Paramedic 2: Epinephrine harms/helps in out of hospital cardiac arrest

A critical appraisal of the PARAMEDIC 2 trial (epinephrine in out of hospital cardiac arrest)

After years of waiting, PARAMEDIC 2, the large RCT of epinephrine for out of hospital cardiac arrest, has finally been published. So we can now definitively say that epinephrine is harmful. Wait, maybe it helps? Can a positive study demonstrate harm? Maybe this EBM stuff isn’t so easy after all

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Articles of the month (July 2018)

A monthly (ish) summary of the emergency medicine literature

You will probably notice a new format to the articles of the month. I was getting sick of not being able to find papers that I knew I had previously commented upon. Having them listed as one 10 papers in the articles of the month made them very difficult to search for. Therefore, on bigger, more important papers, I have started writing stand alone blog posts. I will still include those papers in the articles of the month, but the summary will be truncated, with a link to the blog for all the details. The articles of the month will probably still contain extra articles, including papers that don’t warrant their own post and my usual “just for fun” kind of papers. Let me know what you think. Continue reading “Articles of the month (July 2018)”

Tamsulosin for kidney stones: The STONE trial

Another randomized control trial of “medical expulsive therapy”

This again? I know I’ve covered tamsulosin for nephrolithiasis a number of times before. I image most people can predict the results of this study. It may seem a bit repetitive, but I think there is an important EBM lesson in this data. Continue reading “Tamsulosin for kidney stones: The STONE trial”

IV fluids do not cause cerebral edema in pediatric DKA (Kuppermann 2018)

Does IV fluid rate or tonicity contribute to the rate of cerebral edema in pediatric DKA?

Some children with diabetic ketoacidosis develop cerebral edema and have bad neurologic outcomes. Unfortunately, when this happens, fingers are frequently pointed at emergency physicians for our overzealous use of intravenous fluids. Children are not little adults, we are told, and cannot tolerate the same volumes of fluids. Or perhaps it is the use of hypotonic fluids. Either way, we are given very strong recommendations to avoid “aggressive” IV fluids, and to avoid hypotonic fluids. (TREKK 2014; Dunger 2004) However, the evidence base for these recommendations is very weak, relying entirely on observational data. (Hom 2008) This observational data indicates an association, but that does not translate to causation. Children receiving more fluids tend to be sicker and more likely to develop cerebral edema in the first place, meaning the association with fluids could be entirely based on confounding. A case control study done in 2001 found no association with volume of fluid resuscitation, but instead with acidosis and renal failure (markers of disease severity). (Glaser 2001) To date, there has been a lot of conjecture, but not a lot of answers. Finally, we have a large, randomized trial to guide our management…

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Bias in medical research

A glossary of common research biases

A bias in evidence based medicine is any factor that leads to conclusions that are systematically different from the truth.  Continue reading “Bias in medical research”

Bougie is better (Driver 2018)

Should we use a bougie routinely for our first attempt at intubation?

I love the bougie as a rescue technique for difficult airways, but many people use the bougie routinely on their first attempt. I discussed some previous retrospective data from this group in the March 2018 Articles of the Month. Now, they provide us with the best evidence to date, in the form of a RCT. Continue reading “Bougie is better (Driver 2018)”


Summary of a RCT looking at tranexamic acid in intracerebral hemorrhage

This is a new post format for First10EM. When it comes to evidence based medicine, I have kept to 2 general formats: the deep dive (aka tPa for stroke) and the semi-monthly “articles of the month” which covers any paper I have read and found interesting. The problem with the articles of the month format is that it makes it very difficult to find comments on older papers. If you wanted to find my commentary on the WOMAN trial, a search would just lead you to a post titled “articles of the month May 2017”, which isn’t super helpful. Therefore, I am going to start writing more posts that cover individual papers. This means that they will be shorter reads, and that you will see First10EM pop up in your feed a little more often. I hope this this is helpful rather than annoying. Either way, I am always looking for feedback. (The podcast every month or two with Casey Parker will continue.)

Our first paper looks at the silver bullet of modern emergency medicine – a drug so beloved that I am surprised it is even considered ethical to study it anymore – tranexamic acid, and its role in nontraumatic intracerebral hemorrhage.

Continue reading “TXA in ICH (TICH-2)”