Journal Club

January Journal Club

Wednesday January 30, 2013
11:00 AM
Prior Hall HSL
 
Journal Club Vignette
 
45 yom with history of hypertension and smoking presents with 12 hours of a sensation that the room is moving around him. It is constant but worse with movement. He has vomited only once but feels very nauseated. He also feels unsteady. He can ambulate. No fevers or chills. No headaches, numbness, tingling, or weakness. No history of this and no history of TIA or stroke. No syncope. Vitals are normal. Exam reveals a well appearing male who sits very still in the bed. Cranial nerves are intact. Finger to nose is intact as well as heel/shin. He has normal strength, sensation, speech, and gait. However during the exam he becomes rather symptomatic and vomits. You are wondering if he needs an MRI to evaluate for central causes of vertigo. You've heard about something called the HINTS exam but aren't really sure how to perform it or how helpful it can be in ruling out central causes. You decide to do a literature search to help you with this patient.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Patients with acute vertigo
Intervention:HINTS exam
Comparison:Standard work up for central causes of vertigo (MRI)
Outcome:Ability to rule out central causes
 
Search Strategy: "HINTS exam" AND "stroke" also tried Vertigo AND stroke
 
Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE: HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009 40:11 p3504-10.
 
Download Article   PubMed Entry
 
Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE: Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ 2011 183:9 pE571-92.
 
Download Article   PubMed Entry
 
Chen L, Lee W, Chambers BR, Dewey HM: Diagnostic accuracy of acute vestibular syndrome at the bedside in a stroke unit. J Neurol 2011 258:5 p855-61.
 
Download Article   PubMed Entry
 
Extra Articles:
 
Lawhn-Heath C, Buckle C, Christoforidis G, Straus C: Utility of head CT in the evaluation of vertigo/dizziness in the emergency department. Emerg Radiol 2013 20:1 p45-9.
 
Download Article   PubMed Entry
 

back to top

February Journal Club

Wednesday February 20, 2013
11:00 AM
Prior Hall HSL 6th Floor
 
Journal Club Vignette
 
A 32 year old male presents to your emergency department with shortness of breath. He states that he first noticed this about a week ago while working out. He normally goes to the gym 3-4 times a week on a regular basis. Over the last week he has noticed that he wasn't able to work out at his regular pace and became very short of breath while doing his normal routine. The following days he became short of breath even while walking, though it was subtle at first. He is otherwise healthy, has no PMH, no medications, and does not smoke. His vitals are HR 111, pulse ox 94%, BP 135/80 and respirations 20/min. A CTPE scan is positive for acute pulmonary embolus. He is otherwise healthy and a very reliable patient. You wonder if it is possible that this patient can be treated for his PE as an outpatient. You have heard of the pulmonary embolism severity index (PESI) that helps to identify those low risk patients that may be safely treated as an outpatient. You decide to investigate if this PESI score has been validated and will apply to your patient.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Patients with acute PE
Intervention:Outpatient management
Comparison:Standard therapy (admission)
Outcome:Mortality, morbidity, complications
 
Search Strategy: Pubmed:
 
Aujesky D, Perrier A, Roy PM, Stone RA, Cornuz J, Meyer G, Obrosky DS, Fine MJ: Validation of a clinical prognostic model to identify low-risk patients with pulmonary embolism. J Intern Med 2007 261:6 p597-604.
 
Download Article   PubMed Entry
 
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 60:5 p651-662.e4.
 
Download Article   PubMed Entry
 
Zondag W, den Exter PL, Crobach MJ, Dolsma A, Donker ML, Eijsvogel M, Faber LM, Hofstee HM, Kaasjager KA, Kruip MJ, Labots G, Melissant CF, Sikkens MS, Huisman MV: Comparison of two methods for selection of out of hospital treatment in patients with acute pulmonary embolism. Thromb Haemost 2013 109:1 p47-52.
 
Download Article   PubMed Entry
 
Extra Articles:
 
Zondag W, Mos IC, Creemers-Schild D, Hoogerbrugge AD, Dekkers OM, Dolsma J, Eijsvogel M, Faber LM, Hofstee HM, Hovens MM, Jonkers GJ, van Kralingen KW, Kruip MJ, Vlasveld T, de Vreede MJ, Huisman MV: Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost 2011 9:8 p1500-7.
 
Download Article   PubMed Entry
 

back to top

March Journal Club

Wednesday March 27, 2013
11:00 AM
Prior Hall HSL 6th Floor
 
Journal Club Vignette
 
A 54 year old post-menopausal patient comes in concerned about abdominal pain that has been present for the last 4 months. She was seen in the ED 1 week prior with the same complaint and had normal labs, normal vital signs, no vaginal bleeding, a normal pelvic exam and a normal CT abd/pelvis. Her vital signs are stable. She has already been evaluated by GYN 1 month prior and had a negative workup. Repeat labs today are normal, vitals are stable. She is tolerating PO. She has a follow up appointment with GI in 1 month. After discusssing with the patient that you cannot find a reason for her pain, but you reasssure her that you do not think there is anything serious, that it is safe for her to go home, and that further workup can be done as at outpatient. You offer the patient pain medication, but she states that she does not want pain medication, she wants answers. As are preparing to discharge the patient and have her follow-up with her primary care doctor and her GI appointment. The patient becomes very upset and states that you are not doing your job and wishes to file a complaint against you. You begin to think for yourself, "is there anything else I can do to make this patient feel satisfied with her visit in the ED? Was there anything about my evaluation of the patient that I could have changed that could have resulted in a better encounter? You do a literature search in Pubmed for Emergency Department Patient Satisfaction.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Patients in the emergency department
Intervention:New communication or customer service strategies
Comparison:Current standard of care
Outcome:Increased patient satisfaction
 
Search Strategy:
 
Boudreaux ED, D'Autremont S, Wood K, Jones GN: Predictors of emergency department patient satisfaction: stability over 17 months. Acad Emerg Med 2004 11:1 p51-8.
 
Download Article   PubMed Entry
 
Downey LV, Zun LS: The correlation between patient comprehension of their reason for hospital admission and overall patient satisfaction in the emergency department. J Natl Med Assoc 2010 102:7 p637-43.
 
Download Article   PubMed Entry
 
Toma G, Triner W, McNutt LA: Patient satisfaction as a function of emergency department previsit expectations. Ann Emerg Med 2009 54:3 p360-367.e6.
 
Download Article   PubMed Entry
 
Extra Articles:
 
Patel PB, Vinson DR: Physician Email and Telephone Follow-up After Emergency Department Visit Improves Patient Satisfaction: A Cross-Over Trial. Ann Emerg Med 2013 in press.
 
Download Article   PubMed Entry
 

back to top

April Journal Club

Wednesday April 24, 2013
11:00 AM
Prior Hall HSL 6th Floor
 
Journal Club Vignette
 
Vignette: A 29 yom presents by EMS with a GSW to the abdomen. He is awake but drowsy. His vitals en route were BP 110/80, HR 96, RR 20, and O2 sat 99% RA. He is otherwise a healthy guy. You move him over and notice his airway is intact but his repeat BP in the ED is 86/60 and his heart rate is climbing. He has a small bullet wound to the left mid abdomen and is moaning in pain. You decide to start resuscitating him and start NS boluses and order uncrossmatched blood. You consider starting the massive transfusion protocol. Repeat BP after 1L NS is 90/60 and heart rate is 106. The trauma attending orders to transfuse 2 units of blood. You remember you once heard that it's better if you let them remain slightly hypotensive rather than resuscitating to a normal BP, but can't remember all of the details. After the case is over, you decide to look up the data on this topic.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Trauma patients who are hypotensive
Intervention:Permissive hypotension
Comparison:Standard resuscitation back to normal BP
Outcome:Mortality, ability to survive to definitive bleeding control in OR
 
Search Strategy:
 
Duke MD, Guidry C, Guice J, Stuke L, Marr AB, Hunt JP, Meade P, McSwain NE, Duchesne JC: Restrictive fluid resuscitation in combination with damage control resuscitation: time for adaptation. J Trauma Acute Care Surg 2012 73:3 p674-8.
 
Download Article   PubMed Entry
 
Dutton RP, Mackenzie CF, Scalea TM: Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma 2002 52:6 p1141-6.
 
Download Article   PubMed Entry
 
Morrison CA, Carrick MM, Norman MA, Scott BG, Welsh FJ, Tsai P, Liscum KR, Wall MJ, Mattox KL: Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma 2011 70:3 p652-63.
 
Download Article   PubMed Entry
 

back to top

May Journal Club

Wednesday May 29, 2013
11:00 AM
Prior Hall HSL 6th Floor
 
Journal Club Vignette
 
A 53 y/o male presents to your emergency department with epistaxis. He had a small nosebleed yesterday that resolved with pressure. He tried pressure again today, but it just won¹t stop. He takes aspirin 81mg daily for his history of CAD, but otherwise is not on any anticoagulant medications. Upon arrival he is applying pressure to his nose but there is still bleeding. His vitals are BP 144/84, HR 86, T 98.2, RR 18, SaO2 98%RA. On exam he has blood coming from his left nare and you can locate an area that appears to be an anterior bleed. He has no blood coming from his oropharynx. You apply pressure for 15 minutes without success. You then silver nitrate cauterization but it still won¹t stop. You then place a RhinoRocket and the bleeding stops. You observe him and the epistaxis remains resolved. Upon discharge you wonder if you need to prescribe him antibiotics since he has nasal packing in place. You decide to perform a literature search to determine if this has been studied before.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:ED Patients with Epistaxis
Intervention:No use of antibiotics with nasal packing
Comparison:Routine use of antibiotics with nasal packing
Outcome:Complications, Infection
 
Search Strategy: pubmed, epistaxis and antibiotic, or nasal packing and antibiotic
 
Biswas D, Mal RK: Are systemic prophylactic antibiotics indicated with anterior nasal packing for spontaneous epistaxis?. Acta Otolaryngol 2009 129:2 p179-81.
 
Download Article   PubMed Entry
 
Biggs TC, Nightingale K, Patel NN, Salib RJ: Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs?. Ann R Coll Surg Engl 2013 95:1 p40-2.
 
Download Article   PubMed Entry
 
Pepper C, Lo S, Toma A: Prospective study of the risk of not using prophylactic antibiotics in nasal packing for epistaxis. J Laryngol Otol 2012 126:3 p257-9.
 
Download Article   PubMed Entry
 

back to top

July Journal Club

Wednesday July 31, 2013
11:00 AM
Prior Hall HSL 6th Floor
 
Journal Club Vignette
 
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:
Intervention:
Comparison:
Outcome:
 
Search Strategy:
 
Woo JK, Chiu RY, Thakur Y, Mayo JR: Risk-benefit analysis of pulmonary CT angiography in patients with suspected pulmonary embolus. AJR Am J Roentgenol 2012 198:6 p1332-9.
 
Download Article   PubMed Entry
 
Wiener RS, Schwartz LM, Woloshin S: When a test is too good: how CT pulmonary angiograms find pulmonary emboli that do not need to be found. BMJ 2013 347: pf3368.
 
Download Article   PubMed Entry
 
Green SM, Yealy DM: Right-sizing testing for pulmonary embolism: recognizing the risks of detecting any clot. Ann Emerg Med 2012 59:6 p524-6.
 
Download Article   PubMed Entry
 

back to top

August Journal Club

Wednesday August 28, 2013
11:00 AM
Prior HSL
 
Journal Club Vignette
 
A 40 year old male presents to your emergency department in cardiac arrest. He was found unresponsive at the scene and EMS was called while bystander CPR was initiated. He arrives intubated, with IV access, and CPR in progress by EMS. He has already been given three rounds of epinephrine. He is transferred to the bed, attached to the monitor, and resuscitation is continued. During the first pulse check, bedside cardiac ultrasound is performed and shows an absence of cardiac motion with no significant pericardial effusion. The monitor shows PEA. You resume CPR and continue to work through the PEA algorithm. As the code continues you wonder if cardiac standstill on ultrasound can aid in your decision to continue or hold resuscitation. After your shift, you perform a literature search to assist you in answering this question.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Patients in cardiac arrest
Intervention:Bedside ultrasound identifying an absence of cardiac motion
Comparison:Bedside ultrasound identifying cardiac motion
Outcome:Mortality
 
Search Strategy:
 
Blyth L, Atkinson P, Gadd K, Lang E: Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review. Acad Emerg Med 2012 19:10 p1119-26.
 
Download Article   PubMed Entry
 
Cureton EL, Yeung LY, Kwan RO, Miraflor EJ, Sadjadi J, Price DD, Victorino GP: The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest. J Trauma Acute Care Surg 2012 73:1 p102-10.
 
Download Article   PubMed Entry
 
Blaivas M, Fox JC: Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med 2001 8:6 p616-21.
 
Download Article   PubMed Entry
 

back to top

September Journal Club

Wednesday September 25, 2013
11 AM
Prior HSL
 
Journal Club Vignette
 
There is no vignette for this journal club because the articles for this month have different topics.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:None
Intervention:None
Comparison:None
Outcome:None
 
Search Strategy: None
 
Hennings JR, Fesmire FM: A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med 2012 30:6 p994-1000.
 
Download Article   PubMed Entry
 
Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C: Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013 368:1 p11-21.
 
Download Article   PubMed Entry
 
Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, Reed ME, Holmes JF: Risk of traumatic intracranial hemorrhage in patients with head injury and preinjury warfarin or clopidogrel use. Acad Emerg Med 2013 20:2 p140-5.
 
Download Article   PubMed Entry
 

back to top

October Journal Club

Wednesday October 30, 2013
11:00 AM
Prior HSL
 
Journal Club Vignette
 
A 38 year-old man with a history of Crohn’s Disease presents to your ED complaining of worsening abdominal pain, nausea, vomiting, and shortness of breath. He has been to the emergency department twice in the past month for abdominal complaints, with one admission for symptom control. He has a history of multiple abdominal surgeries and small bowel obstructions. Vital Signs are HR of 112, BP 130/82, T 99.2, RR 22, O2 sat 94%. On physical exam the pt appears uncomfortable, abdomen is diffusely tender, but soft, with hyperactive bowel sounds, lungs are clear to auscultation. EKG shows sinus tachycardia. His symptoms continue despite IVF, and IV pain and nausea medications. During a chart review you see the pt has had 8 abdominal CT scans in the past year. You think the pt will likely need readmission for symptom control, but you wonder if the pt needs an abdominal CT- particularly in the setting of multiple CT scans in the past? Also, the pt is complaining of SOB, does he deserve a CT-PE protocol as well? Your head is spinning, but you decide to do a literature search to help you do the right thing for this patient.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Patients with IBD
Intervention:CT Scan of Abdomen, VenousThromboEmbolism investigation?
Comparison:Symptom control only
Outcome:CT findings requiring intervention, including PE
 
Search Strategy: IBD and CT scan, IBD and VTE, IBD and readmission
 
Hazratjee N, Agito M, Lopez R, Lashner B, Rizk MK: Hospital readmissions in patients with inflammatory bowel disease. Am J Gastroenterol 2013 108:7 p1024-32.
 
Download Article   PubMed Entry
 
Kerner C, Carey K, Mills AM, Yang W, Synnestvedt MB, Hilton S, Weiner MG, Lewis JD: Use of abdominopelvic computed tomography in emergency departments and rates of urgent diagnoses in Crohn's disease. Clin Gastroenterol Hepatol 2012 10:1 p52-7.
 
Download Article   PubMed Entry
 
Murthy SK, Nguyen GC: Venous thromboembolism in inflammatory bowel disease: an epidemiological review. Am J Gastroenterol 2011 106:4 p713-8.
 
Download Article   PubMed Entry
 
Extra Articles:
 
Baumgart DC, Sandborn WJ: Inflammatory bowel disease: clinical aspects and established and evolving therapies. Lancet 2007 369:9573 p1641-57.
 
Download Article   PubMed Entry
 

back to top

November Journal Club

Wednesday November 27, 2013
11:00 AM
Prior HSL
 
Journal Club Vignette
 
67 year old male presents with shortness of breath and cough. Pt reports his cough is worse at night and reports he has had to sleep in his Lazyboy for the past 2 nights, because he can't lay flat. Pt denies chest pain at this point. Pt reports he has had three stents placed in his heart, they were placed there in 2006. Pt reports he has been taking his aspirin as directed. On chart review, you note his Echo from 2 months ago shows an EF of 25%. Pt reports he has been admitted for this five times this year.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Patients with heart failure.
Intervention:Ability to discharge patients home w/ diagnosis of acute CHF
Comparison:Standard admission for diuresis.
Outcome:Mortality comparison.
 
Search Strategy: Review of AccessEM articles related to acute heart failure
 
Schrock JW, Emerman CL: Observation unit management of acute decompensated heart failure. Heart Fail Clin 2009 5:1 p85-100, vii.
 
Download Article   PubMed Entry
 
Collins SP, Storrow A: Acute heart failure risk stratification: can we define low risk?. Heart Fail Clin 2009 5:1 p75-83, vii.
 
Download Article   PubMed Entry
 
Stiell IG, Clement CM, Brison RJ, Rowe BH, Borgundvaag B, Aaron SD, Lang E, Calder LA, Perry JJ, Forster AJ, Wells GA: A risk scoring system to identify emergency department patients with heart failure at high risk for serious adverse events. Acad Emerg Med 2013 20:1 p17-26.
 
Download Article   PubMed Entry
 
​​

back to top