The BREACH

Reviews and summaries of the latest Emergency Medicine research papers. We try to cover 10 of the best articles each month. Please visit our website for written summaries and to search past editions: www.the-breach.com

August 12th, 2019    

Ultrasound for Small Bowel Obstruction

Small bowel obstruction (SBO) can be a big problem if we don't recognise it quickly - bowel necrosis, perforation, sepsis and death are among the potential consequences. History and examination can suggest the diagnosis, but blood tests are largely unhelpful. This is a condition that is almost always diagnosed on imaging, and our usual go-to is the abdominal X-ray (AXR).

 

 

The problem is that they're not always as obvious as the above X-ray. AXR actually performs rather poorly as a diagnostic test for SBO, with less than 70% sensitivity on average. This has led to some researchers deriding it as "the least useful imaging modality for the diagnosis of SBO", and others maintaining, "there is no place for plain abdominal radiography in the workup of adult patients with acute abdominal pain".

 

 

Have you ever had a SBO with a normal AXR? I know I have, because dilated, oedematous, fluid-filled loops don't show up on plain films. Luckily for my patient, there was sufficient clinical suspicion to get a CT so no harm was done. But CTs are expensive, time-consuming (there's usually a queue!), expose the patient to radiation, and necessitate potentially unsafe journeys away from the Emergency Department.

 

 

So is there an alternative solution? Does ultrasound really have a role here? Let's find out...

 

August 1st, 2019    

Acute pancreatitis: recommendations from the World Congress of Emergency Surgery

A 48 year old lady presents with a twelve hour history of epigastric pain radiating through to the back and copious non-bilious vomiting. She has no medical history of note but her amylase comes back as 1400. This is acute pancreatitis, of course. You pick up the phone to arrange a surgical review, but some uncertainties swirl around your head as you do so: which scoring system should you use? What will happen next for the patient? Does she need antibiotics? Should she be nil by mouth?

 

Leppaniemi A, Tolonen M, Tarasconi A et al. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg. 2019 Jun;14:27

 

 

For detailed show notes please visit our website: https://the-breach.com

 

July 23rd, 2019    

Troponin-negative chest pain: who needs further testing?

Background

Your patient had chest pain. You’re happy that you’ve ruled out respiratory causes, aortic dissection and acute MI.    Their ECG shows no ischaemia and troponin is not raised. So what now?

In the majority of cases, of course,  this patient can go home. The question is, what kind of follow up does he or she need? And how quickly should it happen? In short, is there a way you can estimate the risk of cardiac events and what level of risk is acceptable?

The paper

American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on suspected non-ST elevation acute coronary syndromes, et al. Clinical policy: critical issues in the evaluation and management of emergency department patients with suspected non-ST-elevation acute coronary syndromes. Ann Emerg Med. 2018 Nov;72(5):e65-e106​[1]

 

For detailed show notes please visit our website: https://the-breach.com

 

July 17th, 2019    

Psychogenic Non-Epileptic Attacks (PNEA)

 

Background

 

If you've been around the Emergency Department for a while, then you're likely to have seen your fair share of pseudoseizures. This infamous condition can be frustrating for a busy ED doc (this post from GomerBlog captures the feeling for many). Additionally, it can be challenging at times to tell a pseudoseizure from an epileptic seizure. All in all, they are a bit of a strange entity - Neurological? Psychological?... Faking?

 

Most of us have much to learn about pseudoseizures. Even the name is wrong: what used to be called pseudoseizures was re-defined as PNES (psychogenic non-epileptic seizures) at the turn of the century, and even this has now changed to PNEA (psychogenic non-epileptic attacks).

 

I offer the following two papers to help us understand PNEA. The first is a recent opinion piece, co-authored by a neurologist and a psychiatrist. The second is a systematic review and meta-analysis looking at which clinical signs can distinguish PNEA from epileptic seizures.

 

Paper 1 - overview of PNEA

 

Tolchin B, Martino S, Hirsch LJ. Treatment of patients with psychogenic nonepileptic attacks. JAMA. 2019 Apr;321(20):1967-1968​[1]​

 

 

Paper 2 - how can you be sure it's PNEA?

 

Avbersek A, Sisodiya S. Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures? J Neurol Neurosurg Psychiatry. 2010;81:719-725​[5]​

 

 

For detailed show notes please visit our website: https://the-breach.com

 

July 11th, 2019    

How to manage a bleeding socket

 

Background

 

OK, so I'll freely admit it: this post probably isn't going to help you save a life, and it's unlikely to rock your world (that much). But we are emergency medicine doctors, and our patients seek us out whenever they experience what they consider a medical emergency. We are generalists, but we strive to specialise in the first 30 minutes of everything bad that can happen to people...

 

OK, enough hyperbole already! Your patient is bleeding from their mouth and it won't stop. What are you going to do? Let's take a few minutes to consider the troublesome post-extraction bleeding tooth socket.

 

The paper

 

Moran IJ, Richardson L, Heliotis M. A bleeding socket after tooth extraction. BMJ. 2017 Apr;357​[1]​

 

 

For detailed show notes please visit our website: https://the-breach.com

 

July 4th, 2019    

Wide-complex tachycardias

 

Background

 

Seeing the rhythm below on a monitor can be a bit of a brown trousers moment in a busy ED. Where is this patient? Who is seeing them? Are they conscious? Is this VT or something weird? - And, more importantly, how am I going to treat them?

 

Image from Ventricular Tachycardia - Monomorphic VT, Life in the Fast Lane ECG library, available at https://litfl.com/ventricular-tachycardia-monomorphic-ecg-library/

 

The paper

 

Littman L, Olson E, Gibbs M. Initial evaluation and management of wide-complex tachycardia: a simplified and practical approach. Am J Emerg Med. 2019;37(7):1340-1345​[1]​

 

 

For detailed show notes please visit our website: https://the-breach.com

 

June 27th, 2019    

Eye trauma: could you manage a retrobulbar haemorrhage?

 

Background

 

Patients with head injuries sometimes present with a closed, swollen eye. We rightly worry about intracranial bleeding in these cases, but there are some important eye injuries to consider too. Dr Anna MacDonald​[1]​ suggests that the following four time-critical, sight-threatening diagnoses should be foremost in our minds when assessing a patient with blunt ocular trauma...

 

  1. Retrobulbar haemorrhage with orbital compartment syndrome
  2. Globe rupture
  3. Retinal detachment
  4. High grade ('8-ball') hyphema with acute glaucoma

 

The first of these, retrobulbar haemorrhage (RBH), is a fairly rare condition and many of us will be unfamiliar with its features and recommended management. A recent paper in the EMJ tried to assess the competency of UK ED docs in treating RBH, and identified some issues...

 

The paper

 

Edmunds MR, Haridas AS, Morris DS, Jamalapuram K. Management of acute retrobulbar haemorrhage: a survey of non-ophthalmic emergency department physicians. Emerg Med J 2019;36(4):245-247 ​[2]​

 

 

For detailed show notes please visit our website: https://the-breach.com

 

June 21st, 2019    

What is the risk of AKI following contrast CT in septic patients?

 

Background

 

The concept of contrast-induced nephropathy (CIN) came from a 1954 paper​[1]​ and has been widely taught over the last 60 years. However, recent studies have questioned the true incidence of CIN, and even whether it exists at all. There are in fact many robust RCTs​[2,3]​ now showing no association between contrast administration and acute kidney injury (AKI). The earlier confusion seems to have arisen for several reasons:​[4]​

 

  • Older contrast dyes had a higher osmolarity than modern ones and possibly were nephrotoxic. They were also used in larger volumes
  • Older studies rarely used control groups, so although some patients developed an AKI after contrast CT, it is impossible to know whether this would have happened anyway (without the CT)
  • Many studies take small fluctuations in creatinine as evidence of 'kidney injury' but it is debatable whether these equate to actual patient-centred outcomes like need for dialysis

 

 

The paper

 

Hinson JS, Al Jalbout N, Ehmann MR, Klein EY. Acute kidney injury following contrast media administration in the septic patient: a retrospective propensity-matched analysis. J Crit Care. 2019;51:111-116​[5]​

 

 

For detailed show notes please visit our website: https://the-breach.com

 

June 16th, 2019    

Does your patient really have a UTI?

 

Background

 

How often do we test the urine of patients with no urinary symptoms? How often are we prompted to send samples for culture after a random dipstick test? How often are these patients prescribed antibiotics even when they have no clinical signs of a UTI? If your Emergency Department is anything like mine, each of these things happen quite often.

 

"What's the harm?" you may ask. Well, besides poor use of resources, there are the side effects of treatment, increasing antimicrobial resistance, and the risk that you miss another condition because you stop workup when a UTI is 'found'.

 

Like any test, you've got to know why you're running it and what you are looking for.

 

  • Suspected renal colic? Useful test
  • Urinary frequency, urgency, dysuria or suprapubic pain? Useful test
  • Abdominal pain or PV bleeding in a woman of child-bearing age? Useful test
  • Type 1 diabetic with abdominal pain and vomiting? Useful test
  • Pregnant woman with hypertension and headache? Useful test
  • Elderly lady who is a little more confused than usual? Actually not so useful
  • Gentleman who fell while getting out of the bath? Not useful
  • Middle-aged lady who had an episode of chest pain? No
  • Young chap with a cough? Oh come on!

 

 

The paper

 

Nicolle L, Gupta K, Bradley S. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis. March 2019 [Epub ahead of print]​[1]​

 

For detailed show notes please visit our website: https://the-breach.com

 

June 8th, 2019    

New standards of care for cauda equina syndrome

Background

  

Lower back pain is common and cauda equina syndrome (CES) is rare, but the consequences can be devastating. Young people can be left with lifelong incontinence and paraplegia if surgery is delayed or the diagnosis is missed. 

 

The best initial investigation is of course an MRI, but these are expensive and difficult to get in many hospitals, especially out-of-hours. From an EM perspective, a suspected case of CES often involves protracted discussions with radiology, orthopaedics and neurosurgery and can be something of a challenge.

 

If only there were a set of nationally-agreed standards detailing which patients require an MRI and which of these need urgent surgery...

  

The paper

 

Society of British Neurological Surgeons (SBNS) and British Association of Spinal Surgeons (BASS). Standards of care for investigation and management of cauda equina syndrome. December 2018​[1]​

 

For detailed show notes please visit our website: https://the-breach.com

 

 

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