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Showing posts from 2017

Under Pressure: Review of Management of Hypertension in Neurological Emergencies

Objectives: Explore the data for safety and efficacy of urgent BP lowering in hemorrhagic stroke.Is there any benefit from management of elevated BP in acute ischemic stroke that is not a candidate for tPA?What is the data for BP target in aSAH awaiting definitive management?

Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial

Journal Club SummaryMethodology Score: 4/5 Usefulness Score: 4.5/5

D'Onofrio G, et al
JAMA. 2015 Apr 28;313(16):1636-44.
Full Article

A Randomized Controlled Noninferiority Trial of Single Dose of Oral Dexamethasone Versus 5 Days of Oral Prednisone in Acute Adult Asthma

Journal Clubs Summary Methodology Score: 3/5 
Usefulness Score: 3.5/5 Rehrer MW, et al.
Ann Emerg Med. 2016 Nov;68(5):608-613.
Abstract Link

The ABCDE’s of Quality Improvement

What is Quality Improvement (QI)? You have all heard the latest buzzword in healthcare: “quality improvement”, or QI. Yet many healthcare professionals still only have a vague idea of what that truly means, and likely an even poorer understanding of how it might apply to their frontline practice. Conceptually, QI can be defined as the “combined and unceasing efforts of everyone - healthcare professionals, patients and their families, researchers, payers, planners and educators - to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)”1. 

Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study.

Journal Club Summary Methodology Score:4/5 Usefulness Score:4/5 Stanley AJ, et al. BMJ. 2017 Jan 4;356:i6432. Full Article This multicentre, multinational study assessed the ability of five upper gastrointestinal bleeding scores to predict outcomes including death, re-bleeding, need for endoscopy, transfusion, surgery or interventional radiology, and length of hospital stay, finding that the Glasgow Blatchford score is best at predicting the composite outcome of intervention or death, although AIMS65 was best at predicting mortality. While applying the scores as recommended may result in missing a small number of significant outcomes, they are easy to apply and can help expedite disposition planning, whether outpatient management or hospital-based intervention. By: Dr. Daniel James
Epi lessonComposite OutcomesIt is not unusual for studies to select a composite outcome as their primary outcome measure. The necessity to do so is often justified by the rare occurrence of the primary outcome of t…

Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial.

Journal Club Summary
Methodology Score: 3/5                    Usefulness Score:  3.5/5 NijssenEC, et al Lancet.2017Feb 20. [Epub ahead of print] Abstract Link

Zika Virus – What we know and what we don’t

The Zika Virus exploded onto the international health scene in the last several months. It was first discovered in humans in 1951 and remained limited to Africa and Asia until the first major outbreak in Micronesia in 2007. Since then the virus has continued to evolve and spread from the Pacific Islands and French Polynesia to the main major outbreak in South America in early 2015 and finally to the US in January 2016.

Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial

Journal Club SummaryMethodology Score: 4/5                    Usefulness Score:  3/5
Lascarrou JB, et al. JAMA. 2017 Feb 7;317(5):483-493. Abstract Link

Risk of Acute Kidney Injury After Intravenous Contrast Media Administration

Journal Club SummaryMethodology Score: 4/5                    Usefulness Score: 3.5/5
Hinson JS, et al. Ann Emerg Med. 2017 Jan 19 [Epub ahead of print] Full Article

Pediatric Airway Management in the Emergency Department

Pediatric endotracheal intubation is an uncommon procedure in the Emergency Department (ED); even in high volume tertiary pediatric centres the incidence has been reported at 8-10/10,000 patients. While infrequent, pediatric airway management is an essential and life-saving skill that all ER physicians must be prepared for.  Much of the knowledge and skill set from the adult world is applicable here, however there are several important differences that are unique to the pediatric population.

Effect of Noninvasive Ventilation Delivered by Helmet vs. Facemask on the Rate of Endotracheal Intubation in Patients with Acute Respiratory Distress Syndrome

SummaryMethodology Score: 4/5
Usefulness Score: 3.5/5

Patel BK, et al. JAMA. 2016 Jun 14;315(22):2435-41
Full Article

Editorial: Unmasking a Role for Noninvasive Ventilation in Early Acute Respiratory Distress Syndrome. Beitler JR, et al. JAMA. 2016 Jun 14;315(22):2401-3.

This single-centre, non-blinded RCT of ICU ARDS patients, found that NIV delivered by a novel helmet, as compared to a standard NIV facemask, reduced intubations (18.2% vs. 61.5%; P <0.001) and hospital mortality (27.3% vs. 48.7%; P= 0.04). Despite its few methodological flaws, this study supports the existing literature on the advantage of oxygen delivered via helmet over facemask in avoiding intubation in ARDS, and future studies should focus on its impact in heart failure or hypercapneic respiratory failure.
By: Dr. Shannon Fernando 
Epi lesson:
Interim Analyses and Stopping Rules
In clinical trials, an interim analysis is one that is conducted before data collection has been completed to determin…

Focus on POCUS: Subacute, Progressive Dyspnea while Swimming

A male in his 60’s presents with progressive dyspnea on exertion x 1 month starting while he was swimming in the ocean. He had not been diving.  He has no significant medical history and takes no medications.

Diagnosis of Acute Cardiogenic Pulmonary Edema (ACPE) with Point-of-Care Ultrasound

Point-of-Care Ultrasonography (POCUS) is a valuable tool in the diagnostic armamentarium of the emergency physician. We have been successfully using it to the place lines, diagnose AAAs and assess the cardiac function of our dyspnea patients for awhile now. But what about the lungs? Typically air is thought of as the enemy of ultrasound, but can we successfully use it to diagnose acute respiratory conditions despite this? In this Grand Rounds review, Dr. Elizabeth Lalande goes through the use of POCUS in the diagnosis of Acute Cardiogenic Pulmonary Edema in the undifferentiated, dyspneic patient. 

Clindamycin versus trimethoprim-sulfamethoxazole for uncomplicated skin infections

Journal Club SummaryMethodology Score: 4/5                    Usefulness Score: 2/5
Miller LG, et al. N Engl J Med.2015Mar 19;372(12):1093-103. Full Article

Focus on POCUS: Palpitations and Dyspnea Post-AVR

This case is brought to you by Dr. Robert Ohle, PGY5 in emergency medicine, who assessed the patient and captured all of the ultrasound images! Case Vignette: A female in her 20's presents to the emergency department 15 days after major cardiac surgery to repair a congenital aortic valve defect. Her chief complaint is palpitations and shortness of breath, which have been constant and ongoing for the last 4 days. She has no PND or orthopnea, no calf swelling, or history of DVT/PE. She has no past medical history other than the aortic valve defect and is on no medications. Her exam shows a well looking young female in no acute distress. Her vitals are BP 110/40, HR 110, afebrile, O2 99% on room air, RR 18. Her sternotomy incision site looks healthy. Her lungs are clear and there is a loud cardiac murmur, but both the senior resident and staff are unable to tell if it is systolic or diastolic because of the patient’s tachycardia. There are no signs of DVT. Routine bloodwork including car…

Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine - The POKER Study: A Randomized Double-Blind Clinical Trial

Journal Club SummaryMethodology Score: 4/5
Usefulness Score:  3.5/5

Ferguson I, et al.
Ann Emerg Med. 2016 Nov;68(5):574-582.
Abstract Link

SIRS? No SIRS? Understanding Sepsis in the Emergency Department after Sepsis-3.

Use of the term “sepsis” continues to be controversial. We understand that patients with infection can manifest an immune-mediated systemic response, and are at risk of deterioration, organ dysfunction, and death. At what point in that cascade the patient is termed “septic” remains the centre of ongoing debate. In 2016, under the coordination of Drs. Mervyn Singer and Cliff Deutschman, a task force of experts in sepsis research were assembled to create The Third International Consensus Definitions and Clinical Criteria of Sepsis and Septic Shock (Sepsis-3)[1]. Prior to this, the most recent set of definitions were released in 2001[2], and our understanding of sepsis has since changed. Thus, the definition of sepsis required an update. These definitions have been a source of major disagreement, but their major tenets must be known and understood by Emergency Department (ED) physicians, in order to apply them correctly.

Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis: The HYPRESS Randomized Clinical Trial

Journal Club Summary
Methodology Score: 3/5                    Usefulness Score:  2.5/5
KehD, et al. JAMA.2016Nov 1;316(17):1775-1785 Abstract Link In this multicenter placebo-controlled double-blind RCT, the authors concluded that in adults with severe sepsis, hydrocortisone IV infusion does not prevent progression of severe sepsis to septic shock. While this study was well done overall, the group had concerns about the removal of patients with adverse events from the modified intention-to-treat analysis, the lack of reporting of time to antibiotics, powering the study to detect a very high (15%) difference between groups. This not being an ED study the results are not applicable to our population. By: Dr. Stephanie Barnes
EDITORIAL: Yende S,et al. Evaluating Glucocorticoids for Sepsis: Time to Change Course.  JAMA.2016Nov 1;316(17):1769-1771.
Epi lessonRandomization by Pocock minimization algorithmFebruary 2017
A random allocation of …

REBOA: Resuscitative Endovascular Balloon Occlusion of the Aorta

The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has become a topic of considerable interest as of late, primarily to treat non-compressible truncal hemorrhage (NCTH). However, it is beginning to expand into other causes of non-compressible bleeding.  Why do we care? Bleeding is the 2nd leading cause of traumatic death behind only traumatic brain injury (TBI). Additionally, it is the number one cause of preventable death in trauma, causing 85% of all preventable trauma deaths.  Furthermore, 35% of all pre-hospital deaths and over 40% of deaths within the first 24 hours following trauma are attributed to bleeding (Kauvar, Lefering, & Wade, 2006).  One article states that there are around 60 000 civilian deaths per year in the US secondary to traumatic bleeding (Sauaia et al., 1995). Is this REBOA thing new?! Nope. 
The concept and use of REBOA has been around since at least 1954, when Lieutenant Colonel Carl Hughes of the US military published an article desc…