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.
A monthly collection of the most interesting emergency medical literature I have encountered
Here is this month’s summary of my favorite reads from the medical literature.
A simple clinical test to rule out PE? (Yeah right)
Amin Q, Perry JJ, Stiell IG, Mohapatra S, Alsadoon A, Rodger M. Ambulatory vital signs in the workup of pulmonary embolism using a standardized 3-minute walk test. CJEM. 2015;17:(3)270-8. PMID: 26034913
I love this study, although unfortunately it isn’t useful for clinical practice. It is a prospective cohort study of 114 patients, either in an ED or a thrombosis clinic, who were suspected of or had newly confirmed PE. They had patients walk for 3 minutes, and then measured heart rate and oxygen saturation. An increase in HR >10 had a sensitivity of 96.6% and a specificity of 31% for PE. A drop in O2 sat ≥2% had a sensitivity of 90.2% and a specificity of 39.3%. The combination of both had a sensitivity of 100% (95% CI 87-100) and a specificity of 11% (95% CI 6-21).
Bottom line: Although vitals signs seem to change in PE patients when walking, this is a pilot study and isn’t ready for prime time. The horrible specificity of this test may render it clinically useless.
We miss very few MIs, no matter what people want to tell you
Weinstock MB, Weingart S, Orth F, et al. Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission. JAMA Intern Med. 2015. PMID: 25985100
A bunch of big names on this one: David Newman, Scott Weingart, Michael Weinstock. This is a retrospective review, with decent methods, looking at 11,230 patients admitted for an ACS rule out, but who had 2 normal troponins in the ED. In total, 20 of those patients (0.18%; 95%CI 0.11-0.27) had any of: an arrhythmia, STEMI, cardiac arrest, or death during their hospitalization. If you exclude patients with abnormal vital signs or abnormal ECGs, only 4 out of 7266 (0.06%; 95%CI 0.02-0.14%) patients had any of those outcomes.
Bottom line: If you are ruled out by biomarkers and ECG, you are probably ruled out as well as we will ever be able to accomplish.
Patient oriented outcomes: PPIs don’t improve any of them
Cabot JC, Shah K. Are proton-pump inhibitors effective treatment for acute undifferentiated upper gastrointestinal bleeding? Ann Emerg Med. 2014;63:(6)759-60. PMID: 24199839
I know we just talked about the use of PPIs in GI bleeds, but I will throw this in as a bit of staged repetition. This is one of the Annal’s systematic review snap shot series, covering the Cochrane review of the same topic. I will quote: “In conclusion, this systematic review does not demonstrate improvement in clinically important outcomes with proton-pump inhibitor treatment before index endoscopy for undifferentiated upper gastrointestinal bleeding”
Bottom line: We need to choose wisely and stop using PPIs for our GI bleed patients
You actually heard a pericardial friction rub! Now what?
Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369:(16)1522-8. PMID: 23992557
An RCT of 240 patients with acute pericarditis, comparing colchicine (0.5mg daily if 70kg) to placebo. All patients got NSAIDs. The primary outcome of incessant or recurrent pericarditis was decreased from 38% with placebo to 17% with colchicine. Colchicine also decreased symptoms at 72 hours, at 1 week, and hospitalizations. Adverse events were not increased in this study, but everyone knows that colchicine can be nasty at higher doses, like those that used to be used for gout.
Bottom line: I tend to prescribe colchicine for pericarditis based on a NNT of about 5 to decrease recurrence or prolonged symptoms
Speaking of which, the correct colchicine dose is low dose
Terkeltaub RA, Furst DE, Bennett K, Kook KA, Crockett RS, Davis MW. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62:(4)1060-8. PMID: 20131255 (free full text)
Hopefully anyone using colchicine for gout has already seen this one. This is a double blind, placebo controlled RCT comparing low dose (1.2mg once then 0.6mg 1 hour later) to high dose (4.8mg over 6 hours) colchicine and to placebo. Pain was significantly improved in about 35% of both colchicine groups, but only 15% of placebo. Severe diarrhea and nausea were both increased by the high dose colchicine, but not the low dose.
Bottom line: Colchicine is equally effective at lower doses than traditionally given, but much better tolerated.
Steri-strips for good cosmetic outcomes
Gkegkes ID, Mavros MN, Alexiou VG, Peppas G, Athanasiou S, Falagas ME. Adhesive strips for the closure of surgical incisional sites: a systematic review and meta-analysis. Surg Innov. 2012;19:(2)145-55. PMID: 21926099
This is a systematic review including 12 RCTs of 1317 patients, comparing the use of adhesive strips to sutures in closing surgical wounds. They found no difference in cosmetic results, infection, or dehiscence. Of course, this is in clean surgical wounds.
Bottom line: Almost every paper I read on wounds just reinforces my inherent bias that it doesn’t really matter how you close wounds – within reason.
More of the same
Mattick A, Clegg G, Beattie T, Ahmad T. A randomised, controlled trial comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair. Emerg Med J. 2002;19:(5)405-7. PMID: 12204985
An RCT of 44 emergency department pediatric patients comparing steri-strips with dermabond. Both a plastic surgeon and the parents judged cosmetic outcomes. There were no differences between the two groups.
Bottom line: Again, just clean it out and get the edges close. Humans have been healing for millennia.
Reading articles about droperidol leaves me in a state that may require some droperidol
Calver L, Isbister GK. High dose droperidol and QT prolongation: analysis of continuous 12-lead recordings. Br J Clin Pharmacol. 2014;77:(5)880-6. PMID: 24168079
I included the much larger study by the same group last month, but it is always nice to explore how many high level decisions in medicine lack a scientific basis. In this prospective observation study, they gave 46 psychiatric patients between 10 and 25 mg of IV droperidol for sedation. All were placed on holter monitors. There were no dysrhythmias. Only 4 patients had any lengthening of their QT and all 4 had other reasons for this, such as methadone.
Bottom line: We should not give up excellent medications based on shoddy science.
Options, for when they take our good drugs away or we run into ‘drug shortages’
Gaffigan ME, Bruner DI, Wason C, Pritchard A, Frumkin K. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015. PMID: 26048068
This is a double-blind RCT of 64 adults with migraines comparing haloperidol 5mg IV to metoclopramide 10mg IV. Both medications offered excellent pain relief, 57/100mm for haloperidol and 49/100mm for metoclopramide (no difference). The metoclopramide group required more rescue medications. There was more restlessness with haloperidol.
Bottom line: Like magnesium (that we discussed a few months ago), Haldol is another option I will keep in mind for the treatment of migraines.
A classic: The FEAST trial
This is a classic RCT that randomized 3170 febrile pediatric patients in resource poor environments to either 20ml/kg NS, 20ml/kg albumin, or no bolus. All patients were severely ill with either impaired consciousness or respiratory distress plus signs of impaired perfusion. 48 hour mortality was significantly worse in the bolus groups than the no bolus group (10.5% versus 7.3%). Mortality was also worse at 4 weeks.
Bottom line: In an African setting, poorly perfused pediatric patients do worse with a fluid bolus. Although these results probably don’t generalize to our population, it does remind us that IV fluids are a drug and should be treated as such.
Bonus: This is a free open access article discussing the mechanisms of increased mortality in FEAST. This paper was discussed a great deal at the SMACC conference, and some experts think FEAST is more applicable to our patients than we have recognized.
Vasopressor? Peripheral line is fine
Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care. 2015;30:(3)653.e9-17. PMID: 25669592
This systematic review looked for any primary studies or case reports that described local tissue injury from vasopressor extravasation, and includes 85 articles and 270 patients. Although there are reports of tissue injuries after peripheral vasopressor administration, these tend to occur after very long use (the average duration of infusion was 55.9 hours.)
Bottom line: Although data is pretty limited, I would be very comfortable starting vasopressors through a peripheral line. Long term management should probably include central access.
What is a placebo controlled trial of sucrose for pain? You compare sugar pills to sugar pills
Harrison D, Yamada J, Adams-Webber T, Ohlsson A, Beyene J, Stevens B. Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years. Cochrane Database Syst Rev. 2015;5:CD008408. PMID: 25942496
This Cochrane review identified 8 studies encompassing 808 pediatric patients, examining the utility of sucrose or other sweet tasting solutions in decreasing the pain of needles. The studies were all small and of moderate quality. Overall, sweetened substances did not seem to lower pain scores no matter what scoring system you used. Prior studies have concluded benefit – but always after trying to assess the look on a neonate’s face. Judging pain in neonates may be difficult, but I think there is an inherent flaw in saying that a child smiled more after the sugar, so it must have hurt less.
Bottom line: If you think a child is in pain, please give them a pain medication, rather than the key ingredient of every placebo ever made.
Speaking of placebos, a needle may not be better than pills
Schwartz NA, Turturro MA, Istvan DJ, Larkin GL. Patients’ perceptions of route of nonsteroidal anti-inflammatory drug administration and its effect on analgesia. Acad Emerg Med. 2000;7:(8)857-61. PMID: 10958124
I love this study. For 64 patients presenting to the ED with an MSK injury, they gave everyone a juice drink that actually had 800mg of ibuprofen in it (unknown to the patients). They then randomized them to either get placebo pills that looked liked 800mg of ibuprofen or a placebo IM injection resembling 60mg of ketorolac. The patients and the nurses were all blinded. There were no differences in pain on a visual analog scale in the 2 hours that followed, contradicting prior research that indicated that needle based placebos are ‘stronger’ than pill based placebos.
Bottom line: Don’t give patients IM/IV medications just for the placebo affect. Oral NSAIDs are almost always appropriate.
An expensive placebo made popular by sports stars
Rowden A, Dominici P, D’Orazio J, et al. Double-blind, Randomized, Placebo-controlled Study Evaluating the Use of Platelet-rich Plasma Therapy (PRP) for Acute Ankle Sprains in the Emergency Department. J Emerg Med. 2015. PMID: 26048069
Less relevant to emergency medicine, but I have been asked about platelet rich plasma therapy by patients and friends. This is the (placebo?) therapy of sports stars such as Kobe Bryant, in which your own platelets plus some cytokines are injected back into you to treat tendonitis among other things. This was a double blind RCT comparing platelet rich plasma therapy to placebo for acute ankle sprain in the ED. There was no change in pain or function at day 0, 3, or 8.
Bottom line: Despite the huge amount of money being spent on this by rich athletes, it is unlikely to benefit your patients.
Placebos may not help, but medications can actually hurt you
Fralick M, Macdonald EM, Gomes T, et al. Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: population based study. BMJ. 2014;349:g6196. PMID: 25359996 (Free open access)
This is another great massive case control study from David Juurlink and his group looking at the Ontario drug benefit database. They identified all patients who died suddenly and were treated with either an ACEi or an ARB. Those patients who had been on antibiotics within the 7 days before their death were matched to controls who hadn’t received antibiotics. There were 1027 sudden deaths after antibiotics (out of 38879 total sudden deaths.) Using amoxicillin as the baseline, there was an increased risk of sudden death with co-trimoxazole (OR 1.38 95% CI 1.09-1.76) and ciprofloxacin (OR 1.29 95% CI 1.03-1.62). Risk was not increased with nitrofurantoin or norfloxacin. Of course, all standard problems with database observational studies apply.
Bottom line: A tiny absolute risk in the greater scheme of things, but you might want to consider if your UTI patients are on an ACEi or ARB and all else is equal.
Raising a skeptical eyebrow at the literature
White T, Mellick LB. Debunking medical myths: the eyebrow shaving myth. Emerg Med Open J. 2015; 1(2): 31-33. (Free open access)
I love medical myths, so although this myth has never affected my practice in the emergency department, I thought that I would include it. These authors did a systematic review of the literature to determine if shaving of the eyebrows causes problems with eyebrow regrowth. They did not find a single case report or study that would support this myth. There is one tiny study in which they shaved the eyebrows of volunteers and followed them for 6 months, and they all grew back fine.
Bottom line: I don’t know. If you want to shave some eyebrows, go for it.
Steroids for low back pain?
Balakrishnamoorthy R, Horgan I, Perez S, Steele MC, Keijzers GB. Does a single dose of intravenous dexamethasone reduce Symptoms in Emergency department patients with low Back pain and RAdiculopathy (SEBRA)? A double-blind randomised controlled trial. Emerg Med J. 2015;32:(7)525-30. PMID: 25122642
The idea of using corticosteroids for low back pain seems to pop up every once in a while. Although I have never seen it used, I understand there are a number of people who use this regularly. This was a double-blind RCT of 58 patients with acute low back pain in the ED comparing dexamethasome 8mg IV (1 dose) to placebo. At 24 hours, the dexamethasone group averaged 1.86/10 lower pain scores on a visual analogue scale. At 6 weeks pain scores and function were identical. (They report that the dexamethasone group had a lower ED length of stay, but the length of stay in the placebo group was almost 19 hours, which is incomprehensible to me.)
Bottom line: Like steroids for a lot of MSK conditions, there seems to be short term, but not long term improvement in pain.
We now know the evidence. How do you provoke change? Through shame
Yeh DD, Naraghi L, Larentzakis A, et al. Peer-to-peer physician feedback improves adherence to blood transfusion guidelines in the surgical intensive care unit. J Trauma Acute Care Surg. 2015;79:(1)65-70. PMID: 26091316
This trial attempted to address the slow uptake of evidence based guidelines surrounding more restrictive transfusion targets for post-op patients. It was a before and after study in a single tertiary surgical ICU. In the intervention period, if physicians ordered a transfusion in a stable patient that didn’t adhere to the guidelines, they received a follow-up email and education from a colleague. The rate of ‘inappropriate transfusions’ went from 25% to 2%. 30 day readmission rates and mortality were unchanged.
Bottom line: If you want physicians to change their behavior, you shouldn’t just teach them. You should provide peer to peer feedback, aka shame.
Cheesy Joke of the Month
Why was the Kleenex dancing?
Because it had a little boogie in it
FOAMed of the month
Why should we be giving fentanyl IN at triage? Check our this rant via the SGEM and Dr. Anthony Crocco:
A monthly collection of the most interesting emergency medical literature I have encountered
Myth: Wound eversion magically eliminates scarring
Kappel S, Kleinerman R, King TH, et al. Does wound eversion improve cosmetic outcome?: Results of a randomized, split-scar, comparative trial. J Am Acad Dermatol. 2015;72:(4)668-73. PMID: 25619206
This is a prospective, randomized trial of post-op skin surgery patients where they closed half of the wound using wound eversion and the other half using basic planar approximation. The patients and 2 assessors were blinded and there was no significant difference in appearance at 3 or 6 months. This is in clean surgical wounds, so external validity to the ED is questionable. However, the authors looked for science supporting the dogma of wound eversion, and not surprisingly: there is none.
Bottom line: This is enough for me to stop dogmatically teaching wound eversion – though with only one study, I am always ready to change my mind.
Mark DG, Vinson DR, Hung YY, et al. Lack of improved outcomes with increased use of targeted temperature management following out-of-hospital cardiac arrest: a multicenter retrospective cohort study. Resuscitation. 2014;85:(11)1549-56. PMID: 25180922
A retrospective, before and after study of 1119 patients in a system where therapeutic hypothermia for out of hospital cardiac arrest was implemented in 2009. Despite the fact that you would expect improved outcomes just because of improved medical care over the half decade the study ran, there was no difference in mortality or neurologic outcomes whether or not you were cooled.
Bottom line: Thanks to TTM, we already know that cooling is not necessary. We should remember that fever avoidance is currently only a theory without significant evidence basis.
Kids don’t like being cold either
Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children. N Engl J Med. 2015;372:(20)1898-1908. PMID: 25913022
You probably would have been fine applying the TTM data to children, as they are just little adults, but we now have some pediatric specific data. This is a multicentre RCT of pediatric (2 days to 18 years) out of hospital cardiac arrest, comparing 33.0 with 36.8 degree Celsius targets. As you might expect, there was no difference in survival or functional outcomes up to one year. However, the raw numbers were better in the hypothermic children, despite being non-statistically significant.
Bottom line: There is no reason to put kids on ice outside of the context of further clinical trials.
Rate control in atrial fibrillation cage match: the cardiology approach (beta blockers) versus the emergency medicine approach (calcium channel blockers)
Martindale JL, et al. β-Blockers versus calcium channel blockers for acute rate control of atrial fibrillation with rapid ventricular response: a systematic review. Eur J Emerg Med. 2015;22:(3)150-4. PMID: 25564459
This is a systematic review of calcium channel blocker versus beta blockers for acute rate control of atrial fibrillation. They could only find 2 quality studies, which were very small. In these studies, diltiazem was better than metoprolol (RR 1.8 95% CI 1.2-2.6) for rate control.
Bottom line: The very limited evidence seems to fit with clinical experience: calcium channels blockers are more likely to get patients controlled in the ED.
The toughest question in the resus room? Maybe if a.fib is the cause of or the result of hemodynamic instability
Scheuermeyer FX, Pourvali R, Rowe BH, et al. Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm. Ann Emerg Med. 2015;65:(5)511-522.e2. PMID: 25441768
This is a retrospective chart review (well done, but a chart review) of 416 patients with atrial fibrillation and an acute medical illness, out of British Columbia. They compared those patients who had their atrial fibrillation actively managed, versus those in whom the focus was only in treating the underlying condition. No one died in this study. Patients who had either rate or rhythm control had significantly increased rates of major adverse events, primarily increased requirement for pressors and increased intubations.
Bottom line: In sick medical patients who happen to have atrial fibrillation, focus on basic resuscitation over rate/rhythm control.
The new angioedema meds
Bas M et al. A randomized trial of icatibant in ACE-inhibitor-induced angioedema. New England Journal of Medicine. 2015;372(5):418-25. PMID: 25629740
This is one of a few new, very expensive treatments for hereditary angioedema. It is a selective bradykinin B2 receptor antagonist. This was a phase 2 RCT of 30 patients who either received Icatibant or standard therapy of steroids and anti-histamines for patients with ACE inhibitor induced angioedema. The icatibant group responded quicker (8 hours versus 27 hours) and had more complete resolution of their symptoms. The biggest concern with this study (aside from the tiny size and industry involvement) is that, although the standard therapy group probably represents usual care, ideal care might involve use of FFP instead.
Bottom line: In a very small study, icatibant seems to decrease angioedema a lot quicker than ‘usual care’.
Lots of Os up the nose
Frat JP, Thille AW, Mercat A, et al. High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure. N Engl J Med. 2015. PMID: 25981908
This is a multi-centre randomized, open label study of high flow, humidified nasal oxygen, versus standard oxygen face mask, versus non-invasive positive pressure ventilation in adult, hypoxic patients. (CHF and exacerbations of asthma or chronic respiratory failure was excluded, so in other words this is primarily pneumonia patients.) There was no difference in their primary outcome of need for intubation, although they powered the study to detect a 20% difference, which is probably larger than the clinically important difference. This biggest news is that 90 day mortality was decreased in the high flow oxygen group (12%, versus 23% with standard oxygen and 28% in NIPPV), but this is a secondary outcome so should be interpreted with caution.
Bottom line: High flow nasal oxygen seems to be at least as good as NIPPV or facemask oxygen (in this select group of patients). This is enough for me to try this with alert pneumonia patients who don’t obviously need intubation.
More evidence PPIs aren’t completely safe
Antoniou T et al. Proton pump inhibitors and the risk of acute kidney injury in older patients: a population-based cohort study. CMAJ Open 2015;3(2):E166-71. (Free full text here)
Using the Ontario Drug Benefit database, these authors compared the cohort of patients with newly prescribed PPIs with a propensity matched group as a control. They excluded anyone also prescribed known nephrotoxic drugs, or with basically any other renal risk factors. People on PPIs were more likely to develop acute kidney injury, with a hazard ratio of 2.52 (95% CI 2.27-2.79). Out of 290,000 patients studied, 1787 were admitted to hospital with AKI – about 8 more than controls for every 1000 patient years on PPIs.
Bottom line: No medication is without side effects, but we treat some like they are water. Early studies will always emphasize benefits and downplay harms.
You don’t need fancy lenses and mirrors to see the retina
Vrablik ME et al. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta-analysis. Ann Emerg Med 2015; 65(2):199-203. PMID: 24680547
This meta-analysis attempted to determine the accuracy of ultrasound for diagnosis of retinal detachment in the hands of emergency physicians. In population with a prevalence of detachment between 15% and 38%, they found a sensitivity of ultrasound of 97-100% and a specificity of 83-100%. Of course, these studies are often done with experienced ultrasonographers or after specific training.
Bottom line: I think this definitely has a place in the ED.
Bonus: This castlefest lecture is a great resource for ocular ultrasound, with free CME
A little more diagnostic technology: iPhone otoscopes
Richards JR, Gaylor KA, Pilgrim AJ. Comparison of traditional otoscope to iPhone otoscope in the pediatric ED. Am J Emerg Med. 2015. PMID: 25979304
These authors compared a traditional otoscope with a new one that attaches to your iphone and gives you a video display. There was reasonable agreement between the new one and the old one, although residents and attendings still disagreed about the findings a lot. They claim that the iPhone scope changed the final diagnosis a number of times, but without a clear gold standard I wouldn’t focus on that result.
Bottom line: I am not sure how important it is to treat anything they found here, which limits the value of the tool – but this could be a great way to teach students otoscopy.
Can the D-Dimer be improved? (Well, it can’t get any worse, can it?)
Jaconelli Y and Crane S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: Should we use an age adjusted D-dimer threshold in managing low risk patients with suspected pulmonary embolism? Emerg Med J 2015;32(4):335-7. PMID: 25804861
This is a systematic review (published before last month’s paper, and so not including it) that found 13 papers addressing the use of an age adjusted d-dimer (less than age x 10). Most of the studies were retrospective, so not of high quality. The authors conclusion is “In older patients suspected of having a PE, with a low pretest possibility, an age-adjusted D-dimer increases specificity with minimal change in the sensitivity, thereby increasing the number of patients who can be safely discharged without further investigations.”
Bottom line: It is looking like the age adjusted d-dimmer in low pre-test probability patients will result in a post-test probability below the test threshold, while increasing specificity.
Speaking of PE testing, the CTPA is not a perfect test
Miller WT, Marinari LA, Barbosa E, et al. Small Pulmonary Artery Defects Are Not Reliable Indicators of Pulmonary Embolism. Ann Am Thorac Soc. 2015. PMID: 25961445
In this study, they took all of the CT scans that were read as positive for PE in one radiology system, and had the scan review by 4 subspeciality thoracic radiologists. 15% of scans read as showing a subsegmental PE by community radiologists were thought to be false positives by the specialists. Another 27% were thought to be indeterminate. This only represents disagreement among radiologists and not the inherent false positives of the test itself.
Bottom line: A positive CT scan is not an objective finding. Before subjecting patients to lifelong anticoagulation, a second opinion on the read might be warranted.
PEs come from the legs – those IVC filters make sense, right?
Mismetti P, Laporte S, Pellerin O, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial. JAMA. 2015;313:(16)1627-35. PMID: 25919526
Prosecptive RCT with blinded outcome assessors, but unblinded patients and treating physicians, randomized 399 patients with PE plus a DVT plus a marker of severity to either anticoagulation alone or anticoagulation plus a retrievable IVC filter. Recurrent PE occurred in 3% of the filter group (all fatal) and 1.5% of the no filter group (2 of 3 fatal) for a non statistically significant relative risk of 2.0 (95% CI 0.51 – 7.89).
Bottom line: IVC filter don’t decrease the rate of PE in patients than can be anticoagulated.
Medications don’t cure kidney stones
Pickard R et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet. 2015. PMID: 25998582
Flomax was pushed for renal stones based on a number a small studies with horrible methods and a few meta-analyses of those horrible studies. There has already been one large RCT with excellent methods demonstrating that Flomax doesn’t work. This should be the nail in the coffin. This is a multicentre placebo controlled RCT of 1167 adult patients with CT confirmed renal stones. They were randomized to either tamsulosin 0.4mg, nifedipine 30mg, or placebo. There was no difference between any of the groups in the number of patients requiring urologic intervention. (About 80% of the patients passed spontaneously, and 20% required an intervention in all groups.)
Bottom line: There is no role for medical expulsive therapy in renal colic.
Antibiotics don’t work for diverticulitis? Is nothing sacred?
Shabanzadeh DM, Wille-Jørgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev. 2012;11:CD009092. PMID: 23152268
This is a Cochrane systematic review that was able to identify 3 RCTs looking at the use of antibiotics for uncomplicated diverticulitis. Only one compared antibiotics to no antibiotics, the other two compared different types and courses of antibiotics. There was no difference in any of the regimens. In other words, no antibiotics was the same as antibiotics.
Bottom line: Not enough to change my practice, but it is good to know that we have minimal footing to our current practice.
Antibiotics in appendicitis? The right side of the bowel is different from the left, right?
Varadhan KK, Humes DJ, Neal KR, Lobo DN. Antibiotic therapy versus appendectomy for acute appendicitis: a meta-analysis. World J Surg. 2010;34:(2)199-209. PMID: 20041249
This meta-analysis concludes surgery may have a lower risk of complications than antibiotics (RR 0.43 95% CI 0.16-1.18). A little more than 30% of patients treated with antibiotics will actually require surgery. The authors seem to think biases in current study favour the antibiotics group, so real outcomes might be worse.
Bottom line: We don’t really get to make this decision anyway, but surgery is probably still the gold standard.
One last one on antibiotics: If you are going to treat with oral (which you probably should in most cases) don’t give a dose IV in the department
Haran JP, Hayward G, Skinner S, et al. Factors influencing the development of antibiotic associated diarrhea in ED patients discharged home: risk of administering IV antibiotics. Am J Emerg Med. 2014;32:(10)1195-9. PMID: 25149599
This is a prospective cohort study of 247 patients, all of whom were being treated with outpatient oral antibiotics. They compared those who received an IV dose in the ED to those who did not. 25.7% of the IV group developed antibiotic associated diarrhea versus 12.3% in the no IV group (a number needed to harm of 7.5).
Bottom line: Unnecessary IV antibiotics harm our patients.
The best drugs are probably those they keep away from us
Calver L, Page CB, Downes MA, et al. The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2015. PMID: 25890395
This is a prospective observational study of 1009 patients in Australia, all of whom received 10mg of droperidol for sedation of acute behavioral disturbances, and second dose at 15 min as needed. Out of those 1009 patients, 13 developed a long QT, and 7 of those had other contributing causes such as methdone or amiodarone. There were no incidences of tosades de pointes.
Bottom line: The black box warning against droperidol is likely without scientific merit. I would use it if it were available to me. Given how useful this medication is, it might be worth fighting for.
Let’s do two on poo
Gerding DN, Meyer T, Lee C, et al. Administration of spores of nontoxigenic Clostridium difficile strain M3 for prevention of recurrent C. difficile infection: a randomized clinical trial. JAMA. 2015;313:(17)1719-27. PMID: 25942722
We are all colonized with C.diff., so we should be experts in getting rid of it. This is a new one to me. They took patients who completed their treatment for C.diff. and infected them C.diff. Only, this strain of C.diff does not form toxins. This reduced recurrence of clinical infection from 30% to 11%.
Bottom line: You can treat Clostridium difficile with Clostridium difficile. Maybe we should infect ourselves prophylactically?
Drekonja D, Reich J, Gezahegn S, et al. Fecal Microbiota Transplantation for Clostridium difficile Infection: A Systematic Review. Ann Intern Med. 2015;162:(9)630-8. PMID: 25938992
A systematic review, but there are only 2 RCTs to include. In one RCT, fecal trasplant led to 81% of patients having symptom resolution, versus only 31% in the vancomycin group. In another, they demonstrated no difference between NG and rectal routes for the transplant, with about 70% resolution of symptoms. (I’d choose the rectal route, thanks.)
Bottom line: Still really not enough science to warrant a bottom line, but if C.Diff is turning your life to sh*t, consider someone else’s sh*t: it might make you feel better.
Apparently science is useless for xanthrochromia.
Chu K, Hann A, Greenslade J, Williams J, Brown A. Spectrophotometry or visual inspection to most reliably detect xanthochromia in subarachnoid hemorrhage: systematic review. Ann Emerg Med. 2014;64:(3)256-264.e5. PMID: 24635988
This is a systematic review of 10 studies comparing visual inspection to spectrophotometry for detection of xanthrochromia. Visual inspection: sensitivity 83.3% and specificity 95.7%. Spectrophotometry: sensitivity 86.5% and 85.8%. (The gold standard varied from angiography to clinical follow-up.)
Bottom line: There is no clear difference between the two, but neither seem great. Isn’t there some way for the lab to test for the chemical that makes the fluid yellow?
1 + 1 + 1 = 3?
Angus DC, Barnato AE, Bell D, et al. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive Care Med. 2015. PMID: 25952825
Surprise. The meta analysis of three trials that said the same thing, says the same thing: EGDT is not superior to usual care in 2015. What is worth mentioning is that this is a very good meta-analysis because the investigators of all three trials went out of their way to ensure they were using the same definitions and outcomes before starting.
Bottom line: We can be very confident that we don’t need to be following the protocols of the original EGDT study.
Game changer (x2) for neonatal resuscitation?
Gruber E, Oberhammer R, Balkenhol K, et al. Basic life support trained nurses ventilate more efficiently with laryngeal mask supreme than with facemask or laryngeal tube suction-disposable–a prospective, randomized clinical trial. Resuscitation. 2014;85:(4)499-502. PMID: 24440666
A prospective, RCT comparing ventilation with facemask vs the LMA supreme (LMA-S) vs the laryngeal tube suction-disposable (LTS-D) device in neonatal resuscitation. A lot of the outcomes were of questionable relevance, but ventilation failed in 34% of patients with facemask, 22% with the LTS-D, and 2% with the LMA-S. Higher tidal volumes were delivered with both the LTS-D and the LMA-S than the facemask (470ml vs 240ml). All these resuscitations were run by nurses, so external validity may be questionable.
Trevisanuto et al. Supreme Laryngeal Mask Airway versus Face Mask during Neonatal Resuscitation: A Randomized Controlled Trial. The Journal of Pediatrics. 2015. PMID: 26003882
This is another prospective randomized trial (neither of these could be blinded) of LMA-S versus facemask in 142 neonatal resuscitations of infants greater than 34 weeks or 1500 grams. The LMA resulted in higher 5 minute APGAR scores, less intubations, and lower admissions to NICU.
Overall bottom line: These two prospective studies paint a picture of better ventilation as well as improved patient important outcomes, such as intubations and NICU admissions, when an LMA is used over standard facemask ventilation for neonatal resuscitation. This might cause some culture shock when we run upstairs, but I think this is worth instituting.
Another myth: The subglottic area is the narrowest area of the pediatric airway
Dalal PG, Murray D, Messner AH, Feng A, McAllister J, Molter D. Pediatric laryngeal dimensions: an age-based analysis. Anesth Analg. 2009;108:(5)1475-9. PMID: 19372324
These authors measured the cross sectional area of the airways of 153 children (6months to 13 years) using video bronchoscopy under general anesthesia, and they found that it is the glottis not the cricoid that is the narrowest portion of the airway.
Bottom line: Probably shouldn’t change your daily practice, still pick a tube small enough to pass the cords, but just remember that a lot of what we “know” and teach is wrong. Always keep an open mind in medicine.
Cheesy Joke of the Month
As the doctor completed an examination of the patient, he said, “I can’t find a cause for your complaint. Frankly, I think it’s due to drinking.”
“In that case,” said the patient, “I’ll come back when you’re sober”
FOAMed Resource of the Month
Its not actually up an running yet, but I am really excited about the idea, so its more something to keep an eye out for. If anyone has played around with Coursera or EdX, you know there is a lot of incredible high quality education available for free in just about any subject. These are called MOOCs (massive open online courses). Well, there will soon be an equivalent for emergency medicine education, created for ALiEM: http://www.aliem.com/sneak-peak-aliemu/