November 2016 EM Articles

*NNR This Month = 78

You'd have to read 2746 articles to find these 35 wonders of modern science.

*NNR - number needed to read

Cognitive rest and graduated return to usual activities versus usual care for mild traumatic brain injury: A randomized controlled trial of emergency department discharge instructions.
Acad Emerg Med. 2016 Oct 28. doi: 10.1111/acem.13073. [Epub ahead of print]
Spoon Feed: This study does not change my practice.  What this study may have found is that both groups didn't read or follow discharge instructions rather than finding a failure of cognitive rest after concussion. Neurons are injured in concussion and need to heal.  Excessive physical and cognitive load makes people with concussion feel worse.  It only makes sense to tell people with concussion they have a sprained brain, and like a sprained ankle, they need to rest for a while to allow time for healing.

The Predictive Value of Preendoscopic Risk Scores to Predict Adverse Outcomes in Emergency Department Patients With Upper Gastrointestinal Bleeding: A Systematic Review.
Acad Emerg Med. 2016 Nov;23(11):1218-1227. doi: 10.1111/acem.13101. Epub 2016 Nov 1.
Spoon Feed: None of the clinical risk scores for predicting adverse outcome in upper GI bleed were great.  A Glasgow Blatchford score of 0 had sensitivity of 99% but specificity of only 8%.

The Influence of Age on the Diagnostic Performance of White Blood Cell Count and Absolute Neutrophil Count in Suspected Pediatric Appendicitis.
Acad Emerg Med. 2016 Nov;23(11):1235-1242. doi: 10.1111/acem.13018. Epub 2016 Oct 31.
Spoon Feed: Appendicitis scoring systems should use age-adjusted WBC cutoffs.  Also, recognize the limitations of WBC count in ruling out appendicitis.  A normal WBC count decreases the post-test probability of disease but doesn't rule it out.

Elderly patients are at increased risk for treatment failure in outpatient management of purulent skin infections.
Am J Emerg Med. 2016 Oct 29. pii: S0735-6757(16)30776-8. doi: 10.1016/j.ajem.2016.10.060. [Epub ahead of print]
Spoon Feed: Have a lower admission threshold for elderly patients with purulent skin infection.

Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis.
Am J Emerg Med. 2016 Nov 2. pii: S0735-6757(16)30775-6. doi: 10.1016/j.ajem.2016.10.059. [Epub ahead of print]
Spoon Feed: Hyperpronation beats supination/flexion for nursemaid's elbow. 

Diagnostic performance of a biomarker panel as a negative predictor for acute appendicitis in adult emergency department patients with abdominal pain.
Am J Emerg Med. 2016 Nov 11. pii: S0735-6757(16)30836-1. doi: 10.1016/j.ajem.2016.11.027. [Epub ahead of print]
CONCLUSION: "This biomarker panel exhibited high sensitivity and negative predictive value for acute appendicitis in this prospective adult cohort, thereby potentially reducing the dependence on CT for the evaluation of possible acute appendicitis."

Surgical Versus Nonsurgical Treatment for Midshaft Clavicle Fractures in Patients Aged 16 Years and Older: A Systematic Review, Meta-analysis, and Comparison of Randomized Controlled Trials and Observational Studies.
Am J Sports Med. 2016 Nov 18. pii: 0363546516673615. [Epub ahead of print]
Spoon Feed: Midshaft clavicle fractures were once treated non-operatively but are increasingly repaired surgically with improved outcomes over non-op treatment.  This is important because we need to refer these patients to orthopedics for prompt follow up after ED discharge.

The Effect of Bedside Ultrasonographic Skin Marking on Infant Lumbar Puncture Success: A Randomized Controlled Trial.
Ann Emerg Med. 2016 Nov 14. pii: S0196-0644(16)31063-0. doi: 10.1016/j.annemergmed.2016.09.014. [Epub ahead of print]
CONCLUSION: "Ultrasonography assisted site marking improved infant lumbar puncture success in a tertiary care pediatric teaching hospital. This method has the potential to reduce unnecessary hospitalizations and exposures to antibiotics in this vulnerable population."

Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial.
Ann Emerg Med. 2016 Nov;68(5):574-582.e1. doi: 10.1016/j.annemergmed.2016.05.024. Epub 2016 Jul 22.
CONCLUSION: "Ketofol and propofol resulted in a similar incidence of adverse respiratory events requiring the intervention of the sedating physician. Although propofol resulted in more hypotension, the clinical relevance of this is questionable, and both agents are associated with high levels of patient satisfaction."

Managing Initial Mechanical Ventilation in the Emergency Department.
Ann Emerg Med. 2016 Nov;68(5):614-617. doi: 10.1016/j.annemergmed.2016.04.059. Epub 2016 Jun 9.

Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians.
Ann Intern Med. 2016 Nov 1. doi: 10.7326/M16-0570. [Epub ahead of print]
Spoon Feed: This is an excellent summary of acute gout therapy.

Giant Cell Arteritis.
Ann Intern Med. 2016 Nov 1;165(9):ITC65-ITC80. doi:10.7326/AITC201611010.
Spoon Feed: Quoted from the article: "The diagnosis of GCA should be considered in patients older than 50 years who present with new-onset, localized, unilateral headache; ischemic symptoms in the cervicocranial and upper vascular territories (e.g., jaw claudication, vision aberration or loss); and muscle stiffness of the neck, shoulder, or pelvic girdle. Typical physical examination findings include tenderness, swelling, and erythema over the temporal artery and flow abnormalities of large vessels (e.g., bruits, asymmetrical pulse or blood pressure). Most patients have markedly elevated ESR or CRP. GCA involvement of large vessels is common and subclinical in most patients. Temporal artery biopsy is considered the gold standard for diagnosis."

Treatment is with high dose prednisone, which should be started ASAP, even if prior to temporal artery biopsy.

Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial.
BMJ. 2016 Nov 16;355:i5650. doi: 10.1136/bmj.i5650.
Spoon Feed: Ankle PT after a mild sprain may not be helpful in making an excellent recovery.

Health consequences of shift work and insufficient sleep.
BMJ. 2016 Nov 1;355:i5210. doi: 10.1136/bmj.i5210.
Spoon Feed: Getting adequate time to sleep is key to being healthy when you work nights.  It's life and death.  And if you are an administrator reading this and do not pay extra for your night shift workers, please reconsider based on the solid evidence that it takes a toll on your employees' health.

Conventional Versus Compression-Only Versus No Bystander Cardiopulmonary Resuscitation for Pediatric Out-of-Hospital Cardiac Arrest.
Circulation. 2016 Nov 22. pii: CIRCULATIONAHA.116.023831. [Epub ahead of print]
Spoon Feed: Until a more definitive study, conventional CPR may be preferred over compression-only CPR in pediatric arrest.

Low-Dose Aspirin for Primary Prevention of Cardiovascular Events in Patients with Type 2 Diabetes: 10-year Follow-up of a Randomized Controlled Trial.
Circulation. 2016 Nov 15. pii: CIRCULATIONAHA.116.025760. [Epub ahead of print]
CONCLUSIONS: "-Low-dose aspirin did not affect the risk for cardiovascular events, but increased risk for gastrointestinal bleeding in patients with type 2 diabetes in a primary prevention setting."

Cardiac Mortality Among 200 000 Five-Year Survivors of Cancer Diagnosed at 15 to 39 Years of Age: The Teenage and Young Adult Cancer Survivor Study.
Circulation. 2016 Nov 15;134(20):1519-1531. Epub 2016 Nov 7.
Spoon Feed: If a young person presents with chest pain and has had prior treatment for cancer, his or her risk of cardiac disease is far greater than the baseline population.

Pre-hospital management of mass casualty civilian shootings: a systematic literature review.
Crit Care. 2016 Nov 8;20(1):362.
Spoon Feed: One way we as a specialty can push back against the evil of these tragic events is to rescue as many salvageable victims as we can.  This means we are going to have to practice mass casualty active shooter simulation scenarios.

Prognostic impact of restored sinus rhythm in patients with sepsis and new-onset atrial fibrillation.
Crit Care. 2016 Nov 18;20(1):373.
Spoon Feed: New a-fib is associated with increased mortality in sepsis patients.  These patients may benefit from restoration of normal sinus rhythm.

Long-term prognosis after out-of-hospital resuscitation of cardiac arrest in trauma patients: prehospital trauma-associated cardiac arrest.
Emerg Med J. 2016 Oct 26. pii: emermed-2014-204596. doi: 10.1136/emermed-2014-204596. [Epub ahead of print]
Spoon Feed: If hypoxia is the cause of traumatic arrest, the prognosis is better than expected.  Most of the time CPR in traumatic arrest is futile, but maybe not as bad as we thought.

Assessment of heart rate, acidosis, consciousness, oxygenation, and respiratory rate to predict noninvasive ventilation failure in hypoxemic patients.
Intensive Care Med. 2016 Nov 3. [Epub ahead of print]
CONCLUSIONS: "The HACOR scale variables are easily obtained at the bedside. The scale appears to be an effective way of predicting NIV failure in hypoxemic patients. Early intubation in high-risk patients may reduce hospital mortality."

Endotracheal Intubation with the King Laryngeal Tube™ In Situ Using Video Laryngoscopy and a Bougie: A Retrospective Case Series and Cadaveric Crossover Study.
J Emerg Med. 2016 Nov 19. pii: S0736-4679(16)30906-4. doi: 10.1016/j.jemermed.2016.10.026. [Epub ahead of print]
Spoon Feed: If a King LT was placed because it was a difficult airway, removal could place you in a "can't intubate - can't oxygenate" situation.  It appears safe to insert the video laryngoscope while ventilating through the King, then deflate the large balloon to reveal the cords, place a bougie, and intubate past the King LT.

A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits.
J Emerg Med. 2016 Nov;51(5):498-507. doi: 10.1016/j.jemermed.2016.06.057. Epub 2016 Sep 10.
Spoon Feed: A city-wide plan of care for frequent ED users who come for pain-related complaints decreased the number of visits and the number of opiate prescriptions.

Pediatric Concussion Management in the Emergency Department: A National Survey of Parents.
J Pediatr. 2016 Nov 16. pii: S0022-3476(16)31205-7. doi: 10.1016/j.jpeds.2016.10.071. [Epub ahead of print]
Spoon Feed: Parental expectations for pediatric ED concussion care are high.  Many of the expectations we can and should meet.  But I won't be signing any return to play forms in the ED.  This needs to be done by their primary doctor or sports medicine clinician.  They can't return to play until asymptomatic.  If they were asymptomatic, they wouldn't have come into the ED.

Big Children or Little Adults? A Statewide Analysis of Adolescent Isolated Severe Traumatic Brain Injury Outcomes at Pediatric versus Adult Trauma Centers.
J Trauma Acute Care Surg. 2016 Oct 31. [Epub ahead of print]
CONCLUSION: "Although the optimal treatment facility for adolescent patients is frequently debated, patients aged 15-17 presenting with isolated sTBI may experience similar outcomes when managed at pediatric and adult trauma centers."

Association Between Tracheal Intubation During Pediatric In-Hospital Cardiac Arrest and Survival.
JAMA. 2016 Nov 1;316(17):1786-1797. doi: 10.1001/jama.2016.14486.
Spoon Feed: Intubation during pediatric arrest does not appear to benefit and may be harmful.

Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis: The HYPRESS Randomized Clinical Trial.
JAMA. 2016 Nov 1;316(17):1775-1785. doi: 10.1001/jama.2016.14799.
Conclusions and Relevance: "Among adults with severe sepsis not in septic shock, use of hydrocortisone compared with placebo did not reduce the risk of septic shock within 14 days. These findings do not support the use of hydrocortisone in these patients."

Association of Bystander Cardiopulmonary Resuscitation With Overall and Neurologically Favorable Survival After Pediatric Out-of-Hospital Cardiac Arrest in the United States: A Report From the Cardiac Arrest Registry to Enhance Survival Surveillance Registry.
JAMA Pediatr. 2016 Nov 12. doi: 10.1001/jamapediatrics.2016.3643. [Epub ahead of print]
Spoon Feed: Bystander CPR improved the odds of neurologically intact survival in pediatric patients, but only if conventional CPR was performed.

Safety of lumbar puncture in comatose children with clinical features of cerebral malaria.
Neurology. 2016 Oct 28. pii: 10.1212/WNL.0000000000003372. [Epub ahead of print]
CONCLUSION: "In comatose children with suspected CM who were clinically stable, we found no evidence that LP increases mortality, even in children with objective signs of raised intracranial pressure."

Identifying Children at Risk of Malignant Bordetella pertussis Infection.
Pediatr Crit Care Med. 2016 Nov 1. [Epub ahead of print]
Spoon Feed: HR > 180, WBC > 25K, and neutrophil to lymphocyte ratio > 1 were good predictors of malignant pertussis.

Management of Pediatric Forearm Torus Fractures: A Systematic Review and Meta-Analysis.
Pediatr Emerg Care. 2016 Nov;32(11):773-778.
Spoon Feed: A simple volar slab, velcro wrist splint, or soft cast was better than a rigid cast for pediatric torus fractures of the forearm.

CPR Induced Consciousness During Out-of-Hospital Cardiac Arrest: A Case Report on an Emerging Phenomenon.
Prehosp Emerg Care. 2016 Oct 28:1-5. [Epub ahead of print]
CONCLUSION: "CPR induced consciousness is emerging as a new phenomenon challenging providers of high quality CPR during cardiac arrest resuscitation. Our case report describes the manifestations of CPR induced consciousness as well as the resuscitative challenges which occur during resuscitation. Further research is required to determine the true frequency of this condition as well as treatment algorithms that would allow for appropriate and safe management for both the patient and EMS providers."

Causes of Prehospital Misinterpretations of ST Elevation Myocardial Infarction.
Prehosp Emerg Care. 2016 Nov 18:1-8. [Epub ahead of print]
CONCLUSION: "The leading causes of false positive automated interpretation of STEMI were ECG artifact and non-ischemic causes of ST-segment elevation. FN were rare and were related to ST-segment elevation or ST/T ratio that did not meet the software algorithm threshold."

Bystander cricothyroidotomy with household devices - A fresh cadaveric feasibility study.
Resuscitation. 2016 Nov 1;110:37-41. doi: 10.1016/j.resuscitation.2016.10.015. [Epub ahead of print]
Spoon Feed: You might be able to do an emergency cric with a pocket knife and ballpoint pen, but an untrained bystander will certainly not do well with this in a real patient that actually bleeds.

Can a serum acetaminophen concentration obtained less than 4 hours post-ingestion determine which patients do not require treatment with acetylcysteine?
Clin Toxicol (Phila). 2016 Oct 28:1-7. [Epub ahead of print]
Spoon Feed: You really do need a 4-hour APAP level.  But if the <4 hour level is undetectable or "very low" you are in the clear.

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