April’s journal club looked at four clinical questions regarding the diagnosis and expectant course of renal stones. Can the STONE score help you determine if your patient’s flank pain is due to a renal stone? Which is better to confirm your clinical suspicion of a renal stone, ultrasound or CT? How likely will your patient’s kidney stone pass spontaneously? What is the accuracy of hematuria to predict a renal stone in the patient with flank pain?

The evaluation of a child for non-accidental trauma (NAT) is an infrequent, yet high risk endeavor for emergency physicians.  Abusive head injury is the most common cause of death in cases of non-accidental trauma and up to 30% of cases of child maltreatment are misdiagnosed at first health care contact.  There is a growing body of literature that helps to frame the workup and risk stratification of children at risk for NAT.  This month’s journal club focused on 3 articles centered on risk factors and diagnosis of abusive injuries. 

Computed tomography (CT) is a commonly used imaging modality in the US. In 2013, greater than 74 million CT scans were ordered.  Although recently there has been a decrease in the need for contrast for certain diagnostic needs, contrast remains very important in the diagnosis of pulmonary embolus, aortic pathology, infectious processes, and other soft-tissue pathology. Acute kidney injury (AKI) has been a concern for many years and the teaching has been that contrast can increase the risk of acute kidney injury.  Recent literature has addressed this issue and this month’s journal club offers a synopsis of these articles.  

Geriatric patients (> age 65) account for almost 1 in 5 of all cervical spine fractures, with 50% of cervical spine fractures occurring at the C1/C2 level.  Recent literature has questioned whether these clinical decision rules may be applied in the geriatric population, where over half of identified cervical spine fractures result from ground level falls.  Furthermore the reliability of physical exam, specifically midline tenderness, has been questioned in elderly patients.  January's journal club examined three articles that addressed this specific population of blunt trauma patients at risk for cervical spine injury. 

Ischemic stroke is one of the most frequently encountered neurologic emergencies. It can be a truly debilitating diagnosis, and yet classically, there has only been one treatment available for small and large vessel occlusions alike– tPA. Now, with the widespread availability of CT angiography and the advent and maturation of interventional techniques such as mechanical thrombectomy, the management of large vessel occlusion (LVO) strokes is rapidly evolving and is increasingly distinct from the management of other strokes. This is truly an exciting time in stroke care, so for this month’s journal club we focused on three questions relevant to the emergency provider:  1) What is the utility of prehospital clinical scales for rapidly identifying LVO strokes? 2) Should patients with suspected LVO be taken to the nearest stroke center or bypass smaller hospitals to reach a comprehensive stroke center?  3)  How effective is mechanical thrombectomy vs. tPA alone?

Low back pain is one of the most common emergency department presentations. Though diagnosis is often straightforward, pain management can be a source of frustration for both the patient and the provider, especially as we focus on limiting narcotic prescriptions given the spreading opiate crisis. In an effort to manage pain, practitioners often counsel patients on the use of over the counter medications or discharge them with a prescription, but what is the evidence behind these medications that we commonly use for back pain? For this month’s journal club, we reviewed three articles that studied the use of acetaminophen, NSAIDS plus muscle relaxers or opiates, and corticosteroids for the management of acute low back pain.

Angioedema (non-pitting edema of submucosal tissues) results in infrequent, but high-risk emergency department visits. Since airway edema can make oropharyngeal and nasopharyngeal intubation impossible, our focus is on early and aggressive pharmacologic treatment to prevent life threatening airway obstruction. Recall that angioedema can come from two broad physiologic mechanisms: histamine mediated (ie allergic in nature which may have urticaria or other evidence of anaphylaxis) or bradykinin mediated (eg hereditary angioedema, ACE-induced angioedema). Histaminergic mediated typically responds well to aggressive antihistamines, steroids, and epinephrine. Bradykinin mediated, however, does not.  This month we focused on this type of angioedema that can be non-responsive to our typical first line therapies. 

Cellulitis is commonly treated in the emergency department.  Patients who present with cellulitis incur significant health care costs and may be over-treated with antibiotics.  For our August journal club, we selected articles that would help providers avoid treatment errors that lead to high costs, unwanted side effects, overuse of antibiotics and unnecessary admissions.

With nearly 1 million US emergency department (ED) visits attributed to acute heart failure (AHF) annually, heart failure is a serious illness frequently managed by emergency physicians. More than 80% of visits result in hospital admission, and readmission rates may range from 30-60% within 3 to 6 months of initial discharge. ED visits related to AHF are expected to continue to rise with the aging population and improved survival rates in patients with chronic heart failure and acute coronary syndromes. One critical issue facing emergency physicians caring for AHF patients is deciding upon disposition: admission (with or without monitoring) or discharge (with or without early follow-up). Consensus guidelines are available to support decision-making around diagnosis and treatment; however, no current guidelines provide an evidence-based approach to disposition. For this month’s journal club, we reviewed three papers examining decision aids developed to assist emergency physicians in determining risk in AHF patients.