10+1 papers for the Northern Emergency Medicine conference. St.Emlyn’s

top 10 papers from 2016 critical appraisal St.Emlyn's

I had the honour to speak at the very first Northern Emergency Medicine conference back in 2014 (I think). I had a fantastic time and met so many enthusiastic and superb emergency clinicians. This year I’m lucky enough to be invited back to give two talks. One is on the future of emergency medicine and is closely based on my SMACC talk from Dublin which you can see here. The other talk is a quick review of important and interesting papers from the last year. Conference organisers and delegates seem to like these talks as a quick review of what’s happened in the world of evidence based medicine and in truth they are fun to put together too. The problem is that with 20 mins and 10+1 papers there is no way on earth that we can do in depth critical appraisals and I’m not going to bombard the audience with horrible slides full of text. Rather the talk will about getting people interested. This blog with links to more detailed analysis is to back up the talk and a little more thought and reflection before action.

In preparing this year’s talk I was, as always, hugely aided by looking through the archives of St.Emlyn’s, FOAMcast1, the SGEM2EMlitofnote3, EMCRIT4, ALiEM5, ERCAST6 and a range of other fabulous blogs and podcasts that keep me up to date. Thanks to everyone who helps us be better clinicians.

Let’s get on with it……

  1.  The REASON trial.7 We covered this non-randomised controlled trial of Ultrasound in refractory PEA/asystole cardiac arrest patients in October. 953 OOHCA patients had an USS at the beginning and end of resuscitation. Those who had cardiac actiity on USS had a marginally higher survival rate. 3.8% vs 0.6%. They also noted (in passing really) that USS identified pathologies that were amenable to treatment. Bottom line: No activity and prolonged arrest has a dismal prognosis, but is not absolute7,8. You may be able to identify pathologies amenable to treatment with USS.
  2. The RINSE trial 9. Hypothermia for cardiac arrest patients has had a rollercoaster of enthusiasm, skepticism and failure over the last few years. The TTM trial10 suggested that it was less important than avoidance of hypothermia, but there was still a pathophysiological argument that early cooling might improve ROSC. This was the aim of the RCT RINSE trial. Patients in cardiac arrest were infused with cold saline or standard care. 1198 patients enrolled but no change in outcome. Hospital discharge was 10.2% vs.11.4%.  This looks like another failed hypothermia trial but the devil is in the detail. Many patients simply did not get cooled, did not get the cold saline or just stayed warm. Is this a failure of hypothermia as a treatment or a failure of our ability to cool?
  3. Dex or Pred for children’s asthma?11 It was great to see a trial from friends in Ireland on the use of dexamethasone in paediatric asthma. In essence this RCT compared single dose Dexamethasone vs a course of prednisolone for childhood asthma  in the ED. It’s a really well set up non-inferiority trial and basically tells us that you can use either. Perhaps this should be no surprise as in PEM we use Dex for Croup!12 Anyway, the bottom line is that Dex is well tolerated and seems to be as good as prednisolone, it’s easier to administer and the parents don’t have to bother with prescriptions and dosing at home.
  4. Is Ketofol worth the hassle?13 I was a big fan of ketofol until the evidence started arriving that perhaps it wasn’t that amazing14. Another RCT this year found the same conclusion. Ketofol vs Propofol showed no real clinically important difference between the two medications. Non significant differences were found in hypotension (propofol worse) and delirium (ketamine worse). Bottom line is that there isn’t a massive difference, you just need to manage pain, sedation, amnesia and anxiolysis as a balanced process15. I still occasionally use ketofol in patients who are still in pain, but in the vast majority of cases propofol + an appropriate balanced analgesia approach works just dandy.
  5. Alcohol and nausea.16 Here’s a quick and easy trick you can use on your next shift whilst waiting for the antiemetics to work (or for someone to find the keys to the cupboard to get them in the first place. Nausea is one of the most distressing things patients descibe in ED and we must remember that suffering is not just about pain. Michelle Lin describes this trick on a plane flight and points out that people either think this is amazing or they’ll tell you that it’s known it as an aged yarn with no evidence. Anyway, this is an RCT of sniffing an isopropyl alcohol swab to relieve nausea and the findings are that it works. In 84 enrolled patients nausea scores on a 10 point scale reduced by about 3 and the patients were happy. It’s cheap, quick and looks cool when it works so give it a try.
  6. Amiodarone, Lidocaine or placebo in cardiac arrest? 17This was a randomised,double-blind trial of patients aged 18 or over with non-traumatic cardiac arrest where the rhythm was either shock-refractory VF/pulseless VT or recurrent VF/pulseless VT. Patients received either Amiodarone, Lidocaine or placebo. The bottom line is that the drugs made no difference in this trial although it may have been underpowered to detect a difference as large as 3%. At this stage it means that we should probably not pursue the use of these drugs at the moment, but rather focus on stuff that does make a difference like good CPR. It’s also worth mentioning a paper in Circulation from Japan18 suggesting that we should keep going for 40 mins to ensure no survivors are missed.
  7. The PESIT trial3,19,20. This trial is here for a couple of reasons, but largely because it might spark bad behaviour (in truth it already has). This trial from Italy used a Wells/d-dimer strategy to look for PEs in patients with syncope.The headline figure was that they found PEs in 17% of patients. Like WOW! How many have we missed over the years as I’ve not diagnosed anything like that number. Here’s the problem. That figure was derived from a cohort of admitted patients and many of them had signs of DVT or PE. They are not the unselected patients in the ED that we see. Although some idiots who read this trial think that we now need to screen everyone who faints, we don’t. The bottom line is that PE is a potential finding (but not necessarilly cause) in a fair proportion of admitted patients. The clinical significance of that is unclear, and for us? We should probably keep doing what we do and if the patient looks as though they have signs associated with PE we should investigate. We must not screen everyone!
  8. Impact Brain Apnoea21. A bit of an indulgence this as it’s a paper I co-authored. It’s also in memory of John Hinds who we lost last year in a tragic motorcycle accident. I like this paper for lots of reasons, but in particular the realisation that  important pathophysiological mechanisms can be lost to history only to re-emerge as technology (in this case motorsport) make them relevant again. If you don’t already know impact brain apnoea is a condition where a blow to the head with minimal anatomical damage leads to apnoea and death in the absence of intervention. I’ve seen it at the racetrack as have others involved with prehospital care close to the time of impact. Bottom line here is that we need to ensure that patients with apnoea post trauma get their As and Bs sorted quickly and probably by bystanders. Maybe IBA should be part of ALS training in schools?
  9. Head position for intubation.22 Thanks to Lauren and Jeremy, our lovely friends from FOAMcast 23for reminding me of this paper on how to position our patients for intubation in the ED. Also check out SCANCRIT too24. Elevating the head to 30 degrees is something I’ve done for a long time (when sensible to do so), and now this retrospective study supports what I was taught in my anaesthesia rotation by some old school and rather fabulous teachers. In essence they looked at 500+ out of theatre intubations (though not in ED) and compared airway complications in those who were sat up at 30 degrees with those lain flat. Bottom line is that sitting the patient up reduces airway complications by half. Although these were not ED patients I think it’s reasonable to suspect that similar things apply. So if your patient can tolerate it and it’s sensible intubate with them at 30 degrees (and with ear to sternal notch too).
  10. The REACT-2 trial.25 Do we always need a whole body CT (WBCT)? I worry about the amount of radiation we use, especially in younger trauma patients. Past studies have shown that WBCT can reduce mortality but I’m sure you’ve had the experience of ordering one on the basis of mechanism of injury only to find minimal or even no injury. You’ve just exposed your patient to lots of radiation and you should feel bad. Well perhaps not as you really don’t want to miss anything either. In this RCT trauma patients were randomised to either WBCT or a more focused appoach. 1403 patients were randomised on fairly liberal criteria (as compared to Virchester)  and in terms of mortality there was no difference. There was slightly less radiation in the selective group but relatively little difference equivalent to on average 0.3mSv which in a 20 year old would cause one extra cancer for every 28000 scans (you read that right so let’s not get our knickers in a twist).
  11. Burnout Biomarkers.26 It’s always good to finish on something a little unusual. Thanks to Ryan Radecki for spotting this one, last year and at SMACC he reminded us that sex improves the passage of renal stones, this year it’s burnout and biomarkers. Burnout is a real phenomena and in the current NHS urgent care system a lived experience for many of us. This small but interesting study looked at S100B levels in EM residents in Turkey. They found that S100B levels which are a marker of brain injury and activation were highest in those who had the greatest burnout and depression scores. It’s unclear what we can do with this information and it would be very interesting to see it repeated and perhaps observed in a prospective study. My take home from this study is also my big message for 2017. Love your emergency medicine, but love yourself and your colleagues too. It’s tough out there and we all need to look out for each other.

Thanks so much for your time, energy and enthusiasm.

vb

S

@EMManchester

Before you go please don’t forget to…

References

1.
FOAMcast review of 2016. FOAMcast. http://foamcast.org/. Published January 2017. Accessed January 4, 2017.
2.
the SGEM. The Skeptics guide to emergency medicine. http://thesgem.com/. Published 2016. Accessed January 4, 2017.
3.
The impending PE apocolypse. EMlitofnote. http://www.emlitofnote.com/?p=3640. Published 2016. Accessed January 4, 2017. [Source]
4.
EM Critical Care: Scott Weingart. EMCRIT. http://emcrit.org/. Published 2017. Accessed January 4, 2017.
5.
Michelle Lin at ALiem. ALiEM. https://www.aliem.com/. Published 2017. Accessed January 4, 2017.
6.
Practice Changers. ERCAST. http://blog.ercast.org/practice-changers/. Published January 2017. Accessed January 4, 2017.
7.
Gaspari R, Weekes A, Adhikari S, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016;109:33-39. doi: 10.1016/j.resuscitation.2016.09.018
8.
Blyth L, Atkinson P, Gadd K, Lang E. Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review. Acad Emerg Med. 2012;19(10):1119-1126. [PubMed]
9.
Bernard S, Smith K, Finn J, et al. Induction of Therapeutic Hypothermia During Out-of-Hospital Cardiac Arrest Using a Rapid Infusion of Cold Saline: The RINSE Trial (Rapid Infusion of Cold Normal Saline). Circulation. 2016;134(11):797-805. [PubMed]
10.
Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013;369(23):2197-2206. [PubMed]
11.
Cronin J, McCoy S, Kennedy U, et al. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Ann Emerg Med. 2016;67(5):593-601.e3. [PubMed]
12.
Riding the Dex express. St.Emlyn’s. http://stemlynsblog.org/croup-riding-the-dex-express/. Published 2016. Accessed January 4, 2017.
13.
Ferguson I, Bell A, Treston G, New L, Ding M, Holdgate A. Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial. Ann Emerg Med. 2016;68(5):574-582.e1. [PubMed]
14.
Is Ketofol the milk of human kindness. St.Emlyn’s. http://stemlynsblog.org/ketofol-milk-human-kindness-procedural-sedation-st-emlyns/. Published 2016. Accessed January 4, 2017.
15.
Balanced Sedation. St.Emlyn’s. http://stemlynsblog.org/balanced-sedation-in-the-ed-st-emlyns/. Published 2012. Accessed January 4, 2017.
16.
Beadle K, Helbling A, Love S, April M, Hunter C. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2016;68(1):1-9.e1. [PubMed]
17.
Kudenchuk PJ, Brown SP, Daya M, et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2016;374(18):1711-1722. doi: 10.1056/nejmoa1514204
18.
Nagao K, Nonogi H, Yonemoto N, et al. Duration of Prehospital Resuscitation Efforts After Out-of-Hospital Cardiac ArrestCLINICAL PERSPECTIVE. Circulation. 2016;133(14):1386-1396. doi: 10.1161/circulationaha.115.018788
19.
The case of the incidental bystander. EMCRIT. http://emcrit.org/emnerd/the-case-of-the-incidental-bystander/. Published 2016. Accessed January 4, 2017.
20.
Prandoni P, Lensing A, Prins M, et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016;375(16):1524-1531. [PubMed]
21.
Wilson M, Hinds J, Grier G, Burns B, Carley S, Davies G. Impact brain apnoea – A forgotten cause of cardiovascular collapse in trauma. Resuscitation. 2016;105:52-58. [PubMed]
22.
Khandelwal N, Khorsand S, Mitchell S, Joffe A. Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg. 2016;122(4):1101-1107. [PubMed]
23.
Head up position . FOAMcast. http://foamcast.org/2016/06/27/episode-52-the-esophagus/. Published 2016. Accessed January 4, 2017.
24.
Head up intubation. SCANCRIT. http://www.scancrit.com/2016/06/10/head-up-intubation/. Published 2016. Accessed January 4, 2017.
25.
Sierink JC, Treskes K, Edwards MJR, et al. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. The Lancet. 2016;388(10045):673-683. doi: 10.1016/s0140-6736(16)30932-1 [Source]
26.
Gulen B, Serinken M, Eken C, et al. Serum S100B as a Surrogate Biomarker in the Diagnoses of Burnout and Depression in Emergency Medicine Residents. Acad Emerg Med. 2016;23(7):786-789. [PubMed]

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