October ’17 Journal Club

Summary #1

Jen Finch, DO PGY-3

Savino, P. Brian, et al. “Direct Versus Video Laryngoscopy for Prehospital Intubation: A Systematic Review and Meta-Analysis.” Academic Emergency Medicine, vol. 24, no. 8, 2017, pp. 1018–1026. Pubmed, doi:10.1111/acem.13193.

Main Point/Limitations

Meta-analysis of 8 articles to determine success in the prehospital setting with intubation using Direct Laryngoscopy (DL) vs Video Laryngoscopy (VL). Data extracted included number of patients that intubation was attempted, intubation success and failure, first-pass success and failure, comparison of success with DL vs VL and comparison of success among physician and non-physician providers. Physician providers were in the prehospital setting.

Physician providers were found to have a lower success rate with VL and nonphysician providers had lower success with DL. Limitations included significant heterogeneity, some data in individual studies that was not included in meta-analysis (ie, mean number of intubation attempts), definition of first pass intubation success is variable. Authors note that it is unclear if the results are totally generalizable to US EMS systems, which they consider another limitation.

Take Home Point

Video laryngoscopy could result in higher intubation success rates in the prehospital setting. There are restrictive factors to consider (ie, cost). Other alternatives are better-more training and continued practice with rarely used skills. Success rates when compared to physicians may not be an appropriate or useful measure to consider. More research is needed into this subject.

Summary #2

Alex Spiewak, DO PGY-2

Boutis K, Plint A, Stimec J, Miller E, Babyn P, Schuh S, Brison R, Lawton L, Narayanan UG. Radiograph-Negative Lateral Ankle Injuries in Children Occult Growth Plate Fracture or Sprain? JAMA Pediatr. 2016;170(1):e154114. doi:10.1001/jamapediatrics.2015.4114

Main Point/Limitations

A well managed and well executed study challenging previous dogma that all pediatric ankle injuries with fibular tenderness that did not show X-ray evidence of fracture were Saltar Harris-1 fractures (SH1DF). Previously all these children would require splinting and orthopedic follow-up. This study found that SH1DF were actually quite rare in radiograph negative childern. At three months there was no functional difference between children who had only MRI identified SH1DF and those who had sprains who were treated with removable ankle brace.

Take Home Summary

SH1DF are quite rare in radiograph negative children with lateral ankle tenderness. A removable ankle brace and supportive care measures with pediatrician follow-up is a reasonable management plan.

Summary #3

Erik Arnits, DO PGY-1

Ridderikhof ML et al. Acetaminophen or Nonsteroidal Anti-Inflammatory Drugs in Acute Musculoskeletal Trauma: A multicenter, Double-Blind, Randomized, Clinical Trial: Annals of Emergency Medicine. 1-12. 2017.

Main Point/Limitations

Multi-center study in the Netherlands that compared acetaminophen to diclofenac and diclofenac + acetaminophen in minor musculoskeletal injuries in the ED (defined at no fracture or dislocation). Primary outcome was measured at the end of 90 minutes and measured on the Numeric Rating Scale for pain. Their study of 547 adults over 18 years old found that acetaminophen (1000mg), was non-inferior to diclofenac (50 mg) and/or acetaminophen + diclofenac. Mean decreases were not significant between the treatment groups.

All patients were pre-treated with omeprazole, making adverse events difficult to study and attribute to one medication treatment. Phases 2 and 3 were underpowered due to loss to follow up (which was looking at days of further treatment).

Take Home Summary

Take your pick of the three treatments in treating minor MSK pain in the ED. With risk of GI bleed from NSAIDs, it might be better to put them just on acetaminophen long term, pick any of the 3 treatments for when they are in the ED. The study did not have enough power to conclude on data farther than 90 minutes after treatment. Adverse events were inconclusive due to confounder of omeprazole being given to every patient.