Academic Emergency Medicine

Diagnostic Accuracy of the HINTS Exam in an Emergency Department: A Retrospective Chart Review

A total of 2,309 patients met criteria for inclusion in the study. Physician uptake of the HINTS exam was high, with 450 (19.5%) dizzy patients receiving all or part of the HINTS. A large majority of patients (96.9%) did not meet criteria for receiving the test as described in validation studies; most often this was because patients lacked documentation of nystagmus or described their symptoms as intermittent. In addition, many patients received both HINTS and Dix-Hallpike exams, which are intended for use in mutually exclusive patient populations. In no case was dizziness due to a central cause identified using the HINTS exam.

American Journal of Emergency Medicine

No good free articles this month

Annals of Emergency Medicine

Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report.

Is Routine Testing Necessary When Empirically Treating Patients With Suspected Gonorrheal and Chlamydia Infections?

• Sensitivity only 55% for gonorrhea with urine or endocervical swab so authors recommend empiric treatment rather than waiting for results. There is a counter-argument in the same issue but this one makes more sense to me. Probably should incorporate population characteristics and patient shared-decision making.

Young man with odynophagia

• A 30-year-old man presented to the emergency department with throat pain and oral intolerance of fluids for several hours. Earlier that day, an outpatient operation was aborted after multiple unsuccessful intubation attempts in the operating room. The patient had unremarkable vital signs, noting only odynophagia. Computed tomography (CT) of the neck and an esophagram with water-soluble contrast were acquired.

Bridging Oceans and Thrombolysis April 2021 Annals of Emergency Medicine Journal Club

• This small trial found a trend toward benefit for the non-lytic group when comparing between patients treated with EVT alone versus EVT plus IVT for acute CVA.

BMJ

Postural Hypotension

Circulation

No good free articles this month

EMCRIT

Neuroleptic Malignant Syndrome

Anticholinergic Intoxication

Sodium channel blocker toxicity (including tricyclic antidepressants)

PulmCrit – ACEP task force on septic shock should replace the Surviving Sepsis Campaign

• The ACEP consensus-based task force report was just published (see lead article in Annals of EM section above). Although spearheaded by ACEP, the report is also endorsed by the Society of Hospital Medicine (SHM) and the Society of Critical Care Medicine (SCCM).

Emergency Medicine Journal

No good free articles this month

EMRAP

No good articles this month

JAMA

Giardiasis

NEJM

Postpartum Hemorrhage

• Review article

Tocilizumab in Hospitalized Patients with Severe Covid-19 Pneumonia

• No benefit at 28 days.

Interleukin-6 Receptor Antagonists in Critically Ill Patients with Covid-19

• In critically ill patients with Covid-19 receiving organ support in ICUs, treatment with the interleukin-6 receptor antagonists tocilizumab and sarilumab improved outcomes, including survival, at 90 days.

Adrenal Incidentaloma

• All patients with an adrenal mass that is discovered during diagnostic testing for another condition (an “incidentaloma”) should undergo biochemical testing to detect pheochromocytoma and excess cortisol secretion, and those who also have high blood pressure should undergo biochemical testing to detect primary hyperaldosteronism.
• Patients with pheochromocytoma should undergo adrenalectomy after adequate presurgical alpha- blockade and beta-blockade, if necessary.
• Patients with mild autonomous cortisol excess and primary hyperaldosteronism may benefit from adrenalectomy, but treatment should be individualized.
• Nonfunctioning adrenal tumors that have an attenuation of 10 Hounsfield units or less on computed tomographic (CT) evaluation and that are smaller than 4 cm in greatest diameter generally do not warrant intervention or long-term follow-up.
• All other adrenal incidentalomas with indeterminate features on imaging may warrant additional imaging with contrast-enhanced CT, magnetic resonance imaging with chemical-shift analysis, positron-emission tomography–CT with 18F-fluorodeoxyglucose, or all of these tests. The management of these masses should be individualized and should involve a multidisciplinary team consisting of an endocrinologist, an endocrine surgeon, and a radiologist.

Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis

• No difference

Vancomycin Infusion Reaction — Moving beyond “Red Man Syndrome”

• Authors recommend replacing red man syndrome with infusion reaction for all non-immune mediated reactions.
• Uptodate uses the term vancomycin flushing syndrome or vancomycin infusion reaction.
• The two can be distinguished if it is the first time a patient has been exposed to vancomycin it will not be an IgE reaction.
• Otherwise they can be difficult to distinguish and may require allergy consult/testing to distinguish.
• Typically the infusion reaction is characterized by upper body, neck an face greater than lower body flushing, erythema and itching. Pain and muscle spasms in the back and chest as well as dyspnea and hypotension may occur.

Lower or Higher Oxygenation Targets for Acute Hypoxemic Respiratory Failure

• No difference

Vestibular Schwannomas

• Review article

REBELEM

REBEL Cast Ep98: Intravenous Contrast and Long-Term Kidney Impairment

• In this methodologically novel trial (Goulden R et al. Association of Intravenous Radiocontrast With Kidney Function: A Regression Discontinuity Analysis. JAMA Intern Med 2021. [Link is HERE]) there was no association between IV contrast from CTPA and worsening eGFR up to 6 months after index ED visit.  Although a randomized clinical trial would be great, this may be the highest-level evidence we achieve.  This trial plus other observational trials on this topic all point to a change in protocols to allow for IV contrast in patients regardless of kidney function.

GCS<8, Then Intubate?

• In summary, the evidence for using a patient’s GCS score is mixed. Recent review articles have highlighted the paucity of strong evidence behind the classic adage of “GCS less than 8, intubate”. Orso D et al. Endotracheal intubation to reduce aspiration events in acutely comatose patients: a systematic review. Scand J Trauma Resusc Emerg Med. 2020. 

Twitter

Amal Mattu

Academic Emergency Medicine

The silver linings of covid-19 uplifting effects of the pandemic

• telemedicine, ppe, respect for healthcare workers, time with family, management of hypoxia

American Journal of Emergency Medicine

None this month

Annals of Emergency Medicine

Assessment of the Thyromental Height Test as an Effective Airway Evaluation Tool

• Several tools to assess airway difficulty but they require patient cooperation.
• Thyromental height does not require patient cooperation and has both best sensitivity and moderate specificity.
• Authors: “Early evidence on the thyromental height test is promising, given its higher sensitivity, reasonable specificity, and wider potential for application in the ED. However, to date no ED-, EMS-, or video laryngoscopy–based studies have been completed, to our knowledge.

Antibiotics Versus Appendectomy for Acute Appendicitis: Are Antibiotics Really Noninferior? March 2021 Annals of Emergency Medicine Journal Club

• Article in review: CODA Collaborative. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med. 2020;383:1907-1919.
• Two groups were equal in 30d health status, antibiotic group had higher rate of complications but mostly because of patients with appendicolith.
• In the antibiotics group:
  • 41% underwent surgery by 90 days if appendicolith present
  • 25% underwent surgery by 90days if no appendicolith was present
• Complications in Pts without Appendicolith:
  • Antibiotics: 3.7 per 100 participants
  • Surgery: 3.5 per 100 participants
• Great summary in REBELEM

Prospective Randomized Trial of Standard Left Anterolateral Thoracotomy Versus Modified Bilateral Clamshell Thoracotomy Performed by Emergency Physicians

• Cadaver study, physicians preferred the modified bilateral clamshell, less iatrogenic injuries.
• Great review of the technique in REBELEM.
  • Use scalpel to cut down to intercostal muscle from axilla to axilla under nipples.
  • Use trauma shears to cut through intercostal muscle and through sternum, using two fingers to protect lung.

A Boy With A Sublingual Mass

• Sublingual ranula is a relatively common finding in the pediatric population, especially during the first and second decade of life, pseudocystic lesion, outpatient referral to ENT.

BMJ

Severe covid-19 pneumonia: pathogenesis and clinical management

• Best algorithm I’ve seen for guiding when to intubate sick covid-19 patients.
• Uses two metrics (P/F and ROX) to guide the decision which are both on MDCALC.
• P/F used for NIV and ROX is used for HFNC.

Circulation

Diagnostic Performance of High Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite United States Cohort

• First and largest prospective multisite US cohort study to evaluate hs-cTnT strategies to date
• NPV reached >99% with the combo 0 and 1 hour HS troponin plus a low heart score but using that approach only allowed 30.8% of patients to be discharged.
• There was a high rate of MACE at 30 days (14.4%)
• The study raises questions about whether HS-trop will improve efficiency if the discharge rate is 30.8%
• See RebelEM for details.

Emergency Medicine Journal

None this month

EMRAP

None this month

JAMA

None this month

NEJM

Atopic Dermatitis

Epistaxis

• Useful algorithm for treatment.

Intranasal Naloxone Administration

Strawberry Tongue in Streptococcal Pharyngitis

• Strawberry tongue seen in Strep but also in Kawasaki’s, this patient had 2 Kawasaki findings (tongue and lymphadenopathy) but needs fever for 5d and four additional findings (she had no rash, conjunctival injection or peripheral edema/erythema/desquamation).

PLOS ONE

Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021

• In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8–96.3%), specificity of 20.0% (19.0–21.0%), negative likelihood ratio of 0.22 (0.19–0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75%probability with +5 or more points).

REBELEM

The DEVT + SKIP Trials: Does Systemic Thrombolysis Prior to Endovascular Treatment Improve Outcomes in Large Vessel Occlusion Strokes?

• We now have three randomized controlled trials (DIRECT-MT, DEVT, SKIP) as well as retrospective, non-randomized data (Phan 2017, Rai 2018) looking at this question.
• In all three RCTs, the endovascular arm performed numerically better than the combination arm. This would appear to support a move towards endovascular therapy alone.

Diagnostic Performance of High Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite United States Cohort

• Review of the Circulation study: Diagnostic Performance of High Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite United States Cohort.
• Addition of the HEART score to an initial hs-TnT below the limit of quantification improves sensitivity and NPV for cardiac events increasing patient safety, but this strategy does rule-out fewer patients (30.8%).

Single Troponin Testing in ED Patients With Suspected Acute Myocardial Infarction

• Clinical Take Home Point: Discharging patients presenting to the ED with chest pain after a single negative conventional troponin and proper risk stratification with the HEART score can be considered to be as safe as serial troponin testing while being less time consuming, less costly and therefore more patient oriented.
• Paper: Wassie et al. Single versus serial measurements of cardiac troponin in the evaluation of emergency department patients with suspected acute myocardial infarction. JAMA Network Open 2021.

Stroke

Management of Central Retinal Artery Occlusion

A, Fundus photograph of the normal right eye. Note the normal fovea (white arrow) and the normal retinal arteries (white arrowheads). B, Fundus photograph of a left CRAO showing diffuse retinal whitening (black arrow) with a cherry red spot (yellow arrow), attenuated arteries (orange arrowheads). Note the difference in color of the edematous retina compared with the normal right eye.

World Journal of Emergency Medicine

Comparison of intraosseous access and central venous catheterization in Chinese adult emergency patients: A
prospective, multicenter, and randomized study

• The success rates of the first attempt and the procedure time were statistically significant between the IO group and the CVC group (91.7% vs. 50.0%, P<0.001; 52.0 seconds vs. 900.0 seconds, P<0.001).

American J of Emerg Med

Comparison of sustained rate control in atrial fibrillation with rapid ventricular rate metoprolol vs diltiazem

• No difference

COVID-19 in pregnancy and the puerperium: A review
for emergency physicians

Annals of Emergency Medicine

Management and Outcomes of Children With Nursemaid’s Elbow

• Radial head subluxation in 1-3 year olds is a clinical diagnosis that does not require radiographic confirmation unless a fracture is suspected.
• X-rays were done is 28.5% of patients.
• 0.3% of patients had fractures.
• Avoid unnecessary x-rays in this population.

Home Management Versus Primary Care Physician Follow-up of Patients With Distal Radius Buckle Fractures: A Randomized Controlled Trial

• Distal radius buckle (torus) fractures are the most common fractures of childhood and carry an excellent prognosis.
• Removable wrist splint for 2-4 weeks without sports.
• May return to sports after 2-4 weeks as long as they wear the splint.
• Splint removal after 4-6 weeks as long as no pain with good range of motion.
• Home management just as good as PCP referral.
• No ortho referral needed.

Risk of Leukemia in Children With Peripheral Facial Palsy

• Among 644 patients age 5 months to 17 years with acute onset palsy, 5 had leukemia identified as the cause, all demonstrated blasts on their CBC.
• Steroids can decrease the blast count, delaying the diagnosis, also increases risk of tumor lysis syndrome.
• Authors suggest a screening CBC for all kids with facial palsy before initiating steroids.

Man With Shortness of Breath

• An otherwise healthy 35-year-old active duty military infantryman presented to the emergency department, complaining of intermittent dyspnea over one-week duration, which was worsened by exertion. He recalled some unusual left leg cramping three weeks before and reported an uncomplicated tooth extraction one week before, but denied any invasive surgeries.
• This case demonstrates multiple rare but specific radiographic findings of pulmonary embolism. These include the Westermark, knuckle, and Fleischner signs, in addition to Hampton’s hump.

Man with Double Vision

A 36-year-old man presented to the emergency department with double vision. Four weeks before, he had been struck in the face and he underwent open reduction and internal fixation of a mandibular fracture. He had intact cranial nerves in the immediate postoperative period. On examination, he displayed preserved visual acuity, a right-sided cranial nerve III palsy with an inferiorly abducted right eye, loss of medial and upward gaze, significant right-sided ptosis, and asymmetric mydriasis (Figure 1 and Video E1 [available online at http://www.annemergmed.com]). A bruit was auscultated over the affected eye.

Computed tomographic angiography of the brain revealed arterial filling of the cavernous sinus, consistent with a right-sided carotid-cavernous fistula and a dilated right ophthalmic vein.

Management of Postabortion Complications for the Emergency Medicine Clinician

• Good review and algorithms to identify and manage the rare serious complication of bleeding and infection.

Retrospective Review of Pregnant Patients Presenting for Evaluation of Acute Neurologic Complaints

• Between January 1, 2010, and May 31, 2017, 205 pregnant patients presented to the ED with a neurologic chief complaint. The majority of patients had a normal neurologic examination result. Patients with an abnormal examination result were not more likely to have clinically significant imaging findings.
• Within our population, 28% underwent imaging, and noncontrast magnetic resonance imaging was the most common modality. Five patients had clinically significant imaging findings. Specifically, 3.3% of patients with abnormal examination result had significant findings and 2.3% of those with a normal examination result had significant findings.
• A normal examination result does not adequately exclude serious intracranial pathology, and diagnostic vigilance is justified.

The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial

• In patients presenting to an ED with atraumatic epistaxis that is uncontrolled with simple first aid measures, topical tranexamic acid applied in the bleeding nostril on a cotton wool dental roll is no more effective than placebo at controlling bleeding and reducing the need for anterior nasal packing.

BMJ

Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study

• The Canadian TIA Score stratifies patients seven day risk for stroke, with or without carotid endarterectomy/carotid artery stenting, and is now ready for clinical use.
• Incorporating this validated risk estimate into management plans should improve early decision making at the index emergency visit regarding benefits of hospital admission, timing of investigations, and prioritization of specialist referral.
• Excluded: had neurological deficits for more than 24 hours (that is, a stroke according to the World Health Organizationí s definition), had a decreased level of consciousness from their baseline (that is, Glasgow Coma Scale <15 in previously cognitively normal patients), had an alternative diagnosis (for example, hypoglycemia, seizure, electrolyte imbalance, or migraine), presented more than seven days after onset of the neurological symptoms, or were treated with tissue plasminogen activator or embolectomy for an acute stroke.
  • 7607 consecutively enrolled adult patients (80.6% of all potentially eligible patients)108 (1.4%) had a subsequent stroke within 7d
  • 83 (1.1%) had carotid endarterectomy/carotid artery stenting within 7d
  • 9 patients had both within 7d leaving 182 with outcomes
  • Low risk: 16.3% of patients, 7d risk of CVA or carotid procedure ≤0.5%;
  • Medium risk: 72.1% of patients, 7d risk of CVA or carotid procedure 2.3%;
  • High Risk: 11.6% of patients, 7d risk of CVA or carotid procedure: 5.9%;

• Authors recommend Head CT and routine follow-up for low risk patients, CTA head/neck for medium risk and with rapid follow-up.

Emerg Med J

None

EMRAP

Critical Care Mailbag: Intubating with Severe Acidosis- Weingart

• BIG PEARL: avoid intubation in severe metabolic acidosis patients, if possible, allow them to continue their compensatory breathing until you can correct underlying problem (especially true for easily fixable problems like DKA, less so for severe sepsis).
• Smaller pearl: cause of acidosis as important as the actual number in determining prognosis, low pH from COPD, DKA or even salicylate poisoning easier to resuscitate and better prognosis than septic shock.
• Scant evidence for bicarb boluses but Weingart doesn’t use because if patient is already maxed out on respiratory compensation, the added bicarb simply gets converted to CO2 that can no longer be blown off.
• Weingart does use 3 amps of NaBicarb in D5W drip for salicylate poisoning, but not for DKA
• Place on Vent with NIV mask with pressure support to augment respiratory drive before intubation to determine the minute ventilation that needs to be matched after intubation.
• Once patient is induced but before paralysis occurs, patient should be switch to vent settings RR 12, TV 8cc/kg, this lower RR should reduce risk of gastric dissension and vomiting.
• Once patient is intubated, empiric settings RR 30, TV 8cc/kg.
• Ask RT to confirm patient is exhaling whatever they are inhaling and not air stacking due to the high RR.
• If patient is air stacking, switch to the square breathing curve with a high inspiratory flow rate.

Chest Pain in Pregnancy: Part 3 Pulmonary Embolism- Bavolek

• Endorses the Years adjusted d-dimer approach based on the 2019 van der Pol NEJM study.
• See my post on shared decision-making for PE work-up in pregnancy.

Cerebral Venous Thrombosis

• Consider in patients with headache and hypercoagulable states: pregnancy, ocps, malignancy…
• CT venogram or MR venogram

Community Acquired Pneumonia II

• IDSA recommends only 5 days of antibiotics, not 7-14.
• Discourage azithromycin alone due to high resistance from Strep Pneumo.
• Amoxicillin plus Doxy or Macrolide for atypicals if healthy,<65 and no recent antibiotics
• Augmentin plus Doxy or Macrolide if comorbidities or >/=65 or recent antibiotics
• UPTODATE has good recommendations.

JAMA

Single vs Serial Measurements of Cardiac Troponin Level in the Evaluation
of Patients in the Emergency Department With Suspected
Acute Myocardial Infarction

• Retrospective cohort study
• 27 918 patient encounters (16 212 women [58.1%]; mean [SD] age, 58.7 [15.2] years) were included in the study.
• Of patients with an initial troponin measurement below the level of detection, 14 459 (51.8%) were discharged after a single troponin measurement, and 13 459 (48.2%) underwent serial troponin tests.
• After adjustment for cardiac risk factors and comorbidities, there was no statistically significant difference in the primary outcome of acute myocardial infarction or cardiac mortality within 30 days between the 2 groups (single troponin, 56 [0.4%] vs serial troponin, 52 [0.4%]; adjusted odds ratio, 1.41 [95% CI, 0.96-2.07]).
• Patients discharged after a single troponin test had lower rates of coronary artery bypass graft (adjusted odds ratio, 0.24 [95% CI, 0.11-0.48]) and invasive coronary angiography (adjusted odds ratio, 0.46 [95% CI, 0.38-0.56]).
• This study suggests that patients are routinely discharged from the ED after a single negative troponin test result, and when compared with serial troponin testing, a single troponin test appears safe based on current physician decision-making, with no difference in rates of 30-day cardiac mortality and acute myocardial infarction, which are low in both groups.

NEJM

Management of Antithrombotic Therapy after Acute Coronary Syndromes

• Primarily for hospitalists and cardiologists.
• Didn’t realize that addition of anticoagulant therapy to anti platelet therapy has been shown to improve outcomes after ACS but is not routinely done due to increased risk of bleeding.

Circadian Mechanisms in Medicine

Thorax

Development and validation of a prediction model for 30-day mortality in hospitalised patients with COVID-19: the COVID-19 SEIMC score

• Highly recommended by Evidence Alerts

Despite physiologic reasons why pregnant women would be at increased risk for PE (hypercoagulable state, venous stasis ), they surprisingly have roughly the same rate of diagnosed PE (32/100k) as the general population of women under the age of 40 according to Olmsted County data published by Heit and referenced by Kline, as long as you remove isolated DVT and postpartum state. Early postpartum state, on the other hand, has roughly a 10 fold increased risk (421/100k). Normal physiologic changes of pregnancy such as dyspnea, leg swelling, increased resting heart rate can all mimic PE. For this reason, as well as the specter of missing potentially deadly PE that harms two patients simultaneously, physicians have been found to overtest for VTE, with a rate of positive VTE around 4% (Kline 2014 and van der Pol 2019), which is 1/3 the rate of positive workups in the general population. To make matters worse, the traditional workup, endorsed by American Thoracic Society and ACOG in 2011, did not use risk assessment or D-Dimer in pregnant patients due to lack of prospective trials and instead went directly to duplex and CT or VQ. As Kline breaks down in his 2015 review of the workup for PE, the risks to pregnant moms from CT not only include the 1 in 500 chance of a fatal cancer, but also the 26% chance of a non-diagnostic study study (higher cardiac output and higher plasma volume during pregnancy make the timing of the bolus less reliable), and the 6-10% chance of a false positive study in low risk populations which subjects the patient to 3-6 months of anticoagulation.

For many emergency clinicians, the NEJM publication of van der Pol’s Pregnancy-Adapted Years Algorithm for Diagnosis of Suspected Pulmonary Embolism in 2019 was all we needed to begin offering patients an alternative to mandatory CT for all low risk PE workup. Righini had already published a Pregnancy PE protocol that employed risk assessment with a normal D-Dimer but unfortunately this only reduced CT utilization in 22% of pregnant patients.

The challenge with using Years to guide management is that some leading expert guidelines (ACOG and ATS) which have not been updated since 2011 still recommend CT for all or, in the case of UpToDate, are calling for a second validation study before recommending the Years approach. Years was validated by the Righini group in a post-hoc fashion and showed a 0% miss rate but a prospective validation study is not yet published.

So what is a pregnant patient and a well-intentioned physician to do?

Shared decision-making!

Here is my attempt at a shared decision-making script to help patients decide what feels best for them.

Shared decision-making for workup of PE in Pregnancy

American J of Emerg Med

Electrocardiographic Manifestations of COVID-19

• COVID-19 is a potentially critical illness associated with a variety of ECG abnormalities, with up to 90%of critically ill patients demonstrating at least one abnormality.
• The ECG abnormalities in COVID-19 may be due to cytokine storm, hypoxic injury, electrolyte abnormalities, plaque rupture, coronary spasm, microthrombi, or direct endothelial or myocardial injury.
• While sinus tachycardia is the most common abnormality, others include supraventricular tachycardias such as atrial fibrillation or flutter, ventricular arrhythmias such as ventricular tachycardia or fibrillation, various bradycardias, interval and axis changes, and ST segment and T wave changes.
• Several ECG presentations are associated with poor outcome, including atrial fibrillation, QT interval prolonga-tion, ST segment and T wave changes, and ventricular tachycardia/fibrillation.

Annals of Emergency Medicine

Emergence of Extended-Spectrum b-Lactamase Urinary Tract Infections Among Hospitalized Emergency Department Patients in the United States

• Growing percentage of hospitalized patients with UTI have resistance to ceftriaxone (17% overall during the study period of 2018-2019) but some areas of the country are much higher.

• Authors cite a 2009 study by Kumar that showed a 5 fold reduction in survival for septic shock patients who received initial empiric antibiotics that lacked in-vitro activity against the offending pathogen.
• 24% resistance to Ceftriaxone among Enterobact. isolates, 3% resistance to Pip-Taz.
• Among ESBL-confirmed isolates, resistance to Pip-Taz was 18%.
• Resistance>10% is the recommended trigger to broaden coverage.
• Authors recommend a carbapenem or amikacin for hospitalized UTI and acknowledge there is no PO option for outpatients.
• Uptodate recommends a carbapenem for septic shock patients with suspected UTI.
• Per Johnson, Acute Pyelonephritis in Adults (NEJM 2018), choose an antibiotic of a different class for initial empirical treatment of pyelonephritis when the local resistance rate to the antibiotic being considered exceeds 10%, with a lower threshold for critically ill patients.
• Bottom-line: know your hospital’s antibiogram, upgrade from Ceftriaxome if resistance is >10%.

Improved Testing and Design of Intubation Boxes During the COVID-19 Pandemic

• Intubation boxes don’t reduce aerosol but adding a vacuum and active air filtration did.

Prevalence of SARS-Cov-2 Antibodies in Emergency Medicine Providers

• Although studies from NYC early in the pandemic showed a high prevalence of prior Covid infection (31.2% and 46%) among ED providers, this study from San Francisco showed a low seroprevalence of antibodies (1%).

Normocellular Community-Acquired Bacterial Meningitis in Adults: A Nationwide Population-Based Case Series

• 2% of bacterial meningitis has normal CSF fluid cell count!
• 25% fatality rate among normocellular meningitis cases.
• Authors suggest empiric treatment in cases with a high suspicion despite normal CSF until cultures come back.

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia (Executive Summary)

• The Pneumonia Severity Index (PSI) and CURB-65 decision aids can support clinical judgement by identifying patients at low risk of mortality who may be appropriate for outpatient treatment. Although both decision aids are acceptable, the PSI is supported by a larger body of evidence and is preferred by other society guidelines (ATS/IDSA 2019 guidelines).
• Given the lack of evidence, the decision to administer a single dose of parenteral antibiotics prior to oral therapy should be guided by patient risk profile and preferences (Consensus recommendation).

BMJ

Easily Missed? Cauda Equina Syndrome

• Red flags for caudal equina in patients with sciatica
  • Onset of bilateral numbness or weakness in the legs
  • Onset of any sense of numbness or pins and needles around the anus (a “numb bum”) or genitals
  • Any alteration in the sensation of a full bladder, desire to pass urine, or awareness of passing urine

Emerg Med J

Identification of very low risk acute chest pain patients without troponin testing

• Providers completed HEAR assessments on 4979 patients and HEAR scores<1 occurred in 9.0% (447/4979) of patients. Among these patients, MACE at 30 days occurred in 0.9% (4/447; 95% CI 0.2% to 2.3%) with two deaths, two MIs and 0 revascularisations. The sensitivity and negative predictive value for MACE in the HEAR <1 was 97.8% (95%CI 94.5% to 99.4%) and 99.1% (95% CI 97.7% to 99.8%), respectively, and were not improved by troponin testing. Troponin testing in patients with HEAR <1 correctly reclassifi ed two patients diagnosed with MACE, and was elevated among seven patients without MACE yielding an NRI of 0.9% (95%CI −0.7 to 2.4%).
• Conclusion These data suggest that patients with HEAR scores of 0 and 1 represent a very low􀀁 risk group that may not require troponin testing to achieve a missed MACE rate <1%.

EMRAP

• Syncope- Amal Mattu
  • Canadian Syncope Risk Score recommended!
  • Validated in JAMA March 2020 study: Multicenter Emergency Department Validation of the Canadian Syncope Risk Score
  • Available on MDCALC
  • Per Mattu:
    • “Patients with very low to low risk (-3 to 0 points) can be discharged home with a low event rate
    • Patients with intermediate risk (1-3 points) have an 8% risk of bad outcome at 30 days (0.1% risk of death). Shared decision making is appropriate here.
    • Patients with higher risk (> 4 points) probably should be admitted in consideration of their high rate of bad outcomes, despite the low diagnostic yield.”
• Cranial Burr Hole (emergent epidural or subdural evacuation)- Jess Mason and David Beffa
  • Free 5 minute “how to do it” video: https://www.emrap.org/episode/cranialburrhole/cranialburrhole
  • “Steps of procedure (to be done on the side of the blown pupil) Knowing the anatomy from the CT head will be helpful. You can measure the thickness of the skull table so you know approximately how deep you need to go.
  • Prepare the site using sterile technique.
  • If no CT is available and the procedure is done blind, the entry site is 2 cm superior and 2 cm anterior to the tragus on the ipsilateral side of the blown pupil
  • Have an assistant hold the patient’s head hard and steady during the procedure.
  • Make a 3-5 cm vertical skin incision down to bone.
  • Insert self-retaining scalp retractor to expose periosteum.
  • Expose the skull and elevate the periosteum using the periosteal elevator.
  • Trephination technique varies by device. You may feel a change from smooth to rough as you move from outer to inner skull table.
  • An epidural hematoma will start to drain when you get through the inner table. If a subdural hematoma is present, an additional step is needed which involves a 3-sided incision to form a flap in the dura mater.
  • Place a sterile dressing.”
• Eye vs Brain– Evie Marcolini, MD and Anand Swaminathan, MD
  • Diplopia easy to distinguish, monocular diplopia most likely ocular pathology, whereas binocular diplopia is usually CNS .
    • Cranial Nerve Palsy: 3, 4, 6 (think SAH when CN 3 palsy, abduction only -no adduction, supraduction or infraduction, with acute HA)
    • Internuclear Ophthalmoplegia
  • Hard to distinguish between ocular and CNS pathology with painless, non-red, non-post-op, atraumatic monocular vision loss!
    • Uptodate has a nice algorithm for monocular vision loss.
    • The challenge is the ddx for painless, non-red, non-post-op, atraumatic monocular vision loss includes both ocular and CNS etiology.
    • Ocular: lens, vitreous hemorrhage, posterior uveitis, acute maculopathy, retinal detachment (peripheral or central loss), retinal vein occlusion, ischemic optic neuropathy (eg temporal arteritis).
    • CNS- retinal or ophthalmic artery occlusion
    • If after exam, history and ultrasound you’re not sure, patient needs transfer to tertiary center with both neurology and ophthalmology.

JACEP Open

Not all HEART scores are created equal: identifying “low-risk” patients at higher risk

• ED patients being evaluated for acute coronary syndrome shows that HEART scores of 0–5 are generally at low risk for death or acute myocardial infarction within 30 days, but points obtained from different components of the score are associated with different risk elevations.
• Specifically, any points obtained due to elevated troponin values (even in the intermediate range, cor-responding to troponin = 1 or 2 points) as well as ST deviations (cor-responding to ECG = 2 points) were predictive of higher risk than an equal number of points obtained from the other components.
• Although the HEART score still reliably identifies low-risk ED patients, further research on refinements to the score (eg, allocating additional points to the troponin component and correspondingly recalibrating the cut-off score to better match a 1% acceptable risk threshold for further testing) may better assess the risks facing patients with suspected acute coronary syndrome, allow for better risk stratification of patients with chest pain, and merits further study.

NEJM

Bupropion and Naltrexone in Methamphetamine Use Disorder

Doctor as Street-Level Bureaucrat

Atrial Fibrillation

Academic Emergency Medicine

Awake Prone Positioning in COVID-19 Hypoxemic Respiratory Failure: Exploratory Findings in a Single-center Retrospective Cohort Study

• Awake prone positioning was not associated with lower intubation rates. Caution is necessary before widespread adoption of this technique, pending results of clinical trials.

Annals of Emergency Medicine

Obtaining Blood Cultures Before the Administration of Antibiotics and other Emergency Department Fables: An Analysis of the FABLED Study

• “These data ought not change our current practice of obtaining blood cultures before antibiotic administration. As illness severity increases, the relative importance of early antibiotic administration likely takes precedence over the potential identification of a causative organism. The take-home point for ED clinicians is that timely antibiotic administration should not be delayed because of difficulties in obtaining appropriate samples for blood cultures.”

A Prospective Evaluation of Point-of-Care Ultrasonographic Diagnosis of Diverticulitis in the Emergency Department

• “Compared with CT, point-of-care ultrasonography had a sensitivity of 92% (95%confidence interval 88% to 96%), specificity of 97% (95% confidence interval 94% to 99%), positive predictive value of 94% (95%confidence interval 90% to 97%), and negative predictive value of 96% (93% to 98%) in the diagnosis of diverticulitis.”
• Check out the new 5 minute Sono Diverticulitis video later in this post

Are Emergency Practitioners Able to Diagnose Posterior Chamber Abnormalities With Point-of-Care Ocular Ultrasonography?

• In the studies limited to emergency physicians, ocular point-of-care ultrasonography had a pooled sensitivity of 92% (95% CI 67% to 99%) and specificity of 91%(95% CI 85% to 95%).
• The authors found emergency practitioner diagnosis of other posterior chamber abnormalities, including lens dislocation, globe rupture, intraocular foreign body, and vit-reous hemorrhage, using point-of-care ultrasonography to be accu-rate, but with wide CIs.
• The safety of point-of-care ultrasonography for assessment of a ruptured globe or an intraocular foreign body through a penetrating injury has not been established, and using it is not recommended.

Can an Emergency Department–Initiated Intervention Prevent Subsequent Falls and Health Care Use in Older Adults? A Randomized Controlled Trial

• The two key interventions were pharmacist review of medications and physical therapy consult.
• Compared with usual care participants (n=55), intervention participants (n=55) were half as likely to experience a subsequent ED visit (adjusted incidence rate ratio 0.47 [95% CI 0.29 to 0.74]) and one third as likely to have fall-related ED visits (adjusted incidence rate ratio 0.34 [95% CI 0.15 to 0.76]) within 6 months.

Critical Care Delivery Solutions in the Emergency Department: Evolving Models in Caring for ICU Boarders

• An ED length of stay of greater than 6 hours is estimated to be associated with a 10% increase in hospital mortality.
• A primary determinant (of ICU boarding) is ineffective throughput, reflective of a limited supply of beds, inadequate staffing for the available beds, or ineffective use of beds.
• 5 models to respond to boarding, easiest is the far right Ed-Base Critical Care Consultation Model.

Missed Opportunities to Diagnose and Intervene in Modifiable Risk Factors for Older Emergency Department Patients Presenting After a Fall

• In 96% of cases (335/349) in which one or more modifiable risk factors were present, they were not diagnosed. The most commonly missed risk factors were high-risk medications and visual acuity deficits.
• CDC 12 question checklist
• Visual acuity
• Orthostatics
• Beer’s Medication List
• Fall Prevention Algorithm
• Timed Up and Go test- sit in an arm chair, pt has to get up and walk 10 feet in 12 seconds.
• Test strength at shoulders, elbows, hips, knees.
• Test sensation in feet to rule out peripheral neuropathy.

Circulation

Randomized Pilot Clinical Trial of Early Coronary Angiography Versus No Early Coronary Angiography After Cardiac Arrest Without ST-Segment Elevation The PEARL Study

• No mortality benefit to early Cath lab for ROSC patients without STEMI

5 Minute Sono

5 minute Sono Diverticulitis

• Large curvilinear probe
• Graded compression up and down

• Diverticula

• Bowel wall>5mm

• Prominent fluid-filled bowel loops

• Pericolic free fluid

• Increased pericolic fat (hyperechoic)

• Abscess

JAMA

Comparison of Acetaminophen (Paracetamol) With Ibuprofen for Treatment of Fever or Pain in Children Younger Than 2 Years A Systematic Review and Meta-analysis

• Overall, 19 studies (11 randomized; 8 nonrandomized) of 241 138 participants from 7 countries and various health care settings (hospital-based and community-based) were included.
• In this study, use of ibuprofen vs acetaminophen for the treatment of fever or pain in children younger than 2 years was associated with reduced temperature and less pain within the first 24 hours of treatment, with equivalent safety.

NEJM

Severe Covid-19

Spontaneous Coronary-Artery Dissection

Pathophysiology of Inflammatory Bowel Diseases

Examination of the Neck Veins

Cytokine Storm

Changes in Seizure Frequency and Antiepileptic Therapy during Pregnancy

Summary of Uptodate December 2020 as well as “Dysuria- Evaluation and Differential Diagnosis in Adults“, American Family Physician article Nov 2015.

Download the summary

Academic Emergency Medicine

• Myocardial Infarction Can Be Safely Excluded by High-sensitivity Troponin I Testing 3 Hours After Emergency Department Presentation
• Randomized Double-blind Trial of Intramuscular Droperidol, Ziprasidone, and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department.
  • Another study showing the superiority of Droperidol for agitation: adequate sedation in 15 minutes better with Droperidol (64%) than Ziprasidone (35%) or Lorazepam (29%) and lower incidence of respiratory depression with Droperidol (12%) than with Ziprasidone (36%) or Lorazepam (48%).
  • Nice review of Droperidol with Reuben Strayer on EMRAP.
  • Listen to Strayer’s EMCRIT podcast on managing agitation summarized here.

American Journal of Emergency Medicine

• Complication of vasopressor infusion through peripheral venous catheter: A systematic review and meta-analysis
  • another systematic review of peripheral vasopressors showing the incredibly low rate of major complications from this approach
  • only 5 major complications (peripheral venous thrombosis) out of 1835 patients.

Annals of Emergency Medicine

• What Is the Accuracy of the Aortic Dissection Detection Risk Score?
  • Systematic review of all studies using the ADD-RS score with or without D-Dimer to rule out aortic dissection.
  • 8 retrospective studies and 1 prospective study (Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes. The ADvISED Prospective Multicenter Study. Circulation. 2017)
  • In a low prevalence setting (pretest probability 5%) ADD-RS >/=1 has a failure rate of 0.8% and an ADD-RS of 2 plus a normal D-dimer has a failure rate of 0.1%.
  • For a higher prevalence of AD (20% pretest probability), failure rate of ADD-RS alone would be 3.8%, but when adding a negative D-Dimer, the failure rate of 1 is 0.2% and 2 is 0.5%.
  • In summary, in a 5% pretest probability group, ADD-RS=0 rules out AD or ADD-RS=1 plus a negative D-Dimer rules out AD and in a 20% pretest probability group, an ADD-RS=0 or 1 plus a negative D-Dimer rules out AD.
• What Is the Efficacy of the European Society of Cardiology 0/1-Hour Algorithm for Diagnosing Acute Myocardial Infarction? High-sensitivity troponin.
  • HS-troponin will replace traditional older troponin assays.
  • This synopsis of a study in Heart showed better than 98% sensitivity for MI with a 0/1 hour protocol if pain was ❤ hours or a single troponin if pain was >3 hours.
  • The authors cite that a 2% miss rate may not be acceptable in the US but it is just one more study which reinforces the inevitable move toward high-sensitivity troponin.
• Should Nonsteroidal Anti-Inflammatory Drugs Be Used to Provide Analgesia for Fractures?
  • Pro and con pieces on whether to use NSAIDS.
  • Both pieces agree NSAIDS work well for pain, equivalent to opiates in multiple studies.
  • Both agree that risk of fracture healing is not significant when NSAIDS are used for first 72 hours.
  • Pro NSAID article argues the risk of fracture healing occurs if NSAIDS are used for>30 days, Con article says risk occurs after 3 days.

• Annals explanation: “Tubercular lymphadenitis presents as a nontender, slowly progressive, unilateral swelling most commonly in the cervical region, classically named scrofula. Because of softer cartilage in children’s airways, mediastinal lymphadenitis can cause significant morbidity and even mortality owing to mass effect on the esophagus and tracheobronchial tree.”

• Annals explanation: “Pott’s puffy tumor. A subperiosteal abscess with associated osteomyelitis of the frontal bone, often referred to as a Pott’s puffy tumor, is a rare entity in children. It can affect children of all ages, but most frequently affects adolescents. It is often a complication of acute bacterial rhinosinusitis, but has also been associated with trauma, surgery, drug use, mastoiditis, and dental infections. Clinical features include fever, headache, and forehead or scalp swelling and tenderness. Patients may also present with vomiting, lethargy, seizures, or altered mental status, depending on the extent of intracranial involvement. Diagnosis is clinical and radiographic, most commonly with CT, magnetic resonance imaging, or both. Management includes antimicrobials in addition to surgical drainage of the abscess, which is commonly polymicrobial with streptococcal, staphylococcal, and anaerobic organisms. The patient underwent operative drainage shortly after diagnosis and was maintained with broad-spectrum antibiotics for several days. She has since made a full recovery.”

BMJ

• Virology, transmission, and pathogenesis of SARS-CoV-2
• Using antibiotics wisely for respiratory tract infection in the era of covid-19
• Diabetic ketoacidosis with SGLT2 inhibitors

Chest

Fluid Response Evaluation in Sepsis Hypotension and Shock A Randomized Clinical Trial

• Randomized trial where control group got usual fluid care strategy and intervention arm got a restrictive fluid strategy driven by passive leg raise and measurement of stroke volume with a noninvasive bioreactance electrode system. The restrictive fluid group had half as many patients requiring mechanical ventilation and one third as many patients requiring dialysis.
• Currently many EDs don’t have the SV technology but it is a good reminder that less fluid is probably better.
• Poor man’s PLR is to measure the pulse pressure (systolic bp-diastolic bp) 30-90 seconds after performing PLR. PLR done by starting patient in 45 degree upright position and then laying them flat and raising legs to 45 degrees.

Clinical Infectious Disease

Infectious Diseases Society of America Guidelines on Infection Prevention for Health Care Personnel Caring for Patients with Suspected or Known COVID-19

• Latest recommendations from IDSA on how to protect healthcare workers.
• Nothing new except they no longer have a recommendation to wear double gloves and shoe coverings.

EMRAP

• Cardiology Corner: Pulmonary Embolism Updates- Mattu
  • Mattu spotlights the 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) published in Jan 2020 which recommends:
  • Use YEARS (Lancet 2017) clinical score on MDCALC to rule out PE with a low probability score and D-Dimer<1000. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study, Lancet 2017.
  • Use Pregnancy-Adapted YEARS (NEJM 2019) to rule out PE with a low probability and D-Dimer <1000. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. Adjusted D-Dimer allowed reduced CT utilization (61%) compared to a similar algorithm without an adjusted D-dimer (84%)- (Righini M, Robert-Ebadi H, Elias A, et al. Diagnosis of pulmonary embolism during pregnancy: a multicenter prospective management outcome study. Ann In- tern Med 2018;169:766-73).

• Critical-care-mailbag-tube-exchange
  • Weingart breaks down how to replace an endotracheal tube with a cuff rupture or some type of obstruction.
• High-flow-nasal-cannula-oxygen
  • only works for type 1 hypoxemia respiratory failure, not type 2 hypercarbic respiratory failure.
  • Mallemat recommends starting at highest settings 60LPM, 100% FiO2, then weaning down as needed.

JAMA

Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia. The SALSA Randomized Clinical Trial

• Another study showing the benefit of hypertonic saline bolus to treat symptomatic hyponatremia. Unfortunately many hospitals do not allow hypertonic saline boluses, instead insisting on slow infusions of hypertonic saline not to exceed 30ml/hr, or they insist on using a central line despite studies cited by UPTODATE showing peripheral infusion is safe (Incidence of Adverse Events During Peripheral Administration of Sodium Chloride J Intensive Care Med. 2018 and Safety of Continuous Peripheral Infusion of 3% Sodium Chloride Solution in Neurocritical Care Patients Am J Crit Care. 2016).
• I was able to get my hospital to agree to the 100cc hypertonic saline bolus after citing the articles and blog posts referenced here, citing that UPTODATE recommends rapid intermittent bolus therapy for severe symptomatic hyponatremia, and explaining that without the bolus option physicians are forced to use normal saline which can paradoxically lower the already low sodium concentration in SIADH patients because the saline infusion induces a diuresis of concentrated urine which (read the explanation in this UPTODATE chapter).

NEJM

• Migraine
  • Review article more geared to primary care but has a nice tables of three classes of migraine and algorithm for outpatient treatment and prevention.
  • My one page summary.

• Esophageal Motility Disordersand Gastroesophageal Reflux Disease
• Rethinking Covid-19 Test Sensitivity — A Strategy for Containment
  • rather than focus on super sensitive PCR tests that are more expensive and have a slower turnaround, choose less sensitive antigen tests which cost <$5 and can be done at home or point of care with quick results.
  • the key is frequent testing to catch someone early in their period of transmissibility to break chain of spread.
  • since the trajectory of virus replication is exponential at beginning, the difference in time between when a low sensitivity and high sensitivity test become positive could be a matter of hours.

• “You Are Now Entering a Guilt-free Zone”
  • Proactively stating, “before we go on, I need to tell you something about me, I don’t do guilt,” can help ease a patient’s anxiety about answering questions of health behaviors (e.g. drugs, tobacco, alcohol, etc).

Resuscitation

Cardiopulmonary Resuscitation during the COVID-19 pandemic. Do supraglottic airways protect against aerosol-generation?

Great ECG weekly from Amal Mattu on August 10, 2020. Attached is a 1 page summary with ECG pictures, supplemented by info from Steve Smith’s blog and LITFL.

Summary of UPTODATE Pregnancy and Diagnostic Imaging (radiation and contrast risk)