July 2017 EM Articles

*NNR THIS MONTH = 78

You'd have to read 2664 articles to find these 34 diamonds in the rough.

*NNR - number needed to read

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.

Accuracy of Computed Tomography Imaging Criteria in the Diagnosis of Adult Open Globe Injuries by Neuroradiology and Ophthalmology.  Acad Emerg Med. 2017 Jun 29. doi: 10.1111/acem.13249. [Epub ahead of print]
Spoon Feed: CT was specific for open globe but not sensitive.  The best CT predictors of open globe were change in globe contour and vitreous hemorrhage.  Open globe is a clinical or surgical diagnosis.  CT alone can't rule it out.

 

Randomized Controlled Double-Blind Trial Comparing Haloperidol Combined with Conventional Therapy to Conventional Therapy Alone in Patients with Symptomatic Gastroparesis.  Acad Emerg Med. 2017 Jun 24. doi: 10.1111/acem.13245. [Epub ahead of print]
Spoon Feed: Haloperidol markedly reduced pain and nausea in ED patients with gastroparesis compared to usual care.  But be careful.  Haloperidol is not without side effects, such as hypotension, extrapyramidal movement, akathisia, neuroleptic malignant syndrome, and QT-prolongation.

 

Outcomes following possible undiagnosed aneurysmal subarachnoid hemorrhage: a contemporary analysis.  Acad Emerg Med. 2017 Jul 4. doi: 10.1111/acem.13252. [Epub ahead of print]
Spoon Feed: Prior studies have shown that sentinel bleeds lead to worse outcomes if missed and subsequent aneurysmal subarachnoid hemorrhage (SAH) occurs, but this Kaiser Permanente case-control study suggests this may be a myth.

 

Comparison of four scoring systems used to predict mortality in patients with acute upper gastrointestinal bleeding in the emergency room.  Am J Emerg Med. 2017 Jun 27. pii: S0735-6757(17)30502-8. doi: 10.1016/j.ajem.2017.06.053. [Epub ahead of print]
AUTHORS' CONCLUSION: In patients with acute UGIB in the ED, the AIMS65 and Glasgow-Blatchford scores are clinically more useful for predicting 30-day mortality than the preendoscopic Rockall and preendoscopic Baylor scores. The AIMS65 score might be more ideal for risk stratification in the ED setting.

 

The critical care literature 2016.  Am J Emerg Med. 2017 Jul 13. pii: S0735-6757(17)30565-X. doi: 10.1016/j.ajem.2017.07.036. [Epub ahead of print]

 

Effectiveness of Apneic Oxygenation During Intubation: A Systematic Review and Meta-analysis.  Ann Emerg Med. 2017 Jul 13. pii: S0196-0644(17)30582-6. doi: 10.1016/j.annemergmed.2017.05.001. [Epub ahead of print] . AND
Apneic oxygenation during intubation in the emergency department and during retrieval: A systematic review and meta-analysis.  Am J Emerg Med. 2017 Jun 24. pii: S0735-6757(17)30497-7. doi: 10.1016/j.ajem.2017.06.046. [Epub ahead of print]
Spoon Feed: Blasting nasal cannula oxygen (apneic oxygenation) during endotracheal intubation of ED patients led to higher O2 saturation, decreased episodes of desaturation, and improved first-pass success.

 

Clostridium difficile Infection Among US Emergency Department Patients With Diarrhea and No Vomiting.  Ann Emerg Med. 2017 Jul;70(1):19-27.e4. doi: 10.1016/j.annemergmed.2016.12.013. Epub 2017 Feb 24.
Spoon Feed: In a largely adult population, those presenting to the ED with diarrhea only and no vomiting had C. difficile colitis as the cause in 10%, and almost 40% lacked risk factors.

 

Yoga, Physical Therapy, or Education for Chronic Low Back Pain: A Randomized Noninferiority Trial.  Ann Intern Med. 2017 Jul 18;167(2):85-94. doi: 10.7326/M16-2579. Epub 2017 Jun 20.
Authors' Conclusion: A manualized yoga program for nonspecific cLBP was noninferior to PT for function and pain.

 

Missed Opportunities for Measles, Mumps, Rubella Vaccination Among Departing U.S. Adult Travelers Receiving Pretravel Health Consultations.  Ann Intern Med. 2017 Jul 18;167(2):77-84. doi: 10.7326/M16-2249. Epub 2017 May 16.
Authors' Conclusion: Of U.S. adult travelers who presented for pretravel consultation at GTEN sites, 16% met criteria for MMR vaccination according to the provider's assessment, but fewer than half of these travelers were vaccinated. An increase in MMR vaccination of eligible U.S. adult travelers could reduce the likelihood of importation and transmission of measles virus.

 

Coffee Drinking and Mortality in 10 European Countries: A Multinational Cohort Study.  Ann Intern Med. 2017 Jul 11. doi: 10.7326/M16-2945. [Epub ahead of print] AND
Association of Coffee Consumption With Total and Cause-Specific Mortality Among Nonwhite Populations.  Ann Intern Med. 2017 Jul 11. doi: 10.7326/M16-2472. [Epub ahead of print]
Spoon Feed: Not only is coffee not bad for you, it could save your life!  This study of over half a million people in 10 European countries found coffee consumption was associated with decreased overall mortality in men and women.

 

Analgosedation practices and the impact of sedation depth on clinical outcomes among patients requiring mechanical ventilation in the emergency department: a cohort study.  Chest. 2017 Jun 20. pii: S0012-3692(17)31076-0. doi: 10.1016/j.chest.2017.05.041. [Epub ahead of print]
Spoon Feed: Excessive sedation of intubated patients in the ED was associated with increased in-hospital mortality.  Aim for a RASS > -3.

 

IV Magnesium Sulfate for Bronchiolitis: A Randomized Trial.  Chest. 2017 Jul;152(1):113-119. doi: 10.1016/j.chest.2017.03.002. Epub 2017 Mar 9.
Spoon Feed:  Don't use IV magnesium for bronchiolitis.  It doesn't work and it may cause harm.

 

Noninvasive iPhone Measurement of Left Ventricular Ejection Fraction Using Intrinsic Frequency Methodology.
Crit Care Med. 2017 Jul;45(7):1115-1120. doi: 10.1097/CCM.0000000000002459.
Spoon Feed: Noninvasive measurement of ejection fraction with an iPhone app is possible and very accurate.  When this becomes publicly available, it will be a game changer.

 

Effects of IV Acetaminophen on Core Body Temperature and Hemodynamic Responses in Febrile Critically Ill Adults: A Randomized Controlled Trial.  Crit Care Med. 2017 Jul;45(7):1199-1207. doi: 10.1097/CCM.0000000000002340.
AUTHORS' CONCLUSIONS: Among febrile critically ill adults, treatment with acetaminophen decreased temperature, blood pressure, and heart rate. IV acetaminophen thus produces modest fever reduction in critical care patients, along with clinically important reductions in blood pressure.

 

Ibuprofen versus placebo effect on acute kidney injury in ultramarathons: a randomised controlled trial.  Emerg Med J. 2017 Jul 5. pii: emermed-2016-206353. doi: 10.1136/emermed-2016-206353. [Epub ahead of print]
AUTHORS' CONCLUSION: There were increased rates of AKI in those who took ibuprofen, and although not statistically inferior to placebo by a small margin, there was a number needed to harm of 5.5 people to cause 1 case of AKI. Consideration should therefore be taken before ingesting NSAID during endurance running as it could exacerbate renal injury.

 

Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Meta-Analysis of Randomized Controlled Trials.  J Bone Joint Surg Am. 2017 Jun 21;99(12):1051-1057. doi: 10.2106/JBJS.16.01068. AND
Treatment of Displaced Midshaft Clavicle Fractures: Figure-of-Eight Harness Versus Anterior Plate Osteosynthesis: A Randomized Controlled Trial.  J Bone Joint Surg Am. 2017 Jul 19;99(14):1159-1165. doi: 10.2106/JBJS.16.01184.
Spoon Feed: More patients are having operative repair for displaced midshaft clavicle fractures.  This meta-analysis of 6 RCTs found that the rate of nonunion was markedly reduced and final functional outcome was also improved (though not as strikingly) with operative management.

 

Top 10 Myths Regarding the Diagnosis and Treatment of Cellulitis.  J Emerg Med. 2017 Jul 3. pii: S0736-4679(17)30436-5. doi: 10.1016/j.jemermed.2017.05.007. [Epub ahead of print]
Spoon Feed: This was a fun article that searched the literature and dispensed with 10 myths about cellulitis.

 

Assessing clinical probability of pulmonary embolism: prospective validation of the simplified geneva score in outpatients.  J Thromb Haemost. 2017 Jul 8. doi: 10.1111/jth.13770. [Epub ahead of print]
Spoon Feed: A simplified Geneva Score is safe to use in place of the Geneva score and is simpler, with each criterion being worth one point.  Low to Intermediate pretest probability plus negative D-dimer with the simplified Geneva ruled out PE as well as the regular Geneva score.

 

Diagnosis of acute pulmonary embolism.  J Thromb Haemost. 2017 Jul;15(7):1251-1261. doi: 10.1111/jth.13694.
Spoon Feed: If clinical gestalt for PE is low, use PERC to rule out PE.  If not ruled out, use a validated tool to determine pretest probability of PE: Wells, Revised Geneva, or simplified versions of either score.  If non-high or "unlikely" pretest probability, order D-dimer, adjusting for age (<500 or <age x 10).  If D-dimer is negative, PE is ruled out.  If positive, order CT pulmonary angiogram.  For more, check out the peer-reviewed lecture I did for Academic Emergency Medicine, PE Workup in 5 Steps.

 

Cervical spine evaluation and clearance in the intoxicated patient: a prospective western trauma association multi-institutional trial and survey.  J Trauma Acute Care Surg. 2017 Jul 19. doi: 10.1097/TA.0000000000001650. [Epub ahead of print]
Spoon Feed: A negative c-spine CT had 99.9% NPV for clinically significant c-spine injury in intoxicated patients.  The Western Trauma Association recommends c-spine clearance, even in intoxicated patients, if gross motor function is normal, no neurologic complaints, and negative c-spine CT per experienced radiologist.  Be careful out there, and get institutional buy-in if you plan to put this into practice.

 

Every minute counts: Time to delivery of initial massive transfusion cooler and its impact on mortality.  J Trauma Acute Care Surg. 2017 Jul;83(1):19-24. doi: 10.1097/TA.0000000000001531.
AUTHORS' CONCLUSION: Delays in MT protocol activation and delays in initial cooler arrival were associated with prolonged time to achieve hemostasis and an increase in mortality. Independent of products ratios, every minute from time of MT protocol activation to time of initial cooler arrival increases odds of mortality by 5%.

 

Asymptomatic cervical spine fractures: Current guidelines can fail older patients.  J Trauma Acute Care Surg. 2017 Jul;83(1):119-125. doi: 10.1097/TA.0000000000001497.
AUTHORS' CONCLUSION: Study results indicate that one fifth of patients with a c-spine fracture reported no pain on initial presentation and denied tenderness to palpation on examination. The presence or absence of pain may be an unreliable indicator of c-spine fracture in an aging population. When used in conjunction with existing clearance guidelines, denial of pain may lead to missed injury. We recommend liberal c-spine imaging for older trauma patients with significant mechanism of trauma.

 

Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients With Chest Pain.  JAMA Intern Med. 2017 Jun 26. doi: 10.1001/jamainternmed.2017.2432. [Epub ahead of print]
Spoon Feed: ED stress testing in addition to standard workup with ECG and biomarkers led to more downstream testing (angiography) and more interventions (PCI or CABG), but this didn't translate into fewer acute myocardial infarctions at one year.  The whole premise of a stress test is to find a blocked artery non-invasively, open it, and decrease future risk of acute myocardial infarction (AMI).  But that is not what happened.  EM Nerd has a helpful post on this article, The Case of the Failed Assumptions.

 

Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis.  Lancet. 2017 Jul 8;390(10090):e21-e33. doi: 10.1016/S0140-6736(17)31744-0.
AUTHORS' INTERPRETATION: On the basis of the available data, we see no role for single-agent paracetamol for the treatment of patients with osteoarthritis irrespective of dose. We provide sound evidence that diclofenac 150 mg/day is the most effective NSAID available at present, in terms of improving both pain and function. Nevertheless, in view of the safety profile of these drugs, physicians need to consider our results together with all known safety information when selecting the preparation and dose for individual patients.

 

A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses.  N Engl J Med. 2017 Jun 29;376(26):2545-2555. doi: 10.1056/NEJMoa1607033.
Spoon Feed: Even small abscesses, <5cm, benefitted from antibiotics.  This is contrary to some prior studies' findings that I&D alone was adequate for small abscesses.

 

Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke.  N Engl J Med. 2017 Jun 22;376(25):2437-2447. doi: 10.1056/NEJMoa1615715.
Spoon Feed: Supine position to improve cerebral blood flow in ischemic stroke patients did not impact outcome positively or negatively compared to head-of-bed elevation 30 degrees.

 

Idarucizumab for Dabigatran Reversal - Full Cohort Analysis.  N Engl J Med. 2017 Jul 11. doi: 10.1056/NEJMoa1707278. [Epub ahead of print]
Spoon Feed: Idarucizumab reverses anticoagulation 100% due to dabigatran in the test tube. It seemed to stop active bleeding in patients in about 2.5 hours, and reported operative hemostasis was good.  But since this was an open label trial with no control group, we don't know how the outcomes would have compared with patients who were treated with other procoagulants or who were not treated.

 

Utility of Lumbar Puncture in Children Presenting With Status Epilepticus.  Pediatr Emerg Care. 2017 Jul 11. doi: 10.1097/PEC.0000000000001225. [Epub ahead of print]
Spoon Feed: Meningitis was a very rare cause of status epilepticus (SE) in this retrospective single-center review.

 

Predicting Risk of Serious Bacterial Infections in Febrile Children in the Emergency Department.  Pediatrics. 2017 Jul 5. pii: e20162853. doi: 10.1542/peds.2016-2853. [Epub ahead of print]
AUTHORS' CONCLUSIONS: Diagnostic models discriminated well between pneumonia, other SBIs, and no SBI in febrile children in the emergency department. Improvements in the classification of nonevents have the potential to reduce unnecessary hospital admissions and improve antibiotic prescribing. The benefits of this improved risk prediction should be further evaluated in robust impact studies.

 

Allergy Testing in Children With Low-Risk Penicillin Allergy Symptoms.  Pediatrics. 2017 Jul 3. pii: e20170471. doi: 10.1542/peds.2017-0471. [Epub ahead of print]
Spoon Feed: All children in the PED who were low risk for true penicillin allergy on this questionnaire were confirmed to have no penicillin allergy with skin testing.

 

Implementation of the universal BLS termination of resuscitation rule in a rural EMS system.  Resuscitation. 2017 Jul 13;118:75-81. doi: 10.1016/j.resuscitation.2017.07.004. [Epub ahead of print]
Spoon Feed: The universal basic life support termination of resuscitation (BLS-TOR) rule was effective in reducing futile transports in a rural EMS system.

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