May 2017 EM Articles

*NNR THIS MONTH = 107

You'd have to read 3315 articles to find these 31 academic wonders.

*NNR - number needed to read

Validation of the No Objective Testing Rule and Comparison to the HEART Pathway.
Acad Emerg Med. 2017 May 11. doi: 10.1111/acem.13221. [Epub ahead of print]
AUTHORS' CONCLUSIONS: "Within a US cohort of ED patients with chest pain, the NOTR and HEART Pathway were 100% sensitive for MACE at 30 days. However, the HEART Pathway identified more patients suitable for early discharge than the NOTR."

Adverse events with ketamine versus ketofol for procedural sedation on adults: a double-blinded, randomized controlled trial.
Acad Emerg Med. 2017 May 11. doi: 10.1111/acem.13226. [Epub ahead of print]
AUTHORS' CONCLUSION: "We found a significant reduction in recovery reactions and emesis frequencies among adult patients receiving emergency procedural sedations with ketofol, as compared with ketamine."

Magnetic Resonance Imaging Versus Ultrasound as the Initial Imaging Modality for Pediatric and Young Adult Patients With Suspected Appendicitis.
Acad Emerg Med. 2017 May;24(5):569-577. doi: 10.1111/acem.13180. Epub 2017 Apr 24.
Spoon Feed: Both ultrasound and rapid MRI are viable initial imaging options in young patients with suspected appendicitis, but in this study, MRI led to increased length of stay and significantly increased ED charges.

Risk of Intracranial Hemorrhage in Ground Level Fall with Antiplatelet or Anticoagulant Agents.
Acad Emerg Med. 2017 May 5. doi: 10.1111/acem.13217. [Epub ahead of print]
Spoon Feed: Older patients taking antiplatelet agents, including aspirin 81mg, or anticoagulants have tSAH about 3.5% of the time with simple ground level fall.

Impact of Hospital "Best Practice" Mandates on Prescription Opioid Dispensing after an Emergency Department Visit.
Acad Emerg Med. 2017 May 23. doi: 10.1111/acem.13230. [Epub ahead of print]
Spoon Feed: Statewide, non-specific mandates may help a little.  Local and departmental policy change, with provider buy in, is even better.

Accuracy of Point of Care Ultrasonography for Diagnosing Acute Appendicitis: A Systematic Review and Meta-Analysis.
Acad Emerg Med. 2017 May 2. doi: 10.1111/acem.13212. [Epub ahead of print]
AUTHORS' CONCLUSION: "POCUS has a relatively high sensitivity and specificity for diagnosing acute appendicitis, though the data presented is limited by the quality of the original studies and large confidence intervals. In the hands of an experienced operator, POCUS is an appropriate initial imaging modality for diagnosing appendicitis. Based on our results, it is premature to utilize POCUS as a standalone test or to rule out appendicitis."

Undetectable concentrations of an FDA-approved high-sensitivity cardiac Troponin T assay to rule out acute myocardial infarction at emergency department arrival.
Acad Emerg Med. 2017 May 19. doi: 10.1111/acem.13229. [Epub ahead of print]
AUTHORS' CONCLUSIONS: "When used in real-world clinical practice conditions, hsTnT concentrations < 6 ng/L (below the lower reportable limit for an FDA-approved assay) at the time of ED arrival can rule out AMI with very high sensitivity and negative predictive value. The sensitivity for MACE is unacceptably low, thus a single-troponin rule-out strategy should only be used in the context of a structured risk evaluation."

A 0h/1h protocol for safe early discharge of chest pain patients.
Acad Emerg Med. 2017 May 13. doi: 10.1111/acem.13224. [Epub ahead of print]
AUTHORS' CONCLUSION: "An ADP using the guideline recommended 0h/1h hs-cTnT strategy rapidly identified patients with a very low risk of 30-day MACE including UA where no further cardiac testing would be needed. This could potentially allow safe early discharge of about 40% of ED chest pain patients."

Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of-care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis.
Acad Emerg Med. 2017 May;24(5):523-551. doi: 10.1111/acem.13181.
AUTHORS' CONCLUSIONS: "Presence of AA is more likely in patients with undifferentiated abdominal pain migrating to the RLQ or when cough/hop pain is present in the physical examination. Once AA is suspected, no single history, physical examination, laboratory finding, or score attained on PAS can eliminate the need for imaging studies. Operating characteristics of ED-POCUS are similar to those reported for RUS in literature for diagnosis of AA. In ED patients suspected of AA, a positive ED-POCUS is diagnostic and obviates the need for CT or MRI while negative ED-POCUS is not enough to rule out AA."

Diagnostic Value and Effect of Bedside Ultrasound in Acute Appendicitis in the Emergency Department.
Acad Emerg Med. 2017 May;24(5):578-586. doi: 10.1111/acem.13169. Epub 2017 Apr 25.
AUTHORS' CONCLUSION: "Point-of-care ultrasonography, when performed in ED for the diagnosis of AA, has high sensitivity and specificity and had a positive impact on the clinical decision making of EPs."

Emergency Physicians Are Able to Detect Right Ventricular Dilation with Good Agreement Compared to Cardiology.
Acad Emerg Med. 2017 Apr 28. doi: 10.1111/acem.13210. [Epub ahead of print]
Spoon Feed: This is an encouraging study; bedside echo that answers a specific question, in this case - is the RV dilated or not - may be reliably performed, even by novice sonographers in the ED.

Accuracy of Physical Exam, Ankle-Brachial Index, and Ultrasonography in the Diagnosis of Arterial Injury in Patients with Penetrating Extremity Trauma: A Systematic Review and Meta-Analysis.
Acad Emerg Med. 2017 May 11. doi: 10.1111/acem.13227. [Epub ahead of print]
Spoon Feed: Arterial injury may be ruled out with a careful physical exam showing no hard or soft signs and ABI 0.9 or greater.  My practice is, when in doubt, I get a CTA.

Intranasal fentanyl and inhaled nitrous oxide for fracture reduction: The FAN observational study.
Am J Emerg Med. 2017 May;35(5):710-715. doi: 10.1016/j.ajem.2017.01.004. Epub 2017 Jan 5.
Spoon Feed: Intranasal fentanyl and N2O is a rapid way to perform pediatric sedation with no IV, but more patients cried, grimaced, and kicked during the procedure; and 12% vomited.

Comparison of the Mallampati Classification in Sitting and Supine Position to Predict Difficult Tracheal Intubation: A Prospective Observational Cohort Study.
Anesth Analg. 2017 May 19. doi: 10.1213/ANE.0000000000002108. [Epub ahead of print]
Spoon Feed: Checking a Mallampati score while supine is more accurate for predicting a difficult airway than in the seated position.

Relationship Between a Sepsis Intervention Bundle and In-Hospital Mortality Among Hospitalized Patients: A Retrospective Analysis of Real-World Data.
Anesth Analg. 2017 May 12. doi: 10.1213/ANE.0000000000002085. [Epub ahead of print]
AUTHORS' CONCLUSIONS: "The University of California, San Francisco, sepsis bundle was associated with a decreased risk of in-hospital mortality across hospital units after robust control for confounders and risk adjustment. The adjusted NNT provides a reasonable and achievable goal to observe measureable [sic] improvements in outcomes for patients diagnosed with SS/SS."

An Observational Study to Determine Whether Routinely Sending Patients Home With a 24-Hour Supply of Topical Tetracaine From the Emergency Department for Simple Corneal Abrasion Pain Is Potentially Safe.
Ann Emerg Med. 2017 May 2. pii: S0196-0644(17)30195-6. doi: 10.1016/j.annemergmed.2017.02.016. [Epub ahead of print]
Spoon Feed: This study found 1% tetracaine for 24 hours to be safe for treating pain from corneal abrasion.

Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial.
Ann Emerg Med. 2017 May 2. pii: S0196-0644(17)30264-0. doi: 10.1016/j.annemergmed.2017.03.006. [Epub ahead of print]
Spoon Feed: Prednisone 40mg daily x 4 days was not helpful in reducing itching in patients with simple urticaria.

Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial.
Ann Intern Med. 2017 May 16;166(10):689-697. doi: 10.7326/M16-1600. Epub 2017 Apr 25.
Spoon Feed: The HEART score is one safe way to help risk stratify chest pain patients.

A Multicenter, Randomized Trial of Ramped Position versus Sniffing Position during Endotracheal Intubation of Critically Ill Adults.
Chest. 2017 May 6. pii: S0012-3692(17)30881-4. doi: 10.1016/j.chest.2017.03.061. [Epub ahead of print]
Spoon Feed: For less experienced intubators in the ICU, ramped position offered no benefit over the sniffing position.  However, I'm concerned this article doesn't reflect the ramped position I use in practice.  With avoidance of neck hyperextension, I think the ramped position remains advantageous, especially in morbidly obese patients.

    Clinician's Guide to Early Rule-Out Strategies With High-Sensitivity Cardiac Troponin.
    Circulation. 2017 Apr 25;135(17):1612-1616. doi: 10.1161/CIRCULATIONAHA.117.026717.
    Spoon Feed: Consider these best practices when implementing a high sensitivity troponin strategy to rule out MI.  First, there are differences in assays.  The hs-TnI assay performs better in early presenters.  The hs-TnT assay performs better in late presenters.  The assay just approved in the US is hs-TnT.

    Best practice for hsTn-based early rule-out of MI should integrate the following (and I paraphrase...):

    1. Strategies combining clinical criteria, such as HEART, etc plus biomarkers have greater diagnostic accuracy.  And you must know time of onset to know the best rule-out strategy.
    2. Doing a delta troponin strategy (rather than a single troponin on presentation) improves diagnostic accuracy and NPV.  The author said a 0/1-hour strategy may be reasonable.
    3. If you choose to do a single hs-Tn rule-out, set the "positive" hs-Tn lower than the 99th percentile upper reference limit (URL) if drawn < 2 hours from symptom onset.
    4. The "delta" hs-Tn value must be set a priori.  For hs-TnI, it is a delta of <2 ng/mL at 1-hour or < 3 ng/mL at 3-hours.  Or the European Society of Cardiology recommends the 3-hour delta hs-Tn be <99th percentile URL or < 50% of the URL.

    The Impact of the Sepsis-3 Septic Shock Definition on Previously Defined Septic Shock Patients.
    Crit Care Med. 2017 May 24. doi: 10.1097/CCM.0000000000002512. [Epub ahead of print]
    Spoon Feed: Learn the new Sepsis-3 definition of septic shock, but realize that the old definition, "sepsis-induced hypotension persists after adequate fluid resuscitation, associated with perfusion abnormalities and organ dysfunction," still identifies a group of very ill individuals with high mortality.

    Variation in Emergency Department vs Internal Medicine Excess Charges in the United States.
    JAMA Intern Med. 2017 May 30. doi: 10.1001/jamainternmed.2017.1598. [Epub ahead of print]
    Spoon Feed: Get ready to face the societal and legislative backlash from this bash of ED billing practices.  Internal Medicine just threw us under the bus.  Mud slinging like this article won't solve the problem

    A Model for Electronic Handoff Between the Emergency Department and Inpatient Units.
    J Emerg Med. 2017 May 12. pii: S0736-4679(17)30317-7. doi: 10.1016/j.jemermed.2017.03.027. [Epub ahead of print]
    Spoon Feed: Electronic, asynchronous sign-out to the admitting team was widely used, reduced time to admission order completion, and seemed to be safe in this single center retrospective study.

    Intentional Misuse and Abuse of Loperamide: A New Look at a Drug with "Low Abuse Potential".
    J Emerg Med. 2017 May 10. pii: S0736-4679(17)30230-5. doi: 10.1016/j.jemermed.2017.03.018. [Epub ahead of print]
    Spoon Feed: Loperamide abuse is increasingly seen.  It can be rarely associated with cardiac conduction system disturbances.  Talk to poison control, and put these patients on a monitor.

    Novel oral anticoagulants and trauma: The results of a prospective American Association for the Surgery of Trauma Multi-Institutional Trial.
    J Trauma Acute Care Surg. 2017 May;82(5):827-835. doi: 10.1097/TA.0000000000001414.
    Spoon Feed: NOACs were not associated with an increased risk of traumatic ICH compared to other anticoagulant or antiplatelet agents. 

    A Highly Sensitive and Specific Combined Clinical and Sonographic Score to Diagnose Appendicitis.
    J Trauma Acute Care Surg. 2017 Apr 28. doi: 10.1097/TA.0000000000001551. [Epub ahead of print]
    AUTHORS' CONCLUSION: "Our scoring system based entirely on US findings was highly sensitive and specific for appendicitis, and it significantly improved when combined with the Alvarado Score. After prospective evaluation, the combined US-Alvarado score might replace the need for CT imaging in a majority of patients."

    Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A Randomized Clinical Trial.
    JAMA. 2017 May 23;317(20):2088-2096. doi: 10.1001/jama.2017.5653.
    Spoon Feed: For uncomplicated cellulitis in otherwise healthy patients, cephalexin alone is probably adequate.

    Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study.
    Lancet. 2017 May 23. pii: S0140-6736(17)30885-1. doi: 10.1016/S0140-6736(17)30885-1. [Epub ahead of print]
    Spoon Feed: This simplified protocol worked well and provided a one-size-fits-all approach to the workup of VTE.

    Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial.
    Lancet. 2017 Apr 26. pii: S0140-6736(17)30638-4. doi: 10.1016/S0140-6736(17)30638-4. [Epub ahead of print]
    Spoon Feed: TXA reduced mortality in women with postpartum hemorrhage without increase risk of thromboembolic events.

    Time to Treatment and Mortality during Mandated Emergency Care for Sepsis.
    N Engl J Med. 2017 May 21. doi: 10.1056/NEJMoa1703058. [Epub ahead of print]
    Spoon Feed: One of the most important tasks we do in sepsis care, after identifying it, is to start appropriate antibiotics.  This is associated with mortality reduction.

    Early Prediction Model of Patient Hospitalization From the Pediatric Emergency Department.
    Pediatrics. 2017 May;139(5). pii: e20162785. doi: 10.1542/peds.2016-2785.
    AUTHORS' CONCLUSIONS: "This approach can accurately predict patient hospitalization early in the ED encounter by using data commonly available in most electronic medical records. Such early identification can be used to advance patient placement processes and shorten ED boarding times."