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
Internet Book of Emergency Medicine 