First10EM Journal Club: March 2024

Welcome back for another episode of nerdy evidence based goodness with Dr Justin Morgenstern. As always we will be dissecting some data and looking into the literature of Emergency medicine.

Below are the papers that we will discuss and click on the links to get the free PDF versions so that you can follow along, make up your own mind and get your inner nerd excited.

If you want to see Justin in the video format and his new Youtube series then click here:

If you would like to check out my current ultrasound training project then click here: WACHS Ultrasound

Otherwise – enjoy the show and see you in a few weeks.

High dose nitro for SCAPE

Siddiqua N, Mathew R, Sahu AK, Jamshed N, Bhaskararayuni J, Aggarwal P, Kumar A, Khan MA. High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial. Emerg Med J. 2024 Jan 22;41(2):96-102. doi: 10.1136/emermed-2023-213285. PMID: 38050078

Bottom line: High dose nitroglycerin seems to result in better outcomes in SCAPE, at least according to this small, single center, unblinded trial. 

Is our PPE evidence-based?

Diekema DJ, Nori P, Stevens MP, Smith MW, Coffey KC, Morgan DJ. Are contact precautions “essential” for the prevention of healthcare-associated methicillin-resistant Staphylococcus aureus? Clin Infect Dis. 2023 Sep 21:ciad571. doi: 10.1093/cid/ciad571. PMID: 37738565

Bottom line: Evidence based medicine is important, even in infection control. 

Great evidence for button battery ingestions (if you are treating a dead pig)

Chiew AL, Lin CS, Nguyen DT, Sinclair FAW, Chan BS, Solinas A. Home Therapies to Neutralize Button Battery Injury in a Porcine Esophageal Model. Ann Emerg Med. 2023 Sep 19:S0196-0644(23)00671-6. doi: 10.1016/j.annemergmed.2023.08.018. PMID: 37725021

Bottom line: There are a lot of issues with trying to extrapolate from cadaveric animal studies, but I see limited risk (unless you use this therapy as an excuse to delay endoscopy). Until we see more science, it seems very reasonable to provide honey, jam, or sucralfate (which wasn’t studied here), every 10 minutes while arranging for that emergent scope. 

Myths and misconceptions about the treatment of acute hyperkalemia

Gupta AA, Self M, Mueller M, Wardi G, Tainter C. Dispelling myths and misconceptions about the treatment of acute hyperkalemia. Am J Emerg Med. 2022 Feb;52:85-91. doi: 10.1016/j.ajem.2021.11.030. PMID: 34890894

Myth 1: Kayexalate is safe and useful. 

Myth 2: Lactated Ringer’s is contraindicated in hyperkalemia.  

Myth 3: The ECG changes from hyperkalemia are predictable and reliable. 

Myth 4: All patients with hyperkalemia should be treated with calcium. 

Nebulized ketamine: the solution to a non-existent problem?

Kampan S, Thong-On K, Sri-On J. A non-inferiority randomized controlled trial comparing nebulized ketamine to intravenous morphine for older adults in the emergency department with acute musculoskeletal pain. Age Ageing. 2024 Jan 2;53(1):afad255. doi: 10.1093/ageing/afad255. PMID: 38251742

Bottom line: Although it is always useful to have more tools in your belt, I can’t see this study having much clinical relevance at all. 

Small BVMs: When physiologic theory fails

Snyder BD, Van Dyke MR, Walker RG, Latimer AJ, Grabman BC, Maynard C, Rea TD, Johnson NJ, Sayre MR, Counts CR. Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest. Resuscitation. 2023 Dec;193:109991. doi: 10.1016/j.resuscitation.2023.109991. PMID: 37805062

Bottom line: In this before and after cohort, the change to a smaller BVM was associated with lower rates of ROSC. 

Peripheral pressors: not only safe, but beneficial?

Yerke JR, Mireles-Cabodevila E, Chen AY, Bass SN, Reddy AJ, Bauer SR, Kokoczka L, Dugar S, Moghekar A. Peripheral Administration of Norepinephrine: A Prospective Observational Study. Chest. 2023 Aug 21:S0012-3692(23)05350-3. doi: 10.1016/j.chest.2023.08.019. Epub ahead of print. PMID: 37611862

At this point, I sort of assume that everyone knows it is OK to run vasopressor peripherally. First10EM readers should, given that we have covered the topic previously, with an update post with more evidence here. Casey wrote a protocol for peripheral noradrenaline 9 years ago… in 2015!.

Bottom line: Although there is a small risk of extravasation, the benefits of running vasopressors will outweigh that risk in many patients. Although I miss performing the procedure, these days I almost always leave the central line until the patient is stabilized and settled into their ICU bed. 

Is pregnancy a disease?

Smajdor A, Räsänen J. Is pregnancy a disease? A normative approach. J Med Ethics. 2024 Jan 29:jme-2023-109651. doi: 10.1136/jme-2023-109651. PMID: 38286592

Please address your outraged emails to Dr Justin Morgenstern… he picked this paper!

A randomized deception trial?

Iyer R, Park D, Kim J, Newman C, Young A, Sumarsono A. Effect of chair placement on physicians’ behavior and patients’ satisfaction: randomized deception trial. BMJ. 2023 Dec 15;383:e076309. doi: 10.1136/bmj-2023-076309. PMID: 38101923

Bottom line: if you can find a chair, please sit upon it as you do your job.

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