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All you need is nitrous
We are privileged to publish a wonderful randomised controlled trial this month. Seiler et al randomised children undergoing painful procedures under sedation with 70% nitrous oxide to receive additional intranasal fentanyl or a placebo. They assessed pain and sedation scale during the following 12 hours, which is quite an undertaking. Ultimately, this was a negative trial: intranasal fentanyl made no difference. So, will this trial win you over to nitrous oxide 70%? Will you abandon intranasal fentanyl? To make your decision, you’ll need to read the full paper!
Precision emergency medicine: a new approach
When preparing this month’s primary survey, I was pleasantly surprised to see Charles Reynard’s paper on the list for the March edition. I am privileged to be Charles’ supervisor and senior author, and in this issue the journal features a paper that testifies to Charles’ hard work and determination to advance the boundaries of our practice. In Emergency Medicine, we must often make decisions based on our judgements about the likely benefit and potential harm of treatment, but those judgements are usually subjective. This work tries to make that process more objective, by using data from the literature to calculate the probability that patients with suspected acute coronary syndromes will derive net benefit from different antiplatelet regimens. After three systematic reviews, a utilitarian decision analysis and prospective validation in a real patient cohort, the study concludes that if the probability of acute coronary syndrome exceeds 8% then patients are likely to derive overall benefit from treatment with ticagrelor and aspirin, as opposed to receiving aspirin alone. Clopidogrel had no role. Read the paper for the full information. Could it herald a new approach to precision medicine in the Emergency Department?
Is the patient history complete without including sexual orientation and gender identity?
The traditional approach to history taking in Emergency Medicine is pragmatic and focused on extracting the key information that we really need to know in order to make clinical decisions. But is that actually what patients want? In this issue, Kodadek et al venture into some topical and fascinating territory, exploring the perceptions of both patients and healthcare providers about whether physicians should routinely enquire about sexual orientation and gender identity. The physicians took a pragmatic approach: if the information won’t change clinical decisions, then they don’t see a reason to seek it. Very interestingly, however, patients saw things quite differently. In order for their physicians to provide holistic care, they felt that their physicians ought to know that information. This an extremely thought-provoking piece, which introduces concepts that many emergency physicians may not have previously paid great attention to. However, it is clearly worthy of the attention and careful consideration of every emergency physician. Make sure you read the paper, and then ask yourself: should we be doing more to routinely seek this information in our daily practice?
Are x-rays a thing of the past in chest injury?
It’s well known that chest radiographs are insensitive for diagnosing rib fractures. However, patients often want to know if they’ve fractured a rib or only have bruising. What’s more, the incidence of pulmonary complications is higher in patients who have confirmed rib fractures. Is this, therefore, a diagnosis we ought to be chasing in the Emergency Department? And, if so, is a radiograph or an ultrasound a more appropriate diagnostic modality in that situation? In this issue, Ceri Battle (who created the STUMBL decision tool for patients with blunt chest wall injury) et al report on a systematic review comparing chest radiography to ultrasound for the diagnosis of rib fractures. It would appear that ultrasound has superior accuracy, but will this paper convince you to change your practice?
In this issue we also cover a number of other important issues. The Wood’s lamp has been a pillar of the clinical examination for patients with eye complaints for many years. But just how sensitive is it as a diagnostic test? Hooker et al have asked just that question. You can also read about how expertise in martial arts could help to control external bleeding, how well emergency physicians comply with hand hygiene measures, and about access to appropriate healthcare for critically burned patients in India. All in all, we are thrilled with this outstanding issue of the journal, which offers plenty of thought provoking and potentially practice-changing science.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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