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

Academic Emergency Medicine

Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE- 2): Low- risk, recurrent abdominal pain in the emergency department

• 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
• Treatment
  • None
• Prognosis
  • Most cases mild but case fatality rate 3.6% among African studies

Circulation (need to review May 31)

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

• 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

Neurologic emergencies in pregnancy

Emergency Medicine Journal

Understanding and interpreting artificial intelligence, machine learning and deep learning in Emergency Medicine

EMRAP

Crashing Asthmatic

• Bipap IPAP 10-15, EPAP 2
• If tidal volumes poor with Bipap they likely will not improve with noninvasive.

Near-Hanging Injuries

• 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?

Nasal Fracture

Breakthrough VTE

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

Firearm Homicide and Suicide During the COVID-19 Pandemic. Implications for Clinicians and Health Care Systems

• 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.
  • UC Davis handout on how to discuss gun safety with 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

Preeclampsia

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.

REBEL Core Cast 80.0 – Compartment Syndrome

Resuscitation

None

Academic Emergency Medicine

Accuracy of the European Society of Cardiology 0/1- , 0/2- , and
0/3- hour algorithms for diagnosing acute myocardial infarction

• 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:
  1. Screen everyone for homelessness
  2. Hand out insurance application (quadruples chance of obtaining insurance).
  3. Provide location of closest social services office to apply for transitional and permanent housing.
  4. Provide location of closest low cost/free ambulatory care services/dental care.
  5. 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

Risks of deep vein thrombosis, pulmonary embolism, and bleeding after covid-19: nationwide self-controlled cases series and matched cohort study

• 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.

Just the facts: how to diagnose and manage patients with multiple myeloma in the emergency department?

• 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

Just the facts: drowning

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 321 – CV-EMCrit – Acute Valve Disasters – Critical Aortic & Mitral Regurgitation and Bonus: VSDs with Trina Augustin

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
  1. The Art of Learning- Josh Waitzkin
  2. Joy on Demand- Chade-Meng Ten
  3. Happiness- Daniel Haybron

Emergency Medicine Journal

None

EMRAP

Acute Angle Closure Glaucoma

• Initial treatment is 4 topical drops, given 1-2 minutes apart and repeated q5minutes for a total of 3 doses of each drop.
  1. Timolol (B-blocker- decrease aqueous humor production)
  2. Dorzolamide (carbonic anhydrase inhibitor- decrease aqueous humor production)
  3. Latanoprost (prostaglandin analogue- increase aqueous humor outflow)
  4. Brimonidine (alphagan) or apraclonidine (alpha agonist- decrease aqueous humor production and increase outflow)
  5. Uptodate also recommends 2% pilocarpine
• IV mannitol or diamox if pressure not improved when IOP rechecked at 30 minutes.

JAMA

Aspirin Use to Prevent Cardiovascular Disease US Preventive Services Task Force Recommendation Statement

• 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

Femoral artery Doppler ultrasound is more accurate than manual palpation for pulse detection in cardiac arrest

Academic Emergency Medicine

Patient values and preferences in pulmonary embolism testing in the emergency department

• Insight into patients’ expectations
  • Patients expect 100% certainty from their physician
  • Trust CT and multiple tests over physician judgement

• These beliefs require additional physician time to educate

American Journal of Emergency Medicine

None

Annals of Emergency Medicine

Naloxone and Buprenorphine Prescribing Following US Emergency Department Visits for Suspected Opioid Overdose: August 2019 to April 2021

• Naloxone and Bupe only prescribed after 1 in 13 and 1 in 12 opiate overdoses respectively.

BMJ

None

Circulation

American Heart Association’s Life’s Simple 7: Lifestyle Recommendations, Polygenic Risk, and Lifetime Risk of Coronary Heart Disease

• Don’t smoke, Stay lean, Low Cholesterol, Eat well, Exercise, Manage BP, Manage Sugar

CJEM

Wide-complex tachycardias in the ED: how do we make good care even better?

• Differentiate primary WCT (AF, Aflutter, Sinus Tach, VT) from secondary WCT (see list below of most common).
• Treat appropriately
• Slow rate<100
• Anticoagulate AF, Aflutter

Diagnosis and management of wide complex tachycardia in the emergency department

Wide Complex Tachycardia Differentiation: A Reappraisal of the State‐of‐the‐Art

A blueprint for building an emergency department quality improvement and patient safety committee

EMCRIT

EMCrit 319 – Safe and Smart Reversal of Anticoagulation / Anti-platelet Agents in 2022

Emergency Medicine Journal

None

EMRAP

Tracheostomy Emergency

• Try to pass suction catheter.
• If can’t pass, then deflate cuff and bag through mouth
• If Trach is more than 7 days old then can attempt to replace
• If no Trach then place a 6.0 ETT
• Pass Trach over a bougie

Crashing Aortic Stenosis

• Best way to improve hypotension is with vasopressors
  • Phenylephrine useful because no increase in HR, careful if patient already has bradycardia.
  • Vasopressin also good, similar hemodynamic effects to phenylephrine, start at .04 units/minute
  • Goal is to get MAP to 65 to improve coronary perfusion which will improve contractility.
• Weingart starts with vasopressin and then adds phenylephrine or norepinephrine.
• Patients usually too unstable for major surgery
• Valvuloplasty with interventional cardiology can be very useful.

Pharmacology Corner: Potassium Binders

• No high quality studies showing efficacy of kayexelate
• Serious adverse effects: colonic necrosis
• Veltasa reduces potassium 0.6 meq at 2 hours and no difference at 6 hours.

Intranasal Ketamine and “Ketadex”

JAMA

None

Journal of Emergency Medicine

None

Lancet

Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial

• No benefit to prehospital transfusion

Duration of effectiveness of vaccines against SARS-CoV-2 infection and COVID-19 disease: results of a systematic review and meta-regression

• Vaccine efficacy dropped by 10% from 1 month to 6 months against severe disease but dropped by 25% against symptomatic disease.

Paul Farmer- Obituary

“He put the poor, the marginal, the disabled…he put them first”

NEJM

Decompression Sickness and Arterial Gas Embolism

The Patient Resident

Extracorporeal Kidney-Replacement Therapy for Acute Kidney Injury

Chronic Pancreatitis

CT or Invasive Coronary Angiography in Stable Chest Pain

• Among patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure- related complications was lower with an initial CT strategy.

PEDIATRICS

None

REBELEM

REBEL Core Cast 77.0 – Pyogenic Flexor Tenosynovitis

• Think about flexor tenosynovitis in a patient with atraumatic finger pain.  They may have any combination of these signs:
  • Tenderness along the course of the flexor tendon
  • Symmetrical swelling of the finger – often called the sausage digit
  • Pain on passive extension of the finger and
  • Patient holds the finger in a flex position at rest for increased comfort

The SCOUT–CAP Trial: 5d Abx vs. 10d Abx in Pediatric CAP

• 5d course as good as 10d
  • UPTODATE supports this conclusion and cites this study

REBEL Cast Ep108: The PLUS Trial – Balanced vs Unbalanced Fluids in the Critically Ill

• Finfer, S et al. Balanced Multielectrolyte Solution Versus Saline in Critically Ill Adults. NEJM 2022
• In critically ill adults in the ICU requiring intravenous fluids, it appears the type of fluid does not make a difference on the outcomes of mortality or AKI.

Resuscitation

Academic Emergency Medicine

No Feb issue as of March 2, 2022, 2:20pm

American Journal of Emergency Medicine

Dispelling myths and misconceptions about the treatment of acute hyperkalemia

Annals of Emergency Medicine

Rapid Rule-Out of Myocardial Infarction After 30 Minutes as an Alternative to 1 Hour: The RACING-MI Cohort Study

Moving Upstream: A Social Emergency Medicine Approach to Opioid Use Disorder

Man With Eye Pain and Decreased Vision

• A healthy 39-year-old man presented to the emergency department with 2 days of nontraumatic severe left eye pain and progressive visual loss to the point of blindness. Upon physical examination, the patient reported only flashes of light in the left eye, with sluggish pupillary response and painful extraocular movements. The result of slit lamp examination was unremarkable, and ocular pressures were normal. The result of right eye examination was unremarkable. An emergency physician conducted point-of-care ocular ultrasound, demonstrating evidence of papilledema and optic nerve inflammation 

BMJ

Diagnosis of deep vein thrombosis with D-dimer adjusted to clinical probability: prospective diagnostic management study

• DVT was considered excluded without further testing by Wells low clinical pretest probability and D-dimer <1000 ng/mL or Wells moderate clinical pretest probability and D-dimer <500 ng/mL. All other patients had proximal ultrasound imaging. Repeat proximal ultrasonography was restricted to patients with initially negative ultrasonography, low or moderate clinical pretest probability, and D-dimer >3000 ng/mL or high clinical pretest probability and D-dimer >1500 ng/mL.

• Of the 1275 patients with no proximal DVT on scheduled testing who did not receive anticoagulant treatment, eight (0.6%, 95% confidence interval 0.3% to 1.2%) were found to have venous thromboembolism during follow-up. Compared with a traditional DVT testing strategy, this diagnostic approach reduced the need for ultrasonography from a mean of 1.36 scans/patient to 0.72 scans/patient (difference −0.64, 95% confidence interval −0.68 to −0.60), corresponding to a relative reduction of 47%.

Circulation

None

CJEM

Just the facts: how to diagnose and manage patients with multiple myeloma in the emergency department?

EMCRIT

None

Emergency Medicine Journal

Teach-back of discharge instructions in the emergency department: a pre–post pilot evaluation

• AHRQ recommends as a health literacy tool
• AMA produced an instructional video (see last 5 minutes)

EMRAP

Devil’s Advocate- Traumatic Arthrotomy

• Konda SR et al. Computed tomography scan to detect traumatic arthrotomies and identify periarticular wounds not requiring surgical intervention: an improvement over the saline load test. J Orthop Trauma 2013; 27: 498-504.
  • As good as saline load test

Drugs in Atrial Fibrillation with RVR

• Mag 2-4g IV
• Dilt 10 as good as .25mg/kg
• If BP low, give 2g CaGluconate

JAMA

Effect of Noninvasive Respiratory Strategies on Intubation or Mortality
Among Patients With Acute Hypoxemic Respiratory Failure and COVID-19
The RECOVERY-RS Randomized Clinical Trial

• The requirement for tracheal intubation or mortality within 30 days was significantly lower with CPAP (36.3%; 137 of 377 participants) vs conventional oxygen therapy (44.4%; 158 of 356 participants) (absolute difference, −8% [95% CI, −15% to −1%], P = .03), but was not significantly different with HFNO (44.3%; 184 of 415 participants) vs conventional oxygen therapy (45.1%; 166 of 368 participants) (absolute difference, −1% [95% CI, −8% to 6%], P = .83). 
• Proning not studied but probably more important than oxygen delivery system

Defining Optimal Respiratory Support for Patients With COVID-19

Journal of Emergency Medicine

None

Lancet

None

NEJM

Stabilizing Health Care’s Share of the GDP

Inherited Patients Taking Opioids for Chronic Pain — Considerations for Primary Care

PEDIATRICS

None

REBELEM

Andexanet Alfa Vs. Four-Factor PCC: Is Andexanet Alfa Worth The Hype?

• This limited study found no statistically significant difference in stability of oral FXi related ICH after the administration of AA or 4F-PCC. However, the inherent potential bias and small participant numbers limit generalizability and therefore larger prospective studies are needed. 4F-PCC is cheaper and more widely available than AA ($5670/patient, compared to $22,120-$49,500/patient);

Resuscitation

Vasopressin and glucocorticoids for in-hospital cardiac arrest: A systematic review and meta-analysis of individual participant data

• Improved chance of ROSC but not statistically significant improved hospital discharge.

Academic Emergency Medicine

Efficacy of empiric antibiotic management of septic olecranon bursitis without bursal aspiration in emergency department patients

• good results with abs without aspiration
• Uptodate recommends aspiration only if overlying skin shows impaired perfusion from tense effusion or if no improvement after 36-48hrs of abx.

American Journal of Emergency Medicine

None

Annals of Emergency Medicine

Venous Thromboembolism in Patients Discharged From the Emergency Department With Ankle Fractures: A Population-Based Cohort Study

• The 90-day incidence of venous thromboembolism among patients discharged from the ED with ankle fractures requiring immobilization was 1.3%. These patients had a 5.7- to 6.3-fold increased hazard compared to matched controls. Certain patients immobilized for ankle fractures are at higher risk of venous thromboembolism, and this should be recognized by emergency physicians.

Bloodless Management of the Anemic Patient in the Emergency Department

Oral Ondansetron Administration in Children Seeking Emergency Department Care for Acute Gastroenteritis: A Patient-Level Propensity-Matched Analysis

• Among preschool-aged children with gastroenteritis seeking ED care, oral ondansetron administration was associated with a reduction in index ED visit intravenous fluid administration; it was not associated with intravenous fluids administered within 72 hours, hospitalization, or vomiting and diarrhea in the 24 hours following discharge.

BMJ

Atorvastatin versus placebo in patients with covid-19 in intensive care: randomized controlled trial

• No benefit but safe

Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials

• The findings suggest that SSRIs provide high rates of remission with low risk of adverse events for the treatment of panic disorder. Among SSRIs, sertraline and escitalopram were associated with high remission and low risk of adverse events. The findings were, however, based on studies of moderate to very low certainty levels of evidence, mostly as a result of within study bias, inconsistency, and imprecision of the findings reported.

Circulation

None

CJEM

Two troponins, one troponin, none… the dawn of troponin‐less decision aids

External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing

Results Of the 1150 patients included in this study, 820 (71.3%) had no history of CAD, 97 (8.4%) had index AMI and 123 (10.7%) had 30-day MACE. In patients with no prior history of CAD, HEAR ≤ 1 identifi ed 202 (24.6%) of patients as very low risk for 30-day MACE with 98.4% (95% CI 91.6ñ 99.9%) sensitivity. Among all patients, HEAR ≤ 1 identifi ed 202 (17.6%) patients as very low risk for 30-day MACE with 99.2% (95% CI 95.6ñ 99.9%) sensitivity.
Conclusions A HEAR score ≤ 1 can identify more than 17% of all patients as very low risk for index AMI and 30-day MACE and unlikely to benefi t from troponin testing. Broad implementation of this strategy could lead to signifi cant resource savin

EMCRIT

Just the Facts: How to assess a patient with constant significant vertigo and nystagmus in the emergency department

Emergency Medicine Journal

None

EMRAP

Unprovoked Seizures in Children

• LP if <6 months, 6-12 months various options
• No imaging typically
• No meds usually

Cardiology Corner: Post-MI Dysrhythmias

• Accelerated Idioventricular Rhythm (AIVR)
  • The presence of AIVR in a patient presenting with concern for acute coro-nary syndrome (ACS) should prompt cath lab activation.

• Non-sustained monomorphic VT (< 30 seconds)
  • No decrease in mortality/morbidity
  • No need to start anti-arrhythmics 
• Sustained monomorphic VT (Lasting > 30 seconds or unstable).
  • Shock if unstable
  • Amiodarone if stable

Skip the NG Tube in SBO?

• A “Best BETs” in 2014 concluded, “There is no scientific evidence for the routine use of nasogastric tubes in adults with small bowel occlusion.”
• They are routinely rated as the most painful procedure performed in the ED.
• Bottom line: Nasogastric tubes clearly do harm in terms of patient discomfort and there is no evidentiary basis for their role in the modern management of SBO. This doesn’t mean that nasogastric tubes play no role. They may be useful in patients with vomiting refractory to antiemetics or patients with distended stomachs. We simply do not know who benefits from them and instead of being a routine part of care, selective use makes more sense.

Imaging of Rib Fractures

• Rib fractures that are not seen on a chest radiograph are generally not clinically significant (2/3 of rib fxs seen on CT are missed on plain film)
• Fractures of the first and second ribs place patients at high risk for vascular injuries. If seen on a chest radiograph, CT angiography of the neck should be performed.
• When read by a radiologist, rib series are not more sensitive than a standard two-view chest x-ray, and result in twice the amount of ionizing radiation to the patient.

JAMA

None

Journal of Emergency Medicine

Multisystem Inflammatory Syndrome in Children

Journal of Trauma and Acute Care Surgery

Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm

Lancet

None

NEJM

Early Remdesivir to Prevent Progression to Severe Covid-19 in Outpatients

• Among nonhospitalized patients who were at high risk for Covid-19 progression, a 3-day course of remdesivir had an acceptable safety profile and resulted in an 87% lower risk of hospitalization or death than placebo.

The Goldilocks Time for Remdesivir — Is Any Indication Just Right?

Medical Conditions and High-Altitude Travel

Rapid Diagnostic Testing for SARS-CoV-2

Snake Envenomation

PEDIATRICS

None

REBELEM

None

Resuscitation

None

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

Academic Emergency Medicine

SGEM#323: Mama I’m comin’ home—For outpatient treatment of a pulmonary embolism

• @RozhenalMD : In my experience the limiting factor is often the fact that some insurance plans cover rivaroxaban and others cover apixaban, apparently none cover both. So it’s practically impossible to figure this out and send them home on a doac unless it’s 2 pm on a Tuesday. Hence, obs.
• Reply by author @LWestafer: We get around this with initial coupons. https://eliquis.com/eliquis/hcp/resources#panel- element-2… either 30d free or 10$ copay regardless of insurance- I tell patients they may get switched but this will get them started

Topiramate (Topamax) for migraine prophylaxis

• First line treatment per Uptodate
• Current dosing recommendations of topiramate for migraine prophylaxis approved by the FDA is to start at 25 mg a night for week 1, 25 mg twice a day for week 2, 25 mg in the morning and 50 mg in the evening on week 3, and finally 50 mg both morning and evening starting week 4.12 In patients with significant side effects, rapid discontinuation without tapering is favored.
• As of November 2020, a one-month supply of topiramate (50 mg twice daily) costs $9.00 to $11.81.
• Side effects: drowsy, dizzy, fatigue, also associated with long term and short cognitive dysfunction

American Journal of Emergency Medicine

Multisystem inflammatory syndrome in children with COVID-19 Review Article

High flow nasal cannula for adult acute hypoxemic respiratory failure in the ED setting

Annals of Emergency Medicine

Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests

• Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS.
• According to this 1 hour YouTube lecture from AIUMultrasound, the study takes less than 2 minutes and requires minimal experience to perform.

United States Best Practice Guidelines for Primary Palliative Care in the Emergency Department

• If you would not be surprised if the patient was to die within the next year, consider a palliative care consult.

BMJ

None

Circulation

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

• In patients with acute chest pain and suspected ACS who are deemed low-risk (<1% 30-day risk of death or MACE), it is reasonable to discharge home without admission or urgent cardiac testing.

EMCRIT

Transvenous Pacemakers

1. Introducer Sheath is in (If the patient NEEDS a pacemaker–an experienced person should put in the introducer)
2. Position the Patient so you can see the monitor
3. Put the damn sterile sheath on the wire
4. Test the balloon (Special Syringe only allows 1.5 ml of air)
5. Attach to wire extender to the box, the pacemaker pins and tighten!!!! (Write Negative=Distal on your Pacemaker Drawer)
6. Have your partner set the box. Rate 2x intrinsic and V Output 20 mA
7. attribution neededOrient the curve
8. Advance to 15 cm
9. Call for balloon up (Note be GENTLE with balloon inflation/and only passive deflation. Down until 1.3 cc)
10. Advance somewhat rapidly until you see electrical capture (monitor shows big electrical spikes with lbbb morphology) then confirm mechanical capture by looking at rate of pulse ox or having someone check pulses or looking at ultrasound arterial pulse.
11. Do the turn down dance
12. Deflate Balloon/lock stopcock
13. Secure by first clamping down on the wire then attaching down distal and clamping proximal portions of sheath and suture the introducer to the patient
14. Hang box on IV pole
15. Check Sensitivity Settings
16. Get an Xray (RV placement will show the wire cross the midline)
17. Place in VVI

Emergency Medicine Journal

None

EMRAP

Pediatric Pearls: Congenital Heart Disease Part 1

Cardiology Corner: Updates in SVT

2021 CAEP (Ian Stiell) Atrial Fibrillation Algorithm

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

Diagnostic Strategies for Suspected Pulmonary Embolism- editorial

Journal of Emergency Medicine

None

Lancet

None

NEJM

A Randomized Trial of Intravenous Alteplase before Endovascular Treatment for Stroke

• tPA plus endovascular treatment no better than endovascular treatment alone

Peritoneal Dialysis

• In contrast to spontaneous bacterial peritonitis in patients with cirrhosis, which is diagnosed when the neutrophil count is 250 per μl or higher, peritoneal dialysis–related peritonitis is diagnosed with a white-cell count as low as 100 per μl if there are 50% or more neutrophils.

PEDIATRICS

Corticosteroids in the Treatment of Pediatric Retropharyngeal and Parapharyngeal Abscesses

• Retrospective study: Of the 2259 patients with RPAs and PPAs, 1677 (74.2%) were in the noncorticosteroid group and 582 (25.8%) were in the corticosteroid group. There were no significant differences in age, sex, or insurance status. There was a lower rate of drainage in the corticosteroid cohort (odds ratio: 0.28; confidence interval: 0.22–0.36). Patients in this group were more likely to have repeat computed tomography imaging performed, had lower hospital costs, and were less likely to have opioid medications administered. The corticosteroid cohort had a higher 7-day emergency department revisit rate, but there was no difference in length of stay (rate ratio 0.97; confidence interval: 0.92–1.02).

REBELEM

REBEL Core Cast 69.0 – Epiglottitis

• For patients with advanced inflammation, prophylactic intubation may be necessary. Involve consultants early for a possible awake intubation in the OR, and with preparations to convert to a surgical airway, if necessary.

REBEL Cast Ep104: VAM-IHCA – Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest

• Clinical Take Home Point: The combination of vasopressin and methylprednisolone compared to placebo during in-hospital cardiac arrest resulted in more ROSC but had no statistically significant difference in the more patient oriented outcomes of survival and survival with favorable neurologic status at 30 and 90d. In fact, survival at 30 days appeared to be worse in the VAM group. At this time, we cannot recommend the addition of vasopressin and methylprednisolone in the management of IHCA.

Academic Emergency Medicine

Peripheral Nerve Block for Hip Fracture

• The American Academy of Orthopedic Surgeons recommends regional analgesia for preoperative pain control in patients with hip fracture (strong evidence).¹¹ Based on the available evidence, the review summarized here found that PNB reduced pain on movement, shortened time to first mobilization, and resulted in lower rates of delirium and chest infections. Thus, we have assigned a color recommendation of green (benefit > harm) for PNB for hip fracture. Further study is needed to evaluate PNB in periods and settings other than the perioperative period and the potential benefit of continuous infusion versus single injection. However, current data support that this would be a valuable intervention for hip fractures that could be utilized in the ED.

Neuraminidase inhibitors for treatment of influenza

• In summary, the existing data indicate that NAIs reduce the duration of symptoms by less than 1 day in patients with confirmed or suspected influenza. The use of NAIs to treat influenza does not prevent hospitalization and is associated with adverse events. Therefore, we have assigned a color recommendation of yellow (unclear if it provides benefit, more data needed) to this treatment.

American Journal of Emergency Medicine

None

Annals of Emergency Medicine

Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria

• Modified Sgarbossa Criteria in LBBB- sensitivity was significantly higher than that of the original Sgarbossa criteria (91% versus 52% and 80% versus 49%, respectively; P<.001 for all) and high specificity was maintained (90% versus 98% and 99% versus 100%, respectively).
• This study showed MSC were more sensitive than the original Sgarbossa criteria; specificity was high for both rules. The MSC may contribute to clinical decisionmaking for patients with ventricular paced rhythm. [Ann Emerg Med. 2021;78:517-529.]

BMJ

Effectiveness and safety of non-steroidal anti-inflammatory drugs and opioid treatment for knee and hip osteoarthritis: network meta-analysis

• Etoricoxib 60 mg/day and diclofenac 150 mg/day seem to be the most effective oral NSAIDs for pain and function in patients with osteoarthritis. However, these treatments are probably not appropriate for patients with comorbidities or for long term use because of the slight increase in the risk of adverse events. Additionally, an increased risk of dropping out due to adverse events was found for diclofenac 150 mg/day. Topical diclofenac 70-81 mg/day seems to be effective and generally safer because of reduced systemic exposure and lower dose, and should be considered as first line pharmacological treatmentfor knee osteoarthritis. The clinical benefit of opioid treatment, regardless of preparation or dose, does not outweigh the harm it might cause in patients with osteoarthritis.

Acute urinary retention and risk of cancer: population based Danish cohort study

• CONCLUSIONS: Acute urinary retention might be a clinical marker for occult urogenital, colorectal, and neurological cancers. Occult cancer should possibly be considered in patients aged 50 years or older presenting with acute urinary retention and no obvious underlying cause.
• The absolute risk of prostate cancer after a first diagnosis of acute urinary retention was 5.1% (n=3198) at three months, 6.7% (n=4233) at one year, and 8.5% (n=5217) at five years. Within three months of follow-up, 218 excess cases of prostate cancer per 1000 person years were detected. An additional 21 excess cases per 1000 person years were detected during three to less than 12 months of follow-up, but beyond 12 months the excess risk was negligible. 

Common intestinal stoma complaints

Circulation

None

EMCRIT

None

Emergency Medicine Journal

None

EMRAP

Pharmacology Rounds: Beers Criteria

• Avoid first antihistamines, second generation ok (loratadine)
• Nitrofurantoin (on the list bc not effective if cr cl<30, otherwise ok for short term)
• NSAIDS: incr cv and go complications, naproxen safest, safer than ibuprofen
• Antipsychotics: increased risk from prolonged use

Neutropenic Fever

• Fever: Temperature greater than 101ºF (38.3ºC) or sustained of 100.4ºF (38ºC) for at least an hour.
• Neutropenia: Absolute neutrophil count (ANC) < 1000 with an expected decrease to 500, or an ANC of < 500.
• The most common (and deadly) bacterial sources of infection are gram negative bac-teria. There is also a higher rate of resistant organisms and opportunistic infections.
• If there is no obvious source of infection, the work-up should include 2 blood cultures (1 from indwelling line, if present), liver function tests, bilirubin, chest x-ray (if upper or lower respiratory infectious symptoms), and respiratory viral panel.
• Administer empiric antibiotics as quickly as possible:
• Provide gram negative coverage with antipseudomonal activity: cefepime or a carbapenem if concern for ESBL.
• Piperacillin-tazobactam is another common choice.
• Vancomycin can be considered if an indwelling line is suspected to be the source of infection, or if they are hypotensive or toxic-appearing.
• Some patients may need fungal or viral coverage.
• Which patients can go home?
• Use MASCC calculator on MDCALC.
• This should only be done in consultation with oncology.

Watchman Procedure

• A cardiology procedure that eliminates the left atrial appendage, thus reducing the risk of clot formation in patients with atrial fibrillation (paroxysmal or chronic).
• Performed via percutaneous access through the femoral artery.
• Over approximately 45 days, the myocardium grows over the device that is placed in the appendage.
• Patients require anticoagulation for the first 45 days due to increased risk of thrombo-embolic disease, but do not require chronic anticoagulation.
• Watchman device versus systemic anticoagulation:
  • Lower hemorrhagic stroke rate with the device. Lower cardiovascular mortality with the device. No difference in ischemic stroke rate.
• Overall complication rate: approximately 1-8% (most occurring immediately post-procedure). Cardiac perforation leading to tamponade.

JAMA

Comparison of New Pharmacologic Agents With Triptans for Treatment of Migraine

• For pain freedom or pain relief at 2 hours after the dose, lasmiditan, rimegepant, and ubrogepant were associated with higher ORs compared with placebo but lower ORs compared with most triptans. However, the lack of cardiovascular risks for these new classes of migraine-specific treatments may offer an alternative to triptans.

Effect of Vasopressin and Methylprednisolone vs Placebo on Return of Spontaneous Circulation in Patients With In-Hospital Cardiac Arrest: A Randomized Clinical Trial. (article not open access).

Association of Tramadol vs Codeine Prescription Dispensation With Mortality and Other Adverse Clinical Outcomes (no open access)

• Compared with codeine, tramadol dispensation was significantly associated with a higher risk of all-cause mortality (incidence, 13.00 vs 5.61 per 1000 person-years; HR, 2.31 [95% CI, 2.08-2.56]; ARD, 7.37 [95% CI, 6.09-8.78] per 1000 person-years), cardiovascular events (incidence, 10.03 vs 8.67 per 1000 person-years; HR, 1.15 [95% CI, 1.05-1.27]; ARD, 1.36 [95% CI, 0.45-2.36] per 1000 person-years), and fractures (incidence, 12.26 vs 8.13 per 1000 person-years; HR, 1.50 [95% CI, 1.37-1.65]; ARD, 4.10 [95% CI, 3.02-5.29] per 1000 person-years). No significant difference was observed for the risk of falls, delirium, constipation, opioid abuse/dependence, or sleep disorders.

J Am Geriatr Soc. 

Effect of age on treatment outcomes in benign paroxysmal positional vertigo: A systematic review (no open access)

• Although more CRPs (Canalith Repositioning Procedures- Epley’s maneuvers) are needed, the rate of complete recovery in older adults is similar to that observed in younger adults.

Journal of Emergency Medicine

None

Lancet

Study of mirtazapine for agitated behaviours in dementia (SYMBAD): a randomised, double-blind, placebo-controlled trial

• No benefit, increased mortality.

NEJM

Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis

• No difference if you wait until walled off.

Clinical Features of Vaccine-Induced Immune Thrombocytopenia and Thrombosis

PEDIATRICS

Recommendations for Prevention and Control of Influenza in Children, 2021–2022

REBELEM

REBEL Core Cast 66.0 – Congenital Cardiac Issues

• Once you figure out the neonate that presented to your ED is sick, run through a differential of why then can be sick so you don’t anchor. I like to use TIMOT (Trauma, Infection, Metabolic, Organs, Tox) but use whatever works for you.
• Use your detailed history looking for risk factors to help you narrow the differential down. Do a good hands-on physical exam. Work them up more than you would a standard baby and do things like you would to an adult such as a bedside US. These will all lead you to the diagnosis of a congenital cardiac disease
• You have two options now: they either have a cyanotic lesion that requires prostaglandins and a dose of 0.05-0.2 mg/kg/min and will need to be intubated. Or they are in full blown heart failure and require lasix at 1 mg/kg and pressors, typically a combination of dobutamine and norepinephrine.
• Don’t be a hero but don’t have imposter syndrome. You can manage these kids, but do so with support from your PICU, cardiac surgeon or transferring institution. What you are doing in the ED is temporizing to keep them alive to definitive therapy which is usually a combination of ECMO and/or surgery. Get them out of your department ASAP.

REBEL Cast Ep101: The TOMAHAWK Trial – Angiography after OHCA without STEMI

• Clinical Take Home Point: In hemodynamic and electrically stable patients with OHCA and no STEMI after ROSC, an immediate-angiography strategy does not appear to improve 30-day mortality. It appears that an approach of intensive care first followed by delayed angiography if clinically indicated is preferred.

The DisCoVeRy Trial: Remdesivir in COVID-19 – An Expensive Version of Tamiflu?

• Clinical Take Home Point: Although earlier trials showed a signal of benefit for remdesivir improving time to recovery, no trials have shown an improvement in mortality, a more important clinical outcome.  Additionally, this is now the third trial showing no clinical benefit of remdesivir. The current evidence does not support the use of remdesivir in hospitalized patients with symptoms for more than 7 days and requiring oxygen support.  This story sounds much like another antiviral medication used for another viral illness (i.e. Tamiflu for influenza), except this medication is much more expensive ($3k – 5k for a 5 day course).

Rebellion 21: Clap Back – Gonorrhea and Chlamydia Updates via Jenny Beck-Esmay, MD

• Testing:
  • Male: 1^st catch urine sample (Not a clean catch urine – midstream) as good as urethral swab
  • Female:Vaginal swab as sensitive as cervical swab (Can be collected by the patient themselves)
  • Urine: Needs to be 1^st catch urine (Not a clean catch urine – midstream); Not as sensitive as vaginal or cervical swab