Use of alteplase from 4.5 to 9 hours in patients with ischemic stroke but with salvageable brain on perfusion imaging was superior to placebo (aRR 1.44, 95%CI 1.01-2.06; NNT = 17). Symptomatic hemorrhage was more common in the alteplase group.
It was a big job for ALiEM to come up with the list of 52 landmark articles you need to know as an Emergency Physician. But it's an even bigger job to sit down and read them. In fact, most of us just won't be able to find the time to do it. Because they are so important to know, I wanted to make it easier to get the gist of these articles. So each Saturday in 2017, I briefly summarized one of these key articles. For your convenience, here are the links and excerpts for each of the 52 in 52 article summaries in one place. Enjoy. And please share this with a friend. Special thanks to Dr. Michelle Lin for allowing me to partner with ALiEM and use the combined logos.
Patients who had blunt trauma with CPR > 10 minutes, penetrating trauma with CPR > 15 minutes, or asystole without tamponade should not undergo resuscitative thoracotomy in the ED as it would be futile.
The Canadian CT Head Rule was 100% sensitive for ruling out clinically important brain injury. It had higher specificity than the New Orleans Criteria, which meant fewer people would need a CT scan by using the Canadian rule.
Sudden-onset, severe ("worst-ever"), sharp chest pain was the hallmark type A and B aortic dissection. Ripping or tearing pain was present in only half of patients. Classic features of aortic regurgitation murmur and pulse deficit were frequently lacking.
In patients with penetrating trauma, it was better to allow prehospital hypotension and hasten transport for definitive repair prior to beginning volume resuscitation than to try to normalize vital signs in the field by giving IV fluid.
Spinal cord injury without radiographic abnormality (SCIWORA) was very rare, 27/34069 (0.08%). Although NEXUS enrolled 3000 patients <18 years, down to age 1, all patients with SCIWORA were adults in this cohort.
The NEXUS criteria can be used to determine which patients do not need c-spine x-rays. Since this was published, we have shifted to predominantly CT imaging, which is more sensitive. Also, we have learned that NEXUS is not as sensitive in elderly patients.
There was no difference in cosmetic outcome with use of absorbable vs. nonabsorbable suture for pediatric lacerations, though there was a nonsignificant trend to absorbable being superior. There was also no difference in dehiscence or infection rate between the two.
Norepinephrine and dopamine were equal with regard to mortality in shock, except for the subgroup with cardiogenic shock, in which the dopamine group fared worse. There were twice as many dysrhythmias in the dopamine group, largely atrial fibrillation.
A non-invasive approach to monitoring sepsis patients by using lactate clearance rather than central venous O2 saturation was just as effective once central venous pressure and mean arterial pressure were optimized.
Even though early goal-directed therapy has subsequently been shown to be no more effective than usual care, this landmark trial put a spotlight on sepsis care, especially starting aggressive measures as early as possible in the ED.
This early study of thrombolytics plus heparin for submassive PE showed no mortality benefit but did show a decrease in need for escalation of care compared with heparin alone. Subsequent studies call lytics for submassive PE into question, so take the current evidence into account.
Allowing parents the option to wait and see if their child did not improve or worsened in 48 hours after the diagnosis of acute otitis media in the ED vs. filling the prescription right away resulted in a dramatic reduction in antibiotic use with little downside in this RCT.
The PERC rule is a powerful diagnostic tool. If you determine a patient has low clinical gestalt for PE and all 8 PERC criteria are negative, then PE has been ruled out without checking a D-dimer or CT.