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

November 9th, 2018    

Thiamine before glucose in alcoholics

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

 

November 9th, 2018    

A non-surgical option for appendicitis?

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

 

Journal of the American Medical Association, September 2018

 

November 8th, 2018    

Comparison of deroofing and aspiration for burn blisters

It is now generally accepted that burn blisters should not be left because the blister fluid exerts pressure on the burn, which then affects the microcirculation and impedes healing. The London and South East England Burn Network recommends deroofing all large and thin-walled blisters, but apparently “the benefits of aspiration vs deroofing have been discussed for many years by medical experts“ (according to this paper). Might this be a possible alternative?

 

Medicine, April 2018

 

November 8th, 2018    

Acute heart failure management

Many experts now advocate against a ‘furosemide for all’approach to acute heart failure (AHF), based on the idea that there is a heterogeneity to the condition – namely, that there are actually 3 distinct conditions that we commonly lump together as AHF.

 

Journal of Emergency Medicine, September 2018

 

November 8th, 2018    

How reassuring is that initial ECG, really?

We are pretty good at asking for a repeat ECG if the first one doesn’t look quite right. If the initial ECG looks normal, however,we are less likely to get a second. Maybe we should. These studies certainly suggest that serial ECGs save lives.

 

Recent retrospective study: Annals of Noninvasive Electrocardiology, July 2017

 

Larger, data registry analysis: American Heart Journal, January 2013

 

November 7th, 2018    

A novel scoring tool for alcohol withdrawal

The CIWA score has been around since 1989, has been externally validated multiple times and is recommended in the guidelines of many countries. However, the original author always maintained that it was not designed to be used as a recipe for pharmacological treatment (certain scores necessitating certain doses of benzodiazepine). It is also rather time consuming and prone to inaccuracy (many elements are scored from patient-reported subjective symptoms, which can be lied about or exaggerated)...Enter the SHOT score

 

Academic Emergency Medicine, October 2010

 

November 7th, 2018    

Symptom-triggered therapy for alcohol withdrawal

Several papers over the last 20 years have shown the benefits of symptom-triggered therapy (STT) rather than a fixed-dose reducing schedule for alcohol withdrawal (see below for an example algorithm). The advantages include reduced length of stay, reduced rate of seizures and reduced cumulative dose of benzodiazepine. STT is also recommended by NICE in their 2010 guideline CG100 (updated in 2017), where they also recommend determining the severity of withdrawal with the help of a tool such as the CIWA-Ar, and that treatment should be withheld if there are no longer any symptoms of withdrawal. This is the first paper to consider this approach in the Emergency Department.

 

EMJ, October 2018

Example STT protocol: https://emergencymedicinecases.com/alcohol-withdrawal-delirium-tremens/

 

November 7th, 2018    

IV fluids for alcohol intoxication?

Alcohol intoxicated patients are often given IV fluids in the belief that this will sober them up and get them out quickly. Does it work?

 

American Journal of Emergency Medicine, April 2018

Australian study: https://www.ncbi.nlm.nih.gov/pubmed/24308613

Best Bets: https://bestbets.org/bets/bet.php?id=701

 

November 6th, 2018    

What is the prevalence of PE in patients presenting with syncope?

Syncope is a common presenting complaint. The serious causes we worry about include arrhythmias, ACS and structural heart disorders but PE is also in the differential. A 2016 paper by Prandoni et al shocked everyone by finding a prevalence of 17.3% in hospitalised syncope patients. The authors suggested that everyone with syncope should be investigated for PE.

 

AmericanJournal of Emergency Medicine, April 2018

Prandoni: New England Journal of Medicine, October 2016

 

November 6th, 2018    

Can I clear the C-spine if there are ‘distracting injuries’?

The NEXUS and Canadian C-spine rules were published around the same time nearly 20 years ago. Both have been validated in large multi-centre trials and are widely used around the world. One of the difficulties in using NEXUS has always been how to define a ‘distracting injury’, the presence of which means you cannot clear the C-spine. Does a Colles fracture count? How about a limb amputation? Or a cut finger?

 

Journal of Trauma and Acute Care Surgery, September 2018

 

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