First10EM Journal Club: February 2024

Welcome to the first episode for 2024 – and we have a range of papers covering the big life threatening issues to the tiniest pinky finger injuries and a lot in between. There is something for everyone in here!

We try to answer a few questions that you may have not even pondered such as: should all Psych patinets get an MRI? Should you replace fingernails on crushed digits? Should anybody be doing REBOA in 2024? Are topical anaesthetic drops safe for folk with eye abrasions?

As is always the case – the papers we discuss are free to download by just clicking the links in the sections below… so don’t trust me, go read them for yourself!

Jain A, Greig AVH, Jones A, Cooper C, Davies L, Greshon A, Fletcher H, Sierakowski A, Dritsaki M, Nguyen TTA, Png ME, Stokes JR, Dakin H, Cook JA, Beard DJ, Gardiner MD; NINJA Collaborative. Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial. Br J Surg. 2023 Mar 30;110(4):432-438. doi: 10.1093/bjs/znad031. PMID: 36946338

Bottom line: This is a well done RCT that demonstrates pretty convincingly that you should not bother trying to but fingernails back on after nail bed repair (and my guess is you definitely shouldn’t be removing them either).

Carson JL, Brooks MM, Hébert PC, et al; MINT Investigators. Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia. N Engl J Med. 2023 Nov 11. doi: 10.1056/NEJMoa2307983. PMID: 37952133

Bottom line: This is our biggest trial looking at liberal versus restrive transfusion in the context of MI, and we are left without a clear answer. 

Blackman G, Neri G, Al-Doori O, Teixeira-Dias M, Mazumder A, Pollak TA, Hird EJ, Koutsouleris N, Bell V, Kempton MJ, McGuire P. Prevalence of Neuroradiological Abnormalities in First-Episode Psychosis: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2023 Oct 1;80(10):1047-1054. PMID: 37436735

Bottom line: Patients with first episode psychosis do not need routine MRIs base on this data. They do need a careful history and physical, as a subset will have pathology. MRIs may be warranted in a small subset of patients, but those MRIs do not need to occur in an emergency department.

Myran DT, Harrison LD, Pugliese M, Solmi M, Anderson KK, Fiedorowicz JG, Perlman CM, Webber C, Finkelstein Y, Tanuseputro P. Transition to Schizophrenia Spectrum Disorder Following Emergency Department Visits Due to Substance Use With and Without Psychosis. JAMA Psychiatry. 2023 Sep 27:e233582. doi: 10.1001/jamapsychiatry.2023.3582. Epub ahead of print. PMID: 37755727

Bottom line: Substance abuse and psychiatric disease go hand in hand. Doctors who treat one must be experts in the other as well. We do not do our patients any favours by deflecting their care.

Wenger NS, Sanz Vidorreta FJ, Dudley MT, Walling AM, Hogarth M. Consequences of a Health System Not Knowing Which Patients Are Deceased. JAMA Intern Med. 2023 Dec 4:e236428. doi: 10.1001/jamainternmed.2023.6428. Epub ahead of print. PMID: 38048124

Summary: although dead people may be allowed to vote, they should not be included in the scientific literature?.

Green SM, Tomaszewski C, Valente JH, Lo B, Milne K. Use of Topical Anesthetics in the Management of Patients With Simple Corneal Abrasions: Consensus Guidelines from the American College of Emergency Physicians. Ann Emerg Med. 2024 Feb 6:S0196-0644(24)00004-0. doi: 10.1016/j.annemergmed.2024.01.004. PMID: 38323950

This is not really news, as we have covered the evidence ad nauseum in the past,

Bottom line: A shared decision making conversation is still a good idea (if only to prepare patients for a future ophthalmology tirade), but I have yet to have a patient decline short term use of topical anesthetics to control the pain from their corneal abrasion. 

Jansen JO, Hudson J, Cochran C, et al. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA. 2023 Oct 12. doi: 10.1001/jama.2023.20850. PMID: 37824132

Bottom line: In our only RCT of REBOA in trauma to date, REBOA increased mortality, and therefore the device is clearly not ready for clinical use. 

Siebert JN, Salomon C, Taddeo I, Gervaix A, Combescure C, Lacroix L. Outdoor Cold Air Versus Room Temperature Exposure for Croup Symptoms: A Randomized Controlled Trial. Pediatrics. 2023 Sep 1;152(3):e2023061365. doi: 10.1542/peds.2023-061365. PMID: 37525974

Bottom line: This is by far the best evidence we have on the topic, and perhaps the best evidence we will ever see. If you are looking for short term symptom relief, and you are careful about avoiding harms, it seems reasonable to counsel parents about using cold air to improve symptoms from croup. 

Fincham GW, Strauss C, Cavanagh K. Effect of coherent breathing on mental health and wellbeing: a randomised placebo-controlled trial. Sci Rep. 2023 Dec 13;13(1):22141. doi: 10.1038/s41598-023-49279-8. PMID: 38092805

Bottom line: This is the highest quality study of breathwork to date, and it is pretty definitively negative. I think this tells us that specific breathing patterns are unlikely to be helpful, but still leaves open the possibility that a daily practice of quiet breathing (at any rate) could have beneficial effects. 

Tiebie EG, Baerends EP, Boeije T, Frankenmolen PG, Lameijer H, van den Berg W, van Stralen KJ, Ridderikhof ML, Bredenoord AJ. Efficacy of cola ingestion for oesophageal food bolus impaction: open label, multicentre, randomised controlled trial. BMJ. 2023 Dec 11;383:e077294. doi: 10.1136/bmj-2023-077294. PMID: 38081653

Bottom line: Cola ingestion changes nothing, but does increase pain, and therefore should be avoided.

Evans CS, Slovis C. Revisiting the Ten Commandments of Emergency Medicine: A Resident’s Perspective. Ann Emerg Med. 2021 Mar;77(3):367-370. doi: 10.1016/j.annemergmed.2020.10.013. PMID: 33618812

30 years ago, Corey Slovis published a paper entitled “The Ten commandments of Emergency Medicine”. This paper revists those commandments 30 years later to discuss what might have changed. Not science, but it is an interesting paper that might provoke some discussion or thought.

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