Annals of Emergency Medicine

Clinical Effects of Psychedelic Substances Reported to United States Poison Centers: 2012 to 2022

• Hallucinogenic amphetamines (MDMA), lysergic acid diethylamide, tryptamines (such as N, N-dimethyltryptamine), phencyclidine, hallucinogenic mushrooms, hallucinogenic plants, and ketamine and ketamine analogs. Over half of psychedelic exposures reported to US poison centers had symptoms that required treatment, severe residual or prolonged symptoms, or death. Increases in psychedelic use may lead to increased frequency of adverse events and health care utilization.

Comparing Intubation Rates in Patients Receiving Parenteral Olanzapine With and Without a Parenteral Benzodiazepine in the Emergency Department

• No difference in cardiorespiratory depression between patients receiving only olanzapine versus olanzapine plus a benzodiazepine

ACEP Clinical Policy: Critical Issues in the Evaluation and Management of Adult Out-of-Hospital or Emergency Department Patients Presenting With Severe Agitation

• Is there a superior parenteral medication or combination of medications for the acute management of adult out-of-hospital or emergency department patients with severe agitation?
  • Level A recommendations. None specified.
  • Level B recommendations. For more rapid and efficacious treatment of severe agitation in the emergency department, use a combination of droperidol (5mg) and midazolam (2.5mg IM or IV if <50kg, 5mg if >50kg) or an atypical antipsychotic, olanzapine (5mg IM/IV) in combination with midazolam (2.5mg IM or IV if <50kg, 5mg if >50kg). If a single agent must be administered, use droperidol or an atypical antipsychotic (olanzapine) due to the adverse effect profile of midazolam alone.
  • Level C recommendations. In situations where safety of the patient, bystanders, or staff is a concern, consider ketamine (intravenous or intramuscular) to rapidly treat severe agitation in the ED (Consensus recommendation).
• No recommendations for or against the use of specific agents in the out-of-hospital setting can be made at this time (Consensus recommendation).
• No recommendation for or against the use of specific agents in patients above the age of 65 years can be made at this time (Consensus recommendation).

Clinical Policy: Use of Thrombolytics for the Management of Acute Ischemic Stroke in the Emergency Department

• Lytics can be offered and given prior to endovascular thrombectomy.

CJEM

None

EMCRIT

Managing Emergency Endotracheal Intubation Utilizing a Bougie

• Advantages when used with standard geometry laryngoscopy:
  • improved field of view as the bougie approaches the glottis compared to a larger ETT
  • narrower profile also beneficial for airway edema, epiglottis

• Disadvantages
• Procedure
  • Preparation
    • Curve the bougie using the “snail tail” technique. Curving may reduce the need to remove the bougie and reshape it later if the trachea cannot be cannulated on the first attempt with a straight bougie.
    • Grip
      Utilizing a right-handed “tripod” grip proximal to the midpoint of the bougie (Figure 5) allows the middle finger that is behind/under the bougie to apply leverage, which may facilitate microadjustments of the coudé tip.
    • Operators should look into the mouth as the bougie is inserted and not the screen if video laryngoscopy is utilized. If curved, the bougie can be inserted at the midline alongside the curve of the laryngoscope (Figure 6) with a rotational motion that brings the coudé tip toward the glottis. The coudé tip is angled anteriorly as it passes through the cords.
    • If kept straight, the bougie should be inserted initially at the corner of the mouth.
    • If the coude hangs up at the tracheal cartilage rotate clockwise.
    • Advancement can cease once the black line (23 cm) is even with the teeth or if “hold up” occurs.
    • The ETT should be advanced over the bougie past the corner of the mouth to the glottis. As the bevel tip approaches the glottis, it should be intentionally rotated 90° counterclockwise and advanced into the trachea to the proper depth. Counterclockwise rotation directs the ETT bevel posteriorly, which avoids hang-up on the arytenoids
  • Troubleshooting
    Challenges with advancing the bougie or the ETT exist, but operators should employ the following maneuvers if experiencing difficulty.²¹ Failing to respond appropriately to these challenges has been described as distinct performance errors noted during standard geometry video laryngoscopy.²²
    • Bougie Hang-Up
      If the coudé tip becomes stuck on the anterior tracheal rings despite optimal vallecula manipulation, there are remedies. Continuing to hold the bougie’s shaft, operators should discontinue forward pressure and apply a 90° rotation to release the coudé tip and allow advancement. If rotation fails, the operator can move to the proximal end of the bougie and employ a “twirl” technique that will transfer rotational forces to the coudé tip and release it from the tracheal rings.
    • ETT Hang-Up
      If the ETT cannot be advanced through the glottis over the bougie, it is often stuck on the arytenoids. Operators should halt forward pressure, pull back slightly on the ETT, and rotate the ETT bevel tip 90° counterclockwise to the 12 o’clock position in the tracheal opening before advancing into the trachea.
    • Loss of View Due to Premature Removal of Laryngoscope
      Operators may hastily remove the laryngoscope before visualizing the ETT going through the cords over the bougie. This causes the tongue and oropharyngeal structures to collapse posteriorly and can potentially inhibit ETT delivery. If this occurs, operators should re-establish the view first instead of withdrawing the ETT or bougie (Video E13, available at http://www.annemergmed.com).

RACC Lit Review December

• Steroids, Steroids, Steroids
  • Give steroids for resistant septic shock, ARDS, & severe CAP
  • Chaudhuri, Dipayan, Andrea M. Nei, Bram Rochwerg, Robert A. Balk, Karim Asehnoune, Rhonda Cadena, Joseph A. Carcillo, et al. “2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia.” Critical Care Medicine 52, no. 5 (May 2024): e219–33. https://doi.org/10.1097/CCM.0000000000006172.

• Effect of Order of Intubation Meds on FPS
  • Catoire, Pierre, Brian Driver, Matthew E. Prekker, and Yonathan Freund. “Effect of Administration Sequence of Induction Agents on First-Attempt Failure during Emergency Intubation: A Bayesian Analysis of a Prospective Cohort.” Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, October 18, 2024. https://doi.org/10.1111/acem.15031.
  • Give Roc before Etomidate (Roc takes 60 seconds to fully paralyze)

• Low-Dose Tenecteplase for PE
  • 1/2 Dose tenecteplase
  • Hammond, Jennifer, Dean Cataldo, Christopher Allison, and Seth Kelly. “Reduced-Dose Tenecteplase in High-Risk Pulmonary Embolism.” Journal of Emergency Medicine 0, no. 0 (November 2, 2024). https://doi.org/10.1016/j.jemermed.2024.10.011.

EMRAP

Cardiology Corner: Asymptomatic QTc Prolongation

Amal Mattu, MD, and Anand Swaminathan, MD

Amal and Swami discuss QTc prolongation. We all know what to do with patients who present to our ED with a syncopal episode in the setting of a prolonged QT, but what about QT prolongation in asymptomatic patients? Listen as they discuss how to manage the asymptomatic patient with QT prolongation.

• Why is a prolonged QT in the setting of syncope clinically significant?
  • The danger of the prolonged QT in syncope is torsade de pointes
  • Differential: hypocalcemia, hypokalemia, hypomagnesemia, congenital long QT syndrome, or medication side effect
  • Disposition: admit patients with prolonged QTc to a telemetry bed in the setting of syncope
• Definition of a prolonged QTc interval:
  • In men, corrected QT interval >440 msec
  • In women, corrected QT interval >460 msec
  • The corrected QT interval adjusts for QT length at heart rate extremes. The most accurate QTc calculation is between heart rates of 60 to 100 beats per minute.
• At what QTc should we begin to worry about torsade?
  • Increased risk for torsade begins at >500 msec.
  • We do not need to calculate the QTc manually. The QTc provided by an ECG is reliable in the absence of artifact.
    • Consider calculating the QT in specific cases such as drug overdoses or ECGs with artifact.
• How should we be managing asymptomatic patients (ie, those not presenting with syncope and those without a family history of sudden cardiac death) with a prolonged QT?
  • There is no standard of care. 
  • Amal recommends the following:
    • Check electrolytes and, if possible, correct abnormal findings.
    • Perform a thorough medication history and address changes of medications with the patient’s primary care provider (PCP) or do so yourself in the ED.
    • If incidental finding without a discernible cause, then be sure to recommend follow-up for prolonged QTc with PCP. 
• How soon should patients follow up when they are discharged with an incidental finding of a prolonged QT?
  • There is no current standard of care. Consider changing the urgency of follow-up based on the QT interval. A QT interval of 600-700 may need an urgent follow-up in 1-2 days, as opposed to routine follow-up for QTs in the 500 range.
  • Asymptomatic patients with a prolonged QT should be discharged irrespective of the length of the QT. Be sure to arrange follow-up or consult cardiology to arrange prompt follow-up for extremes.
• How can we better manage patients with a prolonged QT who are chronically on QT-prolonging medications?
  • If the QT >600 msec, or if there has been a rapid rise in a patient’s QT, then consider calling their PCP and coordinating changes to their medications. 
  • If prescribing new medications, remember that we often prescribe QT-prolonging agents (eg, ondansetron, prochlorperazine, quinolones).
    • Avoid putting patients at higher risk of torsades. Look for alternative medications or avoid QT-prolonging medications altogether.
      • Consider benzodiazepines or scopolamine patches for nausea.
      • Consider cephalosporins instead of quinolones.
      • Consider metoclopramide (Reglan) instead of ondansetron (Zofran) or haloperidol (Haldol), as it has less of a QT-prolonging effect.
• Should we order an ECG before giving haloperidol to acutely agitated patients?
  • This is not necessary. The benefit of sedating a patient who is agitated and a danger to themselves and staff outweighs the risk of QT prolongation with haloperidol or droperidol.
  • Get an ECG if the patient requires repeat doses.
  • Summary:
    • Managing asymptomatic patients with a prolonged QT is not as clear cut as managing patients presenting with syncope. Remember our commonly used QT-prolonging medications, and consider alternative treatments for complaints such as nausea, migraines, and infections. Finally, be sure to arrange close follow-up for patients being discharged with this common incidental finding. 

Phenobarbital dosing for the treatment of alcohol withdrawal syndrome: a review of the literature Brooks L, Reinert JP. J Pharm Technol. 2024;40(4):186-193.

SUMMARY:

• Despite growing interest in phenobarbital as an alternative for ED treatment of alcohol withdrawal in both clinical and research settings, most ED practitioners still rely on benzodiazepines as a first-line therapy. However, the culture may be changing, as we recently covered the Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4) on the topic of ED management of nonopioid use disorders. In the section on alcohol withdrawal syndrome, the authors favored phenobarbital.
• Phenobarbital is a barbiturate with a dual mechanism of action and an affinity for both GABA and glutamate receptors, whereas benzodiazepines have affinity toward only GABA. This dual affinity underlies phenobarbital’s unique mechanism of action, which differs from those of even other shorter-acting barbiturates. Phenobarbital has been studied and used effectively in both emergency and ICU settings. It has a rapid onset of action, at approximately 15 minutes, and an extremely long duration of action, thus enabling less frequent dosing.
• Because many ED providers have never used phenobarbital, the authors conducted a comprehensive literature review to describe and elucidate the best dosing strategies to aid in personal practice or in the development of new hospital guidelines regarding phenobarbital use.
• The review included articles describing clinical outcomes, complete dosing strategies, and adverse effects related to the use of phenobarbital for alcohol withdrawal, and excluded articles that could not differentiate the effects of phenobarbital vs another medication. Six articles met the inclusion and exclusion criteria: 4 using a fixed-dose approach, and 2 comparing weight-based vs fixed dosing. In general, the fixed-dose approach involved initial administration of 260 mg, with an option for additional doses every 15 to 30 minutes, with a maximum of 4 doses in the ED. The average number of doses administered was approximately 3, and clinical outcomes were positive, including discharge rates comparable to those with other agents. In the studies examining weight-based vs fixed dosing, no differences were observed in ICU length of stay; mortality; or adverse events, including respiratory depression/failure or hypotension.
• Across all trials, the message is clear that phenobarbital was used safely and effectively.
• The authors are forthright regarding the limitations of their systematic review, including the small total number of studies, heterogeneous outcome assessment measures, and variations in the total medication amounts given. The goal was not to change practice but to provide information and a literature summary for physicians who might want to try a new protocol.
• PMID: 39157637
• EDITOR’S COMMENTARY: In this systematic review, the authors reviewed 6 identified papers to make the point that phenobarbital use in the ED for alcohol withdrawal syndrome is both safe and effective. The authors suggest that hospital administrators should use the findings to create new protocols for the management of alcohol withdrawal. Given that the new GRACE-4 guidelines also include phenobarbital, we might actually see these protocols get developed. If you have never tried it, 260 mg IV is a good first dose for most adults, and you should reevaluate in approximately 15 to 30 minutes. It does work and might even be better than benzos for some outcomes.

First10EM

WOMAN-2: TXA has no role in postpartum hemorrhage

• The WOMAN 2 trial is a large double-blind RCT that shows no benefit of TXA in the prevention of postpartum hemorrhage, which fits with all of the existing literature demonstrating no role for TXA in the management of postpartum hemorrhage. We still cannot comment on the role of TXA in massive post-partum hemorrhage, as none of the research to date has really captured that group of patients.

A Randomized Controlled Comparison of Guardian-Perceived Cosmetic Outcome of Simple Lacerations Repaired With Either Dermabond, Steri-Strips, or Absorbable Sutures. Pediatr Emerg Care. 2024 Aug 15.

• I have a long series of articles looking at the science behind laceration repair, and I think the simplest answer is: nothing you do matters. Or, if you don’t like that level of nihilism, you could phrase it as, the human body has amazing mechanisms to repair the skin, and our job is mostly to set the natural healing up for success (aka get out of the way). This is an RCT from a single pediatric emergency department, randomizing children with small linear lacerations (less than 5 cm long, less than 5 mm gap, and less than 12 hours old) to dermabond, steri-strips, or absorbable sutures. The primary outcome was cosmetic appearance as rated by the child’s parent at 3 months. They include 55 patients, and three groups had statistically similar outcomes (although the dermabond group was rated 15 points higher on the visual analog scale, which might be clinically significant, and so this tiny study is just too tiny.) Likewise, although none of the secondary outcomes were statistically significant, the point estimates look worse for sutures in length of stay, pain, and overall satisfaction. At the end of the day, this trial doesn’t add much, because they only enrolled small linear lacerations, and we already knew that these healed no matter what you do. (Honestly, most of the lacerations in this study with a median length of 1.5 cm would have probably had the same outcome with a bandaid). At this point, I have almost entirely abandoned sutures in my practice. Dermabond and/or steristrips will close more than 95% of the lacerations we see.
  • Bottom line: This tiny single center trial doesn’t add a lot, but gives me another opportunity to pitch abandoning sutures to you. You will be more efficient, cause less pain, have happier patients, and your outcomes will be identical. 

Correction Rates and Clinical Outcomes in Hospitalized Adults With Severe Hyponatremia: A Systematic Review and Meta-Analysis

NEJM

Sepsis and Septic Shock

Nonsurgical Management of Chronic Venous Insufficiency

REBELEM

REBEL Core Cast 132.0 – Recent-Onset AFib

Take Home points:

• If the patient is low risk with CHA₂DS₂-VASc (men < 2, women < 3), cardioversion is safe up to 48 hours from onset.
• In higher risk patients, we should reserve cardioversion unless there is clear onset less than 12 hours or the patient has been anticoagulated for 3 weeks.
• Consider anticoagulation in every patient with atrial fibrillation whether they are cardioverted or referred.
• Electrical cardioversion (> 95%) is more likely to be successful than chemical cardioversion (~ 60%).
• Cardioversion recommendations exclude patients with recent strokes or valvular heart disease.