August 2017 EM Articles

*NNR THIS MONTH = 60

You'd have to read 2519 articles to find these 42 behemoths of biostats.

*NNR - number needed to read

 

NOTE: If it says "Spoon Feed," it is the summary we wrote.  If it says, "AUTHORS' CONCLUSION," it is an article of interest but we did not summarize it; this is the conclusion from the actual abstract.

 

EmergeNcy Department use of Apneic Oxygenation versus usual care during rapid sequence intubation: A randomized controlled trial (The ENDAO Trial). Acad Emerg Med. 2017 Aug 9. doi: 10.1111/acem.13274. [Epub ahead of print]
Spoon Feed: Patients intubated in the Emergency Department with usual care (no apneic oxygenation, AO) vs AO (via nasal cannula) did not have significant differences in lowest mean oxygen saturation.

 

Pulmonary Embolism Testing among Emergency Department Patients who are Pulmonary Embolism Rule-out Criteria Negative. Acad Emerg Med. 2017 Aug 8. doi: 10.1111/acem.13270. [Epub ahead of print]
AUTHORS' CONCLUSION: In an academic ED, a significant proportion of PERC-negative patients underwent testing for PE, including CT or VQ scan without d-dimer risk stratification. Future areas of research may include evaluating factors which lead clinicians to pursue PE testing in PERC-negative patients and implementing clinical pathways to minimize practice variability among these patients.

 

Patient Navigation for Patients Frequently Visiting the Emergency Department: A Randomized, Controlled Trial. Acad Emerg Med. 2017 Aug 21. doi: 10.1111/acem.13280. [Epub ahead of print]
AUTHORS' CONCLUSION: Our data showed that the overall number of return ED visits and costs did decrease for both groups, potentially inferring a placebo effect for the use of a PN, however the decrease in ED visits and costs were greater in the treatment group. One year follow-up noted an increase in PCP visits in the navigation group. Use of a PN may be cost effective.

 

Pediatric Emergency Department Utilization and Reliance by Insurance Coverage in the United States. Acad Emerg Med. 2017 Aug 18. doi: 10.1111/acem.13281. [Epub ahead of print]
AUTHORS' CONCLUSIONS: Health insurance coverage was associated with overall ED utilization, repeat ED utilization, and ED reliance. Demographic characteristics, including gender, age, income, and race/ethnicity were important predictors of ED utilization and reliance.

 

Change in Care Transition Practice for Patients with Non-Specific Chest Pain after ED Evaluation 2006-2012. Acad Emerg Med. 2017 Aug 18. doi: 10.1111/acem.13279. [Epub ahead of print]
Spoon Feed: From 2006 - 2012, admission rates for low risk chest pain dropped 41%.  This may have been due to decreased reimbursement for such hospital stays.

 

The pediatric submersion score predicts children at low risk for injury following submersions. Acad Emerg Med. 2017 Aug 18. doi: 10.1111/acem.13278. [Epub ahead of print]
AUTHORS' CONCLUSIONS: A risk score can identify children at low risk for submersion-related injury who can be safely discharged from the ED after observation.

 

A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making. Acad Emerg Med. 2017 Aug;24(8):895-904. doi: 10.1111/acem.13214. Epub 2017 Jun 19.
Spoon Feed: Implicit racial bias is likely affecting us in the ED, but whether that translates into impacting clinical decision making remains to be seen.

 

Prevalence of pulmonary embolism in patients presenting to the emergency department with syncope. Am J Emerg Med. 2017 Jul 31. pii: S0735-6757(17)30639-3. doi: 10.1016/j.ajem.2017.07.090. [Epub ahead of print]
Spoon Feed: The prevalence of PE in patients with syncope may be far less that the PESIT trial indicated: 1.4% vs. 17%.

 

A prospective randomized, double-dummy trial comparing IV push low dose ketamine to short infusion of low dose ketamine for treatment of  pain in the ED. Am J Emerg Med. 2017 Aug;35(8):1095-1100. doi: 10.1016/j.ajem.2017.03.004. Epub 2017 Mar 3.
Spoon Feed: A slow infusion of ketamine for pain control was as effective as IV push, with less sedation and far fewer patients having a feeling of unreality.

 

Provider and Practice Factors Associated With Emergency Physicians' Being Named in a Malpractice Claim. Ann Emerg Med. 2017 Jul 26. pii: S0196-0644(17)30786-2. doi: 10.1016/j.annemergmed.2017.06.023. [Epub ahead of print]
AUTHORS' CONCLUSION: In this sample of emergency physicians, 1 in 11 were named in a malpractice claim during 4.5 years. Total number of years in practice and visit volume were the only identified factors associated with being named, suggesting that exposure to higher patient volumes and longer practice experience are the primary contributors to malpractice risk.

 

Cost-effectiveness of Magnetic Resonance Imaging in Cervical Spine Clearance of Neurologically Intact Patients With Blunt Trauma. Ann Emerg Med. 2017 Aug 18. pii: S0196-0644(17)30889-2. doi: 10.1016/j.annemergmed.2017.07.006. [Epub ahead of print]
AUTHORS' CONCLUSION: MRI is not cost-effective for further evaluation of unstable injury in neurologically intact patients with blunt trauma after a negative cervical spine CT result.

 

Acute Kidney Injury After Computed Tomography: A Meta-analysis. Ann Emerg Med. 2017 Aug 12. pii: S0196-0644(17)30881-8. doi: 10.1016/j.annemergmed.2017.06.041. [Epub ahead of print]
AUTHORS' CONCLUSION: We found no significant differences in our principal study outcomes between patients receiving contrast-enhanced CT versus those receiving noncontrast CT. Given similar frequencies of acute kidney injury in patients receiving noncontrast CT, other patient- and illness-level factors, rather than the use of contrast material, likely contribute to the development of acute kidney injury.

 

The Efficacy of Crotalidae Polyvalent Immune Fab (Ovine) Antivenom Versus Placebo Plus Optional Rescue Therapy on Recovery From Copperhead Snake Envenomation: A Randomized, Double-Blind, Placebo-Controlled, Clinical Trial. Ann Emerg Med. 2017 Aug;70(2):233-244.e3. doi: 10.1016/j.annemergmed.2017.04.034. Epub 2017 Jun 13.
Spoon Feed: Crotalidae polyvalent immune antivenom (CroFab) improved limb disability in patients bitten by copperhead snakes.

 

Clinical Review: Loperamide Toxicity. Ann Emerg Med. 2017 Aug;70(2):245-252. doi: 10.1016/j.annemergmed.2017.04.008. Epub 2017 May 13.
Abstract: Loperamide is a nonprescription opioid widely used for the treatment of diarrhea. Although it is relatively safe at therapeutic doses, increasing reports describe its misuse and abuse at very high doses either for euphoric effects or to attenuate symptoms of opioid withdrawal. Life-threatening loperamide toxicity can result from the relatively new clinical syndrome of loperamide-induced cardiac toxicity. These patients are often young and may present in cardiac arrest or with unheralded, recurrent syncope in conjunction with ECG abnormalities, including marked QT-interval prolongation, QRS-interval widening, and ventricular dysrhythmias. Features of conventional opioid toxicity may also be present. The mainstays of treatment include advanced cardiac life support and supportive care, although selected patients may be candidates for overdrive pacing, intravenous lipid emulsion, or extracorporeal membrane oxygenation. In patients who survive loperamide toxicity, consideration should be given to the treatment of an underlying opioid use disorder, if present.

 

Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination: A Randomized Controlled Trial. Ann Intern Med. 2017 Aug 15. doi: 10.7326/M16-2843. [Epub ahead of print]
Authors' Conclusion: Inclusion of an electronic resource with time constraints did not adversely affect test performance and did not change the specific skill or factor targeted by the examination. Further study on the effect of resource inclusion on other examinations is warranted.

 

Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health. Ann Intern Med. 2017 Aug 1. doi: 10.7326/M17-0865. [Epub ahead of print]
Authors' Conclusion: More than one third of U.S. civilian, noninstitutionalized adults reported prescription opioid use in 2015, with substantial numbers reporting misuse and use disorders. Relief from physical pain was the most commonly reported motivation for misuse. Economic disadvantage and behavioral health problems may be associated with prescription opioid misuse. The results suggest a need to improve access to evidence-based pain management and to decrease excessive prescribing that may leave unused opioids available for potential misuse.

 

Performance of Low Dose Perfusion Scintigraphy and Computed Tomographic Pulmonary Angiography for Pulmonary Embolism in Pregnancy. Chest. 2017 Aug 17. pii: S0012-3692(17)31398-3. doi: 10.1016/j.chest.2017.08.005. [Epub ahead of print]
Spoon Feed: Low dose perfusion-only (LDQ) nuclear scan (the "Q" of the V/Q scan) or CTPA are the imaging studies of choice to diagnose PE in pregnant women.  LDQ (using one-third the normal technetium) has lower radiation dose and may be preferred over CTPA, assuming the CXR is normal.

 

Clinical Characteristics of Pertussis-Associated Cough in Adults and Children: A Diagnostic Systematic Review and Meta-Analysis. Chest. 2017 Aug;152(2):353-367. doi: 10.1016/j.chest.2017.04.186. Epub 2017 May 13.
Spoon Feed: I couldn't state it better than the author's conclusion: "In adult patients, the presence of whooping or posttussive vomiting should rule in a possible diagnosis of pertussis, whereas the lack of a paroxysmal cough or the presence of fever should rule it out. In children, posttussive vomiting is much less helpful as a clinical diagnostic test."

 

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017 Aug 8;136(6):e137-e161. doi: 10.1161/CIR.0000000000000509. Epub 2017 Apr 28.

 

2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2017 Aug 1;136(5):e25-e59. doi: 10.1161/CIR.0000000000000498. Epub 2017 Mar 9.

 

2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2017 Aug 1;136(5):e60-e122. doi: 10.1161/CIR.0000000000000499. Epub 2017 Mar 9.

 

A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients. Crit Care. 2017 Jul 31;21(1):192. doi: 10.1186/s13054-017-1787-x.
Spoon Feed: We've known this for a while, and this systematic review pools evidence to once again show that prehospital intubation (PHI), in this case of trauma patients, was associated with greater mortality than when it was done in the ED.

 

Quick Sequential Organ Failure Assessment and Systemic Inflammatory Response Syndrome Criteria as Predictors of Critical Care Intervention Among Patients With Suspected Infection. Crit Care Med. 2017 Jul 28. doi: 10.1097/CCM.0000000000002622. [Epub ahead of print]
AUTHORS' CONCLUSIONS: Emergency department patients with suspected infection and low quick Sequential Organ Failure Assessment scores frequently receive critical care interventions. The misclassification of these patients as "low risk," in combination with the low sensitivity of quick Sequential Organ Failure Assessment greater than or equal to 2, may diminish the clinical utility of the quick Sequential Organ Failure Assessment score for patients with suspected infection in the emergency department.

 

Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis. J Trauma Acute Care Surg. 2017 Aug;83(2):218-224. doi: 10.1097/TA.0000000000001546.
AUTHORS' CONCLUSION: As currently used, FAST has a low sensitivity for IAI, misses IAI-I and rarely impacts management in pediatric BAT.

 

High ratio plasma resuscitation does not improve survival in pediatric trauma patients. J Trauma Acute Care Surg. 2017 Aug;83(2):211-217. doi: 10.1097/TA.0000000000001549.
Spoon Feed: A high plasma to PRBC to platelet transfusion ratio was not beneficial in pediatric massive trauma transfusion.

 

Targeted Temperature Management for 48 vs 24 Hours and Neurologic Outcome After Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2017 Jul 25;318(4):341-350. doi: 10.1001/jama.2017.8978.
Authors' Conclusions and Relevance: In unconscious survivors from out-of-hospital cardiac arrest admitted to the ICU, targeted temperature management at 33°C for 48 hours did not significantly improve 6-month neurologic outcome compared with targeted temperature management at 33°C for 24 hours. However, the study may have had limited power to detect clinically important differences, and further research may be warranted.

 

Effect of Oral Prednisolone on Symptom Duration and Severity in Nonasthmatic Adults With Acute Lower Respiratory Tract Infection: A Randomized Clinical Trial. JAMA. 2017 Aug 22;318(8):721-730. doi: 10.1001/jama.2017.10572.
Spoon Feed: Oral steroids were of no benefit for non-asthmatic patients with bronchitis.

 

Does This Child Have Pneumonia?: The Rational Clinical Examination Systematic Review. JAMA. 2017 Aug 1;318(5):462-471. doi: 10.1001/jama.2017.9039.
Spoon Feed: The lungs are better seen than heard. This is the adage Dr. Wrenn taught and this study proves true.  Low SpO2 and increased work of breathing were the best predictors of radiographic pneumonia in children; auscultatory findings and tachypnea were poor. Get a CXR if hypoxic or working hard to breathe unless it is obviously bronchiolitis or asthma.

 

Behavioral Approach to Appropriate Antimicrobial Prescribing in Hospitals: The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) Participatory Intervention Study. JAMA Intern Med. 2017 Aug 1;177(8):1130-1138. doi: 10.1001/jamainternmed.2017.0946.
Authors' Conclusions and Relevance: Use of a behavioral approach preserving prescriber autonomy resulted in an increase in antimicrobial appropriateness sustained for at least 12 months. The approach is inexpensive and could be easily transferable to various health care environments.

 

Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr. 2017 Aug 21. doi: 10.1001/jamapediatrics.2017.2135. [Epub ahead of print]
Spoon Feed: This large multi-center prospective study of pediatric sedation found adverse events occurred in 12%, most mild desaturation or vomiting.  Severe adverse events occurred in 1%.  Ketamine given alone was the safest drug.  Propofol alone, ketamine + fentanyl, or ketamine + propofol were associated with greater risk for severe adverse events.

 

Testing for Respiratory Viruses in Children: To Swab or Not to Swab. JAMA Pediatr. 2017 Aug 1;171(8):798-804. doi: 10.1001/jamapediatrics.2017.0786.
Authors' Conclusions and Relevance: It is not good enough to "do" just because we "can." We suggest that for many healthy immune-competent children presenting with typical viral respiratory tract symptoms, the diagnosis can be made clinically, and frontline clinicians should think critically before automatically requesting a somewhat uncomfortable, expensive respiratory viral test, the result of which may not contribute to the child's treatment.

 

Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children. JAMA Pediatr. 2017 Aug 1;171(8):740-746. doi: 10.1001/jamapediatrics.2017.0885.
Spoon Feed: If a pediatric surgeon needs to delay appendectomy, you can reassure families this is a safe practice and will not increase the risk for adverse outcomes, like perforation.

 

Angiotensin II for the Treatment of Vasodilatory Shock. N Engl J Med. 2017 Aug 3;377(5):419-430. doi: 10.1056/NEJMoa1704154. Epub 2017 May 21.
AUTHORS' CONCLUSIONS: Angiotensin II effectively increased blood pressure in patients with vasodilatory shock that did not respond to high doses of conventional vasopressors.

 

Upgoing thumb sign: A sensitive indicator of brain involvement? Neurology. 2017 Jul 25;89(4):370-375. doi: 10.1212/WNL.0000000000004157. Epub 2017 Jun 28.
Spoon Feed: The "upgoing thumb sign" can be used as part of a comprehensive neurological evaluation to help distinguish stroke mimic from actual stroke.  It won't replace MRI, but it can be part of the neurological exam, just like we use the Babinski sign.  One editorial from 1993 suggested calling it the Hachinski-Babinski, after the discover.  Here's how to do it.

 

Effects of increasing IV tPA-treated stroke mimic rates at CT-based centers on clinical outcomes. Neurology. 2017 Jul 25;89(4):343-348. doi: 10.1212/WNL.0000000000004149. Epub 2017 Jun 28.
AUTHORS' CONCLUSIONS: Thrombolysis of stroke mimics is increasing at our CT-based spoke hospitals and not at our MRI-based hub hospitals. Caution should be used in interpreting clinical outcomes based on large stroke databases when stroke diagnosis at discharge is unclear. Inadvertent reporting of treated stroke mimics as strokes will artificially elevate overall favorable clinical outcomes with additional downstream costs to patients and the health care system.

 

Oral fluoroquinolones and risk of secondary pseudotumor cerebri syndrome: Nested case-control study. Neurology. 2017 Aug 22;89(8):792-795. doi: 10.1212/WNL.0000000000004247. Epub 2017 Jul 28.
Spoon Feed: Fluoroquinolone antibiotics were associated with idiopathic intracranial hypertension (IIH).

 

Medication overuse headache: An entrenched idea in need of scrutiny. Neurology. 2017 Aug 18. pii: 10.1212/WNL.0000000000004371. doi: 10.1212/WNL.0000000000004371. [Epub ahead of print]
Spoon Feed: Medication overuse headache (MOH), also known as rebound headache or drug-induced headache, may be the stuff of legend.  The evidence for it is sketchy. The authors say, "Until the evidence is better, we should avoid dogmatism about the use of symptomatic medication."

 

Fluid Bolus Over 15-20 Versus 5-10 Minutes Each in the First Hour of Resuscitation in Children With Septic Shock: A Randomized Controlled Trial. Pediatr Crit Care Med. 2017 Aug 2. doi: 10.1097/PCC.0000000000001269. [Epub ahead of print]
Spoon Feed: PALS recommends giving a fluid bolus to children in shock over 5-10minutes.  This study showed that giving it more slowly, over 15-20 minutes likely decreased the need for mechanical ventilation.

 

Short-Term Peripheral Vasoactive Infusions in Pediatrics: Where Is the Harm? Pediatr Crit Care Med. 2017 Aug;18(8):e378-e381. doi: 10.1097/PCC.0000000000001230.
AUTHORS' CONCLUSIONS: Vasoactive infusions through peripheral IV in children admitted to the PICU with shock were observed to have a low incidence of peripheral IV infiltration and extravasation and resultant tissue injury. Short-term delivery of vasoactives via peripheral IV catheter in a highly monitored PICU setting appears to be safe.

 

Trend and Outcomes of Video Laryngoscope Use Across PICUs. Pediatr Crit Care Med. 2017 Aug;18(8):741-749. doi: 10.1097/PCC.0000000000001175.
AUTHORS' CONCLUSIONS: Using National Emergency Airway Registry for Children data, we described patient-centered adverse outcomes associated with video laryngoscopy compared with direct laryngoscopy for tracheal intubation in the largest reported international cohort of children to date. Data from this study may be used to design sufficiently powered prospective studies comparing patient-centered outcomes for video laryngoscopy versus direct laryngoscopy during endotracheal intubation.

 

Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions. Resuscitation. 2017 Jul 25. pii: S0300-9572(17)30302-7. doi: 10.1016/j.resuscitation.2017.07.021. [Epub ahead of print]
Spoon Feed: Point of care ultrasound (POCUS) may be very useful during CPR, but it should not get in the way of chest compressions.  If you're going to use it, get in there quick and get out of the way or choose a view that allows continuous chest compressions (i.e. subxiphoid).

 

Epinephrine dosing interval and survival outcomes during pediatric in-hospital cardiac arrest. Resuscitation. 2017 Aug;117:18-23. doi: 10.1016/j.resuscitation.2017.05.023. Epub 2017 May 25.
Spoon Feed: Current PALS and ACLS algorithms recommend repeat epinephrine doses q3-5 minutes.  This study suggested that this is too frequent and that outcome may be better if doses were spaced 8-10 minutes had significantly better survival.

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