Welcome to the jet-lagged 38th 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!
- Rob is back and dominating this week with a new podcast that asks Do we still need spinal tap following a negative CT in worst headache of life?. The podcast reviews a recently published article and gets view points from Scott Weingart from EMCrit and Ryan Radecki from Emergency Medicine Literature of Note. They also tackle the tough topic of awake blunt trauma patients with a negative cervical spine CT who still have neck pain. Do they need an MRI? And Rob gives an insight into what Casey Parker’s Broome Docs is all about.
The Usual Suspects
- Scott continues to amaze us with his insights into ED critical care and this podcast is bound to have you in awe of how far some places go to care for critically ill patients. Podcast 57 looks at Resuscitative Extra-Corporeal Life Support for Cardiac Arrest (ECMO)in the emergency department. The podcast gives us the patient perspective, details the inclusion and exclusion criteria and provides a nice review on what ECMO is all about.
- Is high-dose insulin better than vasopressors in treating toxin-induced cardiogenic shock? - more anecdotal evidence to support the use of Insulin as an inotrope in toxicological patients showing signs of cardiogenic shock.
- Silibinin or Silly Putty for Mushroom Poisoning? - There is currently little evidence to support treatment in mushroom poisoning with silibinin. Hopefully, following the completion of the multicentre trial there will be a bit more light shed on this topic.
- Did Michael Jackson swallow a fatal dose of propofol? This case might be more than just a media circus, it might actually provide some fascinating toxicology issues.
- Had the pleasure to meet the great Impactednurse in Adelaide last week — he’s just as awesome in person as he is online. Check out his post from the conference CENA swag bag, some highlights from Day 1 and the his summary and highlights from the conference in the Wrap: CENA 2011. ’ Stayed tuned for my review and highlights from the conference, just got to do battle with some night shifts first.’
- Very Influential Persons. A nice look at dealing with administrative emergencies and influential people requiring treatment in the ED. How do you approach these patients?
- The impactednurse.com Facebook page is back, make sure you’ve Liked it.
- Oxygen prevented hypoxia. Yep. In case you didn’t know “high-flow oxygen reduces the frequency of hypoxia during ED propofol sedation in adults”, maybe MJ would have benefitted from knowing this — the rest of us should already know this!
- Delta CVP with PEEP and fluid responsiveness — although Cliff agrees that “CVP should not be used to make clinical decisions regarding fluid management”, he has been slightly swayed by this study and gives us food for thought with this study that we might be able to assess fluid responsiveness in mechanically ventilated patients using the CVP measurement and PEEP.
- Don’t have a Level 1 rapid infuser? Make your own! It looks simple and easy: easy rapid infusion set up.
- Is there nothing ketamine can’t do? - Not really…. We just need to start using this drug more to find out how good it really is!!!
- Joe’s pick of the week is by Nick Jouriles: Ten Things I Have Learned Since Residency. What are your 10 things?
- Wide Complex Tachycardia — Ventricular Tachycardia or Supraventricular Tachycardia with Aberrancy?
- Is it STEMI or Non STEMI? What you call it has consequences.
The Rest Of The Best
- Absit Omen - a tough case needs to be treated with awesome team week, for a successful outcome.
- Does giving heparin early improve mortality in PE?: Three Answers in increasing detail - the take home point from all this: “PE is a bugger of a disease to diagnose, and even to work out what a diagnosis means. Heparin may well help in PE, in fact I’m pretty sure it does for some people at the very least. And it may well help to give it early, at least in terms of hours or days as opposed to minutes (like tPA in MI). I’m just not sure this gives us the answer.”
- Treat with booze or drugs? and haemodialysis works well.
- Not too much, not too little…get your Naloxone just right! an excellent guide to managing the opioid overdose and titrating naloxone to get the right effect -great post.
- Chest pain ECHOs, Casey puts his newly learnt ECHO skills to the test in a hypotensive patient with chest pain – what did he find?
- N-acetylcysteine Overdose With Anaphylactoid Reaction and Myocardial Infarction - was this patients demise all caused by the NAC or did the adrenaline play a part as well?
- Ethanol Hand Sanitizer Abuse - is infection control causing harm to our patients?
- Back Pain, Harbinger of Death some fascinating research results on patients presenting to the ED with back pain – and best of all it come from the same place as the home of the LITFL lives.
A huge week over at The NNT with these 4 deep dive reviews:
- Statins for Acute Coronary Syndrome - in summary 100% of patients saw no benefit.
- Prophylactic Antibiotics for Cirrhotics with Upper GI Bleed - in summary 77% saw no benefit, 4.7% were helped by preventing death and 23% were helped by preventing infection.
- Probiotics for Acute Infectious Diarrhoea - in summary patients were helped by a 1-day decrease in the duration of their diarrhoea.
- Colloid Solutions for Resuscitation in Critically Ill Patients - wow no benefit what so ever, but no harm either!!!
Pearl of the week looks at Warfrin Related Nephropathy:
- An acute increase in the INR over 3 in patients with chronic kidney disease (CKD) is often associated with an unexplained acute increase in serum creatinine and an accelerated progression of CKD.
- Kidney biopsy in a subset of these patients showed obstruction of the renal tubule by red blood cell casts, and this appears to be the dominant mechanism of the acute kidney injury. This has been termed warfarin-related nephropathy (WRN).In 15,258 patients who initiated warfarin therapy during a 5-year period, 4006 had an INR over 3 and creatinine measured at the same time. A presumptive diagnosis ofWRN was made if the creatinine increased by over 0.3 mg/dl within 1 week after the INR exceeded 3 with no record of haemorrhage. WRN occurred in 20.5% of the entire cohort, 33.0% of the CKD cohort, and 16.5% of the no-CKD cohort. Other risk factors included age, diabetes mellitus, hypertension, and cardiovascular disease. The 1-year mortality was 31.1% in patients with WRN compared with 18.9% in those without WRN, an increased risk of 65%.
- Take home message: Although the mechanisms are not clear, be very wary of even a small creatinine bump in patients presenting with an INR > 3 on warfarin therapy. Yet another reason to fear warfarin…
- Urinary Tract Infection in the Elderly Trauma Patient - Bottom Line: Urinary tract infections are especially bad for the elderly. As part of your daily rounds on any patient, look at every tube and line and ask yourself “is that really needed any more?” If not, get rid of it before it kills your patient!
- Anticoagulation Reversal In Trauma - Michael provides a nice simple sheet to guide you though reversing patients on anticoagulants, worth printing of and putting in your resus area were it counts.
- The Wrath of Dr. Khan - ZDoggMD boldly probes were no finger has probed before and pits the internal medicine team vs the emergency department team in true star trek fashion.
Twee-D and Twitcal Care
Tweet of the trade this week:
News from the Fastlane
- If you haven’t read it yet, readit now: The Power Of Social Media Leads To Reversal. This post shows web 2.0 in action and how it can transform medical education.
The Final Words
- There are known knowns, known unknowns, and unknown unknowns…
— Donald Rumsfeld
- “I love ED night shift nurses. For them, rules are optional”
— Daniel Sheridan
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