tag:blogger.com,1999:blog-7950778722454561442024-03-05T18:26:54.615-08:00EmergencyMedJCEmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.comBlogger176125tag:blogger.com,1999:blog-795077872245456144.post-55691140652284243952023-12-11T22:40:00.000-08:002023-12-11T22:45:16.159-08:00Emergency department versus operating room intubation of patients undergoing immediate hemorrhage control surgery<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhhg5oJ7FZ56W-mx7YdmAIwaIir29ezb470mdGAp615BySzK0mQIqNFlc9q6HAWR9-avkNLJRAQkDJwF7aZS2qrXh3MFvXNUKM9F8STaZPBSfs5VWcY3JoiMCZik52yPwKXYNTExVRsz_7mNzFLj723aNnEnmI1VRUzh96cUeIgvOIfeJxKQIYxhNj7Iuw" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="2433" data-original-width="3500" height="222" src="https://blogger.googleusercontent.com/img/a/AVvXsEhhg5oJ7FZ56W-mx7YdmAIwaIir29ezb470mdGAp615BySzK0mQIqNFlc9q6HAWR9-avkNLJRAQkDJwF7aZS2qrXh3MFvXNUKM9F8STaZPBSfs5VWcY3JoiMCZik52yPwKXYNTExVRsz_7mNzFLj723aNnEnmI1VRUzh96cUeIgvOIfeJxKQIYxhNj7Iuw" width="320" /></a></div><br />There are <b>theoretical
reasons why endotracheal intubation can make trauma patients worse. </b>Induction agents can cause hypotension. Positive pressure ventilation decreases venous return and can decrease cardiac output. This
is not to mention the potential complications of the procedure itself. <p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Of course,
all of this must be <b>balanced</b> with the possible need for a definitive
airway and to ensure oxygenation & ventilation. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">So… for
trauma patients requiring surgery, <b>is it better to intubate in the ED or wait to go to the
operating theatre?</b> <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">This study
looked at the <b>National Trauma Data Bank</b> (<i>registry data… beware</i>)
and identified <b>9,667 patients</b> at 253 trauma centers who underwent
hemorrhage control surgery within 60 minutes of ED arrival. To <b>attempt to
minimize confounding</b>, they excluded patients with GCS <8, dead on
arrival, ED thoracotomy, or those “with clinical indications for intubation.”<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The <b>primary
outcome was mortality</b> when comparing ED intubation vs. in theatre. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The unadjusted
mortality for those intubated in the ED was <b>17% vs. 7%</b> in theatre.
Absolute increase of 10% or a number needed to kill (NNK) of 10. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Intubating
in the ED is lethal!?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Wait a
minute…<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Of course,
the <b>sicker patients are more likely to get intubated in the ED!</b> <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">This study
was no exception. ED patients had <b>markedly higher injury severity scales</b>. They
had lower GCS, more chest, lung, heart, thoracic vascular and liver injury. They
were more tachycardic and twice as likely to get a thoracotomy for hemorrhage
control. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The authors
<b>tried the usual fancy statistical adjustments</b> that we often see with
observational study design, but this is <b>far from a perfect science</b>.
Studies like this invariably have some residual confounding which makes the interpretation
difficult. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">To be fair,
the <b>authors do a good job of mentioning the study limitations</b> but unfortunately
<b>overstate their conclusion. </b><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">There
is an <b><u>association</u> between ED intubation and worse outcomes</b>. Yes, <b>but
is this a causal relationship?</b> That is the big question which can only be
answered with a randomized clinical trial. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">Covering:<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="ES-CO" style="mso-ansi-language: ES-CO;">Dunton Z,
Seamon MJ, Subramanian M, et al. </span>Emergency department versus operating room
intubation of patients undergoing immediate hemorrhage control surgery.<i> J
Trauma Acute Care Surg</i>. 2023;95:69-77. <a href="https://journals.lww.com/jtrauma/abstract/2023/07000/emergency_department_versus_operating_room.11.aspx" target="_blank">[link to article]</a><o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-11194187930984303382023-12-11T20:37:00.000-08:002023-12-11T20:37:24.762-08:00“Diagnostic accuracy of clinical examination to identify life-and limb-threatening injuries in trauma patients”<p><b></b></p><div class="separator" style="clear: both; text-align: center;"><b><a href="https://blogger.googleusercontent.com/img/a/AVvXsEiz4rfctchPuDuiEot9kC7PyM8kQCBeTULFGbi9C5VW4ancKUbKIjdrAN4pqUhbsOiUsHoJSLyc3JPPPp_mUmL-ioPOO5LPxiRpqA8PSmw_UwcjKNew4soQC4vXVT5fwwBnvVeaC1oM9HCEHgb5IAYzrGJMWEUG4S2FX06KZ0aNxK38ZKSliK6RSWBOivM" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="550" data-original-width="550" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEiz4rfctchPuDuiEot9kC7PyM8kQCBeTULFGbi9C5VW4ancKUbKIjdrAN4pqUhbsOiUsHoJSLyc3JPPPp_mUmL-ioPOO5LPxiRpqA8PSmw_UwcjKNew4soQC4vXVT5fwwBnvVeaC1oM9HCEHgb5IAYzrGJMWEUG4S2FX06KZ0aNxK38ZKSliK6RSWBOivM" width="240" /></a></b></div><b><br />How good is
the physical examination</b> for finding life threatening stuff in trauma patients?<p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">This study
sought to answer this question but the <b>title is somewhat misleading</b>. It should
have been a bit longer as below:<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: center;"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">Diagnostic
accuracy of the single pre-hospital physical examination to identify life and limb
threatening injuries performed by a doctor in the field around London, UK without
using adjuncts who had no idea they were going to participate in a study and
may or may not have collected or written down information as sought by the
investigative team. <o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">It’s
clear that I was not involved in the peer review process of this paper. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Since the
<b>methods employed never really had a hope of answering the research question</b>, I’m
not going to go into much details of the paper. Nevertheless, I still think
their conclusion is correct! “Clinical examination… has only a moderate ability
to detect life and limb threatening injuries.”<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Even
a broken clock is correct twice a day. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Just to
reiterate, this was a <b>retrospective</b> study of a <b>single</b> physical exam. It was
performed <b>pre-hospital</b>, possibly in an austere environment with <b>no ultrasound
or other adjuncts</b>. The doctor very likely had other significant priorities; i.e.
scoop and run. It <b>cannot speak to the utility of serial examinations</b> or those
performed a bit later as things evolve. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><b>My fear</b> is
someone may pull this paper out of their pocket to suggest that we need to do
away with physical exam and perform full body CT scans in all trauma patients. <b>This
could likely cause harm</b>, especially in lower risk trauma patients or pediatrics.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><i>Covering:</i><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Wohlgermut JM,
Marsden ME, Stoner RS, et al. Diagnostic accuracy of clinical examination to
identify life- and limb-threatening injuries in trauma patients. Scand J Trauma
Resusc Emerg Med. 2023;31:18 <a href="https://sjtrem.biomedcentral.com/articles/10.1186/s13049-023-01083-z">[link
to free full text article]</a><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-52000816782490071922023-12-11T16:55:00.000-08:002023-12-11T16:55:54.011-08:00Emergency Department REBOA in trauma patients with exsanguinating hemorrhage- Finally an RCT!<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjsEkLNugk0oAHnXpm1XRAahFgJrT0qvaRon9pkiVmX4tjECxQOtTi0_xfHAf1LloRIZzBV1gv59ZRDE1DEXQxn-pIGi8m_Z9uuU-C0buz5hcoafx4oew4XZ9jpCvvAGNSZKobqzJxkpekrlaFl-13zyP3PtvOaj2Hh_Lh3ZRUwhcBjgmIlnV7CJ7pvNNQ" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="400" data-original-width="698" height="183" src="https://blogger.googleusercontent.com/img/a/AVvXsEjsEkLNugk0oAHnXpm1XRAahFgJrT0qvaRon9pkiVmX4tjECxQOtTi0_xfHAf1LloRIZzBV1gv59ZRDE1DEXQxn-pIGi8m_Z9uuU-C0buz5hcoafx4oew4XZ9jpCvvAGNSZKobqzJxkpekrlaFl-13zyP3PtvOaj2Hh_Lh3ZRUwhcBjgmIlnV7CJ7pvNNQ" width="320" /></a></div><br />Resuscitative
Endovascular Balloon Occlusion of the Aorta has had lots of exciting coverage over
the past few years. But despite the hype, <b>we don’t really know if it helps or
harms patients.</b><p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Huh… <b>Why</b>
don’t we know if it works? <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><b>Existing
data has exclusively been <u>observational</u></b>. Researchers have passively sat back
and looked to see if there are outcome differences between those who got REBOA
and those who didn’t. The problem is these are <b>two VERY different groups</b>. Despite
all the fancy statistical analysis, it is <b>impossible to properly adjust</b>
for all the between group confounding. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">What is the
best way to get rid of confounding?<o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">Randomization.<o:p></o:p></span></b></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The process
of randomization ensures that there are equal amounts of known and unknown
confounders in each group. Problems solved… theoretically. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">So here is
the first randomized clinical trial of REBOA in trauma!<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The
UK-REBOA RCT was conducted in <b>16 major trauma centers in the UK</b>. Patients with
exsanguinating hemorrhage were enrolled over <b>4+ years</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The <b>primary
outcome </b>was all-cause <b>mortality</b> at 90 days. There were lots of secondary
outcomes. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Results?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><b>90 patients</b>
were enrolled almost all (97%) with <b>blunt</b> trauma. As expected, they were <b>super
sick</b> with a median injury severity score (ISS) of 41.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">In the end,
the trial was <u>stopped for harm</u>. <b>Mortality was 54% with REBOA vs. 42% in the standard
care </b>arm. Number needed to kill (NNK) is 8. In addition, all the secondary outcomes and bleeding seemed to be worse with REBOA. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Does this signal
the <b>death of REBOA?</b><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Probably
not. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Unfortunately,
this paper has <b>lots of limitations</b>. The biggest of which is <b>only 19</b>
out of <b>46</b> patients randomized to REBOA <b>got the device inserted and balloon
inflated</b>. It is hard to demonstrate a treatment effect when most patients don’t
get the treatment. But perhaps this shows the real-world difficulties of
performing REBOA. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Critics of
this paper will highlight <b>many other issues:</b> training of providers, time
delays, specific device used, small numbers, stopped early, baseline
differences favored the control arm, no penetrating trauma, etc.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Despite all
the issues, I think there is a <b>big take home point. <o:p></o:p></b></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><b>REBOA is very
hard to study.</b><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">These authors
went to great efforts. They included 16 centers over 4+ years and still they
had major issues. In the end, I doubt we will see much better evidence anytime soon. Nevertheless, I think we will see a shift away from REBOA... <a href="https://www.youtube.com/watch?v=9vQaVIoEjOM" target="_blank">don't believe the hype</a>. <o:p></o:p></span></p><p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><br /></span></p>
<p class="MsoNormal"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">Covering:<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="ES-CO" style="mso-ansi-language: ES-CO;">Jansen, JO,
Hudson J, Cochran C, et al. </span>Emergency Department Resuscitative Endovascular
Balloon Occlusion of the Aorta in Trauma Patients with Exsanguinating
Hemorrhage: The UK-REBOA Randomized Clinical Trail. <i>JAMA</i>. 2023;330(19):1862-1871.
<a href="https://jamanetwork.com/journals/jama/article-abstract/2810757">[Link
to article]</a><o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><span style="mso-spacerun: yes;"> </span><o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-4393892442591490752023-12-10T23:13:00.000-08:002023-12-10T23:13:22.316-08:00Aspirin vs Enoxaparin for thromboprophylaxis after a fracture<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjI4tyxwTGXRbvwTPOpuxGp-A4zDJV9mZUwDkScSy6WMjpAiiyVDPkPDgeEYHSJZPK2fezBit_VRG8xZKxnP83aDTpBG0AbgxSrNOTG86Y9AKQPD_75rNkxBF8nnhjKFylyxa47pvc3b6j6KaRcH6TYGsB2Q-iLG05dzQbBJtaseki4KMciLUVYwq6bMEM" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="1632" data-original-width="2449" height="213" src="https://blogger.googleusercontent.com/img/a/AVvXsEjI4tyxwTGXRbvwTPOpuxGp-A4zDJV9mZUwDkScSy6WMjpAiiyVDPkPDgeEYHSJZPK2fezBit_VRG8xZKxnP83aDTpBG0AbgxSrNOTG86Y9AKQPD_75rNkxBF8nnhjKFylyxa47pvc3b6j6KaRcH6TYGsB2Q-iLG05dzQbBJtaseki4KMciLUVYwq6bMEM" width="320" /></a></div><br />You are
sending home a patient from the ED with a broken ankle after you carefully
crafted a new plaster. Hmmmm… <b>do you need to worry about DVT prophylaxis?</b><p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Guidelines
and local practice vary. When you see this variation, it invariably means there
is <b>not</b> <b>conclusive evidence to inform practice.</b> <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Perhaps
this RCT from the <b>New England Journal of Medicine</b> might help?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">These
researchers from the USA conducted a <b>pragmatic, multicentre, randomized
non-inferiority trial.</b> They included patients who had a fracture of an
extremity (hip to midfoot or shoulder to wrist) that were <b><u>treated
operatively</u></b> or who had <b>pelvic or acetabular fracture</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Patients
were randomized to <b>aspirin 81mg BD</b> vs. <b>enoxaparin 30mg BD</b> while
in hospital but <u>could get whatever after discharge</u> “according to the
clinical protocols of each hospital.” <i>(For what it’s worth, BD aspirin is
not a typo…)<o:p></o:p></i></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">Primary
outcome</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;"> was death
from any cause and <b>secondary outcomes</b> looked at PE’s, DVT’s and bleeding
complications. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Results?<o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">12,211
patients</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;"> were
included! Mean age <b>44 years old</b> and 87% had lower extremity fractures.
Median <b>BMI was 27</b>. On average, patients received about <b>9 in-hospital
doses</b> of thromboprophylaxis and were prescribed a 21-day supply of whatever
upon discharge. <o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">Primary
outcome</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;">… <b>no
difference</b> at 0.7% mortality in both groups. There was <b>statistically
more DVT’s in the aspirin group</b> by a whopping 0.8% margin (NNT 125). PE’s were no
different and nor were complications. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">What should
we conclude in the ED?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Yes, this
is the tricky. The patients included in this study were <b>not patients discharged from the ED</b>.
Extrapolating the findings from this RCT to our population is problematic. Bummer…<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">In
addition, I’m disappointed <b>they did not standardize the take home
thromboprophylaxis</b>. This likely made it much more difficult to find
differences between the groups as patients were likely to cross-over. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Further,
this trial <b>did not restrict enrollment to high-risk patients</b>. These are
precisely the patients I want to target… another bummer. It is very possible
that enrolling all-comers diluted down the benefits & differences of
therapy. Who knows… but it’s common sense. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">In the end,
<b>I don’t think this should substantially change</b> how we think about ED patients
that we send home with fractures. Nevertheless, I anticipate this study will influence
the guidelines… we <b>might see some more aspirin being recommended</b>. But I'm not sure if this is for the better or worse.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><i>Covering:</i><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">METRC
Consortium, Aspirin or Low-Molecular-Weight Heparin for Thromboprophylaxis
after a Fracture. <i>N Engl J Med</i> 2023;338:203-13. <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2205973" target="_blank">[Link to article]</a><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-28978468708682509652023-09-15T00:18:00.001-07:002023-09-17T22:54:21.205-07:00Intra-articular Hematoma Block Compared to Procedural Sedation for Closed Reduction of Ankle Fractures<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEg-PDUmfYN_M3VmY4DiWBhJK5WG7-pqRopqWtPuLjviFqqprPqwVtOhkGJiJtJ0KIRUW9HjvVDyIgxElze63SsGmCyMB6LYe5D0bmA9hDSl3Dx-COlbJ3VDKyWNGBR0qzzA6nWx4lV1XvFMx7OCpnfaRml_9h9Y6qAi9V2xXrJz-xZMxqG7adw0ixZ9Bo8" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="537" data-original-width="370" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEg-PDUmfYN_M3VmY4DiWBhJK5WG7-pqRopqWtPuLjviFqqprPqwVtOhkGJiJtJ0KIRUW9HjvVDyIgxElze63SsGmCyMB6LYe5D0bmA9hDSl3Dx-COlbJ3VDKyWNGBR0qzzA6nWx4lV1XvFMx7OCpnfaRml_9h9Y6qAi9V2xXrJz-xZMxqG7adw0ixZ9Bo8" width="165" /></a></div><br />I must have missed this paper originally published in 2018
in Foot and Ankle International… perhaps my subscription has lapsed.<p></p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">Either way, I’m intrigued. <o:p></o:p></p>
<p class="MsoNormal">These researchers sought to compare <b>intra-articular hematoma
blocks</b> (IAHB) vs. <b>procedural sedation</b> to aid in the reduction of <b>displaced
ankle fractures</b> (fracture subluxations or dislocations). <o:p></o:p></p>
<p class="MsoNormal">This was a retrospective chart review without great methods…
but what the hell. <o:p></o:p></p>
<p class="MsoNormal">They identified <b>221 patients that underwent IAHB</b> vs. <b>114
who got PS</b> over 11 years in their single ED in Minnesota. The primary outcome
was rate of successful reduction. But they also looked at reduction attempts,
time to successful reduction, length of stay in the ED and some adverse events. However, they did not report on adequacy of pain reduction or patient satisfaction.
<o:p></o:p></p>
<p class="MsoNormal">A hematoma block was performed using <b>10 to 12ml of 1%
lignocaine without adrenalin</b> that was <b>injected into the tibiotalar joint</b>.
Ultrasound guidance was not used (but in my opinion can be helpful). <o:p></o:p></p>
<p class="MsoNormal">Results?<o:p></o:p></p>
<p class="MsoNormal">Patients were not randomised and as such, there were some substantial
differences between the groups. As you can discern from the numbers, they liked
their hematoma blocks twice as much as procedural sedation. However, more patients
with complete dislocations got sedation. <o:p></o:p></p>
<p class="MsoNormal">The <b>rate of successful reduction was about the same in
both groups</b>. About <b>70%</b> were reduced with one attempt and 25% more by
the second. Overall, there was a <b>90% success rate</b>. <o:p></o:p></p>
<p class="MsoNormal">As for safety, one patient in the procedural sedation group got
intubated… yikes!<o:p></o:p></p>
<p class="MsoNormal">This study has many limitations and is not high-quality evidence.
Nevertheless, it is yet another paper demonstrating the utility and uptake of hematoma
blocks for displaced ankle fractures. Even the <a href="https://www.nejm.org/doi/full/10.1056/NEJMvcm1511693#:~:text=Apply%20varus%20and%20medial%20force,and%20hindfoot%20under%20the%20tibia." target="_blank">New England Journal of Medicine</a>
has jumped on board with these blocks for ankles. <o:p></o:p></p>
<p class="MsoNormal">The beauty of a haematoma block is no need for a resuscitation
room and lots of resources. It can quickly be performed by a single provider. In
addition, a further reduction attempts can easily take place as the block will
last for a while. <o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><i>Covering:<o:p></o:p></i></p>
<p class="MsoNormal">MacCormick LM, Baynard T, Williams B, et al. Intra-articular
Hematoma Block Compared to Procedural Sedation for Closed Reduction of Ankle
Fractures. Foot & Ankle Int. 2018;39:1162-8. <a href="https://journals.sagepub.com/doi/10.1177/1071100718780693?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed" target="_blank">[Link to article]</a><o:p></o:p></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-43613015736035048812023-09-14T21:55:00.001-07:002023-09-17T23:09:09.647-07:00Have you heard about the HEAR score?<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEiWT45JQoMzpzSydI_969HqKYTkNYffOQ_sfoELRrZN-13b7RgaMA2lGFhxdAIeT83dsEnu946e-vmWipJIwBR-Xc1ShjM4fM8IN-vtFc1Gg6XCidjbHbvp9AT7Y2aS0e2GN05LK7jS-I7JqnG0PoFqA369vizbQIOeQBDAWAvpzqhxfD3HbpcK932El14" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="1758" data-original-width="1265" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEiWT45JQoMzpzSydI_969HqKYTkNYffOQ_sfoELRrZN-13b7RgaMA2lGFhxdAIeT83dsEnu946e-vmWipJIwBR-Xc1ShjM4fM8IN-vtFc1Gg6XCidjbHbvp9AT7Y2aS0e2GN05LK7jS-I7JqnG0PoFqA369vizbQIOeQBDAWAvpzqhxfD3HbpcK932El14" width="173" /></a></div><br />We’ve all heart about the <b>HEART score</b> for risk
stratification of patients with chest pain in the ED. Take away the troponin and
you’ve got the HEAR score!<p></p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">Yes, the HEAR score tries to identify patients at very low
risk of ACS that don’t even need a troponin. The thought is this will decrease
resource utilisation and improve patient flow. <o:p></o:p></p>
<p class="MsoNormal">The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952041/" target="_blank">original “derivation” of the HEAR score</a> was in 2020 by
Smith LM, et al. These subsequent researchers from Calgary (<a href="https://en.wikipedia.org/wiki/Calgary_Stampede" target="_blank">go stampede!</a>) sought
to externally validate this strategy.<o:p></o:p></p>
<p class="MsoNormal">They conducted a secondary analysis of a prospective cohort study
of patients with chest pain that got a troponin to exclude MI in their single
ED.<o:p></o:p></p>
<p class="MsoNormal">They enrolled 1150 patients. Of those, 8% had index MI and
11% with MACE by 30 days. <b>HEAR score <u><1</u> identified 202 (17.6%) of patients
at very low risk of adverse events with a 99% sensitivity</b> (95% CI 95.6-99.9%). Only one patient out of 202 was missed. <o:p></o:p></p><p class="MsoNormal">As with most screening tools that are highly sensitive, it often means they are <b>terribly non-specific</b>. The HEAR score is no exception. As such, it should only be used as a <u>one-way decision instrument</u>. </p>
<p class="MsoNormal">The authors of this study appropriately conclude that this very low risk cohort of HEAR <u><</u>1 is unlikely to
benefit from troponin testing and will lead to significant resource
savings.<o:p></o:p></p>
<p class="MsoNormal">This is <b>not exactly ground-breaking</b>. A young patient with a low-risk
story, a normal ECG, and no risk factors is very unlikely to have a problem. <o:p></o:p></p>
<p class="MsoNormal">Sure, it’s probably fine to skip the troponin. I think a lot
of us have been doing this over the years via gestalt. But at least this study
quantifies the risk and provides support for those clinicians who want to avoid troponin
testing in very low risk patients. <o:p></o:p></p>
<p class="MsoNormal">Perhaps the greatest use of HEAR score is to <b>allow you sleep
at night</b>… perhaps a bit of medico-legal defense when you document the score and send that low risk patient home
without blood tests.<o:p></o:p></p><p class="MsoNormal"><br /></p><p class="MsoNormal"><i>Covering:</i></p><p class="MsoNormal">O'Rielly CM, Andruchow JE, McRae AD. External validation of a low HEAR score to identify emergency department patients at very low risk of major adverse cardiac events without troponin testing. CJEM. 2022;24:68-74. <a href="https://pubmed.ncbi.nlm.nih.gov/34273102/" target="_blank">[link to article]</a></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-74079508227142667232022-08-10T17:28:00.000-07:002022-08-10T17:28:15.174-07:00Not so FAST? How a study on lung ultrasound got it wrong…<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhP5AxtABe-cKI9_og1tjaVG-D8NBE0VZHvt8Rct6755vsKn-kC-BqniwLnLXk7fcGL7GMl9EvVwQF9FaFQINcxkayWOAYYm6HVi8LjEERG0JpcwAvNBniXRLB8SXLTtYw_Fj-DdgLVZCfSHOqDcYVv8pL1AFKeRTwPYDAqQcN2RTdBUFBdMo2AMR2r/s600/thumb_transducers_01.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="400" data-original-width="600" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhP5AxtABe-cKI9_og1tjaVG-D8NBE0VZHvt8Rct6755vsKn-kC-BqniwLnLXk7fcGL7GMl9EvVwQF9FaFQINcxkayWOAYYm6HVi8LjEERG0JpcwAvNBniXRLB8SXLTtYw_Fj-DdgLVZCfSHOqDcYVv8pL1AFKeRTwPYDAqQcN2RTdBUFBdMo2AMR2r/s320/thumb_transducers_01.jpg" width="320" /></a></div><br />This study
out of UC San Diego set out to determine the<b> accuracy of lung ultrasound vs.
supine portable chest x-ray for the detection of traumatic pneumothorax.</b><p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Yes, I also
thought this research questions had been suitably answered. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">In 2020, a <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013031.pub2/full" target="_blank">CochraneReview</a> included <b>13 prospective paired comparative accuracy studies</b> and
concluded that <b>ultrasound was about 90% sensitive vs. 50% for a chest x-ray.</b> Both
are highly specific. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Regardless
of the consistent evidence, let’s consider <b>face validity</b>. Anyone who is
competent in lung ultrasound knows that ultrasound is much better at finding
pneumothorax. There is no planet in the solar system where a supine portable
chest x-ray is going to be more sensitive than ultrasound. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">But <b>this study concludes the opposite</b>… chest x-ray was better!<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Huh? How could this be?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">This was a
<b>retrospective registry review</b>. Retrospective data is often poor quality. Registry
data is even worse. Garbage in... garbage out. Ironically, <b>this study would never have been included in
the Cochrane review. </b><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">What is the
probability that this single study with worse quality evidence is correct and all
the consistent higher quality studies are wrong?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Yes, the
<b>probability is close to zero</b>.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">But where
did this study really go wrong? <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">I think the
authors answered the question themselves, <i>“… in a non-study environment,
such as ours, the pleural views were not universally performed with the same
rigor as in a prospective study designed specifically to detect pneumothorax.”<o:p></o:p></i></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">I think
this is probably the answer. <o:p></o:p></span></p>
<p class="MsoNormal">There are <b><u>many</u>
other problems with this study</b>, but I’m limited by word count. So briefly, the methods for assessment of diagnostic accuracy of a test were performed backwards. They used the wrong probes for lung ultrasound. They used the wrong clinicians to perform and interpret the ultrasound. That was only to name a few...</p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">As expected,
there were <b>many concerned letters to the editor</b>. Even one from Dr Giovanni Volpicelli who
is the world leader and pioneer of lung ultrasound. But the authors stuck with
the strategy of “never admit you are wrong” and doubled-down in their conclusions.
<o:p></o:p></span></p>
<p class="MsoNormal">A bit sad really...</p><p class="MsoNormal"><br /></p><p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><i>Covering:</i></span></p><p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Santorelli JE, Chau H, Godat L, et al. Not so FAST- Chest ultrasound underdiagnoses traumatic pneumothorax. <i>J Trauma Acute Care Surg</i>.2022;92:44-8.<a href="https://journals.lww.com/jtrauma/Abstract/2022/01000/Not_so_FAST_Chest_ultrasound_underdiagnoses.8.aspx" target="_blank">[link to article]</a></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-50337133627825503022022-06-03T16:33:00.000-07:002022-06-03T16:33:48.809-07:00Nonoperative or Surgical Treatment of Acute Achilles’ Tendon Rupture<p><b><span lang="EN-US"></span></b></p><div class="separator" style="clear: both; text-align: center;"><b><a href="https://blogger.googleusercontent.com/img/a/AVvXsEg_0wy5Jty4pdWOv70HuYtgWXhyJxH9lQg1p1rCQI2MCht9QxZ7ySfUiZ2cjuqIylnhD5y32WUFHWfeJ5cSIcwwqBS9MUPIacwRi_8t7UyQfjUKGpsdqJMyDfNRy39AjYckic0mZjRoK5lKhtnYu2ct1Eknfax9A87xBbj_hxIvbx80V84Stxo7wb3E" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="499" data-original-width="640" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEg_0wy5Jty4pdWOv70HuYtgWXhyJxH9lQg1p1rCQI2MCht9QxZ7ySfUiZ2cjuqIylnhD5y32WUFHWfeJ5cSIcwwqBS9MUPIacwRi_8t7UyQfjUKGpsdqJMyDfNRy39AjYckic0mZjRoK5lKhtnYu2ct1Eknfax9A87xBbj_hxIvbx80V84Stxo7wb3E" width="308" /></a></b></div><b><br />Why</b><span lang="EN-US"> do emergency clinicians need to
know about this paper? Afterall, we will not be making treatment decisions about
to operate or not…</span><p></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">Two
reasons</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;">.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">First, we need
to know the <b>“next step”</b> and be able to inform our patients of what the
treatment options are likely to be. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Second, this
was an RCT published in the <b>New England Journal of Medicine</b>. This is the
highest impact medical journal on the planet. Papers published here <b>set the
guidelines</b> about how we practice medicine. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">These authors
from Norway randomized <b>554 patients</b> with acute Achilles tendon rupture
to <b>one of three treatment arms: <u>conservative</u>, <u>open repair</u>, or <u>minimally
invasive surgery</u>.</b><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The <b>primary
outcome</b> was the change in the <b>Achilles tendon Total Rupture Score</b> at
<b>12 months</b>. They also looked at incidence of tendon <b>re-rupture</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">They standardized
the aftercare & rehabilitation in all groups. They required casts and weight
bearing as tolerated using an ankle-food orthosis with heel wedges for 6-8
weeks. They did not report on earlier return to functional status between
groups. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Results?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">At 12
months, there was <b>no difference</b> in the rupture score. As expected, there
were <b>more re-ruptures in the conservative</b> vs. surgical arms (<b>6.2%</b>
vs. 0.6%). And there were more <b>nerve injuries</b> in the surgical groups. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">All studies
have <b>limitations</b> and this one is no exception. An RCT is only as good as
the measuring tool of its primary outcome. I’m not sure what to make of the rupture
score and self-reporting may have led to bias. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">What are we
to make of this?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">In the long
term, <b>there probably is no big difference</b> between conservative vs.
surgical management. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Nevertheless,
there is probably <b>enough wiggle room with the interpretation of this study</b> for orthopedists
to continue doing whatever they like. Conservative seems fine in the long run,
but there are higher rates of re-rupture. Surgical treatment is about the same
but comes with the potential for nerve injury and infection. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Seems like
we are right back where we started!<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">Covering:<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Myhrvold S,
Brouwer E, Andresen T, et al. Nonoperative or Surgical Treatment of Acute
Achilles’ Tendon Rupture. N Engl J Med 2022;386:1409-20. <a href="https://www.nejm.org/doi/pdf/10.1056/NEJMoa2108447" target="_blank">[link to article]</a><o:p></o:p></span></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-5181939688082404392022-06-03T01:54:00.000-07:002022-06-03T01:54:47.312-07:00Risk of delayed intracranial hemorrhage after an initial negative CT in patients on DOACs with mild traumatic brain injury<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEinTpSll9BpWVlU79Xa4LFeNx1dpN7OvN9V7eiPOfVOcVi2W46I-pmPcEfHs4s4Hsz4-8UlzqNkWio06sqCI8EaHQkldWEgERcr8fh-fZImrO3-v_naMRttwn3sex1yer2nUv_1h96KvLyrrAFlFJr9bjWVDSgy1U9jA795C3uzpBjmH1szn2qjqcwt/s500/Rivaroxaban-Tablets.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="500" data-original-width="500" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEinTpSll9BpWVlU79Xa4LFeNx1dpN7OvN9V7eiPOfVOcVi2W46I-pmPcEfHs4s4Hsz4-8UlzqNkWio06sqCI8EaHQkldWEgERcr8fh-fZImrO3-v_naMRttwn3sex1yer2nUv_1h96KvLyrrAFlFJr9bjWVDSgy1U9jA795C3uzpBjmH1szn2qjqcwt/w320-h320/Rivaroxaban-Tablets.jpg" width="320" /></a></div><br />To identify
delayed hemorrhage, some clinicians will <b>repeat a head CT</b> in patients on <b>NOAC’s
</b>with <b>mild traumatic brian injury</b> (TBI) after the initial<b> head CT is negative</b>.<p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">How common
is delayed hemorrhage with DOAC’s? <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Hmmm….<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">These
authors from Italy performed a retrospective multicentre observational study.
They found <b>1426 patients</b> taking NOAC’s who were evaluated in the ED for
mild TBI (GCS 14-15). Of these <b>916</b> (68%) underwent 24 hours of observation and a
repeat CT after the initial one was negative. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">In the end,
only <b>14 (1.5%)</b> patients had <b>delayed hemorrhage </b>found on repeat CT. None of these
patients had neurosurgery or died <i>(but I presume they had their DOAC’s withheld).</i><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Another
interesting aspect… no delayed hemorrhages were found in patients who had the initial
head CT greater than 8 hours after injury. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The findings
of this study are similar with others looking at warfarin. Consistency in
the literature is comforting. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">So, we have
a pretty simple message. <b>Routine delayed head CT is not necessary</b>. But
1.5% is not zero… so we still need to be a little careful. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">And another
question… is it DOAC’s or NOAC’s?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">Covering
<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="ES-CO" style="mso-ansi-language: ES-CO;">Turcato G,
Cipriano A, Zaboli A, et al. </span>Risk of delayed intracranial haemorrhage after
an initial negative CT in patients on DOACs with mild traumatic brain injury.
<i>Am J Emerg Med.</i> 2022;53:185-189. <a href="https://www.sciencedirect.com/science/article/abs/pii/S0735675722000225?via%3Dihub" target="_blank">[link to article]</a><o:p></o:p></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-52517190387988747522022-06-03T00:15:00.000-07:002022-06-03T00:15:18.330-07:00Single dose phenobarbital for the outpatient treatment of alcohol withdrawal... interesting<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxo2d6669YzFMnQ02Wz2fpdJNnERt0K2FXzA_NfYRL6hfcE0vgAcCXNlBax1ufBx07aq02xt2zg-XvGb98HjMpVbJLN5m-xTBl5mzPhEvo2nirP-JeZMn5ocCew1AH54TnFsTgO2LVRce5G4RGdHr3vd9Ay2gb9M_1vm2hQp3t_f7scVSmPws9NBJi/s817/nick.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="654" data-original-width="817" height="256" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxo2d6669YzFMnQ02Wz2fpdJNnERt0K2FXzA_NfYRL6hfcE0vgAcCXNlBax1ufBx07aq02xt2zg-XvGb98HjMpVbJLN5m-xTBl5mzPhEvo2nirP-JeZMn5ocCew1AH54TnFsTgO2LVRce5G4RGdHr3vd9Ay2gb9M_1vm2hQp3t_f7scVSmPws9NBJi/s320/nick.jpg" width="320" /></a></div><br />Phenobarbital
has <b>some ideal properties</b> for the treatment of alcohol withdrawal. In particular,
it has a <b>long half life</b> (about 100 hours) allowing for a single dose without the requirement for prescriptions.<p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">However, there
are some genuine <b>safety concerns</b> especially if they are mixed with other drugs
or alcohol. And there is little high-quality evidence to support it’s use in patients being sent home from the ED. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">This is a
<b>retrospective chart review</b> of patients discharged from a single ED in
California over a three-year period with a <b>discharge diagnosis of alcohol
withdrawal</b>. Patients were stratified into <b>three categories</b>; those who got benzo’s,
benzo’s plus phenobarbital or just phenobarbital alone. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The <b>primary
outcome</b> was <b>return ED encounter within 3 days</b> of the index visit. <i>(Yes, this is an odd primary outcome, but it was chosen for pragmatic purposes as below...)</i><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><b>470 patients</b>
were included. <b>235</b> got benzo’s, <b>133</b> got phenobarbital, and <b>102</b> got the combination
special. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Results?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Treatment
with <b>phenobarbital </b>(alone or in combination) <b>was associated with a decreased
odds ratio of a return ED visit within 3 days</b>. (AOR 0.45 95% CI 0.23, 0.88<span style="mso-spacerun: yes;"> </span>and AOR 0.33 95% CI 0.15,0.74 respectively).<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The cynic
in me wonders if this is because phenobarb patients died… (But
this was probably not the case as the author were eventually able to account for most patients)<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">It is
interesting to note that patients who received phenobarbital <b>got much more GABA
agonist medication</b> than those that simply got benzodiazepines. <b>Four times</b> as
much was given if you adjust for drug equivalence. Perhaps this is why they
were less likely to return?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Unfortunately,
this paper <b>does not address the big question of safety</b>. It would take a
much larger study with more robust methodology (that avoids loss to follow-up) to answer this. And such a study
would be very difficult to undertake as this cohort of patients are unreliable and not likely to be compliant with study protocols etc. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">What’s the
<b>take home message</b>? <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Phenobarbital
for the outpatient treatment of alcohol withdrawal is <b>tempting</b>, but there is
<b>arguably not enough evidence</b> to support its routine use. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><i>Covering: </i><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="ES-CO" style="mso-ansi-language: ES-CO;">Lebin A,
Mudan A, Murphy CE, et al. </span>Return Encounters in Emergency Department
Patients Treated with Phenobarbital Versus Benzodiazepines for Alcohol Withdrawal.
<b>J Med Tox</b>. 2022;18:4-10. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8758850/" target="_blank"><span style="mso-spacerun: yes;"> </span>[link to full text of article]</a><o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-51140142317097028772022-06-02T22:02:00.000-07:002022-06-02T22:02:32.396-07:00Risk for recurrent VTE in patients with subsegmental PE managed without anticoagulation- A prospective study<p><br /></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1WoxuO6WmhDDBF759NntWEoPRVtRA8-6iLGzz7XIb95AR7i6w2s682gBXeR8-fxBme4SJaWNVlxWIKyTbpcTT0_ThDWKcJlYI03Z2c5DX5Ib-YW9CRRFwPJDr5XqO9_qCa2JJ-eTFEqdvsY8MHx7JxLCuBJ8rLGoQDTle8KnNZTpebfijdLUrN_1p/s244/microscope%20with%20kid.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="244" data-original-width="206" height="244" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1WoxuO6WmhDDBF759NntWEoPRVtRA8-6iLGzz7XIb95AR7i6w2s682gBXeR8-fxBme4SJaWNVlxWIKyTbpcTT0_ThDWKcJlYI03Z2c5DX5Ib-YW9CRRFwPJDr5XqO9_qCa2JJ-eTFEqdvsY8MHx7JxLCuBJ8rLGoQDTle8KnNZTpebfijdLUrN_1p/s1600/microscope%20with%20kid.jpg" width="206" /></a></div><br />Modern imaging
technologies have put a virtual microscope into the human body and can find smaller
and less significant disease. Our treatment of these conditions often falls under old recommendations meant for more substantial illness. Can treatment of mild disease result in more harm than benefit?<o:p></o:p><p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">This
question is particularly true when it comes to subsegmental PE. Does it require
anticoagulation?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">These
researchers found <b>266 patients with low-risk subsegmental PE</b> and referred them to a thrombosis clinic for management. The patients <b>underwent lower extremity
ultrasound to exclude DVT</b> at the time of diagnosis and one week later. Patients without DVT had <b>anticoagulation withheld</b> and they were followed
up for <b>90 days</b> looking for evidence of recurrent VTE.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">In the end,
<b>8</b> (3% 95% CI, 1.6%-6.1%) <b>out of the 266 patients developed VTE</b>. The authors report
higher rates in some subgroups but this analysis is not really justified given the low number of recurrences. </span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">There are some important limitations to remember. These patients were low risk. They did
not have cancer nor prior VTE. They all had repeated leg ultrasound to exclude DVT.
Long term rates beyond 90 days were not assessed. In addition, false positive
CTPA's may have skewed the results towards lower rates of recurrent disease. <o:p></o:p></span></p><p class="MsoNormal"><span lang="EN-US">What are we to conclude?<o:p></o:p></span></p><p class="MsoNormal"><span lang="EN-US"></span></p><p class="MsoNormal"><b><span lang="EN-US">Recurrent VTE in low-risk patients with subsegmental PE is pretty low</span></b><span lang="EN-US">. This may be a good time for shared decision making.</span></p><p class="MsoNormal"><br /></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><i>Covering: </i><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="ES-CO" style="mso-ansi-language: ES-CO;">Le Gal G,
Kovacs M, Bertoletti L, et al. </span>Risk for Recurrent Venous Thromboembolism
in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation.
<i>Ann Intern Med</i>. 2022;175:29-35 <a href="https://www.acpjournals.org/doi/full/10.7326/M21-2981" target="_blank">[link to article]</a><o:p></o:p></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-79067240563890942852022-04-14T19:01:00.000-07:002022-04-14T19:01:54.539-07:00Cannabinoid hyperemesis syndrome: A 6-year audit of adult presentations to a single ED in Melbourne<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgi3XPOnAyadwkEwRd1HNOvx7r5S7BnXjSbjO6HNdznYkxYv9NdjH3lF4MTD9INgy_YXQqfiqNGArwJQC3gJ8xGA9vL_yaSNeYa-TrEBzsILgYe4Adsvcn9a4qKUQ_hE22aUr59Dq5vuFUwp3Ljk1i_Yl_e3r9yNJIq8I2FnClHqLpQPE3e9Tj3RAFP" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="360" data-original-width="480" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEgi3XPOnAyadwkEwRd1HNOvx7r5S7BnXjSbjO6HNdznYkxYv9NdjH3lF4MTD9INgy_YXQqfiqNGArwJQC3gJ8xGA9vL_yaSNeYa-TrEBzsILgYe4Adsvcn9a4qKUQ_hE22aUr59Dq5vuFUwp3Ljk1i_Yl_e3r9yNJIq8I2FnClHqLpQPE3e9Tj3RAFP" width="320" /></a></div><br />I'll preface everything by stating this paper is <b>not high science</b>.<p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Sorry…<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">These authors
performed a <b>retrospective chart review</b> on adult patients who they
thought had <b>cannabinoid hyperemesis syndrome</b> (CHS) in their <b>single ED</b>
in northern Melbourne.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Obviously,
the <b>diagnosis</b> of CHS is based on <b>clinical findings</b>. There is no
blood test for CHS and no agreed formal diagnostic criteria. So, who knows if
they identified all patients with CHS or if the ones they diagnosed truly had it?
<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Nevertheless,
there might be a few useful pieces of information… so let’s continue on our magic
carpet ride. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">142
patients were included. 77 were unique presentations and the rest were frequent
visitors.<o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">I’m not
going to report their clinical features</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;"> as this formed part of how they identified patients
in the first place… kind of an incorporation bias. (Suffice to say, they were
vomiting a lot.) Plus, the retrospective nature of the data means a lot of things
were probably not recorded (i.e. relief from hot shower was only written down
11% of the time).<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">More objectively,
I was interested to see that <b>most had elevated white blood cell counts and
lactates</b>. Median WBC was <b>14</b> (IQR 11.2-16.8) and lactate was <b>1.95</b>
(IQR 1.4-2.9)<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">These
doctors also <b>liked droperidol</b> and the authors go on to state, “<i>Response
to droperidol (or haloperidol) as previously reported may also guide clinicians
in their determination as to whether CHS should be considered.”<o:p></o:p></i></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Arguably
the best part of the paper is their proposed <b>CHUNDER score</b> to aid
in the diagnosis of CHS. This mnemonic stands for, “<b>C</b>yclical vomiting, <b>H</b>istory
of regular cannabis, <b>U</b>nder fifty years old, <b>N</b>ormal lipase, <b>D</b>iagnosis
of exclusion, <b>E</b>levation of CRP<50, and <b>R</b>eduction in symptoms
after droperidol. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">I’m chunder
struck…<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">Covering:<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="ES-CO" style="mso-ansi-language: ES-CO;">Rotella J,
Ferretti O, Raisi E, et al. </span>Cannabinoid hyperemesis syndrome: A-year
audit of adult presentations to an urban district hospital. 2022 Feb 23. doi:
10.1111/1742-6723.13944 <a href="https://onlinelibrary.wiley.com/doi/10.1111/1742-6723.13944" target="_blank">[link to article]</a><o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-35092337379494286302022-04-14T18:18:00.001-07:002022-04-14T18:18:47.387-07:00Association of IV Contrast with Renal Function- A Regression Discontinuity Analysis<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjBWd9WaunOfwDc6rgbWN-ek_rDfuFRH420d5kAqtXzXrZh_bYLQeAInmrpth3zG9KzlnnqPcyLo5QL_p7A2O5k9ALB7y9RayvGD7IFLa_wGXwV7bjuj3pWncpnkhUQ2G7lIY-kkAkSAMH6VqEUKfjZbo3GJEl1hAZJ32Fb6Hr4Od5mM6ZpvQ9aArkp" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="600" data-original-width="600" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEjBWd9WaunOfwDc6rgbWN-ek_rDfuFRH420d5kAqtXzXrZh_bYLQeAInmrpth3zG9KzlnnqPcyLo5QL_p7A2O5k9ALB7y9RayvGD7IFLa_wGXwV7bjuj3pWncpnkhUQ2G7lIY-kkAkSAMH6VqEUKfjZbo3GJEl1hAZJ32Fb6Hr4Od5mM6ZpvQ9aArkp" width="240" /></a></div><br />IV Contrast
has been around for decades. How come we still do not know whether its causes
renal damage!<p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Well, today
is your lucky day…<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">These
researchers conducted a randomized double-blind placebo-controlled trial of IV
contrast in 2000 patients with borderline renal function to determine if there
was any meaningful worsening in patient-oriented outcomes.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Just
kidding!<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">There are
limits in conducting clinical trials… the biggest of which boils down to <b>ethics</b>
and <b>feasibility</b>. Sometimes, an RCT is not going to happen. So, we are stuck
with <b>observational studies</b> which have the inherent trouble in dealing
with <b>confounding</b> and attributing <b>causality</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">In an
attempt to overcome these limitations, these researchers performed a <b>regression
discontinuity design (RDD).</b><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Huh?!?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The RDD
relies upon the existence of a continuous variable (i.e. D-dimer) for which
there is a cut-off that determines treatment or investigation. Patients on
either side of the cut off have much different probabilities of investigation
but probably are reasonably matched for confounding factors.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Pretty
clever…<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">These
researchers included <b>adult patients who had a D-dimer test</b> during an <b>ED
visit</b> over a 5-year period in the <b>province of Alberta, Canada</b>. They
compared the group that had elevated D-dimers vs. those that were normal. The <b>primary
outcome</b> was <b>long term renal function</b> (up to six months from ED
visit). <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Results?<o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">150,028
patients</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;"> met
inclusion criteria. <b>Mean baseline eGFR was 86</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">There was <b>no
evidence of renal damage</b> with a <b>change of eGFR of only 0.4</b> (95%CI
-4.9 to 4.0) up to 6 six months later. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The authors
conclude; </span></p><p class="MsoNormal" style="text-align: center;"><span lang="EN-US" style="mso-ansi-language: EN-US;"><i><span style="font-size: medium;">“To our knowledge, this study provides the strongest evidence to
date that intravenous contrast is not associated with significant kidney
injury…”</span></i><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">This <u>overall</u>
conclusion is correct. <b>But...</b> we are not worried about patients with near normal
renal function to start with. We are much more interested in the cohort that
has <u>borderline</u> function.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">They <b>tried
a subgroup analysis</b> by looking at patients with eGFR <45 but state that
the analysis was hindered by <b>missing data</b> and <b>small numbers</b>. This
is unfortunate. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">What should
we conclude?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Overall, the
modern IV contrast agents probably don’t do much to kidneys. But we are not
entirely sure in the cohort with more severe baseline renal impairment. <o:p></o:p></span></p><p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><br /></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><i>Covering: </i><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Goulden R,
Rowe B, Abrahamowicz M, et al. Association of Intravenous Radiocontrast with
Kidney Function. A Regression Discontinuity Analysis. JAMA Intern Med.
2021;181:767-774. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022267/" target="_blank">[Link to article]</a><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-48046478674847799222022-04-09T21:45:00.000-07:002022-04-09T21:45:47.477-07:00Rapid agitation control with ketamine in the ED: A Randomized Controlled Trial<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjwFnhpYeEl1luXjpWWRYFgfY7ZpXs8aZaGxAALgOBNfV0JTH0_hyRzbUG_zeSToiOQDXwGjUyNyX3rxosrsDaLge6C-yCLvBKgudRKIyVrZBe5Yx3vC7ZPYLvsHuIS_AYriyWS_tdHERpbD6sP3F4sDnxSJZsi384ApiXz-pRFgblqGUc6GrhVOVm0" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="801" data-original-width="640" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEjwFnhpYeEl1luXjpWWRYFgfY7ZpXs8aZaGxAALgOBNfV0JTH0_hyRzbUG_zeSToiOQDXwGjUyNyX3rxosrsDaLge6C-yCLvBKgudRKIyVrZBe5Yx3vC7ZPYLvsHuIS_AYriyWS_tdHERpbD6sP3F4sDnxSJZsi384ApiXz-pRFgblqGUc6GrhVOVm0" width="192" /></a></div><br />Agitated
patient tearing apart the ED...? Which IM medication do you give?<p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">These
authors from a single ED in Vancouver randomized patients to either <b>ketamine 5mg/kg</b> IM vs. <b>midazolam 5mg plus haloperidol 5mg</b>
IM. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Their <b>primary
outcome</b> was <b>time to</b> <b>adequate sedation</b> as measured on a validated
agitation score. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><i>(They tried
to blind the dose but it’s hard to blind ketamine when we all know what it looks
like. Either way, this was probably only a minor source of potential bias.)</i><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Results?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Enrolment
was cut a bit short at <b>80 patients</b> due to the start a supposed global
pandemic. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Median time
to adequate sedation was <b>6 minutes</b> in the ketamine group vs. <b>15 minutes</b> in those randomized to midazolam/haloperidol. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">So, <b>ketamine
is the clear winner</b>?!?!<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">There are <b>two
major reasons why this conclusion is wrong</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">Firstly</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;">, they compared a <b>grizzly bear
dose of ketamine</b> to a <b>low dose of midazolam & haloperidol</b>. For
what it is worth, I usually start with midazolam 10mg and <u>droperidol</u> 10mg (unless
there is reason to start lower… elderly, co-morbid, etc.) Droperidol works faster than haloperidol.<o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">Secondly</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;">, <b>they</b> <b>asked the wrong research
question</b>. I care less about how quickly someone is sedated and care much more
about how well it works overall. <span style="mso-spacerun: yes;"> </span>I’m
sure a dose of IM sux would work pretty quick too. Or even a bullet to the head
would have an immediate calming effect (but would be associated
with excess mortality.) <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">How often
did the ketamine group require re-sedation? How well did the patients wake up? Lots
of adults complain about side effects of ketamine including dysphoria to
emergence phenomenon. But what could go wrong with giving an agitated patient a medication
similar to PCP?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">To be fair
to the researchers, <b>it is difficult to objectively measure, “how well did it
work?”</b> It's complicated and there is some subjectivity in this question. Time to sedation is
much easier to measure… but just because we can measure something accurately does
not necessarily mean it is important. <a href="https://en.wikipedia.org/wiki/Streetlight_effect" target="_blank">(This kind of reminds me of the streetlight effect).</a><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">In short
summary, I’m willing to believe a big slug of ketamine will cause someone to
drop quickly. But is this the best thing for the patient? I doubt it. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">Covering:<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Barbic D,
Andolfatto G, Grunau, et al. Rapid Agitation Control with Ketamine in the ED- A
Blinded, Randomized Controlled Trial. <i>Ann Emerg Med</i>. 2021;78:788-795
<a href="https://www.annemergmed.com/article/S0196-0644(21)00433-9/fulltext" target="_blank">[link to full text article]</a><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-63844649154682545202022-04-09T15:12:00.000-07:002022-04-09T15:12:41.443-07:00The erector spinae plane block for acute pain management in ED patients with rib fractures<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEiDcQzrNiy1GDt2m8DHjknZdgt9BYvhkEzLAxoCv1t37s4_mlNBQh8fJToOCRgOD8JzWzO3Afbix8GhTmla-FY2KRJRxRO-B4-B1zfwhkhNHtA0kf_yCMZcTzqynJtGQngYLC5wASkrkC_b5IT1n05b8CiMtILfo_-VK_9u_GctbUIkNEHm7tLo04ge" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="201" data-original-width="251" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEiDcQzrNiy1GDt2m8DHjknZdgt9BYvhkEzLAxoCv1t37s4_mlNBQh8fJToOCRgOD8JzWzO3Afbix8GhTmla-FY2KRJRxRO-B4-B1zfwhkhNHtA0kf_yCMZcTzqynJtGQngYLC5wASkrkC_b5IT1n05b8CiMtILfo_-VK_9u_GctbUIkNEHm7tLo04ge" width="300" /></a></div><br />The <b>erector
spinae plane block</b> provides analgesia for rib fractures. It is similar to 3
in 1 blocks that we are comfortable performing for femoral neck fractures. It requires
ultrasound guidance and high volume (30-40ml) of dilute anesthetic to allow the
medication to spread below a fascial plane. <p></p><p>For a decent video demonstrating
the block, check out: <a href="https://www.youtube.com/watch?v=O9RB0K7f8pM">https://www.youtube.com/watch?v=O9RB0K7f8pM</a></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Interestingly,
the block was <b>only just described</b> in the anesthesia literature in 2016
but it has already become quite the rage.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Why? It is <b>simple,
effective and the incidence of complications is felt to be low</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">However, it
looks like it hasn’t really made its way into the Emergency Department. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Enter two
Canadian emergency doctors who published a <b>case series of 9 patients</b>. Ok… a pilot study and not great science.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The <b>mean
reduction in NRS pain scores</b> went from about <b>10 to 3.5</b>. So, it seemed
to work pretty darn well. Of course, they cannot make any claims about safety,
but other literature has somewhat addressed this. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The authors
appropriate state that more research is needed but they <i>“feel that the erector
spinae plane block should be considered in patients with acute rib fracture
pain as a method of pain control in multi-modal analgesia.”<o:p></o:p></i></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">I think this
is probably a <b>fair conclusion</b>. We perform a multitude of blocks in the ED.
With appropriate training, this can probably be added to our armamentarium. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">Covering:
<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Surdhar I,
Jelic T. The erector spinae plane block for acute pain management in emergency department
patients with rib fractures. Can J Emerg Med. 2022;24:50-54. <a href="https://link.springer.com/article/10.1007/s43678-021-00203-x" target="_blank">[link to article]</a><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-80462134572429774582021-11-23T22:47:00.002-08:002021-11-23T22:47:34.737-08:00Dexamethasone in hospitalized patients with COVID-19<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjd3wGS7_XAnQY5Ebzv7HSpgspjVLrJyjsP180NUEUWYhxFWEs3lEkWbZ0DeeYpJLBzvJ40eM9VCya6le_GcSNcUIZp8Q-_MOcxlpXBu3rwtpdiPxpapq1SzVpKI_zrWtjuXNGtw9t-PTE/" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="500" data-original-width="500" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjd3wGS7_XAnQY5Ebzv7HSpgspjVLrJyjsP180NUEUWYhxFWEs3lEkWbZ0DeeYpJLBzvJ40eM9VCya6le_GcSNcUIZp8Q-_MOcxlpXBu3rwtpdiPxpapq1SzVpKI_zrWtjuXNGtw9t-PTE/" width="240" /></a></div><br />Prior to
the publication of this study, there was quite a lot of debate about the
efficacy of dexamethasone for hospitalized patients with COVID. <p></p><p>But not now…</p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The <b>RECOVERY
trial</b> was designed to quickly look at many potential treatments for COVID. A
whopping <b>176 NHS organizations in the UK</b> were involved and with no
shortage of patients to enroll. <o:p></o:p></span></p>
<p class="MsoNormal"><u><span lang="EN-US" style="mso-ansi-language: EN-US;">Hospitalized</span></u><span lang="EN-US" style="mso-ansi-language: EN-US;"> patients with COVID were randomized
to get either <b>6mg of dexamethasone daily</b> for 10 days or usual care
alone. <o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">Primary
outcome</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;"> was <b>all
cause mortality</b> at 28 days. There were lots of prespecified secondary
outcomes. <o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">6425 patients</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;"> were recruited from <b>March to
June 2020</b>. Overall, <b>22.9%</b> of patients in the dexamethasone group <b>died</b>
vs. <b>25.7%</b> in the usual care arm. <b>Absolute difference of 2.8%</b> for
a number needed to treat <b>(NNT) of 36</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">But the <b>benefit
seemed to be best in the sickest patients</b> that were ventilated; <b>NNT 8</b>. There was a
<u>trend towards harm</u> in the healthier group not requiring oxygen. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">There are <b>some
limitations</b> to this study, the biggest being our care of COVID has changed since
it was conducted, care was not standardized, and this was an unvaccinated
cohort. Nevertheless, it was generally well performed and (for now) it is
considered <b>practice changing</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Dexamethasone
is <b>no “magic bullet”</b> but another piece of the puzzle that might provide
some benefit to those sick enough to be hospitalized with COVID. However, <u>no
therapies have come even close to the benefits we see with vaccination</u>.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Get ‘em all
vaccinated!<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">Covering:<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The
RECOVERY Collaborative Group, Dexamethasone in Hospitalized Patients with
COVID-19. N Engl J Med 2021;384:693-704. <a href="https://www.nejm.org/doi/full/10.1056/nejmoa2021436">[link to full text article]</a><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-35790441962288505802021-10-19T02:02:00.000-07:002021-10-19T02:02:06.825-07:00MRI of cervical spine in trauma: A retrospective single-centre audit of patient outcomes<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQSZ97yi3JHjcF4XxVVggVChCq8slfmKN1wSPZlmiuYJ6jqEDckYCumz8rVYOepkp1DxZaJTtBuyewIsvfq_Kvz1qnWYThcPZZp8l6Cy0uIiy5YtqlqNVnObpY8hoJb2N-1VCb4MxEblo/" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="630" data-original-width="630" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQSZ97yi3JHjcF4XxVVggVChCq8slfmKN1wSPZlmiuYJ6jqEDckYCumz8rVYOepkp1DxZaJTtBuyewIsvfq_Kvz1qnWYThcPZZp8l6Cy0uIiy5YtqlqNVnObpY8hoJb2N-1VCb4MxEblo/" width="240" /></a></div><br />In patients with a <b>normal cervical spine CT but
persistent tenderness or neurology, how often is a subsequent MRI abnormal</b>? And what happens afterwards? Here's an answer from Gelong...<p></p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: center;"><i>(Spoiler alert... the real question should be, "does MRI find occult injury that results
in <b>genuine improvements in patient-oriented outcomes?</b> Or does it <b>cause
harm</b> from <b>overdiagnosis</b>?")</i><o:p></o:p></p>
<p class="MsoNormal">These authors from a single centre, looked retrospectively
at a cohort of trauma patients that had both a negative cervical spine CT and a
subsequent MRI. (Adult patients had to be alert and <72 hours between the
studies.)<o:p></o:p></p>
<p class="MsoNormal">Results?<o:p></o:p></p>
<p class="MsoNormal"><b>228 patients</b> were included.<o:p></o:p></p>
<p class="MsoNormal">Of the <b>181 patients</b> that had the MRI for <b>persistent
tenderness</b>, 35 (<b>20%</b> or one-in-five) had an <b>abnormal MRI</b>. Of
those, 14 were treated with a rigid collar and <b>no patients underwent surgery</b>.
<o:p></o:p></p>
<p class="MsoNormal">Of the <b>47 patients</b> that had the MRI for <b>neurological
findings</b>, 11 (<b>23%</b>) had an abnormal MRI. Four patients were managed
with collars. <b>Two patients required surgery</b> and the manuscript described
their presentation & hospital course. Their <b>neurologic issues were not subtle</b>.
<o:p></o:p></p>
<p class="MsoNormal">The authors appropriately conclude that the <b>MRI is of “questionable”
utility</b> in those without neurology. <o:p></o:p></p>
<p class="MsoNormal"><b>But could the MRI be even worse? </b>Could it identify injuries
that would heal just fine had we never found them only to subject patients to
weeks of unnecessary immobilisation, discomfort, and potential harm? Unfortunately, this was not really addressed in this study.<o:p></o:p></p>
<p class="MsoNormal">With technology advances, MRI will only get more sensitive at
finding “abnormalities." In addition, MRI will become more readily available. We
need to have some serious discussions; just because we can, should we? <o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><i>Covering: <o:p></o:p></i></p>
<p class="MsoNormal">Foster G, Russel B, Hibble B, et al. Magnetic resonance
imaging cervical spine in trauma: A retrospective single-centre audit of
patient outcomes. Emerg Med Aus. 2021 Sep 3.doi: 10.1111/1742-6723.13842. <a href="https://onlinelibrary.wiley.com/doi/10.1111/1742-6723.13842">[link to
article]</a><o:p></o:p></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-71215034495218252812021-10-17T23:29:00.000-07:002021-10-17T23:29:36.011-07:00The effectiveness of intradermal sterile water injection for low back pain in the ED: A prospective, randomized controlled trial<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhx0fa4sOVIOP9VLNpCeOwAbMGa2kOuMWt8r_qUxvYRZ9zB9hZ2wFivK4LZb2xs1BVxN5dc1ci66OfMYmlA_ZJr81Ycl9pOMFXjKOqv_csP8I47z8-ZbrgbDo0aYoxO0fJVLcimozHmvSo/" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="458" data-original-width="479" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhx0fa4sOVIOP9VLNpCeOwAbMGa2kOuMWt8r_qUxvYRZ9zB9hZ2wFivK4LZb2xs1BVxN5dc1ci66OfMYmlA_ZJr81Ycl9pOMFXjKOqv_csP8I47z8-ZbrgbDo0aYoxO0fJVLcimozHmvSo/" width="251" /></a></div><br />Intradermal
water injection to alleviate low back pain?<p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Believe it
or not, water injection has been around for many years, especially in the
delivery suite. There are some proposed mechanisms as to why or how it might
work. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">But can water injection work in the Emergency Department? <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">These
authors from a single center in Turkey, <b>randomized low back pain patients</b>
who all got IV NSAIDS to either <b>intradermal water injection</b> or <b>nothing </b>else.<o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">Inclusion
criteria</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;"> were
adults 18-65 years old with a VAS pain score of >4. They <b>excluded</b>
trauma, chronic back pain, those that had pain medications prior to arrival, diabetes,
or BMI >30. <o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">Outcomes</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;"> were reduction of pain at 10, 20,
30 minutes and 24 hours. They also looked at patient satisfaction, need for rescue
medication, etc.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Results?<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">112
patients enrolled and the <b>water worked FANTASTIC!</b> Everything they could
measure was better. <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: center;"><b><span lang="EN-US" style="mso-ansi-language: EN-US;"><span style="font-size: large;"><i>Hallelujah…
we have a miracle!</i></span><o:p></o:p></span></b></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Unfortunately,
there are some <b>serious problems</b> with this study.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The <b>manuscript
is awful</b> and serves as a <b>red flag</b> as to the professionalism and
conduct of these researchers. I would have genuinely believed that they used Google Translate
and submitted a draft without changes. But there are words in the manuscript
that don’t even exist on Google!<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Regardless
of the sloppy manuscript, there are serious methodological issues that likely
render the conclusions invalid.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">It was <b>not
blinded.</b> <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Of course,
patients were not blinded, but nor were the clinicians in the study who also collected
the outcome measures. This could have resulted in substantial <b>subject and observer
bias</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">And of
course, there is the <b>placebo effect…</b> <o:p></o:p></span></p>
<p class="MsoNormal"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">(But to
be fair to these researchers, what is the placebo for water? Or how can you perform
sham water injection? I don’t know.) <o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">In short
summary, <b>this terribly presented paper’s findings are very likely due to
bias and placebo effect. <o:p></o:p></b></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">But is it
unethical to use undisclosed placebo? Holy hallelujah can of worms…<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">Covering:<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Tekin E,
Gur A, Bayraktar M, et al. The effectiveness of intradermal sterile water
injection for low back pain in the emergency department: A prospective,
randomized controlled study. Am J Emerg Med 2021;42:103-109. <a href="https://www.sciencedirect.com/science/article/abs/pii/S0735675721000413?via%3Dihub">[link
to article]</a><o:p></o:p></span></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-61313959484019196672021-10-15T20:31:00.000-07:002021-10-15T20:31:00.241-07:00Risk stratification of patients admitted to hospital with covid-19- the 4C Mortality Score<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_m4adMY7OPjSc2t3DB7PrtiftZjtHotaNtTUuCTRFfJ8wbxGfc-ZoCt3M5PL1CereZ4S47tzw5DU-MuCD-K7OxMpx-TOhHWHykIh24jQUh8LlkY2RLWCH8krj9_i3mOglboP2cjgJfck/" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="1139" data-original-width="1121" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_m4adMY7OPjSc2t3DB7PrtiftZjtHotaNtTUuCTRFfJ8wbxGfc-ZoCt3M5PL1CereZ4S47tzw5DU-MuCD-K7OxMpx-TOhHWHykIh24jQUh8LlkY2RLWCH8krj9_i3mOglboP2cjgJfck/" width="236" /></a></div><br />This group
of researchers from the UK sought to develop and validate a pragmatic risk
score to <b>predict mortality in patients admitted to hospital with COVID</b>.<p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">This <b>prospective
cohort study</b> was performed at <b>260 hospitals</b> in the UK in <b>early
2020</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">35,463</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;"> patients were included in the <b>derivation</b>
phase and <b>22,361</b> in the internal <b>validation</b>. The mortality was
about 30% of these admitted patients… yikes!<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">They used a
<b>complicated</b> three stage model building process and used some regression
analysis, machine learning and lots of other things probably best understood by
those with a PhD in biostatistics. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">In the end,
they came up with <b>8 variables to predict mortality</b>. They included <u>age</u>,
<u>sex</u>, number of <u>comorbidities</u>, <u>respiratory rate</u>, <u>oxygen
saturations</u>, <u>GCS</u>, <u>urea</u>, and <u>CRP</u>.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Although they
intended for this score to be quite simple, nobody is going to memorize the
components and how to add things up. Fortunately, <a href="https://www.mdcalc.com/4c-mortality-score-covid-19">mdcalc.com</a> can do
it for you. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The
researchers also compared their score to 15 others in existence and thought <b>theirs
to be the best. <o:p></o:p></b></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">So, <b>use
this score if you like</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Some would
argue that this score is already outdated. In the last year we have learned a
lot more about COVID. Treatments have changed. And biggest limitation of all, most of the data was derived from an <b>unvaccinated cohort</b>.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Either way,
this score has some utility. And it’s just like all risk stratification scores
out there. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Yes… <i>(wait
for it)</i> … <b>sicker patients do worse.</b><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Or more
specifically; <u>sicker</u> patients with <u>worse</u> manifestation of <u>disease</u>, who are <u>older</u>
with more <u>comorbid</u> illness, have <u>worse x-rays</u> & <u>blood tests</u>, and <u>lack of
response</u> to initial treatment <b>do worse</b>. <o:p></o:p></span></p>
<p class="MsoNormal">I use that score for everything. But for some reason, I can't find it on Mdcalc.</p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">Covering:<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Knight SR,
Ho A, Pius R, et al. Risk stratification of patients admitted to hospital with
covid-19 using the ISARIC WHO Clinical Characterisation Protocol: development
and validation of the 4C Mortality Score. BMJ 2020;370:m3339. <a href="https://www.bmj.com/content/370/bmj.m3339">[Link to full text article]</a><o:p></o:p></span></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-69863155712442450362021-10-15T15:10:00.001-07:002021-10-15T15:10:18.588-07:00Point-of-Care hip ultrasound leads to expedited results in ED patients with suspected septic arthritis<p class="MsoNormal"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-g3rPA0lIDlSKAxzDwQo9ShPPWVfkQW2DmExTkkhTq__4zMRedd6o6Ojypg2eTdnBuE50u34mUxKY-9fSlm6HVVGE_sXSBkgT1YVm70eOwQ-_i13wymCjXkIFnlAqr5n2k47mm3eMAUg/" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="522" data-original-width="630" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-g3rPA0lIDlSKAxzDwQo9ShPPWVfkQW2DmExTkkhTq__4zMRedd6o6Ojypg2eTdnBuE50u34mUxKY-9fSlm6HVVGE_sXSBkgT1YVm70eOwQ-_i13wymCjXkIFnlAqr5n2k47mm3eMAUg/" width="290" /></a></div><br />The
title tells it all; if you do something yourself, it happens faster. Case
closed...<p></p>
<p class="MsoNormal"><span lang="EN-US">But perhaps
there is a little more we can learn from this paper. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">These authors
from beautiful Charlottesville, Virginia looked retrospectively at <b>62 patients</b>
who got an <b>ultrasound for possible septic arthritis</b> in their ED.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">They
compared the group that had the ultrasound done by <b>ED doctors (POCUS</b>)
vs. those done in <b>radiology</b>. No surprise the POCUS group had the study
done faster; about <b>1 hour vs. 3 hours</b>.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">They also
looked at time to arthrocentesis which was also faster when performed by the ED
doctor; about <b>3 hours vs. 10 hours</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">Of course,
this study was only from a <b>single center</b>, it was <b>not randomized</b>, and
they had very <b>small numbers</b>. <b>Only 10</b> arthrocentesis were
performed by the ED doctors <b>over 3 years</b>. It can make no genuine claims about safety.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">Hmmmm…<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">As ED doctors,
we are very happy at tapping various joints. I’ve done tons of knees. And some shoulders,
elbows, wrists, ankles and toes. But I’ve never aspirated a hip. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">For some
reason the <b>hip has been taboo</b>. Perhaps it is due to the less common
nature and the higher incidence in the pediatric population. It's a deeper joint and more difficult
to physically confirm the presence of an effusion. Furthermore, historic blind aspiration techniques were outside our realm. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">This is not
the first study looking at POCUS to guide hip arthrocentesis in the ED and we
are <b>now supported by a growing literature base. <o:p></o:p></b></span></p>
<p class="MsoNormal"><span lang="EN-US">EP’s are clearly
owning ultrasound guided needle-based procedures. Perhaps hip arthrocentesis
will eventually fall to the responsibility of the Emergency Physician. </span></p><p class="MsoNormal"><span lang="EN-US">Hmmmm….<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US"> </span></p>
<p class="MsoNormal"><i><span lang="EN-US">Covering:<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="EN-US">Thom C,
Ahmed A, Kongkatong M, et al. Point-of-care hip ultrasound leads to expedited
results in emergency department patients with suspected septic arthritis. JACEP
Open 2020;1:512-20. <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/emp2.12167" target="_blank">[link to full text article]</a><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US"> </span></p>
<p> </p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-7642114482378791262021-09-02T21:37:00.001-07:002021-09-02T21:37:46.176-07:00Utilization of Prophylactic Antibiotics After Nasal Packing for Epistaxis<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjr77poHCbGDto5-GwJKP4t3ZBsS0KHE9QgJO_YwS4XUmAfDdnFXsnFC21kNP-rtsTJQVqXY2d0_tTow4DR3FwWndbhLBb9uYsll2HHqd-tXBRtHLbURzac98_8SLLczNiCnutFsDNCd5c/" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="348" data-original-width="319" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjr77poHCbGDto5-GwJKP4t3ZBsS0KHE9QgJO_YwS4XUmAfDdnFXsnFC21kNP-rtsTJQVqXY2d0_tTow4DR3FwWndbhLBb9uYsll2HHqd-tXBRtHLbURzac98_8SLLczNiCnutFsDNCd5c/" width="220" /></a></div><br />When I
trained, I was told I needed to prescribe prophylactic antibiotics after I placed
nasal packing. It was thought this reduced the potential for toxic shock syndrome
or sinusitis. Is this recommendation evidence based?<p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Hmmmm…<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">This <b>single
ED in Manhattan</b> retrospectively reviewed <b>275 cases of anterior nasal
packing</b> and determined the rates of antibiotics given and evidence of benefit. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Most patients
that got non-absorbable packs <i>(Merocel, RapidRhino)</i> got antibiotics. Those with
absorbable packs <i>(Surgicel, Gelfoam)</i> did not. <span style="mso-spacerun: yes;"> </span>Although this aspect of the study is robust,
it is hardly important… I just don’t care. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">I want to know
<b>how many patients got benefit from antibiotics</b>. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Out of the
275 cases, there was one episode of sinusitis in each group. Looks like it
doesn’t matter? <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">But there
is a <b>fatal flaw. </b><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">They didn’t
really look for outcomes. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Only 40% of
the patients had documented follow up! In addition, this would have been poor quality retrospective
data. <o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">If you
don’t look for something, you will not find it</span></b><span lang="EN-US" style="mso-ansi-language: EN-US;">. Interesting that this study got published. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Probably the
best thing to come out of this “study” is their <b>review of the literature</b>.
<span style="mso-spacerun: yes;"> </span>In a nutshell, there is moderate
evidence to show that antibiotics are not needed after nasal packing. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Good enough
for me. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">Covering:<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Hu L,
Gordon SA, Swaminathan A, et al. Utilization of Prophylactic Antibiotics after
Nasal Packing for Epistaxis. J Emerg Med. 2021;60:140-149. <a href="https://www.jem-journal.com/article/S0736-4679(20)31055-6/pdf">[link to
article]</a><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-85468330630577044162021-09-02T20:46:00.000-07:002021-09-02T20:46:27.511-07:00Elevated blood pressures are common in the ED, but are they important?<p class="MsoNormal"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiMBKMK5jyIL0_WXK5C5xwUC8mPw5QLqxenwrIv9znCZu-429mZTzAVTftvxNPrCZQgyNCfGY387Z94x79f7pbhVozTd9qDdUekF8XgutfBKO_Sr3v67Ak23mu5kfIneZuuPAEs-mjhfzM/" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="740" data-original-width="1000" height="237" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiMBKMK5jyIL0_WXK5C5xwUC8mPw5QLqxenwrIv9znCZu-429mZTzAVTftvxNPrCZQgyNCfGY387Z94x79f7pbhVozTd9qDdUekF8XgutfBKO_Sr3v67Ak23mu5kfIneZuuPAEs-mjhfzM/" width="320" /></a></div><br />No.<p></p>
<p class="MsoNormal"><span lang="EN-US"><i>You can
stop reading now if you want…</i><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">This was an
<b>electronic medical record review</b> of <b>30,278 adults</b> treated and released
from the University of Alberta ED in 2016. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">They
identified those that had <b>elevated BP’s at triage</b> <b>and
cross-referenced</b> them with multiple data bases to <b>see if they developed
cardiovascular events by 2 years</b>. <i>(Databases
included hospital EDIS, Pyxis, Pharmaceutical Information Network,
administrative data holdings, National Ambulatory Care Reporting systems,
outpatient billing claims etc.)<o:p></o:p></i></span></p>
<p class="MsoNormal"><span lang="EN-US">Of the 30,278
that were treated and released, <b>about half had elevated BP’s at triage</b>.
70% had no prior history of hypertension and eventually about a quarter of those
subsequently received a diagnosis of chronic hypertension. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">After
adjusting for confounders, <b>high BP at triage was <u>not</u> associated with
adverse cardiovascular outcomes within 2 years of the ED visit.</b><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">I’m willing
to believe this is true… but there are many methodologic limitations. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US"><b>Don’t be
mesmerized by the huge number of patients</b>… this does not guarantee quality. Nor
do large numbers reduce bias.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">I’m
concerned about a <b>potential “garbage in & garbage out” phenomenon</b>.
The veracity of this study is predicated on the quality of the information in
many large databases. (For example, a large database in the USA shows <a href="https://www.bmj.com/content/347/bmj.f7102">the rate of virgin births</a>
at 0.5%)<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">There were
a <b>lot of other issues</b>; retrospective design, residual confounding, use of
triage BP’s, lack of follow up, possible non-differential misclassification, etc. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">So, are
elevated BP’s in the ED important? <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US">I still say
no, but not necessarily due to this study. Heck, at least hypertension is better than hypotension. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US"> </span></p>
<p class="MsoNormal"><i><span lang="EN-US">Covering:<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="EN-US">McAlister
FA, Youngson E, Rowe B. Elevated Blood Pressures are Common in the Emergency
Department but Are they Important? A Retrospective Cohrt Study of 30,278
Adults. Ann Emerg Med. 2021;77:425-432. <a href="https://www.annemergmed.com/article/S0196-0644(20)31363-9/fulltext">[link
to article]</a><o:p></o:p></span></p>
<p> </p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-51247573122143032122021-09-02T19:05:00.000-07:002021-09-02T19:05:16.863-07:00Accuracy of OMI ECG findings vs traditional STEMI criteria for diagnosis of acute coronary occlusion MI... the OMI manifesto?<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgG6oB4OuH1x4f5Hc1Qkhu1IC-lOREWRqVUBNfnsZj7CWdZ_z1kp_YvsKHHzKSpvgoZh-V0RvXeVoeOwd7shjQohzmB-IHAs2QZ58_LKAyw464NTeCr2i8eKj0KzjZeC8K51oP40UCBwRQ/" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" data-original-height="350" data-original-width="350" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgG6oB4OuH1x4f5Hc1Qkhu1IC-lOREWRqVUBNfnsZj7CWdZ_z1kp_YvsKHHzKSpvgoZh-V0RvXeVoeOwd7shjQohzmB-IHAs2QZ58_LKAyw464NTeCr2i8eKj0KzjZeC8K51oP40UCBwRQ/" width="240" /></a></div><br />I’ve heard
of many manifestos.<p></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">There’s the
Communist Manifesto, the US Declaration of Independence, the Unabomber
Manifesto and now we’ve got the <a href="http://hqmeded-ecg.blogspot.com/2018/04/the-omi-manifesto.html">OMI
Manifesto</a>. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><i>(Ok… it’s not
a freakin manifesto. But good to know about anyway.)</i><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">The charge
is being led by the master sensei Dr Stephen Smith <a href="http://hqmeded-ecg.blogspot.com/">(of ECG blog fame)</a> and his student Dr
Pendell Meyers. They’ve published quite a few articles looking at additional
ECG criteria to identify patients that may benefit from emergent reperfusion of
an acute coronary occlusion. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">They
hypothesized that blinded interpretation of their new OMI criteria would be
more accurate than the traditional STEMI criteria. <o:p></o:p></span></p>
<p class="MsoNormal"><b><span lang="EN-US" style="mso-ansi-language: EN-US;">OMI
criteria?<o:p></o:p></span></b></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><b>OMI</b> <i>(occlusion
MI)</i> is basically <b>STEMI criteria <u>plus</u> </b>some STEMI equivalents including:<o:p></o:p></span></p>
<blockquote style="border: none; margin: 0 0 0 40px; padding: 0px;"><p class="MsoNormal" style="text-align: left;"><span lang="EN-US" style="mso-ansi-language: EN-US;"><i>Subtle STE
not meeting criteria, hyperacute T waves, reciprocal ST depression and/or
negative hyperacute T waves, STD worrisome for posterior MI, suspected new Q
waves, terminal QRS distortion, positive Sgarbossa criteria, any inferior STE with
SZTD or T wave inversion in aVL</i></span></p></blockquote>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Without going
into any details of the study, <b>they thought the OMI criteria were great</b>.
Sensitivity went up from about 40% to 85%. Specificity remained around 90%. <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Unfortunately,
the <b>manuscript</b> as published in the open access journal <i>IJC Heart &
Vasculature</i> is quite difficult to follow. It is <b>poorly presented</b> and
would have benefited from substantial revision. Either way, you don’t need to
read it… the message is rather simple and has a degree of face validity (albeit
with many limitations). <o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">What are we
to <b>conclude?</b><o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><b>If you are an
expert at ECG interpretation, you can probably identify more patients with acute
coronary occlusion MI</b> by using OMI <i>criteria (which most of us are already
doing to some extent).</i> Whether additional patients genuinely benefit from
an aggressive intervention is officially not known.<o:p></o:p></span></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;"><o:p> </o:p></span></p>
<p class="MsoNormal"><i><span lang="EN-US" style="mso-ansi-language: EN-US;">Covering:<o:p></o:p></span></i></p>
<p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language: EN-US;">Meyers P,
Bracey A, Lee D, et al. Accuracy of OMI ECG findings versus STEMI criteria for
diagnosis of acute coronary occlusion myocardial infarction. <i>IJC Heart &
Vasc</i>. 2021:33; 100767 <a href="https://www.sciencedirect.com/science/article/pii/S2352906721000555">[link
to full text article]</a><o:p></o:p></span></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0tag:blogger.com,1999:blog-795077872245456144.post-38942626262270930972021-07-05T23:20:00.004-07:002021-07-06T23:50:44.200-07:00Effectiveness and safety of small-bore chest tubes (20 Fr) for chest trauma patients<p><span style="font-family: "Times New Roman", serif; font-size: 13.5pt;">The optimal chest tube size for the relief of traumatic
haemo/pneumothorax is not known. Traditionally, garden hoses up to 36 to 40 Fr
in size have been recommended. The outer diameter of one of these tubes is up
to 13mm… ouch!</span></p>
<p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN-US" style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;">A more recent observational study caused ATLS/EMST
to recommend tubes a bit small at 28-32 Fr. This is still something I don’t
think I would want hanging out of my chest.</span><span style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN-US" style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;">Not based on any high-quality evidence, these
authors from Kobe, Japan <b>decided that 20 Fr or an 8 Fr pigtail was good
enough.</b> After some time, they decided to describe their results. Yes…
this was their methods.</span><span style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN-US" style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;">Results?</span><span style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN-US" style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;">Over 5 years, they put in <b>107 chest tubes</b>.
About 90% were 20 Fr and the rest were pigtail catheters. The mean Injury
Severity Scale (ISS) was 17.8.</span><span style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN-US" style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;">There were 8 (7.8%) tube related complications, and
none were due to tube obstruction. There were 4 retained haemothoraxes and 4
unresolved pneuomothoraxes.</span><span style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN-US" style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;">The authors conclude that it might be reasonable to
safely manage chest trauma patients with small-bore chest tubes.</span><span style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN-US" style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;">This retrospective observational study is of
low-quality evidence and <b>should not change practice.</b> But it
may provide some clinical equipoise to support a proper randomized trial. This
should definitively answer the research question.</span><span style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN-US" style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;">After all these years, I’m <b>quite surprised
a large RCT has not been conducted</b>. It strikes me that it should be
feasible and ethical to perform. These are usually the major challenges in
conducting experimental trials. A review of clinicaltrials.gov shows only one
small study out of Egypt but it is not yet recruiting.</span><span style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN-US" style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;">What are we waiting for? (There must be something
I’m missing…Bueller... Bueller ?)</span><span style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><i></i></p><div class="separator" style="clear: both; text-align: center;"><i><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDpmRwKYq8uBUYnTeyBcwMx-I-5PGJyWjbX25Ouik_ILKi8cBoRAcRdvXgnDt-I36DkKL5fCIwnn7HRJ4517chEM28MWJhCj-OeBwSdwUSYiDtryhiBrlBflnX1_5XWGFhDC8dnShRFhU/s1100/chest-tube-insertion.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="734" data-original-width="1100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDpmRwKYq8uBUYnTeyBcwMx-I-5PGJyWjbX25Ouik_ILKi8cBoRAcRdvXgnDt-I36DkKL5fCIwnn7HRJ4517chEM28MWJhCj-OeBwSdwUSYiDtryhiBrlBflnX1_5XWGFhDC8dnShRFhU/s320/chest-tube-insertion.jpg" width="320" /></a></i></div><i><br /><span lang="EN-US" style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><br /></span></i><p></p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><i><span lang="EN-US" style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;">Covering:</span></i><span style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN-US" style="color: black; font-family: "Times New Roman",serif; font-size: 13.5pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;">Maezawa T, Yanai M, Young Huh J, et al.
Effectiveness and safety of small-bore tube thoracostomy (<u><</u>20 Fr) for
chest trauma patients: A retrospective observational study. <i>Am J Emerg
Med</i>. 2020;38:2658-2660. <a href="https://www.ajemjournal.com/article/S0735-6757(20)30822-6/pdf" target="_blank">[link to article]</a></span></p>
<p class="MsoNormal"><o:p> </o:p></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com1tag:blogger.com,1999:blog-795077872245456144.post-28763087661907417322021-07-05T23:00:00.005-07:002021-07-05T23:01:54.221-07:00A randomized, noninferiority trial of two doses of IV ketamine for analgesia in the ED<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjK5eCwfCUTcNONVnw6nXL_DxdgdKCHv8jxe2_HQWqg15exZeau7XS0zLEjIanrwAwDcoH1GNeQYqAqqMfQlCjuci79KI7DxyBAFl98ljMsZfVzMe164Rc3aoHEaSSyI1LnfyIK92jUkfc/s712/horse+head.jpg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="712" data-original-width="570" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjK5eCwfCUTcNONVnw6nXL_DxdgdKCHv8jxe2_HQWqg15exZeau7XS0zLEjIanrwAwDcoH1GNeQYqAqqMfQlCjuci79KI7DxyBAFl98ljMsZfVzMe164Rc3aoHEaSSyI1LnfyIK92jUkfc/s320/horse+head.jpg" /></a></div><br />This study aimed to determine if a <b>low dose of ketamine
(0.15mg/kg)</b> was just as good (or bad) as a <b>higher dose (0.3mg/kg).</b><p></p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">This single ED in Chicago conducted a <b>double-blind RCT</b> that
included adult patients with acute pain (flank, abdo, back, musculoskeletal or
headache) and had a <b><u>></u>5 on their initial NRS</b>.<o:p></o:p></p>
<p class="MsoNormal">There were several <b>exclusion criteria</b> including patients
that had <b>chronic pain or currently taking opioids</b>. This is arguably the
patient population who would likely be best targeted for ketamine… but I digress. <i><o:p></o:p></i></p>
<p class="MsoNormal">Ketamine was given as initial therapy <b>without
co-administration</b> of any other analgesics. Yikes!<o:p></o:p></p>
<p class="MsoNormal">Oh… and the ketamine was given as a <b>slow IV infusion</b> over 15
minutes <i>(to decrease side effects and increase nursing hassle).<o:p></o:p></i></p>
<p class="MsoNormal">The <b>primary outcome</b>, NRS, was measured at 30 minutes.
They also measured <b>adverse events</b> with the Richmond Agitation Sedation Scale
(RASS) the Side Effect Rating Scale of Dissociative Anaesthetics (SERSDA). <i>(Ketamine
is so special, it even comes with its own measure tool for side effects.)<o:p></o:p></i></p>
<p class="MsoNormal">Results?<o:p></o:p></p>
<p class="MsoNormal"><b>98 patients</b> were enrolled and there was <b>no statistical
difference </b>in the primary outcome nor side effects at 30 minutes. The authors
conclude a lower dose is fine. <o:p></o:p></p>
<p class="MsoNormal">I disagree.<o:p></o:p></p>
<p class="MsoNormal">As a surrogate of patient satisfaction, the authors asked
the patients, <span style="font-size: medium;"><i>“would you take this medication again for similar pain?</i>” </span>An <b>astounding
number said no</b>; <b>25%</b> vs. <b>40%</b> in the low and high dose respectively. This is
arguably the <b>most important outcome of this study</b>… patients really didn’t like
this stuff <i>(even when given slowly to minimize side effects).</i><o:p></o:p></p>
<p class="MsoNormal">Let’s face it, <b>we would never use ketamine this way</b>.
It is not first line therapy. Would never use it in isolation. We would target
our patient population differently. And logistically, we probably would not
give an infusion. <o:p></o:p></p>
<p class="MsoNormal">So, what can we conclude? Don’t use ketamine this way. <o:p></o:p></p>
<p class="MsoNormal">Generally speaking, <b>the hype and enthusiasm for subdissociative ketamine for
pain is ridiculous</b>. Yes, it has its place. But bang-for-buck, it’s a dirty drug;
it doesn’t work that well and comes with many side effects.<o:p></o:p></p><p class="MsoNormal"><br /></p>
<p class="MsoNormal"><i>Covering:<o:p></o:p></i></p>
<p class="MsoNormal">Lovett S, Reed T, Riggs R, et al. A randomized,
noninferiority, controlled trial of two doses of intravenous subdissociative
ketamine for analgesia in the emergency department. Acad Emerg Med.
2021;00:1-8. DOI:10.1111/acem.14200 <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/acem.14200" target="_blank">[link to article]</a><o:p></o:p></p>EmergencyMedJChttp://www.blogger.com/profile/06365319853920218406noreply@blogger.com0