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Best Articles of 2020

December 31, 2020

Top Articles – 2020


Ketamine vs Etomidate – Hypotension At Induction – Ketamine was associated with a greater risk of peri-intubation hypotension than etomidate.
Ketamine versus Etomidate and Peri-Intubation Hypotension: A National Emergency Airway Registry Study. Acad Emerg Med. 2020 Jun 26. doi: 10.1111/acem.14063. Online ahead of print.


RAFF2 – Electrical vs Pharmacological Conversion of Atrial Fibrillation – There was no significant difference in overall rate of conversion from atrial fibrillation to normal sinus rhythm with procainamide infusion followed by electrical cardioversion, if needed, compared to placebo infusion followed by electrical cardioversion.
Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial. Lancet. 2020 Feb 1;395(10221):339-349. doi: 10.1016/S0140-6736(19)32994-0.

Early Rhythm Control for A-fib | EAST-AFNET 4 Trial – Early rhythm control of atrial fibrillation was associated with a lower risk of cardiovascular outcomes, including cardiovascular-related death as well as stroke and hospitalization for worsening heart failure or acute coronary syndrome.
Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020 Aug 29. doi: 10.1056/NEJMoa2019422. Online ahead of print.

How Accurate Is Your ECG Interpretation? – We all have room for improvement in ECG interpretation. Training improves accuracy.
Accuracy of Physicians’ Electrocardiogram Interpretations: A Systematic Review and Meta-analysis. JAMA Intern Med. 2020 Sep 28;e203989. doi: 10.1001/jamainternmed.2020.3989. Online ahead of print.

Critical Care

VITAMINS for Septic Shock? Hydrocortisone, Ascorbic Acid, and Thiamine for Septic Shock – A combination of vitamin C, thiamine, and hydrocortisone does not appear to lead to improved outcomes or more rapid resolution of septic shock compared to hydrocortisone alone.
Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock: The VITAMINS Randomized Clinical Trial. JAMA. 2020 Jan 17. doi: 10.1001/jama.2019.22176. [Epub ahead of print]

HYVCTTSSS RCT – Vit C, Thiamine, Hydrocortisone Cocktail – A combination of hydrocortisone, thiamine, and vitamin C for sepsis patients did not improve 28-day mortality.
Combined treatment with hydrocortisone, vitamin C, and thiamine for sepsis and septic shock (HYVCTTSSS): A randomized controlled clinical trial. Chest. 2020 Mar 31. pii: S0012-3692(20)30552-3. doi: 10.1016/j.chest.2020.02.065. [Epub ahead of print]

ORANGES RCT – More on “Metabolic” Resuscitation – Hydrocortisone, ascorbate, and thiamine may lead to more rapid resolution of shock. But don’t drink the ORANGE Kool-aid yet.
Outcomes of Metabolic Resuscitation Using Ascorbic Acid, Thiamine, and Glucocorticoids in the Early Treatment of Sepsis: The ORANGES Trial. Chest. 2020 Jul;158(1):164-173. doi: 10.1016/j.chest.2020.02.049. Epub 2020 Mar 17.

ACTS RCT – Ascorbic Acid, Corticosteroids, Thiamine for Septic Shock – There was no benefit of ascorbic acid, hydrocortisone, and thiamine on improving 72-hour SOFA score in adults with septic shock.
Effect of Ascorbic Acid, Corticosteroids, and Thiamine on Organ Injury in Septic Shock: The ACTS Randomized Clinical Trial. JAMA. 2020 Aug 18;324(7):642-650. doi: 10.1001/jama.2020.11946.

PEPTIC RCT – PPI or H2-blocker for Ulcer Prophylaxis? – There was no difference in 90-day mortality when comparing proton pump inhibitors to H2-receptor blockers for stress ulcer prophylaxis in critically ill patients.
Effect of Stress Ulcer Prophylaxis With Proton Pump Inhibitors vs Histamine-2 Receptor Blockers on In-Hospital Mortality Among ICU Patients Receiving Invasive Mechanical Ventilation: The PEPTIC Randomized Clinical Trial. JAMA. 2020 Jan 17. doi: 10.1001/jama.2019.22190. [Epub ahead of print]

Anaphylaxis Guidelines for 2020 – Epinephrine is the key drug for anaphylaxis. Give it early in suspected cases. Antihistamines and glucocorticoids are permissible but not very helpful and certainly should not supersede epinephrine.
Anaphylaxis-a 2020 Practice Parameter Update, Systematic Review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Analysis. J Allergy Clin Immunol. 2020 Apr;145(4):1082-1123. doi: 10.1016/j.jaci.2020.01.017. Epub 2020 Jan 28.

Does Low Tidal Volume Matter in the Emergency Department? – Starting low tidal volume ventilation in the ED is associated with lower mortality and overall better outcomes.
Lung-Protective Ventilation and Associated Outcomes and Costs Among Patients Receiving Invasive Mechanical Ventilation in the Emergency Department. Chest. 2020 Sep 20;S0012-3692(20)34522-0. doi: 10.1016/j.chest.2020.09.100. Online ahead of print.

Personalized Pressors – REACT Study Group – A personalized approach to vasopressor management may improve kidney outcomes.
Relative Hypotension and Adverse Kidney-related Outcomes among Critically Ill Patients with Shock. A Multicenter, Prospective Cohort Study. Am J Respir Crit Care Med. 2020 Nov 15;202(10):1407-1418. doi: 10.1164/rccm.201912-2316OC.


COVID-19 All in One Place – This was the epic post we did for COVID-19 this year. You can read all the other article summaries we wrote about COVID-19 here.

Insulin-Glucose for Hyperkalemia – How Bad Is Hypoglycemia? – 10 units of IV regular insulin plus 25g of IV dextrose causes highly variable changes in blood sugar. Delayed hypoglycemia is common.
Blood glucose reduction in patients treated with insulin and dextrose for hyperkalaemia. Emerg Med J. 2019 Oct 25. pii: emermed-2019-208744. doi: 10.1136/emermed-2019-208744. [Epub ahead of print]

Does Oseltamivir Really Work? ALIC4E RCT- Non-Industry Funded Trial – Oseltamivir shortens duration of influenza by 1 day. The effect on duration is muted in young, healthy patients (0.7 days shorter) and amplified in older patients with comorbidities (2-3 days shorter).
Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial. Lancet. 2019 Dec 12. pii: S0140-6736(19)32982-4. doi: 10.1016/S0140-6736(19)32982-4. [Epub ahead of print]

PEN-FAST – Penicillin Allergy Risk Tool – Using the PEN-FAST rule, patients with low-risk penicillin allergies can be identified without need for formal allergy testing.
Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med. 2020 Mar 16. doi: 10.1001/jamainternmed.2020.0403. [Epub ahead of print]

Move Over San Francisco – Canadian Syncope Score Validated – The Canadian Syncope Risk Score was successfully validated as a tool to risk stratify ED patients presenting with acute syncope. Patients at low risk for serious outcomes at 30 days can be safely discharged.
Multicenter Emergency Department Validation of the Canadian Syncope Risk Score. JAMA Intern Med. 2020 Mar 23. doi: 10.1001/jamainternmed.2020.0288. [Epub ahead of print]

Major Consensus Statement on IV Contrast Nephropathy – This is a summary of the major American College of Radiology/National Kidney Foundation (ACR/NKF) consensus statements.
Use of Intravenous Iodinated Contrast Media in Patients With Kidney Disease: Consensus Statements From the American College of Radiology and the National Kidney Foundation. Radiology. 2020 Mar;294(3):660-668. doi: 10.1148/radiol.2019192094. Epub 2020 Jan 21.

And Thus Ends the GI Cocktail – Antacid monotherapy is as effective, if not more effective, than GI cocktails with lidocaine, is more palatable, and has fewer side effects.
Antacid monotherapy is more effective in relieving epigastric pain than in combination with lidocaine. A randomized double-blind clinical trial. Acad Emerg Med. 2020 Jun 29. doi: 10.1111/acem.14069. Online ahead of print.


Status Epilepticus – Three Anticonvulsants Head-to-Head – ESETT RCT – For status epilepticus refractory to benzodiazepines, the anticonvulsant medications levetiracetam, fosphenytoin, and valproate had similar rates of seizure cessation (all roughly half of patients), with similar incidence of serious adverse events.
Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019 Nov 28;381(22):2103-2113. doi: 10.1056/NEJMoa1905795.

Rant – More HINTS We Have a Problem – HINTS was misapplied 97% of the time by emergency physicians in patients with dizziness. Five patients that clinicians thought had central vertigo by HINTS all did not. Four of six patients who had proven central vertigo all had intermittent symptoms that sounded more like benign positional vertigo.
Diagnostic accuracy of the HINTS exam in an emergency department: A retrospective chart review. Acad Emerg Med. 2020 Nov 10. doi: 10.1111/acem.14171. Online ahead of print.


Cast or Walking Boot for Achilles Tendon Rupture? – A walking boot vs rigid cast resulted in equal outcomes and adverse events, including tendon re-rupture rate at 9 months for patients with Achilles tendon rupture.
Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation. Lancet. 2020 Feb 8;395(10222):441-448. doi: 10.1016/S0140-6736(19)32942-3.

Do NSAID, COX-2, or Opioid Rxs Increase Non-Union Risk? – Selective COX-2 inhibitors appear to increase risk for fracture non-union. Regular NSAIDs do not. Opioids may also increase non-union risk, although this association may have been confounded.

Risk of Nonunion with Nonselective NSAIDs, COX-2 Inhibitors, and Opioids.
J Bone Joint Surg Am. 2020 May 25. doi: 10.2106/JBJS.19.01415. [Epub ahead of print]

Musculoskeletal Pain – New ACP | AAFP Guidelines – Topical NSAIDS (with or without menthol), followed by oral NSAIDs or acetaminophen, should be used to treat non-low back musculoskeletal pain in adults. Opioids, including tramadol, are not recommended.
Nonpharmacologic and Pharmacologic Management of Acute Pain From Non-Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline From the American College of Physicians and American Academy of Family Physicians. Ann Intern Med. 2020 Aug 18. doi: 10.7326/M19-3602. Online ahead of print. AND Management of Acute Pain From Non-Low Back Musculoskeletal Injuries: A Systematic Review and Network Meta-analysis of Randomized Trials. Ann Intern Med. 2020 Aug 18. doi: 10.7326/M19-3601. Online ahead of print.


ACEP Opioid Policy Statement – This is an ACEP Clinical Policy statement to address four key questions about opioid use in the ED.
Clinical Policy: Critical Issues Related to Opioids in Adult Patients Presenting to the Emergency Department. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Opioids. Ann Emerg Med. 2020 Sep;76(3):e13-e39. doi: 10.1016/j.annemergmed.2020.06.049.


Epinephrine for Pediatric OHCA Mirrors PARAMEDIC2 – Epinephrine for out-of-hospital cardiac arrest in children improved return of spontaneous circulation but not 1-month survival or survival with good neurological outcome.
Pre-Hospital Administration of Epinephrine in Pediatric Patients With Out-of-Hospital Cardiac Arrest. J Am Coll Cardiol. 2020 Jan 21;75(2):194-204. doi: 10.1016/j.jacc.2019.10.052.

Surviving Sepsis – Pediatric Version – Recognize sepsis fast; have a protocol; tailor therapy to specific needs and available resources; be ready to resuscitate sick kids.
Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(Suppl 1):10-67. doi: 10.1007/s00134-019-05878-6.

Does Crystalloid Harm Pediatric Hemorrhagic Shock Patients? – Resuscitating pediatric trauma patients in hemorrhagic shock with >1 crystalloid bolus is associated with longer mechanical ventilation and ICU and hospital length of stay.
Timing and Volume of Crystalloid and Blood Products in Pediatric Trauma – An EAST Multicenter Prospective Observational Study. J Trauma Acute Care Surg. 2020 Mar 30. doi: 10.1097/TA.0000000000002702. [Epub ahead of print]

Outcome of Pediatric Bradycardia- Poor Perfusion vs PEA – Bradycardia with poor perfusion is associated with better survival with favorable neurologic outcome than pulseless cardiac arrest in critically ill children receiving CPR.
Survival and Hemodynamics During Pediatric Cardiopulmonary Resuscitation for Bradycardia and Poor Perfusion Versus Pulseless Cardiac Arrest. Crit Care Med. 2020 Jun;48(6):881-889. doi: 10.1097/CCM.0000000000004308.

Optimal Defibrillation Dose for Children – For children with ventricular fibrillation or pulseless ventricular tachycardia, a defibrillation dose of 2 J/kg was associated with the highest survival to discharge. Doses outside the range of 1.7-2.5 J/kg had lower survival.
Improved survival to hospital discharge in pediatric in-hospital cardiac arrest using 2 Joules/kilogram as first defibrillation dose for initial pulseless ventricular arrhythmia. Resuscitation. 2020 Aug;153:88-96. doi: 10.1016/j.resuscitation.2020.05.048. Epub 2020 Jun 6.

Practice of Emergency Medicine

Ten Ways to Improve Physician-Nurse Communication – Successful communication between emergency physicians and nurses requires strategies to improve knowledge sharing, streamlining plan of care, acknowledging patient status changes, and awareness of team dynamics.
Ten Best Practices for Improving Emergency Medicine Provider-Nurse Communication. J Emerg Med. 2020 Mar 4. pii: S0736-4679(19)30939-4. doi: 10.1016/j.jemermed.2019.10.035. [Epub ahead of print]

Gosh, It’s Quiet – Does Saying the Q-Word Bring Disaster? – Mean overall workload in a medical microbiology team was not significantly different when the word “quiet” was uttered compared to when it was not.
Q fever-the superstition of avoiding the word “quiet” as a coping mechanism: randomised controlled non-inferiority trial. BMJ. 2019 Dec 18;367:l6446. doi: 10.1136/bmj.l6446.

Diagnosing and Treating Systemic Racism – There are practical steps we can take to root out and counter the effects of racism in medicine.
Diagnosing and Treating Systemic Racism. N Engl J Med. 2020 Jun 10. doi: 10.1056/NEJMe2021693. [Epub ahead of print]


Epinephrine for OHCA – A Meta-analysis – In out-of-hospital cardiac arrest, epinephrine improves ROSC and survival to hospital discha
rge, showing clear advantage over placebo/no drug.
Epinephrine for out of hospital cardiac arrest: A systematic review and meta-analysis of randomized controlled trials. Resuscitation. 2019 Nov 4. pii: S0300-9572(19)30675-6. doi: 10.1016/j.resuscitation.2019.10.026. [Epub ahead of print]

2020 Adult Basic and Advanced Life Support Guidelines – Spoon-Feed Version – The 2020 AHA adult basic and advanced life support guidelines have been updated. This is the Spoon Feed.
Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. doi: 10.1161/CIR.0000000000000916. Epub 2020 Oct 21. See also https://www.ahajournals.org/doi/10.1161/CIR.0000000000000916

2020 Pediatric Basic and Advanced Life Support Guidelines – Spoon-Feed Version – The 2020 AHA pediatric basic and advanced life support guidelines have been updated. Here is the Spoon Feed.
Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S469-S523. doi: 10.1161/CIR.0000000000000901. Epub 2020 Oct 21.


Universal Screening for Blunt Cerebrovascular Injury? – Clinical decision tools had poor diagnostic accuracy compared with universal CTA for blunt cerebrovascular injury. Up to 23% of serious injuries may have been missed without universal screening.
BLUNT CEREBROVASCULAR INJURY – THE CASE FOR UNIVERSAL SCREENING. J Trauma Acute Care Surg. 2020 Jun 8. doi: 10.1097/TA.0000000000002824. [Epub ahead of print]

Spontaneous Pneumothorax – Chest Tube or Watchful Waiting? – Conservative management of moderate-to-large size spontaneous pneumothorax was noninferior to interventional management, with lower risk of complications and recurrence.
Conservative versus Interventional Treatment for Spontaneous Pneumothorax. N Engl J Med. 2020 Jan 30;382(5):405-415. doi: 10.1056/NEJMoa1910775.

CODA RCT – Antibiotics or Surgery for Appendicitis? – Antibiotic treatment vs appendectomy for appendicitis had non-inferior 30-day quality of life scores, but need for subsequent surgery and complications were greater in the antibiotic group, especially in patients with an appendicolith.
A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. 2020 Oct 5. doi: 10.1056/NEJMoa2014320. Online ahead of print.

Venous Thromboembolism

Is It Time to Adjust D-dimer Thresholds to Our Clinical Pretest Probability? – Using the Wells Score to categorize patients as low, moderate, or high clinical pretest probability in conjunction with adjusted positive D-dimer thresholds at >1000 ng/mL for a low or >500 ng/mL for a moderate Wells Score, the authors reduced diagnostic chest imaging in the ED with no incidence of missed venous thromboembolism at 90 days.
Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability. N Engl J Med. 2019 Nov 28;381(22):2125-2134. doi: 10.1056/NEJMoa1909159.

Clinical Pre-test Prob vs. Age-adjusted D-dimer for DVT – The Meta Analysis – In the diagnosis of deep venous thrombosis, both age-adjusted D-dimer and D-dimer adjusted by clinical pre-test probability were found to be similar (read: not statistically different) in sensitivity, specificity, negative predictive value, and utility* in this meta-analysis.
Clinical pre-test probability adjusted versus age-adjusted D-dimer interpretation strategy for DVT diagnosis: A diagnostic individual patient data meta-analysis. J Thromb Haemost. 2019 Dec 23. doi: 10.1111/jth.14718.

Outpatient PE Treatment in the DOAC Era – In this systematic review, outpatient treatment of patients with pulmonary embolism deemed low-risk by a clinical decision tool demonstrated a low incidence of mortality, recurrent venous thromboembolism, or major bleeding at 90 days. There was no association between direct oral anticoagulant use and rates of adverse outcomes.
Outpatient Treatment of Low-Risk Pulmonary Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review [published online ahead of print, 2020 Aug 11]. Acad Emerg Med. 2020;10.1111/acem.14108. doi:10.1111/acem.14108

What are your thoughts?