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

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

 

July 11th, 2019    

How to manage a bleeding socket

 

Background

 

OK, so I'll freely admit it: this post probably isn't going to help you save a life, and it's unlikely to rock your world (that much). But we are emergency medicine doctors, and our patients seek us out whenever they experience what they consider a medical emergency. We are generalists, but we strive to specialise in the first 30 minutes of everything bad that can happen to people...

 

OK, enough hyperbole already! Your patient is bleeding from their mouth and it won't stop. What are you going to do? Let's take a few minutes to consider the troublesome post-extraction bleeding tooth socket.

 

The paper

 

Moran IJ, Richardson L, Heliotis M. A bleeding socket after tooth extraction. BMJ. 2017 Apr;357​[1]​

 

 

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

 

July 4th, 2019    

Wide-complex tachycardias

 

Background

 

Seeing the rhythm below on a monitor can be a bit of a brown trousers moment in a busy ED. Where is this patient? Who is seeing them? Are they conscious? Is this VT or something weird? - And, more importantly, how am I going to treat them?

 

Image from Ventricular Tachycardia - Monomorphic VT, Life in the Fast Lane ECG library, available at https://litfl.com/ventricular-tachycardia-monomorphic-ecg-library/

 

The paper

 

Littman L, Olson E, Gibbs M. Initial evaluation and management of wide-complex tachycardia: a simplified and practical approach. Am J Emerg Med. 2019;37(7):1340-1345​[1]​

 

 

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

 

-