Articles of the Month (August 2016)

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

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

Articles of the Month (March 2016)

My monthly summaries of the medical literature

Every month I select the best medical articles I have read and provide brief summaries and critical appraisals. Here are this month’s articles:

The paper you are most likely to hear about this month: antibiotics and abscesses

Talan DA, Mower WR, Krishnadasan A. Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. The New England journal of medicine. 374(9):823-32. 2016. PMID: 26962903

Until now, the data on abscess management has been pretty clear: all you need is cold hard steel. No packing, and definitely no antibiotics. Has management just become much more confusing? This is a large, multi-center RCT comparing trimethoprim-sulfamethoxazole (320mg/1600mg MID for 1 week) to placebo in 1247 adult patients with acute abscess greater than 2cm in diameter. For the primary outcome of clinical cure at 7 days, the antibiotics group was better (80.5% versus 73.6%; absolute difference 6.9% 95%CI 2.1-11.7%; NNT = 14). There were also decreases in several secondary outcomes, such as new skin infections at other sites. However, there was an increase in GI side effects by about 7% (42.7% vs 36.1%). A cure rate of only 75% is really low and doesn’t represent the patients I see. This is probably because these are not simple abscess, with a median cellulitis area of 6.5×5.0cm, 20% of the cohort with a cellulitis area greater than 75cm2, and many patients “met other guideline criteria for antibiotics treatment”. (You can read some other opinions on REBEL EM, EM Nerd, and EM Literature of Note.)

Bottom line: This isn’t a game changing paper. It tells you to keep using antibiotics in the patients you are already using them in – complex abscesses with cellulitis – and doesn’t tell us a lot about the average abscess.


How ready are you for a mass casualty event?

Bhalla MC, Frey J, Rider C, Nord M, Hegerhorst M. Simple Triage Algorithm and Rapid Treatment and Sort, Assess, Lifesaving, Interventions, Treatment, and Transportation mass casualty triage methods for sensitivity, specificity, and predictive values. The American journal of emergency medicine. 33(11):1687-91. 2015. PMID: 26349777

I found this paper fascinating. I won’t get into detail about the performance of the scores, because the data is retrospective, and there is too much information that these scores use that would not be well recorded. However, I think this is a great study to read. I had never been exposed to a mass casualty triage system before, nor do I think I have been adequately trained in this aspect of emergency medicine. The algorithms are interesting. It’s worth a read.

Bottom line: Are you for a mass casualty event? This article might help


How do you tell if a patient needs more pain medication? Ask them

Chang AK, Bijur PE, Holden L, Gallagher EJ. Efficacy of an Acute Pain Titration Protocol Driven by Patient Response to a Simple Query: Do You Want More Pain Medication? Annals of emergency medicine. 2015. PMID: 26074387

I am strongly biased to like this study, because I was always thaught this is the way that pain medicine should be given (by Jerry Hoffman, I think). This is a prospective cohort of 215 adult patients presenting to the ED for acute painful conditions that the attending physician thought required an opioid. All patients received hydromorphone 1mg IV, followed by up to 3 more 1mg IV doses every 30 minutes driven entirely by their response to the question “Do you want more pain medication?” There were delays in administration of medication, so the max was actually 4mg over 4 hours. 205 of the 207 patients (99% 95%CI 97-100%) achieved pain control on 1 or more occasions during the study; 97% were either satisfied or very satisfied with their pain treatment. About 20% of patients wanted more pain meds at each interval. What can we learn from this study? The design of the study allows us to conclude that this method will leave most people satisfied with their pain control, and that almost everyone will reach a point where they don’t want any more analgesia. However, with no comparison, we have no idea if this technique is any better or worse than other methods. Personally, I am interested in how this would compare to patient controlled analgesia – which would require a larger upfront investment, but I think would be more tolerable for nursing workloads.

Bottom line: Asking patients is a reasonable method to determine if they need more analgesia


2 is not be better than 1 when in comes to needles

Martin SP, Chu KH, Mahmoud I, Greenslade JH, Brown AF. Double-dorsal versus single-volar digital subcutaneous anaesthetic injection for finger injuries in the emergency department: A randomised controlled trial. Emergency medicine Australasia : EMA. 2016. PMID: 26991958

Injections in the palm always seemed painful to me, so I always stuck with the double dorsal injection technique. I don’t remember why I changed, but my success rate is much better with the single palmar injection, so I’ve never looked back. The study: 86 adult patients in an RCT comparing a double-dorsal to a single-palmar injection technique for digital nerve block. There was no difference in the pain of injection between the two techniques (almost 4/10). The techniques were equally successful (65% success with double-dorsal and 72% with single-palmar). Really, none of those numbers are great.

Bottom line: Stick with the bloc you are used to – and maybe add some bicarb to get the pain on injection down?


Dumb and dumberer

Maltese F, Adda M, Bablon A. Night shift decreases cognitive performance of ICU physicians. Intensive care medicine. 42(3):393-400. 2016. PMID: 26556616

This is a prospective, randomized, cross-over study of 51 ICU doctors (27 residents, 21 attendings) who were randomized to either work a night shift or rest at home (and then were crossed over to the opposite group). Between 10am and noon the next day they went through a series of psychological tests. Not surprisingly, working memory, information process speed, and perceptual reasoning were all worse after a night shift. Cognitive flexibility was not statistically different. The clear issue with the study is we have no idea how these psychological tests translate into patient care, or whether the measured differences are actually clinically important differences.

Bottom line: Night shifts are hard. It’s hard to make good decisions at 4am. (One of many reasons I like the idea of casino shifts).


How safe is that treatment really?

Saini P, Loke YK, Gamble C, Altman DG, Williamson PR, Kirkham JJ. Selective reporting bias of harm outcomes within studies: findings from a cohort of systematic reviews. BMJ (Clinical research ed.). 349:g6501. 2014. PMID: 25416499 [free full text]

These authors attempt to examine the accuracy of reporting of harms in clinical trials. They identified trials that had been included in systematic reviews, and then evaluated each trial for how they reported harms (ie, harms measured and reported, harms not measured, harms measured but only partially reported, harms not even mentioned…). When looking at all Cochrane reviews, they found that the studies only partially reported or didn’t report harms at all 76% of the time. In a group a systematic review designed specifically to look at adverse events, 47% of studies still did not report or only partially reported a single primary harm outcome. This tendency of the literature has been discussed before. We tend to minimize our discussion of harms, which obviously skews our conclusions when looking at the entirety of the literature.

Bottom line: For every medicine you use, remember that the harms are probably greater than those reported in clinical trials


Clinical correlation required

Mark DG, Sonne DC, Jun P. False negative interpretations of cranial computed tomography in aneurysmal subarachnoid hemorrhage. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2016. PMID: 26918885

This is a chart review that identified 452 patients diagnosed with subarachnoid hemorrhage, and looked at the subset of 18 patients (4%) who were diagnosed by lumbar puncture after a normal CT. The supposedly normal CTs were then reviewed by 2 speciality neuro-radiologists, and in 9 of the 18 (50%) the neuro-radiologists thought there was evidence of bleed on the scan initially reported as normal. The false negative rate was 71% (5 of 7) for the scans done within 6 hours of headache. Of course, re-reading studies without the time pressures of a normal shift, especially when LPs have already shown blood (although these radiologists were blinded) might be easier.

Bottom line: Radiology isn’t perfect. Not all radiologists are created equal. This might still be the fatal flaw in the famous Perry study


But doc, it hurts A LOT

Body R, Lewis PS, Carley S, Burrows G, Haves B, Cook G. Chest pain: if it hurts a lot, is heart attack more likely? European journal of emergency medicine : official journal of the European Society for Emergency Medicine. 23(2):89-94. 2016. PMID: 25340995

Does the pain score correlate with the chance of MI? This is a secondary analysis of a data set collected for a prospective cohort study that included emergency department patients with suspected cardiac chest pain. They looked at the pain scores of the patients with a final diagnosis of MI, as compared with those who ruled out. Although there was a statistical difference, with the average pain in the MI group being 8/10 (interquartile range 5-8) and the non-MI group being 7/10 (IQR 6-8) (p=0.03), those numbers obviously don’t help clinically. This is reinforced by their analysis that showed the area under the receiver operating curve was 0.58, so essentially a coin flip. The amount of pain might have influenced the original physicians in terms of who was included in the dataset, which would skew these numbers.

Bottom line: The intensity of pain does not seem to help diagnostically in ACS.


Not the worry, that blurry vision and headache should be gone in … 90 days?

Kriz PK, Stein C, Kent J. Physical Maturity and Concussion Symptom Duration among Adolescent Ice Hockey Players. The Journal of pediatrics. 2016. PMID: 26781190

How long do pediatric concussion symptoms last? This is a prospective cohort of 145 patients aged 13-18 years who were referred to a sports medicine clinic. The mean symptom duration was 45 days (though with wide confidence intervals of +/- 49 days). About half (48%) of patients had symptoms for more than 28 days, and 13% had symptoms beyond 90 days. So perhaps concussion symptoms last longer than we usually counsel, but I worry about a significant selection bias here, as we don’t refer most kids with concussion to sport medicine clinics, and this is only 145 children from 3 clinics over 2.5 years. It probably represents the worst case scenario.

Bottom line: Some children will have prolonged concussion symptoms. Counselling and follow up instructions should keep this in mind


I have to say, the heart is what won me over when it comes to POCUS

Martindale JL, Wakai A, Collins SP. Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2015. PMID: 26910112

This is a systematic review looking the diagnosis of congestive heart failure in the emergency department. Probably because CHF actually encompasses a few different underlying pathologies, their major finding was that no factors were good enough to single handedly rule in or rule out CHF. Some likelihood ratios: Audible S3 +LR 4.0, CXR signs of edema +LR 4.8, B lines on bedside US +LR 7.4, no B-lines -LR 0.16, and reduced ejection fraction on bedside echo +LR 4.1. (Remember you want a positive likelihood ratio of 10 or more to rule in, and a negative likelihood ratio of 0.1 or less to rule out.)

Bottom line: Ultrasound may be our best tool for diagnosing CHF, but no findings can be used in isolation to rule in or rule out the disease.


There are now bottles of water labeled “gluten free”

Zanini B, Baschè R, Ferraresi A. Randomised clinical study: gluten challenge induces symptom recurrence in only a minority of patients who meet clinical criteria for non-coeliac gluten sensitivity. Alimentary pharmacology & therapeutics. 42(8):968-76. 2015. PMID: 26310131

I get asked a lot about gluten, as I am sure many people do, not just by emergency medicine patients, but also friends and families. In this study they took 35 patients who had tested negative for celiac disease but self-identified as being gluten intolerant and in a double blind, cross-over design they exposed the patients to either gluten free or normal flour. 12 (49%) of the patients thought the gluten-free flour contained gluten – what you might guess if the guess was pure chance. I think the evidence is pretty convincing that gluten is not the issue for most people without celiac disease. These patients definitely have symptoms, but there are almost certainly other etiologies than gluten. I worry that the focus on gluten pushed by some ‘experts’ is doing patients a disservice.

Bottom line: In people without celiac disease, symptoms are not consistently reproduced by gluten.


The case of the killer iPhone

Tri JL, Severson RP, Hyberger LK, Hayes DL. Use of cellular telephones in the hospital environment. Mayo Clinic proceedings. 82(3):282-5. 2007. PMID: 17352363

These authors brought 2 telephones into different patient rooms and made phone calls while observing various medical devices. In total they did 300 tests of 192 difference devices in 75 patient rooms, and they were unable to document a single case of the cellular telephone interfering with medical equipment.

Bottom line: The ban on cel phones may be based on a myth?

Continued…

Lawrentschuk N, Bolton DM. Mobile phone interference with medical equipment and its clinical relevance: a systematic review. The Medical journal of Australia. 181(3):145-9. 2004. PMID: 15287832 [free full text]

This is a systematic review looking at the question of mobile phone interference with medical equipment. They identified 8 studies that tested a total of 936 devices. (Studies ranged from 1994-2002, so technology may have changed since.) They found that interference did occur in as many as 6% of tests. However, essentially all of this interference occurred when the phone was within 1 meter of the device – so you probably have to be trying to cause interference, like they were in these studies, rather than just using phones normally. Also, the results of the interference were not recorded, so it’s difficult to know if any of it was clinically relevant. (Some brief interference on an ECG monitor is irrelevant, but I would care about a pacemaker that stopped pacing.)

Bottom line: This is a little more complex than the last paper indicated, but it appears phones are safe as long as they are more than a meter from medical equipment. (Although that might be hard in some of the cramped resuscitation rooms I have worked in.)


NSAIDs for 11/10 pain

Pathan SA, Mitra B, Straney LD. Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial. Lancet (London, England). 2016. PMID: 26993881

This is a double blind RCT of 1644 adult patients with renal colic (1316 confirmed on CT) comparing morphine (0.1mg/kg IV) to diclofenac (75mg IM) to acetaminophen (1 gram IV). For a primary outcome of a 50% reduction in pain at 30 minutes, diclofenac was more effective than either morphine or acetaminophen, which weren’t different from each other (OR 1·35, 95% CI 1·05-1·73, p=0·0187). This means that 68% of the diclofenac group had a 50% reduction in pain, as compared to 61% with morphine and 66% with acetaminophen – not a huge absolute difference. One interesting number is that only 12% of the IM diclofenac group needed any rescue medication, so it might be possible to manage renal colic without ever starting an IV. Adverse events were statistically higher in the morphine group, but really quite low (1-3%) in all groups. Personally, I like a multimodal pain approach, and will probably continue to combine NSAIDS and opioids.

Bottom line: It might be true that NSAIDs are slightly more effective in renal colic


#FOAMed of the Month

This is a really short post on the Nurse Path, but I love it because it is a simple yet brilliant method for improving communication and patient safety. The key is that for medication checks, rather than reading out the dose and asking the person confirm ‘yes or no’, which could result in confirmation bias or error, you simply ask “what is this?” That forces the other person to slow down and actually read the medication out loud. I imagine this technique could also be used in another of other situations as well.


 

 

Cheesy Joke of the Month

Two orthopedic surgeons are on opposite sides of a lake.

One surgeon yells to the other, “How do you get to the other side?”

The other responds, “You are on the other side!”

Articles of the month (February 2016)

There are new sepsis definitions! Hurrah?

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

Bottom line: Talk about qSOFA if you want to sound in the know, but clinically I would ignore this paper


Procedural sedation consent: “Don’t worry, it’s super safe… it’s the Michael Jackson drug.”

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.

Bottom line: Procedural sedation is safe, but we should have a sense of these numbers for adverse events.


Still not using topical anesthetics for corneal abrasions? Could topical NSAIDs be a better choice?

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.)

Bottom line: Topical NSAIDs may decrease pain from corneal abrasions, but I don’t think this data is enough to support using them over other agents (especially considering their cost.)


Xanthrochromia AKA hey Bob, does this look kinda yellow to you?

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?

Bottom line: Neither method of detecting xanthochromia is perfect, which adds another layer of complexity to the question of who we should be LPing after CT


Foley free pee?

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.

Bottom line: You can make children pee using this technique. Not sure where to fit that into practice.


I never get tired of talking about nerve blocks

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).

Bottom line: I will keep using nerve blocks for all hip fractures. I’m not too worried about the location of the fracture.


Diverticulitis – antibiotics, seeds, or exercise

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:

  • “The AGA suggests that antibiotics should be used selectively, rather than routinely, in patients with acute uncomplicated diverticulitis. (Conditional recommendation, low quality of evidence).” (They note that so far the RCTs showing no benefit of antibiotics have been in inpatients with CT proven diverticulitis.)
  • “The AGA suggests against routinely advising patients with a history of acute diverticulitis to avoid consumption of nuts and popcorn. (Conditional recommendation,very-low quality of evidence).” This is another one of those myths that we breeze over, but can really ruin patients’ quality of life
  • “The AGA suggests advising patients with diverticular disease to consider vigorous physical activity. (Conditional recommendation, very low quality of evidence).” This makes sense, but it has not been part of my discharge script – until now.

People are going to start thinking I have a personal vendetta against antibiotics

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).

Bottom line: Antibiotics probably help in UTIs, just not as much as you think


One more time: dex is as good as pred in asthma

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.

Bottom line: Once again, dex is great for asthma


Sticking with obvious pediatric topics: ondansetron works

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.

Bottom line:  Surprise? Ondansetron does help vomiting kids orally hydrate.


When your heart leaves you speechless

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.

Bottom line: This is interesting trivia, but the association of aphasia with cardioembolism is clinically irrelevant.


A Salter Harris Myth Update

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.

Bottom line: Salter Harris 1 fractures are rare and of questionable clinical relevance. Stop casting all these kids.


How important are c-spine precautions in submersion victims?

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.

Bottom line: A submerged patient is very unlikely to have a c-spine injury if there isn’t obvious signs of trauma


Modified Sgarbossa criteria – now for more than just ECG geeks?

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.

Bottom line: Like many things on the ECG, proportion probably matters, but it isn’t well studied.

Read more on Dr. Smith’s blog here, here, or here.


 

How many diseases can you diagnose at 20 feet?

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.

Bottom line: Worth a read through if you want to better understand your eye exam.


Intralipid review

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.

Bottom line: I will probably use intralipid if this comes up, but we really need better science in toxicology.


Osteoarthritis is not an xray diagnosis

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.

Bottom line: Xray cannot provide any valuable information about osteoarthritis of the hip


Should we let residents use Google on shift?

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%.

Bottom line: Google doesn’t look worse than these specific medical tools, but I really want my residents to be right more than 60% of the time in an open book test.


Cheesy Joke of the Month

What did the pirate say on his 80th birthday?

Aye Matey


 

#FOAMed of the Month

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:

BRASH syndrome on PulmCrit

 

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/