First10EM Journal Club: April 2025

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G’day and welcome to another instalment of the Journal Club with Dr Justin Morgenstern.

This month we cover some diltiazem papers, a few on airway hacks, some population studies and discuss some nerwer management options for big PEs, and kids seizures.

Unfortunately, we had soe technical glitches which means that the usual video / Youtube version will not be available – so you will have to stare at a picture of Justin as you listen to the chat!

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I have never pre-treated with calcium prior to bolusing a Ca-channel blocker… and this paper wont change that!

Az A, Sogut O, Dogan Y, Akdemir T, Ergenc H, Umit TB, Celik AF, Armagan BN, Bilici E, Cakmak S. Reducing diltiazem-related hypotension in atrial fibrillation: Role of pretreatment intravenous calcium. Am J Emerg Med. 2025 Feb;88:23-28. doi: 10.1016/j.ajem.2024.11.033. Epub 2024 Nov 17. PMID: 39577214

An additional note raised by Scott Weingart is related to the significant whole body burning that is often caused by calcium chloride. Justin’s full blog write up is here. 

Bottom line: Calcium probably has some minor hemodynamic effects, but when diltiazem is used correctly, adverse events are incredibly rare, and therefore there is really no reason for prophylaxis.

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Speaking of diltiazem, does it cause patients to bleed to death?

Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson A, Murray KT. Serious Bleeding in Patients With Atrial Fibrillation Using Diltiazem With Apixaban or Rivaroxaban. JAMA. 2024 May 14;331(18):1565-1575. doi: 10.1001/jama.2024.3867. PMID: 38619832

Bottom line: There is an association between diltiazem and increased bleeding in patients on DOACs (as compared to metoprolol), but this is almost certainly the result of obvious confounders, so I can’t see any reason to change current practice. 

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Morgenstern vs Westafer – the battle of the brains… and the winner is science?

Morgenstern J, Radecki R, Westafer L, Niforatos JD, Atkinson P. CJEM debate: clinical decision rules-thinking beyond the algorithm.CJEM. 2025 Feb 3. doi: 10.1007/s43678-025-00870-0. PMID: 39900742

You can read Justin’s full write up on why  decision rules are ruining medicine. 

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Mechanical thrombectomy vs. Catheter-directed tPA for medium-sized PEs…. but no clear comparision!

Jaber WA, Gonsalves CF, Stortecky S, Horr S, Pappas O, Gandhi RT, Pereira K, Giri J, Khandhar SJ, Ammar KA, Lasorda DM, Stegman B, Busch L, Dexter DJ 2nd, Azene EM, Daga N, Elmasri F, Kunavarapu CR, Rea ME, Rossi JS, Campbell J, Lindquist J, Raskin A, Smith JC, Tamlyn TM, Hernandez GA, Rali P, Schmidt TR, Bruckel JT, Camacho JC, Li J, Selim S, Toma C, Basra SS, Bergmark BA, Khalsa B, Zlotnick DM, Castle J, O’Connor DJ, Gibson CM; PEERLESS Committees and Investigators*. Large-Bore Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis in the Management of Intermediate-Risk Pulmonary Embolism: Primary Results of the PEERLESS Randomized Controlled Trial. Circulation. 2025 Feb 4;151(5):260-273. doi: 10.1161/CIRCULATIONAHA.124.072364. Epub 2024 Oct 29. PMID: 39470698

Bottom line: At this point there is absolutely no evidence that mechanical thrombectomy or catheter directed thrombolysis help patients. There might be times where they are reasonable, even without evidence, such as in a very sick patient with contraindications to systemic thrombolysis. However, neither of these procedures should be used routinely until we see real evidence.

Justin’s full write up of this paper is here. 

Lauren Westafer, Justin & Dr. Bourke Tillman do a great discussion of the modern management of intermediate and high risk PE at length on this recent Emergency Medicine Cases podcast, and Justin has a write up of more evidence here. 

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People still use the physical exam to confirm ETT placement??!!

Hansel J, Law JA, Chrimes N, Higgs A, Cook TM. Clinical tests for confirming tracheal intubation or excluding oesophageal intubation: a diagnostic test accuracy systematic review and meta-analysis. Anaesthesia. 2023 Aug;78(8):1020-1030. doi: 10.1111/anae.16059. Epub 2023 Jun 16. PMID: 37325847

This is Casey’s pet topic of the month and a personal peeve in airway management.

Bottom line: The only test you should use to confirm endotracheal tube position is waveform capnography. – save yourself 30 seconds of somebody else’s life!!

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The ETT as a poor man’s LMA?

Markham T, AlFarra AS, Tejani M, Tate DJ, Barrera JE, Paladugu S, Saroukhani S, Jiang Y. Effectiveness of Ventilation via an Endotracheal Tube in Pharynx Versus a Facemask in Patients With Potentially Difficult Airway: A Randomized, Crossover, and Blind Trial. Anesth Analg. 2025 Feb 1;140(2):280-289. doi: 10.1213/ANE.0000000000007273. Epub 2024 Dec 20. PMID: 39705182

This is a weird McGyverism – using an ETT in the place of a device that is universally availabel and works extremely well – the humble LMA!

Bottom line: We generally suck at BVM, so looking for alternatives, especially in difficult patients (obese with a beard), makes sense. However, I am not sure BVM is the correct comparison to this technique, as it appears to me more of a replacement for an LMA.

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Environmental pollution is bad for humans and the rest of the planet – this study correlates pollution with venous thrombotic diseases.

Lutsey PL, Misialek JR, Young MT, Berman J, Leiser CL, Pope ZC, Cushman M, Folsom AR, Kaufman JD. Air pollution is associated with increased risk of venous thromboembolism: the Multi-Ethnic Study of Atherosclerosis. Blood. 2025 Mar 6;145(10):1089-1096. doi: 10.1182/blood.2024026399. PMID: 39652776

Bottom line: There are limitations that significantly limit certainty, but there seems to be an association between air pollution and VTE (among numerous other health implications). 

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It is time to use ketamine for seizures? Or better question: at which time should we use it?

Amr A. Othman, Abdelrahim A. Sadek, Esraa A. Ahmed, Elsayed Abdelkreem, MD, PhD. Combined Ketamine and Midazolam Versus Midazolam Alone for Initial Treatment of Pediatric Generalized Convulsive Status Epilepticus (Ket-Mid Study): A Randomized Controlled Trial Pediatric Neurology 167 (2025) 24e32

Bottom line: When used very late in status epilepticus, ketamine plus midazolam is better than midazolam alone, but we should be cautious of the limitations of this small single center study looking at a very different population than we are used to treating.

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One Policy to Rule Them All

Spellberg B. The Policy to Override Policies-One Policy to Rule Them All. JAMA Intern Med. 2024 Dec 1;184(12):1408-1409. doi: 10.1001/jamainternmed.2024.4625. PMID: 39401007

This is the “deep thinker” of the month – a paper to make us reconsider about how we run our hospitals and who can make the pragmatic and potentially game-changing decisions whilst in the middle of busy practice. This describes a fascinating policy created in a single hospital that handed executive privileges to the coal-face clinical staff adn it seems to be a win-win for their hospital and patients.

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If you listen into the podcast regularly then you will know that we sometimes disappear down nerdy rabbit holes ( I blame Justin!) – this month was no exception – we somehow got talking about the New World Screw-worm … so here is a picture or two to help you visualise the horror!

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