Annals of Emergency Medicine 2015

Treatment

1. Bugden S, Shean K, Scott M et al. Skin Glue Reduces the Failure Rate of Emergency Department-Inserted Peripheral Intravenous Catheters: A Randomized Controlled Trial. Ann Emerg Med. 2015 Dec 31. pii: S0196-0644(15)01535-8. doi:10.1016/j.annemergmed.2015.11.026. [Epub ahead of print]

CONCLUSION: This study supports the use of skin glue in addition to standard care to reduce peripheral intravenous catheter failure rates for adult emergency department patients admitted to the hospital. PMID: 26747220

Comment: Have you ever gotten a hard fought IV only to lose it minutes later?  This is now a thing of the past.  Just super glue the IV in place.  In reality, I'm not sure what I think about this.  It may be a good idea in patients with particularly difficult access but certainly not as a routine.

 

2.  Hollander JE, Gatsonis C, Greco EM et al. Coronary Computed Tomography Angiography Versus Traditional Care: Comparison of One-Year Outcomes and Resource Use. Ann Emerg Med. 2015 Oct 22. pii: S0196-0644(15)01302-5. doi: 10.1016/j.annemergmed.2015.09.014 [Epub ahead of print]

CONCLUSION: A coronary CT angiography-based strategy for evaluation of patients with low- to intermediate-risk chest pain who present to the ED does not result in increased resource use during 1 year. A negative coronary CT angiography result is associated with a less than 1% major adverse cardiac event (MACE) rate during the first year after testing. PMID: 26507904

Comment: The coronary CTA group and traditional group had the same (1%) incidence of MACE, so it appears the warranty period on  coronary CTA is at least 1 year.

 

3.  McCarthy ML, Shokoohi H, Boniface KS et al. Ultrasonography Versus Landmark for Peripheral Intravenous Cannulation: A Randomized Controlled Trial. Ann Emerg Med. 2015 Oct 13. pii: S0196-0644(15)01272-X. doi: 10.1016/j.annemergmed.2015.09.009. [Epub ahead of print]

CONCLUSION: Ultrasonographic peripheral intravenous cannulation is advantageous among patients with difficult or moderately difficult intravenous access but is disadvantageous among patients anticipated to have easy access. PMID: 26475248

Comment: Why one would use an ultrasound in an easy IV start, I don't know.  If you can see or feel the vein, don't use ultrasound. If you can't, use it.

 

4. Kuan WS, Ibrahim I, Leong BS et al. Emergency Department Management of Sepsis Patients: A Randomized, Goal-Oriented,  Noninvasive Sepsis Trial. Ann Emerg Med. 2015 Oct 13. pii: S0196-0644(15)01273-1. doi: 10.1016/j.annemergmed.2015.09.010. [Epub ahead of print]

CONCLUSION: Protocol-based fluid resuscitation of patients with severe sepsis and septic shock with the noninvasive cardiac output monitor and passive leg-raising maneuver did not result in better outcomes compared with usual care. Future studies to demonstrate the use of the noninvasive protocol-based care in patients with preexisting fluid overload states may be warranted. PMID: 26475246

Comment: With passive leg raise (to simulate a 300mL bolus) and noninvasive measurement of stroke volume index to measure fluid responsiveness (SVI increase >20% = 1L NS, SVI increase 10-20% = 500mL NS), clearance of lactate was not better than usual treatment.  But this noninvasive cardiac output monitor is really fascinating.

 

5. Cronin JJ, McCoy S, Kennedy U et al. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Ann Emerg Med. 2015 Oct 10. pii: S0196-0644(15)01154-3. doi: 10.1016/j.annemergmed.2015.08.001. [Epub ahead of print]

CONCLUSION: In children with acute exacerbations of asthma, a single dose of oral dexamethasone (0.3 mg/kg) is noninferior to a 3-day course of oral prednisolone (1 mg/kg per day) as measured by the mean PRAM score on day 4. PMID: 26460983

Comment: We are already doing this, only with a dose of 0.6mg/kg, max. 16mg (maybe we can lower the dose...).  There is no need to write a prescription for an outpatient course of oral steroids for asthma. Get 100% compliance and equal outcomes.

 

6. Chinnock B, Hendey GW. Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success. Ann Emerg Med. 2015 Sep 10. pii: S0196-0644(15)01188-9. doi: 10.1016/j.annemergmed.2015.08.007. [Epub ahead of print]

CONCLUSION: Although there were baseline differences between groups, irrigation of the abscess cavity during incision and drainage did not decrease the need for further intervention. PMID: 26416494

Comment: I was always taught the solution to pollution was dilution.  Maybe not with abscesses.

 

7. Friedman BW, Cabral L, Adewunmi V et al. Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency
Department-Based Randomized Clinical Trial. Ann Emerg Med. 2015 Aug 27. pii: S0196-0644(15)01085-9. doi:
10.1016/j.annemergmed.2015.07.495. [Epub ahead of print]

CONCLUSION: Intravenous diphenhydramine, when administered as adjuvant therapy with metoclopramide, does not improve migraine outcomes. PMID: 26320523

Comment: I don't use diphenhydramine to improve headache but to blunt akathisia. And I use 12.5 - 25mg, not 50mg. It looks like it didn't help with pain or akathisia.

 

8. Furyk JS, Chu K, Banks C et al. Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled,
Randomized, Multicenter Trial. Ann Emerg Med. 2015 Jul 13. pii: S0196-0644(15)00480-1. doi:
10.1016/j.annemergmed.2015.06.001. [Epub ahead of print]

CONCLUSION: We found no benefit overall of 0.4 mg of tamsulosin daily for patients with distal ureteric calculi less than or equal to 10 mm in terms of spontaneous passage, time to stone passage, pain, or analgesia requirements. In the subgroup with large stones (5 to 10 mm), tamsulosin did increase passage and should be considered. PMID: 26194935

Comments: If a stone is <5mm, tamsulosin is unlikely to help and has a potential side effect of hypotension.

 

9. Motov S, Rockoff B, Cohen V et al. Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial.Ann Emerg Med. 2015 Sep;66(3):222-229.e1. doi: 10.1016/j.annemergmed.2015.03.004. Epub 2015 Mar 26.

CONCLUSION: Subdissociative intravenous ketamine administered at 0.3 mg/kg provides analgesic effectiveness and apparent safety comparable to that of intravenous morphine for short-term treatment of acute pain in the ED. PMID: 25817884

Comment: Subdissociative ketamine is safe and effective.

 

10. Graudins A, Meek R, Egerton-Warburton D et al. The PICHFORK (Pain in Children Fentanyl or Ketamine) trial: a randomized
controlled trial comparing intranasal ketamine and fentanyl for the relief of moderate to severe pain in children with limb injuries. Ann Emerg Med. 2015 Mar;65(3):248-254.e1. doi: 10.1016/j.annemergmed.2014.09.024. Epub 2014 Nov 18.

CONCLUSION: Intranasal fentanyl and ketamine were associated with similar pain reduction in children with moderate to severe pain from limb injury. Ketamine was associated with more minor adverse events. PMID: 25447557

Comment: What's with the name PICHFORK! What parent would agree to enroll their child in that trial? Anyway, both medications worked for pain given intranasally.  More patients had adverse events with ketamine, more had dizziness.

 

11. Miner JR, Moore JC, Austad EJ et al. Randomized, double-blinded, clinical trial of propofol, 1:1 propofol/ketamine, and 4:1 propofol/ketamine for deep procedural sedation in the emergency department. Ann Emerg Med. 2015 May;65(5):479-488.e2. doi: 10.1016/j.annemergmed.2014.08.046. Epub 2014 Oct 16.

CONCLUSION: We found a similar frequency of airway and respiratory adverse events leading to intervention between propofol alone and either 1:1 or 4:1 ketofol. PMID: 25441247

Comment: The unifying issue here is the more propofol, the more respiratory depression.  I prefer ketamine alone unless the patient needs muscle relaxation as part of the sedation, such as hip dislocation.

 

12. Scheuermeyer FX, Pourvali R, Rowe BH et al. Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute
Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm. Ann Emerg Med. 2015 May;65(5):511-522.e2. doi: 10.1016/j.annemergmed.2014.09.012. Epub 2014 Nov 6.

CONCLUSION: In ED patients with complex atrial fibrillation or flutter, attempts  at rate and rhythm control are associated with a nearly 6-fold higher adverse event rate than that for patients who are not managed with rate or rhythm control. Success rates of rate or rhythm control attempts appear low. PMID: 25441768

Comment: In patients who go into atrial fibrillation in the setting of another acute illness, less is more.  Unless they are hemodynamically unstable (and need cardioversion), aggressive rate or rhythm control is likely to do more harm than good and is likely to fail anyway.

 

13. Hoppe JA, Kim H, Heard K. Association of emergency department opioid initiation with recurrent opioid use. Ann Emerg Med. 2015 May;65(5):493-499.e4. doi: 10.1016/j.annemergmed.2014.11.015. Epub 2014 Dec 18.

CONCLUSION: Opioid-naive ED patients prescribed opioids for acute pain are at increased risk for additional opioid use at 1 year. PMID: 25534654

Comment: What are we supposed to do with this information? Over 1/10 patients prescribed an opiate will go on to recurrent use.  You could be creating a monster with each narcotic prescription.  For me, if I am uncertain, I won't prescribe an opiate in light of this study.  But for those with a truly painful condition (e.g. fracture, etc.), this won't change my practice.

 

14. Cohen L, Athaide V, Wickham ME et al.  The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review. Ann Emerg Med. 2015 Jan;65(1):43-51.e2. doi: 10.1016/j.annemergmed.2014.06.018. Epub 2014 Jul 23.

CONCLUSION: According to the available literature, the use of ketamine in critically ill patients does not appear to adversely affect patient outcomes. PMID: 25064742

Comment: Ketamine increases cardiac output and may increase intracranial pressure, though that is not clear, but none of this translates into adverse patient outcomes based on the best evidence to date.

Diagnostic

1. Sharp AL, Vinson DR, Alamshaw F et al. An Age-Adjusted D-dimer Threshold for Emergency Department Patients With
Suspected Pulmonary Embolus: Accuracy and Clinical Implications. Ann Emerg Med. 2015 Aug 27. pii: S0196-0644(15)00616-2. doi:
10.1016/j.annemergmed.2015.07.026. [Epub ahead of print]

CONCLUSION: An age-adjusted D-dimer limit has the potential to reduce chest imaging among older ED patients and is more accurate than a standard threshold of 500 ng/dL. Our findings support the adoption of an age-adjusted D-dimer cutoff in community EDs. PMID:26320520

Comment: Almost 3000 CT scans could have been averted, but 26 cases of PE would have been missed.  I am going to start using an age adjusted cut off (age x 10).

 

2. Asha SE, Miers JW. A Systematic Review and Meta-analysis of D-dimer as a Rule-out Test for Suspected
Acute Aortic Dissection. Ann Emerg Med. 2015 Oct;66(4):368-78. doi: 10.1016/j.annemergmed.2015.02.013.
Epub 2015 Mar 21.

CONCLUSION: This meta-analysis suggests that a negative D-dimer result may be useful to help rule out acute aortic dissection in low-risk patients. PMID: 25805111

From Annals of Emergency Medicine

From Annals of Emergency Medicine

Comment: It's hard to know what to do with this study. For a patient to have a low pretest probability, they would not have any signs or symptoms that make me worry about aortic dissection anyway.

 

3. Hannon M, Mannix R, Dorney K et al. Pediatric cervical spine injury evaluation after blunt trauma: a clinical
decision analysis. Ann Emerg Med. 2015 Mar;65(3):239-47. doi: 10.1016/j.annemergmed.2014.09.002.
Epub 2014 Oct 16.

CONCLUSION: The model highlights that clinical clearance and screening radiographs in a hypothetical trauma pediatric population are preferred strategies, whereas CT scanning is rarely the initial optimal evaluation. PMID: 25441248

Comment: This is an important study. Based on the best available evidence, the best strategy for c-spine clearance in pediatric patients is clinical clearance, plain x-ray if positive, focused CT if radiographs are concerning. With an average risk of malignancy from pediatric neck CT of 1/250, this should not be the first imaging modality unless the pretest probability of c-spine injury is very high, 24.9% in this analysis.

 

4. Kwok MY, Yen K, Atabaki S et al. Sensitivity of plain pelvis radiography in children with blunt torso trauma. Ann Emerg Med. 2015 Jan;65(1):63-71.e1. doi: 10.1016/j.annemergmed.2014.06.017. Epub 2014 Jul 30.

CONCLUSION: Plain anteroposterior pelvic radiographs have a limited sensitivity for identifying children with pelvic fractures or dislocations after blunt trauma, including patients undergoing operative intervention and those with
hypotension. PMID: 25086474

Comment: Skip the plain pelvis x-ray in kids with blunt trauma. If there is concern for serious torso trauma, CT is indicated regardless and will demonstrate pelvic injury more accurately.

 

5. Schwartz TM, Tai M, Babu KM et al. Lack of association between Press Ganey emergency department patient satisfaction scores and emergency department administration of analgesic medications. Ann Emerg Med. 2014 Nov;64(5):469-81. doi: 10.1016/j.annemergmed.2014.02.010. Epub 2014 Mar 27.

CONCLUSION: Overall Press Ganey ED patient satisfaction scores were not primarily
based on in-ED receipt of analgesic medications or opioid analgesics; other
factors appear to be more important. PMID: 24680237

Comment: This crushes a dogma I believed and espoused, namely that patient satisfaction scores were worse if you did the right thing and didn't hand out narcotics like candy at Halloween.  But this isn't true. What patients really want is to be cared for, kept up to date on how their ED workup is progressing, and apprised of delays.  This is labor and time intensive, but it's true and I need to quit whining and just do it.

 

Review


1. Wilcox SR, Kabrhel C, Channick RN. Pulmonary Hypertension and Right Ventricular Failure in Emergency Medicine. Ann Emerg Med. 2015 Sep 2. pii: S0196-0644(15)01115-4. doi: 10.1016/j.annemergmed.2015.07.525. [Epub ahead of print]

Quick Summary: 1. Use norepinephrine and inotropes in shock patients.  2. Use caution and only give small, 250mL fluid boluses.  3. Treat any underlying condition that may worsen hypercapnea or hypoxia.  4. Keep any home meds or infusions going at all times.  5. Try NOT to intubate if possible.  6. Consult early with the Pulmonary Hypertension specialist. PMID: 26342901

 

2. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Use of Intravenous tPA for Ischemic Stroke:, Brown MD, Burton JH, Nazarian DJ, Promes SB. Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department.Ann Emerg Med. 2015 Sep;66(3):322-333.e31. doi: 10.1016/j.annemergmed.2015.06.031.

CONCLUSIONS: Quoted below.

1. "Is IV tPA safe and effective for patients with acute ischemic stroke if given within 3 hours of symptom onset?
Patient Management Recommendations
Level A recommendations: None specified.
Level B recommendations: With a goal to improve functional outcomes, IV tPA should be offered and may be given to selected patients with acute ischemic stroke within 3 hours after symptom onset at institutions where systems are in place to safely administer the medication. The increased risk of symptomatic intracerebral hemorrhage (sICH) should be considered when deciding whether to administer IV tPA to patients with acute ischemic stroke.
Level C recommendations: When feasible, shared decisionmaking between the patient (and/or his or her surrogate) and a member of the health care team should include a discussion of potential benefits and harms prior to the decision whether to administer IV tPA for acute ischemic stroke. (Consensus recommendation)"
2. "Is IV tPA safe and effective for patients with acute ischemic stroke treated between 3 to 4.5 hours after symptom onset?
Patient Management Recommendations
Level A recommendations: None specified.
Level B recommendations : Despite the known risk of sICH and the variability in the degree of benefit in functional outcomes, IV tPA may be offered and may be given to carefully selected patients with acute ischemic stroke within 3 to 4.5 hours after symptom onset at institutions where systems are in place to safely administer the medication.
Level C recommendations: When feasible, shared decisionmaking between the patient (and/or his or her surrogate) and a member of the health care team should include a discussion of potential benefits and harms prior to the decision whether to administer IV tPA for acute ischemic stroke. (Consensus recommendation)." 

Comment:  This policy answered two questions.  Answers are more measured than past iterations. PMID: 26304253

 

3. Mosier JM, Hypes C, Joshi R, WHITMORE SAGE!!, et al. Ventilator Strategies and Rescue Therapies for Management of Acute Respiratory Failure in the Emergency Department. Ann Emerg Med. 2015 Nov;66(5):529-41. doi: 10.1016/j.annemergmed.2015.04.030. Epub 2015 May 23. PMID: 26014437

From Annals of Emergency Medicine

From Annals of Emergency Medicine

Comment: Great job, Sage! This diagram pretty much sums it up.


4. Juurlink DN, Gosselin S, Kielstein JT et al. Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup. Ann Emerg Med. 2015 Aug;66(2):165-81. doi: 10.1016/j.annemergmed.2015.03.031.
Epub 2015 May 15.

CONCLUSION: Salicylates are readily removed by extracorporeal treatment, with intermittent hemodialysis being the preferred modality. The signs and symptoms of salicylate toxicity listed [i.e. altered mental status, acute respiratory distress syndrome, standard therapy is failing, or severe acidemia (pH ≤7.20)] warrant extracorporeal treatment, as do high concentrations regardless of clinical status. PMID:25986310

Comment: Know the indications to dialyze and consult tox and nephrology early on to get consensus and make arrangements.


5. Meyers L, Frawley T, Goss S, Kang C. Ebola virus outbreak 2014: clinical review for emergency physicians. Ann Emerg Med. 2015 Jan;65(1):101-8. doi: 10.1016/j.annemergmed.2014.10.009. Epub
2014 Oct 23. PMID: 25455908

Comment: Thankfully this epidemic has slowed and seems to be over.  But in an epidemic, the right travel history and a febrile patient means isolation and measures to protect yourself and others from exposure.  A recent article shows it is harder than you might think to avoid contamination doffing PPE.


6. Slessor D, Hunter S. To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis. Ann Emerg Med. 2015 Mar;65(3):297-307.e16. doi: 10.1016/j.annemergmed.2014.08.020. Epub 2014 Oct 23.

CONCLUSION: There may be a role for ED thoracotomy after blunt trauma, but only in a limited group of patients. Good outcomes have been achieved for patients who had vital signs on admission and for patients who received an ED thoracotomy within 15 minutes of cardiac arrest. The proposed guideline should be used to determine which patients should be considered for an ED thoracotomy, according to level 4 evidence. PMID: 25443990

Comment: The chance of survival with good neurologic outcome was 1.5% overall.  If no vital signs on admission or over 15 minutes has elapsed since arrest, the outcome is universally poor.

Clinical Prediction Rules


1. Atzema CL, Dorian P, Fang J et al. A Clinical Decision Instrument for 30-Day Death After an Emergency Department Visit for Atrial Fibrillation: The Atrial Fibrillation in the Emergency Room (AFTER) Study. Ann Emerg Med. 2015 Sep 18. pii: S0196-0644(15)00595-8. doi: 10.1016/j.annemergmed.2015.07.017. [Epub ahead of print]

CONCLUSION: Using a population-based sample, we derived and validated both a complex and a simplified instrument that predicts mortality after an emergency visit for atrial fibrillation. These may aid clinicians in identifying high-risk  patients for hospitalization while safely discharging more patients home. PMID: 26387928

Comment: Six variables with the mnemonic TrOPs-BAC predicted mortality in atrial fibrillation.

 

2. Greenslade JH, Parsonage W, Than M et al. A Clinical Decision Rule to Identify Emergency Department Patients at Low Risk
for Acute Coronary Syndrome Who Do Not Need Objective Coronary Artery Disease Testing: The No Objective Testing Rule. Ann Emerg Med. 2015 Sep 10. pii: S0196-0644(15)01187-7. doi:
10.1016/j.annemergmed.2015.08.006. [Epub ahead of print]

From Annals of Emergency Medicine

From Annals of Emergency Medicine

From Annals of Emergency Medicine

From Annals of Emergency Medicine

CONCLUSION: We have derived a clinical decision rule for chest pain patients with negative early cardiac biomarker and ECG testing results that identifies 31% at low risk and who may not require objective testing for coronary artery disease. A prospective trial is required to confirm these findings. PMID: 26363570

Comment: The last line is important. This has not been externally validated yet. Although it is promising and very simple!