October 2017 EM Articles


You'd have to read 2707 articles to find these 43 beauts from the interwebs.

*NNR - number needed to read


Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy.  Acad Emerg Med. 2017 Sep 28. doi: 10.1111/acem.13326. [Epub ahead of print]
Spoon Feed: This study found it was mechanically impossible to maintain 30-40N of downward force during the laryngoscopy phase of RSI.


Behavioral Changes in Children after Emergency Department Procedural Sedation.  Acad Emerg Med. 2017 Oct 9. doi: 10.1111/acem.13332. [Epub ahead of print]
AUTHORS' CONCLUSION: For children undergoing procedural sedation in the ED, two in five children have high pre-procedure anxiety and almost one in four have significant negative behaviors 1-2 weeks after discharge. Highly anxious and non-white children have increased risk of negative behavioral changes which have not been previously recognized in the ED setting.


Effect of the Macintosh curved blade size on direct laryngoscopic view in edentulous patients.  Am J Emerg Med. 2017 Sep 28. pii: S0735-6757(17)30793-3. doi: 10.1016/j.ajem.2017.09.050. [Epub ahead of print]
CONCLUSIONS: Compared to a standard-sized Macintosh blade, a smaller-sized Macintosh curved blade improved the laryngeal exposure in edentulous patients.


Outcomes in variceal hemorrhage following the use of a balloon tamponade device.  Am J Emerg Med. 2017 Oct;35(10):1500-1502. doi: 10.1016/j.ajem.2017.04.035. Epub 2017 Apr 20.
AUTHORS' CONCLUSION: In this cohort of patients undergoing BTD placement for variceal hemorrhage, approximately 59% of patients were alive at discharge and 41% were alive after one year. Placement of a BTD as a temporizing measure in the management of acute variceal hemorrhage may be helpful, particularly when utilized as a bridge to more definitive therapy.


The differential diagnosis of wide QRS complex tachycardia.  Am J Emerg Med. 2017 Oct;35(10):1525-1529. doi: 10.1016/j.ajem.2017.07.056. Epub 2017 Jul 17.
Abstract: Wide complex tachycardia is defined as a cardiac rhythm with a rate greater than 100 beats/min (bpm) and a QRS complex duration greater than 0.10 to 0.12seconds (s) in the adult patient; wide complex tachycardia (WCT) in children is defined according to age-related metrics. The differential diagnosis of the WCT includes ventricular tachycardia and supraventricular tachycardia with aberrant intraventricular conduction, including both relatively benign and life-threatening dysrhythmias. This review focuses on the differential diagnosis of WCT with a discussion of strategies useful in making the appropriate diagnosis, when possible.


Differences in test ordering between nurse practitioners and attending emergency physicians when acting as Provider in Triage.  Am J Emerg Med. 2017 Oct;35(10):1426-1429. doi: 10.1016/j.ajem.2017.04.027. Epub 2017 Apr 14.
AUTHORS' CONCLUSION: NPs in the PIT role ordered slightly less diagnostic tests than attending physicians. This slight difference did not affect time spent in an ED bed. By the end of the ED stay, there was no significant difference in total test categories ordered between provider types. PIT staffing with NPs does not appear to be associated with excess test ordering or prolonged ED patient stays.


The "Ear-Sternal Notch" Line-How Should You Lie?  Anesth Analg. 2017 Sep 14. doi: 10.1213/ANE.0000000000002493. [Epub ahead of print]
Spoon Feed: We’ve all been taught to use the “sniffing position” when intubating patients in a supine position. However, when adding ramped positioning for pre-oxygenation and intubation, fidelity to the “sniffing position” degrades. A couple Australian anesthesiologists have written a letter to clarify the proper technique.


Ibutilide Effectiveness and Safety in the Cardioversion of Atrial Fibrillation and Flutter in the Community Emergency Department.  Ann Emerg Med. 2017 Sep 29. pii: S0196-0644(17)31381-1. doi: 10.1016/j.annemergmed.2017.07.481. [Epub ahead of print]
Spoon Feed: Ibutilide works to chemically cardiovert rapid atrial fibrillation (afib) in just over half of cases but was associated with the feared complication, ventricular tachycardia (VT), in 0.6%.


Subgroup Analysis of Antibiotic Treatment for Skin Abscesses.  Ann Emerg Med. 2017 Oct 4. pii: S0196-0644(17)31383-5. doi: 10.1016/j.annemergmed.2017.07.483. [Epub ahead of print]
Spoon Feed: We can't draw firm conclusions from this paper, since it was not designed or powered to detect differences in subgroups with skin abscesses.  But it was notable that patients who received TMP/SMX did better across all subgroups than those who received placebo, including those with larger abscesses; especially those with fever, history of MRSA, or MRSA positive culture.


Acetaminophen or Nonsteroidal Anti-Inflammatory Drugs in Acute Musculoskeletal Trauma: A Multicenter, Double-Blind, Randomized, Clinical Trial.  Ann Emerg Med. 2017 Oct 13. pii: S0196-0644(17)31506-8. doi: 10.1016/j.annemergmed.2017.08.041. [Epub ahead of print]
AUTHORS' CONCLUSION: Pain treatment with acetaminophen was not inferior to that with diclofenac or the combination of acetaminophen and diclofenac in acute minor musculoskeletal extremity trauma, both in rest and with movement.


HIV Prevention and Treatment: The Evolving Role of the Emergency Department.  Ann Emerg Med. 2017 Oct;70(4):562-572.e3. doi: 10.1016/j.annemergmed.2017.01.018. Epub 2017 Mar 25.
Abstract: Historically, the role of the emergency physician in HIV care has been constrained to treating sick patients with opportunistic infections and postexposure prophylaxis for occupational exposures. However, advances in HIV care have led to medications that have substantially fewer issues with toxicity and resistance, opening up an exciting new opportunity for emergency physicians to participate in treating the HIV virus itself. With this new role, it is crucial that emergency physicians be familiar with the advances in testing and medications for HIV prevention and treatment. To our knowledge, to date there has not yet been an article addressing this expansion of practice. We have compiled a summary of what the emergency physician needs to know, including misconceptions associated with antiretroviral therapy, medication complexity, toxicity, resistance, and usability. Additionally, we review potential indications for prescribing these drugs in the emergency department, including the role of the emergency physician in postexposure prophylaxis, preexposure prophylaxis, and treatment of acute HIV, as well as how emergency physicians can engage with chronic HIV infection.


Urinary Tract Infection.  Ann Intern Med. 2017 Oct 3;167(7):ITC49-ITC64. doi: 10.7326/AITC201710030.
Abstract: Urinary tract infections (UTIs) are common in both inpatient and outpatient settings. This article provides an evidence-based, clinically relevant overview of management of UTIs, including screening, diagnosis, treatment, and prevention. Conditions covered include acute cystitis (both uncomplicated and complicated), catheter-associated UTI, and asymptomatic bacteriuria in both women and men.


Incidence, clinical management, and mortality risk following self harm among children and adolescents: cohort study in primary care.  BMJ. 2017 Oct 18;359:j4351. doi: 10.1136/bmj.j4351.
Authors' Conclusions Gaining a better understanding of the mechanisms responsible for the recent apparent increase in the incidence of self harm among early-mid teenage girls, and coordinated initiatives to tackle health inequalities in the provision of services to distressed children and adolescents, represent urgent priorities for multiple public agencies.


Diagnosis and management of postpartum haemorrhage.  BMJ. 2017 Sep 27;358:j3875. doi: 10.1136/bmj.j3875.
PMID: 28954732 


Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study.  BMJ. 2017 Oct 10;359:j4366. doi: 10.1136/bmj.j4366.
Spoon Feed: Female surgeons had small but significantly improved 30-day mortality and other surgical outcomes over male surgeons, all other factors being equal.


Morphine Use in the ED and Outcomes of Patients With Acute Heart Failure: A Propensity Score-Matching Analysis Based on the EAHFE Registry.  Chest. 2017 Oct;152(4):821-832. doi: 10.1016/j.chest.2017.03.037. Epub 2017 Apr 12.
Spoon Feed: Morphine was associated with worse short-term mortality: 20% vs. 12.7%.


High-Sensitivity Cardiac Troponin and the Risk Stratification of Patients with Renal Impairment Presenting with Suspected Acute Coronary Syndrome.  Circulation. 2017 Oct 4. pii: CIRCULATIONAHA.117.030320. doi: 10.1161/CIRCULATIONAHA.117.030320. [Epub ahead of print]
Authors' Conclusions -In suspected acute coronary syndrome, high-sensitivity cardiac troponin identified fewer patients with renal impairment as low-risk and more as high-risk, but with lower specificity for type 1 myocardial infarction. Irrespective of diagnosis, patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function, and should be considered for further investigation and treatment.


Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association.  Circulation. 2017 Oct 3. pii: CIR.0000000000000527. doi: 10.1161/CIR.0000000000000527. [Epub ahead of print]
AUTHORS' CONCLUSIONS: Many of the recommendations are based on limited data, so authors conclude with specific questions for further research.


Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.  Circulation. 2017 Oct 13. pii: CIRCULATIONAHA.117.029457. doi: 10.1161/CIRCULATIONAHA.117.029457. [Epub ahead of print]
Authors' Conclusions -Integration of ADD-RS (both =0 or ≤1) with DD may be considered to standardize diagnostic rule-out of AAS.


Pre-emptive ice cube cryotherapy for reducing pain from local anaesthetic injections for simple lacerations: a randomised controlled trial.  Emerg Med J. 2017 Oct 12. pii: emermed-2017-206585. doi: 10.1136/emermed-2017-206585. [Epub ahead of print]
Spoon Feed: Applying an ice cube (inside a sterile glove) to the skin near a laceration for 2 minutes significantly reduced pain from local anesthetic injection.


Waveform capnography: an alternative to physician gestalt in determining optimal intubating conditions after administration of paralytic agents.  Emerg Med J. 2017 Oct 10. pii: emermed-2017-206922. doi: 10.1136/emermed-2017-206922. [Epub ahead of print]
Spoon Feed: Using loss of wave capnography rather than gestalt assessment of relaxation after paralytic administration for RSI in the ED led to shorter time to intubation and increased first-pass success.


Association of magnetic resonance imaging for back pain on seven-day return visit to the Emergency Department.  Emerg Med J. 2017 Oct;34(10):677-679. doi: 10.1136/emermed-2016-206250. Epub 2017 May 2.
Spoon Feed: Getting an MRI for back pain does not reduce recurrent patient visits within a week.  The only time we should get an MRI for back pain in the ED is if there is a clinical concern that the findings may prompt emergent surgery, such as for cauda equina, epidural abscess, or impinging mass (may need radiation), etc.


Use of Prophylactic Ondansetron with Intravenous Opioids in Emergency Department Patients: A Prospective Observational Pilot Study.  J Emerg Med. 2017 Oct 5. pii: S0736-4679(17)30616-9. doi: 10.1016/j.jemermed.2017.06.040. [Epub ahead of print]
Spoon Feed: Prophylactic ondansetron given with IV opiates did not decrease the rate of nausea or vomiting.


Electrocardiographic Criteria for the Diagnosis of Left Ventricular Hypertrophy.
  J Am Coll Cardiol. 2017 Apr 4;69(13):1694-1703. doi: 10.1016/j.jacc.2017.01.037.
Spoon Feed: Adding the magnitudes of the deepest S wave anywhere in the ECG to the deepest S wave in lead V4 (SD + SV4) was the most sensitive ECG test for LVH (62%) while maintaining specificity above 90%.


Inferior Vena Cava Filters to Prevent Pulmonary Embolism: Systematic Review and Meta-Analysis.  J Am Coll Cardiol. 2017 Sep 26;70(13):1587-1597. doi: 10.1016/j.jacc.2017.07.775.
AUTHORS' CONCLUSIONS: Very few prospective controlled studies, with limited quality of evidence, exist regarding the efficacy and safety of IVC filters. Overall, filters appear to reduce the risk of subsequent PE, increase the risk for DVT, and have no significant effect on overall mortality.


No added value of the age-adjusted D-dimer cut-off to the YEARS algorithm in patients with suspected pulmonary embolism.  J Thromb Haemost. 2017 Sep 22. doi: 10.1111/jth.13852. [Epub ahead of print]
Authors' Conclusion: In our cohort, there was no added value of implementing ADJUST in the YEARS algorithm.


Treatment options for severe pulmonary embolism during pregnancy and the postpartum period: a systematic review.
  J Thromb Haemost. 2017 Oct;15(10):1942-1950. doi: 10.1111/jth.13802. Epub 2017 Sep 12.
Spoon Feed: Treatment with lytics, surgical or percutaneous embolectomy, or ECMO for acute PE (mostly massive or with arrest) in pregnancy out to 6 weeks postpartum was associated with 94% overall maternal survival and 88% fetal survival.  Major bleeding occurred in 17% of pregnant women and 58% of those in the postpartum period.


Effect of Routine Low-Dose Oxygen Supplementation on Death and Disability in Adults With Acute Stroke: The Stroke Oxygen Study Randomized Clinical Trial.  JAMA. 2017 Sep 26;318(12):1125-1135. doi: 10.1001/jama.2017.11463.
Authors' Conclusions and Relevance: Among nonhypoxic patients with acute stroke, the prophylactic use of low-dose oxygen supplementation did not reduce death or disability at 3 months. These findings do not support low-dose oxygen in this setting.


Effect of an Early Resuscitation Protocol on In-hospital Mortality Among Adults With Sepsis and Hypotension: A Randomized Clinical Trial.  JAMA. 2017 Oct 3;318(13):1233-1240. doi: 10.1001/jama.2017.10913.
Spoon Feed: Early sepsis treatment with protocolized IV fluid, pressors, and transfusions vs usual care was undertaken in Zambia, and resulted in much higher mortality.  Most patients had HIV.  This is yet another strike against a form of early goal-directed therapy (EGDT) vs. usual sepsis care.


Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial.  JAMA. 2017 Oct 10;318(14):1335-1345. doi: 10.1001/jama.2017.14171.
Authors' Conclusions and Relevance: In patients with moderate to severe ARDS, a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality. These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients.


Coronary Computed Tomography Angiography vs Functional Stress Testing for Patients With Suspected Coronary Artery Disease: A Systematic Review and Meta-analysis.  JAMA Intern Med. 2017 Oct 2. doi: 10.1001/jamainternmed.2017.4772. [Epub ahead of print]
Spoon Feed: There was no mortality difference based on which stress test was done, coronary CTA (CCTA) or functional stress testing.  But CCTA led to more downstream testing.  Either test is fine, but know that tests may have unintended consequences.


Association of Acute Kidney Injury With Concomitant Vancomycin and Piperacillin/Tazobactam Treatment Among Hospitalized Children.  JAMA Pediatr. 2017 Oct 2:e173219. doi: 10.1001/jamapediatrics.2017.3219. [Epub ahead of print]
Authors' Conclusions and Relevance: Coadministration of IV vancomycin and piperacillin/tazobactam may increase the risk of AKI in hospitalized children. Pediatricians must be cognizant of the potential added risk of this combination therapy when making empirical antibiotic choices.


The clinical significance of isolated traumatic subarachnoid hemorrhage in mild traumatic brain injury: A meta-analysis.  J Trauma Acute Care Surg. 2017 Oct;83(4):725-731. doi: 10.1097/TA.0000000000001617.
AUTHORS' CONCLUSIONS: These patients experience very low rates of radiographic progression and neurologic deterioration and rarely require neurosurgical intervention or die due to neurological injury.


A highly sensitive and specific combined clinical and sonographic score to diagnose appendicitis.  J Trauma Acute Care Surg. 2017 Oct;83(4):643-649. doi: 10.1097/TA.0000000000001551.
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 computed tomography imaging in a majority of patients.


Age of Red Cells for Transfusion and Outcomes in Critically Ill Adults.  N Engl J Med. 2017 Sep 27. doi: 10.1056/NEJMoa1707572. [Epub ahead of print]
Authors' Conclusions The age of transfused red cells did not affect 90-day mortality among critically ill adults.


Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine.  Neurology. 2017 Oct 18. pii: 10.1212/WNL.0000000000004642. doi: 10.1212/WNL.0000000000004642. [Epub ahead of print]
AUTHORS' CONCLUSIONS: IV hydromorphone is substantially less effective than IV prochlorperazine for the treatment of acute migraine in the ED and should not be used as first-line therapy.


Sonographically Occult Abscesses of the Buttock and Perineum in Children.  Pediatr Emerg Care. 2017 Sep 25. doi: 10.1097/PEC.0000000000001294. [Epub ahead of print]
Spoon Feed: Sonographically occult perineal abscess in children was surprisingly common, 28% (61/217).  More than half had I&D within 4 hours of radiology-obtained ultrasound.  What this shows is that abscess of the perineum can have a high false negative rate.


A Systematic Review of Testicle Survival Time After a Torsion Event.  Pediatr Emerg Care. 2017 Sep 25. doi: 10.1097/PEC.0000000000001287. [Epub ahead of print]
Spoon Feed: Consider testicular torsion a surgical emergency even if it is past the usual 6-8 hour mark, which is traditionally taught as the outer limit of testicular viability.  This study found that the testicle could still be salvaged over half the time from 13-24 hours from onset.


A Prospective Study of the Causes of Bruises in Premobile Infants.  Pediatr Emerg Care. 2017 Oct 16. doi: 10.1097/PEC.0000000000001311. [Epub ahead of print]
Spoon Feed: Bruising in premobile children means trouble.  The most important take home is: "More than half of premobile infants with initially unexplained bruises were found to be abused."  Bruising before they're cruising needs a workup and DCS referral.


Jinx or Not?: There Is Nothing Like a "Black Cloud" Syndrome.  Pediatr Emerg Care. 2017 Oct;33(10):686-689. doi: 10.1097/PEC.0000000000000663.
Spoon Feed: There is no such thing as a "black cloud."  Those who self-identified as a black-cloud, were also identified as such by their peers, but a look at the actual PED metrics showed no statistical difference, except higher admission rate.  I'm not sure I believe this, but there you go...


Recommendations for Prevention and Control of Influenza in Children, 2017 - 2018.  Pediatrics. 2017 Oct;140(4). pii: e20172550. doi: 10.1542/peds.2017-2550. Epub 2017 Sep 4.
Abstract: This statement updates the recommendations for routine use of the seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children. The American Academy of Pediatrics recommends annual seasonal influenza immunization for everyone 6 months and older, including children and adolescents. Highlights for the upcoming 2017-2018 season include the following:1. Annual universal influenza immunization is indicated with either a trivalent or quadrivalent (no preference) inactivated vaccine;2. The 2017-2018 influenza A (H1N1) vaccine strain differs from that contained in the 2016-2017 seasonal vaccines. The 2017-2018 influenza A (H3N2) vaccine strain and influenza B vaccine strains included in the trivalent and quadrivalent vaccines are the same as those contained in the 2016-2017 seasonal vaccines: a. trivalent vaccine contains an A/Michigan/45/2015 (H1N1)pdm09-like virus, an A/Hong Kong/4801/2014 (H3N2)-like virus, and a B/Brisbane/60/2008-like virus (B/Victoria lineage); and b. quadrivalent vaccine contains an additional B virus (B/Phuket/3073/2013-like virus [B/Yamagata lineage]);3. Quadrivalent live attenuated influenza vaccine (LAIV4) is not recommended for use in any setting in the United States during the 2017-2018 influenza season. This interim recommendation, originally made in 2016, followed observational data from the US Influenza Vaccine Effectiveness Network revealing that LAIV4 performed poorly against influenza A (H1N1)pdm09 viruses in recent influenza seasons;4. All children with an egg allergy of any severity can receive an influenza vaccine without any additional precautions beyond those recommended for any vaccine;5. All health care personnel should receive an annual seasonal influenza vaccine, a crucial step in preventing influenza and reducing health care-associated influenza infections, because health care personnel often care for individuals at high risk for influenza-related complications; and6. Pediatricians should attempt to promptly identify children suspected of having influenza infection for timely initiation of antiviral treatment, when indicated, to reduce morbidity and mortality. Best results are seen when treated within 48 hours of symptom onset.


Scene Safety and Force Protection in the Era of Ultra-Potent Opioids.  Prehosp Emerg Care. 2017 Sep 28:1-6. doi: 10.1080/10903127.2017.1367446. [Epub ahead of print]
Spoon Feed: Inadvertent poisoning with an opiate in the prehospital setting is unlikely, especially with routine personal protective equipment (gloves).


Comparative effectiveness of antiarrhythmics for out-of-hospital cardiac arrest: A systematic review and network meta-analysis.  Resuscitation. 2017 Oct 14;121:90-97. doi: 10.1016/j.resuscitation.2017.10.012. [Epub ahead of print]
AUTHORS' CONCLUSIONS: Amiodarone and lidocaine were the only agents associated with improved survival to hospital admission in the NMA. For the outcomes most important to patients, survival to hospital discharge and neurologically intact survival, no antiarrhythmic was convincingly superior to any other or to placebo.

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