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

November 10th, 2019    

Top 10 papers of 2018-2019

 

The BREACH podcast is 1 year old this week!

 

Thank you so much to everyone for supporting us, sharing on social media and telling your friends and colleagues. Our episodes have been downloaded 13,500 times and people from 97 countries have tuned in. It's wonderful to be part of the international FOAM movement.

 

We thought we'd celebrate by looking back through each of the 76 papers we've reviewed and choosing our favourite 10. This is a list of the most important, practice-changing, and interesting studies of the last year - enjoy!

 

Paper 10: Are biphasic allergic reactions real?

 

Clinically important biphasic reactions are exceptionally rare, and may not even exist. Prolonged monitoring is unlikely to be necessary in the majority of cases

 

Paper 9: Upside-down position for children with SVT

 

This study showed a high success rate with this manoeuvre, which is simple to do and to teach to parents (and quite possibly fun for the child!)

 

 

Paper 8: Could you manage a retrobulbar haemorrhage?

 

This paper found that most ED doctors were unaware of the need for intervention rather than imaging in this condition, and would not be happy to perform a lateral canthotomy as a sight-saving measure

 

 

Paper 7: Recovery time in children with concussion

 

If a child presents with features of concussion after a head injury, they can be advised that most of the symptoms will have resolved by 2 weeks in boys and younger children, or 4 weeks in adolescent girls.

 

 

Paper 6: Chest drains for small traumatic pneumothoraces?

 

An ‘occult’ pneumothorax or haemothorax seen only on CT can in many cases be treated conservatively

 

 

Paper 5: Do patients need to fast before procedural sedation?

 

During procedural sedation, aspiration is a risk that is trivially small and is not reduced by fasting. This study does not support delaying sedation to meet established fasting guidelines in children

 

 

Paper 4: Stop testing the urine of elderly patients!

 

Do not test the urine of patients without symptoms of a UTI. You may find evidence of asymptomatic bacteriuria, but this does not need an antibiotic prescription in most cases. 

 

Paper 3: Ultrasound for small bowel obstruction

 

Ultrasound is nearly as accurate as CT for the diagnosis of small bowel obstruction. It is unlikely to replace CT, but is much better than X-ray for assessing this condition.

 

 

Paper 2: Posterior stroke: a simple approach

 

Consider posterior stroke in every dizzy patient. Ask about timing and triggers rather than trying to define what they mean by dizzy. Sudden onset constant dizziness = labyrinthitis or posterior stroke; triggered dizzy episodes = BPPV or postural hypotension; random dizzy episodes = vestibular migraine, Meniere's or posterior TIA

 

 

Paper 1: Risk of AKI in septic patients after contrast CT

 

This study found no evidence to support the practice of withholding contrast for fear of precipitating AKI in septic patients

 

 

 

Bonus paper: Martial arts to control external bleeding

 

This technique offers a fast and efficient way to stem blood loss from limb wounds, and lets you use ninja skills in the ED - give it a try!

 

 

Bonus paper: Captain Morgan for hip dislocations

 

This technique allows you to apply a lot of force to the hip in a controlled manner, without getting yourself into precarious positions. Give it a try!

 

 

 

November 2nd, 2019    

Glucagon for oesophageal food impaction?

 

Background

 

Your patient was enjoying a steak several hours previously and felt a piece get stuck in his throat. He's tried making himself vomit and drinking Coke but the feeling isn't going away. Now he's unable to swallow his own saliva and is asking what you can do to fix the problem.

 

This situation isn't all that unusual - I probably see several cases a year. Only a minority of these require endoscopic removal, and we generally keep them in the department a while to see if it resolves on its own. Besides Coke, medical options include hyoscine butylbromide (Buscopan), glyceryl trinitrate solution (GTN) and benzodiazepines. Each time it happens though, there's usually someone on the shop floor who suggests glucagon...

 

Glucagon - why?

 

What, glucagon? You may remember it from medical school as the hormone that counteracts insulin, being secreted by the pancreas when all the "glucose-is-gone"©. You know that glucagon acts on the liver to increase blood glucose, but you may not know about an interesting side effect, first discovered in the 1970s: glucagon is also a smooth muscle relaxant.

 

It is thought that IM glucagon reduces the resting pressure of the lower oesophageal sphincter, thereby allowing an obstructing food bolus to pass safely into the stomach. Wonderful! But is there any evidence that it works?

 

"Oh Barrie, you're always going on about evidence! It must work, otherwise no one would be using it..."

 

The paper

 

Peksa GD, DeMott JM, Slocum GW, et al. Glucagon for relief of acute esophageal foreign bodies and food impactions: a systematic review and meta-analysis. Pharmacotherapy. 2019 Apr;39:463- 472​[1]​

 

This recent systematic review and meta-analysis had a comprehensive search strategy and only included studies with a comparator group. The authors found 5 studies, which spanned 23 study sites and included 1,185 patients.

 

Overall, the rate of relief from the impaction was no different between glucagon and placebo groups (30.2% vs 33.0%). Adverse events, however, were commoner in those treated with glucagon (15.0% vs 0%) - these included vomiting, retching, hypotension and lightheadedness.

 

I know from experience that glucagon often makes patients vomit. This may have the side effect of bringing up the impacted bolus, but it may also increase the risk of aspiration and oesophageal injury.

 

Limitations

 

Every meta-analysis is prone to some degree of heterogeneity, as the data in them is gathered from studies by different authors at different times in different locations, using different methodology. In this case, the original studies included different types of impaction (food or foreign bodies), used different definitions of treatment success (symptomatic relief or radiographic findings), didn't all include rates of underlying oesophageal pathology, and didn't control for time to treatment.

 

However, the rates of success are similar to previous studies, and the sample size should be sufficient to even out these differences. In any case, such factors are reflective of the way patients present to us in the ED - undifferentiated, with a symptom rather than a diagnosis.

 

Why I like this paper

 

The beauty of this paper is that only studies with control groups are included. Without this, a success rate of 30% looks pretty good for glucagon. When you learn that passively observing the patient also has a success rate of 30%, glucagon looks much less impressive.

 

The bottom line

 

There is no evidence that glucagon is any better than simply doing nothing for oesophageal food impaction. It is quite good at making your patient vomit, however.

 

Ongoing research

 

Note: Last year we came across a small case series​[2]​, where oesophageal food impactions were relieved by swallowing GTN solution. A phase 4 trial, the ONEFIT study, completed recruitment in April 2019 and may tell us a little more about this option when the results are published.

 

More FOAMed on this...

 

 

References

  1. Peksa G, DeMott J, Slocum G, Burkins J, Gottlieb M. Glucagon for Relief of Acute Esophageal Foreign Bodies and Food Impactions: A Systematic Review and Meta-Analysis. Pharmacotherapy [Internet] 2019;39(4):463–72. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30779190
  2. Willenbring B, Schnitker C, Stellpflug S. Oral Nitroglycerin Solution May Be Effective for Esophageal Food Impaction. J Emerg Med [Internet] 2018;54(5):678–80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29519719

 

October 21st, 2019    

The problem with ABGs

 

I recently came across the following recommendation in the 2017 British Thoracic Society (BTS) guideline for oxygen use in adults​. It is a ‘Grade A recommendation’, which means that it is intended to be mandatory and should be incorporated into critical care pathways wherever possible. Here it is:

 

“Local anaesthesia should be used for all ABG specimens except in emergencies.”

I was surprised, because it seems that we hardly ever use local anaesthesia for arterial blood gas (ABG) sampling.

Then I started thinking about how often we do ABGs and how rarely they change management in any meaningful way. I’ll try to explain my point of view. Please refer to our website for detailed notes: www.the-breach.com

7 common reasons for doing needless ABGs

7 irritating things about ABGs

It's not all bad: what ABGs are good for

 

October 7th, 2019    

Posterior stroke: a simple approach

Your patient is an elderly lady who feels dizzy. Her bloods are all normal and she wants to go home, but she's too dizzy to walk unaided. Her positive urine dipstick is urging you to call it a UTI and move on, but you wonder if she could be having a posterior stroke. You faintly remember something about a 'hinting' exam and getting patients to slap their hands together... You wonder if you should get a CT head, and if that would be enough to exclude the diagnosis. If only the guys at The BREACH covered an article reviewing posterior stroke...

Well, you're in luck. Step away from that urine sample! This paper is going to answer all your questions

Gurley KL, Edlow JA. Avoiding misdiagnosis in patients with posterior circulation ischaemia: a narrative review. Acad Emerg Med 2019 Jul. [Epub ahead of print]

September 22nd, 2019    

Probability calculator for UTI in young children

You're reviewing an infant in Paediatric ED with a temperature. They're not too unwell, but the poor parents have been trying to catch a urine sample for 4 hours and everyone's getting a little stressed. If only you could estimate the pre-test probability that the child had a UTI - then you might not even need the sample... And even if you get the sample, how should you interpret it? Just how significant is 1+ leucocytes?

Shaikh N, Hoberman A, Hum S, et al. Development and validation of a calculator for estimating the probability of urinary tract infection in young febrile children. JAMA Pediatr. 2018;172(6):550-556

September 11th, 2019    

Chest tubes for traumatic pneumothorax and haemothorax: review of evidence

Your elderly patient has been in a car accident and is feeling a little breathless, with pain on the right side of their chest. Their chest X-ray (CXR) shows a small pneumothorax, with some blunting of the costophrenic angle that might just be blood... What is the next step? Surgical chest drain or Seldinger technique? What size of tube is best? And do they even need urgent intervention?

 

Tube thoracostomy (insertion of a chest drain or tube) has been used to drain pus and excess air from the chest since ancient times. Over the last 100 years, we have gradually moved from large metal tubes to smaller flexible ones. Small-bore tubes were initially used in children, but are now becoming the norm across all age groups.

 

I was lucky to have trauma surgeon and cardiothoracic specialist Dr Irphan Yonis with me on the show this week to discuss this topic, as well as other related issues in the current management of chest trauma.

 

September 4th, 2019    

The Captain Morgan technique for reducing hip dislocations

Your patient is in a lot of pain, their leg is shortened and internally rotated, and the X-rays show a dislocated hip. If they're young they've probably been in a car accident and their knee has hit the dashboard. If they are older with a non-native hip, they might have just tried to get up from a low seat or crossed their legs.

 

However it happened, you need to reduce it. If your patient has a native femoral head, it is at risk of avascular necrosis (AVN), and the risk increases with every passing hour (in one study, 53% of patients developed AVN if the hip remained out of joint for more than 6 hours).

 

The traditional method (the Allis technique) requires you to jump up on the trolley and use your brute strength to haul the hip back into place. It's difficult, bad for your back, risks YOU breaking YOUR hip, and looks like torture - make sure the patient's relatives are safely in another room before you start.

 

Is there a better method? You bet there is! Let me introduce you to the Captain...

 

** Note: at 08:48 I say to place one hand under the patient's distal CALF. It should of course be under their distal THIGH. Sorry! **

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...

 

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