Torticollis: A Real Pain in the Neck

2

By the time you’ve worked in the Emergency Department for more than a week it’s highly likely you’ll have seen a patient who has a bit of a sore neck after a relatively minor bump in their car. A little less often we see patients presenting with a fixed torticollis, their head held over to one side with pain associated with attempts to return it to a normal position. Torticollis as a presenting symptom can represent a number of pathologies, some of which are related to dystonia. The word torticollis comes from the Latin tortus (twisted) and collum (neck).

The torticollis can occur in a variety of directions:

Simple torticollis where there is no rotation of the head but uneven muscle tone present

Rotational torticollis where the face is turned towards the shoulder

Lateral torticollis where the head is tilted, ear to shoulder

While this is often benign, you’ll be pleased to know that it’s yet another seemingly innocuous condition which can sometimes represent some important and sinister pathology and as such it’s worth thinking about carefully, both in the context of immediate management and appropriate safety-netting, review and follow-up.

“A Car Drove Into The Back Of Mine!”

In those with a history of trauma, cervical dystonia can occur relatively quickly after trauma (immediately to a few days afterwards) or quite some time afterwards (delays of a few months have been reported although I wonder how reliably these can be attributed back to initiating trauma, particularly for minor injuries).

The trauma is usually associated with immediate pain and followed by a reduced range of movement and abnormal head posturing. If the patient has a history of trauma and meets criteria for imaging then radiographs may be helpful as dystonia can occur in the presence of bony injury. While movements should be minimised, please don’t try to force these patients into a rigid collar!

Just be careful and thorough with these patients. Perform a neurological examination and check the history carefully to make sure there are no features which might point you to possible sinister causes – think fever, weight loss, night sweats, reduced appetite…

In patients with a significant mechanism of injury, torticollis is an ominous sign. It is often associated with unifacet dislocation or fracture of the occipital condyle (which follows a high-energy injury). These patients frequently have associated neurological findings and often need cervical spine CT and subsequent MR scan – a chat with your friendly radiology colleague is required!

“Doctor, That Vomiting Girl in Bed 6 Looks a Bit Funny…”

Certain medications can precipitate acute dystonic reactions. For dystonic reactions developing acutely in the ED the most likely culprit is metoclopramide and acute oculogyric crises are most commonly seen with metoclopramide in young women, although patients may present in a similar way after taking their own phenytoin, carbamazepine or antipsychotics. Patients often have speech disturbance or staring. The recommended treatment in the UK is intravenous procyclidine 5-10mg for acute dystonia and it is usually effective in 5-10mins.

The video below shows a frightening reaction to metoclopramide; it’s easy to see why patients will need a good deal of explanation afterwards!

“I Just Woke Up Like This, Doc.”

Most often (around 85% of cases) there is no clear history of trauma; the patient has simply woken up like this in the morning. Acute idiopathic torticollis is the most common presentation – there is no history of trauma, the adult wakes with the neck stuck in a particular position and the vast majority of cases will resolve spontaneously within 1-2 weeks. There was an RCT of benztropine for the relief of acute non-traumatic neck pain (not FOAM) in the EMJ in 2014 which failed to demonstrate superiority.

“My Neck Hurts and I Don’t Feel Well!”

While acute idiopathic torticollis can present in children as well as in adults, it can also be a sign of some underlying nastiness and this is more true of the paediatric population (though it can occur in adults as well).

Torticollis can be associated with infection of the structures of the neck: think pharyngitis, tonsillitis, retropharyngeal abscess, otitis media, osteomyelitis, sinusitis, adenitis and even upper lobe pneumonia. Look for sickness in these patients who may not automatically have their vital signs recorded at triage. In the presence of fever or tachycardia, or in a patient who also reports constitutional symptoms, examine fully and investigate for possible infections.

We do occasionally see torticollis as a first presentation of a neoplastic cause; tumours in the cerebellopontine angle/posterior fossa cause a compensatory torticollis, so neurological examination of upper limbs, lower limbs, gait, co-ordination and cranial nerves is also important (you might alternatively identify the congenital strabismus or nystagmus which has led to the compensatory torticollis).

Finally, children can have atlantoaxial subluxation (C1 on C2) which may be related to juvenile arthritis or result from ligamentous laxity following infection in the neck (Grisel’s syndrome). This free electronic poster below outlines three typical paediatric clinical cases of non-resolving torticollis and shows the importance of follow-up – click the image to see a bigger version in PDF format.

Screen Shot 2015-05-03 at 17.36.47

These conditions may not be apparent at first presentation and since most are idiopathic and self resolving, follow-up is key; particularly in paediatric patients. If the symptoms are persisting, imaging of the brain and cervical spine is appropriate (MR scan is probably better than CT).

 

“My Baby is Making Weird Movements!”

Congenital torticollis is rare and usually related to in-utero positioning or birth trauma causing abnormal neck positioning, presenting in the first few weeks of life. Ultrasound can confirm the diagnosis and the muscles involved (most commonly ipsilateral sternocleidomastoid).

Sandifer syndrome may also cause paroxysmal dystonia with opisthotonic posturing: this is associated with reflux in babies (the diagnosis is more likely if episodes are associated with feeding) and can be very frightening for parents who think their baby is having a seizure.

So in summary:

1

  • Most are atraumatic and spontaneous and will resolve spontaneously: analgesia (and possibly benzodiazepines) constitute first-line treatment
  • If there is a history of a traumatic mechanism of injury, imaging can be helpful
  • Thorough assessment for potential infection and neurological signs is very important (the key here is thorough history-taking and examination)
  • Those which are not resolving should be reassessed; consider planned follow-up for kids and clear safety netting for all patients

Natalie

 

Before you go please don’t forget to…

Behind the Scenes at St Emlyn’s

Hello again :-)

We’d like to think you might have missed us a little in the last ten days or so when the St Emlyn’s blog has been offline (if you hadn’t noticed our absence, please nod and smile – it’s what we British people do).

As you can see we’re back and more than a little relieved – and we are really sorry for the brief hiatus BUT it does give us a great opportunity to provide you with a little more information about the inner workings at this, Virchester’s finest healthcare institution.

St Emlyn’s: An International Hospital

St Emlyn’s is truly a virtual hospital; the medical staff come from all over the UK to work here, most without ever actually leaving their houses. But there’s a little more to it than that. The physical virtual space in which St Emlyn’s exists is a real place – in Western Australia.

The Father of FOAM: Behind the Scenes

As you probably know, FOAM was conceptualised at ICEM 2012 in Dublin over a pint of Guinness – but for more than five years before ICEM 2012, Life in the Fast Lane had been doing its thing; sailing the as yet unnamed ship of free, open access medical education into uncharted waters. And at its helm – the inimitable Mike Cadogan.

Image courtesy of Domnhall Brannigan

Mike is key to the success of St Emlyn’s. When the virtual hospital opened its doors shortly after ICEM, Mike was on hand to guide and advise. Since those early days Mike has not only been our go-to guy for the more technical aspects of social media, coding, search engine optimisation and blogging (if it sounds like I know what I’m talking about here I apologise because I really don’t) but he also helped us to migrate the whole site over to a server he runs in Western Australia (together with a collection of other FOAM blogs).

In the last few weeks the servers have been under attack from hackers to an unprecedented degree, taking most of the co-hosted blogs offline. Thanks to Mike’s hard work it looks like most are back up and running.

Why are we telling you this?

Well, obviously we didn’t enjoy our time offline – but mainly we wanted to use our first opportunity back online to express our collective wholehearted love and gratitude towards Mike for all of his hard work.

Mike, we wouldn’t be where we are without your input. We certainly wouldn’t be back online again. We – and I’m sure I speak on behalf of the whole FOAM community here – are so grateful for all your help and hard work! And we want you to know – YOU’RE AWESOME.

JC: Getting Chilly Quickly 4. Doing It For The Kids

DOING IT FOR THE KIDS

We have looked at therapeutic hypothermia not once, not twice, but three times already here at St Emlyn’s; most of our ED consultants also work, at least some of the time, down the long corridor in our paediatric ED – so our interest in how we can best look after our post-cardiac arrest patients extends to children as well.

By the wonder that is twitter, it was a matter of moments after the publication of this particular paper that it was tweeted to me as something I might be interested in reading (thank you so much, James Tooley!)

Of course, Cliff Reid was first off the starting blocks with his appraisal over at Resus.me while Salim Rezaie has written a review at Academic Life in EM which I have peer-reviewed.

That said, before I had a look at either of their appraisals I did read the paper myself (something I’d recommend to all FOAM colleagues) and we plan to look at the paper in the real life journal club as well as here in the virtual one; my thoughts are below and also over at PEMLit.org.

NEJM

Kudos to NEJM for making the paper open access – please go and read through it yourself before reading reviews here or on any other sites. Click the abstract above which will take you to the NEJM site and the full paper.

What kind of study was this?

This was a single-blinded, multicentre randomised controlled trial of therapeutic hypothermia versus therapeutic normothermia for paediatric out-of-hospital cardiac arrest. Patients who presented after requiring at least 2mins of chest compressions and with an ongoing requirement for mechanical ventilation after return of circulation were randomised in a ratio of 1:1 by permuted blocks stratified by age into either hypothermia (targeted temperature of 33deg for 48h, then targeted temperature of 36.8deg for another 72h) or normothermia (targeted temperature of 36.8deg for 120h).

It’s important to note that this was therapeutic normothermia, so even in the control group there was an active intervention to tightly control the temperature between 36.0-37.5 degrees rather than just allowing the temperature to react spontaneously.

Who was studied?

The subjects were recruited over just more than three years from 36 sites (there were 38 sites involved but two did not recruit any patients).  The patients were aged between 48 hours and 18 years and the trial itself was conductive in the Paediatric Intensive Care Unit.

Patients were included if they had received two minutes or more of chest compressions with a subsequent return of circulation but ongoing need for mechanical ventilation. They were then excluded if they could not be randomised within 6 hours of return of circulation, if they scored 5 or 6 for the motor component of the Glasgow Coma Score (implying rapid return to normal conscious level and presumably short anticipated need for mechanical ventilation), a decision by the treating team to withhold aggressive therapy or major trauma as the cause for the cardiac arrest (this seems reasonable as traumatic cardiac arrest has different aetiology).

The primary outcome of interest was survival at 12 months with a “good functional outcome” and the authors were looking for an absolute effect size of 15-20%.

Patients were also excluded if their baseline performance score (VABS-II) was <70 since this was determined to be the marker of good neurological function used as the primary outcome measure at 12 months.

There were 1355 patients meeting the inclusion criteria but after initial exclusions 295 were randomised, 155 to therapeutic hypothermia and 140 to therapeutic normothermia. Results were analysed using an intention-to-treat protocol; this means that patients were analysed according to the group to which they were initially randomised, irrespective of whether they received the intended intervention, the alternative intervention or withdrew from the study altogether after randomisation.

However, 25 patients were found after randomisation to have a baseline performance score <70 so these patients were not included in the analysis of the primary outcome, leaving 138 in the hypothermia group and 122 in the normothermia group for analysis.

The study also explored some secondary outcomes; survival at 12 months and change in neurobehavioural function (defined as the difference in VABS-II score at 12 months from pre-cardiac arrest baseline).

What did they find?

For the primary outcome there was no significant difference between the two groups in survivors with VABS-II score at 12 months;

27/138 in the hypothermia group had a VABS-II score >70 at 12 months

15/122 in the normothermia group had a VABS-II score >70 at 12 months.

The authors calculated a risk difference of 7.3 percentage points (95% confidence interval -1.5 to 16.1) and a relative likelihood of 1.54 (95% confidence interval 0.86 to 2.76).

Although that sounds like a significant difference, the confidence intervals are really important here.

For the risk difference, the 95% confidence interval crosses zero; this means that the “true” value could be 0% difference between the groups. For the relative likelihood, although the confidence interval doesn’t cross zero, remember this is a likelihood: a ratio, where we equivalence occurs at 1 rather than at zero, so it is the fact that the confidence interval crosses 1 which indicates no significant difference between the groups.

In the secondary outcomes (table 2) there was a similar result of no difference in survival at 12 months between the groups, irrespective of neurological function. The authors note that survival over time was significantly longer within the therapeutic hypothermia group (mean survival for hypothermia group 149±14 days compared with 119±14 days) and there is a Kaplan-Meier curve on page 22 of the supplementary material which demonstrates this nicely. This rather leads us to question what we are trying to achieve; survival without the functional score criteria implies survival with poor quality of life. It is not my place to argue here what constitutes meaningful quality of life and I would be interested to hear the thoughts of the parents of these children surviving with poor functional scores, especially if they ultimately die later. There are some big moral and ethical questions here but if anything they do not encourage me to pursue hypothermia in these patients.

Interestingly, the Kaplan-Meier curve shows for both groups the majority of deaths occurred within the first 28 days; the authors tell us this was 87/153 (57%) in the hypothermia group and 93/139 (67%) in the normothermia group with no statistically significant difference between them (P=0.08).

Anything else interesting about this study?

There’s loads of other really interesting data in this study. Aside from the outcome measures, it’s useful to know more about the aetiology and prognosis of paediatric out-of-hospital cardiac arrest. Firstly we can see from table 1 that the majority of cardiac arrests occured due to respiratory causes – it’s good to know that what we teach on APLS is based on evidence! The rates were 111/75 (72%) in the hypothermia group and 102/140 (73%) in the normothermia group.

I was surprised that the rhythm was VF or VT in as many as 23 patients (14 in the hypothermia group, 9 in the normothermia group). Although the paper doesn’t give p values for the baseline characteristics in table 1 the authors have flagged those baseline characteristics with a P<0.05 (number of pre-hospital adrenaline doses and in-hospital adrenaline doses), suggesting this was not a significant difference between the groups even if it does seem higher than I would expect.

I was equally surprised to see that the median time to CPR from cardiac arrest was so low; 3 mins for the hypothermia group and 2 mins for the normothermia group. It’s not clear whether this represents rapid EMS response times or bystander CPR (which occured in 68% of the hypothermia group and 63% of the normothermia group)  but I can’t help but wonder whether how well we could achieve that in the UK.

The median time to ROSC is interesting too, 23 mins in the hypothermia group and 28 mins in the normothermia group. We tend to spend longer in our resuscitation attempts for children in cardiac arrest than we do in adults and previous studies have looked at outcomes with resuscitation attempts over 20 minutes in children, showing that good neurological outcomes can occur even after prolonged resuscitation.

Problems with the paper and areas for future work

There are a few sticking points here; there was no reasonable way to use blinding to prevent bias in the intervention groups and although the authors have sensibly used an independent observer to collect the outcome data without knowing which group each subject was randomised to, the data was collected by telephone interview and there is nothing to stop a parent asking whether the researcher thought that their child being cooled had made a difference, for example.

The authors themselves acknowledge that children in the hypothermia group might have been alive longer due to the confounding effect of the hypothermia on the clinical team’s ability to determine futility.

We must also remember that these were out-of-hospital arrests; what should we do with those patients who have a cardiac arrest in-hospital? Is there a benefit from hypothermia for that group of patients?

What does it mean for us in practice?

Remembering that in this study the null hypothesis was no difference between the groups, this study doesn’t prove that hypothermia is harmful or not beneficial; there is simply insufficient evidence to reject the null hypothesis of no difference, based on this study.

So: should we cool our paediatric out-of-hospital cardiac arrest patients? At present, there is no evidence of benefit from this paper – but that doesn’t mean that the benefit doesn’t exist. For now I think we have to follow local protocols and hope for more evidence from larger trials, difficult as that might be to collect. That said, it’s still an important trial because it gives clinicians greater freedom to deviate from protocols when necessary if the evidence of benefit is difficult to prove.

 

Natalie May

 

FCEM-style Questions

  1. What is a likelihood ratio?
  2. What is meant by the sensitivity analysis mentioned in the first paragraph of the Outcomes section and why is it performed? (If you need help, there’s a nice open access article here)
  3. Why is Intention-To-Treat analysis important in a study like this one?

See also this FCEM style review over at PEMLit.

 

Feeling Fit in Chicago: Join the smaccRUN!

CHICAGO

Details of the long anticipated smaccRUN 2015 are finally here.

Have a listen to the promo podcast featuring the seriously skilled, incredibly athletic half-man, half-machine that is Jesse Spurr, friend of St Emlyns and ICU Nurse Educator Extraordinare. Find out about how #smaccRUN came about and how you can get involved in Chicago at SMACC, regardless of how fit or unfit you are.

Just remember: it’s not a race, it’s going to be hot and it’s all about having fun so please commit to having a great time with some like-minded running fans and don’t break yourself! Make sure you’ve got your sweatbands ordered in advance – it’s going to be a hot one!

When and Where?

We’ve planned two runs and for both the meeting point is at the front of the Sheraton Chicago Hotel & Towers:

Monday 22nd June at 3pm

Saturday 27th June at 9am

(the hangover run post FOAMaoke, followed by a rather sweaty breakfast at Yolk Streeterville around 10am)

Register your intention to join us here!

It’ll help us know whether we need to warn Yolk in advance :-)

And if you fancy running more than twice? You can use the #smaccRUN hashtag or tweet the @smaccRUN account to arrange meet-ups with other attendees.

Not started training yet? It’s not too late! Download a couch to 5K app (there are loads of free ones – I started running 18 months ago with this one), commit to training for 30mins three times a week and you’ll be looking great and feeling awesome when the time comes to pound the shores of Lake Michigan. – Nat

Get your lycra on, there’s no excuse – see you there, it’ll probably be warmer than Sweden!IMG_1278

 

JC: One Benzo Fits All? Lorazepam vs Diazepam for Paediatric Status Epilepticus

Loraz Diaz Status Epilepticus

It’s been a little quiet of late here in the lofty towers of St Emlyn’s Virtual Hospital, not because the patients have stopped coming (trust me, they haven’t) but because many of the clinicians have spent their non-working hours squirreled away desperately designing talks for SMACC.

Now that the 1st May submission deadline has passed I’m pleased to report that not only has clinical care continued at Virchester but the commitment to delivering evidence-based Emergency Medicine is alive and well too; the Journal Club lives on!

Last week we looked at this paper from JAMA by the PECARN group (Paediatric Emergency Care Applied Research Network – a research collaborative not unlike PERUKI) which set out to answer the question: which is the better first line benzodiazepine for fitting children, lorazepam or diazepam?

You can read the abstract below: click on the image and it will take you to the the full paper at JAMA which is currently free-to-access.

Screen Shot 2015-05-03 at 14.48.13

What Kind of Paper is This?

The authors tell us that this is a double-blind, randomised clinical trial comparing efficacy of intravenous lorazepam with intravenous diazepam in children presenting to the ED with generalise convulsive status epilepticus.

Who and What Was Studied?

Children aged 3 months – 18 years presenting with generalised tonic-clonic status epilepticus were recruited at 11 academic Paediatric Emergency Departments in the US across a recruitment period of four years and two weeks. 273 patient were included in primary efficacy analysis, 140 of whom received IV diazepam (0.2mg/kg) and 133 received lorazepam (0.1mg/kg).

The primary outcome was cessation of status epilepticus within ten minutes of the initial dose of study medication with sustained absence of convulsions for 30 minutes. The authors defined end of status epilepticus as the time when the convulsive activity stopped as long as there was a return to normal level of consciousness within four hours.

The study also looked at some safety endpoints, namely severe respiratory depression occurring within four hours and requiring assisted ventilation, and some secondary outcomes such as time to return to baseline conscious level.

Patients were followed up for 24hrs or until hospital discharge (whichever came first) with a telephone call at 30 days to determine the incidence of adverse events after discharge.

Tell Me More About Status Epilepticus In This Paper

There’s an interesting definition of what we mean by status epilepticus which consists of the following descriptors:

1. 3 or more convulsions within the preceding hour and currently experiencing a convulsion OR

2. 2 or more convulsions in succession with no recovery of consciousness and currently experiencing a convulsion OR

3. A current single convulsion of at least 5 minutes’ duration.

The third definition was the one which prompted some discussion in the St Emlyn’s journal club, not because we wouldn’t treat these children with benzodiazepines (the APLS fitting child algorithm advises treatment if a seizure has not stopped within 5 minutes) but the idea that this constitutes status epilepticus. APLS in the UK defines status epilepticus as “continuous and generalised convulsions for more than 30 minutes”. In practice, this difference in definition doesn’t matter all that much if we agree that all three of these groups of children are those in whom we would be reaching for one of these medications with the aim of stopping the seizure, but it does rather broaden the eligibility criteria which potentially has the dual effect of making recruitment easier and altering the baseline proportion of those patients likely to achieve the primary outcome without the intervention.

What Did They Find?

Data was analysed per-protocol, rather than on an intention-to-treat basis (see below).

The study found no significant difference in the primary efficacy outcomes with cessation of status epilepticus (sustained for at least 30 minutes) in 72.1% of the diazepam group and 72.9% of the lorazepam group (absolute efficacy difference 0.8%, 95% confidence interval -11.4% to 9.8%).

The number of patients requiring assisted ventilation was quite high – 26 in each group (16.0% in the diazepam group, 17.6% of the lorazepam group) – but there was no demonstrable difference in proportions (absolute risk difference 1.6%, 95% confidence interval -9.9% to 6.8%). Looking at the secondary outcomes, there was a statistically significant difference in time to return to baseline conscious level in favour of diazepam. There are some interesting diagrams in the supplemental content which you can access here (it will download as a PDF) – have a look particularly at eFigure 3 which shows nicely the difference in proportions fully awake at 4hrs.

The authors conclude that treatment with lorazepam did not result in improved efficacy or safety compared with diazepam and as such their findings do not support preferential use of lorazepam for paediatric status epilepticus.

Protocols and Intentions

In this paper, the subjects were analysed only if their treatment matched the protocol laid out originally. As you can see in the CONSORT diagram on page 1655, this meant that quite a lot of patients were excluded from the final analysis and the reasons are given (for example, receiving open label medication or receiving late administration of a second dose of study medication). This is called per protocol analysis and is better for non-inferiority studies where deviation from the study protocol makes it more likely you’ll find no difference between the treatments and the trial will be positive (the treatment in question will be deemed non-inferior).

In contrast, intention-to-treat analysis means that all the subjects are analysed as part of the group to which they were randomised – even if they didn’t receive any treatment at all and dropped out of the study altogether. This sort of analysis is more pragmatic; it gives you a good idea of whether the effects are likely to be replicated in real life as it takes account of the reasons that subjects drop out of therapeutic trials (like horrendous, intolerable side-effects of medications). Intention to treat analysis is good for superiority trials as it has a conservative effect; if you find that the treatment in question really is demonstrably superior despite the dropouts then it is likely it really is superior.

Problems With The Paper And Questions It Generates

Once again we come up against the superiority/non-inferiority/equivalence conundrum. The authors state that the purpose of the study was to test the primary hypothesis that lorazepam is superior in efficacy and safety to diazepam for the treatment of paediatric status epilepticus. So if the study fails to show a difference then that must mean lorazepam is inferior, right?

Well… No. The study is powered to detect whether one treatment (lorazepam) is superior to the other (diazepam). A non-inferiority trial would require more patients and this particular study would be underpowered to detect non-inferiority. Given that it’s a superiority study, the per protocol analysis has implications as above: it would have been better to harness the conservative influence of intention to treat analysis from the outset so that if a difference had been detected we could have been more certain of its legitimacy.

Going back to the original methodology there are some potential issues with the blinding in this study; although opaque syringe cylinders were used, the switched-on Virchester trainees noted that when paediatric medications are administered intravenously in the UK there is usually a small clear plastic extension line with luer lock ports attached to the cannula – we’ve had no guarantee that the difference between diazepam and lorazepam wouldn’t have been determinable by looking at the infusing fluid in the extension line even if you couldn’t tell the difference between the syringes.

We also had some issues with the recording of the primary outcome which was determined by the treating physician. Ideally this would be determined by an independent individual, particularly for non-numerical clinical outcomes. We wondered if the study team had calculated a Kappa Statistic for this and postulated that if they had it probably wouldn’t demonstrate good levels of inter-observer agreement. Combine poorly undertaken blinding with lack of independence in measuring the primary outcome and the study suddenly looks rather shaky.

What Does This Mean for Status Epilepticus in the Paediatric ED?

Our consensus at the real-life St Emlyn’s journal club was that this study wasn’t going to change our practice. APLS protocols advice lorazepam for paediatric status epilepticus and we found no reason to deviate from that – however, should we find lorazepam in short supply then we felt reasonably confident that we would have no issues reaching for intravenous diazepam instead (in either case keeping a bag-valve-mask nearby).

Finally, Some FCEM-Critical-Appraisal-Style Questions

  1. The study group used an age-stratified, permuted block randomisation. What is block randomisation and why is it used in therapeutic trials?
  2. When performing a sample size calculation, the authors aimed to a achieve a power of 80%. What is a power calculation and what are its components? (There’s help here if you need it!)
  3. In analysing the number of patients requiring assisted ventilation, the authors calculated an absolute risk difference. What is the difference between absolute and relative risk reductions?
  4. Your clinical director decides to replace lorazepam with diazepam for paediatric status epilepticus in your ED. Do you agree with her decision? Give four reasons from the paper to support your answer.

Natalie

 

Before you go please don’t forget to…