April 2017 EM Articles

*NNR THIS MONTH = 116

You'd have to read 2908 articles to find these 25 sparkly gems.

*NNR - number needed to read

 

Intravenous versus Non-Intravenous Benzodiazepines for the Abortion of Seizures: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
Acad Emerg Med. 2017 Mar 25. doi: 10.1111/acem.13190. [Epub ahead of print]
Spoon Feed: If there is any delay in obtaining IV access, give benzodiazepines by a non-IV route to control seizure activity faster.

 

Emergency Department Vital Signs and Outcomes after Discharge.
Acad Emerg Med. 2017 Apr 4. doi: 10.1111/acem.13194. [Epub ahead of print]
Spoon Feed: Pay attention to discharge vitals, especially in patients over age 65.

 

D-Dimer Interval Likelihood Ratios for Pulmonary Embolism.
Acad Emerg Med. 2017 Apr 1. doi: 10.1111/acem.13191. [Epub ahead of print]
Spoon Feed: It looks like we can start thinking of the D-dimer test based on interval likelihood ratios rather than a dichotomous positive or negative, with 500 ng/mL as the cutoff.

 

Direct Versus Video Laryngoscopy for Prehospital Intubation: A Systematic Review and Meta-analysis.
Acad Emerg Med. 2017 Apr 1. doi: 10.1111/acem.13193. [Epub ahead of print]
Spoon Feed: VL is a good way to improve first-pass success in the prehospital setting, especially for care providers who don't intubate frequently.

 

The Timing of Early Antibiotics and Hospital Mortality in Sepsis.
Am J Respir Crit Care Med. 2017 Mar 27. doi: 10.1164/rccm.201609-1848OC. [Epub ahead of print]
Spoon Feed: Once sepsis is detected, start broad spectrum antibiotics as soon as possible.  Delays were associated with mortality: 1 hour = 1%.

 

Clinical Judgment Is Not Reliable for Reducing Whole-body Computed Tomography Scanning after Isolated High-energy Blunt Trauma.
Anesthesiology. 2017 Mar 27. doi: 10.1097/ALN.0000000000001617. [Epub ahead of print]
Spoon Feed: Clinical judgment alone is not very accurate in predicting serious injury compared with whole-body CT.  However, patients with a completely normal exam are very unlikely to have anything serious found on CT.

 

When to Pick the Nose: Out-of-Hospital and Emergency Department Intranasal Administration of Medications.
Comment: This has got to be one of the best journal article titles I have ever seen!
Ann Emerg Med. 2017 Mar 25. pii: S0196-0644(17)30194-4. doi: 10.1016/j.annemergmed.2017.02.015. [Epub ahead of print]
"Abstract: The intranasal route for medication administration is increasingly popular in the emergency department and out-of-hospital setting because such administration is simple and fast, and can be used for patients without intravenous access and in situations in which obtaining an intravenous line is difficult or time intensive (eg, for patients who are seizing or combative). Several small studies (mostly pediatric) have shown midazolam to be effective for procedural sedation, anxiolysis, and seizures. Intranasal fentanyl demonstrates both safety and efficacy for the management of acute pain. The intranasal route appears to be an effective alternative for naloxone in opioid overdose. The literature is less clear on roles for intranasal ketamine and dexmedetomidine."

 

Quick SOFA Scores Predict Mortality in Adult Emergency Department Patients With and Without Suspected Infection.
Ann Emerg Med. 2017 Apr;69(4):475-479. doi: 10.1016/j.annemergmed.2016.10.007. Epub 2017 Jan 19.
Spoon Feed: qSOFA was associated with several important outcomes in this single center retrospective study.

 

Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits.
Ann Emerg Med. 2017 Apr;69(4):397-403.e5. doi: 10.1016/j.annemergmed.2016.08.462. Epub 2016 Nov 10.
Spoon Feed: Retail clinics have a role as a convenient place to obtain needed healthcare, but so far have not made a meaningful impact on low acuity ED patient volume.

 

Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection: A Collaborative Meta-analysis.
Ann Intern Med. 2017 Apr 18. doi: 10.7326/M16-2562. [Epub ahead of print]
Spoon Feed: I'm not ready to jump on the single high sensitivity troponin bandwagon.  The assay approved in the US, hs-cTnT performs less well in early presenters.  Why not keep them there 1 more hour and get a repeat?

 

Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial.
BMJ. 2017 Apr 7;357:j1341. doi: 10.1136/bmj.j1341.
Spoon Feed: If you need an infant urinalysis, and clean catch is acceptable, the Quick Wee method can help you get the sample in less than 5 minutes.

 

Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study.
BMJ. 2017 Apr 12;357:j1415. doi: 10.1136/bmj.j1415.
Spoon Feed: There was an association with short-term steroid use and several adverse outcomes.

 

Hyperbaric oxygen therapy is associated with lower short- and long-term mortality in patients with carbon monoxide poisoning.
Chest. 2017 Apr 17. pii: S0012-3692(17)30723-7. doi: 10.1016/j.chest.2017.03.049. [Epub ahead of print]
Spoon Feed: Hyperbaric oxygen therapy for carbon monoxide poisoning decreased mortality, NNT = 10.

 

Risk of Cerebrovascular Events in 178 962 Five-Year Survivors of Cancer Diagnosed at 15 to 39 Years of Age: The TYACSS (Teenage and Young Adult Cancer Survivor Study).
Circulation. 2017 Mar 28;135(13):1194-1210. doi: 10.1161/CIRCULATIONAHA.116.025778. Epub 2017 Jan 25.
Spoon Feed: Cancer as a young person increases subsequent risk for cerebrovascular events.  Cancer is in itself a risk factor for stroke.

 

Validating the Manchester Acute Coronary Syndromes (MACS) and Troponin-only Manchester Acute Coronary Syndromes (T-MACS) rules for the prediction of acute myocardial infarction in patients presenting to the emergency department with chest pain.
Emerg Med J. 2017 Mar 31. pii: emermed-2016-206366. doi: 10.1136/emermed-2016-206366. [Epub ahead of print]
AUTHORS' CONCLUSIONS: "MACS and T-MACS accurately risk stratify very low risk patients. The T-MACS rule would allow for more patients to be discharged early. The potential for missed MACE events means that further outpatient testing for coronary artery disease may be required for patients identified as very low risk."

 

Early Invasive Versus Selective Strategy for Non-ST-Segment Elevation Acute Coronary Syndrome: The ICTUS Trial.
J Am Coll Cardiol. 2017 Apr 18;69(15):1883-1893. doi: 10.1016/j.jacc.2017.02.023.
Spoon Feed: There was no long-term advantage at 10 years to an early invasive vs selective invasive strategy strategy for NSTEMI.

 

Adverse Events During a Randomized Trial of Ketamine Versus Co-Administration of Ketamine and Propofol for Procedural Sedation in a Pediatric Emergency Department.
J Emerg Med. 2017 Apr 19. pii: S0736-4679(17)30238-X. doi: 10.1016/j.jemermed.2017.03.024. [Epub ahead of print]
Spoon Feed
Keep it simple in kids.  Ketamine/propofol had no advantage over ketamine alone for procedural sedation in pediatric patients.

 

Do Slow and Steady Residents Win the Race? Modeling the Effects of Peak and Overall Resident Productivity in the Emergency Department.
J Emerg Med. 2017 Apr 12. pii: S0736-4679(17)30231-7. doi: 10.1016/j.jemermed.2017.03.019. [Epub ahead of print]
Spoon Feed
The ED workflow has unavoidable peak hours in volume.  The key is improving off-peak hours by pushing ourselves to see new patients while managing existing ones.

 

Emergency Medicine Myths: Cerebral Edema in Pediatric Diabetic Ketoacidosis and Intravenous Fluids.
J Emerg Med. 2017 Apr 12. pii: S0736-4679(17)30224-X. doi: 10.1016/j.jemermed.2017.03.014. [Epub ahead of print]
AUTHORS' CONCLUSIONS: "Pediatric CE in DKA is rare but severe. Multiple mechanisms result in this disease, and many patients experience subclinical CE. Intravenous fluids are likely not associated with development of CE, and 10-mL/kg or 20-mL/kg i.v. bolus is safe."

 

Changes in Provider Prescribing Patterns After Implementation of an Emergency Department Prescription Opioid Policy.
J Emerg Med. 2017 Apr;52(4):538-546. doi: 10.1016/j.jemermed.2016.07.120. Epub 2017 Jan 19.
Spoon Feed
ED opioid policies can make a big impact on prescribing patterns in a group of providers and help curb the current epidemic of opiate abuse.

 

Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial.
JAMA. 2017 Apr 18;317(15):1535-1543. doi: 10.1001/jama.2017.3417.
Spoon Feed
This study says that more patients may feel better with a dose of dexamethasone for sore throat.  But we have to bear in mind the study in BMJ this month about risks of short term steroids that no treatment is without risk.

 

Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis.
JAMA. 2017 Apr 11;317(14):1451-1460. doi: 10.1001/jama.2017.3086.
Spoon Feed
Spinal manipulative therapy is a part of the armamentarium for acute low back pain treatment.  Keep in mind, c-spine manipulation is a different thing altogether, with more associated harms.

 

Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children: A Meta-analysis.
JAMA Pediatr. 2017 Mar 27. doi: 10.1001/jamapediatrics.2017.0057. [Epub ahead of print]
Spoon Feed: Non-operative treatment is an option for pediatric acute appendicitis.  But I don't plan to recommend it to patients.  Neither does Skeptical Scalpel or Journal Watch.

 

ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis.
Neurology. 2017 Apr 11;88(15):1468-1477. doi: 10.1212/WNL.0000000000003814. Epub 2017 Mar 29.
Spoon Feed: Current neuroimaging missed 9% of cerebrovascular events.

 

A Comparison of Pediatric Weight Estimation Methods for Emergency Resuscitation.
Pediatr Emerg Care. 2017 Apr 11. doi: 10.1097/PEC.0000000000001137. [Epub ahead of print]
Spoon Feed: If you need to know the child's weight, just ask the parent.  It was the most accurate weight estimate in this prospective comparison study.