Broome Docs

G’day and welcome to another instalment of the Journal Club with Dr Justin Morgenstern.

This month we cover some diltiazem papers, a few on airway hacks, some population studies and discuss some nerwer management options for big PEs, and kids seizures.

Unfortunately, we had soe technical glitches which means that the usual video / Youtube version will not be available – so you will have to stare at a picture of Justin as you listen to the chat!

Az A, Sogut O, Dogan Y, Akdemir T, Ergenc H, Umit TB, Celik AF, Armagan BN, Bilici E, Cakmak S. Reducing diltiazem-related hypotension in atrial fibrillation: Role of pretreatment intravenous calcium. Am J Emerg Med. 2025 Feb;88:23-28. doi: 10.1016/j.ajem.2024.11.033. Epub 2024 Nov 17. PMID: 39577214

An additional note raised by Scott Weingart is related to the significant whole body burning that is often caused by calcium chloride. Justin’s full blog write up is here. 

Bottom line: Calcium probably has some minor hemodynamic effects, but when diltiazem is used correctly, adverse events are incredibly rare, and therefore there is really no reason for prophylaxis.

Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson A, Murray KT. Serious Bleeding in Patients With Atrial Fibrillation Using Diltiazem With Apixaban or Rivaroxaban. JAMA. 2024 May 14;331(18):1565-1575. doi: 10.1001/jama.2024.3867. PMID: 38619832

Bottom line: There is an association between diltiazem and increased bleeding in patients on DOACs (as compared to metoprolol), but this is almost certainly the result of obvious confounders, so I can’t see any reason to change current practice. 

Morgenstern J, Radecki R, Westafer L, Niforatos JD, Atkinson P. CJEM debate: clinical decision rules-thinking beyond the algorithm.CJEM. 2025 Feb 3. doi: 10.1007/s43678-025-00870-0. PMID: 39900742

You can read Justin’s full write up on why  decision rules are ruining medicine. 

Jaber WA, Gonsalves CF, Stortecky S, Horr S, Pappas O, Gandhi RT, Pereira K, Giri J, Khandhar SJ, Ammar KA, Lasorda DM, Stegman B, Busch L, Dexter DJ 2nd, Azene EM, Daga N, Elmasri F, Kunavarapu CR, Rea ME, Rossi JS, Campbell J, Lindquist J, Raskin A, Smith JC, Tamlyn TM, Hernandez GA, Rali P, Schmidt TR, Bruckel JT, Camacho JC, Li J, Selim S, Toma C, Basra SS, Bergmark BA, Khalsa B, Zlotnick DM, Castle J, O’Connor DJ, Gibson CM; PEERLESS Committees and Investigators*. Large-Bore Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis in the Management of Intermediate-Risk Pulmonary Embolism: Primary Results of the PEERLESS Randomized Controlled Trial. Circulation. 2025 Feb 4;151(5):260-273. doi: 10.1161/CIRCULATIONAHA.124.072364. Epub 2024 Oct 29. PMID: 39470698

Bottom line: At this point there is absolutely no evidence that mechanical thrombectomy or catheter directed thrombolysis help patients. There might be times where they are reasonable, even without evidence, such as in a very sick patient with contraindications to systemic thrombolysis. However, neither of these procedures should be used routinely until we see real evidence.

Justin’s full write up of this paper is here. 

Lauren Westafer, Justin & Dr. Bourke Tillman do a great discussion of the modern management of intermediate and high risk PE at length on this recent Emergency Medicine Cases podcast, and Justin has a write up of more evidence here. 

Hansel J, Law JA, Chrimes N, Higgs A, Cook TM. Clinical tests for confirming tracheal intubation or excluding oesophageal intubation: a diagnostic test accuracy systematic review and meta-analysis. Anaesthesia. 2023 Aug;78(8):1020-1030. doi: 10.1111/anae.16059. Epub 2023 Jun 16. PMID: 37325847

This is Casey’s pet topic of the month and a personal peeve in airway management.

Bottom line: The only test you should use to confirm endotracheal tube position is waveform capnography. – save yourself 30 seconds of somebody else’s life!!

Markham T, AlFarra AS, Tejani M, Tate DJ, Barrera JE, Paladugu S, Saroukhani S, Jiang Y. Effectiveness of Ventilation via an Endotracheal Tube in Pharynx Versus a Facemask in Patients With Potentially Difficult Airway: A Randomized, Crossover, and Blind Trial. Anesth Analg. 2025 Feb 1;140(2):280-289. doi: 10.1213/ANE.0000000000007273. Epub 2024 Dec 20. PMID: 39705182

This is a weird McGyverism – using an ETT in the place of a device that is universally availabel and works extremely well – the humble LMA!

Bottom line: We generally suck at BVM, so looking for alternatives, especially in difficult patients (obese with a beard), makes sense. However, I am not sure BVM is the correct comparison to this technique, as it appears to me more of a replacement for an LMA.

Lutsey PL, Misialek JR, Young MT, Berman J, Leiser CL, Pope ZC, Cushman M, Folsom AR, Kaufman JD. Air pollution is associated with increased risk of venous thromboembolism: the Multi-Ethnic Study of Atherosclerosis. Blood. 2025 Mar 6;145(10):1089-1096. doi: 10.1182/blood.2024026399. PMID: 39652776

Bottom line: There are limitations that significantly limit certainty, but there seems to be an association between air pollution and VTE (among numerous other health implications). 

Amr A. Othman, Abdelrahim A. Sadek, Esraa A. Ahmed, Elsayed Abdelkreem, MD, PhD. Combined Ketamine and Midazolam Versus Midazolam Alone for Initial Treatment of Pediatric Generalized Convulsive Status Epilepticus (Ket-Mid Study): A Randomized Controlled Trial Pediatric Neurology 167 (2025) 24e32

Bottom line: When used very late in status epilepticus, ketamine plus midazolam is better than midazolam alone, but we should be cautious of the limitations of this small single center study looking at a very different population than we are used to treating.

Spellberg B. The Policy to Override Policies-One Policy to Rule Them All. JAMA Intern Med. 2024 Dec 1;184(12):1408-1409. doi: 10.1001/jamainternmed.2024.4625. PMID: 39401007

This is the “deep thinker” of the month – a paper to make us reconsider about how we run our hospitals and who can make the pragmatic and potentially game-changing decisions whilst in the middle of busy practice. This describes a fascinating policy created in a single hospital that handed executive privileges to the coal-face clinical staff adn it seems to be a win-win for their hospital and patients.

If you listen into the podcast regularly then you will know that we sometimes disappear down nerdy rabbit holes ( I blame Justin!) – this month was no exception – we somehow got talking about the New World Screw-worm … so here is a picture or two to help you visualise the horror!

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:

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.)

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-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.

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.

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

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.

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

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. 

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.

Welcome back to the pre-Xmas edition of the Broomedocs & First10EM Journal club.

This month we cover a few out-of-hospital arrest trials. More PECARN goodness and we answer the question: are ants better doctors than human doctors? There is a bunch more – so have a listen or watch us on Youtube feed below. You can read all the papers on the links in the show notes right here.

Taccone FS, Rynkowski Bittencourt C, Møller K, Lormans P, Quintana-Díaz M, Caricato A, Cardoso Ferreira MA, Badenes R, Kurtz P, Søndergaard CB, Colpaert K, Petterson L, Quintard H, Cinotti R, Gouvêa Bogossian E, Righy C, Silva S, Roman-Pognuz E, Vandewaeter C, Lemke D, Huet O, Mahmoodpoor A, Blandino Ortiz A, van der Jagt M, Chabanne R, Videtta W, Bouzat P, Vincent JL; TRAIN Study Group. Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury: The TRAIN Randomized Clinical Trial.JAMA. 2024 Oct 9. doi: 10.1001/jama.2024.20424. PMID: 39382241

We did liberal versus conservative blood transfusion in brain injury in October, with the HEMOTION trial, but were left in the awkward spot where the results look better with liberal transfusion, but the trial was statistically negative. As a follow up, we have the TRAIN trial, which is another open-label multicenter RCT comparing liberal to conservative transfusion strategies in brain injury. Full post here.

DiNubile MJ. Skepticism: a lost clinical art. Clin Infect Dis. 2000 Aug;31(2):513-8. doi: 10.1086/313945. Epub 2000 Sep 14. PMID: 10987714

Couper K, Ji C, Deakin CD, Fothergill RT, Nolan JP, Long JB, Mason JM, Michelet F, Norman C, Nwankwo H, Quinn T, Slowther AM, Smyth MA, Starr KR, Walker A, Wood S, Bell S, Bradley G, Brown M, Brown S, Burrow E, Charlton K, Claxton Dip A, Dra’gon V, Evans C, Falloon J, Foster T, Kearney J, Lang N, Limmer M, Mellett-Smith A, Miller J, Mills C, Osborne R, Rees N, Spaight RES, Squires GL, Tibbetts B, Waddington M, Whitley GA, Wiles JV, Williams J, Wiltshire S, Wright A, Lall R, Perkins GD; PARAMEDIC-3 Collaborators. A Randomized Trial of Drug Route in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2024 Oct 31:10.1056/NEJMoa2407780. doi: 10.1056/NEJMoa2407780. Epub ahead of print. PMID: 39480216

Vallentin MF, Granfeldt A, Klitgaard TL, Mikkelsen S, Folke F, Christensen HC, Povlsen AL, Petersen AH, Winther S, Frilund LW, Meilandt C, Holmberg MJ, Winther KB, Bach A, Dissing TH, Terkelsen CJ, Christensen S, Kirkegaard Rasmussen L, Mortensen LR, Loldrup ML, Elkmann T, Nielsen AG, Runge C, Klæstrup E, Holm JH, Bak M, Nielsen LR, Pedersen M, Kjærgaard-Andersen G, Hansen PM, Brøchner AC, Christensen EF, Nielsen FM, Nissen CG, Bjørn JW, Burholt P, Obling LER, Holle SLD, Russell L, Alstrøm H, Hestad S, Fogtmann TH, Buciek JUH, Jakobsen K, Krag M, Sandgaard M, Sindberg B, Andersen LW. Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest. N Engl J Med. 2024 Oct 31. doi: 10.1056/NEJMoa2407616. Epub ahead of print. PMID: 39480221

We have 2 studies looking at the same question published in the same edition of the NEJM, so I will tackle them together. (You can find more details in the full blog post.) Which is better in out of hospital cardiac arrest: IV or IO?

PARAMEDIC 3 randomized 6,000 (but they were supposed to get to 15,000) patients with out of hospital arrest from multiple EMS agencies in the UK to either an IO or IV to start. Their primary outcome was survival at 30 days, and there was no difference between the two groups (4.5% of the IO group and 5.1% of the IV group). Favourable neurologic outcomes were seen in 2.7% versus 2.8%. ROSC and sustained ROSC to hospital handover were both slightly higher with IV (2% absolute). There will be some conversation about the slight difference in ROSC here, but if people are not surviving that conversation is irrelevant (and if anything, this ROSC seems to represent harm). 

IVIO is a similar trial from Denmark, in which 1749 adult patients with out of hospital cardiac arrest were randomized to an IO or an IV as their first method of vascular access. The primary outcome here was ROSC, and there was no difference (30% with IO vs 29% with IV, RR 1.06, 95% CI 0.9-1.24). There were no differences in survival (12% with IO vs 10% with IV) or neurologically intact survival (9% vs 8%).

Ivankovic M, Schwartz KL. Shorter courses of antibiotics. CMAJ. 2024 Nov 3;196(37):E1266. doi: 10.1503/cmaj.240246. PMID: 39496357

Less is more for almost every common indication for oral antibiotics in reality.

Bannelier H, Kapfer T, Roussel M, Freund Y, Alame K, Catoire P, Vromant A. Failure rate of D-dimer testing in patients with high clinical probability of pulmonary embolism: Ancillary analysis of three European studies. Acad Emerg Med. 2024 Nov 1. doi: 10.1111/acem.15032. PMID: 39487597

Thom C, Larsen M, Kongkatong M, Ottenhoff J, Moak J. It’s Not Cyclic Vomiting Syndrome Until Dietl’s is Ruled Out: A Case for Point of Care Renal Ultrasound. J Emerg Med. 2024 Oct;67(4):e346-e350. doi: 10.1016/j.jemermed.2024.05.003. Epub 2024 May 16. PMID: 39183114

Barton MS, Chaumet MSG, Hayes J, Hennessy C, Lindsell C, Wormer BA, Kassis SA, Ciener D, Hanson H. A Randomized Controlled Comparison of Guardian-Perceived Cosmetic Outcome of Simple Lacerations Repaired With Either Dermabond, Steri-Strips, or Absorbable Sutures. Pediatr Emerg Care. 2024 Aug 15. doi: 10.1097/PEC.0000000000003244. Epub ahead of print. PMID: 39141836

Justin has a long series of articles looking at the science behind laceration repair, and I think the simplest answer is: nothing you do matters.

Schnadower D, Tarr PI, Casper TC, Gorelick MH, Dean JM, O’Connell KJ, Mahajan P, Levine AC, Bhatt SR, Roskind CG, Powell EC, Rogers AJ, Vance C, Sapien RE, Olsen CS, Metheney M, Dickey VP, Hall-Moore C, Freedman SB. Lactobacillus rhamnosus GG versus Placebo for Acute Gastroenteritis in Children. N Engl J Med. 2018 Nov 22;379(21):2002-2014. doi: 10.1056/NEJMoa1802598. PMID: 30462938

Jaballah R, Toumia M, Youssef R, Ali KBH, Bakir A, Sassi S, Yaakoubi H, Kouraichi C, Dhaoui R, Sekma A, Zorgati A, Beltaief K, Mezgar Z, Khrouf M, Bouida W, Grissa MH, Saad J, Boubaker H, Boukef R, Msolli MA, Nouira S. Piroxicam and paracetamol in the prevention of early recurrent pain and emergency department readmission after renal colic: Randomized placebo-controlled trial. Acad Emerg Med. 2024 Aug 19. doi: 10.1111/acem.14996. Epub ahead of print. PMID: 39161087

Frank ET, Buffat D, Liberti J, Aibekova L, Economo EP, Keller L. Wound-dependent leg amputations to combat infections in an ant society. Curr Biol. 2024 Jul 22;34(14):3273-3278.e3. doi: 10.1016/j.cub.2024.06.021. Epub 2024 Jul 2. PMID: 38959879

This might be the best paper we have ever discussed on the blog/podcast. Ants are better at managing traumatic leg wounds than we are by several orders of magnitude!

Welcome back to the podcast and this is a special one – we have created the first Video podcast in which you can gaze lovingly at Justin as he rants, drops pearls and shares all the latest nerdy EBM from the desk. Papers below with link and video at the bottom on Youtube

Palatinus HN, Johnson MA, Wang HE, Hoareau GL, Youngquist ST. Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest. Resuscitation. 2024 Aug;201:110266. doi: 10.1016/j.resuscitation.2024.110266. Epub 2024 Jun 9. PMID: 38857847

Bottom line: This before and after study demonstrates an association between early IM epinephrine and survival from cardiac arrest. However, there are simply too many confounders in a before and after study design to trust the results. This is hypothesis generating, and warrants a follow-up RCT. 

Leonard JC, Harding M, Cook LJ, Leonard JR, Adelgais KM, Ahmad FA, Browne LR, Burger RK, Chaudhari PP, Corwin DJ, Glomb NW, Lee LK, Owusu-Ansah S, Riney LC, Rogers AJ, Rubalcava DM, Sapien RE, Szadkowski MA, Tzimenatos L, Ward CE, Yen K, Kuppermann N. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. 2024 Jul;8(7):482-490. doi: 10.1016/S2352-4642(24)00104-4. Epub 2024 Jun 4. PMID: 38843852

Soucy Z, Cheng D, Vilke GM, Childers R. Systematic Review: The Role of Intravenous and Oral Contrast in the Computed Tomography Evaluation of Acute Appendicitis. J Emerg Med. 2020 Jan;58(1):162-166. doi: 10.1016/j.jemermed.2019.10.034. Epub 2019 Dec 13. PMID: 31843324

Bottom line: This information is not new. I was taught this in residency. However, it might be new to your radiology group, so if they are still using oral contrast (with all of its many problems) it might be worth starting a conversation.

Chiarlitti N, Graves Z, Lavoie C, Reid RER. Does Examination Table Paper Use Mitigate the Risk of Disease Transmission in a Family Medicine Clinic? Ann Fam Med. 2024 May-Jun;22(3):230-232. doi: 10.1370/afm.3092. PMID: 38806257

Barnicle RN, Bracey A, Weingart SD. Managing Emergency Endotracheal Intubation Utilizing a Bougie. Ann Emerg Med. 2024 Jun 22:S0196-0644(24)00232-4. doi: 10.1016/j.annemergmed.2024.04.021. PMID: 38912998

Luo Z, Li Y, Li W, Li Y, Nie Q, Shi Y, Wang J, Ji Q, Han X, Liu S, Li D, Wang S, Li Z, Jia D, Ge H, Xu P, Feng Z, Li F, An F, Tai N, Yue L, Xie H, Jin X, Liu H, Dang Q, Z hang Y, Sun L, Wang J, Huang H, Chen L, Ma Y, Cao Z, Wang C; HAPPEN Investigators. Effect of High-Intensity vs Low-Intensity Noninvasive Positive Pressure Ventilation on the Need for Endotracheal Intubation in Patients With an Acute Exacerbation of Chronic Obstructive Pulmonary Disease: The HAPPEN Randomized Clinical Trial. JAMA. 2024 Sep 16:e2415815. doi: 10.1001/jama.2024.15815. Epub ahead of print. PMID: 39283649

Coyle C, Shi J, Leonard JC. Antibiotic prophylaxis in pediatric dog bite injuries: Infection rates and prescribing practices. J Am Coll Emerg Physicians Open. 2024 Jun 4;5(3):e13210. doi: 10.1002/emp2.13210. PMID: 38841297

IBottom line: A lot of people are still using prophylactic antibiotics in dog bites, but the logic behind that strategy (treat 100 patients to avoid the same treatment in 5) makes absolutely no sense.

Wang F, Xu X, Yang J, Min L, Liang S, Chen Y. Height and lung cancer risk: A meta-analysis of observational studies. PLoS One. 2017 Sep 26;12(9):e0185316. doi: 10.1371/journal.pone.0185316. PMID: 28949980

Cuker A, Kavakli K, Frenzel L, Wang JD, Astermark J, Cerqueira MH, Iorio A, Katsarou-Fasouli O, Klamroth R, Shapiro AD, Hermans C, Ishiguro A, Leavitt AD, Oldenburg JB, Ozelo MC, Teitel J, Biondo F, Fang A, Fuiman J, McKay J, Sun P, Rasko JEJ, Rupon J; BENEGENE-2 Trial Investigators. Gene Therapy with Fidanacogene Elaparvovec in Adults with Hemophilia B. N Engl J Med. 2024 Sep 26;391(12):1108-1118. doi: 10.1056/NEJMoa2302982. PMID: 39321362

Welcome to a special edition of the Journal Club with Justin. This month we recorded live with a bunch of fantastic Broome junior doctors. Justin gate-crashed our local journal club to share his approach to “reading a paper” ( Video version here) and then we dived into a bunch of new papers… and one really old one. Thanks to Drs Emily Wishart, Josh Briotti and Will Arnott who were brave enough to join the chaos and unscripted nerd fest that we put on every month or two.

So follow along with the papers below and read to make up your own mind about the evidence presented.

Turgeon AF, Fergusson DA, Clayton L,et al. Liberal or Restrictive Transfusion Strategy in Patients with Traumatic Brain Injury. N Engl J Med. 2024 Jun 13. doi: 10.1056/NEJMoa2404360. PMID: 38869931

Bottom line: This large multi-center RCT comparing liberal and restrictive transfusion triggers in patients with traumatic brain injury was statistically negative, but may actually support more liberal transfusion. 

Mols EM, Haak H, Holland M, Schouten B, Ibsen S, Merten H, Christensen EF, Nanayakkara PWB, Nickel CH, Weichert I, Kellett J, Subbe CP, Kremers MNT; Safer@Home Research Consortium. Can acutely ill patients predict their outcomes? A scoping review. Emerg Med J. 2024 May 28;41(6):342-349. doi: 10.1136/emermed-2022-213000. PMID: 38238065

Nielsen AB, Holm M, Lindhard MS, et al. Oral versus intravenous empirical antibiotics in children and adolescents with uncomplicated bone and joint infections: a nationwide, randomised, controlled, non-inferiority trial in Denmark. Lancet Child Adolesc Health. 2024 Jul 15:S2352-4642(24)00133-0. doi: 10.1016/S2352-4642(24)00133-0. Epub ahead of print. PMID: 39025092

Roberts et al, Subarachnoid haemorrhage in the emergency department (SHED): a prospective, observational, multicentre cohort study. Emergency Medicine Journal Published Online First: 12 September 2024. doi: 10.1136/emermed-2024-214068

Zouche I, Guermazi W, Grati F, Omrane M, Ketata S, Cheikhrouhou H. Intravenous magnesium sulfate improves orotracheal intubation conditions: A randomized clinical trial. Trends in Anaesthesia and Critical Care. 2024; 57:101371-.

You can read more on BroomeDocs: MagA: Making Airways Great Again?

The Relationship Between Herpes Zoster, Syphilis and Chickenpox. JAMA. 2019 Nov 5;322(17):1722. doi: 10.1001/jama.2018.15583. PMID: 31688874

How will we look with the retrospectoscope in 100 years? Probably not that bright!