Best of the Best
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It was a great refresher to go back over the articles we covered in 2017. We have hand-picked some of our favorites. Take just a few minutes to skim through the titles and excerpts to lock in some of the most important highlights from 2017.
Happy New Year!
Airway | Procedure
- For less experienced intubators in the ICU, ramped position offered no benefit over the sniffing position. However, this article doesn’t reflect the ramped position used by anesthesia or the ED. With avoidance of neck hyperextension, I think the ramped position remains advantageous, especially in morbidly obese 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]
- 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.
- The “Ear-Sternal Notch” Line-How Should You Lie? Anesth Analg. 2017 Sep 14. doi: 10.1213/ANE.0000000000002493. [Epub ahead of print]
- For better success at subclavian central venous catheter placement, have the patient turn their head 30 degrees toward the side of insertion to increase the cross sectional area of the vein.
- The Effect of Head Position on the Cross-sectional Area of the Subclavian Vein. Anesth Analg. 2017 Aug 31. doi: 10.1213/ANE.0000000000002446. [Epub ahead of print]
- This study found it was mechanically impossible to maintain 30-40N of downward force during the laryngoscopy phase of RSI.
- Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy. Acad Emerg Med. 2017 Sep 28. doi: 10.1111/acem.13326. [Epub ahead of print]
- Applying an ice cube (inside a sterile glove) to the skin over a laceration for 2 minutes significantly reduced pain from local anesthetic injection.
- 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]
- In hypertensive patients with acute decompensated heart failure and shortness of breath, bolus IV NTG 1 or 2 mg was safe and reduced ICU admission and length of stay. It may take me a while to warm up to such large NTG doses. PharmERToxGuy reviewed this article, and @EMNerd discussed bolus IV NTG on UMEM pearls.
- Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017 Jan;35(1):126-131. doi: 10.1016/j.ajem.2016.10.038. Epub 2016 Oct 18.
- The HEART score was a safe way to help risk stratify chest pain patients in real-world practice. For more on HEART and other scoring systems, see Amal Mattu’s algorithmic approach in the module he wrote for Evidence Care.
- 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.
Critical Care | Pulmonary
- Take a quick look at the high points in this summary. It’s worth reminding yourself about the basics of sepsis care. Surviving Sepsis has taken the emphasis off protocolized initial resuscitation and placed it on common sense, rapid treatments. You may also want to read a more critical take on 6 myths promoted by the new surviving sepsis guidelines.
- Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017 Jan 17. doi: 10.1097/CCM.0000000000002255. [Epub ahead of print]
- Thrombolytic therapy for submassive PE didn’t change the incidence of chronic thromboembolic pulmonary hypertension.
t of Thrombolytic Therapy on the Long-Term Outcome of Intermediate-Risk Pulmonary Embolism. J Am Coll Cardiol. 2017 Mar 28;69(12):1536-1544. doi: 10.1016/j.jacc.2016.12.039.
- It looks like we can start thinking of the D-dimer test based on interval likelihood ratios rather than a dichotomous positive or negative (with 500 ng/mL as the cutoff). EM Lit of Note has some thoughts on this article.
- D-Dimer Interval Likelihood Ratios for Pulmonary Embolism. Acad Emerg Med. 2017 Apr 1. doi: 10.1111/acem.13191. [Epub ahead of print]
- A cocktail of IV vitamin C, hydrocortisone, and thiamine appeared to dramatically reduce mortality in this small, exploratory, before/after study. (Note: This was included because it received so much attention this year. We remain very skeptical until this is proven with a proper, prospective study or RCT.)
- 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.
ENT | Ophthalmology
- This study found 1% tetracaine for 24 hours appeared to be safe for treating corneal abrasion pain. REBEL EM has an outstanding post, a mythbusters type, which includes this study. It’s a great read.
- 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]
- In patients age 5 years through adulthood with sore throat of any cause, use of a single, low-dose steroid (most often dexamethasone 10mg or 0.6mg/kg for children, max 10mg; most given orally) were twice as likely to have complete pain relief at 24 hours.
- Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ. 2017 Sep 20;358:j3887. doi: 10.1136/bmj.j3887.
- For patients on antiplatelet agents with epistaxis, tranexamic acid (TXA)-soaked pledgets were far more effective than lidocaine with epinephrine-soaked pledgets at stopping bleeding within 10 minutes and were better tolerated by patients.
- Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med. 2017 Nov 10. doi: 10.1111/acem.13345. [Epub ahead of print]
- There was no association with IV contrast and short-term acute kidney injury or progression to dialysis at 6 months in patients with a creatinine < 4. Journal Watch had a free summary of this article as did EM Lit of Note.
- Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Ann Emerg Med. 2017 Jan 19. pii: S0196-0644(16)31388-9. doi: 10.1016/j.annemergmed.2016.11.021. [Epub ahead of print]
- When in doubt, err on the side of admission – even if you get push back. When people feel bad enough to come to the ED, it often means something is really wrong, even if it’s not apparent on a surface level. Also, err on the side of ordering a few more tests when you’re not sure, especially in patients who are altered, dyspneic, or have generalized malaise.
- Early death after discharge from emergency departments: analysis of national US insurance claims data. BMJ. 2017 Feb 1;356:j239. doi: 10.1136/bmj.j239.
- There was an association with short-term steroid use and several adverse outcomes.
- Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ. 2017 Apr 12;357:j1415. doi: 10.1136/bmj.j1415.
- Prednisone 40mg daily x 4 days was not helpful in reducing itching in patients with simple urticaria. JWatch has a free summary.
- 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]
- Haloperidol markedly reduced pain and nausea in ED patients with gastroparesis compared to usual care. Plus, it led to fewer admissions. But be careful. Haloperidol is not without side effects, such as hypotension, extrapyramidal movement, akathisia, neuroleptic malignant syndrome, and QT-prolongation.
- 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]
- For uncomplicated cellulitis in otherwise healthy patients, cephalexin alone is probably adequate. Read more on EM Lit of Note.
- 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.
- Even small abscesses, <5cm, benefitted from antibiotics (TMP/SMX or clindamycin). This is contrary to some prior studies’ findings that I&D alone was adequate for small abscesses. TOTAL EM did a podcast on this article.
- 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.
- Even with current neuroimaging we may miss up to 9% of cerebrovascular events. However, you may want to read the in depth analysis. This may not reflect missed events purely due to false negative neuroimaging.
- ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology. 2017 Apr 11;88(15):1468-1477. doi: 10.1212/WNL.0000000000003814. Epub 2017 Mar 29.
- Administering prophylactic low-dose oxygen (2-3L/min) to non-hypoxemic patients with acute stroke did not reduce death or disability at 3 months.
- 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.
- The primary outcome (quick and sustained headache relief) was achieved in 60% of the IV prochlorperazine + diphenhydramine group vs 31% in the IV hydromorphone group with a NNT of 4. As a result, the study was stopped early.
- Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine. Neurology. 2017 Nov 14;89(20):2075-2082. doi: 10.1212/WNL.0000000000004642. Epub 2017 Oct 18.
Orthopedics | Sports
- A simple volar slab or velcro wrist splint or “soft cast” was better than a rigid cast for pediatric torus fractures of the forearm.
- Management of Pediatric Forearm Torus Fractures: A Systematic Review and Meta-Analysis. Pediatr Emerg Care. 2016 Nov;32(11):773-778.
- Physical rest after concussion appears to be unhelpful, even harmful, in children and young people after concussion. This is a major paradigm shift.
- Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016 Dec 20;316(23):2504-2514. doi: 10.1001/jama.2016.17396.
- Diazepam doesn’t help low back pain. Here is RCT data that proves it. REBEL EM covered this article in depth.
- Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Low Back Pain. Ann Emerg Med. 2017 Jan 19. pii: S0196-0644(16)31214-8. doi: 10.1016/j.annemergmed.2016.10.002. [Epub ahead of print]
Pain | Sedation
- For analgesia, there was no difference in 10mg, 15mg, and 30mg of IV ketorolac.
- Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2016 Dec 14. pii: S0196-0644(16)31244-6. doi: 10.1016/j.annemergmed.2016.10.014. [Epub ahead of print]
- For every 48 patients given a short-term opiate prescription in the ED, 1 became a long-term opiate user. Over-prescribing opiates in the ED may have significant downstream effects and could open the door to long-term opiate use in our patients. The NYT has a great article and interview with the lead author. Reuben Strayer, EM Updates, also has an outstanding analysis.
- Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use. N Engl J Med. 2017 Feb 16;376(7):663-673. doi: 10.1056/NEJMsa1610524.
- A 5-sentence letter to the NEJM editor in 1980 was cited over 600 times to support opiate prescribing, which was not the point of the original letter. We bought the line that opiates for legitimate pain were not addictive but didn’t consider the source.
- A 1980 Letter on the Risk of Opioid Addiction. N Engl J Med. 2017 Jun 1;376(22):2194-2195. doi: 10.1056/NEJMc1700150.
- Ketamine is a helpful adjunct in patients with severe pain that have already been treated with opiates. Skeptics Guide to EM has an epic post on low-dose ketamine use in
the ED as does Emergency Medicine Cases.
- Ketamine as an Adjunct to Opioids for Acute Pain in the Emergency Department: A randomized controlled trial. Acad Emerg Med. 2017 Feb 8. doi: 10.1111/acem.13172. [Epub ahead of print]
- A slow infusion of ketamine for pain control was as effective as IV push, with less sedation and far fewer patients having a feeling of unreality.
- A prospective randomized, double-dummy trial comparing IV push low dose ketamine to short infusion of low dose ketamine for treatment of pain in the ED. Am J Emerg Med. 2017 Aug;35(8):1095-1100. doi: 10.1016/j.ajem.2017.03.004. Epub 2017 Mar 3.
- For kids 6 – 23 months with acute otitis media, 10 days of antibiotic therapy was better than 5 days. EM Nerd had some issues with this study. See why.
- Shortened Antimicrobial Treatment for Acute Otitis Media in Young Children. N Engl J Med. 2016 Dec 22;375(25):2446-2456. doi: 10.1056/NEJMoa1606043.
- Sometimes caregivers or patients are rude. The best thing we can do is anticipate it and mentally prepare before the encounter so we can still perform well as a team.
- Rudeness and Medical Team Performance. Pediatrics. 2017 Jan 10. pii: e20162305. doi: 10.1542/peds.2016-2305. [Epub ahead of print]
- After using ketamine for pediatric procedural sedation, 22% of children experienced negative behavioral symptoms measured 1-2 weeks after ED discharge. The most common symptoms were apathy/withdrawal and separation anxiety. You may want to warn families of these possible side effects.
- Behavioral Changes in Children after Emergency Department Procedural Sedation. Acad Emerg Med. 2017 Oct 9. doi: 10.1111/acem.13332. [Epub ahead of print]
- Early intubation in adult in-hospital arrest was associated with poorer outcomes and worse neurologically-intact survival. Emphasize high quality CPR and defibrillation, while deemphasizing early ETT placement.
- Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA. 2017 Jan 24. doi: 10.1001/jama.2016.20165. [Epub ahead of print]
- Intubation during pediatric arrest did not appear to benefit and may be harmful.
- Association Between Tracheal Intubation During Pediatric In-Hospital Cardiac Arrest and Survival. JAMA. 2016 Nov 1;316(17):1786-1797. doi: 10.1001/jama.2016.14486.
- No one survived to discharge if they had out-of-hospital arrest not witnessed by EMS, non-shockable initial rhythm, and no ROSC before the third epinephrine dose. This could help us set expectations for the family and may help the ICU team identify potential donors earlier.
- Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med. 2016 Dec 6;165(11):770-778. doi: 10.7326/M16-0402. Epub 2016 Sep 13.
Trauma | Surgery
- Etomidate and ketamine were equally safe when used as trauma airway induction agents. Journal Watch did an excellent free summary of this article.
- Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients. Ann Emerg Med. 2017 Jan;69(1):24-33.e2. doi: 10.1016/j.annemergmed.2016.08.009.
- MRI rarely changes management in patients with negative CT and persistent neck pain.
- Cervical spine MRI in patients with negative CT: A prospective, multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). J Trauma Acute Care Surg. 2017 Feb;82(2):263-269. doi: 10.1097/TA.0000000000001322.