First10EM Journal Club: July 2022

Welcome to another episode of the Journal Club with Dr Justin Morgenstern. This one is a bit epic and we start with a really important discussion around diagnostic strategies for palliative patients in the ED. There are a bunch of papers around PE and some interesting old school stuff that you likely would never consider unless you read it here! As always the articles are linked to free PDFs so you can make your own decisions.

Vitamin C in sepsis: STOP IT, we do not LOVE IT

Lamontagne F, Masse MH, Menard J, et al; LOVIT Investigators and the Canadian Critical Care Trials Group. Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit. N Engl J Med. 2022 Jun 23;386(25):2387-2398. doi: 10.1056/NEJMoa2200644. PMID: 35704292

Bottom line: Sepsis is not treated with vitamins. Be wary of low quality before and after research. 

Is apixaban better than rivaroxaban?

Dawwas GK, Leonard CE, Lewis JD, Cuker A. Risk for Recurrent Venous Thromboembolism and Bleeding With Apixaban Compared With Rivaroxaban: An Analysis of Real-World Data. Ann Intern Med. 2022 Jan;175(1):20-28. doi: 10.7326/M21-0717. Epub 2021 Dec 7. PMID: 34871048

Bottom line: This observational data suggests apixaban may be both more effective and safer than rivaroxaban, but there are so many limitations when trying to adjust retrospective data from a large database, confidence in this finding should be very low.

IVC induced D-dimer… a trial of 20 healthy volunteers 20 years ago…

Heffner A, Kline J. Role of the peripheral intravenous catheter in false-positive D-dimer testing. Acad Emerg Med. 2001 Feb;8(2):103-6. doi: 10.1111/j.1553-2712.2001.tb01272.x. PMID: 11157283

Bottom line: This is a very small study using only healthy volunteers, so take it with a grain of salt. However, it probably makes sense to try to ensure your DDimer is taken on the first blood draw, rather than after the patient has had an IV in place for hours in the ED.

One more PE study: Do subsegmental PEs matter?

Le Gal G, Kovacs MJ, Bertoletti L, et al. Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation : A Multicenter Prospective Cohort Study. Ann Intern Med. 2022 Jan;175(1):29-35. doi: 10.7326/M21-2981. Epub 2021 Nov 23. PMID: 34807722

Bottom line: The risk of recurrent VTE in subsegmental PEs may not be negligible. As we gather more data on the topic, the best approach for emergency physicians is to ensure that you are only testing for PE in high risk patients.

Bedside genomics… Brave New World of medicine

McDermott JH, Mahaveer A, James RA, Booth N, Turner M, Harvey KE, Miele G, Beaman GM, Stoddard DC, Tricker K, Corry RJ, Garlick J, Ainsworth S, Beevers T, Bruce IA, Body R, Ulph F, MacLeod R, Roberts PL, Wilson PM, Newman WG; PALOH Study Team. Rapid Point-of-Care Genotyping to Avoid Aminoglycoside-Induced Ototoxicity in Neonatal Intensive Care. JAMA Pediatr. 2022 May 1;176(5):486-492. doi: 10.1001/jamapediatrics.2022.0187. PMID: 35311942

Bottom line: I include this for interest’s sake only, as it sounds more like science fiction than medicine at this point (at least based on the funding of the emergency departments I work in), but it will be an interesting field to watch over the coming years.

You can read a little more from the lead author of the paper on the St Emlyn’s website.

“Oral Is the New IV” – can we treat every infection with oral antibiotics?

Wald-Dickler N, Holtom PD, Phillips MC, Centor RM, Lee RA, Baden R, Spellberg B. Oral Is the New IV. Challenging Decades of Blood and Bone Infection Dogma: A Systematic Review. Am J Med. 2022 Mar;135(3):369-379.e1. doi: 10.1016/j.amjmed.2021.10.007. Epub 2021 Oct 27. PMID: 34715060

Bottom line: Even in the worst infections, there is no reason to choose IV antibiotics over oral.

Can we say “Quiet” in the ED… yes. But this trial is silly

Geller JE, Strickland PO, Bucher JT. The use of the word “quiet” in the emergency department is not associated with patient volume: A randomized controlled trial. Am J Emerg Med. 2022 Mar 16;56:10-12. doi: 10.1016/j.ajem.2022.03.020. Epub ahead of print. PMID: 35339973

Bottom line: In the name of critical thinking education, I will continue to discuss how quiet my department is every single shift (and risk physical disability and lost friendships in the process)

DO NOT DELAY URGENT CONTRAST CTs WAITING FOR BLOOD WORK!!

Macdonald DB, Hurrell C, Costa AF, McInnes MDF, O’Malley ME, Barrett B, Brown PA, Clark EG, Hadjivassiliou A, Kirkpatrick IDC, Rempel JL, Jeon PM, Hiremath S. Canadian Association of Radiologists Guidance on Contrast Associated Acute Kidney Injury. Can Assoc Radiol J. 2022 May 24:8465371221083970. doi: 10.1177/08465371221083970. Epub ahead of print. PMID: 35608223 [free full text]

If you are an Aussie (or a Kiwi) the guidelines are very similar. The RANZCR Guidelines are here – but here is the bottom line:

DO NOT DELAY URGENT CONTRAST CTs WAITING FOR BLOOD WORK!!

Dr Josh Farkas @Pulmcrit simplified algorithm for Ct with contrast in ED

I imagine all readers know this already, but a full evidence review on the topic is available here.

Bottom line: These radiology guidelines tell us that we should not delay urgent contrast CT scans just to see renal blood work. Good luck getting that implemented. 

Reassuring patients is an art… not an investigation.

Rolfe A, Burton C. Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA Intern Med. 2013 Mar 25;173(6):407-16. doi: 10.1001/jamainternmed.2013.2762. PMID: 23440131

Bottom line: It is our job to reassure our patients with good education and time spent at the bedside. Tests can’t do that job for us.

Marketing-based versus evidence-based treatment in trigeminal neuralgia

Keppel Hesselink JM, Schatman ME. Phenytoin and carbamazepine in trigeminal neuralgia: marketing-based versus evidence-based treatment. J Pain Res. 2017 Jul 17;10:1663-1666. doi: 10.2147/JPR.S141896. PMID: 28761370

Bottom line: The evidence for carbamazepine in trigeminal neuralgia is incredibly weak. You could probably treat it exactly like any other neuropathic pain syndrome.

COVID guidelines need to be based on evidence…

Zhao S, Lu S, Wu S, et al. Analysis of COVID-19 Guideline Quality and Change of Recommendations: A Systematic Review Health Data Science. 2021; 2021:1-22. https://doi.org/10.34133/2021/9806173

Bottom line: This is about way more than COVID. Most guidelines are awful. You must read guidelines like any other published paper: with a very critical eye, focused primarily on methodology.

Injecting venomous spiders isn’t as bad as you might think!

Bush SP, Naftel J. Injection of a whole black widow spider. Ann Emerg Med. 1996 Apr;27(4):532-3. doi: 10.1016/s0196-0644(96)70256-1. PMID: 8604882

Bottom line: There is no presentation too far fetched for emergency medicine. 

 

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