Funtabulously Frivolous Friday Five 114

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia…introducing Funtabulously Frivolous Friday Five 114

Question 1

What is the smirnoff reflex?

  • Sterno-brachial reflex
  • No it’s not a cocktail trick, it is a blow to the sternum with a reflex hammer which results in adduction of the arm.
  • The reflex is a partial manifestation of Chodzko’s reflex, a multi-reflex phenomenon where a blow to the sternum with a reflex hammer results in contraction of various muscles of the arm either bilateral or unilateral. This is assumed to be a sign of hyper irritability. [Reference]

Question 2

What did Captain Cook use to treat Scurvy?captain cook

  • Sauerkraut, malt vinegar and boiled fruit concentrate
  • Cook never carried fresh limes or lemons.
  • The sauerkraut and a concentrated fruit mixture was boiled and therefore lost most of its vitamin C.
  • It was 20 years after Cook’s death that the British sailors had lemon juice as standard supply [Reference]

Question 3

How fast do you have to walk to avoid the grim reaper?grim reaper

  • More than 5km/hr
  • The Grim Reapers preferred walking speed is 0.82m/s (3km/hr) and his maximum speed is likely just below 1.36 m/s (5km/hr).
  • This was established in a Sydney research project of ageing men.
  • 1705 men aged 70 and over were followed for nearly 60 months. They observed that older men who walked faster were able to avoid death… [Reference]

Question 4

What is connection between Sir Thomas Lauder Brunton and ‘Poppers?’

  • Amyl Nitrate
  • Lauder Brunton examined the use of amyl nitrate in the treatment of angina pectoris along with many other agents published in his 1875 thesis the “Experimental investigation of the action of medicines“.
  • Poppers is a slang term given to alkyl nitrites which may be inhaled for recreational purposes, especially in preparation for sex. The most common agent used is amyl nitrate.

Question 5

Why is Boyle’s law relevant to the aeromedical retrieval physician.

  • Boyles Law describes the relationship between pressure and volume in a closed system if the temperature is kept constant.
  • Why is this important?
  • Because a tiny pneumothorax can be converted to a massive tension pneumothorax at cabin altitude because the cabin pressure decreases and the volume of the pneumothorax increases as the aircraft climbs to cruise altitude.
  • Aircraft pressurisation offsets this to some degree, but the average commercial jet flying at 30,000 feet still has a cabin pressure equivalent to 6,000-8,000 feet above seal level. [Reference]

…and in other news

//www.youtube.com/watch?v=Q3Ao3dASeQE

The post Funtabulously Frivolous Friday Five 114 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Research and Reviews in the Fastlane 097

Research and Reviews in the Fastlane

Welcome to the 97th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Emergency Medicine, CardiologyR&R Hall of Famer - You simply MUST READ this!Brooker JA et al. The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates. Acad Emerg Med 2015; 22(7):883-6. PMID: 26118834

  • This article looks at the role medicolegal concerns play in the management of patients with chest pain. The authors found that up to 30% of patients would not have been admitted if physicians had an established “acceptable miss-rate” or worked in a zero medicolegal risk environment. Maybe it’s time that we make some real headway in these areas in order to cut down on unnecessary healthcare spending.
  • Recommended by: Anand Swaminathan
  • Read More: Expunging “Zero-Miss” from Chest Pain Evaluations (EM Lit of Note)

The Best of the Rest

Emergency Medicine, PulmonaryHutchinson BD et al. Overdiagnosis of Pulmonary Embolism by Pulmonary CT Angiography. Am J Roentgenol. 2015; 205(2): 271-7. PMID: 6204274

  • Pulmonary embolism (PE) is a favorite topic among emergency providers and recent efforts have focused on evidence based practices to combat overtesting. This retrospective, single center study from Ireland had 3 chest radiologists, blinded to clinical data and prior reads, look at 174 CTPAs positive for PE. These radiologist read 45 of these positive scans (25.9%) as negative, with excellent interrater reliability (k=0.83). False positive scans were more often solitary PE. Our “gold standard” is not imperfect and overtesting with an imperfect test is a good setup for downstream consequences.
  • Recommended by:Lauren Westafer

Pain Management, Emergency MedicineSin B et al. The Use of Subdissociative-dose Ketamine for Acute Pain in the Emergency Department. Acad Emerg Med 2015; 22(3): 251-7. PMID: 25716117

  • Probably the vast majority of people reading this review is a fan of ketamine for multiple indications, from RSI to procedural sedation. The authors performed a systematic review of the current literature of sub-dissociative doses of ketamine (SDDK) for analgesia in the Emergency Department. Four papers, including 428 were identified. The data was fairly heterogeneous overall in terms of outcomes and its results. Two of the 4 studies failed to identify any benefit compared to opiates. The authors conclude that there is no good evidence to support or refute the use of SDDK for analgesia in the ED.
  • Recommended by: Daniel Cabrera
  • Read More: Comfortably Numb: Low Dose Ketamine as Adjunct for ED Pain Control (The SGEM)

Pediatrics, Trauma, RadiologyHolmes JF et al Pediatric Emergency Care Applied Research Network (PECARN). Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013; 62(2): 107-116. PMID: 23375510

  • We all know that we would like to avoid unneccessary ionizing radiation in the most radio-sensitive patients – kids. Abdominal trauma, though, is difficult to evaluate in children. Is there a set of clinical features that help define a low-risk pediatric population? Take a look and see what the evidence says.
  • Recommended by: Sean Fox
  • Read More: Low Risk for Intra Abdominal Trauma (Pediatric EM Morsels)

Critical Care, ResuscitationLegrand M et al. Ten tips for managing critically ill burn patients: follow the RASTAFARI! Intensive Care Med 2015; 41(6): 1107-9. PMID 25573501

  • Short paper with 10 good tips for managing severe burn patients in the first 24-48 hours before transfer to at burn center including prehospital and early in-hospital care. The article gives some good pointers how to use the Parkland formula and how to modify the “rule of nines” in the prehospital setting. But most importantly – a VERY good mnemonic …..yeah man!
  • Recommended by: Soren Rudolph

Emergency MedicineMalka ST, et al. Weapons Retrieved After the Implementation of Emergency Department Metal Detection. J Emerg Med 2015 PMID: 26153030

  • Insane. Insane and likely not conceivable for those outside of the United States. This short and small study describes the type and quantity of weapons retrieved when one ED placed metal detectors at the front door for all ambulatory patients. They found, on average, 218 weapons/month, including:
    • firearms
    • knives
    • chemical sprays
    • other (brass knuckles, box cutters, etc…)
  • One more stunning example of the issue of weapons and safety currently at play in our society at large.
  • Recommended by: Jeremy Fried

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

The post Research and Reviews in the Fastlane 097 appeared first on LITFL: Life in the Fast Lane Medical Blog.

LITFL Review 194

LITFL review

Welcome to the 194th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

resizer When is ST elevation not ACS? Read Stephen Smith’s blog for a great case demonstrating that ST elevation = ischemia but not necessarily coronary occlusion. [AS]

The Best of #FOAMed Emergency Medicine

  • A primer on xanthochromia from Boring EM. [AS]
  • EM Cases discusses the workup and management of patients with sickle cell disease presenting to the ED with pain. [AS]
  • CTPA’s might not be quite the gold standard test you were hoping for, a review of a paper on the topic from emlitofnote is well worth a read. [SL]

The Best of #FOAMcc Critical Care

The Best of #FOAMus Ultrasound

  • Excellent case and discussion of the utility of ultrasound in the assessment of vision loss or acute vision change from ALiEM. [AS]

The Best of #FOAMim Internal Medicine

The Best of Medical Education and Social Media

  • Excellent tips from Ross Fisher on overcoming performance anxiety and making your presentation great. [AS]

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

The post LITFL Review 194 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Funtabulously Frivolous Friday Five 113

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia…introducing Funtabulously Frivolous Friday Five 113

Question 1

What did Valsalva (1666-1723) note as “..leaving the tongue tingling unpleasantly for the better part of the day

  • Gangrenous pus
  • He also noted that it did “not taste good“.
  • The things we do for science…. [Reference]

Question 2

What does the acronym “gomer” (or goomer) stand for? Which book first featured the use of the acronym – “gomer”? What is the sequel to that book?

  • Get Out of My Emergency Room
  • Features heavily in the Samuel Shem book “The House of God” (1978) and used to refer to patients who have “..lost —often through age- what goes into being a human being”.
  • The lesser known sequel is “Mount Misery

Question 3

The non-fiction book “The Hot Zone” by Richard Preston, features a scene when two scientists sniff a culture flask for the distinctive smell of Pseudomonas contamination. What does the flask actually contain?

  • Reston virus
  • Reston virus is one of the filoviruses.
  • While this belongs to the Ebola virus genus, it is not known to be pathogenic to humans. Not such good news if you are a crab-eating macaque…

crab-eating-macaque.

Question 4

A Great Physician should not pay attention to status, wealth or age; neither should he question whether the particular person is attractive or unattractive, whether he is an enemy or friend, whether he is a Chinese or a foreigner, or finally, whether he is uneducated or educated. He should meet everyone on equal grounds. He should always act as if he were thinking of his close relatives” – what is this from and who wrote it?

  • Sun Simiao (581-682)
  • Sun Simiao wrote the text – “On the Absolute Sincerity of Great Physicians“, from which the excerpt is taken. It is often referred to as the “Chinese Hippocratic Oath”.[Reference]

Question 5

While examining your patients neck you notice that the carotid pulse is absent on one side. What might this be due to, and what is this sign called?

  • Berry’s sign
  • Eponymous sign named after Dr James Berry relating to malignant thyromegaly – tumour encasing the carotid and muffling the pulsations.

 

…and in other news

//www.youtube.com/watch?v=RVv8VdHReh0

The post Funtabulously Frivolous Friday Five 113 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Research and Reviews in the Fastlane 096

Research and Reviews in the Fastlane

Welcome to the 96th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Social Media, Emergency MedicineR&R Hall of Famer - You simply MUST READ this!Roland D, Brazil V. Top 10 ways to reconcile social media and ‘traditional’ education in emergency care. Emerg Med J 2015. PMID: 26253148

  • Social media has been viewed by some as a threat to traditional medical education. However the educational principles of social media, while sometimes innovative in their delivery, are often no different than long-standing techniques and methods. Bottom Line: Social Media is a medium, NOT a curriculum and a way to disseminate scholarly work on a world wide scale.
  • Recommended by: Salim Rezaie

The Best of the Rest

Airway, AnaestheticsLeeuwenburg T. Airway management of the critically ill patient: modifications of traditional rapid sequence induction and intubation. Crit Care Horizons 2015; 1: 1-10. Free Open Access Link

  • This is the first published article in the incredible free open access critical care journal launched by Rob MacSweeney
  • Variations in RSI technique exist between individuals, specialties, institutions and countries. This paper by Kangaroo islands finest explores these variations practice and highlights specific measures for consideration in the critically ill. No specific recommendations are made but this paper may serve as basis for development of standard operation procedures at an institutional level.
  • Recommended by:Soren Rudolph

Pediatrics, ResusctiationMoreira ME et al. Color-Coded Prefilled Medication Syringes Decrease Time to Delivery and Dosing Error in Simulated Emergency Department Pediatric Resuscitations. Ann Emerg Med 2015;66:(2)97-106.e3. PMID: 25701295

  • Pediatric resuscitations are stressful at the best of times and pediatric dosing of resuscitation medications can be complicated, increasing the risk of medication errors. This group came up with an ingenious solution, in that single pre-filled syringes are color-coded in a rainbow pattern that corresponds to the Broselow tape we all know and love. All you have to do is discard down to the color that corresponds to the size of the child, and you are sure to be giving the right dose. This study assessed the speed and accuracy of medication administration in simulated pediatric resuscitations. 10 teams consisting of physicians and nurses participated in a cross over study, so that they did one simulation with the new syringes and one without. Time to delivery of medications was quicker with the new syringes (47 versus 19 seconds, a difference of 27 seconds; 95%CI 21-33 seconds). Teams were also more accurate using the new color-coded syringes, with dosing errors occurring 17% of the time with the conventional approach and 0% of the time with the new syringes (absolute difference 17%; 95% CI 4-30%). Obviously a simulation based study is not real life – but I would actually expect more stress and therefore more errors is a real resuscitation.
  • Recommended by: Justin Morgenstern

Pediatrics, Trauma, RadiologyHussein W et al. Trends in Advanced Computed Tomography Use for Injured Patients in United States Emergency Departments: 2007-2010. Acad Emerg Med.2015; 22(6):663-9. PMID: 25996245

  • Emergency CT imaging in trauma continues to increase, while yield unsurprisingly declines. Won’t somebody please think of the children?
  • Recommended by: Ryan Radecki
  • Read More: Still Not Choosing Wisely in Trauma Imaging (EM Lit of Note)

Cardiology, Emergency Medicine, ResuscitationClaveau D, et al. Complications Associated With Nitrate Use in Patients Presenting With Acute Pulmonary Edema and Concomitant Moderate or Severe Aortic Stenosis. Ann Emerg Med 2015. PMID: 26002298

  • An outstanding retrospective chart review and accompanying editorial which questions the (pseudo?-) axiom of avoiding nitrates in the patient in pulmonary edema with aortic stenosis.
  • In the study, the authors matched patients presenting in pulmonary edema who received nitrates without any AS to those with moderate and severe disease. They found no difference in episodes of significant hypotension and conclude that “Cautious use of nitroglycerin in patients with moderate or severe aortic stenosis and presenting with acute pulmonary edema may be safer strategy than traditionally thought.”
  • While limited by the retrospective nature of the methodology, this study does provide the best current evidence on what happens when we give nitro to our AS patients in pulmonary edema. The accompanying editorial by David Newman is a great read regarding the interpretation of this new piece of evidence and how it fits into our current state of knowledge.
  • Recommended by: Jeremy Fried
  • Read More:Newman DH. Negative Studies Are Usually Right: Vetting the Pseudoaxioms. Ann Emerg Med 2015. PMID: 26215668

Emergency Medicine, PsychiatryCalver L et al. The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med 2015. PMID: 25890395

  • This is another study demonstrating the safety of droperidol in the ED for control of agitation. This prospective, observational study included over 1400 patients and found no episodes of torsades de pointes or other lethal dysrhythmias. Despite a handful of cases that were reported under suspicious circumstances, the overwhelming evidence appears to support the use of this drug. Unfortunately, the drug is no longer available in many places.
  • Recommended by: Anand Swaminathan

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

The post Research and Reviews in the Fastlane 096 appeared first on LITFL: Life in the Fast Lane Medical Blog.