March 2017 EM Articles

*NNR THIS MONTH = 141

You'd have to read 3100 articles to find these 22 riveting reads.

*NNR - number needed to read

The Association of Electrocardiographic Abnormalities and Acute Coronary Syndrome in Emergency Patients With Chest Pain.
Acad Emerg Med. 2017 Mar;24(3):344-352. doi: 10.1111/acem.13123.
Spoon Feed: ECG is never used alone for cardiac risk stratification, but some ECG findings are more concerning than others.  For example, a patient with chest pain and new ST depression in two contiguous leads (i.e. criterion 5) would have >50% probability of MACE in 30 days based on the ECG alone.  Don't send this one home!

 

Comparing the effectiveness of vapocoolant spray and lidocaine/procaine cream in reducing pain of intravenous cannulation: A randomized clinical trial.
Am J Emerg Med. 2017 Feb 27. pii: S0735-6757(17)30153-5. doi: 10.1016/j.ajem.2017.02.039. [Epub ahead of print]
Spoon Feed: Vapocoolant spray reduces pain from IV cannulation in the ED, and if there is time, EMLA cream is even more effective.

 

Favorable Neurocognitive Outcome with Low Tidal Volume Ventilation After Cardiac Arrest.
Am J Respir Crit Care Med. 2017 Mar 7. doi: 10.1164/rccm.201609-1771OC. [Epub ahead of print]
Spoon Feed: Simply dialing down the tidal volume < 8 mL/kg improves neurologically-intact survival post-arrest.  For this and other reasons, learn to Manage the Vent Like a Pro.

 

Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration.
Anesthesiology. 2017 Mar;126(3):376-393. doi: 10.1097/ALN.0000000000001452.
Spoon Feed: Much of this is not applicable to ED procedural sedation, but there are a few pearls for us in this guideline. Plus, you need to know what your anesthesia colleagues are thinking when you admit patients who are likely going to need a trip to the OR.

 

Individual Gestalt Is Unreliable for the Evaluation of Quality in Medical Education Blogs: A METRIQ Study.
Ann Emerg Med. 2017 Mar 2. pii: S0196-0644(16)31662-6. doi: 10.1016/j.annemergmed.2016.12.025. [Epub ahead of print]
Spoon Feed: A group of people, at least 42, can reliably rate the quality of a blog.  Individual rating of gestalt quality was not a reliable measure.

 

Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial.
Ann Emerg Med. 2017 Mar 1. pii: S0196-0644(17)30028-8. doi: 10.1016/j.annemergmed.2017.01.013. [Epub ahead of print]
Spoon Feed: Simply starting a lung-protective mechanical ventilation strategy in the ED appeared to make a big difference in important clinical outcomes in this study.

 

Initiating Diagnostic Studies on Patients With Abdominal Pain in the Waiting Room Decreases Time Spent in an Emergency Department Bed: A Randomized Controlled Trial.
Ann Emerg Med. 2017 Mar;69(3):298-307. doi: 10.1016/j.annemergmed.2016.06.040. Epub 2016 Aug 12.
Spoon Feed: We have been doing this for years at my shop.  This rigorous, randomized study design makes a compelling case for this practice, at least in patients with abdominal pain.

 

Benefits and Harms of Intensive Blood Pressure Treatment in Adults Aged 60 Years or Older: A Systematic Review and Meta-analysis.
Ann Intern Med. 2017 Mar 21;166(6):419-429. doi: 10.7326/M16-1754. Epub 2017 Jan 17.
Author's Conclusion: Treatment to at least current guideline standards for BP (<150/90 mm Hg) substantially improves health outcomes in older adults. There is less consistent evidence, largely from 1 trial targeting SBP less than 120 mm Hg, that lower BP targets are beneficial for high-risk patients. Lower BP targets did not increase falls or cognitive decline but are associated with hypotension, syncope, and greater medication burden.

 

Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis.
BMJ. 2017 Mar 14;356:j760. doi: 10.1136/bmj.j760.
Spoon Feed: Writing combined prescriptions for both opiates and benzodiazepines markedly increased the risk of opiate overdose.  Stay away from the killer combo.

 

Neuraminidase inhibitors during pregnancy and risk of adverse neonatal outcomes and congenital malformations: population based European register study.
BMJ. 2017 Feb 28;356:j629. doi: 10.1136/bmj.j629.
Spoon Feed: Oseltamivir was safe for use during pregnancy.

 

Systemic Inflammatory Response Syndrome, Quick Sequential Organ Function Assessment, and Organ Dysfunction: Insights From a Prospective Database of ED Patients With Infection.
Chest. 2017 Mar;151(3):586-596. doi: 10.1016/j.chest.2016.10.057. Epub 2016 Nov 19.
AUTHORS' CONCLUSIONS: SIRS was associated with organ dysfunction and mortality, and abandoning the concept appears premature. A qSOFA score ≥ 2 showed high specificity, but poor sensitivity may limit utility as a bedside screening method. Although mortality for organ dysfunction was comparable between Sepsis-2 and Sepsis-3, more prognostic and clinical information is conveyed using Sepsis-2 regarding number and type of organ dysfunctions. The SOFA score may require recalibration.

 

Direct Comparison of Four Very Early Rule-Out Strategies for Acute Myocardial Infarction Using High-Sensitivity Cardiac Troponin I.
Circulation. 2017 Mar 10. pii: CIRCULATIONAHA.116.025661. doi: 10.1161/CIRCULATIONAHA.116.025661. [Epub ahead of print]
Spoon Feed: High sensitivity troponin may allow for a very rapid MI rule out.  But many remain very skeptical about this diagnostic test.  Mattu wrote a piece for Medscape in 2011 (free subscription required or email me and I will send you a Dropbox link to it.)  EMLoN wrote a fairly favorable review of this article.

 

What is propensity score modelling?
Emerg Med J. 2017 Mar;34(3):129-131. doi: 10.1136/emermed-2016-206542. Epub 2017 Jan 31.
Spoon Feed: Propensity scores are a way to account for confounding in observational studies so we can have more confidence that an outcome is truly associated with an exposure.  If you want to read more, this is a good place to start.  Now my brain hurts.

 

The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients.
Injury. 2017 Feb 22. pii: S0020-1383(17)30084-0. doi: 10.1016/j.injury.2017.02.013. [Epub ahead of print]
Spoon Feed: NEXUS was not as sensitive in patients older than 65.  These people need imaging.  Interestingly, the Canadian C-spine rule takes age >65 into account.  Canada 2; United States 0

 

Impact of Thrombolytic Therapy on the Long-Term Outcome of Intermediate-Risk Pulmonary Embolism.
J Am Coll Cardiol. 2017 Mar 28;69(12):1536-1544. doi: 10.1016/j.jacc.2016.12.039.
Spoon Feed: It looks like thrombolytic therapy for submassive PE didn't change the incidence of chronic thromboembolic pulmonary hypertension.

 

Impact of Scribes on Billed Relative Value Units in an Academic Emergency Department.
J Emerg Med. 2017 Mar;52(3):370-376. doi: 10.1016/j.jemermed.2016.11.017. Epub 2016 Dec 14.
Spoon Feed: Scribes appear to be revenue positive in higher acuity adult patients.  The jury is still out on low acuity patients and pediatric patients.

 

Ultrasound for Diagnosis of Appendicitis in a Community Hospital Emergency Department has a High Rate of Nondiagnostic Studies.
J Emerg Med. 2017 Feb 28. pii: S0736-4679(17)30003-3. doi: 10.1016/j.jemermed.2017.01.003. [Epub ahead of print]
Spoon Feed: I think ultrasound is the right first imaging test to rule out appendicitis, but it's very important to set family expectations low and inform them that the study is often not diagnostic and that more imaging may be needed.

 

Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis.
Neurology. 2017 Mar 8. pii: 10.1212/WNL.0000000000003786. doi: 10.1212/WNL.0000000000003786. [Epub ahead of print]
Spoon Feed: If you plan to have a stroke, do it in Cleveland.  A MSTU reduced the time to treatment drastically.

 

Cervical artery dissection in patients ≥60 years: Often painless, few mechanical triggers.
Neurology. 2017 Mar 3. pii: 10.1212/WNL.0000000000003788. doi: 10.1212/WNL.0000000000003788. [Epub ahead of print]
Spoon Feed: Think about cervical artery dissection in patients over 60 even if they lack some of the usual features, such as neck pain, mechanical trigger, or migraine.  Practically speaking, it means intentionally looking for the subtle imaging findings and performing adequate imaging to evaluate for it if CeAD is otherwise suspected.

 

The Use of a Triage-Based Protocol for Oral Rehydration in a Pediatric Emergency Department.
Pediatr Emerg Care. 2017 Mar 9. doi: 10.1097/PEC.0000000000001070. [Epub ahead of print]
Spoon Feed: Triage nursing protocols that allow early use of ondansetron and oral fluids significantly reduced the number of children who needed IV fluid without prolonging length of stay.

 

Testing for Urinary Tract Infection in the Influenza/Respiratory Syncytial Virus-Positive Febrile Infant Aged 2 to 12 Months.
Pediatr Emerg Care. 2017 Mar 9. doi: 10.1097/PEC.0000000000001073. [Epub ahead of print]

a = >1% risk regardless of other risk factors other than being uncircumcised. http://pediatrics.aappublications.org/content/pediatrics/128/3/595/F2.large.jpg

a = >1% risk regardless of other risk factors other than being uncircumcised. http://pediatrics.aappublications.org/content/pediatrics/128/3/595/F2.large.jpg

Spoon Feed: Febrile children 2-12 months of age with RSV or influenza may still have UTI as a source of the fever.  However, this study suggests that we may be able to base urine testing on the patient's risk of UTI, with urine testing only in kids with > 1% risk.

 

Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: a systematic review and meta-analysis.
Resuscitation. 2017 Mar 2. pii: S0300-9572(17)30083-7. doi: 10.1016/j.resuscitation.2017.02.021. [Epub ahead of print]
AUTHORS' CONCLUSION: POC focused echocardiography can be used to identify reversible causes and predict short-term outcome in patients with cardiac arrest. In patients with a low pretest probability for ROSC, absence of SCM on echocardiography can predict a low likelihood of survival and guide the decision of resuscitation termination.