One of the talks I gave today at North York General’s Emergency Medicine Update was an “EBM Lightning Round” going over my picks for articles of the year. These are the articles I picked, and the rapid bottom line for each:
Vallentin MF, Granfeldt A, Meilandt C, et al. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021 Nov 30. doi: 10.1001/jama.2021.20929. PMID: 34847226
BOTTOM LINE: We shouldn’t be using calcium routinely in cardiac arrest, but keep your eye out for specific indications like hyperkalemia and calcium channel blocker overdose.
Dankiewicz J, Cronberg T, Lilja G, et al: TTM2 Trial Investigators. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. N Engl J Med. 2021 Jun 17;384(24):2283-2294. doi: 10.1056/NEJMoa2100591. PMID: 34133859
Le May M, Osborne C, Russo J, et al. Effect of Moderate vs Mild Therapeutic Hypothermia on Mortality and Neurologic Outcomes in Comatose Survivors of Out-of-Hospital Cardiac Arrest: The CAPITAL CHILL Randomized Clinical Trial. JAMA. 2021 Oct 19;326(15):1494-1503. doi: 10.1001/jama.2021.15703. PMID: 34665203
BOTTOM LINE: At this point, we can be pretty sure that hypothermia provides no benefit to our patients. It isn’t clear whether fever prevention actually helps, but for now targeting normothermia will be considered best practice.
Lin J, Figuerado Y, Montgomery A, Lee J, Cannis M, Norton VC, Calvo R, Sikand H. Efficacy of ketamine for initial control of acute agitation in the emergency department: A randomized study. Am J Emerg Med. 2021 Jun;44:306-311. doi: 10.1016/j.ajem.2020.04.013. PMID: 32340820
Barbic D, Andolfatto G, Grunau B, Scheuermeyer FX, Macewan B, Qian H, Wong H, Barbic SP, Honer WG. Rapid Agitation Control With Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial. Ann Emerg Med. 2021 Aug 2:S0196-0644(21)00433-9. doi: 10.1016/j.annemergmed.2021.05.023 PMID: 34353650
BOTTOM LINE: Ketamine is faster, but maybe not safer. Use it in severely agitated patients who are truly a danger to themselves and others, but be careful of indication creep.
The BOUGIE trial: Driver BE, Semler MW, Self WH, et al. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA. 2021 Dec 8. doi: 10.1001/jama.2021.22002 PMID: 34879143
BOTTOM LINE: In the average doctor’s hands, there probably isn’t a difference whether you choose bougie or stylet for your first attempt at intubation, but we need to be masters of both techniques. Personally, I want to do a lot better than an 80% first pass success.
Schmidt AS, Lauridsen KG, Møller DS, Christensen PD, Dodt KK, Rickers H, Løfgren B, Albertsen AE. Anterior-Lateral Versus Anterior-Posterior Electrode Position for Cardioverting Atrial Fibrillation. Circulation. 2021 Dec 21;144(25):1995-2003. doi: 10.1161/CIRCULATIONAHA.121.056301. Epub 2021 Nov 24. PMID: 34814700
BOTTOM LINE: This is the best evidence we have, and is enough to convince me that anterior-lateral pad position is the best for most patients when cardioverting atrial fibrillation.
Finfer S, Micallef S, Hammond N, Navarra L, Bellomo R, Billot L, Delaney A, Gallagher M, Gattas D, Li Q, Mackle D, Mysore J, Saxena M, Taylor C, Young P, Myburgh J; PLUS Study Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. N Engl J Med. 2022 Jan 18. doi: 10.1056/NEJMoa2114464. Epub ahead of print. PMID: 35041780
Zampieri FG, Machado FR, et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA. 2021 Aug 10. doi: 10.1001/jama.2021.11684. PMID: 34375394
BOTTOM LINE: Based on multiple large, high quality trials, normal saline is not hurting our patients. It probably doesn’t matter what IV fluid you choose. Use whatever you want, and try to ignore the people who will inevitably criticize your choice.
Pappal RD, Roberts BW, Mohr NM, Ablordeppey E, Wessman BT, Drewry AM, Winkler W, Yan Y, Kollef MH, Avidan MS, Fuller BM. The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med. 2021 May;77(5):532-544. doi: 10.1016/j.annemergmed.2020.10.012 PMID: 33485698
BOTTOM LINE: In this study, 2.7% of patients reported being awake and having memories of a period during which they were intubated and paralyzed in the ED. We’ve got to do better.
Goulden R, Rowe BH, Abrahamowicz M, Strumpf E, Tamblyn R. Association of Intravenous Radiocontrast With Kidney Function: A Regression Discontinuity Analysis. JAMA Intern Med. 2021 Apr 5. doi: 10.1001/jamainternmed.2021.0916 PMID: 33818606
BOTTOM LINE: I think everyone in emergency medicine already knows this, but this is the best data we have so far: IV contrast does not cause kidney damage. If you need a contrast scan, you should not be worrying about the kidneys.
McAlister FA, Youngson E, Rowe BH. Elevated Blood Pressures Are Common in the Emergency Department but Are They Important? A Retrospective Cohort Study of 30,278 Adults. Ann Emerg Med. 2021 Apr;77(4):425-432. doi: 10.1016/j.annemergmed.2020.11.005. Epub 2021 Feb 10. PMID: 33579586
Bottom line: We also already knew this, but asymptomatic hypertension is not an emergency. These patients can be sent home without any testing or treatment.
Freund Y, Chauvin A, Jimenez S, Philippon AL, Curac S, Fémy F, Gorlicki J, Chouihed T, Goulet H, Montassier E, Dumont M, Lozano Polo L, Le Borgne P, Khellaf M, Bouzid D, Raynal PA, Abdessaied N, Laribi S, Guenezan J, Ganansia O, Bloom B, Miró O, Cachanado M, Simon T. Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial. JAMA. 2021 Dec 7;326(21):2141-2149. doi: 10.1001/jama.2021.20750. PMID: 34874418
Bottom line: By now, age adjusted DDimer and YEARS are both tools you should be using routinely in your assessment of PE. This study tells us that the COMBO is even better. If you fail YEARS, you can use an age adjusted DDimer.
Mora-López L, Ruiz-Edo N, Estrada-Ferrer O, Piñana-Campón ML, Labró-Ciurans M, Escuder-Perez J, Sales-Mallafré R, Rebasa-Cladera P, Navarro-Soto S, Serra-Aracil X; DINAMO-study Group. Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO-study): A Multicentre, Randomised, Open-label, Noninferiority Trial. Ann Surg. 2021 Nov 1;274(5):e435-e442. doi: 10.1097/SLA.0000000000005031. PMID: 34183510
BOTTOM LINE: Its time to change practice. Patients with uncomplicated diverticulitis don’t need antibiotics.
Reuben A, Appelboam A, Stevens KN, Vickery J, Ewings P, Ingram W, Jeffery AN, Body R, Hilton M, Coppell J, Wainman B, Barton A. The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial. Ann Emerg Med. 2021 Jun;77(6):631-640. doi: 10.1016/j.annemergmed.2020.12.013. Epub 2021 Feb 19. PMID: 33612282
BOTTOM LINE: The best available evidence suggests TXA doesn’t help in epistaxis. However, if your only other option is packing, there may still be a role for selective use as we wait for more data.
Post R, Germans MR, Tjerkstra MA, Vergouwen MDI, Jellema K, Koot RW, Kruyt ND, Willems PWA, Wolfs JFC, de Beer FC, Kieft H, Nanda D, van der Pol B, Roks G, de Beer F, Halkes PHA, Reichman LJA, Brouwers PJAM, van den Berg-Vos RM, Kwa VIH, van der Ree TC, Bronner I, van de Vlekkert J, Bienfait HP, Boogaarts HD, Klijn CJM, van den Berg R, Coert BA, Horn J, Majoie CBLM, Rinkel GJE, Roos YBWEM, Vandertop WP, Verbaan D; ULTRA Investigators. Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial. Lancet. 2021 Jan 9;397(10269):112-118. doi: 10.1016/S0140-6736(20)32518-6. Epub 2020 Dec 23. PMID: 33357465
BOTTOM LINE: There is no benefit of giving TXA to patients with subarachnoid hemorrhage, and there may even be a hint of harm.
Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial Bias in Pulse Oximetry Measurement. N Engl J Med. 2020 Dec 17;383(25):2477-2478. doi: 10.1056/NEJMc2029240. PMID: 33326721
Valbuena VSM, Barbaro RP, Claar D, et al. Racial Bias in Pulse Oximetry Measurement Among Patients About to Undergo ECMO in 2019-2020, A Retrospective Cohort Study. Chest. 2021 Sep 27:S0012-3692(21)04065-4. doi: 10.1016/j.chest.2021.09.025. PMID: 34592317
BOTTOM LINE: We now have multiple studies that demonstrate that the pulse oximeter is less accurate in patients with darker skin. Pay particular attention when the clinical presentation doesn’t match the number.
Mas-Dalmau G, Villanueva López C, et al. Delayed Antibiotic Prescription for Children With Respiratory Infections: A Randomized Trial. Pediatrics. 2021 Mar;147(3):e20201323. doi: 10.1542/peds.2020-1323. Epub 2021 Feb 11. PMID: 33574163
BOTTOM LINE: In almost every study, delayed antibiotics seem to result in the same thing: unnecessary antibiotic prescriptions and increased harm as compared to just not prescribing antibiotics when they are not indicated.
Writing Committee Members, Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021 Nov 30;78(22):e187-e285. doi: 10.1016/j.jacc.2021.07.053. Epub 2021 Oct 28. PMID: 34756653
BOTTOM LINE: The biggest and most important change is that low risk patients don’t need any testing for coronary artery disease. Stop ordering stress tests, and just let the patient follow up with their family doctor.
