Category: Journal club

Journal club: SAH and systematic reviews

Thanks to Dr Szechi Freidanck for her presentation.




Take home points:

  1. The quality of a systematic review is determined by the relative quality of the included and excluded studies. The AMSTAR tool is a way to assess the methodological rigor of the systematic review
  2. A Likelihood ratio of close to 1 means a test is not practically useful
  3. Aim to rapidly assess headaches to facilitate CT brain early where possible; but beware of diagnostic momentum – the history is king in cases of headache, and poor initial assessments can have downstream effects for the patient

Thinking about research episode 1

Thanks to Prof Anne-Maree Kelly – we reviewed these articles this week:


Take home points:

  1. critically unwell patients in whom desaturation was particularly critical were not included
  2. not statistically powered to detected clinically significant desaturations
  3. apnoeic oxygenation has minimal harm – and its introduction likely has had intangible effects on our practice in terms of adherence to checklists


shoulder dislocation

Take home points

  1. a well designed study with patient centred outcomes
  2. some methodology issues in that pain rating was surveyed after the intervention
  3. your armamentarium for shoulder reduction should include at least one non sedation technique, and using a patient centred self-reduction technique allows the patient control over their medical experience

After the party: a journal club case

Thanks Dr Peter Ritchie for forwarding this article about an interesting case.




Key points:

  1. Rarer diagnoses are often encountered in daily ED practice hidden amongst common symptoms
  2. attention to details that do not fit usual patterns (eg. in this case abnormal renal function that was not accountable by dehydration, abnormal liver function tests; band forms on full blood count) may re-direct the clinician to new differentials and help stall diagnosis momentum

Thrombolysis in PEA arrest and PE

Thrombolysis in PEA with confirmed PE


Thanks Elliott Adamson for this presentation about the PEAPETT study.

Key points:

  1. Suggests that thrombolysis with tPA in PEA arrest with confirmed PE has benefit
  2. Logically contrasts with other studies of thrombolysis in PEA arrest (all causes) which does not appear to show particular benefit
  3. Despite minimal proven benefit of thrombolysis in PEA arrest where cause is unclear, consideration of thrombolysis is still important (reversible causes – 4Hs and 4Ts) particularly in younger patients where overall outcome likely to be better

Sepsis, new-onset AF and restored sinus rhythm – prognostic impact

prognostic impact of restored sinus rhythm - sepsis - new-onset AF


Key points:

  1. single centre, retrospective cohort study
  2. 503 patients with sepsis – (263 without new onset AF; 240 with new onset AF)
  3. sinus rhythm restored in 165 of 240; mix of amiodarone / beta-blockers / calcium channel blocker / digoxin / DCR
  4. mortality of new onset AF group highest (61.3%) vs new AF with restored sinus rhythm (26.1%) vs no new AF (17.5%)
  5. hypothesis that restoring sinus rhythm may improve outcomes


  1. excluded patients with ICU stay < 3 days and those > 90 yrs old
  2. new onset AF group were older, higher prevalence of hypertension, CCF and coronary artery disease
  3. new onset AF group had higher Sepsis-related Organ Failure Assessment (SOFA) score (9.3 vs 7.0) and APACHE II scores (24.6 vs 21.6) to no AF group


  1. applicability to ED management already limited given exclusion criteria of ICU patients staying < 3 days
  2. higher mortality may simply reflect higher sepsis burden +/- co-morbidities
  3. Unclear if intervention or sepsis management resulted in reversion to sinus
  4. no single intervention tested in this study

Other thoughts?

AMA position statement: Euthanasia

Euthanasia and physician assisted suicide is a recurring topic of public discourse.

The Australian Medical Association (AMA) has released their position statement which highlights:

  1. prioritisation of good quality end of life care
  2. ensuring that co-morbid conditions that may impact on a patient’s desire for euthanasia have been adequately and optimally managed (e.g. mental health conditions, cognitive disorders, chronic disease)

The AMA does not endorse euthanasia but acknowledges that there is a diverse range of opinion both within the medical profession and public and that ongoing conversation about the ethical and legal implications is important.

See the full statement (2016) below:

see also Aged Care Liaison Service – Palliation