LITFL: Life in the Fast Lane Medical Blog http://lifeinthefastlane.com Emergency medicine and critical care medical education blog Thu, 20 Aug 2015 12:57:42 +0000 en-US hourly 1 Research and Reviews in the Fastlane 096 http://lifeinthefastlane.com/research-and-reviews-in-the-fastlane-096/ http://lifeinthefastlane.com/research-and-reviews-in-the-fastlane-096/#respond Wed, 19 Aug 2015 23:12:42 +0000 http://lifeinthefastlane.com/?p=139958 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 […]

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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.

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LITFL Review 193 http://lifeinthefastlane.com/litfl-review-193/ http://lifeinthefastlane.com/litfl-review-193/#respond Sun, 16 Aug 2015 20:00:21 +0000 http://lifeinthefastlane.com/?p=140117 Welcome to the 193rd 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 […]

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LITFL review

Welcome to the 193rd 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 See FOAM4GP’s Simplify the Message on how to explain a medical condition or treatment to a patient using something in their lives they can relate to. Or as Orson Scott Card puts it, “Metaphors have a way of holding the most truth in the least space.” [ML]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

The Best of #FOAMped Paediatrics

The Best of #FOAMim Internal Medicine

  • Latest in the Louisville Lecture series on pharmacogenetics. Kristen Reynolds takes a look at adverse drug reactions occurring secondary to identifiable genetic risk factors: the evidence supporting genetic testing, common mutations (CYP phenotypes), and how to decide whom to test. [ML]

The Best of Medical Education and Social Media

  • Lucky for us, still available online: an excellent guide and resource on getting started on twitter from Injectable Orange. [AS]

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

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CCC Update 011 http://lifeinthefastlane.com/ccc-update-011/ http://lifeinthefastlane.com/ccc-update-011/#respond Sat, 15 Aug 2015 14:13:30 +0000 http://lifeinthefastlane.com/?p=139102 Here is the eleventh update to the Critical Care Compendium, your LITFL guide to the core and not-so-core knowledge base required of a critical care physician.

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Updates to the LITFL Critical Care Compendium are coming thick and fast at the moment. Here’s a quick summary as these entries don’t appear in the LITFL blog feed, and you otherwise need to search for them using search keywords in the CCC table, by googling “litfl ccc searchterm” or by searching GoogleFOAM. Remember, constructive feedback is the fuel that LITFL runs on, hit us with it!

Here’s what is new in the CCC since CCC Update 010:

Cerebral venous thrombosis
This condition reared its head in the last round of FCICM exam vivas I believe — and it wouldn’t surprise me if it turned up in the written exam in the (very) near future. The presentation is variable (headache +/- anything else) and diagnosis can be tricky.  Diagnosing CVT requires a high index of suspicion — ensure your antennae are especially pricked up in those with risk factors (such as thrombophilia, oestrogen excess or local factors predisposing to thrombosis like head and neck infections). Remember that the presence of haemorrhages (which are common) are not a contra-indication to therapeutic anticoagulation.
Coroner’s clot
A CCC Update without a new airway entry just doesn’t cut the mustard, so here you go… The feared ‘coroner’s clot’ was the cause of one death in the famous NAP4 study: “In one case, an inhaled blood clot after tonsillectomy produced total tracheal obstruction which was initially attributed to asthma and led to fatal cardiac arrest.” Know about it then face your fears.
The Elderly and Critical Care
This page centers on defining the physiological and pathological changes seen in the elderly that are of relevance to the critical care physician. I expect it will continue to evolve as this is a really important topic IMO. The benefits and harms of ICU admission for the elderly is a complex topic, and an increasingly important one. I’ve taken frailty out and given it its own page.

Extremity injuries
Extremity injuries are sometimes under appreciated when faced with the maelstrom of the critically ill multi-trauma patient. However, there are a host of life and limb threats to be found when extremities are traumatised. This page gives you an approach and includes life-threatening haemorrhage, crush, compartment syndromes, neurological injuries, degloving and open fractures. Extremity arterial injury is dealt with in more detail on it’s own page.

Extremity arterial injury
Direct pressure goes along way, but there is more to it than that. An approach is provided covering the hard and soft signs of arterial injury, including the role of the arterial pressure index (API) and CT angiography. Management goes beyond direct pressure, and includes resuscitation, tourniquet use and both surgical and IR interventions.
Fluid balance
Having added a critical appraisal of fluid bolus therapy and exciting topic of de-resuscitation and postive fluid balance and last time round, it seemed necessary to have a page on the humble concept of fluid balance, with a focus on the pros and cons of the equally humble fluid balance chart. You can’t join the intensivist club unless you develop a nagging urge to eradicate positive fluid balances from your ICU… just remember that the fluid balance chart usually lies.
Frailty syndrome
“Frailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserves that confers vulnerability that predisposes to the accumulation of deficits as well as adverse outcomes from acute stressors”. Assessment of frailty and poor physiological reserve is becoming increasingly important for intensivists because it portends poor outcomes despite the mobilsation of an armada of intensive care therapies, equipment and interventions — which come with a hefty price tag. Frailty accounts for much of the badness associated with the critical care of the elderly — yet though they are associated, not all elderly are frail, and not all frail are elderly.
ICU-acquired weakness
This is a potentially crippling sequela of critical illness / critical care that can really undo a lot of good critical care leave the patient with persistent disability. ICUAW is a common issue that probably doesn’t get the respect it deserves. Part of the answer to the problem may (or may not) be early mobilisation (see below).
Mobilisation in ICU
This page considers the physiological benefits of patient positioning and mobilisation in the ICU, as well as the pros and cons of mobilisation and the barriers to performing it. Early mobilisation in particular is a hot topic, with the results of the TEAM study pilot trial hopefully being released soon…. Early mobilisation may help attenuate the impact of ICU acquired weakness on the longterm outcomes of critically ill patients. The evidence to date is reviewed, but the story is far from over.
Multi-Organ Dysfunction Syndrome (MODS)
We all know it when we see it, as it is the sine qua non of full-blooded critical illness. Yet, it remains unclear what triggers MODS, or why it only seems to occur in certain patients or whether it could even be an adaptive process.

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Funtabulously Frivolous Friday Five 112 http://lifeinthefastlane.com/funtabulously-frivolous-friday-five-112/ http://lifeinthefastlane.com/funtabulously-frivolous-friday-five-112/#comments Fri, 14 Aug 2015 00:00:21 +0000 http://lifeinthefastlane.com/?p=135620 More good old fashioned medical trivia with Funtabulously Frivolous Friday Five 112

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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 112

Question 1

How did Dr Joseph-Ignace Guillotin die?

  • Furunculosis
  • Not by his invention, contrary to folklore, but by an infected carbuncle on his shoulder.
  • Interestingly the first guillotine contraption was designed in Halifax, Yorkshire which was used as a deterrent for would be cloth thieves. The rope, pulley iron axe system between two wooden uprights may well have inspired Guillotin to come up with his mechanical method for execution.
  • Guillotin apparently despised public executions which discriminated against the poor who were hung as opposed to the rich who were cleanly beheaded.
  • Guillotin’s suggestions were noted by Dr Antoine Louis who was Secretary of the Academy of Surgeons. He produced the first guillotin as we know it but despite Guillotin’s family objecting his name stuck to the device.
  • In its first ten years, historians estimate 15,000 people were decapitated. Only Nazi Germany has used it to execute more, with an estimated 40,000 criminals being guillotined between 1938 and 1945. [Reference – The general book of ignorance. The noticeably Stouter Edition. John Lloyd and John Mitchinson]

Question 2

What is a Catamenial pneumothorax?

  • Pneumothorax occurring in conjunction with menstruation.
  • Patients typically suffer about five episodes before the relationship with the menstrual cycle is recognized.
  • Respiratory symptoms usually develop within 24 to 48 h of the onset of menstrual flow.
  • Most pneumothoraces are right sided, but left sided and bilateral examples are reported. [PMID 20473170]

Question 3

Who Discovered Penicillin?Penicillin

  • Bedouin tribesmen in North Africa
  • Sir Alexander Fleming is a long way down the list.
  • Bedouin tribesmen were creating healing ointments from the mould on donkey harnesses for over a thousand years. This was observed by Dr Ernest Duchesne a french army doctor who watched Arab stable boys cure saddle sores from the mould on the harnesses. He did his own research and cured guinea pigs from typhoid with this mould. He identified the mould as Penicillium glaucum and sent his thesis to Pasteur which was ignored.
  • Duchesne continued his army duties and later died of TB (ironically a disease his discovery could have cured… ). Duchesne was later posthumously honoured 5 years after Sir Alexander Fleming received his Nobel Prize for his re-discovery of penicillin.[Reference – The general book of ignorance. The noticeably Stouter Edition. John Lloyd and John Mitchinson]

Question 4

Where might you find someone with Monge’s Disease?

  • Up a mountain
  • Also known as Chronic Mountain Sickness, Monges’ Disease is named after Carlos Monge Medrano after his description in 1925 of people living at high altitude in places such as the Himalayas greater than 3000 metres above sea level.
  • The disease manifests as polycythaemia, headaches, dizziness, tinnitus, breathlessness, palpitations, sleep disturbance, fatigue, anorexia, mental confusion, cyanosis and even clubbing. [Reference]

Question 5

What non-infectious neurological disease is Adolf Hitler thought to have?

  • Parkinson’s Disease.
  • Various reports and pieces of film indicate that Hitler had the diagnostic triad of bradykinesia, tremor and rigidity.
  • It is likely that the disease affected his personality and temperament. [Reference]

…and in other news

//www.youtube.com/watch?v=ay5_HgZLDoE

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Research and Reviews in the Fastlane 095 http://lifeinthefastlane.com/research-and-reviews-in-the-fastlane-095/ http://lifeinthefastlane.com/research-and-reviews-in-the-fastlane-095/#respond Wed, 12 Aug 2015 23:51:05 +0000 http://lifeinthefastlane.com/?p=139271 Research and Reviews (R&R) in the FastLane 95th edition – experts worldwide tell us what they think is worth reading from the literature

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Research and Reviews in the Fastlane

Welcome to the 95th 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 5 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

Resuscitation, Critical Care, Emergency MedicineR&R Hall of Famer - You simply MUST READ this!Brewer JM, et al. Can Vasopressors Safely Be Administered Through Peripheral Intravenous Catheters Compared With Central Venous Catheters? Ann Emerg Med 2015. PMID: 26210381

  • This systematic review snapshot examines the issue of vasopressor use through peripheral lines, and concludes that “Although the safety profile of peripheral administration of vasopressors remains uncertain, most reported adverse events are associated with a distal peripheral site or prolonged duration of administration.”
  • The average time of pressor infusion before local tissue injury occurred was 56 hours.
  • The take home point is that it seems to be safe and most likely better for the patient to avoid delays in administration of vasopressors by initiating through a peripheral line. If pressors are more than a short term need a central line should be placed.
  • Recommended by: Jeremy Fried

The Best of the Rest

Emergency Medicine, RadiologyMervak BM et al. Rates of Breakthrough Reactions in Inpatients at High Risk Receiving Premedication Before Contrast-Enhanced CT. Am J Roent 2015; 205(1):77-84. PMID: 26102383

  • This article reveals the lack of knowledge about contrast reactions, but also reinforces the real risk of repeat reactions despite treatment. The authors found that despite premedication, patients with a history of a prior reaction were still at a significantly increased risk of a recurrent reaction. The bottom line is that premedication may not work. Be ready to treat these patients aggressively if symptoms occur.
  • Recommended by:Daman Langguth

Emergency Medicine, RespiratoryRaja AS, et al. Effects of Performance Feedback Reports on Adherence to Evidence-Based Guidelines in Use of CT for Evaluation of Pulmonary Embolism in the Emergency Department: A Randomized Trial. Am J Roentgenol. 2015;1-5. PMID: 26204114

  • We know we order too many CTPAs for pulmonary embolism (PE) in the United States but changing provider behavior is difficult. These authors randomized providers to a control group or to an intervention of quarterly, individualized feedback on adherence to guidelines for CTPA ordering. They found a statistically significant 6.9% absolute increase in ordering adherence in the intervention group, with 85% adhering to the guidelines following the intervention. Timely, individualized feedback is likely one component to improving the implementation of evidence based guidelines for PE workup.
  • Recommended by: Lauren Westafer

Wilderness MedicineHew-Butler T et al. Statement of the Third International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Clin J Sport Med. 2015; 25(4): 303-20. PMID: 26102445 (FREE OPEN ACCESS ARTICLE)

  • A consensus guideline from a meeting of experts that encapsulates the state-of-the-art in understanding exercise-associated hyponatraemia (EAH). Athletes are still at risk of potentially fatal consequences from drinking too much water during exercise. Disturbingly, more cases of EAH are occurring with ‘non-endurance’ physical activity – even Bikram Yoga! This free-to-access paper tells you everything you need to know about how to diagnose and manage EAH, and includes explanations of the physiology that underpins this enigmatic condition. Don’t drink too much during exercise, “drink to thirst”!
  • Recommended by: Chris Nickson
  • Read More: Test yourself on LITFL’s updated Environmental Enigma 001

Emergency Medicine, UrologyFuryk JS et al. Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial. Ann Emerg Med. 2015. PMID: 26194935

  • Tamsulosin (Flomax) has been prescribed to patients with renal colic for the better part of a decade despite minimal good evidence to support its use. This is another paper showing no benefit in all comers with ureteral colic to medical expulsive therapy (MET) with tamsulosin. There is a suggestion of benefit in a small subgroup (distal stones > 5 mm) but this group can only be identified by CT; a study that’s typically unnecessary in standard ureteral colic management.
  • Recommended by: Anand Swaminathan
  • Read More: The Adventure of the Impassable Stone (EM Nerd); And the Stoning Continues (EM Lit of Note); Medical Expulsion Therapy with Tamsulosin in Ureteral Colic (emdocs.net)

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.

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Concussion in Sport 2015 http://lifeinthefastlane.com/concussion-in-sport-2015/ http://lifeinthefastlane.com/concussion-in-sport-2015/#respond Wed, 12 Aug 2015 12:14:59 +0000 http://lifeinthefastlane.com/?p=139835 Concussion in rugby: An overview and ethical considerations - guest post by Tane Eunson

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Concussion in rugby: An overview and ethical considerations – is a guest post by Tane Eunson – a student of the game (5th year M.B.B.S.)

Sports related concussions are in the spotlight more than ever with extensive media coverage and record settlements making headlines worldwide. As rugby’s showpiece quadrennial event fast approaches, we look at an overview of concussion in rugby and the ethical issues surrounding it.

To tackle this issue head on, we must first understand what concussion is. A panel of medical and neurological experts, the “Zurich Group”, at the 4th International Conference on Concussion in Sport in 2012 defined concussion as “a complex pathophysiological process affecting the brain, induced by biomechanical forces” [Reference McCrory et al PDF].

International rugby’s governing body, “World Rugby”, promotes a more useable definition for the layman: “a traumatic brain injury resulting in a disturbance of brain function… common symptoms being headache, dizziness, memory disturbance or balance problems” [Reference]. Importantly, this latter definition also effectively conveys the seriousness of the event with “a traumatic brain injury”.

A 2014 meta-analysis of concussion in rugby found an overall incidence of 4.73 concussions per 1,000 player match hours. This is a particularly high incidence and there are over 200,000 registered rugby players on both sides of the Tasman strapping on the boots each weekend, so we understand concussion is a common injury [PMID 25138311]. Additionally, updated 2014 guidelines for the management of sports-related concussion in Australian general practice summarised the associated complications of concussion into 5 points. [Reference]

  • Impaired performance and increased risk of injury on return to play: Slowed reaction times and cognitive deficits may lead to increased risk of further injury.
  • Acute, progressive diffuse cerebral oedema:
    Also known as ‘second impact syndrome’ where the brain can fatally swell following repeated trauma when the initial insult was not noted.
  • Prolonged symptoms:
    There is level 2 evidence that 5-10% of concussed athletes take >10 days to recover and approximately 1% take >3 months.
  • Depression and other mental health issues:
    Evidence exists for a 2-3x increase in relative risk of clinical depression in retired footballers.
  • Cumulative cognitive deficits i.e. Chronic traumatic encephalopathy (CTE): Recurrent head trauma has been associated with progressive deterioration in brain function.

The final complication, CTE, may be the most damaging in the long-term and illuminates how little we actually now about the chronic effects of concussion. For instance, we know very little about the type, amount or frequency of force required to induce a pathological process. However, we think repeated insults are a major risk factor and that early return to play has poorer outcomes.

Despite our knowledge gaps, CTE has recently worked its way into the lay press and NFL vernacular. This follows a tragic spate of retired player’s suicides linked to CTE and a $1 billion dollar settlement on the back of a 2011 lawsuit alleging “the NFL knew or should have known players who sustain repetitive head injuries are at risk of suffering… early-onset of Alzheimer’s Disease, dementia, depression, deficits in cognitive functioning, reduced processing speed, attention, and reasoning, loss of memory, sleeplessness, moods swings, personality changes, and the debilitating and latent disease known as Chronic traumatic encephalopathy.” [Reference] The settlement is to support retired NFL players who may experience detrimental health effects later in life likely linked to prior head injury.

Therefore, we have a broad definition and a modest understanding of concussion’s deleterious effects, but how de we first diagnose it?

In short: with difficulty.

The signs and symptoms of concussion can vary, can evolve over days and are largely non-specific. There is no objective marker to test for and hence diagnosis is significantly based on clinical assessment. To facilitate assessment, the ‘Zurich Group’ recommended use of the Standardised Concussion Assessment Tool 3rd edition (SCAT3) [Reference PDF]. The SCAT 3 is a checklist including Glasgow Coma Scale, Maddocks questions, symptom evaluation and cognitive assessment, with neck, balance and co-ordination examinations. [Reference] It is to be used by a medical practitioner in the event of a suspected concussion, but it is still not a diagnostic tool. Ultimately, diagnosis remains the premise of the practitioner’s clinical judgement, regardless of the SCAT3’s findings.

In the quest to develop accurate concussion guidelines, rugby is also using the Head Injury Assessment Tools (HIA 1, 2, 3) [Reference] and the King-Devick test [PMID 25748294], which can be downloaded as an app on iPad or iPhone. Additionally, recent advances allow sideline medical professionals to immediately review video footage of Super Rugby and International matches for signs suggestive of concussion; such as loss of consciousness, impaired balance and abnormal posturing.

Hence, once we have done our best to diagnose what we believe is a concussion and the player is medically stable, what next?

World Rugby emphasises the seriousness of a concussive event and endorses the advice “rest the body, rest the brain”. This entails the player not returning to the field of play and then progressing through the 6 stages of the ‘Graduated Return To Play protocol (GRTP)’. This protocol takes approximately 1 week to complete if each stage is readily achieved and the player must receive medical clearance before returning to play. Although new guidelines will be in place for the RWC2015 which suggest minimum of one week rest prior to the start of the GRTP unless advanced level of concussion care is available.

Thus, we have an idea of what we are looking for, with the inclination that it has serious long-term effects and how best to approach it with our current knowledge. However, overshadowing these components are a number of ethical issues one must concurrently negotiate.

One of the core values underpinning medical ethics is the patient’s autonomy to choose or refuse treatment. In the case of a suspected concussion, the player relinquishes this autonomy to paternalistic decision-making. Without negotiation, a concussed player is removed from the field of play, sometimes overtly disapprovingly, for monitoring and management. In this instance, where we really aren’t sure what the full effects of concussion are, is it justified to take control of another person’s autonomy?

Informed consent is closely related to autonomy and is when one is presented with all the pertinent information such that they can deliberate and make a decision on a course of treatment11. In the heat of action, informed consent can fall by the wayside, particularly in the case of concussion where players may not have the faculties to deliberate and make clear decisions.

Another core ethical value is beneficence, where the practitioner must act in the best interest of the ‘patient’. Often coupled with beneficence is the notion of non-maleficence, where one should do no harm11. These are particularly complex issues given the lack of understanding surrounding exactly how harmful concussion is and how best to manage it. Compounding the issue in professional sport is the butterfly effect that a single performance can have on an athlete’s or team’s fortunes. In this situation another ethical issue known as double effect can occur, where a single action can have two consequences. For instance, is removing a star player from the game saving them from CTE in their retirement but also squandering the hopes of a championship?

This notion leads into perhaps the most pervasive and delicate ethical issue facing doctors in professional sport; ‘conflict of interest’. The doctor has an immediate obligation to the player, but is also obligated to the team, the management and the shareholders. Complicating things further is the inherent and pervasive presence of financial reward in professional sport. When multiple parties apply conflicting pressure, whose needs does the doctor oblige and how do they make that decision?

The keys are:

  • increasing understanding through ongoing research,
  • education, and
  • the presence of a neutral practitioner

To deny someone’s autonomy, we should be confident that we are acting in his or her best interests. We become more confident of this when we know we are acting with beneficence and non-maleficence. At present, research indicates we likely are acting in this manner, but we need clarity from further research into recognition, management and complications. Learning from and collaborating with research in other contact sports, such as NFL and NRL, will facilitate progression and development.

When we can develop more accurate and accessible testing protocols, with a deeper appreciation of what the acute and chronic effects are, then we can optimise management and educate those involved. Education leads to ‘buy-in’ and this is required from top-tier management, to the medical practitioners, to the players. When we have buy-in, especially from the players, then we have trust and understanding that leads to informed consent. Consent in this instance need not be left entirely to the playing field; instead the foundations should be laid in the classroom.

The final issue of conflict of interest can be partly addressed by the presence of a ‘neutral’ game day doctor. The neutral doctor wields powers to remove any player from the field to be tested for concussion. By having neutrality, they are largely immune to conflicts of interest, while also absorbing some pressure placed on the team doctor. This process has already been implemented at the professional level of Super Rugby and Internationals.

In summary, concussion is a traumatic brain injury that is commonly encountered in the sport of rugby union. Despite being commonplace, much research is required surrounding concussion’s long-term effects and how best to diagnose and manage it. World Rugby has aligned themselves with the ‘Zurich Group’ for current best practise guidelines, such as the SCAT and the “Graduated Return to Play” protocol. Medical practitioners involved with concussed players need to be aware of ethical considerations such as autonomy, informed consent, beneficence, non-maleficence, and conflict of interest. With increased understanding via research and collaboration, educating all key stakeholders and with the presence of an impartial medical party, the rugby medical practitioner can approach these issues with confidence.

References:

  1. Paul McCrory et al. Consensus Statement on Concussion in Sport-the 4th International Conference on Concussion in Sport Held in Zurich, November 2012. Clinical Journal of Sport Medicine. 2013;23(2):89-117. [PDF]
  2. World Rugby. Concussion Guidance for the General Public. 2015 [21/07/2015]. [Reference]
  3. Andrew J Gardner, Grant L Iverson, W Huw Williams, Stephanie Baker, Stanwell. P. A Systematic Review and Meta-Analysis of Concussion in Rugby Union. Sports Medicine. 2014;44:171-1731. [PMID 25138311]
  4. Michael Makdissi, Gavin Davis, Paul McCrory. Updated guidelines for the management of sports-related concussion in general practice. Australian Family Physician. 2014;43(3). [Reference]
  5. United States District Court. National Football Players’ Concussion Injury Litigation. 2011. [Reference]
  6. Consensus statement: SCAT3. British Journal of Sports Medicine. 2013;47(5):259. [Reference]
  7. International Rugby Board. Head Injury Assessment Tool. [Reference]
  8. D. King, C. Gissane, P.A. Hume, M. Flaws. The King-Devick test was useful in management of concussion in amateur rugby union and rugby league in New Zealand. Journal of the Neurological Sciences. 2015;351:58-64. [PMID 25748294]
  9. Australia Rugby. Concussion Management Fact Sheet. 2012. [Reference]
  10. Edward Doe. In: A systematic review of guidelines for graduated return to play following concussion or suspected concussion in rugby union., 2015 University of York.
  11. Michael Boylan. Medical Ethics 2nd edition. 2013
  12. D. Testoni, C.P. Hornik, P.B. Smith, D.K. Benjamin Jr, R.E. McKinney Jr. Sports Medicine and Ethics. american Journal of Bioethics. 2013;13(10):4-12.

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LITFL Review 192 http://lifeinthefastlane.com/litfl-review-192/ http://lifeinthefastlane.com/litfl-review-192/#comments Sun, 09 Aug 2015 20:21:01 +0000 http://lifeinthefastlane.com/?p=139589 Welcome to the 192nd LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the web

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LITFL review

Welcome to the 192nd 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

resizerAn excellent review from St. Emlyn’s of the NICE guidelines in major trauma. Far more progressive than ATLS. [AS]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMtox Toxicology

The Best of #FOAMped Paediatrics

  • Damian Roland shares his thoughts about the use of patient videos to help us learn. After all, history taking involves much more than just the words that come out the patient’s mouth, [TRD]

The Best of #FOAMim Internal Medicine

  • Latest in the Louisville Lecture series on thyroid disease [ML]
  • Ever wondered why we order CRP and ESR and what the results really mean for our patients? This superb review from foam4GP will tell you what you want to know. [SL]

The Best of Medical Education and Social Media

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

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Funtabulously Frivolous Friday Five 111 http://lifeinthefastlane.com/funtabulously-frivolous-friday-five-111/ http://lifeinthefastlane.com/funtabulously-frivolous-friday-five-111/#respond Fri, 07 Aug 2015 07:36:04 +0000 http://lifeinthefastlane.com/?p=135612 More good old fashioned medical trivia with Funtabulously Frivolous Friday Five 111

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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 111

Question 1

You notice a unusual looking, reddish, fern-like design on a friend’s shoulder. You assume that it is a ‘henna tattoo’…but it is not. What is it, how did she get it and how long will it last?
lichtenberg figure

  • Lichtenberg figures
  • Also known as called “lightning flowers” can appear across the skin after being struck by lightning.
  • They are transient and fade after a few days. [Reference]

Question 2

What are the Greville Chester great toe and Cairo toe examples of?

  • Prosthetics
  • These are the earliest example of prosthetics – artificial toes found on mummified bodies, made from linen glue and plaster.
  • They helped you keep your thongs on!! [Reference]

 

cairo toe

Question 3

“Kids are different today, I hear every mother say. Mother needs something today to calm her down and though she’s not really ill, there’s a little yellow pill. She goes running for the shelter of a mother’s little helper, and it helps her on her way, gets her through her busy day” What is Mother’s little helper? Who wrote the song?

  • Diazepam.
  • Mick Jagger/Keith Richards wrote the song and it was released in 1966. [Reference]

Rolling stones

Question 4

Thomas Wharton is bringing dessert to your dinner gathering, what might you expect and what is it made from?

  • Jelly
  • Wharton’s jelly is a mucopolysaccharide based substance found in the umbilical cord and in the eye.
  • When it is exposed to temperature changes it collapses structures within the umbilical cord, thus acting as a physiological clamp approximately 5 minutes after birth.
  • Let’s hope he brings ice cream instead. [Reference]

Question 5

It’s not one you might have in your procedure log, but what is the “intracarotid sodium amobarbital procedure” used for? Bonus point for the test’s eponymous name.

  • It’s a diagnostic procedure to determine which hemisphere is dominant for speech (and memory/cognitive processing)
  • Used prior to undergoing surgical procedures for epilepsy.
  • The test helps determine whether an awake craniotomy is required.
  • Otherwise known as the Wada test named after Canadian neurologist and epileptologist – Dr Juhn Atsushi Wada [Reference]

…and in other news

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

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Research and Reviews in the Fastlane 094 http://lifeinthefastlane.com/research-and-reviews-in-the-fastlane-094/ http://lifeinthefastlane.com/research-and-reviews-in-the-fastlane-094/#comments Wed, 05 Aug 2015 23:23:45 +0000 http://lifeinthefastlane.com/?p=138889 Research and Reviews (R&R) in the FastLane 94th edition - experts worldwide tell us what they think is worth reading from the literature

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Research and Reviews in the Fastlane

Welcome to the 94th 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 5 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

Critical CareR&R Hall of Famer - You simply MUST READ this!

Landoni G et al. Mortality in Multicenter Critical Care Trials: An Analysis of Interventions With a Significant Effect. Crit Care Med 2015; 43(8):1559-68. PMID: 25821918

  • Although completed in 2013, a really interesting ,thought provoking and not to mention practice changing article. Although there are some issues with samples sizes and efforts to blind interventions.This article has significant implications for clinicians translating evidence into practice.
  • 7 decreasing mortality
  1. Noninvasive ventilation (NIV) for specific population with acute respiratory failure
  2. Mild hypothermia after cardiac arrest
  3. Prone positioning
  4. Low tidal volume ventilation in acute respiratory distress syndrome (ARDS)
  5. Tranexamic acid in patients with or at high risk of traumatic hemorrhagic shock
  6. Daily interruption of sedatives in critically ill patients
  7. Albumin administration in cirrhotic patients with spontaneous bacterial peritonitis
  • And 8 shown to increase mortality including hydroxyethyl starch in septic shock, IV salbutamol in ARDS, Supranormal systemic oxygen delivery and intensive insulin therapy.
  • Recommended by: Sa’ad Lahri

The Best of the Rest

Emergency Medicine, Pediatrics, ResuscitationMoler FW et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. NEJM 2015; 372(20): 1898-908. PMID: 25913022

  • Therapeutic hypothermia in children did not confer a statistically significant magnitude of benefit, but it would be erroneous to offer this as proof of lack of efficacy.
  • Recommended by: Ryan Radecki
  • Read More: Chillin’ Children After OHCA (EM Lit of Note)

PediatricsMohanta MP. Growing pains: practitioners’ dilemma. Indian Pediatr 2014; 51(5):379-83. PMID: 24953579

  • Be careful with the child how has leg pain. Is it simply “growing pains?” This is a nice article describing the dilemma we face when jumping on that diagnosis.
  • Recommended by: Sean Fox
  • Read More: Growing Pains (Pediatric EM Morsels)

Emergency Medicine, TraumaJull AB et al. Honey as a topical treatment for wounds. Cochrane Database of Systematic Reviews 2015, Issue 3. PMID: 25742878

  • Honey has being used in the treatment of burns and lacerations for centuries. The authors performed a systematic review of randomized and semi-randomized studies using honey for the treatment of burns vs. other conventional strategies such as colloid dressings. Eleven studies including 3011 patients were analyzed. It appears that there is high-quality evidence indicating that honey is better than dressing and low-quality evidence to support that is better than silver-based products (SBP). Also there is less risk of adverse outcomes using honey than SBP. Sounds like a sweet thing to prescribe!
  • Recommended by: Daniel Cabrera

Pre-Hospital, Resuscitation Ringh M et al. Mobile-Phone Dispatch of Laypersons for CPR in Out-of-Hospital Cardiac Arrest. NEJM 2015; 372: 2316-25. PMID: 26061836

  • Mobile phones are ubiquitous so why not use them to contact nearby CPR trained lay people to respond to patients with out-of-hospital cardiac arrest? This Sweedish study investigates the use of this simple technology and found that it significantly increased the number of patients who received CPR out-of-hospital from 48% to 62%. These are exactly the type of interventions we should be focused on in OHCA.
  • 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.

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Simon and Neil get plastered – the Backslab http://lifeinthefastlane.com/practical-guide-to-the-backslab/ http://lifeinthefastlane.com/practical-guide-to-the-backslab/#comments Tue, 04 Aug 2015 00:29:54 +0000 http://lifeinthefastlane.com/?p=138732 Practical guide: How to apply the backslab in adults and paediatrics.

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A practical guide to the application of backslabs, splints, CAM boots and Darco shoes for your paediatric and adult patients.The videos are designed to show you how to do each backslab when required, indications are listed but those that are not are usually discussed with orthopaedics (protocols may vary at different sites). In addition you can follow the links at the bottom for additional tips and videos.

Volar Backslab:

  • Volar plate avulsion fractures
  • Phalangeal fractures
  • Metacarpal fractures

Thumb Spica:

  • 1st Metacarpal fracture
  • Scaphoid fracture (in some shops)

Below Elbow Backslab:

  • Scaphoid fracture (in our shop)
  • Buckle fracture involving the volar surface
  • Distal radius fracture

Buckle Splint:

  • Buckle Fracture only involving a breach in the dorsal cortex

Above Elbow Backslab and 3/4 backslab:

  • Distal radius and ulnar fractures (more than the ulnar styloid)
  • Distal radius fracture with significant angulation
  • Supracondylar fractures (however Gartland I and II are usually placed in a collar and cuff)
  • Medial condyle fracture
  • Olecranon fracture (non-displaced and not involving the joint)
  • Radial neck fractures
  • Mid shaft radius and ulnar fractures

Darco Shoe:

  • Undisplaced Toe Fractures

The CAM Boot:

  • High grade ankle sprains
  • Simple avulsions fracture of the distal fibula
  • Undisplaced salter Harris I or II fractures of the distal fibula
  • Base of 5th Avulsion fractures
  • Undisplaced metatarsal fractures

Below Knee Backslab:

  • Multiple metatarsal fractures
  • Base of 5th fractures that are not avulsion fractures

Above Knee Backslab:

  • Undisplaced Tibial shaft Fractures

Richard Splint:

  • Patella Dislocation
  • Patella Fracture

Additional Resources

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