Top Articles – 2022
Anesthesia/Airway
New 2022 ASA Difficult Airway Guidelines
The American Society of Anesthesiologists (ASA) has released new difficult airway guidelines that replace the previous 2013 version. Here’s what you need to know in the ED.
2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2021 Nov 11. doi: 10.1097/ALN.0000000000004002. Online ahead of print.
PREPARE II RCT – Does a Bolus Reduce Cardiovascular Collapse Post-Intubation?
A 500mL fluid bolus does not reduce the incidence of cardiovascular collapse in critically ill patients undergoing endotracheal intubation.
Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA. 2022 Jun 16. doi: 10.1001/jama.2022.9792. Online ahead of print.
Mac 3 or Mac 4 for Intubation? | MacSize-ICU Results Surprising
There was an association with increased first attempt intubation success during direct laryngoscopy when using a Macintosh 3 laryngoscope blade compared to a Macintosh 4 blade.
Impact of Macintosh blade size on endotracheal intubation success in intensive care units: a retrospective multicenter observational MacSize-ICU study. Intensive Care Medicine. August 16, 2022. Doi: 10.1007/s00134-022-06832-9
Mounting Evidence that Paralysis Awareness is a Big Problem
In this single center cohort of 886 patients, 5 patients had definite awareness during paralysis. However, there were 61 patients determined to have possible awareness, meaning upwards of 7.4% of patients could have been aware.
Recall of awareness during paralysis among emergency department patients undergoing tracheal intubation. Chest. 2022 Sep 08. Doi: https://doi.org/10.1016/j.chest.2022.08.2232
Cardiology
Anterior-Lateral or Anterior-Posterior Pads for A-fib Cardioversion?
Anterior-lateral positioning is superior to anterior-posterior electrode positioning in biphasic cardioversion of atrial fibrillation.
Anterior-Lateral Versus Anterior-Posterior Electrode Position for Cardioverting Atrial Fibrillation. Circulation. 2021 Dec 21;144(25):1995-2003. doi: 10.1161/CIRCULATIONAHA.121.056301. Epub 2021 Nov 24.
Don’t Stress Over the Stress Test – Does 72-hour Stress Testing Matter?
More intense follow-up noninvasive cardiac stress testing within 72 hours among patients with chest pain discharged from the ED was associated with greater major adverse coronary outcomes at 60 days, but this was mainly driven by more downstream procedures.
Higher intensity of 72-h noninvasive cardiac test referral does not improve short-term outcomes among emergency department patients with chest pain. Acad Emerg Med. 2022 Jan 22. doi: 10.1111/acem.14448. Online ahead of print.
New AHA Heart Failure Guidelines for Emergency Medicine – Spoon-Feed Version
These are the take home points for emergency medicine from the AHA heart failure guidelines. There are some novel therapies for heart failure you need to know.
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-e1032. doi: 10.1161/CIR.0000000000001063. Epub 2022 Apr 1. Erratum in: Circulation. 2022 May 3;145(18):e1033.
New Expert Pathway for Chest Pain from ACC – Spoon-Feed Version
This is the latest on how to work up possible acute coronary syndrome in the ED.
2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022 Oct 6;S0735-1097(22)06618-9. doi: 10.1016/j.jacc.2022.08.750. Online ahead of print.
New ACEP Policy on Acute Heart Failure
ACEP released acute heart failure syndrome (AHFS) consensus recommendations that cover: diagnosis with lung ultrasound, risk stratification, high-dose nitroglycerin, and early diuretics.
Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Heart Failure Syndromes: Approved by ACEP Board of Directors, June 23, 2022. Ann Emerg Med. 2022 Oct;80(4):e31-e59. doi: 10.1016/j.annemergmed.2022.05.027.
Transcutaneous Pacing – What’s the Best Pad Placement?
Placing transcutaneous cardiac pacer pads in the anteroposterior position required less energy to successfully capture.
Anteroposterior Pacer Pad Position Is More Likely to Capture Than Anterolateral for Transcutaneous Cardiac Pacing. Circulation. 2022;146(14):1103-1104. doi:10.1161/CIRCULATIONAHA.122.060735
Critical Care
CLASSIC RCT – Does Fluid Restriction Lower ICU Mortality?
In large a multicenter RCT of patients admitted to the ICU with septic shock, there was no difference in 90-day all-cause mortality when following a restrictive IV fluid protocol vs. standard protocol.
Restriction of Intravenous Fluid in ICU Patients with Septic Shock. N Engl J Med. 2022 Jun 17. doi: 10.1056/NEJMoa2202707. Online ahead of print.
What Are the Racial Differences in Pulse Oximetry?
Occult hypoxemia occurred more often in Black than White inpatients. Is 92% SpO2 actually 87% SaO2?
Racial bias and reproducibility in pulse oximetry among medical and surgical inpatients in general care in the Veterans Health Administration 2013-19: multicenter, retrospective cohort study. BMJ. 2022 Jul 6;378:e069775. doi: 10.1136/bmj-2021-069775.
Medicine/ID/Pulmonary
Do Macrolides Reduce Mortality in Community Acquired Pneumonia?
Among adults with culture-confirmed bacteremic pneumococcal pneumonia, empiric macrolide therapy was associated with 45% reduction in the odds for mortality, regardless of macrolide treatment duration, an effect was not seen with quinolones.
The Effect of Macrolides on Mortality In Bacteremic Pneumococcal Pneumonia: A Retrospective Nationwide Cohort Study, Israel, 2009-2017. Clin Infect Dis. 2022 Apr20;ciac317. Doi: 10.1093/cid/ciac317.
How to Distinguish Bacterial vs. Viral Conjunctivitis
The presence of certain clinical findings can help clinicians gauge the likelihood of bacterial versus viral conjunctivitis, although data are limited.
Does This Patient With Acute Infectious Conjunctivitis Have a Bacterial Infection?: The Rational Clinical Examination Systematic Review. JAMA. 2022 Jun 14;327(22):2231-2237. doi: 10.1001/jama.2022.7687.
Neurology/Stroke/Psych
No LP if CT Negative Out to 24 Hours?
When using multislice CT (MSCT) scanners this study suggests it may be possible to extend the timeframe from headache onset within which aneurysmal subarachnoid hemorrhage (aSAH) can be effectively ruled out with imaging alone. They found that when MSCT was employed within 24 hours of symptom onset, the sensitivity of detecting aSAH remained 100%.
Sensitivity of modern multislice CT for subarachnoid haemorrhage at incremental timepoints after headache onset: a 10-year analysis. Emerg Med J. 2021 Nov 24;emermed-2020-211068. doi: 10.1136/emermed-2020-211068. Online ahead of print.
ATTENTION RCT – Thrombectomy Benefits Basilar Artery Occlusion Stroke?
Endovascular thrombectomy was associated with improved functional neurologic outcomes compared to best medical care for patients with basilar-artery occlusion who presented within 12 hours of stroke onset. However, thrombectomy was also associated with significant procedural complications and an increased risk of intracranial hemorrhage.
Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion. N Engl J Med. 2022 Oct 13;387(15):1361-1372. doi: 10.1056/NEJMoa2206317.
Orthopedics/Sports
The Achilles’ Heals…Without Surgery? Non-op vs Operative Management RCT
Patients with Achilles’ tendon rupture undergoing surgical repair, either open or minimally-invasive, did not have better outcomes at 12 months compared to non-operative treatment. However, those managed nonoperatively had a higher rate of tendon rerupture.
Nonoperative or Surgical Treatment of Acute Achilles’ Tendon Rupture. N Engl J Med. 2022 Apr 14;386(15):1409-1420. doi: 10.1056/NEJMoa2108447.
Pain/Procedure/Sedation
Droperidol Prolongs QT 30 msec – Does This Matter?
Low-dose droperidol prolonged the QTc in non-agitated ED patients who were prospectively monitored, but effects were transient and not associated with dysrhythmias.
Prospective real-time evaluation of the QTc interval variation after low-dose droperidol among emergency department patients. Am J Emerg Med. 2022 Feb;52:212-219. doi: 10.1016/j.ajem.2021.12.039. Epub 2021 Dec 22.
They Catch on Fire – Electrocautery Trephination with Acrylic Nails
Electrocautery trephination of acrylic nail products attached to simulated digits was associated with a high likelihood of ignition (83/200; 41.5%). Based on this limited data, electrocautery trephination of acrylic nails should be avoided to reduce risk of further patient harm.
Up in Flames: The Safety of Electrocautery Trephination of Subungual Hematomas with Acrylic Nails. West J Emerg Med. 2022 Feb 23;23(2):183-185. doi: 10.5811/westjem.2021.10.53567.
Avoiding Laryngospasm During Pediatric Sedation – What Are Risk Factors?
The prevalence of laryngospasm was 3.3/1000 children. Concurrent URI, airway procedure, and use of combined ketamine + propofol were associated with increased risk.
Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation. Annals of Emergency Medicine. 2022 Jun22;S0196-0644(22)00323-7.
Pediatrics
SCOUT-CAP – Is Shorter Duration Better for Pediatric Pneumonia?
A composite outcome encompassing both clinical response and adverse effects of antibiotics was superior in children who received 5 vs 10 days of antibiotics for pediatric community acquired pneumonia.
Short- vs Standard-Course Outpatient Antibiotic Therapy for Community-Acquired Pneumonia in Children: The SCOUT-CAP Randomized Clinical Trial. JAMA Pediatr. 2022 Jan 18. doi: 10.1001/jamapediatrics.2021.5547. Online ahead of print.
Does IV Magnesium Make Kids with Asthma Worse?
IV magnesium (IV-Mg) was associated with worsening asthma score in children, greater odds of hospitalization, and no acceleration of exacerbation resolution in hospitalized patients.
Prospective Observational Study of Clinical Outcomes After Intravenous Magnesium for Moderate and Severe Acute Asthma Exacerbations in Children. J Allergy Clin Immunol Pract. 2021 Dec 13:S2213-2198(21)01366-0. doi: 10.1016/j.jaip.2021.11.028. Epub ahead of print.
Managing Massive and Submassive PE in Children
This is a spoon-feed version of the management of massive and submassive PE in children.
Acute Management of High-Risk and Intermediate-Risk Pulmonary Embolism in Children: A Review. Chest. 2022 Mar;161(3):791-802. doi: 10.1016/j.chest.2021.09.019. Epub 2021 Sep 26.
Pediatric Appendicitis – Is Non-Op Management Safe?
Nonoperative management (NOM) for uncomplicated appendicitis has become more common over the past 10 years in the pediatric population. Although many children do well, those who have recurrences have higher rates of surgical complications and hospitalizations.
Nonoperative Management of Uncomplicated Appendicitis. Pediatrics. 2022 Apr 18;e2021054693. doi: 10.1542/peds.2021-054693. Online ahead of print.
Can We Use Droperidol for Pediatric Agitation?
This systematic review suggests that droperidol is both safe and effective for treating agitation in the pediatric population.
A Systematic Review of the Effectiveness and Safety of Droperidol for Pediatric Agitation in Acute Care Settings. Acad Emerg Med. 2022 May 1. doi: 10.1111/acem.14515. Online ahead of print.
Is LP Needed for Febrile Infants 29-60 days with Abnormal UA?
Febrile infants 29-60 days with a positive UA had no cases of bacterial meningitis. These patients do not need a lumbar puncture.
Serious Bacterial Infections in Young Febrile Infants With Positive Urinalysis Results. Pediatrics. 2022 Sep 13;e2021055633. doi: 10.1542/peds.2021-055633. Online ahead of print.
Should We Use Steroids for Pediatric Bell’s Palsy?
There was no statistical difference in 1, 3, or 6 month facial recovery with prednisolone vs placebo for children with Bell’s palsy in this underpowered RCT. I plan to keep using steroids, though opinions on this will differ.
Efficacy of Prednisolone for Bell Palsy in Children: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial. Neurology. 2022 Aug 25;10.1212/WNL.0000000000201164. doi: 10.1212/WNL.0000000000201164. Online ahead of print.
Just Push It Down? Esophageal Bougienage for Coins
Esophageal bougienage is an underutilized bedside technique for managing retained esophageal coins.
Esophageal Bougienage for Management of Lodged Esophageal Coins: Safe, Effective, Efficient, and Underused. Pediatr Emerg Care. 2022 Sep 30. doi: 10.1097/PEC.0000000000002849. Online ahead of print.
Practice of EM
50 Years Since Tuskegee Syphilis Study – What Lessons Have We Learned?
We need to understand our recent history. The syphilis study is a story we must tell, internalize, and learn from so we won’t make the same mistakes again.
Fiftieth Anniversary of Uncovering the Tuskegee Syphilis Study: The Story and Timeless Lessons. Am J Respir Crit Care Med. 2022 May 15;205(10):1145-1158. doi: 10.1164/rccm.202201-0136SO.
Resuscitation
Prehospital Cardiac Arrest – Is Advanced Airway or BVM Best?
Endotracheal tube or supraglottic airway vs bag-valve mask airway management in prehospital cardiac arrest made no difference in neurologically favorable survival at 30-days when controlled for clinical differences.
Prehospital airway management for out-of-hospital cardiac arrest: A nationwide multicenter study from the KoCARC registry. Acad Emerg Med. 2022 Jan 22. doi: 10.1111/acem.14443. Online ahead of print.
BOX RCT – What’s the Right MAP Target for OHCA Patients?
There was no difference in death or discharge with profound disability among comatose patients with out of hospital cardiac arrest (OHCA) randomized to a mean arterial pressure (MAP) goal of 63 or 77 mm Hg.
Blood-Pressure Targets in Comatose Survivors of Cardiac Arrest. N Engl J Med. 2022 Aug 27. doi: 10.1056/NEJMoa2208687. Online ahead of print.
BOX RCT – What’s the Right PaO2 Goal for OHCA Patients?
There was no difference in death or discharge with profound disability in patients with high or low PaO2 targets.
Oxygen Targets in Comatose Survivors of Cardiac Arrest. N Engl J Med. 2022 Aug 27. doi: 10.1056/NEJMoa2208686. Online ahead of print.
Refractory Ventricular Fibrillation – What’s the Best Defibrillation Strategy?
For the treatment of refractory ventricular fibrillation (VF) in out-of-hospital cardiac arrest, survival to hospital discharge was more common among patients who received double sequential external defibrillation (DSED) and vector-change (VC) defibrillation than those who received standard defibrillation.
Defibrillation Strategies for Refractory Ventricular Fibrillation. N Engl J Med. 2022 Nov 6. doi: 10.1056/NEJMoa2207304. Online ahead of print.
Trauma/Surgery
CODA RCT | Pills or Knife for Appendicitis – Long-Term Outcomes
The CODA trial initially found antibiotic treatment was noninferior to surgery for acute appendicitis at 30 days. In this follow up letter on long-term outcomes (up to 4 years), the incidence of appendectomy in the antibiotic group was higher than pooled results from prior trials.
Antibiotics versus Appendectomy for Acute Appendicitis – Longer-Term Outcomes. N Engl J Med. 2021 Dec 16;385(25):2395-2397. doi: 10.1056/NEJMc2116018. Epub 2021 Oct 25.
It’s Only a Flesh Wound! Selective Non-operative Management of Abdominal Stab Wounds
In abdominal stab wound patients without criteria for immediate operative intervention, 24 hours of observation was sufficient to identify a failure of conservative management.
Prospective Evaluation of the Selective Nonoperative Management of Abdominal Stab Wounds: When is it Safe to Discharge? J Trauma Acute Care Surg. 2022 Jul 5. doi: 10.1097/TA.0000000000003733. Epub ahead of print.
The TBI SBP Sweet Spot – Is 130-180 mmHg the New Normotension?
In-hospital mortality of TBI patients decreased linearly as the lowest observed out-of-hospital systolic blood pressure increased, with the lowest mortality between 130 and 180 mmHg.
Optimal Out-of-Hospital Blood Pressure in Major Traumatic Brain Injury: A Challenge to the Current Understanding of Hypotension. Ann Emerg Med. 2022 Jul;80(1):46-59. doi: 10.1016/j.annemergmed.2022.01.045. Epub 2022 Mar 24.
Stop the Bleeding…of Unnecessary Care – Another Strike Against Delayed Head CT
No significant difference in delayed intracranial hemorrhage (dICH) was seen in patients on antithrombotic (AT) medication vs. no AT among patients with repeat CT.
Findings on Repeat Posttraumatic Brain Computed Tomography Scans in Older Patients With Minimal Head Trauma and the Impact of Existing Antithrombotic Use. Ann Emerg Med. 2022 Oct 31;S0196-0644(22)00580-7. doi: 10.1016/j.annemergmed.2022.08.006. Online ahead of print.
Venous Thromboembolism
The Ideal PE Rule-Out? RCT – PERC+YEARS+Age-Adjusted D-Dimer
In PERC positive patients, use of YEARS with age-adjusted D-dimer was noninferior to an age-adjusted D-dimer strategy alone.
Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial. JAMA. 2021 Dec 7;326(21):2141-2149. doi: 10.1001/jama.2021.20750.
“Adjust-Unlikely” vs. YEARS – A New Winning Strategy to Reduce CT in Suspected PE
Assessing pretest probability using a modified, age-adjusted clinical decision tool (“Adjust-Unlikely”) vs YEARS reduces CT imaging in patients with suspected pulmonary embolism (PE). “Adjust-Unlikely” missed no PEs. YEARS had a larger reduction of imaging but missed a few PEs.
Comparison of YEARS and Adjust-Unlikely D-dimer Testing for Pulmonary Embolism in the Emergency Department [published online ahead of print, 2022 Nov 10]. Ann Emerg Med. 2022;S0196-0644(22)01118-0.
