You've given your patient IM adrenaline, they're breathing normally and feeling well again. You'd like to discharge them with an Epipen but there's a little voice at the back of your head: "What if they have a biphasic reaction at home and they can't take the pen in time?" Prior studies have found biphasic reaction rates as high as 20%, and there are reports of reactions happening as long as 4 days after the initial anaphylaxis. Studies so far have tended to be underpowered, retrospective and with widely differing definitions of 'allergy' and 'biphasic reaction' (we're not really concerned about a slight rash appearing on day 2, after all).

Anesthesiology, November 2018

Annals of Emergency Medicine, June 2014

On its 40th anniversary (in 2014) the GCS was updated by Prof Teasdale, one of the original developers. He also advised against combining the components if one aspect was non-testable (testing verbal response in an intubated patient, for example). Earlier this year he wrote another paper with the aim of increasing the prognostic accuracy of the GCS while losing none of its simplicity.

Journal of Neurosurgery, June 2018

Head injury is a common presentation to the paediatric ED. Most children don't require a CT and can be sent home with advice on when to return (if they develop any signs of raised ICP). But how long will it take to recover? This is an important question, particularly if the child has important exams (or a vital football match) coming up. The literature to date (mainly small retrospective studies) is all over the place on this question, with expected recovery time ranging from days to years. This paper is the first large prospective study to investigate this.

JAMA Pediatrics, November 2018

Contrast-induced nephropathy (CIN) is traditionally defined as acute kidney injury occuring within 48 hours of the administration of IV contrast (but see this large meta-analysis, reviewed in May's edition of The BREACH, that largely debunks this concept). The current paper looks at two commonly-proposed strategies for reducing the risk of CIN.

New England Journal of Medicine, February 2018

Two large trials from the 1990s showed a beneficial effect for aspirin in patients without prior MI or stroke ('primary prevention'). However, there is a growing consensus that this may not be the case any more, because risk factors are now managed more aggressively (smoking, blood pressure and cholesterol). As risk factors decrease the absolute risk reduction from aspirin also decreases and may now be outweighed by the increased risk of bleeding.

ARRIVE trial, The Lancet, September 2018

ASCEND trial, New England Journal of Medicine, October 2018

ASPREE trial, New England Journal of Medicine, October 2018

Previous studies have found that around half of the cannulas we insert in the ED are never used. This is perhaps no big deal, as we generally take blood samples when they are inserted. However, compared to simple venepuncture, IV cannulas can be more painful and time-consuming to insert, and can lead to more complications (thrombophlebitis, site infection, bleeding, etc). This study looked at an intervention to try to reduce the amount of IV lines placed in the ED.

Academic Emergency Medicine, June 2018

Hyperkalaemia is probably the most feared electrolyte disturbance, as the first symptom can be sudden death (VF arrest). There are always going to be cases where we are presented with the ECG before the blood results are available (the gas machine is broken, the patient couldn't be bled at triage, etc). Wouldn't it be great if we could gauge the patient's risk of short-term adverse events based on their ECG?

Western Journal of Emergency Medicine, August 2017

Pregnancy increases the risk of PE. Symptoms like breathlessness and tachycardia make us think of PE, but these are often present in pregnancy anyway. D-dimer can be useful in selected low risk cases for ruling out PE, but pregnant women are usually excluded from studies so there remains a question over its utility in pregnancy. This paper addressed this issue directly, and is the first prospective study of the diagnostic workup for PE in pregnancy to be published.

Annals of Internal Medicine, December 2018

Part of the Expert Clinical Management series, reviews by experts in a particular field that summarise the best available evidence on a topic. 

(Annals of Emergency Medicine, May 2018)

There is a growing number of patients who present to A&E with hypertension, either recorded by themselves at home, in a pharmacy, or by their GP. Other patients may have high blood pressure as an incidental finding when they present with another complaint. There is a temptation to treat these numbers, either with nifedipine (peak plasma concentration 2-3hr) or – even worse - amlodipine (peak plasma concentration 6-8hr). This prolongs ED stay and may be unsafe (who is monitoring their BP if they go home before the drug has reached peak levels?)

 

Retrospective observational study: Annals of Emergency Medicine, November 2018.

Clinical review and expert opinion article: JAMA Internal Medicine, May 2018