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

Raam R, Tabatabai RR. Headache in the emergency department: avoiding misdiagnosis of dangerous secondary causes, an update. Emerg Med Clin North Am 2021 Feb;39(1):67-85. doi: 10.1016/j.emc.2020.09.004. PMID: 33218663.

Powers WJ. Acute ischemic stroke. N Engl J Med 2020 Jul 16;383(3):252-60. doi: 10.1056/NEJMcp1917030. PMID: 32668115.

Long DA, Koyfman A, Long B. Oncologic emergencies: palliative care in the emergency department setting. J Emerg Med 2021 Feb;60(2):175-91. doi: 10.1016/j.jemermed.2020.09.027. PMID: 33092975.

Musey PI Jr, Bellolio F, Upadhye S, Chang AM, Diercks DB, Gottlieb M, et al. Guidelines for reasonable and appropriate care in the emergency department (GRACE): recurrent, low-risk chest pain in the emergency department. Acad Emerg Med 2021 Jul;28(7):718-44. doi: 10.1111/acem.14296. Epub 2021 Jul 6. PMID: 34228849.

Herring AA, Perrone J, Nelson LS. Managing opioid withdrawal in the emergency department with buprenorphine. Ann Emerg Med 2019 May;73(5):481-7. doi: 10.1016/j.annemergmed.2018.11.032. PMID: 30616926.

Gottlieb M. Shoulder dislocations in the emergency department: a comprehensive review of reduction techniques. J Emerg Med 2020 Apr;58(4):647-66. doi: 10.1016/j.jemermed.2019.11.031. PMID: 31917030.

PSP Investigators. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med 2020 Jan 30;382(5):405-15. doi: 10.1056/NEJMoa1910775. PMID: 31995686.    

Maughan BC, Frueh L, McDonagh MS, Casciere B, Kline JA. Outpatient treatment of low-risk pulmonary embolism in the era of direct oral anticoagulants: a systematic review. Acad Emerg Med 2021 Feb;28(2):226-39. doi: 10.1111/acem.14108. PMID: 32779290.

Wardi G, Brice J, Correia M, Liu D, Self M, Tainter C. Demystifying lactate in the emergency department. Ann Emerg Med 2020 Feb;75(2):287-98. doi: 10.1016/j.annemergmed.2019.06.027.

Williamson DA, Chen MY. Emerging and reemerging sexually transmitted infections. N Engl J Med 2020 May 21;382(21):2023-2032. doi: 10.1056/NEJMra1907194. PMID: 32433838.

Peck KA, Ley EJ, Brown CV, Moore EE, Sava JA, Ciesla DJ, et al. Early anticoagulant reversal after trauma: a western trauma association critical decisions algorithm. J Trauma Acute Care Surg 2021 Feb 1;90(2):331-6. doi: 

Academic Emergency Medicine

None

American Journal of Emergency Medicine

Modified PRIEST score for identification of very low-risk COVID patients

Annals of Emergency Medicine

Risk of Traumatic Brain Injuries in Infants Younger than 3 Months With Minor Blunt Head Trauma

• Of the 514/1081 (47.5%) infants who met the PECARN low-risk criteria, 1/514 (0.2%, 95% confidence interval [CI] 0.005% to 1.1%), had clinically important traumatic brain injuries1/514 (0.2%, 95% confidence interval [CI] 0.005% to 1.1%)

Managing Diabetic Ketoacidosis in Children

Caring for Transgender Patients: Complications of Gender-Affirming Genital Surgeries

Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department

Preventing Post-Lumbar Puncture Headache

• Use pencil tip (Sprotte or Whittacre) rather cutting tip (Quincke) needles to reduce risk of post LP headache, does not affect success of LP.

BMJ

Circulation

Early Rhythm Control Therapy in Patients With Atrial Fibrillation and Heart Failure

EMCRIT

Emergency Medicine Journal

Multicentre external validation of the Canadian Syncope Risk Score to predict adverse events and comparison with clinical judgement

EMRAP

Heat Stroke

• Use a body bag (the same ones used to transport patients to the morgue) to cool patient rapidly in 20-30 minutes. Put patient in the bag and fill with ice and water.

Critical Care Mailbag: Perfusion Index

• Pulse ox waveform depends on perfusion index (ratio of pulsatile blood over non-pulsatile blood), <0.5 has a poor waveform.
• Low cardiac output (cardiogenic shock) or vasoconstriction (hemorrhagic shock) cause lower perfusion index and poor waveform, while septic shock tends to be warm and hypotensive due to poor vasoconstriction.

Myasthenia Gravis

• Have patient count to 40, if they can’t get past 15, patient at risk for respiratory failure.
• Avoid Succinylcholine, unpredictable response

Tachycardia in Pregnancy

• Diltiazem, Adenosine, Procainamide good
• Amiodarone bad
• Cardiovert if necessary, avoid abdomen

JAMA

None available free. Basics trial showed no difference between NS and balanced crystalloid but not available for free.

Journal of Emergency Medicine

Journal of Clinical Virology

Comparing the diagnostic accuracy of rapid antigen detection tests to real time polymerase chain reaction in the diagnosis of SARS-CoV-2 infection: A systematic review and meta-analysis

• Sensitivity of RADTs is 68%, 99% specific.  Sensitivity 87% in patients with </=5 days of symptoms.

Lancet

Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure- a randomised, controlled, multinational, open-label meta-trial

• See review of article in REBELEM below.

NEJM

Medicare for More — Why We Still Need a Public Option and How to Get There

Treatment of Acute Uncomplicated Appendicitis

PEDIATRICS

None

REBELEM

The PRIEST Score: Predicting Adverse Outcomes in COVID-19

Rebellion21: 5 Things Your Intensivist Wishes You did in the ED for Critically Ill Patients via Sara Gray, MD

1. Optimize Resuscitation
   1. POCUS to assess fluid resuscitation
   2. Adequate IV access
   3. Foley
   4. NG tube
   5. HOB elevation
   6. Early antibiotics in appropriate cases
2. Optimize Ventilator Parameters
   1. Wean FiO2 as tolerated (Avoid hyperoxia)
   2. TV 4 – 8cc/kg ideal body weight
   3. Continuous EtCO2 tracing
3. Sedation Strategy
   1. Optimize pain control – Analgesia 1^st strategy
   2. Add sedation 2^nd
4. Peripheral Pressors Safely
   1. Big (≥18g) IV in a proximal site to prevent extravasation
   2. Check site q1hr for color, temperature, and perfusion (Compare to contralateral side)
5. Communication
   1. What is patients code status? Who did you confirm code status with?
   2. Easy or difficult airway? Has ramifications for how quickly/safely extubation can occur

RECOVERY RS: CPAP vs HFNO vs Conventional Oxygen Therapy in COVID-19

• For patients with COVID-19 pneumonia and acute hypoxemic respiratory failure, CPAP reduced the need for intubation compared to conventional oxygen therapy. However, HFNO did not reduce the need for intubation compared to conventional oxygen therapy. Neither intervention showed a statistically significant mortality benefit compared to conventional oxygen therapy, however, the study was not powered for this outcome.  Although the conclusion of the trial is CPAP > HFNO > COT, there may be some scenarios where HFNO > CPAP to reduce adverse events (i.e awake prone positioning, patient nutrition, etc).  
• IBCC/Farkas agrees.

Awake Proning for COVID-19 Acute Hypoxemic Respiratory Failure

• This is the highest-level evidence we have to date on awake prone positioning. In this trial of patients with hypoxemic respiratory failure due to COVID-19, awake prone positioning reduced the incidence of treatment failure (intubation and death), which was primarily driven by decreased intubation compared to standard care.  Not only was there no signal of harm from awake prone positioning, but even longer durations of awake prone positioning (>8hrs/day) were associated with a lower risk of treatment failure.

Academic Emergency Medicine

Antibiotics for culture- positive asymptomatic bacteriuria in pregnant women can prevent pyelonephritis

• Abx reduce complications in culture positive asymptomatic bacteriuria, which is a subset of asymptomatic bacteriuria before culture performed.
• Uptodate makes no mention of checking UA in pregnant patients with abnormal vaginal bleeding. I was taught in residency to do this to rule out occult UTI as a cause of threatened miscarriage, then the UA always comes back with a few wbcs or bacteria and I feel obliged to treat. I’m gonna stop!

Ankle– brachial index for diagnosis of arterial injury in penetrating extremity trauma

• ABI not good enough by itself to rule out vascular injury but if ABI normal (>0.9) and no hard signs then you are done.
• ABI performed by measuring normal brachial cuff systolic bp and dividing by systolic bp measured at the ankle with the cuff just above the malleoli.
• Eastern Association of Surgery in Trauma guideline says:
  • patients with hard signs go to the OR
  • patients with no hard signs, a normal exam and a normal ABI (>0.9) may be discharged (proximity to a vessel not enough to do CTA).
  • patients without hard signs but with an abnormal exam or ABI should get CTA.

American Journal of Emergency Medicine

None this month

Annals of Emergency Medicine

Rapid Agitation Control With Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial

• Ketamine 6 minutes vs Haldol 5mg Midazolam 5mg 15 minutes

A Prospective Evaluation of Clinical HEART Score Agreement, Accuracy, and Adherence in Emergency Department Chest Pain Patients

• ED clinicians had only moderate agreement with research HEART scores. Combined with uncertainties regarding accuracy in predicting major adverse cardiac events, we urge caution in the widespread use of the HEART score as the sole determinant of ED disposition.

A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages

• Droperidol 5mg and Olanzapine (Zyprexa) 10mg achieved sedation in same time 16 minutes with same side effect incidence

BMJ

None this month

Circulation

Myocarditis With COVID-19 mRNA Vaccines

Diagnosis and Management of Myocarditis in Children

EMCRIT

None this month

Emergency Medicine Journal

EMRAP

Extremity Arterial injury

Electrical Storm

Pediatric Pearls- Insulin Pumps

JAMA

None this month

NEJM

Case 24-2021: A 63-Year-Old Woman with Fever, Sore Throat, and Confusion

Therapeutic Anticoagulation with Heparin in Critically Ill Patients with Covid-19

Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19

• Showed a benefit to therapeutic anticoagulation in non-critically ill but this benefit was small per Uptodate and other studies have not shown a benefit and the incidence of thromboembolic events in hospitalized patients are lower now than earlier in the pandemic, possibly related to the use of steroids and tocilizumab.

PEDIATRICS

Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old

REBELEM

COVID-19 and Anticoagulation: Full Dose or Prophylactic Dose?

• In CRITICALLY ILL patients with COVID-19, an initial strategy of therapeutic-dose anticoagulation is not associated with a greater probability of survival to hospital discharge or a greater number of days free of cardiovascular or respiratory organ support vs usual-care pharmacologic thromboprophylaxis
• In NON-CRITICALLY ILL patients with COVID-19, an initial strategy of therapeutic-dose anticoagulation is associated with a greater probability of survival to hospital discharge or a greater number of days free of cardiovascular or respiratory organ support vs usual-care pharmacologic thromboprophylaxis
• In NON-CRITICALLY ILL patients with COVID-19, there is a clear signal of benefit, however with all the protocol violations and variable treatment arms it would still be reasonable to discuss with the inpatient team to help guide the decision (Although, in my practice and at my institution most patients who are not critically ill and don’t have contraindications, we have changed our protocols to full dose anticoagulation).

Academic Emergency Medicine

Guidelines for reasonable and appropriate care in the
emergency department (GRACE): Recurrent, low- risk chest
pain in the emergency department

American Journal of Emergency Medicine

No articles this month

Annals of Emergency Medicine

Managing a Cutaneous Abscess in the Emergency
Department

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

BMJ

Use of cast immobilisation versus removable brace in adults with an ankle fracture: multicentre randomised controlled trial

• No difference in outcome at 16 weeks
• Population was all ankle fractures managed nonoperatively
• Duration on non-weightbearing, period of immobilization up to clinician and patient.

Circulation

AHA Scientific Statement. Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association

EMCRIT

PulmCrit – Is piperacillin-tazobactam safe in patients with penicillin allergy?

Subarachnoid Hemorrhage (SAH)

Emergency Medicine Journal

Diagnostic yield of bacteriological tests and predictors of severe outcome in adult patients with COVID-19 presenting to the emergency department

• In this retrospective study of patients receiving blood cultures at a hospital in The Netherlands, we found that 6.3% of patients with SARS- CoV-2 had positive blood cultures and all were considered contaminated. Overall bacterial coinfection using other diagnostics was 1.4%. This suggests that in patients known to have SARS- CoV-2, blood cultures are unlikely to be of use.

• Procalcitonin and the Pneumonia Severity Index seem most promising to recognise patients at risk for severe outcome of COVID-19 when presenting to the ED.

EMRAP

Traumatic Arthrotomy

• A traumatic arthrotomy is a laceration that extends into the joint capsule exposing the intra-articular surface to the environment. It is important to identify, as operative washout, debridement and proper closure of the joint capsule is required.
• Instill saline into the joint and see if it leaks out through the laceration. Leakage of saline means you have an arthrotomy.
• For the knee, a load of 194 mL achieves 95% sensitivity.
• Keese GR, Boody AR, Wongworawat MD, Jobe CM. The Accuracy of the Saline Load Test in the Diagnosis of Traumatic Knee Arthrotomies. Journal of Orthopaedic Trauma. 2007;21(7):442-443. doi: 10.1097/BOT.0b013e31812e5186.

Frontiers in Medicine

The Risk of COVID-19 Related Hospitalsation, Intensive Care Unit
Admission and Mortality in People With Underlying Asthma or COPD: A
Systematic Review and Meta-Analysis

• Risk increased with COPD but not with asthma.

JAMA

Ways to Quit Smoking

Lancet

Acute respiratory distress syndrome

NEJM

Administration of Supplemental Oxygen

Cerebral Venous Thrombosis

Depression in Adolescents

Hematuria in Adults

Initial Management of Seizure in Adults

Substance Use among Men Who Have Sex with Men

PLOS ONE

Relative sensitivity of anterior nares and nasopharyngeal swabs for initial detection of
SARS-CoV-2 in ambulatory patients: Rapid review and meta-analysis

• Sensitivity of anterior nares is lower (82-88%) than nasopharyngeal (98%) but in a population with 10% positivity, the negative predictive value is still greater than 98%.

REBELEM

None

Academic Emergency Medicine

Functional Neurological Disorder in the Emergency Department

• Evolving definition of the previously termed conversion disorder, now called functional neurological disorder (FND) in which there is loss of motor or sensory or presence of seizure activity without any evidence of structural pathology.
• Can be thought of as a software problem rather than a hardware problem
• Two useful tests are hip abductor sign (hip abduction felt on one side while and hoover’s sign

American Journal of Emergency Medicine

Lay-rescuers in drowning incidents: A scoping review

• Lay rescue highly dangerous and can result in 2 drowning deaths, recommendations are to rescue from land (e.g. pole, buoy, etc).

Anesthesia Pain Med

The Role of Opioids in Pain Management in Elderly Patients with Chronic Kidney Disease: A Review Article

Annals of Emergency Medicine

Adverse Events Among Emergency Department Patients With Cardiovascular Conditions: A Multicenter Study

• Management errors were varied and remarkable for the frequency of patients with elevated troponin levels which were not repeated, and there was no indication that the elevated value was appreciated in the health record.
• For patients with atrial fibrillation, unappreciated dual diagnoses (eg, acute heart failure, community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease), clinical severity, and missing the underlying cause contributed to diagnostic errors (eg, pulmonary embolism, community-acquired pneumonia).
• 3 cases of patients experiencing adverse drug effects related to warfarin and 3 related to direct oral anticoagulants.
• Two patients with recent-onset atrial fibrillation and elevated Congestive Heart Failure, Hypertension, Age, Diabetes, previous Stroke scores were discharged without anticoagulation and returned with severe strokes.
• Although patients discharged with syncope had fewer adverse events, the majority of events (10) were diagnostic errors, and 2 key contributing factor themes were failure to seek an underlying cause (eg, end-stage heart failure, community-acquired pneumonia, gastrointestinal bleeding) and lack of recognition of injuries related to the fall from syncope (eg, missed fractures)

Does Intravascular Temperature Management Improve Outcomes Compared With Surface Cooling in Comatose Adults After Cardiac Arrest?

• Although intravascular temperature management does not improve survival compared with surface-cooling methods in post–cardiac arrest patients, it may improve neurologic outcomes.

Adolescent Male With Severe Renal Trauma

• A 15-year-old previously healthy boy was admitted for a blunt abdominal trauma owing to a cycling crash. On admission he was alert; blood pressure and pulse rate were 145/95 mm Hg and 75 beats/min, respectively. Physical examination result was remarkable for severe left-sided flank pain with guarding. No others injuries were found. His urine was like blood and laboratory tests showed a normal hemoglobin level, at 13.5 g/dL, with hematocrit level 40.9%.
• An abdominal ultrasonographic scan showed major left kidney trauma (Figure 1). A computed tomographic (CT) scan confirmed a grade IV renal laceration, according to the American Association for the Surgery of Trauma classification (Figure 2).

Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial

• IV Haldol .05mg/kg better than IV Zofran

BMJ

Treatment of opioid use disorder in primary care

• Prescription Opioid Misuse Index is 82% sensitive and 92% specific with a score >/=2.

Circulation

High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction: A Stepped-Wedge Cluster Randomized Controlled Trial

• Reduced hospitalization by 59% and LOS by 3.3 hours with better 1 year mortality and MI outcomes.

EMCRIT

Traumatic Brain Injury (TBI)

Posterior Reversible Encephalopathy Syndrome (PRES)

PulmCrit – A history of hypothermia for cardiac arrest, 2002-2021 (RIP)

EMCrit 300 – Airway Continuous Quality Improvement and the Resus Airway Bundle

Emergency Medicine Journal

No articles this month

EMRAP

ACEP Statement on Antitussives

• Avoid any meds for cough in kids.
• Can you honey if >/=1yo.

Dysuria (not a UTI)

JAMA

No articles this month

NEJM

Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest

• In patients with coma after out-of-hospital cardiac arrest, targeted hypothermia did not lead to a lower incidence of death by 6 months than targeted normothermia.

HIV Infection Screening, Diagnosis, and Treatment

The Evolving Challenge of Infections in Cirrhosis

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

REBELEM

Should we Consider Endovascular Therapy for Acute Basilar Artery Occlusion?

Droperidol: Making a Comeback!!!

• Gaw CM et al. Effectiveness and Safety of Droperidol in a United States Emergency Department. AJEM 2020.
• Over 6000 cases no fatal arrhythmias or deaths.

Academic Emergency Medicine

Multivariable risk scores for predicting short-term outcomes for emergency department patients with unexplained syncope: A systematic review

• Conclusion: “Many risk stratification scores are not validated or not sufficiently accurate for clinical use. The CSRS is an accurate validated prediction score for ED patients with unexplained syncope. Its impact on clinical decision making, admission rates, cost, or outcomes of care is not known.”

Can we predict which COVID-19 patients will need transfer to intensive care within 24 hours of floor admission?

• Of the 542 included patients, 46 (10%) required transfer to ICU within 24 hours of admission. The final composite model, adjusted for age and admission location, included history of heart failure and initial oxygen saturation of <93% plus either white blood cell count > 6.4 or glomerular filtration rate < 46. The odds ratio (OR) for decompensation within 24 hours was 5.17 (95% confidence interval [CI] = 2.17 to 12.31) when all criteria were present. For patients without the above criteria, the OR for ICU transfer was 0.20 (95% CI = 0.09 to 0.45).

A qualitative study of emergency department patients who survived an opioid overdose: Perspectives on treatment and unmet needs

• Take home: use the brief negotiation interview (BNI) to help motivate patients to start Suboxone.

American Journal of Emergency Medicine

No articles this month

Annals of Emergency Medicine

Between Emergency Department Visits: The Role of Harm Reduction Programs in Mitigating the Harms Associated With Injection Drug Use

• Harm reduction for ED patients with injection drug use includes free dispensation of Naloxone (learn more about how EDs can get free naloxone to dispense here), and syringe services programs (find the SSP closest to you here).

The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department

• 2.6% of patients intubated patients recall an awareness of paralysis, with a two-fold risk among patients paralyzed with rocuronium (have your sedative ready to hang immediately after intubation).

BMJ

Treatment of opioid use disorder in primary care

California Bridge

Important Takeaways: HHS Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder

• Here’s the most important takeaway of the “HHS Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder”: All prescribers with a valid state license and DEA can register for an X wavier without mandatory training. It’s now a simple process. Get your X waiver TODAY!

Circulation

No articles this month

EMCRIT

IBCC – Approach to the poisoned patient

IBCC – Cardiac glycoside poisoning (including digoxin)

IBCC – Thrombotic microangiopathies (TTP, HUS, et al.)

Emergency Medicine Journal

No articles this month

EMRAP

Pharmacology Rounds: Electrolyte Repletion

• PO Potassium Bicarbonate more palatable than KCl, dose is 50meq PO
• Oral Magnesium Oxide 400-800mg tablet
• Mag IV 4-8g if Mag<1, 2-4g if mag 1-1.4, 1-2g if Mag 1.5-1.9.
• Calcium: 2g CaGluconate over 1 hour if sick.
• Phosphate: typically replete if Phos<1, give Potassium Phos if K is low, give Sodium Phos if serum potassium is high, can give 15, 30 or 45 mmol depending on how low phosphate level is, typically 15 mmol/hr

Talking About Code Status

• Ask permission to share bad news: “I am afraid I have serious news. Would it be ok if I share?”
• Align: “We need to work together quickly to make the best decisions for her care”.
• Baseline function: “To decide which treatments might help her the most, I need to know more about her, what type of activities was she doing before her illness.”
• “How much more would she be willing to go through for the possibility of more time?”
• Summarize

Neonatal Resuscitation Updates

• Good tone and respirations: hand baby to mom
• Poor tone: warm baby, stimulate, suction if signs of obstruction
• Place on monitor
• If HR<100 start BVM
• If HR<60, intubate, cpr, epi dose .03-.05 mg/kg
• Compressions: 3 compressions to 1 breath, 120 total/min, 90 compressions, 30 breaths
• Preferred venous access is a 5f umbilical vein line, inserted in the little mouth of the umbilical stump face (umbilical arteries are the eyes, vein is the mouth). insert the 5f line 4-5cm until blood returns.
• IO also an option but has a higher failure rate than in older kids.
• Consider termination of CPR after 20 minutes with no detectable heart rate.

JAMA

Effect of Helmet Noninvasive Ventilation vs High-Flow Nasal Oxygen on Days Free of Respiratory Support in Patients With COVID-19 and Moderate to Severe Hypoxemic Respiratory FailureThe HENIVOT Randomized Clinical Trial

• No difference

NEJM

Gastric Emptying Abnormalities in Diabetes Mellitus

The Number Needed to Prescribe — What Would It Take to Expand Access to Buprenorphine?

Bringing Harm Reduction into Health Policy — Combating the Overdose Crisis

Management of the Difficult Airway

Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion

• No difference from medical management

REBELEM

Twitter

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).