Annals of Emergency Medicine

Managing Emergency Endotracheal Intubation Utilizing a Bougie

Managing Awake Intubation

Heat Stroke Management Updates: A Description of the Development of a Novel In-Emergency Department Cold-Water Immersion Protocol and Guide for Implementation

Assessment of Prognostic Scores for Emergency Department Patients With Upper Gastrointestinal Bleeding

Selecting Tube Size for Traumatic Thoracostomy

• After insertion, clinicians should monitor for signs warranting immediate operative intervention including initial drainage of more than 1500 mL and persistent drainage (150 to 200mL/h for 2 to 4 hours)

EMCRIT

EMCrit 393 – CV-EMCrit – Inotrope Basics Part 1 and 2

What Heart Rate to Shoot For?

90-110 in most patients (may go higher if compensating for RHF or extremely low EF)

The Inotropes

Dobutamine, the ChronoInotrope

Hits B1, B2 and at higher doses, alpha

Not as much vasodilation as milrinone, but a lot of chronotropy and the possibility of arrhythmia induction

Dose: 1-5 mcg/kg/min (can go up to 10, but you start risking excessive chronotropy)

Milrinone, the InoDilator

Phosphodiesterase-3 (PDE-3) inhibitor that increases cAMP levels in cardiac myocytes by inhibiting cAMP breakdown by the PDE-3 enzyme leading to increased availability of Ca

Inotropy, lusitropy, but not as much chronotropy. Also comes with vasodilation (arterial, venous, and pulmonary arterial)

Our Dose Recs: 0.125 – 0.25 mcg/kg/min (max out at 0.37 mcg/kg/min)

45 minutes to see effect, avoid in ED because of long half life and Epi can do most of what Milrinone does.

Inotropic Epinephrine, Dual-faced: the pure Inotrope/Inopressor

0.01-0.08 mcg/kg/min (for a 70 kg pt, this is 1-5 mcg/min)

Hits B1, B2, and at higher doses, Alpha

Digoxin, Original-G

Trina uses this in AF with RVR in patients with reduced EF

30-45 min before you see clinical effects after a bolus

Delayed clearance with renal dysfunction

125-250 mcg bolus, may repeat x 1, two hours after 1st dose

after those 2 boluses, you really need levels

Calcium, “God’s” Inotrope

Correct low ionized calcium, will improve inotropy and hypotension if ionized calcium is low.

Dopamine, Fool’s Inotrope

Just don’t do it, just don’t…

Specific Scenarios

Septic Shock

1. Norepi
2. Epi if need more inotropy- 0.01-0.08 mcg/kg/min (for a 70 kg pt, this is 1-5 mcg/min)
3. Add Vaso if need more vasoconstriction .03-.04 units/min, add early bc an infusion without a loading dose may take 30 min to show effect
4. If ionized calcium low, replace it, will give significant improvement in inotropy and blood pressure
5. Serious

Cardiogenic Shock without hypotension

1. Milrinone low dose

Cardiogenic Shock with hypotension

1. Norepi
2. Epi if need more inotropy- 0.01-0.08 mcg/kg/min (for a 70 kg pt, this is 1-5 mcg/min)
3. If ionized calcium low, replace it, will give significant improvement in inotropy and blood pressure

Right Heart Failure (or PE induced RHF)

1. Start with the vasopressor to protect coronary perfusion but
2. Vaso .03-.04 units/min
3. Epi 0.01-0.08 mcg/kg/min (for a 70 kg pt, this is 1-5 mcg/min)
4. Norepi if you need more squeeze

Atrial Fibrillation with RVR and Shock (EMCRIT Episode 20 Feb12, 2010)

1. Sync Cardioversion 200j Biphasic AP pads- usually won’t work so proceed to 2. Best sedative meds 5-7 mg Etomidate and 10-15 mg Ketamine.
2. Screen for WPW (wide complex tachy 250-300, shock early shock often, light them up!
3. Phenyephrine for MAP support without increasing HR
4. Amiodarone 150mg bolus followed by infusion 1mg/min OR
5. Diltiazem 2.5mg/min until HR<100 or you max out at 50mg
6. Magnesium 2g IV over 20 minutes may repeat x 1 in 1 hour

Bradycardic Shock

1. Initiate Medical and Electrical treatment arms simultaneously
2. Transcutaneous pacing
3. Atropine and Epinephrine
4. Atropine 1mg
5. Epinephrine drip or push dose
6. Calcium 3g IV over 5-10min
7. Isoproterenol great for bradycardia but very expensive so pharmacy may not carry it
8. Dobutamine helps increase HR but may cause hypotension

Anaphylactic Shock

1. IM Epi 0.5mg (not 0.3) Q5 min until you start the IV drip 
2. Clean Epi drip 5-20ug/min If No Clean Epi rapidly available then do dirty epi drip
3. Dirty Epi drip Push 1mg in 1000cc NS and then run wide open which in a 18g IV is usually between 20-30ml/min or if you can set it on the pump it is 1ug/10ml/min which for a 10ug/min infusion is 600ml per hour.
4. Decadron 10mg IV (no steroid taper necessary)

EMRAP

Urology Suite: Stone Cold Facts

Chris Reilly, MD, and Meghan Cooper, DO

Dr. Reilly and Dr. Cooper discuss the diagnosis and ED management of kidney stones.

Kidney Stones: 

• Does size matter?
  • Stones <5 mm have >90% chance of passing in 2-4 weeks.
  • Stones 5-7mm have a 50%-60% chance of passing.
  • Stones >7mm have a <30% chance of passing. 
  • Prior stone formers may be able to pass larger stones and have lesser symptoms. 
• Hydronephrosis and obstruction may lead to pyelovenous backflow, increasing the chance of infection. 
• Staghorn canaliculi act as a nidus for recurrent infections but do not necessarily increase the risk for sepsis. 
• Nonsteroidal anti-inflammatory drugs (NSAIDs) are the preferred pain regimen and more effective than opiates. 
• Imaging:
  • In undifferentiated or sicker patients, computed tomography (CT) may be indicated.
  • For well-appearing patients who appear to have uncomplicated kidney stones, it is reasonable to try expectant management for 2-3 weeks with strict return precautions. 
  • Renal ultrasound may rule out other pathology or show some features of kidney stones (eg, hydronephrosis, absence of ureteral jets) 
• Lab testing has a limited role in diagnosis of kidney stones but may be helpful preoperatively or to assess underlying kidney function. Impaired kidney function is not an absolute indication for surgery unless there is a solitary kidney or bilateral obstruction. 
• It is reasonable to consider outpatient management with antibiotics and strict return precautions for patients with a positive urinalysis and kidney stones if they are well-appearing and non-septic.
• Risky features for kidney stones that may warrant admission include pregnancy, immunosuppression, solitary kidney, renal dysfunction, or uncontrolled pain/nausea. 

PEARL: Many patients with kidney stones can be managed as outpatients; the most important feature is clinical appearance as these patients can become quite septic.

Spinal Epidural Abscess

David Talan, MD

Dr. Dave Talan discusses the difficult and often missed diagnosis of spinal epidural abscess. This segment reviews the most common risk factors, imaging of choice, and antibiotic coverage for this elusive cause of back pain. 

• Diagnosing spinal epidural abscess
  • On average, it is diagnosed on the third ED visit.
    • Only 10% of patients present with the classic triad of fever, back pain, and neurological deficits.
  • Risk factors:
    • Intravenous drug use
    • Diabetes
    • Transplant history
    • Bacteremia
    • Recent spinal procedure
  • Spinal epidural abscesses affect the thoracic back more commonly than other causes of back pain; therefore, thoracic pain should raise your level of concern
  • Erythrocyte sedimentation rate (ESR) is not specific and may not be sensitive in early infection.
  • Order magnetic resonance imaging (MRI) with contrast of the whole spine given the frequency of skip lesions
    • Prioritize transfer if MRI is unavailable at your institution.
  • A CT myelogram relies on accuracy of locating the epidural abscess by history and exam.
• Treatment
  • Draw blood cultures.
  • Antibiotics:
    • If septic, start empiric antibiotics that cover Staphylococcus and gram-negative bacteria, including Pseudomonas, with vancomycin and a broad-spectrum cephalosporin
    • If the patient is being taken to the operating room immediately, you may defer antibiotics to allow neurosurgery to obtain an accurate intraoperative culture.

PEARL: Spinal epidural abscess is a difficult diagnosis that you will miss if you don’t know the risk factors. If suspicious, MRI with contrast is the diagnostic test of choice; CT myelogram is insufficient.

Pediatric ECGs 

Whitney Johnson, MD, and Mimi Lu, MD

Dr. Whitney Johnson and Dr. Mimi Lu discuss pediatric ECGs and the approach to pediatric chest pain. This segment elucidates some pediatric ECG findings to be wary of and underlines important indications for ordering an ECG in children that you may not expect.

• When to get an ECG
  • An ECG is often ordered reflexively by triage before seeing the patient.
  • Have a low threshold; seeing more ECGs will help develop interpretation skills.
  • Consider an ECG in patients with syncope, chest pain, dizziness, persistent unexplained tachycardia, recurrent febrile seizure, or epilepsy.
  • Optimize the ECG by obtaining it after fever, pain, and anxiety are controlled.
• Interpreting Pediatric ECGs
  • The vast majority of principles from adult ECGs can be applied to children 10 or older.
    • When in doubt, use reference resources for normal values for age.
  • Axis deviation
    • Babies are born with a right axis that transitions to a normal axis at around 6 months of age. 
    • A right-deviated axis past 6 months may indicate right ventricular hypertrophy or congenital heart disease.
  • P-waves should be upright
    • Inverted P-waves may indicate an ectopic atrial tachycardia.
  • T-wave inversions
    • V1 should be upright for the first week of life before inverting.
      • Failure to invert may indicate right ventricular hypertrophy.
    • T-waves invert back to upright from 3-8 years of age and should not flip again.
    • Compare to a previous ECG to determine level of concern.
  • Narrow tachycardia is 1 of 3 things: supraventricular tachycardia (SVT), sinus tachycardia, or atrial flutter with 2:1 conduction.
  • Arrhythmia
    • Expand the rhythm strip or increase box lengths to uncover an arrhythmia.
    • The most common arrhythmia is supraventricular atrioventricular reentrant tachycardia (AVRT).
• Approach to Pediatric Chest Pain
  • Age-appropriate questioning is key:
    • Ask about decreased exercise intolerance, feeding intolerance, cyanosis with feeding, or failure to thrive.
    • Consider myocarditis and ask about antecedent illness.
  • Consider adding a troponin when the story does not make sense; eg, teens with chest pain in the middle of the night.

PEARL: Have a low threshold to order an ECG in pediatric patients, especially in patients with syncope, chest pain, persistent unexplained tachycardia, or recurrent febrile seizure.

Critical Care Mailbag: All Things Vasopressin

Anand Swaminathan, MD, and Scott Weingart, MD

Dr. Swaminathan and Dr. Weingart discuss the mechanism, dosing, and administration of vasopressin in the ED. Their conversation covers which patients may benefit most from vasopressin and the potential future of vasopressin bolus to determine vasopressin responsiveness.

• Mechanism of Vasopressin
  • Produced in the hypothalamus and secreted by the posterior pituitary in response to high sodium or low blood pressure
  • Acts upon the 3 vasopressin receptors:
    • V1 – Vasoconstriction
    • V2 – Antidiuretic effect
    • V3 – Adrenocorticotropic hormone release from the central nervous system
• Dosing of Vasopressin
  • Single-agent dose is 0.01-0.06 units/minute. 
  • When combined with other agents, the maximum dose is 0.04 units/minute.
    • Higher doses are associated with ischemic complications.
• Administration of Vasopressin
  • Two common approaches for starting vasopressin drips:
    • Add as a second-line pressor once the norepinephrine dose reaches an arbitrary threshold (0.2 μg/kg/minute or 10 μg/minute).
    • Start simultaneously with norepinephrine in patients who have liver failure, who are taking an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACE/ARB), or who you estimate to have been septic for ~24 hours at the time of their presentation.
  • There is no evidence showing the safety of vasopressin in peripheral lines.
  • There is new evidence suggesting that responsiveness to a bolus of vasopressin can determine which patients will benefit from a vasopressin drip.

PEARL: Consider early vasopressin administration in patients who may have vasopressin deficiency from liver failure, ACE/ARB use, or prolonged sepsis.

Ectopic Pregnancy Management

Dara Kass, MD, and Anand Swaminathan, MD

Summary: In the landscape of uncertain decision-making regarding early pregnancy and medical care, the onus falls heavily on ED physicians to deliver more holistic and complete care for these patients. Dr. Kass and Dr. Swaminathan discuss the diagnosis and management of ectopic pregnancy in the ED in our current political and legal climates.

Uncertain Landscape of Early Pregnancy Management

• The reality is that shared decision-making as to whether a pregnant patient wants to continue a pregnancy is not available to every patient across the nation.
  • Can the patient get close follow-up ObGyn care? How fast can an ObGyn come to discuss methotrexate as a treatment option (if available)?
• States with restrictions on medical care have fewer ObGyns available for consultation, which puts a higher burden on ED physicians. 
• Management and care of early pregnancy used to be relatively predictable but now, with legislative changes, things have become more unpredictable.
  • ED physicians have to be sharper with our care, more informed, and very clear on what we are going to do. 

How does the value of beta human chorionic gonadotropin (beta-hCG) influence care?

• The interpretation of an ultrasound in the context of beta-hCG value allows us to put the clinical picture together: is this an early intrauterine pregnancy (IUP)? A pregnancy of unknown location? An ectopic pregnancy?
• The American College of Obstetricians and Gynecologists (ACOG) states that a beta-hCG level up to 3,500 mIU/mL with no IUP has zero likelihood of being a viable pregnancy.
  • It may not be an ectopic pregnancy but could be a non-viable IUP.
  • With beta-hCG in a window from 2,000 to 4,000 mIU/mL with a possible IUP, ED physicians in New York State can discuss treatment options with patients, depending on whether the pregnancy is desired or not, in addition to discussing risks of possible ectopic pregnancy.
  • Now, around the country, we are seeing that at beta-hCG levels <4,000 mIU/mL, patient choice is being removed.
    • ED physicians are now being put in a position where that decision is being pushed to later in the pregnancy, which increases our responsibility to ensure better follow-up, better communication, and better engagement with our consultants, given that risk of adverse outcomes is higher.
• Beta-hCG <2000 mIU/mLwith no IUP = expectant management (repeat hCG, repeat ultrasound).
• Beta-hCG >4000 mIU/mLwith no IUP = non-viable pregnancy regardless of location; patient needs treatment because if it is an ectopic pregnancy and it ruptures, the outcomes can be disastrous. 
• Beta-hCG 2000-4000 mIU/mL (gray area) = remote possibility to have viable pregnancy, so we consult ObGyn to discuss various options with patients depending on what state and ED the patient is in.
• We all need to make uniform decisions as emergency medicine physicians so that it is not just physicians in restricted states who are thinking about a new way to make these decisions. 

Transvaginal Ultrasound

• If a patient has an IUP on ultrasound and hasn’t received assisted reproductive therapy, an ectopic pregnancy is functionally ruled out.
  • The risk of heterotopic pregnancy without assisted reproductive care is very low. (1:10,000)
  • If the patient is receiving assisted reproductive care, the risk of heterotopic pregnancy increases.
• If a patient has an unruptured ectopic pregnancy, consult an ObGyn, who will review images and hCG levels and decide whether to offer the patient methotrexate or surgery.
  • These patients need additional laboratory testing and need to be admitted after administration of methotrexate to repeat beta-hCG and ensure levels are decreasing.
  • Failure of beta-hCG to decrease after methotrexate will result in a surgical procedure. 
  • If beta-hCG is decreasing on days 4 and 7 after methotrexate administration, the patient should have a weekly ObGyn appointment to repeat beta-hCG levels until they are zero.
    • In some environments in the country, that “weekly follow-up” may actually be an ED visit for a beta-hCG level because patients don’t have anywhere else to go for follow-up.
    • Access to this type of ObGyn medical care is changing around the country, and it is our job to deliver essential care to these patients if they cannot obtain it elsewhere.

Methotrexate Contraindications 

• Renal insufficiency, immunodeficiency, active pulmonary disease, peptic ulcer disease, hypersensitivity to methotrexate, heterotopic pregnancy with viable IUP, and patients who are breastfeeding
• Pregnancy contraindications include beta-hCG >5,000 mIU/mL or presence of fetal cardiac activity

Complications of Delaying Care

• From the standpoint of long-term complications, offering a patient methotrexate as a treatment modality for an ectopic pregnancy is different from offering a patient surgery. 
• Abdominal surgery means the patient will lose a fallopian tube and will be admitted to the hospital for a period of time, and it can affect fertility.
• If we don’t act early or we delay care for our own legal protections, we limit our patient’s treatment options and can cause long-term complications.
• The medico-legal climate is changing surrounding ectopic pregnancy care and, unfortunately, by discharging a patient who has an untreated ectopic pregnancy, you may run the risk of an Emergency Medicine Treatment and Labor Act (EMTALA) violation.

Administration of Rhogam 

• The new ACOG recommendations still recommend administration of Rhogam in a patient with an ectopic pregnancy who is Rh negative, actively bleeding, and at less than 12 weeks’ gestation.
• A patient who is not bleeding and who is terminating a pregnancy for whatever reason (including ectopic pregnancy and elective terminations) does not require Rhogam.

PEARL: The medicine of ectopic pregnancy management has not changed; rather, changes in access to medical care, unevenness of care, and the current political and legal landscape surrounding pregnancy termination are challenging us as emergency medicine physicians. The onus is on us to be our patients’ advocates in the different environments in which we encounter and treat these patients across the country.

First10EM

January Research Roundup

Hyponatremia: Are we all doing this wrong?

Ayus JC, Moritz ML, Fuentes NA, Mejia JR, Alfonso JM, Shin S, Fralick M, Ciapponi A. Correction Rates and Clinical Outcomes in Hospitalized Adults With Severe Hyponatremia: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2024 Nov 18:e245981. doi: 10.1001/jamainternmed.2024.5981. PMID: 39556338

Bottom line: This meta-analysis of observational data shows an association between slower sodium correction in severe hyponatremia and increased mortality. These results are not definitive, but considering the rarity of demyelination, and the magnitude of the mortality results, this should probably influence clinical practice until we get the proper RCTs.

Nice graphic from the nephrology journal club as a nice overview of hyponatremia management:

NEJM

Medicaid on the Chopping Block

Heart Failure with Preserved Ejection Fraction

Striking a Balance — Advancing Physician

Identification and Treatment of Alcohol Use Disorder

Sport-Related Concussion

REBELEM

Clinical Conundrum: Should Acute Asthma Exacerbations Be Discharged From the ED With Combination Beta Agonist/Corticosteroid Inhalers?

• Written by Steve Orellana DO,REBEL Core, REBEL EM
• Bottom Line: Current research suggests we should replace prescriptions for a SABA inhaler (i.e. albuterol) with a LABA-ICS combination inhaler as it can be used both for maintenance therapy and as a rescue inhaler. Furthermore, Budesonide + Formoterol is a safe patient-centered option that is at least as effective, if not better, than SABA alone. This change does not alter the recommendation of treating with a systemic steroid (ie dexamethasone, prednisone etc). The practice of discharging a patient with SABA inhalers alone should be ended.
• Prescription: Budesonide/formoterol 80/4.5 μg/puff, 1-2 puffs once to twice daily for maintenance, and then 1-2 puffs every 2-4 hours as needed for asthma symptoms, with instructions to go to the ED if more than that is required.

D-Dimer in High-Risk PE: A Gamble Worth Taking?

Author Conclusion: “In this study, ruling out pulmonary embolism in high-risk patients based on D-dimer below the age-adjusted threshold was safe, with no missed pulmonary embolism. However, the sample size was not large enough to draw a definitive conclusion on the safety of this strategy.”

Clinical Take Home Point: It may be reasonable to consider forgoing CTPA imaging in high-risk PE patients if they have a negative D-dimer, but more research that is prospective with larger cohorts is needed to determine the safety of this approach

All the articles in pdf hyperlinked.

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).

Adjusting the Approach to Diagnosis of Deep Venous Thrombosis December 2022 Annals of Emergency Medicine Journal Club

• 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

Efficacy of awake prone positioning in patients with covid-19 related hypoxemic respiratory failure: systematic review and meta-analysis of randomized trials

Circulation

Single High-Sensitivity Point-of-Care Whole-Blood Cardiac Troponin I Measurement to Rule Out Acute Myocardial Infarction at Low Risk

CJEM

Prolonged observation or routine reimaging in older patients following a head injury is not justified

The evidence base for intra-articular lidocaine for closed manual reduction of acute anterior shoulder dislocation continues to grow

EMCRIT

EMCrit 338 – End of Year Question & Answer Session

Emergency Medicine Journal

EMRAP

Pigtail Catheter for Pneumothorax- Weingart

Don’t Order Troponin for SVT

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

Association Between Individual Primary Care Physician Merit-based Incentive Payment System Score and Measures of Process and Patient Outcomes

• 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

Alcohol-Associated Hepatitis

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

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

Academic Emergency Medicine

Point-of-care echocardiography of the right heart improves acute heart failure risk stratification for low-risk patients: The REED-AHF prospective study

American Journal of Emergency Medicine

None

Annals of Emergency Medicine

Models for Implementing Emergency Department–Initiated Buprenorphine With Referral for Ongoing Medication Treatment at Emergency Department Discharge in Diverse Academic Centers

Managing Elbow Dislocations

Man with right eye pain and decreased vision

Man presents to ED with right eye pain and decreased vision after hammering a nail.

BMJ

Rivaroxaban treatment for six weeks versus three months in
patients with symptomatic isolated distal deep vein thrombosis:
randomised controlled trial

• 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

Poor Timing and Failure of Source Control Are Risk Factors for Mortality in Critically Ill Patients with Secondary Peritonitis

Association Between Time to Source Control in Sepsis and 90-Day Mortality

• Source control in peritonitis more important that antibiotics, if fact abx made no difference in outcome.

Excluding Hollow Viscus Injury for Abdominal Seat Belt Sign Using Computed Tomography

Diagnostic Accuracy of Pelvic Radiographs for the Detection of Traumatic Pelvic Fractures in the Elderly

• Like hip fractures, plain films also miss pelvic fractures

Emergency Medicine Journal

EMRAP

Ascending Cholangitis

Cardiac Transplant Challenges

Pediatric Transplant Patients

Massive Hemorrhage Protocol

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

Gout

Oxygen-Saturation Targets for Critically Ill Adults Receiving Mechanical Ventilation

Monkeypox

Noninvasive Respiratory Support for Adults with Acute Respiratory Failure

PEDIATRICS

None

REBELEM

None

Resuscitation

None

American Journal of Emergency Medicine

The effect of early vasopressin use on patients with septic shock: A systematic review and meta-analysis

• 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

EMCrit Wee – Resus SCRAM Kit Dump Bag, Crash RX Drug Bag, and the Equipment I prefer for Resuscitative Intubation

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

The 2022 American College of Cardiology guideline on the evaluation and disposition of acute chest pain

• 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

Extremity Ischemia After Jellyfish Envenomation: A Case Report and Systematic Review of the Literature

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

Myocarditis

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

Hypocalcemia

Hypercalcemia

Resuscitation

Head and thorax elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival

Academic Emergency Medicine

Association between advanced image ordered in the emergency department on subsequent imaging for abdominal pain patients

• 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.

Efficacy of ketorolac in the treatment of acute migraine attack: A systematic review and meta-analysis

• 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 in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial

• 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

Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis

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

Non-sterile gloves and dressing versus sterile gloves, dressings and drapes for suturing of traumatic wounds in the emergency department: a non-inferiority multicentre randomised controlled trial

• 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

Introduction- Pneumonia

• 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.

Bell’s Palsy

Alcoholic Ketoacidosis

• 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

Concordance of SARS-CoV-2 Results in Self-collected Nasal Swabs vs Swabs Collected by Health Care Workers in Children and Adolescents

•  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.

Effect of Helmet Noninvasive Ventilation vs Usual Respiratory Support on Mortality Among Patients With Acute Hypoxemic Respiratory Failure Due to COVID-19The HELMET-COVID Randomized Clinical Trial

• 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.

Effect of High-Flow Nasal Cannula Oxygen vs Standard Oxygen Therapy on Mortality in Patients With Respiratory Failure Due to COVID-19The SOHO-COVID Randomized Clinical Trial

• 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

Chronic Urticaria

Supporting, Not Reporting — Emergency Department Ethics in a Post-Roe Era

Gastroesophageal Reflux Disease

PEDIATRICS

Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation 

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 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

Academic Emergency Medicine

Intravenous acetaminophen does not reduce morphine use for pain relief in emergency department patients: A multicenter, randomized, double-blind, placebo-controlled trial

Ultrasound for the diagnosis of shoulder dislocation and reduction: A systematic review and meta-analysis

• 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

Acute Opioid Withdrawal Following Intramuscular Administration of Naloxone 1.6 mg: A Prospective Out-Of-Hospital Series

• 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

The impact of post-intubation hypotension on length of stay and mortality in adult and geriatric patients: a cohort study

• 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

Neuromuscular Disorders

Approach to CNS infection

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

Bleeding AV Shunt

• 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?

Association of COVID-19 vs Influenza With Risk of Arterial and Venous Thrombotic Events Among Hospitalized Patients

• 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

The DINAMO Study: Efficacy and Safety of Non-Antibiotic Outpatient Treatment in Mild Acute Diverticulitis

• 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.

Academic Emergency Medicine

None

American Journal of Emergency Medicine

None

Annals of Emergency Medicine

The Aerosol-Generating Effect Among Noninvasive Positive Pressure Ventilation, High-Flow Nasal Cannula, Nonrebreather Mask, Nasal Cannula, and Ventilator-Assisted Preoxygenation

• 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.

Prognosis and persistence of smell and taste dysfunction in patients with covid-19: meta-analysis with parametric cure modelling of recovery curves

• 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.

Posterior Tibial Nerve Block

• 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.

Spinal Epidural Abscess

• 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

Effect of Fluid Bolus on CV Collapse Among Critically Ill Patients Undergoing Tracheal Intubation (No Open Access)

• No benefit

Journal of Emergency Medicine

None

Lancet

None

NEJM

Pulmonary Embolism

Tobacco Addiction

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 1^st 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.

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.

Fentanyl versus placebo with ketamine and rocuronium for patients undergoing rapid sequence intubation in the emergency department: The FAKT study— A randomized
clinical trial

• 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

CAEP position statement on improving emergency care for persons experiencing homelessness: executive summary

EMCRIT

Neuro-Oncology Emergencies

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

SARS-CoV-2 Positivity in Ambulatory Symptomatic Patients Is Not Associated With Increased Venous or Arterial Thrombotic Events in the Subsequent 30 Days

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

The After Dinner Dip

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:

1. Restrictive fluid strategy ≠ fewer deaths at 90 days than standard fluid therapy
2. 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

• systematic review and meta-analysis of 6 RCTs and 2 observational trials showing improved reperfusion and early neurologic improvement with tenecteplase compared to alteplase

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

Effect of vasopressin and methylprednisolone vs. placebo on long-term outcomes in patients with in-hospital cardiac arrest a randomized clinical trial

• No benefit