Evidence Base Medicine is a challenge in clinical practice!

I highly recommend you to take a look at this article published in American Heart Journal last week(Feb, 2015). The authors identified 11 class 1A(means the best evidence) in  STEMI or UA/NSTEMI and they followed them form clinical trial publication til meaningful application into clinical practice.  It took 16 years for clinician to apply those evidence into practice.

For example evidence for ASA published in 1988 and took 2 years to come into guideline but it took 14 years till 2004 that we give 90% of our patients Aspirin for STEMI, UA/NSTEMI.
Does it make sense to you?

Headache After Trauma in Children

Another great PECARN study: Headache in Traumatic Brain Injuries From Blunt Head Trauma published in Pediatrics, Feb 2015. The objective was to determine risk of TBI in children after trauma with no other sign or symptoms beyond headache. of 27,495 patients, 12, 675 (46.1%) had headache. From 12,675 patient, 2462 (19.6%) had isolated headaches.

Interestingly, clinically important TBI ocuured in 0 of  2462 patients. That means if you have a patient with isolated headaches means  no LOC, AMS, no sever HA, no sign of base skull fx , vomiting, seizure,… patient can be safely discharged with parents and does not require a CT!

 

Link to article

Migraine Headache: Prochlorperazine + diphenhydramine versus Metoclopramide + diphenhydramine

​Pediatrics published an article regarding Migraine treatment in children. This is a retrospective study that has shown us non opioid medication has pretty significant effects in the treatment of Migraine. The treaatment plan is very regular that we usually practice. Compazine, Reglan, Benadryl, NSAIDS,… Patient with Metcolopramid returned to ED visit more often than group who received Prochlorperazine. 5.8 % of patient with Prochlorperazine treatment returned within 3 days vs 7.5 % in Metoclopramide group. when it combined with diphenhydramine, Prochlorperazine + diphenhydramine had 5.5% return visit versus 8.6 % in Metoclopramide + diphenhydramine. We have already known that Prochlorperazine is superior tometoclopramide, but this study has some limitations that we need to take into account:

1. Retrospectve!
2. We do not know reasons for revisit of Patients to ED???
3. we do not have the dosage that they used!
4. we do not have standard pain scales to know 10/10 came back or 5/5 returned!

New Drug for ACE-Inhibitor–Induced Angioedema!

NEJM published new treatment for ACEI-induced Angioedema. This study funded by Shire (a Biopharmaceuticals Company) and the Federal Ministry of Education and Research of Germany. Icatibant with generic name of FIRAZYR was administrated to 27 patients with ACEI angioedema in the setting of double blind, randomised phase 2 study. As we know the usual treatment of allergic reaction with Steroid and H1, H2 blocker were not promising in ACEI induced angioedema due to different mechanism of histamine-mediated reaction! But what else an ED physician can do when there is a patient with swollen face and airway compromise except early airway intervention! The primary outcome was  the time to the complete resolution of edema after administration of Icatibant. The time for Icatibant was 8.0 hours compare with 27.1 hours in receiving standard therapy. This drug is not currently licensed for this indication per article.

Head CT for Syncope/Dizziness

Another study from AJR in Jan 2015 focused on dizziness/syncope. Due to difficulty to define definition of dizziness among patients, they used 3 terms of Dizziness, Syncope, andNear Syncope. They retrospectively looked at 253 patients with these complaints and found 3 clinical factors associated with positive findings: 1. age older than 60, 2. a focal neurological deficit, and 3. acute head trauma. Their conclusion is: Most patients presenting with syncope or dizziness to the emergency department may not benefit from head CT unless they have 3 above clinical factors.

Link to Article

Ketamine for Pain Relief

I used Low Dose Ketamine for Pain relief in ED, and I had a very good experience with it, but new study in AJEM Feb, 6, showed that compare with morphine ,LD Ketmaine shares same characteristics  regarding vital signs changes , adverse events, provider, and nurse satisfaction scores. The only difference was LDK provided maximum pain score reduction within 5 minutes versus Morphine within 100 min. LD ketamine means 0.3 mg/kg IV, and Morphine was used as 0.1 mg/kg.

Link To abstract