Top Articles – 2019

Airway/Anesthesia

• ACEP Unscheduled Sedation Guidelines – a summary of key aspects of emergency sedation.
  Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline. Ann Emerg Med. 2019 May;73(5):e51-e65. doi: 10.1016/j.annemergmed.2019.02.022.

• Why Not Ramp All Intubations? New RCT Suggests We Should – Bed-up-head-elevated (BUHE, aka ramped) position improved glottic view with Mac direct laryngoscopy (DL) over sniffing position and was noninferior to the GlideScope (GS) laryngeal view.
  Comparison of Macintosh Laryngoscopy in Bed-up-Head-Elevated Position With GlideScope Laryngoscopy: A Randomized, Controlled, Noninferiority Trial. Anesth Analg. 2019 Jul 23. doi: 10.1213/ANE.0000000000004349.

• What’s the Right Pediatric ETT Size? – The formula (age/4) + 3.5, with a cuffed tube makes more sense anatomically.
  Tracheal Size and Morphology on the Reconstructed CT Imaging. Pediatr Crit Care Med. 2019 Aug;20(8):e366-e371. doi: 10.1097/PCC.0000000000001996.

Cardiology

• Syncope – Low-Risk, 2h ECG Monitor, Home? – A low-risk Canadian Syncope Risk Score plus 2 hours of ECG monitoring in the ED was able to identify 99.8% of patients at low risk for 30-day serious arrhythmic outcome.
  Duration of Electrocardiographic Monitoring of Emergency Department Patients with Syncope. Circulation. 2019 Jan 21. doi: 10.1161/CIRCULATIONAHA.118.036088.

• COACT RCT – Post-Arrest Angiography Without STEMI – no difference in 90-day survival or other outcomes with immediate vs delayed cardiac catheterization in patients who were post-cardiac arrest and had no STEMI criteria.
  Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. N Engl J Med. 2019 Mar 18. doi: 10.1056/NEJMoa1816897.

• Early or Delayed Cardioversion for Atrial Fibrillation – Delayed cardioversion at 48h compared to early cardioversion was non-inferior.
  Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. N Engl J Med. 2019 Apr 18;380(16):1499-1508. doi: 10.1056/NEJMoa1900353. Epub 2019 Mar 18.

• Does 72h Outpatient Stress for ACS Matter? – Stress testing within 72 hours of ED discharge in patients deemed low risk for ACS was completed in just 31.3% and was not associated with reduction in major adverse cardiac events (MACE) at 30 days.
  Evaluation of Outpatient Cardiac Stress Testing After Emergency Department Encounters for Suspected Acute Coronary Syndrome. Ann Emerg Med. 2019 Apr 5. pii: S0196-0644(19)30054-X. doi: 10.1016/j.annemergmed.2019.01.027.

• Fluoroquinolones and Sudden Death – Fluoroquinolone antibiotics were associated with an increased odds of serious arrhythmic event from 7 up to 90 days after taking them.
  Fluoroquinolone use and serious arrhythmias: A nationwide case-crossover study. Resuscitation. 2019 Jun;139:262-268. doi: 10.1016/j.resuscitation.2019.04.030. Epub 2019 Apr 25.

• Compass MI – Taking the Guess Work Out of High-Sensitivity Troponin – The new tool, Compass MI, allows you to choose high-sensitivity troponin i or t (hsTni or hsTnt), initial cutoff, early/late delta troponin, and calculates the diagnostic performance you can expect.
  Application of High-Sensitivity Troponin in Suspected Myocardial Infarction. N Engl J Med. 2019 Jun 27;380(26):2529-2540. doi: 10.1056/NEJMoa1803377.

• Single Syringe Adenosine for SVT – Adenosine 6mg in 20mL of saline as a single syringe push vs the usual 6mg push and rapid flush with 20mL saline was non-inferior for SVT.
  Single Syringe Administration of Diluted Adenosine. Acad Emerg Med. 2019 Oct 30. doi: 10.1111/acem.13879.

Critical Care

• PReVENT RCT – Low or Intermediate Tidal Volume in Non-ARDS – low vs intermediate tidal volume did not impact meaningful ICU outcomes.
  Effect of a Low vs Intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care Unit Patients Without ARDS: A Randomized Clinical Trial. JAMA. 2018 Nov 13;320(18):1872-1880. doi: 10.1001/jama.2018.14280.

• PreVent RCT – Bag-Mask Ventilation During RSI? – Bag-mask ventilation during the apneic phase of RSI improved oxygenation compared to standard RSI and did not increase the rate of complications – but this is controversial.
  Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2019 Feb 18. doi: 10.1056/NEJMoa1812405.

• ANDROMEDA-SHOC
  K – Capillary Refill vs. Lactate – This study showed no difference, but see this Bayesian Reanalysis before you make up your mind a cap refill approach doesn’t really help. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019 Feb 19;321(7):654-664. doi: 10.1001/jama.2019.0071.

• Be SMART – Balanced Fluid for Sepsis – Balanced crystalloids for ICU patients with sepsis was associated with a lower 30-day in-hospital mortality.
  Balanced Crystalloids Versus Saline in Sepsis: A Secondary Analysis of the SMART Trial. Am J Respir Crit Care Med. 2019 Aug 27. doi: 10.1164/rccm.201903-0557OC.

• Peripheral Pressors for All? Peripheral Norepinephrine Infusion – Estimated risk was 1-8 extravasation events per 10,000 patients and no serious complications.
  Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg. 2019 Sep 27. doi: 10.1213/ANE.0000000000004445.

• ICU-ROX – Conservative Oxygenation vs Usual Care – There was no difference in ventilator-free days in mechanically ventilated ICU patients when the SpO2 range was 90 to 97% vs 90% to no upper limit.
  Conservative Oxygen Therapy during Mechanical Ventilation in the ICU. N Engl J Med. 2019 Oct 14. doi: 10.1056/NEJMoa1903297.

• PrePARE – Fluid Bolus Before Intubation and Cardiovascular Collapse – A 500mL fluid bolus prior to intubation of critically ill ICU patients did not reduce the rate of cardiovascular collapse.
  Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomised controlled trial. Lancet Respir Med. 2019 Oct 1. pii: S2213-2600(19)30246-2. doi: 10.1016/S2213-2600(19)30246-2.

Medicine/ID/Pulmonary

• Near Syncope = Syncope in Elderly – near syncope is as bad as syncope in the elderly.
  Comparison of 30-Day Serious Adverse Clinical Events for Elderly Patients Presenting to the Emergency Department With Near-Syncope Versus Syncope. Ann Emerg Med. 2018 Dec 7. pii: S0196-0644(18)31420-3. doi: 10.1016/j.annemergmed.2018.10.032.

• New IDSA Influenza Guidelines – This covers testing, treatment, complications, and more.
  Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza.  Clin Infect Dis. 2018 Dec 19. doi: 10.1093/cid/ciy866.

• Do We Still Need Annual TB Skin Testing? – No.
  Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019. MMWR Morb Mortal Wkly Rep. 2019 May 17;68(19):439-443. doi: 10.15585/mmwr.mm6819a3.

• VAPI – Vaping Associated Pulmonary Illness – What You Need to Know – Vaping has been associated with severe acute lung injury. Plus, it kind of looks dumb.
  Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin – Preliminary Report. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614.

• New 2019 IDSA-ATS Community Acquired Pneumonia Guidelines – Spoon Feed – Reduce blood cultures, ditch procalcitonin, reduce anaerobic coverage for aspiration, no more empiric corticosteroids, no more HCAP with knee jerk broad spectrum antibiotics, and more.
  Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. doi: 10.1164/rccm.201908-1581ST.

• Is 5 Days of Penicillin For Strep Pharyngitis Enough? – A 5-day course of penicillin was non-inferior to a 10-day course for group A streptococcal pharyngitis.
  Penicillin V four times daily for five days versus three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci: randomised controlled, open label, non-inferiority study. BMJ. 2019 Oct 4;367:l5337. doi: 10.1136/bmj.l5337.

Neurology/Stroke

• EXTEND – Alteplase Up to 9 Hours Out? – Alteplase from 4.5 to 9 hours or upon awakening in patients with ischemic stroke with salvageable brain on perfusion imaging was superior to placebo, NNT = 17.
  Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke. N Engl J Med. 2019 May 9;380(19):1795-1803. doi: 10.1056/NEJMoa1813046.

• Stroke Guidelines – 2019 Update From the AHA – This is what’s new since last year. It is a lot.
  Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418. doi: 10.1161/STR.0000000000000211. Epub 2019 Oct 30.

• Acute Headache – ACEP Policy Statment – This is important.
  Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache: Approved by the ACEP Board of Directors June 26, 2019 Clinical Policy Endorsed by the Emergency Nurses Association (July 31, 2019). Ann Emerg Med. 2019 Oct;74(4):e41-e74. doi: 10.1016/j.annemergmed.2019.07.009.

• Cerebellar Bleed – Does Neurosurgery Help? – Surgical decompression of a cerebellar intracerebral hemorrhage may improve survival, but it does not seem to improve survival with favorable neurological outcome.
  Association of Surgical Hematoma Evacuation vs Conservative Treatment With Functional Outcome in Patients With Cerebellar Intracerebral Hemorrhage. JAMA. 2019 Oct 8;322(14):1392-1403. doi: 10.1001/jama.2019.13014.

OB/GYN

• Lean Left – IVC Compression in Pregnancy – A 30° left tilt in late pregnancy was most effective in reducing uterine compression of the IVC in this MRI study. However, nearly a quarter of women achieved the greatest IVC volume with a 30° right tilt.
  Effect of Right-Lateral Versus Left-Lateral Tilt Position on Compression of the Inferior Vena Cava in Pregnant Women Determined by Magnetic Resonance Imaging. Anesth Analg. 2019 Apr 3. doi: 10.1213/ANE.0000000000004166.

Pain/Procedure

• Time to Take an Ax to the Wood’s Lamp? – Sensitivity was 52%.
  Prospective study of the sensitivity of the Wood’s lamp for common eye abnormalities. Emerg Med J. 2019 Jan 10. pii: emermed-2018-208235. doi: 10.1136/emermed-2018-208235.

• Ibuprofen – 400mg, 600mg, or 800mg? – 400 mg of oral ibuprofen offers a similar decrease in pain score compared to both 600 mg and 800 mg.
  Comparison of Oral Ibuprofen at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2019 Aug 2. pii: S0196-0644(19)30449-4. doi: 10.1016/j.annemergmed.2019.05.037.

Pediatrics

• AAP – No More Hypotonic MIVF – The AAP now recommends isotonic fluid (+/- KCl and dextrose) in children >28 days to <18 years who need maintenance IV fluid.
  Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics. 2018 Dec;142(6). pii: e20183083. doi: 10.1542/peds.2018-3083.

• Prevalence of UTI With Bronchiolitis – When UTI was defined as a positive urine culture plus abnormal UA, the prevalence of concomitant UTI in febrile infants with bronchiolitis was 0.8%. Association of Diagnostic Criteria With Urinary Tract Infection Prevalence in Bronchiolitis: A Systematic Review and Meta-analysis.  JAMA Pediatr. 2019 Jan 28. doi: 10.1001/jamapediatrics.2018.5091.

• New Landmark PECARN Rule for Infant Fever – Infants ≤60 days are low risk for serious bacterial infection (SBI) if they have a negative urinalysis, ANC ≤4090/µL, and procalcitonin ≤1.71 ng/mL. NPV was 99.6%; negative likelihood ratio (NLR) 0.04.
  A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. 2019 Feb 18. doi: 10.1001/jamapediatrics.2018.5501.

• Exercise to Treat Concussion? – Light aerobic activity that doesn’t evoke concussion symptoms speeds recovery vs. rest.
  Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial.  JAMA Pediatr. 2019 Feb 4. doi: 10.1001/jamapediatrics.2018.4397.

• Do Infants 29-60 Days With UTI Need LP? – Prevalence of concomitant bacterial meningitis in infants 29-60 days old with UTI was 0.25%.
  Risk of Meningitis in Infants Aged 29 to 90 Days with Urinary Tract Infection: A Systematic Review and Meta-Analysis. J Pediatr. 2019 Jun 20. pii: S0022-3476(19)30536-0. doi: 10.1016/j.jpeds.2019.04.053.

• Risk of Meningitis in Infants with UTI – Among infants treated for UTI without CSF testing (n=505, mostly 31-60 days old), there were no cases (95% CI 0-0.6%) of delayed meningitis within 7 days of discharge.
  Testing for Meningitis in Febrile Well-Appearing Young Infants With a Positive Urinalysis. Pediatrics. 2019 Aug 8. pii: e20183979. doi: 10.1542/peds.2018-3979.

Resuscitation

• Antiarrhythmics In Arrest – New ILCOR Update – Lidocaine, in place of amiodarone, is now a viable, equally effective option in patients with VF/pVT refractory to defibrillation.
  European Resuscitation Council Guidelines for Resuscitation: 2018 Update – Antiarrhythmic drugs for cardiac arrest. Resuscitation. 2018 Nov 26. pii: S0300-9572(18)31096-7. doi: 10.1016/j.resuscitation.2018.11.018.

• Advanced Airway for Pediatric Cardiac Arrest – Should We Just Bag? – There may be a slight advantage for pediatric cardiac arrest patients in survival with good neurological outcome by using simple bag-valve mask ventilation over advanced airway management.
  Advanced airway interventions for paediatric cardiac arrest: A systematic review and meta-analysis. Resuscitation. 2019 Mar 9. pii: S0300-9572(19)30055-3. doi: 10.1016/j.resuscitation.2019.02.040.

• Should We Use Advanced Airway for Pediatric Arrest? – There was no survival advantage at 1-month for patients with advanced airway management (AAM) vs none.
  Prehospital advanced airway management for paediatric patients with out-of-hospital cardiac arrest: A nationwide cohort study. Resuscitation. 2019 Sep 17. pii: S0300-9572(19)30614-8. doi: 10.1016/j.resuscitation.2019.09.007

• Targeted Temperature for Non-shockable Rhythm – NNT = 22.
  Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. N Engl J Med. 2019 Oct 2. doi: 10.1056/NEJMoa1906661.

• PALS Update – Pediatric Advanced Life Support in 2019 – These are the updated recommendations for airway management, ECPR, and targeted temperature management in pediatric cardiac arrest in and out of hospitals.
  2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019 Nov 14:CIR0000000000000731. doi: 10.1161/CIR.0000000000000731.

Tox

• Tox Myth-Bust – Prehospital Exposure to Fentanyl Analogs – This position statement by ACMT and AACT addresses specific concerns about occupational exposure to fentanyl with the literature that is currently available.
  ACMT and AACT position statement: preventing occupational fentanyl and fentanyl analog exposure to emergency responders. Clin Toxicol (Phila). 2018 Apr;56(4):297-300. doi: 10.1080/15563650.2017.1373782. Epub 2017 Sep 5.

Trauma

• Clearing the Pediatric C-Spine – This expert panel came up with a comprehensive algorithm to clear the c-spine in children with trauma.
  Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. J Bone Joint Surg Am. 2019 Jan 2;101(1):e1. doi: 10.2106/JBJS.18.00217.

• Simple Cool Running Water Reduces Burn Severity in Children – Cool running water for 20 minutes within 3 hours of injury for children with burns was associated with a marked reduction in need for skin grafting and possibly burn depth and need for hospitalization.
  Cool Running Water First Aid Decreases Skin Grafting Requirements in Pediatric Burns: A Cohort Study of Two Thousand Four Hundred Ninety-five Children. Ann Emerg Med. 2019 Aug 29. pii: S0196-0644(19)30538-4. doi: 10.1016/j.annemergmed.2019.06.028.

• CRASH 3 – TXA for TBI – TXA appears to have a slight 28-day mortality benefit in traumatic brain injury (TBI) patients with a GCS ≥9, especially when given early.
  Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet. October 14 2019.

Venous Thromboembolism

• Prevalence of PE in Syncope (Spoiler Alert: It’s lower than PESIT) – Prevalence was 0.6%.
  Prevalence of Pulmonary Embolism Among Emergency Department Patients With Syncope: A Multicenter Prospective Cohort Study. Ann Emerg Med. 2019 Jan 25. pii: S0196-0644(18)31535-X. doi: 10.1016/j.annemergmed.2018.12.005. See also Syncope in PE – More Evidence for a Lower Prevalence.

• PE in Pregnancy – YEARS Algorithm – This safely and accurately ruled out pulmonary embolism (PE) for pregnant patients and reduced the rate of CT pulmonary angiography (CTPA) across all trimesters.
  Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism.  N Engl J Med. 2019 Mar 21;380(12):1139-1149. doi: 10.1056/NEJMoa1813865.