ACEP and Essentials 2014
Pearls and Highlights
Nov 26 2014
Sean Wormsbecker
Peter Macdonald
Janice Wong
Katie Sullivan
Strictly an overview...
• Brief synopses of interesting topics
• Not comprehensive reviews of topics
• Generate discussion and interest for future
rounds
Essentials Pearls
Sean Wormsbecker
Topical Tetracaine in Corneal Abrasions
• 1: Topical tetracaine used for 24 hours is safe and rated highly
effective by patients for the treatment of pain caused by
corneal abrasions: a double-blind, randomized clinical trial.
Waldman N, Densie IK, Herbison P. Acad Emerg Med. 2014
Apr;21(4):374-82
• RCT of 122 patients with simple corneal abrasions on slit lamp
• No difference in healing (uptake of fluorescein on repeat
exam)
• Similar pain scoring, but treatment group reported better
“effectiveness of treatment”
Topical Tetracaine in Corneal Abrasions
• Ready for primetime?
– Small study
– No contrary evidence of harm
• What do our colleagues say?
Post-Arrest Cooling
• Targeted temperature management at 33°C versus 36°C after
cardiac arrest. Nielsen N, Wetterslev J, Cronberg T et al. NEJM.
2013 Dec 5;369(23):2197-206
• Multicentre RCT of 950 patients randomized to tight
temperature control of 33°C versus 36°C
• Primary outcome all cause mortality at six months
• Secondary outcome modified Rankin score >=4 at six months
• No significant difference
Post-Arrest Cooling
• Perhaps focus less on the number, more on
the process
– Criticism of original data was lack of
protocolization of care in control arm, poor fever
control
• Again, what do our colleagues say?
Age-Adjusted D-Dimer in PE
• Age-adjusted D-dimer cutoff levels to rule out pulmonary
embolism: the ADJUST-PE study. Righini M, Van Es J, Den Exter
PL et al. JAMA. 2014 Mar 19;311(11):1117-24
• Multicentre prospective validation of using age x 10 as a cutoff for ruling out PE in Wells Criteria low risk patients
• 3346 patients enrolled over 3 years, of which 87% were low
risk, of which 28% were <500, 11% were age-adjusted
negative
• 1/810 (0.1%) nonfatal PE in <500, 1/337 (0.3%) nonfatal PE in
age-adjusted, 7/1481 (0.5%) still had PE or DVT with negative
CTPA (!)
Age-Adjusted D-Dimer in PE
• Authors felt most applicable to patients >75,
as this group is most likely to have a false
positive d-dimer at <500
• Application of age adjustment increased
negative d-dimer from 6.6% to 29.7% with no
additional misses in this group
Etomidate and Sepsis
• Single-dose etomidate is not associated with increased
mortality in ICU patients with sepsis: analysis of a large
electronic ICU database. McPhee LC, Badawi O, Fraser GL et
al. Crit Care Med. 2013 Mar;41(3):774-83
• Retrospective Database study of 750 000 patients
• Sought out septic patients intubated in the ICU (not ED)
• N= 2,014: Single dose etomidate = 1,102 and no etomidate =
912
• Attempted matching age, comorbidities, but etomidate arm
actually sicker
• No difference in mortality
Etomidate and Sepsis
• Is this relevant to us?
– Why use instead of ketamine?
• What do our colleagues say?
Tranexamic Acid and Epistaxis
• A new and rapid method for epistaxis treatment using injectable
form of tranexamic acid topically: a randomized controlled trial.
Zahed R, Moharamzadeh P, Alizadeharasi S et al. Am J Emerg Med.
2013 Sep;31(9):1389-92.
• N=216, 15 cm cotton pledget was soaked in the IV form of TXA
(500mg in 5ml) and inserted in the bleeding nares (no formal
packing) versus formal packing with pledgets soaked in epi and
lidocaine
• 71% of the TXA vs. 31% of the nasal packing group stopped
bleeding by 10 minutes (OR 2.3, p<0.001)
• Rebleeding was less common in the TXA group (4.7% vs. 12.8% at
24 hours and 2.8% vs. 11.0% at 7 days)
• Time to discharge and ED complications also favored the TXA group
Tranexamic Acid and Epistaxis
• Apples and Oranges?
– We use rapid rhino, not conventional packs
• Consider as adjunct?
Preoxygenation and RSI
• Weingart, Scott D., and Richard M. Levitan. "Preoxygenation and
prevention of desaturation during emergency airway
management." Annals of emergency medicine 59.3 (2012): 165175.
• Preoxygenation: Adequate time on TRUE 100% O2
– CPAP masks or BVM with PEEP valve for patients unable to obtain sats
greater than 93-95% by conventional means
– Ideally should be >3 minutes or 8 deep breaths in awake patients
– Patients should be in head-elevated position during pre-oxygenation (or
reverse trendelenberg in the spinal patient
– Controversial/not yet primetime: use of ketamine to allow NIPPV to
preoxygenate in the combative patient with intact airway reflexes and
respiratory effort – “Delayed Sequence Intubation”
• Maintenance of Oxygenation with Apneic Oxygenation via NP
Preoxygenation and RSI
• Most of us have adopted high-flow NP
oxygenation
• Value in establishing a common
preoxygenation protocol/checklist for our RTs?
• Consider DSI in the “right” patient?
The Dallas Protocol in Pediatric DKA
• Low morbidity and mortality in children with diabetic ketoacidosis
treated with isotonic fluids. White PC1, Dickson BA. J Pediatr. 2013
Sep;163(3):761-6. doi: 10.1016/j.jpeds.2013.02.005. Epub 2013 Mar
15.
• Compared a simplified 3 stage protocol of fluids
to standard care
• Gives overall more Na and H2O compared to
conventional care
• Showed extremely low rates of death/disability
compared to rates quoted by ADA (0.08% versus
0.3%)
The Dallas Protocol in Pediatric DKA
The Dallas Protocol in Pediatric DKA
• Would require pre-mixed solutions
• So far has not been validated at other sites
• Worth discussing with our colleagues?
ACEP Highlights
Peter Macdonald
SSTI
Uncomplicated cellulitis without evidence of
abcess formation
• No evidence that adding Septra to treatment
is beneficial
• Treat with Keflex alone
SSTI
Treatment of Abcess may change
• I+D
• Soon to released paper found that treatment
with TMP/SMS is more effective than placebo
• 93% vs 85.7% cure rate
• Secondary outcomes better as well – recurrence,
need for hospital visits, infections in family
members
• Stay tuned
TAMIFLU
• Indications for use have not changed despite
Cochrane review stating that it has limited
efficacy
• May lessen duration of symptoms by ½ day
• No change in mortality
• Reason for “no indication change” may be
related to $1.3 billion US govt spent
stockpiling this med?
PROCESS TRIAL
• EGDT is as good as “usual” sepsis care in terms
of mortality
• Keys to treatment are early fluids and
antibiotics, measure lactate and use serial
lactates…lactate clearance is still a reasonable
marker.
• MAP 60 – 65 is reasonable goal
• Avoid pressors – increase mortality
• No need for blood transfusion unless Hb<7
PEDIATRIC INFECTIONS
Jerry and Rick
• Relationship between pediatric UTI and long
term renal sequella is limited.
• Should be no need to catheterize febrile
pediatric patients to obtain a urine
PEDIATRIC INFECTIONS
Duration of symptoms in children
• Croup – 2 days
• Sore throat – 7 days
• Bronchiolitis – 2 wks
• Common cold / bronchitis – 25 days
ACEP 2014
Pearls
Janice Wong
Purpura…
… in the IVDU patient?
Levamisole-Induced Necrosis Syndrome
•
•
•
•
Cocaine adulterant
Antihelminthic, immunomodulant
Causes agranulocytosis, vasculitis
Found in 82% cocaine-related seizures (2011)
Optimal Positioning for LP in children
evaluated by bedside U/S
Pediatrics 2010; 125: e1149–e1153
Goal: maximize interspinous space
• 28 subjects, median age 5 years, u/s
evaluation of interspinous space in 5 positions
• Use of portable u/s @ L3/L4, L4/L5 levels
CONCLUSIONS
• The interspinous space of the lumbar spine was maximally
increased with children in the sitting position with flexed hips
• In the lateral recumbent position, neck flexion does not
increase the interspinous space and may increase morbidity
A New Technique
For Fast and Safe Collection
of Urine in Newborns
Arch Dis Child 2013; 98: 27-29
ACEP 2014 Pearls
Katie Sullivan
ACEP PEARLS
• ALL VF arrests should go for EARLY PCI, even
w/o STEMI on EKG (increased survival to
hospital discharge)
• hsTroponin (quickly becoming standard of
care) dx AMI in 0-2 hrs (when will this come to
Fraser Health?)
ACEP PEARLS
• Consider lytics for Intermediate Risk PE (RV
dysfnx, +trop)
– Mortality benefit
– CAUTION with pts >65 yrs (increased major bleeding
and ICH)
– Consider using ½ dose of lytics
• Evidence for NIPPV in Asthma, Chest Trauma and
Procedural Sedation
• Random household toxins: Cinnamon acts as a
caustic when swallowed in excess
References for ACEP Pearls
•
Therapeutic Hypothermia:
Nielsen N, Wetterslev J, Cronberg T et al. Targeted Temperature Management at 33oC vs. 36oC after Cardiac Arrest. New Engl J Med 2013; 369:2197-2206
Kim F, Nichol G, Maynard C et al. Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurologic Status Among Adults with Cardiac Arrest A Randomized Clinical Trial. JAMA 2014;
311: 45-52
•
PCI Post Cardiac Arrest:
Hollenbeck RD, McPherson JA, Mooney MR et al. Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI. Resus 2014;85:88-95
Callaway CW, Schmicker RH, Brown SP et al. Early coronary angiography and induced hypothermia are associated with survival and functional recovery after out-of-hospital cardiac arrest. Resus
2014;85:657-63
•
HsTroponin:
Bandstein N, Ljung R, Johansson M et al. Undetectable High Sensitivity Cardiac Troponin T Level in the Emergency Department and Risk of Myocardial Infarction. JACC 2014 (in press)
•
Age-Adjusted D-Dimer:
Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism The ADJUST-PE Study. JAMA 2014;311:1117-24
•
Lytics in PE
Chatterjee S, Chakraborty A, Weinberg I et al. Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality, Major Bleeding and Intracranial Hemorrhage A Meta-analysis. JAMA
2014;311:2414-2421
Meyer G, Vicaut E, Danays T et al. Fibrinolysis for Patients with Intermediate-Risk Pulmonary Embolism. NEJM 2014;370:1402-11
•
NIPPV:
Ram FS, Wellington S, Rowe B et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev
2005(3):CD004360
The safety and efficacy of noninvasive ventilation in patients with blunt chest trauma: a systematic review. Crit Care 2013;17:R142
NIPPV for Procedural Sedation. Am J Emerg Med 2010;28:750
•
Cinnamon Toxicity:
Doctors warn teens about taking the “cinnamon challenge” in a new Report. Associated Press April 22, 2013 (Chicago)
Grant-Alfieri A. Pediatrics 2013.
Thanks!
(Let me know what you want to hear more of)