A Comfortable Miss Rate? Who Needs an LP after CT?

Clinical Scenario: A middle-aged man with a history of hypertension, diabetes mellitus, obesity, and peripheral vascular disease presents to the ED after an episode of syncope about 30 minutes ago. He is now completely alert and oriented and complains of a severe headache. Your initial workup, including basic labs, EKG, troponin, and non-contrast head CT, is unremarkable, and you prepare to admit him for observation and an inpatient syncope workup. The hospitalist service calls back to request a lumbar puncture to rule out subarachnoid hemorrhage before the patient comes up to the floor. Should you get the LP?

Clinical Question: In patients with a non-diagnostic non-contrast head CT, is a lumbar puncture necessary to completely rule out subarachnoid hemorrhage?

Literature Review:  In medical school, we all learn that head CT alone is not sufficient to rule out a subarachnoid hemorrhage (SAH) in a patient with a sufficiently suspicious history- you also need a lumbar puncture (LP), to evaluate for blood in the CSF or xanthochromia. On standardized tests, no patient with risk factors and a sudden-onset headache gets to escape the LP needle… but is this the right way to go about things in clinical practice?

Most experts and clinical guidelines continue to recommend LP after negative head CT in patients at high risk of SAH. In the 2012 guidelines for the diagnosis and treatment of SAH, the American Heart Association and American Stroke Association recommend that “head CT, if nondiagnostic, should be followed by lumbar puncture (Class I, Level of Evidence: B).”[1] This recommendation is based mainly on older studies demonstrating decline in the sensitivity of head CT over the course of days.

However, newer studies using modern multi-detector CT scanners may have identified a subclass of patients in whom an LP is not required to rule out SAH.  Perry and colleagues performed a multi-center prospective cohort study to assess the sensitivity of modern third-generation CT in ED patients being evaluated for SAH [2]. Patients presenting to 11 Canadian tertiary care referral centers between November 2000 and December 2009 with suspected SAH were prospectively enrolled. Alert (GCS=15) patients over 15 years of age presenting with non-traumatic acute headache or syncope associated with headache were included in the study. Exclusion criteria included the presence of focal neurologic deficits or papilledema, known history of CNS abnormality (such as neoplasm, aneurysm, or shunt), recurrent headaches, and transfer from another center with an established diagnosis of SAH. The gold standard for diagnosis of SAH was subarachnoid blood on non-contrast head CT, any visually identified xanthochromia on CSF analysis, or RBCs in the final tube of CSF collected AND aneurysm identified on CT angiography. A major weakness of the study was that not all patients enrolled had both a head CT and a lumbar puncture. In an attempt to correct for this weakness, all patients who did not have a definitive diagnosis based on neuroimaging OR a negative LP were followed for six months to ascertain their outcomes. By the conclusion of the study, 3,132 patients had been enrolled; of these, 240 had confirmed SAH. For all comers, the sensitivity of head CT was 92.9% (95% CI 89.0%-95.5%) and the negative predictive value was 99.4% (99.1%-99.6%). However, for patients who were scanned within six hours of headache onset, the sensitivity of head CT was 100% (97.0%-100%), and the negative predictive value was 100% (99.5%-100%). Likelihood ratios were not reported; however, using data available in the paper, they were calculated as a negative likelihood ratio of 0.07 (0.05-0.11) for all comers, and an impressive 0.00 (0.00-0.03) for patients scanned within six hours of headache onset. 

The results of this study were later replicated by Backes and colleagues [4]. In this retrospective single-center cohort study, patients presenting to the ED with a history suspicious for SAH between 2005 and 2012 were enrolled. Patients with clinical suspicion of a non-traumatic SAH and a normal level of consciousness (GCS=15) were included. Exclusion criteria included unknown time of symptom onset, focal neurologic deficits on presentation, referral from another hospital with a confirmed diagnosis of SAH, and LP in the month before presentation. At the study site, all patients with suspicion of SAH undergo non-contrast head CT, and all patients with a nondiagnostic head CT undergo LP with CSF analysis at least 12 hours after symptom onset; patient databases were reviewed to generate a study population of 250 patients who met criteria.  In all comers, head CT had a sensitivity of 95.4% (89.5%-98.5%), negative predictive value of 96.6% (92.2%-98.9%), and negative likelihood ratio of 0.05 (0.02-1.11). In patients scanned within 6 hours of symptom onset, sensitivity was 98.5% (92.1%-100%), negative predictive value 98.6% (92.3%-100%), and negative likelihood ratio 0.02 (0.00-0.10). In fact, only one patient with a non-diagnostic head CT had any findings on LP; this was a patient with atypical symptoms who was subsequently found to have a bleeding cervical AVM. The authors conclude that in patients with typical symptoms who present and are scanned within six hours of headache onset, there is no need for an LP after non-diagnostic head CT to rule out SAH. Weaknesses of this study included its small sample size and retrospective design.

There are, of course, many patients who still warrant an LP after non-diagnostic head CT. Patients with an altered level of consciousness or focal neurologic deficits were excluded from the above studies and require more intensive diagnostics. These findings are not generalizable to patients with an unknown time of symptom onset, significant anemia, pediatric patients, or patients who present to community centers that lack 24/7 coverage by experienced neuroradiologists—note that both studies were performed at academic tertiary referral centers. Some experts also raise the possibility that stopping the ED workup after a non-diagnostic head CT might miss minor “sentinel” bleeds [5], citing a 1987 study showing that head CT missed “sentinel” bleeds in 55% of patients, while LP, when performed, was positive in all patients later diagnosed with SAH[6]. However, this study was performed in 1987, prior to the introduction of modern third-generation CT scanners, and any attempt at replication would likely show improved testing characteristics for CT alone.

Clinical Takehome : In alert adult patients with a suspected non-traumatic SAH and no focal neurologic deficits who are scanned within 6 hours of symptom onset, a non-diagnostic head CT is sufficient to exclude SAH in patients with a low to moderate pre-test probability of SAH.

Submitted by Kevin Baumgartner, PGY-1
Faculty Reviewed by Brian Cohn

Additional related #FOAMed resources:
LP for subarachnoid hemorrhage: The 700 Club
SGEM #134: on what British docs say about LP    

References: 
1. Connolly et al. “Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guide for healthcare professionals from the American Heart Association/American Stroke Association.” Stroke 2012 Jun; 43(6): 1711-1737 
2. Perry et al. “Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study.” BMJ 2011; 343 
3. Alan Schwartz. “Diagnostic Test Calculator.” Department of Medical Education, University of Illinois at Chicago. [http://araw.mede.uic.edu/cgi-bin/testcalc.pl] 
4. Backes et al. “Time-dependent characteristics of head computed tomography in patients suspected of nontraumatic subarachnoid hemorrhage.” Stroke 2012 Aug; 43(8):2115-9 
5. Singer RJ, Ogilvy CS, Rodorf G. “Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage.” UpToDate. Literature review complete through September 2015; article last updated September 2013. 
6. Leblanc R. “The minor leak preceding subarachnoid hemorrhage.” J Neurosurg 1987; 66(1):35

The Times They Are A Changin': the "No Zone" Approach to Management of Penetrating Neck Trauma

Clinical Case: You're working a busy evening shift when a middle aged woman is brought in by EMS from the scene of a car accident.  She has a deep laceration to her anterior neck near the level of the cricoid cartilage from a glass shard.  She is neurologically intact, talking with a normal voice and is in no respiratory distress.  However, there is a continuous and brisk oozing of blood from the wound.

Clinical Question: What imaging is indicated in hemodynamically stable, neurologically intact patients with penetrating neck injuries?  What should the typical disposition be?

Literature Review:

Any neck wound that extends deep to the platysma is considered a penetrating neck wound, and it is estimated that they represent 5-10% of all trauma patients who arrive to the emergency department. Two common ways of anatomically dividing the neck include using the sternocleidomastoid to divide the neck into anterior and posterior triangles, or dividing the neck into three zones [1]:

In the event of penetrating injury to the neck, airway compromise should be immediately assessed, with early intubation for airway protection if there is any concern for expanding neck hematoma or concerns for airway injury.  An attempt can be made to orotracheally intubate (bougies have been suggested as excellent initial adjuncts [2]), but plans should be made to move to early cricothyroidotomy if the airway is unable to be secured from above. After securing the airway and establishing hemodynamic stability, the neck wound should be carefully inspected.  Injuries that breach the platysma may have caused significant underlying injury, and it is best to avoid probing these wounds at the bedside, as this could disrupt hemostasis.  Aside from risk of vascular disruption, patients with penetrating neck injuries warrant consideration of tracheal and esophageal compromise.  Signs of tracheal injury include air bubbling at the wound, hemoptysis, subcutaneous emphysema, and stridor.  Esophageal injuries can be initially be asymptomatic, and a missed injury can lead to neck space infection and mediastinitis [3].   Emergent surgical consultation is warranted, as patients with hemodynamic instability and/or "hard signs" of vascular or aerodigestive tract injury should go for emergent neck exploration [3].

Classically, management of hemodynamically stable patients with penetrating neck injuries was based on an anatomic "zone-based" approach mentioned above, with zone II injuries often going directly to surgical exploration and zone I and III injuries undergoing angiography, bronchoscopy, and esophagoscopy.  This approach was developed in the 1970’s, but it had several problems [4].  First, there may be poor correlation between the location of the neck wound and internal organ involvement, as there may be traversing of zones internally. Secondarily, the adoption of a mandatory-exploration policy lead to a high negative exploration rate (53% - 56%)[4,5].

With the rapid improvement and dissemination of the use of  CT over the past few decades, a “No Zone” management approach based on careful physical exam with CT angiography has been shown in surgical literature to decrease resource utilization and unnecessary surgical exploration, making the rigid zone approach less relevant [3].   Several studies have examined the sensitivity and specificity of CT angiography in stable patients with penetrating neck injury.  A study by Inaba et. al. prospectively evaluated an algorithm in which patients with "soft signs" of injury (venous oozing, non-expanding hematoma, minor hemoptysis, dysphonia, dysphagia, or small amount of subcutaneous emphysema) underwent an initial evaluation with CT-angiography and asymptomatic patients were observed [6].  Over a 31-month period, 453 patients with penetrating neck trauma were prospectively evaluated in their study.  186 of these patients had "soft signs" of clinical injury, and underwent CT angiography as their initial method of evaluation.  38.2% of these patients had an injury to zone II of the neck.  Using an aggregate gold standard of the final diagnosis at discharge which included operative exploration, catheter-based angiography, bronchoscopy, esophagogram and esophagoscopy results and clinical follow-up (duration not specified),  the sensitivity and specificity of CT Angiography for vascular or aerodigestive injury was 100% and 97.5 % respectively.  There were two patients who had false-positive findings of vascular injury (irregularities in the ICA) that were not present on follow-up with surgical exploration and/or angiography, and three patients had air tracking suspicious for aerodigestive tract injury that was not confirmed on follow-up imaging and endoscopic studies. 

As mentioned above, the "No Zone" approach combining clinical exam with imaging evaluation has the potential to decrease unnecessary neck exploration. A study by Osborn et. al. examined the rate of negative neck explorations in patients who were taken to the OR who did not have hard signs of injury.  They compared the rate of negative neck explorations amongst those patients who had a CT-A as part of their initial evaluation and those who did not, and found that CT angiography significantly reduced the negative neck exploration rate [7]:

Source: Osborn et al. (2008)

 In their review of penetrating neck trauma management, Shiroff at al. shared the algorithm below, comparing the traditional vs. "no zone" approach:

Image Source:  Reference 3

Take Home Points: Patients with penetrating neck trauma who are hemodynamically unstable or  display hard signs of vascular or aerodigestive should receive immediate surgical consultation with consideration for operative or invasive management.  As the traditional, anatomic approach to management of penetrating neck trauma is associated with a high rate of negative neck exploration, patients with soft signs of injury should be initially evaluated with CT angiography which has a high sensitivity for clinically-significant injury.

Submitted by Philip Chan, PGY-3
Edited by Maia Dorsett (@maiadorsett), PGY-4
Faculty reviewed by jason wagner (@TheTechDoc)

References
[1] Tintinalli’s Emergency Medicine, 7e.  Ch 257. 

[2] Daniel, Y., de Regloix, S., & Kaiser, E. (2014). Use of a Gum Elastic Bougie in a Penetrating Neck Trauma. Prehospital and disaster medicine, 29(02), 212-213.
[3] Shiroff, A. M., Gale, S. C., Martin, N. D., Marchalik, D., Petrov, D., Ahmed, H. M., ... & Gracias, V. H. (2013). Penetrating neck trauma: a review of management strategies and discussion of the ‘No Zone’approach. The American Surgeon, 79(1), 23-29.
[4] Prichayudh, S., Choadrachata-anun, J., Sriussadaporn, S., Pak-art, R., Sriussadaporn, S., Kritayakirana, K., & Samorn, P. (2015). Selective management of penetrating neck injuries using “no zone” approach. Injury.
[5] Varghese, A. (2013). Penetrating neck injury: a case report and review of management. Indian Journal of Surgery, 75(1), 43-46.
[6] Inaba, K., Branco, B. C., Menaker, J., Scalea, T. M., Crane, S., DuBose, J. J., ... & Demetriades, D. (2012). Evaluation of multidetector computed tomography for penetrating neck injury: a prospective multicenter study. Journal of Trauma and Acute Care Surgery, 72(3), 576-584.

[7] Osborn, T. M., Bell, R. B., Qaisi, W., & Long, W. B. (2008). Computed tomographic angiography as an aid to clinical decision making in the selective management of penetrating injuries to the neck: a reduction in the need for operative exploration. Journal of Trauma and Acute Care Surgery, 64(6), 1466-1471.

An Imperfect Science: Diagnosis of CSF Shunt Malfunction

Clinical scenario: Your patient is a 20 yo male with a history of VP shunt placement as a child for obstructive hydrocephalus. He was brought to the emergency department by his family because of decreased responsiveness over the past day. On arrival to the emergency department, he has aniscoria (L greater than R), no verbal response, and withdraws his extremities symmetrically. An emergent non-contrast head CT shows no change in ventricular size from prior CT scan one year prior and a VP shunt series demonstrates no evidence of fracture of the shunt line. Clearly, something is critically wrong with the patient, but is it his VP shunt to blame?

Clinical question: What is the spectrum of shunt complications? What is the sensitivity of clinical exam and various imaging modalities in detecting shunt malfunction?

Literature Review: There are multiple forms of CSF shunts, the most common of which is the Ventriculo-Peritoneal shunt (as opposed to ventriculo-atrial & ventriculo-pleural) which shunts CSF into the peritoneal cavity. A CSF shunt is composed of a proximal catheter, reservoir, valve and distal catheter [1]. The proximal catheter starts in the frontal horn of the lateral ventricle and exits through a burr hole to connect to the reservoir which is located in the subcutaneous tissue (this is what is accessed when neurosurgery taps a shunt). Flow from the reservoir to the distal catheter is regulated by a one way valve. Programmable shunts allow for the setting of a specific pressure above which fluid drains through a valve. This is sometimes adjusted in one direction or another for VP shunt patients who experience headaches, lightheadedness or other symptoms related to the pressure when their evaluation is negative for obstruction, infection etc. For VP shunts, the distal catheter is then tunneled into the peritoneum

Image Source: Cancer Research UK / Wikimedia Commons

As an emergency physician, one must be familiar with the presentation and diagnosis of shunt complications because they are relatively common; incidence of VP shunt failure is close to 40% at one year and 50% at two years from initial shunt placement, at least in the pediatric population where it has been most actively studied[2]. There are multiple types of shunt malfunctions leading to increased intracranial pressure, including but not limited to:

1. Mechanical Obstruction - Most proximally, the catheter can be obstructed by blood, debris or in-growth of the choroid plexus. The catheter position within the lateral ventricle can also migrate. Kinking or fracture along the catheter track at any point will also lead to shunt failure, as will distal obstruction which can occur when the catheter adheres to the omentum or erodes into intra-abdominal organs.

2. Infection - This often presents with shunt failure, and occurs most commonly within 6 months of placement due to intraoperative contamination with skin flora. The overall incidence of shunt infection is common (8-10%).

3. Ventricular Loculations - Loculations within the ventricle can create non-communicating pockets of CSF that are not drained by the VP shunt. If these grow, they can cause symptoms of hydrocephalus.

At least in very young children, depressed level of consciousness, nausea/vomiting, headache, irritability, and fluid tracking along the shunt site are highly predictive of shunt malfunction (see positive LR below). However, none of these clinical signs and symptoms are adequately sensitive to rule out shunt malfunction in their absence [2,3]. Some signs like abdominal pain/peritonitis are less commonly seen, but more highly predictive of shunt infection.

LR, Sensitivity, & Specificity for clinical signs and symptoms associated with shunt failure in two large pediatric studies

In addition to overall clinical exam and picture, radiographic imaging plays a central role in the emergency department evaluation of VP shunt malfunction.

CT scans are the most commonly used imaging modality to evaluate for shunt malfunction. While enlarged ventricles (when compared with prior imaging studies) are the canonical feature of shunt obstruction, other CT findings correlated with increased intracranial pressure include effacement of the cortical sulci, loss of the basal cisterns and periventricular edema due to transependymal CSF absorption [4]. Based on multiple retrospective pediatric studies using surgical shunt revision as a "gold standard", CT has a sensitivity for shunt malfunction of anywhere between 53% to 92% [4,5; see Table below]. In one small retrospective study of 174 adults evaluated for shunt malfunction with both shunt series and head CT, head CT had a sensitivity of only 52%, a specificity of 78% and negative predictive value of 88% for shunt malfunction [6]. This study only included patients who had had shunt series performed, so it may have underestimated the sensitivity of CT by excluding patients who were evaluated with CT alone. While this is a wide range of estimations for sensitivity, the important point is that a negative head CT does not completely rule out a shunt malfunction.

Shunt series radiographs are used to identify mechanical shunt defects such as shunt discontinuity or kinking. Studies in both children [4,7] and adults [6] support the conclusion that although the yield and sensitivity of radiographic shunt series is very low (see Table below), it is not zero. Shunt series rarely (~ 1-2%) detect abnormalities not identified on initial CT that prompt surgical revision. Therefore, shunt series are still indicated in the evaluation of potential shunt malfunction.

Table 2 from Boyle and Nigrovic, 2015. Reference 4.

In some cases, more commonly in pediatric institutions, MRI protocols have been instituted to reduce cranial radiation in children [4,8,9]. This has been made possible in part due to advances in MRI technology that have allowed for development of "ultra-fast" or Rapid MRI protocols that can acquire images in a span of ~ 1-4 minutes. Rapid Cranial MRI has been studied in comparison to CT for detection of ventricular shunt malfunction in the pediatric population, and appears to be comparable at least with respect to specificity and accuracy [8]. When considering using MRI in place of CT, the provider should be aware that some VP shunts have a programmable shunt valves that can be affected by the magnetic force of the MRI machine and may need to be readjusted after the exam. For this reason, it is common practice to obtain coned-down radiographs of a small indicator usually located near the proximal portion of the distal catheter to identify the setting prior to MR and then again after MR. If the programmed setting has changed, the neurosurgeon can use a magnet to reprogram the setting. The radiologist uses an indicator that looks like a clockface to determine the settings. 

Image source: http://www.ajnr.org

Take home Points: Malfunction and infection are common complications of CSF shunts. No single clinical exam finding or image study is sufficient to rule out shunt malfunction, and clinical management should take into account patient history, overall clinical picture, diagnostic data and neurological assessment.
 
Submitted by Maia Dorsett @maiadorsett
Faculty Reviewed by Peter Panagos and Richard Griffey
 
References: 
1. Wallace, A. N., McConathy, J., Menias, C. O., Bhalla, S., & Wippold, F. J. (2014). Imaging Evaluation of CSF Shunts. American Journal of Roentgenology, 202(1), 38-53.
2.Garton, H. J., Kestle, J. R., & Drake, J. M. (2001). Predicting shunt failure on the basis of clinical symptoms and signs in children. Journal of neurosurgery, 94(2), 202-210.
3. Piatt Jr, J. H., & Garton, H. J. (2008). Clinical diagnosis of ventriculoperitoneal shunt failure among children with hydrocephalus. Pediatric emergency care, 24(4), 201-210.
4. Boyle, T. P., & Nigrovic, L. E. (2015). Radiographic Evaluation of Pediatric Cerebrospinal Fluid Shunt Malfunction in the Emergency Setting. Pediatric emergency care, 31(6), 435-440.
5.Lehnert, B. E., Rahbar, H., Relyea-Chew, A., Lewis, D. H., Richardson, M. L., & Fink, J. R. (2011). Detection of ventricular shunt malfunction in the ED: relative utility of radiography, CT, and nuclear imaging. Emergency radiology, 18(4), 299-305.
6. Griffey, R. T., Ledbetter, S., & Khorasani, R. (2007). Yield and utility of radiographic “shunt series” in the evaluation of ventriculo-peritoneal shunt malfunction in adult emergency patients. Emergency radiology, 13(6), 307-311.
7. Desai, K. R., Babb, J. S., & Amodio, J. B. (2007). The utility of the plain radiograph “shunt series” in the evaluation of suspected ventriculoperitoneal shunt failure in pediatric patients. Pediatric radiology, 37(5), 452-456.
8.Boyle, T. P., Paldino, M. J., Kimia, A. A., Fitz, B. M., Madsen, J. R., Monuteaux, M. C., & Nigrovic, L. E. (2014). Comparison of rapid cranial MRI to CT for ventricular shunt malfunction. Pediatrics, 134(1), e47-e54.
9. Koral, K., Blackburn, T., Bailey, A. A., Koral, K. M., & Anderson, J. (2012). Strengthening the argument for rapid brain MR imaging: estimation of reduction in lifetime attributable risk of developing fatal cancer in children with shunted hydrocephalus by instituting a rapid brain MR imaging protocol in lieu of head CT. American Journal of Neuroradiology, 33(10), 1851-1854.10.

Consultant Teachings No. 2: Thoracolumbar Spinal Fractures - A Spine Consult Isn't Always Necessary

Clinical Scenario:  You are working one evening in the emergency department when an intoxicated young female is brought in by EMS after being involved in a reportedly high speed MVC.  She is clinically intoxicated, uncooperative and tachycardic.  She gets a pan-scan CT which identifies some facial fractures and isolated transverse process fractures of the thoracic spine.  As you decide on the next steps to take care of the patient, you debate whether to discuss the patient with a Spine specialist.

Clinical Question: Which spinal fractures should you discuss with a Spine specialist?  Are there some that do not require any intervention at all?

Literature Review:  With the increased availability and increased utilization of CT scanners in the ED, it has become common practice to “pan-scan” patients who present after a trauma, especially those patients who are obtunded/intoxicated or present following a high risk mechanism.  The use of the CT scan to identify thoracic or intrabdominal injuries has concomitantly lead to an increase in diagnosis of fractures of the thoracic and lumbar spine.  As an example, in one retrospective study conducted in the UK of 303 blunt trauma patients who had a Chest/Abdomen/Pelvis CT performed, only six scans (2%) identified thoracic injury and four (1.3%) demonstrated intrabdominal injury while 51 scans (17%) demonstrated an injury to the thoracolumbar spine [1].

With respect to screening for thoracolumbar spinal injuries specifically, the Eastern Association for the Surgery of Trauma practice guideline now recommends CT scan as the primary imaging modality [2]. This is based on a body of evidence that strongly supports that CT scan is more sensitive than X-ray for detection of thoracolumbar spinal injuries.  For example, in one small German study of 107 minor trauma patients, radiographs had a sensitivity of only 49.2% and specificity of 54.7% for thoracolumbar spinal injury compared with CT scan which served as "gold standard" [3].

While CT scan is more sensitive, not all the spinal fractures that are found are clinically significant (i.e. requiring spine precautions or bracing/surgical intervention) [4].  For example, in the small German study cited above X-ray alone missed 16/28 fractures of the the mid thoracic spine, but none of these were considered  unstable [3].  Of the 94 fractures identified in 51 patients by Chest/Abdomen/Pelvis CT in the UK study, 43 (46%) were considered not clinically significant [1].  Thus, the increased sensitivity of our diagnostic evaluation of trauma not only increases our detection of clinically important fractures, but otherwise stable spinal trauma.

Spine consultation for certain types of stable spinal injuries often comes at the expense of increased patient wait times, prolonged spinal precautions,  increased institutional cost, decreased patient satisfaction, and possibly even poorer outcomes if such consultation delays a patient’s transfer to the floor or ICU [4].   Below is a guide to approaching and managing two types of commonly seen fractures in the Emergency Department.

Transverse Process Fractures  

Source: www. waybuilder.net

Transverse Processes (TPs) of the vertebrae primarily function as sites of paraspinal muscle and ligament attachments. They are part of the posterior column in the classic Denis “three column” classification, which divides the spinal column into anterior, middle and posterior structural elements. The vertebral body consists of the anterior and middle columns and is the main axial load bearing part of the spinal unit. The posterior column consists of the elements behind the vertebral body, with the most important components being the pedicles, facet joints and ligamentous complex. Stability for the spinal column is maintained through a series of attachments between the various spinal elements (anterior, middle and posterior). An isolated TP fracture is a stable fracture and does not compromise spinal stability. Additionally, isolated TP fractures are not associated with neurologic deficits. The spinal cord and nerve roots are not in proximity to the TPs, nor are they at high risk of displacing in a manner that would put the nerve root or cord at risk.

A small 2008 retrospective study from the University of Missouri looked at a cohort of 84 patients with TP fractures; 47 were isolated and 37 were associated with other spine fractures [5]. In this study, no patients with isolated TP fractures required surgery or bracing for spinal stability. Furthermore, none of these patients had any neurologic deficits. The authors concluded that conservative management of isolated TP fractures was appropriate, without the need for orthopaedic or neurosurgical consultation. However, if the TP fracture is associated with another spinal fracture such as a vertebral body fracture, a specialist consultation is warranted for treatment recommendations regarding the associated injury, but not necessarily the TP fracture itself. Of course, a cervical TP fracture that extends into the transverse foramen also necessitates additonal imaging and likely spinal consultation, as it may warrant a CT angiogram for evaluation of vertebral artery damage.

Compression Fractures

Vertebral compression fractures are the most common fragility fracture, affecting approximately 25% of people over the age of 70. Compression fractures are a result of axial force on the anterior column that results in a wedge deformity of the vertebral body. The vast majority of compression fractures do not require surgical intervention. Moreover, these fractures are often stable due to their impacted nature. No study has proven that bracing vertebral compression fractures prevents further vertebral collapse, decreases pain, or improves patient satisfaction. Treatment of most vertebral body compression fractures can focus on reducing associated pain with appropriate pain medications. A thorough approach to a patient presenting with an acute compression fracture should include the following:

1: Patient factors: What was the mechanism of injury (simple fall or high-energy injury)? Is the patient ambulatory, bed or wheelchair bound? Are there significant medical comorbidities (ie morbid obesity, extensive pulmonary disease) that would make bracing an ineffective or even dangerous treatment option? Is the patient’s pain controlled enough to obtain an accurate neurologic exam? Is the patient tender over the spinal segment in question?

2: Fracture factors: Is the fracture stable or unstable? The best way to evaluate is to use the patient’s own physiologic forces to see if there is further displacement of the fracture. Barring any neurologic deficits, plain supine AND upright radiographs of the affected area should be obtained. The goal is to see if there is any significant height loss or increased kyphosis between the series. If not, it’s a safe bet that the fracture is stable.

Given a stable fracture, the next step is determined primarily by patient comfort level. If the patient is able to tolerate sustained physiologic loads (ie sitting or standing), it is reasonable to send them home with observation only, no bracing required. Follow up could be provided by their primary care provider or PM&R. If they are in too much pain to stand or sit despite appropriate analgesia, an extension orthosis (like an off-shelf TLSO) is sometimes beneficial and can be provided by the spine consultant on call. If the compression deformity is acute and deemed to be unstable, if there are any neurologic deficits or other associated spinal pathologies, certainly a spine consultation is necessary and appropriate at that time.

Take Home Points:  The increased use of CT imaging, especially in trauma, may lead to the identification of injuries that do not necessarily warrant intervention other than pain control.  For neurologically intact patients, it is useful for the emergency physician to be aware of which fractures warrant either bracing or surgical intervention as unnecessary  consultation can lead to prolonged length of stay and increased cost without significant benefit to the patient.

Submitted by Chris Cosgrove, Orthopedic Surgery PGY-2
Faculty Reviewed by : Lukas Zebala, MD, Assistant Professor, Orthopaedic Surgery

Everyday EBM Editor Maia Dorsett (@maiadorsett)

References:
1. Venkatesan, M., Fong, A., & Sell, P. J. (2012). CT scanning reduces the risk of missing a fracture of the thoracolumbar spine. Journal of Bone & Joint Surgery, British Volume, 94(8), 1097-1100.
2. Sixta, S., Moore, F. O., Ditillo, M. F., Fox, A. D., Garcia, A. J., Holena, D., ... & Cotton, B. (2012). Screening for thoracolumbar spinal injuries in blunt trauma: An Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery, 73(5), S326-S332.
3. Karul, M., Bannas, P., Schoennagel, B. P., Hoffmann, A., Wedegaertner, U., Adam, G., & Yamamura, J. (2013). Fractures of the thoracic spine in patients with minor trauma: Comparison of diagnostic accuracy and dose of biplane radiography and MDCT. European journal of radiology, 82(8), 1273-1277.
4. Homnick, A., Lavery, R., Nicastro, O., Livingston, D. H., & Hauser, C. J. (2007). Isolated thoracolumbar transverse process fractures: call physical therapy, not spine. Journal of Trauma and Acute Care Surgery, 63(6), 1292-1295.
5. Bradley, L et al. Isolated transverse process fractures: spine service management not needed. J Trauma 2008 Oct; 65(4):832-6.

Does cardiac standstill on bedside echo equal 100% mortality?

You’re in the midst of catching up on notes during a hectic overnight shift when out of the corner of your eye you see a stretcher zoom into the trauma bay – with an EMT leaning over the side performing chest compressions. As the team gathers, the paramedics give report. The patient is a middle-aged male, no known past medical history, who was acting normally about half an hour ago when he suddenly collapsed in front of his family. They started CPR within a couple minutes of the patient collapsing, and called EMS. The paramedics continued CPR, placed a supraglottic airway, and placed the patient on the monitor. He has had a slow, organized rhythm without pulse throughout the arrest. He has received several doses of epinephrine without response. The patient has been pulseless for a little over half an hour by the time he arrives. The ED crew takes over CPR, IV access is obtained, and the patient switched over to the ER monitors, which show a slow, wide-complex, relatively disorganized rhythm. The patient shows no signs of life. Your attending physician calls for the ultrasound, and calls out to the team that if the bedside echo shows cardiac standstill, you will consider terminating further resuscitative efforts.

Clinical Question:

Does cardiac standstill on bedside echo universally predict mortality in OHCA?

Needle that belly!

An infant female with no significant history presents to your trauma bay after reported accidental blunt trauma to the abdomen, the patient arrives from a referral hospital where plain films demonstrated free air. On arrival the patient show signs of hemodynamic instability and an elevated lactate. The patient was decompressed with "needle peritoneumostomy" prior to going to the OR for exploration. 

Clinical Question:

Can “tension pneumoperitoneum” cause hemodynamic instability?

Literature Review:

The presence of "free air" in the peritoneum is often diagnostically significant; however, the gas itself is rarely of clinical importance. An exception to this rule is in the case of a tension pneumoperitoneum. Tension pneumoperitoneum (TPP), also known as hyperacute abdominal

Example of pneumoperitoneum & football sign

compartment syndrome [1], or abdominal tamponade [2], is a rare, but potentially deadly event. Similar to tension pneumothorax, the underlying mechanism is a tissue flap that acts as a one-way valve for air release, resulting in a progressive increase in intra-abdominal pressure. The increasing peritoneal pressures may rapidly lead to respiratory compromise due to diaphragmatic elevation and a drop in cardiac output resulting from decreased venous return or aortic outflow due to occlusion. [3] This can progress to cardiovascular collapse and respiratory failure and eventually death. [2]

In one of the earliest reported cases in 1913, tension pneumoperitoneum was theorized to be a consequence of gas forming bacteria in the abdominal cavity. [4] Now it is known that tension pneumoperitoneum is usually a consequence of hollow viscus perforation, post-operative complications, positive pressure ventilation or other insulflation-dependent procedures (eg, colonoscopy, endoscopy, cystoscopy or air enema). There has even been reported cases from CPR. [9,10] However, there are few published case reports of TPP as a result of blunt force trauma. [3,6]

As Low As Reasonably Achievable

Your patient is a 40-something female who has never been to your facility before but reports a history of chronic abdominal pain of undetermined etiology. She has had an appendectomy and a cholecystectomy. She is now presenting with two days of right-sided cramping abdominal pain associated with nausea without vomiting and lightheadedness. Screening labs protocoled by the triage nurse are unremarkable, and a bedside RUQ ultrasound is negative for significant pathology. After two doses of morphine she is still visibly uncomfortable in the stretcher. The team is reticent to pursue further diagnostics, but given the fact that she currently carries no diagnosis for her symptoms and is still in considerable distress, and the lack of any prior imaging in your EMR, the decision is made to order a CT abdomen/pelvis with contrast.

Clinical Question:

Given the fact that the pre-test probability for finding significant pathology in this patient is low, how worried should you be about exposing your patient to further ionizing radiation?

Hippocratic Medicine No. 2: Between a Rock and a Hard Place

Clinical Scenario:
You are working in the emergency department on a typical busy day. There are fifteen boarding patients waiting for their bed upstairs, another thirty-plus in the waiting room.  You walk into a room to assess a 75 yo female with confusion. Family says that she has been confused: forgetting to put on one shoe, unable to finish her crossword puzzles, and no longer able to bowl without throwing a gutter ball. Amazingly, the urinalysis is negative. Concerned that she may have had a subacute stroke, you order a head CT without contrast which shows “a large amount of vasogenic edema concerning for neoplasm.” The radiologist recommends a follow up MRI for further evaluation. The consulting neurologist instead asks for a Head CT (HCT) with contrast, reasoning they would not be the admitting service if the patient is found to have a mass. Neurosurgery recommends an MRI to evaluate for a suspected mass, and you learn that it will be 8 hours before the patient can go to MRI. With the pressure of the waiting room, the full rooms, and the boarding patients in the ED, you reluctantly order the HCT with contrast, which shows a right parietal neoplasm. Having rarely, if ever, ordered HCT with contrast, you ask- What are the indications for HCT with contrast in a patient with subacute onset of focal neurological deficits?

Literature Review:
The American College of Radiology (ACR) publishes evidence-based guidelines to help direct the efficacious use of radiologic studies. Their 2012 Appropriateness Criteria for Focal Neurologic deficits discusses the use of HCT vs. MRI. HCT without contrast is recommended for initial evaluation in this case. While contrast can provide additional information, “some pathology is difficult to visualize with CT under any circumstances,” and “MRI is more sensitive than CT for detecting primary and secondary brain lesions and for defining extent of disease.” Additionally, MRI spares the patient exposure to ionizing radiation and “provides information that…approaches the accuracy of a neuropathologic diagnosis” [1].  Specifically, for our patient with subacute onset of neurological deficits, the ACR recommends a HCT without contrast for acute screening. The highest rated imaging for further evaluation is an MRI head with and without contrast, rated an 8/9 for “usually appropriate.” A HCT with contrast was rated a 4/9, for “may be appropriate,” with the typical indication being inability to get an MRI. This patient had no contraindications to MRI and should not have had the contrasted HCT. Eight hours later she had a MRI to more appropriately plan her operative course. 

@WUSTL_EM FOAMed Digest #7: Best of the Best of the Best Sir! ...With Honors

To build on my “Intro to FOAMed” lecture from Tuesday, I thought I would use the Digest this week to highlight some of the highest-quality resources out there for those of you just dipping your toes into the FOAMy goodness. You can’t go wrong adding these to your Feedly. Well-referenced, expert review, open discussion with prompt response – they’re really setting the bar for the FOAMed world.

And don’t worry – in the spirit of FOAMed the lecture and slides will be posted as soon as the video editing is done.

Now come on in, the water’s fine!

Three Stars:

1. Academic Life in EM (ALiEM) continues to be one of the paragons of the FOAMed community. Check out this “Diagnose on Sight” case from this week – don’t want to give it away, but you will see it time and time again during your Children’s shifts. Make note of the reference list and pre-publication review from a practicing clinician. Supremely high quality.

2. I must credit my inspiration for this FOAMed Digest – the LITFL Review from Life in the Fast Lane. Curated by some of the sharpest tacks around, it’s a great way to get familiar with the variety of resources out there. Lots of good stuff this time around, including links to Amal Mattu’s EKG video review of QT prolongation, the latest edition of FOAMCast (all about the spleen!), and the St. Emlyn’s view of the new NICE guidelines for managing acute heart failure.

EXTRA CREDIT: If you need help keeping up with the EM primary literature, the Research & Reviews in the Fastlane segment is a great place to start!

3. EM Lyceum takes the “flipped classroom” concept to the next level. Every month or so, they publish a series of clinical questions focused on a particular topic. This time, it was trauma. The point is to ponder those questions, discuss them in a group, and maybe even do your own research. The EM Lyceum group then publishes the best evidence-based answers they could find in an exceptionally well-referenced summary. Pearl from this month: Bust out the PCC for ICH on warfarin, but no good evidence for PCC in your “average” coagulopathic trauma patient.  

#FOAMed Digest No.5: But This One Goes to 11

Time once again for your mid-week blast of FOAMy goodness from around the interwebs. There’s no particular subject today; instead we’re going to highlight some of the better podcasts/vodcasts that updated this week. Podcasts are great. They break up the monotony of reading (and the monotony of mundane things like laundry, grocery shopping, training for this damn marathon…). For the more distractible among us, they usually come in easily-digestible 20-30 minute morsels. They expose you to different presentation styles, and allow you to match a face and a voice with the big names in FOAMed. Most of them also feature written show notes with references as well, which allows you both to reinforce the things you learned while listening, and also to dig deeper into topics you’re interested in.

Fun for the whole family!

Three Stars:

1. I think FOAMcast, authored by residents and EM social media savants Jeremy Faust and Lauren Westafer, might be the first example of “metaFOAM.” They peruse the FOAM world for interesting recent posts, then integrate that information with relevant material from the most popular EM textbooks (i.e., “Rosenalli”), other relevant blogs/podcasts, primary literature, and even Rosh Review questions. This week they use a post from ALiEM on calcium channel blockers vs beta blockers for A-Fib as a jumping-off point for a discussion on ED management of A-Fib and A-Flutter. There’s links to vodcasts from Scott Weingart and Amal Mattu on narrow-complex tachydysrhythmias, and plenty of cited references from the primary literature (including one from our own Brian Cohn!). It’s good stuff.

2. Speaking of the Godfather of ED EKG, Dr. Mattu has two quick cases for you to ponder. Remember: T-wave inversion does not always mean cardiac ischemia!

Remember: Gotta think tox in a seemingly unprovoked wide complex tachycardia!

3. Steve Carroll at EM Basic provides an excellent analysis of the ED management of asymptomatic hypertension, including references to the relevant ACEP Clinical Policy document and other FOAMed resources.

Oldie But Goodie:

Chris Nickson, creator and administrator of Life in the Fast Lane, gave an excellent talk at the original SMACC conference in March 2013 with the confidence-inspiring title, “All Doctors are Jackasses.” Why are we jackasses? Because we don’t do enough to understand how we think and how we make decisions, and this leads us to make errors. Watch Nickson’s lecture and begin to understand how to remedy this situation.

(EXTRA CREDIT: Links in the show notes to the other SMACC talks in the “Mind of the Resuscitationist” plenary by Weingart, Cliff Reid, and Simon Carley.)

F(FN)OAMed:

By this point you guys all know how awesome EM:RAP is, but this week is particularly relevant because Herbert & Co. just released an “EM:RAP Mini” segment about the newly-published “Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis” trial in the New England Journal. For those of you that aren’t familiar, this was a study in which we participated, and our own Drs. Aubin and Griffey are authors on the paper! An excellent summary of this paper is found on the Emergency Medicine Ireland blog, with a link to download the EM:RAP Mini segment in the show notes.

The Gunner Files:

1. Time to synthesize the knowledge you gained about non-surgical management of pediatric appendicitis at Journal Club last month. Dr. Cohn is back with another excellent EMJClub podcast along with Drs. Trehan and Horst, summarizing the primary literature.

2. EMin5 is back at it with a review of the four types of shock, in a little over four minutes.

3. From the Maryland Critical Care Project, an excellent lecture from Neuro Critical Care and ED intensivist Dr. Wendy Chang describing the ED management of status epilepticus. She covers the gamut from first-line benzos to second-line AEDs and third-line agents for initiation of therapeutic coma.

4. The good people at the All NYC EM blog posted a lecture given during their conference day by the FOAMed superstar Dr. Haney Mallemat. He covers all the basics of ultrasound evaluation of pericardial effusion and tamponade, even ultrasound-guided pericardiocentesis.

5. In case you’re not familiar, US Air Force Pararescuemen, a.k.a. “PJs,” are the ultimate badasses. Just look at it this way: think becoming a SEAL is tough? PJ training has an even higher failure rate. But I digress.

Former PJ and critical care flight retrieval medic Mike Lauria is now in medical school, and is making a bit of a splash in the FOAMed community as an expert on training, thinking, and operating in high-stress environments. Scott Weingart recently interviewed him on EMCrit about the concept of “mental toughness,” how that translates from the combat realm to the ED, and how to incorporate it into physician training. Really interesting stuff.

That Others May Live,

Sam Smith, PGY-3

#FOAMed Digest No. 4: Butter My Biscuit, Baby

Welcome back, to the brand new edition of the WUEMR FOAMed Digest. Get out your Tintinalli’s and strap in, because we’re going back to basics today. It’s all about the bread and butter. The things any PGY-2 setting off to an overnight Saturday shift in the Deuce should have down cold…yet us seniors still screw up on the daily.

FOAMed…ENGAGE!

Three Stars:

1. If my last shift at Children’s is any indication, the season is upon us – pharyngitis in every exam room. Casey Parker over at Broome Docs (a blog authored by EPs & GPs practicing in rural Australia), presents a magnificent summary of the data surrounding rapid strep swabs, antibiotic use for symptom relief, and antibiotic use for preventing secondary complications of strep. As always, be sure to check out the original literature for yourself. And don’t miss Minh Le Cong’s excellent counterpoint in the comments, which is also well-referenced.

2. What’s your record for most C-collars cleared in one shift? (When you hit double-digits, then we can talk.) The best tools in our arsenal for clearing C-spine in low-risk patients remain the Canadian C-spine and NEXUS instruments. But which one should you use? Do you even remember which criteria belong in each rule, or do you find yourself trying to apply the “Canadi-EXUS” criteria, like I do? Luckily for us, Alayna Hawling at BoringEM authored an excellent rundown and comparison – with a pretty flowchart!

3. As much as you want to start the fist-pumping and beer-chugging as soon as you drop that tube past the cords, your work with the intubated patient is not done, my friend! We’ve already touched on our persistently poor rates of achieving adequate analgesia & sedation in the intubated patient. Another part of quality post-intubation care is knowing what to do if your ventilated patient acutely decompensates. Check out Chris Cresswell’s summary of the DOTTS mnemonic over at EM Tutorials.

(EXTRA CREDIT: He also included a link to Scott Weingart’s notes regarding care of the crashing ventilated patient, which are well worth a look.)

Oldie But Goodie:

There’s been some e-mail discussion lately among our attendings regarding the best way to clean lacs prior to closure. Back in February, Ken Milne at the Skeptic’s Guide (along with Eve Purdy, a rockstar med student and creator of the excellent Manu et Corde blog) published a piece dedicated to breaking down the dogma of management of simple lacerations. Tap water vs sterile water, sterile gloves vs clean gloves, to sew or not to sew…it’s all covered here. Plus there’s links to other excellent FOAMed resources regarding wound care dogma.

F(FN)OAMed:

The good folks over at EB Medicine recently published a stem-to-stern guide to UTI diagnosis and management in the ED, all based on best available evidence. A bit lengthier than your average blog post, but incredibly high-yield and well worth your time. It’s a bit difficult for me to place a direct link here, but you can find it simply by logging into your account at EBMedicine, following the link to browse issues of Emergency Medicine Practice, and opening the July 2014 issue on UTI.
(As always, contact your friendly neighborhood Social Media Committee member if you need help obtaining access to EB Medicine resources.)

The Gunner Files:

1. Hard to get through a Deuce shift without breaking out the prochlorperazine at least once. We’ve all seen patients get jittery, agitated, or downright whacky following its use. Does Benadryl help? A PharmD expert at ALiEM has a good lit review of the topic.

2. Short and sweet: some diabetic medications are more likely to cause harmful hypoglycemia after overdose than others. Quick table-based rundown over at ALiEM.

3. It is asthma season, and you may find yourself in the worst-case-asthma-scenario of impending need for intubation. Check out this post from The Kings of County regarding care for the sick asthmatic, including intubation and mechanical ventilation issues.

4. FOAMed is taking the world by storm! Does the UK College of Emergency Medicine launching a dedicated FOAMed site mean it’s officially gone mainstream? Don’t worry – we were all into FOAMed before it was cool. But seriously, check out this vodcast on diagnostics in EM, and not feel quite so much increase in sphincter tone when Carpenter or Cohn pimp you on likelihood ratios or Bayesian analysis.

5. Another classic from the Skeptic’s Guide, this time addressing another oh-so-common ED complaint: renal colic. Fluids? Flomax? Any good evidence for either? In news that will surprise no one, Ken Milne is skeptical.

Never stop learning,

Sam Smith, PGY-3

#FOAMed Digest No. 3: You Need Me On That Wall

Emergency Medicine physicians practice in a unique environment. We must synthesize plans for  diagnosis, management, and disposition while utilizing input from almost every subspecialty, and the ED is the ultimate proving ground for diagnostic tests and treatment modalities of every sort. Unsurprisingly, a fair deal of controversy and debate exists regarding the optimum management of patients. (For reference, see any Trauma Case Conference featuring Drs. Schuerer and Aubin.) The “best evidence” is often poor evidence. We in Emergency Medicine retain the rebellious spirit of our founders, and are always looking for new and innovative techniques. Some physicians are too quick to jump on the bandwagon, and others lag behind the curve when it comes to adopting new practices.

The selections this time around are not meant to tell you the best way to do things. The algorithms and practice patterns suggested are not universally adopted, written in textbooks, or taught as part of any standard curriculum. They are meant to promote thought, to prompt you to read the primary literature for yourself, to encourage you to seek the opinions of other experts on the subject, and to form your own conclusions. Hopefully they will inspire you to suggest new ideas to your seniors and attendings during your next shift – or even question ideas you think are unsound. Maybe, just maybe, they will even inspire a new research or QI project. FOAMed is by design perfectly adapted to assist you in this quest.

Ramblers, let’s get ramblin’.

Three Stars:

1. Ken Milne at the Skeptic’s Guide to Emergency Medicine pretty much sets the bar when it comes to FOAMed of the latest EBM topics. He asks his clinical questions in the PICO format, he applies a rigorous quality checklist when analyzing the available literature, and includes in his discussion other FOAMed experts (including on occasion our very own Chris R. Carpenter, a.k.a. “Captain Cranium”). This episode he turns his skeptical eye to a topic sure to generate heated discussions for years to come: tPA for stroke.

2. If there’s anyone that looms larger in the ED Critical Care world than Weingart, it’s Resuscitationist Extraordinaire Cliff Reid. His lecture from the SMACC Gold conference hit resuscitation dogma like an A-bomb, leaving irradiated bits of unfounded practice patterns strewn about the Outback countryside.

(EXTRA CREDIT: Reid’s talk from the original SMACC conference, “Making Things Happen,” should be required viewing for anyone wanting to be a Trauma Senior someday.)

3. If pediatric surgeons have come to accept ultrasound as a stand-alone diagnostic method for appendicitis, maybe there’s hope that someday ultrasound can also be used as a radiation-sparing technique for diagnosis of small bowel obstruction. Academic Life in EM has an excellent run-down of the technique and comparative research studies.
(EXTRA CREDIT: The book Evidence-Based Emergency Care, authored in part by our own Captain Cranium Chris R. Carpenter, has a chapter dedicated to the inferiority of plain films for SBO diagnosis. You can read it for free online via Becker Library.)

Oldie But Goodie:

I think here in a few more years this will reach “accepted standard practice” level, and maybe even “textbook” level, but it’s not there yet. It should be: there’s good evidence to show kayexelate doesn’t work, and may even cause harm. Let Weingart and the PaperChase fellows from EM:RAP give you the ammunition you need to stand up to any pesky floor seniors.

F(FN)OAMed:

In a very enlightening segment from this month’s EM:RAP, Rob Orman interviews a community ED practitioner, Dr. Cameron Berg, regarding his hospital’s new Accelerated Diagnostic Protocol for low-risk chest pain. While his exact algorithm hasn’t been externally validated and probably isn’t ready for prime-time at our shop, the evidence-based and pragmatic approach is certainly worth considering. And he provides links to almost all of his references in the show notes!

The Gunner Files:

1. The “Research & Reviews” segment on Life in the Fast Lane is worth checking out every week. A group of some of the brightest minds in the FOAMed world get together and spoon-feed us summaries some of the most relevant, practice-changing, or downright strangest papers in the EM literature.

2. Josh Farkas over at PulmCrit wrote an excellent piece laying out his argument for super-high-flow NC (think 30-45L!) as an acceptable method of preoxygenation before RSI. It’s also got a good rundown of apneic oxygenation using NC (which we all should be doing every time), and an enlightening counterpoint from the grand maester of ED Critical Care, Scott Weingart.

3. Pediatric EM expert Sean Fox provides an excellent summary of the neonatal ALTE on his blog Pediatric EM Morsels.

4. Two EM airway heavyweights, Rich Levitan and Reuben Strayer, slug it out in the ultimate Direct Laryngoscopy vs Video Laryngoscopy debate, posted to the Prehospital and Retrieval Medicine podcast hosted by Minh Le Cong.

5. All of us will be the bearer of the -07 phone at some point, and that means you better have your act together when discussing decision-making capacity. Bill Johnston, EMT-P and author of the excellent blog Prehospital Wisdom, shares his fundamentally sound and no-bullshit method for determining capacity in the field.

In the words of Ken Milne: “Meet ‘em, greet ‘em, treat ‘em, and street ‘em!”

Sam Smith, PGY-3