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

August 27th, 2019    

Managing an acute upper gastrointestinal bleed

 

Something a little different this week... I invited one of our senior gastroenterology registrars (Dr Chris White) on the podcast to discuss a recent paper on gastrointestinal (GI) bleeding.

 

Stanley A, Laine L. Management of acute upper gastrointestinal bleeding. BMJ 2019;364:I536

 

The paper aimed to "provide a comprehensive and evidence-based summary of the assessment and management of patients with acute upper GI bleeding". We endeavored to do the same in our recording. Find a summary of the main points on our blog site: https://the-breach.com

 

August 18th, 2019    

Procedural sedation - consensus and update

 

Cardioversion, shoulder or hip reduction, manipulating unstable fractures - in many cases these procedures would be distressing and inhumane without sedation. It's a common thing to do in the ED, and most of us are quite comfortable with the procedure. Like everything, though, there's always room for improvement.

 

The paper below is the most up-to-date guidance on unscheduled sedation, and it has several important tips and recommendations - well worth 2 minutes of your time!

 

The paper

 

Green SM, Roback MG, Krauss BS, et al. Unscheduled procedural sedation: a multidisciplinary consensus practice guideline. Ann Emerg Med 2019;73:51-65

 

This is a multidisciplinary consensus guideline on procedural sedation, published in the USA three months ago. It is in fact extremely multidisciplinary, with contribution or endorsement from Emergency Medicine, Anaesthetics, Cardiology, Paediatrics, Radiology, Endoscopy, Maxillofacial, Toxicology, Academics, trainees and nurses. It details some evidence-based best practice for sedating patients in the Emergency Department.

 

August 12th, 2019    

Ultrasound for Small Bowel Obstruction

Small bowel obstruction (SBO) can be a big problem if we don't recognise it quickly - bowel necrosis, perforation, sepsis and death are among the potential consequences. History and examination can suggest the diagnosis, but blood tests are largely unhelpful. This is a condition that is almost always diagnosed on imaging, and our usual go-to is the abdominal X-ray (AXR).

 

 

The problem is that they're not always as obvious as the above X-ray. AXR actually performs rather poorly as a diagnostic test for SBO, with less than 70% sensitivity on average. This has led to some researchers deriding it as "the least useful imaging modality for the diagnosis of SBO", and others maintaining, "there is no place for plain abdominal radiography in the workup of adult patients with acute abdominal pain".

 

 

Have you ever had a SBO with a normal AXR? I know I have, because dilated, oedematous, fluid-filled loops don't show up on plain films. Luckily for my patient, there was sufficient clinical suspicion to get a CT so no harm was done. But CTs are expensive, time-consuming (there's usually a queue!), expose the patient to radiation, and necessitate potentially unsafe journeys away from the Emergency Department.

 

 

So is there an alternative solution? Does ultrasound really have a role here? Let's find out...

 

August 1st, 2019    

Acute pancreatitis: recommendations from the World Congress of Emergency Surgery

A 48 year old lady presents with a twelve hour history of epigastric pain radiating through to the back and copious non-bilious vomiting. She has no medical history of note but her amylase comes back as 1400. This is acute pancreatitis, of course. You pick up the phone to arrange a surgical review, but some uncertainties swirl around your head as you do so: which scoring system should you use? What will happen next for the patient? Does she need antibiotics? Should she be nil by mouth?

 

Leppaniemi A, Tolonen M, Tarasconi A et al. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg. 2019 Jun;14:27

 

 

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

 

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