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.”

Assisted Suicide (Carter V Canada)

In February of this year, the Supreme Court of Canada unanimously decided that an absolute ban on assisted suicide is unconstitutional.

In September of 1993, I was 11 years old and just starting 6th grade. At the same time, a woman by the name of Sue Rodriguez was fighting in front of the Supreme Court for the right to assisted suicide, an act she could not perform herself because of her debilitating ALS. I had never heard of assisted suicide before, nor had I really contemplated the end of life or the suffering of others. I was mostly interested in baseball cards and girls, but Sue Rodriguez lost her case, and all of a sudden I was outraged.

By the end of that year, my teachers grew bored of my endless essays on the topic. I spouted human rights and dignity. I spoke of pain and suffering. I often quoted Sue Rodriguez in asking “whose body is this?” In short, I was an annoying kid, but I had very strong beliefs; beliefs that I still mostly hold today.

So in some respect, I was surprised at the significant sadness I felt when I heard of the Supreme Court’s decision in Carter vs Canada. This was a decision I had always felt was legally and morally correct. It should have felt like a victory, but it just filled my heart with sorrow. I wasn’t hearing a victory for human rights and personal freedoms. I was just hearing a disheartening cry for help.

I have spent more than half of the two decades between these decisions training to become a physician. Although I now practice emergency medicine, my passion throughout medical school was always palliative care. I spent most of my elective time with the palliative care team. Amongst the exhausting grind of medical training, my time in palliative care was rejuvenating. To many, that may sound strange, but I am sure that anyone who has witnessed good palliative care will understand me.

So many things we do in medicine have such a small impact. I can talk for hours about diet and exercise, knowing that most patients will never be able to make a significant change. I arrange rehab for patients, only to see them back in the department drunk and injured again. As a family doctor, I was devoted to preventative medicine, tackling diabetes, hypertension, and cholesterol, but it was impossible to know if I had ever actually helped a particular patient.

My days in palliative care were such a refreshing change. We would start the day rounding on newly referred patients, with pain, or nausea, or shortness of breath so severe their regular doctor could not find a way to help them. We would talk to the patient and listen to their hopes and goals. Then we would start an aggressive treatment plan. When we finished our day by rounding on the same patients again, every patient would feel better. We were making instant, impactful changes. I had never seen patients so grateful. Nothing else I do is as rewarding.

What this time in palliative care taught me is that we can treat suffering, but sadly, it is something that we frequently do poorly. So when I hear the arguments for assisted suicide, I no longer hear the logic about personal liberty and the right to choose. Instead, I hear a faulty premise. I hear patients that are suffering, who think that the only way to stop their suffering is death. That is heart breaking, but I think it is wrong. Suffering can be treated. Suffering must be treated, and we must do a better job of treating it before we ever consider death as the answer.

When an individual presents to the emergency department with suicidal thoughts, we don’t discuss their personal rights. We recognize their suffering and we do everything in our power to help them. We must similarly recognize suicidal ideation in the terminally ill as a sign of suffering and do everything we can to treat it.

I won’t debate whether assisted suicide is right or wrong. I think that is the wrong question. The better question is: how can we help these individuals, who are obviously in desperate need? We need to demand better palliative care in this country. If done properly, I think much of the desire for assisted suicide would quickly disappear.

Research, Rants, and Ramblings

Today I am going to launch a secondary feature on my site, called Research, Rants, and Ramblings, where I will be able to break from my usual format and share my thoughts on a wider variety of topics. I don’t plan on publishing here often, but anyone who knows me knows that I love to rant, so this will give me the occasional outlet. Also, I currently write a monthly literature review newsletter for my group highlighting the best articles I read each month, and I thought I would share that here as well, in case anyone was interested.

For anyone who is not interested in receiving updates about these non-core First10EM topics, I would suggest using the following RSS feed, which will only contain the core content:
http://www.First10EM.com/category/first10em-cases/feed/

If you want to receive updates about everything on First10EM, you can continue to use this RSS feed:
http://www.First10EM.com/feed/

Massive Hemoptysis

A simplified approach to the initial assessment and management of emergency department patients with massive hemoptysis

Case

The charge nurse grabs your arm and pulls you into the resuscitation bay, where EMS have just unloaded a 45 year old guy in obvious distress, coughing up a significant amount of blood. The paramedic tells you, “He doesn’t speak English, so we don’t know a lot about him. My guess is that he has already coughed up about 250ml of blood on route. He still sating OK, and his pressure is holding, but I’m just glad we got here. He’s all yours doc…”

  Continue reading “Massive Hemoptysis”

Procedure: Umbilical Vein Catheterization

A review of umbilical vein catheterization

Case

You find yourself leading a code pink in L&D, with no pediatricians to be found. You have already moved efficiently through the neonatal resuscitation algorithm, but despite clearing the airway, bagging, and chest compressions, the baby is still flat with a HR of 50. It is time for medications, but your experienced neonatal nurses have not been able to get a line. They look at you expectantly: “umbilical line, doc?”…

  Continue reading “Procedure: Umbilical Vein Catheterization”

Neonatal (Newborn) Resuscitation

Case

Code pink in labour and delivery, and you are the only doctor in the hospital tonight…

 There is a newer version of this post available, based on the updated 2015 ILCOR/AHA/ERC NRP guidelines. Please click here to see the most recent version.  Continue reading “Neonatal (Newborn) Resuscitation”

The Simplified Approach to PEA (non-traumatic)

A simplified approach to the initial assessment and management of emergency department patients in PEA

Case

A 60 year old woman is brought into your resus room VSA with CPR in progress. The paramedics tell you that she had a witnessed arrest and bystander CPR was performed for 4 minutes before they arrived on scene. They found her in PEA, took over CPR, started an IV, and rapidly transported as they were only 5 minutes out…


Continue reading “The Simplified Approach to PEA (non-traumatic)”