Emergency medicine resuscitation – When minutes matter…
A monthly collection of interesting emergency medicine articles appraised to keep your practice informed.
I decided to take a break last month, for the first time in a few years. I imagine some people were hoping I would take I much more extended vacation, but I am sorry to say, you are stuck with me. I might be a little rusty, though, after a month off, so cut me some slack…
As always, the audio version is available on the BroomeDocs podcast (if you can tolerate very poor quality banter that Casey and I produce).
Continue reading “Articles of the Month (March 2017)”
Another month and another batch of articles to keep your practice informed. As always, I have no specific selection criteria. These are all just papers that I found interesting. I am always happy to receive suggestions if you encounter a paper that makes you think. And, of course, make sure to have a listen to me and Casey Parker making fools of ourselves as we try to come up with intelligent things to say about these papers on the BroomeDocs podcast. Continue reading “Articles of the Month (January 2017)”
Singer M, Deutschman CS, Seymour CW. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 315(8):801-10. 2016. PMID: 26903338 [free full text]
There are new sepsis guidelines. I guess that warrants headline news, and there has been a lot of excitement on the medical internet. However, they are really just the opinions of 19 experts, aren’t backed by any quality prospective data, and probably shouldn’t change your management. If you want to read more, I wrote a full post on the topic: Sepsis 3.0 – No thank you
Bellolio MF, Gilani WI, Barrionuevo P. Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 23(2):119-34. 2016. PMID: 26801209
What exactly are the risks of procedural sedation? I know them qualitatively, but when having an informed choice conversation, are you able to quote the actual incidence? I know I couldn’t. This is a systematic review and meta-analysis to determine the incidence of adverse events in ED procedural sedation (limited to after 2004). They found 55 articles that covered 9652 procedural sedations. The most common adverse events: hypoxia (40/1000 but only 23/1000 were <90%), vomiting (16/1000), hypotension (15/1000), and apnea (12/1000). The serious adverse events: laryngospasm (4/1000), intubation (1.6/1000), aspiration (1.2/1000). If you are interested, they do break some of these numbers down based on what agent was used. There was a fair amount of heterogeneity in the definitions used in the original studies. Also pediatrics was excluded.
Calder LA, Balasubramanian S, Fergusson D. Topical nonsteroidal anti-inflammatory drugs for corneal abrasions: meta-analysis of randomized trials. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 12(5):467-73. 2005. PMID: 15860701 [free full text]
Most people have heard me rant about the myth that topical anesthetics are harmful in corneal abrasions. (If you haven’t, watch for an upcoming episode of EMCases Journal Jam, or come to the North York General Emergency Medicine Update this year.) However, an essential part of informed choice is reviewing the alternatives. How do topical NSAIDs perform in managing the pain of corneal abrasions? (Hat tip to Nadia Awad @Nadia_EMPharmD for sending me this paper.) This is a systematic review and meta-analysis that identified 11 RCTs (they don’t report the total sample size, but they were all relatively small studies). I find this paper a little hard to follow, because they report 5 high quality studies to be included in the meta-analysis, but then include only 3 in the forrest plot. Looking at just these 3 trials (n=459), topical NSAIDs did decrease pain, with a weighted mean difference of -1.30 (95%CI -1.56 to -1.03) on a 10 point pain scale. There are a few issues with this data. First: it’s hard to interpret a weighted mean difference, but the minimum change on a 10 point pain score generally considered to be clinically important is 1.4. Second: there is a lot of data that could not be included because of the way the original trials were reported. Third: although a formal funnel plot couldn’t be done, the authors admit a possibility of publications bias. Fourth: There is not enough data on safety, but there was at least one recurrent corneal erosion in the NSAID group. Fifth: The funding source of the original trials was not discussed, but it might be important considering that not a single one of the trials had allocation concealment. Finally: the comparison groups were varied, but often just placebo. It might be better to compare to the less expensive oral NSAIDs (or topical anesthetics.)
Chu K, Hann A, Greenslade J, Williams J, Brown A. Spectrophotometry or visual inspection to most reliably detect xanthochromia in subarachnoid hemorrhage: systematic review. Annals of emergency medicine. 64(3):256-264.e5. 2014. PMID: 24635988
This is a systematic review looking at studies (English only) that included patients presenting with a headache who had LPs where the CSF was sent for xanthrochromia. The gold standard for SAH was either angiography or follow up (not perfect). The studies were also highly heterogenous. Not surprisingly, visual inspection, AKA “hey Bob, does this look kinda yellow to you”, was not perfect, with a sensitivity of 84%, specificity of 96%, positive LR of 14.1 and negative LR of 0.35. However, the fancy spectrophotometry was not any better, with a sensitivity of 87%, specificity of 86%, positive LR of 6.6 and negative LR of 0.29. The included studies are not of high enough quality to be sure about any of those numbers. I just don’t understand how we don’t have something better yet – obviously some chemical is turning the fluid yellow – could the makers of super-ultra-sensitive troponins not just create a test that detects whatever this compound is?
Herreros Fernández ML, González Merino N, Tagarro García A. A new technique for fast and safe collection of urine in newborns. Archives of disease in childhood. 98(1):27-9. 2013. PMID: 23172785
Here is a contribution from Dr. Kate Bingham. You probably know how I feel about getting urines in pediatric patients. (If you don’t, you can read this.) However, for newborns, a urine culture is going to get done. This paper describes a technique to get the urine without a foley. Basically, feed kid, wait 25 min, clean genitals, hold baby under armpits (standing position), tap suprapubic area at 100/min for 30 seconds, then massage low back for 30 seconds. Repeat until pee is produced, and make sure you catch it in specimen bottle. Does it work? Of the 80 patients they tried this on (no comparison group), they were successful in 69 (86%). Median time to sample collection was 45 seconds. My only concern is if I miss the urine and I have to start all over again (maybe after antibiotics). This is interesting, but I so rarely get newborn urines, I will probably stick with a Foley for now.
Dickman E, Pushkar I, Likourezos A. Ultrasound-guided nerve blocks for intracapsular and extracapsular hip fractures. The American journal of emergency medicine. 2015. PMID: 26809928
One rebuttal I have often encountered when talking about nerve blocks for hip fractures is that the block is less likely to work in certain fracture patterns. This is a secondary analysis of data from a previously conducted prospective RCT looking at 77 patients and comparing the effectiveness of ultrasound guided femoral nerve block in intracapsular versus extracapsular hip fractures. They were the same, and both were good (pain scores from 6.5/10 just under 4/10 at 2 hours).
Stollman N, Smalley W, Hirano I, . American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology. 149(7):1944-9. 2015. PMID: 26453777
This is the new acute diverticulitis guideline from the American Gastroenterological Association Institute (that was as hard to type as it was to read.) I found three of their recommendations interesting:
Gágyor I, Bleidorn J, Kochen MM, Schmiemann G, Wegscheider K, Hummers-Pradier E. Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial. BMJ (Clinical research ed.). 351:h6544. 2015. PMID: 26698878 [free full text]
Are antibiotics useful in UTI? I actually think so, but there have been previous studies that illustrate that a lot of UTIs will clear on their own. This was a randomized, double dummy, placebo controlled trial in which 484 women (18-65 years old) received either fosfomycin 3 grams PO or ibuprofen 400mg TID for three days. 69% of the women in the ibuprofen only group had complete resolution of their symptoms, and didn’t use any antibiotics in the next 28 days. That is impressive, but the antibiotics did provide some benefit. The ibuprofen group had more dysuria, based on their definition of ‘non-inferiority’, although the actual numbers for pain look pretty similar. Also there were 5 patients in the ibuprofen group who developed pyelonephritis as compared to only one in the fosfomycin group, although the difference was not statistically significant (p=0.12). I think antibiotics help, but this study reminds us that if you are on the fence, there is no reason to rush the antibiotics. Nearly 7/10 women will clear their UTI without your help. Also, if you call someone back with a positive culture, but they no longer have symptoms, they almost certainly don’t need treatment (assuming they aren’t pregnant).
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 this topic before, but repetition is key in both science and education. This was a randomized, open-label non-inferiority trial comparing a single dose of dexamethasone (0.3mg/kg orally) to prednisolone (1mg/kg PO for 3 days) in 245 children aged 2-16 with known asthma. There was no difference in the primary outcome of PRAM score at day 4 (0.91 versus 0.91; absolute difference 0.005; 95%CI 0.35 to 0.34), although I am not sure this is the most clinically important outcome. There weren’t any differences in the secondary outcomes, such as admission to hospital, length of stay, or return visits.
Danewa AS, Shah D, Batra P, Bhattacharya SK, Gupta P. Oral Ondansetron in Management of Dehydrating Diarrhea with Vomiting in Children Aged 3 Months to 5 Years: A Randomized Controlled Trial. The Journal of pediatrics. 169:105-109.e3. 2016. PMID: 26654135
This is another paper I might have skipped because the results seem obvious, but I have recently seen it argued that we use ondansetron too liberally, so I guess it’s worth looking at. This is a well done, double blinded, placebo controlled RCT that enrolled 170 children between 3 months and 5 years of age with acute vomiting and diarrhea and clinical signs of dehydration. Although I worry that the primary outcome of failure of ORT, defined as features of some dehydration after 4 hours of ORT, is a little subjective, the trial was appropriately blinded and placebo controlled. Failure was 31% with ondansetron as compared to 61.5% with placebo, an absolute risk reduction of 30%, or a NNT of about 3. The 30% failure rate does seem high to me though, as I almost never have a kid fail ORT.
Wasserman JK, Perry JJ, Dowlatshahi D. Isolated transient aphasia at emergency presentation is associated with a high rate of cardioembolic embolism. CJEM. 17(6):624-30. 2015. PMID: 25782453
This is a prospective cohort of 2360 TIA patients, 41 of whom had isolated aphasia at the time of presentation. Patients with isolated aphasia were twice as likely to have a cardiac source of embolism (22.0% vs 10.6%, p=0.037). This is strong, believable data, but I disagree with the authors’ conclusion that “emergency patients with isolated aphasia with a TIA warrant a rapid and thorough assessment for a cardioembolic source”. Non-aphasic patients still had an 11% chance of a cardiac source as compared to 22% with aphasia. Those two numbers clearly necessitate the exact same work up.
Boutis K, Plint A, Stimec J. Radiograph-Negative Lateral Ankle Injuries in Children: Occult Growth Plate Fracture or Sprain? JAMA pediatrics. 170(1):e154114. 2016. PMID: 26747077
Almost everyone has heard my Salter 1 Rant. Here is some more evidence. This is a prospective cohort of 140 children between 5 and 12 years of age with clinically suspected Salter Harris 1 fractures of the ankle. They were all treated with a removable splint (yes – the pediatric tertiary centers are doing this, so you can too). Then all of the children had an MRI at one week. Of the 140 children, 108 had ligamentous injuries on MRI. So take home #1: Despite the old dogma about ligaments being stronger than pediatric bone, children do get ligamentous injuries. Another 27 had isolated bone contusions. Only 4 children (3.0%, 95% CI 0.1-5.9%) actually has Salter Harris 1 fractures, and only 2 of those had any evidence of growth plate injury. And even more important, at 1 month follow up, there was no difference in function between those with MRI confirmed fracture and those without.
Watson RS, Cummings P, Quan L, Bratton S, Weiss NS. Cervical spine injuries among submersion victims. The Journal of trauma. 51(4):658-62. 2001. PMID: 11586155
This is a chart review of all submersion victims in the Seattle area between 1974 and 1996. There were a total of 2244 submersion victims, 34% of whom survived until hospital discharge. The prevalence of c-spine injury was 0.49% overall and 0.38% of those who received any medical care (not pronounced dead on scene). All people with c-spine injuries had obvious trauma. (One, for example, was a victim from a plane crash.) The biggest pitfall of this chart review is that someone with a spine injury from submersion might only be coded as a spine injury at discharge, because that was the important injury. These patients would not have been found by the review. However, this isn’t the only reason to be skeptical of cervical collars, so I have no problem removing it if I need better access to a submerged patient’s airway.
Meyers HP, Limkakeng AT, Jaffa EJ. Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: A retrospective case-control study. American heart journal. 170(6):1255-64. 2015. PMID: 26678648
This paper is worth a look, if just to review some ECGs. It is a retrospective case-control study looking to validate a modified Sgarbossa rule for diagnosing STEMI in LBBB. This rule uses the ratio of ST elevation to S wave, rather than a set 5mm cut off for the anterior leads. Based on their 258 patients (only 9 with true STEMI), they report a better sensitivity than the original criteria (80% vs 49%, p<0.001) and equal specificity (99% vs 100% p=0.5). I already use these criteria, but I think we should be cautious about the current evidence base. This is retrospective and based on only 9 patients with acute coronary occlusion. More importantly, I wonder about the inter-rater reliability when we are taking multiple measurement in millimetres and dividing them. I already know from reading Dr Smith’s (excellent) blog that he frequently sees small amounts of ST depression that I would have missed or measured differently.
Read more on Dr. Smith’s blog here, here, or here.
Narayana S, McGee S. Bedside Diagnosis of the ‘Red Eye’: A Systematic Review. The American journal of medicine. 128(11):1220-1224.e1. 2015. PMID: 26169885
I’ll just do a very quick note on this systematic review. because I found two numbers interesting. For ruling in “serious eye disease”, photophobia is good (LR+ = 8.3; 95%CI 2.7 – 25.9), but photophobia by indirect illumination (shining the light in the opposite eye) is amazing (LR+ = 28.8; 95%CI 1.8 – 459). The other number I found interesting is that bacterial conjunctivitis can almost be ruled out by “failure to observe a red eye at 20 feet”, although I am not sure there is huge clinical value of differentiating bacterial from viral conjunctivitis.
Hoegberg LC, Bania TC, Lavergne V. Systematic review of the effect of intravenous lipid emulsion therapy for local anesthetic toxicity. Clinical toxicology (Philadelphia, Pa.). 2016. PMID: 26853119
Another quick one: A systematic review of intralipid therapy in local anesthetic toxicity. It might be worth a deep dive, but the quality of the evidence is just so poor that it’s hard to trust any conclusions. For what it is worth, they conclude that intralipid appears effective, but there is no evidence that it is more effective than vasopressors.
My real reason for bringing this up is to lament the quality of toxicology literature in general. I have heard people argue that it would be unethical to randomize these dying patients in order to get good data, but we have to remember that in the absence of good data, the care they are getting is entirely random anyway. The random factor is just the belief of the physician who happens to be on that day. Although these are rare cases, we have the technology to gather data from around the world. We need to do better.
Kim C, Nevitt MC, Niu J. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ (Clinical research ed.). 351:h5983. 2015. PMID: 26631296 [free full text]
This study looks at data from 2 large cohort studies: The Framingham study (in which every patient over 50 got a pelvic x-ray, regardless of symptoms) and the osteoarthritis initiative study (which included 4366 patients thought to be at risk for knee arthritis, and again everyone was imaged.) Xray is not predictive of osteoarthritis. In Framingham, only 15.6% of patients with frequent pain (clinical OA) had radiographic evidence of OA and only 20.7% of those patients whose xray indicated OA actually had clinical symptoms. Likewise, In the osteoarthritis initiative study, only 9.1% of patients with symptoms had xray changes, and only 23.8% of patients with xray changes had symptoms.
Kim S, Noveck H, Galt J, Hogshire L, Willett L, O’Rourke K. Searching for answers to clinical questions using google versus evidence-based summary resources: a randomized controlled crossover study. Academic medicine : journal of the Association of American Medical Colleges. 89(6):940-3. 2014. PMID: 24871247 [free full text]
Rushing around the emergency department, it is obviously tempting to just google something rather than find a specific medical resource, but how good is google? This is a prospective, randomized, controlled, crossover study in which they took 48 internal medicine residents and asked them to answer a series of medical questions. They were randomized to answer 5 questions, either using Google or using their choice of DynaMed, First Consult, or Essential Evidence Plus. They then ‘crossed over’ and answered another 5 questions using the opposite tool. This was repeated for 48 weeks. There was no difference in time to correct answer, response rate, or accuracy. They found answers for 80% of the questions, but the correct answer in only 60%.
What did the pirate say on his 80th birthday?
Aye Matey
I often lament the current state of medical science. Data is unreported. Secondary outcomes are reported as primary. Harm outcomes aren’t even mentioned.
COMPare (CEBM Outcome Monitoring Project) is a group of people trying to fix this. You can read a short blog post about it here. In short, they compare publications with the original trial protocol, report discrepancies, write letters to the editors, and report on their progress. It’s an interesting project that is worth checking out.
However, I guess that’s not really education, so I will add a second #FOAMed selection:
Have ever heard of BRASH syndrome? You’ve probably seen it, but if you are like me, you had probably never heard of it before this month:
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…
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.
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:
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.
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?
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.
Appelboam A, Reuben A, Mann C. Randomised Evaluation of modified Valsalva Effectiveness in Re-entrant Tachycardias (REVERT) study. BMJ open. 4(3):e004525. 2014. PMID: 24622951 [free full text]
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.
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.
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.
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.
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.
Maybe a better summary of this paper is on of my favorite videos by ZDoggMD: https://www.youtube.com/watch?v=NAlnRHicgWs
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.
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.
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.
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.
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.
HEAT trial: Young P, Saxena M, Bellomo R. Acetaminophen for Fever in Critically Ill Patients with Suspected Infection. The New England journal of medicine. 2015. PMID: 26436473 [free full text]
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.
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.
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.
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/
Patient: Doctor, I broke my arm in 3 places. What should I do?
Doctor: Stop going to those places
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:
BoringEM came up with a great series of infographics
I am on vacation this month and I am trying hard to make it a real vacation. So I am not reading any medical literature, even if I have a minute while wait in line at the Colosseum (yes, that has happened before.) Instead of my usual articles of the month, covering the most recent papers I have been reading, I am going to summarize a few classic emergency medicine papers. Most people probably know all of these already, but it is good to review the evidence behind our practice occasionally. Enjoy…
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342:(18)1301-8. PMID: 10793162
This is an RCT of 861 mechanically ventilated patients with ALI or ARDS, designed as a 2×2 trial (half of which examined ketoconazole, but that arm of the trial was stopped due to lack of efficacy.) They randomized patients to the now famous ARDSnet protocol of low tidal volumes to limit plateau pressures or a traditional ventilation strategy. The ARDSnet protocol resulted in a decrease in mortality (31.0% versus 39.8%, p=0.007).
Andersen HR, Nielsen TT, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. 2003;349:(8)733-42. PMID: 12930925 [free full text]
This is a substudy of GUSTO II. It is a prospective multicenter RCT that assigned 1138 patients presenting within 12 hours of their STEMI to either primary angioplasty or thrombolytic (t-PA). For their primary outcome, a composite of death, non-fatal reinfarction, and non-fatal stroke at 30 days, angioplasty had better outcomes (8.0% versus 13.7% p<0.001). This effect was entirely from non-fatal re-infarction, as stroke and death were unchanged – a problem with composite outcomes. Interestingly, and something that we don’t tend to talk about a lot, or at least I was never taught, there was no difference in that composite outcome at 6 months (14.1 vs 16.1% statistically insignificant.)
Mahadevan M, Graff L. Prospective randomized study of analgesic use for ED patients with right lower quadrant abdominal pain. Am J Emerg Med. 2000;18:(7)753-6. PMID: 11103723
I only know the medical world after this study was published, but many people probably still remember the days when surgeons wouldn’t let us treat patients’ pain because it would ruin the abdominal exam. This is a randomized, double blind trial of 68 adult patients suspected of appendicitis, given either tramadol or placebo. Of course, pain was lower in the group that received pain medication (although not by a lot). Not only was the analgesic group examinable, but actually had more specific exams for appendicitis.
Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343:(2)94-9. PMID: 10891516 [free full text]
Jerry Hoffman. Nexus. This is classic emergency medicine. We should all know the criteria:
This was a prospective, multi-centre observational study that included 34,069 patients who had imaging of the cervical spine after blunt trauma and found 818 cervical spine injuries. The decision instrument was 99% sensitive (95%CI 98-99.6%) with a negative predictive value of 99.8% (95%CI 98.0-99.6%). Of course, you do have to accept the specificity of 12.9%. Only 1 of the 8 patients missed had a clinically significant injury that required a surgical intervention.
Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349:(26)2510-8. PMID: 14695411 [free full text]
This is a prospective cohort of 8283 alert trauma patients comparing NEXUS and Canadian c-spine rule (CCR). There were 169 (2%) clinically important c-spine injuries. Unfortunately, in 10% of patients physicians did not properly apply the CCR – they did not assess range of motion as defined. Of course, if a decision instrument is easily misinterpreted (even with the Hawthorne effect of a study) that will affect its utility in practice. How you interpret this study depends entirely on what you do with those patients. If you exclude them, the CCR looks great (sensitivity of 99.4% and specificity of 45.1%). However, if you include them, the sensitivity drops to 95.3% and specificity is 50.7%. This compares with NEXUS with a sensitivity of 90.7% and a specificity of 36.8%. Obviously, neither test performed quite as well as we would hope in this cohort.
Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med. 2004;351:(13)1306-13. PMID: 15385657 [free full text]
This is a multi-centre, double-blind, RCT that included 720 children with mild croup who were randomized to either dexamethasone 0.6mg/kg to a max dose of 20mg or placebo. The children receiving dexamethasone had less “return to medical care” – 7.3% versus 15.3%, p<0.001. The dexamethasone group also had slightly lower croup scores and slept about 1 hour a day more than the placebo group.
Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol. 1995;20:(6)362-8. PMID: 8649915
This is an RCT of admitted pediatric patients with croup comparing dexamethasone at doses of 0.15mg/kg, 0.3mg/kg, and 0.6mg/kg. There was no difference in length of hospital stay, use of epinephrine, croup scores, or representations for medical care.
Fonseca BK, Holdgate A, Craig JC. Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch Pediatr Adolesc Med. 2004;158:(5)483-90. PMID: pubmed
This is a meta-analysis of 16 RCTs involving 1545 children comparing enteral to intravenous rehydration in the treatment of gastroenteritis. (Unfortunately, I have been told by medical-legal types that I am never allowed to make the diagnosis of “gastroenteritis”, so I am not sure who I will apply this study to.) Oral rehydration has significantly fewer adverse events including death and seizure (relative risk 0.36 95%CI 0.14-0.89) and significantly reduced hospital stay (mean decrease of 21 hours). There was no difference in the treatment effect or weight gain. The failure rate for enteral therapy was 4%.
de Gans J, van de Beek D; European Dexamethasone in Adulthood Bacterial
Meningitis Study Investigators. Dexamethasone in adults with bacterial
meningitis. N Engl J Med. 2002 Nov 14;347(20):1549-56. PMID: 12432041 [free full text]
This is a multi-centre, prospective RCT of 301 adult patients suspected of having meningitis and having either cloudy CSF, bacteria on CSF gram stain, or a CSF white count >1000. Patients were randomized to either placebo or dexamethasone 10mg IV q6h for 4 days, with the first dose give 20 minutes before or concurrently with antibiotics (initial antibiotics treatment was with amoxicillin alone). 7% of the steroid group died as compared to 15% of placebo (p=0.04; relative risk 0.48 95%CI 0.24-0.96). There was no difference in hearing loss or focal neurologic abnormalities. Note that steroids and antibiotics were given only after waiting for the CSF results.
However, although this study is considered a classic, it is at odds with the bulk of the literature.
Brouwer MC, McIntyre P, Prasad K, van de Beek D. Corticosteroids for acute bacterial meningitis. The Cochrane database of systematic reviews. 6:CD004405. 2013. PMID: 23733364
This review covers 25 studies involving 4121 participants. Steroids did NOT provide a statistically significant mortality advantage (RR 0.90, 95%CI 0.80-1.01). However, steroids did results in less hearing loss (RR 0.74 95%CI 0.63-0.87).
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:(19)1368-77. PMID: 11794169 [free full text]
This paper is now infamous and certainly created its share of controversy. It was a randomized trial of 263 patients with severe sepsis who were randomized to a specific treatment protocol or standard care. Rivers was able to show a significant mortality benefit, 30.5% versus 46.5% (p=0.009). However, we now know that the specifics of his protocol were mostly irrelevant, you just need to care for your sepsis patients.
Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340:(6)409-17. PMID: 9971864 [free full text]
This is a multi-centre RCT based in Canada that included 838 adult ICU patients with anemia Hb≤ 90 (excluding chronic anemia and patients with active blood loss.) They were randomized to either a restrictive transfusion strategy (transfuse with a Hb <70; target 70-90) or a liberal strategy (transfuse with a Hb < 10; target 100-120). There was not a statistical significance in 30 day mortality (18.7% in restrictive versus 23.3% in liberal). The liberal group had higher in-hospital mortality and cardiac events (secondary outcomes.)
Stiell IG, Wells GA, Field B. Advanced cardiac life support in out-of-hospital cardiac arrest. The New England journal of medicine. 351(7):647-56. 2004. PMID: 15306666 [free full text]
This is a prospective multicenter before and after trial that compared outcomes with basic life support paramedic crews (who had defibrillators) to advanced crews with full ACLS training including medications. 5638 adult patients with out of hospital cardiac arrest were included. The advanced life support paramedics resulted in more ROSC (12.9% vs 18%) and more admissions to hospital (10.9% vs 14.6%), but without any change in survival to hospital discharge (5.0 vs 5.1%).
Why didn’t skeleton cross the road?
He has no guts
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.
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.
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
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.
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.
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.
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.
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.
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.
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?
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.
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.”
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.
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.)
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”.
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.
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.
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.
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.
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.
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.
What is the difference between surgeons and God?
God doesn’t think he is a surgeon
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.
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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.
Vaillancourt S, Guttmann A, Li Q, Chan IY, Vermeulen MJ, Schull MJ. Repeated emergency department visits among children admitted with meningitis or septicemia: a population-based study. Ann Emerg Med. 2015;65:(6)625-632.e3. PMID: 25458981
This is a retrospective cohort of children 30 days to 5 years old who were hospitalized with the final diagnosis of either meningitis or septicemia. They were looking specifically at the children that had bounce backs. In total, 521 children were diagnosed with meningitis or septicemia, 114 (21.9%) of whom had been seen at a hospital in the 5 days prior to that diagnosis. The children all had similar mortality, lengths of stay, and critical care use whether you diagnosed them on the first visit or on the bounce back. Furthermore, meningitis and septicemia is very rare in pediatrics. There were a total of 511 cases in all of Ontario over the entire 5 years of this study. That is 511 out of 2,397,427 ED visits in this age group, or 0.02%, and you are only missing 20% of those on the first visit.
Green SM, Nigrovic LE, Krauss BS. Sick kids look sick. Ann Emerg Med. 2015;65:(6)633-5. PMID: 25536869
This is the excellent editorial that goes with the above paper. I just wanted to include a few quotes:
“A second explanation, simpler and more plausible, is that sepsis or meningitis was not present at the initial visit. The first diagnoses of nonserious viral or bacterial infections were not in error; however, after discharge these children had the rare misfortune of an unanticipated progression of illness.” Ie, don’t kick yourself too hard if you have a bounceback
“The study data of Vaillancourt et al suggest that, outside of the neonatal period, sepsis and meningitis are not occult conditions and that, accordingly, “sick kids look sick.” ”
“The status quo is working.”
“These results encourage emergency physicians to trust the power and value of their clinical gestalt.”
Trenkamp RH and Perez FJ. Heel compressions quadruple the number of Bystanders who can perform chest compressions for ten minutes. Am J Emerg Med. 2015. In Print. PMID: not yet available
This is an observational study in which a convenience sample of 49 individuals, who acted as their own controls, were asked to perform 10 minutes of chest compressions, first in the standard fashion, then using their heel. They describe this process as: the shoeless rescuer straddles the patient’s head facing the patient’s feet, with one foot next to the patient’s ear and the heel of the other foot placed on the chest at the standard CPR point. (A video of this maneuver is provided.) Defining adequate compressions as 100-120 two inch compressions per minute, overall 16% were able to maintain manual compression at 10 minutes and 65% were able to do 10 minutes of heel compressions. Performance of both got worse with age.
Perkins GD, Lall R, Quinn T, et al. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet. 2015;385:(9972)947-55. PMID: 25467566
This is a prospective, randomized control trial of 4471 adult patients with out of hospital cardiac arrest, comparing mechanical CPR (the LUACS-2 device) to conventional CPR. There was no difference in return of circulation, or survival to hospital, at 30 days, at 90 days, or at 1 year. Personally, I find these results confusing. Although I am always biased to assume that new technologies are not going to be better than current practice (because they so rarely are), in this case we know that the one thing that matters for survival in cardiac arrest is consistent, good chest compressions. We also know that people tire and generally don’t provide great compressions, whereas the machine never tires. Based on that theory, the machine should clearly be better. Obviously we are missing something. Maybe it takes too long to get the machine on in the first place? Maybe no technology is capable of raising people from the dead?
Zonfrillo MR, Kim KH, Arbogast KB. Emergency Department Visits and Head Computed Tomography Utilization for Concussion Patients From 2006 to 2011. Acad Emerg Med. 2015. PMID: 26111921
This is a large database study looking at CT usage in concussion from 2006 to 2011 in the US. Overall, 0.5% of ED visits ended in a diagnosis of concussion. Although you might think we all know the CT head decision rules by now, the rate of CT in concussion increased by an absolute value of 11%. Conversely, the injury severity score decreased.
Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012;59:(6)460-8.e1-7. PMID: 22626015
This is a prospective observational trial of 1064 adult patients with blunt head trauma on either warfarin (768 patients) or clopidogrel (296 patients) designed to look for delayed intracranial hemorrhage. These were patients with relatively minor trauma, mostly ground level falls, and 88% having a GCS of 15 at the time of examination. 7% had a bleed on the first scan (12% if on clopidogrel and 5% on warfarin). No patients on clopidogrel and 4/687 (0.6% 95%CI 0.2-1.5%) of patients on warfarin had a delayed intracranial hemorrhage. The major limitation of this study is that not everyone had CT scans.
Fromm C, Suau SJ, Cohen V, et al. Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department. J Emerg Med. 2015. PMID: 25913166
This is a randomized, double-blind study comparing metoprolol (0.15mg/kg) and diltiazem (0.25mg/kg) in 106 adult patients with atrial fibrillation. The primary outcome of HR<100 at 30 minutes was achieved in 95.8% of the diltiazem group and 46.4% of the metoprolol group (p<0.0001). Diltiazem was better at all time points measured. There was no difference between in groups in term of adverse outcomes (hypotension or bradycardia).
Levy PD, Mahn JJ, Miller J, et al. Blood pressure treatment and outcomes in hypertensive patients without acute target organ damage: a retrospective cohort. Am J Emerg Med. 2015. PMID: 26087706
A retrospective cohort of 1016 adult patients with a blood pressure greater than 180/110 and no signs or symptoms of acute organ damage. About 43% were given some kind of treatment, and there was no difference in ED revisits or mortality whether you were treated or not. Of course, this type of association doesn’t prove anything – maybe there was a reason some people were treated and others weren’t.
Wolf SJ, Lo B, Shih RD, et al. American College of Emergency Physicians Clinical Policies Committee. Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 2013 Jul;62(1):59-68. PMID: 23842053
A few points from this policy (the policy contains only level C recommendations):
1) In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required.
2) In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required
Newman DH, Ackerman B, Kraushar ML, et al. Quantifying Patient-Physician Communication and Perceptions of Risk During Admissions for Possible Acute Coronary Syndromes. Ann Emerg Med. 2015;66:(1)13-18.e1. PMID: 25748480
This is a great paper by David Newman. They did paired surveys of patients being admitted to rule out ACS and their treating physicians to determine if patients and their physicians were on the same page with regards to the risk of MI (the reason the patient was being admitted). After having a conversation about admission, the patient and physician estimates of risk were only within 10% of each other 36% of the time. When asked about the chance of dying if an MI occurred at home, patients estimated the mortality at 80% compared to physicians estimates at 10%.
Stein JC, Wang R, Adler N, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Ann Emerg Med. 2010;56:(6)674-83. PMID: 20828874
This is a systematic review and meta-analysis that includes 10 studies of 2057 patients looking at the accuracy of emergency physician performed ultrasound for ectopic pregnancy. The sensitivity (patients with an ectopic who had no IUP on ultrasound) was 99.3%, with a negative predictive value of 99.9% in this population with a 7.5% incidence of ectopic pregnancy.
McDowell M, Nguyen S, Schlechter J. A Comparison of Various Contemporary Methods to Prevent a Wet Cast. J Bone Joint Surg Am. 2014;96:(12)e99. PMID: 24951750
This non blinded trial compared six methods of keeping casts dry. There were 2 commercial products, compared to a plastic bag with duct tape, double plastic bags with duct tape, a plastic bag with a rubber band, or glad cling wrap. The weighed the cast after submerging in water for 2 minutes (so more intense than a shower) to determine water absorption. Plastic wrap and a single bag with duct tape were the least effective. A double bag with duct tape was 100% effective, as were the commercial products.
Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012;2:CD003431. PMID: 22336789
This cochrane systematic review of the medical management of anal fissures covers 75 trials and 5031 patients of different medical therapies. Topical nitroglycerin increased early cure rates from about 35% to 49% compared to placebo, an NNT of 7, but about half of patients had late relapses. No conclusions can be made about calcium channel blockers or botox, because all studies were severely under-powered. Surgical therapy (which I have never referred for) was significantly better than any medical therapy, but does have a small risk of incontinence.
Stibich AS, Yagan M, Sharma V, Herndon B, Montgomery C. Cost-effective post-exposure prevention of poison ivy dermatitis. Int J Dermatol. 2000;39:(7)515-8. PMID: 10940115
I didn’t know that you could prophylactically treat poison ivy after coming into contact with the plant, but before developing a rash. 20 healthy “volunteer” medical students were used them as their own controls. They exposed the students to poison ivy at 4 different spots. 2 hours later, the applied 0.5ml of either dial dish soap, Tecnu (a commercial product designed to chemically inactivate poison ivy), or Goop (a commercial cleaning product), and then rinsed the skin. They left the 4th area untouched as a control (but for some reason didn’t even rinse it off – just left it covered.) All three products were similar, but seem to decrease severity of the rash as compared to control. Ii was unclear if the study was blinded in any way.
Vahidi E, Shakoor D, Aghaie Meybodi M, Saeedi M. Comparison of intravenous lidocaine versus morphine in alleviating pain in patients with critical limb ischaemia. Emerg Med J. 2015;32:(7)516-9. PMID: 25147364
Like low dose ketamine, although to a lesser extent, I have heard a lot about using IV lidocaine for pain control this past year. This is a small RCT of 40 patients with ischemic limbs comparing IV morphine (0.1mg/kg) and IV lidocaine (2mg/kg). In patients with pain starting at 7.5/10, pain in the lidocaine group was better at 15 minutes (5.75/10 vs 7/10) and 30 minutes (4.25/10 versus 6.5/10), although those numbers may not be clinically significant.
Solomon RC. Coffers brimming, ethically bankrupt. Ann Emerg Med. 2012;59:(2)101-2. PMID: 22078890
An older editorial, but worth a read. The summary is that although we make a lot of excuses for why we take money from drug companies, none are any good. As individuals and as a group, we must just stop.
Lakoski SG, Savage PD, Berkman AM, et al. The safety and efficacy of early-initiation exercise training after acute venous thromboembolism: a randomized clinical trial. J Thromb Haemost. 2015;13:(7)1238-44. PMID: 25912176
A very small randomized, controlled trial that included 19 patients with PE, 9 of whom were randomized to a 3 month program including exercise and weight loss. They commit a cardinal sin by claiming to have multiple primary outcomes, but it looks like the exercise group lost weight and was more fit as compared to the usual care group. Of course, a grain or two of salt is required, but it looks like an interesting area for future research.
When to fly to get there on time? Six million flights analyzed. Decision Science News. 2015.
http://www.decisionsciencenews.com/2014/11/06/flight-delays/
This is a database study that looked at all the flight data in the United States for the year of 2013 to determine when you are most likely to be delayed. Not surprisingly, the later your flight is in the day, the longer a delay you can expect, until about 10pm, when the delays start to fall again. There are some graphs you can look at.
Why can’t you tell when a pterodactyl is going to the bathroom?
Because their P is silent
The world of critical care and open access medical education suffered an incredible loss this month with the passing of Dr. John Hinds. He was one of the most inspirational individuals I have encountered in my life, and although I only shook his hand a single time, his words have forever changed me.
It is hard to pick just one of this many incredible talks, but I know both my wife and I were blown away by his keynote speech at the SMACC conference in Chicago: “Crack the chest and get crucified”:
http://intensivecarenetwork.com/hinds-crack-the-chest-get-crucified/
