July 2009

A Systematic Review of Corticosteroids in the Treatment of Severe Sepsis and Septic Shock in Adults

This thorough review confirms that steroids have no clear benefit on mortality in severe sepsis / septic shock. Looking at prolonged courses of low dose steroids, there may be a beneficial effect but this did not reach statistical significance.

JAMA. 2009 Jun 10;301(22):2362-75

http://www.ncbi.nlm.nih.gov/pubmed/19509383

Evaluation of emergency medicine trainees’ ability to use transport equipment

47 senior emergency medicine trainees from three Australian hospitals were tested three pieces of transport equipment from their own EDs: portable ventilator, infusion pump, and monitor-defibrillator. They didn’t do as well as you’d want....how would you fare?

Emerg Med Australas. 2009 Jun;21(3):170-7

http://www.ncbi.nlm.nih.gov/pubmed/19527275

Investigating pressure bandaging for snakebite in a simulated setting: Bandage type, training and the effect of transport

Previous work showed that systemic spread of venom from a snakebite to the limb could be prevented or delayed by complete immobilisation of the limb in combination with a pressure bandage of 55-70 mmHg or 40-70 mmHg in the lower and upper limbs, respectively. An assessment of the public’s and health care professionals’ ability to apply this ‘Aussie wrap’ revealed elasticised bandages to be far more likely than crepe bandages to achieve appropriate pressures, even after training, and a 30 minute ambulance ride further rendered the pressures achieved by crepe bandages inadequate.

Emerg Med Australas. 2009 Jun;21(3):184-90

http://www.ncbi.nlm.nih.gov/pubmed/19527277

Is cerebral oxygenation negatively affected by infusion of norepinephrine in healthy subjects?

An interesting study on nine healthy volunteers demonstrated noradrenaline infusions to increase MAP without increasing cardiac output (by increasing systemic vascular resistance). Measures of cerebral (frontal lobe) oxygenation, jugular venous saturation, and mean flow velocity in the middle cerebral artery all reduced with increasing doses of noradrenaline. The authors conclude that doses greater than 0.1 mcg/kg/min may reduce cerebral oxygenation. However increases in noradrenaline lowered paCO2 (through increases pulmonary ventilation) and it is unknown whether this was the major contributor to reduced oxygenation. It is also hard to ascertain the relevance to patients receiving noradrenaline, who unlike the healthy volunteers are not driven to supranormal blood pressures. In the meantime we will continue to attempt to optimise cerebral perfusion pressure using vasoactive drugs, but should be mindful that gross estimates of CPP may not tell us what we’re doing to cerebral oxygenation.

Br J Anaesth. 2009 Jun;102(6):800-5

http://www.ncbi.nlm.nih.gov/pubmed/19376788

Measuring the performance of an inter-hospital transport service

“There is currently no consensus on how the performance of an interhospital transport service can be measured” say the busy Children’s Acute Transport Service (CATS) in London, who classify their indicators under headings of safety, speed, efficiency, and satisfaction. They include a number of useful outcome measurements (such as unplanned subsequent transfers, and need for urgent intensive care interventions at the receiving hospital) that should stimulate other retrieval services - adult and paediatric - to look out how they measure their own performance. Nice paper, proving once again that paediatricians are not just little doctors.

Arch Dis Child. 2009 Jun;94(6):414-6

http://www.ncbi.nlm.nih.gov/pubmed/19174393

Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: a randomized controlled trial

In an nutshell: you can nebulise fentanyl in a dose of 4 mcg/kg for kids of 4 years of age and over and get pain relief equivalent to i.v. morphine 0.1 mg/kg

Emerg Med Australas. 2009 Jun;21(3):203-9

http://www.ncbi.nlm.nih.gov/pubmed/19527280

Practical anatomic landmarks for determining the insertion depth of central venous catheter in paediatric patients

The level of the carina is usually chosen as the target depth for internal jugular vein catheters in children to avoid catheter tip perforation of the right atrium or intrapericardial SVC. This level can now be estimate

d using external landmarks following this study of 90 children under 5 years of age. Ready? Right....

Find the sticky-out bit of the medial head of the right clavicle (point A in diagram) and measure its distance to a point halfway towards the internipple line (B). Add this to the distance between the insertion point of the catheter in the neck (I) and the medial head of the right clavicle (A again) and subtract 0.5. This gives you the catheter tip insertion distance in cm. It doesn’t apply to left sided or subclavian lines, but it seems useful for paediatric RIJV lines.

Br J Anaesth. 2009 Jun;102(6):820-3

http://www.ncbi.nlm.nih.gov/pubmed/19380312

Routine Early Angioplasty after Fibrinolysis for Acute Myocardial Infarction

Oh dear......A randomised controlled trial of 1059 patients who were thrombolysed for STEMI in centres without access to percutaneous coronary intervention (PCI) compared ‘standard’ timing of PCI (median time from randomisation to catheterisation 32 hrs) with urgent transfer and PCI (within 6 hours -actual median time from thrombolysis to ballooon inflation 3.9 hrs). The composite end point of death, reinfarction, heart failure, cardiogenic shock or recurrent ischaemia at 30 days was reduced in the intervention group from 17.2 to 11% (NNT = 16). The authors suggest that previous studies not showing such a benefit pre-dated modern stents and antiplatelet therapies. The study was not powered to detect differences in the individual components of the composite end point. It will be interesting to see if cardiologists consider this a bandwagon to jump upon, in which case let ambulance retrieval services beware!

N Engl J Med. 2009 Jun 25;360(26):2705-18

http://www.ncbi.nlm.nih.gov/pubmed/19553646

Use of a stylet for insertion of a Classic LMA

The most common problem in inserting the LMA classic is difficulty in passing it through the posterior pharynx, a problem made worse by a loss of curvature produced by repeated autoclaving. A stylet can be used to create a bend at two points: near the junction of the mask and the tube, and at the middle of the tube. The mask can then be inserted against the hard palate and swung inward. Care must be taken to avoid protruding the stylet beyond the aperture bar.

Resuscitation. 2009 Aug;80(8):964

http://www.ncbi.nlm.nih.gov/pubmed/19523741

Answers to July CME Questions:

1) T 2) F 3) F 4) T 5) T