March 12, 2020

Background: Most published clinical guidelines on the management of primary spontaneous pneumothorax (PSP) advocate for a conservative approach of observation for small asymptomatic pneumothoraces (PTX).(1,2) However, procedural re-expansion with a catheter or chest tube is recommended for all large pneumothoraces, regardless of symptomatology or clinical stability.(1) More recently, smaller chest tubes (i.e. pigtail catheters) have been used as this can potentially cause less pain. Typically, patients who get chest tubes or pigtail catheters require hospitalization for management of the tube. But, chest tubes are not without risk: there are multiple reports in the literature describing terrible consequences of chest tubes including bleeding, infections and empyemas, and misplacement into vital organs like the liver, spleen, and heart.(3-5) An alternative approach to this invasive procedure is to do nothing, unless the pneumothorax becomes physiologically significant. In an effort to reduce these risks and discomfort to the patient, the clinical quandary becomes: can a large pneumothorax be managed using a conservative observation-only approach, without placement of catheters or chest tubes? To date there have been no randomized clinical trials comparing these two polar opposite management strategies until now (The PSP Trial).

May 20, 2019

Background: Atrial fibrillation (AF) is a common cardiac dysrhythmia encountered in the emergency department (ED), affecting 2.7 million - 6.1 million Americans annually. Hospitalizations with AF as the primary diagnosis total >467,000 annually. AF is associated with a 5-fold increased risk of ischemic stroke, a 3-fold increase in risk of heart failure, and a 2-fold increased risk of mortality. (1) Previous RCTs comparing outcomes of rhythm-control using antiarrhythmics with rate-control in patients with AF failed to show a benefit of rhythm control on mortality. (2,3) However, for some patients, rhythm control improves symptoms and is associated with a better quality of life. (4) Given that up to 70% of AF terminates spontaneously within 24 hours, can we adopt a delayed, or wait-and-see (WAS), approach to AF in the ED and avoid early cardioversion? (5).