Welcome to the first in a new series of monthly podcasts at the RCFN looking at recent literature. There’s been a lot of feedback requesting literature round ups and hopefully this podcast will help to scratch that particular itch.
We are very much standing (maybe wobbling) on the shoulders of giants here and it’s worth noting some of the guys who have been doing this type of thing long before us:
- Emergency Medical Abstracts ($$)- now 30 years of monthly audio reviews of the literature
- Life in the Fast Lane – research and reviews
- EM Lit of Note
- The SGEM
- EM:RAP and their paper chase section ($$)
- The Bottom Line
- Critical Care Reviews
- HEFT EM Cast papers of the month
- First 10 EM
Paper Number 1
This is a perpetual fight in the ED I find. Increasingly we seem to have moved toward VBGs for almost everything and the ABG has got quite a pounding for being painful, cumbersome and unnecessary. The two areas with dubious accuracy have been hypercarbia and the VBG in severe shock. This is now the second paper (including AM Kelly – the VBG guru) we’ve seen looking at an algorithm that avoids an ABG for every COPD exacerbation. (note the NICE guidelines recommend this).
This paper is observational data – everyone got paired venous and arterial and they tried to correlate the ph, HCO3 and CO2 etc… They enrolled 234 pts and found good correlation for all the numbers apart from CO2 which is not surprising. Effectively they suggest if you have a normal VBG (ph, HCO3 and CO2 <6) then an ABG is not going to help you. This would have saved 2/3 of people from an ABG. They also suggest a reasonable algorithm about when to do the ABG.
Other FOAMed resources
Paper Number 2
Simple but effective trial – important to give adequate analgesia in patients with hip fracture. No-one was previously sure which block was better for pain relief. Physicians all have personal preference. This RCT shows FIB equivalent to femoral nerve block in the ED.
Other FOAMed resources:
- StEmlyns - check out their references for some comprehensive FOAMed reading…
Paper Number 3
This is a really important topic with the trend towards more ED led airway management to catch up with Australian and US practice. This systematic reivew was looking to quantify how much experience is needed in order to get to 80 and 90% ETI intubation success rates.
- 13 studies with a total of over 1,400 students and over 19,000 patients.
- The students were first year residents, medical students or paramedic students.
- Studies were performed in operating theatres (excluding one).
They found that 51-75 of ET intubations needed to be performed to achieve a success of intubation of at least 90%, with 1-43 intubations required to achieve an 80% success rate. To achieve first pass success rate of at least 90% one paper demonstrated there was a requirement for over 200 ET intubations.
Questions to be answered - what first pass success rate is acceptable? Can we extrapolate that to ED practice as not ED based papers? How are we likely to proceed with airway management in the UK?
Paper Number 4
Relevant and useful, CVC insertion can take a while and butchering with multiple attempts at peripheral iv cannuala insertion with futility is bad! This was a convenience sample – not necessarily the sort of patients I’d be going for; 7 discharged from ED and 26 admitted. They were also using longer than our standard cannualae! What ever happened to the good old external jugular!! There’s a great discussion on this paper over on Ryan’s site and the comments are well worth a read.
Paper Number 5
A lot of research on how we make decisions is based around theoretical cases with various nuggets provided at different stages to see how that changes things. This is real time in-situ decisioning making research. They followed a bunch of experienced french EPs and did qualitative research on how and why they did what they did. They said this was “focussed ethnography” research which was a new thing to me. The doc wore a camera – something like a GoPro or a Google Glass it sounds like and these were used with interviews to talk about how decisions were made. the quotes make this paper INMHO and its nice to see it documented that the reason we make decisions is governed by such subtle, complicated factors as “I know frank…” Hat tip to Jeremy Fried and LITFL for the tip off to this paper
Paper Number 6
The HEAT trial examined patients with a fever on ITU being treated for infection and randomly assigned 6 hourly paracetamol or placebo until either resolution of fever/cessation of treatment for infection or until discharge from ITU. Primary outcome of ITU free days at 28 days. They found no statistically significant difference in the number of ITU free days between the groups and interestingly they also found no difference between 28 or 90 day mortality between the 2 groups. Goes with an increasingly large evidence base that the knee jerk reaction to treat an infection driven fever is not proven to be in the benefit of the patient.
Personally I like Paul Young’s take on his own trial:
— Ken Milne (@TheSGEM) February 10, 2016
@iceman_ex these are all correct answers.
— Paul Young (@DogICUma) February 11, 2016
Other FOAMed resources: