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

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

 

 

June 3rd, 2019    

Which technique is best for reducing a pulled elbow?

 

Background

 

The triage nurse comes to tell you that s/he has a toddler with a pulled elbow in triage. You want to reduce it straightaway and send the child home, high-fiving the whole family on their way out. You wonder which reduction technique is most likely to be successful...

 

 Pulled elbow is a painful condition of acute onset, resulting in sudden loss of function in the affected limb of a child​[1]​. The mechanism of injury is often a sudden pull on the ipsilateral hand/forearm (e.g. parent pulling the child up a kerb​[2]​, or even the child pulling its hand away impulsively), resulting in subluxation of the radial head. Pulled elbow can also be caused by a fall​[3]​ or twist. Typically, the child will suddenly cry out in pain and then refuse to use their arm. A snap or click may be heard​[4]​. The arm is held slightly flexed and twisted inwards​[5]​, without any bruising or swelling. Pain may be felt at the shoulder or wrist as well as the elbow​[5,6]​.

 

 Two main reduction techniques are described: supination-flexion (the traditional method) and hyperpronation.

  

Krul M, van der Wouden JC, Kruithof EJ, van Suijlekom-Smit LWA, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database of Systematic Reviews 2017, Issue 7​[7]​

 

 

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

 

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