2014 Top Articles – by Drs. Stella Yiu and Jeff Freeman

Below is a fantastic list of the most relevant articles from 2014, some are practice changing, some will make you think and others remind you not to do things in the ED that don’t help our patients. The list below was presented by Drs. Stella Yiu (@Stella_Yiu) and Jeff Freeman at the 2015 NCCEM Conference.

Critical Plays

• Multicenter, RCT Protocolized Care for Early Septic Shock (ProCESS) at 31 US hospitals
• Results: n = 1351, in 1^st 6 h, more fluids in the protocol-based standard-therapy group
• No difference in mortality at 60/90/365 days (18-20%) or organ support
• Bottom line:  Identify sepsis quickly, with early fluids and antibiotics. Management with ScvO2 monitoring, pressors or specific MAP targets still unproven (independently) to change mortality.

• 51 sites, n= 1600, usual care compared to Goal directed therapy
• Results: more fluids in 1^st 6 hr + pressor in EGDT group, no mortality difference (18%)
• Limitation: Hawthorne effect from EGDT team being present?
• Bottom line: sepsis care has come a long way with lower mortality no need for SvO2 measurement, central line, transfusion or arterial line

• ICU study of transfusion trigger in randomized patients with septic shock comparing Hgb threshold at 70 or 90 g/L.  At 90 days there were no differences in mortality, ischemic events or critical interventions though the higher threshold patients had a median of three extra transfusions (of leukoreduced packed red cells). 
• Bottom line: another study suggesting no benefit from aggressively transfusing patients to maintain hemoglobin >90 g/L[JF1] 

• Randomized, open-label trial comparing 776 patients with septic shock treated to a MAP target of either 80-85 mm Hg or 65-70 mm Hg.
• Results: No difference in mortality at either 28 or 90 days
• Bottom line: No compelling evidence that higher BP resuscitation improves outcome[JF2] 

• Systematic review on mortality benefits and bleeding risks with thrombolytic therapy vs anticoagulation, with subset of stable patients+RV dysfunction (Intermediate risk)
• Results (16 studies): Thrombolytics associated with lower all cause mortality (OR 0.53; 95% CI 0.32-0.88; NNT = 59), higher major bleed (OR 2.73, NNH =18) including ICH

• 1,005 patients with submassive PE (hemodynamic stability with RV strain and étroponins) given heparin (UFH) with either tenecteplase or placebo
• Results: No mortality benefit at day 7/30 (less hemodynamic compromise [unsure clinical significance]- balanced out by increased rates of major extracranial bleeding at 7 days (6.3% vs. 1.2%; NNH 20) and strokes at 7 days (2.4% vs. 0.2%; NNH 45).
• Limitations: Not powered to detect differences in mortality
• Bottom line: Consider Lytic in <65 yo in stable submassive PE

Game Changing Plays

• Prospective development and validation of a clinical decision rule to safely rule out adult patients with at least 5 minutes of chest pain symptoms suggestive of ischemia.  Age, sex, risk factors, diaphoresis, and pain qualities were combined into a weighted rule, which in combination with EKG and 2 hour negative troponin, was able to safely identify 40–50% of patients presenting to the ED with possible cardiac chest pain as having low risk of short-term (30 day) complications.
• Limitations: a moderately cumbersome rule, not validated outside of their setting
• Bottom line: Their decision rule (EDACS-ADP: available at MDCALC.com) seems to be a quick and easy risk stratification tool for sending home low risk patients

• 2776 adult patients with flank or abdominal pain were randomized to US or CT (1/2 of ultrasounds were done at bedside by EP).  Initial US had less radiation than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events at 30 days, pain scores, return ED visits, or hospitalizations.
• Bottom line: patients with low risk for non-renal pathology seem to do just as well with ultrasound as an initial screening tool – Emergency docs can do this safely with training.

• Retrospective study comparing standard I/D vs. loop drainage in 142 patients )5 weeks – 18 yrs, 75% MRSA)(excluded: face, scalp, hands, feet), x 10 days + warm soaks, DC when no drainage/induration (x 1 follow up) Treatment failure:  16.5% I/D vs 4% LOOP
• Highest failure in head and neck for I/D, buttock for LOOP
• Limitations: those who had sedation had better outcome, some done in OR
• Bottom line: Loop drainage should be considered a safe option to I& D of abscesses

• 3 sites, prospective, observational study
•  Ketamine IV 1mg/kg + 0.5mg/kg to dissociation, High-flow O₂+ NRB/NIPPV x 3 min
• Muscle relaxant + nasal cannula apneic oxygenation, and intubation 45-60 sec post
• Results: 64 pts (2 excluded – no post DSI Sat, but both had 100% sat on ABG), Sat from a mean of 89.9% →98.8%, with an increase of 8.9% (95% CI 6-10%).
• Limitations: not randomized, all MDs with extensive ketamine experience
• Bottom line: Ketamine is an option for delayed intubation in experienced hands

• A nice summary of available human and animal data guiding selection of a PCC in the protocols for NOAC-associated hemorrhage.  A simple figure reviews an approach using PCC’s, transfusions, and possibly dialysis for dabigatran.
• Limitations: “These protocols are based on limited human data”
• Bottom line: See thrombosiscanada.ca for up to date guidelines on NOAC bleeding

• High-quality medical education resources and interactions should be free and accessible to all who care for patients.
• Bottom line: Use Google FOAM as your search engine (but buyer beware)

• Meta-analysis of 32 studies of alpha blockers in treatment for ureteral stones. 
• Results: Stone expulsion time was 2.9 days shorter with the use of alpha blockers.  Also reduced the number of pain episodes, the need for other analgesic and hospitalization.
• Bottom line: alpha-blockers results in a higher stone-free rate and a shorter time to stone expulsion

Trick Plays 

• Prospective, double-blinded RCT of 116 patients with uncomplicated corneal abrasions – 1% tetracaine vs. saline q30 minutes prn pain for 24 hours
• Limitations: poor blinding, underpowered, and poor follow-up
• Bottom line:  Likely that tetracaine does not increase infections or delay healing when used for 24 hours and improves satisfaction

• Prospective RCT(n = 70) of 8mg dex +10mg metoclopramide vs. 1gm Mg over 15 min
• Limitations: No NSAIDS in ‘conventional’ therapy, little details about pts
• Results: Sig. decrease for Mg at 20 min (35% change), 1 hour (71%) and 2 hr (90%)
• Bottom line: Consider Magnesium in your arsenal of migraine treatment 

• Case series of 4 patients, using Propofol as slow infusion (1 minute) until pt fell asleep without change in end-tidal CO2 or a change in resp rate or O₂ sat.
• Mean LOS usually is 6.5 hours (95% CI 6.16-6.84) vs 3.1 hour (95% CI 2-4.8)
• Limitation: Procedure (1: 1 RN, MD) and monitoring cost, propofol dependency
• Bottom line: If failed all kinds of migraine meds, consider, but need ++ monitoring

• Commonly used in chronic pain management, the options for ED use of lidocaine are not as well recognized.   This review article summarizes the diverse options for lidocaine, including multiple routes in varied conditions.  Worth reconsidering in renal colic, headache, intractable, neuropathic, complex and chronic pain.
• Bottom line:  Add lidocaine as a safe option into your pain management arsenal.

• A blinded RCT in patients given morphine0.1 mg/kg, then placebo or low dose ketamine (0.15 or 0.3 mg/kg)
• Results: n = 69 (over 10 months!): lost 9 before drug
• Pain scores decreased over time, but difference higher in ketamine group
• Bottom line: Another tool to treat pain, particularly for pain refractory to opioids.

• Florida study of 52 patients treated with ketamine by EMS with 4 mg/kg IM.  96% were sedate quickly, most within 2 minutes.
• Limitations:  ½ of patients were given IM midazolam also, of which 3/52  needed bagging
• Bottom line:  Ketamine is mostly safe in agitated delirium to quickly gain control

Fumbles and Interceptions  

• Small RCT (n=79) comparing 5 days prednisone to placebo
• Results: no statistically significant differences in pain, return to work or activities at Day 5 (limited by 15% of patients lost to follow-up)
• Bottom line:  No evidence for use of steroids in uncomplicated minor back pain

• Results: Failure rate of conventional (< 500): 3-mo VTE risk: 1/810 (0.1%, 95% CI, 0.0%-0.7%).
• Failure rate adjusted cutoff: 1/331 (0.3% [95% CI, 0.1%-1.7%) (*? up to 7/331)
• Limitations: Low risk cohort (only 13% have wells score> 4), 2 pretest assessments, 6 D-dimer assays. Not RCT
• Bottom line: Not ready to be used

• Double-blinded RCT comparing 4 mg IV ondansetron, 20 mg IV metoclopramide, or placebo in 258 undiffentiated ED patients with nausea or vomiting.
• Results: no difference in symptoms by VAS change or satisfaction at 30 min in this group with mostly opiate induced nausea or gastroenteritis.
• Limitations: only 3 pts per day, 30 minutes as end point, only moderate nausea
• Bottom line:  Another small but convincing study that antiemetics in the ED have minimal effects on most patients – stick to fluids or treat for sedation if necessary.

• Best evidence review, not new study. Only 1 multicentre RCT: no significant difference (underpowered), about 30% success (usual spontaneous resolution rate)
• Bottom line: Do not use glucagon. Not a higher success rate and can cause vomiting

• Best evidence review. A summary of previous studies suggesting lack of proven efficacy in patient-oriented outcomes.
• Bottom line: PPI does not change patient-oriented outcomes in acute UGI bleed

• 159 patients were admitted and treated with antibiotics, 12% required surgery in first week with mean length of stay of nonoperatively managed patients  of 0.4 days
• Bottom line:  This non-operative approach, similar to diverticulitis, should be compared with morbidity and costs of simple laparoscopic appendectomy