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Showing posts from February, 2016

Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill

Journal Club Summary
Methodology Score: 2.5/5       Usefulness Score:  3/5
Semler MW, et al. Am J Respir Crit Care Med.2015 Oct 1. [Epub ahead of print] Abstract Link
This randomized, open-label, pragmatic trial of 150 adults undergoing intubation in a medical ICU found that the median lowest arterial oxygen saturation was 92% with apneic oxygenation versus 90% with usual care (95% confidence interval for the difference -1.6% to 7.4%; P = .16). Unfortunately, the first RCT of apneic oxygenation versus usual care outside the operating room was underpowered for a clinically important outcome; the results of this small single centre trial should not impact the use of a cheap, low risk intervention that may yet have benefit in critically ill patients.   By: Dr. Nicholas Costain
Epi lessonIntention-to-treat (ITT) Analyses Intention-to-treat (ITT) analyses are widely recommended as the preferred approach to the analysis of most clinical trials. The basic intention-to-treat principle is that partici…

High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure

Journal Club Summary:Methodology Score: 4/5                  Usefulness Score: 4/5
Frat JP, et al. N Engl J Med. 2015 Jun 4;372(23):2185-96. Full Article
Editorial: Saving lives withhigh-flownasaloxygen Matthay MA N Engl J Med.2015 Jun 4;372(23):2225-6.
This ICU RCT compared high flow nasal cannula vs NIPPV vs non rebreather facemask in acute hypoxemic respiratory failure without hypercapnia (primarily patients with pneumonia and excluding COPD or pulmonary edema). This is the first RCT directly comparing NIPPV to high flow oxygen therapy and found that ICU mortality outcomes were significantly worse in the NIPPV group and improved in the high flow nasal cannula group in this patient population. By: Dr. Rory Connolly
Epi lesson: Minimal Clinically Important Difference in Clinical Trials

Novel Migraine Therapies!

For those of us who work in the Emergency Department, we are very well versed in migraine management. We see these patients frequently, and typically don't hesitate to utilize our typical maxeran/toradol/fluids combo, as it is typically very effective. But what if your first, second and even third line treatments are ineffective?

Prior to considering neurology consultation for further management, perhaps we should consider one of the more controversial and novel treatments, such as propofol or magnesium. How about migraine preventative therapy, what's the evidence behind dexamethasone in preventing recurrence? Here we seek to further delve into novel migraine therapies in the ED

PropofolThe initial evidence for propofol for refractory migraines come from a single-centre, open-label trial at an outpatient headache clinic. Ultimately, they found a 95.4% average reduction in headache severity in patients receiving propofol 20-30 mg IV q3-5 minutes, with no adverse events or rescue …

Spinal Immobilization: Just a pain in the neck?

The principles behind spinal immobilization, including the utilization of backboards and cervical collars was derived from expert opinion in the 1960's [1-3], and has never been subjected to a randomized controlled trial or high quality observational study.

Significantly more patients are immobilized than will actually have a fracture [4], and whether or not immobilization actually improves outcomes for those who do have a fracture, is highly debatable. 

Backboards should not be used once the patient reaches the Emergency Department (ED)Backboards have numerous well documented risks of harm:Increased field time for paramedicsPressure ulcers [5]Decreased tidal volumes [6,7]Increased painIncreases unnecessary imagingProfessional organizations such as the American College of Emergency Physicians (ACEP) and the National Association of EMS Physicians (NAEMSP) support changing EMS practice to the selective use of backboards in the prehospital setting, and removal of patients from the back…