Interesting literature October 2008

Recent gems from the literature that we could use or should know about:

Pre-hospital Care and Trauma
There have been recent concerns expressed about the possibility of FAST scanning by our retrieval team prolonging scene times, but what about on board the helicopter in flight? Can it be done? Would the results be accurate? Looks like our counterparts in South Australia have answered the question
If anyone has full text online access to the journal Injury, please let me in!

A dilemma we sometimes face: big trauma mechanism, but the patient seems fine. Do we immobilise? Do we give oxygen? Do we take to a trauma centre? Well here’s some Australian evidence that supports what we’ve known inside all along: mechanism alone does not usefully predict major injury in patients whose physiology and physical exam are normal

Identifying raised ICP using ultrasound of the eyes: This technique has been known about for a while but the evidence base hasn’t been strong. A recent Indian study adds further weight to the conclusions of this year’s BestBet on the topic: that there is a correlation between raised ICP and an optic nerve sheath diameter greater than 5mm. Likely to change our practice in pre-hospital and retrieval work? You decide!
Optic nerve ultrasound

Cardiovascuar Critical Care

AHA/ACC guidelines for STEMI – implications for emergency medicine practice. This helpful summary provides a useful update as well as guidance for when particular procedures and drugs are indicated. Could be useful for retrieval practice, for example in assessing the appropriateness of a request to transfer a patient for rescue PCI.

Heart failure therapy – out with the old, in with the new: Morphine’s role in acute heart failure has been questioned for a while now. This article from New Zealand summarises what’s known. Take home message: don’t use it as a heart failure treatment – it doesn’t work and could be harmful.

What about CPAP/BiPAP? We know that works right? The most solid evidence to date – a multicentre RCT – says nope! Outcomes are the same as ‘medical’ therapy, other than a small difference in patient-reported dyspnoea. Nice to know we don’t need to transport heart failure patients on NIV now – fix ‘em medically or intubate them.

So gimme something that works for heart failure!! Okay, but you’re not going to like it……Ultrafiltration seems to work better than diuretics, with a lasting benificial effect on the hormonal components of heart failure. A bit fiddly at the moment because it requires a similar set up to haemofiltration (central access, ICU nurses, a haemofilter). From a retrieval point of view let’s hope it doesn’t catch on Australia until the newer peripheral access devices become available.

On the subject of central venous access, there are some things that will improve your chances of hitting the femoral vein : reverse Trendenlberg position, Valsalva maneouvre, or pushing on the abdomen in the RUQ. Combining them improves things further.

And finally…

Want a useful update on evidence-based management of GI bleeding? This one is brand new and fits in your pocket – from the Scottish Intercollegiate Guidelines Network (SIGN)

That’s it for now….enjoy!!