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

December 5th, 2018    

Management of Bell’s palsy

Part of the Expert Clinical Management series, reviews by experts in a particular field that summarise the best available evidence on a topic. 

(Annals of Emergency Medicine, May 2018)

December 4th, 2018    

Asymptomatic hypertension

There is a growing number of patients who present to A&E with hypertension, either recorded by themselves at home, in a pharmacy, or by their GP. Other patients may have high blood pressure as an incidental finding when they present with another complaint. There is a temptation to treat these numbers, either with nifedipine (peak plasma concentration 2-3hr) or – even worse - amlodipine (peak plasma concentration 6-8hr). This prolongs ED stay and may be unsafe (who is monitoring their BP if they go home before the drug has reached peak levels?)

 

Retrospective observational study: Annals of Emergency Medicine, November 2018.

Clinical review and expert opinion article: JAMA Internal Medicine, May 2018

 

December 4th, 2018    

Paracetamol for febrile seizures

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

 

December 4th, 2018    

Lead misplacement on the ECG

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

 

December 4th, 2018    

Ottawa rule for subarachnoid haemorrhage

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

 

December 4th, 2018    

Davos method for shoulder reduction

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

 

December 4th, 2018    

Tamsulosin for renal stones

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

 

December 3rd, 2018    

Does amiodarone help in cardiac arrest?

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

 

December 3rd, 2018    

Nebulised tranexamic acid for haemoptysis

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

 

December 2nd, 2018    

European Society of Cardiology guidelines on STEMI

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

 

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