The end of another month can only mean one thing: I have once again read too many articles, and I feel the need to share them all with you. I think there is an excellent spectrum of really interesting papers this month, and as always I discuss them at length with Casey Parker on the Broome Docs podcast. Continue reading “Articles of the month (October 2016)”
There are new sepsis definitions! Hurrah?
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.
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.
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
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?
#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:
A monthly collection of the most interesting emergency medical literature I have encountered.
Here is this month’s summary of my favorite reads from the medical literature…
Bronchiolitis – it will take your breath away
Willwerth BM, Harper MB, Greenes DS. Identifying hospitalized infants who have bronchiolitis and are at high risk for apnea. Ann Emerg Med. 2006;48:(4)441-7. PMID: 16997681
Its that time of year. Some children are beginning to hold their breath in anticipation of Christmas. Or, maybe that was an apneic spell from bronchiolitis? Which children are at risk? This is a retrospective cohort of 691 children less than 6 months old who were admitted to the hospital for bronchiolitis looking at risk factors associated with apnea. The authors found that full term babies less than 1 month old, preterm babies less than 48 weeks post-conception, and babies whose caregivers had already witnessed an apnea spell were at higher risk for further apnea spells. Overall 19 (2.5% 95%CI 1.7-4.3) children had apnea spells while admitted, and all 19 met one of the criteria above.
Bottom line: 2.5% is relatively low risk, but breathing is relatively important. I would have the pediatricians review the kids that fall into these categories.
More bronchiolitis and the need for oxygen
Cunningham S, Rodriguez A, Adams T. Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. Lancet (London, England). 386(9998):1041-8. 2015. PMID: 26382998
This is a multi-center, randomized, controlled trial of children aged 6 weeks to 12 months admitted to hospital with bronchiolitis. This children were either placed on a standard sat probe or one that was altered so that a sat of 90% would display as 94%. Staff were instructed to provide oxygen to any child with a sat less than 94%. (94% seems like a pretty high target. I am more interested in whether we should be starting oxygen at say 92% or 88% or even lower.) I think they chose a pretty poor primary outcome: time to resolution of cough. For what it’s worth, it was equivalent, but did we really think oxygen could cure cough? Some secondary outcomes were also not affected, but none capture why I give oxygen. Oxygen is given when children are approaching the steep portion of the oxygen-hemoglobin dissociation curve to prevent precipitous drops, desaturations, and bad outcomes. The authors do report no change in ‘adverse events’, but if you look at the supplement, respiratory adverse events were things like cough and otitis media. Although I believe we probably over-treat bronchiolitis, this is another in a slew of papers that fails to actually prove that it is safe to withhold oxygen or discharge patients with low oxygen saturations.
Bottom line: Oxygen saturation is still an important parameter to monitor in bronchiolitis. We don’t know the ideal saturation to target.
Children inhaling salt water – no, not drowning, but bronchiolitis treatment
Silver AH, Esteban-Cruciani N, Azzarone G. 3% Hypertonic Saline Versus Normal Saline in Inpatient Bronchiolitis: A Randomized Controlled Trial. Pediatrics. 2015. PMID: 26553190
This is a randomized, double-blind, controlled trial from a single pediatric hospital comparing 4 ml of either 3% saline or 0.9% saline nebulized every 4 hours in 227 children under 12 months old with bronchiolitis. There was no difference in any of the many outcomes they measured, including length of stay, ICU admission, readmission, and objective respiratory findings. Of course, it’s possible that normal saline is more therapeutic than no treatment – but, come on, you know that nothing works in bronchiolitis.
Bottom line: No treatments work in bronchiolitis. Do you think we will ever come to terms with that?
It might just be the season, but it seems like I am obsessed with wheezing kids
Cronin JJ, McCoy S, Kennedy U. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Annals of emergency medicine. 2015. PMID: 26460983
I have covered dexamethasone versus prednisone for asthma before, but here is another RCT. In 245 pediatric patients (aged 2-16) with asthma, they compared a single dose of dexamethasone (0.3mg/kg) to prednisolone (1mg/kg) for 3 days. Their primary outcome was a PRAM score on day 4 and there was no difference between the two.
Bottom line: I will continue using the easier single dose dexamethasone over prednisone.
More shots fired in the continuing Roc versus Sux RSI battle
Tran DT, Newton EK, Mount VA, Lee JS, Wells GA, Perry JJ. Rocuronium versus succinylcholine for rapid sequence induction intubation. The Cochrane database of systematic reviews. 10:CD002788. 2015. PMID: 26512948
This one is going to ruffle a few feathers. Let’s start with the author’s conclusions: “Succinylcholine created superior intubation conditions to rocuronium in achieving excellent and clinically acceptable intubating conditions.” This is a cochrane review that includes 50 trials covering 4151 patients. For “excellent intubating conditions” succinylcholine was superior to rocuronium (RR 0.86 95%CI 0.81-0.92). The problem with this conclusion is the significant heterogeneity in the included studies. For me, the biggest concern is varying doses. In fact, the authors even conclude that if you use 1.2mg/kg of rocuronium (the appropriate dose for RSI) there was no difference between roc and sux. Unfortunately, they make the erroneous conclusion that sux is still better because it has a shorter duration of paralysis. In emergent airways, short paralysis is not a good thing.
Bottom line: Ignore the conclusions, rocuronium at a proper dose (1.2mg/kg) is a great paralytic for RSI.
One of my favorite myths to rant about – and apparently some very smart people out there agree with me
Swaminathan A, Otterness K, Milne K, Rezaie S. The Safety of Topical Anesthetics in the Treatment of Corneal Abrasions: A Review. The Journal of emergency medicine. 49(5):810-5. 2015. 26281814
I spoke about topical anesthetics for corneal abrasions at rounds earlier this year. (My handout from that talk can be found here.) This is a systematic review looking at the same topic. They identify 2 emergency department studies and 4 ophthalmology studies (after a procedure called photorefractive keratectomy – essentially a iatrogenic corneal abrasion) that prospectively evaluated the use of topical anesthetics for corneal abrasions. All the studies were small. Topical anesthetics resulted in no complications. Overall, topical anesthetics appear to be effective, with clinically and statistically significant pain score reduction in 5 of 6 studies.
Bottom line: Treat your patient’s pain. A short course of topical anesthetic is probably safe and almost certainly effective for corneal abrasions.
Acute HIV – a diagnosis I am probably missing
Early HIV infection presents as a mononucleosis-like infection, making it very difficult to diagnose. Although I generally dislike using the emergency department for public health screening, if HIV is not diagnosed during this initial stage, many years may pass before it is diagnosed, not only hurting the patient, but also putting their many contacts at risk. This is a letter to the editor describing a study where they retrospectively took all blood samples that were sent for epstein barr virus at Massachusetts General Hospital and tested them for HIV RNA. They found that 1.2% (7/563) has an acute HIV infection and another 0.8% (4/563) had chronic HIV.
Bottom line: This is well above the threshold for screening for HIV. Perhaps monospot and HIV testing should be paired?
1 more: Non specific viral illness or acute HIV?
Pincus JM, Crosby SS, Losina E, King ER, LaBelle C, Freedberg KA. Acute human immunodeficiency virus infection in patients presenting to an urban urgent care center. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 37(12):1699-704. 2003. PMID: 14689354 [free full text]
Sticking with the same topic, these authors tested all patients presenting with viral symptoms and 1 or more HIV risk factors at their urban urgent care centre for HIV. (They were very broad with their HIV risk factors: any sexual contact, any injection drug use, any crack use, or any alcohol use in the last 2 months.) Of the 499 patients included, 5 (1.0%) were diagnosed with an acute HIV infection and another 6 (1.2%) were diagnosed with chronic HIV. They did not have any false positives.
Bottom line: Depending on your work environment, it may be worth screening for HIV in patients with viral illnesses.
It’s all about that aVL
Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. The American journal of emergency medicine. 2015. PMID: 26542793
Is that Inferior ST elevation indicative of STEMI? Or is it pericarditis? aVL might hold the key. This is a retrospective look at 3 different groups. Of 154 patients with a final diagnosis of inferior STEMI, all 154 had some degree of ST depression in aVL. Of the 49 patients with pericarditis, 49 had some degree of inferior ST elevation, but none had any ST depression in aVL. There was a third cohort with subtle inferior ST elevation (less than 1mm) but confirmed vessel occlusion on cath. Of these 54 patients, 49 had ST depression in aVL. The authors conclude that ST depression is highly sensitive for inferior STEMI and specific for pericarditis.
Bottom line: I will certainly look at aVL, but would love to see this repeated prospectively
If you want to read more about this and see some example ECGs, check out the blog post by senior author Dr Steve Smith: http://hqmeded-ecg.blogspot.ca/2015/11/new-paper-published-on-significance-of.html
Cold – the pure green coffee (ask Dr. Oz) of the brain
Another in the cold brain is not healthy brain category. This is a multicentre, randomized controlled trial of 387 adult patients (out of 2498 screened patients) with traumatic brain injury and persistently elevated ICP after sedation, elevation of the head of the bed, and mechanical ventilation. They were randomized to either get or not get hypothermia (target between 32 and 35 degrees Celsius for 48 hours.) The trial was stopped early for harm. Their primary outcome (neuro status based on the extended Glasgow outcome scale) was worse in the hypothermia group (OR 1.53 95%CI 1.02-2.30). Mortality was also worse (OR 1.45 95%CI 1.01-2.10). The biggest problem with the study was that they included patients up to 10 days after injury, which could just be too late for the magical power of cold to work.
However, I don’t think we should find this too surprising. Hypothermia has been tried for many conditions, including TBI, in the past with limited success. The general failure of hypothermia is one of the reasons to remain highly skeptical of those two small, biased trials that indicated that it worked in cardiac arrest. It may be reasonable to continue using hypothermia for the time being, but if anyone gets around to actually repeating the hypothermia versus placebo trial in cardiac arrest, we shouldn’t be surprised if it turns out to have no effect.
Bottom line: No hypothermia for trauma
Dual antiplatelets for stroke/TIA?
Wang Y, Pan Y, Zhao X. Clopidogrel With Aspirin in Acute Minor Stroke or Transient Ischemic Attack (CHANCE) Trial: One-Year Outcomes. Circulation. 132(1):40-6. 2015. PMID: 25957224
This is one of those trials that will get talked about, but I worry we will over apply the results. This is a large multicenter randomized trial in which 5170 Chinese patients with high risk TIA or minor CVA were randomized to either clopidogrel 75mg daily for 3 months plus aspirin 75 mg daily for 21 days or aspirin 75 mg daily for 3 months. The primary outcome of stroke at 1 year occurred in 10.6% of the combo group as compared to 14.0% of the aspirin alone group (hazard ratio, 0.78; 95% confidence interval, 0.65-0.93; P=0.006). Bleeding was the same in both groups. I think there are a few important caveats. First, you should question the generalizability of these results to your patients unless you work in China, because the rates of smoking in China are unlike those anywhere else in the world. Second, it is unlikely that the combination of ASA and clopidogrel has the same bleeding rates as ASA alone. That doesn’t fit well with previous studies or general experience. This should remind us that RCTs are usually not well designed to identify harms and will often over estimate the benefit to harm ratio.
Bottom line: I would not be changing my practice to include dual antiplatelet therapy based on this study alone.
Great ultrasound tip – try using both probes for IUP
Tabbut M, Harper D, Gramer D, Jones R. High-frequency linear transducer improves detection of an intrauterine pregnancy in first trimester ultrasound. The American Journal of Emergency Medicine. Article in Press. PMID:
Traditionally, we are taught to use a curvilinear abdominal probe when performing transabdominal ultrasound to detect first trimester pregnancy. This study looked at adding the high frequency linear transducer after failure to identify IUP with the standard transducer. Of 81 initial scans, 27 patients did not have an IUP visualised with the curvilinear probe. Of those, 9 (33%) were found to have an IUP by using the linear probe.
Bottom line: It’s probably worth trying the linear probe if you can’t see an IUP with the curvilinear.
Cricoid pressure: the evidence?
Algie CM, Mahar RK, Tan HB, Wilson G, Mahar PD, Wasiak J. Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation. The Cochrane database of systematic reviews. 11:CD011656. 2015. PMID: 26578526
This is a Cochrane review designed to look for any RCT evidence of the value of cricoid pressure in either emergent or elective airways. The review really says nothing of value, because there is no evidence to review. So why include it? Because sometimes it’s important to know that there is no evidence to review. If anyone ever gets too dogmatic on either side of the cricoid pressure debate, they should probably be ignored.
Bottom line: There is no evidence supporting the use of cricoid pressure. I abandoned it a long time ago, but I would be happy to see an RCT done to confirm or contradict my current practice.
Sex is better than flomax!
Doluoglu OG, Demirbas A, Kilinc MF. Can Sexual Intercourse Be an Alternative Therapy for Distal Ureteral Stones? A Prospective, Randomized, Controlled Study. Urology. 86(1):19-24. 2015. PMID: 26142575
By now, everyone should know that tamsulosin does not help patients with kidney stones, but that doesn’t mean we should give up on our patients. Is there anything else we can do to help? In this randomized, controlled study 75 adult patients with nephrolithiasis were randomized to either 1) being asked to have sex at least 3-4 times a week, 2) tamsulosin 0.4mg a day, or 3) usual care. There were no placebos (although if you can come up with a placebo version of sex I want to hear about it.) The mean time to stone expulsion was only 10 days (95%CI 4.2-15.8 days) in the sex group, versus 16.6 (95%CI 8.1-25.1 days) with tamsulosin and 18 (95%CI 15.5-23.5 days) with usual care (p=0.0001). I foresee a large number of men looking for medical notes explaining this therapy to their wives. Perhaps there may even be a few malingerers without stones looking to get this prescription?
Bottom line: Sex is good
When is dementia not dementia?
Djukic M, Wedekind D, Franz A, Gremke M, Nau R. Frequency of dementia syndromes with a potentially treatable cause in geriatric in-patients: analysis of a 1-year interval. European archives of psychiatry and clinical neuroscience. 265(5):429-38. 2015. PMID: 25716929
Dementia is a horrible diagnosis that we can’t do anything about. But is it always? In this retrospective review of patients admitted to hospital with dementia, the authors searched for reversible causes. Of the patients previously diagnosed with dementia, the authors were able identify a potentially reversible cause in 23%. Of the newly diagnosed dementia, 31% had potentially reversible causes. The common reversible causes included low B12, depression, alcoholism, and normal pressure hydrocephalus. I wouldn’t hang my hat on any of the numbers, given the retrospective nature of the trial, but this should serve as a reminder that we might be able to help some of these patients. If you can reverse dementia, that is a true save.
Bottom line: Some dementia is reversible. These causes should be searched for.
Dikembe Mutombo is wagging his finger – Block!
Riddell M, Ospina M, Holroyd-Leduc JM. Use of Femoral Nerve Blocks to Manage Hip Fracture Pain among Older Adults in the Emergency Department: A Systematic Review. CJEM. 2015. PMID: 26354332
My appraisal may be biased because I love nerve blocks, especially when I can do them with an ultrasound. This is a systematic review of randomized control trials asking the question: does the use of a femoral nerve block reduce pain, opioid use, delirium, or improve function in adults over 65 with an acute hip fracture. They found 7 RCTs covering a total of 224 patients – so the studies were small. Also, only one trial was placebo controlled. The remainder compared the nerve block to opioids. The authors appropriately did not perform a meta-analysis, as the studies were heterogenous, so a single numerical summary is not possible. The best summary is that the nerve block group consistently had both statistically and clinically significant reduction in their pain scores as compared to placebo, used less opioid, and had fewer complications.
Bottom line: Nerve blocks work great for hip fractures. We should be using these.
From Dikembe Mutombo to Mark Spitz
Browne KM, Murphy O, Clover AJ. Should we advise patients with sutures not to swim? BMJ (Clinical research ed.). 348:g3171. 2014. PMID: 24859900
I always find it a little frustrating when my non-medical friends ask me questions about medicine that seem really simple, but that I honestly can’t answer. What exactly did I learn in all those years of school? The most recent question was: “when can I started swimming again after getting stitches?” This is a review, if you can call a search that unearthed only a single case report a review, trying to answer that question. Yes, apparently in the entire medical literature there is a single reported case of a wound infection that occurred after swimming – and that was in a hospital rehab pool which is probably more likely to be colonized with strange bugs than your average swimming pool. The authors try to shape this into a practical answer, but I think the best answer we can give is “we don’t know”. Early showering after surgery has been shown to be safe, so maybe you could extrapolate from that.
Bottom line: There is much in medicine that we simply don’t know
Which is more important: rinsing your dishes before they go in the dishwasher, or rinsing out the inside of an abscess?
Chinnock B, Hendey GW. Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success. Annals of emergency medicine. 2015. PMID: 26416494
I was never taught to irrigate abscesses in residency. It was only this year that I discovered that this has been suggested by numerous guidelines. But not so fast. This is a non-blinded RCT of 209 patients with cutaneous abscesses randomized to irrigation or no irrigation. There was no difference in the need for further treatment (I&D, antibiotic change, or admission) at 30 days between the 2 groups (15% vs 13%). Unfortunately a huge number of these patients were put on antibiotics (91% in the irrigation and 73% in the no irrigation group), which we know are unnecessary in most abscesses, but contaminate the results here.
Bottom line: This wasn’t common practice where I trained and we never saw many bouncebacks. I won’t start irrigating abscesses based on this.
Should the Bee Gees pause for a breath (at 30:2)?
“Well, you can tell by the way I use my walk, I’m a woman’s man. No time to talk… Ah,ha,ha,ha, stayin’ alive”. This is a large randomized controlled trial of 23,711 adult patients with out of hospital cardiac arrest comparing the standard 30:2 ratio of chest compressions to rescue breaths, to continuous chest compressions at 100/min with 10 asynchronous breaths a minute. The primary outcome of survival to hospital discharge was identical, 9.0% in the continuous chest compression group and 9.7% in the 30:2 group. Neurologically intact survival was 7.0% and 7.7% respectively. The biggest issue with the data is that everyone got extremely high quality CPR, and the compression fraction was almost identical in both groups, so it would have been difficult to demonstrate any difference.
Bottom line: Personally, I like continuous compressions with asynchronous breaths more, but this trial supports whatever you are comfortable with as long as you are doing high quality CPR.
A quick and easy rule out blood test for aortic dissection? Get real
Asha SE, Miers JW. A Systematic Review and Meta-analysis of D-dimer as a Rule-out Test for Suspected Acute Aortic Dissection. Annals of emergency medicine. 66(4):368-78. 2015. PMID: pubmed
This is a systematic review and meta-analysis looking to determine the diagnostic accuracy of D-dimer as a rule out test of aortic dissection. In total they found 5 studies including a total of 1600 patients. My first point of concern is that 1035 of those patients came from a single study, which could potentially dominate a meta-analysis, and that study was not designed to test the accuracy of D-dimer. In fact, the study enrolled 1455 patients, but only 1035 were counted in this meta-analysis, because the other patients never even had a D-dimer drawn. The results they present are pretty impressive, with a pooled sensitivity of 98% (95%CI 96-100%), specificity of 42% (95%CI 39-45%), negative likelihood ratio of 0.05 and positive likelihood ratio of 2.11. However, I would be very careful interpreting those results. Not only are the majority of the patients from a registry where D-dimer didn’t have to be drawn, but these were almost all patients admitted to CCUs, so very different from our ED population. Finally, although you would be using this test to try to avoid CTs, the poor specificity in a lower risk population could actually paradoxically lead to increased CT usage, much like D-dimer for PE.
Bottom line: This study isn’t enough to support D-dimer to rule out aortic dissection in the ED.
“Unreasonable haste is the direct road to error” – Moliere
Fanari Z, Abraham N, Kolm P. Aggressive Measures to Decrease “Door to Balloon” Time and Incidence of Unnecessary Cardiac Catheterization: Potential Risks and Role of Quality Improvement. Mayo Clinic proceedings. 2015. PMID: 26549506
An important lesson in unintended consequences. We know that short door to balloon times are important for STEMI patients. This is a study from a single hospital where they instituted a number of measures to decrease the door to balloon time. And it worked! Well – they managed to get the door to balloon time decreased by 15 minutes, which is excellent. However, it’s important to measure patient oriented outcomes and in this cohort the false positive STEMI rate rose from 7.7% to 16% and there was an increased mortality in this false positive group.
Bottom line: Inappropriate benchmarks can result in physicians rushing, more errors, and patient harms.
Don’t let an endotracheal tube make your patient worse
Kim WY, Kwak MK, Ko BS. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PloS one. 9(11):e112779. 2014. PMID: 25402500 [free full text]
Emergency physicians love procedures and intubation is one of our favorite. Sometimes this leads to us being a little overzealous about intubating very early, when an immediate airway is not necessary. This is a case control study of 41 critically ill adult patients that had a cardiac arrest after intubation (out of a total of 2404 critically ill patients who were intubated – or 1.7%.) Pre-Intubation hypotension (a systolic blood pressues ≤ 90) was independently associated with post-intubation arrest (OR 3.67 95%CI 1.58-8.55.) The case control design may not provide precise numbers, but I think this is a good reminder that some patients need good resuscitation before we attempt intubation.
Bottom line: Resuscitation before intubation in hypotensive patients
Cheesy Joke of the Month
There are two cows in a field. The first cow turns to the second and asks, “did you hear about the outbreak of mad cow disease?” The second cow responds: “Good thing I am a helicopter.”
#FOAMed of the month
Every month this section could probably just be filled with my favorite talks from SMACC. I will try to include some different FOAM in coming months, but these talks were so go that even though I listened to them live, I have listened to them all again at home. This is why I have been telling everyone who will listen they should join me in Dublin in June. The first tickets sold out very fast, but some more will go on sale December 1st at 5pm EST (if my math is right.)
For now, these talks were amazing:
Crack the chest. Get crucified. (John Hinds) – I know I have recommended this one before, but it is worth more than one watch.