Clinical Question to be answered
Can we use oxygen to treat acute migraine?
Title of paper
High-flow oxygen therapy for treatment of acute migraine: A randomized crossover trial
Journal and year
Cephalgia, 2016
Lead Author
Singhal
Name of contributor
Andy Neill
Patients studied
Very select bunch of well established and well defined migraineurs (!) with frequent headaches. Definitely not your general, likely primary, non specific headache
Intervention
High flow O2 in their home (!) at onset of migraine
Comparison
High flow air from an identical appearing cylinder
Primary outcome
headache reduction at 30 mins
Summary of results
No difference! (they describe benefits in the secondary outcomes but the numbers are so small that this is all a bit silly)
Strengths
Well defined migraine patients | treated in their homes! | good randomisation and blinding | good primary outcome
Weaknesses
Tiny numbers | no power calculation | ended early | delayed usual meds really making it placebo rather than comparing with the best current treatment
Clinical Bottom Line
High flow O2 at home didn’t help in this tiny study. Contrast this with Ozkurt
Any other FOAM sites where you found it or who have discussed it already so that we can be sure to give kudos
Clinical Question to be answered
Does immediate wbct in major trauma reduce mortality compared to usual management?
Title of paper
Journal and year
Lancet, 2016
Lead Author
Sierink JC
Name of contributor
Craig Davidson
Patients studied
Major trauma patients >18 years
Intervention
Whole body CT
Comparison
Selective CT as dictated by the clinicians
Primary outcome
Mortality
Summary of results
No improvement in mortality or any secondary outcome
Strengths
Randomised, prospective, pragmatic, patient centred outcome.
Weaknesses
Not blinded, some cross-over, ? Sicker group in WBCT group (based on ISS)
Clinical Bottom Line
Protocolised immediate WBCT increases radiation exposure but doesn’t reduce mortality. Doesn’t mean it’s wrong but decision should be based on clinical findings not used as a screen. Particularly important in younger patients.
Any other FOAM sites where you found it or who have discussed it already so that we can be sure to give kudos
Clinical Question to be answered
Does having a senior doctor in triage enhance ED performance?
Title of paper
Journal and year
EMJ, 2016
Lead Author
Abdulwahid
Name of contributor
Nikki Abela
Patients studied
Systematic review and meta-analysis of papers from 1994-2014, 25 relevant studies were retrieved, 12 were weak quality, 9 moderate and 4 strong.
Primary outcome
Improved ED performance measured by indicators: waiting time, length of stay, left without being seen, and left without treatment complete.
Summary of results
Significant reduction in length of stay, waiting time and some reduction in some studies of patients leaving without being seen, but no change in occurrence of adverse events.
Strengths
Good analysis and review, strong papers with a good number of studies
Weaknesses
No clear benefit in terms of patient satisfaction, cost effectiveness, or adverse events.
Clinical Bottom Line
Are we doing this to meet targets or improve patient outcomes?
Further Reading
Great post by Adrian Boyle on RCEM Learning on how to appraise a systematic review.
UPDATE:
Dr Abdulwahid pointed out on twitter that Mortality was included in the paper, but few studies had it as a main outcome.
Clinical Question to be answered
How should we sedate agitated patients?
Title of paper
A prospective study of ketamine versus haloperidol for severe prehospital agitation
Journal and year
Clinical Toxicology, 2016
Lead Author
Cole
Name of contributor
Andy Neill
Patients studied
Pre hospital patients with acute agitation (measured on a well described scale) but importantly NOT agitated delirium patients (where they use ketamine as standard of care already). Conducted in Minneapolis (through Hennepin) over a year in 2014/2015
Intervention
Ketamine 5mg/kg was on the ambulances for 6 months of the year
Comparison
Haloperidol 10mg was on the ambulances for the other 6 months of the year
Primary outcome
Time to adequate sedation (determined by the paramedic or ED staff)
Summary of results
146 patients | 64 ketamine | 82 haloperidol. Ketamine rocked. Sedation in 5 mins v 17 mins. Lots more reported adverse effects in the ketamine group but the bulk reported were hypersalivaton. Intubation was 40% for ketamine v 4% for haloperidol. Mainly for “failure to protect airway” which seems to be a surrogate for (we feel they’re a bit sedated – which i thought was the point…) but there were a few laryngospasms and apnoeas in there too
Strengths
Well described and organised study (esp the prehospital part). Experienced EMS crews doing this. I think their data is fairly sound (how you interpret it is another question…)
Weaknesses
Do these people really need sedation in the first place. They were specifically targeting the less agitated patients and the +2 on their scale i don’t think should have been sedated at all. What happened to deescalation and a cup of tea? We also don’t really know why all those patients were tubed and did they really need to be (the rate isn’t particularly well accounted for by their data)
Clinical Bottom Line
Ketamine will get you to where you want to be but carries risks and you have to be prepared to deal with the cosequences
Any other FOAM sites where you found it or who have discussed it already so that we can be sure to give kudos