Decision making tools, infographs, testicles and MI’s to name a few, but here are a load of snippets from the world of FOAMem. Enjoy!
Ouch….and ouch again!
Time is testicle! We all know sooner is better, but a systematic review of testicle survival time after a torsion event has helped quantify likely successful survival of the testicle. This is albeit irrespective of atrophy and decreased function and is based on the number of hours after the event. They encourage aggressive management, even if pain is ongoing for longer than the 6-8 hours always talked about as the cut-off.
eFAST it…you are less likely to miss a big one!
Here is a study from Switzerland, looking retrospectively at 109 patients with blunt trauma who underwent both eFAST and CT. They demonstrated that the pneumothoraces missed by eFAST were smaller, in more atypical locations and less often needed drainage. It goes to show if there is one, and it is significant enough a focused, two-point eFAST in blunt trauma should detect it.
Simple tools go a long way…well, that’s the opposite of what I was told at school!!
Another acute coronary syndrome decision tool in the works. The MACS (Manchester Acute Coronary Syndromes) decision rule is another tool aimed at reducing unnecessary hospital admissions in those with a low likelihood of a major adverse myocardial events. This time it looks at hs-cTnT, heart type fatty acid binding protein and some subjective measures from the patient or the clinician at the time of presentation. It is hoped that this tool can be effectively implemented, will need only a single blood test and will aid critical decision making within that golden the four hour window. Previous observational research has shown that it might be useful and this pilot trial would seem to back this up, but more work is needed.
See it in action here:
Use a decision aid…it trumps clinicians’ judgement, doesn’t it??
Are we better than our decision aids? This paper from the Americans tried to determine whether the use of decision aids was superior to the performance of independent physicians’ judgement. A small number, 21, of their searched studies did and in those, only two of the decision aids were superior to the physicians clinical judgement. An interesting thought, especially with all the focus on decision aids in the ED, such as the MACS mentioned above.
Just pop them through the scanner…all of them!
Think before you pan-scan? It’s become an accepted standard in the trauma centre for the primary management of the major trauma patient, but how are we selecting these patients? Dr Caroline Leech writes in the EMJ that we are still not sure who will benefit from this ‘mirror-signal-manoever’ practice and it varies widely between units. She argues that with the risks of radiation, incidental findings, missed injury and contrast induced nephropathy, (see previous edition here of ED bytes for discussion on that one), that in those in whom we haven’t identified any life-threatening pathology that we might consider consent and we may need to look at the development of a validated clinical decision rule.
But…you might find something!!
With reference to the above findings of Dr Leech, it’s worth thinking about the retrospective analysis from Kroczek et al looking at non-traumatic incidental findings from whole body CT in trauma patients. They found three quarters of all polytrauma patients undergoing WBCT had incidental findings of which nearly 10% needed urgent treatment or investigation. For both the nearly 10% that needed urgent attention and the over 90% that didn’t, the burden of these incidental findings may pose a challenge to the ED physician.
Advice of the week
Some very practical, useful advice from RCEM learning on back pain advice. We all see it, a lot of it can be quite heart-sink, but maybe by implementing the steps outlined in this back pain advice we can improve our satisfaction from these encounters.
Have a click through these nice slides on it all…
Videos of the week!
A brilliant look at an ED thoracotomy
I was shown this video of an ED thoracotomy, fascinating both from a procedural standpoint and from the human factors side of things. A lot going on but an compelling watch.
ROSC…what do w ego now?!
Should you take your patient with ROSC, without a STEMI on their ECG to the cath lab? Rebel EM have analysed this paper from Millin et al which is a good read and demonstrates that althought there isn’t a STEMI, that doesn’t mean there isn’t a culprit lesion which would benefit from an emergency cath.
Fab one on PE from the EM3 crowd!
Post Partum Haemorrhage
Click the link to see a rather nice pathway on Post Partum Haemorrhage from the BMJ.
Dan 11th September 2017
Written by: Dr Dan Weston
Senior Editor: Dr Jonny Wilkinson