Orthopedics

@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.  





Oldie But Goodie:

This post isn’t actually that old, but it’s about older patients, so we’re gonna count it. On the heels of Dr. Galante’s lecture from last month, Ken Milne at the Skeptics’ Guide to Emergency Medicine takes on Chris Carpenter’s systematic review of ED tool to predict fall risk ingeriatric patients from this months Annals.
This is a can’t-miss episode, as it is the initial installment of the “Hot Off The Press” series. You can watch in real-time as the FOAMed and published-journal worlds start to merge. Each episode of this series will feature a critical analysis and interview with an author of a paper just published in Annals or CJEM. The audience (i.e., everyone) will have a chance to respond with their own post-publication peer review via social media outlets. The top responses will be featured in a future publication in each journal. Knowledge translation and crowdsourced feedback at the speed of social media!

F(FN)OAMed:

If you’re going to pick one podcast to listen to religiously, that podcast should probably be EM:RAP. This month, be sure to check out the segment on IV contrast myths.
Take-home points: Iodine is not an allergen. Seafood allergy does not increase risk of anaphylaxis to IV contrast any more than any other given allergy, although previous reaction to IV contrast or past history of atopy does increase risk. And most notably – premedication with steroids has not been shown to decrease the number of severe reactions.

The Gunner Files:

1. Check out Scott Weingart’s interview with Dr. John Hinds regarding his approach to the patient with blunt traumatic arrest.
In Dr. Hinds’ shop, before they do anything else they: 1) intubate, 2) perform bilateral finger thoracostamies, 3) place a pelvic binder, 4) reduce any gross long-bone deformities, 5) start uncrossmatched transfusion. Only then do they start a formalized assessment. Really interesting stuff.

2. Similar to the R&R from the Fastlane mentioned above, Ryan Radecki’s EM Lit of Note blog is another excellent version of a curated primary literature review. Here is his critical appraisal summary of a systematic review and meta-analysis comparing trauma “pan scan” with more selective imaging.

3. The most recent installment of the EM BASIC podcast is your panic-free look at what we know about Ebola – screening, clinical signs & symptoms, diagnosis, isolation, and treatment.

4. The ultimate skeptic, Rory Spiegel of EM Nerd, turns his nihilistic eye towards the cash cow of cardiac interventionalists everywhere – PCI. Turns out, there’s not a lot of evidence to support its use outside the realm of emergent intervention for STEMI.

5. In the most recent podcast on Emergency Medicine Cases, an EM sports medicine specialist and an orthopedic surgeon help you to avoid falling prey to the “Commonly Missed (Uncommon) Orthopedic Injuries.” Want to know how not to miss a DRUJ? Lisfranc? Perilunate? Tune in.


Never stop learning,


C. Sam Smith, PGY-3

#FOAMed Digest No. 2: Breathless Love

Welcome back! Fresh new FOAMy goodness for you, this time with an emphasis on airway and pulmonary care. Let’s do it!

Three Stars:

1. No way around it: “Delayed Sequence Intubation” is the new hotness. If you want to be one of the cool kids, you better get on board. I’ll let the more graphically-minded folks at EMCurious lay it all out for you with a prototypical case. Don’t miss the links – more excellent FOAMed resources on DSI.
(And Weingart’s seminal paper on the subject is required reading at this point.)
(And, oh yeah, ketamine does NOT increase ICP. Let’s use these two systematic reviews 1 & 2 to stop the foolishness already.)

2. Someday you will need to perform a cricothyrotomy. Accept it as reality, and do everything you can to prepare for it. Start here, with Weingart’s lecture on the surgical airway delivered at the SMACC Gold conference last fall. This page from the EMCrit blog has compiled all sorts of great surgical airway resources from around the FOAMed world all in one spot, including can’t-miss stuff about the scalpel-finger-bougie technique and Weingart’s pre-intubation checklist. You should probably add it to your favorites list now.

3. Wouldn’t be a FOAMed Digest without getting a little off-topic, and Rick Body’s recent contributions over at St. Elmyn’s regarding ACS & “low-risk” chest pain in the ED are too good to pass up. Great post analyzing his recent paper, which concluded ED physicians simply aren’t capable of ruling out ACS in chest pain patients with an acceptable accuracy using only the clinical exam. Dr. Body also gives you a run-down of how to properly utilize high-sensitivity troponin in his talk from SMACC Gold.
(Link to Body's paper here.)

Oldie But Goodie:

By the end of our Ultrasound rotation, we can all diagnose pneumothorax with ultrasound at the bedside. It’s time to take it next-level. A-lines, B-lines, pneumonia vs edema…the experts at the Ultrasound Podcast help you figure it all out in a two-part 1 & 2 podcast.

F(FN)OAMed:

Sanjay Arora and Mike Menchine, hosts of the PaperChase segment on EM:RAP, summarize the current literature about how terrible we are at adequately sedating patients after RSI. Roc lasts longer than Sux – the patients won’t be able to tell us they need sedation!
(Links to relevant papers in the show notes.)

The Gunner Files:

1. Brett Sweeny at EMDocs provides an exhaustive review of FOAMed resources regarding permissive hypotension in trauma. Great lectures and podcasts from some of the brightest minds in EM & trauma surgery.

2. We’re seeing it already – asthma cases are starting to pile up over on the SLCH side. Luckiliy for you, Pediatric EM rockstar Andy Sloas just published an excellent podcast on the evaluation and management of asthma in the Peds ED.

3. Next time you’re consulting Ortho or Plastics for a hand injury, sound like you know what you’re talking about. The folks over at EMin5 hit you with the quick rundown on the neuro exam of the hand.

4. Last week, St. Elmyn’s helped the rooks get up to speed when it came to dealing with the dyspneic patient in the ED (and I bet the seniors learned a thing or two as well). This time, get your mind right when faced with a syncopal patient.

5. Who doesn’t love infographics? And if they actually help us learn something about managing septic patients, that’s just a bonus! Very well done by EMCurious, with embedded links to the relevant studies!

6. New podcast from R.E.B.E.L.EM, summarizing the results of a meta-analysis just published this month in Annals which concluded prehospital application of NIPPV in patients with severe respiratory distress regardless of cause reduced need for intubation (NNT 8) and in-hospital mortality (NNT 18). 
w00t prehospital medicine!
(Original pub here.)

That’s all, folks! Go get your learn on!

Sam Smith, PGY-3