Broome Docs by Dr Casey Parker

January 27, 2025 First10EM Journal Club: January 2025

Welcome to the first episode of the Broomedocs podcast for 2025. Justin and I are back for more nerdy goodness to make you smarter in the Resus room, or at a pub trivia night more likley… wether it is about salt correction, dissection or infection we can help you out! Listen in and learn!

Or if you don’t have enough Youtube content featuring aging bearded men – you can watch over on Justin’s channel here:

Airway, breathing, cellphone: a new vital sign?

Garcia SI, Jacobson A, Moore GP, Frank J, Gifford W, Johnson S, Lazaro-Paulina D, Mullan A, Finch AS. Airway, breathing, cellphone: a new vital sign? Int J Emerg Med. 2024 Nov 22;17(1):177. doi: 10.1186/s12245-024-00769-0. PMID: 39578750

Bottom line: This is a well done observational study that demonstrates an association between cell phone use and disposition to home, but I think the complexity really highlights the difficulty of making strong conclusions from observational data, and I can’t imagine that this data is at all helpful clinically. (I would be worried if people were using this as a data point to make medical decisions.)

Hyponatremia: Are we all doing this wrong?

Ayus JC, Moritz ML, Fuentes NA, Mejia JR, Alfonso JM, Shin S, Fralick M, Ciapponi A. Correction Rates and Clinical Outcomes in Hospitalized Adults With Severe Hyponatremia: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2024 Nov 18:e245981. doi: 10.1001/jamainternmed.2024.5981. PMID: 39556338

Bottom line: This meta-analysis of observational data shows an association between slower sodium correction in severe hyponatremia and increased mortality. These results are not definitive, but considering the rarity of demyelination, and the magnitude of the mortality results, this should probably influence clinical practice until we get the proper RCTs.

WOMAN are so negative

WOMAN-2 Trial Collaborators. The effect of tranexamic acid on postpartum bleeding in women with moderate and severe anaemia (WOMAN-2): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2024 Oct 26;404(10463):1645-1656. doi: 10.1016/S0140-6736(24)01749-5. PMID: 39461792

Bottom line: The WOMAN 2 trial is a large double-blind RCT that shows no benefit of TXA in the prevention of postpartum hemorrhage, which fits with all of the existing literature demonstrating no role for TXA in the management of postpartum hemorrhage.

Full blog post here.

More negative TXA research

Yassi N, Zhao H, Churilov L, Wu TY, Ma H, Nguyen HT, Cheung A, Meretoja A, Mai DT, Kleinig T, Jeng JS, Choi PMC, Duc PD, Brown H, Ranta A, Spratt N, Cloud GC, Wang HK, Grimley R, Mahawish K, Cho DY, Shah D, Nguyen TMP, Sharma G, Yogendrakumar V, Yan B, Harrison EL, Devlin M, Cordato D, Martinez-Majander N, Strbian D, Thijs V, Sanders LM, Anderson D, Parsons MW, Campbell BCV, Donnan GA, Davis SM; STOP-MSU Trial Investigators. Tranexamic acid versus placebo in individuals with intracerebral haemorrhage treated within 2 h of symptom onset (STOP-MSU): an international, double-blind, randomised, phase 2 trial. Lancet Neurol. 2024 Jun;23(6):577-587. doi: 10.1016/S1474-4422(24)00128-5. Epub 2024 Apr 20. PMID: 38648814

We have covered TXA relatively extensively (probably too extensively for the value of the product) in the past, including previous negative trials in intracerebral hemorrhage.

Epipens don’t work? (Not so fast)

Sim M, Sharma V, Li K, Gowland MH, Garcez T, Shilladay C, Pumphrey R, Patel N, Turner PJ, Boyle RJ. Adrenaline Auto-Injectors for Preventing Fatal Anaphylaxis. Clin Exp Allergy. 2024 Oct 9. doi: 10.1111/cea.14565. Epub ahead of print. PMID: 39383344

Profundus Trial – Can we actually exclude acute aortic syndromes with this protocol? 100% seems too good to be true

Morello et al., Diagnosis of acute aortic syndromes with ultrasound and D-dimer: the PROFUNDUS study. European Journal of Internal Medicine, https://doi.org/10.1016/j.ejim.2024.05.029

You can listen to my 27-minute rant on Youtube here: https://youtu.be/j_ejoaVynXI

This multinational trial looked at a three-pronged diagnostic protocol in the ED for adults with suspected acute aortic syndromes. The protocol used the ADD score, a POCUS echo protocol and D-dimer to try and exclude AAS in the ED. They recruited 1979 patients with 9% ultimately diagnosed with AAS. The bottom line was that they had ZERO misses at 30-day follow up. They estimated that they would have prevented 40% of patients from requiring Advanced imaging.

ADD score is really a very blunt tool and does not add much to standard ED doc thinking. Every patient got a “not simple” bedside echo and based on the ADD score and the echo findings was stratified as low or high pre-test probability.

The low risk group [1581 pt] got a Dimer (age adjusted was as good as < 500ng with more specificity ~6%) and either ruled out (none had a AAS if low PTP and negative dimer) or if positive went onto CT or MRI. The dimer “caught another 36 patients with AAS”

The high risk group [398pts] – 40% ultimately ruled in for AAS – so they were very high risk!

If you could achieve this process in your ED – then great. However, the elephant in the room is that the need to do a relatively comprehensive “expert level” POCUS exam on every patient makes this unfeasible in most places. Some views eg. suprasternal views are tricky and niche.

I think that the protocol could be simplified and reversed in order such that clinical risk is high vs low. Dimer is useful in the low risk group. The high risk group, or those with a positive Dimer get a echo – primarily to either – speed up imaging if echo can see a flap (37 x RR of AAS)… or look for alternate diagnosis. In this trial patients with echo findings got their scan at 1 hour vs 2 hours for the echo negative folk.

Problems with this trial

– AAS patients do not present with a flashing light- we see them in the context of “chest pain” and it is difficult to know from this inclusion criteria how these patients were selected as “having AAS as a meaningful diagnostic concern”. Given the high burden of echo for all, it would be nice to have a more objective inclusion criteria?

– Does the ADD score really add much to simple gestalt/ commonsense? Justin will have clear thoughts on this!

– no echo images were formally recorded for QI or to assess interobserver reliability – this is a big miss as we know that echo is far from perfect – and this would have added some useful safety data (e.g. 1.4% of patients with a “flap” on echo had a normal CT or MRI… I want to know how many had “inadequate views” as this is a real barrier to applying echo in ED practice.

– we do not know what the other 91% of cases were diagnosed with – that would be useful to know. Did they pick a heap of PEs? Was echo useful in the 91% not having AAS?

Bottom Line: if you have access to expert echo skills this trial suggests that you could use it to achieve a very highly sensitive exam for AAS, it will probably also expedite thise with dissection into the OR. However, you need to think about the opportunity:cost of echoing every patient with chest pain… there is probably a better way.

Side effects of decision rules, or the law of unintended consequences

Weber EJ, Carlton EW. Side effects of decision rules, or the law of unintended consequences. Emerg Med J. 2019 Jan;36(1):2-3. doi: 10.1136/emermed-2018-208151. Epub 2018 Oct 25. PMID: 30361207

Killer antibiotic stewardship

Dark P, Hossain A, McAuley DF, Brealey D, Carlson G, Clayton JC, Felton TW, Ghuman BK, Gordon AC, Hellyer TP, Lone NI, Manazar U, Richards G, McCullagh IJ, McMullan R, McNamee JJ, McNeil HC, Mouncey PR, Naisbitt MJ, Parker RJ, Poole RL, Rostron AJ, Singer M, Stevenson MD, Walsh TS, Welters ID, Whitehouse T, Whiteley S, Wilson P, Young KK, Perkins GD, Lall R; ADAPT-Sepsis Collaborators. Biomarker-Guided Antibiotic Duration for Hospitalized Patients With Suspected Sepsis: The ADAPT-Sepsis Randomized Clinical Trial. JAMA. 2024 Dec 9. doi: 10.1001/jama.2024.26458. PMID: 39652885

Bottom line: If you are willing to risk a substantial increase in mortality, you can cut back on antibiotic use by following a patient’s procalcitonin.

If it looks like a brain – your should eat it?

B.BENNETT. Doctrine of Signatures: An Explanation of Medicinal Plant :Discovery or Dissemination of Knowledge?’ Economic Botany, 61(3), 2007, pp. 246-255.

The Doctrine of Signatures asserts that the form of a plant reveals their therapeutic values. Classic examples include the use of liverwort to treat hepatic ailments, bloodroot for blood disorders and walnuts for brain ailments. My personal favourite is the use of saxifrage – its root are able to split rock as they grow in rocky outcrops – therefore it is used to treat renal stones!

The DOS has a long history dating back to many prehistoric peoples and modern day traditional herbalism in many remote parts of the world.

In the post-Renaissance era the DOS was largely ridiculed by the emerging European scientific community. In 1825 Dr Hahnemann described it as “the folly of the ancients” – he then went on to found the concept of homeopathy….

On its surface the Doctrine of Signatures does seem ludicrous – the resemblance of the roots of the common purslane to faecal worms lead it to be used by traditional American healers for intestinal worms?

The reality is much more fascinating. Ethnobotanists have studied the relationships between form and function – the Europeans made a reverse attribution error. Many of these plants do actually contain bioactive chemicals which have been used successfully for millennia – the shape of the leaf or root is simply an aide-memoire to recall the use in people with non-written languages. No ancient people really thought that a heart-shaped leaf would cure heart disease due to its form. – they simply used the form as a way of cataloging the natural pharmacopeia around them. Turns out that purslane root is actually an effective anti-helmintic!

So before we ridicule our ancient forebears we should take a moment to consider what passes for medicine in 2025 with very little scientific study or benefit. Just pop onto Youtube and you can find many influencers pushing various plants and herbal fixes based upon the literal and ridiculous assertion that form determines function in “alternate medicine” – clearly these folk have not learned from the wisdom of the ages.

...more

Share Broome Docs

Sign up to save your podcasts

Broome Docs

FAQs about Broome Docs:

How many episodes does Broome Docs have?

Broome Docs episodes:

FAQs about Broome Docs:

How many episodes does Broome Docs have?