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Best Articles of 2023

January 1, 2024

Top Articles – 2023

Written by Clay Smith

It’s been a great year for EM research. These are my top picks across a range of EM subject areas. Enjoy!


DEVICE RCT – VL vs DL for Critically Ill Adults
Video laryngoscopy (VL) was associated with higher rates of first attempt intubation success compared to direct laryngoscopy (DL) for critically ill patients in the ICU and ED. Furthermore, use of VL was associated with better views of the glottis and was especially helpful for clinicians with less intubation experience.
Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. [published online ahead of print, 2023 Jun 16]. N Engl J Med. 2023;10.1056/NEJMoa2301601. doi:10.1056/NEJMoa2301601


Is 0/2 Hour hsTnT Rule Out Ready for Prime Time? 
This secondary analysis of the STOP CP cohort study found that in isolation, using a 0/2 hour hs-cTnT rule-out protocol did not achieve a NPV ≥ 99% for 30-day cardiac death or MI (CDMI). When combined with a low risk History, ECG, Age, and Risk factor (HEAR) score, it did – but at the cost of significantly decreased efficacy (ruling out only 30.7% of patients).
Performance of the 0/2-Hour hs-cTnT Accelerated Diagnostic Protocol in a Multisite United States Cohort. Acad Emerg Med. 2023 Nov 4. doi: 10.1111/acem.14827. Epub ahead of print.

More Boxcars? Transfusion Trigger for STEMI and NSTEMI
Liberalizing the transfusion threshold to 10 g/dL (compared to 7-8 g/dL) for patients with myocardial infarction did not improve composite outcomes of myocardial infarction or death at 30 days.
Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia. N Engl J Med. 2023 Nov 11. doi: 10.1056/NEJMoa2307983. Epub ahead of print.

AHA Guideline | 10 Tips Life-Threatening Toxicity From Poisoning
Here are ten tips from the AHA for the next super-sick poisoned patient you encounter.
2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2023 Sep 18. doi: 10.1161/CIR.0000000000001161. Online ahead of print.

Myth-Bust – Can We Give Nitrates to RV Infarction?
New evidence has demonstrated that previous dogma to withhold nitrates from patients with right ventricular myocardial infarction (RVMI) may be incorrect.
Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emerg Med J. 2023 Feb;40(2):108-113. doi: 10.1136/emermed-2021-212294. Epub 2022 Sep 30.

Critical Care

CLOVERS RCT – Restrictive or Liberal Fluid Before Pressors?
This unblinded superiority trial found no significant difference in mortality among patients who were randomized to a restrictive fluid strategy with earlier use of vasopressors or liberal fluid administration for treatment of sepsis-induced hypotension.
Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. NEJM. 2023 Feb 9; 388:499-510, DOI: 10.1056/NEJMoa2212663.


Transfusion Trigger – New AABB Guidelines for Adults and Children
For hemodynamically stable adults and children, 7g/dL is the best transfusion trigger, with a few exceptions.
Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA. 2023 Oct 12. doi: 10.1001/jama.2023.12914. Online ahead of print.

ACORN RCT – Piperacillin-Tazobactam or Cefepime?
In this randomized control trial of patients receiving cefepime or piperacillin-tazobactam, there was no difference in risk of acute kidney injury between the two groups. However, those who received cefepime were more likely to have neurologic side effects.
Cefepime vs Piperacillin-Tazobactam in Adults Hospitalized With Acute Infection: The ACORN Randomized Clinical Trial. JAMA. 2023 Oct 14:e2320583. doi: 10.1001/jama.2023.20583. Online ahead of print.

BP Wildly Varies With Wrong Cuff Size
This randomized controlled trial demonstrated a clinically significant difference in blood pressure measurements when inappropriately sized BP cuffs were used on patients.
Effects of Cuff Size on the Accuracy of Blood Pressure Readings: The Cuff(SZ) Randomized Crossover Trial. JAMA Intern Med. 2023 Aug 7;e233264. doi: 10.1001/jamainternmed.2023.3264. Online ahead of print.

RECOVERY RCT – High or Low Dose Dexamethasone for COVID-19?
In this large, randomized controlled trial, hypoxic patients requiring simple or no oxygen who received higher dose dexamethasone (20mg for 5 days, then 10mg for 5 days) had a higher mortality compared to patients who received usual care, most of whom were treated with 6mg per day of dexamethasone for 10 days.
Higher dose corticosteroids in patients admitted to hospital with COVID-19 who are hypoxic but not requiring ventilatory support (RECOVERY): a randomised, controlled, open-label, platform trial. Lancet. 2023 May 6;401(10387):1499-1507. doi: 10.1016/S0140-6736(23)00510-X. Epub 2023 Apr 13.


New ACEP Clinical Policy on Acute Ischemic Stroke
This ACEP Clinical Policy examined four specific clinical questions related to ED management of acute ischemic stroke, which are summarized below.
Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Acute Ischemic Stroke. Ann Emerg Med. 2023 Aug;82(2):e17-e64. doi: 10.1016/j.annemergmed.2023.03.007.

New AHA SAH Guidelines – Spoon-Feed Version
Aneurysmal subarachnoid hemorrhage (aSAH) is a deadly condition. Here’s a quick summary of the 40-page AHA/ASA evidence-based guidelines for diagnosis and management.
2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2023 May 22. doi: 10.1161/STR.0000000000000436. Epub ahead of print.

Guidelines for Reasonable and Appropriate Care in the Emergency Department 3 (GRACE-3) – Acute Dizziness and Vertigo in the Emergency Department 
The GRACE-3 group (SAEM) provides us with a guideline based on their review we covered previously with the evidence for evaluating and managing adult patients presenting to emergency departments for acute dizziness. Emergency clinicians need additional training in physical exam techniques related to acute dizziness in order to perform them effectively, which should be a specialty-wide goal for the future.
Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med. 2023 May;30(5):442-486. doi: 10.1111/acem.14728.

TRACE-2 RCT – Tenecteplase vs Alteplase for Stroke
Tenecteplase was non-inferior to alteplase in patients with acute ischemic stroke who were eligible for intravenous thrombolytic therapy but ineligible or refused endovascular thrombectomy.
Tenecteplase versus alteplase in acute ischaemic cerebrovascular events (TRACE-2): a phase 3, multicentre, open-label, randomised controlled, non-inferiority trial. Lancet. 2023 Feb 8;S0140-6736(22)02600-9. doi: 10.1016/S0140-6736(22)02600-9. Online ahead of print.


OPAL RCT – No More Opioids for Back Pain
Opioid pain medications offer no benefit compared to placebo for patients with acute back or neck pain.
Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet. 2023 Jun 27:S0140-6736(23)00404-X. doi: 10.1016/S0140-6736(23)00404-X. Epub ahead of print.


NINJA RCT – Should We Replace the Nail After Nail Bed Repair?
In this multicenter, randomized controlled trial comparing suturing the fingernail back onto the nail bed versus simply covering the nail bed with a non-adherent dressing after repair of a nail bed injury, there was no statistically significant difference in infection rate or cosmetic outcome.
Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial. Br J Surg. 2023 Mar 30;110(4):432-438. doi: 10.1093/bjs/znad031.

Propofol Dose (per kg) Drops From Infant to Teen
The dose of propofol to achieve a desired level of sedation decreased linearly with increasing age in this extensive retrospective review of pediatric procedural sedations.
Age-Stratified Propofol Dosage for Pediatric Procedural Sedation and Analgesia. Anesth Analg. 2023 Mar 1;136(3):551-558. doi: 10.1213/ANE.0000000000006196. Epub 2023 Feb 17.


Viruses LOWER Procalcitonin? Impact of Viral Infection on PCT in Febrile Infants
Procalcitonin (PCT) is suppressed in young febrile infants in the presence of confirmed viral infection (CVI), which lowers its sensitivity to detect bacterial infection (BI). Infants meeting the AAP cutoff of 0.5 ng/mL, even in the presence of CVI, should undergo full diagnostic workup for BI.
Effect of Viral Illness on Procalcitonin as a Predictor of Bacterial Infection in Febrile Infants. Hosp Pediatr. 2023 Nov 1;13(11):961-966. doi: 10.1542/hpeds.2022-007070.

900% Greater Odds of Going Home – Nasal Fentanyl for Pediatric Sickle Cell Crisis
In this large, multi-center retrospective study of academic pediatric emergency departments across the US and Canada, researchers found that children presenting with sickle cell disease vaso-occlusive events had nine times (900%) greater adjusted odds of discharge home if given intranasal fentanyl (INF).
Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso-occlusive pain: A multicenter pediatric emergency medicine perspective. Am J Hematol. 2023 Apr;98(4):620-627. doi: 10.1002/ajh.26837. Epub 2023 Feb 6.

Pediatric Sinusitis – Plain Amoxicillin or Amoxicillin-Clavulanate?
For pediatric patients with acute sinusitis, amoxicillin-clavulanate does not offer treatment benefit over amoxicillin alone and is more likely to be associated with gastrointestinal (GI) side effects and yeast infections than amoxicillin.
Treatment Failure and Adverse Events After Amoxicillin-Clavulanate vs Amoxicillin for Pediatric Acute Sinusitis. JAMA. 2023 Sep 19;330(11):1064-1073. doi: 10.1001/jama.2023.15503.

Myth Bust – Does Croup Really Get Better in Cold Air?
Is taking a croupy child outdoors in the cold air a myth or evidence-based practice? Turns out, the RCT shows it actually works!
Outdoor Cold Air Versus Room Temperature Exposure for Croup Symptoms: A Randomized Controlled Trial. Pediatrics. 2023 Aug 1;e2023061365. doi: 10.1542/peds.2023-061365. Online ahead of print.

Does Prehospital Transfusion of Pediatric Trauma Patients Save Lives?
A reduction in both 24-hour and in-hospital mortality was seen among children who received a transfusion after traumatic injury in the prehospital setting compared to those who were transfused in the emergency department.
Association of Prehospital Transfusion With Mortality in Pediatric Trauma. JAMA Pediatr. 2023 Jul 1;177(7):693-699. doi: 10.1001/jamapediatrics.2023.1291.

SCOUT RCT | 5 or 10-day Treatment for Pediatric UTI?
This multi-center, double-blinded, non-inferiority trial found that short-course antimicrobial therapy had relatively low treatment failure rates compared to standard-course in children diagnosed with UTI who showed clinical improvement after 5 days of antibiotics.
Short-Course Therapy for Urinary Tract Infections in Children: The SCOUT Randomized Clinical Trial. JAMA Pediatr. 2023 Jun 26:e231979. doi: 10.1001/jamapediatrics.2023.1979. Epub ahead of print.

Is Doxycycline Safe in Children?
There is no association of doxycycline and tooth staining in children under 8 when used at usual dose and duration.
Antibiotic Exposure and Dental Health: A Systematic Review. Pediatrics. 2023 Jun 2;e2023061350. doi: 10.1542/peds.2023-061350. Online ahead of print.

CT C-Spine Negative? Clear The Kid’s Collar
In this large, single-institution retrospective review of pediatric blunt trauma patients, no clinically significant injuries (requiring operative intervention) were missed when using multi-detector CT scan as the imaging modality of choice.
Pediatric Cervical Spine Clearance: A 10-year Evaluation of Multi-Detector Computed Tomography at a Level 1 Pediatric Trauma Center. J Trauma Acute Care Surg. 2023 Apr 19. doi: 10.1097/TA.0000000000003929. Epub ahead of print.

BTW…Cold Baby – Does Incidental Infant Hypothermia Warrant Workup?
Well-appearing neonates with incidentally noted hypothermia at a routine visit are at a low risk for serious infection and may not warrant a full sepsis evaluation.
Jain SB, Anderson T, Mikhail D, Banerjee R, Arnold DH. Serious infections are rare in well-appearing neonates with hypothermia identified incidentally at routine visits. Am J Emerg Med. 2022 Dec 13;65:1-4. doi: 10.1016/j.ajem.2022.12.008. Epub ahead of print.

Practice of EM/ED Operations

The Real Risks of Boarding in the Emergency Department
In this large, multicenter prospective cohort study in France, researchers found that patients ≥75 years who were admitted overnight boarding in the ED had higher rates of in-hospital mortality, length of stay, and adverse events.
Overnight Stay in the Emergency Department and Mortality in Older Patients. JAMA Intern Med. 2023 Dec 1;183(12):1378-1385. doi: 10.1001/jamainternmed.2023.5961.

Is 98.6F (37C) Wrong?
Normal oral temperature is hard to define, but this large cross-sectional study suggests that the average is not 37oC (98.6oF).
Defining Usual Oral Temperature Ranges in Outpatients Using an Unsupervised Learning Algorithm. JAMA Intern Med. 2023 Oct 1;183(10):1128-1135. doi: 10.1001/jamainternmed.2023.4291.

Experienced or Rusty? Physician Age and Patient Mortality
Emergency physician (EP) advancing age was associated with higher 7-day patient mortality. This is a call to keep current with literature, clinical skills, and best practices.
Association Between Emergency Physician’s Age and Mortality of Medicare Patients Aged 65 to 89 Years After Emergency Department Visit. Ann Emerg Med. 2023 Sep;82(3):301-312. doi: 10.1016/j.annemergmed.2023.02.010. Epub 2023 Mar 23.

Leaving So Soon? Why Women Are Retiring from EM Early
On average, female EM physicians leave clinical practice 12 years younger than their male counterparts, after fewer years of practice, and the amount of time spent in the workforce is decreasing over time. We need to identify and implement systemic fixes to stop this.
Emergency medicine physician workforce attrition differences by age and gender. Acad Emerg Med. 2023 Jun 14. doi: 10.1111/acem.14764. Online ahead of print.


Updates on Neonatal Resuscitation from the American Heart Association
The American Heart Association updated their neonatal resuscitation recommendations based on new evidence. The update focuses on umbilical cord management and best practices for administering positive pressure ventilation. Check-out these videos on neonatal resuscitation on Journal Feed!
2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2023 Nov 16. doi: 10.1161/CIR.0000000000001181. Online ahead of print.

CT FIRST – Full Body CT Post-OHCA – Does CT Help?
A full-body CT protocol in resuscitated adults with out of hospital cardiac arrest (OHCA) more often – and more quickly – found the cause of arrest than standard of care CT but did not improve neurologically intact survival.
Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study. Resuscitation. 2023 Jul;188:109785. doi: 10.1016/j.resuscitation.2023.109785. Epub 2023 Apr 3.


In the first ever randomized clinical trial (RCT) of resuscitative endovascular balloon occlusion of the aorta (REBOA), exsanguinating patients receiving REBOA and standard care suffered greater mortality than those receiving standard care alone. But don’t throw those balloons away just yet, this study had significant limitations.
Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA. 2023 Oct 12:e2320850. doi: 10.1001/jama.2023.20850. Online ahead of print.

When to Crack the Pediatric Chest – New Guidelines
Emergency department thoracotomy (EDT) is recommended in pulseless pediatric patients with signs of life* who have penetrating thoracic/abdominopelvic trauma; if pulseless with signs of life* and blunt trauma, a conditional recommendation is made.
Emergency department thoracotomy in children: A Pediatric Trauma Society, Western Trauma Association, and Eastern Association for the Surgery of Trauma systematic review and practice management guideline. J Trauma Acute Care Surg. 2023 Sep 1;95(3):432-441. doi: 10.1097/TA.0000000000003879. Epub 2023 Mar 11.

New ACEP Clinical Policy on Mild TBI
ACEP has issued an updated Clinical Policy to provide evidence-based guidelines for management of adult patients presenting to the ED with mild traumatic brain injury based on systematic review of available literature.
Clinical Policy: Critical Issues in Management of Adult Patients Presenting to the Emergency Department with Mild Traumatic Brain Injury. Ann Emerg Med. 2023 May; 81(5): e63-e105. doi: 10.1016/j.annemergmed.2023.01.014.

Venous Thromboembolism

NSAIDs + OCPs = More VTEs?
This Danish nationwide cohort study found that in reproductive-age women, NSAID use alone increased the risk of venous thromboembolism (VTE). The magnitude of risk was compounded by concomitant use of hormonal contraception.
Venous thromboembolism with use of hormonal contraception and non-steroidal anti-inflammatory drugs: nationwide cohort study. BMJ 2023; 382 :e074450 doi:10.1136/bmj-2022-074450.

Subsegmental PE – Hold the Anticoagulation?
Structured surveillance without anticoagulation of patients with isolated subsegmental pulmonary embolism (ssPE) rarely occurs in community practice. After applying CHEST guidelines, ~5% of patients with isolated subsegmental PE are eligible for surveillance.
Samuel G Rouleau, Mahesh J Balasubramanian, Jie Huang, Tad Antognini, Mary E Reed, David R Vinson. Prevalence of and Eligibility for Surveillance Without Anticoagulation Among Adults With Lower-Risk Acute Subsegmental Pulmonary Embolism. JAMA Netw Open. 2023;6(8):e2326898. Published 2023 Aug 1. doi:10.1001/jamanetworkopen.2023.26898