EM Journal Club
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Welcome to the Emergency Medicine Journal Club Website. 
Each month we post critically appraised topic summaries (CATS) or individual article critical appraisals in subject areas appropriate to emergency medicine were discussed in our monthly EM journal club at Eastern Virginia Medical School (EVMS).  We appreciate comments and suggestions so feel free to make contact. (mail) 
 


July 2014
Intranasal Naloxone 

P: In patients with acute opiate overdose

I: Does the use of intranasal (IN) Narcan

C: Compared to parenteral Narcan

O: Provide effective antidotal response and improved safety profile

Articles:

Kerr D, Kelly AM, Dietze P, Jolley D, Barger B. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction. 2009 Dec;104(12):2067-74.  
Critical Appraisal Answer Key

Kelly AM, Kerr D, Dietze P, Patrick I, Walker T, Koutsogiannis Z. Randomised trial of intranasal versus intramuscular naloxone in prehospital treatment for suspected opioid overdose. Med J Aust. 2005 Jan 3;182(1):24-7.
Critical Appraisal Answer Key


Merlin MA, Saybolt M, Kapitanyan R, Alter SM, Jeges J, Liu J, Calabrese S, Rynn KO, Perritt R, Pryor PW 2nd. Intranasal naloxone delivery is an alternative to intravenous naloxone for opioid overdoses. Am J Emerg Med. 2010 Mar;28(3): 296-303 
Critical Appraisal Answer Key
 

May 2014 EGDT Revisited

P: In patient’s with evidence of severe sepsis or septic shock


CRASH-2 trial collaborators Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010 Jul 3; 23-32. 2010 Jun 14.

Critical Apprasal Answer Key

Reza Zahed et al., A new and rapid method for epistaxis treatment using injectable form of Tranexamic acid topically: a randomized controlled trial Obstet Gynecol. 2010 Oct;116(4):865-75.

Lukes AS et al Tranexamic acid treatment for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010 Oct;116(4):865-75.



March 2014 Post-Arrest Cardiac Catherization

P: Adult patients with out of hospital cardiac arrest who achieve return of spontaneous circulation

I:  Early cardiac catherization

C: Compared to delayed cardiac catherization

O: Improve patient outcomes, survival to hospital discharge, good neurological recovery

Hollenbeck RD, McPherson JA, Mooney MR, Unger BT, Patel NC, McMullan PW Jr, Hsu CH, Seder DB, Kern KB. Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI. Resuscitation. 2013 Aug 6.
Critical Appraisal Answer Key

Dumas F, Cariou A. Immediate percutaneous coronary intervention is associated with better survival after out of hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Circ Cardiovasc Interv. 2010 Jun 1;3(3):2007 
Critical Appraisal Answer Key

Larsen  JM,  Ravkilde  J.  Acute  coronary  angiography  in  patients resuscitated from outofhospital cardiac arrest a systematic review and meta- analysis. Resuscitation. 2012 Dec;83(12):142733
Critical Appraisal Answer Key

  


February 2014 Child Abuse Screening & Professionalism in Medicine

Guenther E, Randomized prospective study to evaluate child abuse documentation in the emergency department  Acad Emerg Med. 2009 Mar;16(3):249-57
Critical Appraisal Answer Key

Louwers EC, Effects of systematic screening and detection of child abuse in emergency departments. Pediatrics. 2012 Sep;130(3):457-64. 
Critical Appraisal Answer Key

Cho CS Resident perspectives on professionalism lack common consensus. Ann Emerg Med. 2014 Jan;63(1):61-7. 

Wyer PC. On carts and horses: professionalism and the crisis in assessment of graduate medical education. Ann Emerg Med. 2014 Jan;63(1):68-70.



January 2014 Therapeutic Hypothermia Revisited

P: In patient’s presenting to the ED with ROSC after cardiac arrest

I:  Does aggressive post-arrest cooling to 33C 

C: Compared to less aggressive cooling or a "fever control" approach

O: Improve functional neurological outcomes and survival to hospital discharge

Bernard et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.N Engl J Med. 2002 Feb 21;346(8):557-63.

Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002 Feb 21;346(8):549-56.

Nielsen N, TTM Trial Investigators. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013 Dec 5;369(23):2197-206. 

Kim et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: a randomized clinical trial. 

JAMA. 2014 Jan 1;311(1):45-52. 


November 2013 Asymptomatic Hypertension

P: In patient’s presenting to the ED with asymptomatic hypertension

I:  Does routine screening labs, ECG, CXR or acute medication intervention

C: Compared to referral for out patient follow-up

O: Improve patient outcomes such as death and disability (i.e. CVA, ARF)

Nishijima DK, Paladino L, Sinert R. Routine testing in patients with asymptomatic elevated blood pressure in the ED. AM J Emerg Med. 2010 Feb;28(2):235-42.

Karras DJ, Kruus LK, Heilpern KL. Utility of routine testing for patients with asymptomatic severe blood pressure elevation in the emergency department. Ann Emerg Med. 2008 Mar;51(3):231-9    

Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Asymptomatic Hypertension in the ED. Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department. Ann Emerg Med.2006 Mar;47(3);237-49.


October 2013 Xa Inhibitors for DVT & PE

P: In patient’s with evidence of an acute DVT/PE

I:  Is the use of Xa inhibitors such as rivaroxaban

C: Compared to LMWH plus warfarin

O: Associated with improved patient outcomes (compliance, bleeding, recurrent DVT/PE)

EINSTEIN Investigators  Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med. 2010 Dec 23;363(26):2499-510

EINSTEIN–PE Investigators Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med. 2012 Apr 5;366(14):1287-97

Vinson DR, Zehtabchi S, Yealy DM. Can selected patients with newly diagnosed pulmonary embolism be safely treated without hospitalization? A systematic review. Ann Emerg Med. 2012 Nov;60(5):651-662

 
September 2013 Cerebral Edema and DKA

P: In pediatric patient’s DKA undergoing fluid resuscitation for severe dehydration  
I:  Does aggressive fluid resuscitation 
C: Compared to moderate fluid resuscitation
O: Predispose to development of cerebral edema?

 

August 2013 

P: In patients presenting to the ED with acute STEMI

I: Is the routine use of B-blockers

C: Compared to withholding therapy

O: Associated with improved morbidity and mortality

Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group. Lancet. 2005 Nov 5;366(9497):1622-32.

 Hirschl MM, et al. Benefit of immediate beta-blocker therapy on mortality in patients with ST-segment elevation myocardial infarction. Crit Care Med. 2013 Jun;41(6):1396-404

Roberts R, et al. Immediate versus deferred beta-blockade following thrombolytic therapy in patients with acute myocardial infarction. Results of the Thrombolysis in M
Myocardial Infarction (TIMI) II-B Study
. Circulation. 1991 Feb;83(2):422-37.


July 2013 Apenic Oxygenation

P: In apneic ED patients undergoing intubation
I: Does pre-oxygenation with high flow nasal cannula 
C: Compared to current standard of care
O: Improve procedural related hypoxia and other patient outcomes

Frumin MJ, Apneic oxygenation in man. Anesthesiology. 1959 Nov-Dec;20:789-98.

Teller LE,  Pharyngeal insufflation of oxygen prevents arterial desaturation during apnea. Anesthesiology. 1988 Dec;69(6):980-2.

Ramachandran SK, Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth. 2010 May;22(3):164-8

Taha SK, Nasopharyngeal oxygen insufflation following pre-oxygenation using the four deep breath technique. Anaesthesia. 2006 May;61(5):427-30.

May 2013 Coronary CT 

P: In low risk ED patients with a c/c of chest pain
I: Does the use of stress testing or CCTA
C: Compared to serial enzymes and ECG's alone
O: Provide diagnostic benefit without harm

Diercks DB, Counselman FL, Nagurney JT et al  Incremental value of objective cardiac testing in addition to physician impression and serial contemporary troponin measurements in women. Acad Emerg Med. 2013 Mar;20(3):265-70. 

Hermann LK, Weingart SD, et al .The limited utility of routine cardiac stress testing in emergency department chest pain patients younger than 40 years.

Ely S, Chandra A, Mani G, et al Utility of observation units for young emergency department chest pain patients. J Emerg Med. 2013 Feb;44(2):306-12.

MINDBENDER: Prasad V, Cifu A, Ioannidis JP. Reversals of established medical practices: evidence to abandon ship. JAMA. 2012 Jan 4;307(1):37-8.

April 2013

P: Adult emergency department patients with life-threatening hyperkalemia. 
I: Treatment with gastrointestinal cation-exchange resin (kayexalate) plus other potassium lower regimens
C: Treatment with potassium lower regimens other than cation-exchange resins
O: Hyperkalemia-related mortality, duration of hyperkalemia, adverse effects attributed to kayexalate.


Flinn RB, Merrill JP, Welzan WR: Treatment of the oliguric patient with a new sodium ion- exchange resin and sorbitol: A preliminary report. N Engl J Med 264: 111–115, 1961

Scherr L, Ogden DA, Mead AW, Spritz N,
Rubin AL: Management of hyperkalemia 2001 with a cation-exchange resinN Engl J Med 264: 115–119, 1961

Meghan J. Elliott, Paul E. Ronksley, Management of patients with acute hyperkalemia CMAJ October 19, 2010

Jabre P, Belpomme V, et al Family presence during cardiopulmonary resuscitation N Engl J Med. 368(11):1008-18 2013 Mar 14;



September 2013

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


August 2013

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


July 2013

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


May 2013

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging

 

April 2013

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


March 2013

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


February 2013

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


January 2013

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


December 2012 Happy Holidays
November 2012

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


October 2012

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


September 2012

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


August 2012

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


July 2012

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


May 2012

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


April 2012

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


March 2012

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


February 2012

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


January 2012

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


December 2011 Happy holidays! 

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging

November 2011

P: In children with acute bronchiolitis and no prematurity or underlying cardiopulmonary disease

I: Does the use of inhaled racemic epinephrine

C: Compared to “usual standard of care”

O: Improve respiratory status, need for hospital admission hospital.

Critical Appraisal: Plint,A, Epinephrine and Dexamethasone in Children with Brochiolitis NEJM, 2009. 360 2079-89

October 2011  
PICO Question
Algorithm-aided diagnostic decision making 
Comparison: Routine ED care
Outcome: PE protocol CT order rates, PE-related mortality


August 2011 !!! Hurricaine IRENE Cancels JC: Residents in Despair !!!

P: In patient’s undergoing diagnostic CT whose results include incidental findings

I:  Can a structured approach to assessment/ follow-up/ clinical relevance

C: Compared to “routine” approaches to patient follow-up

O: Provide a means to identify clinically relevant findings and minimize unnecessary f/u imaging


July 2011 

 


May 2011 Acute Heart Failure
 Critical Appraisal: Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes. Ann Emerg Med 2007 May;49(5):627-69           Link to Article 

Critical Appraisal:  Felker MG,  et al. Diuretic strategies in patients with acute decompensated heart
failure. N Engl J Med 2011; 364: 797-80
    


 
April 2011  Topics in Atrial Fibrillation  
 Critical Appraisal