June 2017 EM Articles

*NNR THIS MONTH = 56

You'd have to read 2533 articles to find these 45 marvels of modern statistics.

*NNR - number needed to read

Identifying Low-risk Patients for Early Discharge From Emergency Department Without Using Subjective Descriptions of Chest Pain: Insights From Providing Rapid Out of Hospital Acute Cardiovascular Treatment (PROACT) 3 and 4 Trials.  Acad Emerg Med. 2017 Jun;24(6):691-700. doi: 10.1111/acem.13183. Epub 2017 May 12.
AUTHORS' CONCLUSION: The diagnostic protocols performed well without their chest pain characteristics component. Further studies are suggested to explore the performance of ADPs when these simplified ADPs are combined with high-sensitive troponin assays.

 

H1-antihistamines Reduce Progression to Anaphylaxis Among Emergency Department Patients With Allergic Reactions.  Acad Emerg Med. 2017 Jun;24(6):733-741. doi: 10.1111/acem.13147.
Spoon Feed: This study gives evidence that treating patients with an allergic reaction with a H1-antagonist is a best practice and may decrease the chance of disease progression to anaphylaxis.

 

Serum sodium correction rate and the outcome in severe hyponatremia.  Am J Emerg Med. 2017 May 31. pii: S0735-6757(17)30430-8. doi: 10.1016/j.ajem.2017.05.050. [Epub ahead of print]
AUTHORS' CONCLUSION: We observed that serum sodium correction rate ≥0.3 and <0.5mmol/h was associated with a shorter length of hospital stay and a major survival rate.

 

Low yield of blood and wound cultures in patients with skin and soft-tissue infections.  Am J Emerg Med. 2017 May 26. pii: S0735-6757(17)30420-5. doi: 10.1016/j.ajem.2017.05.039. [Epub ahead of print]
Spoon Feed: Blood cultures are low yield in routine patients with skin and soft-tissue infection.  Don't do it unless your patient has one of the above high-risk features.  False positive cultures are common and require costly follow up for patients.

 

Serum procalcitonin levels as a diagnostic marker for septic arthritis: A meta-analysis.  Am J Emerg Med. 2017 Jun 7. pii: S0735-6757(17)30453-9. doi: 10.1016/j.ajem.2017.06.014. [Epub ahead of print]
AUTHORS' CONCLUSION: PCT is more valuable than CRP for distinguishing SA from non-SA.

 

New Sepsis Definition (Sepsis-3) and Community-acquired Pneumonia Mortality: A Validation and Clinical Decision-making Study.  Am J Respir Crit Care Med. 2017 Jun 14. doi: 10.1164/rccm.201611-2262OC. [Epub ahead of print]
AUTHORS' CONCLUSIONS: qSOFA and CRB outperformed SIRS and presented better clinical usefulness as prompt tools for CAP patients in the emergency department. Among the tools for a comprehensive patient assessment, PSI had the best decision-aid tool profile.

 

Effects of Age and Disease Severity on Systemic Corticosteroid Responses in Asthma.  Am J Respir Crit Care Med. 2017 Jun 1;195(11):1439-1448. doi: 10.1164/rccm.201607-1453OC.
AUTHORS' CONCLUSIONS: One in five patients with SA exhibit greater than or equal to 10% improvement in FEV1 with parenteral corticosteroid. Those likely to respond had greater bronchodilator responsiveness and fractional exhaled nitric oxide levels. In adults, differences in airflow obstruction and symptoms between SA and NONSA persist after parenteral corticosteroids, suggesting a component of corticosteroid nonresponsive pathobiology in adults with SA that may differ in children.

 

High-Flow Nasal Cannula Versus Conventional Oxygen Therapy in Emergency Department Patients With Cardiogenic Pulmonary Edema: A Randomized Controlled Trial.  Ann Emerg Med. 2017 Jun 7. pii: S0196-0644(17)30324-4. doi: 10.1016/j.annemergmed.2017.03.028. [Epub ahead of print]
AUTHORS' CONCLUSION: In patients with cardiogenic pulmonary edema in the ED, high-flow nasal cannula therapy may decrease the severity of dyspnea during the first hour of treatment.

 

Blind Intubation through Self-pressurized, Disposable Supraglottic Airway Laryngeal Intubation Masks: An International, Multicenter, Prospective Cohort Study.  Anesthesiology. 2017 Jun 1. doi: 10.1097/ALN.0000000000001710. [Epub ahead of print]
AUTHORS' CONCLUSIONS: The supraglottic airway device reliably provided a good airway and allowed blind intubation in nearly 80% of patients. It is thus a reasonable initial approach to airway control. Muscle relaxation can be used safely when unparalyzed leak pressure is adequate.

 

Improving Recognition of Pediatric Severe Sepsis in the Emergency Department: Contributions of a Vital Sign-Based Electronic Alert and Bedside Clinician Identification.  Ann Emerg Med. 2017 May 27. pii: S0196-0644(17)30315-3. doi: 10.1016/j.annemergmed.2017.03.019. [Epub ahead of print]
AUTHORS' CONCLUSION: Electronic sepsis alert for severe sepsis demonstrated good sensitivity and high specificity. Addition of clinician identification of electronic sepsis alert-negative patients further improved sensitivity. Implementation of the electronic sepsis alert was associated with improved recognition of severe sepsis.

 

Rib Fracture Diagnosis in the Panscan Era.  Ann Emerg Med. 2017 May 27. pii: S0196-0644(17)30431-6. doi: 10.1016/j.annemergmed.2017.04.011. [Epub ahead of print]
AUTHORS' CONCLUSION:  Under trauma imaging protocols that commonly incorporate chest CT, two thirds of rib fractures were observed on chest CT only. Patients with rib fractures had higher admission rates and mortality than those without rib fractures. First or second rib fractures were associated with significantly higher mortality and great vessel injury.

 

Comparative Effectiveness of Patient-Controlled Analgesia for Treating Acute Pain in the Emergency Department.  Ann Emerg Med. 2017 Jun 7. pii: S0196-0644(17)30360-8. doi: 10.1016/j.annemergmed.2017.03.064. [Epub ahead of print]
AUTHORS' CONCLUSION: The findings of this study do not favor patient-controlled analgesia over usual ED care for acute pain management.

 

The Bougie and First-Pass Success in the Emergency Department.  Ann Emerg Med. 2017 Jun 7. pii: S0196-0644(17)30509-7. doi: 10.1016/j.annemergmed.2017.04.033. [Epub ahead of print]
Spoon Feed: Bougie use was associated with improved first-pass success in this single-center study with routine bougie use for most intubations in the ED.

 

Emergency Physician Use of Cognitive Strategies to Manage Interruptions.  Ann Emerg Med. 2017 Jun 7. pii: S0196-0644(17)30512-7. doi: 10.1016/j.annemergmed.2017.04.036. [Epub ahead of print]
Spoon Feed:  Managing interruptions by delaying or rejecting the interruption may improve safety when they occur during critical tasks.

 

Application of the MASCC and CISNE Risk-Stratification Scores to Identify Low-Risk Febrile Neutropenic Patients in the Emergency Department.  Ann Emerg Med. 2017 Jun;69(6):755-764. doi: 10.1016/j.annemergmed.2016.11.007. Epub 2016 Dec 29.
Spoon Feed: The CISNE score beat the MASCC score for determining which patients with fever and neutropenia may have been safe for outpatient management.

 

Growth and Rupture Risk of Small Unruptured Intracranial Aneurysms: A Systematic Review.  Ann Intern Med. 2017 Jun 6. doi: 10.7326/M17-0246. [Epub ahead of print]
Spoon Feed: As CTA use increases, so does detection of small UIAs.  Most are unlikely to grow, and rupture rates are low but may be up to 1% per year in larger, 7mm aneurysms.

 

Antibiotic Prescribing for Nonbacterial Acute Upper Respiratory Infections in Elderly Persons.  Ann Intern Med. 2017 Jun 6;166(11):765-774. doi: 10.7326/M16-1131. Epub 2017 May 9.
AUTHORS' CONCLUSION: In this low-risk elderly cohort, 46% of patients with a nonbacterial AURI were prescribed antibiotics. Patients were more likely to receive prescriptions from mid- or late-career physicians with high patient volumes and from physicians who were trained outside of Canada or the United States.

 

Moderate alcohol consumption as risk factor for adverse brain outcomes and cognitive decline: longitudinal cohort study.  BMJ. 2017 Jun 6;357:j2353. doi: 10.1136/bmj.j2353
AUTHORS' CONCLUSIONS: Alcohol consumption, even at moderate levels, is associated with adverse brain outcomes including hippocampal atrophy. These results support the recent reduction in alcohol guidance in the UK and question the current limits recommended in the US.

 

Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED.  Chest. 2017 Jun;151(6):1295-1301. doi: 10.1016/j.chest.2017.02.003. Epub 2017 Feb 16.
Spoon Feed: ED POCUS was very accurate for the diagnosis of dyspnea and led to an answer much faster than standard ED workup.

 

Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study.  Chest. 2017 Jun;151(6):1229-1238. doi: 10.1016/j.chest.2016.11.036. Epub 2016 Dec 6.
Spoon Feed: A cocktail of IV vitamin C, hydrocortisone, and thiamine appeared to dramatically reduce mortality in this small, exploratory, before/after study. 

 

Cardiopulmonary Resuscitation in Adults and Children With Mechanical Circulatory Support: A Scientific Statement From the American Heart Association.  Circulation. 2017 Jun 13;135(24):e1115-e1134. doi: 10.1161/CIR.0000000000000504. Epub 2017 May 22.
Spoon Feed: LVADs and other mechanical circulatory support devices are increasing used.  We need to know the basics of how they work and how to troubleshoot them.  This full text article is a must read.

 

Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid: single biomarker re-derivation and external validation in three cohorts.  Emerg Med J. 2017 Jun;34(6):349-356. doi: 10.1136/emermed-2016-205983. Epub 2016 Aug 26.
Spoon Feed: T-MACS is a viable rule-out (or rule-in) option to aid clinical decision making in patients with chest pain using hs-TnT (now available in the US).  Don't miss this blog post on St. Emlyns by lead author Rick Body about this article.

 

Outcomes in Patients With Chest Pain Discharged After Evaluation Using a High-Sensitivity Troponin T Assay.  J Am Coll Cardiol. 2017 May 30;69(21):2622-2630. doi: 10.1016/j.jacc.2017.03.586.
AUTHORS' CONCLUSIONS: Patients directly discharged from the ED with unspecified chest pain experienced fewer MACEs and had a better risk profile when evaluated with hsTnT. Our findings suggest that more true at-risk patients were identified and admitted. The implementation of hsTnT assays in Swedish hospitals has improved evaluations in the ED.

 

Management of Patients with Predicted Difficult Airways in an Academic Emergency Department.  J Emerg Med. 2017 Jun 9. pii: S0736-4679(17)30339-6. doi: 10.1016/j.jemermed.2017.04.003. [Epub ahead of print]
AUTHORS' CONCLUSIONS: Difficult airways were predicted in 11% of non-arrest patients requiring intubation in the ED, the majority of which were managed using an NMBA and a video laryngoscope with a high first-pass success.

 

Safety of multidetector computed tomography pulmonary angiography to exclude pulmonary embolism in patients with a likely pretest clinical probability.  J Thromb Haemost. 2017 Jun 2. doi: 10.1111/jth.13746. [Epub ahead of print]
Spoon Feed: Patients with a "PE likely" pretest probability may be considered ruled out for PE after negative CTPA with no additional testing, assuming the same (or lower) prevalence of PE in your setting.

 

Impact of Critical Care Air Transport Team (CCATT) ventilator management on combat mortality.  J Trauma Acute Care Surg. 2017 May 30. doi: 10.1097/TA.0000000000001607. [Epub ahead of print]
Spoon Feed: Prehopital ARDSnet ventilation strategies appear to reduce mortality, ICU length of stay, and days on the ventilator.

 

Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial.  JAMA. 2017 Jun 13;317(22):2290-2296. doi: 10.1001/jama.2017.6322.
Spoon Feed: FAST exam didn't have an impact on the care of stable children with torso trauma.

 

Association of Adverse Events With Antibiotic Use in Hospitalized Patients.  JAMA Intern Med. 2017 Jun 12. doi: 10.1001/jamainternmed.2017.1938. [Epub ahead of print]
Spoon Feed: Adverse effects from antibiotics are very common, up to 20% of the time in hospitalized patients.  Only use them when needed.

 

Glucose Self-monitoring in Non-Insulin-Treated Patients With Type 2 Diabetes in Primary Care Settings: A Randomized Trial.  JAMA Intern Med. 2017 Jun 10. doi: 10.1001/jamainternmed.2017.1233. [Epub ahead of print]
AUTHORS' CONCLUSIONS: In patients with non-insulin-treated type 2 diabetes, we observed no clinically or statistically significant differences at 1 year in glycemic control or HRQOL between patients who performed SMBG compared with those who did not perform SMBG. The addition of this type of tailored feedback provided through messaging via a meter did not provide any advantage in glycemic control.

 

Effect of Nebulized Hypertonic Saline Treatment in Emergency Departments on the Hospitalization Rate for Acute Bronchiolitis: A Randomized Clinical Trial.  JAMA Pediatr. 2017 Jun 5:e171333. doi: 10.1001/jamapediatrics.2017.1333. [Epub ahead of print]
Spoon Feed: Hypertonic saline nebulized treatments did not reduce hopitalization in children with bronchiolitis.  Just use suction, supplemental oxygen as needed, and IV hydration in children who can't take liquids.  Otherwise, there are not many good options.

 

Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children.  JAMA Pediatr. 2017 Jun 19. doi: 10.1001/jamapediatrics.2017.0885. [Epub ahead of print]
AUTHORS' CONCLUSION: Delay of appendectomy within 24 hours of presentation was not associated with increased risk of complicated appendicitis or adverse outcomes. These results support the premise that appendectomy can be safely performed as an urgent rather than emergency procedure.


Randomized Trial of Icatibant for Angiotensin-Converting Enzyme Inhibitor-Induced Upper Airway Angioedema.  J Allergy Clin Immunol Pract. 2017 May 25. pii: S2213-2198(17)30172-1. doi: 10.1016/j.jaip.2017.03.003. [Epub ahead of print]
Spoon Feed: Icatibant did not improve outcome compared to placebo for ACE-I associated angioedema.

 

Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis.  N Engl J Med. 2017 Jun 8;376(23):2223-2234. doi: 10.1056/NEJMoa1701380. Epub 2017 Mar 21.
AUTHORS' CONCLUSIONS: In this meta-analysis of individual patient data, EGDT did not result in better outcomes than usual care and was associated with higher hospitalization costs across a broad range of patient and hospital characteristics. (Funded by the National Institute of General Medical Sciences and others; PRISM ClinicalTrials.gov number, NCT02030158 .).

 

Endovascular therapy for ischemic stroke: Save a minute-save a week.  Neurology. 2017 May 30;88(22):2123-2127. doi: 10.1212/WNL.0000000000003981. Epub 2017 Apr 28.
AUTHORS' CONCLUSIONS: Small reductions in endovascular delays lead to marked health benefits over patients' lifetimes. Services need to be optimized to reduce delays to endovascular therapy.

 

A 1980 Letter on the Risk of Opioid Addiction.  N Engl J Med. 2017 Jun 1;376(22):2194-2195. doi: 10.1056/NEJMc1700150.
Spoon Feed: This is a classic example of failure to go back to the source of information.  We as physicians uncritically bought the line that opiates for legitimate pain were not addictive, which was not even close to what this original letter to the editor was about.

 

Acute Myocardial Infarction.  N Engl J Med. 2017 May 25;376(21):2053-2064. doi: 10.1056/NEJMra1606915.

 

Diagnosis of DWI-negative acute ischemic stroke: A meta-analysis.  Neurology. 2017 Jun 14. pii: 10.1212/WNL.0000000000004120. doi: 10.1212/WNL.0000000000004120. [Epub ahead of print]
Spoon Feed: False negative DWI MRI imaging happens in about 7% of cases.  If you strongly suspect ischemic stroke clinically, especially posterior stroke, press to admit for further workup.

 

The Epidemiology, Management, and Outcomes of Bacterial Meningitis in Infants.  Pediatrics. 2017 Jun 9. pii: e20170476. doi: 10.1542/peds.2017-0476. [Epub ahead of print]
Spoon Feed: E. coli and GBS were the most common pathogens causing meningitis in infants under 90 days in this cohort. Add ampicillin for the first month to cover Listeria.  If gram-negative meningitis is present, consider adding or changing to a carbapenem (like meropenem).

 

Effectiveness of different compression-to-ventilation methods for cardiopulmonary resuscitation: A systematic review.  Resuscitation. 2017 Jun 2. pii: S0300-9572(17)30243-5. doi: 10.1016/j.resuscitation.2017.05.032. [Epub ahead of print]
AUTHORS' CONCLUSIONS: Our results demonstrated that for adults, CPR 30:2 is associated with better survival and favourable neurological outcomes when compared to CPR 15:2. For children, more patients receiving CPR with either 15:2 or 30:2 compression-to ventilation ratio experienced favourable neurological function, survival, and ROSC when compared to CO-CPR for children of all ages, but for children <1years of age, no statistically significant differences were observed.

 

Academic Primer Series: Key Papers About Teaching with Technology.  West J Emerg Med. 2017 Jun;18(4):729-736. doi: 10.5811/westjem.2017.2.33076. Epub 2017 May 1.
AUTHORS' CONCLUSION: This is a key reading list for junior faculty members and faculty developers interested in teaching with technology. The commentary contextualizes the importance of these papers for medical educators, to optimize use of technology in their teaching or incorporate into faculty development.

 

Utility of the History and Physical Examination in the Detection of Acute Coronary Syndromes in Emergency Department Patients.  West J Emerg Med. 2017 Jun;18(4):752-760. doi: 10.5811/westjem.2017.3.32666. Epub 2017 May 3.
Spoon Feed: History and exam features are not useless in the evaluation of patients with chest pain, but they must be used as part of a risk stratification strategy that includes ECG and troponin.

 

Pitfalls in Electrocardiographic Diagnosis of Acute Coronary Syndrome in Low-Risk Chest Pain.  West J Emerg Med. 2017 Jun;18(4):601-606. doi: 10.5811/westjem.2017.1.32699. Epub 2017 Apr 17.
Spoon Feed: Learn the ECG patterns for posterior MI, left main disease, the ominous isolated T-wave inversion in aVL, large upright T-wave in V1, and Wellen's warning.  This full text article is mandatory reading.  Enjoy!

 

Evaluating the Laboratory Risk Indicator to Differentiate Cellulitis from Necrotizing Fasciitis in the Emergency Department.  West J Emerg Med. 2017 Jun;18(4):684-689. doi: 10.5811/westjem.2017.3.33607. Epub 2017 May 12.
Spoon Feed: Don't rely on the LRINEC score to distinguish which patients do or do not have necrotizing fasciitis (NF).  It fails as a reliable diagnostic screening test.  NF remains a clinical diagnosis.

 

Index to Predict In-hospital Mortality in Older Adults after Non-traumatic Emergency Department Intubations.  West J Emerg Med. 2017 Jun;18(4):690-697. doi: 10.5811/westjem.2017.2.33325. Epub 2017 Apr 19.
AUTHORS' CONCLUSION: The model may be useful in identifying older adults at high risk of death after ED intubation.

 

Derivation and Validation of The Prehospital Difficult Airway IdentificationTool (PreDAIT): A Predictive Model for Difficult Intubation.  West J Emerg Med. 2017 Jun;18(4):662-672. doi: 10.5811/westjem.2017.1.32938. Epub 2017 Apr 17.
AUTHORS' CONCLUSION: We have developed a simple tool using five factors that may aid prehospital providers in the identification of difficult ETI.