Journal Club

March Journal Club

Thursday March 31, 2011
6:30 PM
5510 Cramblet Hall Conference Room
 
Journal Club Vignette
 
A 35 year old female presents to the ED with one day of increasing back pain. The patient states that she has a history of chronic back pain for which she takes Oxycontin twice per day as well as Percocet every 4- 6 hours for breakthrough pain. The patient states that she recently ran out of her medication and is unable to get in to her primary care doctors office for one week. She states her pain is increased as well since she ran out of her pain medication and she is asking for something IV for her pain. She states she normally receives Dilaudid and Phenergan when she comes to the ED for pain. On review of her records, she has had multiple visits to the ED over the last year for similar pain related complaints, in which many of the visits she does indeed receive parenteral medications as well as narcotic prescriptions. On her OARRS report, she has multiple prescriptions from several providers over the last year. She has a history of Fibromyalgia as well as Reflex Sympathetic Dystrophy from an injury she sustained in a MVC 4 years ago. On exam, her vitals are stable; she is tearful with diffuse spinal tenderness but is otherwise neurologically intact. Your attending asks you how you would like to treat her pain and if you want to prescribe her pain medication to go home or not. Your Department does not currently have a policy on managing pain in chronic pain patients so you decide to do a literature search to further investigate.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Chronic ED pain patients
Intervention:Acute pain control and/or alternative management
Comparison:Home PO meds
Outcome:Improved pain control, patient satisfaction
 
Search Strategy: Pubmed; Keywords: chronic pain AND emergency department Limits: English, Adults, last 10 years Results: 434 articles. 3 selected for review:
 
Baker K: Chronic pain syndromes in the emergency department: identifying guidelines for management. Emerg Med Australia 2005 17:1 p57-64.
 
Download Article   PubMed Entry
 
Patanwala AE, Keim SM, Erstad BL: Intravenous opioids for severe acute pain in the emergency department. Ann Pharmacother 2010 44:11 p1800-9.
 
Download Article   PubMed Entry
 
Richards JR, Richards IN, Ozery G, Derlet RW: Droperidol Analgesia for Opioid-Tolerant Patients. J Emerg Med 2010 : p epub ahead of print.
 
Download Article   PubMed Entry
 

back to top

April Journal Club

Thursday April 28, 2011
6:30 PM
5510 Cramblet Hall Conference Room
 
Journal Club Vignette
 
You have joined a new ED group after finishing your EM residency. The group recently received their annual patient satisfaction scores and overall they were average compared to similar-sized institutions in the same regional area. The group has recently instituted a new bonus pool and a significant portion of the pool will be distributed based on the patient satisfaction scores of individual physicians. The medical director of the group would like you to identify a few ways that the group can improve the patient satisfaction of the physicians. Specifically, he wants you to identify things the physicians can do to improve their scores over the next year without any financial investment by the group. You are unsure of what factors influence patient's perception of care and satisfaction so you do a literature search to investigate.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:ED patients
Intervention:Physician behavior and/or activities
Comparison:Standard behavior
Outcome:Improve patient satisfaction scores
 
Search Strategy: Pubmed; Keywords: patient satisfaction AND emergency department Limits: English, Adults, last 10 years Results: 951 articles. 3 selected for review:
 
Boudreaux ED, O'Hea EL: Patient satisfaction in the Emergency Department: a review of the literature and implications for practice. J Emerg Med 2004 26:1 p13-26.
 
Download Article   PubMed Entry
 
Lin YK, Lin CJ: Factors predicting patients' perception of privacy and satisfaction for emergency care. Emerg Med J 2010 : p. epub
 
Download Article   PubMed Entry
 
Jeanmonod R, Boyd M, Loewenthal M, Triner W: The nature of emergency department interruptions and their impact on patient satisfaction. Emerg Med J 2010 27:5 p376-9.
 
Download Article   PubMed Entry
 
Extra Articles:
 
Emergency Department Pulse Report: Press Ganey Associates, Inc. 2010
 
Download Article
 

back to top

May Journal Club

Thursday May 26, 2011
6:30 PM
5510 Cramblet Hall Conference Room
 
Journal Club Vignette
 
You are the new chair of your city's emergency response planning committee. As the new chair, it is your job to evaluate the current protocols to determine if any need to be changed and/or updated. One such protocol that has caught your eye is the city's current plan and response to a Mass Casualty Incident (MCI). The city currently uses the START (Simple Triage And Rapid Treatment) for triage of injured victims. However, you are also aware that the CDC, as well as ACEP, have both advocated for the use of the SALT (Sort-Assess-Lifesaving interventions-Treatment/Transport) triage methodology. However, you are unfamiliar with the pros and cons of each and are unsure if one system is superior to the other. As such, you decide to investigate if there is any literature that supports one over the other. You are particularly interested in how each of them performs in a real setting.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Mass Casualty Patients
Intervention:SALT Triage
Comparison:START/SMART Triage
Outcome:Sensitivity, Specificity, NPV, PPV, LR+, LR-
 
Search Strategy: Pubmed; Keywords: mass casualty incident AND triage Limits: English, Adults, last 10 years Results: articles. 3 selected for review:
 
Kahn CA, Schultz CH, Miller KT, Anderson CL: Does START triage work? An outcomes assessment after a disaster. Ann Emerg Med 2009 54:3 p424-30, 430.e1.
 
Download Article   PubMed Entry
 
Lerner EB, Schwartz RB, Coule PL, Pirrallo RG: Use of SALT triage in a simulated mass-casualty incident. Prehosp Emerg Care 2009 14:1 p21-5.
 
Download Article   PubMed Entry
 
Cone DC, Serrra J, Kurland L: Comparison of the SALT and Smart triage systems using a virtual reality simulator with paramedic students. Eur J Emerg Med 2011 : epub.
 
Download Article   PubMed Entry
 

back to top

July Journal Club

Thursday July 28, 2011
6:30 PM
5510 Cramblet Hall Conference Room
 
Journal Club Vignette
 
A 55 year old male presents to the ED with one day of intermittent chest pain. He states the pain is dull and achy lasting several minutes at a time. He typically gets pain like this once or twice a month but it usually goes away with one Nitro. Today the pain is more severe, lasting longer, and not responsive to nitro. He has a history of diabetes, hypercholesterolemia, and coronary artery disease with a stent to his LAD 3 years ago. On exam, his vitals are stable and he is slightly diaphoretic. His ECG has T wave inversions in his lateral leads which are new from priors. His first Troponin was normal. You diagnose him with Unstable Angina, give him 325 mg of Aspirin, 300 mg of Plavix, 0.4 mg of SL Nitro followed by a Nitro drip which has been titrated so that the patient is pain free. You also would like to start additional anti-coagulation but you are unsure if the patient will be going to the catheterization lab or not in the next 24 hours so are uncertain about starting low molecular heparin as opposed to unfractionated heparin. You decide to explore for yourself.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:ED Patients with USA/NSTEMI
Intervention:Low-molecular weight heparin
Comparison:Unfractionated heparin
Outcome:Mortality, reinfarction, recurrent angina, bleeding complications
 
Search Strategy: Pubmed; Keywords: acute coronary syndrome AND low molecular weight heparin Limits: English, Adults, Clinical Trials Adults Results: 93 articles. 3 selected for review:
 
Cohen M, Demers C, Gurfinkel EP, Turpie AG, Fromell GJ, Goodman S, Langer A, Califf RM, Fox KA, Premmereur J, Bigonzi F: A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med 1997 337:7 p447-52.
 
Download Article   PubMed Entry
 
Berkowitz SD, Stinnett S, Cohen M, Fromell GJ, Bigonzi F: Prospective comparison of hemorrhagic complications after treatment with enoxaparin versus unfractionated heparin for unstable angina pectoris or non-ST-segment elevation acute myocardial infarction. Am J Cardiol 2001 88:11 p1230-4.
 
Download Article   PubMed Entry
 
Blazing MA, de Lemos JA, White HD, Fox KA, Verheugt FW, Ardissino D, DiBattiste PM, Palmisano J, Bilheimer DW, Snapinn SM, Ramsey KE, Gardner LH, Hasselblad V, Pfeffer MA, Lewis EF, Braunwald E, Califf RM: Safety and efficacy of enoxaparin vs unfractionated heparin in patients with non-ST-segment elevation acute coronary syndromes who receive tirofiban and aspirin: a randomized controlled trial. JAMA 2004 292:1 p55-64.
 
Download Article   PubMed Entry
 
Extra Articles:
 
Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP, Jacobs AK: 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/ Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011 123:18 p2022-60.
 
Download Article   PubMed Entry
 

back to top

August Journal Club

Thursday August 25, 2011
6:30 PM
5510 Cramblet Hall Conference Room
 
Journal Club Vignette
 
A 35 year old male presents to the ED by EMS after being “found down”. The patient gives a limited history but his friends who are present give further information. The patient was at a party drinking heavily. His friends state that he wandered upstairs and they found him a few minutes later “passed out” on the floor. There was no vomiting that they are aware of. They state he drinks socially and every once in awhile he gets intoxicated like this. On PE, the patient’s vital signs are stable and he smells of alcohol. There is no evidence of trauma. His PERRLA, his conjunctiva are injected bilaterally, his gag reflex is intact, and responds to painful stimuli appropriately as well as intermittently responding to verbal stimuli. Approximately one hour after arrival, the patient is more alert, awake, and responds to most questions appropriately and has a GCS of 15. Your attending wants you to order a head CT to ensure there is no ICH or other acute injury as he is still intoxicated. You are unsure of whether or not the test is indicated since the patient appears to be improved but still has alcohol on board.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:ED Patients with alcohol intoxication
Intervention:Non-contrast Head CT
Comparison:Observation
Outcome:Sensitivity, Specificity, NPV, PPV, Prevalence, Incidence of Significant injury
 
Search Strategy: Pubmed; Keywords: alcohol intoxication AND head CT Limits: English, Adults, Clinical Trials Adults Results: 31 articles. 3 selected for review:
 
Taylor TR, Mhlanga J, Thomas A: Alcohol-related head injury: impact on acute CT workload in a major trauma centre. Br J Neurosurg 2009 23:6 p622-4.
 
Download Article   PubMed Entry
 
Godbout BJ, Lee J, Newman DH, Bodle EE, Shah K: Yield of head CT in the alcohol-intoxicated patient in the emergency department. Emerg Radiol 2011 online publication.
 
Download Article   PubMed Entry
 
Bracken ME, Medzon R, Rathlev NK, Mower WR, Hoffman JR: Effect of intoxication among blunt trauma patients selected for head computed tomography scanning. Ann Emerg Med 2007 49:1 p45-51.
 
Download Article   PubMed Entry
 

back to top

September Journal Club

Thursday September 29, 2011
6:30 PM
5510 Cramblet Hall Conference Room
 
Journal Club Vignette
 
A 40 year old male presented to the ED with a dislocated left shoulder after falling down from standing. After you present to your attending, the plan is to use procedural sedation for the closed reduction. Your attending would like you to get the patient ready and to choose the medication of your choice and he will be in when once everything is ready. You consent the patient, put the patient on a monitor along with a continuous pulse oximeter, and order the medication of your choice. Your attending asks if you would like to use ETCO2 monitoring to help identify respiratory depression during the procedure. You are unsure if this would improve patient monitoring and decide to do a literature search:
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:ED Patients with procedural sedation
Intervention:End tidal CO2 monitoring + routine care
Comparison:Routine care
Outcome:Hypoxia, respiratory depression +/- intervention, hypotension, mortality
 
Search Strategy: Pubmed; Keywords: procedural sedation AND capnography Limits: English, Adults, Clinical Trials Adults Results: 33 articles. 3 selected for review:
 
Burton JH, Harrah JD, Germann CA, Dillon DC: Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices? Acad Emerg Med 2006 13:5 p500-4.
 
Download Article   PubMed Entry
 
Sivilotti ML, Messenger DW, van Vlymen J, Dungey PE, Murray HE: A comparative evaluation of capnometry versus pulse oximetry during procedural sedation and analgesia on room air. CJEM 2010 12:5 p397-404.
 
Download Article   PubMed Entry
 
Waugh JB, Epps CA, Khodneva YA: Capnography enhances surveillance of respiratory events during procedural sedation: a meta-analysis. J Clin Anesth 2011 23:3 p189-96.
 
Download Article   PubMed Entry
 

back to top

November Journal Club

Thursday November 17, 2011
6:30 PM
5510 Cramblet Hall Conference Room
 
Journal Club Vignette
 
You are doing a ride along with EMS and are dispatched to the scene of an MVC. John Doe, is a 40 year old male involved in a roll over MVC. He has an obvious deformity to his left forearm and complains of abdominal pain. The passenger in the MVC was pronounced dead on scene. His vital signs are as follows: BP 140/90 HR 120 RR 20 O2 sat 96%. The level 1 trauma center is approximately 50 minutes away by ground transport. Your EMS system does not have strict protocols on when to utilize air transport of injured patients. It is left up to the discretion of the treating provider. You are unsure whether this patient should be transported via ground or helicopter to the trauma center and if there is a benefit to air transport other than more rapid transport time to definitive care.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Adult trauma patients from the scene of injury
Intervention:Helicopter transport
Comparison:Ground transport
Outcome:Mortality, Cost effectiveness, Safety
 
Search Strategy: Pubmed; Keywords: helicopter transport AND trauma Limits: English, Adults, humans Results: 195 articles. 3 selected for review:
 
Sullivent EE, Faul M, Wald MM: Reduced mortality in injured adults transported by helicopter emergency medical services. Prehosp Emerg Care 2011 15:3 p295-302.
 
Download Article   PubMed Entry
 
Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O'Keefe MF: Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis. J Trauma 2006 60:6 p1257-65; discussion 1265-6.
 
Download Article   PubMed Entry
 
McVey J, Petrie DA, Tallon JM: Air versus ground transport of the major trauma patient: a natural experiment. Prehosp Emerg Care 2009 14:1 p45-50.
 
Download Article   PubMed Entry
 
​​

back to top