Articles of the month (May 2018)

A monthly (ish) summary of the emergency medicine literature

Welcome to another edition of the (bi)monthly medical articles that caught my attention. As always, you can hear Casey and I ramble on about these articles and other quasi-related medical issues on the BroomDocs podcast. Continue reading “Articles of the month (May 2018)”

Articles of the month (July 2016)

Another month and another edition of the articles of the month. However, this time I have some very exciting news. I have teamed up with Casey Parker (the brilliant, smooth-talking Australian physician, not the adult film star) to produce an audio version of these summaries. You will be able to find this podcast on http://broomedocs.com/, a great FOAM website that everyone should probably be following anyway. This is the first edition, and we will likely tweak the format with time, so if you have any feedback (hopefully more constructive than, “Justin, you have the perfect voice for silent films”), we would love for you to get in touch. Continue reading “Articles of the month (July 2016)”

Articles of the month (November 2015)

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

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

Bronchiolitis – it will take your breath away

Willwerth BM, Harper MB, Greenes DS. Identifying hospitalized infants who have bronchiolitis and are at high risk for apnea. Ann Emerg Med. 2006;48:(4)441-7. PMID: 16997681

Its that time of year. Some children are beginning to hold their breath in anticipation of Christmas. Or, maybe that was an apneic spell from bronchiolitis? Which children are at risk? This is a retrospective cohort of 691 children less than 6 months old who were admitted to the hospital for bronchiolitis looking at risk factors associated with apnea. The authors found that full term babies less than 1 month old, preterm babies less than 48 weeks post-conception, and babies whose caregivers had already witnessed an apnea spell were at higher risk for further apnea spells. Overall 19 (2.5% 95%CI 1.7-4.3) children had apnea spells while admitted, and all 19 met one of the criteria above.

Bottom line: 2.5% is relatively low risk, but breathing is relatively important. I would have the pediatricians review the kids that fall into these categories.


More bronchiolitis and the need for oxygen

Cunningham S, Rodriguez A, Adams T. Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. Lancet (London, England). 386(9998):1041-8. 2015. PMID: 26382998

This is a multi-center, randomized, controlled trial of children aged 6 weeks to 12 months admitted to hospital with bronchiolitis. This children were either placed on a standard sat probe or one that was altered so that a sat of 90% would display as 94%. Staff were instructed to provide oxygen to any child with a sat less than 94%. (94% seems like a pretty high target. I am more interested in whether we should be starting oxygen at say 92% or 88% or even lower.) I think they chose a pretty poor primary outcome: time to resolution of cough. For what it’s worth, it was equivalent, but did we really think oxygen could cure cough? Some secondary outcomes were also not affected, but none capture why I give oxygen. Oxygen is given when children are approaching the steep portion of the oxygen-hemoglobin dissociation curve to prevent precipitous drops, desaturations, and bad outcomes. The authors do report no change in ‘adverse events’, but if you look at the supplement, respiratory adverse events were things like cough and otitis media. Although I believe we probably over-treat bronchiolitis, this is another in a slew of papers that fails to actually prove that it is safe to withhold oxygen or discharge patients with low oxygen saturations.

Bottom line: Oxygen saturation is still an important parameter to monitor in bronchiolitis. We don’t know the ideal saturation to target.  


Children inhaling salt water – no, not drowning, but bronchiolitis treatment

Silver AH, Esteban-Cruciani N, Azzarone G. 3% Hypertonic Saline Versus Normal Saline in Inpatient Bronchiolitis: A Randomized Controlled Trial. Pediatrics. 2015. PMID: 26553190

This is a randomized, double-blind, controlled trial from a single pediatric hospital comparing 4 ml of either 3% saline or 0.9% saline nebulized every 4 hours in 227 children under 12 months old with bronchiolitis. There was no difference in any of the many outcomes they measured, including length of stay, ICU admission, readmission, and objective respiratory findings. Of course, it’s possible that normal saline is more therapeutic than no treatment – but, come on, you know that nothing works in bronchiolitis.

Bottom line: No treatments work in bronchiolitis. Do you think we will ever come to terms with that?


It might just be the season, but it seems like I am obsessed with wheezing kids

Cronin JJ, McCoy S, Kennedy U. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Annals of emergency medicine. 2015. PMID: 26460983

I have covered dexamethasone versus prednisone for asthma before, but here is another RCT. In 245 pediatric patients (aged 2-16) with asthma, they compared a single dose of dexamethasone (0.3mg/kg) to prednisolone (1mg/kg) for 3 days. Their primary outcome was a PRAM score on day 4 and there was no difference between the two.

Bottom line: I will continue using the easier single dose dexamethasone over prednisone.


More shots fired in the continuing Roc versus Sux RSI battle

Tran DT, Newton EK, Mount VA, Lee JS, Wells GA, Perry JJ. Rocuronium versus succinylcholine for rapid sequence induction intubation. The Cochrane database of systematic reviews. 10:CD002788. 2015. PMID: 26512948

This one is going to ruffle a few feathers. Let’s start with the author’s conclusions: “Succinylcholine created superior intubation conditions to rocuronium in achieving excellent and clinically acceptable intubating conditions.” This is a cochrane review that includes 50 trials covering 4151 patients. For “excellent intubating conditions” succinylcholine was superior to rocuronium (RR 0.86 95%CI 0.81-0.92). The problem with this conclusion is the significant heterogeneity in the included studies. For me, the biggest concern is varying doses. In fact, the authors even conclude that if you use 1.2mg/kg of rocuronium (the appropriate dose for RSI) there was no difference between roc and sux. Unfortunately, they make the erroneous conclusion that sux is still better because it has a shorter duration of paralysis. In emergent airways, short paralysis is not a good thing.

Bottom line: Ignore the conclusions, rocuronium at a proper dose (1.2mg/kg) is a great paralytic for RSI.


One of my favorite myths to rant about – and apparently some very smart people out there agree with me

Swaminathan A, Otterness K, Milne K, Rezaie S. The Safety of Topical Anesthetics in the Treatment of Corneal Abrasions: A Review. The Journal of emergency medicine. 49(5):810-5. 2015. 26281814

I spoke about topical anesthetics for corneal abrasions at rounds earlier this year. (My handout from that talk can be found here.) This is a systematic review looking at the same topic. They identify 2 emergency department studies and 4 ophthalmology studies (after a procedure called photorefractive keratectomy – essentially a iatrogenic corneal abrasion) that prospectively evaluated the use of topical anesthetics for corneal abrasions.  All the studies were small. Topical anesthetics resulted in no complications. Overall, topical anesthetics appear to be effective, with clinically and statistically significant pain score reduction in 5 of 6 studies.

Bottom line: Treat your patient’s pain. A short course of topical anesthetic is probably safe and almost certainly effective for corneal abrasions.


Acute HIV – a diagnosis I am probably missing

Rosenberg ES, Caliendo AM, Walker BD. Acute HIV infection among patients tested for mononucleosis. The New England journal of medicine. 340(12):969. 1999. PMID: 10094651 [free full text]

Early HIV infection presents as a mononucleosis-like infection, making it very difficult to diagnose. Although I generally dislike using the emergency department for public health screening, if HIV is not diagnosed during this initial stage, many years may pass before it is diagnosed, not only hurting the patient, but also putting their many contacts at risk. This is a letter to the editor describing a study where they retrospectively took all blood samples that were sent for epstein barr virus at Massachusetts General Hospital and tested them for HIV RNA. They found that 1.2% (7/563) has an acute HIV infection and another 0.8% (4/563) had chronic HIV.

Bottom line: This is well above the threshold for screening for HIV. Perhaps monospot and HIV testing should be paired?


1 more: Non specific viral illness or acute HIV?

Pincus JM, Crosby SS, Losina E, King ER, LaBelle C, Freedberg KA. Acute human immunodeficiency virus infection in patients presenting to an urban urgent care center. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 37(12):1699-704. 2003. PMID: 14689354 [free full text]

Sticking with the same topic, these authors tested all patients presenting with viral symptoms and 1 or more HIV risk factors at their urban urgent care centre for HIV. (They were very broad with their HIV risk factors: any sexual contact, any injection drug use, any crack use, or any alcohol use in the last 2 months.) Of the 499 patients included, 5 (1.0%) were diagnosed with an acute HIV infection and another 6 (1.2%) were diagnosed with chronic HIV. They did not have any false positives.

Bottom line: Depending on your work environment, it may be worth screening for HIV in patients with viral illnesses.


It’s all about that aVL

Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. The American journal of emergency medicine. 2015. PMID: 26542793

Is that Inferior ST elevation indicative of STEMI? Or is it pericarditis? aVL might hold the key. This is a retrospective look at 3 different groups. Of 154 patients with a final diagnosis of inferior STEMI, all 154 had some degree of ST depression in aVL. Of the 49 patients with pericarditis, 49 had some degree of inferior ST elevation, but none had any ST depression in aVL. There was a third cohort with subtle inferior ST elevation (less than 1mm) but confirmed vessel occlusion on cath. Of these 54 patients, 49 had ST depression in aVL. The authors conclude that ST depression is highly sensitive for inferior STEMI and specific for pericarditis.

Bottom line: I will certainly look at aVL, but would love to see this repeated prospectively

If you want to read more about this and see some example ECGs, check out the blog post by senior author Dr Steve Smith: http://hqmeded-ecg.blogspot.ca/2015/11/new-paper-published-on-significance-of.html


 

Cold – the pure green coffee (ask Dr. Oz) of the brain

Andrews PJ, Sinclair HL, Rodriguez A. Hypothermia for Intracranial Hypertension after Traumatic Brain Injury. The New England journal of medicine. 2015. PMID: 26444221 [free full text]

Another in the cold brain is not healthy brain category. This is a multicentre, randomized controlled trial of 387 adult patients (out of 2498 screened patients) with traumatic brain injury and persistently elevated ICP after sedation, elevation of the head of the bed, and mechanical ventilation. They were randomized to either get or not get hypothermia (target between 32 and 35 degrees Celsius for 48 hours.) The trial was stopped early for harm. Their primary outcome (neuro status based on the extended Glasgow outcome scale) was worse in the hypothermia group (OR 1.53 95%CI 1.02-2.30). Mortality was also worse (OR 1.45 95%CI 1.01-2.10). The biggest problem with the study was that they included patients up to 10 days after injury, which could just be too late for the magical power of cold to work.

However, I don’t think we should find this too surprising. Hypothermia has been tried for many conditions, including TBI, in the past with limited success. The general failure of hypothermia is one of the reasons to remain highly skeptical of those two small, biased trials that indicated that it worked in cardiac arrest. It may be reasonable to continue using hypothermia for the time being, but if anyone gets around to actually repeating the hypothermia versus placebo trial in cardiac arrest, we shouldn’t be surprised if it turns out to have no effect.

Bottom line: No hypothermia for trauma


Dual antiplatelets for stroke/TIA?

Wang Y, Pan Y, Zhao X. Clopidogrel With Aspirin in Acute Minor Stroke or Transient Ischemic Attack (CHANCE) Trial: One-Year Outcomes. Circulation. 132(1):40-6. 2015. PMID: 25957224

This is one of those trials that will get talked about, but I worry we will over apply the results. This is a large multicenter randomized trial in which 5170 Chinese patients with high risk TIA or minor CVA were randomized to either clopidogrel 75mg daily for 3 months plus aspirin 75 mg daily for 21 days or aspirin 75 mg daily for 3 months. The primary outcome of stroke at 1 year occurred in 10.6% of the combo group as compared to 14.0% of the aspirin alone group (hazard ratio, 0.78; 95% confidence interval, 0.65-0.93; P=0.006). Bleeding was the same in both groups. I think there are a few important caveats. First, you should question the generalizability of these results to your patients unless you work in China, because the rates of smoking in China are unlike those anywhere else in the world. Second, it is unlikely that the combination of ASA and clopidogrel has the same bleeding rates as ASA alone. That doesn’t fit well with previous studies or general experience. This should remind us that RCTs are usually not well designed to identify harms and will often over estimate the benefit to harm ratio.

Bottom line: I would not be changing my practice to include dual antiplatelet therapy based on this study alone.


Great ultrasound tip – try using both probes for IUP

Tabbut M, Harper D, Gramer D, Jones R. High-frequency linear transducer improves detection of an intrauterine pregnancy in first trimester ultrasound. The American Journal of Emergency Medicine. Article in Press. PMID:

Traditionally, we are taught to use a curvilinear abdominal probe when performing transabdominal ultrasound to detect first trimester pregnancy. This study looked at adding the high frequency linear transducer after failure to identify IUP with the standard transducer. Of 81 initial scans, 27 patients did not have an IUP visualised with the curvilinear probe. Of those, 9 (33%) were found to have an IUP by using the linear probe.

Bottom line: It’s probably worth trying the linear probe if you can’t see an IUP with the curvilinear.


Cricoid pressure: the evidence?

Algie CM, Mahar RK, Tan HB, Wilson G, Mahar PD, Wasiak J. Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation. The Cochrane database of systematic reviews. 11:CD011656. 2015. PMID: 26578526

This is a Cochrane review designed to look for any RCT evidence of the value of cricoid pressure in either emergent or elective airways. The review really says nothing of value, because there is no evidence to review. So why include it? Because sometimes it’s important to know that there is no evidence to review. If anyone ever gets too dogmatic on either side of the cricoid pressure debate, they should probably be ignored.

Bottom line: There is no evidence supporting the use of cricoid pressure. I abandoned it a long time ago, but I would be happy to see an RCT done to confirm or contradict my current practice.  


Sex is better than flomax!

Doluoglu OG, Demirbas A, Kilinc MF. Can Sexual Intercourse Be an Alternative Therapy for Distal Ureteral Stones? A Prospective, Randomized, Controlled Study. Urology. 86(1):19-24. 2015. PMID: 26142575

By now, everyone should know that tamsulosin does not help patients with kidney stones, but that doesn’t mean we should give up on our patients. Is there anything else we can do to help? In this randomized, controlled study 75 adult patients with nephrolithiasis were randomized to either 1) being asked to have sex at least 3-4 times a week, 2) tamsulosin 0.4mg a day, or 3) usual care. There were no placebos (although if you can come up with a placebo version of sex I want to hear about it.) The mean time to stone expulsion was only 10 days (95%CI 4.2-15.8 days) in the sex group, versus 16.6 (95%CI 8.1-25.1 days) with tamsulosin and 18 (95%CI 15.5-23.5 days) with usual care (p=0.0001). I foresee a large number of men looking for medical notes explaining this therapy to their wives. Perhaps there may even be a few malingerers without stones looking to get this prescription?

Bottom line: Sex is good


When is dementia not dementia?

Djukic M, Wedekind D, Franz A, Gremke M, Nau R. Frequency of dementia syndromes with a potentially treatable cause in geriatric in-patients: analysis of a 1-year interval. European archives of psychiatry and clinical neuroscience. 265(5):429-38. 2015. PMID: 25716929

Dementia is a horrible diagnosis that we can’t do anything about. But is it always? In this retrospective review of patients admitted to hospital with dementia, the authors searched for reversible causes. Of the patients previously diagnosed with dementia, the authors were able identify a potentially reversible cause in 23%. Of the newly diagnosed dementia, 31% had potentially reversible causes. The common reversible causes included low B12, depression, alcoholism, and normal pressure hydrocephalus. I wouldn’t hang my hat on any of the numbers, given the retrospective nature of the trial, but this should serve as a reminder that we might be able to help some of these patients. If you can reverse dementia, that is a true save.

Bottom line: Some dementia is reversible. These causes should be searched for.


Dikembe Mutombo is wagging his finger – Block!

Riddell M, Ospina M, Holroyd-Leduc JM. Use of Femoral Nerve Blocks to Manage Hip Fracture Pain among Older Adults in the Emergency Department: A Systematic Review. CJEM. 2015. PMID: 26354332

My appraisal may be biased because I love nerve blocks, especially when I can do them with an ultrasound. This is a systematic review of randomized control trials asking the question: does the use of a femoral nerve block reduce pain, opioid use, delirium, or improve function in adults over 65 with an acute hip fracture. They found 7 RCTs covering a total of 224 patients – so the studies were small. Also, only one trial was placebo controlled. The remainder compared the nerve block to opioids. The authors appropriately did not perform a meta-analysis, as the studies were heterogenous, so a single numerical summary is not possible. The best summary is that the nerve block group consistently had both statistically and clinically significant reduction in their pain scores as compared to placebo, used less opioid, and had fewer complications.

Bottom line: Nerve blocks work great for hip fractures. We should be using these.


From Dikembe Mutombo to Mark Spitz

Browne KM, Murphy O, Clover AJ. Should we advise patients with sutures not to swim? BMJ (Clinical research ed.). 348:g3171. 2014. PMID: 24859900

I always find it a little frustrating when my non-medical friends ask me questions about medicine that seem really simple, but that I honestly can’t answer. What exactly did I learn in all those years of school? The most recent question was: “when can I started swimming again after getting stitches?” This is a review, if you can call a search that unearthed only a single case report a review, trying to answer that question. Yes, apparently in the entire medical literature there is a single reported case of a wound infection that occurred after swimming – and that was in a hospital rehab pool which is probably more likely to be colonized with strange bugs than your average swimming pool. The authors try to shape this into a practical answer, but I think the best answer we can give is “we don’t know”. Early showering after surgery has been shown to be safe, so maybe you could extrapolate from that.

Bottom line: There is much in medicine that we simply don’t know


Which is more important: rinsing your dishes before they go in the dishwasher, or rinsing out the inside of an abscess?

Chinnock B, Hendey GW. Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success. Annals of emergency medicine. 2015. PMID: 26416494

I was never taught to irrigate abscesses in residency. It was only this year that I discovered that this has been suggested by numerous guidelines. But not so fast. This is a non-blinded RCT of 209 patients with cutaneous abscesses randomized to irrigation or no irrigation. There was no difference in the need for further treatment (I&D, antibiotic change, or admission) at 30 days between the 2 groups (15% vs 13%). Unfortunately a huge number of these patients were put on antibiotics (91% in the irrigation and 73% in the no irrigation group), which we know are unnecessary in most abscesses, but contaminate the results here.

Bottom line: This wasn’t common practice where I trained and we never saw many bouncebacks. I won’t start irrigating abscesses based on this.


Should the Bee Gees pause for a breath (at 30:2)?

Nichol G, Leroux B, Wang H. Trial of Continuous or Interrupted Chest Compressions during CPR. The New England journal of medicine. 2015. PMID: 26550795 [free full text]

“Well, you can tell by the way I use my walk, I’m a woman’s man. No time to talk… Ah,ha,ha,ha, stayin’ alive”. This is a large randomized controlled trial of 23,711 adult patients with out of hospital cardiac arrest comparing the standard 30:2 ratio of chest compressions to rescue breaths, to continuous chest compressions at 100/min with 10 asynchronous breaths a minute. The primary outcome of survival to hospital discharge was identical, 9.0% in the continuous chest compression group and 9.7% in the 30:2 group. Neurologically intact survival was 7.0% and 7.7% respectively. The biggest issue with the data is that everyone got extremely high quality CPR, and the compression fraction was almost identical in both groups, so it would have been difficult to demonstrate any difference.

Bottom line: Personally, I like continuous compressions with asynchronous breaths more, but this trial supports whatever you are comfortable with as long as you are doing high quality CPR.


A quick and easy rule out blood test for aortic dissection? Get real

Asha SE, Miers JW. A Systematic Review and Meta-analysis of D-dimer as a Rule-out Test for Suspected Acute Aortic Dissection. Annals of emergency medicine. 66(4):368-78. 2015. PMID: pubmed

This is a systematic review and meta-analysis looking to determine the diagnostic accuracy of D-dimer as a rule out test of aortic dissection. In total they found 5 studies including a total of 1600 patients. My first point of concern is that 1035 of those patients came from a single study, which could potentially dominate a meta-analysis, and that study was not designed to test the accuracy of D-dimer. In fact, the study enrolled 1455 patients, but only 1035 were counted in this meta-analysis, because the other patients never even had a D-dimer drawn. The results they present are pretty impressive, with a pooled sensitivity of 98% (95%CI 96-100%), specificity of 42% (95%CI 39-45%), negative likelihood ratio of 0.05 and positive likelihood ratio of 2.11. However, I would be very careful interpreting those results. Not only are the majority of the patients from a registry where D-dimer didn’t have to be drawn, but these were almost all patients admitted to CCUs, so very different from our ED population. Finally, although you would be using this test to try to avoid CTs, the poor specificity in a lower risk population could actually paradoxically lead to increased CT usage, much like D-dimer for PE.

Bottom line: This study isn’t enough to support D-dimer to rule out aortic dissection in the ED.


“Unreasonable haste is the direct road to error” – Moliere

Fanari Z, Abraham N, Kolm P. Aggressive Measures to Decrease “Door to Balloon” Time and Incidence of Unnecessary Cardiac Catheterization: Potential Risks and Role of Quality Improvement. Mayo Clinic proceedings. 2015. PMID: 26549506

An important lesson in unintended consequences. We know that short door to balloon times are important for STEMI patients. This is a study from a single hospital where they instituted a number of measures to decrease the door to balloon time. And it worked! Well – they managed to get the door to balloon time decreased by 15 minutes, which is excellent. However, it’s important to measure patient oriented outcomes and in this cohort the false positive STEMI rate rose from 7.7% to 16% and there was an increased mortality in this false positive group.

Bottom line: Inappropriate benchmarks can result in physicians rushing, more errors, and patient harms.


Don’t let an endotracheal tube make your patient worse

Kim WY, Kwak MK, Ko BS. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PloS one. 9(11):e112779. 2014. PMID: 25402500 [free full text]

Emergency physicians love procedures and intubation is one of our favorite. Sometimes this leads to us being a little overzealous about intubating very early, when an immediate airway is not necessary. This is a case control study of 41 critically ill adult patients that had a cardiac arrest after intubation (out of a total of 2404 critically ill patients who were intubated – or 1.7%.) Pre-Intubation hypotension (a systolic blood pressues ≤ 90) was independently associated with post-intubation arrest (OR 3.67 95%CI 1.58-8.55.) The case control design may not provide precise numbers, but I think this is a good reminder that some patients need good resuscitation before we attempt intubation.

Bottom line: Resuscitation before intubation in hypotensive patients


Cheesy Joke of the Month

There are two cows in a field. The first cow turns to the second and asks, “did you hear about the outbreak of mad cow disease?” The second cow responds: “Good thing I am a helicopter.”


 

#FOAMed of the month

Every month this section could probably just be filled with my favorite talks from SMACC. I will try to include some different FOAM in coming months, but these talks were so go that even though I listened to them live, I have listened to them all again at home. This is why I have been telling everyone who will listen they should join me in Dublin in June. The first tickets sold out very fast, but some more will go on sale December 1st at 5pm EST (if my math is right.)

For now, these talks were amazing:

Lessons from the Princess Bride (Amal Mattu)

When to stop resuscitation (Roger Harris)

What is a good death (Ashley Shreves)

Crack the chest. Get crucified. (John Hinds) – I know I have recommended this one before, but it is worth more than one watch.

Dogmalysis and pseudoaxioms (David Newman)

Bouncing back after tragedy (Rob Rogers)

Educational theory for the clinician (Jonathon Sherbino)

 

Articles of the month (April 2015)

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

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

Troponin is king – why even send an CK?

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

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

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


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

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

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

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


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

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

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

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


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

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

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

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


Another one with strange conclusions

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

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

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


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

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

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

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


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

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

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

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


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

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

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

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


More is not always better

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

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

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


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

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

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

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


Should H.pylori be an ED problem?

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

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

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


The “rocket launcher” hip reduction technique

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

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

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


Another reduction technique: syringe rolling for mandible reduction

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

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

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


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

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

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

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


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

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

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

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


Clowns cause pregnancy; AKA completely irrelevant paper of the month 

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

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

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


#FOAMed suggestion of the month

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

Cheesy Joke of the Month

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