To provide a resource for evidence-based Emergency Medical education, this list of must-read landmark articles was created to supplement the Emergency Medicine (EM) internship year of training. There are 52 articles so that one article can be read at leisure each week of the year. I searched national databases and polled faculty at the University of Washington to identify articles that faculty would expect any EM resident to be familiar with or that they felt were practice-changing in EM. Articles were selected for the final list based on the quality of study design, sample size, and relevance for EM residents.
Nasogastric lavage (NGL) seems to be a logical procedure in the evaluation of patients with suspected upper GI bleeding, but does the evidence support the logic? Most studies state that endoscopy should occur within 24 hours of presentation, but the optimal timing within the first 24 hours is unclear. Rebleeding is the greatest predictor of mortality, and these patients benefit from aggressive, early endoscopic hemostatic therapy and/or surgery. So what are the arguments for and against NGL?
A patient with advanced alcoholic cirrhosis with ascitic fluid leaking from a paracentesis puncture site from a procedure done 2 days prior. Dermabond had initially been applied post-procedure, but it had come loose, and ascitic fluid had been saturating dressing after dressing.
Do you know what the Blatchford clinical prediction score is for upper GI bleeding? It can help you predict whether a patient with an upper GI bleed is severe and requires urgent intervention.
Hot off the presses, JAMA just came out with a great Clinical Rational Examination article on this topic. Thanks to Dr. Ryan Radecki (EMLitOfNote) for the heads up. The likelihood ratios and Blatchford risk stratification score are so useful that I’m breaking my PV rule to keep things down to the size of one index card. Note the absence of a NG lavage result to help you risk stratify for an upper GI bleed requiring urgent intervention using the Blanchard score.
This month’s issue of JAMA addresses the question “Does this patient have a blunt intra-abdominal injury?” as part of the always-popular Rational Clinical Examination series.
The systematic review of the literature summarizes the accuracy of findings for your blunt trauma patient in diagnosing intra-abdominal injuries. Specifically, likelihood ratios (LR) are summarized. These LRs can be used to plot on the Bayes nomogram below. You draw a straight line connecting your pretest probability and the LR. This yields your posttest probability.
In the most recent EM Clinics of North America publication, Dr. Panebianco et al. discussed the evidence behind diagnostic tests for acute abdominal pain. There were some really great teaching points in this broad-reaching topic.
My favorite pearl: A 3-way acute abdominal series is too insensitive to rule-out any major acute causes of abdominal pain with confidence. So stop ordering them routinely. If you are worried about a perforated viscus, order an upright chest x-ray instead — more accurate and less radiation.
Primum non nocere. Do no harm.
We so often recommend and give NSAIDs to patients for various painful conditions. We also commonly administer ketorolac (toradol) in the ED, because it works so amazingly well for renal colic. When giving various NSAIDs, what is the relative risk (RR) for an upper GI bleed or perforation in the first year?