I took another month off, but the blog and accompanying podcast are back with what I think is an interesting collection of articles… Continue reading “Articles of the month (May 2017)”
The end of another month can only mean one thing: I have once again read too many articles, and I feel the need to share them all with you. I think there is an excellent spectrum of really interesting papers this month, and as always I discuss them at length with Casey Parker on the Broome Docs podcast. Continue reading “Articles of the month (October 2016)”
Welcome to another edition of the First1oEM articles of the month – a collection of my favorite reads from the emergency medicine literature.
Location, location, location
Drennan IR, Strum RP, Byers A et al. Out-of-hospital cardiac arrest in high-rise buildings: delays to patient care and effect on survival. Canadian Medical Association Journal. 2016. [article]
This was a retrospective study looking at a cardiac arrest registry. They decided to look at the floor that you lived on to see if it impacted your survival from cardiac arrest (with the primary analysis looking above or below the 3rd floor). They found that living on higher floors was associated with an increased likelihood of death. In the raw numbers, 4.2% of patients living below the 3rd floor survived, compared to only 2.6% of those living on or above the 3rd floor (p=0.002). Survival above floor 16 was only 0.9%, and no one living above the 25th floor survived. The theory is that higher floors mean longer delays to EMS arrival, and therefore the ever important chest compression and defibrillation.
Bottom line: Choose your home wisely
What’s the best antibiotic to bring on your trip to Las Vegas?
Geisler WM, Uniyal A, Lee JY. Azithromycin versus Doxycycline for Urogenital Chlamydia trachomatis Infection. The New England journal of medicine. 373(26):2512-21. 2015. PMID: 26699167
This is a randomized, controlled non-inferiority trial comparing azithromycin (1 gram PO once) to doxycycline (100mg PO BID for 7 days) in 587 adolescents with chlamydia infections. For the primary outcome of treatment failure at 28 days, there were no treatment failures in the doxycycline group as compared to 5 (3.2% 95%CI 0.4-7.4%) in the azithromycin group. Based on their assumptions, they could not establish the noninferiority of azithromycin in this group, although I imagine the result will vary greatly depending on local resistance patterns.
Bottom line: I will continue using doxycycline as my first line agent
The Quixotic quest for the chest pain decision rule
Greenslade JH, Parsonage W, Than M. A Clinical Decision Rule to Identify Emergency Department Patients at Low Risk for Acute Coronary Syndrome Who Do Not Need Objective Coronary Artery Disease Testing: The No Objective Testing Rule. Annals of emergency medicine. 2015. PMID: 26363570
We would all love a good rule to use to send chest pain patients home. This is a secondary analysis of 2 prior prospective ED trials including a total of 2396 chest pain patients. They derive 3 different rules that are supposed to tell you which patients don’t need further testing after biomarkers and ECGs. (Of course, if you have listened to me in the past, you will know that stress testing is not helpful in our low risk chest pain patients.) I am not going to go into the rules themselves, because I think the study is too flawed to be helpful. Incorporation bias is the major downfall of this study. Classic cardiac risk factors are a large component of these rules, but previous research has consistently shown that having classic cardiac risk factors does not help predict whether a patient’s chest pain is ACS in the emergency department. So how could those risk factors possibly help in a decision rule? It’s because the definition of ACS included unstable angina and revascularization, both of which are subjective outcomes determined by the cardiologist, and the cardiologists had access to the risk factor information. A patient with 5 risk factors is more likely to be cathed, but that doesn’t mean the cath was necessary. Similarly, a patient with more risk factors is more likely to be given the diagnosis of unstable angina. The risk factors didn’t predict the diagnosis of ACS, they were the cause of it.
Bottom line: It is unlikely that we will find easy decision tools for chest pain patients, but for the time being we should be happy that most patients are so low risk that they should be sent home without stress testing.
How prepared are you to run a neonatal resuscitation?
Yamada NK, Yaeger KA, Halamek LP. Analysis and classification of errors made by teams during neonatal resuscitation. Resuscitation. 96:109-13. 2015. [pubmed]
I like the idea here: these authors videotaped a total of 250 real neonatal resuscitations and reviewed the tape to determine how well the neonatal resuscitation algorithm was followed. Continuous quality improvement in our most stressful resuscitations makes sense. These authors report that 23% of the actions observed were errors as compared to the published algorithm. However, I don’t think the errors were truly important errors. The most common error was failure to have a cap to place on the child’s head – is that really essential in the first minutes of resuscitation of an apneic neonate? There were some important errors reported, though, with half of the 12 intubation attempts lasting longer than 30 seconds. Although I don’t think this study really demonstrates it, neonatal resuscitations are stressful and rapid paced, making errors probable. Mental practice and simulation are great tools to help prevent these errors, in my very biased opinion.
Bottom line: Quality improvement in your most stressful resuscitations is a good idea.
Best treatment for pediatric gastro? Prevention
Soares-Weiser K, Maclehose H, Bergman H. Vaccines for preventing rotavirus diarrhoea: vaccines in use. The Cochrane database of systematic reviews. 11:CD008521. 2012. PMID: 23152260
This is a Cochrane systematic review of two different vaccines (monovalent versus pentavalent) for rotavirus. They identified 29 RCTs covering 101,671 infants for the monovalent vaccine and 12 RCTs covering 84,592 infants for the pentavalent vaccine. Unfortunately, most studies use the relatively non-sensical “rotavirus specific diarrhea” as an endpoint, but it definitely seems to be decreased (RR 0.33 95% CI 0.21-0.50 for the monovalent). All cause diarrhea was also decreased in the trials that looked at it, with an NNT of about 40 for any diarrhea and 100 to prevent a hospitalization. There was no change in mortality. They did not document an increase in adverse reactions, but efficacy studies often under report harms.
Bottom line: The rotavirus vaccine prevents serious diarrhea – maybe that’s an easier sell than the measles?
Overtreatment and anticoagulation for atrial fibrillation
Hsu JC, Chan PS, Tang F, Maddox TM, Marcus GM. Oral Anticoagulant Prescription in Patients With Atrial Fibrillation and a Low Risk of Thromboembolism: Insights From the NCDR PINNACLE Registry. JAMA internal medicine. 175(6):1062-5. 2015. PMID: 25867280
With the rise of the new, expensive anticoagulants, we are beginning to see a push to get these agents started for atrial fibrillation patients in the emergency department, ignoring the tiny daily risk of stroke and the importance for long term monitoring that we cannot provide. This is a registry based study. Out of a total of about 360,000 atrial fibrillation patients in the study, 11,000 had a score of 0 on two major stroke scales. However, 25% of this extremely low risk population was on blood thinner contrary to current guidelines.
Bottom line: We over treat patients. For everything. Remember that studies are generally the best possible scenario for medications, and that results in the real world will be worse as we expand treatment to patients who would not have been included in the studies. (If you want to watch this happen in real time, just watch interventional treatment for stroke over the next few years.)
This is a basic review of the Zika virus that is currently causing a significant pandemic through Central and South America, and has potentially been linked to a significant number of birth defects (microcephaly) in Brazil. Zika is another mosquito borne virus without a specific treatment (like Dengue or Chikungunya). The symptoms are described as a milder version of Dengue fever, with fever, myalgias, eye pain, and maculopapular rash. Treatment is supportive.
Bottom line: Another emerging illness to be aware of in the returned traveller.
Can you really multitask?
Skaugset LM, Farrell S, Carney M. Can You Multitask? Evidence and Limitations of Task Switching and Multitasking in Emergency Medicine. Annals of emergency medicine. 2015. PMID: 26585046
Emergency physicians are masters of multitasking – or so we think. This review explains that most of what we think of as multitasking is really rapidly switching between tasks, and even if you are good at it, this task switching slows you down and results in error. Unfortunately, the solution promoted in most other fields – limiting interruptions – just isn’t feasible in emergency medicine. Some suggestions this review makes to help: prioritize tasks according to acuity, recognize when interruptions can be delayed or redirected, practice skills so they become automatic (and don’t add to cognitive load), and use mental frameworks or external brains to limit cognitive work. Of course, optimizing your departmental workflow to limit interruptions, especially at critical times, is also important.
Bottom line: There is no such thing as multitasking, just rapid task-switching.
Should we add TXA to the water supply?
Fox H, Hunter F. BET 1: Intravenous tranexamic acid in the treatment of acute epistaxis. Emergency medicine journal : EMJ. 32(12):969-70. 2015. PMID: 26598634
This is another one of those situations that we have to make decisions in the absence of any real evidence. The authors of this review were unable to find any studies to answer their specific question about the use of IV TXA in acute epistaxis. However, they do note that there are a few studies that show benefit of oral TXA in epistaxis as well as the study of topical TXA that I have previously discussed in this newsletter. Furthermore, the use of intravenous TXA in elective sinus surgery seems to limit blood loss, and we all know about the evidence for IV TXA in trauma. So there is no direct evidence, but plenty of reasons we might guess it could help.
Bottom line: I have never used IV TXA for epistaxis, but use it topically all the time. You can bet if I have a patient with severe epistaxis, I will give it a shot.
Much like TXA, I love skin glue
Bugden S, Shean K, Scott M. Skin Glue Reduces the Failure Rate of Emergency Department-Inserted Peripheral Intravenous Catheters: A Randomized Controlled Trial. Annals of emergency medicine. 2015. PMID: 26747220
Tape and tegaderm has always seemed like a rather ineloquent method of securing IVs to me. In this non-blinded RCT of 380 peripheral IVs, they compared standard tegaderm and tape to skin glue (1 drop at the skin insertion site and one under the hub – this can be seen in this video.) For the primary outcome of IV failure (infection, phlebitis, occlusion, or dislodgement) at 48 hours, the skin glue was better (17% failure vs 27%, absolute difference 10% 95%CI 2-18%). The study was underpowered to assess the components of the composite outcome, but most of the failures were dislodgement. I don’t follow people for 48 hours – but a 27% failure rate with usual care seems high to me. Also, skin glue is likely more expensive. However, an NNT of 10 to avoid another IV stick would probably be attractive to many patients.
Bottom line: Skin glue is an option for securing PIVs – maybe difficult ones you really care about?
I love ultrasound for looking at things, but for breaking up clots?
Piazza G, Hohlfelder B, Jaff MR. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study. JACC. Cardiovascular interventions. 8(10):1382-92. 2015. PMID: 26315743
This is a large prospective study, but I won’t get too much into the details because their primary outcomes were a bunch of surrogate markers rather than patient important outcomes. Why included it then? They used a novel device that uses ultrasound to try to break up the PE, and then gave tPA at the very slow rate of 1mg/hr. So far the lytics for submassive PE trials have shown some promise, but aren’t convincing. Alternate methods (non-bolus) of giving the medication might be the thing that tip the balance in favour of lytics. But mostly I wanted to include this article to bring up two excellent blog posts written by Josh Farkas about ultrasound guided thrombolysis and controlled thrombolysis of submassive PE.
Bottom line: My guess is that we will find that lytics are beneficial in submassive PE over the coming years, once we find the correct subset of patients and the best dose. (This is a big departure for me, because I am much more used to saying that things won’t work. That is almost always the safer bet.)
Ondansetron and the dreaded QT
Moffett PM, Cartwright L, Grossart EA, O’Keefe D, Kang CS. Intravenous Ondansetron and the QT Interval in Adult Emergency Department Patients: An Observational Study. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 23(1):102-5. 2016. [pubmed]
Droperidol, possibly the most useful medication I have never had the opportunity to use, was taken away because of what it could do to the QT interval, right around the time when ondansetron was coming to market. Then, as ondansetron was coming off patent, we found out that it prolonged the QT just like droperidol did. OK, I will take off my tin foil hat to write the rest of this. This is a prospective observational trial of 22 adult patients receiving ondansetron at a single hospital. They did ECGs at baseline and every 2 minutes for 20 minutes. The QT did lengthen by 20 msec (95% CI 12-26 msec), but this is almost certainly clinically insignificant. There were no adverse events.
Bottom line: Yes, ondansetron will prolong the QT. No, it won’t be a problem. (Maybe avoid it if the patient overdosed on methadone, lithium, and haldol and tells you he has a family history of congenital long QT syndrome.)
But little Johnny just aint right
Nishijima DK, Holmes JF, Dayan PS, Kuppermann N. Association of a Guardian’s Report of a Child Acting Abnormally With Traumatic Brain Injury After Minor Blunt Head Trauma. JAMA pediatrics. 169(12):1141-7. 2015. PMID: 26502172
I’ve included papers on the low risk of significant head injuries in children with isolated vomiting and isolated loss of consciousness before. This time we will look at whether parental concern that their child is acting abnormally, in isolation, is indicative of blood in the brain. This is another secondary analysis of the PECARN database. Out of 43,399 children in the original study, only 1297 were reported as acting abnormally. Of those, 411 (32%) had abnormal behaviour as their only finding. Only 1 child of these 411 had a clinically significant injury (0.2% 95% CI 0-1.3%). Of the smaller subset who had CTs performed, 4 out of 185 (2.2%) had any sign of traumatic brain injury. So injuries were rare, even when the parents report the child is not behaving normally.
Bottom line: Once again, you have to evaluate the entire patient, not just single variables. Observation is probably a better test than CT.
How good is the ECG for hyperkalemia?
Montague BT, Ouellette JR, Buller GK. Retrospective review of the frequency of ECG changes in hyperkalemia. Clinical journal of the American Society of Nephrology : CJASN. 3(2):324-30. 2008. PMID: 18235147 [free full text]
Remember memorizing the classic progression of ECG changes in hyperkalemia: peaked Ts, prolonged PR, flatted Ps, wide QRS, then the deadly sine wave? Well, forget it. This is a chart review that looks at the ECGs of 90 hyperkalemic patients. (This is actually a reasonable topic for chart review, given that both the potassium level and the ECG are likely to be objective and easily identified on the chart.) Only half of the patients had any ECG signs of hyperkalemia, and only 18% met their strict criteria (which meant peaked Ts that were documented to resolve as the potassium decreased.) Although the ECG was insensitive for hyperkalemia, that might not be the important question. I don’t care as much about the number of the potassium, but whether it is affecting the heart – and the ECG might be a better marker of cardiac outcomes, but we don’t know from this study.
Bottom line: The ECG is not sensitive for hyperkalemia.
A guideline that say something sensical? I must be dreaming
Kearon C, Akl EA, Ornelas J et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline. Chest. 2016. [free full text]
This is a new guideline from the American College of Chest Physicians covering antithrombotic therapy for VTE. The recommendation to know about: “For subsegmental PE and no proximal DVT, we suggest clinical surveillance over anticoagulation with a low risk of recurrent VTE (Grade 2C).” That’s right – they are suggesting NOT treating certain PEs! They also recognize the high false positive rate of CTPA, which I have discussed here before. When is a subsegmental PE likely to be a true positive? “We suggest that a diagnosis of subsegmental PE is more likely to be correct (i.e. a true-positive) if: (1) the CT pulmonary angiogram (CTPA) is of high quality with good opacification of the distal pulmonary arteries; (2) there are multiple intraluminal defects; (3) defects involve more proximal sub-segmental arteries (i.e. are larger); (4) defects are seen on more than one image; (5) defects are surrounded by contrast rather than appearing to be adherent to the pulmonary artery; (6) defects are seen on more than one projection; (7) patients are symptomatic, as opposed to PE being an incidental finding; (8) there is a high clinical pre-test probability for PE; and D-Dimer level is elevated, particularly if the increase is marked and otherwise unexplained.” The best way to avoid this dilemma all together is still to avoid ordering CTs in low risk patients.
Bottom line: Not all PEs are really PEs. Not all PEs require treatment.
Speaking of which
Nielsen HK, Husted SE, Krusell LR. Anticoagulant therapy in deep venous thrombosis. A randomized controlled study. Thrombosis research. 73(3-4):215-26. 1994. PMID: pubmed
I may have included this one before. Its really the only RCT of anticoagulation for VTE that exists as far as I know. This is a prospective, randomized trial of 90 patients with proven, symptomatic DVTs comparing anticoagulation (heparin followed by warfarin) with an NSAID (phenylbutazone). All the patients had VQ studies performed, both initially and for follow up. About half of the patients had PEs (asymptomatically). There was no difference between the groups with regards to regression of DVT, recurrent DVT, or PE up to 60 days. In terms of mortality, there was one death in the anticoagulation group and none in the NSAID group. The only difference was that the anticoagulation group had an 8% rate of bleeding complications while they report no adverse events from the NSAID. Now this is a small and imperfect study – but quite amazingly, it’s the only real study of anticoagulation for VTE, and it’s negative!
Bottom line: In the only RCT of anticoagulation in DVTs (half of whom had PEs), there was no difference between using an anticoagulant or an NSAID. I know which I would prefer.
You thought diagnostics was difficult? How about pain caused by analgesics?
Tabner A, Johnson G. Codeine: An Under-Recognized and Easily Treated Cause of Acute Abdominal Pain. The American journal of emergency medicine. 33(12):1847.e1-2. 2015. PMID: 25983269
I have no idea what to do with this one. They present 2 case reports of patients with abdominal pain in whom the ultimate diagnosis was sphincter of Oddi spasm secondary to codeine use. Both patients’ pain resolved rapidly with naloxone (400mcg), which is not one of my usual analgesics. But how should we use this information? I imagine that you could do a lot of harm trying to treat abdominal pain with naloxone. This is definitely an interesting diagnosis – and one that I have never seen, or at least recognized.
Bottom line: Maybe one more reason that codeine should not be used
Back pain? Do we really have to talk about back pain? Ugh
Friedman BW, Dym AA, Davitt M. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA. 314(15):1572-80. 2015. PMID: 26501533
It’s sort of frustrating that trial after trial comes out telling us nothing really works for low back pain. Obviously we need to do something for our patients. This is a randomized, double-blind, placebo controlled trial comparing naproxen plus placebo to naproxen plus cyclobenzaprine and to naproxen plus oxycodone and acetaminophen in adults with acute non-traumatic lumbar back pain. For the primary outcome of a scale measuring pain and function, there was no difference between the groups. There were more adverse effects in the cyclobenzaprine and oxydodone/acetaminophen groups. The biggest weakness of this study was that there was relatively poor compliance with all treatment regimens, but that makes it more like real life.
Bottom line: Naproxen monotherapy is probably better. Adding cyclobenzaprine or oxycodone/acetaminophen just increases adverse effects.
Sir, you have a severe antibiotipenia – we need to start an infusion, STAT
The BLISS trial: Abdul-Aziz MH, Sulaiman H, Mat-Nor MB. Beta-Lactam Infusion in Severe Sepsis (BLISS): a prospective, two-centre, open-labelled randomised controlled trial of continuous versus intermittent beta-lactam infusion in critically ill patients with severe sepsis. Intensive care medicine. 2016. PMID: 26754759
This wasn’t even on my radar: should we be giving antibiotics (specifically beta-lactams) as a continuous infusion? I know, we all heard about time dependent versus dose dependent antibiotics in medical school, but I honestly thought that was useless pharmacological drivel, because the studies I have seen so far have indicated that dosing regimen doesn’t matter much when we are giving antibiotics. (Maybe because we are giving so many antibiotics to people who really don’t need them?) Anyhow, on to the study: this was a prospective, randomized, open-label study of 140 adult ICU patients with severe sepsis being treated with cefepime, meropenem, or piperacillin/tazobactam. They were randomized to either receive their antibiotics as a continuous infusion, or by the usual intermittent dosing. The primary outcome was clinical cure, and was lower in the continuous group (56% vs 34%; absolute difference 22% 95%CI 10-40%, p=0.011). Unfortunately, I’m not sure that is the most important outcome, and the study wasn’t powered for mortality, so there was no significant mortality difference despite the numbers being better in the continuous group.
Bottom line: Continuous administration of beta-lactam antibiotics is interesting, and definitely warrants further study focusing on mortality differences
Want to see how quickly I can contradict myself?
Dulhunty JM, Roberts JA, Davis JS. A Multicenter Randomized Trial of Continuous versus Intermittent β-Lactam Infusion in Severe Sepsis. American journal of respiratory and critical care medicine. 192(11):1298-305. 2015. PMID: 26200166
Hold your horses. The previous study was open-label, but there is another, larger study that was double-blinded. This is a double-blind, double-dummy multi-center randomized controlled trial of 432 ICU patients with severe sepsis being treated with meropenem, ticarcillin-clavulanate, or piperacillin-tazobactam, again comparing continuous versus intermittent dosing. For the primary outcome, ICU free days alive at day 28, there was no significant difference between the groups (18 vs 20 day, p=0.38). 90 day mortality was also the same, 26% in the continuous group vs 28% with intermittent antibiotics (p=0.67). So was the previous study just an example of the bias that can occur with open-label studies, or might there be a small but real difference that these studies were just under-powered to detect?
Bottom line: This will require a massive trial to answer definitively. For now, intermittent dosing is just so much easier that it should probably remain the preferred method of antibiotic administration.
Cheesy Joke of the Month
Why did the scarecrow get an an award?
He was outstanding in his field
#FOAMed of the month
We vastly overestimate the benefits of many of the medications that we tell our patients are essential. As a result, you can hear many of the elderly coming well before you see them from the rattle of all the pills. A large percentage of emergency department visits are from medication side-effects, but most of these are misdiagnosed. So although this tool was designed more for family physicians, I think it probably has a role in emergency medicine as well
This is a tool developed by some very intelligent Canadian doctors (including the team behind another amazing FOAMed resource: The Best Science Medicine podcast) to help clinicians and patients make decisions about reducing or stopping medications. The thing I miss most about family medicine was the ‘drugectomy’: it was astounding how many patients would feel so much better just because we stopped a few of their less necessary or unnecessary medications.
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
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
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)?
“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:
Crack the chest. Get crucified. (John Hinds) – I know I have recommended this one before, but it is worth more than one watch.
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: https://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
Magnesium the wonder drug, now for migraines
Shahrami A et al. Comparison of therapeutic effects of magnesium sulfate vs. dexamethasone/metoclopramide on alleviating acute migraine headache. J Emerg Med 2015; 48(1): 69-76. PMID 25278139
In this RCT, they compared IV magnesium (1 gram) to the combination of metoclopramide 10mg IV and dexamethasome 8mg IV. Magnesium was more effective at 20min, 1 and 2 hours. I would note, that although metoclopramide is what we generally have to use now because of drug shortages or silly rules, prochlorperazine (Stemetil) and droperidol are both better for migraine. Also, previous studies of metoclopramide in migraine have used a 20mg dose, although 10mg is what tends to be ordered.
Bottom line: Intravenous magnesium might be a useful tool in the treatment of migraines
This PROMISEs to be the biggest paper of the month
The ProMISe trial. Mouncey et al. Trial of Early, Goal-Directed Resuscitation for Septic Shock. NEJM. 2015 (Ahead of print). PMID: 25776532
This is the third and final large trial of early goal directed therapy for septic shock, and shockingly it tells us pretty much the same thing the first two did: EGDT adds nothing to usual care. This is an open label, multi-center RCT from the UK with a total of 1260 patients. Patients were randomized to receive the classic EGDT protocol or ‘usual care’. There was no difference in mortality, (29% at 90 days). Of course, ‘usual care’ may look a lot more like EGDT than it used to.
Bottom line: Septic patients need antibiotics, fluids, and most importantly someone to care about them. Ditch the high tech stuff.
Emergency doctors are ECG experts, we don’t need a second opinion next week
Proano L et al. Cardiology electrocardiogram overreads rarely influence patient care outcome. Am Jour Emerg Med 2014;32(11):1311-14. PMID: 25200503
This is a retrospective review at a single teaching hospital over 21 months, with 38,490 ECGs reviewed. Of the 16,011 patients that were discharged, 22 patients required follow up for discordant readings (0.1%). Of those 22, after review only 2 were determined to require a change in management. The remainder were considered ‘non specific’ or the ED doc turned out to be right. Of the 2 with changed management, one was for ‘possible ACS’ who ultimately had a completely negative workup. The other was a missed atrial flutter, but nothing changed about their management except also getting a negative workup.
Bottom line: Having cardiology over read ED ECGs results in a change of management in somewhere between 0 and 0.01% of patients (and adds a bunch of false positives).
We don’t listen to our own literature (ACLS still doesn’t work)
Sanghavi BS et al. Outcomes After Out-of-Hospital Cardiac Arrest Treated by Basic vs Advanced Life Support. JAMA Intern Med. 2015;175(2):196-204. PMID: 25419698
We already know this, because it has been over a decade since OPALS (in Ontario) proved that ACLS doesn’t work. This is an observational cohort study of American medicare patients with out of hospital cardiac arrest, based on whether they were treated by an ACLS or BLS crew. Survival to hospital discharge was better with BLS (13.1% vs 9.2%). Survival at 90 days was better with BLS (8.0% vs 5.4%).
Bottom line: ACLS doesn’t work. Stop wasting time with IVs and drugs. And most importantly, can we please remove any kind of ACLS training from my hospital credentialing requirements?
Related: Less is also more for airway management in cardiac arrest
McMullan J et al. Airway management and out-of-hospital cardiac arrest outcome in the CARES registry. Resuscitation 2014, 85(5):617-622. PMID: 24561079
This is a retrospective registry review of 10,691 out of hospital cardiac arrests that demonstrated that patients that did not have advanced airways placed during the initial resuscitation were more likely to survive to hospital discharge with good neurological outcomes (OR 4.24 95% CI 3.26-5.20). The use of supraglottic airways was associated with worse outcomes than endotracheal intubation. Of course, these are just associations in a very complex scenario with multiple confounders.
Bottom line: Use good technique and provide slow ventilations with a bag valve mask, unless you believe there is a good reason to do something more advanced.
Patients don’t understand us
Shif Y et al. What CPR means to surrogate decision makers of ICU patients. Resuscitation 2015 (In print). PMID: 25711518
This is qualitative research on communication and understanding of CPR by surrogate decision makers in the ICU. (I love this stuff, but probably mostly because my master’s was based in qualitative research and communication. Realistically, this study probably just states the obvious.) Less than half of surrogate decision makers identified cardiac arrest as the indication for CPR. Only 8% could identify the major components of CPR (although the technical details probably don’t matter that much.) Mostly importantly, 72% thought that the survival rate post CPR is greater than 75%.
Bottom line: It takes a lot of time, but we really do need to teach our patients about medicine.
Ketamine will not make your head explode (although, if my head did explode, I would probably be grateful to be in the K-hole)
Cohen L et al. The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review. Annals of Emergency Medicine 2015; 65(1):45-51. PMID: 25064742
This systematic review found a total of 10 studies, all in the ICU or OR as they were actually measuring ICPs. Mostly ketamine didn’t change ICP or CPP. In two studies, ICP actually decreased with ketamine. In two studies it did go up, but by 2-4 mmHg, so clinically meaningless. There were no changes in neurological outcomes, ICU length of stay, or mortality.
Bottom line: Ketamine is a wonder drug that can do anything, possibly even solve our boarding crisis, so go ahead and use it whenever you want.
Also, tetracaine is not going to melt your eyeballs
Waldman N et al. Topical tetracaine used for 24 h is safe and rated highly effective by patients for the treatment of pain caused by corneal abrasions: a double-blind, randomized clinical trial. Acad Emerg Med 2014; 21:374-382. PMID: 24730399
This is a prospective double blind RCT in which patients with corneal abrasions were allowed to use tetracaine 1% q30min PRN for pain after simple corneal abrasions (versus saline placebo). This is not the first study to look at this, and the dogma is based on a handful of ridiculous case reports. There were no complications (to be fair 116 patient trial is not big enough to be sure it is safe.) It is a weird trial, because pain scores didn’t go down, but patients were more satisfied with their care if they were given tetracaine.
Bottom line: Patients with painful conditions deserve good pain control. If I had a corneal abrasion, you can be sure I would be using a topical anesthetic.
One day we may not radiate our patients at all – apparently you can use ultrasound to look for bowel obstruction?
Jang TB etl al. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J. 2011;28(8):676-8. PMID: 20732861
A prospective study of 76 patients with suspected SBO, all of who had a CT scan done. Residents were given a 10 training session on using bedside ultrasound to assess for bowel obstruction. The bedside ultrasound had a sensitivity of 91% and a specificity of 84% compared to the CT gold standard. Compare that to abdominal plain films, which had a sensitivity of 46% and a specificity of 67%.
Bottom line: Ultrasound is much better than plain films for the assessment of SBO.
Yet another reason not to order urine tox screens
Felton at al. 13-Year-Old Girl With Recurrent, Episodic, Persistent Vomiting: Out of the Pot and Into the Fire. Pediatrics 2015 (Ahead of print). PMID: 25733759
OK, this is only a case report and only gets in because I have an axe to grind. I hate urine toxicology screens and believe they should never be ordered in the ED. But it does raise an interesting tidbit to keep in mind: apparently pantoprozole can cause a false positive urine tox screen for marijuana.
Bottom line: Never rely on a urine tox screen.
NPO time irrelevant for procedural sedation
Godwin SA et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014;63(2):247-58. PMID: 24438649
As part of the ACEP clinical policy process, they did a systematic review. They found 5 studies that cover thousands of patients, and found no evidence that fasting decreased aspiration or other adverse events. The official policy is “Level B: Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.”
Bottom line: Just make sure they actually take the Doritos out of their mouth before starting.
GCS 8, just wait
Duncan R and Thakore S. Decreased Glasgow Coma Scale does not mandate endotracheal intubation in the emergency department. J Emerg Med 2009;37(4):451-5. PMID: 19272743
An older paper that came across my desk that I think is worth including because I know practice varies wildly in this regard, and I have debated this point with multiple folks. This is a prospective study of 73 overdose patients with decreased LOC who were watched, not intubated (GCS ranged from 3 to 14). No patient with a GCS under 8 worsened, required intubation, or aspirated.
Bottom line: GCS under 8 shouldn’t be an automatic intubation in tox patients
Best way to avoid the pain of an ABG – don’t do one. Second best way: use an insulin needle?
Ibrahim I et al. Arterial Puncture Using Insulin Needle Is Less Painful Than With Standard Needle: A Randomized Crossover Study. Acad Emerg Med 2015 (Ahead of print). PMID: 25731215
Although I don’t think ABGs are very helpful most of the time, you might want to calculate an A-a gradient or something some day. This was a randomized study of healthy volunteers comparing a standard 23 gauge to an insulin needle for arterial stabs. Not surprisingly, both pain and complications were lower with the smaller needle. However, hemolysis went up, so not great if you really want a K – but why do you want to know the arterial K?
Bottom line: If you really feel like doing an ABG, use a smaller needle.
Infomercials in the Lancet?
Goldstein JN et al. Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial. Lancet 2015 (ahead of print). PMID: 25728933
This is an open label RCT of 181 patients comparing PCC (Beriplex) to FFP before an ‘urgent surgery or procedure’. Based on rated ‘effective hemostasis’ being achieved in 90% of the PCC group and 75% of the FFP group, the authors conclude that PCC is superior to FFP. Sadly, this article appears to have been written directly by the drug company (if you read the funding statement), had protocol changes as it went, and relies on reporting of a surrogate end point. Despite all that, the treatments were actually identical. Difference in surgical blood loss between the two groups: 12 ml. Total number of units of blood transfused – identical in both groups.
Bottom line: This trial will be used to push an expensive medication, but it should be interpreted as the opposite: never use PCC just to get someone to surgery.
Hepatic encephalopathy is treated with diarrhea (lactulose is not special)
Rahimi RS et al. Lactulose vs polyethylene glycol 3350-electrolyte solution for treatment of overt hepatic encephalopathy: the HELP randomized clinical trial. JAMA Intern Med 2014; 174(11):1727-1733. PMID: 25243839
This is a small RCT comparing PEG 3350 to lactulose for patients with hepatic encephalopathy. PEG 3350 resulted in more rapid resolution of symptoms than lactulose.
Bottom line: PEG 3350 might be better, but certainly isn’t worse than lactulose for the treatment of hepatic encephalpathy.
Your kid is allergy prone? Feed him peanuts
Du Toit et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. NEJM 2015; 372:802-813. PMID: 25705822
This is the RCT to show anyone who ever tells you that there some are things we just can’t study. They took 640 children at risk of developing peanut allergy because they already had an egg allergy or severe eczema and randomized them to either eat or not a peanut based snack. The results are relatively astounding. If you didn’t have a positive skin test at the beginning of the study, being exposed to peanuts decreased your chance of developing a peanut allergy by 12% (NNT = 8). If you had a positive skin test at the outset, being exposed to peanut protein decreased your allergy rate by 25% (NNT =4)!
Bottom line: More of a general interest than emergency medicine specific paper. This is strong support for the cleanliness hypothesis of increasing allergies – if you want to avoid allergy, increase antigen exposure in kids.
Cheesy Joke of the Month
I went to a zoo recently, and the only animal there was a dog…
It was a shitzu
A simplified approach to the initial assessment and management of emergency department patients in PEA
A 60 year old woman is brought into your resus room VSA with CPR in progress. The paramedics tell you that she had a witnessed arrest and bystander CPR was performed for 4 minutes before they arrived on scene. They found her in PEA, took over CPR, started an IV, and rapidly transported as they were only 5 minutes out…