Subscribe to our newsletter to receive information on new and updated content

 

Aug 2016: New in EM

Warning

The content you’re about to read or listen to is at least two years old, which means evidence and guidelines may have changed since it was originally published. This content item won’t be edited but there will be a newer version published if warranted. Check the new publications and curriculum map for updates

Clinical Question to be answered

Can we use oxygen to treat acute migraine?

Title of paper

High-flow oxygen therapy for treatment of acute migraine: A randomized crossover trial

Journal and year

Cephalgia, 2016

Lead Author

Singhal

Name of contributor

Andy Neill

Patients studied

Very select bunch of well established and well defined migraineurs (!) with frequent headaches. Definitely not your general, likely primary, non specific headache

Intervention

High flow O2 in their home (!) at onset of migraine

Comparison

High flow air from an identical appearing cylinder

Primary outcome

headache reduction at 30 mins

Summary of results

No difference! (they describe benefits in the secondary outcomes but the numbers are so small that this is all a bit silly)

Strengths

Well defined migraine patients | treated in their homes! | good randomisation and blinding | good primary outcome

Weaknesses

Tiny numbers | no power calculation | ended early | delayed usual meds really making it placebo rather than comparing with the best current treatment

Clinical Bottom Line

High flow O2 at home didn’t help in this tiny study. Contrast this with Ozkurt

Any other FOAM sites where you found it or who have discussed it already so that we can be sure to give kudos

UMEM pearls

Clinical Question to be answered

Does immediate wbct in major trauma reduce mortality compared to usual management?

Title of paper

REACT-2

Journal and year

Lancet, 2016

Lead Author

Sierink JC

Name of contributor

Craig Davidson

Patients studied

Major trauma patients >18 years

Intervention

Whole body CT

Comparison

Selective CT as dictated by the clinicians

Primary outcome

Mortality

Summary of results

No improvement in mortality or any secondary outcome

Strengths

Randomised, prospective, pragmatic, patient centred outcome.

Weaknesses

Not blinded, some cross-over, ? Sicker group in WBCT group (based on ISS)

Clinical Bottom Line

Protocolised immediate WBCT increases radiation exposure but doesn’t reduce mortality. Doesn’t mean it’s wrong but decision should be based on clinical findings not used as a screen. Particularly important in younger patients.

Any other FOAM sites where you found it or who have discussed it already so that we can be sure to give kudos

Clinical Question to be answered

Does having a senior doctor in triage enhance ED performance?

Title of paper

The impact of senior doctor assessment at triage on emergency department performance measures: systematic review and meta-analysis of comparative studies

Journal and year

EMJ, 2016

Lead Author

Abdulwahid

Name of contributor

Nikki Abela

Patients studied

Systematic review and meta-analysis of papers from 1994-2014, 25 relevant studies were retrieved, 12 were weak quality, 9 moderate and 4 strong.

Primary outcome

Improved ED performance measured by indicators: waiting time, length of stay, left without being seen, and left without treatment complete.

Summary of results

Significant reduction in length of stay, waiting time and some reduction in some studies of patients leaving without being seen, but no change in occurrence of adverse events.

Strengths

Good analysis and review, strong papers with a good number of studies

Weaknesses

No clear benefit in terms of patient satisfaction, cost effectiveness, or adverse events.

Clinical Bottom Line

Are we doing this to meet targets or improve patient outcomes?

Further Reading

Great post by Adrian Boyle on RCEM Learning on how to appraise a systematic review.

UPDATE:

Dr Abdulwahid pointed out on twitter that Mortality was included in the paper, but few studies had it as a main outcome.

Clinical Question to be answered

How should we sedate agitated patients?

Title of paper

A prospective study of ketamine versus haloperidol for severe prehospital agitation

Journal and year

Clinical Toxicology, 2016

Lead Author

Cole

Name of contributor

Andy Neill

Patients studied

Pre hospital patients with acute agitation (measured on a well described scale) but importantly NOT agitated delirium patients (where they use ketamine as standard of care already). Conducted in Minneapolis (through Hennepin) over a year in 2014/2015

Intervention

Ketamine 5mg/kg was on the ambulances for 6 months of the year

Comparison

Haloperidol 10mg was on the ambulances for the other 6 months of the year

Primary outcome

Time to adequate sedation (determined by the paramedic or ED staff)

Summary of results

146 patients | 64 ketamine | 82 haloperidol. Ketamine rocked. Sedation in 5 mins v 17 mins. Lots more reported adverse effects in the ketamine group but the bulk reported were hypersalivaton. Intubation was 40% for ketamine v 4% for haloperidol. Mainly for “failure to protect airway” which seems to be a surrogate for (we feel they’re a bit sedated – which i thought was the point…) but there were a few laryngospasms and apnoeas in there too

Strengths

Well described and organised study (esp the prehospital part). Experienced EMS crews doing this. I think their data is fairly sound (how you interpret it is another question…)

Weaknesses

Do these people really need sedation in the first place. They were specifically targeting the less agitated patients and the +2 on their scale i don’t think should have been sedated at all. What happened to deescalation and a cup of tea? We also don’t really know why all those patients were tubed and did they really need to be (the rate isn’t particularly well accounted for by their data)

Clinical Bottom Line

Ketamine will get you to where you want to be but carries risks and you have to be prepared to deal with the cosequences

Any other FOAM sites where you found it or who have discussed it already so that we can be sure to give kudos

UMEM pearls again…

Other items you may enjoy

December 2016 New in EM December 2016 New in EM
Patient Handover For those of you who werent able to attend and for those of you who want to listen again to some of the great talks, this month well be bringing...you some of the superb plenary sessions on the podcast
June 2016: New in EM Summer is coming which means it's time to sit in a dark room while the sun blazes staring at your computer screen reading the latest literature...

Leave a Reply