Emergency Archives - Broome Docs

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