didn’t have to be drawn, but these were almost all patients admitted to CCUs, so very different from our ED population. Finally, although you would be using this test to try to avoid CTs, the poor specificity in a lower risk population could actually paradoxically lead to increased CT usage, much like D-dimer for PE.

Bottom line: This study isn’t enough to support D-dimer to rule out aortic dissection in the ED.

“Unreasonable haste is the direct road to error” – Moliere

Fanari Z, Abraham N, Kolm P. Aggressive Measures to Decrease “Door to Balloon” Time and Incidence of Unnecessary Cardiac Catheterization: Potential Risks and Role of Quality Improvement. Mayo Clinic proceedings. 2015. PMID: 26549506

An important lesson in unintended consequences. We know that short door to balloon times are important for STEMI patients. This is a study from a single hospital where they instituted a number of measures to decrease the door to balloon time. And it worked! Well – they managed to get the door to balloon time decreased by 15 minutes, which is excellent. However, it’s important to measure patient oriented outcomes and in this cohort the false positive STEMI rate rose from 7.7% to 16% and there was an increased mortality in this false positive group.

Bottom line: Inappropriate benchmarks can result in physicians rushing, more errors, and patient harms.

Don’t let an endotracheal tube make your patient worse

Kim WY, Kwak MK, Ko BS. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PloS one. 9(11):e112779. 2014. PMID: 25402500 [free full text]

Emergency physicians love procedures and intubation is one of our favorite. Sometimes this leads to us being a little overzealous about intubating very early, when an immediate airway is not necessary. This is a case control study of 41 critically ill adult patients that had a cardiac arrest after intubation (out of a total of 2404 critically ill patients who were intubated – or 1.7%.) Pre-Intubation hypotension (a systolic blood pressues ≤ 90) was independently associated with post-intubation arrest (OR 3.67 95%CI 1.58-8.55.) The case control design may not provide precise numbers, but I think this is a good reminder that some patients need good resuscitation before we attempt intubation.

Bottom line: Resuscitation before intubation in hypotensive patients

Cheesy Joke of the Month

There are two cows in a field. The first cow turns to the second and asks, “did you hear about the outbreak of mad cow disease?” The second cow responds: “Good thing I am a helicopter.”


#FOAMed of the month

Every month this section could probably just be filled with my favorite talks from SMACC. I will try to include some different FOAM in coming months, but these talks were so go that even though I listened to them live, I have listened to them all again at home. This is why I have been telling everyone who will listen they should join me in Dublin in June. The first tickets sold out very fast, but some more will go on sale December 1st at 5pm EST (if my math is right.)

For now, these talks were amazing:

Lessons from the Princess Bride (Amal Mattu)

When to stop resuscitation (Roger Harris)

What is a good death (Ashley Shreves)

Crack the chest. Get crucified. (John Hinds) – I know I have recommended this one before, but it is worth more than one watch.

Dogmalysis and pseudoaxioms (David Newman)

Bouncing back after tragedy (Rob Rogers)

Educational theory for the clinician (Jonathon Sherbino)


Articles of the month special edition: Continuous chest compressions versus standard 30:2 CPR

This is a new study, hot off the press, from the resuscitation outcomes consortium. Usually I save up new papers and talk about them all in the articles of the month. However, I have been on a bit of an ACLS kick this month, starting with a summary on the new 2015 ILCOR guidelines and then an update of my approach to neonatal resuscitation to reflect these new guidelines. So when I saw this new cardiac arrest study, it seemed worthy of its own post.

Continue reading “Articles of the month special edition: Continuous chest compressions versus standard 30:2 CPR”

First10EM on theSGEM!

I was honoured to be invited on The Skeptics Guide to Emergency Medicine this week to discuss the FLORALI trial with Ken Milne.

The episode is: SGEM#135: The Answer My Friend is Blowin’ in your Nose – High Flow Nasal Oxygen


I had previously mentioned this paper in the May 2015 edition of my Articles of the Month.

My Bottom line: High flow nasal oxygen seems to be as good as NIPPV or facemask oxygen (in this select group of patients). This is enough for me to try this with alert pneumonia patients who don’t obviously need intubation.

I personally like high flow nasal oxygen for a lot of these patients, because it seems to be more comfortable, allow for easier communication, and provides the option of oral intake. This study certainly is not enough to justify the expense of purchasing one of these units if you don’t already have one. However, if there is already one in your department, I say give it a trial.

Two major questions remain, in my mind:

  1. In these hypoxic patients, when should we be intubating? Does placing a patient on high flow nasal oxygen simply delay the inevitable intubation? Might that lead to worse outcomes?
  2. Was this study underpowered to show a benefit? They powered the study to show a 20% decrease in intubation and the study was negative. However, the point estimates were better for high flow nasal oxygen in all categories. Also, a secondary outcome of mortality at 90 days was statistically better in the high flow group. We need more trials to determine the real effect of high flow nasal oxygen.

For a proper skeptical take on this paper, go listen to the episode!



Frat JP, Thille AW, Mercat A, et al. High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure. N Engl J Med. 2015. PMID: 25981908

Articles of the month (October 2015)

A monthly collection of the most interesting emergency medical literature I have encountered.

Its that time again. Here are my favorite medical reads of the last month – well, actually, last 2 months. There are some really good papers in this edition. I hope you enjoy…

1 good ECG begets another

Riley RF, Newby LK, Don CW, et al. Diagnostic time course, treatment, and in-hospital outcomes for patients with ST-segment elevation myocardial infarction presenting with nondiagnostic initial electrocardiogram: a report from the American Heart Association Mission: Lifeline program. Am Heart J. 2013;165:(1)50-6. PMID: 23237133

This is a registry study of 41.560 patients diagnosed with a STEMI. Of those patients, 4,566 had an initial ECG that was non-diagnostic. About ⅓ had converted to STEMI within 30 minutes of their first ECG, and 75% within 90 minutes. The groups were otherwise similar.

Bottom line: About 1/10 STEMIs are not evident on the initial ECG. If the story is good, get repeats.

When should we crack the chest?

Seamon MJ, Haut ER, Van Arendonk K. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. The journal of trauma and acute care surgery. 79(1):159-73. 2015. PMID: 26091330

This is a systematic review by the EAST group that included 72 studies an 10,238 patients looking to answer the question: should patients who present pulseless after critical injuries undergo emergency department thoracotomy to improve survival and neurologically intact survival?. Their review and recommendations are divided into 6 groups:

  1. Pulseless, signs of life, penetrating thoracic injury
    • Strongly recommend ED thoracotomy (EDT)
    • 182/853 patients survived hospitalization, 53/454 neurologically intact
  2. Pulseless, no signs of life, penetrating thoracic injury
    • Strongly favour EDT
    • 77/920 survived, 25/641 neurologically intact
  3. Pulseless, signs of life, penetrating extrathoracic injury
    • Conditionally recommend EDT
    • 25/160 survived, 14/85 neurologically intact
  4. Pulseless, no signs of life, penetrating extrathoracic injury
    • Conditionally recommend EDT
    • 4/139 survived, 3/6 neurologically intact
  5. Pulseless, signs of life, blunt injury
    • Conditionally recommend EDT
    • 21/454 survived, 7/298 neurologically intact
  6. Pulseless, no signs of life, blunt injury
    • Conditionally DO NOT recommend EDT
    • 7/995 survived, 1/825 neurologically intact

There a definitely a few issues with the data. Systematic reviews are only as good as the studies included, and none of the included studies were great. In case you were wondering, the reason that the denominator for neurologically intact survival and overall survival are different is that some studies didn’t report neurologic status.

Bottom line: This is a procedure we need to be prepared to do in the context of penetrating trauma patients who had signs of life. Even smaller community hospitals should have a plan for these patients before they arrive.

Ultrasound before thoracotomy?

Inaba K, Chouliaras K, Zakaluzny S. FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation. Annals of surgery. 262(3):512-8. 2015. PMID: 26258320

The criteria for thoracotomy based on ‘signs of life’ always seemed a bit soft to me. Could the omnipresent ultrasound probe help us make the decision to crack the chest? These authors prospectively enrolled all patients at their centre undergoing a resuscitative thoracotomy over the course of 3.5 years. They obtained cardiac views with an ultrasound on all these patients. In total, they performed 187 thoracotomies. 126 patients had cardiac standstill on ultrasound, and ZERO survived. If there was cardiac motion on ultrasound, 9/54 patients survived. The biggest problem with this data is probably the generalizability. 187 thoracotomies in 3 years is A LOT. My guess is these physicians are more skilled at both the thoracotomy (obviously) but also the cardiac ultrasound than I am. Might the ultrasound probe just delay the necessary procedure?

Bottom line: No cardiac activity on ultrasound might be a good reason not to perform a thoracotomy.

Some more trauma: NEXUS CT chest tool

Rodriguez RM, Langdorf MI, Nishijima D. Derivation and Validation of Two Decision Instruments for Selective Chest CT in Blunt Trauma: A Multicenter Prospective Observational Study (NEXUS Chest CT). PLoS medicine. 12(10):e1001883. 2015. PMID: 26440607 [free full text]

This is the second attempt at a NEXUS CT chest tool. This paper covers both the derivation and validation studies of the new tool. It total, they prospectively enrolled 11,477 blunt trauma patients over 14 years of age at 8 level 1 trauma centres. They came up with two different instruments: one just for major injuries and another for major and minor injuries. In the validation, the CT-All tool (designed to catch major and minor injuries) had a 99.2% sensitivity and 20.8% specificity for major injury, and a 95.4% sensitivity and 25.5% specificity for all injuries. One major problem is the validation only occurred in patients who actually had CTs (less than half of the cohort) so it is hard to say how it will work when applied to all comers. The authors think this will decrease CT scanning, but like all decision instruments, the implementation should be specifically studied. If applied to lower risk populations, it could actually increase scanning.

Bottom line: If you have ordered a CT chest for blunt trauma, you could check this rule to see if you could safely cancel the scan

Let’s do a couple papers on SVT. First: The Valsalva to rule them all

Appelboam A, Reuben A, Mann C. Randomised Evaluation of modified Valsalva Effectiveness in Re-entrant Tachycardias (REVERT) study. BMJ open. 4(3):e004525. 2014. PMID: 24622951 [free full text]

This one has been talked about a lot since it came out. It is a multi-centre, non-blinded randomized control trial of 428 adult patients with supraventricular tachycardia comparing the standard Valsalva maneuver to a modified Valsalva. The modified Valsalva was performed by forced blowing for 15 seconds in the sitting position (standard Valsalva), but then patients were immediately laid flat and had their legs elevated to 45 degrees for 15 seconds. (A video of the procedure can be seen here.) At one minute after the procedure 17% of the standard Valsalva group and 43% of the modified group were in sinus rhythm (OR 3.7 95%CI 2.3-5.8 NNT=3.8). This translated into 19% fewer patients requiring adenosine (69% vs 50%, p=0.0002, NNT=5.3). The authors say that blowing into a 10ml syringe will replicate the Valsalva they performed with fancier equipment.

Bottom line: This is a simple, free technique that might save our patient uncomfortable medical interventions. Using it until further research is done seems like a no brainer.

SVT #2: Why I never use adenosine

Lim SH, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 80(5):523-8. 2009
. PMID: 19261367

This is a RCT of 206 adult patients with SVT randomized to either adenosine or a calcium channel blocker. The dosing of the CCBs was either verapamil 1mg/min to a max of 20 mg or diltiazem 2.5mg/min to a max of 50mg. Adenosine dosing was 6mg followed by 12 mg if needed. Calcium channel blockers did a better job converting to sinus rhythm (98% vs 86.5% p=0.002). 1 patient in the CCB group developed transient hypotension as compared to none in the adenosine group.

Bottom line: Calcium channel blockers are more effective than adenosine and don’t have the horrible side effects. I always start with a CCB, and my patients have thanked me every single time for not exposing them to the horrors of adenosine.

SVT#3: More adenosine bashing

Holdgate A, Foo A. Adenosine versus intravenous calcium channel antagonists for the treatment of supraventricular tachycardia in adults. The Cochrane database of systematic reviews. 2006. PMID: 17054240

Just to complete the topic, this is the Cochrane review looking at calcium channel blockers versus adenosine in SVT. They found no significant difference in either reversion or relapse. Obviously, minor adverse events (the horrible chest pains, shortness of breath, and headaches) were higher in the adenosine group (10.8 versus 0.6% p<0.001). There was no statistical difference in hypotensive events, but all that occurred were in the calcium channel blocker groups (3/166 patients as compared to 0/171 patients.) There were no major adverse outcomes.

Bottom line: Again, similar efficacy but your patients will love you if you shelf the adenosine.

Apneic oxygenation: does it help in critical care?

The FELLOW trial: Semler MW, Janz DR, Lentz RJ. Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill. American journal of respiratory and critical care medicine. 2015. PMID: 26426458

This is a randomized, controlled, non-blinded trial comparing apneic oxygenation during intubation to no apneic oxygenation in 150 adult patients in a single ICU. Apneic oxygen was provided by the addition of oxygen through nasal prongs at 15L/min. The primary outcome, lowest achieved oxygen saturation, was not different between the groups (median of 92% with usual care and 90% with apneic oxygenation). There were no differences in any of the secondary outcomes (incidence of hypoxemia, severe hypoxemia, desaturation, or change in saturation from baseline.) Apneic oxygenation has been shown to work in stable surgical patients – why would it be different here? The big reason is that this was not a comparison of apneic oxygenation to apnea, like would occur in a standard RSI. 73% of patients received either BiPAP or BVM during the apneic period. Of course nasal prongs aren’t adding anything to patients receiving positive pressure ventilation. These patients are not at all like the patients I generally intubate.

Bottom line: I will continue to use apneic oxygenation for standard RSI, but if my patient requires BiPAP or bagging for oxygenation, I will forget the nasal prongs.

A 3 wish program to personalize the death experience

Cook D, Swinton M, Toledo F. Personalizing Death in the Intensive Care Unit: The 3 Wishes Project: A Mixed-Methods Study. Annals of internal medicine. 163(4):271-9. 2015. PMID: 26167721

I think one of medicine’s greatest current failures is the way we deal with death. That is a problem, seeing as death is the only certainty in medicine. This is a qualitative description of a program designed to personalize death in the ICU. To honor each patient, they asked dying patients, their families, and the clinicians to make 3 wishes that might provide dignity for the patient. The wishes were mostly simple, but profound, such as using a patient’s nickname, allowing a mother to lie in bed with her dying son, organizing volunteer work for family members, or celebrating a birthday. There were 5 categories of wishes: 1) humanizing the environment; 2) personal tributes; 3) family reconnections; 4) rituals and observances; and 5) “paying it forward”. The authors thought these added value through three domains: dignifying the dying patient, giving the family a voice, and fostering clinician compassion.

Bottom line: I don’t care much about the evidence here: This is a great idea, and if I end up in your ICU I hope this is the kind of care I receive.

Maybe a better summary of this paper is on of my favorite videos by ZDoggMD:

An end to the low risk chest pain madness?

Mahler SA, Riley RF, Hiestand BC. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circulation. Cardiovascular quality and outcomes. 8(2):195-203. 2015. PMID: 25737484

This is a prospective, randomized control trial of 282 adult patients with symptoms of possible ACS without ST elevation, randomized to the use of the HEART pathway or usual care. The HEART pathway is a combination of the HEART score with 0 and 3 hour troponins. It was a relatively low risk group, with 6.4% of patients having an MI at 30 days. Using the HEART pathway reduced the use of cardiac testing from 69% to 57%, and none of the low risk group had any adverse events. The HEART pathway also increased early discharges and decreased length of stay. The two major problems with this study are its small size and the American setting. Although the score allow more patients to be discharged home in a setting where everyone is admitted, the results might be different if your chest pain admission rate is low to begin with, like it is where I work.

Bottom line: The HEART score may help decrease testing in low risk chest pain patients, but more evidence is required

PRP: All the superstar athletes are all using it, so it must work

Filardo G, Di Matteo B, Di Martino A. Platelet-Rich Plasma Intra-articular Knee Injections Show No Superiority Versus Viscosupplementation: A Randomized Controlled Trial. The American journal of sports medicine. 43(7):1575-82. 2015. PMID: 25952818

This is a randomized, double blind, controlled trial comparing platelet rich plasma (PRP) injections to injections of hyaluronic acid for knee osteoarthritis. Each group got three weekly injections of their study medication. Symptoms and function were identical between the groups at 2,6 and 12 months. Considering that hyaluronic acid has been shown to have essentially no clinically relevant benefit, this comparison may as well have been with placebo. As a side note, it drives me nuts that so many people refer to this as “platelet rich plasma therapy”. “Therapy” implies to patients that it might actually do some good and skews the process of informed choice. So far, there is nothing therapeutic about platelet rich plasma.

Bottom line: Platelet rich plasma therapy sounded good in theory, but it looks like it will be another fruitless intervention.

The “gold standard” for PE isn’t so gold.

Hutchinson BD et al. Overdiagnosis of Pulmonary Embolism by Pulmonary CT Angiography. Am J Roentgenol. 2015; 205(2): 271-7. PMID: 6204274

The patient was low risk, but you decided to order the CT anyway. Thank goodness you did, because it is positive for a PE. Well, not so fast. This is a retrospective look at 937 CTPAs for PE over 1 year at a single center. They had 3 blinded radiologists review each study, using their consensus as the gold standard. Of the 174 studies that were initially read as positive, these radiologists disagreed with that read (thought it was a false positive) in 45 cases (25.9%). This is consistent with multiple other studies.

Bottom line: We are likely harming many patients with unnecessary lifelong anticoagulation. In borderline cases, it might be worth asking for a second opinion on the read of the CT.

How normal is normal saline?

SPLIT trial: Young P, Bailey M, Beasley R. Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial. JAMA. 2015. PMID: 26444692

We have been hearing for a while now that normal saline, because of the large excess of chloride and resultant acidosis, is bad for sick patients. This is a multi-centre blinded, randomized trial of 2278 adult ICU patients comparing normal saline to a balanced solution (plasmalyte 148). There was no difference in the primary outcome of acute kidney injury (9.6% with plasmalyte and 9.2% with saline, p=0.77). There was also no difference in renal replacement therapy, ICU days, mechanical ventilation, or mortality. A few weaknesses of this study were that the median amount of fluid given was only 2L per patient and most patients received fluid prior to enrollment, a lot of which was balanced solution. The biggest problem for emergency medicine is that 70% of patients went to the ICU after elective surgeries, so these results are probably not generalizable to our septic patients who start out significantly acidotic.

Bottom line: Despite a lot of theory, there is still no good evidence that we should be giving up on normal saline.

Are delayed antibiotics truly a death sentence?

Sterling SA, Miller WR, Pryor J, Puskarich MA, Jones AE. The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis. Critical care medicine. 43(9):1907-15. 2015. PMID: 26121073

People have been quoting a 7% increased mortality with every hour antibiotics are delayed for a long time. Unfortunately, this is based off a single study, and we seemed to forget somewhere along the line that association does not equal causation. This is a meta-analysis of 11 studies covering 16,178 patients with severe sepsis or septic shock. There was no difference in mortality comparing early and late antibiotics groups. Of course, all of these studies are observational, as no severe sepsis patients are being randomized to delayed antibiotics.

Bottom line: Obviously, give antibiotics if you know a patient has an infection – but there is reason to fight with administrators and government agencies if they try to make time to antibiotics a quality metric.

Turning down the heat: can acetaminophen save lives?

HEAT trial: Young P, Saxena M, Bellomo R. Acetaminophen for Fever in Critically Ill Patients with Suspected Infection. The New England journal of medicine. 2015. PMID: 26436473 [free full text]

For some reason, people just love to hate on fever. It is present when people are sick, so it must be bad, right? We better rush to treat it. This is a randomized, double blind trial of 690 adult ICU patients with a fever and suspected infection, comparing acetaminophen 1 gram IV every 6 hours to placebo. Not surprisingly (unless you actually believed treating fever was helping patients) there was no difference in the primary outcome of ICU free days. There was also no difference in mortality at 28 or 90 days.

Bottom line: Tylenol is great, but it isn’t needed for febrile patients

Dopamine is having a tough run

Ventura AM, Shieh HH, Bousso A. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Critical care medicine. 43(11):2292-302. 2015. PMID: 26323041

Sure, it’s a small trial – but it was looking at small patients, so that’s OK. This is a double-blind, randomized controlled trial of 120 pediatric patients with severe sepsis comparing epinephrine to dopamine as the first line vasopressor. The study was stopped early due to increased mortality in the dopamine group (20.6% versus 7%). They also note decreased mortality when epinephrine was given early through a peripheral IV or an IO. Mortality was not the primary outcome, and the trial was small, so I wouldn’t be shocked to see contradictory results in the future.

Bottom line: It’s rare to get this kind of RCT in pediatrics – this is definitely enough for me to shelf dopamine for epinephrine for the time being.

Ultrasound for CHF

Pivetta E, Goffi A, Lupia E. Lung Ultrasound-Implemented Diagnosis of Acute Decompensated Heart Failure in the ED: A SIMEU Multicenter Study. Chest. 148(1):202-10. 2015. PMID: 25654562

This is a multicentre, prospective cohort of 1005 ED patients looking to see if lung ultrasound could add to clinical judgement in the diagnosis of acute heart failure. The gold standard of heart failure was determined by a review of the final chart by a cardiologist and an emergency physician. This isn’t perfect, but there isn’t really a better option for CHF, and they were blinded to the ultrasound results and agreed with each other 97% of the time. Physician judgement alone for CHF is really good, with a sensitivity of 85.3% and a specificity of 90%. If you add ultrasound to this physician judgment, the sensitivity rose to 97% (95% CI, 95%-98.3%) and specificity to 97.4% (95% CI, 95.7%-98.6%), translating into positive and negative likelihood ratios of 22.3 and 0.03 respectively. The biggest caveat is that these were non-consecutive patients, because there had to be a doctor around with enough ultrasound skill (>40 scans) to get enrolled.

Bottom line: In trained physicians, lung ultrasound can help rule in and rule out acute CHF.

The new ACLS guidelines are out

The multiple AHA guidelines are in this issue of Circulation

The ERC guidelines are in Resuscitation

There is too much to go through in this format. The quickest summary is that there is nothing really game changing in these guidelines, so keep providing the high quality care you already do, and don’t rush to waste your money on a new ACLS course. If you want more information, I wrote a post about the biggest changes here:

Cheesy Joke of the Month

Patient: Doctor, I broke my arm in 3 places. What should I do?
Doctor: Stop going to those places

#FOAMed of the month

I was incredibly impressed with the capacity for knowledge translation demonstrated by the free, open access medical education community this month when the new ACLS guidelines came out. Within a week, the internet was awash in summaries, podcasts, and infographics. If my quick summary wasn’t enough for you, here are a few other amazing resources:

BoringEM came up with a great series of infographics

EMCases interviewed a couple authors of the guidelines

REBELCast came up with a top 5 list of their own

Articles of the month (September 2015)

I am on vacation this month and I am trying hard to make it a real vacation. So I am not reading any medical literature, even if I have a minute while wait in line at the Colosseum (yes, that has happened before.) Instead of my usual articles of the month, covering the most recent papers I have been reading, I am going to summarize a few classic emergency medicine papers. Most people probably know all of these already, but it is good to review the evidence behind our practice occasionally. Enjoy…

ARDSnet: The rise of low tidal volumes

Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342:(18)1301-8. PMID: 10793162

This is an RCT of 861 mechanically ventilated patients with ALI or ARDS, designed as a 2×2 trial (half of which examined ketoconazole, but that arm of the trial was stopped due to lack of efficacy.) They randomized patients to the now famous ARDSnet protocol of low tidal volumes to limit plateau pressures or a traditional ventilation strategy. The ARDSnet protocol resulted in a decrease in mortality (31.0% versus 39.8%, p=0.007).

Bottom line: Follow the protocol for your intubated patients. (Copy available here)

GUSTO II: Cath versus lytics

Andersen HR, Nielsen TT, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. 2003;349:(8)733-42. PMID: 12930925 [free full text]

This is a substudy of GUSTO II. It is a prospective multicenter RCT that assigned 1138 patients presenting within 12 hours of their STEMI to either primary angioplasty or thrombolytic (t-PA). For their primary outcome, a composite of death, non-fatal reinfarction, and non-fatal stroke at 30 days, angioplasty had better outcomes (8.0% versus 13.7% p<0.001). This effect was entirely from non-fatal re-infarction, as stroke and death were unchanged – a problem with composite outcomes. Interestingly, and something that we don’t tend to talk about a lot, or at least I was never taught, there was no difference in that composite outcome at 6 months (14.1 vs 16.1% statistically insignificant.)

Bottom line: Angioplasty provides some early benefit over fibrinolytics, but we may be over-emphasizing its benefit. For many centers and specific patients, lytics may still be the best option. (See, I am not just totally against t-PA. I am just for evidence.)

Analgesics for abdominal pain

Mahadevan M, Graff L. Prospective randomized study of analgesic use for ED patients with right lower quadrant abdominal pain. Am J Emerg Med. 2000;18:(7)753-6. PMID: 11103723

I only know the medical world after this study was published, but many people probably still remember the days when surgeons wouldn’t let us treat patients’ pain because it would ruin the abdominal exam. This is a randomized, double blind trial of 68 adult patients suspected of appendicitis, given either tramadol or placebo. Of course, pain was lower in the group that received pain medication (although not by a lot). Not only was the analgesic group examinable, but actually had more specific exams for appendicitis.

Bottom line: If patients are in pain, doctors treat it. I am not sure what surgeons do.

NEXUS: A pain in the neck?

Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343:(2)94-9. PMID: 10891516 [free full text]

Jerry Hoffman. Nexus. This is classic emergency medicine. We should all know the criteria:

  1. No midline cervical tenderness
  2. No focal neurological deficit
  3. Normal alertness
  4. No intoxication
  5. No painful, distracting injury

This was a prospective, multi-centre observational study that included 34,069 patients who had imaging of the cervical spine after blunt trauma and found 818 cervical spine injuries. The decision instrument was 99% sensitive (95%CI 98-99.6%) with a negative predictive value of 99.8% (95%CI 98.0-99.6%). Of course, you do have to accept the specificity of 12.9%. Only 1 of the 8 patients missed had a clinically significant injury that required a surgical intervention.

Bottom line: You can remove c-collars quickly and safely in many patients. If you are EMS, you can probably even prevent them from going on in the first place.

Cage match: NEXUS versus the Canadian C-spine rule

Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349:(26)2510-8. PMID: 14695411 [free full text]

This is a prospective cohort of 8283 alert trauma patients comparing NEXUS and Canadian c-spine rule (CCR). There were 169 (2%) clinically important c-spine injuries. Unfortunately, in 10% of patients physicians did not properly apply the CCR – they did not assess range of motion as defined. Of course, if a decision instrument is easily misinterpreted (even with the Hawthorne effect of a study) that will affect its utility in practice. How you interpret this study depends entirely on what you do with those patients. If you exclude them, the CCR looks great (sensitivity of 99.4% and specificity of 45.1%). However, if you include them, the sensitivity drops to 95.3% and specificity is 50.7%. This compares with NEXUS with a sensitivity of 90.7% and a specificity of 36.8%. Obviously, neither test performed quite as well as we would hope in this cohort.

Bottom line: It is important to know the specifics of clinical decision instruments, including inclusion and exclusion criteria. I still use a combination of both these tools in clinical practice.

Dexamethasone for croup

Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med. 2004;351:(13)1306-13. PMID: 15385657 [free full text]

This is a multi-centre, double-blind, RCT that included 720 children with mild croup who were randomized to either dexamethasone 0.6mg/kg to a max dose of 20mg or placebo. The children receiving dexamethasone had less “return to medical care” – 7.3% versus 15.3%, p<0.001. The dexamethasone group also had slightly lower croup scores and slept about 1 hour a day more than the placebo group.

Bottom line: A NNT of 14 to prevent further visits is your primary benefit in mild croup.

Dexamethasone for croup: But what dose?

Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol. 1995;20:(6)362-8. PMID: 8649915

This is an RCT of admitted pediatric patients with croup comparing dexamethasone at doses of 0.15mg/kg, 0.3mg/kg, and 0.6mg/kg. There was no difference in length of hospital stay, use of epinephrine, croup scores, or representations for medical care.

Bottom line: Dexamethasone at 0.15mg/kg is probably just as good as the 0.6mg/kg we have all been taught.

Rehydration – isn’t that what the GI tract was designed for?

Fonseca BK, Holdgate A, Craig JC. Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch Pediatr Adolesc Med. 2004;158:(5)483-90. PMID: pubmed

This is a meta-analysis of 16 RCTs involving 1545 children comparing enteral to intravenous rehydration in the treatment of gastroenteritis. (Unfortunately, I have been told by medical-legal types that I am never allowed to make the diagnosis of “gastroenteritis”, so I am not sure who I will apply this study to.) Oral rehydration has significantly fewer adverse events including death and seizure (relative risk 0.36 95%CI 0.14-0.89) and significantly reduced hospital stay (mean decrease of 21 hours). There was no difference in the treatment effect or weight gain. The failure rate for enteral therapy was 4%.

Bottom line: You should almost never place an IV in a pediatric gastroenteritis patient.

Steroids for meningitis

de Gans J, van de Beek D; European Dexamethasone in Adulthood Bacterial
Meningitis Study Investigators. Dexamethasone in adults with bacterial
meningitis. N Engl J Med. 2002 Nov 14;347(20):1549-56. PMID: 12432041 [free full text]

This is a multi-centre, prospective RCT of 301 adult patients suspected of having meningitis and having either cloudy CSF, bacteria on CSF gram stain, or a CSF white count >1000. Patients were randomized to either placebo or dexamethasone 10mg IV q6h for 4 days, with the first dose give 20 minutes before or concurrently with antibiotics (initial antibiotics treatment was with amoxicillin alone). 7% of the steroid group died as compared to 15% of placebo (p=0.04; relative risk 0.48 95%CI 0.24-0.96). There was no difference in hearing loss or focal neurologic abnormalities. Note that steroids and antibiotics were given only after waiting for the CSF results.

Bottom line: Steroids decreased mortality, but did not affect neurologic outcomes

However, although this study is considered a classic, it is at odds with the bulk of the literature.

Brouwer MC, McIntyre P, Prasad K, van de Beek D. Corticosteroids for acute bacterial meningitis. The Cochrane database of systematic reviews. 6:CD004405. 2013. PMID: 23733364

This review covers 25 studies involving 4121 participants. Steroids did NOT provide a statistically significant mortality advantage (RR 0.90, 95%CI 0.80-1.01). However, steroids did results in less hearing loss (RR 0.74 95%CI 0.63-0.87).

Bottom line: Unfortunately steroids will probably not save any lives. Given the potential delay to antibiotics if steroids are used as they were in the de Gans study, it is unclear how important the hearing changes are. The steroids for meningitis question is not definitively answered, but any benefits are likely to be small.

Sepsis: early goal directed therapy

Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:(19)1368-77. PMID: 11794169 [free full text]

This paper is now infamous and certainly created its share of controversy. It was a randomized trial of 263 patients with severe sepsis who were randomized to a specific treatment protocol or standard care. Rivers was able to show a significant mortality benefit, 30.5% versus 46.5% (p=0.009). However, we now know that the specifics of his protocol were mostly irrelevant, you just need to care for your sepsis patients.

Bottom line: Dr. Rivers pushed sepsis care forward around the world, but there is no reason to be using this protocol anymore.

Restrictive transfusion policy

Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340:(6)409-17. PMID: 9971864 [free full text]

This is a multi-centre RCT based in Canada that included 838 adult ICU patients with anemia Hb≤ 90 (excluding chronic anemia and patients with active blood loss.) They were randomized to either a restrictive transfusion strategy (transfuse with a Hb <70; target 70-90) or a liberal strategy (transfuse with a Hb < 10; target 100-120). There was not a statistical significance in 30 day mortality (18.7% in restrictive versus 23.3% in liberal). The liberal group had higher in-hospital mortality and cardiac events (secondary outcomes.)

Bottom line: This was the first of many studies showing we give too much blood.

OPALS: What is the value of ACLS?

Stiell IG, Wells GA, Field B. Advanced cardiac life support in out-of-hospital cardiac arrest. The New England journal of medicine. 351(7):647-56. 2004. PMID: 15306666 [free full text]

This is a prospective multicenter before and after trial that compared outcomes with basic life support paramedic crews (who had defibrillators) to advanced crews with full ACLS training including medications. 5638 adult patients with out of hospital cardiac arrest were included. The advanced life support paramedics resulted in more ROSC (12.9% vs 18%) and more admissions to hospital (10.9% vs 14.6%), but without any change in survival to hospital discharge (5.0 vs 5.1%).

Bottom line: This is one of the many studies that indicate ACLS and particularly the use of medications in cardiac arrest don’t work, but might actually be harmful.

Cheesy joke of the month

Why didn’t skeleton cross the road?

He has no guts

Articles of the month (August 2015)

A monthly collection of the most interesting emergency medical literature I have encountered

Here is this month’s summary of my favorite reads from the medical literature.

Simple and brilliant: A pediatric rainbow

Moreira ME, Hernandez C, Stevens AD, et al. Color-Coded Prefilled Medication Syringes Decrease Time to Delivery and Dosing Error in Simulated Emergency Department Pediatric Resuscitations. Ann Emerg Med. 2015;66:(2)97-106.e3. PMID: 25701295

Pediatric resuscitations are stressful at the best of times and pediatric medication doses can be complicated, increasing the risk of medication errors. This group came up with an ingenious solution: single pre-filled syringes that are color-coded in a rainbow pattern that corresponds to the Broselow tape we all know and love. All you have to do is discard down to the color that corresponds to the size of the child and you are sure to be giving the right dose (best explained by looking at a picture).This study assessed the speed and accuracy of medication administration in simulated pediatric resuscitations. 10 teams consisting of physicians and nurses participated in a cross over study, so that they did one simulation with the new syringes and one without. Time to delivery of medications was quicker with the new syringes (47 versus 19 seconds, a difference of 27 seconds; 95%CI 21-33 seconds). Teams were also more accurate using the new color-coded syringes, with dosing errors occurring 17% of the time with the conventional approach and 0% of the time with the new syringes (absolute difference 17%; 95% CI 4-30%). Obviously a simulation based study is not real life – but I would actually expect more stress and therefore more errors during a real resuscitation.

Bottom line: Simple. Brilliant. Worth looking into.

The same group replicated basically the same study with similar results, but this time running the simulations with paramedics:

Stevens AD, Hernandez C, Jones S, et al. Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: A randomized crossover trial. Resuscitation. 2015. PMID: 26247145

Fingers, toes, nose and hose. The epinephrine myth

Ilicki J. Safety of Epinephrine in Digital Nerve Blocks: A Literature Review. J Emerg Med. 2015. PMID: 26254284

I’ve talked about this before, but possibly not in the articles of the month. This is a systematic review looking at the safety of using epinephrine in digital nerve blocks. They found a total of 39 relevant articles, although only 12 of them were RCTs. They report no cases of necrosis attributable to epinephrine. In total, they found 2797 reported cases of digital nerve blocks using epinephrine without any important complications.

Bottom line: This was a myth. Epinephrine is almost certainly safe in fingers and toes if you think it might help you.

Physicians might not be so great around genitals

Stewart CM, Schoeman SA, Booth RA, Smith SD, Wilcox MH, Wilson JD. Assessment of self taken swabs versus clinician taken swab cultures for diagnosing gonorrhoea in women: single centre, diagnostic accuracy study. BMJ. 2012;345:e8107. PMID: 23236033 [free full text]

This is a prospective cohort of 3859 women aged 16 and over who presented to a single sexual health clinical in the UK. Before undergoing their consultation, they were asked to perform a vulvovaginal swab on themselves which was sent for nucleic acid amplification (NAAT). They then had the normal examination by the physician, with urethral and endocervical swabs sent, both for NAAT and culture. Overall, 2.5% of women tested positive for gonorrhoea (using a gold standard of either positive culture or two different NAAT markers being positive.) The self swabs were the most sensitive (99%), followed by physician swab for NAAT (96%), with the endocervical culture being the least sensitive (81%). In patients with symptoms suggestive of STI, both physician and self swab NAAT were 100% sensitive, but the endocervical culture was only 84% sensitive.

Bottom line: Self taken swabs were the most sensitive at detecting gonorrheal infection in these women

Schoeman SA, Stewart CM, Booth RA, Smith SD, Wilcox MH, Wilson JD. Assessment of best single sample for finding chlamydia in women with and without symptoms: a diagnostic test study. BMJ. 2012;345:e8013. PMID: 23236032 [free full text]

This is another study by the same group, using essentially the same methods, but this time focusing on Chlamydia. They included a total of 3973 women. Again, the self swab outperformed the physician performed swab with a sensitivity of 97% (95%CI 95-98%) as compared to 88% (95%CI 85-91%). The reported specificity of 100% is essentially meaningless because they were using the test itself as the gold standard. Similarly, the sensitivity of both tests might be lower than reported as they were not compared to any other gold standard.

Bottom line: Women do a better job collecting swabs for Chlamydia than physicians do

Overall Bottom line: If there is not another reason for a speculum exam, it does not have to be performed solely to obtain cervical swabs. Unfortunately urine testing was not included in these studies, so we do not know how it compares to self swabs.

Using tamsulosin for kidney stones? You must not be reading these e-mails.

Furyk JS, Chu K, Banks C, et al. Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial. Ann Emerg Med. 2015. PMID: 26194935 [free full text]

This is a prospective, randomized, double-blind trial of 403 adults with CT confirmed ureteric stones comparing tamsulosin 0.4mg daily to placebo. There was no benefit for the primary outcome of stone expulsion at 28 days, with 87% passed in the tamsulosin group and 81.9% in the placebo group (5.1% difference; 95%CI -3 to 13%). There was a difference in a secondary outcome, distal stones sized 5-10mm, with 83.3% passing as compared to 61%. Of course this is a secondary outcome, so should not affect your practice. More importantly, the vast majority of these people should not being getting imaged, so you will never know the size of the stone, making this information clinically useless. There was no difference in urologic interventions, pain, or analgesia requirements.

Bottom line: Tamsulosin doesn’t help patients with ureteric stones.

Just in case that wasn’t enough to convince you

Berger D, Ross M, et al. Tamsulosin does not increase one-week passage rate of ureteral stones in Emergency Department patients. Am J Emerg Med. 2015. In Print. PMID:

This is yet another paper indicating tamsulosin has no role in ureterolithiasis. (Its too bad we can’t just start with the high quality studies, rather than following the predictable pattern of a handful of garbage studies showing questionable benefit followed by a lot of time and money spent on multiple good trials that prove that there was never any benefit.) This was a prospective, double-blind RCT with 127 adult patients with CT confirmed ureterolithiasis, randomized to either tamsulosin 0.4mg daily or placebo. There was no difference in the number of patients in whom the stone did not pass (tamsulosin 62.1% 95CI 49-75%; placebo 54.4% 95%CI 40-67%.) There was also no difference in pain scores or analgesic use.

Bottom line: There is no reason to be using tamsulosin in renal colic patients.

Sticking with urology: systematic reviews are pointless if there isn’t any original literature

Hulme P and Wylie K. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 1: tranexamic acid in life-threatening haematuria. Emerg Med J. 2015;32:(2)168-9. PMID: 25605262

They decided to do a review of tranexamic acid use in life-threatening hematuria. They managed to find 3 case reports and 1 prospective observational trial of 8 patients. There were no controls, so its hard to know what to make of the outcomes. It is good to know that none of the patients broke the emergency medicine rule that all bleeding stops… eventually.

Bottom line: For patients peeing blood, you are free to make it up as you go.

It just might be safe to pee in the Amazon

Bauer IL. Candiru–a little fish with bad habits: need travel health professionals worry? A review. J Travel Med. 2013;20:(2)119-24. PMID: 23464720

This is one of those really weird medical myths that I heard when I was younger and just stuck with me as a true. Apparently if you urinate in the Amazon river, there are little fish, called Candiru, that are attracted to the urine and will swim up your urethra. Once there, they have small barbs that lock them into place. These authors did an extensive review of both the scientific and non-scientific literature and report that there has never actually been a confirmed case of this occurring. For some reason, that is an amazing relief to me (and I have never even been to South America). Was I the only one raised on this particular myth?

Bottom line: Feel free to pee in the Amazon, if that’s your thing.

Don’t write off those vital signs just yet

Rodrigo GJ, Neffen H. Assessment of acute asthma severity in the ED: are heart and respiratory rates relevant? The American journal of emergency medicine. 2015. PMID: 26233619

This is a retrospective look at data that was collected prospectively as part of 7 other asthma trials done at a single emergency department. In total, 1192 adult patients were included. They compared heart rate and respiratory rate between two predefined groups: severe asthma (defined as an FEV1 31-50% of expected) and life threatening asthma (defined as an FEV1 <= 30% expected). The HR and RR were not different between the groups (mean of 102 and 22 respectively). They then use logistic regression to show that only FEV1 and O2 saturation were related to the outcome of admission to hospital. Based on this, they conclude that HR and RR are not determinants of acute asthma severity. I think this is probably the wrong interpretation. They use FEV1 as their definition of illness severity rather than hard outcomes. The lack of correlation between FEV1 and vital signs in this study might equally indicate that FEV1 is not a good indicator of disease severity. (It is a disease oriented, not a patient oriented outcome.) Although FEV1 was correlated with admission rates at this hospital, I imagine this just represents the local practices of the hospital: they believe in FEV1 and therefore admit you to hospital if your FEV1 is low, even if you had no other indications for admission.

Bottom line: I would still strongly suggest assessing patients clinically, including vital signs. Don’t let surrogate outcomes like the FEV1 or peak flow rates confuse you in asthma.

Another quick note on measuring asthma severity

Huff JS and Diercks DB. Use of Peak Expiratory Flow Rate Monitoring for the Management of Asthma in Adults in the Emergency Department. Revision of: American College of Emergency Physicians. Use of Peak Expiratory Flow Rate Monitoring for the Management of Asthma in Adults in the Emergency Department. Ann Emerg Med. 2001;38:198.

Without going into all the problems with the base literature on the use of peak flow rates in emergency medicine, I thought I would include the ACEP policy statement for reference. This is an update of their previous policy statement from 2001, with 27 new studies identified and reviewed. Their summary: “The use of PEFR monitoring has not been shown to improve outcomes, reliably predict need for admissions, or limit morbidity or mortality when used during the ED management of adult patients with acute exacerbations of asthma.”

Bottom line: Peak flow is a disease oriented outcome. Focus on patient oriented outcomes.

Sepsis and the rush to early antibiotics

de Groot B, Ansems A, Gerling DH. The association between time to antibiotics and relevant clinical outcomes in emergency department patients with various stages of sepsis: a prospective multi-center study. Critical care. 2015;19:194. PMID: 25925412

This is a prospective, multicentre observational cohort study including a total of 1,168 adult patients with sepsis (although their definition was anyone admitted to hospital with an infection who received IV antibiotics.) The overall mortality of their cohort was 10%, so significantly lower than the trials of severe sepsis we are used to. In this cohort, the length of time it took to give antibiotics was not associated with mortality. Much like the prior studies that showed a higher mortality in patients with delays to antibiotics, we must be aware of the mantra: association is not causation. In the current study, the delay to antibiotics might have been because patients had less severe infections. On the other hand, in prior studies in which antibiotic delays were associated with increased mortality, we might guess that patients were misdiagnosed or inappropriately dispositioned, which could be the true cause of increased mortality. Why did this study come to a different conclusion? One possibility is simply the timing of the studies. It is impossible to practice emergency medicine these days without a keen awareness of sepsis. This heightened awareness may lead to over-treatment in general, such that the few patients that don’t get early antibiotics really don’t require them.

Bottom line: Once you know there is a bacterial infection, obviously give antibiotics. However, there are many factors that will affect the timing of antibiotic administration and it should not be used as a quality of care metric.

We should probably just install CT scanners at triage

Claessens YE, Debray MP, Tubach F, et al. Early Chest CT-Scan to Assist Diagnosis and Guide Treatment Decision for Suspected Community-Acquired Pneumonia. Am J Respir Crit Care Med. 2015. PMID: 26168322

I think this paper is a little ridiculous and I include it only so you can ignore anyone who talks about it (including me, if you would like.) These authors enrolled 319 adult patients with clinically suspected community acquired pneumonia and subjected them to both a chest xray and a CT scan. Not surprisingly, the CT scan found what were interpreted as infiltrates in 33% of patients who had normal chest xrays. The CT findings were used to change management, both in terms of use of antibiotics as well as decision to admit, in a reasonable number of patients. However, it is not clear if any of those management changes were actually warranted. The authors want to use this data to conclude that patients suspected of community acquired pneumonia should all get CT scans. That is absolutely nutty. If we were missing 33% of clinically important pneumonias with current practice, our morgues would be full. Either these are tiny infiltrates that we fight off ourselves (after all, the human species has survived millennia without antibiotics), they are false positives, or we catch the pneumonia on a follow up xray 2 days later with a substantially lower radiation burden. (As a side note, be prepared for a similar problem of overdiagnosis in the many studies I assume will soon be published about using ultrasound for pneumonia, even if it has the advantage of no radiation.)

Bottom line: Just say no to CT scans for pneumonia

Glue works for abrasions too

Singer AJ, Chale S, Taylor M. Evaluation of a liquid dressing for minor nonbleeding abrasions and class I and II skin tears in the emergency department. The Journal of emergency medicine. 48(2):178-85. 2015. PMID: 25456777

This is an open label observational trial with no comparison group,using a convenience sample of 40 patients and 50 total wounds. The wounds were either abrasions or skin tears. They used a cheaper skin adhesive that has not been tested for tensile strength (unlike dermabond). If tensile strength was required, a steristrip was applied before the glue. In follow up, there were no infections and only one patient needed anything else: his glue peeled off on day 3 and he had bandage applied. Of course, with no comparison group, all we can say is “Mikey likes it”.

Bottom line: Glue works in skin. Perhaps there is a role for stocking the cheaper liquid bandaid products sold at drug stores?

A simple, life-saving therapy I didn’t know about

Jamtgaard L, Manning SL, Cohn B. Does Albumin Infusion Reduce Renal Impairment and Mortality in Patients With Spontaneous Bacterial Peritonitis? Ann Emerg Med. 2015. PMID: 26234193

I always find it funny that I finished residency with a head full of practices, like PPIs for GI bleeds, that are demonstrably unhelpful, but at the same time there are potentially life saving treatments that I have never heard about. Albumin for spontaneous bacterial peritonitis is one of those treatments. These authors report a systematic review and meta-analysis of RCTs studying albumin for SBP. In total they found 4 studies that include 288 patients with limited heterogeneity and no evidence of publication bias. Only 1 trial was blinded, but with a hard outcome of mortality that might be less important. The administration of albumin (the 2 largest trials made sure to give it within 6 hours, so this might be an ED therapy) was associated with less renal impairment (OR 0.21 95%CI 0.11-0.42) and lower mortality (OR 0.34 95%CI 0.19-0.60). Dosing varied among studies, but the largest trial used 1.5grams/kg IV at the time of diagnosis and 1gram/kg on day 3.

Bottom line: These are small numbers, but I will be giving albumin to SBP patients until we see more.

Diverticulitis is not necessarily a reason to promote antibiotic resistance

Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012 Apr;99(4):532-9. PMID: 22290281

I included the meta-analysis a few months back, but here is a multicentre RCT of 623 adult patients with CT confirmed uncomplicated diverticulitis (defined as lower abdo pain plus fever, an elevated WBC, and CT consistent with diverticulitis but no abscess or free air) randomized to either antibiotics or not. They used pretty big gun antibiotics: either a 2nd/3rd gen cephalosporin plus metronidazole or a carbapenem or piperacillin-tazobactam. There were no statistical differences between the groups. There were 3 perforations in each group. There were 3 abscesses in the no antibiotics group compared to none in the antibiotics group. 10 patients (3.2%) that started with no antibiotics were given antibiotics eventually. There were no differences in length of hospital stays or recurrent diverticulitis.

Bottom line: It may well be that we don’t need antibiotics for diverticulitis, but these patients were all treated as inpatients, so its probably not up to us to make that call.

Read enough and I might sound like an antibiotic nihilist

Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Annals of family medicine. 5(5):436-43. 2007. PMID: 17893386 [free full text]

I love this article, probably because it hits on two of my favorite soapbox topics: guidelines and antibiotics for sore throats. They searched for any major pharyngitis guidelines and found 10 from different countries and organizations. Two people individually coded each guidelines for all the major recommendations. The key finding of this paper is that despite all of these guidelines being “evidence based”, they arrive at wildly different recommendations. Several guidelines recommend prescribing antibiotics only if the patient is very sick or high-risk, but others suggest treating almost everyone. (If you want to find a guideline that tells you not to give antibiotics, look to Belgium, the Netherlands, England, or Scotland. Interestingly, these were the guidelines that were written by family doctors, as compared to specialists – I knew we had brains.) Not a single publication, including the Cochrane review, was cited by all the guidelines.

Bottom line: Unfortunately, guidelines are rarely an adequate source of evidence based clinical information. (Also, for most parts of the world, pharyngitis probably doesn’t need antibiotics.)

When is a clot a clot?

Morgan C, Choi H. BET 1: Do patients with a clinically suspected subsegmental pulmonary embolism need anticoagulation therapy? Emergency medicine journal : EMJ. 32(9):744-7. 2015. PMID: 26293150

What is the evidence for treating subsegmental pulmonary emboli? This review identified 2 observational trials that included patients with subsegmental PEs who were not anticoagulated. Of the total of 47 patients with untreated subsegmental PEs, none had recurrent venous thromboembolism at 3 months. It would not be surprising if the harms of anticoagulation outweighed the benefits, but 47 patients can’t give enough information to decide either way.

Bottom line: We still really don’t know what to do, but any treatment benefit is likely to be small.

Positive troponins are negative for patients

Hakemi EU, Alyousef T, Dang G, Hakmei J, Doukky R. The prognostic value of undetectable highly sensitive cardiac troponin I in patients with acute pulmonary embolism. Chest. 2015;147:(3)685-94. PMID: 25079900

This is a retrospective chart review of 298 patients with confirmed PEs looking at the prognostic value of a positive high sensitivity troponin. 45% of the group had a negative troponin and therefore 55% had a positive trop. If the troponin was negative, no patients died, needed CPR, or received lytics. Among those with a positive trop, 6% died and 9% had either CPR or lytics given. For a retrospective study, this one is more likely than usual to give us a correct answer as death, lytics, troponin, and to a lesser extent CPR are objective values that are likely to be accurately recorded on a chart.

Bottom line: It’s not surprising, but a positive troponin is likely a bad prognostic factor for PE patients.

Less relevant than the pee fish article?

Morgenstern J, Hegele RA, Nisker J. Simple genetics language as source of miscommunication between genetics researchers and potential research participants in informed consent documents. Public Underst Sci. 2015;24:(6)751-66. PMID: 24751688

This isn’t directly related to emergency medicine, but I was excited that after a few years of being “in press” the article based on my master’s thesis actually got published in print. This was a study that used qualitative methods to analyze the language of informed consent documents in genetics research. The main finding was that apparently simple, easy to understand language can be a source of miscommunication. This can occur because different people or groups of people will understand words differently. An example would be geneticists conceptualizing “disease” as an entity that may or may not cause actual symptoms in the future based on genetic predispositions, while their research participants may think of a “disease” as something they definitely have and will notice the effects of. Might this be applicable to emergency medicine? I think so, but without any good evidence. However, we know that when patients hear the words “congestive heart failure” they envision something that will kill within days – after all, their heart is failing – but this is not necessarily what we are trying to convey with those words. Similarly, we might talk about “low risk chest pain”, but different people might understand those words to indicate a 2% risk, or a 1 in a thousand risk, or a 1 in a million risk.

Bottom line: Communication is essential in emergency medicine. It is an area that probably deserves more attention.

Cheesy Joke of the Month

What is the difference between surgeons and God?

God doesn’t think he is a surgeon

FOAM resource of the month

A new site and podcast that I think will benefit all emergency physicians is:

Rather than being focused on clinical aspects of care, this site is run by Jason Brooks, a performance enhancement coach, with the goal of improving performance (both in the ED and in life in general) and making it sustainable. High level athletes have coaches, why shouldn’t we? I really enjoyed the first few podcasts.

Enjoy the free open access medical education? Think you know someone else who might? It would help me a lot if you spread the word and shared this resource with just one of your friends or colleagues. Even easier, you could also help by just clicking the like button on Facebook. Thank you so much!

Articles of the month (July 2015)

A monthly collection of the most interesting emergency medical literature I have encountered

Here is this month’s summary of my favorite reads from the medical literature.

Sick kids look sick

Vaillancourt S, Guttmann A, Li Q, Chan IY, Vermeulen MJ, Schull MJ. Repeated emergency department visits among children admitted with meningitis or septicemia: a population-based study. Ann Emerg Med. 2015;65:(6)625-632.e3. PMID: 25458981

This is a retrospective cohort of children 30 days to 5 years old who were hospitalized with the final diagnosis of either meningitis or septicemia. They were looking specifically at the children that had bounce backs. In total, 521 children were diagnosed with meningitis or septicemia, 114 (21.9%) of whom had been seen at a hospital in the 5 days prior to that diagnosis. The children all had similar mortality, lengths of stay, and critical care use whether you diagnosed them on the first visit or on the bounce back. Furthermore, meningitis and septicemia is very rare in pediatrics. There were a total of 511 cases in all of Ontario over the entire 5 years of this study. That is 511 out of 2,397,427 ED visits in this age group, or 0.02%, and you are only missing 20% of those on the first visit.

Bottom line: Emergency doctors are doing fine at diagnosing sick children. We don’t need fancy tests like CRPs or procalcitonins. Even if you miss the rare child, as long as you ensure good follow up, outcomes will be identical.

Green SM, Nigrovic LE, Krauss BS. Sick kids look sick. Ann Emerg Med. 2015;65:(6)633-5. PMID: 25536869

This is the excellent editorial that goes with the above paper. I just wanted to include a few quotes:

“A second explanation, simpler and more plausible, is that sepsis or meningitis was not present at the initial visit. The first diagnoses of nonserious viral or bacterial infections were not in error; however, after discharge these children had the rare misfortune of an unanticipated progression of illness.” Ie, don’t kick yourself too hard if you have a bounceback

“The study data of Vaillancourt et al suggest that, outside of the neonatal period, sepsis and meningitis are not occult conditions and that, accordingly, “sick kids look sick.” ”

“The status quo is working.”

“These results encourage emergency physicians to trust the power and value of their clinical gestalt.”

Dead? Kick him in the chest

Trenkamp RH and Perez FJ. Heel compressions quadruple the number of Bystanders who can perform chest compressions for ten minutes. Am J Emerg Med. 2015. In Print. PMID: not yet available

This is an observational study in which a convenience sample of 49 individuals, who acted as their own controls, were asked to perform 10 minutes of chest compressions, first in the standard fashion, then using their heel. They describe this process as: the shoeless rescuer straddles the patient’s head facing the patient’s feet, with one foot next to the patient’s ear and the heel of the other foot placed on the chest at the standard CPR point. (A video of this maneuver is provided.) Defining adequate compressions as 100-120 two inch compressions per minute, overall 16% were able to maintain manual compression at 10 minutes and 65% were able to do 10 minutes of heel compressions. Performance of both got worse with age.

Bottom line: If you are a lone bystander who will have to perform prolonged CPR, you might want to consider using your foot.

But might a machine be better than a kick in the chest?

Perkins GD, Lall R, Quinn T, et al. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet. 2015;385:(9972)947-55. PMID: 25467566

This is a prospective, randomized control trial of 4471 adult patients with out of hospital cardiac arrest, comparing mechanical CPR (the LUACS-2 device) to conventional CPR. There was no difference in return of circulation, or survival to hospital, at 30 days, at 90 days, or at 1 year. Personally, I find these results confusing. Although I am always biased to assume that new technologies are not going to be better than current practice (because they so rarely are), in this case we know that the one thing that matters for survival in cardiac arrest is consistent, good chest compressions. We also know that people tire and generally don’t provide great compressions, whereas the machine never tires. Based on that theory, the machine should clearly be better. Obviously we are missing something. Maybe it takes too long to get the machine on in the first place? Maybe no technology is capable of raising people from the dead?

Bottom line: There is no benefit to mechanical CPR, so don’t go blowing your budgets yet, but they are probably as good as manual CPR, so might be useful in certain specific scenarios (ongoing chest compressions during cardiac cath?)

Did everyone invest in CT scanners when I wasn’t looking?

Zonfrillo MR, Kim KH, Arbogast KB. Emergency Department Visits and Head Computed Tomography Utilization for Concussion Patients From 2006 to 2011. Acad Emerg Med. 2015. PMID: 26111921

This is a large database study looking at CT usage in concussion from 2006 to 2011 in the US. Overall, 0.5% of ED visits ended in a diagnosis of concussion. Although you might think we all know the CT head decision rules by now, the rate of CT in concussion increased by an absolute value of 11%. Conversely, the injury severity score decreased.

Bottom line: Although I though the CAEP choosing wisely choices were incredibly weak, because they should all already be part of basic good clinical practice, I will quote their first recommendation: Don’t order CT head scans in adults and children who have suffered minor head injuries (unless positive for a head injury clinical decision rule).

Should patients on warfarin should just have a daily head CT?

Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012;59:(6)460-8.e1-7. PMID: 22626015

This is a prospective observational trial of 1064 adult patients with blunt head trauma on either warfarin (768 patients) or clopidogrel (296 patients) designed to look for delayed intracranial hemorrhage. These were patients with relatively minor trauma, mostly ground level falls, and 88% having a GCS of 15 at the time of examination. 7% had a bleed on the first scan (12% if on clopidogrel and 5% on warfarin). No patients on clopidogrel and 4/687 (0.6% 95%CI 0.2-1.5%) of patients on warfarin had a delayed intracranial hemorrhage. The major limitation of this study is that not everyone had CT scans.

Bottom line: The rate of delayed intracranial hemorrhage after a normal CT is low. It almost certainly doesn’t warrant routine repeat scans or admissions, but good patient instructions and follow up are reasonable.

Diltiazem over metoprolol for atrial fibrillation. Surprised?

Fromm C, Suau SJ, Cohen V, et al. Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department. J Emerg Med. 2015. PMID: 25913166

This is a randomized, double-blind study comparing metoprolol (0.15mg/kg) and diltiazem (0.25mg/kg) in 106 adult patients with atrial fibrillation. The primary outcome of HR<100 at 30 minutes was achieved in 95.8% of the diltiazem group and 46.4% of the metoprolol group (p<0.0001). Diltiazem was better at all time points measured. There was no difference between in groups in term of adverse outcomes (hypotension or bradycardia).

Bottom line: Another small trial illustrating that calcium channel blockers are probably more effective than beta-blockers at controlling atrial fibrillation in the ED.

This doesn’t change anything: Asymptomatic hypertension still shouldn’t be treated in the ED

Levy PD, Mahn JJ, Miller J, et al. Blood pressure treatment and outcomes in hypertensive patients without acute target organ damage: a retrospective cohort. Am J Emerg Med. 2015. PMID: 26087706

A retrospective cohort of 1016 adult patients with a blood pressure greater than 180/110 and no signs or symptoms of acute organ damage. About 43% were given some kind of treatment, and there was no difference in ED revisits or mortality whether you were treated or not. Of course, this type of association doesn’t prove anything – maybe there was a reason some people were treated and others weren’t.

Bottom line: We still shouldn’t be treating (or working up) asymptomatic hypertension in the ED.

On that note, I might as well include the ACEP clinical policy:

Wolf SJ, Lo B, Shih RD, et al. American College of Emergency Physicians Clinical Policies Committee. Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 2013 Jul;62(1):59-68. PMID: 23842053

A few points from this policy (the policy contains only level C recommendations):

1) In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required.

2) In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required

Bottom line: (Cut and paste from above). We still shouldn’t be treating (or working up) asymptomatic hypertension in the ED.

We no communicate so good

Newman DH, Ackerman B, Kraushar ML, et al. Quantifying Patient-Physician Communication and Perceptions of Risk During Admissions for Possible Acute Coronary Syndromes. Ann Emerg Med. 2015;66:(1)13-18.e1. PMID: 25748480

This is a great paper by David Newman. They did paired surveys of patients being admitted to rule out ACS and their treating physicians to determine if patients and their physicians were on the same page with regards to the risk of MI (the reason the patient was being admitted). After having a conversation about admission, the patient and physician estimates of risk were only within 10% of each other 36% of the time. When asked about the chance of dying if an MI occurred at home, patients estimated the mortality at 80% compared to physicians estimates at 10%.

Bottom line: We do a poor job communicating to patients why we want to admit them to hospital. Without an understanding of their risk, patients cannot possibly make informed decisions that account for their own values and personal risk tolerance.

If you aren’t using bedside ultrasound, you probably also won’t be able to find this post on the internet, but congratulations on your upcoming retirement…

Stein JC, Wang R, Adler N, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Ann Emerg Med. 2010;56:(6)674-83. PMID: 20828874

This is a systematic review and meta-analysis that includes 10 studies of 2057 patients looking at the accuracy of emergency physician performed ultrasound for ectopic pregnancy. The sensitivity (patients with an ectopic who had no IUP on ultrasound) was 99.3%, with a negative predictive value of 99.9% in this population with a 7.5% incidence of ectopic pregnancy.

Bottom line: Bedside ultrasound is excellent for ruling out ectopic.

Whats the best way to keep a cast dry?

McDowell M, Nguyen S, Schlechter J. A Comparison of Various Contemporary Methods to Prevent a Wet Cast. J Bone Joint Surg Am. 2014;96:(12)e99. PMID: 24951750

This non blinded trial compared six methods of keeping casts dry. There were 2 commercial products, compared to a plastic bag with duct tape, double plastic bags with duct tape, a plastic bag with a rubber band, or glad cling wrap. The weighed the cast after submerging in water for 2 minutes (so more intense than a shower) to determine water absorption. Plastic wrap and a single bag with duct tape were the least effective. A double bag with duct tape was 100% effective, as were the commercial products.

Bottom line: Of easily available methods, double plastic bags and duct tape are probably the best for showering with a cast.

Everything you could ever want to know about anal fissures

Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012;2:CD003431. PMID: 22336789

This cochrane systematic review of the medical management of anal fissures covers 75 trials and 5031 patients of different medical therapies. Topical nitroglycerin increased early cure rates from about 35% to 49% compared to placebo, an NNT of 7, but about half of patients had late relapses. No conclusions can be made about calcium channel blockers or botox, because all studies were severely under-powered. Surgical therapy (which I have never referred for) was significantly better than any medical therapy, but does have a small risk of incontinence.

Bottom line: There is poor evidence for any medical therapy. In patients with chronic problems, surgical therapy should be considered.

Your kid rolled in poison ivy – what do you do?

Stibich AS, Yagan M, Sharma V, Herndon B, Montgomery C. Cost-effective post-exposure prevention of poison ivy dermatitis. Int J Dermatol. 2000;39:(7)515-8. PMID: 10940115

I didn’t know that you could prophylactically treat poison ivy after coming into contact with the plant, but before developing a rash. 20 healthy “volunteer” medical students were used them as their own controls. They exposed the students to poison ivy at 4 different spots. 2 hours later, the applied 0.5ml of either dial dish soap, Tecnu (a commercial product designed to chemically inactivate poison ivy), or Goop (a commercial cleaning product), and then rinsed the skin. They left the 4th area untouched as a control (but for some reason didn’t even rinse it off – just left it covered.) All three products were similar, but seem to decrease severity of the rash as compared to control. Ii was unclear if the study was blinded in any way.

Bottom line: If you touch poison ivy, it may be worth putting dish soap on the area and then cleaning thoroughly.

Lidocaine for limb pain – no, not a nerve block

Vahidi E, Shakoor D, Aghaie Meybodi M, Saeedi M. Comparison of intravenous lidocaine versus morphine in alleviating pain in patients with critical limb ischaemia. Emerg Med J. 2015;32:(7)516-9. PMID: 25147364

Like low dose ketamine, although to a lesser extent, I have heard a lot about using IV lidocaine for pain control this past year. This is a small RCT of 40 patients with ischemic limbs comparing IV morphine (0.1mg/kg) and IV lidocaine (2mg/kg). In patients with pain starting at 7.5/10, pain in the lidocaine group was better at 15 minutes (5.75/10 vs 7/10) and 30 minutes (4.25/10 versus 6.5/10), although those numbers may not be clinically significant.

Bottom line: Intravenous lidocaine may be an option for pain, but I am not sure when or why I would use it.

There is no such thing is a free lunch

Solomon RC. Coffers brimming, ethically bankrupt. Ann Emerg Med. 2012;59:(2)101-2. PMID: 22078890

An older editorial, but worth a read. The summary is that although we make a lot of excuses for why we take money from drug companies, none are any good. As individuals and as a group, we must just stop.

Bottom line: I will say it again. There is no such thing as a free lunch.

Patient with a PE – do you admit, send them home, or get them to the gym?

Lakoski SG, Savage PD, Berkman AM, et al. The safety and efficacy of early-initiation exercise training after acute venous thromboembolism: a randomized clinical trial. J Thromb Haemost. 2015;13:(7)1238-44. PMID: 25912176

A very small randomized, controlled trial that included 19 patients with PE, 9 of whom were randomized to a 3 month program including exercise and weight loss. They commit a cardinal sin by claiming to have multiple primary outcomes, but it looks like the exercise group lost weight and was more fit as compared to the usual care group. Of course, a grain or two of salt is required, but it looks like an interesting area for future research.

Bottom line: In the future, we may seen an equivalent to cardiac rehab for our PE patients. For now, I recommend all my patients exercise.

Completely irrelevant to medicine, but maybe the most useful information of the month: flight delays

When to fly to get there on time? Six million flights analyzed. Decision Science News. 2015.

This is a database study that looked at all the flight data in the United States for the year of 2013 to determine when you are most likely to be delayed. Not surprisingly, the later your flight is in the day, the longer a delay you can expect, until about 10pm, when the delays start to fall again. There are some graphs you can look at.

Bottom line: For the next conference you book (like say SMACC in Dublin next year), try to book your flight early in the morning if you don’t want to be delayed.

Cheesy Joke of the Month

Why can’t you tell when a pterodactyl is going to the bathroom?

Because their P is silent

FOAMed of the month

The world of critical care and open access medical education suffered an incredible loss this month with the passing of Dr. John Hinds. He was one of the most inspirational individuals I have encountered in my life, and although I only shook his hand a single time, his words have forever changed me.

It is hard to pick just one of this many incredible talks, but I know both my wife and I were blown away by his keynote speech at the SMACC conference in Chicago: “Crack the chest and get crucified”: