Articles of the Month (January 2018)

A monthly compilation of critical appraisals of the emergency medicine literature.

Welcome to another addition of the Articles of the Month. And yes, I know this is no longer a monthly publication, but it is always published in A month and you get what you pay for. The podcast version can be found over on Broome Docs. Enjoy. Continue reading “Articles of the Month (January 2018)”

Articles of the Month (August 2016)

The best emergency medicine articles that I came across in August 2016

Welcome to another edition of my favorite emergency medicine articles of the month. Once again, there will be an accompanying podcast with the talented and insightful Dr. Casey Parker on the BroomeDocs website where we briefly discuss these articles. Continue reading “Articles of the Month (August 2016)”

Articles of the month (July 2016)

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

Articles of the month (May 2016)

My monthly summary of the best reads from the emergency medicine literature

Welcome to the May 2016 edition of my favourite reads from the medical literature. This will probably be the last post on First10EM for a little while, as I plan to take a summer vacation as well as a prolonged Ireland stay for SMACC.

Gastro game changer

Freedman SB, Willan AR, Boutis K, Schuh S. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. JAMA. 315(18):1966-74. 2016. PMID: 27131100

Kids just want to drink juice, but I’ve been told that if I let kids with gastro drink juice they will die (or something like that). This is a randomized, controlled non-inferiority trial out of the Hospital for Sick Children that compared an electrolyte solution to a combination of half strength apple juice in the ED and the child’s preferred fluid (juice or milk) at home. 647 children aged 6 to 60 months with acute (less than 96 hours) diarrhea or vomiting with mild dehydration were included. For the primary outcome, which unfortunately was a composite of a number of things including IV use, hospitalization, health care contact, and prolonged symptoms, the juice group had a ‘treatment failure’ rate of 16.7% as compared to 25.0% with the electrolyte solution (difference 8.3%; 97.5% CI 2% – infinity). Converting from a non-inferiority analysis to a superiority analysis resulted in a p value of 0.006. In other words, the juice group was statistically better than the electrolyte group. The biggest caveat is that these kids were not sick, so the results could be different in kids with even moderate dehydration.

Bottom line: I am no longer forcing kids to drink something they hate. Whatever their preferred liquid is, it will keep them hydrated.

This is another paper that will be featured on EMCases Journal Jam. If you have questions you want the author to answer, let me know.


I’m not so ENCHANTED

Anderson CS, Robinson T, Lindley RI. Low-Dose versus Standard-Dose Intravenous Alteplase in Acute Ischemic Stroke. The New England journal of medicine. 2016. PMID: 27161018 [free full text]

I am honestly surprised that I managed to read an entire article that started with the statement: “Thrombolytic therapy with intravenous alteplase (recombinant tissue-type plasminogen activator) at a dose of 0.9 mg per kilogram of body weight is an effective treatment for acute ischemic stroke, despite increasing the risk of intracerebral hemorrhage.” (This is a good reminder that when reading articles, it is often best to just skip the introduction. This section is just a non-systematic review of the topic, aka a statement of the author’s biases and opinions.) Moving beyond that, this was a multi-center, prospective, randomized, open-label, non-inferiority trial comparing usual dose tPA (0.9mg/kg) to low dose tPA (0.6mg/kg) in 3310 patient with acute ischemic stroke within 4.5 hours of onset. (As a reminder of how rarely we use this intervention, they screened 69305 patients to enroll those 3310.) The primary outcome was a composite of disability and death, defined as a modified rankin score of 2 or more. There was no statistically significant difference between the two groups (53.2% low dose and 51.1% usual dose, p=0.51). However, the 95% confidence intervals around this result go beyond a pre-specified definition, therefore they were unable to demonstrate non-inferiority. For the primary harm outcome, there was less intracranial bleeding in the low dose group  (1.0% vs 2.1% (p=0.01) by SITS-MOST criteria or 5.9% vs 8.0% (p=0.02) by NINDS criteria). Death at 7 days was lower in the low dose group, but death at 90 days was unchanged. There are a number of problems with this study. I am not going to delve too deeply into the issues of comparing different doses of placebo. (A dose response relationship is generally something we look for in efficacious therapies.) There is really no reason to make a study like this open-label and unfortunately that introduces a number of potential biases. Almost all the follow up was done by phone and the modified Rankin score is notoriously unreliable. Finally, like almost all of this research, the authors have significant conflicts.

Bottom line: High dose, low dose, no dose? I like this line of research. Maybe we can just keep lowering the tPA dose until is diluted by a factor of 10300 and hand care of acute stroke patients over to the homeopaths.

Read more: Rebel EM, The Bottom Line, EM Nerd


Neuropathic analgesia?

Therapeutics Initiative. Benefits and harms of drugs for “neuropathic” pain. Therapeutics Letter. 2016; 96:1-2. [free full text]

We see a lot of chronic pain. More than a lot. Since I started practicing, the number of people on gabapentin or lyrica for their neuropathic pain has skyrocketed. But just how good are these medications? This therapeutics letter looks at the evidence summarized in 11 different Cochrane reviews, and the best evidence on the topic is:

    • The evidence is weak (surprise anyone?) and the available RCTs have a high risk of bias
    • At best, about 1/10 patients will achieve any meaningful reduction in pain
    • Almost everyone has some side effects from these drugs
    • If there is going to be a benefit, you will see in within about 1 week
    • There does not seem to be any benefit in higher doses. (I think this is the most important takeaway, as I often see people on crazy escalating doses)

Bottom line: It might be reasonable to try these medicines, but start at a low dose, and recheck at 1 week if benefits outweigh side effects. If they don’t, stop the drug.


Black box on fluoroquinolones

FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together [available here]

So this isn’t research – it’s a notice of a new black box warning from the FDA. I am often skeptical of these warnings, as in some cases I think they have clearly done more harm than good (droperidol), but I think this one is worth knowing about. They say that “the serious side effects associated with fluoroquinolone antibacterial drugs generally outweigh the benefits for patients with sinusitis, bronchitis, and uncomplicated urinary tract infections who have other treatment options. For patients with these conditions, fluoroquinolone should be reserved for those who do not have alternative treatment options.” I would say this is pretty obvious, as there is no benefit of antibiotics in sinusitis and bronchitis. If a patient has a bad outcome and you are giving them a drug that has no chance of helping them, I would find that hard to defend.

Bottom line: Don’t use fluoroquinolones first in uncomplicated UTIs. Don’t use antibiotics at all in sinusitis or bronchitis.


But can we change our bad antibiotics habits?

Meeker D, Linder JA, Fox CR. Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. JAMA. 315(6):562-70. 2016. PMID: 26864410

We know that antibiotics don’t help for the vast majority of acute respiratory tract infections, but for some reason people just can’t help themselves. Every patient I see in the ED with a cough for 3 days is already on azithromycin or amoxicillin. They come to the ED because they can’t understand why they aren’t getting better on antibiotics. They think they need something stronger. This is a randomized controlled trial trying to get doctors to smarten up. In a total of 243 different clinicians, they tried three different interventions: 1) automated reminders that antibiotics are inappropriate and alternate treatment suggestions 2) the requirement of an ‘antibiotic justification note’ as part of the permanent record, and 3) intermittent e-mails comparing the performance of various doctors. Each clinician was exposed to anywhere from 0 to 3 of the interventions. The control group (no intervention) decreased their prescribing rate by 11% – a good demonstration of the Hawthorne effect. The reminders did nothing. Requiring a justification and being compared to peers decreased inappropriate antibiotic use.

Bottom line: Sadly, simply giving physicians information is not enough to change their practice. We need to be shamed into change. Maybe I should stop writing about the evidence and instead walk around personally shaming people?


Again – we don’t listen to good advice

Rosenberg A, Agiro A, Gottlieb M. Early Trends Among Seven Recommendations From the Choosing Wisely Campaign. JAMA internal medicine. 175(12):1913-20. 2015. PMID: 26457643

I love the choosing wisely campaign – except that we know doctors love to ignore good advice. This is a retrospective look at a billing database (so not necessarily the most reliable data, although the conclusions are believable.) They looked at 7 items that were listed by choosing wisely as being of minimal or no benefit (such as pre-op chest x-ray in the absence of concerning history, or imaging of low back pain without red flags) and looked to see if the number billed for changed over a 3 year period after the recommendations. They didn’t. (OK, imaging for headache went down from 14.9% to 13.4% – not exactly a clinically important change). Horrendously, the use of antibiotics for sinusitis remained at 84%!

Bottom line: Physicians just don’t change their practice when presented with good evidence or advice. It does makes me wonder if I should stop sending these e-mails – as they are probably not accomplishing anything.


Police officer: “Sir, How high are you?” Pothead: “No officer, its ‘Hi, how are you’”

Tefft BC et al.  Prevalence of Marijuana Involvement in Fatal Crashes: Washington, 2010 – 2014. May 2016. Washington, DC: AAA Foundation for Traffic Safety. [free full text]

This is a report by the AAA Foundation for traffic safety. It retrospectively looked at a database from the Washington State Traffic Safety Commission. In Washington State, as many will know, marijuana became legal in December of 2012. This study looked at all motor vehicle collisions that resulted in death and the proportion who had THC (delta-9-tetrahydrocannabinol) in their blood on autopsy. They compared collisions in the 2 years before the new law to the 2 years after the law. Out of the total of 3031 fatal MVCs over 4 years, 303 (10%) involved drivers testing positive for THC. The percentage rose from 8.9% in 2013 (before the law) to 17% in 2014. Of the individuals with positive tests for THC, 39% also had alcohol on board, 16% had other drugs, and 10% had alcohol and other drugs (leaving 34% with only THC detected). There are some problems with this data, the biggest probably being that we don’t know what levels of THC correlate with being impaired. THC wasn’t measured in every case, and sometimes measurement was delayed. Also, the total number of fatalities didn’t increase, just the number with THC on board, so the marijuana could be a bystander rather than a cause of the collisions. However, the issue of impaired driving, and our lack of science to guide us, remains a huge issue as this popular legalization movement continues forward.

Bottom line: Don’t smoke and drive


Would you be surprised if this patient died?

George N, Phillips E, Zaurova M, Song C, Lamba S, Grudzen C. Palliative Care Screening and Assessment in the Emergency Department: A Systematic Review. Journal of pain and symptom management. 51(1):108-19.e2. 2016. PMID: 26335763

I really hate adding work for our overly taxed triage nurses, who end up doing a lot of our screening. However, we are awful at recognizing patients with palliative care needs. This is a review, and I don’t think it is strong enough to completely overhaul triage systems, so I won’t go into the details, but they do conclude that palliative care screening is feasible. My favorite screening question is “would you be surprised if this patient died during this visit or in the coming month?” If no, they should probably have palliative care involved. Of course, the harder part of this equation is actually having adequate palliative resources for all the patients who need them.

Bottom line: Emergency medicine is all about dying patients. Palliative care should be an essential part of our mindset. You can have a much bigger impact by starting palliative care than you ever will handing out antibiotics for sore throats.


Epinephrine is safe in fingers – is that old news by now?

Ilicki J. Safety of Epinephrine in Digital Nerve Blocks: A Literature Review. The Journal of emergency medicine. 49(5):799-809. 2015. PMID: 26254284

This is a systematic review looking at the use of epinephrine in digital blocks. It should be stated up front that the conclusions are only good as the original studies – and they aren’t great. In a total of 30 studies, they identify 2797 blocks performed with epinephrine without any complications. They conclude that epinephrine is safe to use in digital nerve blocks in healthy patients. (Although, to be fair, it probably doesn’t help most of the time.)

Bottom line: This is probably another classic myth, although the data isn’t actually strong enough to definitely conclude safety.


CT first for the scaphoid?

Yin ZG, Zhang JB, Gong KT. Cost-Effectiveness of Diagnostic Strategies for Suspected Scaphoid Fractures. Journal of orthopaedic trauma. 29(8):e245-52. 2015. PMID: 25756914

I hate cost-effectiveness studies. The results hinge on a huge number of assumptions that really can’t be confirmed. However, sometimes they provide some insight that can be interesting. In this study they compared the cost of working up scaphoid fractures using a number of different strategies, such as immediate CT, immediate MRI, MRI on day 3, bone scan on day 3, and x-ray at 2 weeks. Maybe counterintuitively, the immediate CT was the most cost effective approach followed by the immediate MRI. I am not sure that you can take these results to the bank, but it is a good reminder that there a number of costs that we often forget about. Although immediate CT seems expensive, to come to a follow-up visit the patient must miss work, pay for parking, and see another physician. Additionally, being in an unnecessary cast for 2 weeks could result in 2 weeks unnecessarily off work. It’s not time to change yet, but I wouldn’t be surprised if immediate definitive testing for the scaphoid became the standard in the future.

Bottom line: CT first for scaphoid fracture might actually be cheaper than standard practice.


Compassion and the good Samaritan study

Darley JM, Batson CD. “From Jerusalem to Jericho”: A study of situational and dispositional variables in helping behavior. Journal of Personality and Social Psychology. 27(1):100-108. 1973. [article]

This is a classic study from the psychology literature. It is a study of seminary students. Half were told they had to give a talk on the parable of the good Samaritan. The other half were told they had to give a talk on routine seminary jobs. Some students were told they were late for the talk and had to hurry, whereas others were told that they were on time. There was a plant on the way to the lecture hall: a man slumped in a doorway who moaned twice as the students walked by. Whether or not they had been thinking about the parable of the good Samaritan made no difference in whether or not they stopped. The only thing that influenced their decision to help was how hurried they felt. I see a clear connection to emergency medicine. Our job requires an incredible amount of compassion. However, simply thinking about compassion doesn’t seem to help. If we are rushed, we are less likely to be compassionate, whereas if we have time, we will use it. Unfortunately – how many people feel like they have a lot of free time in the emergency department? Managing our departments so physicians are not constantly run off their feet is probably a really good idea. (Of course, that is quite a reach from this research scientifically speaking – but it makes a lot of sense to me.)

Bottom line: Ensuring that physicians aren’t rushed might be crucial in increasing our ability to be compassionate on the job.


Cheesy Joke of the Month

I was sitting in a bar the other night when the waitress yelled out “does anyone know CPR?!”

I yelled back, “yeah, and I know the rest of the alphabet too.”

Everyone laughed. Well, except one guy.


#FOAMed of the month

How is it that one develops mastery? Cliff Reid provides some insight into deliberate practice in the context of getting his ass kicked.

 

Articles of the month (August 2015)

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

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

Simple and brilliant: A pediatric rainbow

Moreira ME, Hernandez C, Stevens AD, et al. Color-Coded Prefilled Medication Syringes Decrease Time to Delivery and Dosing Error in Simulated Emergency Department Pediatric Resuscitations. Ann Emerg Med. 2015;66:(2)97-106.e3. PMID: 25701295

Pediatric resuscitations are stressful at the best of times and pediatric medication doses can be complicated, increasing the risk of medication errors. This group came up with an ingenious solution: single pre-filled syringes that are color-coded in a rainbow pattern that corresponds to the Broselow tape we all know and love. All you have to do is discard down to the color that corresponds to the size of the child and you are sure to be giving the right dose (best explained by looking at a picture).This study assessed the speed and accuracy of medication administration in simulated pediatric resuscitations. 10 teams consisting of physicians and nurses participated in a cross over study, so that they did one simulation with the new syringes and one without. Time to delivery of medications was quicker with the new syringes (47 versus 19 seconds, a difference of 27 seconds; 95%CI 21-33 seconds). Teams were also more accurate using the new color-coded syringes, with dosing errors occurring 17% of the time with the conventional approach and 0% of the time with the new syringes (absolute difference 17%; 95% CI 4-30%). Obviously a simulation based study is not real life – but I would actually expect more stress and therefore more errors during a real resuscitation.

Bottom line: Simple. Brilliant. Worth looking into.

The same group replicated basically the same study with similar results, but this time running the simulations with paramedics:

Stevens AD, Hernandez C, Jones S, et al. Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: A randomized crossover trial. Resuscitation. 2015. PMID: 26247145


Fingers, toes, nose and hose. The epinephrine myth

Ilicki J. Safety of Epinephrine in Digital Nerve Blocks: A Literature Review. J Emerg Med. 2015. PMID: 26254284

I’ve talked about this before, but possibly not in the articles of the month. This is a systematic review looking at the safety of using epinephrine in digital nerve blocks. They found a total of 39 relevant articles, although only 12 of them were RCTs. They report no cases of necrosis attributable to epinephrine. In total, they found 2797 reported cases of digital nerve blocks using epinephrine without any important complications.

Bottom line: This was a myth. Epinephrine is almost certainly safe in fingers and toes if you think it might help you.


Physicians might not be so great around genitals

Stewart CM, Schoeman SA, Booth RA, Smith SD, Wilcox MH, Wilson JD. Assessment of self taken swabs versus clinician taken swab cultures for diagnosing gonorrhoea in women: single centre, diagnostic accuracy study. BMJ. 2012;345:e8107. PMID: 23236033 [free full text]

This is a prospective cohort of 3859 women aged 16 and over who presented to a single sexual health clinical in the UK. Before undergoing their consultation, they were asked to perform a vulvovaginal swab on themselves which was sent for nucleic acid amplification (NAAT). They then had the normal examination by the physician, with urethral and endocervical swabs sent, both for NAAT and culture. Overall, 2.5% of women tested positive for gonorrhoea (using a gold standard of either positive culture or two different NAAT markers being positive.) The self swabs were the most sensitive (99%), followed by physician swab for NAAT (96%), with the endocervical culture being the least sensitive (81%). In patients with symptoms suggestive of STI, both physician and self swab NAAT were 100% sensitive, but the endocervical culture was only 84% sensitive.

Bottom line: Self taken swabs were the most sensitive at detecting gonorrheal infection in these women

Schoeman SA, Stewart CM, Booth RA, Smith SD, Wilcox MH, Wilson JD. Assessment of best single sample for finding chlamydia in women with and without symptoms: a diagnostic test study. BMJ. 2012;345:e8013. PMID: 23236032 [free full text]

This is another study by the same group, using essentially the same methods, but this time focusing on Chlamydia. They included a total of 3973 women. Again, the self swab outperformed the physician performed swab with a sensitivity of 97% (95%CI 95-98%) as compared to 88% (95%CI 85-91%). The reported specificity of 100% is essentially meaningless because they were using the test itself as the gold standard. Similarly, the sensitivity of both tests might be lower than reported as they were not compared to any other gold standard.

Bottom line: Women do a better job collecting swabs for Chlamydia than physicians do

Overall Bottom line: If there is not another reason for a speculum exam, it does not have to be performed solely to obtain cervical swabs. Unfortunately urine testing was not included in these studies, so we do not know how it compares to self swabs.


Using tamsulosin for kidney stones? You must not be reading these e-mails.

Furyk JS, Chu K, Banks C, et al. Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial. Ann Emerg Med. 2015. PMID: 26194935 [free full text]

This is a prospective, randomized, double-blind trial of 403 adults with CT confirmed ureteric stones comparing tamsulosin 0.4mg daily to placebo. There was no benefit for the primary outcome of stone expulsion at 28 days, with 87% passed in the tamsulosin group and 81.9% in the placebo group (5.1% difference; 95%CI -3 to 13%). There was a difference in a secondary outcome, distal stones sized 5-10mm, with 83.3% passing as compared to 61%. Of course this is a secondary outcome, so should not affect your practice. More importantly, the vast majority of these people should not being getting imaged, so you will never know the size of the stone, making this information clinically useless. There was no difference in urologic interventions, pain, or analgesia requirements.

Bottom line: Tamsulosin doesn’t help patients with ureteric stones.


Just in case that wasn’t enough to convince you

Berger D, Ross M, et al. Tamsulosin does not increase one-week passage rate of ureteral stones in Emergency Department patients. Am J Emerg Med. 2015. In Print. PMID:

This is yet another paper indicating tamsulosin has no role in ureterolithiasis. (Its too bad we can’t just start with the high quality studies, rather than following the predictable pattern of a handful of garbage studies showing questionable benefit followed by a lot of time and money spent on multiple good trials that prove that there was never any benefit.) This was a prospective, double-blind RCT with 127 adult patients with CT confirmed ureterolithiasis, randomized to either tamsulosin 0.4mg daily or placebo. There was no difference in the number of patients in whom the stone did not pass (tamsulosin 62.1% 95CI 49-75%; placebo 54.4% 95%CI 40-67%.) There was also no difference in pain scores or analgesic use.

Bottom line: There is no reason to be using tamsulosin in renal colic patients.


Sticking with urology: systematic reviews are pointless if there isn’t any original literature

Hulme P and Wylie K. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 1: tranexamic acid in life-threatening haematuria. Emerg Med J. 2015;32:(2)168-9. PMID: 25605262

They decided to do a review of tranexamic acid use in life-threatening hematuria. They managed to find 3 case reports and 1 prospective observational trial of 8 patients. There were no controls, so its hard to know what to make of the outcomes. It is good to know that none of the patients broke the emergency medicine rule that all bleeding stops… eventually.

Bottom line: For patients peeing blood, you are free to make it up as you go.


It just might be safe to pee in the Amazon

Bauer IL. Candiru–a little fish with bad habits: need travel health professionals worry? A review. J Travel Med. 2013;20:(2)119-24. PMID: 23464720

This is one of those really weird medical myths that I heard when I was younger and just stuck with me as a true. Apparently if you urinate in the Amazon river, there are little fish, called Candiru, that are attracted to the urine and will swim up your urethra. Once there, they have small barbs that lock them into place. These authors did an extensive review of both the scientific and non-scientific literature and report that there has never actually been a confirmed case of this occurring. For some reason, that is an amazing relief to me (and I have never even been to South America). Was I the only one raised on this particular myth?

Bottom line: Feel free to pee in the Amazon, if that’s your thing.


Don’t write off those vital signs just yet

Rodrigo GJ, Neffen H. Assessment of acute asthma severity in the ED: are heart and respiratory rates relevant? The American journal of emergency medicine. 2015. PMID: 26233619

This is a retrospective look at data that was collected prospectively as part of 7 other asthma trials done at a single emergency department. In total, 1192 adult patients were included. They compared heart rate and respiratory rate between two predefined groups: severe asthma (defined as an FEV1 31-50% of expected) and life threatening asthma (defined as an FEV1 <= 30% expected). The HR and RR were not different between the groups (mean of 102 and 22 respectively). They then use logistic regression to show that only FEV1 and O2 saturation were related to the outcome of admission to hospital. Based on this, they conclude that HR and RR are not determinants of acute asthma severity. I think this is probably the wrong interpretation. They use FEV1 as their definition of illness severity rather than hard outcomes. The lack of correlation between FEV1 and vital signs in this study might equally indicate that FEV1 is not a good indicator of disease severity. (It is a disease oriented, not a patient oriented outcome.) Although FEV1 was correlated with admission rates at this hospital, I imagine this just represents the local practices of the hospital: they believe in FEV1 and therefore admit you to hospital if your FEV1 is low, even if you had no other indications for admission.

Bottom line: I would still strongly suggest assessing patients clinically, including vital signs. Don’t let surrogate outcomes like the FEV1 or peak flow rates confuse you in asthma.


Another quick note on measuring asthma severity

Huff JS and Diercks DB. Use of Peak Expiratory Flow Rate Monitoring for the Management of Asthma in Adults in the Emergency Department. Revision of: American College of Emergency Physicians. Use of Peak Expiratory Flow Rate Monitoring for the Management of Asthma in Adults in the Emergency Department. Ann Emerg Med. 2001;38:198.

Without going into all the problems with the base literature on the use of peak flow rates in emergency medicine, I thought I would include the ACEP policy statement for reference. This is an update of their previous policy statement from 2001, with 27 new studies identified and reviewed. Their summary: “The use of PEFR monitoring has not been shown to improve outcomes, reliably predict need for admissions, or limit morbidity or mortality when used during the ED management of adult patients with acute exacerbations of asthma.”

Bottom line: Peak flow is a disease oriented outcome. Focus on patient oriented outcomes.


Sepsis and the rush to early antibiotics

de Groot B, Ansems A, Gerling DH. The association between time to antibiotics and relevant clinical outcomes in emergency department patients with various stages of sepsis: a prospective multi-center study. Critical care. 2015;19:194. PMID: 25925412

This is a prospective, multicentre observational cohort study including a total of 1,168 adult patients with sepsis (although their definition was anyone admitted to hospital with an infection who received IV antibiotics.) The overall mortality of their cohort was 10%, so significantly lower than the trials of severe sepsis we are used to. In this cohort, the length of time it took to give antibiotics was not associated with mortality. Much like the prior studies that showed a higher mortality in patients with delays to antibiotics, we must be aware of the mantra: association is not causation. In the current study, the delay to antibiotics might have been because patients had less severe infections. On the other hand, in prior studies in which antibiotic delays were associated with increased mortality, we might guess that patients were misdiagnosed or inappropriately dispositioned, which could be the true cause of increased mortality. Why did this study come to a different conclusion? One possibility is simply the timing of the studies. It is impossible to practice emergency medicine these days without a keen awareness of sepsis. This heightened awareness may lead to over-treatment in general, such that the few patients that don’t get early antibiotics really don’t require them.

Bottom line: Once you know there is a bacterial infection, obviously give antibiotics. However, there are many factors that will affect the timing of antibiotic administration and it should not be used as a quality of care metric.


We should probably just install CT scanners at triage

Claessens YE, Debray MP, Tubach F, et al. Early Chest CT-Scan to Assist Diagnosis and Guide Treatment Decision for Suspected Community-Acquired Pneumonia. Am J Respir Crit Care Med. 2015. PMID: 26168322

I think this paper is a little ridiculous and I include it only so you can ignore anyone who talks about it (including me, if you would like.) These authors enrolled 319 adult patients with clinically suspected community acquired pneumonia and subjected them to both a chest xray and a CT scan. Not surprisingly, the CT scan found what were interpreted as infiltrates in 33% of patients who had normal chest xrays. The CT findings were used to change management, both in terms of use of antibiotics as well as decision to admit, in a reasonable number of patients. However, it is not clear if any of those management changes were actually warranted. The authors want to use this data to conclude that patients suspected of community acquired pneumonia should all get CT scans. That is absolutely nutty. If we were missing 33% of clinically important pneumonias with current practice, our morgues would be full. Either these are tiny infiltrates that we fight off ourselves (after all, the human species has survived millennia without antibiotics), they are false positives, or we catch the pneumonia on a follow up xray 2 days later with a substantially lower radiation burden. (As a side note, be prepared for a similar problem of overdiagnosis in the many studies I assume will soon be published about using ultrasound for pneumonia, even if it has the advantage of no radiation.)

Bottom line: Just say no to CT scans for pneumonia


Glue works for abrasions too

Singer AJ, Chale S, Taylor M. Evaluation of a liquid dressing for minor nonbleeding abrasions and class I and II skin tears in the emergency department. The Journal of emergency medicine. 48(2):178-85. 2015. PMID: 25456777

This is an open label observational trial with no comparison group,using a convenience sample of 40 patients and 50 total wounds. The wounds were either abrasions or skin tears. They used a cheaper skin adhesive that has not been tested for tensile strength (unlike dermabond). If tensile strength was required, a steristrip was applied before the glue. In follow up, there were no infections and only one patient needed anything else: his glue peeled off on day 3 and he had bandage applied. Of course, with no comparison group, all we can say is “Mikey likes it”.

Bottom line: Glue works in skin. Perhaps there is a role for stocking the cheaper liquid bandaid products sold at drug stores?


A simple, life-saving therapy I didn’t know about

Jamtgaard L, Manning SL, Cohn B. Does Albumin Infusion Reduce Renal Impairment and Mortality in Patients With Spontaneous Bacterial Peritonitis? Ann Emerg Med. 2015. PMID: 26234193

I always find it funny that I finished residency with a head full of practices, like PPIs for GI bleeds, that are demonstrably unhelpful, but at the same time there are potentially life saving treatments that I have never heard about. Albumin for spontaneous bacterial peritonitis is one of those treatments. These authors report a systematic review and meta-analysis of RCTs studying albumin for SBP. In total they found 4 studies that include 288 patients with limited heterogeneity and no evidence of publication bias. Only 1 trial was blinded, but with a hard outcome of mortality that might be less important. The administration of albumin (the 2 largest trials made sure to give it within 6 hours, so this might be an ED therapy) was associated with less renal impairment (OR 0.21 95%CI 0.11-0.42) and lower mortality (OR 0.34 95%CI 0.19-0.60). Dosing varied among studies, but the largest trial used 1.5grams/kg IV at the time of diagnosis and 1gram/kg on day 3.

Bottom line: These are small numbers, but I will be giving albumin to SBP patients until we see more.


Diverticulitis is not necessarily a reason to promote antibiotic resistance

Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012 Apr;99(4):532-9. PMID: 22290281

I included the meta-analysis a few months back, but here is a multicentre RCT of 623 adult patients with CT confirmed uncomplicated diverticulitis (defined as lower abdo pain plus fever, an elevated WBC, and CT consistent with diverticulitis but no abscess or free air) randomized to either antibiotics or not. They used pretty big gun antibiotics: either a 2nd/3rd gen cephalosporin plus metronidazole or a carbapenem or piperacillin-tazobactam. There were no statistical differences between the groups. There were 3 perforations in each group. There were 3 abscesses in the no antibiotics group compared to none in the antibiotics group. 10 patients (3.2%) that started with no antibiotics were given antibiotics eventually. There were no differences in length of hospital stays or recurrent diverticulitis.

Bottom line: It may well be that we don’t need antibiotics for diverticulitis, but these patients were all treated as inpatients, so its probably not up to us to make that call.


Read enough and I might sound like an antibiotic nihilist

Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Annals of family medicine. 5(5):436-43. 2007. PMID: 17893386 [free full text]

I love this article, probably because it hits on two of my favorite soapbox topics: guidelines and antibiotics for sore throats. They searched for any major pharyngitis guidelines and found 10 from different countries and organizations. Two people individually coded each guidelines for all the major recommendations. The key finding of this paper is that despite all of these guidelines being “evidence based”, they arrive at wildly different recommendations. Several guidelines recommend prescribing antibiotics only if the patient is very sick or high-risk, but others suggest treating almost everyone. (If you want to find a guideline that tells you not to give antibiotics, look to Belgium, the Netherlands, England, or Scotland. Interestingly, these were the guidelines that were written by family doctors, as compared to specialists – I knew we had brains.) Not a single publication, including the Cochrane review, was cited by all the guidelines.

Bottom line: Unfortunately, guidelines are rarely an adequate source of evidence based clinical information. (Also, for most parts of the world, pharyngitis probably doesn’t need antibiotics.)


When is a clot a clot?

Morgan C, Choi H. BET 1: Do patients with a clinically suspected subsegmental pulmonary embolism need anticoagulation therapy? Emergency medicine journal : EMJ. 32(9):744-7. 2015. PMID: 26293150

What is the evidence for treating subsegmental pulmonary emboli? This review identified 2 observational trials that included patients with subsegmental PEs who were not anticoagulated. Of the total of 47 patients with untreated subsegmental PEs, none had recurrent venous thromboembolism at 3 months. It would not be surprising if the harms of anticoagulation outweighed the benefits, but 47 patients can’t give enough information to decide either way.

Bottom line: We still really don’t know what to do, but any treatment benefit is likely to be small.


Positive troponins are negative for patients

Hakemi EU, Alyousef T, Dang G, Hakmei J, Doukky R. The prognostic value of undetectable highly sensitive cardiac troponin I in patients with acute pulmonary embolism. Chest. 2015;147:(3)685-94. PMID: 25079900

This is a retrospective chart review of 298 patients with confirmed PEs looking at the prognostic value of a positive high sensitivity troponin. 45% of the group had a negative troponin and therefore 55% had a positive trop. If the troponin was negative, no patients died, needed CPR, or received lytics. Among those with a positive trop, 6% died and 9% had either CPR or lytics given. For a retrospective study, this one is more likely than usual to give us a correct answer as death, lytics, troponin, and to a lesser extent CPR are objective values that are likely to be accurately recorded on a chart.

Bottom line: It’s not surprising, but a positive troponin is likely a bad prognostic factor for PE patients.


Less relevant than the pee fish article?

Morgenstern J, Hegele RA, Nisker J. Simple genetics language as source of miscommunication between genetics researchers and potential research participants in informed consent documents. Public Underst Sci. 2015;24:(6)751-66. PMID: 24751688

This isn’t directly related to emergency medicine, but I was excited that after a few years of being “in press” the article based on my master’s thesis actually got published in print. This was a study that used qualitative methods to analyze the language of informed consent documents in genetics research. The main finding was that apparently simple, easy to understand language can be a source of miscommunication. This can occur because different people or groups of people will understand words differently. An example would be geneticists conceptualizing “disease” as an entity that may or may not cause actual symptoms in the future based on genetic predispositions, while their research participants may think of a “disease” as something they definitely have and will notice the effects of. Might this be applicable to emergency medicine? I think so, but without any good evidence. However, we know that when patients hear the words “congestive heart failure” they envision something that will kill within days – after all, their heart is failing – but this is not necessarily what we are trying to convey with those words. Similarly, we might talk about “low risk chest pain”, but different people might understand those words to indicate a 2% risk, or a 1 in a thousand risk, or a 1 in a million risk.

Bottom line: Communication is essential in emergency medicine. It is an area that probably deserves more attention.


Cheesy Joke of the Month

What is the difference between surgeons and God?

God doesn’t think he is a surgeon


FOAM resource of the month

A new site and podcast that I think will benefit all emergency physicians is:

https://www.phenomenaldocs.com/

Rather than being focused on clinical aspects of care, this site is run by Jason Brooks, a performance enhancement coach, with the goal of improving performance (both in the ED and in life in general) and making it sustainable. High level athletes have coaches, why shouldn’t we? I really enjoyed the first few podcasts.


Enjoy the free open access medical education? Think you know someone else who might? It would help me a lot if you spread the word and shared this resource with just one of your friends or colleagues. Even easier, you could also help by just clicking the like button on Facebook. Thank you so much!

Management of life threatening asthma in the emergency department

An approach to the initial management of the asthma patient presenting to the emergency department in extremis

Case

A 16 year old female with a history of severe asthma is brought to your community emergency department after a week of respiratory symptoms that have suddenly become much worse. She has been admitted to hospital 4 times this year, including one visit to the ICU. Her respiratory rate is 45 and she is using every accessory muscle she has, but she doesn’t appear to be moving much air. In fact, her lungs are silent to auscultation. She looks tired and the monitor shows her vitals as a heart rate of 140, blood pressure of 99/60, and an oxygen saturation of 88%…

Continue reading “Management of life threatening asthma in the emergency department”

Management of severe anaphylaxis in the emergency department

A brief review of the management of the critically ill patient with anaphylaxis in the emergency department

Case

A 31 year old female is brought into the emergency department by ambulance after she collapsed at a family birthday party. She has a diffuse red rash, a blood pressure of 80/40, and an oxygen saturation of 88% on room air. She is wearing a medicalert bracelet. Her uncle guiltily admitted to EMS that he hadn’t told people that the vegan “cheese ball” he brought was actually just pureed nuts…

Continue reading “Management of severe anaphylaxis in the emergency department”