• Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Van den Berghe G. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011 Aug 11;365(6):506-17. Epub 2011 Jun 29. PMID: 21714640.

EPaNIC trial (MC-PrRCT) -> If you parenterally feed a critically ill patient who is already being enterally fed; they get out of ICU alive a tiny bit earlier, endure 2 days less of ventilation and have fewer infections if you start the PN after 8 days rather than within 48hrs… Um…OK! But shouldn’t most of your patients be out of the ICU by then anyway? Especially if they are mostly cardiac surgery patients! (Survivor treatment bias!!!)

Recommended by Matthew Mac Partlin
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• Young PJ, Saxena M, Beasley R, Bellomo R, Bailey M, Pilcher D, Finfer S, Harrison D, Myburgh J, Rowan K. Early peak temperature and mortality in critically ill patients with or without infection. Intensive Care Med. 2012 Jan 31. [Epub ahead of print] PMID: 22290072.

Hot of the press (pun intended). Early fever is associated with improved outcomes in critically ill patients with infection but with worsened outcomes in those without infection. These data provide the basis for the hypothesis that administration of paracetamol to critically ill patients with fever and infection worsens outcome. This hypothesis is being tested in the HEAT trial.

Recommended by Paul Young

• Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010 Oct;56(4):392-401.e1. PMID: 20868907.

The DORM study is an important step towards rehabilitating the reputation of droperidol in the sedation of agitated patients. Droperidol is an (almost) essential emergency drug that we should not be afraid to use when required.

Recommended by Chris Nickson

• Machi MS, Staum M, Callaway CW, Moore C, Jeong K, Suyama J, Patterson PD, Hostler D. The relationship between shift work, sleep, and cognition in career emergency physicians. Acad Emerg Med. 2012 Jan;19(1):85-91. doi:10.1111/j.1553-2712.2011.01254.x. Epub 2012 Jan 5. PMID: 22221346.

While I have no doubt that being tired contributes to mistakes I suspect this study is testing the wrong thing and misses the fact that when we need to cope we probably do

Recommended by Andy Neill

• Solomon RC. Coffers brimming, ethically bankrupt. Ann Emerg Med. 2012 Feb;59(2):101-2. Epub 2011 Nov 10. PMID: 22078890.

A brilliantly written piece outlining our culpability as physicians and our responsibility to make a stand and pay the moral and financial cost of our involvement with big pharma.

Recommended by Andy Neill

• Allgaier R, Vallabh K, Lahri S. Scurvy: A difficult diagnosis with a simple cure. African Journal of Emergency Medicine (2012): Article in Press

“The life of a pirate wasn’t always full of adventure and partying” … A forgotten disease?

Recommended by Sa’ad Lahri and Chris Nickson
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• Klotz L. How (not) to communicate new scientific information: a memoir of the famous Brindley lecture. BJU Int. 2005 Nov;96(7):956-7. PMID: 16225508.

At once unbelievable, horrifying and a lesson in how to give a talk that no one will ever forget. Left me speechless.

Recommended by Chris Nickson
Learn more: LITFL — How to give an unforgettable talk.
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• Marks V. Murder by insulin: suspected, purported and proven — a review. Drug Test Anal 2009 Apr;1:162-76. PMID: 20355194

With the recent series of suspicious hypoglycemic deaths at Stepping Hill Hospital in Greater Manchester (U.K.), this paper takes on added interest. It summarizes 66 cases of known or suspected insulin poisoning, and makes some important points about the forensic issues involved.

Recommended by Leon Gussow

• James MF, Michell WL, Joubert IA, Nicol AJ, Navsaria PH, Gillespie RS. Resuscitation with hydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma). Br J Anaesth. 2011 Nov;107(5):693-702. Epub 2011 Aug 19. PMID: 21857015.

Cliff Reid saw this paper first but it’s worth reading yourself. Conclusions say colloids better for resus. Actual results say quite the opposite. Great paper to read on obfuscation of a key issue.

Recommended by Andy Neill
Learn more: Resus.ME — FIRST: Fluids in Resuscitation; Emergency Medicine Ireland — Colloids for Resus in Trauma

• Roquilly A, Mahe PJ, Seguin P, Guitton C, Floch H, Tellier AC, Merson L, Renard B, Malledant Y, Flet L, Sebille V, Volteau C, Masson D, Nguyen JM, Lejus C, Asehnoune K. Hydrocortisone therapy for patients with multiple trauma: the randomized controlled HYPOLYTE study. JAMA. 2011 Mar 23;305(12):1201-9. PMID: 21427372.

MC-DB-PrRCT: Intubated polytrauma patients (ISS>15) given 7 day H’cort IVI regime have significant lesser incidence of HAP by 28 days. Also shorter ICU and ventilation and just statistically significant lower incidence of ARDS. Lesser surgical wound infection, but higher incidence of UTI, bacteraemia – all non-statistically significant.

Recommended by Matthew Mac Partlin

• Rosenberg H, Al-Rajhi K. ED ultrasound diagnosis of a type B aortic dissection using the suprasternal view. Am J Emerg Med. 2012 Jan 11. [Epub ahead of print] PMID: 22244228.

Great case report of type B aortic dissection diagnosed on bedside ED ultrasound. There are online video clips from this case: Descending aorta Suprasternal view with color doppler Suprasternal view no color Longitudinal aorta

Recommended by Leon Gussow

• Batchvarov VN, Malik M, Camm AJ. Incorrect electrode cable connection during electrocardiographic recording. Europace. 2007 Nov;9(11):1081-90. Epub 2007 Oct 10. Review. PMID: 17932025.

This paper is a thing of beauty for the ECG nerd – all the ways incorrect lead placement can play havoc with an ECG.

Recommended by Chris Nickson
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• Beck LH. Should the actual or the corrected serum sodium be used to calculate the anion gap in diabetic ketoacidosis? Cleve Clin J Med. 2001 Aug;68(8):673-4. PMID: 11510523.

If only I had a dollar for every time someone has asked me the question this little paper succinctly answers…

Recommended by Chris Nickson
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• Knox J, Cowan R, Doyle J & al. Murray Valley encephalitis: a review of clinical features, diagnosis and treatment. MJ; Epub 23 Jan 2012

For Aussies, good review on Murray River encephalitis – a very scary disease.

Recommended by Ioana Vlad
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• McBride JT. The association of acetaminophen and asthma prevalence and severity. Pediatrics. 2011 Dec;128(6):1181-5. Epub 2011 Nov 7. PMID: 22065272.

Does APAP (aka paracetamol aka acetaminophen) cause asthma? This has bugged me since the ISAAC paper of 2008… Now McBride puts it into perspective for us.  Very Persuasive.

Recommended by Colin Parker
Learn more: empem.org – ISAAC blows wheezy whistle on APAP
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• Humphreys I, Saraiya S, Belenky W, Dworkin J. Nasal packing with strips of cured pork as treatment for uncontrollable epistaxis in a patient with Glanzmann thrombasthenia. Ann Otol Rhinol Laryngol. 2011 Nov;120(11):732-6. PMID: 22224315.

Glanzmann thrombasthenia is a rare platelet disorder that can cause bad nose bleeds. Instead, of ligation perhaps crafting a salted pork nasal tampon is the answer… These authors seem to think so. Is it the salt content, the presence of tissue factor, coincidence or something else?

Recommended by Joe Lex

• Kamp MA, Slotty P, Sarikaya-Seiwert S, Steiger HJ, Hänggi D.  Traumatic brain injuries in illustrated literature: experience from a series of over 700 head injuries in the Asterix comic books.  Acta Neurochir (Wien).  2011 Jun;153(6):1351-5; discussion 1355.  PMID: 21472486.

How far can you stick your tongue in your cheek? “A retrospective analysis of traumatic brain injury (TBI) in all 34 Asterix comic books was performed by examining the initial neurological status and signs of TBI. Seven hundred and four TBIs were identified. The majority of persons involved were adult and male. The major cause of trauma was assault (98.8%). Traumata were classified to be severe in over 50% (GCS 3-8).” And on and on and on…

Recommended by Joe Lex

• van Schalkwyk J, Davidson J, Palmer B, Hope V. Ayurvedic medicine: patients in peril from plumbism. N Z Med J. 2006 May 5;119(1233):U1958. PMID: 16680175.

Alternative medicines may be more than than simply ineffective. Think heavy metal poisoning – in these cases, lead – when you come across a patient taking Ayurvedic medicines.

Recommended by Chris Nickson

• Bhatia R, Morley H, Singh J, Offiah C, Yeh J. Craniocervical stab injury: the importance of neurovascular and ligamentous imaging. Emerg Radiol. 2012 Jan;19(1):83-5. Epub 2011 Nov 29. PMID: 22124685

Brilliant case report on what was pretty much a Brown-Sequard syndrome above C1! The CT images of the knife in the atlas are worth it alone.

Recommended by Andy Neill

• Kumar RD, Hirsch NP. Clinical evaluation of stethoscope-guided inflation of tracheal tube cuffs. Anaesthesia. 2011 Nov;66(11):1012-6. doi: 10.1111/j.1365-2044.2011.06853.x. Epub 2011 Aug 18. PMID: 21851343.

A cool, practical study although patient numbers are small.

Recommended by Sa’ad Lahri

• Bershad EM, Suarez JI. Prothrombin complex concentrates for oral anticoagulant therapy-related intracranial hemorrhage: a review of the literature. Neurocrit Care. 2010 Jun;12(3):403-13. Review. PMID: 19967567.

Recommended by Mike Jasumback

• Latronico N, Bolton CF. Critical illness polyneuropathy and myopathy: a major cause of muscle weakness and paralysis. Lancet Neurol. 2011 Oct;10(10):931-41. Review. PMID: 21939902.

Recommended by Oliver Flower

• Armfield DR, Kim DH, Towers JD, Bradley JP, Robertson DD. Sports-related muscle injury in the lower extremity. Clin Sports Med. 2006 Oct;25(4):803-42. PMID: 16962427

Recommended by Andy Neill

• Hudson ML, Moore GP. Defenses to Malpractice: What Every Emergency Physician Should Know. J Emerg Med 2011;41:598-606. PMID: 21094012

Recommended by Leon Gussow

• Nguyen-Khac E, Thevenot T, Piquet MA, Benferhat S, Goria O, Chatelain D, Tramier B, Dewaele F, Ghrib S, Rudler M, Carbonell N, Tossou H, Bental A, Bernard-Chabert B, Dupas JL; AAH-NAC Study Group. Glucocorticoids plus N-acetylcysteine in severe alcoholic hepatitis. N Engl J Med. 2011 Nov 10;365(19):1781-9. PMID: 22070475.

Recommended by Andy Neill
Learn more: Emergency Medicine Ireland – NAC for alcoholic hepatitis

• Vazirani J, Knott JC. Mandatory Pain Scoring at Triage Reduces Time to Analgesia. Ann Emerg Med. 2011 Sep 9. PMID: 21908072

Recommended by Ioana Vlad

• Mellick LB. Torsion of the Testicle: It Is Time to Stop Tossing the Dice. Pediatr Emer Care 2012;28:80-86. PMID: 22217895

Recommended by Leon Gussow

• Abd-el-Maeboud KH, el-Naggar T, el-Hawi EM, Mahmoud SA, Abd-el-Hay S. Rectal suppository: commonsense and mode of insertion. Lancet. 1991 Sep 28;338(8770):798-800. PMID: 1681170

Recommended by Rob Orman
Learn more: ERCAST – The Suppository Conundrum

• Doyal L. Should the skeleton of “the Irish giant” be buried at sea?. BMJ 2011; 343. PMID: 22187392

Recommended by Ioana Vlad

• Weber JM et al. Can Nebulized Naloxone Be Used Safely and Effectively by Emergency Medical Services for Suspected Opioid Overdose? Prehosp Emerg Care 2011 Dec 22. [Epub ahead of print] PMID: 22191727

Recommended by Leon Gussow

• Nielsen AS, Damek DM. Window of opportunity: Flexion myelopathy after drug overdose. J Emerg Med. 2008 Dec 10. PMID: 19081699

Recommended by Ioana Vlad

• James MF, Michell WL, Joubert IA, Nicol AJ, Navsaria PH, Gillespie RS. James MF, Michell WL, Joubert IA, Nicol AJ, Navsaria PH, Gillespie RS. Resuscitation with hydroxyethyl starch improves renal function and  lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma). Br J Anaesth. 2011 Nov;107(5):693-702. PMID: 21857015

This is the first randomized, controlled, double-blind study comparing crystalloids with isotonic colloids in trauma.

Recommended by Cliff Reid
Learn more: Resus.ME – FIRST: Fluid Resuscitation in Severe Trauma

• Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011 Apr;57(4):375-7. PMID: 20817349

Recommended by Michelle Lin
Learn more: Academic Life in Emergency Medicine – Trick of the Trade: Dental Injury

• Magder SA. The ups and downs of heart rate. Crit Care Med. 2012 Jan;40(1):239-45. PMID: 22179340.

How heart rate affects Everything!… and why tachycardia isn’t always bad.

Recommended by Mike Jasumback

• McPherson PA, McEneny J. The biochemistry of ketogenesis and its role in weight management, neurological disease and oxidative stress. J Physiol Biochem. 2011 Oct 8. [Epub ahead of print] PMID: 21983804.

Ketosis in all its glory! The biochemical basis to manage all forms of ketosis!!

Recommended by Mike Jasumback
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• Walkey AJ, Soylemez Wiener R, Ghobrial JM & al. Incident Stroke and Mortality Associated With New-Onset Atrial Fibrillation in Patients Hospitalized With Severe Sepsis. JAMA. 2011;306(20):2248-2254.
  PMID: 22081378.

Severe sepsis + new onset AF increases mortality. Should we then do something about the AF? Or is it simply a marker of sepsis-induced myocardial dysfunction?

Recommended by Ioana Vlad

• Croskerry P. The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them. Academic Medicine 2003;78:775-780. PMID: 12915363.

You won’t be able to avoid cognitive errors such as anchoring, confirmation bias, psych-out error, and Yin-Yang out unless you’re aware of them. Pat Croskerry gives suggestions on tuning up your medical decision-making.

Recommended by Leon Gussow

• Dhaliwal G. The Mechanics of Reasoning. JAMA 2011;306:918-919. PMID: 21900128.

You’ll be surprised at who the best diagnostician(s) on television or radio is. (Hint: it’s not Dr. House or Dr. Oz)

Recommended by Leon Gussow
Learn more: The Poison Review — The Mechanics of Reasoning

• Jain S, Ting HT, Bell M, Bjerke CM, Lennon RJ, Gersh BJ, Rihal CS, Prasad A. Utility of left bundle branch block as a diagnostic criterion for acute myocardial infarction. Am J Cardiol. 2011 Apr 15;107(8):1111-6. Epub 2011 Feb 4. PMID: 21296327.

Time for a change in the guidelines…? Perhaps “New LBBB” at predicting acute MI will have a class downgrade.

Recommended by Sa’ad Lahri

• Keller T, Zeller T, Ojeda F, et al. Serial changes in highly sensitive troponin I assay and early diagnosis of myocardial infarction. JAMA. 2011 Dec 28;306(24):2684-93. PMID:
  22203537.

Magical thinking with increased sensitivity and no decrease in specificity – picked up by the popular media as the greatest thing since sliced bread.

Recommended by Ryan Radecki
Learn more: Emergency Medicine Literature of Note — Yet another highly sensitive troponin

• Kanani A, Schellenberg R, Warrington R. Urticaria and angioedema. Allergy, Asthma & Clinical Immunology 2011 Nov.;7(Suppl 1):S9. PMID: 22165855.

Someone on Twitter linked this and I can’t remember who but it’s a nice summary of urticaria. Even better it justifies that what i do (1st gen, 2nd gen anti-hist, H2 blockers and steroids) are all ok to give together.

Recommended by Andy Neill

• Norman E et al. Rapid Sequence Induction is Superior to Morphine for Intubation of Preterm Infants: A Randomized Controlled Trial. J Pediatr 2011;159:893-9. PMID: 21798556.

Many neonatologists use no drugs for intubating preemies (…and they seem like such nice people!). This is a small RCT but well done study that shows an RSI drug combo was not only safe, it was much better than morphine and atropine alone.

Recommended by Clay Smith
Learn more: Keeping Up with Emergency Medicine — RSI drugs for neonates

• Chumpitazi BP et al. Creation and Initial Evaluation of a Stool Form Scale for Children. J Pediatr 2010;157(4):594-7. PMID: 20826285PMCID:

  PMC2937014.

Wow! The pictures and descriptions of pediatric poo in this article will leave you laughing for a long time!

Recommended by Clay Smith
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• Zier JL, Liu M. Safety of high-concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases. Pediatr Emerg Care. 2011 Dec;27(12):1107-12. PMID: 22134227.

Nitrous oxide – it’s time we had this routinely available as a safe, non-invasive tool for sedation.

Recommended by Ryan Radecki
Learn more: Emergency Literature of Note — Why aren’t you using nitrous yet?

• Stanaway FF, Gnjidic D, Blyth FM, Le Couteur DG, Naganathan DG, Waite L, Seibel MJ, Handelsman DJ, Sambrook PN, Cumming RG. How fast does the Grim Reaper walk? Receiver operating characteristics curve analysis in healthy men aged 70 and over. BMJ. 2011 Dec 15;343:d7679. doi: 10.1136/bmj.d7679. PMID: 22174324 PMCID: PMC3240682

Clever trial with practical advice … as long as your sense of humour is intact.

Recommended by Matthew Mac Partlin
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• Schultz JC, Segal N, Caldwell E, et al. Sodium nitroprusside-enhanced cardiopulmonary resuscitation improves resuscitation rates after prolonged untreated cardiac arrest in two porcine models. Crit Care Med. 2011 Dec;39(12):2705-10. PMID: 21725236.

It’s coming – nitroprusside as a component of ACLS.

Recommended by Ryan Radecki
Learn more: Emergency Medicine Literature of Note — Nitroprusside saves pigs, how about people?

• Walden AP, Nielsen N, Wise MP. Does the evidence support the use of mild hypothermia after cardiac arrest? No. BMJ. 2011 Sep 23;343:d5889. doi:10.1136/bmj.d5889. PMID: 21948589.

Viva agnosticism! Paving the way for the TTM trial

Recommended by Oliver Flower

• Eddleston M, Buckley NA, Eyer P, Dawson AH. Management of acute organophosphorus pesticide poisoning. Lancet. 2008 Feb 16;371(9612):597-607. Review. PMID: 17706760; PMCID: PMC2493390.

Landmark summary paper on Organophosphate poisoning

Recommended by Oliver Flower
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• Craig M, Jeavons R, Probert J, Benger J. Randomised comparison of intravenous paracetamol and intravenous morphine for acute traumatic limb pain in the emergency department. Emergency Medicine Journal 2011 Mar.; PMID: 21362724.

I always really doubted that this stuff works but there’s a couple now suggesting that at least it’s not terrible. Bigger trial needed definitely. Personally I’d want morphine though!

Recommended by Andy Neill

• Kwon A, Sorrells DL Jr, Kurkchubasche AG, Cassese JA, Tracy TF Jr, Luks FI. Isolated computed tomography diagnosis of pulmonary contusion does not correlate with increased morbidity. J Pediatr Surg. 2006 Jan;41(1):78-82; discussion 78-82. PMID: 16410112.

Pulm Contusion is the #1 thoracic injury sustained in Pediatric trauma patients. Depending on the amount of lung involved, it may lead to substantial M&M. How should you image it? CXR wins in this study. CT did define the injury early and more precisely; however, clinical outcomes like ICU days and ventilator days did not correlate with CT findings, but rather did so with CXR findings.

Recommended by Sean Fox
Learn more: Pediatric EM Morsels — Pulmonary contusion

• Zonfrillo MR, Roy AD, Walsh SA. Management of pediatric penetrating oropharyngeal trauma. Pediatric Emergency Care. 2008 Mar;24(3):172-5. PMID: 18347498.

Seriously, why do kids run around with sticks in their mouths? And what do you do when the stick stabs the tonsil?

Recommended by Sean Fox
Learn more: Pediatric EM Morsels — Pediatric oropharyngeal trauma

• Philip J, Bresnihan M, Chambers N. A Christmas tree in the larynx. Paediatr Anaesth. 2004 Dec;14(12):1016-20. PMID: 15601352.

More festive dangers… Maybe Christmas should be canceled?

Recommended by Chris Nickson
Learn more: LITFL — Christmas Canceled?

• Bartlett RH. A critical carol. Being an essay on anemia, suffocation, starvation, and other forms of intensive care, after the manner of Dickens. Chest. 1984 May;85(5):687-93. PMID: 6713979.

“Starling was dead.  Crown Prince of Physiology, discoverer of hormones, physical alchemist of the interstitial space, seeker of truth, finder of wisdom, man of the heart.  Starling was dead as a doornail.”  Thus begins one of the best articles I have ever read in the Critical Care literature.  As the author explains the logic behind treatment of his patient Charles Cratchitt, he is visited by the ghost of Ernest Starling who tediously guides him through the perils of anemia, suffocation, malnutrition and other iatrogenic complications of intensive care.  It is a must-read.

Recommended by Joe Lex
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• Lewis DW. What was wrong with Tiny Tim? Am J Dis Child. 1992 Dec;146(12):1403-7. PMID: 1340779.

Tiny Tim in Dickens’ “A Christmas Carol” was small in stature, so weak he had to be carried around by his father Bob Cratchit, and on the road to death if he did not receive proper therapy. This article proposes that Tiny Tim suffered from distal renal tubular acidosis (type 1), an illness characterized by growth impairment, osteomalacia, and hypokalemic muscle weakness. Although the pathophysiology was not known in Dickens’ time, the condition was often treated with tonics including sodium bicarbonate.  Other authors have suggested Tim suffered from rickets.

Recommended by Leon Gussow

• Willis FR, Adams SL, Doyle S, Everitt IJ, Lovegrove M, Slee J, Sparrow A, Willis J. Children’s Nomenclatural Adventurism and Medical Evaluation study. J Paediatr Child Health. 2009 Dec;45(12):711-4. PMID: 20415998.

A study showing there is a real risk in having weird names!

Recommended by Meredith Borland

• Yanchar N, Pianosi P, Fraser R. Oh Christmas tree, oh Christmas tree … CMAJ. 2004 Dec 7;171(12):1435-6. PMID: 15583176;  PMCID: PMC534571.

Christmas trees and bronchial trees should not mix… A reminder that: “The holiday season is a time for children to explore and taste new things.”

Recommended by Chris Nickson
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• Calver LA, Stokes BJ, Isbister GK. The dark side of the moon. Med J Aust. 2009 Dec 7-21;191(11-12):692-4. PMID: 20028313.

How bad would it be if there was a full moon on New Year’s eve? In this study, violence and acute mental disturbance were associated with a full moon!

Recommended by Trevor Jackson
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• Hayden GF. Alliteration in medicine: a puzzling profusion of p’s. BMJ. 1999 Dec 18-25;319(7225):1605-8. PMID: 10600957; PMCID: PMC28305.

Perhaps people ponder periodically whether whimsical works will inspire, irritate, ignite or influence the lucky lads and ladies at LITFL? Looks likely.

Recommended by Mike Cadogan
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• Waldfogel J. The Deadweight Loss of Christmas. The American Economic Review. Vol. 83, No. 5 (Dec., 1993), pp. 1328-1336

This paper explains why giving gifts is a microeconomic faux pas – just gimme cold hard cash!

Recommended by Trevor Jackson

• Innes G. Successful hospitalization of patients with no discernible pathology. CJEM. 2000 Jan;2(1):47-51. PMID: 17637127.

The classic paper that serves as a nice little reminder about how we can give great gifts to our inpatient colleagues.

Recommended by Andy Brainard
Learn more: LITFL — Patients without discernible pathology
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• Bala TM, Panda M. No poinsettia this Christmas. South Med J. 2006 Jul;99(7):772-3.  PMID: 16866065.

Poinsettia, a common decorative plant at Christmas time, shares several protein allergens with latex. Patients with latex allergy can develop contact dermatitis or bronchospasm when exposed to poinsettia.

Recommended by Leon Gussow

• Krenzelok EP, Jacobsen TD, Aronis J. American mistletoe exposures. Am J Emerg Med. 1997 Sep;15(5):516-20. PMID: 9270395.

The common belief that mistletoe is extremely toxic is a medical myth.

Recommended by Leon Gussow

• Furyk JS, O’Kane CJ, Aitken PJ, Banks CJ, Kault DA. Fast versus slow bandaid removal: a randomised trial. Med J Aust. 2009 Dec 7-21;191(11-12):682-3. PMID: 20028307.

Your mother was right – ripping those band aids off fast is less painful!

Recommended by Peter Allely
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• Burls A, Cabello JB, Emparanza JI, Bayliss S, Quinn T. Oxygen therapy for acute myocardial infarction: a systematic review and meta-analysis. Emerg Med J. 2011 Nov;28(11):917-23. Epub 2011 Feb 23. Review. PMID: 21346260.

The authors looked in vain for articles showing that oxygen therapy was beneficial for patients with acute coronary syndromes.  Their conclusion: not only was supplemental oxygen not beneficial, it was probably harmful.  I think we will have a hard time making this one go away, though.

Recommended by Joe Lex

• Grise EM, Adeoye O, Lindsell C, Alwell K, Moomaw C, Kissela B, Flaherty M, Ferioli S, Khatri P, Broderick J, Kleindorfer D. Emergency Department Adherence to American Heart Association Guidelines for Blood Pressure Management in Acute Ischemic Stroke. Stroke. 2011 Oct 27. [Epub ahead of print] PMID: 22033993.

Remember blood pressure shouldn’t be lowered acutely in acute ischemic stroke – we’re not doing a very good job of it.

Recommended by Ryan Radecki
Learn more: Emergency Literature of Note — ED BP management in acute stroke

• Rémi J, Pfefferkorn T, Owens RL, Schankin C, Dehning S, Birnbaum T, Bender A, Klein M, Adamec J, Pfister HW, Straube A, Feddersen B. The crossed leg sign indicates a favorable outcome after severe stroke. Neurology. 2011 Oct 11;77(15):1453-6.  PMID: 21987641;   PMCID: PMC3198984.

For some time, I’ve been vowing to study the fact that if a patient crosses their legs while waiting to be seen, he will have no actual pathology. I always thought the IRBs would refuse to allow me to prove this important clinical sign. Well these folks managed to get it done. It is not an ED study; it is on stroke patients during admission. And there are all sorts of confounders for what I wanted to prove like you need to be able to move your legs in order to cross them, etc. But I don’t care, I now have more ammunition to get my study through the IRB.

Recommended by Scott Weingart

• Yanaka K, Nose T. Braid dressing for hair-bearing scalp wound. Neurocrit Care. 2004;1(2):217-8. PMID: 16174919.

How do you apply bandages to scalp lacerations? Do they just fall off within minutes? This “hair-braid dressing” technique is a tip from the Neurosurgical literature.

Recommended by Michelle Lin
Learn more: Academic Life in Emergency Medicine — Trick of the trade: Bandaging scalp wounds

• Green T, Green H, Scandlyn J, Kestler A. Perceptions of short-term medical volunteer work: a qualitative study in Guatemala. Global Health. 2009 Feb 26;5:4. PMID: 19245698; PMCID: PMC2662818.

Read this if you are doing short term volunteer work in International Emergency Medicine

Recommended by Chris Curry

• Holloway KA. Combating inappropriate use of medicines. Expert Rev Clin Pharmacol. 2011 May;4(3):335-48. PMID: 22114780.

If you are interested in Global Health read this for the big picture: “Globally, it is possible that less than half of all patients are treated in compliance with guidelines and more than half of all patients fail to take their medicines as prescribed or dispensed.”

Recommended by Chris Curry

• Janneck L, Koyfman A , Takayesu JK. Clinical review of malaria for the emergency physician. African Journal of Emergency Medicine Volume 1, Issue 3, September 2011, Pages 126-130.

A fantastic review of malaria, especially pertinent to the Emergency Physician in the developing world.

Recommended by Sa’ad Lahri
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• Shah SS, Aronson PL, Mohamad Z, Lorch SA. Delayed acyclovir therapy and death among neonates with herpes simplex virus infection. Pediatrics. 2011Dec;128(6):1153-60. Epub 2011 Nov 28. PMID: 22123868.

If you are concerned for HSV in a neonate, send HSV PCR and start the Acyclovir.  Don’t do one without the other. The literature on this topic is generally sparse, but this article reinforces the need to start acyclovir early on (say, in the ED). Other literature also supports the fact that if we don’t consider the therapy in the ED, there is a significant delay in it getting started upstairs.

Recommended by Sean Fox
Learn more: AAEM guidelines — During the Emergency Department Evaluation of a Well Appearing Neonate (<30 days of age) with a Fever, Should Empiric Acyclovir be Initiated?;  Pediatric EM Morsels — Neonatal HSV

• Mallon W. The Life Cycle of a Parasitic Specialist. Emergency Physicians Monthly. [Epub October 4, 2011]

Intemperate, impolitic and juvenalian, this is undoubtedly the most controversial medical essay of the year. A must-read for all fans of gonzo journalism and Jonathan Swift.

Recommended by Leon Gussow
Fultext

• Nicholson TR, Pariante C, McLoughlin D. Stendhal syndrome: a case of cultural overload. BMJ Case Rep. 2009;2009. pii: bcr06.2008.0317. Epub 2009 Feb 20. PMID: 21686859; PMCID: PMC3027955.

As we move into the festive season, full of art and literature, plus start to consider our contributions to #acem2012, it is appropriate to be wary of Stendhal Syndrome.  First described in a Florentine artist, it behoves us all to be wary of the overwhelming psychosis that may be precipitated by the exposure to extraordinary art and beauty.

Recommended by Michelle Johnston
Fultext

• Miller LJ, Philbeck TE, Montez D, Spadaccini CJ. A new study of intraosseous blood for laboratory analysis. Arch. Pathol. Lab. Med. 2010 Sep.;134(9):1253–1260. PMID: 20807043

Seeing as IO access is all the rage, it’s nice to know if we can use the blood we get from them for anything. The answer is yes for Hb, Cl, Gluc, (prob Na) but not K, CO2, plats or WCC. What about pH though? Note these were healthy volunteers so these are NORMAL values.

Recommended by Andy Neill
Learn more: Trauma Professional’s Blog — Lab values from intraosseous blood
Fulltext

• Weekes AJ, Quirke DP. Emergency echocardiography. Emerg Med Clin North Am. 2011 Nov;29(4):759-87, vi-vii. Epub 2011 Sep 23.  PMID: 22040706.

This is a good if not terribly detailed review of echocardiography in the emergency department, a modality that is becoming increasingly important. Without echocardiography, it is impossible to completely evaluate patients in shock or with undifferentiated hypotension.

Recommended by Leon Gussow

The normal intra-abdominal pressure (IAP) is between 5-7 mmHg.

In obese persons normal can range from 9-14mmHg.

Intra-abdominal hypertension (IAH) is an IAP ≥ 12 mmHg.

There are 4 grades of IAH.

• Grade I — 12-15 mmHg
• Grade II — 16-20 mmHg
• Grade III — 21-25 mmHg
• Grade IV — >25 mmHg

Abdominal compartment syndrome (ACS) requires NEW organ failure or dysfunction (especially renal) and an IAP >20 mmHg (i.e. Grade III or IV).

ACS occurs infrequently (5-12% of ICU patients), although IAH may be as common as 50%.

ACS is a consequence of:

• decreased abdominal wall compliance (e.g. abdominal surgery esp tight closure or wall haematoma)
• increased abdominal volume (e.g. masses, fluid, colonic dilatation)
• or a combination of both (obesity, pancreatitis, sepsis/shock, burns, abdominal infection).

Primary ACS is due to an intra-abdominal cause whilst secondary ACS is due to an extra-abdominal cause, particularly overzealous fluid resuscitation. It is more common with major abdominal surgery or trauma.

You ask the nurse, “What is his intra-abdominal pressure?” You get a blank look. Whew, finally some breathing space.

She replies, with another question of her own:

“Can you show me how to measure the abdominal pressure?”

Intra-vesicular (intra-bladder) pressure has been shown to correlate accurately with intra-abdominal pressure.

There are commercially available devices to measure IAP, however the most common method involves using a foley catheter (indwelling catheter) and a manometer.

You start by filling the patients’ empty bladder with 50-100ml of sterile saline through the catheter, then allowing the saline to flow back to the clamp. Occlude the catheter and use a Y-connector to attach a normal manometer. Zero the manometer with the patient supine at the midaxillary line or symphysis pubis, at the end of expiration.

From Cheatham and Safcsak 1998 (click image to enlarge)

IAH reduces splanchnic perfusion, resulting in ischaemia to abdominal organs leading to increased mucosal permeability and bacterial translocation from the GI tract. However renal impairment appears to be the most important physiological change, activating the renin, angiotensin and aldosterone pathways, and leading to acute kidney injury.

Other physiological consequences include:

• cardiovascular — increased central venous pressure, decreased venous return and decreased cardiac output
• respiratory — decreased thoracic compliance resulting in increased inspiratory pressures or decreased tidal volumes.
• intracranial — decreased cerebral perfusion pressure (CPP = MAP – ICP) due to cerebral oedema resulting from decreased venous return from the brain.

If ACS develops, mortality is high, approaching 50%.

The mainstay of treatment may be urgent surgical decompressive laparotomy — so call the surgeons!

Conservative measures include:

• improve abdominal wall compliance —e.g.  positioning (head up >20 degrees, avoid prone position), remove constrictive dressings, analgesia/ sedation, neuromuscular blockade
• decompress intraluminal contents — e.g. NG tube, rectal tube, enemas, prokinetics such as metoclopramide, erythromycin or neostigmine infusion, colonoscopic decompression
• treat intrabdominal space occupying lesions — e.g. paracentesis
• correct fluid overload — e.g. fluid restriction, diuresis, colloids, renal replacement therapy
• optimise  abdominal perfusion pressure (APP = MAP – IAP): target APP > 70 mmHg: fluid resuscitation, vasopressors/ inotropes, invasive monitoring

Check out these algorithms from WSACS (they are pdf downloads):

• IAH assessment
• Overview of IAH/ ACS management
• Medical management of IAH/ ACS

• Kessler C, Hockberger R, Kuhn G. PeRLs: Changing the Way We View Lectures. Acad Emerg Med. 2011 Nov;18(11):1191-2. doi: 0.1111/j.1553-2712.2011.01211.x.  PMID: 22092903.

The journal Academic Emergency Medicine is starting a project to post online peer-reviewed lectures on various emergency medicine topics, so that “”there would no longer be a need for every training program to develop lectures on every topic in the didactic curriculum”". An interesting idea, but it seems to me one with significant negatives.

Recommended by Leon Gussow
Learn more: LITFL — Peer Reviewed Lectures

• Seggie J. Revitalising professionalism. S Afr Med J. 2011 Jul 25;101(8):508-9. PMID: 21920118

‘Medical professionalism is not optional. It is an essential part of being a doctor, no matter how many challenges face us.’

Recommended by Sa’ad Lahri
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• Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE; Infectious Diseases Society of America; European Society for Microbiology and Infectious Diseases. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e103-20. Review.  PMID: 21292654.

What antibiotics should you give for simple cystitis, in the world of resistant bugs and regional antibiotic resistance patterns? The ID Society of America and the European Society for Microbiology and Infectious Diseases guidelines sum up the 2010 recommendations.

Recommended by Michelle Lin
Learn more: Academic Life in EM — Paucis Verbis - Antibiotics for cystitis

• Harrison M, Williams M. The diagnosis and management of transient global amnesia in the emergency department.Emerg Med J. 2007 Jun;24(6):444-5. PMID: 17513554; PMCID: PMC2658295.

Transient global amnesia — if these words don’t mean much to you, you’d better read this brief review.

Recommended by Antonio Celenza
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• Rosenberg H, Beck J. Jujitsu kick to the abdomen: a case of blunt abdominal trauma resulting in hematochezia and transient ischemic colitis. Ann Emerg Med. 2011 Aug;58(2):189-91. Epub 2011 Mar 9. PMID: 21392850.

A while back I had a patient who was an Aussie Rules player who presented with haematochezia following a blow to the abdomen during a game. It had settled so I let him home without a scope, and with advice to return if symptoms recurred… In retrospect, I suspect this is what he had.

Recommended by Chris Nickson

• Sarraf KM, Sadri A, Thevendran G, Vedi V. Approaching the ruptured anterior cruciate ligament. Emerg Med J. 2011 Aug;28(8):644-9. Epub 2010 Nov 22. Review. PMID: 21097944.

Great review article on the ACL. Written by a thoughtful orthopod who is happy not to have an MRI on every knee! Full of pearls on anatomy, diagnosis and management.

Recommended by Andy Neill
Learn more: Emergency Medicine Ireland — Tasty morsels of EM #20

• Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011 May 9;171(9):831-7.  PMID: 21555660;   PMCID: PMC3140219.

A really important paper on PE (i know there are too many…) that shows that there has been a big increase in the number of PEs diagnosed over time, but no change in the mortality rate. This implies that we are just finding lots of PEs that don’t seem to kill people…

Recommended by Andy Neill
Learn more: Emergency Medicine Ireland — Time Trends in PE in the US: Evidence of Overdiagnosis

• Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ. 2003 Dec 20;327(7429):1459-61. Review. PMID: 14684649; PMCID: PMC300808.

The perfect paper to have up your sleeve whenever you encounter the tedious refrain “but there are no RCTs supporting that…”

Recommended by Chris Nickson
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• Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med. 2011 Nov;58(5):427-30. Epub 2011 Jul 30. PMID: 21803447.

Is GCS obsolete in emergency medicine? You may well think so after reading this. A potential paradigm shift.

Recommended by Trevor Jackson

• Guzman JA, Sasidhar M, Stoller JK. Caring for VIPs: nine principles. Cleve Clin J Med. 2011 Feb;78(2):90-4. PMID: 21285340.

Provides great insights into how to look after a VIP patient.

Recommended by Chris Nickson
Learn more: LITFL — Emergency Medicine Update December 2011
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• Heller T, Wallrauch C, Lessells RJ, Goblirsch S, Brunetti E. Short course for focused assessment with sonography for human immunodeficiency virus/tuberculosis: preliminary results in a rural setting in South Africa with high prevalence of human immunodeficiency virus and tuberculosis. Am J Trop Med Hyg. 2010 Mar;82(3):512-5. PMID: 20207884; PMCID: PMC2829920.

In developing countries, HIV and TB pose lots of challenges.Tuberculosis in patients with or without advanced HIV infection may present as smear-negative, extrapulmonary and/or disseminated forms. The authors have adapted the E-FAST exam and called it FASH to assist with the diagnosis of extrapulmonary TB.

Recommended by Sa’ad Lahri
Fulltext: html

• Secko MA, Lazar JM, Salciccioli LA, Stone MB. Can junior emergency physicians use e-point septal separation to accurately estimate left ventricular function in acutely dyspneic patients? Acad Emerg Med. 2011 Nov;18(11):1223-6. doi: 10.1111/j.1553-2712.2011.01196.x. Epub 2011 Nov 1.  PMID: 22044429.

Easy way to estimate left ventricular ejection fraction by eyeballing or measuring how close anterior mitral valve leaflet gets to septum on parasternal long view.

Recommended by Leon Gussow
Fulltext: html

• Eifling M, Razavi M, Massumi A. The evaluation and management of electrical storm. Tex Heart Inst J. 2011;38(2):111-21. Review. PMID: 21494516;  PMCID: PMC3066819.

One of my residents came to ask me about how to manage electrical storm. I realized crashingpatient.com has nothing on this. So to keep her busy, I sent her to Rob’s excellent ERCAST on the subject (see external link). Then I searched the blogosphere and immediately came up with an excellent article courtesy of Dr. RW.

Recommended by Scott Weingart
Learn more: ERCAST — V Tach Storm; Dr RW — Managing patient with electrical storm

 

• Mullins ME, Empey M, Jaramillo D, Sosa S, Human T, Diringer MN. A prospective randomized study to evaluate the antipyretic effect of the combination of acetaminophen and Ibuprofen in neurological ICU patients. Neurocrit Care. 2011 Dec;15(3):375-8.  PMID: 21503807

Hot of the press, more evidence supporting ibuprofen and paracetamol for fever in neuro-ICU patients.

Recommended by Oliver Flower

• Cheng VY, Berman DS, Rozanski A, Dunning AM, Achenbach S, Al-Mallah M, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Chinnaiyan K, Chow BJ, Delago A, Gomez  M, Hadamitzky M, Hausleiter J, Karlsberg RP, Kaufmann P, Lin FY, Maffei E, Raff G, Villines TC, Shaw LJ, Min JK. Performance of the Traditional Age, Sex, and Angina Typicality-Based Approach for Estimating Pretest Probability of Angiographically Significant Coronary Artery Disease in Patients Undergoing Coronary Computed Tomographic Angiography: Results From the Multinational Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry (CONFIRM). Circulation. 2011 Oct 24. [Epub ahead of print] PMID: 22025600.

All the classic risk models for coronary artery disease are probably wrong – it’s a lot lower than we thought.

Recommended by Ryan Radecki
Learn more: EM Literature of Note — We overestimate CAD pretest probability

• Green RS, Djogovic D, Gray S, Howes D, Brindley PG, Stenstrom R, Patterson E, Easton D, Davidow JS; CAEP Critical Care Interest Group. Canadian Association of Emergency Physicians Sepsis Guidelines: the optimal management of severe sepsis in Canadian emergency departments. CJEM. 2008 Sep;10(5):443-59. PMID: 18826733.

Sepsis is our “crying baby”… deserves our full attention with lots of TLC. An excellent evidenced based guideline for managing sepsis in the ED! Although written in 2008, it still is useful with a unique style. Perhaps we should be doing this in each of our countries?

Recommended by Sa’ad Lahri

• Toorenvliet BR, Wiersma F, Bakker RF, Merkus JW, Breslau PJ, Hamming JF. Routine ultrasound and limited computed tomography for the diagnosis of acute appendicitis. World J Surg. 2010 Oct;34(10):2278-85. PMID: 20582544; PMCID: PMC2936677.

Appendicitis is a clinical diagnosis…. maybe not so fast!

Recommended by Sa’ad Lahri

• Purssell E. Systematic review of studies comparing combined treatment with paracetamol and ibuprofen, with either drug alone. Arch Dis Child. 2011 Dec;96(12):1175-9. Epub 2011 Aug 24. PMID: 21868405.

Systematic review of studies comparing combined treatment with paracetamol and ibuprofen  - ‘there is little to recommend the unnecessary use of polypharmaceutical methods to treat a symptom that does not require treatment, when effective monotherapies exist.

Recommended by Cliff Reid

• Danzl DF. Flatology. J Emerg Med. 1992 Jan-Feb;10(1):79-88. Review. PMID: 1629596.

A classic paper on an unpleasant subject – farts.  Danzl approaches this sticky subject with tongue firmly planted in cheek, but he’s done his homework well.  This remains the classic article on this unmentionable topic.

Recommended by Joe Lex

• Kahol K, Satava RM, Ferrara J, Smith ML. Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the “preoperative warm-up” effect. J Am Coll Surg. 2009 Feb;208(2):255-68. Epub 2008 Dec 4.  PMID: 19228538.

As a runner I appreciate the value of the warmup. This study shows the value of warmup exercises prior to surgical procedures.  Can we apply this to Emergency Medicine procedures, such as hip enlocations, intubations or suturing?

Recommended by Michelle Johnson

• Campbell SG, Sinclair DE. Strategies for managing a busy emergency department. CJEM. 2004 Jul;6(4):271-6.). PMID: 17382005.

An intangible skill that the new emergency physician is expected to acquire is how to manage a busy ED. This paper makes the intangible tangible!

Recommended by Chris Nickson, Trevor Jackson
Learn more: LITFL — Managing the busy ED
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• Hendey GW, Avila A. The Captain Morgan technique for the reduction of the dislocated hip. Ann Emerg Med. 2011 Dec;58(6):536-40. Epub 2011 Aug 12.  PMID: 21839540.

Seemingly-great hip reduction technique: highly successful in this study, only requires one operator to perform, and where else do you get to talk about a Rum Mascot in medicine?

Recommended by Graham Walker
Learn more:  Gmergency — The Captain Morgan hip reduction

• van der Meijden OA, Gaskill TR, Millett PJ. Treatment of clavicle fractures: current concepts review. J Shoulder Elbow Surg. 2011 Nov 5. [Epub ahead of print] PMID: 22063756.

This is a quick read to make sure we are staying up to speed with what the Orthopods say should be done with one of the most common fractures in children (and adults). Maybe not all clavicle fractures are going to heal “just fine”… make sure you know who’s at risk for poor outcomes.

Recommended by Sean Fox
Learn more:  Pediatric EM Morsels — Clavicle Fractures

• Kazmi RS, Lwaleed BA. New anticoagulants: how to deal with treatment failure and bleeding complications. Br J Clin Pharmacol. 2011 Oct;72(4):593-603. doi: 10.1111/j.1365-2125.2011.04060.x.  PMID: 21752066; PMCID: PMC3195736.

New anticoagulants are coming on the market every month.  A boon to internists and cardiologists, a pain to ER docs who have to deal with the consequences when something goes wrong.  You’re going to see a lot of papers like this in the near future.

Recommended by Joe Lex, Chris Nickson