Articles of the month (January 2016)

Welcome to another edition of the First1oEM articles of the month – a collection of my favorite reads from the emergency medicine literature.

Location, location, location

Drennan IR, Strum RP, Byers A et al. Out-of-hospital cardiac arrest in high-rise buildings: delays to patient care and effect on survival. Canadian Medical Association Journal. 2016. [article]

This was a retrospective study looking at a cardiac arrest registry. They decided to look at the floor that you lived on to see if it impacted your survival from cardiac arrest (with the primary analysis looking above or below the 3rd floor). They found that living on higher floors was associated with an increased likelihood of death. In the raw numbers, 4.2% of patients living below the 3rd floor survived, compared to only 2.6% of those living on or above the 3rd floor (p=0.002). Survival above floor 16 was only 0.9%, and no one living above the 25th floor survived. The theory is that higher floors mean longer delays to EMS arrival, and therefore the ever important chest compression and defibrillation.

Bottom line: Choose your home wisely


 What’s the best antibiotic to bring on your trip to Las Vegas?

Geisler WM, Uniyal A, Lee JY. Azithromycin versus Doxycycline for Urogenital Chlamydia trachomatis Infection. The New England journal of medicine. 373(26):2512-21. 2015. PMID: 26699167

This is a randomized, controlled non-inferiority trial comparing azithromycin (1 gram PO once) to doxycycline (100mg PO BID for 7 days) in 587 adolescents with chlamydia infections. For the primary outcome of treatment failure at 28 days, there were no treatment failures in the doxycycline group as compared to 5 (3.2% 95%CI 0.4-7.4%) in the azithromycin group. Based on their assumptions, they could not establish the noninferiority of azithromycin in this group, although I imagine the result will vary greatly depending on local resistance patterns.

Bottom line: I will continue using doxycycline as my first line agent


 The Quixotic quest for the chest pain decision rule

Greenslade JH, Parsonage W, Than M. A Clinical Decision Rule to Identify Emergency Department Patients at Low Risk for Acute Coronary Syndrome Who Do Not Need Objective Coronary Artery Disease Testing: The No Objective Testing Rule. Annals of emergency medicine. 2015. PMID: 26363570

We would all love a good rule to use to send chest pain patients home. This is a secondary analysis of 2 prior prospective ED trials including a total of 2396 chest pain patients. They derive 3 different rules that are supposed to tell you which patients don’t need further testing after biomarkers and ECGs. (Of course, if you have listened to me in the past, you will know that stress testing is not helpful in our low risk chest pain patients.) I am not going to go into the rules themselves, because I think the study is too flawed to be helpful. Incorporation bias is the major downfall of this study. Classic cardiac risk factors are a large component of these rules, but previous research has consistently shown that having classic cardiac risk factors does not help predict whether a patient’s chest pain is ACS in the emergency department. So how could those risk factors possibly help in a decision rule? It’s because the definition of ACS included unstable angina and revascularization, both of which are subjective outcomes determined by the cardiologist, and the cardiologists had access to the risk factor information. A patient with 5 risk factors is more likely to be cathed, but that doesn’t mean the cath was necessary. Similarly, a patient with more risk factors is more likely to be given the diagnosis of unstable angina. The risk factors didn’t predict the diagnosis of ACS, they were the cause of it.

Bottom line: It is unlikely that we will find easy decision tools for chest pain patients, but for the time being we should be happy that most patients are so low risk that they should be sent home without stress testing.


 How prepared are you to run a neonatal resuscitation?

Yamada NK, Yaeger KA, Halamek LP. Analysis and classification of errors made by teams during neonatal resuscitation. Resuscitation. 96:109-13. 2015. [pubmed]

I like the idea here: these authors videotaped a total of 250 real neonatal resuscitations and reviewed the tape to determine how well the neonatal resuscitation algorithm was followed. Continuous quality improvement in our most stressful resuscitations makes sense. These authors report that 23% of the actions observed were errors as compared to the published algorithm. However, I don’t think the errors were truly important errors. The most common error was failure to have a cap to place on the child’s head – is that really essential in the first minutes of resuscitation of an apneic neonate? There were some important errors reported, though, with half of the 12 intubation attempts lasting longer than 30 seconds. Although I don’t think this study really demonstrates it, neonatal resuscitations are stressful and rapid paced, making errors probable. Mental practice and simulation are great tools to help prevent these errors, in my very biased opinion.

Bottom line: Quality improvement in your most stressful resuscitations is a good idea. 

If you want to review the newest NRP guidelines, you can see my post here.


Best treatment for pediatric gastro? Prevention

Soares-Weiser K, Maclehose H, Bergman H. Vaccines for preventing rotavirus diarrhoea: vaccines in use. The Cochrane database of systematic reviews. 11:CD008521. 2012. PMID: 23152260

This is a Cochrane systematic review of two different vaccines (monovalent versus pentavalent) for rotavirus. They identified 29 RCTs covering 101,671 infants for the monovalent vaccine and 12 RCTs covering 84,592 infants for the pentavalent vaccine. Unfortunately, most studies use the relatively non-sensical “rotavirus specific diarrhea” as an endpoint, but it definitely seems to be decreased (RR 0.33 95% CI 0.21-0.50 for the monovalent). All cause diarrhea was also decreased in the trials that looked at it, with an NNT of about 40 for any diarrhea and 100 to prevent a hospitalization. There was no change in mortality. They did not document an increase in adverse reactions, but efficacy studies often under report harms.

Bottom line: The rotavirus vaccine prevents serious diarrhea – maybe that’s an easier sell than the measles?


 Overtreatment and anticoagulation for atrial fibrillation

Hsu JC, Chan PS, Tang F, Maddox TM, Marcus GM. Oral Anticoagulant Prescription in Patients With Atrial Fibrillation and a Low Risk of Thromboembolism: Insights From the NCDR PINNACLE Registry. JAMA internal medicine. 175(6):1062-5. 2015. PMID: 25867280

With the rise of the new, expensive anticoagulants, we are beginning to see a push to get these agents started for atrial fibrillation patients in the emergency department, ignoring the tiny daily risk of stroke and the importance for long term monitoring that we cannot provide. This is a registry based study. Out of a total of about 360,000 atrial fibrillation patients in the study, 11,000 had a score of 0 on two major stroke scales. However, 25% of this extremely low risk population was on blood thinner contrary to current guidelines.

Bottom line: We over treat patients. For everything. Remember that studies are generally the best possible scenario for medications, and that results in the real world will be worse as we expand treatment to patients who would not have been included in the studies. (If you want to watch this happen in real time, just watch interventional treatment for stroke over the next few years.)


Zika

Fauci AS, Morens DM. Zika Virus in the Americas – Yet Another Arbovirus Threat. The New England journal of medicine. 2016. PMID: 26761185 [free full text]

This is a basic review of the Zika virus that is currently causing a significant pandemic through Central and South America, and has potentially been linked to a significant number of birth defects (microcephaly) in Brazil. Zika is another mosquito borne virus without a specific treatment (like Dengue or Chikungunya). The symptoms are described as a milder version of Dengue fever, with fever, myalgias, eye pain, and maculopapular rash. Treatment is supportive.

Bottom line: Another emerging illness to be aware of in the returned traveller.

The CDC has issued a travel advisory advising pregnant women to postpone travel to areas in which Zika transmission is occurring.


Can you really multitask?

Skaugset LM, Farrell S, Carney M. Can You Multitask? Evidence and Limitations of Task Switching and Multitasking in Emergency Medicine. Annals of emergency medicine. 2015. PMID: 26585046

Emergency physicians are masters of multitasking – or so we think. This review explains that most of what we think of as multitasking is really rapidly switching between tasks, and even if you are good at it, this task switching slows you down and results in error. Unfortunately, the solution promoted in most other fields – limiting interruptions – just isn’t feasible in emergency medicine. Some suggestions this review makes to help: prioritize tasks according to acuity, recognize when interruptions can be delayed or redirected, practice skills so they become automatic (and don’t add to cognitive load), and use mental frameworks or external brains to limit cognitive work. Of course, optimizing your departmental workflow to limit interruptions, especially at critical times, is also important.

Bottom line: There is no such thing as multitasking, just rapid task-switching.


 Should we add TXA to the water supply?

Fox H, Hunter F. BET 1: Intravenous tranexamic acid in the treatment of acute epistaxis. Emergency medicine journal : EMJ. 32(12):969-70. 2015. PMID: 26598634

This is another one of those situations that we have to make decisions in the absence of any real evidence. The authors of this review were unable to find any studies to answer their specific question about the use of IV TXA in acute epistaxis. However, they do note that there are a few studies that show benefit of oral TXA in epistaxis as well as the study of topical TXA that I have previously discussed in this newsletter. Furthermore, the use of intravenous TXA in elective sinus surgery seems to limit blood loss, and we all know about the evidence for IV TXA in trauma. So there is no direct evidence, but plenty of reasons we might guess it could help.

Bottom line: I have never used IV TXA for epistaxis, but use it topically all the time. You can bet if I have a patient with severe epistaxis, I will give it a shot.


 Much like TXA, I love skin glue

Bugden S, Shean K, Scott M. Skin Glue Reduces the Failure Rate of Emergency Department-Inserted Peripheral Intravenous Catheters: A Randomized Controlled Trial. Annals of emergency medicine. 2015. PMID: 26747220

Tape and tegaderm has always seemed like a rather ineloquent method of securing IVs to me. In this non-blinded RCT of 380 peripheral IVs, they compared standard tegaderm and tape to skin glue (1 drop at the skin insertion site and one under the hub – this can be seen in this video.) For the primary outcome of IV failure (infection, phlebitis, occlusion, or dislodgement) at 48 hours, the skin glue was better (17% failure vs 27%, absolute difference 10% 95%CI 2-18%). The study was underpowered to assess the components of the composite outcome, but most of the failures were dislodgement. I don’t follow people for 48 hours – but a 27% failure rate with usual care seems high to me. Also, skin glue is likely more expensive. However, an NNT of 10 to avoid another IV stick would probably be attractive to many patients.

Bottom line: Skin glue is an option for securing PIVs – maybe difficult ones you really care about?


 I love ultrasound for looking at things, but for breaking up clots?

Piazza G, Hohlfelder B, Jaff MR. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study. JACC. Cardiovascular interventions. 8(10):1382-92. 2015. PMID: 26315743

This is a large prospective study, but I won’t get too much into the details because their primary outcomes were a bunch of surrogate markers rather than patient important outcomes. Why included it then? They used a novel device that uses ultrasound to try to break up the PE, and then gave tPA at the very slow rate of 1mg/hr. So far the lytics for submassive PE trials have shown some promise, but aren’t convincing. Alternate methods (non-bolus) of giving the medication might be the thing that tip the balance in favour of lytics. But mostly I wanted to include this article to bring up two excellent blog posts written by Josh Farkas about ultrasound guided thrombolysis and controlled thrombolysis of submassive PE.

Bottom line: My guess is that we will find that lytics are beneficial in submassive PE over the coming years, once we find the correct subset of patients and the best dose. (This is a big departure for me, because I am much more used to saying that things won’t work. That is almost always the safer bet.)


 Ondansetron and the dreaded QT

Moffett PM, Cartwright L, Grossart EA, O’Keefe D, Kang CS. Intravenous Ondansetron and the QT Interval in Adult Emergency Department Patients: An Observational Study. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 23(1):102-5. 2016. [pubmed]

Droperidol, possibly the most useful medication I have never had the opportunity to use, was taken away because of what it could do to the QT interval, right around the time when ondansetron was coming to market. Then, as ondansetron was coming off patent, we found out that it prolonged the QT just like droperidol did. OK, I will take off my tin foil hat to write the rest of this. This is a prospective observational trial of 22 adult patients receiving ondansetron at a single hospital. They did ECGs at baseline and every 2 minutes for 20 minutes. The QT did lengthen by 20 msec (95% CI 12-26 msec), but this is almost certainly clinically insignificant. There were no adverse events.

Bottom line: Yes, ondansetron will prolong the QT. No, it won’t be a problem. (Maybe avoid it if the patient overdosed on methadone, lithium, and haldol and tells you he has a family history of congenital long QT syndrome.)


 But little Johnny just aint right

Nishijima DK, Holmes JF, Dayan PS, Kuppermann N. Association of a Guardian’s Report of a Child Acting Abnormally With Traumatic Brain Injury After Minor Blunt Head Trauma. JAMA pediatrics. 169(12):1141-7. 2015. PMID: 26502172

I’ve included papers on the low risk of significant head injuries in children with isolated vomiting and isolated loss of consciousness before. This time we will look at whether parental concern that their child is acting abnormally, in isolation, is indicative of blood in the brain. This is another secondary analysis of the PECARN database. Out of 43,399 children in the original study, only 1297 were reported as acting abnormally. Of those, 411 (32%) had abnormal behaviour as their only finding. Only 1 child of these 411 had a clinically significant injury (0.2% 95% CI 0-1.3%). Of the smaller subset who had CTs performed, 4 out of 185 (2.2%) had any sign of traumatic brain injury. So injuries were rare, even when the parents report the child is not behaving normally.

Bottom line: Once again, you have to evaluate the entire patient, not just single variables. Observation is probably a better test than CT.


 How good is the ECG for hyperkalemia?

Montague BT, Ouellette JR, Buller GK. Retrospective review of the frequency of ECG changes in hyperkalemia. Clinical journal of the American Society of Nephrology : CJASN. 3(2):324-30. 2008. PMID: 18235147 [free full text]

Remember memorizing the classic progression of ECG changes in hyperkalemia: peaked Ts, prolonged PR, flatted Ps, wide QRS, then the deadly sine wave? Well, forget it. This is a chart review that looks at the ECGs of 90 hyperkalemic patients. (This is actually a reasonable topic for chart review, given that both the potassium level and the ECG are likely to be objective and easily identified on the chart.) Only half of the patients had any ECG signs of hyperkalemia, and only 18% met their strict criteria (which meant peaked Ts that were documented to resolve as the potassium decreased.) Although the ECG was insensitive for hyperkalemia, that might not be the important question. I don’t care as much about the number of the potassium, but whether it is affecting the heart – and the ECG might be a better marker of cardiac outcomes, but we don’t know from this study.

Bottom line: The ECG is not sensitive for hyperkalemia.


 A guideline that say something sensical? I must be dreaming

Kearon C, Akl EA, Ornelas J et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline. Chest. 2016. [free full text]

This is a new guideline from the American College of Chest Physicians covering antithrombotic therapy for VTE. The recommendation to know about: “For subsegmental PE and no proximal DVT, we suggest clinical surveillance over anticoagulation with a low risk of recurrent VTE (Grade 2C).” That’s right – they are suggesting NOT treating certain PEs! They also recognize the high false positive rate of CTPA, which I have discussed here before. When is a subsegmental PE likely to be a true positive? “We suggest that a diagnosis of subsegmental PE is more likely to be correct (i.e. a true-positive) if: (1) the CT pulmonary angiogram (CTPA) is of high quality with good opacification of the distal pulmonary arteries; (2) there are multiple intraluminal defects; (3) defects involve more proximal sub-segmental arteries (i.e. are larger); (4) defects are seen on more than one image; (5) defects are surrounded by contrast rather than appearing to be adherent to the pulmonary artery; (6) defects are seen on more than one projection; (7) patients are symptomatic, as opposed to PE being an incidental finding; (8) there is a high clinical pre-test probability for PE; and D-Dimer level is elevated, particularly if the increase is marked and otherwise unexplained.” The best way to avoid this dilemma all together is still to avoid ordering CTs in low risk patients.

Bottom line: Not all PEs are really PEs. Not all PEs require treatment.


 Speaking of which

Nielsen HK, Husted SE, Krusell LR. Anticoagulant therapy in deep venous thrombosis. A randomized controlled study. Thrombosis research. 73(3-4):215-26. 1994. PMID: pubmed

I may have included this one before. Its really the only RCT of anticoagulation for VTE that exists as far as I know. This is a prospective, randomized trial of 90 patients with proven, symptomatic DVTs comparing anticoagulation (heparin followed by warfarin) with an NSAID (phenylbutazone). All the patients had VQ studies performed, both initially and for follow up. About half of the patients had PEs (asymptomatically). There was no difference between the groups with regards to regression of DVT, recurrent DVT, or PE up to 60 days. In terms of mortality, there was one death in the anticoagulation group and none in the NSAID group. The only difference was that the anticoagulation group had an 8% rate of bleeding complications while they report no adverse events from the NSAID. Now this is a small and imperfect study – but quite amazingly, it’s the only real study of anticoagulation for VTE, and it’s negative!

Bottom line: In the only RCT of anticoagulation in DVTs (half of whom had PEs), there was no difference between using an anticoagulant or an NSAID. I know which I would prefer.


 You thought diagnostics was difficult? How about pain caused by analgesics?

Tabner A, Johnson G. Codeine: An Under-Recognized and Easily Treated Cause of Acute Abdominal Pain. The American journal of emergency medicine. 33(12):1847.e1-2. 2015. PMID: 25983269

I have no idea what to do with this one. They present 2 case reports of patients with abdominal pain in whom the ultimate diagnosis was sphincter of Oddi spasm secondary to codeine use. Both patients’ pain resolved rapidly with naloxone (400mcg), which is not one of my usual analgesics. But how should we use this information? I imagine that you could do a lot of harm trying to treat abdominal pain with naloxone. This is definitely an interesting diagnosis – and one that I have never seen, or at least recognized.

Bottom line: Maybe one more reason that codeine should not be used


 Back pain? Do we really have to talk about back pain? Ugh

Friedman BW, Dym AA, Davitt M. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA. 314(15):1572-80. 2015. PMID: 26501533

It’s sort of frustrating that trial after trial comes out telling us nothing really works for low back pain. Obviously we need to do something for our patients. This is a randomized, double-blind, placebo controlled trial comparing naproxen plus placebo to naproxen plus cyclobenzaprine and to naproxen plus oxycodone and acetaminophen in adults with acute non-traumatic lumbar back pain. For the primary outcome of a scale measuring pain and function, there was no difference between the groups. There were more adverse effects in the cyclobenzaprine and oxydodone/acetaminophen groups. The biggest weakness of this study was that there was relatively poor compliance with all treatment regimens, but that makes it more like real life.

Bottom line: Naproxen monotherapy is probably better. Adding cyclobenzaprine or oxycodone/acetaminophen just increases adverse effects.


 Sir, you have a severe antibiotipenia – we need to start an infusion, STAT

The BLISS trial: Abdul-Aziz MH, Sulaiman H, Mat-Nor MB. Beta-Lactam Infusion in Severe Sepsis (BLISS): a prospective, two-centre, open-labelled randomised controlled trial of continuous versus intermittent beta-lactam infusion in critically ill patients with severe sepsis. Intensive care medicine. 2016. PMID: 26754759

This wasn’t even on my radar: should we be giving antibiotics (specifically beta-lactams) as a continuous infusion? I know, we all heard about time dependent versus dose dependent antibiotics in medical school, but I honestly thought that was useless pharmacological drivel, because the studies I have seen so far have indicated that dosing regimen doesn’t matter much when we are giving antibiotics. (Maybe because we are giving so many antibiotics to people who really don’t need them?) Anyhow, on to the study: this was a prospective, randomized, open-label study of 140 adult ICU patients with severe sepsis being treated with cefepime, meropenem, or piperacillin/tazobactam. They were randomized to either receive their antibiotics as a continuous infusion, or by the usual intermittent dosing. The primary outcome was clinical cure, and was lower in the continuous group (56% vs 34%; absolute difference 22% 95%CI 10-40%, p=0.011). Unfortunately, I’m not sure that is the most important outcome, and the study wasn’t powered for mortality, so there was no significant mortality difference despite the numbers being better in the continuous group.

Bottom line: Continuous administration of beta-lactam antibiotics is interesting, and definitely warrants further study focusing on mortality differences


 Want to see how quickly I can contradict myself?

Dulhunty JM, Roberts JA, Davis JS. A Multicenter Randomized Trial of Continuous versus Intermittent β-Lactam Infusion in Severe Sepsis. American journal of respiratory and critical care medicine. 192(11):1298-305. 2015. PMID: 26200166

Hold your horses. The previous study was open-label, but there is another, larger study that was double-blinded. This is a double-blind, double-dummy multi-center randomized controlled trial of 432 ICU patients with severe sepsis being treated with meropenem, ticarcillin-clavulanate, or piperacillin-tazobactam, again comparing continuous versus intermittent dosing. For the primary outcome, ICU free days alive at day 28, there was no significant difference between the groups (18 vs 20 day, p=0.38). 90 day mortality was also the same, 26% in the continuous group vs 28% with intermittent antibiotics (p=0.67). So was the previous study just an example of the bias that can occur with open-label studies, or might there be a small but real difference that these studies were just under-powered to detect?

Bottom line: This will require a massive trial to answer definitively. For now, intermittent dosing is just so much easier that it should probably remain the preferred method of antibiotic administration.


Cheesy Joke of the Month

Why did the scarecrow get an an award?

He was outstanding in his field


 

#FOAMed of the month

We vastly overestimate the benefits of many of the medications that we tell our patients are essential. As a result, you can hear many of the elderly coming well before you see them from the rattle of all the pills. A large percentage of emergency department visits are from medication side-effects, but most of these are misdiagnosed. So although this tool was designed more for family physicians, I think it probably has a role in emergency medicine as well

Medstopper: http://medstopper.com/

This is a tool developed by some very intelligent Canadian doctors (including the team behind another amazing FOAMed resource: The Best Science Medicine podcast) to help clinicians and patients make decisions about reducing or stopping medications. The thing I miss most about family medicine was the ‘drugectomy’: it was astounding how many patients would feel so much better just because we stopped a few of their less necessary or unnecessary medications.

Articles of the month (December 2015)

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

Another month and another set of articles proving only that I probably should have spent more time Christmas shopping and less reading journals. Enjoy…

Peripheral thermometers mostly suck, but does it matter?

Niven DJ, Gaudet JE, Laupland KB, Mrklas KJ, Roberts DJ, Stelfox HT. Accuracy of Peripheral Thermometers for Estimating Temperature: A Systematic Review and Meta-analysis. Annals of internal medicine. 163(10):768-77. 2015. PMID: 26571241

I will start this month with a paper just for my friend Dr. Scott Kapoor. This is a systematic review and meta-analysis of 75 studies encompassing 8682 patients looking to compare the accuracy of peripheral thermometers to central thermometers. The peripheral thermometers are not very accurate, especially if you look at hypo or hyperthermia. If you take the core temperature as the gold standard, the peripheral thermometers had a pooled sensitivity and specificity of 64% (95%CI 55-72%) and 96% (95%CI 93-97%) respectively for fever. I don’t have access to the appendices to look at the raw data, but the authors report that all peripheral thermometers were equally bad, with axillary probably being the worst. So sorry Scott, it’s not just the temporal artery thermometers that don’t work, it’s everything peripheral. Luckily, for the vast majority of people being triaged, temperature is irrelevant. For patients you care about, you probably should recheck a core temp.

Bottom line: There is a very good chance peripheral thermometers will miss a fever.


If all your friends jumped off a bridge…

Douketis JD, Spyropoulos AC, Kaatz S. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. The New England journal of medicine. 373(9):823-33. 2015. PMID: 26095867 [free full text]

We frequently admit patients on anticoagulants who will require surgery or procedures that require their anticoagulants to be held. Should we be bridging these patients with some kind of heparin? This is a randomized controlled trial of 1884 adult patients with chronic atrial fibrillation and at least 1 CHADS2 risk factor undergoing surgery (excluding cardiac, neuro, and spinal surgeries). They were randomized to either bridging with dalteparin or placebo. Patients were excluded if the had a mechanical heart valve, recent stroke, or renal failure. The primary outcome of any arterial thromboembolic disease was noninferior, with 4 patients (0.4%) in the non-bridged group and 3 patients (0.3%) in the bridged group having events. Major bleeding was higher in the bridged group (29 patients (3.2%) versus 12 patients (1.3%) p=0.005 NNH=53). Minor bleeding was also increased (20% versus 12%, p<0.001, NNH=11).

Bottom line: This is probably the best evidence to date that the short term risk for atrial fibrillation patients off anticoagulation is low and that bridging therapy is harmful.

Steinberg BA, Peterson ED, Kim S. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation. 131(5):488-94. 2015. PMID: 25499873 [full free text]

This is a retrospective look at a large atrial fibrillation patient registry. They looked at the 2803 patients with non-valvular atrial fibrillation who had an interruption in their anticoagulation, primarily for non-cardiac surgery or endoscopy. 77% of patients were not bridged as compared to 23% who were. Overall adverse events were higher in the bridging group (5.3% versus 2.8% p=0.01), primarily driven by excess bleeding complications. Stroke and MI were not different between the groups. Of course, patients were not randomized, so there were likely reasons that physicians chose to bridge some patients and not others, making any concrete conclusions difficult.

Bottom line: More evidence that bridging is not helpful

As a side note, if all my friends jumped off a bridge, you can bet that I would too. My friends are all sane and mostly intelligent. If they were jumping off a bridge, there is probably a very good reason to do so, like the bridge is on fire or there is rapidly approaching school of flying sharks with lasers on their heads. Also, even if they happened to die, who wants to live in a world where all your friends just died jumping off a bridge?


OK, those were boring topics. Let’s move on: anyone have a VIP guest in the department this holiday season?

Straube S, Fan X. The occupational health of Santa Claus. Journal of occupational medicine and toxicology (London, England). 10:44. 2015. PMID: 26692887 [free full text]

Sadly, this article was a little boring even for a Christmas spoof – but have you ever considered the extreme occupational hazards of Santa Claus? Don’t be surprised if he ends up in an ED near you sometime soon.


Christmas: so many new toys, with so many small parts. It’s the perfect storm for foreign bodies in the airway

Eren S, Balci AE, Dikici B, Doblan M, Eren MN. Foreign body aspiration in children: experience of 1160 cases. Annals of tropical paediatrics. 23(1):31-7. 2003. PMID: 12648322

This is a retrospective review of 1160 children (under 15 years of age) who underwent bronchoscopy for foreign bodies. Almost 2/3rds of the patients with foreign bodies had negative radiography. (There is obviously a selection bias here, because these are only the children in whom the clinicians were concerned enough to perform a bronchoscopy). I will also note that this is an interesting population, because 38% of the foreign bodies were watermelon seeds. However, with a good story, xray is clearly not good enough to exclude foreign bodies.

Bottom line: It is often a difficult sell, but if a child has a good story for aspiration, they probably need a bronchoscopy.


 High flow nasal oxygen in the ED

Bell N, Hutchinson CL, Green TC, Rogan E, Bein KJ, Dinh MM. Randomised control trial of humidified high flow nasal cannulae versus standard oxygen in the emergency department. Emergency medicine Australasia : EMA. 2015. PMID: 26419650

This is an unblinded prospective randomized control trial comparing high flow nasal oxygen to standard care (nasal prongs or face mask) in 100 adult emergency department patients with shortness of breath, a respiratory rate over 24 and an oxygen saturation less than 94%. There were 2 primary outcomes, which is not good from a trial design perspective. For the outcome of a reduction in respiratory rate by 20% within 2 hours, the high flow nasal group was better (66.7% vs 38.5%, p=0.005). For the outcome of an escalation of ventilation requirement, the reported outcomes are less clear, because they included being changed from face mask to high flow nasal oxygen as an “escalation of care”, even though this trial is supposed to be determining if it is any better. Two patients in each group required non-invasive positive pressure ventilation, and one patient was intubated. So I would say there was no change in patient oriented outcomes except the single intubation, and a single outcome is just not enough to draw any conclusions from.

Bottom line: Not a lot to go on here, but it doesn’t look like high flow nasal oxygen will be worse than usual care.


 One step closer to forgetting antibiotics in diverticulitis

Isacson D, Thorisson A, Andreasson K, Nikberg M, Smedh K, Chabok A. Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study. International journal of colorectal disease. 30(9):1229-34. 2015. PMID: 25989930

I have previously talked about the few RCTs indicating that antibiotics might not help in diverticulitis. It is an interesting topic, so I will include new evidence as I find it. This is a prospective cohort of 155 adult patients diagnosed with acute uncomplicated diverticulitis who were managed as outpatients without antibiotics, just pain control and a diet progressing from liquids back to full, as tolerated. Of the 155 patients, only 4 patients (2.5%) failed this outpatient management strategy – which isn’t much different from what you would expect if they had been treated with antibiotics. The biggest problem with this data set is that it doesn’t represent consecutive patients. 66 patients with uncomplicated diverticulitis were seen during the study period but were not enrolled, so there could be some selection bias. There was no control, so antibiotics could have lowered complication rates further – but for the 97.5% of patients without complications, it doesn’t seem that antibiotics were necessary.

Bottom line: A little more evidence indicating that antibiotics may be unnecessary for diverticulitis after all.


 How do fish get high? Seaweed

Vandrey R, Raber JC, Raber ME, Douglass B, Miller C, Bonn-Miller MO. Cannabinoid Dose and Label Accuracy in Edible Medical Cannabis Products. JAMA. 313(24):2491-3. 2015. PMID: 26103034 [free full text]

With legal marijuana on the horizon in Canada, there are many questions we need to be asking about its use. One very basic question is: at current marijuana dispensaries, how accurate are labels with regards to THC content? Individuals were sent out to buy marijuana in San Francisco, Los Angeles, and Seattle, and the THC content was analyzed by liquid chromatography. Of 75 total samples, 13(17%) were accurately labelled, 17(23%) were under-labelled (contained more THC than the label stated), and 45 (60%) were over-labelled. Errors were frequently large, up to 55% under labelled and 99% over labelled. Combined with confusion over appropriate doses, highly concentrated doses in edibles, and differing rates of absorption, dosing errors make it more likely that marijuana users will end up in the ED.

Bottom line: Active ingredients in marijuana products are not well regulated or labelled on available products.


Monthly poll: Who would want this ENT surgeon as their own doctor?

Leopard DC, Williams RG. Nasal Foreign Bodies: A Sweet Experiment. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery. 40(5):420-1. 2015. PMID: 25639608

There are many techniques to get foreign bodies out of children’s noses, but what do you do if they don’t work? Well, if it’s a hard candy, you may not need to do anything. This (presumably bored) ENT surgeon placed 5 different candies in his own nose (Fizzers, Tic Tac, Smarties, Skittles, and Polo mints) and then had the second author perform rhinoscopy every 5 minutes. All 5 candies were completely dissolved in less than an hour. I will let you perform your own critical appraisal of these methods.

Bottom line: Watchful waiting may be reasonable for children with hard candies in their noses.

(In case you were wondering, I would happily take this chap as my doctor)


Alcohol by mouth can make you vomit. On the other hand, alcohol in the nose…

Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Annals of emergency medicine. 2015. PMID: 26679977

This is a randomized trial of a convenience sample of 80 adult patients presenting to the emergency department with a chief complaint of nausea and/or vomiting. Patients were instructed to inhale from a pad of either saline or isopropyl alcohol (the same wipes you would use on the skin before starting an IV) immediately, then 2 and 4 minutes later. Although investigators covered the label of the wipe, I’m pretty sure blinding was eliminated the instant the patient took a sniff. Nausea was measured on a scale of 0 to 10, but only for the first 10 minutes. At the start of the study, patients rated their nausea as a 6/10. At 10 minutes, the saline group still rated their nausea as 6/10 whereas the alcohol group rated theirs as 3/10 (absolute difference 3, 95%CI 2-4 p<0.001). We don’t know what happened after 10 minutes, which is a major limitation. Some other major limitations of this data are the lack of blinding and potential selection bias in a convenience sample.

Bottom line: Maybe inhaling from alcohol wipes decreases nausea

Hines S, Steels E, Chang A, Gibbons K. Aromatherapy for treatment of postoperative nausea and vomiting. The Cochrane database of systematic reviews. 4:CD007598. 2012. PMID: 22513952

Although I was completely unaware of this therapy for nausea, apparently it has been studied before. This Cochrane review found 6 RCTs and 3 non-randomized controlled trials looking at aromatherapy for nausea and vomiting. When compared to placebo, they found that isopropyl alcohol vapour inhalation reduced the number of patients requiring rescue antiemetics (RR 0.30 95%CI 0.09-1.0, p=0.05 so technically not significant), however it was less effective in reducing nausea than standard anti-emetic medications.

Bottom line: Probably shouldn’t be first line, but if I’m huffing alcohol in the break room, it may be because I caught the gastro that’s going around.

For some more on this topic, you can read about it on Academic Life in Emergency Medicine


Nerves were meant for blocking

Flores S, Herring AA. Ultrasound-guided Greater Auricular Nerve Block for Emergency Department Ear Laceration and Ear Abscess Drainage. The Journal of emergency medicine. 2015. PMID: 26589558

This is just a case report, but considering the frequency with which we see ear injuries, and the difficulty of achieving good local anesthesia, having a ultrasound guided nerve block in your back pocket is a great tool. In this article they specifically identify and anesthetize the greater auricular nerve, but a superficial cervical plexus block will get you the same coverage and might be easier. These nerve blocks only cover the posterior aspect of the ear, so you may have difficulty if the injury is more anterior. They can also miss the top of the ear.

Bottom line: Nerve blocks are fantastic for many things in the ED, especially when using ultrasound guidance.

Don’t have access to this paper? You could read about the ultrasound guided superficial cervical plexus block on NYSORA. You could also watch a video on the superficial cervical plexus block on the ultrasound podcast.


We have many effective treatments for hyperkalemia – kayexalate just isn’t one of them

Hagan AE, Farrington CA, Wall GC, Belz MM. Sodium polystyrene sulfonate for the treatment of acute hyperkalemia: a retrospective study. Clinical nephrology. 85(1):38-43. 2016. PMID: 26587776

The evidence behind the use of sodium polystyrene sulfonate (kayexalate) for hyperkalemia is poor. This is a chart review looking at 501 patients who received SPS for hyperkalemia. The chart review methods make it difficult to assess the true effect, but on average after SPS administration, the potassium decreased by 0.93mEq/L. That sounds reasonable, until you realise that the drop occurred over about 8 hours and that most of these patients were given other medications as well. The really concerning part of this paper is that there were 2 cases of bowel necrosis, a known side effect of SPS.

Bottom line: A little more evidence that reinforces my current practice – I don’t use kayexalate to treat hyperkalemia in the ED.

Want to read a little more about the original studies on kayaexalate? Check out this post by Anand Swaminathan on R.E.B.E.L.EM.


Newer is always better, right?

Navarro V, Dagron C, Elie C. Prehospital treatment with levetiracetam plus clonazepam or placebo plus clonazepam in status epilepticus (SAMUKeppra): a randomised, double-blind, phase 3 trial. The Lancet. Neurology. 15(1):47-55. 2016. PMID: 26627366

We all know the downsides of phenytoin in seizures – so it makes sense that researchers are looking at newer (but more expensive) agents. In this industry-funded, randomized, double-blind prehospital trial, they compared clonazepam plus levetiracetam (Keppra) to clonazepam plus placebo in 203 patients with status epilepticus (a seizure lasting more than 5 minutes). The trial was stopped early because an interim analysis revealed no chance that levetiracetam would turn out to be superior to placebo.

Bottom line: Don’t start changing your status epilepticus algorithms yet

Mundlamuri RC, Sinha S, Subbakrishna DK. Management of generalised convulsive status epilepticus (SE): A prospective randomised controlled study of combined treatment with intravenous lorazepam with either phenytoin, sodium valproate or levetiracetam–Pilot study. Epilepsy research. 114:52-8. 2015. PMID: 26088885

This paper complements the last. This is a prospective randomized trial of 150 patients with status epilepticus comparing valproate, phenytoin, and levetiracetam (all in addition to lorazepam). There was no statistical difference between the groups. Because of the small numbers, this is the kind of trial that could miss a clinically significant difference just because it wasn’t statistically different (type 2 error).

Bottom line: Again, there is no reason to abandon our tried and true and cheap medication yet


 Has it been cold enough for leaky gas powered heaters yet?

Hampson NB. Myth busting in carbon monoxide poisoning. The American journal of emergency medicine. 2015. PMID: 26632018

I couldn’t resist this paper – it had “myth” in the title and who doesn’t love carbon monoxide? There isn’t much to say about the the methods, as there were none, but there are a few important review points:

  1. Carbon monoxide levels do not correlate with symptoms and should not be the primary driver of emergency care
  2. A venous blood gas is just as good as an arterial gas for measuring CO levels
  3. CO is very stable in blood samples. You don’t need to rush an iced sample to the lab. In samples of anticoagulated blood, CO levels didn’t change over the course of a month. So this test could be done as an add-on if you forgot to order it initially

Bottom line: Read the three points above – stop trying to just skip to the red text to get your answers quickly

This paper was also covered on the poison review


NOT EMERGENCY MEDICINE, but in headlines everywhere

Jacobs IJ, Menon U, Ryan A et al. Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial. The Lancet. 2015. [free full text]

“Ovarian Cancer Screening Could Reduce Deaths By As Much As 20 Percent”. That is the first headline I encountered, but there are many many more. Expect to hear about this from patients, family, and friends alike. But what did the study actually show? This is a massive prospective trial that randomized 202,638 women into one of two screening protocols or a control group. Like so many cancer trials, the authors unfortunately started the trial very confused and made their primary outcome the factitious ‘disease specific mortality’ instead of all cause mortality. THEY DON’T EVEN REPORT ALL CAUSE MORTALITY! How can you tell if an intervention saves lives if you don’t measure mortality? Disease specific mortality only tells you that there might be changes in what someone happened to write on a death certificate (almost never supported by an autopsy), so is clearly not a patient oriented outcome. That is such a fatal flaw that it is hardly worth noting that there was a significant selection bias (in that healthy individuals are much more likely to volunteer for a study like this), that they had to alter the study protocol part way through, and that if you use the primary statistical outcome listed in the original trial design none of the outcomes were statistically significant. So throw this one into the trash heap, but be prepare for a lot of questions about how this could be the next big thing.

Bottom line: We need to get cancer researchers to start measuring and reporting all cause mortality. Our patients are being confused and harmed by the statistical misinformation that results from the fictional concept of ‘disease specific mortality’

You can read a much more through an intelligent review of this paper by the amazing Casey Parker on Broome Docs.


Cheesy joke of the month

What do you get if you eat Christmas decorations?


Tinsilitis!


#FOAMed of the month

A few videos that demonstrate why you should have a PEEP valve already attached to every BVM you use in the ED (rather than hidden in an RT office somewhere):

Lung Recruitment by Apneic CPAP by George Kovacs via EMCrit

PEEP your glove by George Kovacs

Amazing PEEP 1 –  BVM by AIME

Amazing PEEP 2 – ETT by AIME

Oxygenation – Understanding your BVM Device 2 by George Kovacs

When I started this month’s articles, I only planned on including the videos on the PEEP valve, but then Dr. Kovacs had to release one of the best awake intubation videos ever made. In the end, fully awake, he will show you his own carina:

Airway topicalization for an awake carina selfie

So bottom line of all this, follow George Kovacs and AIME on youtube

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: http://hqmeded-ecg.blogspot.ca/2015/11/new-paper-published-on-significance-of.html


 

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!

 

Reference

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: https://www.youtube.com/watch?v=NAlnRHicgWs


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: http://first10em.com/2015/10/21/acls-2015/



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