Articles of the month (March 2018)

A monthly (ish) summary of the emergency medicine literature

Every two months or so I write a monthly summary of the most interesting medical literature that I have encountered. This is one of those summaries. Continue reading “Articles of the month (March 2018)”

Articles of the Month (March 2016)

My monthly summaries of the medical literature

Every month I select the best medical articles I have read and provide brief summaries and critical appraisals. Here are this month’s articles:

The paper you are most likely to hear about this month: antibiotics and abscesses

Talan DA, Mower WR, Krishnadasan A. Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. The New England journal of medicine. 374(9):823-32. 2016. PMID: 26962903

Until now, the data on abscess management has been pretty clear: all you need is cold hard steel. No packing, and definitely no antibiotics. Has management just become much more confusing? This is a large, multi-center RCT comparing trimethoprim-sulfamethoxazole (320mg/1600mg MID for 1 week) to placebo in 1247 adult patients with acute abscess greater than 2cm in diameter. For the primary outcome of clinical cure at 7 days, the antibiotics group was better (80.5% versus 73.6%; absolute difference 6.9% 95%CI 2.1-11.7%; NNT = 14). There were also decreases in several secondary outcomes, such as new skin infections at other sites. However, there was an increase in GI side effects by about 7% (42.7% vs 36.1%). A cure rate of only 75% is really low and doesn’t represent the patients I see. This is probably because these are not simple abscess, with a median cellulitis area of 6.5×5.0cm, 20% of the cohort with a cellulitis area greater than 75cm2, and many patients “met other guideline criteria for antibiotics treatment”. (You can read some other opinions on REBEL EM, EM Nerd, and EM Literature of Note.)

Bottom line: This isn’t a game changing paper. It tells you to keep using antibiotics in the patients you are already using them in – complex abscesses with cellulitis – and doesn’t tell us a lot about the average abscess.

How ready are you for a mass casualty event?

Bhalla MC, Frey J, Rider C, Nord M, Hegerhorst M. Simple Triage Algorithm and Rapid Treatment and Sort, Assess, Lifesaving, Interventions, Treatment, and Transportation mass casualty triage methods for sensitivity, specificity, and predictive values. The American journal of emergency medicine. 33(11):1687-91. 2015. PMID: 26349777

I found this paper fascinating. I won’t get into detail about the performance of the scores, because the data is retrospective, and there is too much information that these scores use that would not be well recorded. However, I think this is a great study to read. I had never been exposed to a mass casualty triage system before, nor do I think I have been adequately trained in this aspect of emergency medicine. The algorithms are interesting. It’s worth a read.

Bottom line: Are you for a mass casualty event? This article might help

How do you tell if a patient needs more pain medication? Ask them

Chang AK, Bijur PE, Holden L, Gallagher EJ. Efficacy of an Acute Pain Titration Protocol Driven by Patient Response to a Simple Query: Do You Want More Pain Medication? Annals of emergency medicine. 2015. PMID: 26074387

I am strongly biased to like this study, because I was always thaught this is the way that pain medicine should be given (by Jerry Hoffman, I think). This is a prospective cohort of 215 adult patients presenting to the ED for acute painful conditions that the attending physician thought required an opioid. All patients received hydromorphone 1mg IV, followed by up to 3 more 1mg IV doses every 30 minutes driven entirely by their response to the question “Do you want more pain medication?” There were delays in administration of medication, so the max was actually 4mg over 4 hours. 205 of the 207 patients (99% 95%CI 97-100%) achieved pain control on 1 or more occasions during the study; 97% were either satisfied or very satisfied with their pain treatment. About 20% of patients wanted more pain meds at each interval. What can we learn from this study? The design of the study allows us to conclude that this method will leave most people satisfied with their pain control, and that almost everyone will reach a point where they don’t want any more analgesia. However, with no comparison, we have no idea if this technique is any better or worse than other methods. Personally, I am interested in how this would compare to patient controlled analgesia – which would require a larger upfront investment, but I think would be more tolerable for nursing workloads.

Bottom line: Asking patients is a reasonable method to determine if they need more analgesia

2 is not be better than 1 when in comes to needles

Martin SP, Chu KH, Mahmoud I, Greenslade JH, Brown AF. Double-dorsal versus single-volar digital subcutaneous anaesthetic injection for finger injuries in the emergency department: A randomised controlled trial. Emergency medicine Australasia : EMA. 2016. PMID: 26991958

Injections in the palm always seemed painful to me, so I always stuck with the double dorsal injection technique. I don’t remember why I changed, but my success rate is much better with the single palmar injection, so I’ve never looked back. The study: 86 adult patients in an RCT comparing a double-dorsal to a single-palmar injection technique for digital nerve block. There was no difference in the pain of injection between the two techniques (almost 4/10). The techniques were equally successful (65% success with double-dorsal and 72% with single-palmar). Really, none of those numbers are great.

Bottom line: Stick with the bloc you are used to – and maybe add some bicarb to get the pain on injection down?

Dumb and dumberer

Maltese F, Adda M, Bablon A. Night shift decreases cognitive performance of ICU physicians. Intensive care medicine. 42(3):393-400. 2016. PMID: 26556616

This is a prospective, randomized, cross-over study of 51 ICU doctors (27 residents, 21 attendings) who were randomized to either work a night shift or rest at home (and then were crossed over to the opposite group). Between 10am and noon the next day they went through a series of psychological tests. Not surprisingly, working memory, information process speed, and perceptual reasoning were all worse after a night shift. Cognitive flexibility was not statistically different. The clear issue with the study is we have no idea how these psychological tests translate into patient care, or whether the measured differences are actually clinically important differences.

Bottom line: Night shifts are hard. It’s hard to make good decisions at 4am. (One of many reasons I like the idea of casino shifts).

How safe is that treatment really?

Saini P, Loke YK, Gamble C, Altman DG, Williamson PR, Kirkham JJ. Selective reporting bias of harm outcomes within studies: findings from a cohort of systematic reviews. BMJ (Clinical research ed.). 349:g6501. 2014. PMID: 25416499 [free full text]

These authors attempt to examine the accuracy of reporting of harms in clinical trials. They identified trials that had been included in systematic reviews, and then evaluated each trial for how they reported harms (ie, harms measured and reported, harms not measured, harms measured but only partially reported, harms not even mentioned…). When looking at all Cochrane reviews, they found that the studies only partially reported or didn’t report harms at all 76% of the time. In a group a systematic review designed specifically to look at adverse events, 47% of studies still did not report or only partially reported a single primary harm outcome. This tendency of the literature has been discussed before. We tend to minimize our discussion of harms, which obviously skews our conclusions when looking at the entirety of the literature.

Bottom line: For every medicine you use, remember that the harms are probably greater than those reported in clinical trials

Clinical correlation required

Mark DG, Sonne DC, Jun P. False negative interpretations of cranial computed tomography in aneurysmal subarachnoid hemorrhage. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2016. PMID: 26918885

This is a chart review that identified 452 patients diagnosed with subarachnoid hemorrhage, and looked at the subset of 18 patients (4%) who were diagnosed by lumbar puncture after a normal CT. The supposedly normal CTs were then reviewed by 2 speciality neuro-radiologists, and in 9 of the 18 (50%) the neuro-radiologists thought there was evidence of bleed on the scan initially reported as normal. The false negative rate was 71% (5 of 7) for the scans done within 6 hours of headache. Of course, re-reading studies without the time pressures of a normal shift, especially when LPs have already shown blood (although these radiologists were blinded) might be easier.

Bottom line: Radiology isn’t perfect. Not all radiologists are created equal. This might still be the fatal flaw in the famous Perry study

But doc, it hurts A LOT

Body R, Lewis PS, Carley S, Burrows G, Haves B, Cook G. Chest pain: if it hurts a lot, is heart attack more likely? European journal of emergency medicine : official journal of the European Society for Emergency Medicine. 23(2):89-94. 2016. PMID: 25340995

Does the pain score correlate with the chance of MI? This is a secondary analysis of a data set collected for a prospective cohort study that included emergency department patients with suspected cardiac chest pain. They looked at the pain scores of the patients with a final diagnosis of MI, as compared with those who ruled out. Although there was a statistical difference, with the average pain in the MI group being 8/10 (interquartile range 5-8) and the non-MI group being 7/10 (IQR 6-8) (p=0.03), those numbers obviously don’t help clinically. This is reinforced by their analysis that showed the area under the receiver operating curve was 0.58, so essentially a coin flip. The amount of pain might have influenced the original physicians in terms of who was included in the dataset, which would skew these numbers.

Bottom line: The intensity of pain does not seem to help diagnostically in ACS.

Not the worry, that blurry vision and headache should be gone in … 90 days?

Kriz PK, Stein C, Kent J. Physical Maturity and Concussion Symptom Duration among Adolescent Ice Hockey Players. The Journal of pediatrics. 2016. PMID: 26781190

How long do pediatric concussion symptoms last? This is a prospective cohort of 145 patients aged 13-18 years who were referred to a sports medicine clinic. The mean symptom duration was 45 days (though with wide confidence intervals of +/- 49 days). About half (48%) of patients had symptoms for more than 28 days, and 13% had symptoms beyond 90 days. So perhaps concussion symptoms last longer than we usually counsel, but I worry about a significant selection bias here, as we don’t refer most kids with concussion to sport medicine clinics, and this is only 145 children from 3 clinics over 2.5 years. It probably represents the worst case scenario.

Bottom line: Some children will have prolonged concussion symptoms. Counselling and follow up instructions should keep this in mind

I have to say, the heart is what won me over when it comes to POCUS

Martindale JL, Wakai A, Collins SP. Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2015. PMID: 26910112

This is a systematic review looking the diagnosis of congestive heart failure in the emergency department. Probably because CHF actually encompasses a few different underlying pathologies, their major finding was that no factors were good enough to single handedly rule in or rule out CHF. Some likelihood ratios: Audible S3 +LR 4.0, CXR signs of edema +LR 4.8, B lines on bedside US +LR 7.4, no B-lines -LR 0.16, and reduced ejection fraction on bedside echo +LR 4.1. (Remember you want a positive likelihood ratio of 10 or more to rule in, and a negative likelihood ratio of 0.1 or less to rule out.)

Bottom line: Ultrasound may be our best tool for diagnosing CHF, but no findings can be used in isolation to rule in or rule out the disease.

There are now bottles of water labeled “gluten free”

Zanini B, Baschè R, Ferraresi A. Randomised clinical study: gluten challenge induces symptom recurrence in only a minority of patients who meet clinical criteria for non-coeliac gluten sensitivity. Alimentary pharmacology & therapeutics. 42(8):968-76. 2015. PMID: 26310131

I get asked a lot about gluten, as I am sure many people do, not just by emergency medicine patients, but also friends and families. In this study they took 35 patients who had tested negative for celiac disease but self-identified as being gluten intolerant and in a double blind, cross-over design they exposed the patients to either gluten free or normal flour. 12 (49%) of the patients thought the gluten-free flour contained gluten – what you might guess if the guess was pure chance. I think the evidence is pretty convincing that gluten is not the issue for most people without celiac disease. These patients definitely have symptoms, but there are almost certainly other etiologies than gluten. I worry that the focus on gluten pushed by some ‘experts’ is doing patients a disservice.

Bottom line: In people without celiac disease, symptoms are not consistently reproduced by gluten.

The case of the killer iPhone

Tri JL, Severson RP, Hyberger LK, Hayes DL. Use of cellular telephones in the hospital environment. Mayo Clinic proceedings. 82(3):282-5. 2007. PMID: 17352363

These authors brought 2 telephones into different patient rooms and made phone calls while observing various medical devices. In total they did 300 tests of 192 difference devices in 75 patient rooms, and they were unable to document a single case of the cellular telephone interfering with medical equipment.

Bottom line: The ban on cel phones may be based on a myth?


Lawrentschuk N, Bolton DM. Mobile phone interference with medical equipment and its clinical relevance: a systematic review. The Medical journal of Australia. 181(3):145-9. 2004. PMID: 15287832 [free full text]

This is a systematic review looking at the question of mobile phone interference with medical equipment. They identified 8 studies that tested a total of 936 devices. (Studies ranged from 1994-2002, so technology may have changed since.) They found that interference did occur in as many as 6% of tests. However, essentially all of this interference occurred when the phone was within 1 meter of the device – so you probably have to be trying to cause interference, like they were in these studies, rather than just using phones normally. Also, the results of the interference were not recorded, so it’s difficult to know if any of it was clinically relevant. (Some brief interference on an ECG monitor is irrelevant, but I would care about a pacemaker that stopped pacing.)

Bottom line: This is a little more complex than the last paper indicated, but it appears phones are safe as long as they are more than a meter from medical equipment. (Although that might be hard in some of the cramped resuscitation rooms I have worked in.)

NSAIDs for 11/10 pain

Pathan SA, Mitra B, Straney LD. Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial. Lancet (London, England). 2016. PMID: 26993881

This is a double blind RCT of 1644 adult patients with renal colic (1316 confirmed on CT) comparing morphine (0.1mg/kg IV) to diclofenac (75mg IM) to acetaminophen (1 gram IV). For a primary outcome of a 50% reduction in pain at 30 minutes, diclofenac was more effective than either morphine or acetaminophen, which weren’t different from each other (OR 1·35, 95% CI 1·05-1·73, p=0·0187). This means that 68% of the diclofenac group had a 50% reduction in pain, as compared to 61% with morphine and 66% with acetaminophen – not a huge absolute difference. One interesting number is that only 12% of the IM diclofenac group needed any rescue medication, so it might be possible to manage renal colic without ever starting an IV. Adverse events were statistically higher in the morphine group, but really quite low (1-3%) in all groups. Personally, I like a multimodal pain approach, and will probably continue to combine NSAIDS and opioids.

Bottom line: It might be true that NSAIDs are slightly more effective in renal colic

#FOAMed of the Month

This is a really short post on the Nurse Path, but I love it because it is a simple yet brilliant method for improving communication and patient safety. The key is that for medication checks, rather than reading out the dose and asking the person confirm ‘yes or no’, which could result in confirmation bias or error, you simply ask “what is this?” That forces the other person to slow down and actually read the medication out loud. I imagine this technique could also be used in another of other situations as well.



Cheesy Joke of the Month

Two orthopedic surgeons are on opposite sides of a lake.

One surgeon yells to the other, “How do you get to the other side?”

The other responds, “You are on the other side!”

Articles of the month (July 2015)

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

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

Sick kids look sick

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

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

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

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

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

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

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

“The status quo is working.”

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

Dead? Kick him in the chest

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Diltiazem over metoprolol for atrial fibrillation. Surprised?

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

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

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

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

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

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

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

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

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

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

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

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

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

We no communicate so good

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

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

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

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

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

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

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

Whats the best way to keep a cast dry?

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

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

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

Everything you could ever want to know about anal fissures

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

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

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

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

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

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

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

Lidocaine for limb pain – no, not a nerve block

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

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

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

There is no such thing is a free lunch

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

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

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

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

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

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

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

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

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

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

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

Cheesy Joke of the Month

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

Because their P is silent

FOAMed of the month

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

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

Articles of the Month (June 2015)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You actually heard a pericardial friction rub! Now what?

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

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

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

Speaking of which, the correct colchicine dose is low dose

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

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

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

Steri-strips for good cosmetic outcomes

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

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

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

More of the same

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

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

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

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

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

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

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

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

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

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

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

A classic: The FEAST trial

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

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

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

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

Vasopressor? Peripheral line is fine

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

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

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

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

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

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

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

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

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

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

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

An expensive placebo made popular by sports stars

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

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

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

Placebos may not help, but medications can actually hurt you

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

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

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

Raising a skeptical eyebrow at the literature

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

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

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

Steroids for low back pain?

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

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

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

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

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

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

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

Cheesy Joke of the Month

Why was the Kleenex dancing?

Because it had a little boogie in it

FOAMed of the month

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

EBM Lecture Handout #3: Stress testing (part 1)

There are two handouts that cover the literature surrounding the use of exercise stress testing to risk stratify patients in the emergency department. For part one, I am posting, in its entirety, a critically appraised topic I did as a resident research project during my emergency medicine fellowship year. Part 2 can be found here.

Clinical Question

In emergency department chest pain patients with a normal electrocardiograms and negative cardiac biomarkers, can an exercise stress test predict short term risk for death or myocardial infarct? Continue reading “EBM Lecture Handout #3: Stress testing (part 1)”

EBM Lecture Handout #4: Stress Testing (part 2)

In addition to the critically appraised topic in part 1, here are some additional papers on stress testing worth knowing about. Continue reading “EBM Lecture Handout #4: Stress Testing (part 2)”

EBM Lecture Handout #5: Heparin in ACS

It is often good to review why we do what we do. Heparin is a therapy that is started multiple times every day in every emergency department in the world. It is our bread and butter. But what exactly does heparin do? Specifically:

What is the benefit for our patients of giving heparin in the setting of an acute coronary syndrome?

Continue reading “EBM Lecture Handout #5: Heparin in ACS”