Revision Resources

February 24 FOAMed


he optimal management of primary, spontaneous pneumothorax (sPTX) remains an area of active debate. The British Thoracic Society recommends the least invasive approach possible. In contrast, the American College of Chest Physicians favors first-line chest tube drainage for any sPTX with an estimated volume of over 20%.(3) A Cochrane systematic review comparing simple aspiration with drainage for adult cases identified several randomized controlled trials of small, heterogeneous populations with first or recurrent pneumothorax. They concluded that more research of higher quality is needed to strengthen the evidence in favor of one technique over the other. The EXPRED (Exsufflation of Primary Spontaneous Pneumothorax versus Chest Tube Drainage) study aimed to strengthen the evidence that simple aspiration is non-inferior to chest tube placement during the first episode of complete primary pneumothorax.

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Lumbar Punctures

The ancient Egyptian physician Imhotep is often credited with the  discovery of cerebral spinal fluid (CSF) —over 5,000 years ago! However, it wasn’t until the 1890s that purposeful, successful, and safe attempts to access this fluid were documented. Heinrich Quincke, of the eponymous Quincke needle, is often credited with this innovation and although his technique was perhaps not as sterile as that in use today, his second reported patient not only survived 3 lumbar punctures (LP), but symptomatically improved. The LP is now a standard procedure and in 2010 well over 135,000 LPs were performed in Emergency Departments throughout the US.

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REBOA (resuscitative endovascular balloon occlusion of the aorta) has been discussed in the emergency medicine world for quite some time now, but always with very limited data. There have been some observational studies that suggested REBOA was associated with worse outcomes, but the outcomes were largely assumed to be the result of confounders. (Norii 2015, Joseph 2019) There was also some more positive observational data. (Manzano Nunez  2017; Borger van der Burg 2018)

This year, we saw the first RCT published, in the form of the UK-REBOA trial.

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Achilles Tendon Rupture

Achilles tendon rupture is a clinical diagnosis. The Thompson Test should be applied in all suspected cases.

Remember to brace or splint a rupture, even if suspected, in the resting equinus position for optimal healing and prevention of further injury.

Schedule follow up with orthopedics within 1 week for discussion of operative management vs early rehab protocols.

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Non-inferiority Trials

Over the last few years, I have seen a steady increase in the number of non-inferiority trials being published. This makes some sense, as they generally require fewer participants, and are therefore cheaper and easier to run. However, it presents a problem, as most of us (including myself) don’t really understand the statistics being performed, and often a non-inferiority design is inappropriate for the question being asked. Although it will be a little bit nerdy, I think it is time we all try to understand what these non-inferiority trials really mean, and why the design should probably be used less.

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