First10EM Journal Club: December 2024

Welcome back to the pre-Xmas edition of the Broomedocs & First10EM Journal club.

This month we cover a few out-of-hospital arrest trials. More PECARN goodness and we answer the question: are ants better doctors than human doctors? There is a bunch more – so have a listen or watch us on Youtube feed below. You can read all the papers on the links in the show notes right here.

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Taccone FS, Rynkowski Bittencourt C, Møller K, Lormans P, Quintana-Díaz M, Caricato A, Cardoso Ferreira MA, Badenes R, Kurtz P, Søndergaard CB, Colpaert K, Petterson L, Quintard H, Cinotti R, Gouvêa Bogossian E, Righy C, Silva S, Roman-Pognuz E, Vandewaeter C, Lemke D, Huet O, Mahmoodpoor A, Blandino Ortiz A, van der Jagt M, Chabanne R, Videtta W, Bouzat P, Vincent JL; TRAIN Study Group. Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury: The TRAIN Randomized Clinical Trial.JAMA. 2024 Oct 9. doi: 10.1001/jama.2024.20424. PMID: 39382241

We did liberal versus conservative blood transfusion in brain injury in October, with the HEMOTION trial, but were left in the awkward spot where the results look better with liberal transfusion, but the trial was statistically negative. As a follow up, we have the TRAIN trial, which is another open-label multicenter RCT comparing liberal to conservative transfusion strategies in brain injury. Full post here.

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Skepticism: a lost clinical art.

DiNubile MJ. Skepticism: a lost clinical art. Clin Infect Dis. 2000 Aug;31(2):513-8. doi: 10.1086/313945. Epub 2000 Sep 14. PMID: 10987714

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IV vs IO of OOHCA… on neither?

Couper K, Ji C, Deakin CD, Fothergill RT, Nolan JP, Long JB, Mason JM, Michelet F, Norman C, Nwankwo H, Quinn T, Slowther AM, Smyth MA, Starr KR, Walker A, Wood S, Bell S, Bradley G, Brown M, Brown S, Burrow E, Charlton K, Claxton Dip A, Dra’gon V, Evans C, Falloon J, Foster T, Kearney J, Lang N, Limmer M, Mellett-Smith A, Miller J, Mills C, Osborne R, Rees N, Spaight RES, Squires GL, Tibbetts B, Waddington M, Whitley GA, Wiles JV, Williams J, Wiltshire S, Wright A, Lall R, Perkins GD; PARAMEDIC-3 Collaborators. A Randomized Trial of Drug Route in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2024 Oct 31:10.1056/NEJMoa2407780. doi: 10.1056/NEJMoa2407780. Epub ahead of print. PMID: 39480216

Vallentin MF, Granfeldt A, Klitgaard TL, Mikkelsen S, Folke F, Christensen HC, Povlsen AL, Petersen AH, Winther S, Frilund LW, Meilandt C, Holmberg MJ, Winther KB, Bach A, Dissing TH, Terkelsen CJ, Christensen S, Kirkegaard Rasmussen L, Mortensen LR, Loldrup ML, Elkmann T, Nielsen AG, Runge C, Klæstrup E, Holm JH, Bak M, Nielsen LR, Pedersen M, Kjærgaard-Andersen G, Hansen PM, Brøchner AC, Christensen EF, Nielsen FM, Nissen CG, Bjørn JW, Burholt P, Obling LER, Holle SLD, Russell L, Alstrøm H, Hestad S, Fogtmann TH, Buciek JUH, Jakobsen K, Krag M, Sandgaard M, Sindberg B, Andersen LW. Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest. N Engl J Med. 2024 Oct 31. doi: 10.1056/NEJMoa2407616. Epub ahead of print. PMID: 39480221

We have 2 studies looking at the same question published in the same edition of the NEJM, so I will tackle them together. (You can find more details in the full blog post.) Which is better in out of hospital cardiac arrest: IV or IO?

PARAMEDIC 3 randomized 6,000 (but they were supposed to get to 15,000) patients with out of hospital arrest from multiple EMS agencies in the UK to either an IO or IV to start. Their primary outcome was survival at 30 days, and there was no difference between the two groups (4.5% of the IO group and 5.1% of the IV group). Favourable neurologic outcomes were seen in 2.7% versus 2.8%. ROSC and sustained ROSC to hospital handover were both slightly higher with IV (2% absolute). There will be some conversation about the slight difference in ROSC here, but if people are not surviving that conversation is irrelevant (and if anything, this ROSC seems to represent harm). 

IVIO is a similar trial from Denmark, in which 1749 adult patients with out of hospital cardiac arrest were randomized to an IO or an IV as their first method of vascular access. The primary outcome here was ROSC, and there was no difference (30% with IO vs 29% with IV, RR 1.06, 95% CI 0.9-1.24). There were no differences in survival (12% with IO vs 10% with IV) or neurologically intact survival (9% vs 8%).

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Shorter courses of antibiotics

Ivankovic M, Schwartz KL. Shorter courses of antibiotics. CMAJ. 2024 Nov 3;196(37):E1266. doi: 10.1503/cmaj.240246. PMID: 39496357

Less is more for almost every common indication for oral antibiotics in reality.

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Age adjusted D-dimer in high risk patients

Bannelier H, Kapfer T, Roussel M, Freund Y, Alame K, Catoire P, Vromant A. Failure rate of D-dimer testing in patients with high clinical probability of pulmonary embolism: Ancillary analysis of three European studies. Acad Emerg Med. 2024 Nov 1. doi: 10.1111/acem.15032. PMID: 39487597

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Dietl’s syndrome – now you know about it!

Thom C, Larsen M, Kongkatong M, Ottenhoff J, Moak J. It’s Not Cyclic Vomiting Syndrome Until Dietl’s is Ruled Out: A Case for Point of Care Renal Ultrasound. J Emerg Med. 2024 Oct;67(4):e346-e350. doi: 10.1016/j.jemermed.2024.05.003. Epub 2024 May 16. PMID: 39183114

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A tiny trial about tiny wounds.

Barton MS, Chaumet MSG, Hayes J, Hennessy C, Lindsell C, Wormer BA, Kassis SA, Ciener D, Hanson H. A Randomized Controlled Comparison of Guardian-Perceived Cosmetic Outcome of Simple Lacerations Repaired With Either Dermabond, Steri-Strips, or Absorbable Sutures. Pediatr Emerg Care. 2024 Aug 15. doi: 10.1097/PEC.0000000000003244. Epub ahead of print. PMID: 39141836

Justin has a long series of articles looking at the science behind laceration repair, and I think the simplest answer is: nothing you do matters.

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PECARN looks at probiotics for toddlers diarrhea…

Schnadower D, Tarr PI, Casper TC, Gorelick MH, Dean JM, O’Connell KJ, Mahajan P, Levine AC, Bhatt SR, Roskind CG, Powell EC, Rogers AJ, Vance C, Sapien RE, Olsen CS, Metheney M, Dickey VP, Hall-Moore C, Freedman SB. Lactobacillus rhamnosus GG versus Placebo for Acute Gastroenteritis in Children. N Engl J Med. 2018 Nov 22;379(21):2002-2014. doi: 10.1056/NEJMoa1802598. PMID: 30462938

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Justin finds another way he was wrong (he’s a good scientist!)

Jaballah R, Toumia M, Youssef R, Ali KBH, Bakir A, Sassi S, Yaakoubi H, Kouraichi C, Dhaoui R, Sekma A, Zorgati A, Beltaief K, Mezgar Z, Khrouf M, Bouida W, Grissa MH, Saad J, Boubaker H, Boukef R, Msolli MA, Nouira S. Piroxicam and paracetamol in the prevention of early recurrent pain and emergency department readmission after renal colic: Randomized placebo-controlled trial. Acad Emerg Med. 2024 Aug 19. doi: 10.1111/acem.14996. Epub ahead of print. PMID: 39161087

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Are ants better doctors than we are?

Frank ET, Buffat D, Liberti J, Aibekova L, Economo EP, Keller L. Wound-dependent leg amputations to combat infections in an ant society. Curr Biol. 2024 Jul 22;34(14):3273-3278.e3. doi: 10.1016/j.cub.2024.06.021. Epub 2024 Jul 2. PMID: 38959879

This might be the best paper we have ever discussed on the blog/podcast. Ants are better at managing traumatic leg wounds than we are by several orders of magnitude!

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