First10EM on theSGEM!

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

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


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

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

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

Two major questions remain, in my mind:

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

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



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

Articles of the month (October 2015)

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

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

1 good ECG begets another

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

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

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

When should we crack the chest?

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

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

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

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

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

Ultrasound before thoracotomy?

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

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

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

Some more trauma: NEXUS CT chest tool

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

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

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

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

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

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

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

SVT #2: Why I never use adenosine

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

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

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

SVT#3: More adenosine bashing

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

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

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

Apneic oxygenation: does it help in critical care?

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

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

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

A 3 wish program to personalize the death experience

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

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

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

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

An end to the low risk chest pain madness?

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

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

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

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

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

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

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

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

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

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

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

How normal is normal saline?

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

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

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

Are delayed antibiotics truly a death sentence?

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

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

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

Turning down the heat: can acetaminophen save lives?

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

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

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

Dopamine is having a tough run

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

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

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

Ultrasound for CHF

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

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

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

The new ACLS guidelines are out

The multiple AHA guidelines are in this issue of Circulation

The ERC guidelines are in Resuscitation

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

Cheesy Joke of the Month

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

#FOAMed of the month

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

BoringEM came up with a great series of infographics

EMCases interviewed a couple authors of the guidelines

REBELCast came up with a top 5 list of their own

Articles of the month (September 2015)

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

ARDSnet: The rise of low tidal volumes

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

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

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

GUSTO II: Cath versus lytics

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

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

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

Analgesics for abdominal pain

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

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

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

NEXUS: A pain in the neck?

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

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

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

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

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

Cage match: NEXUS versus the Canadian C-spine rule

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

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

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

Dexamethasone for croup

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

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

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

Dexamethasone for croup: But what dose?

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

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

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

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

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

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

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

Steroids for meningitis

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

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

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

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

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

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

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

Sepsis: early goal directed therapy

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

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

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

Restrictive transfusion policy

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

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

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

OPALS: What is the value of ACLS?

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

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

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

Cheesy joke of the month

Why didn’t skeleton cross the road?

He has no guts

Articles of the month (August 2015)

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

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

Simple and brilliant: A pediatric rainbow

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

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

Bottom line: Simple. Brilliant. Worth looking into.

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

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

Fingers, toes, nose and hose. The epinephrine myth

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

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

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

Physicians might not be so great around genitals

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

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

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

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

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

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

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

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

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

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

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

Just in case that wasn’t enough to convince you

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

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

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

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

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

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

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

It just might be safe to pee in the Amazon

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

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

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

Don’t write off those vital signs just yet

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

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

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

Another quick note on measuring asthma severity

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

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

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

Sepsis and the rush to early antibiotics

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

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

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

We should probably just install CT scanners at triage

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

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

Bottom line: Just say no to CT scans for pneumonia

Glue works for abrasions too

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

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

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

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

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

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

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

Diverticulitis is not necessarily a reason to promote antibiotic resistance

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

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

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

Read enough and I might sound like an antibiotic nihilist

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

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

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

When is a clot a clot?

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

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

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

Positive troponins are negative for patients

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

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

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

Less relevant than the pee fish article?

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

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

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

Cheesy Joke of the Month

What is the difference between surgeons and God?

God doesn’t think he is a surgeon

FOAM resource of the month

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

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

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

Articles of the month (July 2015)

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

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

Sick kids look sick

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

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

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

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

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

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

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

“The status quo is working.”

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

Dead? Kick him in the chest

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Diltiazem over metoprolol for atrial fibrillation. Surprised?

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

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

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

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

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

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

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

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

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

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

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

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

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

We no communicate so good

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

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

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

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

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

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

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

Whats the best way to keep a cast dry?

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

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

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

Everything you could ever want to know about anal fissures

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

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

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

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

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

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

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

Lidocaine for limb pain – no, not a nerve block

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

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

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

There is no such thing is a free lunch

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

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

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

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

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

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

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

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

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

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

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

Cheesy Joke of the Month

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

Because their P is silent

FOAMed of the month

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

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

Articles of the Month (June 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.

A simple clinical test to rule out PE? (Yeah right)

Amin Q, Perry JJ, Stiell IG, Mohapatra S, Alsadoon A, Rodger M. Ambulatory vital signs in the workup of pulmonary embolism using a standardized 3-minute walk test. CJEM. 2015;17:(3)270-8. PMID: 26034913

I love this study, although unfortunately it isn’t useful for clinical practice. It is a prospective cohort study of 114 patients, either in an ED or a thrombosis clinic, who were suspected of or had newly confirmed PE. They had patients walk for 3 minutes, and then measured heart rate and oxygen saturation. An increase in HR >10 had a sensitivity of 96.6% and a specificity of 31% for PE. A drop in O2 sat ≥2% had a sensitivity of 90.2% and a specificity of 39.3%. The combination of both had a sensitivity of 100% (95% CI 87-100) and a specificity of 11% (95% CI 6-21).

Bottom line: Although vitals signs seem to change in PE patients when walking, this is a pilot study and isn’t ready for prime time. The horrible specificity of this test may render it clinically useless.

We miss very few MIs, no matter what people want to tell you

Weinstock MB, Weingart S, Orth F, et al. Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission. JAMA Intern Med. 2015. PMID: 25985100

A bunch of big names on this one: David Newman, Scott Weingart, Michael Weinstock. This is a retrospective review, with decent methods, looking at 11,230 patients admitted for an ACS rule out, but who had 2 normal troponins in the ED. In total, 20 of those patients (0.18%; 95%CI 0.11-0.27) had any of: an arrhythmia, STEMI, cardiac arrest, or death during their hospitalization. If you exclude patients with abnormal vital signs or abnormal ECGs, only 4 out of 7266 (0.06%; 95%CI 0.02-0.14%) patients had any of those outcomes.

Bottom line: If you are ruled out by biomarkers and ECG, you are probably ruled out as well as we will ever be able to accomplish.

Patient oriented outcomes: PPIs don’t improve any of them

Cabot JC, Shah K. Are proton-pump inhibitors effective treatment for acute undifferentiated upper gastrointestinal bleeding? Ann Emerg Med. 2014;63:(6)759-60. PMID: 24199839

I know we just talked about the use of PPIs in GI bleeds, but I will throw this in as a bit of staged repetition. This is one of the Annal’s systematic review snap shot series, covering the Cochrane review of the same topic. I will quote: “In conclusion, this systematic review does not demonstrate improvement in clinically important outcomes with proton-pump inhibitor treatment before index endoscopy for undifferentiated upper gastrointestinal bleeding”

Bottom line: We need to choose wisely and stop using PPIs for our GI bleed patients

You actually heard a pericardial friction rub! Now what?

Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369:(16)1522-8. PMID: 23992557

An RCT of 240 patients with acute pericarditis, comparing colchicine (0.5mg daily if 70kg) to placebo. All patients got NSAIDs. The primary outcome of incessant or recurrent pericarditis was decreased from 38% with placebo to 17% with colchicine. Colchicine also decreased symptoms at 72 hours, at 1 week, and hospitalizations. Adverse events were not increased in this study, but everyone knows that colchicine can be nasty at higher doses, like those that used to be used for gout.

Bottom line: I tend to prescribe colchicine for pericarditis based on a NNT of about 5 to decrease recurrence or prolonged symptoms

Speaking of which, the correct colchicine dose is low dose

Terkeltaub RA, Furst DE, Bennett K, Kook KA, Crockett RS, Davis MW. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62:(4)1060-8. PMID: 20131255 (free full text)

Hopefully anyone using colchicine for gout has already seen this one. This is a double blind, placebo controlled RCT comparing low dose (1.2mg once then 0.6mg 1 hour later) to high dose (4.8mg over 6 hours) colchicine and to placebo. Pain was significantly improved in about 35% of both colchicine groups, but only 15% of placebo. Severe diarrhea and nausea were both increased by the high dose colchicine, but not the low dose.

Bottom line: Colchicine is equally effective at lower doses than traditionally given, but much better tolerated.

Steri-strips for good cosmetic outcomes

Gkegkes ID, Mavros MN, Alexiou VG, Peppas G, Athanasiou S, Falagas ME. Adhesive strips for the closure of surgical incisional sites: a systematic review and meta-analysis. Surg Innov. 2012;19:(2)145-55. PMID: 21926099

This is a systematic review including 12 RCTs of 1317 patients, comparing the use of adhesive strips to sutures in closing surgical wounds. They found no difference in cosmetic results, infection, or dehiscence. Of course, this is in clean surgical wounds.

Bottom line: Almost every paper I read on wounds just reinforces my inherent bias that it doesn’t really matter how you close wounds – within reason.

More of the same

Mattick A, Clegg G, Beattie T, Ahmad T. A randomised, controlled trial comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair. Emerg Med J. 2002;19:(5)405-7. PMID: 12204985

An RCT of 44 emergency department pediatric patients comparing steri-strips with dermabond. Both a plastic surgeon and the parents judged cosmetic outcomes. There were no differences between the two groups.

Bottom line: Again, just clean it out and get the edges close. Humans have been healing for millennia.

Reading articles about droperidol leaves me in a state that may require some droperidol

Calver L, Isbister GK. High dose droperidol and QT prolongation: analysis of continuous 12-lead recordings. Br J Clin Pharmacol. 2014;77:(5)880-6. PMID: 24168079

I included the much larger study by the same group last month, but it is always nice to explore how many high level decisions in medicine lack a scientific basis. In this prospective observation study, they gave 46 psychiatric patients between 10 and 25 mg of IV droperidol for sedation. All were placed on holter monitors. There were no dysrhythmias. Only 4 patients had any lengthening of their QT and all 4 had other reasons for this, such as methadone.

Bottom line: We should not give up excellent medications based on shoddy science.

Options, for when they take our good drugs away or we run into ‘drug shortages’

Gaffigan ME, Bruner DI, Wason C, Pritchard A, Frumkin K. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015. PMID: 26048068

This is a double-blind RCT of 64 adults with migraines comparing haloperidol 5mg IV to metoclopramide 10mg IV. Both medications offered excellent pain relief, 57/100mm for haloperidol and 49/100mm for metoclopramide (no difference). The metoclopramide group required more rescue medications. There was more restlessness with haloperidol.

Bottom line: Like magnesium (that we discussed a few months ago), Haldol is another option I will keep in mind for the treatment of migraines.

A classic: The FEAST trial

Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364:(26)2483-95. PMID: 21615299 (free open access)

This is a classic RCT that randomized 3170 febrile pediatric patients in resource poor environments to either 20ml/kg NS, 20ml/kg albumin, or no bolus. All patients were severely ill with either impaired consciousness or respiratory distress plus signs of impaired perfusion. 48 hour mortality was significantly worse in the bolus groups than the no bolus group (10.5% versus 7.3%). Mortality was also worse at 4 weeks.

Bottom line: In an African setting, poorly perfused pediatric patients do worse with a fluid bolus. Although these results probably don’t generalize to our population, it does remind us that IV fluids are a drug and should be treated as such.

Bonus: This is a free open access article discussing the mechanisms of increased mortality in FEAST. This paper was discussed a great deal at the SMACC conference, and some experts think FEAST is more applicable to our patients than we have recognized.

Vasopressor? Peripheral line is fine

Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care. 2015;30:(3)653.e9-17. PMID: 25669592

This systematic review looked for any primary studies or case reports that described local tissue injury from vasopressor extravasation, and includes 85 articles and 270 patients. Although there are reports of tissue injuries after peripheral vasopressor administration, these tend to occur after very long use (the average duration of infusion was 55.9 hours.)

Bottom line: Although data is pretty limited, I would be very comfortable starting vasopressors through a peripheral line. Long term management should probably include central access.

What is a placebo controlled trial of sucrose for pain? You compare sugar pills to sugar pills

Harrison D, Yamada J, Adams-Webber T, Ohlsson A, Beyene J, Stevens B. Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years. Cochrane Database Syst Rev. 2015;5:CD008408. PMID: 25942496

This Cochrane review identified 8 studies encompassing 808 pediatric patients, examining the utility of sucrose or other sweet tasting solutions in decreasing the pain of needles. The studies were all small and of moderate quality. Overall, sweetened substances did not seem to lower pain scores no matter what scoring system you used. Prior studies have concluded benefit – but always after trying to assess the look on a neonate’s face. Judging pain in neonates may be difficult, but I think there is an inherent flaw in saying that a child smiled more after the sugar, so it must have hurt less.

Bottom line: If you think a child is in pain, please give them a pain medication, rather than the key ingredient of every placebo ever made.

Speaking of placebos, a needle may not be better than pills

Schwartz NA, Turturro MA, Istvan DJ, Larkin GL. Patients’ perceptions of route of nonsteroidal anti-inflammatory drug administration and its effect on analgesia. Acad Emerg Med. 2000;7:(8)857-61. PMID: 10958124

I love this study. For 64 patients presenting to the ED with an MSK injury, they gave everyone a juice drink that actually had 800mg of ibuprofen in it (unknown to the patients). They then randomized them to either get placebo pills that looked liked 800mg of ibuprofen or a placebo IM injection resembling 60mg of ketorolac. The patients and the nurses were all blinded. There were no differences in pain on a visual analog scale in the 2 hours that followed, contradicting prior research that indicated that needle based placebos are ‘stronger’ than pill based placebos.

Bottom line: Don’t give patients IM/IV medications just for the placebo affect. Oral NSAIDs are almost always appropriate.

An expensive placebo made popular by sports stars

Rowden A, Dominici P, D’Orazio J, et al. Double-blind, Randomized, Placebo-controlled Study Evaluating the Use of Platelet-rich Plasma Therapy (PRP) for Acute Ankle Sprains in the Emergency Department. J Emerg Med. 2015. PMID: 26048069

Less relevant to emergency medicine, but I have been asked about platelet rich plasma therapy by patients and friends. This is the (placebo?) therapy of sports stars such as Kobe Bryant, in which your own platelets plus some cytokines are injected back into you to treat tendonitis among other things. This was a double blind RCT comparing platelet rich plasma therapy to placebo for acute ankle sprain in the ED. There was no change in pain or function at day 0, 3, or 8.

Bottom line: Despite the huge amount of money being spent on this by rich athletes, it is unlikely to benefit your patients.

Placebos may not help, but medications can actually hurt you

Fralick M, Macdonald EM, Gomes T, et al. Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: population based study. BMJ. 2014;349:g6196. PMID: 25359996 (Free open access)

This is another great massive case control study from David Juurlink and his group looking at the Ontario drug benefit database. They identified all patients who died suddenly and were treated with either an ACEi or an ARB. Those patients who had been on antibiotics within the 7 days before their death were matched to controls who hadn’t received antibiotics. There were 1027 sudden deaths after antibiotics (out of 38879 total sudden deaths.) Using amoxicillin as the baseline, there was an increased risk of sudden death with co-trimoxazole (OR 1.38 95% CI 1.09-1.76) and ciprofloxacin (OR 1.29 95% CI 1.03-1.62). Risk was not increased with nitrofurantoin or norfloxacin. Of course, all standard problems with database observational studies apply.

Bottom line: A tiny absolute risk in the greater scheme of things, but you might want to consider if your UTI patients are on an ACEi or ARB and all else is equal.

Raising a skeptical eyebrow at the literature

White T, Mellick LB. Debunking medical myths: the eyebrow shaving myth. Emerg Med Open J. 2015; 1(2): 31-33. (Free open access)

I love medical myths, so although this myth has never affected my practice in the emergency department, I thought that I would include it. These authors did a systematic review of the literature to determine if shaving of the eyebrows causes problems with eyebrow regrowth. They did not find a single case report or study that would support this myth. There is one tiny study in which they shaved the eyebrows of volunteers and followed them for 6 months, and they all grew back fine.

Bottom line: I don’t know. If you want to shave some eyebrows, go for it.

Steroids for low back pain?

Balakrishnamoorthy R, Horgan I, Perez S, Steele MC, Keijzers GB. Does a single dose of intravenous dexamethasone reduce Symptoms in Emergency department patients with low Back pain and RAdiculopathy (SEBRA)? A double-blind randomised controlled trial. Emerg Med J. 2015;32:(7)525-30. PMID: 25122642

The idea of using corticosteroids for low back pain seems to pop up every once in a while. Although I have never seen it used, I understand there are a number of people who use this regularly. This was a double-blind RCT of 58 patients with acute low back pain in the ED comparing dexamethasome 8mg IV (1 dose) to placebo. At 24 hours, the dexamethasone group averaged 1.86/10 lower pain scores on a visual analogue scale. At 6 weeks pain scores and function were identical. (They report that the dexamethasone group had a lower ED length of stay, but the length of stay in the placebo group was almost 19 hours, which is incomprehensible to me.)

Bottom line: Like steroids for a lot of MSK conditions, there seems to be short term, but not long term improvement in pain.

We now know the evidence. How do you provoke change? Through shame

Yeh DD, Naraghi L, Larentzakis A, et al. Peer-to-peer physician feedback improves adherence to blood transfusion guidelines in the surgical intensive care unit. J Trauma Acute Care Surg. 2015;79:(1)65-70. PMID: 26091316

This trial attempted to address the slow uptake of evidence based guidelines surrounding more restrictive transfusion targets for post-op patients. It was a before and after study in a single tertiary surgical ICU. In the intervention period, if physicians ordered a transfusion in a stable patient that didn’t adhere to the guidelines, they received a follow-up email and education from a colleague. The rate of ‘inappropriate transfusions’ went from 25% to 2%. 30 day readmission rates and mortality were unchanged.

Bottom line: If you want physicians to change their behavior, you shouldn’t just teach them. You should provide peer to peer feedback, aka shame.

Cheesy Joke of the Month

Why was the Kleenex dancing?

Because it had a little boogie in it

FOAMed of the month

Why should we be giving fentanyl IN at triage? Check our this rant via the SGEM and Dr. Anthony Crocco:

Articles of the month (May 2015)

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

Here are my favorite reads from this month. It is a little longer than usual, because apparently what I enjoy doing while sitting pool-side in paradise is catching up on the medical literature. I am sure there is room in the next iteration of the DSM for that.


Myth: Wound eversion magically eliminates scarring

Kappel S, Kleinerman R, King TH, et al. Does wound eversion improve cosmetic outcome?: Results of a randomized, split-scar, comparative trial. J Am Acad Dermatol. 2015;72:(4)668-73. PMID: 25619206

This is a prospective, randomized trial of post-op skin surgery patients where they closed half of the wound using wound eversion and the other half using basic planar approximation. The patients and 2 assessors were blinded and there was no significant difference in appearance at 3 or 6 months. This is in clean surgical wounds, so external validity to the ED is questionable. However, the authors looked for science supporting the dogma of wound eversion, and not surprisingly: there is none.

Bottom line: This is enough for me to stop dogmatically teaching wound eversion – though with only one study, I am always ready to change my mind.

“Therapeutic” hypothermia

Mark DG, Vinson DR, Hung YY, et al. Lack of improved outcomes with increased use of targeted temperature management following out-of-hospital cardiac arrest: a multicenter retrospective cohort study. Resuscitation. 2014;85:(11)1549-56. PMID: 25180922

A retrospective, before and after study of 1119 patients in a system where therapeutic hypothermia for out of hospital cardiac arrest was implemented in 2009. Despite the fact that you would expect improved outcomes just because of improved medical care over the half decade the study ran, there was no difference in mortality or neurologic outcomes whether or not you were cooled.

Bottom line: Thanks to TTM, we already know that cooling is not necessary. We should remember that fever avoidance is currently only a theory without significant evidence basis.

Kids don’t like being cold either

Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children. N Engl J Med. 2015;372:(20)1898-1908. PMID: 25913022 

You probably would have been fine applying the TTM data to children, as they are just little adults, but we now have some pediatric specific data. This is a multicentre RCT of pediatric (2 days to 18 years) out of hospital cardiac arrest, comparing 33.0 with 36.8 degree Celsius targets. As you might expect, there was no difference in survival or functional outcomes up to one year. However, the raw numbers were better in the hypothermic children, despite being non-statistically significant.

Bottom line: There is no reason to put kids on ice outside of the context of further clinical trials.

Rate control in atrial fibrillation cage match: the cardiology approach (beta blockers) versus the emergency medicine approach (calcium channel blockers)

Martindale JL, et al. β-Blockers versus calcium channel blockers for acute rate control of atrial fibrillation with rapid ventricular response: a systematic review. Eur J Emerg Med. 2015;22:(3)150-4. PMID: 25564459

This is a systematic review of calcium channel blocker versus beta blockers for acute rate control of atrial fibrillation. They could only find 2 quality studies, which were very small. In these studies, diltiazem was better than metoprolol (RR 1.8 95% CI 1.2-2.6) for rate control.

Bottom line: The very limited evidence seems to fit with clinical experience: calcium channels blockers are more likely to get patients controlled in the ED.

The toughest question in the resus room? Maybe if a.fib is the cause of or the result of hemodynamic instability

Scheuermeyer FX, Pourvali R, Rowe BH, et al. Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm. Ann Emerg Med. 2015;65:(5)511-522.e2. PMID: 25441768

This is a retrospective chart review (well done, but a chart review) of 416 patients with atrial fibrillation and an acute medical illness, out of British Columbia. They compared those patients who had their atrial fibrillation actively managed, versus those in whom the focus was only in treating the underlying condition. No one died in this study. Patients who had either rate or rhythm control had significantly increased rates of major adverse events, primarily increased requirement for pressors and increased intubations.

Bottom line: In sick medical patients who happen to have atrial fibrillation, focus on basic resuscitation over rate/rhythm control.

The new angioedema meds

Bas M et al. A randomized trial of icatibant in ACE-inhibitor-induced angioedema. New England Journal of Medicine. 2015;372(5):418-25. PMID: 25629740

This is one of a few new, very expensive treatments for hereditary angioedema. It is a selective bradykinin B2 receptor antagonist. This was a phase 2 RCT of 30 patients who either received Icatibant or standard therapy of steroids and anti-histamines for patients with ACE inhibitor induced angioedema. The icatibant group responded quicker (8 hours versus 27 hours) and had more complete resolution of their symptoms. The biggest concern with this study (aside from the tiny size and industry involvement) is that, although the standard therapy group probably represents usual care, ideal care might involve use of FFP instead.

Bottom line: In a very small study, icatibant seems to decrease angioedema a lot quicker than ‘usual care’.

Lots of Os up the nose

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

This is a multi-centre randomized, open label study of high flow, humidified nasal oxygen, versus standard oxygen face mask, versus non-invasive positive pressure ventilation in adult, hypoxic patients. (CHF and exacerbations of asthma or chronic respiratory failure was excluded, so in other words this is primarily pneumonia patients.) There was no difference in their primary outcome of need for intubation, although they powered the study to detect a 20% difference, which is probably larger than the clinically important difference. This biggest news is that 90 day mortality was decreased in the high flow oxygen group (12%, versus 23% with standard oxygen and 28% in NIPPV), but this is a secondary outcome so should be interpreted with caution.

Bottom line: High flow nasal oxygen seems to be at least 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.

More evidence PPIs aren’t completely safe

Antoniou T et al. Proton pump inhibitors and the risk of acute kidney injury in older patients: a population-based cohort study. CMAJ Open 2015;3(2):E166-71. (Free full text here)

Using the Ontario Drug Benefit database, these authors compared the cohort of patients with newly prescribed PPIs with a propensity matched group as a control. They excluded anyone also prescribed known nephrotoxic drugs, or with basically any other renal risk factors. People on PPIs were more likely to develop acute kidney injury, with a hazard ratio of 2.52 (95% CI 2.27-2.79). Out of 290,000 patients studied, 1787 were admitted to hospital with AKI – about 8 more than controls for every 1000 patient years on PPIs.

Bottom line: No medication is without side effects, but we treat some like they are water. Early studies will always emphasize benefits and downplay harms.

You don’t need fancy lenses and mirrors to see the retina

Vrablik ME et al. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta-analysis. Ann Emerg Med 2015; 65(2):199-203. PMID: 24680547

This meta-analysis attempted to determine the accuracy of ultrasound for diagnosis of retinal detachment in the hands of emergency physicians. In population with a prevalence of detachment between 15% and 38%, they found a sensitivity of ultrasound of 97-100% and a specificity of 83-100%. Of course, these studies are often done with experienced ultrasonographers or after specific training.

Bottom line: I think this definitely has a place in the ED.

Bonus: This castlefest lecture is a great resource for ocular ultrasound, with free CME

A little more diagnostic technology: iPhone otoscopes

Richards JR, Gaylor KA, Pilgrim AJ. Comparison of traditional otoscope to iPhone otoscope in the pediatric ED. Am J Emerg Med. 2015. PMID:  25979304

These authors compared a traditional otoscope with a new one that attaches to your iphone and gives you a video display. There was reasonable agreement between the new one and the old one, although residents and attendings still disagreed about the findings a lot. They claim that the iPhone scope changed the final diagnosis a number of times, but without a clear gold standard I wouldn’t focus on that result.

Bottom line: I am not sure how important it is to treat anything they found here, which limits the value of the tool – but this could be a great way to teach students otoscopy.

Can the D-Dimer be improved? (Well, it can’t get any worse, can it?)

Jaconelli Y and Crane S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: Should we use an age adjusted D-dimer threshold in managing low risk patients with suspected pulmonary embolism? Emerg Med J 2015;32(4):335-7. PMID: 25804861

This is a systematic review (published before last month’s paper, and so not including it) that found 13 papers addressing the use of an age adjusted d-dimer (less than age x 10). Most of the studies were retrospective, so not of high quality. The authors conclusion is “In older patients suspected of having a PE, with a low pretest possibility, an age-adjusted D-dimer increases specificity with minimal change in the sensitivity, thereby increasing the number of patients who can be safely discharged without further investigations.”

Bottom line: It is looking like the age adjusted d-dimmer in low pre-test probability patients will result in a post-test probability below the test threshold, while increasing specificity.

Speaking of PE testing, the CTPA is not a perfect test

Miller WT, Marinari LA, Barbosa E, et al. Small Pulmonary Artery Defects Are Not Reliable Indicators of Pulmonary Embolism. Ann Am Thorac Soc. 2015. PMID: 25961445

In this study, they took all of the CT scans that were read as positive for PE in one radiology system, and had the scan review by 4 subspeciality thoracic radiologists. 15% of scans read as showing a subsegmental PE by community radiologists were thought to be false positives by the specialists. Another 27% were thought to be indeterminate. This only represents disagreement among radiologists and not the inherent false positives of the test itself.

Bottom line: A positive CT scan is not an objective finding. Before subjecting patients to lifelong anticoagulation, a second opinion on the read might be warranted.

PEs come from the legs – those IVC filters make sense, right?

Mismetti P, Laporte S, Pellerin O, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial. JAMA. 2015;313:(16)1627-35. PMID: 25919526

Prosecptive RCT with blinded outcome assessors, but unblinded patients and treating physicians, randomized 399 patients with PE plus a DVT plus a marker of severity to either anticoagulation alone or anticoagulation plus a retrievable IVC filter. Recurrent PE occurred in 3% of the filter group (all fatal) and 1.5% of the no filter group (2 of 3 fatal) for a non statistically significant relative risk of 2.0 (95% CI 0.51 – 7.89).

Bottom line: IVC filter don’t decrease the rate of PE in patients than can be anticoagulated.

Medications don’t cure kidney stones

Pickard R et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet. 2015. PMID: 25998582

Flomax was pushed for renal stones based on a number a small studies with horrible methods and a few meta-analyses of those horrible studies. There has already been one large RCT with excellent methods demonstrating that Flomax doesn’t work. This should be the nail in the coffin. This is a multicentre placebo controlled RCT of 1167 adult patients with CT confirmed renal stones. They were randomized to either tamsulosin 0.4mg, nifedipine 30mg, or placebo. There was no difference between any of the groups in the number of patients requiring urologic intervention. (About 80% of the patients passed spontaneously, and 20% required an intervention in all groups.)

Bottom line: There is no role for medical expulsive therapy in renal colic.

Antibiotics don’t work for diverticulitis? Is nothing sacred?

Shabanzadeh DM, Wille-Jørgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev. 2012;11:CD009092. PMID: 23152268

This is a Cochrane systematic review that was able to identify 3 RCTs looking at the use of antibiotics for uncomplicated diverticulitis. Only one compared antibiotics to no antibiotics, the other two compared different types and courses of antibiotics. There was no difference in any of the regimens. In other words, no antibiotics was the same as antibiotics.

Bottom line: Not enough to change my practice, but it is good to know that we have minimal footing to our current practice.

Antibiotics in appendicitis? The right side of the bowel is different from the left, right?

Varadhan KK, Humes DJ, Neal KR, Lobo DN. Antibiotic therapy versus appendectomy for acute appendicitis: a meta-analysis. World J Surg. 2010;34:(2)199-209. PMID: 20041249

This meta-analysis concludes surgery may have a lower risk of complications than antibiotics (RR 0.43 95% CI 0.16-1.18). A little more than 30% of patients treated with antibiotics will actually require surgery. The authors seem to think biases in current study favour the antibiotics group, so real outcomes might be worse.

Bottom line: We don’t really get to make this decision anyway, but surgery is probably still the gold standard.

One last one on antibiotics: If you are going to treat with oral (which you probably should in most cases) don’t give a dose IV in the department

Haran JP, Hayward G, Skinner S, et al. Factors influencing the development of antibiotic associated diarrhea in ED patients discharged home: risk of administering IV antibiotics. Am J Emerg Med. 2014;32:(10)1195-9. PMID: 25149599

This is a prospective cohort study of 247 patients, all of whom were being treated with outpatient oral antibiotics. They compared those who received an IV dose in the ED to those who did not. 25.7% of the IV group developed antibiotic associated diarrhea versus 12.3% in the no IV group (a number needed to harm of 7.5).

Bottom line: Unnecessary IV antibiotics harm our patients.

The best drugs are probably those they keep away from us

Calver L, Page CB, Downes MA, et al. The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2015. PMID: 25890395

This is a prospective observational study of 1009 patients in Australia, all of whom received 10mg of droperidol for sedation of acute behavioral disturbances, and second dose at 15 min as needed. Out of those 1009 patients, 13 developed a long QT, and 7 of those had other contributing causes such as methdone or amiodarone. There were no incidences of tosades de pointes.

Bottom line: The black box warning against droperidol is likely without scientific merit. I would use it if it were available to me. Given how useful this medication is, it might be worth fighting for.

Let’s do two on poo

Gerding DN, Meyer T, Lee C, et al. Administration of spores of nontoxigenic Clostridium difficile strain M3 for prevention of recurrent C. difficile infection: a randomized clinical trial. JAMA. 2015;313:(17)1719-27. PMID: 25942722

We are all colonized with C.diff., so we should be experts in getting rid of it. This is a new one to me. They took patients who completed their treatment for C.diff. and infected them C.diff. Only, this strain of C.diff does not form toxins. This reduced recurrence of clinical infection from 30% to 11%.

Bottom line: You can treat Clostridium difficile with Clostridium difficile. Maybe we should infect ourselves prophylactically?

Drekonja D, Reich J, Gezahegn S, et al. Fecal Microbiota Transplantation for Clostridium difficile Infection: A Systematic Review. Ann Intern Med. 2015;162:(9)630-8. PMID: 25938992

A systematic review, but there are only 2 RCTs to include. In one RCT, fecal trasplant led to 81% of patients having symptom resolution, versus only 31% in the vancomycin group. In another, they demonstrated no difference between NG and rectal routes for the transplant, with about 70% resolution of symptoms. (I’d choose the rectal route, thanks.)

Bottom line: Still really not enough science to warrant a bottom line, but if C.Diff is turning your life to sh*t, consider someone else’s sh*t: it might make you feel better.

Apparently science is useless for xanthrochromia.

Chu K, Hann A, Greenslade J, Williams J, Brown A. Spectrophotometry or visual inspection to most reliably detect xanthochromia in subarachnoid hemorrhage: systematic review. Ann Emerg Med. 2014;64:(3)256-264.e5. PMID: 24635988

This is a systematic review of 10 studies comparing visual inspection to spectrophotometry for detection of xanthrochromia. Visual inspection: sensitivity 83.3% and specificity 95.7%. Spectrophotometry: sensitivity 86.5% and 85.8%. (The gold standard varied from angiography to clinical follow-up.)

Bottom line: There is no clear difference between the two, but neither seem great. Isn’t there some way for the lab to test for the chemical that makes the fluid yellow?

1 + 1 + 1 = 3?

Angus DC, Barnato AE, Bell D, et al. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive Care Med. 2015. PMID: 25952825

Surprise. The meta analysis of three trials that said the same thing, says the same thing: EGDT is not superior to usual care in 2015. What is worth mentioning is that this is a very good meta-analysis because the investigators of all three trials went out of their way to ensure they were using the same definitions and outcomes before starting.

Bottom line: We can be very confident that we don’t need to be following the protocols of the original EGDT study.

Game changer (x2) for neonatal resuscitation?

Gruber E, Oberhammer R, Balkenhol K, et al. Basic life support trained nurses ventilate more efficiently with laryngeal mask supreme than with facemask or laryngeal tube suction-disposable–a prospective, randomized clinical trial. Resuscitation. 2014;85:(4)499-502. PMID: 24440666

A prospective, RCT comparing ventilation with facemask vs the LMA supreme (LMA-S) vs the laryngeal tube suction-disposable (LTS-D) device in neonatal resuscitation. A lot of the outcomes were of questionable relevance, but ventilation failed in 34% of patients with facemask, 22% with the LTS-D, and 2% with the LMA-S. Higher tidal volumes were delivered with both the LTS-D and the LMA-S than the facemask (470ml vs 240ml). All these resuscitations were run by nurses, so external validity may be questionable.

Trevisanuto et al. Supreme Laryngeal Mask Airway versus Face Mask during Neonatal Resuscitation: A Randomized Controlled Trial. The Journal of Pediatrics. 2015. PMID: 26003882

This is another prospective randomized trial (neither of these could be blinded) of LMA-S versus facemask in 142 neonatal resuscitations of infants greater than 34 weeks or 1500 grams. The LMA resulted in higher 5 minute APGAR scores, less intubations, and lower admissions to NICU.

Overall bottom line: These two prospective studies paint a picture of better ventilation as well as improved patient important outcomes, such as intubations and NICU admissions, when an LMA is used over standard facemask ventilation for neonatal resuscitation. This might cause some culture shock when we run upstairs, but I think this is worth instituting.

Another myth: The subglottic area is the narrowest area of the pediatric airway

Dalal PG, Murray D, Messner AH, Feng A, McAllister J, Molter D. Pediatric laryngeal dimensions: an age-based analysis. Anesth Analg. 2009;108:(5)1475-9. PMID: 19372324

These authors measured the cross sectional area of the airways of 153 children (6months to 13 years) using video bronchoscopy under general anesthesia, and they found that it is the glottis not the cricoid that is the narrowest portion of the airway.

Bottom line: Probably shouldn’t change your daily practice, still pick a tube small enough to pass the cords, but just remember that a lot of what we “know” and teach is wrong. Always keep an open mind in medicine.

Cheesy Joke of the Month

As the doctor completed an examination of the patient, he said, “I can’t find a cause for your complaint. Frankly, I think it’s due to drinking.”

“In that case,” said the patient, “I’ll come back when you’re sober”

FOAMed Resource of the Month

Its not actually up an running yet, but I am really excited about the idea, so its more something to keep an eye out for. If anyone has played around with Coursera or EdX, you know there is a lot of incredible high quality education available for free in just about any subject. These are called MOOCs (massive open online courses). Well, there will soon be an equivalent for emergency medicine education, created for ALiEM: