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February 2017 New in EM

Authors: Andy Neill, Dave McCreary / Codes: CAP7, CC21, CMP2 / Published: 01/02/2017

 

Clinical Question:
What is the significance of a sternal fracture found on CT?

Title of Paper:
Sternal fracture in the age of pan-scan

Journal and Year:
Injury

Lead Author:
Perez

Patients Studied:
This is a review of a prospective trauma data set (actually done as part of the NEXUS Chest rule so reasonably thorough data collection)

Outcomes:

  1. the frequency with which sternal fracture (SF) patients are diagnosed by CXR versus chest CT under current imaging protocols
  2. the frequency of surgical procedures related to SF diagnosis
  3. SF patient mortality and hospital length of stay comparing patients with isolated sternal fracture and sternal fracture with other thoracic injury
  4. the frequency and yield of cardiac contusion workups in SF patients.

Summary of Results:

  • 14500 in the study, 2% (290) had sternal fractures.
  • >90% had both CXR and CT (the people we’re interested in in many ways).
  • the vast majority of these (>90% again) were only visualised on CT.
  • a third of the sternal fracs had a medisatinal haematoma, none requiring surgical management.
  • 25% were displaced but only one had fixation
  • most (>80%) had associated injuries (ie haematoma or PTX or rib fracs etc…)
  • very few of those with sternal fracs died and the ones who did seem to die from unrelated injuries (eg the one who died from MI was 3 days later and negative ECG and trop on admission!)
  • a very small number were felt to have cardiac contusion=

Clinical Bottom Line:
A sternal fracture found incidentally on CT scan in a well patient is at very low risk of bad things happening.

Clinical Question:

Does increasing the dose of intravenous ketorolac improve analgesia in emergency department patients with a wide variety of pain syndromes?

Title of Paper:

Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomised Controlled Trial

Journal and Year:
Annals of Emergency Medicine 2016

Lead Author:
Sergey Motov

Patients Studied:

Adults <65 years old presenting to ED with acute flank, abdominal, musculoskeletal or headache pain 5/10 on pain scale

Intervention:
Ketorolac IV dosed at 10, 15 or 30mg

Comparison:

No control group. Comparison is between the three treatment doses.

Primary Outcome:
Reduction in pain score at 30minutes post treatment.

Summary of Results:

All three doses showed significant pain reduction, with no difference in reduction of pain score between the three groups and no difference in use of rescue analgesia (morphine) between the groups.

There was no difference in immediately apparent side-effects (dizziness, nausea, headache) between the groups.

Strengths:

Sample size calculated and achieved for all groups

Primary outcome measures relevant to Emergency Department practice

Weaknesses:
No placebo group for comparison

Short follow up (to 120 minutes) raises question if higher dose could have prolonged analgesic benefit

At this length of follow up the side effects recorded are only those that would be immediately apparent, and not the most relevant concerns with ketorolac use. GI bleeding and Acute Kidney Injury would require longer follow up.

Clinical Bottom Line:

As has been described with other NSAIDs, ketorolac likely has an analgesic ceiling, and its lower than we think. While they cant assess the longer time side effects, it would be a safe estimate to say theyd be less likely the lower the dose you use – so my initial go to dose for IV ketorolac is likely to be 10mg in future, though I dont know what impact this would have on the IM dosing.

Other #FOAMed Resources:

Bryan Hayes, @PharmERToxGuy did a nice hot-of-the-press review on this last month

FOAMcast also briefly discussed this paper in their Favourite Literature of 2016 podcast last month

Clinical Question:
Should we anticoagulate patients going home in lower limb casts?

Title of Paper:
Thromboprophylaxis after Knee Arthroscopy and Lower-Leg Casting

Journal and Year:
NEJM, 2016

Lead Author:
Raymond A. van Adrichem

Patients Studied:
2 trials presented here.

  1. post arthroscopy pts,
  2. patients going home with a below knee cast for a fracture with or without surgery.

Of note the patients were realtively low risk for clots here (ie you would be excluded if you had a prior DVT for example)

Intervention:
LMWH prophylaxis (nadroparin or dalteparin)

Comparison:
No intervention, there was no placebo here.

Primary Outcome:
deep-vein thrombosis or pulmonary embolism within 3 months after the procedure.

Summary of Results:

  • 1500 in the arthroscopy trial
  • 1500 in the casting trial
  • not a huge number of clots and no difference (again they significantly over estimated how many clots would happen especially in the arthroscopy trial – they predicted a 2% rate in the control group and in reality it was 0.7% and 0.4%)
  • again this shows prophylaxis is a very safe thing to do if you decide to do it

Strengths:

Large well performed trial. There haven’t really been any of these for this question

Weaknesses:
Doesn’t address higher risk patients, there were lots of metatarsal fractures in here that they placed in cast (i know these get a removable boot in my current place) which may not be at risk at all. Dan Horner suggested the dosing of the LMWH might be a touch low.

Clinical Bottom Line:
In these lower risk patients with casts, LMWH prophylaxis didn’t seem to help but it did seem very safe and it’s not a perfect trial

Other #FOAMed Resources:
Dan Horner’s Review of this on St Emlyns is a must read

Clinical Question:

Is administration of nitroglycerin by intermittent bolus more effective that by continuous IV infusion

Title of Paper:

Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure

Journal and Year:
American Journal of Emergency Medicine

Lead Author:
Suprat Saely Wilson

Patients Studied:

Adult ED patients being treated for acute pulmonary oedema with IV nitroglycerin.

Intervention:
IV nitroglycerin boluses of at least 0.5mg every 3-5 minutes

Comparison:

IV nitroglycerin by continuous infusion or a combination of infusion with boluses.

Primary Outcome:

Need for ICU admission & hospital length of stay

Summary of Results:

They found that the Bolus group were less likely to need ICU admission (48% vs 69% (infusion alone) and 83% (combination)) and had shorter hospital length of stay (3.7 days vs 4.7 (infusion alone) and 5.0 days (combination)).

There was a low incidence of hypotension in all groups of <6%.

The combination group were significantly sicker however with much higher initial SBP, DBP and respiratory rates.

Strengths:

For a retrospective study they have tried to split the treatment groups well, and they thoroughly analysed to identify baseline differences between them.

They re-ran their analysis to adjust for COPD having found the baseline prevalence to be higher in the Bolus group – and found no impact on their outcome.

Weaknesses:
Retrospective study with the inherent limitations.

The dosing of the infusions was pretty low (median 20 mcg/min for infusion group and 20mcg/min for the combination group) compared to that which most of us would use in these patients.

Clinical Bottom Line:

This study doesnt present strong enough data to argue that bolus therapy alone is better than infusion or combination (Ill continue to start with a bolus and ramp the infusion rate up early). A prospective, protocolled trial would be better suited to answer this question.

Other #FOAMed Resources:

A little blast from the past – back from before FOAMed was FOAMed – EMCrit Podcast 1, Sympathetic Crashing Acute Pulmonary Oedema (SCAPE). The original, and I still think one of the best. I recommend this to SHOs to help get their heads around hypertensive pulmonary oedema

@PharmERToxGuy beat us all to the punch again with this review

Other items you may enjoy

March 2017 March 2017 New in EM
Impedance Threshold Device in trauma Is there a role for the Impedance Threshold Device in hypotensive, spontaneously breathing, trauma patients?
January 2018 January 2018

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