January 2017 EM Articles

*NNR this month = 62

You'd have to read 2787 articles to find these 45 riveting reads.

*NNR - number needed to read

The Impact of a Soiled Airway on Intubation Success in the Emergency Department when using the GlideScope or the Direct Laryngoscope.
Acad Emerg Med. 2017 Jan 20. doi: 10.1111/acem.13160. [Epub ahead of print]
Spoon Feed: Both DL and VL (with a GlideScope) had reduced first-pass success in patients with vomitus or blood in the airway.  But VL was superior to DL in both soiled and clean airways.


The Impact of Emergency Department Census on the Decision to Admit.
Acad Emerg Med. 2017 Jan;24(1):13-21. doi: 10.1111/acem.13103.
ARTICLE CONCLUSION: "Waiting room census and physician load census at time of physician assignment were positively associated with the likelihood that a patient would be admitted, controlling for potential confounders. Our data suggest that disposition decisions in the ED are influenced not only by objective measures of a patient's disease state, but also by workflow-related concerns."


Computed Tomography Use for Adults With Head Injury: Describing Likely Avoidable Emergency Department Imaging Based on the Canadian CT Head Rule.
Acad Emerg Med. 2017 Jan;24(1):22-30. doi: 10.1111/acem.13061.
Spoon Feed: Though it's hard to admit that my pals to the north are smarter than me, it's true.  Proper application of the CCHR could have reduced CT utilization by 37% without missing any injuries requiring surgical intervention.


"I Broke My Ankle": Access to Orthopedic Follow-up Care by Insurance Status.
Acad Emerg Med. 2017 Jan;24(1):98-105. doi: 10.1111/acem.13058.
ARTICLE CONCLUSIONS: "Less than one in seven Medicaid patients could obtain orthopedic follow-up after an ED visit for a fracture, and prices quoted to the uninsured were 30% higher than typical negotiated rates paid by the privately insured. High up-front costs for uninsured patients and low appointment availability for Medicaid patients may leave these patients with no other option than the ED for necessary care."


Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores.
Am J Emerg Med. 2017 Jan 5. pii: S0735-6757(17)30003-7. doi: 10.1016/j.ajem.2017.01.003. [Epub ahead of print]
Spoon Feed: Unstructured physician gestalt of "low risk" or a TIMI score of zero and 2 negative standard troponin assays resulted in zero patients with missed AMI during the index visit to the ED for chest pain.  But before I feel too cavalier about my "gestalting" skills- though the AMI miss rate was zero, the upper 95% CI limit was 3.9%.  Also, this study would have been much stronger if we knew 30-day outcomes for MACE were also zero.


Quick epinephrine administration induces favorable neurological outcomes in out-of-hospital cardiac arrest patients.
Am J Emerg Med. 2017 Jan 3. pii: S0735-6757(16)30969-X. doi: 10.1016/j.ajem.2016.12.066. [Epub ahead of print]
ARTICLE CONCLUSIONS: "In cases of OHCA, it appears that the CPC1-2 rate after 1month can be improved even in cases where the victim is reached >8min after the 119 call, as long as the victim is reached within 16min and emergency responders administer the adrenaline as quickly as possible."


Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure.
Am J Emerg Med. 2017 Jan;35(1):126-131. doi: 10.1016/j.ajem.2016.10.038. Epub 2016 Oct 18.
Spoon Feed: This study suggests that in hypertensive patients with acute decompensated heart failure and shortness of breath, bolus IV NTG 1 or 2mg was safe and reduced ICU admission and length of stay.  It may take me a while to warm up to these enormous NTG doses, but I am seriously considering adding bolus NTG to my crashing heart failure treatment armamentarium.


Documentation of HEART score discordance between emergency physician and cardiologist evaluations of ED patients with chest pain.
Am J Emerg Med. 2017 Jan;35(1):132-135. doi: 10.1016/j.ajem.2016.09.058. Epub 2016 Sep 28.
Spoon Feed: Your HEART score calculation and that of your friendly neighborhood cardiologist are not the same.  You are more suspicious than the cardiologist that the history is concerning for ACS.  Just understand there may be discrepancy and admit the ones you think need to come in, even if cards scores them lower than you.


Body Mass and Weekly Training Distance Influence the Pain and Injuries Experienced by Runners Using Minimalist Shoes.
Am J Sports Med. 2017 Jan 1:363546516682497. doi: 10.1177/0363546516682497. [Epub ahead of print]
ARTICLE CONCLUSIONS: "Runners should limit weekly training distance in minimalist shoes to avoid running-related pain. Heavier runners are at greater risk of injury when running in minimalist shoes."


No Relationship Between Hamstring Flexibility and Hamstring Injuries in Male Amateur Soccer Players.
Am J Sports Med. 2017 Jan;45(1):121-126. doi: 10.1177/0363546516664162. Epub 2016 Oct 1.
ARTICLE CONCLUSION: "In this group of soccer players, hamstring flexibility (measured with the SRT) was not related to hamstring injuries. Age and previous hamstring injuries as possible confounders did not appear to influence this relationship. Other etiological factors need to be examined to further elucidate the mechanism of hamstring injuries."


Cricoid Pressure Controversies: Narrative Review.
Anesthesiology. 2017 Jan 3. doi: 10.1097/ALN.0000000000001489. [Epub ahead of print]
Article Abstract: "Since cricoid pressure was introduced into clinical practice, controversial issues have arisen, including necessity, effectiveness in preventing aspiration, quantifying the cricoid force, and its reliability in certain clinical entities and in the presence of gastric tubes. Cricoid pressure-associated complications have also been alleged, such as airway obstruction leading to interference with manual ventilation, laryngeal visualization, tracheal intubation, placement of supraglottic devices, and relaxation of the lower esophageal sphincter. This review synthesizes available information to identify, address, and attempt to resolve the controversies related to cricoid pressure. The effective use of cricoid pressure requires that the applied force is sufficient to occlude the esophageal entrance while avoiding airway-related complications. Most of these complications are caused by excessive or inadequate force or by misapplication of cricoid pressure. Because a simple-to-use and reliable cricoid pressure device is not commercially available, regular training of personnel, using technology-enhanced cricoid pressure simulation, is required. The current status of cricoid pressure and objectives for future cricoid pressure-related research are also discussed."


Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration.
Anesthesiology. 2017 Jan 3. doi: 10.1097/ALN.0000000000001452. [Epub ahead of print]


Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery: An Analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort.
Anesthesiology. 2017 Jan;126(1):16-27.
ARTICLE CONCLUSIONS: "Withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events. A large randomized trial is needed to confirm this finding. In the interim, clinicians should consider recommending that patients withhold angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers 24 h before surgery."


Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients.
6.Ann Emerg Med. 2017 Jan;69(1):24-33.e2. doi: 10.1016/j.annemergmed.2016.08.009.
Spoon Feed: Etomidate and ketamine were equally safe when used as trauma airway induction agents.


Modeling Hourly Resident Productivity in the Emergency Department.
Ann Emerg Med. 2017 Jan 19. pii: S0196-0644(16)31387-7. doi: 10.1016/j.annemergmed.2016.11.020. [Epub ahead of print]
ARTICLE CONCLUSION: "Emergency medicine resident productivity during a single shift follows a reliable pattern that decreases significantly hourly, a pattern preserved across PGY years and types of shifts. This suggests that resident productivity is a dynamic process, which should be considered in staffing decisions and studied further."


Emergency Department Airway Management of Severe Angioedema: A Video Review of 45 Intubations.
Ann Emerg Med. 2017 Jan 19. pii: S0196-0644(16)31397-X. doi: 10.1016/j.annemergmed.2016.11.027. [Epub ahead of print]
STUDY OBJECTIVE: Angioedema is an uncommon but important cause of airway obstruction. Emergency airway management of angioedema is difficult. We seek to describe the course and outcomes of emergency airway management for severe angioedema in our institution.
METHODS: We performed a retrospective, observational study of all intubations for angioedema performed in an urban academic emergency department (ED) between November 2007 and June 2015. We performed a structured review of video recordings of each intubation. We identified the methods of airway management, the success of each method, and the outcomes and complications of the effort.
RESULTS: We identified 52 patients with angioedema who were intubated in the ED; 7 were excluded because of missing videos, leaving 45 patients in the analysis. Median time from arrival to the ED to the first intubation attempt was 33 minutes (interquartile range 17 to 79 minutes). Nasotracheal intubation was the most common first method (33/45; 73%), followed by video laryngoscopy (7/45; 16%). Two patients required attempts at more invasive airway procedures (retrograde intubation and cricothyrotomy). The intubating laryngeal mask airway was used as a rescue method 5 times after failure of multiple methods, with successful oxygenation, ventilation, and intubation through the laryngeal mask airway in all 5 patients. All patients were successfully intubated.
CONCLUSION: In this series of ED patients who were intubated because of angioedema, emergency physicians used a range of methods to successfully manage the airway. These observations provide key lessons for the emergency airway management of these critical patients.


Outcomes for Emergency Department Patients With Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals.
Ann Emerg Med. 2017 Jan 19. pii: S0196-0644(16)31243-4. doi: 10.1016/j.annemergmed.2016.10.013. [Epub ahead of print]
ARTICLE CONCLUSION: "Although most recent-onset atrial fibrillation and flutter patients were treated aggressively in the ED, there were few 30-day serious outcomes. Physicians underprescribed oral anticoagulants. Potential risk factors for adverse events include longer duration from arrhythmia onset, previous stroke or transient ischemic attack, pulmonary congestion on chest radiograph, and not being in sinus rhythm at discharge. An ED strategy of sinus rhythm restoration and discharge in most patients is effective and safe."


Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning.
Ann Emerg Med. 2017 Jan;69(1):98-107.e6. doi: 10.1016/j.annemergmed.2016.11.003.


The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury.
Ann Emerg Med. 2017 Jan;69(1):62-72. doi: 10.1016/j.annemergmed.2016.08.007. Epub 2016 Sep 28.
Spoon Feed: Hypotension or hypoxia increase mortality in head-injured patients, and both together are even worse.  This is a tangible opportunity for EMS pros to make a big impact and save lives.


Interpretation of Cerebrospinal Fluid White Blood Cell Counts in Young Infants With a Traumatic Lumbar Puncture.
Ann Emerg Med. 2016 Dec 29. pii: S0196-0644(16)31223-9. doi: 10.1016/j.annemergmed.2016.10.008. [Epub ahead of print]
ARTICLE CONCLUSION: Correction of the cerebrospinal fluid WBC count substantially reduced the number of infants with cerebrospinal fluid pleocytosis while misclassifying only 1 infant with bacterial meningitis of those aged 29 to 60 days.  [My comment - take this with a grain of salt.  The sensitivity of corrected CSF WBC count was poor.]


Benefits and Harms of Intensive Blood Pressure Treatment in Adults Aged 60 Years or Older: A Systematic Review and Meta-analysis.
Ann Intern Med. 2017 Jan 17. doi: 10.7326/M16-1754. [Epub ahead of print]
Article Conclusion: "Treatment to at least current guideline standards for BP (<150/90 mm Hg) substantially improves health outcomes in older adults. There is less consistent evidence, largely from 1 trial targeting SBP less than 120 mm Hg, that lower BP targets are beneficial for high-risk patients. Lower BP targets did not increase falls or cognitive decline but are associated with hypotension, syncope, and greater medication burden."


Breast Cancer Screening in Denmark: A Cohort Study of Tumor Size and Overdiagnosis.
Ann Intern Med. 2017 Jan 10. doi: 10.7326/M16-0270. [Epub ahead of print]
Article Conclusion: "Breast cancer screening was not associated with a reduction in the incidence of advanced cancer. It is likely that 1 in every 3 invasive tumors and cases of DCIS diagnosed in women offered screening represent overdiagnosis (incidence increase of 48.3%)."


Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study.
BMJ. 2017 Jan 4;356:i6432. doi: 10.1136/bmj.i6432.
Spoon Feed: A Glasgow Blatchford score of ≤1 accurately predicted which patients presenting with upper GI bleed could be safely managed as outpatients.


Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.
Crit Care Med. 2017 Jan 17. doi: 10.1097/CCM.0000000000002255. [Epub ahead of print]
Spoon Feed: It's worth reminding yourself about the basics of sepsis care.  Surviving Sepsis has taken the emphasis off protocolized initial resuscitation and placed it on common sense, rapid treatments.


Factors influencing time to computed tomography in emergency department patients with suspected subarachnoid haemorrhage.
Emerg Med J. 2017 Jan;34(1):20-26. doi: 10.1136/emermed-2016-205785. Epub 2016 Sep 22.
ARTICLE CONCLUSIONS: "Time from headache onset to imaging is moderately associated with positive imaging for SAH. Delay to hospital presentation accounts for the largest fraction of time to imaging, especially those without SAH. These findings suggest limited opportunity to reduce lumbar puncture rates simply by accelerating in-hospital processes when imaging delays are under 2 hours, as diagnostic yield of imaging decreases beyond the 6-hour imaging window from headache onset."


Alcohol Abuse and Cardiac Disease.
J Am Coll Cardiol. 2017 Jan 3;69(1):13-24. doi: 10.1016/j.jacc.2016.10.048.
ARTICLE CONCLUSIONS: Alcohol abuse increased the risk of AF, MI, and CHF to a similar degree as other well-established risk factors. Those without traditional cardiovascular risk factors are disproportionately prone to these cardiac diseases in the setting of alcohol abuse. Thus, efforts to mitigate alcohol abuse might result in meaningful reductions of cardiovascular disease.


Anterior T-Wave Inversion in Young White Athletes and Nonathletes: Prevalence and Significance.
J Am Coll Cardiol. 2017 Jan 3;69(1):1-9. doi: 10.1016/j.jacc.2016.10.044.
Spoon Feed: Anterior TWI in V1 and V2 appear to be a normal variant in young healthy white people, assuming no family history of arrythmia.


Diazepam and Meclizine Are Equally Effective in the Treatment of Vertigo: An Emergency Department Randomized Double-Blind Placebo-Controlled Trial.
J Emerg Med. 2017 Jan;52(1):23-27. doi: 10.1016/j.jemermed.2016.09.016. Epub 2016 Oct 24.
ARTICLE CONCLUSION: "We found no difference between oral diazepam and oral meclizine for the treatment of ED patients with acute peripheral vertigo."


Net clinical benefit of hospitalization versus outpatient management of patients with acute pulmonary embolism.
11. J Thromb Haemost. 2017 Jan 20. doi: 10.1111/jth.13629. [Epub ahead of print]
Spoon Feed: Managing PE as an outpatient may not only be safe, it may be safer than hospitalization.  The key is proper patient selection.


The original and simplified Wells rules and age-adjusted D-dimer testing to rule out pulmonary embolism: an individual patient data meta-analysis.
J Thromb Haemost. 2017 Jan 20. doi: 10.1111/jth.13630. [Epub ahead of print]
Spoon Feed: You can choose either the original Wells or simplified Wells score for PE with an age-adjusted D-dimer to exclude PE.  I prefer the simpler version, but that's just me.  Hey @mdcalc, when are you going to add the simplified Wells?


Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival.
JAMA. 2017 Jan 24. doi: 10.1001/jama.2016.20165. [Epub ahead of print]
Spoon Feed: Early intubation in adult in-hospital arrest was associated with poorer outcomes and neurologically-intact survival.  Emphasize high quality CPR and defibrillation, while deemphasizing early ETT placement.


Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial.
JAMA. 2017 Jan 24. doi: 10.1001/jama.2016.20603. [Epub ahead of print]
Spoon Feed: I think what this study proved is that these ICU residents were not adequately trained to intubate with either VL or DL - only 2/3 attempts successful on the first try, taking three minutes!  What were they doing in there!?  Untrained residents have trouble getting the airway, and every year of EM training leads to greater first pass success.  The first-pass success in this trial was terrible for both methods, doesn't represent the ED success rates we routinely see, and won't change my practice.


New-Onset Seizure in Adults and Adolescents: A Review.
JAMA. 2016 Dec 27;316(24):2657-2668. doi: 10.1001/jama.2016.18625.
Article Conclusions and Relevance: "Approximately 3% of the population will develop epilepsy but 2 to 3 times as many patients will experience a single seizure or seizure-like event. A diagnosis of epilepsy has significant medical, social, and emotional consequences. A careful patient history and physical examination, electroencephalography, and brain imaging are necessary to separate patients with acute symptomatic seizures, single unprovoked seizures, and nonepileptic events from those with new-onset epilepsy."


Association Between Early Lactate Levels and 30-Day Mortality in Clinically Suspected Sepsis in Children.
JAMA Pediatr. 2017 Jan 9. doi: 10.1001/jamapediatrics.2016.3681. [Epub ahead of print]
Conclusions and Relevance: "In children treated for sepsis in the emergency department, lactate levels greater than 36 mg/dL were associated with mortality but had a low sensitivity. Measurement of lactate levels may have utility in early risk stratification of pediatric sepsis."


Effects of Delayed Umbilical Cord Clamping vs Early Clamping on Anemia in Infants at 8 and 12 Months: A Randomized Clinical Trial.
JAMA Pediatr. 2017 Jan 17. doi: 10.1001/jamapediatrics.2016.3971. [Epub ahead of print]
Conclusions and Relevance: "Delayed cord clamping reduces anemia at 8 and 12 months of age in a high-risk population, which may have major positive effects on infants' health and development."


Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children.
N Engl J Med. 2017 Jan 26;376(4):318-329. doi: 10.1056/NEJMoa1610493. Epub 2017 Jan 24.
Spoon Feed: There was no advantage of therapeutic hypothermia over therapeutic normothermia in pediatric in-hospital arrest.


Glucocorticoid-associated worsening in reversible cerebral vasoconstriction syndrome.
Neurology. 2017 Jan 17;88(3):228-236. doi: 10.1212/WNL.0000000000003510. Epub 2016 Dec 9.
ARTICLE CONCLUSION: "Patients with RCVS at risk for worsening can be identified on basis of baseline features. Iatrogenic factors such as glucocorticoid exposure may contribute to worsening."


Suspected Cerebral Edema in Diabetic Ketoacidosis: Is There Still a Role for Head CT in Treatment Decisions?
Pediatr Crit Care Med. 2017 Jan 19. doi: 10.1097/PCC.0000000000001027. [Epub ahead of print]
Spoon Feed: Head CT does not help you decide whether or not to use hyperosmolar therapy in pediatric DKA with cerebral edema and may delay initiation of treatment.  Treat first; scan later.


Clinical Examination Does Not Predict Response to Albuterol in Ventilated Infants With Bronchiolitis.
Pediatr Crit Care Med. 2017 Jan;18(1):e18-e23. doi: 10.1097/PCC.0000000000000999.
Spoon Feed: It's hard to tell which critically ill, ventilated patients are responders to albuterol.  Nurses, RTs, and physicians were all equally bad.  Objective measures of pulmonary mechanics are a better means to assess this.


Rudeness and Medical Team Performance.
Pediatrics. 2017 Jan 10. pii: e20162305. doi: 10.1542/peds.2016-2305. [Epub ahead of print]
Spoon Feed: Sometimes caregivers or patients are rude.  The best thing we can do is anticipate it and mentally prepare before the encounter so we can still perform well as a team.


D10 in the Treatment of Prehospital Hypoglycemia: A 24 Month Observational Cohort Study.
Prehosp Emerg Care. 2017 Jan-Feb;21(1):63-67. doi: 10.1080/10903127.2016.1189637. Epub 2016 Dec 5.
ARTICLE CONCLUSIONS: "The results of one local EMS system over a 104-week period demonstrate the feasibility, safety, and efficacy of using 100 mL of D10 as an alternative to D50. D50 may also have theoretical risks including extravasation injury, direct toxic effects of hypertonic dextrose, and potential neurotoxic effects of hyperglycemia. Additionally, our data suggest that there may be little or no short-term decrease in blood glucose results after D10 administration."


Prehospital Nitroglycerin in Tachycardic Chest Pain Patients: A Risk for Hypotension or Not?
Prehosp Emerg Care. 2017 Jan-Feb;21(1):68-73. doi: 10.1080/10903127.2016.1194929. Epub 2016 Sep 30.
ARTICLE CONCLUSION: "Hypotension following prehospital administration of NTG was infrequent in patients with chest pain. However, while the absolute risk of NTG-induced hypotension was low, patients with pre-NTG tachycardia had a significant increase in the relative risk of hypotension. In addition, hypotension occurred most frequently in patients presenting with a lower pre-NTG blood pressure, which may prove to be a more discriminating basis for future guidelines. EMS medical directors should review BLS chest pain protocols to weigh the benefits of NTG administration against its risks."


Hot and Cold Drugs: National Park Service Medication Stability at the Extremes of Temperature.
Prehosp Emerg Care. 2017 Jan 6:1-8. doi: 10.1080/10903127.2016.1258098. [Epub ahead of print]
ARTICLE CONCLUSIONS: "We recommend that EMS providers replace atropine, naloxone, diphenhydramine, fentanyl, and midazolam frequently if they are practicing in low call volume or high-temperature environments. Further studies will be needed to determine if re-dosing midazolam, naloxone, and atropine is the appropriate clinical strategy in this setting if adequate clinical effect is not reached with a single dose."


Drones may be used to save lives in out of hospital cardiac arrest due to drowning.
Resuscitation. 2017 Jan 18. pii: S0300-9572(17)30013-8. doi: 10.1016/j.resuscitation.2017.01.003. [Epub ahead of print]
Spoon Feed: Drones could help find drowning victims almost 4 minutes sooner than a large team of lifeguards.


Association between chest compression rates and clinical outcomes following in-hospital cardiac arrest at an academic tertiary hospital.
Resuscitation. 2017 Jan;110:154-161. doi: 10.1016/j.resuscitation.2016.09.015. Epub 2016 Sep 22.
Spoon Feed: Compression rates faster than the recommended 100-120 may result in improved ROSC.  Whether that leads to improved long-term outcome remains to be seen.  To give you an idea how fast that is, the Bee Gees "Stayin' Alive" is 103 beats per minutes, and Taylor Swift's "Shake it Off" is 160.  Foreigner's "Hot Blooded" hits the sweet spot at 130 beats per minute.

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