Welcome to the influential 35th 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!
Top spot this week is occupied by Michelle Lin. Why? For helping us deal with the bug-bear that is distracting injury when trying to clear the C-spine. So what is a Distracting injury in c-spine injuries? Basically, it can be summed up by the following two points:
- If your trauma patient does NOT have chest trauma, it may help you avoid unnecessary cervical spine imaging, as suggested by the NEXUS criteria.
- If your trauma patient DOES have significant chest trauma, have a lower threshold to obtain cervical spine imaging despite the neck being non-tender.
- There’s also this Trick of the Trade: Epley maneuver — time to start taking the spin out of BPV.
The Usual Suspects
- EMcCrit is back with part 2 of Dr. Rivers on Severe Sepsis. This episode addresses CVP and fluid responsiveness, whether end-stage renal failure patients should get lots of fluids and whether vasopressin should be a first line pressor.
- Beyond R.I.C.E.— what else can you offer your patients with soft tissue and ligamentous injuries?
- We Band of Brothers — In the Internet age, attending national meetings may seem unnecessary, but it offers the epinephrine of comradeship — a nice viewpoint from Greg Henry.
- The Perils of Premature Closure — an interesting case with some pearls and pitfalls of the pelvic ultrasound.
Cliff delivers a barrel-load of stellar reviews of recently published trauma papers:
- Trauma mortality and systolic BP — The bottom line: “We recommend triaging adult blunt trauma patients with a SBP < 110 mmHg to resuscitation areas within dedicated trauma units for close monitoring and appropriate management.”
- Score to predict traumatic coagulopathy — is it time for routine pre-hospital blood products, as well as tranexamic acid?
- Exsanguinating cardiac arrest not always fatal — … if the patients have early access to high level care, including haemorrhage control, tracheal intubation and transfusion of blood products.
- Pre-hospital thoracotomy — fascinating results from London looking at physician performed pre-hospital thoracotomy… Is success in early access to the chest?
- A succinct review on the new recommendations for Prehospital Spine Immobilisation for Penetrating Trauma.
- ACLS Guidelines: Special Interventions in Cardiac Arrest — Not all cardiac arrests should follow the same ACLS algorithm. We need to adapt and change things around according to whether we’ve got an asthmatic or anaphylactic patient in cardiac arrest, a pregnant patient or crashing pulmonary embolus patient. This is a nice review of what to do in these special circumstances.
- Now That’s A Shock! — A man with toxic shock syndrome!!
- The Emergency Airway — Remember the Rule of Threes for Optimal BVM.
- Joe’s pick of the week has look at the use of HBO in Burns.
- The virtues and vices of emergency medicine — Reuben skillfully sums up why we do what we do!
- Dr Rob O gives us an update on Suicide risk assessment in the emergency department: a how to guide. Do you know what the high risk features are? This podcast is vital for those of us that don’t have mental health experts on hand to assist in managing these patients while in the ED. Rob also provides an excellent framework for documenting your suicide risk assessment.
A busy week over at Dr Smith’s place. Check out his posts below and his two talks on Wide Complex Tachycardias and Narrow Complex Tachycardias:
- Missed Acute MI, with coronary occlusion — evidenced only by T-wave inversion in V2 and evolving ST depression in V3.
- Chest pain, tachycardia, diffuse ST elevation — What is the diagnosis?
- New England Journal of Medicine on “Bath Salts” — Treatment primarily depends on good supportive care, with benzodiazepines for sedation and seizures, along with fluids, and close monitoring for hyperthermia. You might remeber ‘I’m just trying to keep clean bro‘ on LITFL a year and a half ago…
- Suicides, household chemicals, and cars — a review of suicides by using household chemicals in Japan, noting that the toxic gases most commonly involved in chemical suicides are hydrogen sulfide and hydrogen cyanide.
- Spice toxicity: three patients with confirmed exposure to JWH-018 and/or JWH-073 — patients exposed to “spice” products reported in the medical literature include agitation, paranoia, and tachycardia.
- Review: the bleeding patient on dabigatran — Leon provides some excellent points on managing the effects of the dabigatran — we would most probably recommend reading this article as well, before our ED’s start getting invaded by this drug. [Editor's note: the invasion has begun!]
- The blogging world welcomes back Impactednurse back in print from his short siesta. Ian gives us a some insight into why he took a break from blogging, and these’s a lesson to be learned in it for all us in the blogging world. Anyway enough of the reflective stuff, its great to have Impactednurse back in the LITFL R/V…It has missed you!
- VED: volunteers in the Emergency Department. Ian highlights the programme his hospital has just created having volunteers in the ED, to assist and provide patients and staff with minor things, that count and that make a huge different to the patients, and provides the ED staff with that little extra support….And don’t we need it.
The Rest Of The Best
Andy Neil the dude behind Emergency Medicine Ireland has taken a deep dive into some of the literature and tuned out these two NNT reviews:
- An interesting take on STEMI vs NSTEMI — worth reading!
- What is the Diagnosis? A nice review on the assessment and management of orbital blow-out fractures.
The lads at hqmeded.com have once again put together some great cases on the use of ultrasound in the emergency room.
- 29 yo M painful upper lip
- 37 yo F ectopic pregnancy
- Life in Broome is sweet, a bit too sweet. Managing Type 2 DM in the bush is challenging, but it looks like the guys in Broome have the right approach.
- Hangover Haemetemesis — when to give the PPI and what else do these patients need? — Casey has the answers.
- Double Down for Persistent Refractory Ventricular Fibrillation — an interesting approach to refractory VF: use two defibs and give consecutive, near simultaneous shocks. It might improve ROSC but will it give us the return of neurological function we strive for in these patients?
- Sternal IO is the Best IO — but not the most practical, stick to the humeral head when placing your IO’s!!!
- Adrenaline Neither Wins Nor Fails — So, there’s two ways to look at it: (1) adrenaline works, and we just need to figure out how to salvage more of those with ROSC; or (2) adrenaline is flogging far too great a number of lost husks back to life that will go on to consume ICU resources and expire regardless.
- Impedance Threshold Devices Are Useless – yep we’d have to agree with this one!
Haney Mallemat brings us this weeks pearl on using ultrasound to confirm tracheal intubation:
- Multiple methods of confirming endotracheal tube placement exist, however quantitative waveform capnography is the most reliable method. Unfortunately this may not be immediately available at all medical centers.
- Recent studies demonstrate that bedside ultrasound may assist in the detection of proper endotracheal tube placement.
- The T.R.U.E. (Tracheal Rapid Ultrasound Exam) was demonstrated to be 99% sensitive, 94% specific, 99% PPV, and 94% NPV during intubation.
- The basic exam involves placing a high-frequency linear-array probe on the anterior neck above the sternal notch and identifying the trachea and esophagus during intubation.
- The following video is an example of what you DO NOT want to see during an intubation:
- Assessing Self-Harm Risk or suicide in adolescents is a daunting concept for the occasional player — not anymore with excellent podcast giving you a structured approach to this challenging encounter.
- The Initial Hematocrit Matters —Bottom line: A low hematocrit on the first blood drawn during trauma resuscitation is more helpful that previously thought. Be sure to check those lab values early, and if the hematocrit value is in the mid-30s or lower, start looking for significant sources of bleeding.
- Bystander CPR For People Not In Cardiac Arrest — the benefits greatly out-weigh the risk.
- The 8 Hour Rule For Open Fractures: We’re So Over That —important for fractures lower extremities, maybe not so important in the upper extremit. Also worthy for a nice review of the Gustilo classification system.
- Video-Assisted Intubation Edges Out Direct Lanyngoscopy — Bottom line: Video assisted intubation is superior to the old-fashioned direct laryngoscopic technique.
- It’s to forget everything you know about medicine and just drill bone… Check out Napoleon Dynamite, MD, but take some pain killers before hand becasues your belly is gonna ache with the laughter!
Twee-D and Twitcal Care
A classic Tweet from @flobach:
And Rueben follows up with this:
News from the Fastlane
- If you read the post Own The Oxylog 3000! earlier in the week, Chris has updated it with some handy advice on measuring plateau pressure using the Oxylog 3000.
The Final Words
- “Good judgement comes from experience, and a lot of that comes from bad judgement.”
— Will Rogers
- “One thing I have learned from blogging is to never engage criticism.”
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