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December 2022 Monthly Review
Academic Emergency Medicine
No articles this month
Annals of Emergency Medicine
Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation
- Laryngospasm occurs in 3.3/1000 cases of Ketamine
- Among patients with laryngospasm, the resulting outcomes included desaturation less than 70% for more than 30 seconds (19.7%), procedure not completed (10.6%), emergency airway intervention (10.0%), endotracheal intubation (5.3%), unplanned admission/increase in level of care (2.3%), aspiration (1.1%), and cardiac arrest (0.2%).
Pediatric Procedural Sedation and Laryngospasm: How Much Should I Worry?
- Laryngospasm is rare—approximately 3 in 1,000 sedations performed outside the operating room, and this number may even be lower in the ED setting.
- Serious outcomes are very rare but do occur.
- Risk factors to be aware of are as follows: young age (<1 year), patients with upper respiratory tract infections, patients categorized as ASA class III or higher, procedures involving the upper airway, and sedation with a combination of ketamine and propofol. It is uncertain whether these factors are directly translatable to ED sedations; however, knowing these patient- and medication- related risk factors can help inform emergency physicians in
- sedation planning.
- The findings of Cosgrove et al1 support continued confidence in ketamine as a single agent to provide safe and effective sedations for children.
- Laryngospasm associated with procedural sedation is a rare event regardless of the clinical setting, drug administered, or procedure performed—however, the risk is not zero—reinforcing that all sedation clinicians must be skilled in airway rescue.
- .48% incidence of invasive bacterial infection among 2-6 month olds with fever.
- Only 4 positive CSF cultures (1/5250).
- Awaiting a validation study but suggests that d-dimer testing for DVT will go the way of PE testing where low pre-test probability allows for higher test threshold D-dimer levels.
BMJ
Circulation
CJEM
EMCRIT
EMCrit 338 – End of Year Question & Answer Session
Emergency Medicine Journal
EMRAP
Pigtail Catheter for Pneumothorax- Weingart
First10em
Laceration evidence part 7: Aftercare instructions
- Can wounds get wet?
- Very low level of evidence, but it is probably safe to get wounds wet early after repair, and keeping them clean with soap and water makes physiologic sense.
- Do dressings help?
- There does not seem to be any evidence that dressings improve healing after acute lacerations. It makes sense to use a dressing for comfort, and to absorb blood and exudate in the first 12-24 hours after repair. Obviously, patients can continue to use dressings for aesthetic or comfort reasons if they prefer.
For such a common problem in emergency medicine, there is a striking paucity of evidence to guide our care of lacerations. Nothing I found allowed for definitive conclusions, so clinical judgment and shared decision making are, like always, necessary.
Personally, I tell patients:
- A dressing isn’t required, but you probably want one for the first 24 hours, as some bleeding may still occur. After that point, I would suggest applying a dressing if you are in an environment where the wound might become contaminated, or if you prefer one for cosmetic sake, but I want you to remove the dressing every day to check for signs of infection.
- It is fine to get the wound wet, and in fact I like the idea of keeping the area clean with soap and water. However, I would avoid obviously contaminated water sources, like lakes and public pools until the wound is completely healed.
- Topical antibiotics probably aren’t necessary. They might prevent small pimple-like infections, but there is a risk of an allergic reaction. You can use an over-the-counter preparation if you like.
- I don’t think there is any evidence that vitamin E or expensive scar creams help. Applying a very light layer of vaseline during the first week, to keep the wound moist as it heals, might make sense.
JAMA
- Among US primary care physicians in 2019, MIPS scores were inconsistently associated with performance on process and outcome measures. These findings suggest that the MIPS program may be ineffective at measuring and incentivizing quality improvement among US physicians.
Journal of Emergency Medicine
None
Lancet
None
NEJM
Prescribing Opioids for Pain — The New CDC Clinical Practice Guideline
PEDIATRICS
None
REBELEM
Pigtail Catheter vs Large Bore Chest Tube for Pneumothorax
- We agree with the author’s conclusion. PC performed as well as LBCT in terms of successful drainage and was associated with fewer complications, decreased drainage duration, and decreased length of hospital stay, driven by data on spontaneous pneumothorax.
REBEL Core Cast 92.0 – Perichondritis
- Most common organism is pseudomonas so must treat with fluoroquinolones.
- Inpatient treatment is required if an abscess is suspected.
REBEL Cast Ep113: Defibrillation Strategies for Refractory Ventricular Fibrillation
- Double sequential defibrillation and vector change defibrillation are both feasible treatments for refractory ventricular fibrillation with the later being more practical and cost effective in the prehospital setting. . However, until additional evidence presents itself, the use of double defibrillation on a case-by-case basis should be considered based on operational feasibility such as institution/agency policies, and availability of resources.
7d vs 14d of Antibiotics in Afebrile Men with UTI
- 7d of abx for stable afebrile males with UTI
Resuscitation
November 2022 Monthly Review
Academic Emergency Medicine
American Journal of Emergency Medicine
None
Annals of Emergency Medicine
Man with right eye pain and decreased vision
Man presents to ED with right eye pain and decreased vision after hammering a nail.
BMJ
- 12 weeks better than 6 weeks
Circulation
None
CJEM
The HINTS exam is a skill emergency physicians need to learn, apply and master
Just the facts: point‐of‐care ultrasound for the diagnosis and management of acute heart failure
Just the facts: How to diagnose and manage acute preschool asthma in the ED
EMCRIT
Association Between Time to Source Control in Sepsis and 90-Day Mortality
Excluding Hollow Viscus Injury for Abdominal Seat Belt Sign Using Computed Tomography
- Like hip fractures, plain films also miss pelvic fractures
Emergency Medicine Journal
EMRAP
Macgyver Hacks: Bugs and Enemas
Shock Index and Diastolic Shock Index
First10em
Dose VF: A double sequential defibrillation game changer?
- Study in NEJM looked at out of hospital arrest with refractory vfib or pulseless Vtac after 3 failed attempts at defibrillation.
- Commentary by First10em:
- It has never made any sense to continue to provide the same unsuccessful therapy over and over again, so I think all of us have been changing something after 3 unsuccessful shocks, whether it was simply changing pad position, or adding a second machine.
- Working in a community hospital without access to ECMO or the cath lab, if I have a patient in refractory ventricular fibrillation after 3 shocks, I will perform one of these techniques, but that actually isn’t a change from current practice. I think the plan that might make the most sense is to apply a new set of pads in the anterior-posterior position after the 3rd unsuccessful shock, provide one vector change shock (to limit the risk of machine damage while still gaining potential benefit), and then if that didn’t work try double sequential for the next attempt. I think the potential benefit is worth the relatively limited risk in a hospital setting.
- However, I will continue to emphasize that this is not standard of care, and this is not definitely proven, and we definitely need to see follow-up RCTs.
Are sterile gloves necessary when repairing lacerations in the emergency department?
- No
JAMA
None
Journal of Emergency Medicine
November not yet available
Lancet
None
NEJM
Focused Cardiac Ultrasonography for Right Ventricular Size and Systolic Function
Defibrillation Strategies for Refractory Ventricular Fibrillation
Oxygen-Saturation Targets for Critically Ill Adults Receiving Mechanical Ventilation
Noninvasive Respiratory Support for Adults with Acute Respiratory Failure
PEDIATRICS
None
REBELEM
None
Resuscitation
None
October 2022 Monthly Review
American Journal of Emergency Medicine
- Early initiation of vasopressin in patients within 6 h of septic shock onset was not associated with decreased short-term mortality, new onset arrhythmias, shorter ICU length of stay and length of hospitalization, but can reduce the use of RRT. Further large-scale RCTs are still needed to evaluate the benefit of starting vasopressin in the early phase of septic shock.
Annals of Emergency Medicine
None
BMJ
None
Circulation
None
CJEM
No October issue
EMCRIT
EMCrit 334 – CV-EMCrit – Concise HeartMate 3 LVAD Overview
NeuroEMCrit – Team NeuroEMCrit’s H&R Conference Talk, Part
Emergency Medicine Journal
None
EMRAP
Cardiology Corner: Clinical Conundrums
- CVA and STEMI? AHA says give lytics
Troubleshooting Nephrostomy Tubes
First10em
- routine application of risk scores for patients identified as low risk by these pathways is not recommended, the modified HEART score or EDACS may be considered for selective application especially in cases where the physician believes the patient may be higher risk based on their clinical history or symptoms at presentation
JAMA
None
Journal of Emergency Medicine
Emergency Department Hallway Care From the Millennium to the Pandemic: A Clear and Present Danger
Lancet
None
NEJM
Prevention of and Emergency Response to Drowning
Spontaneous Intracerebral Hemorrhage
Blood-Pressure Targets in Comatose Survivors of Cardiac Arrest
Oxygen Targets in Comatose Survivors of Cardiac Arrest
Myositis
A 37-year-old man presented to the emergency department with a 1-week history of pain and swelling in the left upper arm that had started after blunt trauma to the arm during a soccer practice. He had a history of opioid use disorder, which had been treated with buprenorphine. He reported no intravenous drug use during the past 2 years. The heart rate was 120 beats per minute, the blood pressure 96/54 mm Hg, and the body temperature 37.9°C. Examination of the left upper arm was notable for swelling, tenderness, and crepitus. The overlying skin was red and warm to the touch. A radiograph of the upper arm showed radiolucent areas with air–fluid levels in deep tissue.
PEDIATRICS
None
REBELEM
Resuscitation
September 2022 Monthly Review
Academic Emergency Medicine
- Results: Of the 1385 ED visits with abdominal pain chief complaint and discharged home from the ED, individuals who were not imaged in the ED had significantly higher adjusted odds of being imaged outside the ED within 7 days (adjusted odds ratio [aOR] 6.65, 95% confidence interval [CI] 3.96–11.17, p < 0.001), 14 days (aOR 4.69, 95% CI 3.11–7.07, p < 0.001), and 28 days (aOR 3.1, 95% CI 2.25–4.27, p < 0.001) of being discharged and had a significantly higher adjusted odds of revisiting the study ED (aOR 1.65, 95% CI 1.29–2.12, p < 0.001) and revisiting any ED (aOR 1.47, 95% CI 1.16–1.86, p = 0.001) within 30 days of being discharged.
- Conclusions: Abdominal imaging in the ED was associated with significantly lower imaging utilization after discharge and 30-day revisit rates, suggesting that imaging in the ED may replace downstream outpatient imaging.
- Ketorolac may have similar efficacy to phenothiazines and metoclopramide in treating acute migraine headache. Ketorolac may also offer better pain control than sumatriptan, dexamethasone, and sodium valproate. However, given the lack of evidence due to inadequate number of trials available, future studies are warranted.
American Journal of Emergency Medicine
None
Annals of Emergency Medicine
- Intranasal topical application of tranexamic acid is associated with a lower rate of need for anterior nasal packing and a shortened stay in the ED; it may be considered a part of the treatment for atraumatic anterior epistaxis.
Can’t Stop, Won’t Stop: The Return of Tranexamic Acid for Epistaxis
- Therefore, it is likely that the tranexamic acid literature will continue to evolve, and tranexamic acid should be seen not as a cure-all hemostatic agent but, rather, as a specific tool with unique benefits and limitations. However, in light of this present study and the existing literature, we believe that it is reasonable to use tranexamic acid in patients presenting to the ED with epistaxis given that it is a low-cost, relatively painless intervention that may prevent the discomfort of anterior nasal packing. Future studies should identify the populations that receive the greatest benefit and the role for newer technology (eg, viscoelastic testing to determine whether hyperfibrinolysis is present) to guide antifibrinolytic therapy.
BMJ
Circulation
Early Rhythm Control in Patients With Atrial Fibrillation and High Comorbidity Burden
- Patients with recently diagnosed atrial fibrillation and CHA2DS2-VASc score ≥4 should be considered for ERC to reduce cardiovascular outcomes, whereas those with fewer comorbidities may have less favorable outcomes with ERC.
EMCRIT
None
Emergency Medicine Journal
- Results From 2468 eligible patients, 1480 were randomised in a sterile (n=747) or non-sterile (n=733) protocol. Baseline characteristics were similar in both study arms. The observed wound infection rate in the non-sterile group was 5.7% (95% CI 4.0% to 7.5%) vs 6.8% (95% CI 5.1% to 8.8%) in the sterile group. The mean difference of the wound infection rate of the two groups was −1.1% (95% CI −3.7% to 1.5%).
- Conclusion Although recruitment ceased prior to reaching our planned sample size, the findings suggest that there is unlikely to be a large difference between the non-sterile gloves and dressings for suturing of traumatic wounds and sterile gloves, dressings and drapes for suturing of traumatic wounds in the ED.
EMRAP
- CXR only 70% sensitive for PNA
- Azithromycin no longer sufficient alone for PNA due to S. PNA resistance>25%.
- Needs to be Amox + Azithro or Augmentin + Azithro in patient with comorbid disease or Levaquin but side effect profile worse.
- Alcohol + poor nutrition + dehydration + stressor: Look for stressor (infection and pancreatitis most common)
- Ethylene glycol and methanol toxicity cause severe acidosis (pH<7, Bicarb<10)
- Serum glucose usually low or normal, consider hyperglycemic emergency if glucose>250.
- Treatment
- Give Thiamine 100-200mg IV or IM before glucose unless hypoglycemic (in which case don’t wait)
- D5NS
JAMA
- After hearing and seeing simple instructional materials, children and adolescents aged 4 to 14 years self-collected nasal swabs that closely agreed on SARS-CoV-2 detection with swabs collected by health care workers.
- Results of this study suggest that helmet noninvasive ventilation did not significantly reduce 28-day mortality compared with usual respiratory support among patients with acute hypoxemic respiratory failure due to COVID-19 pneumonia. However, interpretation of the findings is limited by imprecision in the effect estimate, which does not exclude potentially clinically important benefit or harm.
- Among patients with respiratory failure due to COVID-19, high-flow nasal cannula oxygen, compared with standard oxygen therapy, did not significantly reduce 28-day mortality.
Journal of Emergency Medicine
No September issue as of November 3
Lancet
None
NEJM
Nirmatrelvir Use and Severe Covid-19 Outcomes during the Omicron Surge
- Only benefit was in patients >/=65yo
Supporting, Not Reporting — Emergency Department Ethics in a Post-Roe Era
Gastroesophageal Reflux Disease
PEDIATRICS
REBELEM
The ADVOR Trial: Acetazolamide in Acute Decompensated Heart Failure
- Patients with acute decompensated heart failure, clinical signs of volume overload (i.e. edema, pleural effusion, or ascites), and an N-terminal pro-B-type natriuretic peptide level of >1000pg/mL or a B-type natriuretic peptide level of >250pg/mL randomized to:
- IV acetazolamide (500mg qD)
- Exclusion:
- SBP <90mmHg
- eGFR <20mL/min/1.73m2
- In patients with acute decompensated heart failure, and clinical signs of volume overload (i.e. edema, pleural effusion, or ascites) the addition of 500mg of IV acetazolamide to standard loop diuretic therapy resulted in more diuresis, more natriuresis, shorter hospital stay, and an increased likelihood of being discharged without residual signs of volume overload.
COCA Trial Follow-Up: Calcium vs Placebo on Long-Term Outcomes of OHCA
- Author Conclusion: “Effect estimates remained constant over time suggesting harm of calcium but with wide confidence intervals. The results do not support calcium administration during out-of-hospital cardiac arrest.”
- Clinical Take Home Point: Is this the nail in the coffin for calcium in cardiac arrest? Although the results of both the short and long-term outcomes of the COCA trial do not support the use of calcium in all patients with OHCA, there are some populations that may still benefit from this treatment including patients with hyperkalemia, hypocalcemia, and calcium channel blocker overdose.
The BOX Trial: BP & O2 Targets in Comatose Survivors of Cardiac Arrest
- Clinical Take Home Point: In comatose adult patients, with presumed cardiac etiology of their cardiac arrest, with ROSC…
- There appears to be no difference between a restrictive vs liberal oxygenation target regarding the incidence of death or severe disability or coma at 90 days.
- I will continue to titrate FiO2 to maintain a PaO2 range of 68 to 105mmHg (based on this trial) or an SpO2 of 90 to 95% (my bedside practice) in the post arrest setting.
- There appears to be no difference between a restrictive vs liberal oxygenation target regarding the incidence of death or severe disability or coma at 90 days.
- There appears to be no difference between targeting a lower mean arterial pressure (63mmHg) vs a higher mean arterial pressure (77mmHg) regarding the incidence of death or severe disability or coma at 90 days.
- I will continue to target a mean arterial pressure of ≥65mmHg in the post arrest setting.
TEG-Guided Resuscitation of Patients with Cirrhosis and Non-Variceal Bleeding
- “Among patients with advanced cirrhosis with coagulopathy and nonvariceal upper GI bleeding, TEG guided transfusion strategy leads to a significant lower use of blood components compared with SOC (transfusion guided by INR and PLT count), without an increase in failure to control bleed, failure to prevent rebleed, and mortality.”
Resuscitation
None
August 2022 Monthly Review
Academic Emergency Medicine
- Overall, POCUS was 100% (95% confidence interval [CI], 85.6%–100%) sensitive and 100% (95% CI, 79.4%–100%) specific for the diagnosis of shoulder dislocation
- 5 min sono has a great video
Normal shoulder above
Dislocated above
American Journal of Emergency Medicine
None
Annals of Emergency Medicine
- Severe agitation was uncommon following the administration of 1.6 mg IM naloxone and rarely required chemical sedation.
- A single 1.6 mg dose of naloxone reversed respiratory depression in 192 (97% [95% CI: 94% to 99%]) presentations.
BMJ
Gout: diagnosis and management—summary of NICE guidance
- allopurinol or febuxostat to lower uric acid which prevents long term progression
- for acute attacks use steroids or saids depending on pt preference, colchicine is second line for folks who cannot take nsaids (pud risk) or steroids (dm, info risk)
Acute vertigo: getting the diagnosis right
Circulation
None
CJEM
- Post-intubation hypotension was recorded in one out of three patients in the ED but we found no association between post-intubation hypotension and 48-h in-hospital mortality overall in adults or geriatric patients.
EMCRIT
Emergency Medicine Journal
None
EMRAP
Critical Care Mailbag: Tracheostomy Complications
- Tracheostomy replacement
- Can be still be replaced if <7-10d old (mature) but use more caution, ENT consult if time permits, ideally use flexible endoscope, if none then use a bougie.
- Replacement of a Trach with a mature track can be done blindly, assisted by a bougie, or with a flexible endoscope.
Pediatric Pearls: Asthma Smackdown – Part 1 and Part 2
Rural Medicine: Delivery on a plane
- Video Bleeding AV Shunt
- Hold pressure both above and below the site of bleeding.
- Can use figure of 8 suture that takes a bite of both skin and dialysis graft with a non cutting needle (taper needle).
JAMA
What Is Carpal Tunnel Syndrome?
- Hospitalization with COVID-19 before and during vaccine availability, vs hospitalization with influenza in 2018-2019, was significantly associated with a higher risk of venous thromboembolism within 90 days, but there was no significant difference in the risk of arterial thromboembolism within 90 days ((adjusted HR, 1.60 [95% CI, 1.43-1.79]) and during vaccine availability (adjusted HR, 1.89 [95% CI, 1.68-2.12]).
Journal of Emergency Medicine
Ring Removal: A Comprehensive Review of Techniques
Lancet
None
NEJM
Bronchiectasis — A Clinical Review
Confronting Health Worker Burnout and Well-Being
PEDIATRICS
None
REBELEM
- Clinical Question: Is it necessary to prescribe antibiotics to all patients undergoing outpatient management for mild diverticulitis as identified on CT scan?
- Author Conclusion: “Nonantibiotic outpatient treatment of mild AD is safe and effective and is not inferior to current standard treatment.”
Resuscitation
Outcomes of in-hospital cardiac arrest among hospitals with and without telemedicine critical care
- Hospital availability of TCC was not associated with improved outcomes for in-hospital cardiac arrest.
July 2022 Monthly Review
Academic Emergency Medicine
None
American Journal of Emergency Medicine
None
Annals of Emergency Medicine
- aerosol dispersion length greatest for BiPAP (100 cm), followed by
- nasal cannula oxygenation with face coverings (86 cm)
- high-flow nasal cannulas with face coverings (67 cm)
- nonrebreather masks (63 cm)
- CPAP (47 cm)
Sexually Transmitted Infections Treatment Guidelines, 2021
BMJ
Fever therapy in febrile adults- systematic review with meta-analyses and trial sequential analyses
- Fever therapy does not seem to affect the risk of death and serious adverse events.
- Roughly 5% of Covid patients will lose their sense of taste or smell.
Circulation
None
EMCRIT
EMCrit 329 – Bariatric Critical Care and Resus Ready for the Super Obese Patient
- BP- can be falsely high because cuff is too small, can try calf but unknown if this is studied, Scott recommends an art line
- CPAP preox
- Positioning (see pics below): line up external auditory meatus with the sternal line not notch, meaning need to line up with the line from the sternal notch to diploid process.
- Avoid RSI in severely obese patients, DSI safer unless the patient is apneic.
- Intubation Meds
- Etomidate LBW LBW calculator
- Ketamine LBW
- Propofol TBW for drip
- Succinylcholine TBW
- Rocuronium- Some would say IBW, but Calvin Brown [UpToDate in the Biblio] and The EM Airway Course is recommending TBW–That is my rec as well
- DSI approach (per Scott): start with Ketamine 100mg and wait ten seconds, if patient not dissociated give more, this allows you to take a look, if intubation looks easy then redox and paralyze because DSI easier for looking then for passing a tube
- Post-intubation positioning- sitting up so pannus not preventing chest expansion
- Central line- neck or groin better, subclavian has no landmarks
PulmCrit – Myth-busting the conditional nephrotoxicity of piperacillin-tazobactam
- Piperacillin-tazobactam is not generally regarded as a nephrotoxin although it can rarely cause acute tubulointerstitial nephritis, an unusual allergic reaction seen with numerous antibiotics/other meds.
- Vancomycin is an actual nephrotoxin.
- Solution:
- Continue to use Piperacillin-tazobactam
- Avoid Vanco in non-MRSA situations (community acquired-urosepsis/intra-abdominal infections, non purulent cellulitis)
- Discontinue after 24-48 hours if negative MRSA nares PCR and negative blood culture)
- Dose Vanco carefully, monitor levels
- Consider Linezolid or Daptomycin over Vanco for patients at high risk of nephrotoxicity
Emergency Medicine Journal
None
EMRAP
Critical Care Mailbag: Critical Transfusions- Weingart
- Type is ABO group
- Screen evaluates if the patient has any of the common minor antibody groups (such as Rh, Kelly, Duffy).
- Crossmatch”: takes blood that matches the patient for both major and minor antibody groups and reserves it for the patient, essentially taking it out of the pool of available blood.
- Take Home #1: There is no need to routinely obtain Type + Cross on every patient who may need blood.
- If the patient screens “negative” for any minor antibody groups, crossmatch is unnecessary.
- If the patient needs immediate transfusion (eg, in the event of massive GI bleed or trauma with shock), you can transfuse without knowing the minor antibody groups.
- If the patient screens “positive” for minor antibody groups, crossmatch can be helpful in ensuring compatible blood is available.
- Take Home #2: Every hospital should have a system where the blood bank notifies the clinician when the patient screens positive for minor antibodies
- In this situation, taking a number of units out of circulation is important to ensure that when the patient with minor antibodies needs a transfusion, they have the right blood available.
MTP
- In most hospitals, massive transfusion protocol is the only way to rapidly get blood.
However, this approach is often more than is needed and can be wasteful as it utilizes a lot of resources and can shut the blood bank down to other patients. - Many bleeding patients will stabilize after 1-2 units making massive transfusion protocol unnecessary.
- An intermediate pack can be considered
These are immediate-release “universal donor” blood products. Scott recommends the pack consists of 2 units pRBCs and 2 units FFP.
- Great video by Jacob Avila on how to perform this block for the sole of the foot.
- In addition to lacs and FBs, also good for calcaneus fractures.
- When to get MRI?
- Back pain plus fever
- Neuro deficits c/w cord compression
- New back pain plus risk factors (diabetes mellitus, HIV, cancer, renal disease, liver disease, dialysis or recurrent vascular access, alcoholism, IV drug use, immunocompromised, spinal instrumentation/surgery, older age)- order ESR and CRP, if either is high go to MRI, if both normal then workup can be concluded.
- What to MRI?
- Authors recommend MRI of the entire spine with contrast
Inflammatory Bowel Disease in the ED
- CT indicated if:
- Bowel obstruction
- Intra-abdominal sepsis
- Perianal sepsis
JAMA
- No benefit
Journal of Emergency Medicine
None
Lancet
None
NEJM
PEDIATRICS
None
REBELEM
Topical TXA in Atraumatic Anterior Epistaxis Yet Again
- Paper: Hosseinialhashemi M et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Ann Emerg Med 2022.
- Clinical Take Home Point: Based on this trial and the systematic review published in 2021 (Link is HERE), the fact that topical TXA is low cost, simple to use, and has no untoward effects it seems the best 1st line strategy in epistaxis is a TXA soaked pledget with direct pressure. It is unclear whether TXA has benefit in cases where compression with a topical vasoconstrictor fails.
REBEL Core Cast 85.0 – Superficial Venous Thrombosis
- Take Home Points
- SVT >5cm or ❤ cm from the SFJ (sapheno-femoral junction0 should be treated with anti-coagulation.
- The rate of concurrent DVT and PE in patients with SVT is 25% and 5%, respectively.
External Validation of Pittsburgh Cardiac Arrest Category (PCAC) Illness Severity Score
Resuscitation
Pulseless electrical activity in in-hospital cardiac arrest – A crossroad for decisions
- PEA is a crossroad in which the subsequent course is determined. The four distinct presentations of PEA behave differently on important characteristics. A transition to PEA during resuscitation should encourage the resuscitation team to continue resuscitative efforts.
June 2022 Monthly Review
Academic Emergency Medicine
Major adverse cardiac event rates in moderate- risk patients:
Does prior coronary disease matter?
- Among moderate risk ACS patients (HEAR score>3, normal Trop x 2, non-ischemic EKG) who have no h/o CAD, the risk of MACE in 30 days was 1.4% with a negative LR of .08, whereas patients with h/o CAD had 7.1% MACE risk.
- May be the next group to be discharged without objective cardiac testing.
- Adding 100ug of fentanyl increased the incidence of hypotension from 16% to 29%.
American Journal of Emergency Medicine
None
Annals of Emergency Medicine
Managing Posterior Hip Dislocations
BMJ
None
Circulation
None
CJEM
Just the facts: withdrawal of life‐sustaining therapy in the ED
EMCRIT
Emergency Medicine Journal
None
EMRAP
None
JAMA
COVID-19 in 2022—The Beginning of the End or the End of the Beginning?
Medication for Early Pregnancy Termination
Oral Antiviral Medications for COVID-19
Journal of Emergency Medicine
Lancet
Opioid versus opioid-free analgesia after surgical discharge: a systematic review and meta-analysis of randomised trials (abstract only)
- opioid analgesia did not reduce pain but did increase adverse events
NEJM
Albuterol–Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma
- Bronchodilator plus steroid better than bronchodilator alone but drug too expensive for many payers and adding a separate inhaled steroid would achieve the same goal.
Clinical Examination of the Hip
- Primarily a focus on non acute hip pain
- Great differential in Table 1
Diagnosis and Treatment of Frostbite
Restriction of Intravenous Fluid in ICU Patients with Septic Shock
- No difference between standard and restricted fluid strategy but as REBELEM post (see below) points out, the difference between groups in fluid balance was only 700cc so the standard fluid strategy has probably become more conservative.
PEDIATRICS
Asthma and the Risk of SARS-CoV-2 Infection Among Children and Adolescents
- No increased risk
Differentiating Bell’s Palsy From Lyme-Related Facial Palsy (abstract only)
- Bell’s treated with steroids, Lyme Related Facial Palsy (LRFP) treated with antibiotics but not steroids
- In Lyme endemic areas, 27% was LRFP, 68% was Bell’s
- LRFP commonly has a prodrome (fever, HA, mylagias, arthralgias) and presents in June to November.
- Useful 4 minute summary video
Dengue: A Growing Problem With New Interventions
- Vaccine trials underway
- Cause of fever in returning travelers
REBELEM
The CLASSIC Trial: IV Fluid Restriction in Septic Shock
Clinical Take Home Point: In critically ill adult patients with septic shock who received their initial 30cc/kg fluid resuscitation there are two ways to look at ongoing resuscitation based on this trial:
- Restrictive fluid strategy ≠ fewer deaths at 90 days than standard fluid therapy
- Restrictive fluid strategy is not worse than standard fluid therapy in terms of fewer deaths at 90 days (i.e. Safe but not superior to a standard fluid strategy)
A major caveat however is the between group differences of overall fluids given at 5 days (≈1500cc) and the rather small difference in fluid balance between groups (≈750cc) has to make one wonder how much standard care has changed to more of a conservative strategy overall in terms of fluid balance.
Antibiotics in COPD Exacerbations – 2 days vs 7 days
- Authors Conclusions: “Levofloxacin once daily for 2 days is not inferior to 7 days with respect to cure rate, need for additional antibiotics and hospital readmission in AECOPD. Our findings would improve patient compliance and reduce the incidence of bacterial resistance and adverse effects.”
- Our Conclusions: We agree that this study demonstrates non-inferiority of a 2-day course of levofloxacin to a 7-day course. However, the trial has a number of issues including the subjectivity of the outcome measure which may bias the results. Subsequent studies should focus on generating high-quality data looking at short-course antibiotics versus no antibiotics.
- Bottom Line: It remains unclear if mild to moderate AECOPD benefit from antibiotics but, if you are going to prescribe them, a short course appears to be adequate.
- Uptodate: Recommends 3-5 days of antibiotics Augmenting or Levaquin
Tenecteplase vs Alteplase in Acute Ischemic Stroke
Why Tenecteplase over Alteplase:
- Cheaper
- Higher fibrin specificity
- Can be administered as a single bolus (due to longer half-life than alteplase)
- Allows for more rapid treatment without the need for infusion pumps
EPIC Trial: Electrode Positioning in Cardioverting Atrial Fibrillation
- Escalating energy shocks of 100 Joules, 150 J, 200 J and 360 J were delivered until sinus rhythm was restored or a up to a maximum of 4 shocks
- Comparison of Anterior Posterior vs Anterior Lateral
- Risk difference after final shock for obese patients was 15 percentage points (95% CI, 5-25) with a risk ratio of 1.2 (95% CI, 1.05 – 1.36). For non-obese patients, the risk difference after the final shock was 3 percentage points (95% CI, -3 to 9) with a risk ratio of 1.03 (95% CI, 0.96 to 1.10)
- Although this multicenter, randomized, open-label, blinded-outcome trial had a very different patient population than those typically seen in the emergency department, strong consideration should be made in placing the pads in the anterior-lateral positioning during cardioversion. Doing so may very well reduce the number of shocks needed to convert stable atrial fibrillation patients to normal sinus rhythm.
Resuscitation
- No benefit
May 2022 Monthly Review
Academic Emergency Medicine
- GRACE-2 is the follow-up to the super helpful GRACE-1 released last year for recurrent chest pain.
- Unfortunately, GRACE-2 was not able to come up with any powerful recommendations other than the obvious: avoid opiates.
American Journal of Emergency Medicine
None
Annals of Emergency Medicine
Managing Patients With Acute Visual Loss
BMJ
Monkeypox: What do we know about the outbreaks in Europe and North America?
- CDC review for clinicians
- Incubation: 7-14 days
- Transmission
- Transmission between people mostly occurs through large respiratory droplets, normally meaning prolonged contact face to face. But the virus can also spread through bodily fluids. The latest cases have mainly been among men who have sex with men.
- Symptoms
- Fever, headache, muscle aches, backache, swollen lymph nodes, chills, and exhaustion. Typically a rash will develop, which often starts on the face but can then spread to other areas such as the genitals.
- Shortly after the prodrome, a rash appears. Lesions typically begin to develop simultaneously and evolve together on any given part of the body. The evolution of lesions progresses through four stages—macular, papular, vesicular, to pustular—before scabbing over and resolving.
- Testing
- Contact local public health department.
- LA County 213-240-7941 8:30a-5p, after hours 213-974-1234
- Or contact CDC 1-770-488-7100
- Contact local public health department.
- Treatment
- None
- Prognosis
- Most cases mild but case fatality rate 3.6% among African studies
Circulation (need to review May 31)
- Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) now includes 4 medication classes that include sodium-glucose cotransporter-2 inhibitors (SGLT2i): canagliflozin, dapagliflozin, and empagliflozin.
- SGLT2i have a Class of Recommendation 2a in heart failure with mildly reduced ejection fraction (HFmrEF). Weaker recommendations (Class of Recommendation 2b) are made for ARNi, ACEi, ARB, MRA, and beta blockers in this population.
- New recommendations for HFpEF are made for SGLT2i (Class of Recommendation 2a), MRAs (Class of Recommendation 2b), and ARNi (Class of Recommendation 2b). Several prior recommendations have been renewed including treatment of hypertension (Class of Recommendation 1), treatment of atrial fibrillation (Class of Recommendation 2a), use of ARBs (Class of Recommendation 2b), and avoidance of routine use of nitrates or phosphodiesterase-5 inhibitors (Class of Recommendation 3: No Benefit).
CJEM
No May issue, only abstracts supplement
EMCRIT
Cerebral venous thrombosis (CVT)
- CT without contrast is 70% sensitive for CVT which is pretty good considering this is a rare condition and according to J Edlow’s study, 94% have focal neurologic abnormalities.
- Cerebral Venous Thrombosis: Pearls and Pitfalls– EMDOCS
- Indications for CT Venogram (same thing as a CT arteriogram, except that there is more delay between the time that the contrast is administered, and the time that the sequences are acquired):
- Headache: in a pregnant female patient, in a young female on OCPs, or one that is atypical and persistent
- Stroke with no typical risk factors or in the setting of seizure
- Intracranial hypertension with no explanation
- Multiple hemorrhagic infarcts, or hemorrhagic infarcts not in a specific arterial distribution
- Objective neurologic symptoms in a patient with risk factors for CVT
- Indications for CT Venogram (same thing as a CT arteriogram, except that there is more delay between the time that the contrast is administered, and the time that the sequences are acquired):
Neurologic emergencies in pregnancy
Emergency Medicine Journal
EMRAP
- Bipap IPAP 10-15, EPAP 2
- If tidal volumes poor with Bipap they likely will not improve with noninvasive.
- Inaba recommends CTA of the neck for all near-hangings.
Cardiology Corner: JACC Chest Pain Update
- Best piece of the month by Mattu
- Recommends the term “low risk chest pain” rather than atypical chest pain or non cardiac chest pain.
- Agrees with a warranty period (very low risk of ACS) of 2 years for normal angio or clean CCTA, but disagrees that a stress test offers a 1 year warranty period.
- Agrees with JACC recommendation that intermediate or high risk patients can get further testing:
- If<65yo or less obstructive disease is suspected, prefer CCTA.
- If>65yo or more obstructive disease is suspected, prefer stress testing, if either is equivocal, then repeat with the other test.
- Patients with<1% risk of MACE do not require an urgent workup and can be discharged.
Medicolegal Briefs: Myocarditis
- Good warning that myocarditis does carry risk of sudden death from arrhythmia.
- Not sure I would have done an EKG and cardiac workup on a patient with cough, fever and pleuritic CP?
First10EM
Long-term cardiovascular outcomes of COVID-19
Intensive Care Medicine
Challenging management dogma where evidence is non-existent, weak or outdated
- loop diuretic treatment for acute heart failure
- the effectiveness of heparin thromboprophylaxis
- the rate of sodium correction for hyponatraemia
- mantra of “each hour counts” for treating meningitis
JAMA
- 35% increase in the firearm homicide rate in the US between 2019 and 2020
- Physicians can reduce gun violence and suicide by discussing gun safety with their patients.
Treatment of Menopause Symptoms With Hormone Therapy
- Studies have shown that systemic menopausal HRT is effective for treating vasomotor symptoms (hot flashes and night sweats). These treatments are also effective for treating genitourinary syndrome of menopause. However, for vaginal or urinary symptoms without vasomotor symptoms, low-dose vaginal estrogen is recommended.
- Individuals who have menopause-related hot flashes and/or night sweats that are negatively affecting their sleep and quality of life and who are not at high risk of blood clots, breast or endometrial cancer, or heart disease may be good candidates for systemic hormone therapy
Journal of Emergency Medicine
None
Lancet
None
NEJM
Foreign-Body Aspiration in a Child
PEDIATRICS
Nonoperative Management of Uncomplicated Appendicitis
- Retrospective
- 14.1% underwent NOM.
- The odds of NOM significantly increased (odds ratio 1.10 per study quarter, 95% confidence interval [CI] 1.05–1.15).
- The 1-year and 5-year failure rates were 18.6% and 23.3%, respectively. Children who experienced failure of NOM had higher rates of perforation at the time of failure than did the general cohort at the time of initial presentation (45.7% vs 37.5%, P < .001).
- Patients undergoing NOM had higher rates of subsequent related emergency department visits (8.0% vs 5.1%, P < .001) and hospitalizations (4.2% vs 1.4%, P < .001) over a 12-month follow-up period.
Weighing the Risks and Benefits of Nonoperative Management of Appendicitis
- There are several multi-institutional prospective trials underway which should help guide the decision.
REBELEM
REBEL Core Cast 81.0 – Priapism
- Ischemic (low flow)
- Emergency
- Much more common
- Blood gas (perform when cause is uncertain) of corpus cavernosa shows black blood which has pO2<40, pCO2>60, pH<7.25 (UPTODATE)
- Causes
- Pediatric: Sickle cell disease, leukemia
- Adult: Intercavernosal injection (papaverine, phentolamine, PGE1), Anticoagulation, Pharmaceuticals (SSRIs, sedative-hypnotics, erectile dysfunction medications), Illicit drugs (cocaine, ecstasy)
- Noniscemic (high flow)
- Excess arterial inflow resulting in priapism
- Often painless
- Blood gas: pO2>60, pCO2<40, pH>7.25
- Common causes
- Arterial laceration
- Spinal trauma
- Orders
- CBC, Retic count (for sickle cell disease patients)
- Cavernosal blood gas
- 1% lidocaine
- Sterile drapes, Betadine, Sterile Gloves
- Needles: 19g butterfly, 27g needle, 18g needle
- 2 sterile bowls (one holds the NS mixed with phenyl, one to dispose of aspirated blood)
- Or you can use a 3 way stopcock with tubing directly connected to the 500cc NS bag with phenylephrine.
- 10cc syringe x 3
- 500cc NS mixed with 1mg phenylephrine for irrigation.
- 500mcg phenylephrine mixed with 1cc NS for injection.
- Management
- Dorsal Nerve ultrasound guided block https://www.youtube.com/watch?v=lCZq-LEcrjA from the ventral probe position and https://youtu.be/ddpp_wfqNjk which shows the block from the dorsal probe position (see picture below), performed at the base of the penis.
- Can also do a local weal at injection site or a penile ring block.
- If priapism < 4 hours UPTODATE recommends starting with phenylephrine injection (500mcg phenylephrine mixed with 1cc NS for injection).
- If priapism > 4 hours, UPTODATE recommends combining aspiration with irrigation and phenylephrine injection.
- Inject Phenylephrine 200 – 500 mcg (diluted in 1 ml of NS) intracorporal (can use the same 19g butterfly needle per UPTODATE)
- Aspirate using 10ml syringe
- All injecting and aspirating can be done from the base of one corpus cavernosum at either 10 or 2 o’clock because the two cavernosa communicate.
- Dorsal Nerve ultrasound guided block https://www.youtube.com/watch?v=lCZq-LEcrjA from the ventral probe position and https://youtu.be/ddpp_wfqNjk which shows the block from the dorsal probe position (see picture below), performed at the base of the penis.
REBEL Core Cast 80.0 – Compartment Syndrome
Resuscitation
None
April 2022 Monthly Review
Academic Emergency Medicine
- 0/1h algorithm had excellent specificity (94%) and sensitivity (99%, CI 98.5-99.5%)
American Journal of Emergency Medicine
Bioterrorism: An analysis of biological agents used in terrorist events.
2020 webPOISONCONTROL data summary
- webPoisoncontrol is an alternative resource to calling poison control, quick and easy to use, will recommend call to poison control for more complex cases.
Clinical update on COVID-19 for the emergency clinician: Presentation
and evaluation
Annals of Emergency Medicine
Are Emergency Departments Responding to the Aging Demography?
- Discusses NEWS which is a triage screening tool to identify folks who have higher risk for death or ICU care.
- Adding age to NEWS improves the accuracy.
- Also encourages the use of the FRAILTY scale which identifies elderly who may need institutional care.
Thinking Beyond the Emergency Department: Addressing Homelessness in Residency Education
- Great summary of homelessness beneficial to EM physicians far beyond residency.
- Practical steps:
- Screen everyone for homelessness
- Hand out insurance application (quadruples chance of obtaining insurance).
- Provide location of closest social services office to apply for transitional and permanent housing.
- Provide location of closest low cost/free ambulatory care services/dental care.
- Provide location of closest detox/substance abuse facilities.
What Is The Diagnostic Accuracy of Rapid Nucleic Acid Tests for Group A Streptococcal Pharyngitis?
- Rapid Nucleic Acid Tests more sensitive (97% vs 82%) and equally specific to the traditional Rapid Antigen Detection Test (RADT).
- Most hospitals currently use RADT.
- Currently negative RADT requires a follow-up culture in high risk groups per the Uptodate algorithm but rapid nuclear acid test may negate that requirement.
BMJ
- Covid-19 is an independent risk factor for deep vein thrombosis, pulmonary embolism, and bleeding, and that the risk of these outcomes is increased for three, six, and two months after covid-19, respectively
Circulation
None
CJEM
Computed tomography angiography for acute headache may be more painful than lumbar puncture
- While CTA is a good option for acute headache patients with delayed presentation (e.g. > 1 week after headache onset), when LP is contraindicated, not feasible or has indeterminate results, it should not routinely replace LP. CTA will work for 96.7% patients, but will identify incidental aneurysms in 3.3%, leading to difficult decisions for our neurosurgical colleagues, increased patient morbidity and mortality due to unnecessary aneurysm repairs or increased patient anxiety.
- Multiple myeloma patients present commonly with one or more of the “CRAB” symptoms which reflect end organ damage: hyperCalcemia, Renal failure, Anemia, or lytic Bone lesions.
Just the facts: testing patients with suspected pulmonary embolism
EMCRIT
EMCrit Wee – Saving EM: Is Less More? with Atkinson and Innes
- EM is valuable but EDs need to do less, can’t be the catch-all for society’s problems.
- Fascinating conversation with two authors of recent CJEM editorial.
- Authors push for public health solution that offloads noncritical EM to after hours primary care clinics, telemedicine, etc.
- Weingart contends that the specialty is headed for a schism of two specialties: 1) after hours primary care who can also manage sick patients for the first 20 minutes; 2) resuscitationist who has the training and skill set to manage critically ill patients beyond the first 20 minutes.
EMCrit 320 – MotR – Tension & Relaxation | Flow & Burnout
- Amazing podcast on how to achieve flow and reduce burnout
- Great paradigm for balancing relaxation and positive tension
- Great book recommendations
- The Art of Learning- Josh Waitzkin
- Joy on Demand- Chade-Meng Ten
- Happiness- Daniel Haybron
Emergency Medicine Journal
None
EMRAP
- Initial treatment is 4 topical drops, given 1-2 minutes apart and repeated q5minutes for a total of 3 doses of each drop.
- Timolol (B-blocker- decrease aqueous humor production)
- Dorzolamide (carbonic anhydrase inhibitor- decrease aqueous humor production)
- Latanoprost (prostaglandin analogue- increase aqueous humor outflow)
- Brimonidine (alphagan) or apraclonidine (alpha agonist- decrease aqueous humor production and increase outflow)
- Uptodate also recommends 2% pilocarpine
- IV mannitol or diamox if pressure not improved when IOP rechecked at 30 minutes.
JAMA
- net benefit of low-dose aspirin use in adults aged 40 to 59 years who have a 10% or greater 10-year CVD risk is small; that persons not at increased risk for bleeding and willing to take low-dose aspirin daily are more likely to benefit (C recommendation); and recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults 60 years or older (D recommendation).
- 10 year CVD risk calculator is available on MDCALC: ASCVD Risk Calculator.
Secondary Attack Rates for Omicron and Delta Variants of SARS-CoV-2 in Norwegian Households
- Secondary attack rate was 25.1% (95% CI, 24.4%-25.9%) when the variant of the index case was Omicron, 19.4%(95% CI, 19.0%-19.8%) when it was Delta, and 17.9% (95%CI, 17.5%-18.4%) when it was nonclassified.
Journal of Emergency Medicine
None
Lancet
None
NEJM
Cancer-Associated Hypercalcemia
PEDIATRICS
None
REBELEM
None
Resuscitation
Internet Book of Emergency Medicine 