Articles of the month (June 2017 – #dasSMACC edition)

This month’s articles are a little special. Usually, I pick out the articles that catch my eye, but it’s easy to imagine that my biases filter out a lot of interesting medical literature. As there were a number of experts descending on Berlin this month for SMACC, Casey Parker and I invited a few people to suggest a paper and discuss it with us over a beer for our podcast. The conversation was great, and can be found here. These are the articles that were picked:

Continue reading “Articles of the month (June 2017 – #dasSMACC edition)”

Articles of the month (May 2015)

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

Here are my favorite reads from this month. It is a little longer than usual, because apparently what I enjoy doing while sitting pool-side in paradise is catching up on the medical literature. I am sure there is room in the next iteration of the DSM for that.

 

Myth: Wound eversion magically eliminates scarring

Kappel S, Kleinerman R, King TH, et al. Does wound eversion improve cosmetic outcome?: Results of a randomized, split-scar, comparative trial. J Am Acad Dermatol. 2015;72:(4)668-73. PMID: 25619206

This is a prospective, randomized trial of post-op skin surgery patients where they closed half of the wound using wound eversion and the other half using basic planar approximation. The patients and 2 assessors were blinded and there was no significant difference in appearance at 3 or 6 months. This is in clean surgical wounds, so external validity to the ED is questionable. However, the authors looked for science supporting the dogma of wound eversion, and not surprisingly: there is none.

Bottom line: This is enough for me to stop dogmatically teaching wound eversion – though with only one study, I am always ready to change my mind.


“Therapeutic” hypothermia

Mark DG, Vinson DR, Hung YY, et al. Lack of improved outcomes with increased use of targeted temperature management following out-of-hospital cardiac arrest: a multicenter retrospective cohort study. Resuscitation. 2014;85:(11)1549-56. PMID: 25180922

A retrospective, before and after study of 1119 patients in a system where therapeutic hypothermia for out of hospital cardiac arrest was implemented in 2009. Despite the fact that you would expect improved outcomes just because of improved medical care over the half decade the study ran, there was no difference in mortality or neurologic outcomes whether or not you were cooled.

Bottom line: Thanks to TTM, we already know that cooling is not necessary. We should remember that fever avoidance is currently only a theory without significant evidence basis.


Kids don’t like being cold either

Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children. N Engl J Med. 2015;372:(20)1898-1908. PMID: 25913022 

You probably would have been fine applying the TTM data to children, as they are just little adults, but we now have some pediatric specific data. This is a multicentre RCT of pediatric (2 days to 18 years) out of hospital cardiac arrest, comparing 33.0 with 36.8 degree Celsius targets. As you might expect, there was no difference in survival or functional outcomes up to one year. However, the raw numbers were better in the hypothermic children, despite being non-statistically significant.

Bottom line: There is no reason to put kids on ice outside of the context of further clinical trials.


Rate control in atrial fibrillation cage match: the cardiology approach (beta blockers) versus the emergency medicine approach (calcium channel blockers)

Martindale JL, et al. β-Blockers versus calcium channel blockers for acute rate control of atrial fibrillation with rapid ventricular response: a systematic review. Eur J Emerg Med. 2015;22:(3)150-4. PMID: 25564459

This is a systematic review of calcium channel blocker versus beta blockers for acute rate control of atrial fibrillation. They could only find 2 quality studies, which were very small. In these studies, diltiazem was better than metoprolol (RR 1.8 95% CI 1.2-2.6) for rate control.

Bottom line: The very limited evidence seems to fit with clinical experience: calcium channels blockers are more likely to get patients controlled in the ED.


The toughest question in the resus room? Maybe if a.fib is the cause of or the result of hemodynamic instability

Scheuermeyer FX, Pourvali R, Rowe BH, et al. Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm. Ann Emerg Med. 2015;65:(5)511-522.e2. PMID: 25441768

This is a retrospective chart review (well done, but a chart review) of 416 patients with atrial fibrillation and an acute medical illness, out of British Columbia. They compared those patients who had their atrial fibrillation actively managed, versus those in whom the focus was only in treating the underlying condition. No one died in this study. Patients who had either rate or rhythm control had significantly increased rates of major adverse events, primarily increased requirement for pressors and increased intubations.

Bottom line: In sick medical patients who happen to have atrial fibrillation, focus on basic resuscitation over rate/rhythm control.


The new angioedema meds

Bas M et al. A randomized trial of icatibant in ACE-inhibitor-induced angioedema. New England Journal of Medicine. 2015;372(5):418-25. PMID: 25629740

This is one of a few new, very expensive treatments for hereditary angioedema. It is a selective bradykinin B2 receptor antagonist. This was a phase 2 RCT of 30 patients who either received Icatibant or standard therapy of steroids and anti-histamines for patients with ACE inhibitor induced angioedema. The icatibant group responded quicker (8 hours versus 27 hours) and had more complete resolution of their symptoms. The biggest concern with this study (aside from the tiny size and industry involvement) is that, although the standard therapy group probably represents usual care, ideal care might involve use of FFP instead.

Bottom line: In a very small study, icatibant seems to decrease angioedema a lot quicker than ‘usual care’.


Lots of Os up the nose

Frat JP, Thille AW, Mercat A, et al. High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure. N Engl J Med. 2015. PMID: 25981908

This is a multi-centre randomized, open label study of high flow, humidified nasal oxygen, versus standard oxygen face mask, versus non-invasive positive pressure ventilation in adult, hypoxic patients. (CHF and exacerbations of asthma or chronic respiratory failure was excluded, so in other words this is primarily pneumonia patients.) There was no difference in their primary outcome of need for intubation, although they powered the study to detect a 20% difference, which is probably larger than the clinically important difference. This biggest news is that 90 day mortality was decreased in the high flow oxygen group (12%, versus 23% with standard oxygen and 28% in NIPPV), but this is a secondary outcome so should be interpreted with caution.

Bottom line: High flow nasal oxygen seems to be at least as good as NIPPV or facemask oxygen (in this select group of patients). This is enough for me to try this with alert pneumonia patients who don’t obviously need intubation.


More evidence PPIs aren’t completely safe

Antoniou T et al. Proton pump inhibitors and the risk of acute kidney injury in older patients: a population-based cohort study. CMAJ Open 2015;3(2):E166-71. (Free full text here)

Using the Ontario Drug Benefit database, these authors compared the cohort of patients with newly prescribed PPIs with a propensity matched group as a control. They excluded anyone also prescribed known nephrotoxic drugs, or with basically any other renal risk factors. People on PPIs were more likely to develop acute kidney injury, with a hazard ratio of 2.52 (95% CI 2.27-2.79). Out of 290,000 patients studied, 1787 were admitted to hospital with AKI – about 8 more than controls for every 1000 patient years on PPIs.

Bottom line: No medication is without side effects, but we treat some like they are water. Early studies will always emphasize benefits and downplay harms.


You don’t need fancy lenses and mirrors to see the retina

Vrablik ME et al. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta-analysis. Ann Emerg Med 2015; 65(2):199-203. PMID: 24680547

This meta-analysis attempted to determine the accuracy of ultrasound for diagnosis of retinal detachment in the hands of emergency physicians. In population with a prevalence of detachment between 15% and 38%, they found a sensitivity of ultrasound of 97-100% and a specificity of 83-100%. Of course, these studies are often done with experienced ultrasonographers or after specific training.

Bottom line: I think this definitely has a place in the ED.

Bonus: This castlefest lecture is a great resource for ocular ultrasound, with free CME


A little more diagnostic technology: iPhone otoscopes

Richards JR, Gaylor KA, Pilgrim AJ. Comparison of traditional otoscope to iPhone otoscope in the pediatric ED. Am J Emerg Med. 2015. PMID:  25979304

These authors compared a traditional otoscope with a new one that attaches to your iphone and gives you a video display. There was reasonable agreement between the new one and the old one, although residents and attendings still disagreed about the findings a lot. They claim that the iPhone scope changed the final diagnosis a number of times, but without a clear gold standard I wouldn’t focus on that result.

Bottom line: I am not sure how important it is to treat anything they found here, which limits the value of the tool – but this could be a great way to teach students otoscopy.


Can the D-Dimer be improved? (Well, it can’t get any worse, can it?)

Jaconelli Y and Crane S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: Should we use an age adjusted D-dimer threshold in managing low risk patients with suspected pulmonary embolism? Emerg Med J 2015;32(4):335-7. PMID: 25804861

This is a systematic review (published before last month’s paper, and so not including it) that found 13 papers addressing the use of an age adjusted d-dimer (less than age x 10). Most of the studies were retrospective, so not of high quality. The authors conclusion is “In older patients suspected of having a PE, with a low pretest possibility, an age-adjusted D-dimer increases specificity with minimal change in the sensitivity, thereby increasing the number of patients who can be safely discharged without further investigations.”

Bottom line: It is looking like the age adjusted d-dimmer in low pre-test probability patients will result in a post-test probability below the test threshold, while increasing specificity.


Speaking of PE testing, the CTPA is not a perfect test

Miller WT, Marinari LA, Barbosa E, et al. Small Pulmonary Artery Defects Are Not Reliable Indicators of Pulmonary Embolism. Ann Am Thorac Soc. 2015. PMID: 25961445

In this study, they took all of the CT scans that were read as positive for PE in one radiology system, and had the scan review by 4 subspeciality thoracic radiologists. 15% of scans read as showing a subsegmental PE by community radiologists were thought to be false positives by the specialists. Another 27% were thought to be indeterminate. This only represents disagreement among radiologists and not the inherent false positives of the test itself.

Bottom line: A positive CT scan is not an objective finding. Before subjecting patients to lifelong anticoagulation, a second opinion on the read might be warranted.


PEs come from the legs – those IVC filters make sense, right?

Mismetti P, Laporte S, Pellerin O, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial. JAMA. 2015;313:(16)1627-35. PMID: 25919526

Prosecptive RCT with blinded outcome assessors, but unblinded patients and treating physicians, randomized 399 patients with PE plus a DVT plus a marker of severity to either anticoagulation alone or anticoagulation plus a retrievable IVC filter. Recurrent PE occurred in 3% of the filter group (all fatal) and 1.5% of the no filter group (2 of 3 fatal) for a non statistically significant relative risk of 2.0 (95% CI 0.51 – 7.89).

Bottom line: IVC filter don’t decrease the rate of PE in patients than can be anticoagulated.


Medications don’t cure kidney stones

Pickard R et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet. 2015. PMID: 25998582

Flomax was pushed for renal stones based on a number a small studies with horrible methods and a few meta-analyses of those horrible studies. There has already been one large RCT with excellent methods demonstrating that Flomax doesn’t work. This should be the nail in the coffin. This is a multicentre placebo controlled RCT of 1167 adult patients with CT confirmed renal stones. They were randomized to either tamsulosin 0.4mg, nifedipine 30mg, or placebo. There was no difference between any of the groups in the number of patients requiring urologic intervention. (About 80% of the patients passed spontaneously, and 20% required an intervention in all groups.)

Bottom line: There is no role for medical expulsive therapy in renal colic.


Antibiotics don’t work for diverticulitis? Is nothing sacred?

Shabanzadeh DM, Wille-Jørgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev. 2012;11:CD009092. PMID: 23152268

This is a Cochrane systematic review that was able to identify 3 RCTs looking at the use of antibiotics for uncomplicated diverticulitis. Only one compared antibiotics to no antibiotics, the other two compared different types and courses of antibiotics. There was no difference in any of the regimens. In other words, no antibiotics was the same as antibiotics.

Bottom line: Not enough to change my practice, but it is good to know that we have minimal footing to our current practice.


Antibiotics in appendicitis? The right side of the bowel is different from the left, right?

Varadhan KK, Humes DJ, Neal KR, Lobo DN. Antibiotic therapy versus appendectomy for acute appendicitis: a meta-analysis. World J Surg. 2010;34:(2)199-209. PMID: 20041249

This meta-analysis concludes surgery may have a lower risk of complications than antibiotics (RR 0.43 95% CI 0.16-1.18). A little more than 30% of patients treated with antibiotics will actually require surgery. The authors seem to think biases in current study favour the antibiotics group, so real outcomes might be worse.

Bottom line: We don’t really get to make this decision anyway, but surgery is probably still the gold standard.


One last one on antibiotics: If you are going to treat with oral (which you probably should in most cases) don’t give a dose IV in the department

Haran JP, Hayward G, Skinner S, et al. Factors influencing the development of antibiotic associated diarrhea in ED patients discharged home: risk of administering IV antibiotics. Am J Emerg Med. 2014;32:(10)1195-9. PMID: 25149599

This is a prospective cohort study of 247 patients, all of whom were being treated with outpatient oral antibiotics. They compared those who received an IV dose in the ED to those who did not. 25.7% of the IV group developed antibiotic associated diarrhea versus 12.3% in the no IV group (a number needed to harm of 7.5).

Bottom line: Unnecessary IV antibiotics harm our patients.


The best drugs are probably those they keep away from us

Calver L, Page CB, Downes MA, et al. The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2015. PMID: 25890395

This is a prospective observational study of 1009 patients in Australia, all of whom received 10mg of droperidol for sedation of acute behavioral disturbances, and second dose at 15 min as needed. Out of those 1009 patients, 13 developed a long QT, and 7 of those had other contributing causes such as methdone or amiodarone. There were no incidences of tosades de pointes.

Bottom line: The black box warning against droperidol is likely without scientific merit. I would use it if it were available to me. Given how useful this medication is, it might be worth fighting for.


Let’s do two on poo

Gerding DN, Meyer T, Lee C, et al. Administration of spores of nontoxigenic Clostridium difficile strain M3 for prevention of recurrent C. difficile infection: a randomized clinical trial. JAMA. 2015;313:(17)1719-27. PMID: 25942722

We are all colonized with C.diff., so we should be experts in getting rid of it. This is a new one to me. They took patients who completed their treatment for C.diff. and infected them C.diff. Only, this strain of C.diff does not form toxins. This reduced recurrence of clinical infection from 30% to 11%.

Bottom line: You can treat Clostridium difficile with Clostridium difficile. Maybe we should infect ourselves prophylactically?

Drekonja D, Reich J, Gezahegn S, et al. Fecal Microbiota Transplantation for Clostridium difficile Infection: A Systematic Review. Ann Intern Med. 2015;162:(9)630-8. PMID: 25938992

A systematic review, but there are only 2 RCTs to include. In one RCT, fecal trasplant led to 81% of patients having symptom resolution, versus only 31% in the vancomycin group. In another, they demonstrated no difference between NG and rectal routes for the transplant, with about 70% resolution of symptoms. (I’d choose the rectal route, thanks.)

Bottom line: Still really not enough science to warrant a bottom line, but if C.Diff is turning your life to sh*t, consider someone else’s sh*t: it might make you feel better.


Apparently science is useless for xanthrochromia.

Chu K, Hann A, Greenslade J, Williams J, Brown A. Spectrophotometry or visual inspection to most reliably detect xanthochromia in subarachnoid hemorrhage: systematic review. Ann Emerg Med. 2014;64:(3)256-264.e5. PMID: 24635988

This is a systematic review of 10 studies comparing visual inspection to spectrophotometry for detection of xanthrochromia. Visual inspection: sensitivity 83.3% and specificity 95.7%. Spectrophotometry: sensitivity 86.5% and 85.8%. (The gold standard varied from angiography to clinical follow-up.)

Bottom line: There is no clear difference between the two, but neither seem great. Isn’t there some way for the lab to test for the chemical that makes the fluid yellow?


1 + 1 + 1 = 3?

Angus DC, Barnato AE, Bell D, et al. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive Care Med. 2015. PMID: 25952825

Surprise. The meta analysis of three trials that said the same thing, says the same thing: EGDT is not superior to usual care in 2015. What is worth mentioning is that this is a very good meta-analysis because the investigators of all three trials went out of their way to ensure they were using the same definitions and outcomes before starting.

Bottom line: We can be very confident that we don’t need to be following the protocols of the original EGDT study.


Game changer (x2) for neonatal resuscitation?

Gruber E, Oberhammer R, Balkenhol K, et al. Basic life support trained nurses ventilate more efficiently with laryngeal mask supreme than with facemask or laryngeal tube suction-disposable–a prospective, randomized clinical trial. Resuscitation. 2014;85:(4)499-502. PMID: 24440666

A prospective, RCT comparing ventilation with facemask vs the LMA supreme (LMA-S) vs the laryngeal tube suction-disposable (LTS-D) device in neonatal resuscitation. A lot of the outcomes were of questionable relevance, but ventilation failed in 34% of patients with facemask, 22% with the LTS-D, and 2% with the LMA-S. Higher tidal volumes were delivered with both the LTS-D and the LMA-S than the facemask (470ml vs 240ml). All these resuscitations were run by nurses, so external validity may be questionable.

Trevisanuto et al. Supreme Laryngeal Mask Airway versus Face Mask during Neonatal Resuscitation: A Randomized Controlled Trial. The Journal of Pediatrics. 2015. PMID: 26003882

This is another prospective randomized trial (neither of these could be blinded) of LMA-S versus facemask in 142 neonatal resuscitations of infants greater than 34 weeks or 1500 grams. The LMA resulted in higher 5 minute APGAR scores, less intubations, and lower admissions to NICU.

Overall bottom line: These two prospective studies paint a picture of better ventilation as well as improved patient important outcomes, such as intubations and NICU admissions, when an LMA is used over standard facemask ventilation for neonatal resuscitation. This might cause some culture shock when we run upstairs, but I think this is worth instituting.


Another myth: The subglottic area is the narrowest area of the pediatric airway

Dalal PG, Murray D, Messner AH, Feng A, McAllister J, Molter D. Pediatric laryngeal dimensions: an age-based analysis. Anesth Analg. 2009;108:(5)1475-9. PMID: 19372324

These authors measured the cross sectional area of the airways of 153 children (6months to 13 years) using video bronchoscopy under general anesthesia, and they found that it is the glottis not the cricoid that is the narrowest portion of the airway.

Bottom line: Probably shouldn’t change your daily practice, still pick a tube small enough to pass the cords, but just remember that a lot of what we “know” and teach is wrong. Always keep an open mind in medicine.


Cheesy Joke of the Month

As the doctor completed an examination of the patient, he said, “I can’t find a cause for your complaint. Frankly, I think it’s due to drinking.”

“In that case,” said the patient, “I’ll come back when you’re sober”


FOAMed Resource of the Month

Its not actually up an running yet, but I am really excited about the idea, so its more something to keep an eye out for. If anyone has played around with Coursera or EdX, you know there is a lot of incredible high quality education available for free in just about any subject. These are called MOOCs (massive open online courses). Well, there will soon be an equivalent for emergency medicine education, created for ALiEM: http://www.aliem.com/sneak-peak-aliemu/

Articles of the month (March 2015)

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