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Best Articles of 2021

December 31, 2021

Top Articles – 2021


intubateCOVID – How to Get First-Pass Success in COVID Patients
When intubating COVID-19 confirmed or suspected patients, greater experience, use of RSI, use of a PAPR, and intubation in a high vs low-income country were all associated with higher first pass success.
Emergency Airway Management in Patients with COVID-19: A Prospective International Multicenter Cohort Study. Anesthesiology. 2021 Aug 1;135(2):292-303. doi: 10.1097/ALN.0000000000003791. 

BOUGIE RCT – First Pass Success with Bougie vs Stylet
In this large ED and ICU multicenter RCT there was no difference in first pass success rate in intubations done with bougie first or ETT + stylet attempt.
Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA. 2021 Dec 8. doi: 10.1001/jama.2021.22002. Epub ahead of print.


REALITY RCT – PRBC Transfusion in Acute MI
A restrictive vs liberal transfusion strategy in patients with acute MI was non-inferior when considering 30-day MACE (major adverse coronary events).
Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia: The REALITY Randomized Clinical Trial. JAMA. 2021 Feb 9;325(6):552-560. doi: 10.1001/jama.2021.0135.

New “Reverse” Valsalva for SVT
The reverse Valsalva maneuver is a novel technique to terminate supraventricular tachycardia (SVT). Based on a small case series, this simple maneuver appears to be safe, effective, and can be performed by patients alone at home. However, additional studies are needed to establish the actual efficacy of this technique.
The reverse vagal manoeuvre: A new tool for treatment of supraventricular tachycardia? Am J Emerg Med. 2021 Mar;41:66-69. doi: 10.1016/j.ajem.2020.12.061. Epub 2020 Dec 26.

Occlusion vs Nonocclusion MI – Rethinking NSTEMI
A novel paradigm to classify acute MI based on the presence or absence of coronary occlusion—rather than on EKG evidence of ST-segment elevation alone—may identify NSTEMI patients who would benefit from emergent percutaneous coronary intervention.
Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Med. 2021;60(3):273-284. doi:10.1016/j.jemermed.2020.10.026

Shot Through the HEART – Problems with the HEART Score
Emergency departments should reconsider using the HEART score and its variants due to significant concerns regarding the rule’s creation and performance.
A Methodological Appraisal of the HEART Score and Its Variants. Ann Emerg Med. 2021 Apr 28;S0196-0644(21)00118-9. doi: 10.1016/j.annemergmed.2021.02.007. Online ahead of print.

GRACE-1 – Chest Pain Frequent Flyers
GRACE-1 offers eight evidence based guidelines to determine which adult patients with recurrent chest pain are low risk and can be safely sent home from the ED.
Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department. Acad Emerg Med. 2021 Jul 6. doi: 10.1111/acem.14296. Online ahead of print.

AHA Guideline – Chest Pain Workup
Using the acrostic CHEST PAINS, the AHA has issued outstanding new guidelines on the chest pain workup.
2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Oct 28;CIR0000000000001029. doi: 10.1161/CIR.0000000000001029. Online ahead of print.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Oct 28;CIR0000000000001030. doi: 10.1161/CIR.0000000000001030. Online ahead of print.

Critical Care

RELAx RCT – Low vs High PEEP Without ARDS
Low PEEP in mechanically ventilated patients without ARDS was noninferior to high PEEP for number of ventilator-free days.
Effect of a Lower vs Higher Positive End-Expiratory Pressure Strategy on Ventilator-Free Days in ICU Patients Without ARDS: A Randomized Clinical Trial. JAMA. 2020 Dec 22;324(24):2509-2520. doi: 10.1001/jama.2020.23517.

Are Balanced Crystalloids Still Better? – The BaSICS RCT Part 2
A large RCT in Brazilian ICUs found no difference in 90-day mortality between patients who received balanced crystalloids versus normal saline (NS).
Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA. 2021 Aug 10;e2111684. doi: 10.1001/jama.2021.11684. Online ahead of print.

Surviving Sepsis 2021 – Septic Shock Update
Here are the important updates for 2021 since the 2016 Surviving Sepsis guidelines were released.
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-e1143. doi: 10.1097/CCM.0000000000005337.

Executive Summary: Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021 Nov 1;49(11):1974-1982. doi: 10.1097/CCM.0000000000005357.


New Regimen for Gonorrhea and Chlamydia
The new regimen for treating gonorrhea is ceftriaxone 500mg IM, and in patients with unknown chlamydia status, add doxycycline 100mg po bid x 7 days. Azithromycin is out.
Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020 Dec 18;69(50):1911-1916. doi: 10.15585/mmwr.mm6950a6.

New ACEP Community-Acquired Pneumonia Clinical Policy
ACEP has released a new clinical policy statement for the care of community-acquired pneumonia (CAP) in the ED.
Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. doi: 10.1016/j.annemergmed.2020.10.024.

Yes, Your BP Is Up. No, It Doesn’t Matter.
Almost half of adults had an elevated BP measurement when in the ED, but even when ≥160/100, this did not increase risk of adverse cardiovascular outcomes within 2 years.
Elevated Blood Pressures Are Common in the Emergency Department but Are They Important? A Retrospective Cohort Study of 30,278 Adults. Ann Emerg Med. 2021 Feb 9;S0196-0644(20)31363-9. doi: 10.1016/j.annemergmed.2020.11.005. Online ahead of print. 

SALSA RCT – Hypertonic Saline Bolus vs Infusion for Hyponatremia
Intermittent boluses of hypertonic saline for treatment of moderate-to-severe hyponatremia has similar efficacy to a continuous infusion and may be easier to administer with less risk of overcorrection.
Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia: The SALSA Randomized Clinical Trial. JAMA Intern Med. 2021 Jan 1;181(1):81-92. doi: 10.1001/jamainternmed.2020.5519.


Does Suicide Screening in Triage Even Work?
Suicide screening in the ED had extremely poor diagnostic accuracy for predicting subsequent suicide within a month, with a sensitivity of just 18%.
Suicidal ideation is insensitive to suicide risk after ED discharge: performance characteristics of the Columbia-Suicide Severity Rating Scale Screener. Acad Emerg Med. 2020 Dec 21. doi: 10.1111/acem.14198. Online ahead of print.

Canadian TIA Score Beats ABCD2
The Canadian TIA Score has now been validated and is ready for clinical use. Patients with a clinically-defined TIA (no MRI) may be accurately stratified as low, medium, or high risk for subsequent stroke (+/- carotid revascularization) within 7 days.
Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study. BMJ. 2021 Feb 4;372:n49. doi: 10.1136/bmj.n49.

TREAT-CAD RCT – Aspirin or Warfarin for Cervical Arterial Dissection?
Aspirin was not non-inferior to vitamin K antagonists (VKA) in reducing bad clinical and MRI outcomes at 14 days in adult patients with cervical arterial dissection (CAD).
Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial. Lancet Neurol. 2021 May;20(5):341-350. doi: 10.1016/S1474-4422(21)00044-2. Epub 2021 Mar 23.

BASICS RCT – Endovascular Therapy for Basilar Artery Occlusion
There was no statistical difference in endovascular therapy (EVT) compared with usual medical therapy for patients with basilar artery occlusion (BAO).
Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion. N Engl J Med. 2021 May 20;384(20):1910-1920. doi: 10.1056/NEJMoa2030297.


CAM Boot or Cast for Toddler’s Fracture?
Children with a toddler’s fracture who were randomized to a CAM boot were easier to care for, walked sooner, and had no difference in fracture healing compared to those in a cast.
Randomised controlled trial comparing immobilisation in above-knee plaster of Paris to controlled ankle motion boots in undisplaced paediatric spiral tibial fractures. Emerg Med J. 2021 Jun 22;emermed-2020-210299. doi: 10.1136/emermed-2020-210299. Online ahead of print.


MENDS2 – Dexmedetomidine vs Propofol – Which Is Better?
For light sedation in patients with sepsis on the ventilator, there was no difference in outcome or safety between dexmedetomidine and propofol.
Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med. 2021 Feb 2. doi: 10.1056/NEJMoa2024922. Online ahead of print.


for Infant Intubation?

In this study, infants undergoing intubation with standard geometry video laryngoscopy (VL) had a higher first pass success rate and fewer severe complications when compared to infants intubated with direct laryngoscopy (DL).
First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet. 2020 Dec 12;396(10266):1905-1913. doi: 10.1016/S0140-6736(20)32532-0.

SAFER RCT – 5 or 10 Days for Pediatric CAP?
In outpatient children with community acquired pneumonia (CAP), 5 days of amoxicillin was non-inferior to 10 days.
Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA Pediatr. 2021 Mar 8. doi: 10.1001/jamapediatrics.2020.6735. Online ahead of print.

Feed the Baby – Do We Need 6 Hours of NPO for Neonates?
There is no need for 6 hours of pre-procedural NPO time when healthy term newborns are fed formula. At most, 2.5 hours would be enough.
Ultrasound Evaluation of Gastric Emptying Time in Healthy Term Neonates after Formula Feeding. Anesthesiology. 2021 Jun 1;134(6):845-851. doi: 10.1097/ALN.0000000000003773.

Landmark Febrile Neonate, Febrile Infant Guideline from the AAP
This covers the epic, 40-page AAP febrile neonate and febrile infant guideline. This is a game-changing, must-read summary and article.
Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics. 2021 Aug;148(2):e2021052228. doi: 10.1542/peds.2021-052228. Epub 2021 Jul 19. 

Why We Don’t Check C. diff on Babies
C. difficile colonization is very high in children under a year old and decreases with age.
Prevalence of Detection of Clostridioides difficile Among Asymptomatic Children: A Systematic Review and Meta-analysis. JAMA Pediatr. 2021 Aug 2;e212328. doi: 10.1001/jamapediatrics.2021.2328. Online ahead of print.

CAP-IT RCT | Low vs High & 3 vs 7 Days for Pediatric Pneumonia
Outpatient treatment of community-acquired pneumonia (CAP) in children with a lower dose of amoxicillin was noninferior to traditional high-dose amoxicillin, and 3-days of antibiotics was noninferior to 7-days with regard to need for antibiotic retreatment within a month.
Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia: The CAP-IT Randomized Clinical Trial. JAMA. 2021 Nov 2;326(17):1713-1724. doi: 10.1001/jama.2021.17843.

Practice of Emergency Medicine/Education

Podcasting on the Way to Work – Does It Work?
Emergency medicine residents had no change in performance on both initial and delayed recall tests based on podcast material listened to undistracted versus driving.
Maximizing the Morning Commute: A Randomized Trial Assessing the Effect of Driving on Podcast Knowledge Acquisition and Retention. Ann Emerg Med. 2021 Apr 27;S0196-0644(21)00162-1. doi: 10.1016/j.annemergmed.2021.02.030. Online ahead of print. 

Dear White Colleagues in EM | Becoming Better Allies
There are specific actions that non-minority providers can take to effectively help combat racism and inequity.
Dear White People in Emergency Medicine. Ann Emerg Med. 2021 Sep 28:S0196-0644(21)00774-5. doi: 10.1016/j.annemergmed.2021.08.004. Epub ahead of print.


ARREST RCT – ECMO-Facilitated Resuscitation for Refractory VF
Refractory out-of-hospital VF arrest has been considered almost uniformly fatal. ECMO rescue (ECPR) could change that, improving not just survival but good neurologic outcomes!
Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet. 2020 Dec 5;396(10265):1807-1816. doi: 10.1016/S0140-6736(20)32338-2. Epub 2020 Nov 13.

AHA Statement on Opioid-Associated OHCA
The AHA has released a quite comprehensive statement surrounding opioid-associated cardiac arrest. This is an expansive manuscript ranging from epidemiology to pre-hospital treatment, to post-resuscitation care and prevention methods.
Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association. Circulation. 2021 Apr 20;143(16):e836-e870. doi: 10.1161/CIR.0000000000000958. Epub 2021 Mar 8.

TTM2 RCT – Cool Your Jets on Therapeutic Hypothermia
Cooling comatose patients to 33°C after out-of-hospital cardiac arrest did not improve mortality or neurological outcomes compared to simply maintaining normothermia (<37.8°C).
Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. N Engl J Med. 2021;384(24):2283-2294. doi:10.1056/NEJMoa2100591.

More ROSC with Vasopressin and Steroids? – The VAM-IHCA Trial
Patients who suffered in-hospital-cardiac-arrest (IHCA) who received vasopressin and steroids were more likel
y to have return of spontaneous circulation (ROSC) than those who received placebo. However, there was no difference in thirty-day survival, favorable neurologic outcomes, or other health-related quality of life measures.
Effect of Vasopressin and Methylprednisolone vs Placebo on Return of Spontaneous Circulation in Patients With In-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021 Sep 29;e2116628. doi: 10.1001/jama.2021.16628. Online ahead of print.

Is Calcium Effective During a Cardiac Arrest?
Among adults with an out-of-hospital cardiac arrest, providing IV or IO calcium does not significantly improve sustained return of spontaneous circulation (ROSC) when compared to IV/IO saline.
Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021 Dec 14;326(22):2268-2276. doi: 10.1001/jama.2021.20929.


TXA May Increase Mortality in TBI
TXA given in the prehospital setting for isolated traumatic brain injury (TBI) was associated with increased 30-day mortality.
Association Between Prehospital Tranexamic Acid Administration and Outcomes of Severe Traumatic Brain Injury. JAMA Neurol. 2020 Dec 7. doi: 10.1001/jamaneurol.2020.4596. Epub ahead of print.

Venous Thromboembolism

Prevalence of PE in COPD Patients
Prevalence of pulmonary embolism (PE) was about 6% in this prospective trial looking at patients admitted to the hospital with worsening respiratory symptoms in the setting of known COPD.
Prevalence of Pulmonary Embolism Among Patients With COPD Hospitalized With Acutely Worsening Respiratory Symptoms. JAMA. 2021 Jan 5;325(1):59-68. doi: 10.1001/jama.2020.23567. 

D-Dimer in Pregnancy – Can We Trust It?
D-dimer can be safely used to rule out venous thromboembolism (VTE) in pregnant adults with non-high pre-test probability (PTP).
D-Dimer to rule out venous thromboembolism during pregnancy: a systematic review and meta-analysis. J Thromb Haemost. 2021 Jun 23. doi: 10.1111/jth.15432. Online ahead of print.

Can We Trust D-dimer for VTE in COVID-19?
Traditional laboratory cutoff values for D-dimer assays can still be employed in patients with COVID-19 to effectively rule out pulmonary embolism.
The impact of COVID-19 on the sensitivity of D-dimer for pulmonary embolism. Acad Emerg Med. 2021 Aug 23. doi: 10.1111/acem.14348. Online ahead of print.

Pregnancy-Adapted Geneva Score – Pre-test Probability of Acute PE in Pregnancy
In this prospective cohort, a pregnancy-adapted Geneva Score demonstrated better diagnostic accuracy than the original Geneva Score in identifying pregnant patients as low, intermediate, and high risk for acute pulmonary embolism (PE).
Assessing the clinical probability of pulmonary embolism during pregnancy: The Pregnancy-Adapted Geneva (PAG) score. J Thromb Haemost. 2021 Sep 8. doi: 10.1111/jth.15521.