Journal Jam is the EM Cases podcast that brings together leading EM researchers, EM educators and EM clinicians from around the world to discuss practice-changing EM articles; with your hosts Anton Helman & Teresa Chan.
Together, we’re smarter!
This is EM Cases Journal Jam podcast on a randomized control trial of dilute apple juice vs PediaLyte for mild pediatric gastroenteritis. While IV rehydration is required in cases of severe gastroenteritis (which we rarely see in North America) and oral rehydration with electrolyte maintenance solutions is still the mainstay in treating moderate gastroenteritis, could better-tasting, more cost-effective fluids such as diluted apple juice be just as effective as traditional electrolyte solutions in milder cases? Listen to Dr. Justin Morgenstern (@First10EM) interviewing Dr. Stephen Freedman, the world-renowned pediatric EM researcher who put ondansetron for pediatric gastroenteritis on the map and who was one of our guest experts on our main episode on Pediatric Gastroenteritis, Constipation and Bowel Obstruction, about this practice-changing paper. This is followed by a hilarious rant on the topic from Dr. Anthony Crocco ("Ranthony"), the Division head and medical director of pediatric EM at Hamilton Health Sciences.
Journal Jam 7 - Amiodarone vs Lidocaine vs Placebo in Cardiac Arrest: The ALPS Trial. In our most popular EM Cases episode to date - ACLS Guidelines Cardiac Arrest Controversies, we boldly stated, that there has never been an antiarrhythmic medication that has shown any long term survival benefit in cardiac arrest. The use of medications in cardiac arrest has been one of those things that we all do, but that we know the evidence isn’t great for. Yet Amiodarone is still in the newest AHA adult cardiac arrest algorithm for ventricular fibrillation or pulseless ventricular tachycarida – 300mg IV after the 3rd shock with the option to give it again at 150mg after that. Anti-arrhythmics have been shown in previous RCTs to increase the rate of return of spontaneous circulation and even increased survival to hospital admission, however none of them have been able to show a decrease in mortality or a favourable neurological outcome at hospital discharge. In other words, there has never been shown a long term survival or functional benefit - which is a bit disconcerting. But now, we have a recent large randomized, controlled trial that shines some new light on the role of anti-arrythmics in cardiac arrest - The ALPS trial: Amiodarone vs Lidocaine vs placebo in out of hospital cardiac arrest. In this Journal Jam podcast, Justin Morgenstern and Anton Helman interview two authors of the ALPS trial, Dr. Laurie Morrison a world-renowned researcher in cardiac arrest and Dr. Paul Dorian, a cardiac electrophysiologist and one of Canada's leading authorities on arrhythmias about what we should take away from the ALPS trial. It turns out, it's not so simple. We also discuss the value of dual shock therapy for shock resistant ventricular fibrillation and the future of cardiac arrest care.
This is EM Cases Journal Jam Podcast 6 - Outpatient Topical Anesthetics for Corneal Abrasions. I’ve been told countless times by ophthalmologists and other colleagues NEVER to prescribe topical anesthetics for corneal abrasion patients, with the reason being largely theoretical - that tetracaine and the like will inhibit re-epithelialization and therefore delay epithelial healing as well as decrease corneal sensation, resulting in corneal ulcers. With prolonged use of outpatient topical anesthetics for corneal abrasions, corneal opacification could develop leading to decreased vision. Now this might be true for the tetracaine abuser who pours the stuff in their eye for weeks on end, but when we look at the literature for toxic effects of using topical anesthetics in the short term, there is no evidence for any clinically important detrimental outcomes. Should we ignore the dogma and use tetracaine anyway? Is there evidence that the use of topical anesthetics after corneal abrasions is safe and effective for pain control without adverse effects or delayed epithelial healing? To discuss the paper "The Safety of Topical Anesthetics in the Treatment of Corneal Abrasions: A Review" by Drs. Swaminathan, Otterness, Milne and Rezaie published in the Journal of Emergency Medicine in 2015, we have EM Cases’ Justin Morgenstern, a Toronto-based EM Doc, EBM enthusiast as well as the brains behind the First10EM blog and Salim Rezaie, Clinical Assistant Professor of EM and Internal Medicine at University of Texas Health Science Center at San Antonio as well as the Creator & Founder of the R.E.B.E.L. EM blog and REBELCast podcast. In this Journal Jam podcast, Dr. Morgenstern and Dr. Rezaie also discuss a simple approach to critically appraising a systematic review article, how to handle consultants who might not be aware of the literature and/or give you a hard time about your decisions and much more...
Traditionally we've run at least 2 troponins 6 or 8 hours apart to help rule out MI and recently in algorithms like the HEART score we've combined clinical data with a 2 or 3 hour delta troponin to help rule out MI. The paper we'll be discussing here is a multicentre/multinantional study from the Canadian Medical Association Journal from this year out of Switzerland entitled "Prospective validation of a 1 hour algorithm to rule out and rule in acute myocardial infarction using a high sensitivity cardian troponin T assay" with lead author Tobias Reichlin. It not only looks at whether or not we can rule out MI using a delta troponin at only 1 hour but whether or not we can expedite the ruling in of MI using this protocol.
You’d think ketamine was in the ED drinking water! Not only has this NMDA receptor antagonist been used effectively for procedural sedation and rapid sequence intubation, but also, for delayed sequence intubation to buy time for pre-oxygenation, for life-threatening asthma as it has bronchodilatory and anxiolytic effects, for severely agitated psychiatric patients and excited delirium syndrome to dissociate them and get them under control; ketamine has even been used for refractory status epilepticus and for head injured patients as it is thought to have neuroprotective effects. The big question is: How effective is low dose ketamine analgesia for patients with moderate to severe pain in the ED as an adjunct to opiods? Low dose ketamine seems not only to help control pain, but it also has this almost magical effect of making patients indifferent to the pain. Pain is everywhere. And oligoanalgesia occurs in up to 43% of patients in EDs. Can we relieve suffering with low dose ketamine analgesia in the ED?....
In this Journal Jam we have Dr. Michelle Lin from Academic Life in EM interviewing two authors, Dr. Rebecca Smith‑Bindman, a radiologist, and Dr. Ralph Wang an EM physician both from USCF on their article “Ultrasonography versus Computed Tomography for suspected Nephrolithiasis” published in the New England Journal of Medicine in 2014. There is currently a wide practice variation in the imaging work-up of the patient who presents to the ED with a high suspicion for renal colic. On the one extreme, some EM physicians use CT to screen all patients who present with renal colic, while on the other extreme, other EM physicians do not use any imaging on any patient who has had previous imaging. The role of POCUS and radiology department ultrasound as an alternative to CT in the work up of renal colic has not been clearly defined in the ED setting. This study was a pragmatic multi-centre randomized control trial of patients in whom the primary diagnostic concern was renal colic, that tried to answer the question: is there a significant difference in the serious missed diagnosis rate, serious adverse events rate, pain, return visits, admissions to hospital, radiation dose and diagnostic accuracy if the EM provider chose POCUS, radiology department ultrasound or CT for their initial imaging modality of choice. This Journal Jam is peer review by EMNerd's Rory Spiegel. [wpfilebase tag=file id=618 tpl=emc-play /] [wpfilebase tag=file id=619 tpl=emc-mp3 /]