Emergency – Broome Docs: Recent Episodes
Dr Casey Parker
This is a short vodcast breaking down the numbers from the recent SHED trial.
In this video I breakdown the numbers on the bad things that we may find in the workup of acute headaches in the ED, how the CT helps and when and why we might need to perform an LP to identify some subtle pathology.
You can listen to a deep dive on the October Journal club here.
Let me know if you like this format. I will try and do more visual data dives in the future.
PLease pop over to the Youtube channel and subscribe if you like these and check out our US training and other resources that are on the feed .
Welcome to a special edition of the Journal Club with Justin. This month we recorded live with a bunch of fantastic Broome junior doctors. Justin gate-crashed our local journal club to share his approach to “reading a paper” ( Video version here) and then we dived into a bunch of new papers… and one really old one. Thanks to Drs Emily Wishart, Josh Briotti and Will Arnott who were brave enough to join the chaos and unscripted nerd fest that we put on every month or two.
So follow along with the papers below and read to make up your own mind about the evidence presented.
Too much ‘aint enough blood?Turgeon AF, Fergusson DA, Clayton L,et al. Liberal or Restrictive Transfusion Strategy in Patients with Traumatic Brain Injury. N Engl J Med. 2024 Jun 13. doi: 10.1056/NEJMoa2404360. PMID: 38869931
Bottom line: This large multi-center RCT comparing liberal and restrictive transfusion triggers in patients with traumatic brain injury was statistically negative, but may actually support more liberal transfusion.
Can patients predict the future?Mols EM, Haak H, Holland M, Schouten B, Ibsen S, Merten H, Christensen EF, Nanayakkara PWB, Nickel CH, Weichert I, Kellett J, Subbe CP, Kremers MNT; Safer@Home Research Consortium. Can acutely ill patients predict their outcomes? A scoping review. Emerg Med J. 2024 May 28;41(6):342-349. doi: 10.1136/emermed-2022-213000. PMID: 38238065
Oral vs IV ABs… another negative trialNielsen AB, Holm M, Lindhard MS, et al. Oral versus intravenous empirical antibiotics in children and adolescents with uncomplicated bone and joint infections: a nationwide, randomised, controlled, non-inferiority trial in Denmark. Lancet Child Adolesc Health. 2024 Jul 15:S2352-4642(24)00133-0. doi: 10.1016/S2352-4642(24)00133-0. Epub ahead of print. PMID: 39025092
Is early CT actually 100% sensitivity for SAH (Of course not)Roberts et al, Subarachnoid haemorrhage in the emergency department (SHED): a prospective, observational, multicentre cohort study. Emergency Medicine Journal Published Online First: 12 September 2024. doi: 10.1136/emermed-2024-214068
MagA: Making Airways Great Again?Zouche I, Guermazi W, Grati F, Omrane M, Ketata S, Cheikhrouhou H. Intravenous magnesium sulfate improves orotracheal intubation conditions: A randomized clinical trial. Trends in Anaesthesia and Critical Care. 2024; 57:101371-.
You can read more on BroomeDocs: MagA: Making Airways Great Again?
Yes, this paper is more than 100 years oldThe Relationship Between Herpes Zoster, Syphilis and Chickenpox. JAMA. 2019 Nov 5;322(17):1722. doi: 10.1001/jama.2018.15583. PMID: 31688874
How will we look with the retrospectoscope in 100 years? Probably not that bright!
Welcome to another month of nerdy journal jam goodness. This month Justin has served up an eclectic collection of evidence, ethics and educational excellence. As always – we have the full PDFs liked below and you can read more deep thoughts over at First10EM where Justin likes to inconvenience a lot of electrons in his pursuit of educational elegance.
In a surprise to no one who reads First10EM, clinical judgment is better than all decision tools for sepsisKnack SKS, Scott N, Driver BE, Prekker ME, Black LP, Hopson C, Maruggi E, Kaus O, Tordsen W, Puskarich MA. Early Physician Gestalt Versus Usual Screening Tools for the Prediction of Sepsis in Critically Ill Emergency Patients. Ann Emerg Med. 2024 Mar 25:S0196-0644(24)00099-4. doi: 10.1016/j.annemergmed.2024.02.009. Epub ahead of print. PMID: 38530675
Justin has written out his full thoughts here: First10Em – Gestalt,
Bottom line: These decision instruments for sepsis have never been shown to improve upon clinical judgement or improve patient care. Until we have evidence of benefit, they shouldn’t be used, and we should rely on clinical judgement, which this trial demonstrates is quite good.
Do you still suggest emergency medicine to your students?Rosenberg H, Syed S, Atkinson P. CJEM debate series: #StillTheOne-while more challenging than ever, emergency medicine is still the best career path available for medical students. CJEM. 2024 Jun;26(6):381-385. doi: 10.1007/s43678-024-00682-8. Epub 2024 Apr 9. PMID: 38592662
Bottom line: Would you be happy if you kid follow-ed your footsteps into emergency medicine? I think it is important to be honest about the realities of our job for students considering the profession. We don’t do any favours by ‘selling’ the specialty. But I would still choose this path again for myself, so have no problem recommending it to others.
Reflexive Control… sounds a bit scary.. what is it?Iserson KV. Reflexive control in emergency medicine. Am J Emerg Med. 2024 Jul;81:75-81. doi: 10.1016/j.ajem.2024.04.037. Epub 2024 Apr 23. PMID: 38677197
Sorry! WHAT DID YOU SAY?….Adams C, Walsan R, McDonnell R, Schembri A. As loud as a construction site: Noise levels in the emergency department. Australas Emerg Care. 2024 Mar;27(1):26-29. doi: 10.1016/j.auec.2023.07.004. Epub 2023 Jul 31. PMID: 37532590
Bottom line: Emergency departments are noisy, although not ridiculously so.
Can we all just agree that peripheral pressors are just fine?Munroe ES, Heath ME, Eteer M, Gershengorn HB, Horowitz JK, Jones J, Kaatz S, Tamae Kakazu M, McLaughlin E, Flanders SA, Prescott HC. Use and Outcomes of Peripheral Vasopressors in Early Sepsis-Induced Hypotension Across Michigan Hospitals: A Retrospective Cohort Study. Chest. 2024 Apr;165(4):847-857. doi: 10.1016/j.chest.2023.10.027. Epub 2023 Oct 26. PMID: 37898185
Bottom line: If a patient needs a vasopressor, just start it through your peripheral IV, assuming you have one you trust. For the most part, central lines can be left to the ICU team during day time hours (and a good percentage of patients will never need one).
Don’t stress, just give the PPI and carry on.Cook D, Deane A, Lauzier F, et al. Stress Ulcer Prophylaxis during Invasive Mechanical Ventilation. N Engl J Med. 2024 Jul 4;391(1):9-20. doi: 10.1056/NEJMoa2404245. Epub 2024 Jun 14. PMID: 38875111 NCT03374800
Farkas has a deep dive on this topic in PulmCrit.
Maybe ED is not the best place for all patients!Burton C, Mooney C, Sutton L, et al. Effectiveness of a symptom-clinic intervention delivered by general practitioners with an extended role for people with multiple and persistent physical symptoms in England: the Multiple Symptoms Study 3 pragmatic, multicentre, parallel-group, individually randomised controlled trial. Lancet. 2024 Jun 15;403(10444):2619-2629. doi: 10.1016/S0140-6736(24)00700-1. PMID: 38879261
Mythical Membrane Stabilisation memePiktel JS, Wan X, Kouk S, Laurita KR, Wilson LD. Beneficial Effect of Calcium Treatment for Hyperkalemia Is Not Due to “Membrane Stabilization”. Crit Care Med. 2024 Jul 24. doi: 10.1097/CCM.0000000000006376. Epub ahead of print. PMID: 39046789
Welcome to another episode of the Journal Club with Justin. This onth we look at a big trail that may change our airway approach in the ED… and then a pile of things that probably should not be in our practice at this point! So grab a cup, enjoy the nerdy debate and learn with us on the journal club!
As usual – the free PDFs are available by clicking on the titles below – so please read and make up your own minds.
PreOXI: could be a game changerGibbs KW, Semler MW, Driver BE, Seitz KP, et al. Noninvasive Ventilation for Preoxygenation during Emergency Intubation. N Engl J Med. 2024 Jun 13. doi: 10.1056/NEJMoa2313680. PMID: 38869091
Read Justin’s full review of the trial here
Andexanet is expensive and harmful – a drug company sponsored RCT proving it is rubbish!Connolly SJ, Sharma M, Cohen AT, et al. Andexanet for Factor Xa Inhibitor-Associated Acute Intracerebral Hemorrhage. N Engl J Med. 2024 May 16;390(19):1745-1755. doi: 10.1056/NEJMoa2313040. PMID: 38749032
Justin’s Full write up here.
Aslanger: Another OMI pattern to learnAslanger E, Yıldırımtürk Ö, Şimşek B, Sungur A, Türer Cabbar A, Bozbeyoğlu E, Karabay CY, Smith SW, Değertekin M. A new electrocardiographic pattern indicating inferior myocardial infarction. J Electrocardiol. 2020 Jul-Aug;61:41-46. doi: 10.1016/j.jelectrocard.2020.04.008. Epub 2020 Apr 13. PMID: 32526537
NPA to rescue your NGT failures?Huang TY, Lin JR, Chung YT. A preinstalled nasopharyngeal airway in the right nasal passageway to facilitate nasogastric intubation in anesthetized and intubated patients: a prospective randomized controlled trial. BMC Gastroenterol. 2020 Nov 3;20(1):365. doi: 10.1186/s12876-020-01514-6. PMID: 33143639NCT03697642
Is Methylene Blue a magic bullet in sepsis… not sure at this pointPruna A, Bonaccorso A, Belletti A, Turi S, Di Prima AL, D’amico F, Zangrillo A, Kotani Y, Landoni G. Methylene Blue Reduces Mortality in Critically Ill and Perioperative Patients: A Meta-Analysis of Randomized Trials. J Cardiothorac Vasc Anesth. 2024 Jan;38(1):268-274. doi: 10.1053/j.jvca.2023.09.037. Epub 2023 Oct 1. PMID: 37880041
You can read my full discussion of this evidence here: Methylene Blues
Paxlovid does not work for short or long CovidSTOP-PASC: Geng LN, Bonilla H, Hedlin H, et al. Nirmatrelvir-Ritonavir and Symptoms in Adults With Postacute Sequelae of SARS-CoV-2 Infection: The STOP-PASC Randomized Clinical Trial. JAMA Intern Med. 2024 Jun 7:e242007. doi: 10.1
G’day all.
I have been away in the remote jungles of Borneo for a few weeks which was amazing!
Whilst I was off the grid my mate Dr Scott Weingart relesased a podcast that we recorded together. It is a case-based discussion about a super sick patient where my brain was stretched and I used all the neurons available! I wanted to share my relative ignorance with Scott as he is the fountain of knowledge for these super unwell scenarios and has a lot of amazing learning points to share.
As a rural Doc this is a HALO case (High acuity, low occurrence). However, critical illness does not respect geography – so we need to understand these uncommon situations and have a plan – often one that goes well beyond the ALS algorithms.
So have a listen tot he podcast over at EMCrit (HERE). and read the comments which are also very nuanced and raise some great points.
If you are a rural Doc interested in the logistics and approach to Rural Resus then you should also go back to the Rural Resus Explosion episode that we (Scott, Vanessa, Kavi &I) recorded last year (here).
We will be back soon with more nerdy EBM!
Welcome to the June edition of the Journal Club for 2024. Justin and I discuss 7 papers covering a range of topics from securing IVCs in kids to intubating in space and the use of religious sham artifacts in middle-age, French “psychiatry”. Yep, it was a strange month on the pod! Enjoy. Articles linked below and podcast available on your favourite player or YouTube over at the First10EM channel.
Do we need to intubate French drunkards in ED?Freund Y, Viglino D, Cachanado M, Cassard C, Montassier E, Douay B, Guenezan J, Le Borgne P, Yordanov Y, Severin A, Roussel M, Daniel M, Marteau A, Peschanski N, Teissandier D, Macrez R, Morere J, Chouihed T, Roux D, Adnet F, Bloom B, Chauvin A, Simon T. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023 Dec 19;330(23):2267-2274. doi: 10.1001/jama.2023.24391. PMID: 38019968write something here
Justin’s longer / Full write up here.
Marking the midline… is it a thing?Issa EC, Ware PJ, Bitange P, Cooper GJ, Galea T, Bengiamin DI, Young TP. The “Syringe Hickey”: An Alternative Skin Marking Method for Lumbar Puncture. J Emerg Med. 2023 Mar;64(3):400-404. doi: 10.1016/j.jemermed.2023.01.013. PMID: 37019501
Pulmonary primatology is harder than you may thinkDrew T, Võ ML, Wolfe JM. The invisible gorilla strikes again: sustained inattentional blindness in expert observers. Psychol Sci. 2013 Sep;24(9):1848-53. doi: 10.1177/0956797613479386. Epub 2013 Jul 17. PMID: 23863753
Don’t believe anything you read, even in NEJM!Kotani Y, Turi S, Ortalda A, Baiardo Redaelli M, Marchetti C, Landoni G, Bellomo R. Positive single-center randomized trials and subsequent multicenter randomized trials in critically ill patients: a systematic review. Crit Care. 2023 Nov 28;27(1):465. doi: 10.1186/s13054-023-04755-5. PMID: 38017475
A better way to stick your IVs in little veins.Charters B, Foster K, Lawton B, Lee L, Byrnes J, Mihala G, Cassidy C, Schults J, Kleidon TM, McCaffery R, Van K, Funk V, Ullman A. Novel Peripheral Intravenous Catheter Securement for Children and Catheter Failure Reduction: A Randomized Clinical Trial. JAMA Pediatr. 2024 Apr 1:e240167. doi: 10.1001/jamapediatrics.2024.0167. PMID: 38558161
Watch out for the space carrots!Thierry S, Jaulin F, Starck C, Ariès P, Schmitz J, Kerkhoff S, Bernard CI, Komorowski M, Warnecke T, Hinkelbein J. Evaluation of free-floating tracheal intubation in weightlessness via ice-pick position with a direct laryngoscopy and classic approach with indirect videolaryngoscopy. NPJ Microgravity. 2023 Sep 8;9(1):73. doi: 10.1038/s41526-023-00314-y. PMID: 37684267
On Witches, Placebos and the evolution of rationalism in science
Heresy, witchcraft, Jean Gerson, scepticism and the use of placebo controls
R Kirakosian, LMollenbrink, G Zamore, TJ Kaptchuk and K Jensen Journal of the Royal Society of Medicine; 2024, Vol. 117(1) 36–41 DOI: 10.1177/01410768231207260
This is a fascinating read about the history of the humble placebo in science. The origins of rational scientific enquiry at the height of the Middle Ages when witchcraft, demonic possession and religious conflicts made life somewhat irrational.
Another month and another batch of fascinating papers from the Morgenstern vaults. This month is heavy on dermatology for some reason… but still plenty of EBM, Crit care and laughs. Join Justin and I for a sold 80 minutes of nerdy evidence-based ED care. As always, the free PDF version of each of the papers discussed is linked below – so you can check it out for yourself. You could use these for your own local journal club. Don’t forget Justin has a stream on his Youtube channel that does include this podcast and his deeper dives into the data – HERE
You can also check out some random ultrasound education and other goodies on the Broomedocs Youtube channel
Avoiding calls to neurosurgery?! Sign me upJoseph B, Obaid O, Dultz L, Black G, Campbell M, Berndtson AE, Costantini T, Kerwin A, Skarupa D, Burruss S, Delgado L, Gomez M, Mederos DR, Winfield R, Cullinane D; AAST BIG Multi-institutional Study Group. Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. J Trauma Acute Care Surg. 2022 Aug 1;93(2):157-165. doi: 10.1097/TA.0000000000003554. PMID: 35343931
Zwank MD, Kumasaka PG. A new technique for reduction of a posteriorly dislocated hip joint. Am J Emerg Med. 2023 Feb 8:S0735-6757(23)00066-9. doi: 10.1016/j.ajem.2023.01.053. PMID: 36781375
Video: https://ars.els-cdn.com/content/image/1-s2.0-S0735675723000669-mmc1.mp4
Mac 3 vs. Mac 4…. anaesthesia controversies are quite dull!Landefeld KR, Koike S, Ran R, Semler MW, Barnes C, Stempek SB, Janz DR, Rice TW, Russell DW, Self WH, Vonderhaar D, West JR, Casey JD, Khan A. Effect of Laryngoscope Blade Size on First Pass Success of Tracheal Intubation in Critically Ill Adults. Crit Care Explor. 2023 Mar 6;5(3):e0855. doi: 10.1097/CCE.0000000000000855. PMID: 36895888
Yeah, we get it, video is betterRuetzler K, Bustamante S, Schmidt MT, Almonacid-Cardenas F, Duncan A, Bauer A, Turan A, Skubas NJ, Sessler DI; Collaborative VLS Trial Group. Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial. JAMA. 2024 Mar 18:e240762. doi: 10.1001/jama.2024.0762. PMID: 38497992
Preventing poison ivy? Why is there so much I never knewStibich AS, Yagan M, Sharma V, Herndon B, Montgomery C. Cost-effective post-exposure prevention of poison ivy dermatitis. Int J Dermatol. 2000 Jul;39(7):515-8. doi: 10.1046/j.1365-4362.2000.00003.x. PMID: 10940115
More medicine I never knew: an easy test to see scabies burrows?Rauwerdink D, Balak D. Burrow Ink Test for Scabies. N Engl J Med. 2023 Aug 17;389(7):e12. doi: 10.1056/NEJMicm2216654. Epub 2023 Aug 12. PMID: 37578077
.
What weighs more a mole of norepi or a mol of norad?Wieruszewski PM, Leone M, Kaas-Hansen BS, Dugar S, Legrand M, McKenzie CA, Bissell Turpin BD, Messina A, Nasa P, Schorr CA, De Waele JJ, Khanna AK. Position Paper on the Reporting of Norepinephrine Formulations in Critical Care from the Society of Critical Care Medicine and European Society of Intensive Care Medicine Joint Task Force. Crit Care Med. 2024 Apr 1;52(4):521-530. doi: 10.1097/CCM.0000000000006176. PMID: 38240498.
Pfizer…. pft… not so EPIC SRHammond J, Fountaine RJ, Yunis C, Fleishaker D, Almas M, Bao W, Wisemandle W, Baniecki ML, Hendrick VM, Kalfov V, Simón-Campos JA, Pypstra R, Rusnak JM. Nirmatrelvir for Vaccinated or Unvaccinated Adult Outpatients with Covid-19. N Engl J Med. 2024 Apr 4;390(13):1186-1195. doi: 10.1056/NEJMoa2309003. PMID: 38598573
Scarff JR. What’s in a Name? The Problematic Term “Provider”. Fed Pract. 2021 Oct;38(10):446-448. doi: 10.12788/fp.0188. PMID: 34733063
Welcome back for another episode of nerdy evidence based goodness with Dr Justin Morgenstern. As always we will be dissecting some data and looking into the literature of Emergency medicine.
Below are the papers that we will discuss and click on the links to get the free PDF versions so that you can follow along, make up your own mind and get your inner nerd excited.
If you want to see Justin in the video format and his new Youtube series then click here:
https://www.youtube.com/@First10EM
If you would like to check out my current ultrasound training project then click here: WACHS Ultrasound
Otherwise – enjoy the show and see you in a few weeks.
High dose nitro for SCAPESiddiqua N, Mathew R, Sahu AK, Jamshed N, Bhaskararayuni J, Aggarwal P, Kumar A, Khan MA. High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial. Emerg Med J. 2024 Jan 22;41(2):96-102. doi: 10.1136/emermed-2023-213285. PMID: 38050078
Bottom line: High dose nitroglycerin seems to result in better outcomes in SCAPE, at least according to this small, single center, unblinded trial.
Is our PPE evidence-based?Diekema DJ, Nori P, Stevens MP, Smith MW, Coffey KC, Morgan DJ. Are contact precautions “essential” for the prevention of healthcare-associated methicillin-resistant Staphylococcus aureus? Clin Infect Dis. 2023 Sep 21:ciad571. doi: 10.1093/cid/ciad571. PMID: 37738565
Bottom line: Evidence based medicine is important, even in infection control.
Great evidence for button battery ingestions (if you are treating a dead pig)Chiew AL, Lin CS, Nguyen DT, Sinclair FAW, Chan BS, Solinas A. Home Therapies to Neutralize Button Battery Injury in a Porcine Esophageal Model. Ann Emerg Med. 2023 Sep 19:S0196-0644(23)00671-6. doi: 10.1016/j.annemergmed.2023.08.018. PMID: 37725021
Bottom line: There are a lot of issues with trying to extrapolate from cadaveric animal studies, but I see limited risk (unless you use this therapy as an excuse to delay endoscopy). Until we see more science, it seems very reasonable to provide honey, jam, or sucralfate (which wasn’t studied here), every 10 minutes while arranging for that emergent scope.
Myths and misconceptions about the treatment of acute hyperkalemiaGupta AA, Self M, Mueller M, Wardi G, Tainter C. Dispelling myths and misconceptions about the treatment of acute hyperkalemia. Am J Emerg Med. 2022 Feb;52:85-91. doi: 10.1016/j.ajem.2021.11.030. PMID: 34890894
Myth 1: Kayexalate is safe and useful.
Myth 2: Lactated Ringer’s is contraindicated in hyperkalemia.
Myth 3: The ECG changes from hyperkalemia are predictable and reliable.
Myth 4: All patients with hyperkalemia should be treated with calcium.
Nebulized ketamine: the solution to a non-existent problem?Kampan S, Thong-On K, Sri-On J. A non-inferiority randomized controlled trial comparing nebulized ketamine to intravenous morphine for older adults in the emergency department with acute musculoskeletal pain. Age Ageing. 2024 Jan 2;53(1):afad255. doi: 10.1093/ageing/afad255. PMID: 38251742
Bottom line: Although it is always useful to have more tools in your belt, I can’t see this study having much clinical relevance at all.
Small BVMs: When physiologic theory failsSnyder BD, Van Dyke MR, Walker RG, Latimer AJ, Grabman BC, Maynard C, Rea TD, Johnson NJ, Sayre MR, Counts CR. Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest. Resuscitation. 2023 Dec;193:109991. doi: 10.1016/j.resuscitation.2023.109991. PMID: 37805062
Bottom line: In this before and after cohort, the change to a smaller BVM was associated with lower rates of ROSC.
Peripheral pressors: not only safe, but beneficial?Yerke JR, Mireles-Cabodevila E, Chen AY, Bass SN, Reddy AJ, Bauer SR, Kokoczka L, Dugar S, Moghekar A. Peripheral Administration of Norepinephrine: A Prospective Observational Study. Chest. 2023 Aug 21:S0012-3692(23)05350-3. doi: 10.1016/j.chest.2023.08.019. Epub ahead of print. PMID: 37611862
At this point, I sort of assume that everyone knows it is OK to run vasopressor peripherally. First10EM readers should, given that we have covered the topic previously, with an update post with more evidence here. Casey wrote a protocol for peripheral noradrenaline 9 years ago… in 2015!.
Bottom line: Although there is a small risk of extravasation, the benefits of running vasopressors will outweigh that risk in many patients. Although I miss performing the procedure, these days I almost always leave the central line until the patient is stabilized and settled into their ICU bed.
Is pregnancy a disease?Smajdor A, Räsänen J. Is pregnancy a disease? A normative approach. J Med Ethics. 2024 Jan 29:jme-2023-109651. doi: 10.1136/jme-2023-109651. PMID: 38286592
Please address your outraged emails to Dr Justin Morgenstern… he picked this paper!
A randomized deception trial?Iyer R, Park D, Kim J, Newman C, Young A, Sumarsono A. Effect of chair placement on physicians’ behavior and patients’ satisfaction: randomized deception trial. BMJ. 2023 Dec 15;383:e076309. doi: 10.1136/bmj-2023-076309. PMID: 38101923
Bottom line: if you can find a chair, please sit upon it as you do your job.
Welcome to the first episode for 2024 – and we have a range of papers covering the big life threatening issues to the tiniest pinky finger injuries and a lot in between. There is something for everyone in here!
We try to answer a few questions that you may have not even pondered such as: should all Psych patinets get an MRI? Should you replace fingernails on crushed digits? Should anybody be doing REBOA in 2024? Are topical anaesthetic drops safe for folk with eye abrasions?
As is always the case – the papers we discuss are free to download by just clicking the links in the sections below… so don’t trust me, go read them for yourself!
Jain A, Greig AVH, Jones A, Cooper C, Davies L, Greshon A, Fletcher H, Sierakowski A, Dritsaki M, Nguyen TTA, Png ME, Stokes JR, Dakin H, Cook JA, Beard DJ, Gardiner MD; NINJA Collaborative. Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial. Br J Surg. 2023 Mar 30;110(4):432-438. doi: 10.1093/bjs/znad031. PMID: 36946338
Bottom line: This is a well done RCT that demonstrates pretty convincingly that you should not bother trying to but fingernails back on after nail bed repair (and my guess is you definitely shouldn’t be removing them either).
Carson JL, Brooks MM, Hébert PC, et al; MINT Investigators. Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia. N Engl J Med. 2023 Nov 11. doi: 10.1056/NEJMoa2307983. PMID: 37952133
Bottom line: This is our biggest trial looking at liberal versus restrive transfusion in the context of MI, and we are left without a clear answer.
Blackman G, Neri G, Al-Doori O, Teixeira-Dias M, Mazumder A, Pollak TA, Hird EJ, Koutsouleris N, Bell V, Kempton MJ, McGuire P. Prevalence of Neuroradiological Abnormalities in First-Episode Psychosis: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2023 Oct 1;80(10):1047-1054. PMID: 37436735
Bottom line: Patients with first episode psychosis do not need routine MRIs base on this data. They do need a careful history and physical, as a subset will have pathology. MRIs may be warranted in a small subset of patients, but those MRIs do not need to occur in an emergency department.
Myran DT, Harrison LD, Pugliese M, Solmi M, Anderson KK, Fiedorowicz JG, Perlman CM, Webber C, Finkelstein Y, Tanuseputro P. Transition to Schizophrenia Spectrum Disorder Following Emergency Department Visits Due to Substance Use With and Without Psychosis. JAMA Psychiatry. 2023 Sep 27:e233582. doi: 10.1001/jamapsychiatry.2023.3582. Epub ahead of print. PMID: 37755727
Bottom line: Substance abuse and psychiatric disease go hand in hand. Doctors who treat one must be experts in the other as well. We do not do our patients any favours by deflecting their care.
Wenger NS, Sanz Vidorreta FJ, Dudley MT, Walling AM, Hogarth M. Consequences of a Health System Not Knowing Which Patients Are Deceased. JAMA Intern Med. 2023 Dec 4:e236428. doi: 10.1001/jamainternmed.2023.6428. Epub ahead of print. PMID: 38048124
Summary: although dead people may be allowed to vote, they should not be included in the scientific literature?.
Green SM, Tomaszewski C, Valente JH, Lo B, Milne K. Use of Topical Anesthetics in the Management of Patients With Simple Corneal Abrasions: Consensus Guidelines from the American College of Emergency Physicians. Ann Emerg Med. 2024 Feb 6:S0196-0644(24)00004-0. doi: 10.1016/j.annemergmed.2024.01.004. PMID: 38323950
This is not really news, as we have covered the evidence ad nauseum in the past,
Bottom line: A shared decision making conversation is still a good idea (if only to prepare patients for a future ophthalmology tirade), but I have yet to have a patient decline short term use of topical anesthetics to control the pain from their corneal abrasion.
Jansen JO, Hudson J, Cochran C, et al. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA. 2023 Oct 12. doi: 10.1001/jama.2023.20850. PMID: 37824132
Bottom line: In our only RCT of REBOA in trauma to date, REBOA increased mortality, and therefore the device is clearly not ready for clinical use.
Siebert JN, Salomon C, Taddeo I, Gervaix A, Combescure C, Lacroix L. Outdoor Cold Air Versus Room Temperature Exposure for Croup Symptoms: A Randomized Controlled Trial. Pediatrics. 2023 Sep 1;152(3):e2023061365. doi: 10.1542/peds.2023-061365. PMID: 37525974
Bottom line: This is by far the best evidence we have on the topic, and perhaps the best evidence we will ever see. If you are looking for short term symptom relief, and you are careful about avoiding harms, it seems reasonable to counsel parents about using cold air to improve symptoms from croup.
Fincham GW, Strauss C, Cavanagh K. Effect of coherent breathing on mental health and wellbeing: a randomised placebo-controlled trial. Sci Rep. 2023 Dec 13;13(1):22141. doi: 10.1038/s41598-023-49279-8. PMID: 38092805
Bottom line: This is the highest quality study of breathwork to date, and it is pretty definitively negative. I think this tells us that specific breathing patterns are unlikely to be helpful, but still leaves open the possibility that a daily practice of quiet breathing (at any rate) could have beneficial effects.
Tiebie EG, Baerends EP, Boeije T, Frankenmolen PG, Lameijer H, van den Berg W, van Stralen KJ, Ridderikhof ML, Bredenoord AJ. Efficacy of cola ingestion for oesophageal food bolus impaction: open label, multicentre, randomised controlled trial. BMJ. 2023 Dec 11;383:e077294. doi: 10.1136/bmj-2023-077294. PMID: 38081653
Bottom line: Cola ingestion changes nothing, but does increase pain, and therefore should be avoided.
Evans CS, Slovis C. Revisiting the Ten Commandments of Emergency Medicine: A Resident’s Perspective. Ann Emerg Med. 2021 Mar;77(3):367-370. doi: 10.1016/j.annemergmed.2020.10.013. PMID: 33618812
30 years ago, Corey Slovis published a paper entitled “The Ten commandments of Emergency Medicine”. This paper revists those commandments 30 years later to discuss what might have changed. Not science, but it is an interesting paper that might provoke some discussion or thought.
Welcome to another episode of the Emergency Medicine Journal Club with Dr Justin Morgenstern.
This month we cover a bunch of papers that look at a lot of topics and try to answer questions such as:
Can I push Keppra safely? Does BP management in haemorrhagic stroke matter? How good is my intuition about PE diagnosis? Is it a good idea to keep geriatric patients in the ED overnight? (SPOILER: it is not), Does cryoprecipitate save lives in trauma? Should we X-ray children to diagnose constipation (SPOILER: We should not!). Are you being irradiated by the portable Xray machines in your ED?
As always the paper title and PDFs are available below if you want to read the literature and make up your own mind. We highly recommend not taking the advice of a couple of blokes on the internet!
Roussel M, Teissandier D, Yordanov Y, et al. Overnight Stay in the Emergency Department and Mortality in Older Patients. JAMA Intern Med. 2023 Nov 6. doi: 10.1001/jamainternmed.2023.5961.PMID: 37930696
Davenport R, Curry N, Fox EE, Thomas H, Lucas J, Evans A, Shanmugaranjan S, Sharma R, Deary A, Edwards A, Green L, Wade CE, Benger JR, Cotton BA, Stanworth SJ, Brohi K; CRYOSTAT-2 Principal Investigators. Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury: The CRYOSTAT-2 Randomized Clinical Trial. JAMA. 2023 Oct 12. doi: 10.1001/jama.2023.21019. PMID: 37824155 JUSTIN’s Full write up here.
Choosing wisely for kidsFrom the American Academy of Pediatrics and the Canadian Association of Emergency Physicians, we have the Choosing Wisely recommendations for pediatric emergency medicine. The full guidelines are available in multiple locations online.) I don’t think there is anything controversial here (Choosing Wisely usually just states the way too obvious anyway),
Daneman N, Cheng Y, Gomes T, Guan J, Mamdani MM, Saxena FE, Juurlink DN. Metronidazole-associated Neurologic Events: A Nested Case-control Study. Clin Infect Dis. 2021 Jun 15;72(12):2095-2100. doi: 10.1093/cid/ciaa395. PMID: 32303736
Briggs B, Kalra S, Panacek E. Risk of Radiation Exposure to Emergency Department Personnel From Portable Radiographs. J Emerg Med. 2022 Nov;63(5):645-650. doi: 10.1016/j.jemermed.2022.08.002. Epub 2022 Oct 12. PMID: 36243611
Philpott L, Clemensen E, Lau GT. Droperidol versus ondansetron for nausea treatment within the emergency department. Emerg Med Australas. 2023 Aug;35(4):605-611. doi: 10.1111/1742-6723.14174. PMID: 36755492
Freeman JJ, Asfaw SH, Vatsaas CJ, et al. Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma. Trauma Surg Acute Care Open. 2022 Oct 25;7(1):e000886. doi: 10.1136/tsaco-2022-000886. PMID: 36312819
Ishigami J, Charleston J, Miller ER 3rd, Matsushita K, Appel LJ, Brady TM. Effects of Cuff Size on the Accuracy of Blood Pressure Readings: The Cuff(SZ) Randomized Crossover Trial. JAMA Intern Med. 2023 Aug 7:e233264. doi: 10.1001/jamainternmed.2023.3264. PMID: 37548984
van Maanen R, Martens ESL, Takada T, et al. Accuracy of physicians’ intuitive risk estimation in the diagnostic management of pulmonary embolism: an individual patient data meta-analysis. J Thromb Haemost. 2023 May 30:S1538-7836(23)00438-5. doi: 10.1016/j.jtha.2023.05.023. PMID: 37263381
You can read Casey’s extended written post on this trial here: How Good is Gestalt?
Summerlin JA, Scaturo N, Lund JA, Wang KM, Frank MA. Adverse events of undiluted intravenous push levetiracetam. Am J Emerg Med. 2023 Nov;73:182-186. doi: 10.1016/j.ajem.2023.08.046. PMID: 37708595
Marcus GM, Rosenthal DG, Nah G, Vittinghoff E, Fang C, Ogomori K, Joyce S, Yilmaz D, Yang V, Kessedjian T, Wilson E, Yang M, Chang K, Wall G, Olgin JE. Acute Effects of Coffee Consumption on Health among Ambulatory Adults. N Engl J Med. 2023 Mar 23;388(12):1092-1100. doi: 10.1056/NEJMoa2204737. PMID: 36947466
McCreary EK, Johnson MD, Jones TM, Spires SS, Davis AE, Dyer AP, Ashley ED, Gallagher JC. Antibiotic Myths for the Infectious Diseases Clinician. Clin Infect Dis. 2023 Jun 13:ciad357. doi: 10.1093/cid/ciad357. Epub ahead of print. PMID: 37310038
Ma L, Hu X, Song L, Chen X, et al; INTERACT3 Investigators. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet. 2023 Jul 1;402(10395):27-40. doi: 10.1016/S0140-6736(23)00806-1. PMID: 37245517
This is another lecture by the always amazing Dr Justin Morgenstern from the series of talks he delivered on his tour of Perth in September 2023.
In this talk I challenged Justin to go on a very deep dive into the literature around the modern management of the massively bleeding trauma patient. What is the best way to resuscitate and replace all those blood products in these severely unwell people? This was a huge undertaking, Justin magaged to distill all the data into a talk that covers the science (scant as it may be) and the practical application of the numbers at the bedside (or roadside).
Huge thanks to Justin for sharing his wisdom and his dogged dedication to the data!
You can find Justin’s very long and detailed critical appraisal over here at First10EM.
Controversial title… courtesy of Dr Justin Morgenstern.
In this podcast Justin tells me about the evidentiary basis for our modern obsession with clinical decision rules and tools. We discuss the reasons that these tools may seem like a great idea, the reality of practice and how we may be able to do better in the future.
So if you have ever used a decision tool in the ED – Wells, Ottawa, PECARN, San Francisco, HEART…. or any other acronym you need to stop and have a listen to understand what these tools do, and do not achieve.
This month I am back on the SGEM podcast – this time on the all new Paeds section with Dr Dennis Ren. In this episode we do a deep dive into the BUCKLED trial that looked at the use of bedside ultrasound vs. plain film X-rays for the initial investigation of paediatric forearm fractures. This […]
If you are a listener to the Journal Club podcast with Justin, then you will know that we talk a lot about decision-rules and diagnostic tests. The subject of “clinician gestalt” comes up a lot. Although the original meaning of gestalt has been lost – we all know what it is that we are talking about…
We all think we have some degree of “spider sense” when it comes to picking the big, bad diseases in the Emergency Department. But do we really? Can we actually rely on that little voice inside our heads when it comes to making the right calls? Which patient should we run through the CT-of-truth? Can we quantify the power of our gut feelings? Fascinating questions!
So lets do a review of a paper that attempts to answer these questions. Specifically, the question of clinical gestalt for the diagnosis of pulmonary embolism. Here is the paper:
Accuracy of physicians’ intuitive risk estimation in the diagnostic management of pulmonary embolism: an individual patient data meta-analysis. by Dr Roseanne van Maanen et al published in the Journal of Thrombosis and Hemostasis, June 2023. ( https://doi.org/10.1016/j.jtha.2023.05.023 )
As the title suggests – this is a meta-analysis of individual level patient data. The authors have looked at nearly 4000 individual trials and come down to just 16 studies that provided the individual patient data and clinical “gestalt” information. Overall this represents 20,770 unique patients suspected of having a possible PE. The patients were not just Emergency patients – they also included primary care, self-referred, nursing home and ward inpatients.
The trials had to include either an objective, positive diagnosis of pulmonary embolism or at least 30 days of PE-free follow up to count as a ‘negative’.
It is important to note that the majority of these studies were completed in Western Europe and two studies from Canada – there were no Australasian or U.S. trials in the mix. This is important as we know that the pre-test probability and diagnostic yield of PE work up does vary widely across the globe.
The clinicians’ gestalt (intuitive risk estimation) was dichotomised by the question: ” Is PE the most likely diagnosis?” prior to diagnostic testing. For example, if the Wells’s score was applied – then the gestalt was deemed positive if the “PE most likely diagnosis” was answered “yes” and the +3 points given. Different studies used other scoring systems to ‘document’ clinicians’ gestalt eg. Geneva. This diagnostic impression was recorded prior to D-dimer testing.
So in summary – we have 20,000+ patients with symptoms that could be a PE, we have the clinician’s best guess as to whether PE was the ‘most likely diagnosis’ and we have the actual diagnosis post work-up or follow up period. Yes, this is a big data dredge that is full of potential biases, errors and all the usual diagnostic (radiological) uncertainty that plagues PE research. However, it is a big data set and worth a look under the bonnet to try and quantify our brain’s best bets!
So what did they find? How potent is gestalt in the diagnosis of pulmonary embolism?
Bottom line: – the overall rate of pulmonary embolism in this data set was 20 % [range 7.4% to 40.9% ]
In the patients in which the clinicians had a POSITIVE Gestalt the rate of PE was 29% [22.1% to 62.1%]
In the Gestalt NEGATIVE group the rate of PE was 9%.
So if you do the math on relative risk it turns out that overall clinical gestalt roughly triples the chance that a patient will have a PE.
Strangely, the D-dimer levels were doubled (on average) in cases where the gestalt was deemed positive… although only a true cynic would attribute any causality to this observation… we all have days when it seems to be that way! {not science}
If you look at the individual trials then the prize for most accurate gestalt / spider sense must go to the Swiss. The two papers by Perrier et al (2004, 2005) were closest to the pin when it came to picking PEs but not overcalling it! The majority of trials showed a that “PE most likely” was 2-4 times higher than the actual rule-in rate for PE. Only a single trial from Spain (Galipienzo et al, 2012) went the other way… their gestalt under-called the PE rate by about 4%! I am not really sure if this says more about the patient group (secondary referral) or the clinical mindset in Spain?
Probably the most interesting data to be dredged up in this paper is the remarkable consistency of the effect of gestalt over a number of countries, time, clinical settings and patient sub-groups. Kabrhel et al published in 2005 a 583 patient trial that suggested gestalt-accuracy increased slightly with clinical experience. This new paper would refute that effect, although the actual experience levels of the clinicians are widely implied in this current study.
One caveat to all of this was the effect of patient age on the clinical gestalt. The confidence intervals on the relative-risk get very wide, almost exponentially so, after the age of 60. This is probably a result of smaller numbers and therefore less data points… but it is good to know. Maybe our gestalt does get watered down once we start guesstimating in the presence of lots of co-morbid diseases and poly-pharmacy etc?
For me this is really interesting stuff. Fascinating research that tries to answer a question that is really tough tot tease out of the data. Of course, this is not going to change your practice… because we cannot change our gut-feelings and if you believe the authors it may not even be something that you get better at with time and experience.
Love to hear your thoughts – comments below or via the socials.
Casey
We are back with the long-windiest and borderline funny Emergency Medicine journal club to date.
Justin and I are covering some big new trials, some old and unusual papers and a few that just might change your practice. As always the links to the papers are in the write up below and you definitely should read them rather than believe a couple of nerds amusing themselves upon the internet.
Enjoy. Casey
The CLOVERS trial: National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Clinical Trials Network; Shapiro NI, Douglas IS, Brower RG, et al. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. N Engl J Med. 2023 Jan 21. doi: 10.1056/NEJMoa2212663. Epub ahead of print. PMID: 36688507
You can read Justin’s Full write up here.
Lukosiute-Urboniene A, Nekrosius D, Dekeryte I, Kilda A, Malcius D. Clinical risk factors for testicular torsion and a warning against falsely reassuring ultrasound scans: a 10-year single-centre experience. Emerg Med J. 2022 Dec 16:emermed-2021-211946. doi: 10.1136/emermed-2021-211946. Epub ahead of print. PMID: 36526335
Yarter JT, Racht J, Michels KS. Retrobulbar hemorrhage decompression with paracanthal “one-snip” method: Time to retire lateral canthotomy? Am J Emerg Med. 2023 Feb;64:206.e1-206.e3. doi: 10.1016/j.ajem.2022.11.027. Epub 2022 Nov 21. PMID: 36564334
Ehmann MR, Mitchell J, Levin S, Smith A, Menez S, Hinson JS, Klein EY. Renal outcomes following intravenous contrast administration in patients with acute kidney injury: a multi-site retrospective propensity-adjusted analysis. Intensive Care Med. 2023 Jan 30. doi: 10.1007/s00134-022-06966-w. Epub ahead of print. PMID: 36715705
We have covered the myth of contrast nephropathy many times. It is now quite clear that contrast is not the thing that upsets kidneys in acutely unwell patients. We should use it if it is required!
Perry DC, Achten J, Knight R, Appelbe D, Dutton SJ, Dritsaki M, Mason JM, Roland DT, Messahel S, Widnall J, Costa ML; FORCE Collaborators in collaboration with PERUKI. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet. 2022 Jul 2;400(10345):39-47. doi: 10.1016/S0140-6736(22)01015-7. PMID: 35780790 [open access here]
Stiell IG, Clement CM, Grimshaw JM, Brison RJ, Rowe BH, Lee JS, Shah A, Brehaut J, Holroyd BR, Schull MJ, McKnight RD, Eisenhauer MA, Dreyer J, Letovsky E, Rutledge T, Macphail I, Ross S, Perry JJ, Ip U, Lesiuk H, Bennett C, Wells GA. A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments. CMAJ. 2010 Oct 5;182(14):1527-32. doi: 10.1503/cmaj.091974. Epub 2010 Aug 23. PMID: 20732978
In summary – when deciding who needs a CT of their head… use your head, not the Canadian CT HEAD rule! Justin’s Full critical appraisal can be found here.
Sutiman N, Khoo ZX, Ong GYK, Piragasam R, Chong SL. Validation and comparison of the PECARN rule, Step-by-Step approach and Lab-score for predicting serious and invasive bacterial infections in young febrile infants. Ann Acad Med Singap. 2022 Oct;51(10):595-604. doi: 10.47102/annals-acadmedsg.2022193. PMID: 36317570
Anderson TS, Jing B, Auerbach A, Wray CM, Lee S, Boscardin WJ, Fung K, Ngo S, Silvestrini M, Steinman MA. Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge. JAMA Intern Med. 2019 Nov 1;179(11):1528-1536. doi: 10.1001/jamainternmed.2019.3007. PMID: 31424475
Rubin R. Warning About Xylazine, a Veterinary Sedative Found in Illicit Drugs. JAMA. 2022 Dec 20;328(23):2296. doi: 10.1001/jama.2022.20045. PMID: 36538321
Am I the only one thinking that this illicit drug additive seems like a really good antidote to the methamphetamine toxidromes that we are constantly managing in the ED?.
Ben Abdallah S, Mhalla Y, Trabelsi I, Sekma A, Youssef R, Bel Haj Ali K, Ben Soltane H, Yacoubi H, Msolli MA, Stambouli N, Beltaief K, Grissa MH, Khrouf M, Mezgar Z, Loussaief C, Bouida W, Razgallah R, Hezbri K, Belguith A, Belkacem N, Dridi Z, Boubaker H, Boukef R, Nouira S. Twice-Daily Oral Zinc in the Treatment of Patients With Coronavirus Disease 2019: A Randomized Double-Blind Controlled Trial. Clin Infect Dis. 2023 Jan 13;76(2):185-191. doi: 10.1093/cid/ciac807. Erratum in: Clin Infect Dis. 2023 Feb 03;: PMID: 36367144
Justin’s excellent critical appraisal and Full write up here. Beware the possibility of P-hacking here, don’t rush out and buy shares in Zinc mining futures!
Meckler GD, Alqurashi W, Eltorki M, Curtis SJ, Doyle E, Kam AJ, Lim R, MacPhee S, Schuh S, Wright B, Johnson DW. Epinephrine metered-dose inhaler for pediatric croup. Acad Emerg Med. 2023 Feb;30(2):144-146. doi: 10.1111/acem.14616. Epub 2022 Dec 7. PMID: 36307996
Franklin D, Babl FE, George S, Oakley E, Borland ML, Neutze J, Acworth J, Craig S, Jones M, Gannon B, Shellshear D, McCay H, Wallace A, Hoeppner T, Wildman M, Mattes J, Pham TMT, Miller L, Williams A, O’Brien S, Lawrence S, Bonisch M, Gibbons K, Moloney S, Waugh J, Hobbins S, Grew S, Fahy R, Dalziel SR, Schibler A. Effect of Early High-Flow Nasal Oxygen vs Standard Oxygen Therapy on Length of Hospital Stay in Hospitalized Children With Acute Hypoxemic Respiratory Failure: The PARIS-2 Randomized Clinical Trial. JAMA. 2023 Jan 17;329(3):224-234. doi: 10.1001/jama.2022.21805. PMID: 36648469
Justin’s Full write up here
Gøtzsche PC. The terminology we use about medical drugs can be misleading. BMJ. 2023 Mar 17;380:p601. doi: 10.1136/bmj.p601. PMID: 36931639 [free full text]
Haines JD Jr, Chop WM Jr, Swyden SN. Spontaneous pneumothorax, pneumomediastinum, and pneumopericardium in a 16-year-old drug-abusing motorcyclist surrounded by a pack of coyotes. Postgrad Med. 1989 Oct;86(5):79-80. doi: 10.1080/00325481.1989.11704431. PMID: 2798277
Welcome back.
This month I am working on a few projects and have just made a guest appearance on the excellent SGEM podcast discussing a new, novel paper about the role of clinician-performed biliary ultrasound in the ED.
You can read the paper here: Hilsden R, Mitrou N, Hawel J, et al. Point of care biliary ultrasound in the emergency department (BUSED) predicts final surgical management decisions. Trauma Surg Acute Care Open 2022;7:e000944.
You can hear the podcast here: The Skeptics Guide to Emergency Medicine...
Let me know what you think.
Casey
We are back with another episode of the BroomeDocs and First10EM podcast. In this episode we try to answer some of the big questions in Emergency Medicine, we also answer a few that you probably would never have thought to ask! Like…
- How much electricity should we use in refractory VF?
- Should we suck clots out of legs?
- Should you put Tegaderm on eyeballs?
- Is the HEART score valid? Are any clinical decision tools really what we think?
- What happens if you discharge patients with low troponin rise?
- Should you evert the edges of the wounds?
- Can we send kids home with abnormal vital signs?
- Does kissing minor toddler boo-boos help?
- Do men with smaller penises drive fast cars?
So please, sit back relax, have a quiet drink and enjoy some of the nerdiest medical podcasting out there.
DOSE VF: Cheskes S, Verbeek PR, Drennan IR, McLeod SL, Turner L, Pinto R, Feldman M, Davis M, Vaillancourt C, Morrison LJ, Dorian P, Scales DC. Defibrillation Strategies for Refractory Ventricular Fibrillation. N Engl J Med. 2022 Nov 6. doi: 10.1056/NEJMoa2207304. Epub ahead of print. PMID: 3634215
You can read the full critical appraisal here.
Vedantham S, Goldhaber SZ, Julian JA, et al; ATTRACT Trial Investigators. Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis. N Engl J Med. 2017 Dec 7;377(23):2240-2252. doi: 10.1056/NEJMoa1615066. PMID: 29211671
Marks A, Patel D, Chottiner M, Kayarian F, Peksa GD, Gottlieb M. Covered or uncovered: A randomized control trial of Tegaderm versus no Tegaderm for ocular ultrasound. Am J Emerg Med. 2022 Nov;61:87-89. doi: 10.1016/j.ajem.2022.08.044. Epub 2022 Aug 28. PMID: 36057214
Hakimi AA, Carter S, Garg S. Detecting corneal injury with a selfie. Acad Emerg Med. 2022 Nov;29(11):1403-1404. doi: 10.1111/acem.14577. Epub 2022 Aug 17. PMID: 35921203
Green SM, Schriger DL. A Methodological Appraisal of the HEART Score and Its Variants. Ann Emerg Med. 2021 Aug;78(2):253-266. doi: 10.1016/j.annemergmed.2021.02.007. Epub 2021 Apr 29. PMID: 33933300
Khan A, Saleem MS, Willner KD, Sullivan L, Yu E, Mahmoud O, Alsaid A, Matsumura ME. Association of Chest Pain Protocol-Discordant Discharge With Outcomes Among Emergency Department Patients With Modest Elevations of High-Sensitivity Troponin. JAMA Netw Open. 2022 Aug 1;5(8):e2226809. doi: 10.1001/jamanetworkopen.2022.26809. Erratum in: JAMA Netw Open. 2022 Sep 1;5(9):e2235575. PMID: 35969395
Loeb M, Bartholomew A, Hashmi M, Tarhuni W, Hassany M, Youngster I, Somayaji R, Larios O, Kim J, Missaghi B, Vayalumkal JV, Mertz D, Chagla Z, Cividino M, Ali K, Mansour S, Castellucci LA, Frenette C, Parkes L, Downing M, Muller M, Glavin V, Newton J, Hookoom R, Leis JA, Kinross J, Smith S, Borhan S, Singh P, Pullenayegum E, Conly J. Medical Masks Versus N95 Respirators for Preventing COVID-19 Among Health Care Workers : A Randomized Trial. Ann Intern Med. 2022 Nov 29. doi: 10.7326/M22-1966. Epub ahead of print. PMID: 36442064
Kappel S, Kleinerman R, King TH, Sivamani R, Taylor S, Nguyen U, Eisen DB. Does wound eversion improve cosmetic outcome?: Results of a randomized, split-scar, comparative trial. J Am Acad Dermatol. 2015 Apr;72(4):668-73. doi: 10.1016/j.jaad.2014.11.032. Epub 2015 Jan 23. PMID: 25619206
Kazmierczak M, Thompson AD, DePiero AD, Selbst SM. Outcomes of patients discharged from the pediatric emergency department with abnormal vital signs. Am J Emerg Med. 2022 Jul;57:76-80. doi: 10.1016/j.ajem.2022.04.021. Epub 2022 Apr 26. PMID: 35526404
Chandran V, Sekar A, Mishra N. Transoral fractureless penetrating injury to brainstem in a child: a rare presentation. Childs Nerv Syst. 2022 Mar;38(3):505-507. doi: 10.1007/s00381-022-05455-1. Epub 2022 Jan 28. PMID: 35091807
Study of Maternal and Child Kissing (SMACK) Working Group. Maternal kisses are not effective in alleviating minor childhood injuries (boo-boos): a randomized, controlled and blinded study. J Eval Clin Pract. 2015 Dec;21(6):1244-6. doi: 10.1111/jep.12508. Epub 2015 Dec 29. PMID: 26711672
Richardson, Daniel C., et al. “Small Penises and Fast Cars: Evidence for a Psychological Link.” PsyArXiv, 10 Jan. 2023. Web. https://psyarxiv.com/uy7ph
Ketamine vs etomidate in ICU intubation? Matchett G, Gasanova I, Riccio CA, Nasir D, Sunna MC, Bravenec BJ, Azizad O, Farrell B, Minhajuddin A, Stewart JW, Liang LW, Moon TS, Fox PE, Ebeling CG, Smith MN, Trousdale D, Ogunnaike BO; EvK Clinical Trial Collaborators. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. […]
Welcome to another episode of the Journal Club with Dr Justin Morgenstern. This one is a bit epic and we start with a really important discussion around diagnostic strategies for palliative patients in the ED. There are a bunch of papers around PE and some interesting old school stuff that you likely would never consider […]
This week I am making a guest appearance on my Canadian mate Ken Milne’s amazing podcast. Below is the written version of the chat we had about the recent RePHILL trial: prehospital blood products for shocked trauma patients. If you are not already subscribed – please go over to the Skeptics Guide to Emergency Medicine […]
The latest episode of the Journal Club with Dr J Morgenstern is now out. Lots of evidence to reassure you that it’s all a bit unclear! Some great philosophical articles and a super scary Tox plant I never knew to worry about.. Enjoy. Links to article are clickable to access free PDFs and audio is […]
Our first Journal Club for 2022 is out now. You can listen on your favourite podcast player or use the link below. Links to the studies are in the written summary and you can read Justin’s deep and critical thoughts over at First10EM blog. Here is a list of the papers and the bottom lines. […]