Welcome to the spectacular 8th edition!
The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team will cast the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle.
The Most Fair Dinkum Ripper Beaut of the Week!
- The ripper of week has to go to Rob’s podcast on paediatric syncope. The interview with Ray Moreno provides you with all you ever wanted to know about paediatric syncope, and is bound to knock the buggie-smugglers of you. Take home points include up to 80% of paediatric syncope are vasodepressor in nature, cardiac causes represent 2-6% of cases, making a screening ECG essential. Key features on history and physical examination for identifying high-risk patients include exercise-related symptoms, a family history of sudden death, a history of cardiac disease, an abnormal cardiac examination, or an abnormal ECG.
The Usual Suspects
- Cliff’ reviews a large study looking at the limitations of emergency resuscitative thoracotomy, which recommends the procedure to be futile and of limited use in the following circumstances:
- Pre-hospital CPR exceeds 10 minutes after blunt trauma without a response
- Pre-hospital CPR exceeds 15 minutes after penetrating trauma without a response
- Asystole is the presenting rhythm and there is no pericardial tamponade
- Finally some decent research is coming out on the effectiveness of the EZ-IO for use in the pre-hospital setting, the difficult access patient, and resuscitating the critically unwell patient. Hopefully with more studies like this will help break down the barriers of reluctance to use this awesome life-saving piece of equipment.
- What are the risk factors for sustaining a cervical spine injury? An extensive study was carried out by CIREN looking at patients who sustained cervical spine injuries; demonstrated showed the following results:
- Older case occupants are at an increased risk of cervical spine injury (CSI)
- Rollover crashes and severe crashes led to a much higher risk of CSI than other types and severity of MVCs
- Seat belt use is very effective in preventing CSI
- Airbag deployment may increase the risk of occupants sustaining a CSI
- Firecracker ingestion and white phosphorus poisoning is the perfect excuse for a quick tox Q-and-A and to mention ‘smoking stool syndrome’.
- Probably the main thing to learn from Verapamil overdose and lipid emulsion therapy: a case report is that some people still haven’t caught on to using high-dose insulin euglyaemic therapy for calcium channel blocker overdoses.
- Cobra Violation: snake venom as a substance of abuse Wow! Hopefully this doesn’t catch catch on in Australia… It turns out there are drug addicts in India who have resorted to getting voluntarily bitten by cobras to help them get high.
- Sex! Jealousy! Poison!: Welcome to the Supreme Court of the United States or how a burned thumb can get you 6 years in prison…. The saga is continued on Slate.
Academic Life in Emergency Medicine
- Want to improve your powerpoint/keynote presentation skills, want to have your audience zooming in on your presentation, check out the review on using Prezi for your presentation’s, and spice thing’s up a bit.
- Do you rely just on your clinical judgement when deciding on which pneumonia patients can be managed as an outpatient or as an inpatient, or do you prefer clinical judgement and a clinical decision rule to support your plan? This weeks Paucis Verbis card looks at pneumonia risk stratification tools.
- Hot off the press, we all come to love EM Practice, now check out EM Critical Care a soon to be released feature series covering all thing’s critical care for the emergency department, looks like it has an impressive editorial board behind it.
- Can your triage nurse clear a patient’s C-spine? Christopher Carpenter knuckles out the facts of a recent large study looking at this concept?. Remember the longer a patient lays in a C-spine collar the more neck pain their going to have when you examine them.
- Do you fly a lot? Did you know your risk from developing a DVT from flying is around 3-12% and up to 60% of DVT related to air travel present asymptomatically. For a nice review on this topic check-out Long Flight? Be Aware of the Risk of VTE.
- Joe’s talk of the week highlights the many ways medication can be administered… Listen to Novel Methods of Delivering Drugs in the ED.
The Rest of the Best
- The Dog and the team are at it again, this time taking a rap to Immunize your children with their important public health message.
- Ever found yourself feeling guilty for not taking the time during a busy shift to educate your nurse, medical student, intern, or resident? Maybe it’s time to try out The Microskills AKA the “one minute preceptor” approach. This five step approach will improve their case presentation skills, your teaching approach, and overall improve the effectiveness of your shift….Try it out today!!!
- Reuben gives you access to a flow chart for managing cardiac arrest in the emergency department, that’s soon to be published in March 2011 update of EM Practice Guidelines.
EMRAP: Educators Edition:
- Patient sign-out is a dangerous time in the shift for both emergency doctors (medico-legal) and for the patient (morbidity and mortality). The February podcast interviews two emergency medicine experts David Carr and Stella Yiu from Toronto, who give you the low-down on improving your patient sign-outs/handovers and decreasing the risk to both yourself, your colleague, and the the patient.
This pearl comes from Mike Winters looking at Haemodynamic Monitoring in the Ventilated Patient
- Consider pulse pressure variation (PPV) as a method to monitor volume responsiveness in your mechanically ventilated ED patients.
- The theory behind PPV:
- When a positive pressure breath is delivered via the ventilator, pleural pressure rises and causes a decrease in venous return, right heart filling, and right heart output.
- Simultaneously, the positive pressure breath causes an increase in left heart filling and a decrease in left heart afterload. This is reflected clinically as an increase in blood pressure.
- Within a few beats, the decreased right heart output is transmitted to the left heart resulting in a decrease in blood pressure during expiration.
- Patients who are volume depleted can have significant differences in blood pressure between inspiration and expiration – i.e. a large variation in pulse pressure.
- PPV values > 12% have been shown to identify patients who are volume responsive.
- Importantly, PPV works best in vented patients who have no spontaneous respiratory effort, are in sinus rhythm, and receiving 8 ml/kg tidal volumes.
Magder S. Hemodynamic monitoring in the mechanically ventilated patient. Curr Opin Crit Care 2011;17:36-42
- The February edition of toxcast, is a special extended episode featuring the final lecture from the 2010 ACMT. “Withdrawal: A Century of Progress from Bedside to Bench” the lecture is presented by Mark Mycyk starts of with a look at the impact of the brilliant works of Sir William Osler in managing withdrawals, he then takes a look at the history of withdrawals over the past 100 years and the impact that alcohol has had.
- Oli reviews the new 2011 guidelines for cerebral sinus thrombosis, and provides you with a brief review on at risk patients, what’s is the best imaging modality, touches on ED management, and provides an easy to follow algorithm to assist you.
- Asthma is a common presentation at any paediatric ED, Colin and the team takes on asthma in this weeks podcast, from the acute to the severe life threatening presentation, and all the way through to trailing NIV or setting the ventilator for the severe acute crashing asthmatic.
- Performing a simple and quick examination of the eye can differ between patients depending on their presenting complaint . Aaron’s graphical post guide’s you through the eye exam, in a simple, logical easy to follow approach.
- The Gnome has been busy blogging this week,by starting of his 5 facts series targeting malaria, dengue and leishmaniasis, also do you know what the clinical significance of charcot–leyden crystals is?
Twee-D and Twitical Care
Looks like @bungeechump has been stirring the pot again:
Tweet of the week has to go to @fnyc :
News from the Fast Lane
A Word from our Sponsors
- Make the world a better place, wear UCEM underwear! (one way to keep it out of sight…)
The Final Words
“One of the first duties of the physician is to educate the masses not to take medicine” -Sir William Osler
“My doctor gave me six months to live, but when I couldn’t pay the bill he gave me six months more.” -Walter Matthau.
That’s it for now… Hopefully this roundup of the world of electronic emergency medicine and critical care education for everyone helps you to deal with anyone, anything, anywhere at anytime for at least another week!
If you’d like to suggest something for inclusion in the next edition of The LITFL Review, email our roving reporter: kane AT lifeinthefastlane.com