February 2017 EM Articles

*NNR THIS MONTH = 107

You'd have to read 2991 articles to find these 28 riveting reads.

*NNR - number needed to read

Ketamine as an Adjunct to Opioids for Acute Pain in the Emergency Department: A randomized controlled trial.
Acad Emerg Med. 2017 Feb 8. doi: 10.1111/acem.13172. [Epub ahead of print]
Spoon Feed: Ketamine is a helpful adjunct in patients with severe pain that have already been treated with opiates.

 

Prevalence of Brain Injuries and Recurrence of Seizures in Children with Post Traumatic Seizures.
Acad Emerg Med. 2017 Feb 7. doi: 10.1111/acem.13168. [Epub ahead of print]
Spoon Feed: Patients with PTS need a head CT.  Those with a normal head CT may be safely discharged and have very low risk of recurrent seizures.

 

MRI vs. Ultrasound as the initial imaging modality for pediatric and young adult patients with suspected appendicitis.
Acad Emerg Med. 2017 Feb 16. doi: 10.1111/acem.13180. [Epub ahead of print]
AUTHOR'S CONCLUSIONS: In the diagnosis of appendicitis, US first imaging is more time efficient and less costly than rapid MRI despite inconclusive studies after US imaging. Unless the process of obtaining a rapid MRI becomes more efficient and less expensive, US should be the first line imaging modality for appendicitis in patients 2-30 years of age.

 

The impact of emergency department crowding on early interventions and mortality in patients with severe sepsis.
Am J Emerg Med. 2017 Jan 31. pii: S0735-6757(17)30081-5. doi: 10.1016/j.ajem.2017.01.061. [Epub ahead of print]
AUTHOR'S CONCLUSIONS: With increased ED crowding, time to critical severe sepsis therapies significantly increased and protocolized care initiation decreased. As crowding increases, EDs must implement systems that optimize delivery of time-sensitive therapies to critically ill patients.

 

Feasibility of upright patient positioning and intubation success rates at two academic emergency departments.
Am J Emerg Med. 2017 Feb 5. pii: S0735-6757(17)30100-6. doi: 10.1016/j.ajem.2017.02.011. [Epub ahead of print]
Spoon Feed: Elevating the head of the bed helped facilitate first pass success for endotracheal intubation.

 

Ketamine as a first-line treatment for severely agitated emergency department patients.
Am J Emerg Med. 2017 Feb 13. pii: S0735-6757(17)30114-6. doi: 10.1016/j.ajem.2017.02.026. [Epub ahead of print]
Spoon Feed: Ketamine appears to be a very effective and safe first-line drug for agitated patients in the ED.

 

Anti-N-Methyl-d-Aspartate Receptor Encephalitis in Adult Patients Requiring Intensive Care.
Am J Respir Crit Care Med. 2017 Feb 15;195(4):491-499. doi: 10.1164/rccm.201603-0507OC.
Spoon Feed: Early treatment of anti-NMDA receptor encephalitis improved recovery.  But first, you have to make the diagnosis.  Corey Slovis always says, "the eye doesn't see what the mind doesn't know."  ALiEM has a brief, excellent summary.

 

Haloperidol Versus Ondansetron for Treatment of Established Nausea and Vomiting Following General Anesthesia: A Randomized Clinical Trial.
Anesth Analg. 2017 Feb;124(2):438-444. doi: 10.1213/ANE.0000000000001723.
AUTHOR'S CONCLUSIONS: Haloperidol is at worst 13% and 8% less effective than ondansetron by per-protocol analysis and by intention-to-treat analysis, respectively. Thus, it is noninferior to ondansetron for the early treatment of established PONV, but is associated with sedation.

 

Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Low Back Pain.
Ann Emerg Med. 2017 Jan 19. pii: S0196-0644(16)31214-8. doi: 10.1016/j.annemergmed.2016.10.002. [Epub ahead of print]
Spoon Feed: Diazepam doesn't help low back pain.  Here is RCT data that proves it.

 

Risk of Acute Kidney Injury After Intravenous Contrast Media Administration.
Ann Emerg Med. 2017 Jan 19. pii: S0196-0644(16)31388-9. doi: 10.1016/j.annemergmed.2016.11.021. [Epub ahead of print]
Spoon Feed: There was no association with IV contrast for CT and short-term acute kidney injury or progression to dialysis at 6 months, regardless of initial GFR in patients with a creatinine < 4.

 

Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and are Seldom Superior.
Ann Emerg Med. 2017 Feb 23. pii: S0196-0644(16)31520-7. doi: 10.1016/j.annemergmed.2016.12.004. [Epub ahead of print]
Spoon Feed: Use all the clinical decision rules at your disposal and the tools to compare, recall, and apply them to practice.  But your judgment at the bedside is still the final and best decision rule.

 

The Importance of Urine Concentration on the Diagnostic Performance of the Urinalysis for Pediatric Urinary Tract Infection.
Ann Emerg Med. 2017 Feb 3. pii: S0196-0644(16)31512-8. doi: 10.1016/j.annemergmed.2016.11.042. [Epub ahead of print]
Spoon Feed: Take into account the specific gravity when testing for UTI in kids.  Less than 5 WBCs in unspun dilute urine may still indicate a UTI.  If you suspect UTI clinically, obtain a culture regardless of UA/micro results.

 

Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline Update From the American College of Physicians.
Ann Intern Med. 2017 Feb 21;166(4):279-290. doi: 10.7326/M16-1860. Epub 2017 Jan 3.
Recommendation 1: ACP recommends that clinicians prescribe metformin to patients with type 2 diabetes when pharmacologic therapy is needed to improve glycemic control. (Grade: strong recommendation; moderate-quality evidence).
Recommendation 2: ACP recommends that clinicians consider adding either a sulfonylurea, a thiazolidinedione, an SGLT-2 inhibitor, or a DPP-4 inhibitor to metformin to improve glycemic control when a second oral therapy is considered. (Grade: weak recommendation; moderate-quality evidence.) ACP recommends that clinicians and patients select among medications after discussing benefits, adverse effects, and costs.

 

Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline.
Ann Intern Med. 2017 Feb 14. doi: 10.7326/M16-2459. [Epub ahead of print]
Author's Conclusion: Several nonpharmacologic therapies for primarily chronic low back pain are associated with small to moderate, usually short-term effects on pain; findings include new evidence on mind-body interventions.

 

Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline.
Ann Intern Med. 2017 Feb 14. doi: 10.7326/M16-2458. [Epub ahead of print]
Spoon Feed: The best evidence suggests the best pharmacologic treatments for acute pain are moderately helpful, at best, and include NSAIDs, muscle relaxers, and steroids for radicular pain.  There is no evidence to support use of acetaminophen, opiates, benzos, antidepressants, or anti-seizure medications for acute pain.

 

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.
Ann Intern Med. 2017 Feb 14. doi: 10.7326/M16-2367. [Epub ahead of print]
Spoon Feed: There is a growing emphasis on non-pharmacologic treatments for low back pain, and a deemphasis on using opiates.

 

Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study.
BMJ. 2017 Feb 2;356:j273. doi: 10.1136/bmj.j273.
AUTHOR'S CONCLUSIONS: Data on older Medicare patients admitted to hospital in the US showed that patients treated by international graduates had lower mortality than patients cared for by US graduates.

 

Early death after discharge from emergency departments: analysis of national US insurance claims data.
BMJ. 2017 Feb 1;356:j239. doi: 10.1136/bmj.j239.
Spoon Feed: When in doubt, err on the side of admission - even if you get push back from the hospitalist, administrator, or your own government.  When people feel bad enough to come to the ED, it often means something is really wrong, even if it's not apparent on a surface level.  Also, err on the side of ordering a few more tests when you're not sure, especially in patients who are altered, dyspneic, or have generalized malaise.

 

Non-traumatic incidental findings in patients undergoing whole-body computed tomography at initial emergency admission.
Emerg Med J. 2017 Jan 27. pii: emermed-2016-205722. doi: 10.1136/emermed-2016-205722. [Epub ahead of print]
Spoon Feed: One of the unintended consequences of pan-scanning is incidental findings. Make sure you have a mechanism in place to follow these up. Case managers are worth their weight in gold to help with this.

 

High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: a multicenter randomized controlled trial (TRAMONTANE study).
Intensive Care Med. 2017 Feb;43(2):209-216. doi: 10.1007/s00134-016-4617-8. Epub 2017 Jan 26.
Spoon Feed: Nasal CPAP beats HFNC for non-invasive respiratory support in infants with bronchiolitis. 

 

Cervical spine MRI in patients with negative CT: A prospective, multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT).
J Trauma Acute Care Surg. 2017 Feb;82(2):263-269. doi: 10.1097/TA.0000000000001322.
Spoon Feed: MRI rarely changes management in patients with negative CT and persistent neck pain.

 

Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial.
Lancet. 2017 Feb 20. pii: S0140-6736(17)30057-0. doi: 10.1016/S0140-6736(17)30057-0. [Epub ahead of print]
Spoon Feed: In patients with eGFR 30-59, there was no benefit to giving saline prior to IV contrast for CT.

 

Assessing the Risks Associated with MRI in Patients with a Pacemaker or Defibrillator.
N Engl J Med. 2017 Feb 23;376(8):755-764. doi: 10.1056/NEJMoa1603265.
Spoon Feed: A patient with a pacemaker/ICD that is not specifically approved as MRI-safe should still not routinely undergo MRI.  But this study shows that a non-thoracic MRI is not absolutely contraindicated, assuming proper interrogation and programming of the device is done before the scan.  This is not something we can order without buy-in and help from cardiology.

 

Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use.
N Engl J Med. 2017 Feb 16;376(7):663-673. doi: 10.1056/NEJMsa1610524.
Spoon Feed: Opiate pain medication has its place and always will, but use it only when indicated.  Our one-time actions in the ED may have significant downstream effects and could open the door to long-term opiate use in our patients.

 

Amiodarone Versus Lidocaine for Pediatric Cardiac Arrest Due to Ventricular Arrhythmias: A Systematic Review.
Pediatr Crit Care Med. 2017 Feb;18(2):183-189. doi: 10.1097/PCC.0000000000001026.
AUTHOR'S CONCLUSIONS: The confidence in effect estimates is so low that International Liaison Committee on Resuscitation felt that a recommendation to use of amiodarone over lidocaine is too speculative; we suggest that amiodarone or lidocaine can be used in the setting of pulseless ventricular tachycardia/ventricular fibrillation in infants and children.

 

RBC Distribution Width: Biomarker for Red Cell Dysfunction and Critical Illness Outcome?
Pediatr Crit Care Med. 2017 Feb;18(2):134-142. doi: 10.1097/PCC.0000000000001017.
AUTHOR'S CONCLUSIONS: Independent of illness severity in critically ill children, admission RBC distribution width is associated with ICU mortality and morbidity. These data suggest that RBC distribution width may be a biomarker for RBC injury that is of sufficient magnitude to influence critical illness outcome, possibly via oxygen delivery impairment.

 

Seatbelt Syndrome in Children.
Pediatr Emerg Care. 2017 Feb;33(2):120-125. doi: 10.1097/PEC.0000000000001027.
Spoon Feed: A seatbelt contusion on a child's abdomen is a marker of significant and subtle abdominal or spine injury.

 

Are Patients With Loeys-Dietz Syndrome Misdiagnosed With Beals Syndrome?
Pediatrics. 2017 Feb 16. pii: e20161281. doi: 10.1542/peds.2016-1281. [Epub ahead of print]
Spoon Feed: Just kidding!

 

Consciousness induced during cardiopulmonary resuscitation: An observational study.
Resuscitation. 2017 Feb 1;113:44-50. doi: 10.1016/j.resuscitation.2017.01.018. [Epub ahead of print]
Spoon Feed: Some manifestation of CPR induced consciousness occurs about 1% of the time and should not alter the resuscitation efforts.  Obviously, you may want to check for a pulse.