July 2016: New in EM

Clinical Question to be answered

• Does the ECG accurately predict the angio after cardiac arrest?

Title of paper

• Post-Resuscitation ECG for Selection of Patients for Immediate Coronary Angiography in Out-of-Hospital Cardiac Arrest

Journal and year

• Circulation: Cardiovascular Interventions. 2015

Lead Author

• Stær-Jensen

Name of contributor

• Andy Neill

Patients studied

• Prospective data on all cardiac arrest patients with ROSC and without a non cardiac cause from a single centre, Oslo, Norway

Comparison

• split patients in 3 groups 1) clear STEMI, 2) ischemic ECG, 3) no ischemia on ECG

Primary outcome

• association of ECG findings with angio findings

Summary of results

• Occlusion rates (TIMI 0-1) 1) Clear STEMI: 42%, 2) Ischemic ECG: 20%, 3) No ischemia on ECG: 11%. Finally, 37% of clear STEMIs had TIMI 3 flow!

Strengths

• Prospective data | Blinded ECG reads to categorise patients | Clear objective gold standard

Weaknesses

• Unclear what “obvious non cardiac cause” means | the retrospective ECG reading limits the clinical usefulness given the difficulty in ECG interpretation “live” | Ultimately we care about good neurological and this study doesn’t tell us this

Clinical Bottom Line 

• There’s a good chance (1in10 even with normal ECG) your patient post cardiac arrest has a coronary occlusion

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

• I suspect I found this via Steve Smith but can’t be sure…

Clinical Question to be answered

• Is dilute apple juice/preferred fluids AS GOOD AS ORT in children with mild gastroenteritis?

Title of paper

• Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis. A Randomized Clinical Trial

Journal and year

• JAMA 2016

Lead Author

• Freedman

Name of contributor

• Nikki

Patients studied

• 644 children (6 to 60 months (5 years)) with mild gastroenteritis in a tertiary PED in Toronto between 2010-2015.

Intervention

• colour-matched Apple juice or preferred fluids

Comparison

• apple-flavoured ORT

Primary outcome

• Treatment failure within 7 days (IV rehydration, hospitalization, subsequent unscheduled physician encounter, protracted symptoms, crossover, and 3% or more weight loss or significant dehydration at in-person follow-up)

Summary of results

• 647 randomised children, 441 (68.2%) without evidence of dehydration & 644 (99.5%) completed follow-up. Less treatment failure in dilute apple juice/preferred fluids arm (16.7% Vs 25% p<0.001)

Strengths

• Well powered (for non-inferiority), study of a cohort not well researched (minimal or no dehydration), block-randomisation, single-blinded, good follow-up.

Weaknesses

• single-blinded, over half of children not dehydrated anyway, no secondary outcome of “reported refusal to drink”/amount of fluid consumed/patient compliance and crossover at home (do we just need to make ORT tastier), children not blinded to taste

Clinical Bottom Line 

• Further studies needed but dilute apple juice may be appropriate in children with no/minimal dehydration in high income countries.

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

• LITFL Research and Reviews 
• Don’t forget the bubbles 
• REBEL EM 

Clinical Question to be answered

• Do steroids work in acute gout?

Title of paper

• Oral Prednisolone in the Treatment of Acute Gout

Journal and year

• Annals of internal medicine, 2016

Lead Author

• Timothy Hudson Rainer

Name of contributor

• Andy Neill

Patients studied

• 4 Hong Kong EDs | convenience sample of acute gout (with reasonable definition) | excluded warfarin and renal failure (which is very unfortunate given that they’re people i don’t want to use NSAID in…)

Intervention

• prednisolone 30mg, 4 days

Comparison

• indomethacin 50mg TID, 4 days

Primary outcome

• joint pain with rest and activity, measured with VAS and powered for the usual 13mm difference. Cites the famous Knox Todd paper 

Summary of results

• 400 pts | Pain got better with everyone and steroid just as good as NSAID (note the results are presented in a particularly dense fashion i thought)

Strengths

• randomised, well blinded, reasonable outcome, reasonable study population | note this was an equivalence trial which recommends per protocl analysis. Does that make it the same as non inferiority?

Weaknesses

• still doesn’t study the renal failure anticoagualtion group…

Clinical Bottom Line 

• You can use steroids instead of NSAID in your gout patient.

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

• Via EM Ottawa

Thanks again for listening guys. Don’t forget SMACC is going to Berlin next year. See you all there