March 2018

Author: Andy Neill / Codes: C3AP1a, C3AP1b, CAP30, CC15, CC16, CC21, U8, GP1, RespiC10, RP6, RP7, SLO1, SLO10, SLO3, SLO4, SLO7, SLO9, TC2, TP7Published: 01/03/2018


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



Mike Farquhar

Chris Connolly

Mike Farquhar is a consultant in paediatric sleep medicine in London. He’s a prominent voice for sleep health particularly for health care workers. This interview was recorded at the EMTA conference just last year.

Further Watching

Mike on Twitter

Great Lecture by Mike for the RCoA


  • Dave McCreary
  • Andy Neill

Codes: CC21


The arthroscopical and radiological correlation of lever sign test for the diagnosis of anterior cruciate ligament rupture

Author: Deveci, 2015, Springer Plus

Background: ACL tears are common and significant. The traditional tests we have aren’t wonderful and are very much “user dependant”. Early detection of a clinical ACL tear should lead to earlier referral to a specialist with or without further imaging. The Lever test might be better than the usual tests. It involves lying the patient supine with the leg extended and relaxed. A fist is placed under the proximal third of the calf. This results in slight flexion at the knee. Downward pressure is applied over the distal quads. An intact ACL should result in extension at the knee joint. A ruptured ACL should result in posterior translation of the femur on the tibia.


– Turkish, surgical trial

– Young people going for an arthroscopy with probable ACL tears (based on symptoms, MRI or clinical findings)

– They had pre spinal anaesthetic examinations of all the major tests and then a repeat exam under spinal.

– Reference standard was the arthroscopy


– 100 pts

– For baseline – the MRI was 92% sensitive (ie it missed a few full thickness ACL tears)

– The Lever test was significantly better 95% sensitivity vs 60-80% for the others…

– They oddly don’t mention specificity which is annoying…


– this doesn’t say anything about ED examinations where the knee is big swollen and painful. I am yet to try this to see if it is even possible in an acute knee.

– But we do a lot of review clinics for knees in our place and I’ll cerrtainly try it out on them.

– This isn’t the first paper on this.

Further Reading:

– I found this via LITFL and there’s some other references available there

Video of test in action


  • Andy Neill, Mike Prats, Rachel Liu, Chris Muhr, Catherine Nix, Cian McDermott, Ashley Miller

Codes: U8

Paper Referenced:

Weekes AJ, Thacker G, Troha D, Johnson AK, Chanler-Berat J, Norton HJ, et al. Diagnostic Accuracy of Right Ventricular Dysfunction Markers in Normotensive Emergency Department Patients With Acute Pulmonary Embolism. Ann Emerg Med. 2016 Sep;68(3):277–91.

Further Reading:


  • Becky Maxwell
  • Chris Connolly

Codes: CAP30

Becky and Chris talk about Section 136 of the MHA and the recent changes in December 2017 and the excellent summary document on the topic from RCEM


  • Fin McNicol
  • Nikki Abela

Codes: CC15 CC16

Jon Jones is a consultant in EM in Leeds and has a particular interest in major trauma involved in both the RCEM committee on major trauma and his local major trauma network.

This interview was recorded at the RCEM Annual Scientific Conference in Liverpool in October 2017

All of the references discussed in his talk are available in this link.

New Yorker Reference


  • Dave McCreary
  • Andy Neill

Codes: CC21

Clinical Question:

Do steroids improve mortality for patients in septic shock?

Title of Paper:

Adjunctive Glucocorticoid Therapy in Patients with Septic Shock

Journal and Year:

New England Journal of Medicine. 2018.

Lead Author:

Balasubramanian Venkatesh


  • Sepsis is bad with mortality of 30-45%
  • Glucocorticoids have been in and out of vogue for 40 years

◦      1980s – high doses of methylprednisolone found to increased morbidity & mortality

◦      2002/2008 – Lower doses (200mg/day) studied with conflicting results but suggested that it may help with earlier reversal of shock

  • Hydrocortisone currently recommended in septic shock if adequate fluid resuscitation and treatment with vasopressors hasn’t worked

◦      This is a weak recommendation based on low quality of available evidence

  • As such there is variability in practice

Study Design:

  • International, double-blind, parallel group, randomised controlled trial

Patients Studied:

  • Adults on mechanical ventilation with:

◦      Documented or strong suspicion for infection

◦      ≥ 2 SIRS

◦      Treated with vasopressors/inotropes for minimum 4 hours

  • Excluded:

◦      Receiving steroids for another reason

◦      Received etomidate during admission

◦      Were likely to die from pre-existing disease within 90 days of randomisation

◦      Treatment limitations

◦      Had inclusion criteria for >24 hours before randomisation


  • 200mg IV hydrocortisone / day as a 24 hour infusion

◦      For maximum of 7 days

◦      Or until ICU discharge or death


  • Matched placebo

Primary Outcomes:  

  • Any cause mortality at 90 days

Secondary Outcomes:

  • Any cause mortality at 28 days
  • Time to resolution of shock
  • Recurrance of shock
  • ICU length of stay
  • Frequency & duration of mechanical ventilation
  • Frequency & duration of renal replacement therapy
  • Incidence of new onset bacteraemia or fungaemia in days 2-14 post randomisation
  • Receipt of blood transfusion on ICU

Summary of Results:

  • 3658 enrolled patients in final analysis (1832 intervention, 1826 placebo)

Primary outcome:

  • No significant difference in mortality at 90 days

◦      27.9% (hydrocortisone) vs 28.8% (placebo)

Secondary outcomes:

  • No difference in 28 day mortality

◦      22.3% vs 24.3%

  • Shorter time to resolution of shock in hydrocortisone group

◦      3 days vs 4 days

◦      HR 1.32 (p<0.001)

  • Shorter time to ICU discharge in hydrocortisone group

◦      10 vs 12 days

◦      HR 1.14 (p<0.001)

  • Shorter duration of initial ventilation, but balanced out with rates of recurrent ventilation to no difference in number of ventilator free days
  • Fewer blood transfusions in hydrocortisone group
  • No difference in recurrent shock, time to hospital discharge, recurrent ventilation, use and duration of renal replacement therapy.
  • No difference in rate of new bacteraemia or fungaemia

Clinical Bottom Line:

This gives us a definitive answer that there is no mortality benefit with the use of hydrocortisone in resistant septic shock (big sick patients).  The secondary outcome findings are interesting, but thats probably as definitive as secondary outcomes should get.

Don’t forget there are other causes of shock in which hydrocortisone will still be helpful – anaphylaxis, steroid dependence, hypoadrenalism, etc.


There are some cracking, in-depth and significantly more intelligent reviews on this paper out there, namely:


  • Jon Jones
  • Andy Neill

Codes: C3AP1a, C3AP1b

Jon Jones is a consultant in EM in Leeds and has a particular interest in major trauma involved in both the RCEM committee on major trauma and his local major trauma network.

This interview was recorded at the RCEM Annual Scientific Conference in Liverpool in October 2017. The first part was published on the February 2018 Podcast.

All of the references discussed in his talk are available in this link.

New Yorker Reference


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