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:

https://www.youtube.com/watch?v=bDghbN7I_SM&sns=tw

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: http://www.aliem.com/sneak-peak-aliemu/

Articles of the month (April 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.

Troponin is king – why even send an CK?

Le RD et al. Clinical and financial impact of removing creatine kinase-MB from the routine testing menu in the emergency setting. Am J Emerg Med. 2015;33(1):72-5. PMID: 25455047

This is an observational study, looking at a period before and after CK-MB was removed from an automatic order set. Out of 6444 cases included in the study, there were only 17 cases with a positive CK-MB fraction and a negative troponin. All 17 were ultimately determined by the treating physicians to have non-ACS causes (ie, they were false positives). So, CK-MB was not clinically helpful. Removing it from the order set dropped ordering by 80% and saved the hospital about $47,000 a year.

Bottom line: We might want to keep this one in our back pocket for the next time the hospital demands cost savings – dropping the CK helps us and saves money


Speaking of troponin – high sensitivity and the 1 hour rule out

Reichlin T et al. Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay. CMAJ. 2015 (In Print). PMID: 25869867

This prospective observational study of 1320 chest pain patients attempted to validate a 1 hour rule out protocol. Using high sensitivity troponins, patients ruled out if they had trop of 12ng/L or less and a 1 hour delta of 3mg/L or less. They ruled in with a trop of 52ng/L or more or a 1 hour delta of 5ng/L or more. Everyone else was put in longer observation. It was a relatively high risk cohort, with 17% overall having an acute MI. 60% of patients were able to be ‘ruled out’ at 1 hour, and only one of those patients (0.1%) ultimately had an MI. It ruled in 16% of the patients at 1 hour, with 78% being true positives. The remaining 24% that couldn’t be ruled in or ruled out had an 18% chance of an MI – so the prolonged observation work up makes a lot of sense.

Bottom line: This could work (if we had the right assay), but I think our rule in rate for MI is way less than 17% – so this strategy could actually increase our testing and admissions without benefit to our patients 


How often to you order pregnancy tests just for medication use?

Goyal MK et al. 2015. Underuse of pregnancy testing for women prescribed teratogenic medications in the emergency department. Academic Emergency Medicine (in print). PMID: 25639672

A retrospective study using the NHAMCS database (notoriously poor data) but still raises an interesting point. Looking at all women who were given or prescribed FDA pregnancy category D or X medications, only 22% had pregnancy testing done. (I will note that this is one area where I don’t trust NHAMCS at all – there was one study where 50% of patients diagnosed with ectopic pregnancies didn’t have a pregnancy test done – but then how did they get diagnosed with ectopic pregnancy?) This also doesn’t tell us how many of these women were actually pregnant, so it is difficult to tell how big an issue this really is.

Bottom line: Are you checking for pregnancy before giving Advil to ankle sprains in ambulatory care? Should we have quicker point of care testing to make this feasible? Does it matter? 


Non-news of the month: there happen to be some bacteria in your blood post CPR

Coba V et al. The incidence and significance of bacteremia in out of hospital cardiac arrest. Resuscitation. 2014 Feb;85(2):196-202. PMID: 24128800

I ignored this one when it first came around a year ago, but I have heard it repeated so many times, with strange conclusions, that I guess it should be included. This is a prospective observational study of 250 adult out of hospital cardiac arrest patients who they drew blood cultures on in the ED, 38% of whom were found to be bacteremic. But come on, you get bacteremic after brushing your teeth. Are you surprised this happened with crash airways, CPR, and broken ribs? They note that mortality was higher in the bacteremic group, but again, in dead people as mucous membranes break down, I expect more bacteremia. This is a silly surrogate outcome, unless someone can show early antibiotics save lives.

Bottom line: Try to ignore this paper when it is mentioned over and over again in the coming years


Another one with strange conclusions

Schuch S et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-8. PMID: 25138332

This is a double blind RCT from Sick Kids, where they took 213 infants with bronchiolitis and randomized them to either have an accurate pulse ox reading, or one that displayed values that were 3 points higher than the actual value. When higher oxygen sats were shown, admissions went down from 41% to 25%. This is obvious – we admit hypoxic patients. I have heard lots of doctor bashing around this, but what this study didn’t show was that it was safe to discharge home babies with borderline sats. I admit a child with a sat of 89% because they are right at top of the steep part of the oxygen desaturation curve, and I am worried they might get worse. Telling me that the sat is 92% might change my mind – but how do we know those kids didn’t go on to have complications? This study certainly didn’t look for it. (I will admit we probably over-rely on the sat – but until someone proves 89% is safe with no treatment or monitoring, I will keep admitting.)

Bottom line: If you lie to doctors about important clinical parameters, their decisions change


Once again, forget about atypicals in the treatment of community acquired pneumonia

Postma DF et al. Antibiotic treatment strategies for community-acquired pneumonia in adults. NEJM. 2015;372(14):1312-1323. PMID: 25830421

Despite the theory of needing to cover for atypical organisms, this study is another in a long line of papers that all say the same thing. This is a large, multi-centre cluster-randomized trial of 2283 adult patients with community acquired pneumonia who did not require ICU care. They randomized months to to either use beta-lactam monotherapy, a beta-lactam plus a macrolide, or a fluroquiolone. The primary outcome was mortality at 90 days, and was statistically the same in all groups (but actually 1.9% higher in the macrolide group.) Secondary outcomes, like length of stay, were also the same. (The authors do note that during the time of the study, there was a low incidence of atypicals. However, multiple previous studies have show atypicals don’t matter, except maybe legionella.)

Bottom line: We already knew this, but are always taught differently: you don’t need to add a macrolide to beta-lactams to treat community acquired pneumonia. (Empiric evidence trumps petri dishes every day.) 


Dental abscesses are like all abscesses – antibiotics don’t help

Tichter AM and Perry KJ. Are antibiotics beneficial for the treatment of symptomatic dental infections? Ann Emerg Med. 2015;65(3):332-3. PMID: 25477181

This systematic review was able to find 2 RCTs comparing antibiotics (both pen-VK) versus placebo for apical perdiodonitis or abscess. There was no difference in pain, swelling, or infection progression at 24, 48, or 72 hours. All patients were given oral analgesics and ultimately had the definitive management – surgical pulpectomy.

Bottom line: Dental infections are one more diagnosis where we give antibiotics but probably shouldn’t


Was this patient’s DVT caused by an unknown cancer?

Robertson L et al. Effect of testing for cancer on cancer- and venous thromboembolism (VTE)-related mortality and morbidity in patients with unprovoked VTE. Cochrane Database Syst Rev. 2015 [Epub ahead of print] PMID: 25749503

We know that cancer is a risk factor for VTE, so we frequently ask ourselves should we be searching for a potential cancer in people with an apparently unprovoked VTE? This is a Cochrane review, but they could only identify 2 studies with a total of 396 patients – so interpret with caution. Using a a specific suite of screening tests post VTE diagnosis, they did make more early diagnoses of cancer than in patients with usual care, but they were unable to find any cancer specific mortality benefit. (They didn’t even measure all cause mortality.)

Bottom line: This fits well with most screening data we have, in that we can always find more cancer if we look, but we are not good at changing mortality or quality of life (for the better)


More is not always better

Minotti V et al. A double-blind study comparing two single-dose regimens of ketorolac with diclofenac in paindue to cancer. Pharmacoptherapy. 1998;18(3):504-8. PMID: 9620101

With recent drug shortages, the topic of the appropriate ketorolac dose was raised a number of times around the department. This is a double blind RCT comparing ketorolac 10mg or 30mg or diclofenac 75mg (all IM) in adults with acute cancer pain. All three provided equal and reasonable relief over 6 hours. I just picked one, but this is consistent with multiple other studies showing 10 mg = 30 mg of ketorolac.

Bottom line: Toradol 10mg is probably identical to 30mg


We know we don’t talk to our patients – but apparently we can’t even talk to each other

Venkatesh AK et al. Communication of Vital Signs at Emergency Department Handoff: Opportunities for Improvement. Annals of Emergency Medicine. 2015 (in press). PMID: 25805116

This was a prospective observational study looking at ED handoffs. Out of 1163 total handoffs observed, 117 patients had episodes of hypotension, and they were not mentioned for 66 patients (42%). There were 156 patients with hypoxia, and 116 (74%) were not mentioned. (These numbers seem unbelievable, and if you look closer, attending docs rarely left this info out, it was primarily residents.)

Bottom line: Handoffs are important. Take a minute to review all the information. And we should probably be emphasizing this in resident education


Should H.pylori be an ED problem?

Meltzer AC et al. Treating Gastritis, Peptic Ulcer Disease, and Dyspepsia in the Emergency Department: The Feasibility and Patient-Reported Outcomes of Testing and Treating for Helicobacter pylori Infection.  Annals of Emergency Medicine. 2015 (in press). PMID: 25805114

This is a prospective cohort study on a convenience sample of ultimately 212 patients. The attending doctor was asked if the patients’ symptoms could be attributed to gastritis, PUD, or dyspepsia, and if so they tested for H.pylori and treated if positive. 23% of the patients tested positive for H.pylori. With treatment, they were able to eradicate H. pylori in 41% of those patients. At 3 weeks, the pain scores seemed to have decreased about the same amount no matter what had happened to you. For me, this could go either way. I worry about the false positives and a potential anchoring bias where we say this pain couldn’t be ACS just because the patient is H.pylori positive. However, our patients may benefit from early treatment (though they didn’t in this study).

Bottom line: H. Pylori is probably the cause of a lot of the symptoms we see, but we currently don’t have any good strategy to address that


The “rocket launcher” hip reduction technique

Dan M et al. Rocket launcher: A novel reduction technique for posterior hip dislocations and review of current literature. Emergency Medicine Australasia. 2015 (in press). PMID: 25846901

This is a case report of 6 patients, so I wouldn’t pay any attention to the EBM side of things. They describe a technique for hip reduction I hadn’t heard of, and may be helpful for some, especially if you are to short to make the Captain Morgan easy. Essentially, you adjust the height of the bed so that you can put the patients knee over your shoulder. The foot faces forward, like you might picture someone holding a bazooka or ‘rocket launcher’. This allows you to use you shoulder as a fulcrum, and lift with your legs.

Bottom line: Captain Morgan is still my go to, but its nice to have this as a backup


Another reduction technique: syringe rolling for mandible reduction

Gorchynski J et al. The “syringe” technique: a hands-free approach for the reduction of acute nontraumatic temporomandibular dislocations in the emergency department. J Emerg Med. 2014;47(6):676-81. PMID: 25278137

This technique involves placing a syringe (5 or 10cc) between the posterior molars, and then turning the syringe in the direction that would push the mandible backwards (as if a wheel were rolling forward along the bottom teeth). In this prospective, convenience sample, they were successful in 30/31 attempts, with 24 of those attempts taking less than a minute. You can do this without sedation. In fact, patients can do this for themselves.

Bottom line: I haven’t tried it yet – let me know if you do


Angioedema of the bowel: I’ve probably seen it, but I’ve never diagnosed it

Bloom AS and Schranz C. Angiotensin-Converting Enzyme Inhibitor–Induced Angioedema of the Small Bowel—A Surgical Abdomen Mimic. Journal of Emergency Medicine. 2015 (In Press). PMID: 25886983

Just a case report, but I include it because we probably see this, but I had never really heard of it. We won’t necessarily rule it in, but in recurrent abdo pain, I might consider stopping an ace inhibitor as a trial. They note that CT findings, if you happen to get one, include ascites, small bowel thickening and straightening, and dilatation without obstruction.

Bottom line: Medication side effects should be part of the differential diagnosis for every chief complaint


Old people have high D-dimers – don’t send them if you can avoid it, but if you have to…

Righini M et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA 2014;311(11):1117-1124. PMID: 24643601

This is a prospective observational study of 3346 patients with suspected PE (the total rule in rate was 19%), of which a total of 331 had D-dimers greater than 500, but less than age x 10. Using the adjusted D-dimer level of age x 10, they would have missed 1 PE out of 331 patients (0.3%). Unfortunately, not everyone got the gold standard test (CTPA), so it is possible they missed a few more that we don’t know about. However, if the test threshold for PE generally is 2%, and the elderly are particularly prone to renal problems from CT contrast, avoiding 331 CTPAs at the cost of one missed diagnoses might be worth it. The other major problem is that D-dimers are not standardized and there are multiple different assays.

Bottom line: If the D-dimer is less than age x 10, the risk is probably low enough to stop further testing. I use this to (and this is crazy, I know) talk to my patients about whether or not to scan


Clowns cause pregnancy; AKA completely irrelevant paper of the month 

Friedler S et al. The effect of medical clowning on pregnancy rates after in vitro fertilization and embryo transfer. Fertility and Sterility. 2011;95(6):2127-2130. PMID: 21211796

This is just too good not to include. Give women IVF, and then let them play with a clown and 36.4% become pregnant. Remove the clown: only 20.2%.

Bottom line: What exactly are they doing with that clown? 


#FOAMed suggestion of the month

If you haven’t come across it yet, Scott Weingart and Steve Smith put together a list of all the reasons for cath lab activation, including the very subtle details. There are 2 podcasts summarizing, and one very handy pdf. Also, Steve Smith is just giving away his amazing ECG textbook. All can be found at:

Cheesy Joke of the Month

Why don’t you ever see Hippos hiding in trees?
Because they are really f***ing good at it.

Articles of the month (March 2015)

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

Magnesium the wonder drug, now for migraines

Shahrami A et al. Comparison of therapeutic effects of magnesium sulfate vs. dexamethasone/metoclopramide on alleviating acute migraine headache. J Emerg Med 2015; 48(1): 69-76. PMID 25278139

In this RCT, they compared IV magnesium (1 gram) to the combination of metoclopramide 10mg IV and dexamethasome 8mg IV. Magnesium was more effective at 20min, 1 and 2 hours. I would note, that although metoclopramide is what we generally have to use now because of drug shortages or silly rules, prochlorperazine (Stemetil) and droperidol are both better for migraine. Also, previous studies of metoclopramide in migraine have used a 20mg dose, although 10mg is what tends to be ordered.

Bottom line: Intravenous magnesium might be a useful tool in the treatment of migraines

 

This PROMISEs to be the biggest paper of the month

The ProMISe trial. Mouncey et al. Trial of Early, Goal-Directed Resuscitation for Septic Shock. NEJM. 2015 (Ahead of print). PMID: 25776532

This is the third and final large trial of early goal directed therapy for septic shock, and shockingly it tells us pretty much the same thing the first two did: EGDT adds nothing to usual care. This is an open label, multi-center RCT from the UK with a total of 1260 patients. Patients were randomized to receive the classic EGDT protocol or ‘usual care’. There was no difference in mortality, (29% at 90 days). Of course, ‘usual care’ may look a lot more like EGDT than it used to.

Bottom line: Septic patients need antibiotics, fluids, and most importantly someone to care about them. Ditch the high tech stuff.

 

Emergency doctors are ECG experts, we don’t need a second opinion next week

Proano L et al. Cardiology electrocardiogram overreads rarely influence patient care outcome. Am Jour Emerg Med 2014;32(11):1311-14. PMID: 25200503

This is a retrospective review at a single teaching hospital over 21 months, with 38,490 ECGs reviewed. Of the 16,011 patients that were discharged, 22 patients required follow up for discordant readings (0.1%). Of those 22, after review only 2 were determined to require a change in management. The remainder were considered ‘non specific’ or the ED doc turned out to be right. Of the 2 with changed management, one was for ‘possible ACS’ who ultimately had a completely negative workup. The other was a missed atrial flutter, but nothing changed about their management except also getting a negative workup.

Bottom line: Having cardiology over read ED ECGs results in a change of management in somewhere between 0 and 0.01% of patients (and adds a bunch of false positives).

 

We don’t listen to our own literature (ACLS still doesn’t work)

Sanghavi BS et al. Outcomes After Out-of-Hospital Cardiac Arrest Treated by Basic vs Advanced Life Support. JAMA Intern Med. 2015;175(2):196-204. PMID: 25419698

We already know this, because it has been over a decade since OPALS (in Ontario) proved that ACLS doesn’t work. This is an observational cohort study of American medicare patients with out of hospital cardiac arrest, based on whether they were treated by an ACLS or BLS crew. Survival to hospital discharge was better with BLS (13.1% vs 9.2%). Survival at 90 days was better with BLS (8.0% vs 5.4%).

Bottom line: ACLS doesn’t work. Stop wasting time with IVs and drugs. And most importantly, can we please remove any kind of ACLS training from my hospital credentialing requirements?

 

Related: Less is also more for airway management in cardiac arrest

McMullan J et al. Airway management and out-of-hospital cardiac arrest outcome in the CARES registry. Resuscitation 2014, 85(5):617-622. PMID: 24561079

This is a retrospective registry review of 10,691 out of hospital cardiac arrests that demonstrated that patients that did not have advanced airways placed during the initial resuscitation were more likely to survive to hospital discharge with good neurological outcomes (OR 4.24 95% CI 3.26-5.20). The use of supraglottic airways was associated with worse outcomes than endotracheal intubation. Of course, these are just associations in a very complex scenario with multiple confounders.

Bottom line: Use good technique and provide slow ventilations with a bag valve mask, unless you believe there is a good reason to do something more advanced.

 

Patients don’t understand us

Shif Y et al. What CPR means to surrogate decision makers of ICU patients. Resuscitation 2015 (In print). PMID: 25711518

This is qualitative research on communication and understanding of CPR by surrogate decision makers in the ICU. (I love this stuff, but probably mostly because my master’s was based in qualitative research and communication. Realistically, this study probably just states the obvious.) Less than half of surrogate decision makers identified cardiac arrest as the indication for CPR. Only 8% could identify the major components of CPR (although the technical details probably don’t matter that much.) Mostly importantly, 72% thought that the survival rate post CPR is greater than 75%.

Bottom line: It takes a lot of time, but we really do need to teach our patients about medicine.

 

Ketamine will not make your head explode (although, if my head did explode, I would probably be grateful to be in the K-hole)

Cohen L et al. The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review. Annals of Emergency Medicine 2015; 65(1):45-51. PMID: 25064742

This systematic review found a total of 10 studies, all in the ICU or OR as they were actually measuring ICPs. Mostly ketamine didn’t change ICP or CPP. In two studies, ICP actually decreased with ketamine. In two studies it did go up, but by 2-4 mmHg, so clinically meaningless. There were no changes in neurological outcomes, ICU length of stay, or mortality.

Bottom line: Ketamine is a wonder drug that can do anything, possibly even solve our boarding crisis, so go ahead and use it whenever you want.

 

Also, tetracaine is not going to melt your eyeballs

Waldman N et al. Topical tetracaine used for 24 h is safe and rated highly effective by patients for the treatment of pain caused by corneal abrasions: a double-blind, randomized clinical trial. Acad Emerg Med 2014; 21:374-382. PMID: 24730399

This is a prospective double blind RCT in which patients with corneal abrasions were allowed to use tetracaine 1% q30min PRN for pain after simple corneal abrasions (versus saline placebo). This is not the first study to look at this, and the dogma is based on a handful of ridiculous case reports. There were no complications (to be fair 116 patient trial is not big enough to be sure it is safe.) It is a weird trial, because pain scores didn’t go down, but patients were more satisfied with their care if they were given tetracaine.

Bottom line: Patients with painful conditions deserve good pain control. If I had a corneal abrasion, you can be sure I would be using a topical anesthetic.

 

One day we may not radiate our patients at all – apparently you can use ultrasound to look for bowel obstruction?

Jang TB etl al. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J. 2011;28(8):676-8. PMID: 20732861

A prospective study of 76 patients with suspected SBO, all of who had a CT scan done. Residents were given a 10 training session on using bedside ultrasound to assess for bowel obstruction. The bedside ultrasound had a sensitivity of 91% and a specificity of 84% compared to the CT gold standard. Compare that to abdominal plain films, which had a sensitivity of 46% and a specificity of 67%.

Bottom line: Ultrasound is much better than plain films for the assessment of SBO.

 

Yet another reason not to order urine tox screens

Felton at al. 13-Year-Old Girl With Recurrent, Episodic, Persistent Vomiting: Out of the Pot and Into the Fire. Pediatrics 2015 (Ahead of print). PMID: 25733759

OK, this is only a case report and only gets in because I have an axe to grind. I hate urine toxicology screens and believe they should never be ordered in the ED. But it does raise an interesting tidbit to keep in mind: apparently pantoprozole can cause a false positive urine tox screen for marijuana.

Bottom line: Never rely on a urine tox screen.

 

NPO time irrelevant for procedural sedation

Godwin SA et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014;63(2):247-58. PMID: 24438649

As part of the ACEP clinical policy process, they did a systematic review. They found 5 studies that cover thousands of patients, and found no evidence that fasting decreased aspiration or other adverse events. The official policy is “Level B: Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.”

Bottom line: Just make sure they actually take the Doritos out of their mouth before starting.

 

GCS 8, just wait

Duncan R and Thakore S. Decreased Glasgow Coma Scale does not mandate endotracheal intubation in the emergency department. J Emerg Med 2009;37(4):451-5. PMID: 19272743

An older paper that came across my desk that I think is worth including because I know practice varies wildly in this regard, and I have debated this point with multiple folks. This is a prospective study of 73 overdose patients with decreased LOC who were watched, not intubated (GCS ranged from 3 to 14). No patient with a GCS under 8 worsened, required intubation, or aspirated.

Bottom line: GCS under 8 shouldn’t be an automatic intubation in tox patients

 

Best way to avoid the pain of an ABG – don’t do one. Second best way: use an insulin needle?

Ibrahim I et al. Arterial Puncture Using Insulin Needle Is Less Painful Than With Standard Needle: A Randomized Crossover Study. Acad Emerg Med 2015 (Ahead of print). PMID: 25731215

Although I don’t think ABGs are very helpful most of the time, you might want to calculate an A-a gradient or something some day. This was a randomized study of healthy volunteers comparing a standard 23 gauge to an insulin needle for arterial stabs. Not surprisingly, both pain and complications were lower with the smaller needle. However, hemolysis went up, so not great if you really want a K – but why do you want to know the arterial K?

Bottom line: If you really feel like doing an ABG, use a smaller needle.

 

Infomercials in the Lancet?

Goldstein JN et al. Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial. Lancet 2015 (ahead of print). PMID: 25728933

This is an open label RCT of 181 patients comparing PCC (Beriplex) to FFP before an ‘urgent surgery or procedure’. Based on rated ‘effective hemostasis’ being achieved in 90% of the PCC group and 75% of the FFP group, the authors conclude that PCC is superior to FFP. Sadly, this article appears to have been written directly by the drug company (if you read the funding statement), had protocol changes as it went, and relies on reporting of a surrogate end point. Despite all that, the treatments were actually identical. Difference in surgical blood loss between the two groups: 12 ml. Total number of units of blood transfused – identical in both groups.

Bottom line: This trial will be used to push an expensive medication, but it should be interpreted as the opposite: never use PCC just to get someone to surgery.

 

Hepatic encephalopathy is treated with diarrhea (lactulose is not special)

Rahimi RS et al. Lactulose vs polyethylene glycol 3350-electrolyte solution for treatment of overt hepatic encephalopathy: the HELP randomized clinical trial. JAMA Intern Med 2014; 174(11):1727-1733. PMID: 25243839

This is a small RCT comparing PEG 3350 to lactulose for patients with hepatic encephalopathy. PEG 3350 resulted in more rapid resolution of symptoms than lactulose.

Bottom line: PEG 3350 might be better, but certainly isn’t worse than lactulose for the treatment of hepatic encephalpathy.

 

Your kid is allergy prone? Feed him peanuts

Du Toit et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. NEJM 2015; 372:802-813. PMID: 25705822

This is the RCT to show anyone who ever tells you that there some are things we just can’t study. They took 640 children at risk of developing peanut allergy because they already had an egg allergy or severe eczema and randomized them to either eat or not a peanut based snack. The results are relatively astounding. If you didn’t have a positive skin test at the beginning of the study, being exposed to peanuts decreased your chance of developing a peanut allergy by 12% (NNT = 8). If you had a positive skin test at the outset, being exposed to peanut protein decreased your allergy rate by 25% (NNT =4)!

Bottom line: More of a general interest than emergency medicine specific paper. This is strong support for the cleanliness hypothesis of increasing allergies – if you want to avoid allergy, increase antigen exposure in kids.

Cheesy Joke of the Month

I went to a zoo recently, and the only animal there was a dog…

It was a shitzu

Articles of the month (February 2015)

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

Amoxicillin is the antibiotic of choice in pediatric pneumonia

Williams DJ et al. Narrow vs broad-spectrum antimicrobial therapy for children hospitalized with pneumonia. Pediatrics. 2013 Nov;132(5):e1141-8. PMID: 24167170

This was a retrospective record review of 15,564 admitted but not critically ill pediatric patients with community acquired pneumonia. They used propensity scoring, so the results could mean anything, but kids getting amoxicillin had the same outcomes as those with broad spectrum antibiotics such as cefotaxime or ceftriaxone. In fact, IDSA and peds infectious disease society both recommend narrow spectrum antibiotics, which is contrasted to the 90% of children in this study that were given broad spectrum.

Bottom line: Amoxicillin is probably best in pediatric pneumonia.

 

Hans and Franz want to pump you up (steroids for pediatric asthma)

Keeney GE et al. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014;133(3)493-9. PMID: 24515516

A meta-analysis of 6 RCTs of prednisone versus dexamethasone in children with acute asthma exacerbations. There was no difference in relapse at 5 or 30 days. The dexamethasone group was less likely to vomit, both at home and in the ED. (Some studies used 2 doses of dex, some only used 1 versus generally 5 days of prednisone.)

Bottom line: Fewer doses and less vomiting, I am sold on dexamethasone. (My wife adds: “Well Duh! Pediapred tastes like s***. Dex is less volume and way easier to take.”)

 

The ugly stepchild of papers 1 and 2? Steroids for pneumonia

Blum, CA et al. 2015. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial. Lancet (January 16). PMID: 25608756

I don’t buy what they are selling here, but I have already heard about this paper from at least 10 different sources, so you will likely hear about it as well. This is a large, multi-center, double blind RCT of 781 community acquired pneumonia patients, randomized to either get or not get prednisone 50mg PO daily for 1 week. It was a positive study, in that the primary outcome “time to clinical stability”, or ‘normal vital signs’, was 3 days in the prednisone group and 4.4 days with placebo. However, as important as vital signs are, are they really a patient oriented outcome? Has a patient ever said, I know I have this pneumonia, but what I really want is for my heart rate to be 95 instead of 105? Side effects: prednisone obviously caused hyperglycemia, but also (non statistically) doubled pneumonia associated complications. Previous studies showed higher recurrence rates with steroids.

Bottom line: Of course steroids make the numbers look better, but we are probably treating the doctor and not the patient here. Not for me.

Bottom line #2: If you are going to design a study, measure outcomes that matter.

 

Why do we use cervical collars?

Ala’a O et al. 2015. Should suspected cervical spinal cord injury be immobilised?: A systematic review. Injury Journal. (In press). PMID: 25624270

Like many of the things we do, this practice was started based on expert opinion in the pre-EBM era. There are a large number of cadaver and volunteer studies that show that C-collars really don’t prevent movement of the c-spine. What is the clinical evidence? There are a grand total of 8 observational studies ever done. In penetrating trauma, C-collar application was associated with an increase in mortality (OR 8.8), increase scene time, and concealment of neck injuries. In blunt trauma, one study showed that immobilization was associated with worse neurological outcomes. This is balanced by no evidence of benefit. They conclude “there is a clear need for large prospective studies to determine the clinical benefit of prehospital spinal immobilsation.”

Bottom line: I can’t imagine anyone changing their practice, but this does not speak very well to the benefits of cervical spine collars

 

Where are you drilling? Arm might be better than leg, or go straight towards the heart

Pasely J et al. 2015. Intraosseous infusion rates under high pressure: A cadaveric comparison of anatomic sites. Journal of Trauma and Acute Care Surgery 78(2)295-9. PMID: 25757113

Its a cadaver study, so take that as you will – but I am often drilling into dead people in code situations anyhow, so there might be some external validity here. They tried to infuse saline using a pressure bag, and the rates they could get were: 94ml/min in the sternum, 57ml/min in the humerus, and 30 ml/min in the tibia.

Bottom line: Humerus seems twice as fast as the tibia, so maybe that should be our go to spot? I probably wouldn’t suggest drilling sharp things into the sternum, but some people seem to think it’s OK.

 

Speaking of IOs – they are fine for RSI

Barnard EBG et al. 2014. Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study. Emerg Med J (electronic ahead of print). PMID: 24963149

OK, also not really definitive by any means. A prospective observational study, with no controls, in a military setting. 34 patients had their RSI drugs pushed through an IO, first pass success in all but 1 (97%) and that patient was intubated on the second attempt. Although no control, 97% compares well with historical controls.

Bottom line: Go ahead and give RSI drugs through an IO if that is what you have

 

First RCT of massive transfusion protocol

PROPPR Holcomb et al. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma. The PROPPR Randomized Clinical Trial. JAMA. 2015; 313(5)471-82. PMID: 25647203

After a bunch of theoretical stuff and some observational trials, this was the first ever RCT comparing different ratios of PRBCs, FFP, and platelets in a massive transfusion protocol. They compared 1:1:1 PRBCs, FFP and platelets to 2 units of PRBCs for each 1 unit of FFP and platelet equivalent. This was a negative trial, in that there was no difference in mortality between the two groups. However, some people have argued that their goal of a 10% reduction in mortality was too high, that the non-significant trends (including a 4.3% absolutely mortality reduction) favoured the 1:1:1 group, and secondary bleeding end points also favoured the 1:1:1 group. (This study design makes the inherent assumption that some transfusion ratio is a good thing, in that they did not include a usual care arm. While this has been the trendy thing of late, it is entirely based on flawed observational studies.)

Bottom line: This study will be used to support whatever pre-existing beliefs you had on the subject.

 

The new AAP bronchiolitis guidelines are very nihilistic (maybe realistic?)

Ralston SL et al. 2014. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 134(5)e1474-502. PMID 25349312

Quick summary:

Do NOT give ventolin

Do NOT give epinephrine

Do NOT give hypertonic saline (in the ED)

Do NOT give corticosteroids

Diagnosis on Hx/Px, no routine chest xrays

While these guidelines are very evidence based, my EBM self is fighting with my practical self. If there are no treatments, peds is going to have to see 30 kids a day in the ED. Should we just set aside a room for them?

Bottom line: The AAP says don’t do anything for bronchiolitic kids

Two for the price of one: pediatric head injuries aren’t cured by CT

Lee LK et al. (PECARN). Isolated loss of consciousness in children with minor blunt head trauma. JAMA Pediatrics 2014; 168(9)837-43. PMID: 25003654

This is a secondary analysis of the PECARN head injury algorithm. Although overall your chance of clinically important head injury was 2.5% with LOC and only 0.5% without, if you only had LOC and no other PECARN risk factors, your risk of a clinically important injury was the back to baseline at 0.5%.

Bottom line: Loss of consciousness, in the absence of other worrisome findings, has a low risk of clinically important injury and CT scan is unnecessary. (Look at the whole patient, not just one aspect of the history or physical.)

Dayan PS et al. (PECARN). Association of traumatic brain injuries with vomiting in children with blunt head trauma. Annals of Emergency Medicine 2014;63(6)657-65. PMID: 24559605

Another secondary analysis of the PECARN head injury algorithm. Vomiting, without any other PECARN risk factors, had an overall incidence of clinically important injury of 0.2%

Bottom line: Vomiting, in the absence of other worrisome findings, has a low risk of clinically important injury and CT scan is unnecessary. (Look at the whole patient, not just one aspect of the history or physical.)

 

Start sending those stroke patients to the cath lab?

After multiple negative trials in the past, we get 3 new trials on endovascular treatment of stroke. (Given that we aren’t a stroke center and this isn’t going to be a decision you will make in the ED, it is probably best to just skip to the next section. But they will be talked about at cocktail parties.)

MR CLEAN Berkhemer OA et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:(1)11-20. PMID: 25517348

RCT comparing intra-arterial treatment versus usual care in stroke patients. Good neurological outcome (MRS 0-2 at 90 days) in intra-arterial group was 32% versus only 19% in the usual care group. (These are both way worse outcomes than other stroke trials, like NINDS)

EXTEND-IA Campbell BC et al. Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. N Engl J Med. 2015. (Ahead of print) PMID: 25671797

RCT (phase II trial) of patients getting TPA within 4.5 hours with a middle cerebral or internal carotid clot AND evidence of salvageable brain tissue plus or minus endovascular therapy. Was stopped early after only 70 patients (they had to screen over 7,000 patients at 10 hospitals over 2 years to find these 70 patients – so they are highly selected to say the least). There were multiple primary outcomes (bad) but importantly if you got treated 80% had good neurological improvement at 3 days, versus only 37% of those without the endovascular treatment.

ESCAPE Goyal M et al. Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. N Engl J Med. 2015. (Ahead of print) PMID: 25671798

RCT of patients up to 12 hours with proximal anterior circulation occlusions and evidence of good collateral flow plus or minus endovascular therapy. Also stopped early, with a total of 316 patients (wanted 500 originally). They also only managed to recruit about 1 patient a month at each of the 22 hospitals involved – so also very highly selected patients. Functional independence (MRS 0-2) at 90 days was 53% in the endovascular arm and 29% in the usual care arm.

Overall bottom line: The benefit described in these trials is impressive. They are small and all have some flaws (stopping them early probably exaggerates the benefit), but I think it is likely they represent a true benefit. However, the number of eligible patients was tiny. Maybe they have finally found the subset of stroke patients that will benefit from revascularization – like the STEMI patient in a sea of chest pains.

 

Dr. Oz Sucks

Korownyk C et al. Televised medical talk shows–what they recommend and the evidence to support their recommendations: a prospective observational study. BMJ 2014;349:g7346. PMID: 25520234

OK, this isn’t really all that valuable or surprising, because anyone that has ever turned on a TV realizes that Dr. Oz rarely has anything credible to say, and seems to be a lot more interested in selling snake oil than actually helping patients. But in case any one was wondering, these authors prospectively evaluated the claims made on Dr. Oz and The Doctors, and even if a single case report was counted as “evidence” only 50% of the claims made on the shows had any evidence based backing, and a full 15% were completely contradictory to available evidence.

Bottom line: Don’t get your medical advice from a TV shill

 

Let’s review an older one: TTM, putting dead people on ice

Nielsen N et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013 369(23):2197-206. PMID: 24237006

An ‘older’ paper that I am sure everyone has heard about, but it is good to include at least one practice changing quality study every month. After 2 small, low quality studies were published in 2002 (well before I started medical school in case you were wondering), the medical world went nuts for therapeutic hypothermia. But when I started in medicine, there were still some intelligent people (like Jerry Hoffman) who tried to remind us these were small studies, with inherent biases, and that a corner stone of science is replication. (There is a lesson here for so many other topics – but I don’t think I have the balls to mention NINDS and tPA.)

So this was a large, randomized control trial (not blinded) where 950 patients with ROSC after out of hospital cardiac arrest were either brought to 33 or 36 degrees Celsius. There was no difference in outcome.

The comments about this paper have been all over the map. The favorite statement by a lot of very smart people seems to be “this confirms that we desperately need to avoid fever, but 36 degrees is probably good enough.” I would point out, this study says nothing about avoiding fever. In fact, I don’t know of any study that compared fever or no fever post cardiac arrest. So people are either expressing their left over love of hypothermia, or is basing it on animal models, which are – well animal models.

Another approach would be to ask if we have any reason to believe this would work (the beginning of Bayesian reasoning). There were some animal models that support hypothermia, but probably more important is that hypothermia has been tested in humans for a number of conditions other than cardiac arrest – and it doesn’t seem to work.

Bottom line: There is no benefit from hypothermia post cardiac arrest. No one knows much about fever, but many people will talk about it a lot.

Bonus section: This Penn and Teller vaccination video should play continusouly in the waiting room

http://www.kevinmd.com/blog/2015/01/watch-2-magicians-destroy-anti-vaccine-movement-90-seconds.html

Cheesy Joke of the Month

It was a cold February so:

What is the difference between snowmen and snowwomen?

Snowballs

Articles of the month (January 2015)

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

Each month my inner nerd comes out, and I bore my group with an e-mail containing the most interesting EM papers I have read in those 30 days. I figured I would start sharing those summaries here as well, starting at the beginning of 2015. These are obviously very brief, informal summaries. I always suggest reading the paper for yourself. Now to catch up, starting with January 2015…

Beta-blockers might be useful in refractory V.Fib.

Driver BE et al. 2014. Use of esmolol after failure of standardcardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resus 85(10):1337-41. PMID: 25033747

Not a definitive paper (it was retrospective) but raises a treatment that I have never used, or seen used, but have heard talked about a lot recently. In patients with refractory V.fib/ electrical storm, we don’t usually reach for anti-hypertensives, but beta blockers might be a good idea. Use of esmolol in these patients was associated with more ROSC and more neurologically in-tact survival.

Bottom line: Esmolol 500mcg/kg bolus over 1 min then start at 50mcg/kg/min.

 

Patients with a listed penicillin allergy get more C.Diff, MRSA, VRE

Macy E, Contreras R. 2014. Health care use and serious infection prevalence associated with penicillin “allergy” in hospitalized patients: A cohort study. J Allergy Clin Immunol. 133(3):790-6. PMID: 24188976

This was a large retrospective cohort study of 51,000 patients in California. Patients with a listed penicillin allergy received more clinda, vanco, and quinolones. They also had 23% more C.Diff, 14% more MRSA, and 30% more VRE (relative numbers) as compared to their matched, non penicillin allergic patients.

Bottom line: It might be worth digging more into those penicillin allergies.

 

Tranexamic acid topically stops epistaxis

Zahed R et al. 2013. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 31(9):1389-92. PMID: 23911102

A good sized RCT (216 patients) compared usual packing to 500mg (5ml) of TXA on a cotton ball in the anterior nose. This worked quickly (bleeding was stopped at 10 min in 70% of the TXA group compared to only 30% of ant pack group) and lasted (no significant difference in 24 hour rebleed rate between groups, but only 5% in TXA versus 10% in ant pack group had rebleeds). Patients preferred the TXA to packing (what a surprise). Biggest problem with the paper: unable to blind (and I am pretty sure that less than 70% of my anterior packings are still bleeding at 10 minutes.)

Bottom line: Worth trying, as I wouldn’t want to go home with an anterior pack (but my personal experience with this isn’t nearly as positive)

 

Let’s stay on topic: CRASH 2: TXA reduces mortality in trauma

Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised placebo-controlled trial. Lancet 2010; 376: 23-32. PMID: 20554319

I didn’t actually read this this month, but it is a landmark paper, so why not review. I was originally skeptical, but we probably should be doing this until we know better. Summary: Huge RCT (over 20,000 patients) of adult trauma patients the doc thought was at risk of significant bleeding, got 1 gram of TXA over 10min and then another over 8 hours. They showed an absolute decrease in mortality of 1.5% or an NNT of 68. Why was I skeptical – the majority of these patients were in a very rural setting, without access to trauma surgeons (some sites did not even have a fax machine for the randomization procedure) so this may not apply in Canada, and TXA was supposed to work by decreasing bleeding, but it didn’t. However – I am starting this think this might apply to us. We don’t have a trauma surgeon and a lot of time might pass during transfer, so maybe we are more like rural Africa than I originally thought. I would caution however – they conclude that there were no side effects from TXA. However, when looking for side effects the setting might really matter. If a patient in rural Africa gets a DVT or a PE, how easy do you think it is to get the test to prove it? Therefore, this study could easily have missed blood clots in patients sent back to their villages.

Bottom line: Probably all trauma patients sick enough to transfer should get TXA 1 gram IV.

 

Anti-emetics don’t work in adults?

Egerton-Warburton et al. 2014. Antiemetic Use for Nausea and Vomiting in Adult Emergency Department Patients: Randomized Controlled Trial Comparing Ondansetron, Metoclopramide, and Placebo. Annals of Emergency Medicine 64(5): 526-32. PMID: 24818542

This was a prospective, double blind, RCT of 270 patients from Australia comparing zofran versus maxeran versus placebo. And you guessed it, much like everything we do: our treatments don’t work. Or, more accurately, placebo and both the drugs decreased nausea scores by about 2.5 out of 10. More side effects with maxeran. Two problems: 1) Dose – zofran only 4mg, but we often given more; maxeran – they gave 20mg – which might explain the side effects. 2) They only measured outcomes at 30 minutes – maybe anti-emetics help at 2 or 3 hours? However, it was a good RCT and treatment was no better than placebo.

Bottom line: Maybe we slightly overuse these medications?

 

AEDs may have some major problems

Calle PA et al. 2015. Inaccurate treatment decisions of automated external defibrillators used by emergency medical services personnel: Incidence, cause and impact on outcome.Resuscitation (Ahead of print) PMID: 25556589

This one worries me, but I am not sure what to do about it. For 135 consecutive patients (837 total cardiac rhythms) these authors retrospectively looked at the rhythm strip and compared it to what the AED actually did. Out of 148 rhythms that should have been shocked, the AED missed 23 (16%) mostly due to artifact or fine v.fib. It also shocked when it should not have, although with no obvious harm, 4% of the time. (I can’t remember the model of the AED – maybe some are better or worse?)

Bottom line: AEDs might miss shock-able rhythms 16% of the time!!!

 

Apneic oxygenation decreases desaturations during intubation

Wimalasena Y et al. 2014. Desaturation rates during rapid sequence intubation by an Australian helicopter emergency service. Annals of Emergency Medicine. (Online ahead of print) PMID: 25536868

This was one of the papers I spoke about at grand rounds. Not high quality, being a retrospective before and after study. Essentially, this pre-hospital/ retrieval helicopter EMS service in Australia added the use of a nasal canula to their protocol for all intubations. Historically, 22.6% of patients had some desat. With nasal oxygen 16.5% had some desat.

Bottom Line: Essentially no cost, and a NNT of 16 to prevent a desat. Blow some Os up their nose.

 

Mortality decreases when all the best cardiologists are out of the country

Jena AB et al. 2014. Mortality and Treatment Patterns Among Patients Hospitalized With Acute Cardiovascular Conditions During Dates of National Cardiology Meetings. JAMA Intern Med. PMID: 25531231

This article is relatively useless from a science standpoint – but I love the relatively absurd conclusions. It is a retrospective chart review where they looked at the cardiac outcomes for patients admitted during national cardiology meetings (and therefore when all the “top” cardiologists and cardiac surgeons were away). Many fewer procedures were done and MORTALITY WENT DOWN.

Bottom line: Have your heart attack when the leading cardiologists are all out of town.

 

A better aproach to PEA

Littmann L et al. 2014. A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity. Medical Principles and Practice. 23:1-6. PMID: 23949188 Free full text: http://www.karger.com/Article/Pdf/354195

The standard epinephrine and push treatment is actually associated with worse outcomes in PEA. To that end, most guidelines say that in PEA the essential action is to determine the underlying cause.  But the Hs and Ts are hard to remember during a code, and also don’t tell you which cause is the most likely. This new algorithm does through 3 simple steps: 1) QRS wide or narrow? 2) Ultrasound to find cause (Or use clinical judgement) 3) Empiric treatment based on the first 2. This is not one where my summary will suffice – its a 4 page paper and its free. I strongly suggest taking 20 minutes and reading it through. (Or, you can read the First10EM blog post: The simplified approach to PEA)

Bottom line: There is a better way to approach PEA

Cheesy Joke of the Month

A man awoke in the recovery room after a bad car accident. He screamed for his doctor: “Doctor, doctor, I can’t feel my legs!!”

The doctor replied: “I know you can’t – I’ve cut off your arms.”