There are a lot of recurrent themes in this month’s edition (which has clearly shifted from being a monthly to a bimonthly publication). Podcast over on BroomeDocs.
It’s that time again. Sure, there may be a lot to do during the month of December, but what better way to procrastinate than to grab a mug of hot chocolate, sit down in front of the fire, and read about some evidence based medicine….
(If that doesn’t sound appealing, you could toss in some earphones while you do your holiday shopping and listen to me and Casey ramble about these papers in the audio version on the BroomeDocs podcast.) Continue reading “Articles of the month (November 2016)”
My monthly summary of the best reads from the emergency medicine literature
Welcome to the May 2016 edition of my favourite reads from the medical literature. This will probably be the last post on First10EM for a little while, as I plan to take a summer vacation as well as a prolonged Ireland stay for SMACC.
Gastro game changer
Freedman SB, Willan AR, Boutis K, Schuh S. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. JAMA. 315(18):1966-74. 2016. PMID: 27131100
Kids just want to drink juice, but I’ve been told that if I let kids with gastro drink juice they will die (or something like that). This is a randomized, controlled non-inferiority trial out of the Hospital for Sick Children that compared an electrolyte solution to a combination of half strength apple juice in the ED and the child’s preferred fluid (juice or milk) at home. 647 children aged 6 to 60 months with acute (less than 96 hours) diarrhea or vomiting with mild dehydration were included. For the primary outcome, which unfortunately was a composite of a number of things including IV use, hospitalization, health care contact, and prolonged symptoms, the juice group had a ‘treatment failure’ rate of 16.7% as compared to 25.0% with the electrolyte solution (difference 8.3%; 97.5% CI 2% – infinity). Converting from a non-inferiority analysis to a superiority analysis resulted in a p value of 0.006. In other words, the juice group was statistically better than the electrolyte group. The biggest caveat is that these kids were not sick, so the results could be different in kids with even moderate dehydration.
Bottom line: I am no longer forcing kids to drink something they hate. Whatever their preferred liquid is, it will keep them hydrated.
This is another paper that will be featured on EMCases Journal Jam. If you have questions you want the author to answer, let me know.
I’m not so ENCHANTED
I am honestly surprised that I managed to read an entire article that started with the statement: “Thrombolytic therapy with intravenous alteplase (recombinant tissue-type plasminogen activator) at a dose of 0.9 mg per kilogram of body weight is an effective treatment for acute ischemic stroke, despite increasing the risk of intracerebral hemorrhage.” (This is a good reminder that when reading articles, it is often best to just skip the introduction. This section is just a non-systematic review of the topic, aka a statement of the author’s biases and opinions.) Moving beyond that, this was a multi-center, prospective, randomized, open-label, non-inferiority trial comparing usual dose tPA (0.9mg/kg) to low dose tPA (0.6mg/kg) in 3310 patient with acute ischemic stroke within 4.5 hours of onset. (As a reminder of how rarely we use this intervention, they screened 69305 patients to enroll those 3310.) The primary outcome was a composite of disability and death, defined as a modified rankin score of 2 or more. There was no statistically significant difference between the two groups (53.2% low dose and 51.1% usual dose, p=0.51). However, the 95% confidence intervals around this result go beyond a pre-specified definition, therefore they were unable to demonstrate non-inferiority. For the primary harm outcome, there was less intracranial bleeding in the low dose group (1.0% vs 2.1% (p=0.01) by SITS-MOST criteria or 5.9% vs 8.0% (p=0.02) by NINDS criteria). Death at 7 days was lower in the low dose group, but death at 90 days was unchanged. There are a number of problems with this study. I am not going to delve too deeply into the issues of comparing different doses of placebo. (A dose response relationship is generally something we look for in efficacious therapies.) There is really no reason to make a study like this open-label and unfortunately that introduces a number of potential biases. Almost all the follow up was done by phone and the modified Rankin score is notoriously unreliable. Finally, like almost all of this research, the authors have significant conflicts.
Bottom line: High dose, low dose, no dose? I like this line of research. Maybe we can just keep lowering the tPA dose until is diluted by a factor of 10300 and hand care of acute stroke patients over to the homeopaths.
Therapeutics Initiative. Benefits and harms of drugs for “neuropathic” pain. Therapeutics Letter. 2016; 96:1-2. [free full text]
We see a lot of chronic pain. More than a lot. Since I started practicing, the number of people on gabapentin or lyrica for their neuropathic pain has skyrocketed. But just how good are these medications? This therapeutics letter looks at the evidence summarized in 11 different Cochrane reviews, and the best evidence on the topic is:
- The evidence is weak (surprise anyone?) and the available RCTs have a high risk of bias
- At best, about 1/10 patients will achieve any meaningful reduction in pain
- Almost everyone has some side effects from these drugs
- If there is going to be a benefit, you will see in within about 1 week
- There does not seem to be any benefit in higher doses. (I think this is the most important takeaway, as I often see people on crazy escalating doses)
Bottom line: It might be reasonable to try these medicines, but start at a low dose, and recheck at 1 week if benefits outweigh side effects. If they don’t, stop the drug.
Black box on fluoroquinolones
FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together [available here]
So this isn’t research – it’s a notice of a new black box warning from the FDA. I am often skeptical of these warnings, as in some cases I think they have clearly done more harm than good (droperidol), but I think this one is worth knowing about. They say that “the serious side effects associated with fluoroquinolone antibacterial drugs generally outweigh the benefits for patients with sinusitis, bronchitis, and uncomplicated urinary tract infections who have other treatment options. For patients with these conditions, fluoroquinolone should be reserved for those who do not have alternative treatment options.” I would say this is pretty obvious, as there is no benefit of antibiotics in sinusitis and bronchitis. If a patient has a bad outcome and you are giving them a drug that has no chance of helping them, I would find that hard to defend.
Bottom line: Don’t use fluoroquinolones first in uncomplicated UTIs. Don’t use antibiotics at all in sinusitis or bronchitis.
But can we change our bad antibiotics habits?
Meeker D, Linder JA, Fox CR. Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. JAMA. 315(6):562-70. 2016. PMID: 26864410
We know that antibiotics don’t help for the vast majority of acute respiratory tract infections, but for some reason people just can’t help themselves. Every patient I see in the ED with a cough for 3 days is already on azithromycin or amoxicillin. They come to the ED because they can’t understand why they aren’t getting better on antibiotics. They think they need something stronger. This is a randomized controlled trial trying to get doctors to smarten up. In a total of 243 different clinicians, they tried three different interventions: 1) automated reminders that antibiotics are inappropriate and alternate treatment suggestions 2) the requirement of an ‘antibiotic justification note’ as part of the permanent record, and 3) intermittent e-mails comparing the performance of various doctors. Each clinician was exposed to anywhere from 0 to 3 of the interventions. The control group (no intervention) decreased their prescribing rate by 11% – a good demonstration of the Hawthorne effect. The reminders did nothing. Requiring a justification and being compared to peers decreased inappropriate antibiotic use.
Bottom line: Sadly, simply giving physicians information is not enough to change their practice. We need to be shamed into change. Maybe I should stop writing about the evidence and instead walk around personally shaming people?
Again – we don’t listen to good advice
Rosenberg A, Agiro A, Gottlieb M. Early Trends Among Seven Recommendations From the Choosing Wisely Campaign. JAMA internal medicine. 175(12):1913-20. 2015. PMID: 26457643
I love the choosing wisely campaign – except that we know doctors love to ignore good advice. This is a retrospective look at a billing database (so not necessarily the most reliable data, although the conclusions are believable.) They looked at 7 items that were listed by choosing wisely as being of minimal or no benefit (such as pre-op chest x-ray in the absence of concerning history, or imaging of low back pain without red flags) and looked to see if the number billed for changed over a 3 year period after the recommendations. They didn’t. (OK, imaging for headache went down from 14.9% to 13.4% – not exactly a clinically important change). Horrendously, the use of antibiotics for sinusitis remained at 84%!
Bottom line: Physicians just don’t change their practice when presented with good evidence or advice. It does makes me wonder if I should stop sending these e-mails – as they are probably not accomplishing anything.
Police officer: “Sir, How high are you?” Pothead: “No officer, its ‘Hi, how are you’”
Tefft BC et al. Prevalence of Marijuana Involvement in Fatal Crashes: Washington, 2010 – 2014. May 2016. Washington, DC: AAA Foundation for Traffic Safety. [free full text]
This is a report by the AAA Foundation for traffic safety. It retrospectively looked at a database from the Washington State Traffic Safety Commission. In Washington State, as many will know, marijuana became legal in December of 2012. This study looked at all motor vehicle collisions that resulted in death and the proportion who had THC (delta-9-tetrahydrocannabinol) in their blood on autopsy. They compared collisions in the 2 years before the new law to the 2 years after the law. Out of the total of 3031 fatal MVCs over 4 years, 303 (10%) involved drivers testing positive for THC. The percentage rose from 8.9% in 2013 (before the law) to 17% in 2014. Of the individuals with positive tests for THC, 39% also had alcohol on board, 16% had other drugs, and 10% had alcohol and other drugs (leaving 34% with only THC detected). There are some problems with this data, the biggest probably being that we don’t know what levels of THC correlate with being impaired. THC wasn’t measured in every case, and sometimes measurement was delayed. Also, the total number of fatalities didn’t increase, just the number with THC on board, so the marijuana could be a bystander rather than a cause of the collisions. However, the issue of impaired driving, and our lack of science to guide us, remains a huge issue as this popular legalization movement continues forward.
Bottom line: Don’t smoke and drive
Would you be surprised if this patient died?
George N, Phillips E, Zaurova M, Song C, Lamba S, Grudzen C. Palliative Care Screening and Assessment in the Emergency Department: A Systematic Review. Journal of pain and symptom management. 51(1):108-19.e2. 2016. PMID: 26335763
I really hate adding work for our overly taxed triage nurses, who end up doing a lot of our screening. However, we are awful at recognizing patients with palliative care needs. This is a review, and I don’t think it is strong enough to completely overhaul triage systems, so I won’t go into the details, but they do conclude that palliative care screening is feasible. My favorite screening question is “would you be surprised if this patient died during this visit or in the coming month?” If no, they should probably have palliative care involved. Of course, the harder part of this equation is actually having adequate palliative resources for all the patients who need them.
Bottom line: Emergency medicine is all about dying patients. Palliative care should be an essential part of our mindset. You can have a much bigger impact by starting palliative care than you ever will handing out antibiotics for sore throats.
Epinephrine is safe in fingers – is that old news by now?
Ilicki J. Safety of Epinephrine in Digital Nerve Blocks: A Literature Review. The Journal of emergency medicine. 49(5):799-809. 2015. PMID: 26254284
This is a systematic review looking at the use of epinephrine in digital blocks. It should be stated up front that the conclusions are only good as the original studies – and they aren’t great. In a total of 30 studies, they identify 2797 blocks performed with epinephrine without any complications. They conclude that epinephrine is safe to use in digital nerve blocks in healthy patients. (Although, to be fair, it probably doesn’t help most of the time.)
Bottom line: This is probably another classic myth, although the data isn’t actually strong enough to definitely conclude safety.
CT first for the scaphoid?
Yin ZG, Zhang JB, Gong KT. Cost-Effectiveness of Diagnostic Strategies for Suspected Scaphoid Fractures. Journal of orthopaedic trauma. 29(8):e245-52. 2015. PMID: 25756914
I hate cost-effectiveness studies. The results hinge on a huge number of assumptions that really can’t be confirmed. However, sometimes they provide some insight that can be interesting. In this study they compared the cost of working up scaphoid fractures using a number of different strategies, such as immediate CT, immediate MRI, MRI on day 3, bone scan on day 3, and x-ray at 2 weeks. Maybe counterintuitively, the immediate CT was the most cost effective approach followed by the immediate MRI. I am not sure that you can take these results to the bank, but it is a good reminder that there a number of costs that we often forget about. Although immediate CT seems expensive, to come to a follow-up visit the patient must miss work, pay for parking, and see another physician. Additionally, being in an unnecessary cast for 2 weeks could result in 2 weeks unnecessarily off work. It’s not time to change yet, but I wouldn’t be surprised if immediate definitive testing for the scaphoid became the standard in the future.
Bottom line: CT first for scaphoid fracture might actually be cheaper than standard practice.
Compassion and the good Samaritan study
Darley JM, Batson CD. “From Jerusalem to Jericho”: A study of situational and dispositional variables in helping behavior. Journal of Personality and Social Psychology. 27(1):100-108. 1973. [article]
This is a classic study from the psychology literature. It is a study of seminary students. Half were told they had to give a talk on the parable of the good Samaritan. The other half were told they had to give a talk on routine seminary jobs. Some students were told they were late for the talk and had to hurry, whereas others were told that they were on time. There was a plant on the way to the lecture hall: a man slumped in a doorway who moaned twice as the students walked by. Whether or not they had been thinking about the parable of the good Samaritan made no difference in whether or not they stopped. The only thing that influenced their decision to help was how hurried they felt. I see a clear connection to emergency medicine. Our job requires an incredible amount of compassion. However, simply thinking about compassion doesn’t seem to help. If we are rushed, we are less likely to be compassionate, whereas if we have time, we will use it. Unfortunately – how many people feel like they have a lot of free time in the emergency department? Managing our departments so physicians are not constantly run off their feet is probably a really good idea. (Of course, that is quite a reach from this research scientifically speaking – but it makes a lot of sense to me.)
Bottom line: Ensuring that physicians aren’t rushed might be crucial in increasing our ability to be compassionate on the job.
Cheesy Joke of the Month
I was sitting in a bar the other night when the waitress yelled out “does anyone know CPR?!”
I yelled back, “yeah, and I know the rest of the alphabet too.”
Everyone laughed. Well, except one guy.
#FOAMed of the month
How is it that one develops mastery? Cliff Reid provides some insight into deliberate practice in the context of getting his ass kicked.
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!”
A monthly collection of the most interesting emergency medical literature I have encountered.
Another month and another set of articles proving only that I probably should have spent more time Christmas shopping and less reading journals. Enjoy…
Peripheral thermometers mostly suck, but does it matter?
Niven DJ, Gaudet JE, Laupland KB, Mrklas KJ, Roberts DJ, Stelfox HT. Accuracy of Peripheral Thermometers for Estimating Temperature: A Systematic Review and Meta-analysis. Annals of internal medicine. 163(10):768-77. 2015. PMID: 26571241
I will start this month with a paper just for my friend Dr. Scott Kapoor. This is a systematic review and meta-analysis of 75 studies encompassing 8682 patients looking to compare the accuracy of peripheral thermometers to central thermometers. The peripheral thermometers are not very accurate, especially if you look at hypo or hyperthermia. If you take the core temperature as the gold standard, the peripheral thermometers had a pooled sensitivity and specificity of 64% (95%CI 55-72%) and 96% (95%CI 93-97%) respectively for fever. I don’t have access to the appendices to look at the raw data, but the authors report that all peripheral thermometers were equally bad, with axillary probably being the worst. So sorry Scott, it’s not just the temporal artery thermometers that don’t work, it’s everything peripheral. Luckily, for the vast majority of people being triaged, temperature is irrelevant. For patients you care about, you probably should recheck a core temp.
Bottom line: There is a very good chance peripheral thermometers will miss a fever.
If all your friends jumped off a bridge…
Douketis JD, Spyropoulos AC, Kaatz S. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. The New England journal of medicine. 373(9):823-33. 2015. PMID: 26095867 [free full text]
We frequently admit patients on anticoagulants who will require surgery or procedures that require their anticoagulants to be held. Should we be bridging these patients with some kind of heparin? This is a randomized controlled trial of 1884 adult patients with chronic atrial fibrillation and at least 1 CHADS2 risk factor undergoing surgery (excluding cardiac, neuro, and spinal surgeries). They were randomized to either bridging with dalteparin or placebo. Patients were excluded if the had a mechanical heart valve, recent stroke, or renal failure. The primary outcome of any arterial thromboembolic disease was noninferior, with 4 patients (0.4%) in the non-bridged group and 3 patients (0.3%) in the bridged group having events. Major bleeding was higher in the bridged group (29 patients (3.2%) versus 12 patients (1.3%) p=0.005 NNH=53). Minor bleeding was also increased (20% versus 12%, p<0.001, NNH=11).
Bottom line: This is probably the best evidence to date that the short term risk for atrial fibrillation patients off anticoagulation is low and that bridging therapy is harmful.
Steinberg BA, Peterson ED, Kim S. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation. 131(5):488-94. 2015. PMID: 25499873 [full free text]
This is a retrospective look at a large atrial fibrillation patient registry. They looked at the 2803 patients with non-valvular atrial fibrillation who had an interruption in their anticoagulation, primarily for non-cardiac surgery or endoscopy. 77% of patients were not bridged as compared to 23% who were. Overall adverse events were higher in the bridging group (5.3% versus 2.8% p=0.01), primarily driven by excess bleeding complications. Stroke and MI were not different between the groups. Of course, patients were not randomized, so there were likely reasons that physicians chose to bridge some patients and not others, making any concrete conclusions difficult.
Bottom line: More evidence that bridging is not helpful
As a side note, if all my friends jumped off a bridge, you can bet that I would too. My friends are all sane and mostly intelligent. If they were jumping off a bridge, there is probably a very good reason to do so, like the bridge is on fire or there is rapidly approaching school of flying sharks with lasers on their heads. Also, even if they happened to die, who wants to live in a world where all your friends just died jumping off a bridge?
OK, those were boring topics. Let’s move on: anyone have a VIP guest in the department this holiday season?
Sadly, this article was a little boring even for a Christmas spoof – but have you ever considered the extreme occupational hazards of Santa Claus? Don’t be surprised if he ends up in an ED near you sometime soon.
Christmas: so many new toys, with so many small parts. It’s the perfect storm for foreign bodies in the airway
Eren S, Balci AE, Dikici B, Doblan M, Eren MN. Foreign body aspiration in children: experience of 1160 cases. Annals of tropical paediatrics. 23(1):31-7. 2003. PMID: 12648322
This is a retrospective review of 1160 children (under 15 years of age) who underwent bronchoscopy for foreign bodies. Almost 2/3rds of the patients with foreign bodies had negative radiography. (There is obviously a selection bias here, because these are only the children in whom the clinicians were concerned enough to perform a bronchoscopy). I will also note that this is an interesting population, because 38% of the foreign bodies were watermelon seeds. However, with a good story, xray is clearly not good enough to exclude foreign bodies.
Bottom line: It is often a difficult sell, but if a child has a good story for aspiration, they probably need a bronchoscopy.
High flow nasal oxygen in the ED
Bell N, Hutchinson CL, Green TC, Rogan E, Bein KJ, Dinh MM. Randomised control trial of humidified high flow nasal cannulae versus standard oxygen in the emergency department. Emergency medicine Australasia : EMA. 2015. PMID: 26419650
This is an unblinded prospective randomized control trial comparing high flow nasal oxygen to standard care (nasal prongs or face mask) in 100 adult emergency department patients with shortness of breath, a respiratory rate over 24 and an oxygen saturation less than 94%. There were 2 primary outcomes, which is not good from a trial design perspective. For the outcome of a reduction in respiratory rate by 20% within 2 hours, the high flow nasal group was better (66.7% vs 38.5%, p=0.005). For the outcome of an escalation of ventilation requirement, the reported outcomes are less clear, because they included being changed from face mask to high flow nasal oxygen as an “escalation of care”, even though this trial is supposed to be determining if it is any better. Two patients in each group required non-invasive positive pressure ventilation, and one patient was intubated. So I would say there was no change in patient oriented outcomes except the single intubation, and a single outcome is just not enough to draw any conclusions from.
Bottom line: Not a lot to go on here, but it doesn’t look like high flow nasal oxygen will be worse than usual care.
One step closer to forgetting antibiotics in diverticulitis
Isacson D, Thorisson A, Andreasson K, Nikberg M, Smedh K, Chabok A. Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study. International journal of colorectal disease. 30(9):1229-34. 2015. PMID: 25989930
I have previously talked about the few RCTs indicating that antibiotics might not help in diverticulitis. It is an interesting topic, so I will include new evidence as I find it. This is a prospective cohort of 155 adult patients diagnosed with acute uncomplicated diverticulitis who were managed as outpatients without antibiotics, just pain control and a diet progressing from liquids back to full, as tolerated. Of the 155 patients, only 4 patients (2.5%) failed this outpatient management strategy – which isn’t much different from what you would expect if they had been treated with antibiotics. The biggest problem with this data set is that it doesn’t represent consecutive patients. 66 patients with uncomplicated diverticulitis were seen during the study period but were not enrolled, so there could be some selection bias. There was no control, so antibiotics could have lowered complication rates further – but for the 97.5% of patients without complications, it doesn’t seem that antibiotics were necessary.
Bottom line: A little more evidence indicating that antibiotics may be unnecessary for diverticulitis after all.
How do fish get high? Seaweed
Vandrey R, Raber JC, Raber ME, Douglass B, Miller C, Bonn-Miller MO. Cannabinoid Dose and Label Accuracy in Edible Medical Cannabis Products. JAMA. 313(24):2491-3. 2015. PMID: 26103034 [free full text]
With legal marijuana on the horizon in Canada, there are many questions we need to be asking about its use. One very basic question is: at current marijuana dispensaries, how accurate are labels with regards to THC content? Individuals were sent out to buy marijuana in San Francisco, Los Angeles, and Seattle, and the THC content was analyzed by liquid chromatography. Of 75 total samples, 13(17%) were accurately labelled, 17(23%) were under-labelled (contained more THC than the label stated), and 45 (60%) were over-labelled. Errors were frequently large, up to 55% under labelled and 99% over labelled. Combined with confusion over appropriate doses, highly concentrated doses in edibles, and differing rates of absorption, dosing errors make it more likely that marijuana users will end up in the ED.
Bottom line: Active ingredients in marijuana products are not well regulated or labelled on available products.
Monthly poll: Who would want this ENT surgeon as their own doctor?
Leopard DC, Williams RG. Nasal Foreign Bodies: A Sweet Experiment. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery. 40(5):420-1. 2015. PMID: 25639608
There are many techniques to get foreign bodies out of children’s noses, but what do you do if they don’t work? Well, if it’s a hard candy, you may not need to do anything. This (presumably bored) ENT surgeon placed 5 different candies in his own nose (Fizzers, Tic Tac, Smarties, Skittles, and Polo mints) and then had the second author perform rhinoscopy every 5 minutes. All 5 candies were completely dissolved in less than an hour. I will let you perform your own critical appraisal of these methods.
Bottom line: Watchful waiting may be reasonable for children with hard candies in their noses.
(In case you were wondering, I would happily take this chap as my doctor)
Alcohol by mouth can make you vomit. On the other hand, alcohol in the nose…
Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Annals of emergency medicine. 2015. PMID: 26679977
This is a randomized trial of a convenience sample of 80 adult patients presenting to the emergency department with a chief complaint of nausea and/or vomiting. Patients were instructed to inhale from a pad of either saline or isopropyl alcohol (the same wipes you would use on the skin before starting an IV) immediately, then 2 and 4 minutes later. Although investigators covered the label of the wipe, I’m pretty sure blinding was eliminated the instant the patient took a sniff. Nausea was measured on a scale of 0 to 10, but only for the first 10 minutes. At the start of the study, patients rated their nausea as a 6/10. At 10 minutes, the saline group still rated their nausea as 6/10 whereas the alcohol group rated theirs as 3/10 (absolute difference 3, 95%CI 2-4 p<0.001). We don’t know what happened after 10 minutes, which is a major limitation. Some other major limitations of this data are the lack of blinding and potential selection bias in a convenience sample.
Bottom line: Maybe inhaling from alcohol wipes decreases nausea
Hines S, Steels E, Chang A, Gibbons K. Aromatherapy for treatment of postoperative nausea and vomiting. The Cochrane database of systematic reviews. 4:CD007598. 2012. PMID: 22513952
Although I was completely unaware of this therapy for nausea, apparently it has been studied before. This Cochrane review found 6 RCTs and 3 non-randomized controlled trials looking at aromatherapy for nausea and vomiting. When compared to placebo, they found that isopropyl alcohol vapour inhalation reduced the number of patients requiring rescue antiemetics (RR 0.30 95%CI 0.09-1.0, p=0.05 so technically not significant), however it was less effective in reducing nausea than standard anti-emetic medications.
Bottom line: Probably shouldn’t be first line, but if I’m huffing alcohol in the break room, it may be because I caught the gastro that’s going around.
Nerves were meant for blocking
Flores S, Herring AA. Ultrasound-guided Greater Auricular Nerve Block for Emergency Department Ear Laceration and Ear Abscess Drainage. The Journal of emergency medicine. 2015. PMID: 26589558
This is just a case report, but considering the frequency with which we see ear injuries, and the difficulty of achieving good local anesthesia, having a ultrasound guided nerve block in your back pocket is a great tool. In this article they specifically identify and anesthetize the greater auricular nerve, but a superficial cervical plexus block will get you the same coverage and might be easier. These nerve blocks only cover the posterior aspect of the ear, so you may have difficulty if the injury is more anterior. They can also miss the top of the ear.
Bottom line: Nerve blocks are fantastic for many things in the ED, especially when using ultrasound guidance.
Don’t have access to this paper? You could read about the ultrasound guided superficial cervical plexus block on NYSORA. You could also watch a video on the superficial cervical plexus block on the ultrasound podcast.
We have many effective treatments for hyperkalemia – kayexalate just isn’t one of them
Hagan AE, Farrington CA, Wall GC, Belz MM. Sodium polystyrene sulfonate for the treatment of acute hyperkalemia: a retrospective study. Clinical nephrology. 85(1):38-43. 2016. PMID: 26587776
The evidence behind the use of sodium polystyrene sulfonate (kayexalate) for hyperkalemia is poor. This is a chart review looking at 501 patients who received SPS for hyperkalemia. The chart review methods make it difficult to assess the true effect, but on average after SPS administration, the potassium decreased by 0.93mEq/L. That sounds reasonable, until you realise that the drop occurred over about 8 hours and that most of these patients were given other medications as well. The really concerning part of this paper is that there were 2 cases of bowel necrosis, a known side effect of SPS.
Bottom line: A little more evidence that reinforces my current practice – I don’t use kayexalate to treat hyperkalemia in the ED.
Want to read a little more about the original studies on kayaexalate? Check out this post by Anand Swaminathan on R.E.B.E.L.EM.
Newer is always better, right?
Navarro V, Dagron C, Elie C. Prehospital treatment with levetiracetam plus clonazepam or placebo plus clonazepam in status epilepticus (SAMUKeppra): a randomised, double-blind, phase 3 trial. The Lancet. Neurology. 15(1):47-55. 2016. PMID: 26627366
We all know the downsides of phenytoin in seizures – so it makes sense that researchers are looking at newer (but more expensive) agents. In this industry-funded, randomized, double-blind prehospital trial, they compared clonazepam plus levetiracetam (Keppra) to clonazepam plus placebo in 203 patients with status epilepticus (a seizure lasting more than 5 minutes). The trial was stopped early because an interim analysis revealed no chance that levetiracetam would turn out to be superior to placebo.
Bottom line: Don’t start changing your status epilepticus algorithms yet
Mundlamuri RC, Sinha S, Subbakrishna DK. Management of generalised convulsive status epilepticus (SE): A prospective randomised controlled study of combined treatment with intravenous lorazepam with either phenytoin, sodium valproate or levetiracetam–Pilot study. Epilepsy research. 114:52-8. 2015. PMID: 26088885
This paper complements the last. This is a prospective randomized trial of 150 patients with status epilepticus comparing valproate, phenytoin, and levetiracetam (all in addition to lorazepam). There was no statistical difference between the groups. Because of the small numbers, this is the kind of trial that could miss a clinically significant difference just because it wasn’t statistically different (type 2 error).
Bottom line: Again, there is no reason to abandon our tried and true and cheap medication yet
Has it been cold enough for leaky gas powered heaters yet?
Hampson NB. Myth busting in carbon monoxide poisoning. The American journal of emergency medicine. 2015. PMID: 26632018
I couldn’t resist this paper – it had “myth” in the title and who doesn’t love carbon monoxide? There isn’t much to say about the the methods, as there were none, but there are a few important review points:
- Carbon monoxide levels do not correlate with symptoms and should not be the primary driver of emergency care
- A venous blood gas is just as good as an arterial gas for measuring CO levels
- CO is very stable in blood samples. You don’t need to rush an iced sample to the lab. In samples of anticoagulated blood, CO levels didn’t change over the course of a month. So this test could be done as an add-on if you forgot to order it initially
Bottom line: Read the three points above – stop trying to just skip to the red text to get your answers quickly
NOT EMERGENCY MEDICINE, but in headlines everywhere
Jacobs IJ, Menon U, Ryan A et al. Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial. The Lancet. 2015. [free full text]
“Ovarian Cancer Screening Could Reduce Deaths By As Much As 20 Percent”. That is the first headline I encountered, but there are many many more. Expect to hear about this from patients, family, and friends alike. But what did the study actually show? This is a massive prospective trial that randomized 202,638 women into one of two screening protocols or a control group. Like so many cancer trials, the authors unfortunately started the trial very confused and made their primary outcome the factitious ‘disease specific mortality’ instead of all cause mortality. THEY DON’T EVEN REPORT ALL CAUSE MORTALITY! How can you tell if an intervention saves lives if you don’t measure mortality? Disease specific mortality only tells you that there might be changes in what someone happened to write on a death certificate (almost never supported by an autopsy), so is clearly not a patient oriented outcome. That is such a fatal flaw that it is hardly worth noting that there was a significant selection bias (in that healthy individuals are much more likely to volunteer for a study like this), that they had to alter the study protocol part way through, and that if you use the primary statistical outcome listed in the original trial design none of the outcomes were statistically significant. So throw this one into the trash heap, but be prepare for a lot of questions about how this could be the next big thing.
Bottom line: We need to get cancer researchers to start measuring and reporting all cause mortality. Our patients are being confused and harmed by the statistical misinformation that results from the fictional concept of ‘disease specific mortality’
Cheesy joke of the month
What do you get if you eat Christmas decorations?
#FOAMed of the month
A few videos that demonstrate why you should have a PEEP valve already attached to every BVM you use in the ED (rather than hidden in an RT office somewhere):
When I started this month’s articles, I only planned on including the videos on the PEEP valve, but then Dr. Kovacs had to release one of the best awake intubation videos ever made. In the end, fully awake, he will show you his own carina:
So bottom line of all this, follow George Kovacs and AIME on youtube
A monthly collection of the most interesting emergency medical literature I have encountered.
Its that time again. Here are my favorite medical reads of the last month – well, actually, last 2 months. There are some really good papers in this edition. I hope you enjoy…
1 good ECG begets another
Riley RF, Newby LK, Don CW, et al. Diagnostic time course, treatment, and in-hospital outcomes for patients with ST-segment elevation myocardial infarction presenting with nondiagnostic initial electrocardiogram: a report from the American Heart Association Mission: Lifeline program. Am Heart J. 2013;165:(1)50-6. PMID: 23237133
This is a registry study of 41.560 patients diagnosed with a STEMI. Of those patients, 4,566 had an initial ECG that was non-diagnostic. About ⅓ had converted to STEMI within 30 minutes of their first ECG, and 75% within 90 minutes. The groups were otherwise similar.
Bottom line: About 1/10 STEMIs are not evident on the initial ECG. If the story is good, get repeats.
When should we crack the chest?
Seamon MJ, Haut ER, Van Arendonk K. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. The journal of trauma and acute care surgery. 79(1):159-73. 2015. PMID: 26091330
This is a systematic review by the EAST group that included 72 studies an 10,238 patients looking to answer the question: should patients who present pulseless after critical injuries undergo emergency department thoracotomy to improve survival and neurologically intact survival?. Their review and recommendations are divided into 6 groups:
- Pulseless, signs of life, penetrating thoracic injury
- Strongly recommend ED thoracotomy (EDT)
- 182/853 patients survived hospitalization, 53/454 neurologically intact
- Pulseless, no signs of life, penetrating thoracic injury
- Strongly favour EDT
- 77/920 survived, 25/641 neurologically intact
- Pulseless, signs of life, penetrating extrathoracic injury
- Conditionally recommend EDT
- 25/160 survived, 14/85 neurologically intact
- Pulseless, no signs of life, penetrating extrathoracic injury
- Conditionally recommend EDT
- 4/139 survived, 3/6 neurologically intact
- Pulseless, signs of life, blunt injury
- Conditionally recommend EDT
- 21/454 survived, 7/298 neurologically intact
- Pulseless, no signs of life, blunt injury
- Conditionally DO NOT recommend EDT
- 7/995 survived, 1/825 neurologically intact
There a definitely a few issues with the data. Systematic reviews are only as good as the studies included, and none of the included studies were great. In case you were wondering, the reason that the denominator for neurologically intact survival and overall survival are different is that some studies didn’t report neurologic status.
Bottom line: This is a procedure we need to be prepared to do in the context of penetrating trauma patients who had signs of life. Even smaller community hospitals should have a plan for these patients before they arrive.
Ultrasound before thoracotomy?
Inaba K, Chouliaras K, Zakaluzny S. FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation. Annals of surgery. 262(3):512-8. 2015. PMID: 26258320
The criteria for thoracotomy based on ‘signs of life’ always seemed a bit soft to me. Could the omnipresent ultrasound probe help us make the decision to crack the chest? These authors prospectively enrolled all patients at their centre undergoing a resuscitative thoracotomy over the course of 3.5 years. They obtained cardiac views with an ultrasound on all these patients. In total, they performed 187 thoracotomies. 126 patients had cardiac standstill on ultrasound, and ZERO survived. If there was cardiac motion on ultrasound, 9/54 patients survived. The biggest problem with this data is probably the generalizability. 187 thoracotomies in 3 years is A LOT. My guess is these physicians are more skilled at both the thoracotomy (obviously) but also the cardiac ultrasound than I am. Might the ultrasound probe just delay the necessary procedure?
Bottom line: No cardiac activity on ultrasound might be a good reason not to perform a thoracotomy.
Some more trauma: NEXUS CT chest tool
Rodriguez RM, Langdorf MI, Nishijima D. Derivation and Validation of Two Decision Instruments for Selective Chest CT in Blunt Trauma: A Multicenter Prospective Observational Study (NEXUS Chest CT). PLoS medicine. 12(10):e1001883. 2015. PMID: 26440607 [free full text]
This is the second attempt at a NEXUS CT chest tool. This paper covers both the derivation and validation studies of the new tool. It total, they prospectively enrolled 11,477 blunt trauma patients over 14 years of age at 8 level 1 trauma centres. They came up with two different instruments: one just for major injuries and another for major and minor injuries. In the validation, the CT-All tool (designed to catch major and minor injuries) had a 99.2% sensitivity and 20.8% specificity for major injury, and a 95.4% sensitivity and 25.5% specificity for all injuries. One major problem is the validation only occurred in patients who actually had CTs (less than half of the cohort) so it is hard to say how it will work when applied to all comers. The authors think this will decrease CT scanning, but like all decision instruments, the implementation should be specifically studied. If applied to lower risk populations, it could actually increase scanning.
Bottom line: If you have ordered a CT chest for blunt trauma, you could check this rule to see if you could safely cancel the scan
Let’s do a couple papers on SVT. First: The Valsalva to rule them all
This one has been talked about a lot since it came out. It is a multi-centre, non-blinded randomized control trial of 428 adult patients with supraventricular tachycardia comparing the standard Valsalva maneuver to a modified Valsalva. The modified Valsalva was performed by forced blowing for 15 seconds in the sitting position (standard Valsalva), but then patients were immediately laid flat and had their legs elevated to 45 degrees for 15 seconds. (A video of the procedure can be seen here.) At one minute after the procedure 17% of the standard Valsalva group and 43% of the modified group were in sinus rhythm (OR 3.7 95%CI 2.3-5.8 NNT=3.8). This translated into 19% fewer patients requiring adenosine (69% vs 50%, p=0.0002, NNT=5.3). The authors say that blowing into a 10ml syringe will replicate the Valsalva they performed with fancier equipment.
Bottom line: This is a simple, free technique that might save our patient uncomfortable medical interventions. Using it until further research is done seems like a no brainer.
SVT #2: Why I never use adenosine
Lim SH, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 80(5):523-8. 2009. PMID: 19261367
This is a RCT of 206 adult patients with SVT randomized to either adenosine or a calcium channel blocker. The dosing of the CCBs was either verapamil 1mg/min to a max of 20 mg or diltiazem 2.5mg/min to a max of 50mg. Adenosine dosing was 6mg followed by 12 mg if needed. Calcium channel blockers did a better job converting to sinus rhythm (98% vs 86.5% p=0.002). 1 patient in the CCB group developed transient hypotension as compared to none in the adenosine group.
Bottom line: Calcium channel blockers are more effective than adenosine and don’t have the horrible side effects. I always start with a CCB, and my patients have thanked me every single time for not exposing them to the horrors of adenosine.
SVT#3: More adenosine bashing
Holdgate A, Foo A. Adenosine versus intravenous calcium channel antagonists for the treatment of supraventricular tachycardia in adults. The Cochrane database of systematic reviews. 2006. PMID: 17054240
Just to complete the topic, this is the Cochrane review looking at calcium channel blockers versus adenosine in SVT. They found no significant difference in either reversion or relapse. Obviously, minor adverse events (the horrible chest pains, shortness of breath, and headaches) were higher in the adenosine group (10.8 versus 0.6% p<0.001). There was no statistical difference in hypotensive events, but all that occurred were in the calcium channel blocker groups (3/166 patients as compared to 0/171 patients.) There were no major adverse outcomes.
Bottom line: Again, similar efficacy but your patients will love you if you shelf the adenosine.
Apneic oxygenation: does it help in critical care?
The FELLOW trial: Semler MW, Janz DR, Lentz RJ. Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill. American journal of respiratory and critical care medicine. 2015. PMID: 26426458
This is a randomized, controlled, non-blinded trial comparing apneic oxygenation during intubation to no apneic oxygenation in 150 adult patients in a single ICU. Apneic oxygen was provided by the addition of oxygen through nasal prongs at 15L/min. The primary outcome, lowest achieved oxygen saturation, was not different between the groups (median of 92% with usual care and 90% with apneic oxygenation). There were no differences in any of the secondary outcomes (incidence of hypoxemia, severe hypoxemia, desaturation, or change in saturation from baseline.) Apneic oxygenation has been shown to work in stable surgical patients – why would it be different here? The big reason is that this was not a comparison of apneic oxygenation to apnea, like would occur in a standard RSI. 73% of patients received either BiPAP or BVM during the apneic period. Of course nasal prongs aren’t adding anything to patients receiving positive pressure ventilation. These patients are not at all like the patients I generally intubate.
Bottom line: I will continue to use apneic oxygenation for standard RSI, but if my patient requires BiPAP or bagging for oxygenation, I will forget the nasal prongs.
A 3 wish program to personalize the death experience
Cook D, Swinton M, Toledo F. Personalizing Death in the Intensive Care Unit: The 3 Wishes Project: A Mixed-Methods Study. Annals of internal medicine. 163(4):271-9. 2015. PMID: 26167721
I think one of medicine’s greatest current failures is the way we deal with death. That is a problem, seeing as death is the only certainty in medicine. This is a qualitative description of a program designed to personalize death in the ICU. To honor each patient, they asked dying patients, their families, and the clinicians to make 3 wishes that might provide dignity for the patient. The wishes were mostly simple, but profound, such as using a patient’s nickname, allowing a mother to lie in bed with her dying son, organizing volunteer work for family members, or celebrating a birthday. There were 5 categories of wishes: 1) humanizing the environment; 2) personal tributes; 3) family reconnections; 4) rituals and observances; and 5) “paying it forward”. The authors thought these added value through three domains: dignifying the dying patient, giving the family a voice, and fostering clinician compassion.
Bottom line: I don’t care much about the evidence here: This is a great idea, and if I end up in your ICU I hope this is the kind of care I receive.
Maybe a better summary of this paper is on of my favorite videos by ZDoggMD: https://www.youtube.com/watch?v=NAlnRHicgWs
An end to the low risk chest pain madness?
Mahler SA, Riley RF, Hiestand BC. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circulation. Cardiovascular quality and outcomes. 8(2):195-203. 2015. PMID: 25737484
This is a prospective, randomized control trial of 282 adult patients with symptoms of possible ACS without ST elevation, randomized to the use of the HEART pathway or usual care. The HEART pathway is a combination of the HEART score with 0 and 3 hour troponins. It was a relatively low risk group, with 6.4% of patients having an MI at 30 days. Using the HEART pathway reduced the use of cardiac testing from 69% to 57%, and none of the low risk group had any adverse events. The HEART pathway also increased early discharges and decreased length of stay. The two major problems with this study are its small size and the American setting. Although the score allow more patients to be discharged home in a setting where everyone is admitted, the results might be different if your chest pain admission rate is low to begin with, like it is where I work.
Bottom line: The HEART score may help decrease testing in low risk chest pain patients, but more evidence is required
PRP: All the superstar athletes are all using it, so it must work
Filardo G, Di Matteo B, Di Martino A. Platelet-Rich Plasma Intra-articular Knee Injections Show No Superiority Versus Viscosupplementation: A Randomized Controlled Trial. The American journal of sports medicine. 43(7):1575-82. 2015. PMID: 25952818
This is a randomized, double blind, controlled trial comparing platelet rich plasma (PRP) injections to injections of hyaluronic acid for knee osteoarthritis. Each group got three weekly injections of their study medication. Symptoms and function were identical between the groups at 2,6 and 12 months. Considering that hyaluronic acid has been shown to have essentially no clinically relevant benefit, this comparison may as well have been with placebo. As a side note, it drives me nuts that so many people refer to this as “platelet rich plasma therapy”. “Therapy” implies to patients that it might actually do some good and skews the process of informed choice. So far, there is nothing therapeutic about platelet rich plasma.
Bottom line: Platelet rich plasma therapy sounded good in theory, but it looks like it will be another fruitless intervention.
The “gold standard” for PE isn’t so gold.
Hutchinson BD et al. Overdiagnosis of Pulmonary Embolism by Pulmonary CT Angiography. Am J Roentgenol. 2015; 205(2): 271-7. PMID: 6204274
The patient was low risk, but you decided to order the CT anyway. Thank goodness you did, because it is positive for a PE. Well, not so fast. This is a retrospective look at 937 CTPAs for PE over 1 year at a single center. They had 3 blinded radiologists review each study, using their consensus as the gold standard. Of the 174 studies that were initially read as positive, these radiologists disagreed with that read (thought it was a false positive) in 45 cases (25.9%). This is consistent with multiple other studies.
Bottom line: We are likely harming many patients with unnecessary lifelong anticoagulation. In borderline cases, it might be worth asking for a second opinion on the read of the CT.
How normal is normal saline?
SPLIT trial: Young P, Bailey M, Beasley R. Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial. JAMA. 2015. PMID: 26444692
We have been hearing for a while now that normal saline, because of the large excess of chloride and resultant acidosis, is bad for sick patients. This is a multi-centre blinded, randomized trial of 2278 adult ICU patients comparing normal saline to a balanced solution (plasmalyte 148). There was no difference in the primary outcome of acute kidney injury (9.6% with plasmalyte and 9.2% with saline, p=0.77). There was also no difference in renal replacement therapy, ICU days, mechanical ventilation, or mortality. A few weaknesses of this study were that the median amount of fluid given was only 2L per patient and most patients received fluid prior to enrollment, a lot of which was balanced solution. The biggest problem for emergency medicine is that 70% of patients went to the ICU after elective surgeries, so these results are probably not generalizable to our septic patients who start out significantly acidotic.
Bottom line: Despite a lot of theory, there is still no good evidence that we should be giving up on normal saline.
Are delayed antibiotics truly a death sentence?
Sterling SA, Miller WR, Pryor J, Puskarich MA, Jones AE. The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis. Critical care medicine. 43(9):1907-15. 2015. PMID: 26121073
People have been quoting a 7% increased mortality with every hour antibiotics are delayed for a long time. Unfortunately, this is based off a single study, and we seemed to forget somewhere along the line that association does not equal causation. This is a meta-analysis of 11 studies covering 16,178 patients with severe sepsis or septic shock. There was no difference in mortality comparing early and late antibiotics groups. Of course, all of these studies are observational, as no severe sepsis patients are being randomized to delayed antibiotics.
Bottom line: Obviously, give antibiotics if you know a patient has an infection – but there is reason to fight with administrators and government agencies if they try to make time to antibiotics a quality metric.
Turning down the heat: can acetaminophen save lives?
For some reason, people just love to hate on fever. It is present when people are sick, so it must be bad, right? We better rush to treat it. This is a randomized, double blind trial of 690 adult ICU patients with a fever and suspected infection, comparing acetaminophen 1 gram IV every 6 hours to placebo. Not surprisingly (unless you actually believed treating fever was helping patients) there was no difference in the primary outcome of ICU free days. There was also no difference in mortality at 28 or 90 days.
Bottom line: Tylenol is great, but it isn’t needed for febrile patients
Dopamine is having a tough run
Ventura AM, Shieh HH, Bousso A. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Critical care medicine. 43(11):2292-302. 2015. PMID: 26323041
Sure, it’s a small trial – but it was looking at small patients, so that’s OK. This is a double-blind, randomized controlled trial of 120 pediatric patients with severe sepsis comparing epinephrine to dopamine as the first line vasopressor. The study was stopped early due to increased mortality in the dopamine group (20.6% versus 7%). They also note decreased mortality when epinephrine was given early through a peripheral IV or an IO. Mortality was not the primary outcome, and the trial was small, so I wouldn’t be shocked to see contradictory results in the future.
Bottom line: It’s rare to get this kind of RCT in pediatrics – this is definitely enough for me to shelf dopamine for epinephrine for the time being.
Ultrasound for CHF
Pivetta E, Goffi A, Lupia E. Lung Ultrasound-Implemented Diagnosis of Acute Decompensated Heart Failure in the ED: A SIMEU Multicenter Study. Chest. 148(1):202-10. 2015. PMID: 25654562
This is a multicentre, prospective cohort of 1005 ED patients looking to see if lung ultrasound could add to clinical judgement in the diagnosis of acute heart failure. The gold standard of heart failure was determined by a review of the final chart by a cardiologist and an emergency physician. This isn’t perfect, but there isn’t really a better option for CHF, and they were blinded to the ultrasound results and agreed with each other 97% of the time. Physician judgement alone for CHF is really good, with a sensitivity of 85.3% and a specificity of 90%. If you add ultrasound to this physician judgment, the sensitivity rose to 97% (95% CI, 95%-98.3%) and specificity to 97.4% (95% CI, 95.7%-98.6%), translating into positive and negative likelihood ratios of 22.3 and 0.03 respectively. The biggest caveat is that these were non-consecutive patients, because there had to be a doctor around with enough ultrasound skill (>40 scans) to get enrolled.
Bottom line: In trained physicians, lung ultrasound can help rule in and rule out acute CHF.
The new ACLS guidelines are out
The multiple AHA guidelines are in this issue of Circulation
The ERC guidelines are in Resuscitation
There is too much to go through in this format. The quickest summary is that there is nothing really game changing in these guidelines, so keep providing the high quality care you already do, and don’t rush to waste your money on a new ACLS course. If you want more information, I wrote a post about the biggest changes here: http://first10em.com/2015/10/21/acls-2015/
Cheesy Joke of the Month
Patient: Doctor, I broke my arm in 3 places. What should I do?
Doctor: Stop going to those places
#FOAMed of the month
I was incredibly impressed with the capacity for knowledge translation demonstrated by the free, open access medical education community this month when the new ACLS guidelines came out. Within a week, the internet was awash in summaries, podcasts, and infographics. If my quick summary wasn’t enough for you, here are a few other amazing resources:
A monthly collection of the most interesting emergency medical literature I have encountered
Here is this month’s summary of my favorite reads from the medical literature.
Simple and brilliant: A pediatric rainbow
Moreira ME, Hernandez C, Stevens AD, et al. Color-Coded Prefilled Medication Syringes Decrease Time to Delivery and Dosing Error in Simulated Emergency Department Pediatric Resuscitations. Ann Emerg Med. 2015;66:(2)97-106.e3. PMID: 25701295
Pediatric resuscitations are stressful at the best of times and pediatric medication doses can be complicated, increasing the risk of medication errors. This group came up with an ingenious solution: single pre-filled syringes that are color-coded in a rainbow pattern that corresponds to the Broselow tape we all know and love. All you have to do is discard down to the color that corresponds to the size of the child and you are sure to be giving the right dose (best explained by looking at a picture).This study assessed the speed and accuracy of medication administration in simulated pediatric resuscitations. 10 teams consisting of physicians and nurses participated in a cross over study, so that they did one simulation with the new syringes and one without. Time to delivery of medications was quicker with the new syringes (47 versus 19 seconds, a difference of 27 seconds; 95%CI 21-33 seconds). Teams were also more accurate using the new color-coded syringes, with dosing errors occurring 17% of the time with the conventional approach and 0% of the time with the new syringes (absolute difference 17%; 95% CI 4-30%). Obviously a simulation based study is not real life – but I would actually expect more stress and therefore more errors during a real resuscitation.
Bottom line: Simple. Brilliant. Worth looking into.
The same group replicated basically the same study with similar results, but this time running the simulations with paramedics:
Stevens AD, Hernandez C, Jones S, et al. Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: A randomized crossover trial. Resuscitation. 2015. PMID: 26247145
Fingers, toes, nose and hose. The epinephrine myth
Ilicki J. Safety of Epinephrine in Digital Nerve Blocks: A Literature Review. J Emerg Med. 2015. PMID: 26254284
I’ve talked about this before, but possibly not in the articles of the month. This is a systematic review looking at the safety of using epinephrine in digital nerve blocks. They found a total of 39 relevant articles, although only 12 of them were RCTs. They report no cases of necrosis attributable to epinephrine. In total, they found 2797 reported cases of digital nerve blocks using epinephrine without any important complications.
Bottom line: This was a myth. Epinephrine is almost certainly safe in fingers and toes if you think it might help you.
Physicians might not be so great around genitals
Stewart CM, Schoeman SA, Booth RA, Smith SD, Wilcox MH, Wilson JD. Assessment of self taken swabs versus clinician taken swab cultures for diagnosing gonorrhoea in women: single centre, diagnostic accuracy study. BMJ. 2012;345:e8107. PMID: 23236033 [free full text]
This is a prospective cohort of 3859 women aged 16 and over who presented to a single sexual health clinical in the UK. Before undergoing their consultation, they were asked to perform a vulvovaginal swab on themselves which was sent for nucleic acid amplification (NAAT). They then had the normal examination by the physician, with urethral and endocervical swabs sent, both for NAAT and culture. Overall, 2.5% of women tested positive for gonorrhoea (using a gold standard of either positive culture or two different NAAT markers being positive.) The self swabs were the most sensitive (99%), followed by physician swab for NAAT (96%), with the endocervical culture being the least sensitive (81%). In patients with symptoms suggestive of STI, both physician and self swab NAAT were 100% sensitive, but the endocervical culture was only 84% sensitive.
Bottom line: Self taken swabs were the most sensitive at detecting gonorrheal infection in these women
Schoeman SA, Stewart CM, Booth RA, Smith SD, Wilcox MH, Wilson JD. Assessment of best single sample for finding chlamydia in women with and without symptoms: a diagnostic test study. BMJ. 2012;345:e8013. PMID: 23236032 [free full text]
This is another study by the same group, using essentially the same methods, but this time focusing on Chlamydia. They included a total of 3973 women. Again, the self swab outperformed the physician performed swab with a sensitivity of 97% (95%CI 95-98%) as compared to 88% (95%CI 85-91%). The reported specificity of 100% is essentially meaningless because they were using the test itself as the gold standard. Similarly, the sensitivity of both tests might be lower than reported as they were not compared to any other gold standard.
Bottom line: Women do a better job collecting swabs for Chlamydia than physicians do
Overall Bottom line: If there is not another reason for a speculum exam, it does not have to be performed solely to obtain cervical swabs. Unfortunately urine testing was not included in these studies, so we do not know how it compares to self swabs.
Using tamsulosin for kidney stones? You must not be reading these e-mails.
This is a prospective, randomized, double-blind trial of 403 adults with CT confirmed ureteric stones comparing tamsulosin 0.4mg daily to placebo. There was no benefit for the primary outcome of stone expulsion at 28 days, with 87% passed in the tamsulosin group and 81.9% in the placebo group (5.1% difference; 95%CI -3 to 13%). There was a difference in a secondary outcome, distal stones sized 5-10mm, with 83.3% passing as compared to 61%. Of course this is a secondary outcome, so should not affect your practice. More importantly, the vast majority of these people should not being getting imaged, so you will never know the size of the stone, making this information clinically useless. There was no difference in urologic interventions, pain, or analgesia requirements.
Bottom line: Tamsulosin doesn’t help patients with ureteric stones.
Just in case that wasn’t enough to convince you
Berger D, Ross M, et al. Tamsulosin does not increase one-week passage rate of ureteral stones in Emergency Department patients. Am J Emerg Med. 2015. In Print. PMID:
This is yet another paper indicating tamsulosin has no role in ureterolithiasis. (Its too bad we can’t just start with the high quality studies, rather than following the predictable pattern of a handful of garbage studies showing questionable benefit followed by a lot of time and money spent on multiple good trials that prove that there was never any benefit.) This was a prospective, double-blind RCT with 127 adult patients with CT confirmed ureterolithiasis, randomized to either tamsulosin 0.4mg daily or placebo. There was no difference in the number of patients in whom the stone did not pass (tamsulosin 62.1% 95CI 49-75%; placebo 54.4% 95%CI 40-67%.) There was also no difference in pain scores or analgesic use.
Bottom line: There is no reason to be using tamsulosin in renal colic patients.
Sticking with urology: systematic reviews are pointless if there isn’t any original literature
Hulme P and Wylie K. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 1: tranexamic acid in life-threatening haematuria. Emerg Med J. 2015;32:(2)168-9. PMID: 25605262
They decided to do a review of tranexamic acid use in life-threatening hematuria. They managed to find 3 case reports and 1 prospective observational trial of 8 patients. There were no controls, so its hard to know what to make of the outcomes. It is good to know that none of the patients broke the emergency medicine rule that all bleeding stops… eventually.
Bottom line: For patients peeing blood, you are free to make it up as you go.
It just might be safe to pee in the Amazon
Bauer IL. Candiru–a little fish with bad habits: need travel health professionals worry? A review. J Travel Med. 2013;20:(2)119-24. PMID: 23464720
This is one of those really weird medical myths that I heard when I was younger and just stuck with me as a true. Apparently if you urinate in the Amazon river, there are little fish, called Candiru, that are attracted to the urine and will swim up your urethra. Once there, they have small barbs that lock them into place. These authors did an extensive review of both the scientific and non-scientific literature and report that there has never actually been a confirmed case of this occurring. For some reason, that is an amazing relief to me (and I have never even been to South America). Was I the only one raised on this particular myth?
Bottom line: Feel free to pee in the Amazon, if that’s your thing.
Don’t write off those vital signs just yet
Rodrigo GJ, Neffen H. Assessment of acute asthma severity in the ED: are heart and respiratory rates relevant? The American journal of emergency medicine. 2015. PMID: 26233619
This is a retrospective look at data that was collected prospectively as part of 7 other asthma trials done at a single emergency department. In total, 1192 adult patients were included. They compared heart rate and respiratory rate between two predefined groups: severe asthma (defined as an FEV1 31-50% of expected) and life threatening asthma (defined as an FEV1 <= 30% expected). The HR and RR were not different between the groups (mean of 102 and 22 respectively). They then use logistic regression to show that only FEV1 and O2 saturation were related to the outcome of admission to hospital. Based on this, they conclude that HR and RR are not determinants of acute asthma severity. I think this is probably the wrong interpretation. They use FEV1 as their definition of illness severity rather than hard outcomes. The lack of correlation between FEV1 and vital signs in this study might equally indicate that FEV1 is not a good indicator of disease severity. (It is a disease oriented, not a patient oriented outcome.) Although FEV1 was correlated with admission rates at this hospital, I imagine this just represents the local practices of the hospital: they believe in FEV1 and therefore admit you to hospital if your FEV1 is low, even if you had no other indications for admission.
Bottom line: I would still strongly suggest assessing patients clinically, including vital signs. Don’t let surrogate outcomes like the FEV1 or peak flow rates confuse you in asthma.
Another quick note on measuring asthma severity
Huff JS and Diercks DB. Use of Peak Expiratory Flow Rate Monitoring for the Management of Asthma in Adults in the Emergency Department. Revision of: American College of Emergency Physicians. Use of Peak Expiratory Flow Rate Monitoring for the Management of Asthma in Adults in the Emergency Department. Ann Emerg Med. 2001;38:198.
Without going into all the problems with the base literature on the use of peak flow rates in emergency medicine, I thought I would include the ACEP policy statement for reference. This is an update of their previous policy statement from 2001, with 27 new studies identified and reviewed. Their summary: “The use of PEFR monitoring has not been shown to improve outcomes, reliably predict need for admissions, or limit morbidity or mortality when used during the ED management of adult patients with acute exacerbations of asthma.”
Bottom line: Peak flow is a disease oriented outcome. Focus on patient oriented outcomes.
Sepsis and the rush to early antibiotics
de Groot B, Ansems A, Gerling DH. The association between time to antibiotics and relevant clinical outcomes in emergency department patients with various stages of sepsis: a prospective multi-center study. Critical care. 2015;19:194. PMID: 25925412
This is a prospective, multicentre observational cohort study including a total of 1,168 adult patients with sepsis (although their definition was anyone admitted to hospital with an infection who received IV antibiotics.) The overall mortality of their cohort was 10%, so significantly lower than the trials of severe sepsis we are used to. In this cohort, the length of time it took to give antibiotics was not associated with mortality. Much like the prior studies that showed a higher mortality in patients with delays to antibiotics, we must be aware of the mantra: association is not causation. In the current study, the delay to antibiotics might have been because patients had less severe infections. On the other hand, in prior studies in which antibiotic delays were associated with increased mortality, we might guess that patients were misdiagnosed or inappropriately dispositioned, which could be the true cause of increased mortality. Why did this study come to a different conclusion? One possibility is simply the timing of the studies. It is impossible to practice emergency medicine these days without a keen awareness of sepsis. This heightened awareness may lead to over-treatment in general, such that the few patients that don’t get early antibiotics really don’t require them.
Bottom line: Once you know there is a bacterial infection, obviously give antibiotics. However, there are many factors that will affect the timing of antibiotic administration and it should not be used as a quality of care metric.
We should probably just install CT scanners at triage
Claessens YE, Debray MP, Tubach F, et al. Early Chest CT-Scan to Assist Diagnosis and Guide Treatment Decision for Suspected Community-Acquired Pneumonia. Am J Respir Crit Care Med. 2015. PMID: 26168322
Bottom line: Just say no to CT scans for pneumonia
Glue works for abrasions too
Singer AJ, Chale S, Taylor M. Evaluation of a liquid dressing for minor nonbleeding abrasions and class I and II skin tears in the emergency department. The Journal of emergency medicine. 48(2):178-85. 2015. PMID: 25456777
This is an open label observational trial with no comparison group,using a convenience sample of 40 patients and 50 total wounds. The wounds were either abrasions or skin tears. They used a cheaper skin adhesive that has not been tested for tensile strength (unlike dermabond). If tensile strength was required, a steristrip was applied before the glue. In follow up, there were no infections and only one patient needed anything else: his glue peeled off on day 3 and he had bandage applied. Of course, with no comparison group, all we can say is “Mikey likes it”.
Bottom line: Glue works in skin. Perhaps there is a role for stocking the cheaper liquid bandaid products sold at drug stores?
A simple, life-saving therapy I didn’t know about
Jamtgaard L, Manning SL, Cohn B. Does Albumin Infusion Reduce Renal Impairment and Mortality in Patients With Spontaneous Bacterial Peritonitis? Ann Emerg Med. 2015. PMID: 26234193
I always find it funny that I finished residency with a head full of practices, like PPIs for GI bleeds, that are demonstrably unhelpful, but at the same time there are potentially life saving treatments that I have never heard about. Albumin for spontaneous bacterial peritonitis is one of those treatments. These authors report a systematic review and meta-analysis of RCTs studying albumin for SBP. In total they found 4 studies that include 288 patients with limited heterogeneity and no evidence of publication bias. Only 1 trial was blinded, but with a hard outcome of mortality that might be less important. The administration of albumin (the 2 largest trials made sure to give it within 6 hours, so this might be an ED therapy) was associated with less renal impairment (OR 0.21 95%CI 0.11-0.42) and lower mortality (OR 0.34 95%CI 0.19-0.60). Dosing varied among studies, but the largest trial used 1.5grams/kg IV at the time of diagnosis and 1gram/kg on day 3.
Bottom line: These are small numbers, but I will be giving albumin to SBP patients until we see more.
Diverticulitis is not necessarily a reason to promote antibiotic resistance
Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012 Apr;99(4):532-9. PMID: 22290281
I included the meta-analysis a few months back, but here is a multicentre RCT of 623 adult patients with CT confirmed uncomplicated diverticulitis (defined as lower abdo pain plus fever, an elevated WBC, and CT consistent with diverticulitis but no abscess or free air) randomized to either antibiotics or not. They used pretty big gun antibiotics: either a 2nd/3rd gen cephalosporin plus metronidazole or a carbapenem or piperacillin-tazobactam. There were no statistical differences between the groups. There were 3 perforations in each group. There were 3 abscesses in the no antibiotics group compared to none in the antibiotics group. 10 patients (3.2%) that started with no antibiotics were given antibiotics eventually. There were no differences in length of hospital stays or recurrent diverticulitis.
Bottom line: It may well be that we don’t need antibiotics for diverticulitis, but these patients were all treated as inpatients, so its probably not up to us to make that call.
Read enough and I might sound like an antibiotic nihilist
Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Annals of family medicine. 5(5):436-43. 2007. PMID: 17893386 [free full text]
I love this article, probably because it hits on two of my favorite soapbox topics: guidelines and antibiotics for sore throats. They searched for any major pharyngitis guidelines and found 10 from different countries and organizations. Two people individually coded each guidelines for all the major recommendations. The key finding of this paper is that despite all of these guidelines being “evidence based”, they arrive at wildly different recommendations. Several guidelines recommend prescribing antibiotics only if the patient is very sick or high-risk, but others suggest treating almost everyone. (If you want to find a guideline that tells you not to give antibiotics, look to Belgium, the Netherlands, England, or Scotland. Interestingly, these were the guidelines that were written by family doctors, as compared to specialists – I knew we had brains.) Not a single publication, including the Cochrane review, was cited by all the guidelines.
Bottom line: Unfortunately, guidelines are rarely an adequate source of evidence based clinical information. (Also, for most parts of the world, pharyngitis probably doesn’t need antibiotics.)
When is a clot a clot?
Morgan C, Choi H. BET 1: Do patients with a clinically suspected subsegmental pulmonary embolism need anticoagulation therapy? Emergency medicine journal : EMJ. 32(9):744-7. 2015. PMID: 26293150
What is the evidence for treating subsegmental pulmonary emboli? This review identified 2 observational trials that included patients with subsegmental PEs who were not anticoagulated. Of the total of 47 patients with untreated subsegmental PEs, none had recurrent venous thromboembolism at 3 months. It would not be surprising if the harms of anticoagulation outweighed the benefits, but 47 patients can’t give enough information to decide either way.
Bottom line: We still really don’t know what to do, but any treatment benefit is likely to be small.
Positive troponins are negative for patients
Hakemi EU, Alyousef T, Dang G, Hakmei J, Doukky R. The prognostic value of undetectable highly sensitive cardiac troponin I in patients with acute pulmonary embolism. Chest. 2015;147:(3)685-94. PMID: 25079900
This is a retrospective chart review of 298 patients with confirmed PEs looking at the prognostic value of a positive high sensitivity troponin. 45% of the group had a negative troponin and therefore 55% had a positive trop. If the troponin was negative, no patients died, needed CPR, or received lytics. Among those with a positive trop, 6% died and 9% had either CPR or lytics given. For a retrospective study, this one is more likely than usual to give us a correct answer as death, lytics, troponin, and to a lesser extent CPR are objective values that are likely to be accurately recorded on a chart.
Bottom line: It’s not surprising, but a positive troponin is likely a bad prognostic factor for PE patients.
Less relevant than the pee fish article?
Morgenstern J, Hegele RA, Nisker J. Simple genetics language as source of miscommunication between genetics researchers and potential research participants in informed consent documents. Public Underst Sci. 2015;24:(6)751-66. PMID: 24751688
This isn’t directly related to emergency medicine, but I was excited that after a few years of being “in press” the article based on my master’s thesis actually got published in print. This was a study that used qualitative methods to analyze the language of informed consent documents in genetics research. The main finding was that apparently simple, easy to understand language can be a source of miscommunication. This can occur because different people or groups of people will understand words differently. An example would be geneticists conceptualizing “disease” as an entity that may or may not cause actual symptoms in the future based on genetic predispositions, while their research participants may think of a “disease” as something they definitely have and will notice the effects of. Might this be applicable to emergency medicine? I think so, but without any good evidence. However, we know that when patients hear the words “congestive heart failure” they envision something that will kill within days – after all, their heart is failing – but this is not necessarily what we are trying to convey with those words. Similarly, we might talk about “low risk chest pain”, but different people might understand those words to indicate a 2% risk, or a 1 in a thousand risk, or a 1 in a million risk.
Bottom line: Communication is essential in emergency medicine. It is an area that probably deserves more attention.
Cheesy Joke of the Month
What is the difference between surgeons and God?
God doesn’t think he is a surgeon
FOAM resource of the month
A new site and podcast that I think will benefit all emergency physicians is:
Rather than being focused on clinical aspects of care, this site is run by Jason Brooks, a performance enhancement coach, with the goal of improving performance (both in the ED and in life in general) and making it sustainable. High level athletes have coaches, why shouldn’t we? I really enjoyed the first few podcasts.
Enjoy the free open access medical education? Think you know someone else who might? It would help me a lot if you spread the word and shared this resource with just one of your friends or colleagues. Even easier, you could also help by just clicking the like button on Facebook. Thank you so much!