Zworth Reading

Ultrasound-guided pericapsular nerve group block versus intravenous morphine for pain management in older adults with hip fractures: a randomised controlled trial in the emergency departmentLOE 2 (Randomised controlled trial)

Emergency Medicine Journal

Single-centre open-label RCT comparing PENG block to IV morphine 0.1mg/kg in patients ≥65 with hip fracture and pain ≥5/10. Primary outcome was pain reduction at 30 minutes. PENG block showed median 6-point reduction vs 3-point reduction with morphine (p=0.001). No patients in the PENG group required rescue analgesia vs 5.9% in the morphine group. No serious adverse events in either arm.

Honestly I don't think this trial was necessary. We already have a great deal of evidence that these blocks are safe and effective, including better designed trials with proper blinding and sham injections, and systematic review level evidence on top of that. We know hip blocks reduce pain, and pain was the primary outcome here. The stronger argument for doing them is not pain alone. They are opioid sparing, and there is Cochrane review data suggesting they reduce rates of confusion in older adults. Many of us already call anaesthesia for these. This is not a difficult procedure and it is well within our skill set. If you want a refresher on technique, the NYSORA walkthrough is excellent: https://www.youtube.com/watch?v=1mkHrVxdGNg

Bottom line: Take this as a reminder rather than news. Hip blocks work, they spare opioids, and they are a procedure we can be doing ourselves.

Association between the time to norepinephrine initiation and mortality in patients with sepsisLOE 3 (Prospective observational)

Emergency Medicine Journal

Prospective multicentre observational study of 138 patients with sepsis in Thailand. Non-survivors had a longer median time to norepinephrine than survivors, 98.5 minutes versus 49.5 minutes. After multivariable Cox regression, time to norepinephrine remained associated with 28 day mortality, and starting beyond 1 hour carried an adjusted hazard ratio of 2.60, beyond 2 hours 2.96.

This is prospective observational data, so there is no way to draw any conclusion about causation. There are all kinds of reasons the patients who got pressors later may simply have been sicker, or may have been recognised later, and no amount of regression fixes that. The study was also underpowered, and the authors are open about failing to reach their target enrolment because of the pandemic, with baseline imbalances between groups that they attribute to the small sample. It is worth reading this next to the ARISE FLUIDS trial we covered previously, where an early vasopressor approach produced more or less equivalent outcomes. Granted the question there was somewhat different, since it was looking at fluid strategy rather than pressor timing alone. The authors themselves say the real conclusion is that we need randomised trials to define optimal timing.

Bottom line: Keep following the Surviving Sepsis guidelines and weight the randomised data we already have over observational signals like this one.

OMI-nously Yours: Is it time to re-think Code STEMI?Knowledge translation / Opinion

EMOttawa  ·  LOE 5 (Narrative review with expert opinion)

Makes the case for shifting from STEMI/NSTEMI paradigm to OMI/NOMI (occlusion MI vs non-occlusion MI). Reviews evidence that STEMI criteria miss significant occlusions while activating cath lab for some non-occlusive disease.

The OMI literature seems to be more prevalent in the FOAM and EM world than in Cardiology so far. For those of you who have more recently completed cardiology rotations, correct me if I am wrong on that. The truth is that a lot of these ECG findings are things we have been talking about for a long time. Deep symmetric T wave inversion, think Wellens. Significant ST depression in the anterior leads, think posterior MI. Hyperacute and De Winter T waves. Q waves. ST elevation in aVR with diffuse ST depression. We already know these are concerning findings. So this is a useful reminder of everything on the ECG besides ST elevation that can point to complete occlusion.

Bottom line: Even though guidelines for transfer and cath lab activation still use the STEMI and NSTEMI paradigm, if you have access to Cardiology it is reasonable to run a case by them when the ECG has features concerning for OMI.

Evidence Update for Minimally Invasive Surgical Evacuation of Supratentorial Spontaneous Intracerebral Hemorrhage: A Science Advisory From the American Heart AssociationLOE 1 (Science advisory synthesizing RCT evidence)

Stroke  ·  Neurology/Neurosurgery

In patients with supratentorial spontaneous ICH, does minimally invasive surgical evacuation improve functional outcomes compared to medical management alone?

AHA now acknowledges that recent RCT evidence (MISTIE III, ENRICH) supports consideration of minimally invasive surgery for select patients, particularly those with lobar hemorrhage. This represents a shift from prior skepticism about surgical intervention.

We would obviously be discussing these patients with neurosurgery anyway, but it is useful for us to be aware of the evidence and of what the surgical options actually are. The interesting part is that the inclusion criteria for surgical intervention may be broadening, particularly as the minimally invasive approaches continue to improve.

Bottom line: For lobar hemorrhage, minimally invasive evacuation is becoming a consideration. When consulting neurosurgery, the answer may no longer be automatic medical management.

Diagnosis and management of acute hyperkalaemiaLOE 5 (State of the art review)

BMJ

Comprehensive review covering pathophysiology, risk stratification by ECG and clinical context, and updated treatment algorithms. Addresses role of newer potassium binders (patiromer, SZC) in acute and chronic management. Emphasizes that ECG changes correlate poorly with potassium level and shouldn't be the sole driver of treatment urgency.

There is nothing really new here, but I did appreciate the overview of the newer potassium binding agents. It is also nice to get an occasional refresher on the full spectrum of ECG changes in potassium imbalance.

Bottom line: Solid refresher on hyperkalemia management. No paradigm shifts, but useful consolidation of current evidence. Worth skimming if you haven't updated your approach recently.