Academic Emergency Medicine

Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING, and ABCD2 tests: A diagnostic cohort study

• HINTS and STANDING tests reached high sensitivities at 97% and 94% and NPVs at 99% and 98%, respectively. The ABCD2 score failed to predict half of central vertigo cases and had a sensitivity of 55% and a NPV of 87%. The STANDING test was more specific and had a better positive predictive value (PPV; 75% and 49%, respectively; positive likelihood ratio [LR+] = 3.71, negative likelihood ratio [LR–] = 0.09) than the HINTS test (67% and 44%, respectively; LR+= 2.96, LR– = 0.04).
• Conclusions: In the hands of EPs, HINTS and STANDING tests outperformed ABCD2 in identifying central causes of vertigo.

Standing Test

Hot off the press: Self-obtained vaginal swabs for sexually transmitted infection testing

• For the primary outcome, self-swabs had a sensitivity of 95% (95% CI= 88% to 99%) for the detection of NG/CT when com-pared to provider performed swabs. Secondary outcomes revealed an excellent kappa of 93%, and self-swab sensitivities for NG and CT were 97% and 94%, respectively

American Journal of Emergency Medicine

None

Annals of Emergency Medicine

The Emergency Medicine Physician Workforce: Projections for 2030

• 2% annual graduate medical education growth, 3% annual emergency physician attrition, 20% encounters seen by a nurse practitioner or physician assistant, and 11% increase in emergency department visits relative to 2018. This scenario would result in a surplus of 7,845 emergency physicians in 2030.

Implementation of Oral and Extended-Release Naltrexone for the Treatment of Emergency Department Patients With Moderate to Severe Alcohol Use Disorder: Feasibility and Initial Outcomes

• Clinical protocol for ED patients with moderate to severe alcohol use disorder using oral naltrexone and extended-release intramuscular naltrexone together with substance use navigation. Identification of alcohol use disorder, a brief intervention, and initiation of naltrexone resulted in a 15% follow-up rate in formal addiction treatment. Future work should prospectively examine the effectiveness of naltrexone as well as the effect of substance use navigation for ED patients with alcohol use disorder.

Rapid Adoption of Low-Threshold Buprenorphine Treatment at California Emergency Departments Participating in the CA Bridge Program

• Low-threshold ED buprenorphine treatment implemented with a harm reduction approach and active navigation to outpatient addiction treatment was successful in achieving buprenorphine treatment for opioid use disorder in diverse California communities.

Rapid Agitation Control With Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial

• In this randomized controlled trial of 80 adults, the median time to adequate sedation was significantly faster for ketamine 5mg/kg IM versus Midazolam 5mg IM/haloperidol 5mg IM (6 versus 15 minutes, respectively).

Man with sudden visual loss

BMJ

Management of pneumonia in critically ill patients

Circulation

EMCRIT

None

Emergency Medicine Journal

None

EMRAP

Ultrasound in cardiac arrest

• subxiphoid
• have someone count down from 10 seconds, remove probe and wipe with 2 to go

Blast crisis

• >20% blasts, call oncology

JAMA

Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism. A Randomized Clinical Trial

• Excluded:
  • high probability of PE>50%
  • low probability of PE with a PERC score of zero
  • severe illness (resp distress, hypotension, o2 saturation <90%
  • current antico-agulant treatment
  • a current diagnosis of thromboembolism,
  • pregnancy

Diagnostic Strategies for Pulmonary Embolism

Effect of High-Flow Oxygen Therapy vs Conventional Oxygen Therapy on Invasive Mechanical Ventilation and Clinical Recovery in Patients With Severe COVID-19

• Intubation occurred in 34 (34.3%) randomized to high-flow oxygen therapy and in 51 (51.0%) randomized to conventional oxygen therapy (hazard ratio, 0.62; 95% CI, 0.39-0.96; P = .03). The median time to clinical recovery within 28 days was 11 (IQR, 9-14) days in patients randomized to high-flow oxygen therapy vs 14 (IQR, 11-19) days in those randomized to conventional oxygen therapy (hazard ratio, 1.39; 95% CI, 1.00-1.92; P = .047).

Association of Rivaroxaban vs Apixaban With Major Ischemic or Hemorrhagic Events in Patients With Atrial Fibrillation (no open access)

• Among Medicare beneficiaries 65 years or older with atrial fibrillation, treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events.

Contraception Selection, Effectiveness, and Adverse Effects

Journal of Emergency Medicine

None

Lancet

None

NEJM

Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation

• No benefit

Determination of Brain Death

Pulmonary Arterial Hypertension

Latent Tuberculosis Infection

Spontaneous Intracranial Hypotension

PEDIATRICS

None

REBELEM

Meta-Analysis on Topical TXA for Epistaxis

• Janapala RN, et al. Efficacy of Topical Tranexamic Acid in Epistaxis: A Systematic Review and Meta-Analysis. Am J Emerg Med. Nov 2021.
• This meta-analysis highlights the importance of a head-to-head comparison of first line agents in the treatment of epistaxis. Knowing the efficacy of topical TXA compared to other first line vasoconstrictors from this study, it’s not an unreasonable approach to use it as a first line agent. The use of TXA in epistaxis should be left to the discretion of the emergency physician. Although, the NoPAC trial showed no difference in the use of topical TXA, that study was different in that direct pressure plus phenylephrine was used and only after failure were patients randomized to TXA vs placebo. Maybe a better strategy would be direct pressure PLUS TXA as a 1^st line approach to epistaxis as it appears from this study that it does a better job in bleeding cessation when compared to other vasoconstrictors.

REBEL Core Cast 71.0 – Troubleshooting the Vent

• Dislodged- check ETT depth
• Obstruction- pass a suction catheter
• Pneumothorax- ultrasound linear probe
• Equipment failure- look for air leak, volume in more than volume returned
• Stacking of breaths/Dyssynchrony

Posterior Occlusion Myocardial Infarctions and STDmaxV1-4

• Not all occlusion myocardial infarctions (OMIs) present with classic ST-segment elevation (We have covered this on REBEL EM Before HERE, HERE, and HERE). OMIs of the “posterior” and “lateral” walls are the most commonly missed, with >50% of left circumflex occlusions (Posterior and lateral walls suppled by the circumflex artery)not receiving emergent reperfusion. These misses occur because isolated posterior OMIs do not result in classic ST-elevation ECG changes. Instead, posterior OMI results in ST depression which is maximal in V1 to V4 (alternatively, ST-depression of subendocardial ischemia is maximal in V5 to V6).

• In patients with symptoms suggestive of ACS in the ED, the specificity of STDmaxV1-4 was 97% for the diagnosis of posterior OMI and 96% for posterior OMI requiring PCI.  This finding of STDmaxV1-4 is both highly accurate and sufficient without the need for routine posterior leads.

REBEL Core Cast 70.0 – Open Fractures