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
Internet Book of Emergency Medicine 