52 Articles in 52 Weeks
Spoon Feed Version
It was a big job for ALiEM to come up with the list of 52 landmark articles you need to know as an Emergency Physician. But it’s an even bigger job to sit down and read them. In fact, many of us just won’t be able to find the time to do it. Because they are so important to know, I wanted to make it easier to get the gist of these articles. So each Saturday in 2017, I briefly summarized one of these key articles. For your convenience, here are the links and excerpts for each of the 52 in 52 article summaries in one place. Take a few minutes and read through each excerpt. It doesn’t take long to read, and it will give you the scope and sweep of EM over the years. Enjoy. And please share this with a friend. Special thanks to Dr. Michelle Lin and ALiEM for partnering with us.
Ultrasound or CT for Nephrolithiasis
An ultrasound-first strategy, especially for recurrent kidney stones, was a good way to reduce radiation exposure in patients presenting to the ED with renal colic.
When Is ED Thoracotomy Futile
Patients who had blunt trauma with CPR > 10 minutes, penetrating trauma with CPR > 15 minutes, or asystole without tamponade should not undergo resuscitative thoracotomy in the ED as it would be futile.
Bedside IVC Ultrasound to Guide Resuscitation
In this small study, IVC collapse of >/= 50% on bedside ultrasound correlated with a CVP </= 8 cm H2O and was 91% sensitive, 94% specific. But be sure to read the discussion.
ED Ultrasound in Trauma Reduces Time to OR
Point of care limited ultrasound for trauma, aka FAST exam, reduced time to the OR and several other important secondary outcomes.
Canadian CT Head Rule to Reduce CT Use
The Canadian CT Head Rule was 100% sensitive for ruling out clinically important brain injury. It had higher specificity than the New Orleans Criteria, which meant fewer people would need a CT scan by using the Canadian rule.
How Aortic Dissection Presents
Sudden-onset, severe (“worst-ever”), sharp chest pain was the hallmark of type A and B aortic dissection. Ripping or tearing pain was present in only half of patients. Classic features of aortic regurgitation murmur and pulse deficit were frequently lacking.
CRASH-2 Tranexamic Acid in Trauma
Tranexamic acid (TXA) decreased mortality from bleeding in trauma patients. But there are a few caveats to note.
Why We Delay Volume Administration in Penetrating Trauma
In patients with penetrating trauma, it was better to allow prehospital hypotension and hasten transport for definitive repair prior to beginning volume resuscitation than to try to normalize vital signs in the field by giving IV fluid.
SCIWORA in the NEXUS Study
Spinal cord injury without radiographic abnormality (SCIWORA) was very rare, 27/34069 (0.08%). Although NEXUS enrolled 3000 patients <18 years, down to age 1, all patients with SCIWORA were adults in this cohort.
Why We Use NEXUS for C-Spine Clearance
The NEXUS criteria can be used to determine which patients do not need c-spine x-rays. Since this was published, we have shifted to predominantly CT imaging, which is more sensitive. Also, we have learned that NEXUS is not as sensitive in elderly patients.
Absorbable Suture vs Nylon in Pediatric Lacerations
There was no difference in cosmetic outcome with use of absorbable vs. nonabsorbable suture for pediatric lacerations, though there was a nonsignificant trend to absorbable being superior. There was also no difference in dehiscence or infection rate between the two.
Why Norepinephrine is Better than Dopamine for Shock
Norepinephrine and dopamine were equal with regard to mortality in shock, except for the subgroup with cardiogenic shock, in which the dopamine group fared worse. There were twice as many dysrhythmias in the dopamine group, largely atrial fibrillation.
Evidence for Hyperbaric Oxygen for CO Poisoning
Hyperbaric oxygen therapy for carbon monoxide poisoning improved cognitive outcomes at 6 weeks and possibly at 12 months.
Wells Score Plus D-dimer for PE Rule-out
Patients in an ED setting with a low pretest probability based on the Wells score, and a negative D-dimer were safely ruled out for pulmonary embolism without further diagnostic imaging.
The ProCESS of Dismantling Early Goal-Directed Therapy
There was no mortality advantage to early goal-directed therapy (EGDT) over protocol-based care (using lactate clearance), or usual sepsis care.
Lactate Clearance Challenges Goal-Directed Therapy
A non-invasive approach to monitoring sepsis patients by using lactate clearance rather than central venous O2 saturation was just as effective once central venous pressure and mean arterial pressure were optimized.
How Early Goal-Directed Therapy Changed Sepsis Care
Even though early goal-directed therapy has subsequently been shown to be no more effective than usual care, this landmark trial put a spotlight on sepsis care, especially starting aggressive measures as early as possible in the ED.
Why We Use Non-invasive Ventilation for COPD
Non-invasive ventilation (NIV) in patients with acute exacerbation of COPD decreased the need for intubation and re
duced in-hospital mortality.
Alteplase for Submassive PE
This early study of thrombolytics plus heparin for submassive PE showed no mortality benefit but did show a decrease in need for escalation of care compared with heparin alone. Subsequent studies call lytics for submassive PE into question, so take the current evidence into account.
Why We Use Low Tidal Volume for Acute Lung Injury
Low tidal volume ventilation reduced mortality in patients with acute lung injury. If you want to learn more, see this post on Managing the Vent Like a Pro.
Wait-and-See Antibiotics for Otitis Media
Allowing parents the option to wait and see if their child did not improve or worsened in 48 hours after the diagnosis of acute otitis media in the ED vs. filling the prescription right away resulted in a dramatic reduction in antibiotic use with little downside in this RCT.
Why We Use the PERC Rule
The PERC rule is a powerful diagnostic tool. If you determine a patient has low clinical gestalt for PE and all 8 PERC criteria are negative, then PE has been ruled out without checking a D-dimer or CT.
Why Non-invasive Ventilation in CHF Saves Lives
Non-invasive ventilation makes a big impact on patients with acute pulmonary edema – fewer need intubation, and it may reduce mortality.
How to Predict Death from Community-Acquired Pneumonia
Use a score like CURB-65 (or CRB-65 if you don’t have labs) when making clinical decisions about the disposition of patients with community acquired pneumonia.
PECARN – Selectively CT Pediatric Head Injury
You need to know this decision rule cold. Before doing a head CT on any child, think through this decision aid first
C-spine Clearance in Kids Under 3 Years
C-spine injury is rare in children under 3 years. GCS < 14, GCS (eye) of 1, MVC mechanism, or age between 2- 3 years was associated with c-spine injury.
High Risk Features for SAH
The Ottawa SAH Rule is helpful in deciding which patients need further workup in the ED, but make sure your patient is similar to those included in the validation study.
How to Tell a Septic Hip from Transient Synovitis
These 4 predictors are somewhat helpful in distinguishing transient synovitis of the hip from septic arthritis. Note the limitations of the Kocher Criteria when using it in practice, and err on the side of orthopedic consultation and/or admission.
Why We Give Dexamethasone for Mild Croup
Dexamethasone is beneficial for mild croup, not just moderate to severe.
Which Kids Need Abdominal CT in Trauma
These 6 criteria may help when considering the imaging strategy for children with blunt abdominal trauma.
Why We Use Targeted Temperature Not Hypothermia
Targeted temperature management, with a goal of 36°C in unconscious post-arrest patients, appears to be as effective as the more aggressive target of 33°C.
Why We Used Therapeutic Hypothermia Post-arrest
Therapeutic hypothermia appeared to be a very promising therapy for patients resuscitated after VF. It turns out, strict normothermia and avoidance of hyperthermia was actually what mattered most.
TIA Turned Stroke – Avoid It With ABCD2
The ABCD2 score is a fairly good predictor of stroke risk after TIA, but be careful if you’re using it to send patients home.
Why the Window for tPA Got Wider – ECASS III
The window for tPA got wider with this study; ECASS III expanded the time of administration to 4.5 hours.
HINTS to the Cause of Dizziness
HINTS is a 3-part exam that is a powerful bedside discriminator of vertigo caused by a peripheral insult vs. posterior stroke that outperformed MRI.
Why We Give tPA in Stroke
Use of tPA within 3 hours for acute ischemic stroke improved functional outcome at 3 months but increased early risk for intracranial hemorrhage.
Why We Use the Ottawa Ankle Rule
The Ottawa ankle rule may reduce x-ray utilization for foot/ankle injuries.
When to Skip CT Before LP for Meningitis
Patients with suspected bacterial meningitis who have no high-risk clinical features on exam may safely undergo LP without prior CT.
Why We AFFIRM Rate Control for A-fib
Rhythm control for chronic a-fib had no advantage over rate control.
Why We Treat Bell Palsy With Steroids
Corticosteroids are definitely beneficial in Bell palsy. Antiviral agents are not helpful if used alone but have a mild synergistic effect when added to steroids.
Why NG Aspiration for Upper GI Bleed Is Unnecessary
NG tube aspiration or lavage for UGI bleeding is unhelpful as a diagnostic tool.
Necrotizing Fasciitis – LRINEC Score
The LRINEC score is a way to distinguish ordinary skin infections from necrotizing fasciitis. Subsequent studies have called its accuracy into question.
Water or Sterile Saline for Wounds
Wound irrigation with tap water vs sterile saline was just as effective.
Why a Femoral Line Is OK
Femoral lines are as safe as IJ lines and almost as safe as SC lines, when placed with meticulous sterile technique.
Dexamethasone in Bacterial Meningitis
Pretreatment with dexamethasone 10mg IV before or with antibiotics for adults with bacterial meningitis improved neurological outcome and decreased mortality.
Why We Use the Sgarbossa Rule in LBBB
Sgarbossa criteria can help interpret the ECG for STEMI in the setting of LBBB. Subsequent modifications make it even more accurate.
Validation of the San Francisco Syncope Rule
The San Francisco Syncope Rule could safely reduce almost one-quarter of admissions for syncope in this cohort. But later studies found the diagnostic performance to be lower.
Continuous or Interrupted Chest Compressions RCT
A pause in compressions to give rescue breaths made no impact on survival to hospital discharge.
Why We Use BNP Plus Clinical Judgment
Acutely dyspneic patients in the ED can be more accurately diagnosed by adding BNP to clinical judgment.
Why the HEART Score is Used in Low Risk Chest Pain
Patients with a HEART score of 0-3 were very low risk for MACE (1.7%) and may be considered safe for early ED discharge.
Why Transfer for PCI Beats On-Site tPA
DANAMI-2 showed that if door to needle time was <120 minutes, transfer for PCI was superior to on-site fibrinolysis for acute MI.