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

January 1st, 2019    

Management outcomes of children with isolated skull fractures

Head injuries are common in children. Most do not require a CT, and even if they do, the commonest finding is an isolated skull fracture (i.e. just a fracture, with no intracranial haemorrhage). How are these best managed? Previous studies of children with isolated skull fractures suffered from low numbers and poor follow up. The current paper is the largest study to date on this topic. The authors try to determine the risk of deterioration in this group of children.

Annals of Emergency Medicine, June 2018

January 1st, 2019    

Effect of steroid on migraine recurrence

Several meta-analyses over the last 10 years have found a benefit to using dexamethasone as an adjunct for reduced recurrence of migraine (for example, BMJ in 2008 and European Journal of Neurology in 2013). Pooled data estimate a number needed to treat (NNT) of 9. The suspected mechanism is that it works by dampening the state of cerebral neurogenic inflammation. The current study looked to see whether a longer-acting steroid would achieve a better response over the 7 days post-ED presentation.

Annals of Emergency Medicine, November 2018

January 1st, 2019    

Are biphasic allergic reactions real?

You've given your patient IM adrenaline, they're breathing normally and feeling well again. You'd like to discharge them with an Epipen but there's a little voice at the back of your head: "What if they have a biphasic reaction at home and they can't take the pen in time?" Prior studies have found biphasic reaction rates as high as 20%, and there are reports of reactions happening as long as 4 days after the initial anaphylaxis. Studies so far have tended to be underpowered, retrospective and with widely differing definitions of 'allergy' and 'biphasic reaction' (we're not really concerned about a slight rash appearing on day 2, after all).

Anesthesiology, November 2018

Annals of Emergency Medicine, June 2014

January 1st, 2019    

Updates to the Glasgow Coma Score

On its 40th anniversary (in 2014) the GCS was updated by Prof Teasdale, one of the original developers. He also advised against combining the components if one aspect was non-testable (testing verbal response in an intubated patient, for example). Earlier this year he wrote another paper with the aim of increasing the prognostic accuracy of the GCS while losing none of its simplicity.

Journal of Neurosurgery, June 2018

January 1st, 2019    

Recovery time in children with concussion

Head injury is a common presentation to the paediatric ED. Most children don't require a CT and can be sent home with advice on when to return (if they develop any signs of raised ICP). But how long will it take to recover? This is an important question, particularly if the child has important exams (or a vital football match) coming up. The literature to date (mainly small retrospective studies) is all over the place on this question, with expected recovery time ranging from days to years. This paper is the first large prospective study to investigate this.

JAMA Pediatrics, November 2018

January 1st, 2019    

How to reduce the risk of contrast-induced nephropathy? (the PRESERVE trial)

Contrast-induced nephropathy (CIN) is traditionally defined as acute kidney injury occuring within 48 hours of the administration of IV contrast (but see this large meta-analysis, reviewed in May's edition of The BREACH, that largely debunks this concept). The current paper looks at two commonly-proposed strategies for reducing the risk of CIN.

New England Journal of Medicine, February 2018

January 1st, 2019    

Is there any role for aspirin in primary prevention?

Two large trials from the 1990s showed a beneficial effect for aspirin in patients without prior MI or stroke ('primary prevention'). However, there is a growing consensus that this may not be the case any more, because risk factors are now managed more aggressively (smoking, blood pressure and cholesterol). As risk factors decrease the absolute risk reduction from aspirin also decreases and may now be outweighed by the increased risk of bleeding.

ARRIVE trial, The Lancet, September 2018

ASCEND trial, New England Journal of Medicine, October 2018

ASPREE trial, New England Journal of Medicine, October 2018

January 1st, 2019    

Are we placing too many IV cannulas?

Previous studies have found that around half of the cannulas we insert in the ED are never used. This is perhaps no big deal, as we generally take blood samples when they are inserted. However, compared to simple venepuncture, IV cannulas can be more painful and time-consuming to insert, and can lead to more complications (thrombophlebitis, site infection, bleeding, etc). This study looked at an intervention to try to reduce the amount of IV lines placed in the ED.

Academic Emergency Medicine, June 2018

January 1st, 2019    

Can the ECG risk stratify in hyperkalaemia?

Hyperkalaemia is probably the most feared electrolyte disturbance, as the first symptom can be sudden death (VF arrest). There are always going to be cases where we are presented with the ECG before the blood results are available (the gas machine is broken, the patient couldn't be bled at triage, etc). Wouldn't it be great if we could gauge the patient's risk of short-term adverse events based on their ECG?

Western Journal of Emergency Medicine, August 2017

January 1st, 2019    

Diagnosing PE during pregnancy

Pregnancy increases the risk of PE. Symptoms like breathlessness and tachycardia make us think of PE, but these are often present in pregnancy anyway. D-dimer can be useful in selected low risk cases for ruling out PE, but pregnant women are usually excluded from studies so there remains a question over its utility in pregnancy. This paper addressed this issue directly, and is the first prospective study of the diagnostic workup for PE in pregnancy to be published.

Annals of Internal Medicine, December 2018

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