Aktuelle FOAMed Infos rund um die klinische Notfallmedizin, Notfallmedizin und Intensivmedizin, auf den Spuren vom Skeptics Guide to emergency medicine

SGEM#176: Somebody’s Watching Me – Cardiac Monitoring for Chest Pain Podcast: SGEMglobal-Spanish-176 ¡Hola a todos! Nosotros somos Manrique Umaña y Alejandro Moya, y somos sus anfitriones para este episodio de “La Guía para Escépticos para Medicina de Emergencias o SGEM”. Este es un proyecto de transferencia de conocimientos iniciado en el 2012 por el Dr. Ken […]

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Date: March 20th, 2018

Reference: Sawa et al. Risk factors for adverse outcomes in older adults with blunt chest trauma: A systematic review. CJEM March 2018

Guest Skeptic: Dr. Christina Shenvi is an Emergency Physician at University of North Carolina. She is fellowship trained in Geriatric Emergency Medicine and has a podcast called GEMCAST. Christina loves serving as the assistant residency director, writing things, reading things, teaching people, and having kids.

Case: An 85-year-old woman with a history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and type-2 diabetes (DM-2), and her 65-year-old otherwise healthy daughter present to the emergency department after a car accident. It was a low speed motor vehicle collision (MVC) in which they rear-ended a stationary car. However, they were both unrestrained. They both have a Glasgow Coma Scale (GCS) of 15 on arrival and are complaining of chest pain. The physician in the emergency department is deciding what imaging to obtain and will ultimately have to decide the disposition.

Background: Older adults who sustain a blunt traumatic injury to the chest are at higher risk for greater injury severity for a given mechanism, longer lengths of stay, loss of independence, and higher morbidity and mortality than younger patients.

However, it is not a homogeneous population. Some older adults will do relatively well, while others will be at particularly high risk for adverse outcomes.

Clinical Question: What are the main factors that are associated with adverse outcomes in older adults with blunt chest trauma?

Reference: Sawa et al. Risk factors for adverse outcomes in older adults with blunt chest trauma: A systematic review. CJEM March 2018

* Population: Older adults defined as 65-years of age and over. Blunt chest trauma defined as “blunt chest injury resulting in chest wall contusion or rib fractures, with or without immediate life-threatening injury to the lungs or other organ systems.”

* Excluded:

* Review articles, case reports, or case-series

* Population not meeting inclusion criteria

* Did not analyze risk factors for outcome of interest

* Did not examine an outcome of interest

* Intervention: Not applicable

* Comparison: The comparison was prognostic factors for outcomes of interest. The factors were grouped into three categories:

* Patient Factors: Any underlying features, conditions, or demographics present before the injury such as age, sex, co-morbidities.

* Disease Factors: Any risk factors related to the traumatic event such as number of rib fractures, flail chest, mechanism, other associated trauma.

* Institutional Factors: These had to do with the hospital and emergency department such as: was the patient seen by a trauma team, was there a multi-disciplinary team, and were there any adverse events that occurred.

* Primary Outcomes:

* Morbidity: Pneumonia, intubation and intensive care admission

* Mortality: In-hospital or 30-day

* Emergency Department Recidivism

* Length of Stay (LOS)

* Quality of Life (QOL)

* Loss of Independence: Defined as discharge to a higher level of community care than they were admitted from.

Authors’ Conclusions: “While blunt chest wall trauma in older adults is relatively common, the literature on prognostic factors for adverse outcomes in this patient population remains inadequate due to a paucity of high quality studies and lack of consistent reporting standards.”

Quality Checklist for Systematic Review of Prognostic Studies:

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Date: March 18th, 2018

Reference: Zhao et al. The Long-Term Effect of Acupuncture for Migraine Prophylaxis:  A Randomized Clinical Trial. JAMA Internal Medicine 2017

Guest Skeptic: Dr. Alfred Sacchetti is a full time practicing Emergency Physician, who is also the Chief of Emergency Medicine at Our Lady of Lourdes Medical Center in Camden, New Jersey, USA, an Assistant Clinical Professor of Emergency Medicine, an Active Researcher and faculty member for the Emergency Medicine and Acute Care course.  

Case: 40-year-old male appears with what he describes as his typical migraine that has failed his usual home therapies.  In the emergency department after six hours and multiple medications, the patient’s pain is finally under control.  While being discharged he asks if there anything you can offer to prevent headaches from coming back. He states: “I have to fly to Chengdu University of Traditional Chinese Medicine next week on a sales call and don’t want to have the headache return while I am there.”

Background: More than 10% of people (6% men and 18% women) suffer from migraines. This condition represents a significant source of both medical costs and lost productivity. Direct costs are estimated at approximately 17 billion dollars a year. There are also indirect costs of about 15 billion dollars a year mainly due to missed work.

There are many options for treating migraine headaches in the emergency department. When every you see so many treatments for the same problem it is an indication that none of them work very well. One of the best treatment options is just to give the patient a quiet/dark space and time to get some sleep. If that does not work, one good therapy to try is IV metoclopramide. A very good drug that is no longer widely available is droperidol.  Sometimes opioids are required to treat bad headaches in the emergency department.

We have covered ketorolac on SGEM#66 as a possible therapy for acute migraine in the emergency department. The bottom line from that episode was that ketorolac is a reasonable second-line agent. Don’t forget that there is a ceiling effect for NSAIDs that was covered with Chris Bond SGEM#175 featuring a paper by Sergey Motov.

Up to half of patients presenting to the emergency department with their migraines will “bounce-back” to the emergency department within a few days. Dexamethasone has been tried in randomized control trials to prevent bounce-backs.

We covered a SRMA by Coleman et al from the BMJ on SGEM#28: Bang Your Head. It showed that a single parenteral dose of dexamethasone ≥15mg for successfully aborted migraine will significantly reduce early recurrences (NNT=9) with no significant side effects.

The authors of this study felt that because acupuncture has been known to treat migraines, it may also have a role in preventing them as well.

There was a Cochrane review in 2009 [1] that found “There is no evidence for an effect of ‘true’ acupuncture over sham interventions, though this is difficult to interpret, as exact point location could be of limited importance.”

They updated their review in 2016 [2] and claimed acupuncture now did work. Of the studies that included a sham acupuncture group the effect size was small but statistically significant. However, the quality of the evidence was moderate and there was moderate heterogeneity.

* Standard Mean Difference:

* -0.18 (95% CI -0.28 to -0.

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Date: March 6th, 2018

Reference: Zahed et al. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. AEM March 2018.

Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the Director of Simulation Education at Markham Stouffville Hospital in Ontario. He is the creator of the excellent #FOAMed project called First10EM.com

Case: A 77-year-old woman with known coronary artery disease is on clopidogrel and aspirin because of a stent placed four month ago. She has epistaxis that has not resolved despite twenty minutes of well applied anterior pressure. As you are preparing your equipment, she tells you that this is her third episode of epistaxis, and she is really hoping there is some alternative to the anterior packing she had the last two times.

Background: About 60% of the population will experience a nose bleed. There is a bimodal distribution (<10yrs and > 60yrs) with the majority of refractory hemorrhages are seen in the elderly.  In more than two-thirds of the time no cause is identified

An anterior bleed is much more common than a posterior bleed and often occurs at the Kiesselbach’s Plexus. It is usually easy to diagnose anterior versus posterior epistaxis with direct visualization.

There are many causes of epistaxis and a variety of treatments. For the adult management of epistaxis there is something called the Dundee Protocol. We will put a link in the show notes to the protocol.

The American College of Chest Physicians published some evidence-based recommendations in 2012 on anticoagulation therapy [1]. We will summarize some of the recommendations for emergent anticoagulation reversal in the emergency department in the show notes.

TXA is a synthetic derivative of lysine that inhibits fibrinolysis and thus stabilizing clots that are formed. TXA has been widely used in elective surgical cases and has shown decreased need for blood transfusion and reduction in mortality. It made sense to look at it for the treatment of epistaxis.

Zahed et al did a randomized control trial (RCT) in 2013 on using TXA for the treatment of anterior epistaxis [2]. They excluded patients on anticoagulation medications but not those taking antiplatelet drugs

We reviewed that RCT on SGEM#53 and the bottom line was that for patients with anterior epistaxis, consider soaking the packing in TXA to stop the bleeding and get them home sooner.

The SGEM also reviewed the use of TXA in the CRASH-2 on SGEM#80 with Anand Swaminathan. And coming up soon, we have an episode reviewing the use of TXA in post-partum hemorrhage.

Clinical Question: In patients taking antiplatelet medication who present to the emergency department with epistaxis, does topical tranexamic acid result in less bleeding than standard anterior nasal packing?

Reference: Zahed et al. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. AEM March 2018.

* Population: Patients taking antiplatelet medications (aspirin, clopidogrel, or both) with epistaxis continuing after 20 minutes of pressure.

* Exclusions: Traumatic epistaxis, anticoagulant use, inherited bleeding disorders, inherited platelet disorders, INR > 1.5, shock, a bleeding visible vessel, renal disease, or lack of consent.

* Intervention: Anterior packing with a 15cm cotton pledget s...

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Date: February 27th, 2018

Reference: Moran et al. Effect of Cephalexin plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis – A Randomized Clinical Trial. JAMA May 2017.

Guest Skeptic: Chip Lange is an Emergency Medicine Physician Assistant (PA) working primarily in rural Missouri in community hospitals. He also hosts a great #FOAMed blog and podcast called TOTAL EM.

Case: A 22-year-old male with no significant past medical history arrives to your department for an area of tender erythema to the right forearm for two days that has grown in size without purulence or drainage.  With point of care ultrasound, you diagnose cellulitis without the presence of an abscess affecting a 6cm diameter area.  When deciding how to treat for this condition, you have read recently that cephalexin could be used alone and that trimethoprim-sulfamethoxazole (TMP-SMX) may not be needed to cover for methicillin-resistant staphylococcus aureus (MRSA).

Background: There have been multiple SGEM episodes on abscesses but only one on cellulitis. It was with Meghan Groth (@EMPharmGirl). The SGEM bottom line was for patients with uncomplicated cellulitis, TMP-SMX may represent an alternative to clindamycin in patients with no major co-morbidities (SGEM#131).

Typically, with cellulitis we lack a specimen to obtain a culture and blood cultures are frequently not helpful.  With the difficulty to definitively determine the source, Beta-hemolytic streptococci are presumed to be the dominant pathogens.  In the case of purulent skin infections though, MRSA is the most common cause.

Currently, the Infectious Diseases Society of America (IDSA) guidelines for patients with cellulitis without systemic signs of infection, penetrating trauma, injection drug use, or other evidence of MRSA recommend only prescribing antibiotics against streptococci (1).

Clinical Question: Does cephalexin plus TMP-SMX result in higher clinical cure rates in uncomplicated cellulitis versus cephalexin alone?

Reference: Moran et al. Effect of Cephalexin plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis – A Randomized Clinical Trial. JAMA May 2017.

* Population – Patients over twelve years of age with uncomplicated cellulitis (erythema without an abscess, purulent drainage, or wound believed to be of infectious etiology present for less than one week with at least 2cm diameter area of involvement).

* Exclusions: There were 26 exclusions in their supplemental documentation. Some of the exclusions were patients with allergy to study drug, pregnancy/nursing or expected pregnancy, underlying skin conditions in the affected area, history of IV drug use with fever, concurrent infection at another site, or immunosuppression.

* Intervention – Cephalexin 500mg four times daily plus TMP-SMX 160/800 two tables twice daily for seven days

* Comparison – Cephalexin plus placebo for seven days

* Outcome:

* Primary Outcome: Clinical cure at 14-21 days after enrollment. This was defined as not meeting failure criteria that was decided by consensus prior to the study (fever, increase in size >25%, worsening of swelling and tenderness during treatment, no decrease in maximal dimension of erythema, no decrease in swelling or tenderness by the end of treatment and fever or more than minimal erythema, swelling or tenderness by the test-of-clinical-cure...

Aktuelle FOAMed Infos rund um die klinische Notfallmedizin, Notfallmedizin und Intensivmedizin, auf den Spuren vom Skeptics Guide to emergency medicine

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Date: February 14th, 2018

Reference: Venkatesh S et al. Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. NEJM January 2018.

Guest Skeptic: Dr. Rory Spiegel (@EMNerd_) is a clinical instructor at University of Maryland, a recent graduate of Stony Brook’s Resuscitation Fellowship, and a current Critical Care fellow at University of Maryland. He writes an excellent blog called EM Nerd, which he describes as nihilistic ramblings.

Case: 64-year-old male presents to your emergency department with worsening abdominal pain, nausea, vomiting and anorexia for the past week. On presentation he is lethargic and hypotensive. He requires control of his airway and is given a 30 cc/kg fluid bolus and started on norepinephrine. His urine analysis is consistent with a urinary tract infection. Over the course of his emergency department stay he has escalating vasopressor requirements. After starting vasopression, you ask yourself if you should be adding steroids for potential relative adrenal insufficiency?

Background: Corticoid steroids have had a tumultuous history when it comes to their use for the treatment of septic shock. The underlying physiological reasoning is for the most part simple.

There is a certain subset of patients in septic shock whose adrenal axis functions well enough to support them in a state of health but are unable to support them in a state of unwell. It is this state of relative adrenal insufficiency that we hope to combat when administering steroids in patients with septic shock

But when it comes to the clinical evidence supporting the use of glucocorticoid therapy for the treatment of septic shock, we have existed in a state of ambiguity. There have been two contradictory randomized control trials.

The first, the Annane et al trial published in JAMA in 2002, suggested a mortality benefit in favor of the corticosteroid group in the subset of patients who were found to have relative adrenal insufficiency.

The second, the larger CORTICUS study, published in the NEJM in 2008 found no benefit of the use of corticosteroids compared to placebo.

Now these contradictory results could have come about for a number of reasons. First, the patients in the Annane et al trial represented a much sicker population, isolating the subset of patients who truly benefit from steroid supplementation.

While the negative results observed in the CORTICUS trial were the consequence of enrolling a much healthier population and washing out any chance of identifying the underlying signal.

On the other hand, the results of the Annane et al trial may have been due to statistical noise and a small sample size, and CORTICUS represents nothing more than the expected regression to the mean.

There was also the HYPRESS trial that we reviewed on SGEM#168 with Salim Rezaie from REBEL EM. This looked at hydrocortisone to prevent patients with severe sepsis in developing septic shock. While the primary outcome showed no difference between glucocorticoid treatment and placebo, there was also no secondary mortality benefit observed.

The SGEM bottom line from that episode was that the use of hydrocortisone in adult patients with severe sepsis to prevent septic shock cannot be recommended at this time.

Clinical Question: Does the administration of a continuous infusion of hydrocortisone to a general population of patients in septic shock on mechanical ventilation improve survival?

Reference: Venkatesh S et al. Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. NEJM January 2018.

* Population: Adults,

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Date: February 14th, 2018

Reference: Alam N et al. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. The Lancet Nov 2017.

Guest Skeptics: Jay Loosley is the Superintendent of Education at Middlesex-London Paramedic Service. Jenn Doyle is a paramedic educator at Middlesex-London Paramedic Service.

Case: EMS is dispatched to a retirement home. They have a 73-year-old man who complains of weakness and a cough for the last 48 hours. You arrive and find the man lying in bed looking ill. He has a history of hypertension, benign prostatic hypertrophy and osteoarthritis. His medications include ramapril, hydrochlorothiazide and tamsulosin. On examination, he has a temperature of 38.7C, heart rate of 105 beats per minute, respiratory rate of 26, oxygen saturation of 88%. and a blood pressure of 88/50 mmHg. You load him on the stretcher, start an intravenous of normal saline and provide some supplemental oxygen via face mask. Clearly something infectious is going on and you wonder if starting antibiotics on route to the hospital would help?

Background: We have covered sepsis many times on the SGEM over the years (SGEM# 69, 90, 92, 113, and 168). It is a serious condition associated with high morbidity and mortality.

Other serious time-dependent conditions such as myocardial infarction and trauma have been improved significantly with emergency medical services (EMS). It has been reported that over half of patients with sepsis arrive to the emergency department via ambulance [1]. However, it is not clear if patients with suspected sepsis can have improved survival rates if antibiotics are provided in the pre-hospital setting.

There are studies showing that early recognition and prehospital administration of antibiotics are associated with increased survival rates [2-4]. Delay in antibiotics has been associated with an average decrease in survival of 7.6% per hour (Kumar et al).

We need to be skeptical of these retrospective studies, especially when prospective, observational studies have failed to show any association between early antibiotics and a reduction in mortality [5-7].

Now we have better evidence with the publication of the first prospective, randomized study investigating the effects of early antibiotic administration in patients with suspected sepsis.

Clinical Question: Can patients with varying degrees of sepsis benefit from early recognition and prehospital administration of IV antibiotics in the ambulance?

Reference:  Alam N et al. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. The Lancet Nov 2017.

* Population: Adult patients (18 years and older) with a diagnosis of suspected infection, temperature >38C or <36C and at least one other SIRS (systemic inflammatory response syndrome) criteria (HR>90bpm, RR>20bpm, or both)

* Exclusions: Allergy to ceftriaxone, other beta-lactams, know pregnancy or suspected prosthetic joint infection.

* Intervention: Ceftriaxone 2g IV

* Control: Usual care (fluid resuscitation and supplementary oxygen)

* Outcome:

* Primary: All-cause mortality at 28 days

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Date: February 6th, 2018

Reference: Foster SJ et al. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. Lancet January 2018

Guest Skeptic: Dr. Tessa Davis is a Pediatrician specialising in Pediatric Emergency Medicine and currently practicing in a central London hospital. She is also the co-founder of Don’t Forget the Bubbles and on the FeminEM Speaker Bureau.

Case: Tom is a 4-year-old boy who comes into the emergency department with a wheeze following a viral illness. He has been taking salbutamol at home today but he’s still not improving. He has mild work of breathing and a bilateral wheeze. His oxygen saturation is 94% on room air. Tom has no other previous medical history. You start to write up the salbutamol, but should you give him a dose of prednisolone too?

Background: We see “little wheezers” in the emergency department all the time. It is really common during the winter months and often due to a viral infection (1).

There has always been some uncertainty about the benefit of prednisolone for viral wheeze in pre-school children. In 2009, a study by Panickar et al found no positive effect in giving steroids to pre-school children with wheeze (2).

Since then, our practice, and our treatment guidelines, have changed, in spite of questions about the applicability of this study (3,4)

Clinical Question: Does oral prednisolone improve virus-associated wheeze in preschool age children?

Reference:  Foster SJ et al. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. Lancet January 2018

* Population: Patients 24 to 72 months of age with a wheeze plus symptoms or signs of a viral upper respiratory tract infection.

* Exclusions: Oxygen saturations <92% on room air; silent chest; shock or sepsis; previous PICU admission with wheeze; prematurity; other cardiac or respiratory disease; likely alternative diagnosis for the wheeze; or steroid treatment within the preceding 14 days.

* Intervention: Three-day course of oral prednisolone (1mg/kg once daily).

* Comparison: Placebo that it looked, smelled, and tasted like the prednisolone.

* Outcome:

* Primary: Length of stay in the hospital

* Secondary: Re-attendance; readmission; salbutamol usage; and residual symptoms after discharge

Dr. Meredith Borland is the senior author on this publication. She is a paediatric emergency medicine specialist from Perth, Australia and been doing clinical research for a couple of decades. Dr. Meredith is also the director of a tertiary hospital paediatric emergency department. We met at SkiBEEM18 and she agreed to come on the SGEM and discuss her publication.

Authors’ Conclusions: “Oral prednisolone had a clear benefit over placebo at reducing the length of stay in children presenting to a paediatric emergency department with virus–associated wheeze and was well tolerated.”

Quality Checklist for Randomized Clinical Trials:

* The study population included or focused on those in the emergency department. Yes

* The patients were adequately randomized. Yes

* The randomization process was concealed. Yes

* The patients were analyzed in the groups to which they were randomized. No

* The study patients were recruited consecutively (i.e. no selection bias). Unsure.