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

October 7th, 2019    

Posterior stroke: a simple approach

Your patient is an elderly lady who feels dizzy. Her bloods are all normal and she wants to go home, but she's too dizzy to walk unaided. Her positive urine dipstick is urging you to call it a UTI and move on, but you wonder if she could be having a posterior stroke. You faintly remember something about a 'hinting' exam and getting patients to slap their hands together... You wonder if you should get a CT head, and if that would be enough to exclude the diagnosis. If only the guys at The BREACH covered an article reviewing posterior stroke...

Well, you're in luck. Step away from that urine sample! This paper is going to answer all your questions

Gurley KL, Edlow JA. Avoiding misdiagnosis in patients with posterior circulation ischaemia: a narrative review. Acad Emerg Med 2019 Jul. [Epub ahead of print]

September 22nd, 2019    

Probability calculator for UTI in young children

You're reviewing an infant in Paediatric ED with a temperature. They're not too unwell, but the poor parents have been trying to catch a urine sample for 4 hours and everyone's getting a little stressed. If only you could estimate the pre-test probability that the child had a UTI - then you might not even need the sample... And even if you get the sample, how should you interpret it? Just how significant is 1+ leucocytes?

Shaikh N, Hoberman A, Hum S, et al. Development and validation of a calculator for estimating the probability of urinary tract infection in young febrile children. JAMA Pediatr. 2018;172(6):550-556

September 11th, 2019    

Chest tubes for traumatic pneumothorax and haemothorax: review of evidence

Your elderly patient has been in a car accident and is feeling a little breathless, with pain on the right side of their chest. Their chest X-ray (CXR) shows a small pneumothorax, with some blunting of the costophrenic angle that might just be blood... What is the next step? Surgical chest drain or Seldinger technique? What size of tube is best? And do they even need urgent intervention?

 

Tube thoracostomy (insertion of a chest drain or tube) has been used to drain pus and excess air from the chest since ancient times. Over the last 100 years, we have gradually moved from large metal tubes to smaller flexible ones. Small-bore tubes were initially used in children, but are now becoming the norm across all age groups.

 

I was lucky to have trauma surgeon and cardiothoracic specialist Dr Irphan Yonis with me on the show this week to discuss this topic, as well as other related issues in the current management of chest trauma.

 

September 4th, 2019    

The Captain Morgan technique for reducing hip dislocations

Your patient is in a lot of pain, their leg is shortened and internally rotated, and the X-rays show a dislocated hip. If they're young they've probably been in a car accident and their knee has hit the dashboard. If they are older with a non-native hip, they might have just tried to get up from a low seat or crossed their legs.

 

However it happened, you need to reduce it. If your patient has a native femoral head, it is at risk of avascular necrosis (AVN), and the risk increases with every passing hour (in one study, 53% of patients developed AVN if the hip remained out of joint for more than 6 hours).

 

The traditional method (the Allis technique) requires you to jump up on the trolley and use your brute strength to haul the hip back into place. It's difficult, bad for your back, risks YOU breaking YOUR hip, and looks like torture - make sure the patient's relatives are safely in another room before you start.

 

Is there a better method? You bet there is! Let me introduce you to the Captain...

 

** Note: at 08:48 I say to place one hand under the patient's distal CALF. It should of course be under their distal THIGH. Sorry! **

August 27th, 2019    

Managing an acute upper gastrointestinal bleed

 

Something a little different this week... I invited one of our senior gastroenterology registrars (Dr Chris White) on the podcast to discuss a recent paper on gastrointestinal (GI) bleeding.

 

Stanley A, Laine L. Management of acute upper gastrointestinal bleeding. BMJ 2019;364:I536

 

The paper aimed to "provide a comprehensive and evidence-based summary of the assessment and management of patients with acute upper GI bleeding". We endeavored to do the same in our recording. Find a summary of the main points on our blog site: https://the-breach.com

 

August 18th, 2019    

Procedural sedation - consensus and update

 

Cardioversion, shoulder or hip reduction, manipulating unstable fractures - in many cases these procedures would be distressing and inhumane without sedation. It's a common thing to do in the ED, and most of us are quite comfortable with the procedure. Like everything, though, there's always room for improvement.

 

The paper below is the most up-to-date guidance on unscheduled sedation, and it has several important tips and recommendations - well worth 2 minutes of your time!

 

The paper

 

Green SM, Roback MG, Krauss BS, et al. Unscheduled procedural sedation: a multidisciplinary consensus practice guideline. Ann Emerg Med 2019;73:51-65

 

This is a multidisciplinary consensus guideline on procedural sedation, published in the USA three months ago. It is in fact extremely multidisciplinary, with contribution or endorsement from Emergency Medicine, Anaesthetics, Cardiology, Paediatrics, Radiology, Endoscopy, Maxillofacial, Toxicology, Academics, trainees and nurses. It details some evidence-based best practice for sedating patients in the Emergency Department.

 

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

 

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