Welcome to the sensational 31st edition!
The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team will cast the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle.
The Most Fair Dinkum Ripper Beaut of the Week!
- The top spot this week is dominated by Scott Weingart excellent podcast were he debates the Needle or the Knife for the Cricothyrotomy dilemma with fellow friend of the fast lane Minh Le Cong. These two incredible minds battle out the pros and cons of both approaches, a look at the “can’t intubate/can’t oxygenate situation” and how to approach this. The post has an excellent selection of videos to support the concepts they discuss, and Scott even gives us access two another podcast were Minh Discusses Three Examples of Airway Management gone Bad!!
The Usual Suspects
- CRASH-2 and head injury- as Cliff put’s it this drug is going to be talked about for a while and more outcome data is needed to find its true effectiveness.
- What do I do with a high sensitivity troponin? Be very cautious and take this advice into account” Overall, our practice for ordering troponin will need to be urgently reviewed. Single troponin values will continue to be of little to no use in defining disease states in the ED. Identifying a chronic versus an acute elevation will only be revealed by serial troponin testing. The time interval between testing is currently contentious.”
- Cliff highlights the new Australian Resuscitation Council Snakebite Guidelines
- Nice review on managing Fite Bite’s and closed fist injuries.
- The Life Cycle of the Banana: Rethinking Geriatric Falls in the ED – time for a new approach.
- How do you treat infected body piercings?-Leave It In? Take It Out?
- Joe’s podcast of the week comes from Bart Besinger with a look at Radiographs with Subtle Findings
- Trick of the Trade: Splinting and applying a pressure bandage to auricular haematoma’s is one of life’s little challenges…Maybe not anymore with this weeks Trick of the Trade.
- Video of the week: This weeks video is from the amazing author Malcolm Gladwell the author behind the books Blink & Outliers: The Story of Success, with a TED talk on A lesson from spaghetti sauce on appreciating diversity. (Author’s note; Blink is a must read book for all in emergency medicine/nursing. It looks at “the power of thinking without thinking” – something we all do in our specialty every day.
Dr Smith challenges your ECG skills this week with these challenging cases:
- Atrial Fibrillation with RVR and Inferoposterior ST elevation (Injury Pattern)
- Young man with syncope while riding a bike
- Colchicine: tips for avoiding fatal in-hospital toxicity: Bottom line best to avoid Colchicine altogether, and if early signs of toxicity develop cease immediately.
- David go’s at it alone in this month’s podcast tackles The Placebo Paradox: Placebo equals nothing. Doesn’t it? But common surgeries are proven no better than sham surgery. Entire classes of ubiquitous drugs are proven equal to placebo. Thus we may scoff at placebo, but we implicitly confess and embrace the power of placebo every day. Also check out Broome Docs post the two go nicely together.
The Rest Of The Best
- Atrial Fibrillation revealed, Peter hammers out an approach to one of the most annoying rhythms we encounter. This post focuses on when to go with rate control Vs rhythm control, and highlights the 3 drugs you need to know to manage this rhythm.
- Intensity of work in the emergency department- how many interruptions do you get per hour? Does this shit you? Maybe its time to go do anaesthetics!!!
- Catheter removal after retention -interesting points made Andy -might start mentioning this approach and see what response I get!!
- Fluid Controversies Colin and the team tackle the recently published FEAST Trial and the issues surrounding fluid administration in the resuscitation of the sick kiddie!!!
- Nice review on morning sickness in Pregnant and puking - remember it’s not always morning sickness.
- Placebo paradox: Descartes dilemma - Casey gets all ethical on us with a review on a recently published study in the NEJM – and tackles this issue of prescribing placebo’s and finishes it off by asking the tough question ‘What would you do??”
- Outpatient Vs Inpatient Treatment for the PE patient works well if you have the right patient group and excellent follow-up care.
- Long vs Short Axis for US Guided Central Venous Access, Jason provides us with a review of this study and his perspective on it.
- Well I meant to treat it! the intention-to-treat debacle in the ICU setting.
- The lad’s have been busy developing the back-end of the blog, uploading heaps of notes and resources for your academic and studying pleasure. Also have an exam coming up they have all the links to help you pass your Emergency, Intensive Care and Anaesthetics exams.
- Tranexamic Acid – Critique of CRASH-2 -Take home point from this review of the CRASH-2 trial: “while the NNT is pretty high, it is a fairly low-cost intervention with a relevant outcome variable of overall mortality.”
- We Still Can’t Predict Cardiac Outcomes in Syncope although a normal ECG is probably helpful in making your decision – but being younger and healthier probably accounts for more of the differences between their groups.
- CT Is No Longer Adequate To Clear C-Spine - another study that offers little and provides more doubt in our minds.
Haney Mallemat brings us this week pearl on pregnancy and the trauma patient:
Pregnancy causes many physiologic changes, which may be challenging during trauma resuscitation. A few pearls on the ABC’s:
- Increased progesterone levels cause mucosal hyperaemia and edema, increasing risk of bleeding and smaller (i.e., edematous) airway.
- PEARL: Have smaller tubes ready and let the most experienced person intubate.
- The enlarging uterus pushes the diaphragms into the thorax, reducing the total lung capacity and the functional residual capacity.
- PEARL: During intubation, patients in late pregnancy may have less oxygenation reserve and apnea time, desaturating faster during RSI.
- The late stage uterus can compress the IVC when supine, reducing venous return to the heart (i.e., the Supine-Hypotension syndrome) subsequently reducing cardiac output.
- PEARL: Have a 30-degree wedge placed under patient’s right hip, moving the uterus off IVC and improving venous return.
- BONUS PEARL: During resuscitation, ask medical students to manually move the uterus midline, relieving the compressed IVC. They will appreciate that you got them clinically involved.
- The great imitators -is a phrase used for medical conditions that feature nonspecific symptoms and may be confused with a number of other diseases. Most great imitators are systemic in nature.
- What’s a normal heart rate? - That is a tough one!
- ZDoggMD tackles the controversial world of paediatrics, offering some paternal parenting advice in NeoNate Dogg!
Twee-D and Twitcal Care
The master of teaching pathophysiology is back with more brilliance:
News from the Fastlane
- This week heralded the release of two textbooks (On Call Principles And Protocols & Emergency Medicine Diagnosis And Management 6th Edition) by the master of medical education and LITFL supremo @sandnsurf . Together with the Toxicology Handbook second edition (also released in 2011) these books will form the backbone of an integrated medical education syllabus within the framework of LITFL.
The Final Words
- “Another sign the patient has been in the ER too long: she’s away getting an MRI when the preliminary result from her first blood culture comes back.”
- ” You are the storyteller of your own life, and you can create your own legend or not.”
That’s it for now… Hopefully this roundup of the world of electronic emergency medicine and critical care education for everyone helps you to deal with anyone, anything, anywhere at anytime for at least another week! If you’d like to suggest something for inclusion in the next edition of The LITFL Review, email our roving reporter: kane AT lifeinthefastlane.com