# To Be Presented # Done ## July 2024 ### Sepsis Gestalt Paper https://mail.google.com/mail/u/0/#inbox/FMfcgzQVxHbhnbQGhXbQTtLXjPFbTrJM Mike Puskarich, a sepsis expert and senior author of this paper, who has a better explanation than I could have given. He's copied on this email in case you wanted to chat more about it.  Here are his thoughts: Two broad responses, simple and complex. 1. First off - Yes, suspicion of infection is required for the definition of sepsis from a theoretical / consensus definition standpoint, and you hit the nail on the head. Consensus definitions and the Surviving Sepsis Campaign and every other guideline has always included suspicion of infection as part of infection, but no one has ever define what that is or what it means.  And how much of a suspicion of infection? Its not a yes / no answer. So what counts? A 1% chance? 20%? 95? Most seasoned ED clinicians will almost never say any critically ill medical patient has a 0% chance of sepsis, so does that mean every critically ill patient has sepsis because there is some level of suspicion above 0%?  How much of a suspicion do you need before it meets the definition and you act? It's a hard question that no one has ever systematically addressed to my knowledge. (That is actually the focus of our next paper with this data) So, framing this work was hard, and you've picked up on that. We note this in the limitations sections, insofar as using gestalt here is somewhat self-referential and nonsensical.  However, this is one of the idiosyncracies of peer review -  no one would publish a study of how good physicians are at diagnosing sepsis without a comparison group, and there really isn't one.  While you are absolutely right from a theoretical standpoint, that's actually not the main reason we did the study, as the above issues are really just interesting to people who think way too much about sepsis. The real purpose of study was to address the pragmatic application of how hospitals and the medical practice system interpret and apply these tools (that shouldn't be used for screening, but in reality _are_ used for screening), which gets us to the rationale below. 1. From a pragmatic perspective, hospitals use the ICD-10 codes to screen for patients potentially eligible for the SEP-1 core measure. They use the explicit sepsis ICD-10 codes as a first step in this process, which is why this was chosen as the primary outcome. They then go back retrospectively and see if patients ever met SIRS criteria and organ failure, and then assign a time to when sepsis was present. Administrators at many institutions then point a finger at the clinician and say, you "missed" sepsis if you didn't give the required interventions in the required time frame. The problem with this approach, as I'm sure you know, is that there are vastly more patients who meet these criteria than actually end up with the diagnosis ([https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8672442/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8672442/)).  To try to do right by patients (and to maximize how the hospital looks via publicly reported metrics), many institutions institute screening tools (sometimes based on SIRS, sometimes on SOFA, sometimes on an EPIC embedded black box, sometimes a homegrown machine learning algorithm) to fire a Best Practice Advisory or otherwise alert clinicians to the possibility of sepsis. Often these tools are extremely poorly calibrated and misfire / overfire incessantly, annoying clinicians and mitigating any potential effectiveness they would have because clinicians ignore them. However, if the clinician does NOT act on an alert due to being conditioned to believe the alerts are useless, naive administrators often say "A-ha! you screwed up!", not aware that acting on the alert all the time might lead to bad patient care.  Moreover, in some practice settings, adherence to core measure outcomes is actually tied to physician reimbursement and bonuses, leading to a perverse incentive to deliver bad and potentially unnecessary and even harmful care (indiscriminate antibiotics, overly aggressive fluid loading) if it turns out clinician decision making is better than these tools. We sought to quantify that phenomenon, and test whether physician gestalt actually outperforms these automated screening tools, to justify a physician's decision to use their judgment over these alerts and hopefully discourage such practices. Furthermore, medical malpractice cases of missed sepsis often quote things like SIRS criteria being present or an elevated SOFA score as being a complaint of negligence, and in the courtroom there is little room for discussion of things like the false positive rate of these tools. There is no discussion of the poorly quantitated risks associated with just giving everyone who walks in the door with an elevated heart rate and a fever broad spectrum antibiotics and a 30 mL/kg fluid load on arrival, which is what the lawyers in these cases would have juries believe. So, these data were also analyzed to give physicians a leg to stand on to say - yes, sepsis patients tend to have abnormal vitals, labs, organ failure, etc; but lots of other conditions do too, and reliance on these measures alone are probably worse than clinician judgment when applied indiscriminately.  That being said, physicians clearly make mistakes, as evidenced by our table of patients with a sepsis VAS of 0 at both 15 and 60 minutes who indeed had sepsis (and on case review, many of these were quite obvious and should not have been missed in an ideal setting). The ultimate goal of this work, in my opinion, is to develop some kind of machine / AI / informatics _augmentation_ approach, where clinicians can still rely their fine tuned gestalt, but machines can be harnessed to prevent the unforced errors and "swing and a miss" type mistakes that we all fall victim to due to task switching and all the other biases humans are vulnerable to. How to accomplish this is the next step, but we need preliminary data to justify funding for that work. Hope that helps, happy to chat about it more Mike Knack, Sarah K. S., Nathaniel Scott, Brian E. Driver, Matthew E. Prekker, Lauren Page Black, Charlotte Hopson, Ellen Maruggi, Olivia Kaus, Walker Tordsen, and Michael A. Puskarich. “Early Physician Gestalt Versus Usual Screening Tools for the Prediction of Sepsis in Critically Ill Emergency Patients.” _Annals of Emergency Medicine_ 0, no. 0 (March 25, 2024). [https://doi.org/10.1016/j.annemergmed.2024.02.009](https://doi.org/10.1016/j.annemergmed.2024.02.009). Meinel, Thomas R., Duncan Wilson, Henrik Gensicke, Jan F. Scheitz, Peter Ringleb, Ioana Goganau, Johannes Kaesmacher, et al. “Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants.” _JAMA Neurology_ 80, no. 3 (March 1, 2023): 233–43. [https://doi.org/10.1001/jamaneurol.2022.4782](https://doi.org/10.1001/jamaneurol.2022.4782). Mirfazaelian, Hadi, Ian Stiell, Rasoul Masoomi, Khazar Garjani, and Venkatesh Thiruganasambandamoorthy. “Serious Outcomes among Emergency Department Patients with Presyncope: A Systematic Review.” _Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine_, June 9, 2024. [https://doi.org/10.1111/acem.14943](https://doi.org/10.1111/acem.14943). Nowadly, Craig D., James R. Catlin, and Roderick W. Fontenette. “Push-Dose Vasopressin for Hypotension in Septic Shock.” _The Journal of Emergency Medicine_ 58, no. 2 (February 1, 2020): 313–16. [https://doi.org/10.1016/j.jemermed.2019.12.026](https://doi.org/10.1016/j.jemermed.2019.12.026). Priyadarshi, Amit, Sahil Gupta, Pratyusha Priyadarshini, Abhinav Kumar, Junaid Alam, Dinesh Bagaria, Narendra Choudhary, et al. “Role of Low-Pressure Negative Pleural Suction in Patients with Thoracic Trauma - a Randomized Controlled Trial.” _European Journal of Trauma and Emergency Surgery_, June 14, 2024. [https://doi.org/10.1007/s00068-024-02565-0](https://doi.org/10.1007/s00068-024-02565-0). Widmer, Andreas F., Andrew Atkinson, Stefan P. Kuster, Aline Wolfensberger, Steffi Klimke, Rami Sommerstein, Friedrich S. Eckstein, et al. “Povidone Iodine vs Chlorhexidine Gluconate in Alcohol for Preoperative Skin Antisepsis: A Randomized Clinical Trial.” _JAMA_, June 17, 2024, e248531. [https://doi.org/10.1001/jama.2024.8531](https://doi.org/10.1001/jama.2024.8531). Xiong, Yunyun, Bruce C. V. Campbell, Lee H. Schwamm, Xia Meng, Aoming Jin, Mark W. Parsons, Marc Fisher, et al. “Tenecteplase for Ischemic Stroke at 4.5 to 24 Hours without Thrombectomy.” _New England Journal of Medicine_ 391, no. 3 (July 17, 2024): 203–12. [https://doi.org/10.1056/NEJMoa2402980](https://doi.org/10.1056/NEJMoa2402980). Zouche, Imen, Wassim Guermazi, Faiza Grati, Mohamed Omrane, Salma Ketata, and Hichem Cheikhrouhou. “Intravenous Magnesium Sulfate Improves Orotracheal Intubation Conditions: A Randomized Clinical Trial.” _Trends in Anaesthesia and Critical Care_ 57 (August 1, 2024): 101371. [https://doi.org/10.1016/j.tacc.2024.101371](https://doi.org/10.1016/j.tacc.2024.101371). ## June 2024 ### Andexanet for Factor Xa Inhibitor Reversal (ANNEXA-I) Billed as a positive study by the reps, but I don't think so... [See Justin's amazing take](https://first10em.com/andexanet-alfa-expensive-and-harmful/) - Connolly Stuart J., Sharma Mukul, Cohen Alexander T., Demchuk Andrew M., Członkowska Anna, Lindgren Arne G., Molina Carlos A., et al. “Andexanet for Factor Xa Inhibitor–Associated Acute Intracerebral Hemorrhage.” _New England Journal of Medicine_ 390, no. 19 (May 15, 2024): 1745–55. [https://doi.org/10.1056/NEJMoa2313040](https://doi.org/10.1056/NEJMoa2313040). ### Continuous vs. Bolus of B-Lactam Antibiotics--Show that BLING (III) Pain in the butt--Do we need to do this in the ED - Dulhunty, Joel M., Stephen J. Brett, Jan J. De Waele, Dorrilyn Rajbhandari, Laurent Billot, Menino O. Cotta, Joshua S. Davis, et al. “Continuous vs Intermittent β-Lactam Antibiotic Infusions in Critically Ill Patients With Sepsis: The BLING III Randomized Clinical Trial.” _JAMA_, June 12, 2024. [https://doi.org/10.1001/jama.2024.9779](https://doi.org/10.1001/jama.2024.9779). - Abdul-Aziz, Mohd H., Naomi E. Hammond, Stephen J. Brett, Menino O. Cotta, Jan J. De Waele, Anthony Devaux, Gian Luca Di Tanna, et al. “Prolonged vs Intermittent Infusions of β-Lactam Antibiotics in Adults With Sepsis or Septic Shock: A Systematic Review and Meta-Analysis.” _JAMA_, June 12, 2024. [https://doi.org/10.1001/jama.2024.9803](https://doi.org/10.1001/jama.2024.9803). ### More on Intensive Glucose Control Patient-Level Meta-Analysis - Adigbli, Derick, Yang Li, Naomi Hammond, Richard Chatoor, Anthony G. Devaux, Qiang Li, Laurent Billot, et al. “A Patient-Level Meta-Analysis of Intensive Glucose Control in Critically Ill Adults.” _NEJM Evidence_ 0, no. 0 (June 12, 2024): EVIDoa2400082. [https://doi.org/10.1056/EVIDoa2400082](https://doi.org/10.1056/EVIDoa2400082). ### ReDOSE for Dual Sequential Defib Dual-Sequential was better for both refractory and recurrent. - Cheskes, Sheldon, Ian R. Drennan, Linda Turner, Sandeep V. Pandit, and Paul Dorian. “The Impact of Alternate Defibrillation Strategies on Shock-Refractory and Recurrent Ventricular Fibrillation: A Secondary Analysis of the DOSE VF Cluster Randomized Controlled Trial.” _Resuscitation_ 198 (May 2024): 110186. [https://doi.org/10.1016/j.resuscitation.2024.110186](https://doi.org/10.1016/j.resuscitation.2024.110186). ### Bougie with Hyperangulated FROVA bougie was better. FPS was 1% vs. 11% - “Comparison of the Success Rate of Tracheal Intubation between Stylet and Bougie with a Hyperangulated Videolaryngoscope: A Randomised Controlled Trial.” Accessed June 8, 2024. [https://doi.org/10.1111/anae.16202](https://doi.org/10.1111/anae.16202). ### REVISE: SUP on the Vent When you are going to use SUP, use PPI See the [PulmCrit Post](https://emcrit.org/pulmcrit/revise/) - Cook Deborah, Deane Adam, Lauzier François, Zytaruk Nicole, Guyatt Gordon, Saunders Lois, Hardie Miranda, et al. “Stress Ulcer Prophylaxis during Invasive Mechanical Ventilation.” _New England Journal of Medicine_ 0, no. 0. Accessed June 15, 2024. [https://doi.org/10.1056/NEJMoa2404245](https://doi.org/10.1056/NEJMoa2404245). ### PREOXI see the [EMCrit podcast](https://emcrit.org/377) and wee - Gibbs Kevin W., Semler Matthew W., Driver Brian E., Seitz Kevin P., Stempek Susan B., Taylor Caleb, Resnick-Ault Daniel, et al. “Noninvasive Ventilation for Preoxygenation during Emergency Intubation.” _New England Journal of Medicine_ 0, no. 0. Accessed June 14, 2024. [https://doi.org/10.1056/NEJMoa2313680](https://doi.org/10.1056/NEJMoa2313680). ### TNKase for Minor Strokes with Proven Occlusion (TEMPO-2) NIHSS stroke scale (0-5) in patients with proven occlusions - “Tenecteplase versus Standard of Care for Minor Ischaemic Stroke with Proven Occlusion (TEMPO-2): A Randomised, Open Label, Phase 3 Superiority Trial - The Lancet.” Accessed June 16, 2024. [https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)00921-8/abstract](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)00921-8/abstract). ### Emotion about Hemotion No difference, but people smarter than me seem to find a positive signal in here - Turgeon Alexis F., Fergusson Dean A., Clayton Lucy, Patton Marie-Pier, Neveu Xavier, Walsh Timothy S., Docherty Annemarie, et al. “Liberal or Restrictive Transfusion Strategy in Patients with Traumatic Brain Injury.” _New England Journal of Medicine_ 0, no. 0. Accessed June 14, 2024. [https://doi.org/10.1056/NEJMoa2404360](https://doi.org/10.1056/NEJMoa2404360). ### Reflexive Control in EM How we have our heuristics infiltrated - Iserson, Kenneth V. “Reflexive Control in Emergency Medicine.” _The American Journal of Emergency Medicine_ 81 (July 1, 2024): 75–81. [https://doi.org/10.1016/j.ajem.2024.04.037](https://doi.org/10.1016/j.ajem.2024.04.037). ## April 2024 ### STOP-MSU - TXA Still No Good for ICH - Yassi, Nawaf, Henry Zhao, Leonid Churilov, Teddy Y. Wu, Henry Ma, Huy-Thang Nguyen, Andrew Cheung, et al. “Tranexamic Acid versus Placebo in Individuals with Intracerebral Haemorrhage Treated within 2 h of Symptom Onset (STOP-MSU): An International, Double-Blind, Randomised, Phase 2 Trial.” _The Lancet Neurology_ 0, no. 0 (April 19, 2024). [https://doi.org/10.1016/S1474-4422(24)00128-5](https://doi.org/10.1016/S1474-4422(24)00128-5). ### Minimally Invasive Surgery Showed a Mortality Benefit for Lobar Hemorrhage - Pradilla, Gustavo, Jonathan J. Ratcliff, Alex J. Hall, Benjamin R. Saville, Jason W. Allen, Giorgio Paulon, Anna McGlothlin, et al. “Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage.” _New England Journal of Medicine_ 390, no. 14 (April 11, 2024): 1277–89. [https://doi.org/10.1056/NEJMoa2308440](https://doi.org/10.1056/NEJMoa2308440). ### Thrombectomy for More Penumbra Subclasses - Sarraj, Amrou, Ameer E. Hassan, Michael G. Abraham, Santiago Ortega-Gutierrez, Scott E. Kasner, Muhammad Shazam Hussain, Michael Chen, et al. “Endovascular Thrombectomy for Large Ischemic Stroke Across Ischemic Injury and Penumbra Profiles.” _JAMA_ 331, no. 9 (March 5, 2024): 750–63. [https://doi.org/10.1001/jama.2024.0572](https://doi.org/10.1001/jama.2024.0572). ### Should We Still Give TPA to LVO Cases Meta-analysis of 6 RCTs. After 2 hours 20 minutes, the benefit associated with IVT plus thrombectomy was not statistically significant and the point estimate crossed the null association at 3 hours 14 minutes - Kaesmacher, Johannes, Fabiano Cavalcante, Manon Kappelhof, Kilian M. Treurniet, Leon Rinkel, Jianmin Liu, Bernard Yan, et al. “Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke: A Meta-Analysis.” _JAMA_ 331, no. 9 (March 5, 2024): 764–77. [https://doi.org/10.1001/jama.2024.0589](https://doi.org/10.1001/jama.2024.0589). ## March 2024 ### VENT-Avoid - ECCO2 doesn't Work In this study ECCO2 didn't seem to provide much benefit in either avoiding intubation or speeding extubation, but the intriguing thing and maybe the reason why is that patients got better even after not looking better from an hour of NIPPV. Should have been randomized at the point of the need to intubate? - Duggal, Abhijit, Steven A Conrad, Nicholas A. Barrett, Mohamed Saad, Tariq Cheema, Sonal Pannu, Ramiro Saavedra Romero, et al. “Extracorporeal Carbon Dioxide Removal to Avoid Invasive Ventilation During Exacerbations of Chronic Obstructive Pulmonary Disease: VENT-AVOID Trial.” _American Journal of Respiratory and Critical Care Medicine_, January 23, 2024. [https://doi.org/10.1164/rccm.202311-2060OC](https://doi.org/10.1164/rccm.202311-2060OC). ### SPEED Protocol for Ultrasound in Aortic Dissection [] The protocol included a parasternal long-axis (PSLA) view using the phased array transducer as well as (2) trans-verse and sagittal scans of the abdominal aorta, using the curvilinear transducer, from the diaphragmatic hiatus to the bifurcation into the common iliac arteries. Three sonographic signs suggested AoD: a pericardial effusion, an intimal flap, or an aortic outflow track diameter measuring more than 35 mm. **Sens 93.2% Spec 90.9%** - Gibbons, Ryan C., Dylan Smith, Rivka Feig, Molly Mulflur, and Thomas G. Costantino. “The Sonographic Protocol for the Emergent Evaluation of Aortic Dissections (SPEED Protocol): A Multicenter, Prospective, Observational Study.” _Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine_ 31, no. 2 (February 2024): 112–18. [https://doi.org/10.1111/acem.14839](https://doi.org/10.1111/acem.14839). ### DAShED for Aortic Dissection In this multicentre observational study including 5548 patients with symptoms potentially attributable to AAS, 0.3% of patients presenting with potential AAS symptoms did have AAS and 10% of patients with potential AAS symptoms undergo CT. A third of proven patients with AAS still endure a diagnostic delay over 24 hours from time of arrival. - McLatchie, Rachel, Matthew J. Reed, Nicola Freeman, Richard A. Parker, Sarah Wilson, Steve Goodacre, Alicia Cowan, et al. “Diagnosis of Acute Aortic Syndrome in the Emergency Department (DAShED) Study: An Observational Cohort Study of People Attending the Emergency Department with Symptoms Consistent with Acute Aortic Syndrome.” _Emergency Medicine Journal: EMJ_ 41, no. 3 (February 20, 2024): 136–44. [https://doi.org/10.1136/emermed-2023-213266](https://doi.org/10.1136/emermed-2023-213266). ### Norepi Salts are Different! Society of Critical Care Medicine and European Society of Intensive Care Medicine Joint Task Force Use Norepi Base in all discussions, studies, scores, and labeling - Wieruszewski, Patrick M., Marc Leone, Benjamin Skov Kaas-Hansen, Siddharth Dugar, Matthieu Legrand, Cathrine A. McKenzie, Brittany D. Bissell Turpin, et al. “Position Paper on the Reporting of Norepinephrine Formulations in Critical Care from the Society of Critical Care Medicine and European Society of Intensive Care Medicine Joint Task Force.” _Critical Care Medicine_ 52, no. 4 (April 2024): 521. [https://doi.org/10.1097/CCM.0000000000006176](https://doi.org/10.1097/CCM.0000000000006176). ### Ketamine is Still Looking Better Bayesian meta-analysis hints that etomidate may increase mortality - Koroki, Takatoshi, Yuki Kotani, Takahiko Yaguchi, Taisuke Shibata, Motoki Fujii, Stefano Fresilli, Mayuko Tonai, et al. “Ketamine versus Etomidate as an Induction Agent for Tracheal Intubation in Critically Ill Adults: A Bayesian Meta-Analysis.” _Critical Care (London, England)_ 28, no. 1 (February 17, 2024): 48. [https://doi.org/10.1186/s13054-024-04831-4](https://doi.org/10.1186/s13054-024-04831-4). ### Sterile Water Skin Wheals for Renal Colic - Is this Just Placebo??? Acupuncture to Trigger Point to Placebo Injection or is there something more here? RCT single-blind vs. NSAIDS or Tramadol - Az, Adem, Ozgur Sogut, Tarik Akdemir, and Yunus Dogan. “Intradermal Sterile Water Injection: Safe and Effective Alternative for Relief of Acute Renal Colic in the Emergency Department.” _The Journal of Emergency Medicine_ 66, no. 2 (February 1, 2024): 83–90. [https://doi.org/10.1016/j.jemermed.2023.10.014](https://doi.org/10.1016/j.jemermed.2023.10.014). ### I Like My Albumin in Sepsis so Get Off My Case 100 ml of 20% Albumin looked markedly better than 500 ml of Saline (unfair comparison to say the least) in this prospective, cohort trial--not great evidence, but I'll take what I can get. - Gabarre, Paul, Cyrielle Desnos, Alexandra Morin, Louai Missri, Tomas Urbina, Vincent Bonny, Matthieu Turpin, et al. “Albumin versus Saline Infusion for Sepsis-Related Peripheral Tissue Hypoperfusion: A Proof-of-Concept Prospective Study.” _Critical Care_ 28, no. 1 (February 7, 2024): 43. [https://doi.org/10.1186/s13054-024-04827-0](https://doi.org/10.1186/s13054-024-04827-0). ### Ear & Forehead Thermometers investigated thermometers are not reliable as devices to measure radiant temperature, cannot be used to assess body core temperature during exercise, but may be used as a screening device, with **37.5°C as a threshold** for fever in emergency care settings. - Daanen, Hein A. M., Gercora Hoitinga, David J. Kruijt, Kevin S. Koning, Pooh P. Verheijen, Sanne I. M. de Baas, Anouk R. Bergsma, Cathelijne E. Snethlage, Iman Al-Bander, and Lennart P. J. Teunissen. “Body Core Temperature Assessment in Emergency Care Departments.” _The Journal of Emergency Medicine_ 66, no. 3 (March 1, 2024): e277–83. [https://doi.org/10.1016/j.jemermed.2023.10.027](https://doi.org/10.1016/j.jemermed.2023.10.027). ## January 2024 ### Zosyn doesn't cause kidney failure Change--There was no difference in the primary outcome, highest stage of AKI or death at 14 days, between the groups: OR 0.95 (95%CI 0.80-1.13, p = 0.56). No difference was found for the secondary outcome of major adverse kidney event at day 14 between the two groups: absolute difference 1.4% (95%CI -1.0% to 3.8%). Those who received cefepime had fewer days alive without delirium or coma at 14 days: OR 0.79 (95%CI 0.65-0.95), absolute difference 3.4%. 77.2% were receiving vancomycin at enrollment - Qian, Edward T., Jonathan D. Casey, Adam Wright, Li Wang, Matthew S. Shotwell, Justin K. Siemann, Mary Lynn Dear, et al. “Cefepime vs Piperacillin-Tazobactam in Adults Hospitalized With Acute Infection: The ACORN Randomized Clinical Trial.” _JAMA_ 330, no. 16 (October 24, 2023): 1557–67. [https://doi.org/10.1001/jama.2023.20583](https://doi.org/10.1001/jama.2023.20583). ### Contact Precautions for MRSA No benefit from the effectiveness of contact precautions for MRSA - Diekema, Daniel J, Priya Nori, Michael P Stevens, Matthew W Smith, K C Coffey, and Daniel J Morgan. “Are Contact Precautions ‘Essential’ for the Prevention of Healthcare-Associated Methicillin-Resistant Staphylococcus Aureus?” _Clinical Infectious Diseases_, September 21, 2023, ciad571. [https://doi.org/10.1093/cid/ciad571](https://doi.org/10.1093/cid/ciad571). ### Repeat the ECG Post-Arrest The authors state 8 minutes is the cut-off - Savastano, Simone, Enrico Baldi, Sebastian Schnaubelt, and Angelo Auricchio. “Post Resuscitation ST-Segment Elevation: When a Few Minutes Make the Difference between a Class I and a Class III Indication for Immediate Coronary Angiography.” _Resuscitation_ 192 (November 1, 2023): 109971. [https://doi.org/10.1016/j.resuscitation.2023.109971](https://doi.org/10.1016/j.resuscitation.2023.109971). ### RCT of High-Dose Nitro vs. Low Dose for SCAPE 600-1000 mcg bolus and then start at 100 mcg vs. 20-40 with up-titration - Siddiqua, Naazia, Roshan Mathew, Ankit Kumar Sahu, Nayer Jamshed, Jyothiswaroop Bhaskararayuni, Praveen Aggarwal, Akshay Kumar, and Maroof Ahmad Khan. “High-Dose versus Low-Dose Intravenous Nitroglycerine for Sympathetic Crashing Acute Pulmonary Edema: A Randomised Controlled Trial.” _Emergency Medicine Journal_, November 28, 2023. [https://doi.org/10.1136/emermed-2023-213285](https://doi.org/10.1136/emermed-2023-213285). ### Alcohol Hand Decontamination with Gloves On Randomized trial of usual care vs. over glove scrubbing - Thom, Kerri A., Clare Rock, Gwen L. Robinson, Heather R. S. Reisinger, Jure Baloh, Emily Chasco, Yuanyuan Liang, et al. “Alcohol-Based Decontamination of Gloved Hands: A Randomized Controlled Trial.” _Infection Control & Hospital Epidemiology_, November 23, 2023, 1–7. [https://doi.org/10.1017/ice.2023.243](https://doi.org/10.1017/ice.2023.243). ### Meta-Analysis of High vs. Low Fluid Volume in Adults with Sepsis All I want is to be left alone - Sivapalan, Praleene, Karen L. Ellekjaer, Marie K. Jessen, Tine S. Meyhoff, Maria Cronhjort, Peter B. Hjortrup, Jørn Wetterslev, Anders Granholm, Morten H. Møller, and Anders Perner. “Lower vs Higher Fluid Volumes in Adult Patients With Sepsis.” _Chest_ 164, no. 4 (October 2023): 892–912. [https://doi.org/10.1016/j.chest.2023.04.036](https://doi.org/10.1016/j.chest.2023.04.036). ### Adamgammadex will likely replace Sugammadex Same efficacy but less anaphylaxis - Zhang, Yujun, Yingying Jiang, Qian Lei, Chaoyu Li, Shu’an Jin, Qin Wang, Yidan Huang, et al. “Phase III Clinical Trial Comparing the Efficacy and Safety of Adamgammadex with Sugammadex for Reversal of Rocuronium-Induced Neuromuscular Block.” _British Journal of Anaesthesia_ 0, no. 0 (November 24, 2023). [https://doi.org/10.1016/j.bja.2023.10.022](https://doi.org/10.1016/j.bja.2023.10.022). ### Here is an RCT Saying you Don't Need to Intubate Tox Pts with Low GCS GCS 8 or less. intubation was withheld unless an emergency intubation criterion was met. These included seizure, respiratory distress (defined by a peripheral oxygen saturation as measured by pulse oximetry <90% that persisted after nasal cannula oxygen therapy), vomiting, and shock (defined by a systolic blood pressure <90 mm Hg that persisted after 1 L of crystalloid fluid resuscitation). Better composite endpoint of death, ICU stay, hospital stay. - Freund, Yonathan, Damien Viglino, Marine Cachanado, Clémentine Cassard, Emmanuel Montassier, Bénedicte Douay, Jérémy Guenezan, et al. “Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial.” _JAMA_, November 29, 2023. [https://doi.org/10.1001/jama.2023.24391](https://doi.org/10.1001/jama.2023.24391). ### Cola Doesn't Work RCT shows buying the coke is not the way - Tiebie, E G, E P Baerends, T Boeije, P G Frankenmolen, H Lameijer, W Van Den Berg, K J Van Stralen, M L Ridderikhof, and A J Bredenoord. “Efficacy of Cola Ingestion for Oesophageal Food Bolus Impaction: Open Label, Multicentre, Randomised Controlled Trial.” _BMJ_, December 11, 2023, e077294. [https://doi.org/10.1136/bmj-2023-077294](https://doi.org/10.1136/bmj-2023-077294). ### Stop Slamming Bicarb median values of peak end-tidal CO2 after sodium bicarbonate injection increased by 100% (from 21 to 41 mmHg) in all patients, 89.5% (from 21 to 39 mmHg) in the Spont Circ group, and 160.2% (from 15 to 41 mmHg) in the CPR group. median Tduration was 420 s (IQR: 90-639). - Roh, Young-Il, Hyung Il Kim, Sun Ju Kim, Kyoung-Chul Cha, Woo Jin Jung, Yeon Jae Park, and Sung Oh Hwang. “End-Tidal Carbon Dioxide after Sodium Bicarbonate Infusion during Mechanical Ventilation or Ongoing Cardiopulmonary Resuscitation.” _The American Journal of Emergency Medicine_ 76 (February 2024): 211–16. [https://doi.org/10.1016/j.ajem.2023.11.027](https://doi.org/10.1016/j.ajem.2023.11.027). ### Individual Patient MA of Hypothermia for Non-Shockable Rhythms In this individual patient data meta-analysis, including unconscious survivors from OHCA with an initial nonshockable rhythm, hypothermia at 33 °C did not significantly improve survival or functional outcome - Taccone, Fabio Silvio, Josef Dankiewicz, Alain Cariou, Gisela Lilja, Pierre Asfar, Jan Belohlavek, Thierry Boulain, et al. “Hypothermia vs Normothermia in Patients With Cardiac Arrest and Nonshockable Rhythm:  A Meta-Analysis.” _JAMA Neurology_, December 18, 2023. [https://doi.org/10.1001/jamaneurol.2023.4820](https://doi.org/10.1001/jamaneurol.2023.4820). ## October 2023 ### Another RCT on Ketamine vs. Etomidate gave way too much ketamine (2mg/kg) and still no difference in hypotention - Knack, Sarah K. S., Matthew E. Prekker, Johanna C. Moore, Lauren R. Klein, Alexandra H. Atkins, James R. Miner, and Brian E. Driver. “The Effect of Ketamine Versus Etomidate for Rapid Sequence Intubation on Maximum Sequential Organ Failure Assessment Score: A Randomized Clinical Trial.” _The Journal of Emergency Medicine_ 65, no. 5 (November 1, 2023): e371–82. [https://doi.org/10.1016/j.jemermed.2023.06.009](https://doi.org/10.1016/j.jemermed.2023.06.009). - Please See [EMCrit 291](httos://emcrit.org/291) ### Balanced Solutions in Peds In this RCT, Plyte A over saline for AKF in 1st week - Sankar, Jhuma, Jayashree Muralidharan, A. V. Lalitha, Ramachandran Rameshkumar, Mona Pathak, Rashmi Ranjan Das, Vinay M. Nadkarni, et al. “Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial*.” _Critical Care Medicine_ 51, no. 11 (November 2023): 1449. [https://doi.org/10.1097/CCM.0000000000005952](https://doi.org/10.1097/CCM.0000000000005952). ### Probiotics and Central Lines Do Not Mix Retrospective Study. There are two suspected mechanisms for PACVCBSIs. “Inside out” infections and “outside in” infections (24). Inside-out infections are the result of oral consumption of probiotics and translocation of the ingested microbes from the gastrointestinal tract into the bloodstream (24,25). This event is thought to be provoked by gastrointestinal bleeding and conditions that delay the colonic rate of transit (14,17,26). “Outside in” infections occur when CVCs are externally contaminated by probiotic medications (which are often dispensed as powders and become aerosolized when administered) with subsequent BSI (25,27,28). - Mayer, Scott, Colin Bonhag, Patrick Jenkins, Brendon Cornett, Paula Watts, and Dmitriy Scherbak. “Probiotic-Associated Central Venous Catheter Bloodstream Infections Lead to Increased Mortality in the ICU*.” _Critical Care Medicine_ 51, no. 11 (November 2023): 1469. [https://doi.org/10.1097/CCM.0000000000005953](https://doi.org/10.1097/CCM.0000000000005953). ### Cryostat 2 No diff - Davenport, Ross, Nicola Curry, Erin E. Fox, Helen Thomas, Joanne Lucas, Amy Evans, Shaminie Shanmugaranjan, et al. “Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury: The CRYOSTAT-2 Randomized Clinical Trial.” _JAMA_, October 12, 2023. [https://doi.org/10.1001/jama.2023.21019](https://doi.org/10.1001/jama.2023.21019). ### Biplanar View for Central Lines Everything was better - Li, Ying-Ying, Yi-Hao Liu, Lin Yan, Jing Xiao, Xin-Yang Li, Jun Ma, Li-Gang Jia, et al. “Single-Plane versus Real-Time Biplane Approaches for Ultrasound-Guided Central Venous Catheterization in Critical Care Patients: A Randomized Controlled Trial.” _Critical Care_ 27, no. 1 (September 23, 2023): 366. [https://doi.org/10.1186/s13054-023-04635-y](https://doi.org/10.1186/s13054-023-04635-y). ### ACEP Stroke Guidelines TNK at lower (0.25mg/kg) is now guidelines recommended care - American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Acute Ischemic Stroke, Bruce M. Lo, Christopher R. Carpenter, Stephen Ducey, Michael Gottlieb, Amy Kaji, Deborah B. Diercks, et al. “Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Acute Ischemic Stroke.” _Annals of Emergency Medicine_ 82, no. 2 (August 2023): e17–64. [https://doi.org/10.1016/j.annemergmed.2023.03.007](https://doi.org/10.1016/j.annemergmed.2023.03.007). ### BP Cuff Size Large variance when using the wrong size cuffs; especially with falsely high readings for reg cuff in pts who need large and extra-large - Ishigami, Junichi, Jeanne Charleston, Edgar R. Miller III, Kunihiro Matsushita, Lawrence J. Appel, and Tammy M. Brady. “Effects of Cuff Size on the Accuracy of Blood Pressure Readings: The Cuff(SZ) Randomized Crossover Trial.” _JAMA Internal Medicine_ 183, no. 10 (October 1, 2023): 1061–68. [https://doi.org/10.1001/jamainternmed.2023.3264](https://doi.org/10.1001/jamainternmed.2023.3264). ### Brain Tissue Oxygen Monitoring post TBI Did not have neuro intact survival benefits - Payen, Jean-François, Yoann Launey, Russell Chabanne, Samuel Gay, Gilles Francony, Laurent Gergele, Emmanuel Vega, et al. “Intracranial Pressure Monitoring with and without Brain Tissue Oxygen Pressure Monitoring for Severe Traumatic Brain Injury in France (OXY-TC): An Open-Label, Randomised Controlled Superiority Trial.” _The Lancet Neurology_ 22, no. 11 (November 1, 2023): 1005–14. [https://doi.org/10.1016/S1474-4422(23)00290-9](https://doi.org/10.1016/S1474-4422(23)00290-9). ### Older ED Docs have Higher Mortality Medicare patients aged 65 to 89 years treated by emergency physicians aged under 40 years had lower 7-day mortality rates than those treated by physicians aged 50 to 59 years and 60 years or older within the same hospital. - Miyawaki, Atsushi, Anupam B. Jena, Laura G. Burke, Jose F. Figueroa, and Yusuke Tsugawa. “Association Between Emergency Physician’s Age and Mortality of Medicare Patients Aged 65 to 89 Years After Emergency Department Visit.” _Annals of Emergency Medicine_ 82, no. 3 (September 2023): 301–12. [https://doi.org/10.1016/j.annemergmed.2023.02.010](https://doi.org/10.1016/j.annemergmed.2023.02.010). ## September 2023 ### STREAM-2 Half-dose Tenecteplase for OMI outcomes are as good in older (>60) adults, 6 ICH in ~400 pts in TNK group, 3 were protocol violations - Van de Werf, Frans, Arsen D. Ristić, Oleg V. Averkov, Alexandra Arias-Mendoza, Yves Lambert, José F. Kerr Saraiva, Pablo Sepulveda, et al. “STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment–Elevation Myocardial Infarction: A Randomized, Open-Label Trial.” _Circulation_ 148, no. 9 (August 29, 2023): 753–64. [https://doi.org/10.1161/CIRCULATIONAHA.123.064521](https://doi.org/10.1161/CIRCULATIONAHA.123.064521). ### New Brain Injury Paradigm Pts with TBI on initial head CT. Characterized into 3 groups In BIG 1, no patient worsened clinically, 4 of 301 patients (1.3%) had progression on RHCT with no change in management, and none required neurosurgical intervention. In BIG 2, 2 of 295 patients (0.7%) worsened clinically, and 21 of 295 patients (7.1%) had progression on RHCT. Overall, 7 of 295 patients (2.4%) would have required upgrade from BIG 2 to 3 because of neurologic examination worsening or progression on RHCT, but no patient required neurosurgical intervention.  Failing any criteria in Big 1/2 sent you to the higher category All patients who required neurosurgical intervention were BIG 3 (280 of 1,437 patients [19.5%]). Agreement between assigned and final BIG categories was excellent ( κ = 99%). In this cohort, implementing BIG would have decreased CT scan utilization and neurosurgical consultation by 29% overall, with a 100% reduction in BIG 1 patients and a 98% reduction in BIG 2 patients. - Joseph, Bellal, Omar Obaid, Linda Dultz, George Black, Marc Campbell, Allison E. Berndtson, Todd Costantini, et al. “Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma Prospective Multi-Institutional Trial.” _The Journal of Trauma and Acute Care Surgery_ 93, no. 2 (August 1, 2022): 157–65. [https://doi.org/10.1097/TA.0000000000003554](https://doi.org/10.1097/TA.0000000000003554). ### Aramis RCT for no-tpa in mild stroke NIHSS <=5, basically pts did as well with dual-anti-plt therapy. Read the study for the messy details - Chen, Hui-Sheng, Yu Cui, Zhong-He Zhou, Hong Zhang, Li-Xia Wang, Wei-Zhong Wang, Li-Ying Shen, et al. “Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke: The ARAMIS Randomized Clinical Trial.” _JAMA_ 329, no. 24 (June 27, 2023): 2135–44. [https://doi.org/10.1001/jama.2023.7827](https://doi.org/10.1001/jama.2023.7827). ### Secondary Analysis of ALPS Amio within 8 minutes had all the good PIOs. - “Survival by Time‐to‐administration of Amiodarone, Lidocaine, or Placebo in Shock‐refractory Out‐of‐hospital Cardiac Arrest.” Accessed September 13, 2023. [https://doi.org/10.1111/acem.14716](https://doi.org/10.1111/acem.14716). ## July + August 2023 ### You Can Draw Blood Cultures from Art Lines Duh... - Nakayama, Izumi, Junichi Izawa, Koichiro Gibo, Sara Murakami, Taisuke Akiyama, Yuki Kotani, Rie Katsurai, et al. “Contamination of Blood Cultures From Arterial Catheters and Peripheral Venipuncture in Critically Ill Patients: A Prospective Multicenter Diagnostic Study.” _Chest_ 164, no. 1 (July 2023): 90–100. [https://doi.org/10.1016/j.chest.2023.01.030](https://doi.org/10.1016/j.chest.2023.01.030). ### Give the Macrolides in Severe CAP Reduced long-term mortality by almost a third in this retrospective study - Reyes, Luis Felipe, Esteban Garcia, Elsa D. Ibáñez-Prada, Cristian C. Serrano-Mayorga, Yuli V. Fuentes, Alejandro Rodríguez, Gerard Moreno, et al. “Impact of Macrolide Treatment on Long-Term Mortality in Patients Admitted to the ICU Due to CAP: A Targeted Maximum Likelihood Estimation and Survival Analysis.” _Critical Care_ 27, no. 1 (May 31, 2023): 212. [https://doi.org/10.1186/s13054-023-04466-x](https://doi.org/10.1186/s13054-023-04466-x). ### TTL Can be Surgery or EM Published in an EM Journal & TTLs are slightly different than EPs - Taylor, John, et al. “Do Patient Outcomes Differ When the Trauma Team Leader Is a Surgeon or Non-Surgeon? A Multicentre Cohort Study.” _Canadian Journal of Emergency Medicine_, vol. 25, no. 6, 2023, pp. 489–97, [https://doi.org/10.1007/s43678-023-00516-z](https://doi.org/10.1007/s43678-023-00516-z). ### ICONIC on Conservative vs. Hyperoxic Ventilation in Crit Ill Hyperoxia 95-100% didn't seem to do worse in crit ill population - Conservative versus Liberal Oxygenation Targets in Intensive Care Unit Patients (ICONIC): A Randomized Clinical Trial. Accessed August 16, 2023. [https://read.qxmd.com/read/37552556/conservative-versus-liberal-oxygenation-targets-in-intensive-care-unit-patients-iconic-a-randomized-clinical-trial](https://read.qxmd.com/read/37552556/conservative-versus-liberal-oxygenation-targets-in-intensive-care-unit-patients-iconic-a-randomized-clinical-trial). ### Meta Analysis of Major Adverse Events of Crit Ill Intubations Major adverse events are quite common--be prepared - Downing, Jessica, et al. “Prevalence of Peri-Intubation Major Adverse Events among Critically Ill Patients: A Systematic Review and Meta Analysis.” _The American Journal of Emergency Medicine_, vol. 71, 2023, pp. 200–16, [https://doi.org/10.1016/j.ajem.2023.06.046](https://doi.org/10.1016/j.ajem.2023.06.046). ### Effects of High Fio2 on Atelectasis No difference at the higher fiO2 - Jiang, Zhaoshun, Songbin Liu, Lan Wang, Wanling Li, Cheng Li, Feifei Lang, Ruoxi Li, et al. “Effects of 30% vs. 60% Inspired Oxygen Fraction during Mechanical Ventilation on Postoperative Atelectasis: A Randomised Controlled Trial.” _BMC Anesthesiology_ 23, no. 1 (August 8, 2023): 265. [https://doi.org/10.1186/s12871-023-02226-6](https://doi.org/10.1186/s12871-023-02226-6). ### Single Use Metal was Better than Reusable Metal The pendulum has swung the other way - Chang, Daniel R., et al. “Single-Use versus Reusable Metallic Laryngoscopes for Non-Emergent Intubation: A Retrospective Review of 72,672 Intubations.” _Journal of Clinical Anesthesia_, vol. 89, 2023, p. 111187, [https://doi.org/10.1016/j.jclinane.2023.111187](https://doi.org/10.1016/j.jclinane.2023.111187). ### RCT Show Video Mac better than Video Bronch for Intubation in Immobilization For FPS and speed, too small to evaluate for neurologic compromise - Choi, S., et al. “Videolaryngoscopy vs. Flexible Fibrescopy for Tracheal Intubation in Patients with Cervical Spine Immobilisation: A Randomised Controlled Trial.” _Anaesthesia_, vol. 78, no. 8, 2023, pp. 970–78, [https://doi.org/10.1111/anae.16035](https://doi.org/10.1111/anae.16035). ### Streptokinase Nebulized for ARDS Results seem too good to be true. Small study without a true control group. Wait for replication. - Abdelaal Ahmed Mahmoud, Ahmed, Hatem Elmoutaz Mahmoud, Mohamed Ali Mahran, and Marwa Khaled. “Streptokinase Versus Unfractionated Heparin Nebulization in Patients With Severe Acute Respiratory Distress Syndrome (ARDS): A Randomized Controlled Trial With Observational Controls.” _Journal of Cardiothoracic and Vascular Anesthesia_ 34, no. 2 (February 1, 2020): 436–43. [https://doi.org/10.1053/j.jvca.2019.05.035](https://doi.org/10.1053/j.jvca.2019.05.035). ## June 2023 ### TAME Trial There appears to be no benefit (or harm) to targeting mild hypercapnia (50-55) vs. 35-45. - Eastwood, Glenn, Alistair D. Nichol, Carol Hodgson, Rachael L. Parke, Shay McGuinness, Niklas Nielsen, Stephen Bernard, et al. “Mild Hypercapnia or Normocapnia after Out-of-Hospital Cardiac Arrest.” _New England Journal of Medicine_, June 15, 2023, NEJMoa2214552. [https://doi.org/10.1056/NEJMoa2214552](https://doi.org/10.1056/NEJMoa2214552). - [Bottom Line Summary](https://www.thebottomline.org.uk/blog/ebm/tame/?utm_source=feedly&utm_medium=rss&utm_campaign=tame) ### Dizziness Update [From Grace 3](https://onlinelibrary-wiley-com.eresources.mssm.edu/doi/epdf/10.1111/acem.14728?campaign=woletoc) ### STANDING Protocol STANDING is a four-step bedside algorithm that requires (1) identifying spontaneous nystagmus with Frenzel glasses or, alternatively, a positional nystagmus; (2) characterizing the nystagmus direction; (3) assessing the vestibuloocular reflex (head impulse test); and (4) assessing the gait. The objective was to determine its accuracy for diagnosing central vertigo when using by naïve examiners as such as interns and its agreement with senior EPs [10.1111/acem.14659](https://doi-org.eresources.mssm.edu/10.1111/acem.14659) HINTS+ adds hearing check ### Central Paroxysmal Positional Vertigo TABLE 5 Clinical clues that suggest the possibility of a central mimic (CPPV) rather than typical BPPV 1. Presence of symptoms or signs that are not seen in BPPV a. Prominent acute headache b. Diplopia c. Abnormal cranial nerve or cerebellar function and (new) inability to walk 2. Atypical nystagmus characteristics or symptoms during positional tests a. Downbeating nystagmus that is persistenta b. Nystagmus that starts instantaneously, persists for longer than 90 s, or lacks a crescendo–decrescendo pattern of intensity c. Prominent nystagmus with mild or absent associated dizziness or vertigo 3. Poor response to therapeutic maneuvers a. Repetitive vomiting during positional maneuvers b. Unable to cure patient with canal-specific CRMb c. Frequent recurrent symptoms (10.1111/acem.14558) ### Case report of severe subcut emphysema relieved with angiocaths - [https://doi.org/10.1016/j.jemermed.2023.02.019](https://doi-org.eresources.mssm.edu/10.1016/j.jemermed.2023.02.019) ### CT after Cardiac Arrest Higher rate of identified diagnosis of code. Shorter time to diagnosis. Prospective before/after trial of head to pelvis - 10.1016/j.resuscitation.2023.109785 ### XBJ Herbal Remedy shows Mortality Benefit in Sepsis 28-day mortality rate was significantly different between the placebo group and the XBJ group (230 of 882 patients [26.1%] vs 165 of 878 patients [18.8%], respectively; P < .001). The absolute risk difference was 7.3 (95% CI, 3.4-11.2) percentage points - [https://jamanetwork.com/journals/jama/fullarticle/10.1001/jamainternmed.2023.0780?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2023.0780](https://jamanetwork.com/journals/jama/fullarticle/10.1001/jamainternmed.2023.0780?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2023.0780) ### Explanation for Volume Overload with Intravascular Depletion [https://ccforum.biomedcentral.com/articles/10.1186/s13054-023-04496-5](https://ccforum.biomedcentral.com/articles/10.1186/s13054-023-04496-5) ### Interact3 Care Bundle The care bundle protocol included the early intensive lowering of systolic blood pressure (target <140 mm Hg), strict glucose control (target 6·1–7·8 mmol/L in those without diabetes and 7·8–10·0 mmol/L in those with diabetes), antipyrexia treatment (target body temperature ≤37·5°C), and rapid reversal of warfarin-related anticoagulation (target international normalised ratio <1·5) within 1 h of treatment - Open AccessPublished:May 25, 2023DOI:[https://doi.org/10.1016/S0140-6736(23)00806-1](https://doi.org/10.1016/S0140-6736(23)00806-1) ### Negative LP for SAH <2000 RBCs and absent Xanthrochromia - [https://www.annemergmed.com/article/S0196-0644(21)00118-9/fulltext](https://www.annemergmed.com/article/S0196-0644(21)00118-9/fulltext) - [https://journals.lww.com/em-news/Fulltext/2023/06000/Steer_Clear_of_LPs_for_Diagnosing_SAH.5.aspx/?cid=eTOC+Issues.2021-em-news-00132981-202306000-00000&rid=&TargetID=&EjpToken=BAxyHtdmCxvnPqlVbDmkyYZjYNEx-5ezY9uVxV-VIXKcgQVpg9AwxkwJsCX9G4O45KCWzDZDogaWFCEw&mkt_tok=NjgxLUZIRS00MjkAAAGMGzfD0zyEKVXfb0Z0dtaAoxMwv-nm_REc5mUaMxNokQN_OhbaM3yOFGUW_16RrkTATlbrjCCh0UC9_mSAjLwC-vyCJb_U6dSeGQvRitd_y7OEm2j3Wsw](https://journals.lww.com/em-news/Fulltext/2023/06000/Steer_Clear_of_LPs_for_Diagnosing_SAH.5.aspx/?cid=eTOC+Issues.2021-em-news-00132981-202306000-00000&rid=&TargetID=&EjpToken=BAxyHtdmCxvnPqlVbDmkyYZjYNEx-5ezY9uVxV-VIXKcgQVpg9AwxkwJsCX9G4O45KCWzDZDogaWFCEw&mkt_tok=NjgxLUZIRS00MjkAAAGMGzfD0zyEKVXfb0Z0dtaAoxMwv-nm_REc5mUaMxNokQN_OhbaM3yOFGUW_16RrkTATlbrjCCh0UC9_mSAjLwC-vyCJb_U6dSeGQvRitd_y7OEm2j3Wsw) ### GBS and Canuka Scores Can Both Categorize Pts with Low Risk of Death and Intervention in GI Bleeds - [http://dx.doi.org/10.1136/emermed-2022-213052](http://dx.doi.org/10.1136/emermed-2022-213052) ### Intervention to Get Goals of Care Conversations Done - 10.1001/jama.2023.8812 ### Trace2 Tenecteplase for Stroke - 10.1016/S0140-6736(22)02600-9 ### Lower PEEP in COVID - [https://www-atsjournals-org.eresources.mssm.edu/doi/epdf/10.1164/rccm.202301-0154LE?role=tab](https://www-atsjournals-org.eresources.mssm.edu/doi/epdf/10.1164/rccm.202301-0154LE?role=tab) ### How to Implement an EMS Diversion for ECPR - [https://www.sciencedirect.com/science/article/abs/pii/S0300957223000242?dgcid=raven_sd_via_email](https://www.sciencedirect.com/science/article/abs/pii/S0300957223000242?dgcid=raven_sd_via_email) ### IMIST-AMBO - [https://qualitysafety.bmj.com/content/21/8/627](https://qualitysafety.bmj.com/content/21/8/627) ### Nurse to Nurse Familiarity ? Support for Intact Teams? - [https://pubmed.ncbi.nlm.nih.gov/36219472/](https://pubmed.ncbi.nlm.nih.gov/36219472/) ### Status Leveling Burden is a set of behaviors all female physicians must perfect in order to up-level their status with regards to these two groups on the practice site. **Male physicians.** Men are automatically granted higher status purely virtue of their gender. Women physicians must work to bring themselves up to the level of status and respect of their male colleagues. It takes finesse, practice and effort. **Female nurses.** There is an additional set of behaviors women physicians must master in order to maintain status with Female Nurses on the practice site. Again, these specific communications and acts of kindness take finesse, practice and additional effort that male physicians need not expend at work. - [https://doi.org/10.1177/00018392211038505](https://doi.org/10.1177/00018392211038505) ## December 2022 ### Epo and NO seem Similar on Outcome Chart Review - Bosch, Nicholas A., Anica C. Law, Emily A. Vail, Kari R. Gillmeyer, Hayley B. Gershengorn, Hannah Wunsch, and Allan J. Walkey. “Inhaled Nitric Oxide vs Epoprostenol During Acute Respiratory Failure: An Observational Target Trial Emulation.” _Chest_ 162, no. 6 (December 1, 2022): 1287–96. [https://doi.org/10.1016/j.chest.2022.08.001](https://doi.org/10.1016/j.chest.2022.08.001). ### Benefits or Lack Thereof of the Rectal Exam for Trauma Shortcut Review - Beeton, George, Noah Alter, Ruth Zagales, Hassaan Wajeeh, and Adel Elkbuli. “The Benefits and Clinical Application of the Digital Rectal Exam in Trauma Populations: Towards Enhancing Patient Safety and Quality Outcomes.” _The American Journal of Emergency Medicine_ 63 (January 1, 2023): 132–37. [https://doi.org/10.1016/j.ajem.2022.11.004](https://doi.org/10.1016/j.ajem.2022.11.004). ### NRB + NC Seems to be as Good for COVID-19 as HFNC Small retrospective study - Mohd Kamil, Muhammad Khidir, Khadijah Poh Yuen Yoong, Abdul Muhaimin Noor Azhar, Aida Bustam, Ahmad Hariz Abdullah, Mohd Hafyzuddin Md Yusuf, Aliyah Zambri, Ahmad Zulkarnain Ahmad Zahedi, and Hidayah Shafie. “Non-Rebreather Mask and Low-Flow Nasal Cannula vs High-Flow Nasal Cannula in Severe COVID−19 Pneumonia in the Emergency Department.” _The American Journal of Emergency Medicine_ 63 (January 1, 2023): 86–93. [https://doi.org/10.1016/j.ajem.2022.10.029](https://doi.org/10.1016/j.ajem.2022.10.029). ### O2 Sat Targets in Crit Ill Patients on the Vent (Spo2) (90%; goal range, 88 to 92%), an intermediate target (94%; goal range, 92 to 96%), or a higher target (98%; goal range, 96 to 100%) outcome of vent-free days and mortality all same - Semler, Matthew W., Jonathan D. Casey, Bradley D. Lloyd, Pamela G. Hastings, Margaret A. Hays, Joanna L. Stollings, Kevin G. Buell, et al. “Oxygen-Saturation Targets for Critically Ill Adults Receiving Mechanical Ventilation.” _New England Journal of Medicine_ 387, no. 19 (November 10, 2022): 1759–69. [https://doi.org/10.1056/NEJMoa2208415](https://doi.org/10.1056/NEJMoa2208415). - [Bottom Line Review](https://www.thebottomline.org.uk/summaries/icm/pilot-draft/?utm_source=rss&utm_medium=rss&utm_campaign=pilot-draft) ### Does First Pass Still Matter when Your System is High-Level rules to transcend rules form to transcend form - Ljungqvist, Harry, Jussi Pirneskoski, Anssi Saviluoto, Piritta Setälä, Miretta Tommila, and Jouni Nurmi. “Intubation First-Pass Success in a High Performing Pre-Hospital Critical Care System Is Not Associated with 30-Day Mortality: A Registry Study of 4496 Intubation Attempts.” _Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine_ 30, no. 1 (November 21, 2022): 61. [https://doi.org/10.1186/s13049-022-01049-7](https://doi.org/10.1186/s13049-022-01049-7). ### Still Don't Know What the Hell to Do About Delayed ICH Still don't know what to do in this condition. 1% overall rate of DICH within 90 days. Warfarin slightly increased the risk (OR 1.5). DOACs did not. - Liu, Sharon, Shelley L. McLeod, Clare L. Atzema, Peter C. Austin, Kerstin de Wit, Sunjay Sharma, Nicole Mittmann, Bjug Borgundvaag, and Keerat Grewal. “Delayed Intracranial Hemorrhage after Head Injury among Elderly Patients on Anticoagulation Seen in the Emergency Department.” _CJEM_ 24, no. 8 (December 2022): 853–61. [https://doi.org/10.1007/s43678-022-00392-z](https://doi.org/10.1007/s43678-022-00392-z). In a 2nd trial: Among 280 patients who had a repeat brain CT scan, 21 (7.5%) had a new intracranial hemorrhage on the repeat CT scan. But everyone seemed to do well clinically though there was a loss to f/u in this retrospective study - Flaherty, Stephen, Saptarshi Biswas, Dorraine D. Watts, Nina Y. Wilson, Yan Shen, Jeneva M. Garland, Ransom J. Wyse, et al. “Findings on Repeat Posttraumatic Brain Computed Tomography Scans in Older Patients With Minimal Head Trauma and the Impact of Existing Antithrombotic Use.” _Annals of Emergency Medicine_, November 2022. [https://doi.org/10.1016/j.annemergmed.2022.08.006](https://doi.org/10.1016/j.annemergmed.2022.08.006). ### AHRQ Says We Suck, but I say it says we are Pretty Damn Good! 99.7 % of our patients did not have an error leading to death or serious adverse event. Overall diagnostic accuracy in the emergency department (ED) is high, but some patients receive an incorrect diagnosis (~5.7%). Some of these patients suffer an adverse event because of the incorrect diagnosis (~2.0%), and some of these adverse events are serious (~0.3%). This translates to about 1 in 18 ED patients receiving an incorrect diagnosis, 1 in 50 suffering an adverse event, and 1 in 350 suffering permanent disability or death. These rates are comparable to those seen in primary care and hospital inpatient care. - “Diagnostic Errors in the Emergency Department: A Systematic Review.” Accessed December 21, 2022. [https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency/research](https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency/research). - [Faust's Reply](https://insidemedicine.substack.com/p/breaking-government-report-on-er?utm_source=direct&r=5p3cr&utm_campaign=post&utm_medium=web) ## October & November 2022 ### Police Transport in Trauma Police transport was as good as ALS transport in mortality. Prehospital Needle Decomp was shown to reduce mortality compared to trauma center chest tube in another study. - Taghavi, Sharven, Zoe Maher, Amy J. Goldberg, Elliott R. Haut, Shariq Raza, Grace Chang, Leah C. Tatebe, et al. “An Analysis of Police Transport in an Eastern Association for the Surgery of Trauma Multicenter Trial Examining Prehospital Procedures in Penetrating Trauma Patients.” _The Journal of Trauma and Acute Care Surgery_ 93, no. 2 (August 1, 2022): 265–72. [https://doi.org/10.1097/TA.0000000000003563](https://doi.org/10.1097/TA.0000000000003563). ### Tegaderm for Ocular Ultrasound Images were worse with the tegaderm - Marks, Amy, Daven Patel, Mark Chottiner, Fae Kayarian, Gary D. Peksa, and Michael Gottlieb. “Covered or Uncovered: A Randomized Control Trial of Tegaderm versus No Tegaderm for Ocular Ultrasound.” _The American Journal of Emergency Medicine_ 61 (November 1, 2022): 87–89. [https://doi.org/10.1016/j.ajem.2022.08.044](https://doi.org/10.1016/j.ajem.2022.08.044). ### More on Awareness of Paralysis 66 patients (7.4%; 95% CI, 5.8-9.4) determined to possibly (61 patients) or definitely (5 patients) have experienced and recalled awareness of paralysis. No assoc with Roc in this study. - Driver, Brian E., Matthew E. Prekker, Emily Wagner, Jon B. Cole, Michael A. Puskarich, Jamie Stang, Paige DeVries, Ellen Maruggi, and James R. Miner. “Recall of Awareness During Paralysis Among ED Patients Undergoing Tracheal Intubation.” _Chest_, September 8, 2022. [https://doi.org/10.1016/j.chest.2022.08.2232](https://doi.org/10.1016/j.chest.2022.08.2232). ### Source Control in Sepsis ~5,000 patients with community-acquired sepsis, 29% reduction in risk-adjusted odds of 90-day mortality for patients who had early source control (< 6 hours) compared to those with late source control (6-36 hours). Abdominal/GI catastrophes and soft-tissue sources of infection rather than orthopedic or cranial. Another trial specifically in peritonitis showed source control more important than antibiotics - Reitz, Katherine M., Jason Kennedy, Shimena R. Li, Robert Handzel, Daniel A. Tonetti, Matthew D. Neal, Brian S. Zuckerbraun, et al. “Association Between Time to Source Control in Sepsis and 90-Day Mortality.” _JAMA Surgery_ 157, no. 9 (September 1, 2022): 817–26. [https://doi.org/10.1001/jamasurg.2022.2761](https://doi.org/10.1001/jamasurg.2022.2761). - De Pascale, Gennaro, Massimo Antonelli, Mieke Deschepper, Kostoula Arvaniti, Koen Blot, Ben Creagh Brown, Dylan de Lange, et al. “Poor Timing and Failure of Source Control Are Risk Factors for Mortality in Critically Ill Patients with Secondary Peritonitis.” _Intensive Care Medicine_ 48, no. 11 (November 1, 2022): 1593–1606. [https://doi.org/10.1007/s00134-022-06883-y](https://doi.org/10.1007/s00134-022-06883-y). ### A Way to Risk Adjust Studies of Induction Agents in Hemodynamically Unstable Patients the mean SI for ketamine was 0.97 vs 0.83 for etomidate - Foster, Mitchell, Michael Self, Alon Gelber, Brent Kennis, Daniel R. Lasoff, Stephen R. Hayden, and Gabriel Wardi. “Ketamine Is Not Associated with More Post-Intubation Hypotension than Etomidate in Patients Undergoing Endotracheal Intubation.” _The American Journal of Emergency Medicine_ 61 (September 5, 2022): 131–36. [https://doi.org/10.1016/j.ajem.2022.08.054](https://doi.org/10.1016/j.ajem.2022.08.054). ### Burnout Burns Patients - Hodkinson, Alexander, Anli Zhou, Judith Johnson, Keith Geraghty, Ruth Riley, Andrew Zhou, Efharis Panagopoulou, et al. “Associations of Physician Burnout with Career Engagement and Quality of Patient Care: Systematic Review and Meta-Analysis.” _BMJ_ 378 (September 14, 2022): e070442. [https://doi.org/10.1136/bmj-2022-070442](https://doi.org/10.1136/bmj-2022-070442). ###Mild Decrease in HR with Phenyl vs. Norepi in Sepsis and Afib - Law, Anica C., Nicholas A. Bosch, Daniel Peterson, and Allan J. Walkey. “Comparison of Heart Rate After Phenylephrine vs Norepinephrine Initiation in Patients With Septic Shock and Atrial Fibrillation.” _Chest_ 162, no. 4 (October 1, 2022): 796–803. [https://doi.org/10.1016/j.chest.2022.04.147](https://doi.org/10.1016/j.chest.2022.04.147). ### Negative CT = Discharge Seat-Belt Sign? In this most recent study, a negative CT was defined as  1. **No free fluid (free fluid was the leading indicator of occult hollow viscus injury)** 2. No solid organ injury 3. No bowel wall irregular contours, thickening, hematoma or air 4. No abdominal wall soft tissue contusion 5. No mesenteric stranding or hematoma 6. No bowel dilatation - Delaplain, Patrick T., Erika Tay-Lasso, Walter L. Biffl, Kathryn B. Schaffer, Margaret Sundel, Samar Behdin, Mira Ghneim, et al. “Excluding Hollow Viscus Injury for Abdominal Seat Belt Sign Using Computed Tomography.” _JAMA Surgery_ 157, no. 9 (September 1, 2022): 771–78. [https://doi.org/10.1001/jamasurg.2022.2770](https://doi.org/10.1001/jamasurg.2022.2770). ### Just Like For Hip Fractures, Radiographs are Not Great for Finding Pelvic Fractures Radiographs were <50% Sensitive - Ma, Yuntong, Jacob C. Mandell, Tatiana Rocha, Maria ADuran Mendicuti, Michael J. Weaver, and Bharti Khurana. “Diagnostic Accuracy of Pelvic Radiographs for the Detection of Traumatic Pelvic Fractures in the Elderly.” _Emergency Radiology_, October 3, 2022. [https://doi.org/10.1007/s10140-022-02090-w](https://doi.org/10.1007/s10140-022-02090-w). ### Sugammadex for Neuro Exam Just putting into the lit what we've been doing since it came out. Only 11 pts. - Hyland, Sara J., Punit A. Pandya, Cameron J. Mei, and David C. Yehsakul. “Sugammadex to Facilitate Neurologic Assessment in Severely Brain-Injured Patients: A Retrospective Analysis and Practical Guidance.” _Cureus_ 14, no. 10 (October 19, 2022). [https://doi.org/10.7759/cureus.30466](https://doi.org/10.7759/cureus.30466). ### DoseVF: Dual Sequential Defib now Finally Proven Efficacious Pts remaining in Vfib/Tach after 3 shocks in anterolateral. **Added a delay between shocks for DSD.** Also looked at Vector change. DSD was assoc with both discharge from hospital and neuro intact survival. VC was assoc with increased discharge from hospital. - Cheskes, Sheldon, P. Richard Verbeek, Ian R. Drennan, Shelley L. McLeod, Linda Turner, Ruxandra Pinto, Michael Feldman, et al. “Defibrillation Strategies for Refractory Ventricular Fibrillation.” _The New England Journal of Medicine_, November 6, 2022. [https://doi.org/10.1056/NEJMoa2207304](https://doi.org/10.1056/NEJMoa2207304). - See [First10EM](https://first10em.com/dose-vf-a-double-sequential-defibrillation-game-changer/) for a great write-up ### Follow-up [First10EM Piece](https://first10em.com/the-peach-trial-of-seizure-prophylaxis-for-head-bleeds-not-such-a-peach/) ## September 2022 ### TTM for IHCA No difference in this multi-center RCT - Wolfrum, Sebastian, Kevin Roedl, Alexia Hanebutte, Rüdiger Pfeifer, Volkhard Kurowski, Reimer Riessen, Anne Daubmann, et al. “Temperature Control After In-Hospital Cardiac Arrest: A Randomized Clinical Trial.” _Circulation_ 0, no. 0 (n.d.): 10.1161/CIRCULATIONAHA.122.060106. [https://doi.org/10.1161/CIRCULATIONAHA.122.060106](https://doi.org/10.1161/CIRCULATIONAHA.122.060106). ### Should ICH Get Seizure Proph Small study--what should we do... - Peter-Derex, Laure, Frédéric Philippeau, Pierre Garnier, Nathalie André-Obadia, Sébastien Boulogne, Hélène Catenoix, Philippe Convers, et al. “Safety and Efficacy of Prophylactic Levetiracetam for Prevention of Epileptic Seizures in the Acute Phase of Intracerebral Haemorrhage (PEACH): A Randomised, Double-Blind, Placebo-Controlled, Phase 3 Trial.” _The Lancet Neurology_ 21, no. 9 (September 1, 2022): 781–91. [https://doi.org/10.1016/S1474-4422(22)00235-6](https://doi.org/10.1016/S1474-4422(22)00235-6). ### Albumin for Cirrhotic Sepsis 0.5-1g/kg over 3 hrs - Maiwall, Rakhi, Abhinav Kumar, Samba Siva Rao Pasupuleti, Ashini Kumar Hidam, Harshvardhan Tevethia, Guresh Kumar, Amrish Sahney, Lalita Gouri Mitra, and Shiv Kumar Sarin. “A Randomized-Controlled Trial Comparing 20% Albumin to Plasmalyte in Patients with Cirrhosis and Sepsis-Induced Hypotension [ALPS Trial].” _Journal of Hepatology_ 77, no. 3 (September 1, 2022): 670–82. [https://doi.org/10.1016/j.jhep.2022.03.043](https://doi.org/10.1016/j.jhep.2022.03.043). ### More on Tenecteplase 0.25 mg/kg seems to be as good as alteplase - Menon BK, Buck BH, Singh N, et al. **Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial.** Lancet. 2022 Jul 16;400(10347):161-169. doi: 10.1016/S0140-6736(22)01054-6. Epub 2022 Jun 29. (_Original study_) ### Use the 3 Unless Too Big for It Multi-center retrospective, many more got mac 4--mac 3 was better - Godet, Thomas, Audrey De Jong, Côme Garin, Renaud Guérin, Benjamin Rieu, Lucile Borao, Bruno Pereira, et al. “Impact of Macintosh Blade Size on Endotracheal Intubation Success in Intensive Care Units: A Retrospective Multicenter Observational MacSize-ICU Study.” _Intensive Care Medicine_ 48, no. 9 (September 1, 2022): 1176–84. [https://doi.org/10.1007/s00134-022-06832-9](https://doi.org/10.1007/s00134-022-06832-9). ### Propofol Assassins? Prop assoc with increased risk of hemodynamic instability and card arrest - Russotto, Vincenzo, Sheila Nainan Myatra, John G. Laffey, Elena Tassistro, Laura Antolini, Philippe Bauer, Jean Baptiste Lascarrou, et al. “Intubation Practices and Adverse Peri-Intubation Events in Critically Ill Patients From 29 Countries.” _JAMA_ 325, no. 12 (March 23, 2021): 1164–72. [https://doi.org/10.1001/jama.2021.1727](https://doi.org/10.1001/jama.2021.1727). ### MAP Targets after Arrest Targeting a mean arterial blood pressure of 77 mm Hg or 63 mm Hg in patients who had been resuscitated from cardiac arrest did not result in significantly different percentages of patients dying or having severe disability or coma - Kjaergaard, Jesper, Jacob E. Møller, Henrik Schmidt, Johannes Grand, Simon Mølstrøm, Britt Borregaard, Søren Venø, et al. “Blood-Pressure Targets in Comatose Survivors of Cardiac Arrest.” _New England Journal of Medicine_, August 27, 2022. [https://doi.org/10.1056/NEJMoa2208687](https://doi.org/10.1056/NEJMoa2208687). ### Use VL for TEE Probe Insertion - Borde, Deepak, Kumar C, Amish Jasapara, Vijay Shetty, Nilesh Juvekar, Vinayak Desurkar, Jyoti Gaidu, et al. “Use of a Video Laryngoscope to Reduce Complications of Transesophageal Echocardiography Probe Insertion: A Multicenter Randomized Study.” _Journal of Cardiothoracic and Vascular Anesthesia_ 0, no. 0 (July 20, 2022). [https://doi.org/10.1053/j.jvca.2022.07.017](https://doi.org/10.1053/j.jvca.2022.07.017). ### And the Pendulum Swings Back for TXA and Epistaxis - Hosseinialhashemi, Milad, Reza Jahangiri, Ali Faramarzi, Naeimehossadat Asmarian, Sarvin Sajedianfard, Maryam Kherad, Amir Soltaniesmaeili, and Amirhossein Babaei. “Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial.” _Annals of Emergency Medicine_ 80, no. 3 (September 1, 2022): 182–88. [https://doi.org/10.1016/j.annemergmed.2022.04.010](https://doi.org/10.1016/j.annemergmed.2022.04.010). ### Another Bias Confirmed for Sedation for Cardiogenic Shock - Scherer, Clemens, Jan Kleeberger, Antonia Kellnar, Leonhard Binzenhöfer, Enzo Lüsebrink, Thomas J. Stocker, Stefan A. Berghoff, et al. “Propofol versus Midazolam Sedation in Patients with Cardiogenic Shock - an Observational Propensity-Matched Study.” _Journal of Critical Care_ 71 (October 1, 2022): 154051. [https://doi.org/10.1016/j.jcrc.2022.154051](https://doi.org/10.1016/j.jcrc.2022.154051). ## August 2022 ### Awareness during Paralysis Secondary analysis of paralyzed adults in the ED-SED trial - Fuller, Brian M., Ryan D. Pappal, Nicholas M. Mohr, Brian W. Roberts, Brett Faine, Julianne Yeary, Thomas Sewatsky, et al. “Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study.” _Critical Care Medicine_, July 22, 2022. [https://doi.org/10.1097/CCM.0000000000005626](https://doi.org/10.1097/CCM.0000000000005626). ### Hitting the Ratios - Beckermann, Jason, Hayden Swartz, Jill Albright, Wayne Street, Scott Martin, Clint Hagen, Maria Linnaus, and David Ciresi. “Achieving Optimal Massive Transfusion Ratios: The Trauma White Board, Whole Blood, and Liquid Plasma. Real World Low-Tech Solutions for a High Stakes Issue.” _Injury_, June 21, 2022, S0020-1383(22)00418-1. [https://doi.org/10.1016/j.injury.2022.06.009](https://doi.org/10.1016/j.injury.2022.06.009). ### Going Ape over MonkeyPox - Thornhill, John P., Sapha Barkati, Sharon Walmsley, Juergen Rockstroh, Andrea Antinori, Luke B. Harrison, Romain Palich, et al. “Monkeypox Virus Infection in Humans across 16 Countries — April–June 2022.” _New England Journal of Medicine_ 0, no. 0 (July 21, 2022): null. [https://doi.org/10.1056/NEJMoa2207323](https://doi.org/10.1056/NEJMoa2207323). ### A Spike in Stupidity Joint commission has put a 1-hr limit on spiked iv bags. Pharm org Recs meant for compounded preps--not commercial IV bags. - [News, Anesthesiology. “‘Spiking’ and the Joint Commission.” Accessed August 10, 2022](https://emcrit.org/wp-content/uploads/2022/08/IV-Bag-Spiking.pdf) ### Bicarb during Peds Arrest Associated with worse outcomes in a prop. matched secondary analysis - Cashen, Katherine, Ron W. Reeder, Tageldin Ahmed, Michael J. Bell, Robert A. Berg, Candice Burns, Joseph A. Carcillo, et al. “Sodium Bicarbonate Use During Pediatric Cardiopulmonary Resuscitation: A Secondary Analysis of the ICU-RESUScitation Project Trial.” _Pediatric Critical Care Medicine: A Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies_, July 26, 2022. [https://doi.org/10.1097/PCC.0000000000003045](https://doi.org/10.1097/PCC.0000000000003045). ### Finally a Limit to Obs in Abd Stabs - Owattanapanich, Natthida, Camilla Cremonini, Morgan A. Schellenberg, Kazuhide Matsushima, Meghan R. Lewis, Lydia Lam, Matthew J. Martin, and Kenji Inaba. “Prospective Evaluation of the Selective Nonoperative Management of Abdominal Stab Wounds: When Is It Safe to Discharge?” _The Journal of Trauma and Acute Care Surgery_, July 5, 2022. [https://doi.org/10.1097/TA.0000000000003733](https://doi.org/10.1097/TA.0000000000003733). ### Validation of a Better Pocus Pulse Check - Kang, Soo Yeon, Ik Joon Jo, Guntak Lee, Jong Eun Park, Taerim Kim, Se Uk Lee, Sung Yeon Hwang, et al. “Point-of-Care Ultrasound Compression of the Carotid Artery for Pulse Determination in Cardiopulmonary Resuscitation.” _Resuscitation_, July 2, 2022. [https://doi.org/10.1016/j.resuscitation.2022.06.025](https://doi.org/10.1016/j.resuscitation.2022.06.025). ### Another Study Against Post-Arrest Cath for NSTEMI (Should be NOMI) - Hauw-Berlemont, Caroline, Lionel Lamhaut, Jean-Luc Diehl, Christophe Andreotti, Olivier Varenne, Pierre Leroux, Jean-Baptiste Lascarrou, et al. “Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized, Multicentric EMERGE Trial.” _JAMA Cardiology_ 7, no. 7 (July 1, 2022): 700–707. [https://doi.org/10.1001/jamacardio.2022.1416](https://doi.org/10.1001/jamacardio.2022.1416). ## June/July 2022 ### Give Anti-Dysrhythmics ASAP Earlier the better - Rahimi, Mahbod, Paul Dorian, Sheldon Cheskes, Gerald Lebovic, and Steve Lin. “Effect of Time to Treatment With Antiarrhythmic Drugs on Return of Spontaneous Circulation in Shock-Refractory Out-of-Hospital Cardiac Arrest.” _Journal of the American Heart Association_ 11, no. 6 (March 15, 2022): e023958. [https://doi.org/10.1161/JAHA.121.023958](https://doi.org/10.1161/JAHA.121.023958). ### LOVIT: Vitamin C is not just useless for Sepsis, it seems to be Harmful 872 pt RCT. In adults with sepsis receiving vasopressor therapy in the ICU, those who received intravenous vitamin C had a higher risk of death or persistent organ dysfunction at 28 days than those who received placebo. - See the [St. Emlyn's Review](https://www.stemlynsblog.org/jc-vitamin-c-and-sepsis-again-st-emlyns/) - Lamontagne, François, Marie-Hélène Masse, Julie Menard, Sheila Sprague, Ruxandra Pinto, Daren K. Heyland, Deborah J Cook, et al. “Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit.” _New England Journal of Medicine_ 0, no. 0 (June 15, 2022): null. [https://doi.org/10.1056/NEJMoa2200644](https://doi.org/10.1056/NEJMoa2200644). ### CLASSIC Fluid Trial The total difference in fluids administered by day 5 was only ~2L (8.8L vs 10.8L), with a difference of only ~800mls in the cumulative day 5 fluid balance - [Bottom Line Review](https://www.thebottomline.org.uk/summaries/icm/classic-trial/?utm_source=rss&utm_medium=rss&utm_campaign=classic-trial) - New England Journal of Medicine. “Restriction of Intravenous Fluid in ICU Patients with Septic Shock | NEJM.” Accessed June 21, 2022. [https://www.nejm.org/doi/pdf/10.1056/NEJMoa2202707](https://www.nejm.org/doi/pdf/10.1056/NEJMoa2202707). ### Nielsen Meta-Analysis Still no difference!!! - Holgersson, Johan, Martin Abild Stengaard Meyer, Josef Dankiewicz, Gisela Lilja, én Susann Ull, Christian Hassager, Tobias Cronberg, et al. “Hypothermic versus Normothermic Temperature Control after Cardiac Arrest.” _NEJM Evidence_ 0, no. 0 (n.d.): EVIDoa2200137. [https://doi.org/10.1056/EVIDoa2200137](https://doi.org/10.1056/EVIDoa2200137). ### Misinformation on Social Media may lead to Revocation of your Fellow Board Status Slippery slope or finally getting it right? - Baron, Richard J., and Yul D. Ejnes. “Physicians Spreading Misinformation on Social Media — Do Right and Wrong Answers Still Exist in Medicine?” _New England Journal of Medicine_, May 18, 2022. [https://doi.org/10.1056/NEJMp2204813](https://doi.org/10.1056/NEJMp2204813). ### Diuretics vs. Volume Expansion for Sub-Massive PEs Another bias confirmer... - See the [bottom line review](https://www.thebottomline.org.uk/summaries/ferrari/?utm_source=feedly&utm_medium=rss&utm_campaign=ferrari) - Ferrari, Emile, Benjamin Sartre, Mohamed Labbaoui, Nathan Heme, Florian Asarisi, Nassim Redjimi, Etienne Fourrier, et al. “Diuretics Versus Volume Expansion in the Initial Management of Acute Intermediate High-Risk Pulmonary Embolism.” _Lung_ 200, no. 2 (April 2022): 179–85. [https://doi.org/10.1007/s00408-022-00530-5](https://doi.org/10.1007/s00408-022-00530-5). ### NC vs. HFNC for Preox Not much difference - Admin, Annals. “Pre- and Apnoeic High-Flow Oxygenation for Rapid Sequence Intubation in the Emergency Department (the Pre-AeRATE Trial): A Multicentre Randomised Controlled Trial - Annals Singapore,” March 28, 2022. [https://annals-edu-sg.eresources.mssm.edu/pre-and-apnoeic-high-flow-oxygenation-for-rapid-sequence-intubation-in-the-emergency-department-the-pre-aerate-trial-a-multicentre-randomised-controlled-trial/](https://annals-edu-sg.eresources.mssm.edu/pre-and-apnoeic-high-flow-oxygenation-for-rapid-sequence-intubation-in-the-emergency-department-the-pre-aerate-trial-a-multicentre-randomised-controlled-trial/). ### Yes, Easy Access to a Psych ED makes Care Better They built a unit in the ED for suicidal patients - Kim, Allison K., J. Priyanka Vakkalanka, Paul Van Heukelom, Jodi Tate, and Sangil Lee. “Emergency Psychiatric Assessment, Treatment, and Healing (EmPATH) Unit Decreases Hospital Admission for Patients Presenting with Suicidal Ideation in Rural America.” _Academic Emergency Medicine_ 29, no. 2 (2022): 142–49. [https://doi.org/10.1111/acem.14374](https://doi.org/10.1111/acem.14374). ### Put in the Damn A-Line Pretty massive variance for the SBP in the first 24 hours after sICH - Garg, Rajeev K., Bichun Ouyang, Amer Zwein, Varoon Thavapalan, Ajit Indavarapu, Kathryn Cheponis, Nicholas Osteraas, et al. “Systolic Blood Pressure Measurements Are Unreliable for the Management of Acute Spontaneous Intracerebral Hemorrhage.” _Journal of Critical Care_ 70 (August 1, 2022): 154049. [https://doi.org/10.1016/j.jcrc.2022.154049](https://doi.org/10.1016/j.jcrc.2022.154049). ## May 2022 ### Long Covid is Real, but Probably Supra-Tentorial As we probably all thought... - Fantastic Twitter Thread by [@awgaffney](https://twitter.com/awgaffney/status/1528876982754476032?s=12&t=outjqduW_U1wEFwpFqylzQ) - Sneller, Michael C., C. Jason Liang, Adriana R. Marques, Joyce Y. Chung, Sujata M. Shanbhag, Joseph R. Fontana, Haniya Raza, et al. “A Longitudinal Study of COVID-19 Sequelae and Immunity: Baseline Findings.” _Annals of Internal Medicine_, May 24, 2022. [https://doi.org/10.7326/M21-4905](https://doi.org/10.7326/M21-4905). ### Noise in the ED Just like you may have guessed... It is loud! - Background noise in an Emergency Department: an observational study from staff and patient perspectives Murad Emar, Ella Smith, Timothy J Coats doi: https://doi.org/10.1101/2022.05.20.22275148 ### Very Nice Massive Hemoptysis Review Add it your files - Charya, Ananth V., Van K. Holden, and Edward M. Pickering. “Management of Life-Threatening Hemoptysis in the ICU.” _Journal of Thoracic Disease_ 13, no. 8 (August 2021): 5139–58. [https://doi.org/10.21037/jtd-19-3991](https://doi.org/10.21037/jtd-19-3991). ### Adding Fentanyl to Ketamine/Roc Completely makes sense: Use fentanyl only if you need to blunt hypertension Gave same amount of fentanyl in mcg as ketamine in mg vs. NS; ketamine dose 1-2 mg/kg unless hypotensive, then got 0.5-1 mg/kg. Conclusions from Authors: There was an increased incidence of hypotension and reduced incidence of hypertension in the fentanyl group. Clinicians should consider postinduction haemodynamic targets before the decision to use fentanyl as a co-induction agent with ketamine - Ferguson, Ian, Alexander Buttfield, Brian Burns, Cliff Reid, Shamus Shepherd, James Milligan, Ian A. Harris, Anders Aneman, and the Australasian College for Emergency Medicine Clinical Trials Network. “Fentanyl versus Placebo with Ketamine and Rocuronium for Patients Undergoing Rapid Sequence Intubation in the Emergency Department: The FAKT Study—A Randomized Clinical Trial.” _Academic Emergency Medicine_ n/a, no. n/a. Accessed May 28, 2022. [https://doi.org/10.1111/acem.14446](https://doi.org/10.1111/acem.14446). ### Two More on TNK for Ischemic Stroke RCT done in an Aussie MSU using 0.25 mg/kg showed better outcomes with TNK and the 2nd in Norway (NOR-TEST 2-A) using 0.4 mg/kg showed safety concerns and was terminated early. The same trial is continuing with a prespecified 0.25 mg/kg dose - Bivard, Andrew, Henry Zhao, Leonid Churilov, Bruce C. V. Campbell, Skye Coote, Nawaf Yassi, Bernard Yan, et al. “Comparison of Tenecteplase with Alteplase for the Early Treatment of Ischaemic Stroke in the Melbourne Mobile Stroke Unit (TASTE-A): A Phase 2, Randomised, Open-Label Trial.” _The Lancet Neurology_ 21, no. 6 (June 1, 2022): 520–27. [https://doi.org/10.1016/S1474-4422(22)00171-5](https://doi.org/10.1016/S1474-4422(22)00171-5). - Kvistad, Christopher Elnan, Halvor Næss, Bernt H. Helleberg, Titto Idicula, Guri Hagberg, Linn Marie Nordby, Kristian N. Jenssen, et al. “Tenecteplase versus Alteplase for the Management of Acute Ischaemic Stroke in Norway (NOR-TEST 2, Part A): A Phase 3, Randomised, Open-Label, Blinded Endpoint, Non-Inferiority Trial.” _The Lancet Neurology_ 21, no. 6 (June 1, 2022): 511–19. [https://doi.org/10.1016/S1474-4422(22)00124-7](https://doi.org/10.1016/S1474-4422(22)00124-7). ### IV APAP didn't Spare the Mo'Fine Even though IV acetaminophen is now cheap, it probably doesn't add that much to acute pain protocols. These folks used 0.1 mg/kg morphine followed by 0.05 mg/kg q 15 until pain controlled. - Minotti, Bruno, Gregory Mansella, Robert Sieber, Alexander Ott, Christian H. Nickel, and Roland Bingisser. “Intravenous Acetaminophen Does Not Reduce Morphine Use for Pain Relief in Emergency Department Patients: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial.” _Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine_, May 2, 2022. [https://doi.org/10.1111/acem.14517](https://doi.org/10.1111/acem.14517). ### ETCO2 < 30 was Associated with Increased Need for Blood and Trauma Severity I've spoken about it a bunch, here is another study supporting this modality as a severity marker - Portelli Tremont, Jaclyn N., Ricardo A. Caldas, Nicole Cook, Pascal Osi Udekwu, and Scott M. Moore. “Low Initial In-Hospital End-Tidal Carbon Dioxide Predicts Poor Patient Outcomes and Is a Useful Trauma Bay Adjunct.” _The American Journal of Emergency Medicine_ 56 (June 1, 2022): 45–50. [https://doi.org/10.1016/j.ajem.2022.03.034](https://doi.org/10.1016/j.ajem.2022.03.034). ## April 2022 ### Perceptions of DNR Orders Medical team, esp. surgeons equate with no life-sustaining measures - Driggers, Kathryn E., Sydney E. Dishman, Kevin K. Chung, Cara H. Olsen, Andrea B. Ryan, Melissa M. McLawhorn, and Laura S. Johnson. “Perceptions of Care Following Initiation of Do-Not-Resuscitate Orders.” _Journal of Critical Care_ 69 (June 1, 2022): 154008. [https://doi.org/10.1016/j.jcrc.2022.154008](https://doi.org/10.1016/j.jcrc.2022.154008). ### Is the Computer Read Good Enough Can a normal computer read obviate the need for ED Doc overread? - Winters, Leigha J., Ramandeep K. Dhillon, Gurjit K. Pannu, Patrick Terrassa, James F. Holmes, and Mary L. Bing. “Emergent Cardiac Outcomes in Patients with Normal Electrocardiograms in the Emergency Department.” _The American Journal of Emergency Medicine_ 51 (January 1, 2022): 384–87. [https://doi.org/10.1016/j.ajem.2021.11.023](https://doi.org/10.1016/j.ajem.2021.11.023). ### The Word Quiet Found to be Safe - Geller, Jennifer E., Pamela Ohman Strickland, and Joshua T. Bucher. “The Use of the Word ‘Quiet’ in the Emergency Department Is Not Associated with Patient Volume: A Randomized Controlled Trial.” _The American Journal of Emergency Medicine_ 56 (June 1, 2022): 10–12. [https://doi.org/10.1016/j.ajem.2022.03.020](https://doi.org/10.1016/j.ajem.2022.03.020). ### Challenging Dogma when Evidence is Lacking Furosemide for APE, etc. See the PDF - Hofmaenner, Daniel A., and Mervyn Singer. “Challenging Management Dogma Where Evidence Is Non-Existent, Weak or Outdated.” _Intensive Care Medicine_ 48, no. 5 (May 2022): 548–58. [https://doi.org/10.1007/s00134-022-06659-4](https://doi.org/10.1007/s00134-022-06659-4). ### Dopamine Still Sucks as if we needed more... - Suzuki, Reina, Shigehiko Uchino, Yusuke Sasabuchi, Alan Kawarai Lefor, and Masamitsu Sanui. “Dopamine Use and Its Consequences in the Intensive Care Unit: A Cohort Study Utilizing the Japanese Intensive Care PAtient Database.” _Critical Care_ 26, no. 1 (December 2022): 90. [https://doi.org/10.1186/s13054-022-03960-y](https://doi.org/10.1186/s13054-022-03960-y). ### RePHILL Will have Karim Brohi's take out in the next Podcast - Crombie, Nicholas, Heidi A. Doughty, Jonathan R. B. Bishop, Amisha Desai, Emily F. Dixon, James M. Hancox, Mike J. Herbert, et al. “Resuscitation with Blood Products in Patients with Trauma-Related Haemorrhagic Shock Receiving Prehospital Care (RePHILL): A Multicentre, Open-Label, Randomised, Controlled, Phase 3 Trial.” _The Lancet. Haematology_ 9, no. 4 (April 2022): e250–61. [https://doi.org/10.1016/S2352-3026(22)00040-0](https://doi.org/10.1016/S2352-3026(22)00040-0). ### Awareness after ED Intubation First10EM's blog reminded me to mention this one - Pappal, Ryan D., Brian W. Roberts, Nicholas M. Mohr, Enyo Ablordeppey, Brian T. Wessman, Anne M. Drewry, Winston Winkler, et al. “The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department.” _Annals of Emergency Medicine_ 77, no. 5 (May 2021): 532–44. [https://doi.org/10.1016/j.annemergmed.2020.10.012](https://doi.org/10.1016/j.annemergmed.2020.10.012). ## Mar 2022 ### Was the Original Metabolic Cocktail Trial Fraudulent? [Scattrd Corn Blogpost](https://kylesheldrick.blogspot.com/2022/03/evidence-of-fabricated-data-in-vitamin.html) by Kyle Sheldrick ### Shocking Afib At least for Afib, Anterior-Lateral seems to be more effective Circulation_ 144, no. 25 (December 21, 2021): 1995–2003. [https://doi.org/10.1161/CIRCULATIONAHA.121.056301](https://doi.org/10.1161/CIRCULATIONAHA.121.056301). ### Early Norepi despite Preload Propensity score matched < 3 hrs associated with survival and other good stuff AJEM [Early Norepi in AJEM](https://doi.org/10.1016/j.ajem.2022.01.063 "Persistent link using digital object identifier") ### WireSafe Forcing mechanism to recognize the wire is not out I would change it to putting the flushes in there JICS https://doi.org/10.1177/17511437211069318](https://doi.org/10.1177%2F17511437211069318) ### HR for PE Severity A cutoff value of 140 beats/min vs 110 beats/min increased the specificity of the Bova score from 93.2% to 98.0% for identification of intermediate- to high-risk patients. Chest. 2022 Feb doi: 10.1016/j.chest.2021.08.059. Epub 2021 Aug 31. ### Dose of Insulin for HyperK in Kidney Failure 10 was better than 5 without hypoglycemia -0.9 vs. 0.64 [5 versus 10 Units of Intravenous Insulin for Hyperkalemia in Patients With Moderate Renal Dysfunctions](https://journalfeed.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=b242fbb0b6&e=76efe8d219). J Emerg Med. ### More (Albeit Not Great) Evidence to Not Give Mg for Asthma Asthma scoring was worse in kiddies. See the [3MG Trial](https://pubmed.ncbi.nlm.nih.gov/24731521/) Thanks to my buddies at JournalFeed [Prospective Observational Study of Clinical Outcomes After Intravenous Magnesium for Moderate and Severe Acute Asthma Exacerbations in Children](https://journalfeed.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=86967d1f4b&e=76efe8d219). J Allergy Clin Immunol Pract. ### Small IVC May Predict Moderate to Severe Hemorrhage Using a cut off of <=0.8 cm may predict hemorrhage before vital sign abnormalities JEM https://doi.org/10.1016/j.jemermed.2021.07.049 ### ## Jan 2022 ### Reversal of Anti-PLT Agents doesn't seem to confer mortality benefit Big database review in J Trauma doi: 10.1097/TA.0000000000003421 ### The PROPER3 Randomized Clinical Trial Fixed Dose is Non-Inferior to Variable Ann Emerg Med 1000 IU of PCC vs. Manufacturer Recs 10.1016/j.annemergmed.2021.06.016 ### Adverse Events Associated with Flumazenil to Reverse Benzodiazapenes PENNINGA E ET AL.Adverse Events Associated with Flumazenil Treatment for the Management of Suspected Benzodiazepine Intoxication--A Systematic Review with Meta-Analyses of Randomized Trials. Basic Clin Pharmacol Toxicol. 2016 DOI: [10.1111/bcpt.12434](https://doi.org/10.1111/bcpt.12434) ### Comparison of Push-Dose Pressors [10.1016/j.ajem.2021.11.033](https://doi.org/10.1016/j.ajem.2021.11.033 "Persistent link using digital object identifier") ### How (not) to Lower BP for Alteplase Comparison of intermittent versus continuous infusion antihypertensives in acute ischemic stroke [10.1016/j.ajem.2021.11.037](https://doi.org/10.1016/j.ajem.2021.11.037 "Persistent link using digital object identifier") ### TNK is Faster than tPA [10.1161/SVIN.121.000102](https://doi.org/10.1161/SVIN.121.000102)Stroke: Vascular and Interventional Neurology. 2021;1:e000102 ### Stop with the EPI In-Hospital Prioritize the Shock Epinephrine before defibrillation in patients with shockable in-hospital cardiac arrest: propensity matched analysis BMJ 2021; 375 doi: https://doi.org/10.1136/bmj-2021-066534 (Published 10 November 2021) Cite this as: BMJ 2021;375:e066534 ### Global Commentary Stop HAT!!!! No Cocktails at work Marik resigned ### A Nice Rapid Placebo for Low Back Pain [The effectiveness of intradermal sterile water injection for low back pain in the emergency department: A prospective, randomized controlled study](https://journalfeed.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=b2f36c9cf1&e=76efe8d219). Am J Emerg Med. 2021 Apr;42:103-109. doi: 10.1016/j.ajem.2021.01.038. Epub 2021 Jan 20. ### Equilibrating SSC guidelines with individualized Care Jean-Louis Vincent, Mervyn Singer Critical Care volume 25, Article number: 397 (2021) ## Dec 2021 - [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](https://jamanetwork.com/journals/jama/fullarticle/2786819?resultClick=1) - Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest - See [Bottom Line](https://www.thebottomline.org.uk/summaries/coca/?utm_source=feedly&utm_medium=rss&utm_campaign=coca) - Negative with point estimate veering towards harm - Friend to the Show, David Barbic, did an RCT demonstrating Ketamine is better than haldol/midaz for rapid agitation control. All those who use ketamine knew this already but we need studies like this for the doubters. [10.1016/j.annemergmed.2021.05.023] :LOGBOOK: CLOCK: [2021-11-28 Sun 10:15:10]--[2021-11-28 Sun 10:15:12] => 00:00:02 CLOCK: [2021-11-28 Sun 10:15:12]--[2021-11-28 Sun 10:15:13] => 00:00:01 CLOCK: [2021-11-28 Sun 10:15:14] :END: - 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 - Friend to the show, Brian Driver did an amazing study demonstrating that you need to engage the median glossoepiglottic fold or the view is crap. I have countless videos to prove this [10.1016/j.annemergmed.2021.04.024] - Video Laryngoscopy had sig. better 1st pass success than standard in Trauma patients from the NEAR database [10.1016/j.annemergmed.2021.07.115] - Tiny Trial of reversal of anti-coagulation in LVAD patients with ICH showed no complications [Neurocritical Care volume 2021;35:506] - MR Clean-NO IV showed no difference between complications or benefits when pts with LVO were randomized to pre-tPA or none. [10.1056/NEJMoa2107727] - CAPITAL CHILL trial No, 31C is not better than 34C for post-arrest patients. [doi: 10.1001/jama.2021.15703. PMID: 34665203] - P-CAT Trial shows we can use pigtails in traumatic hemothorax See the excelletn St. Emlyns review: [JC: Can we use smaller pigtail drains in traumatic haemothorax? • St Emlyn's](https://www.stemlynsblog.org/jc-can-we-use-smaller-pigtail-drains-in-traumatic-haemothorax/) [10.1097/TA.0000000000003180] - Pre-Charging the Defibrillator Before Rhythm Checks in Cardiac Arrest leads to better compression fraction. See the RebelEM blog for a [great writeup](https://rebelem.com/pre-charging-the-defibrillator-before-rhythm-checks-in-cardiac-arrest/?utm_source=feedly&utm_medium=rss&utm_campaign=pre-charging-the-defibrillator-before-rhythm-checks-in-cardiac-arrest) [34627866] - The method of cricothyroid membrane location that I have taught in the EMCrit classes has now been validated as superior in an RCT. Always go from the notch up rather than from the top down. [10.1213/ANE.0000000000005744] - Your sterile technique game is poor!! [Ultrasound Guidance and Risk for Central Venous Catheter-Related Infections in the Intensive Care Unit: A Post Hoc Analysis of Individual Data of 3 Multicenter Randomized Trials](https://journalfeed.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=d380269856&e=76efe8d219). Clin Infect Dis. 2021 Sep 7;73(5):e1054-e1061. doi: 10.1093/cid/ciaa1817. collapsed:: true - So stop placing them. Use Midlines. Less infection and less occlusion. doi:10.1001/jamainternmed.2021.6844 - Crossed-Leg Sign (Tilli's Sign) actually seemed to have pretty good test characteristics [Annals of Emergency Medicine Volume 78, Issue 4, October 2021, Pages 573-574] - I think this is finally enough to make a departmental policy to use adjusted d-dimer in pregnancy to rule out PE [D-Dimer to rule out venous thromboembolism during pregnancy: a systematic review and meta-analysis. J Thromb Haemost. 2021 Jun 23. doi: 10.1111/jth.15432.] - Reverse Valsalva Maneuver The reverse vagal manoeuvre: A new tool for treatment of supraventricular tachycardia? Am J Emerg Med. 2021 Mar;41:66-69. doi: 10.1016/j.ajem.2020.12.061. Epub 2020 Dec 26. - Bougie Trial Driver et al. ~1100 pts https://jamanetwork.com/journals/jama/fullarticle/2787158 no difference between bougie and stylet, but both groups has 1st pass success at 80.4 and 83% respectively. See [Crit Care Reviews Livestream](https://criticalcarereviews.com/) Not excellent at bougie use - EvK Trial at PGA shows Improved 7 day (but not 28day survival) with ketamine vs. etomidate ([10.1007/s00134-021-06577-x](https://doi.org/10.1007/s00134-021-06577-x)) - - - - -