The standard advice (taught to paediatric trainees and written on handouts to parents) is that paracetamol does not reduce the recurrence rate of subsequent febrile seizures. (However, even the 2017 Cochrane review on prophylaxis for febrile seizures is largely silent about paracetamol – it focuses mainly on anticonvulsants). This recent study from Japan challenges what we thought we knew.

 

Paediatrics, October 2018

The commonest lead misplacement error is to place V1 and V2 too high on the chest (around intercostal space 2 rather than 4). This error can result in deep inverted T waves in V1-3, in keeping with Wellens syndrome (critical LAD stenosis) or a posterior STEMI. The lead misplacement can also lead to an ECG appearance suggestive of several other worrying diagnoses, namely Brugada syndrome, PE (incomplete RBBB), anteroseptal MI, and prior anterior MI (septal Q waves).

 

American Journal of Emergency Medicine, February 2018

The diagnosis of subarachnoid haemorrhage (SAH) is a 'needle in a haystack' phenomenon: it is estimated that of the 2% of ED visits that present with headache, around 2% will actually have a SAH. In 2010 the Ottawa crew came up with yet another high-sensitivity 'rule-out' tool that sought to reduce downstream investigation (CT and LP).

 

American Journal of Emergency Medicine, May 2018

Over 20 different manoeuvres have been described for reduction of shoulder dislocations, which suggests there is no one 'best' method that will be successful in every instance. It is helpful to be familiar with several techniques so that, if one does not work, you can try another.

 

Journal of Bone and Joint Surgery, March 2018

The use of tamsulosin for renal colic makes physiological sense, but the majority of studies supporting it have been small, prone to bias or methodologically flawed. In the last 9 years, three higher-quality RCTs have been published, finding little to support tamsulosin use. The STONE study is the most recent trial to wade into the debate and is the largest RCT on the subject to date.

 

JAMA Internal Medicine, August 2018

Some statements seem perfectly reasonable until you stop and think about them. Take this one from the current Advanced Life Support (2015) manual from the UK Resus Council: "No anti-arrhythmic drug given during cardiac arrest has been shown to increase survival... Despite [this] the balance of evidence is in favour of the use of anti-arrhythmic drugs in cardiac arrest"... What?

 

Resuscitation, November 2018

Another month, and another study suggesting a novel use for tranexamic acid (TXA). In the August edition of The BREACH we covered a Case Report of nebulized TXA being used to good effect in haemoptysis. Now an RCT has been published looking at this same therapy.

 

Chest, October 2018

We have previously alluded to the fact that acute STEMI can present without ST elevation. These new guidelines helpfully spell out exactly which ECG patterns are worrying. These have been discussed in the FOAM world for many years but this is the first time I’ve seen them all together in an official document from an international cardiology group.

 

European Heart Journal, January 2018

There is a reasonably well-established dogma in the ED that giving glucose before thiamine (Pabrinex) to alcoholics can precipitate severe and permanent Wernicke’s encephalopathy. The physiological idea behind it is this: an excessive carbohydrate load leads to the build up of toxic metabolites in the thiamine-deficient brain, because thiamine is a co-factor for several essential enzymes in the Krebs cycle. But is there any evidence for this?

 

Journal of Emergency Medicine, April 2012

Appendicitis is a surgical problem and requires an operation to cure it... Or does it?

 

Journal of the American Medical Association, September 2018