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December 2016 New in EM

Authors: Simon Laing, Nikki Abela, Craig Davidson / Code: CAP17, CC21, PAP17 / Published: 07/12/2017

More picks from the literature from the New in EM team. As always, the links to the papers and any other resources are below. We aim to highlight some interesting papers and compare how they might affect our practice. The final decision is yours though, so get out (or rather stay in) and get reading the articles yourself too.

Clinical Question:
Does VL or DL work better for intubation during cardiac arrest.

Title of Paper:
Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators.

Journal and Year:
Resuscitation 2016

Lead Author:
Jong Won Kim

Name of Contributor:
Craig Davidson

Patients Studied:
140 adult patients presenting to ED with OOHCA or IHCA over a two year period 2011-13. 96% were OOHCA.

Intervention:
First intubation attempt with VL.

Comparison:
First intubation attempt with DL.

Primary Outcome:
The success rate of ETI.

Summary of Results:

  • 140 out 270 eligible intubations included.
  • No significant difference in primary end point.
  • Longer duration of cardiac compression interruption was found during ETI using DL compared with VL (4.0 vs 0.0 s, respectively; p < 0.001). Serious no-flow (consecutive duration of interruption > 10 s) occurred more frequently during DL (18 of 69; 26.1%) compared with VL (0 of 71).
  • OF NOTE: the interruption time for VL was 0.0 (0.01.0). This difference was similar for providers considered highly experienced in ETI.

Strengths:
Prospective, randomised, videoed everything and worked out times from that. Used defibs to monitor time off the chest.

Weaknesses:
Single centre, small cohort, large number of reasonable exclusions, non-blinded outcome assessment. Leaves scope for significant bias.

Clinical Bottom Line:
No difference in success rate but could VL allow intubation without interrupting chest compressions? What do you do currently? Could you do it better?

Other #FOAMed Resources:
http://lifeinthefastlane.com/research-reviews-fastlane-159/

Clinical Question:
What signs, symptoms and tests can rule in and rule out SAH and to what degree?

Title of Paper:
Spontaneous Subarachnoid Haemorrhage: A Systematic Review and Meta-Analysis Describing the Diagnostic Accuracy of History, Physical Exam, Imaging, and Lumbar Puncture with an Exploration of Test Thresholds.

Journal and Year:
Academic Emergency Medicine June 2016

Lead Author:
Christopher Carpenter

Name of Contributor:
Nikki Abela

Study Design:
Systematic review and meta-analysis – 22 studies included

Summary of Results:
Authors analysed what symptoms and signs were highly indicative of SAH. They then looked at clinical decision rules and their ability to rule in and rule out the disease (SAH). They then looked at the sensitivity and specificities of 1. non-contrast CT (within 6 hours and after 6 hours) and LP for SAH.

Strengths:
Robust study with pooled data adds to strong evidence on what and what should not be done for SAH. Authors had good strategies to grade papers as “high risk for bias and low risk for bias”.

SRs and MAs have long been considered the gold standard evidence in EBM.

Weaknesses:
SRs and MAs have received a lot of bad press lately because they can also just pile up bad-evidence and make it look like good evidence by beefing numbers.

Clinical Bottom Line:
The evidence of benefit in LP post-6hr CT is in question, certainly in patients not at high risk. If a good, validated clinical decision rule were to be readily available, we could use this to facilitate shared decision making and avoid the risks of over testing.

Make sure you read the paper, particularly the likelihood ratios for parts of the history and examination, to help inform your gestalt.

Other FOAMed Resources:

Clinical Question:
What is the best method for relocating a pulled elbow?

Title of Paper:
Effectiveness of reduction manoeuvres in the treatment of nursemaid’s elbow: A systematic review and meta-analysis

Journal and Year:
American Journal of Emergency Medicine 2016

Lead Author:
Rens Bexkens

Name of Contributor:
Simon Laing

Study Design:
A systematic review and meta-analysis of the literature comparing the supination-flexion manoeuvre (SF) with the hyper pronation manoeuvre (HP).

Patients Studied:
Children age 8 and under with a pulled elbow (radial head subluxation)

Primary Outcome:
Failure rate of first attempt reduction

Summary of Results:

  • 701 patient in the review, 350 treated with the HP manoeuvre and 351 with the SF manoeuvre.
  • The HP method was more successful than the SF method with a risk ratio of failure of 0.34 (95% CI, 0.23 to 0.49) with a NNT of 3.8

Strengths:

all studies included (quasi) randomised control trials. All trials reported the same outcome (whilst 2 out of the 8 not statistically significant) of the more successful method

Weaknesses:

  • The study used a composite outcome of ‘did not demonstrate a fully functional and pain-free arm after the manoeuver’, ideally this would use have been ‘failure to reduce the subluxation’.
  • Slight variations in technique of pronation, some being described as rapid, some as hyper and some as forced.
  • None of the included trials were high quality

Clinical Bottom Line:
The evidence supports the use of a hyper pronation technique over a supination-flexion technique to reduce a pulled elbow.

Other items you may enjoy

August 2017 The new podcast for August 2017
Day 2 RCEM Bournemouth #RCEM16Beach The second day of the conference started a new chapter for the college as the new president, Taj Hassan, addressed the audience
CFN approach to IDU Struggling to find a resource on how to approach the IDU, check out this podcast

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