#FOAMed Digest No. 6: Ain't Nobody Got Time For That

Welcome back, FOAMheads! My apologies for the delay this week. I ended up being a bit busier than I expected, which not coincidentally brings me to the theme for today's entry.

Sometimes you have a lot on your plate and may not be able to set aside a large chunk of time to watch/listen to a 30-minute-plus podcast. But that doesn't mean you don't have time to get your learn on! This time around, we'll highlight some of the best FOAMed sources of short-and-sweet educational pearls. Easily digestible for the highly-distractible mind of the EM trainee.

There is no moment like the present -- let's get started!

#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

Insulin bolus in DKA?

A middle aged male with a history of IDDM presents with 2 days of nausea and vomiting. He reports running out of his insulin. In triage, FSBS is critical high, FS ketones are 5.0. You start to treat for DKA with bolus of IVF and draw basic labs. You order your insulin infusion and give a 0.10U/kg bolus prior to starting the drip. Your attending questions your actions. 

Clinical Question:

Is there any evidence to support giving an insulin bolus prior to starting a drip in DKA patients?

Literature:

The latest ADA recommendations last updated in 2009 still recommend giving a 0.1U/kg bolus prior to initiating an insulin infusion at 0.1U/kg/hr. This recommendation is based on the theory that DKA represents a significant "insulin resistant" state, and a bolus of insulin is needed to overcome this resistance and effectively reduce serum glucose and suppress gluconeogensis. Much of these recommendations are based on limited studies from the 1980's, measuring active levels of insulin in serum, and none were prospective comparing continuous insulin infusion with and without the bolus. (1) In 2008, Kitbachi Et al performed a randomized prospective study with three arms, those on an insulin infusion at 0.07U/kg/hr with and without a bolus, and those who were only on a infusion at 0.14U/kg/hr. Kitbachi effectively demonstrated that an insulin bolus is unnecessary in those who were started on a infusion at 0.14U/kg/hr. There was no difference in time to optimal glucose, pH, Anion Gap, or bicarbonate. (2) In 2010, Goyal Et al performed a similar study but had two arms, insulin infusion at 0.1U/kg/hr and those with an infusion and a bolus. He showed no difference in length of ED stay or hospital stay, and no difference in time to goal glucose or anion gap closure. (3)

Take Home:

In summary, there appears to be a paucity of evidence supporting the ADA recommendation for an insulin bolus prior to infusion, however there seems to be robust evidence showing at least a noninferiority with insulin infusion alone. Therefore I find there is no reason to continue using an insulin bolus during my standard treatment of DKA.

References:

1) Diabetes in the Emergency Department: Acute Care of Diabetes Patients. Clinical Diabetes April 1, 2011 29:51-59 http://care.diabetesjournals.org/content/32/7/1335.short
2) Kitabchi Et al, Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis? Diabetes Care. 2008 Nov;31(11):2081-5
3) Goyal Et al, Utility of initial bolus insulin in the treatment of diabetic ketoacidosis. J Emerg Med. 2010 May;38(4):422-7. doi: 10.1016/j.jemermed.2007.11.033. Epub 2008 Jun 2.

Submitted by Louis Jamtgaard, PGY-3