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

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

Critical Plays

N Engl J Med 2014; 370:1683-1693 doi: 10.1056/NEJMoa1401602
-       Multicenter, RCT Protocolized Care for Early Septic Shock (ProCESS) at 31 US hospitals
-       Results: n = 1351, in 1st 6 h, more fluids in the protocol-based standard-therapy group
-       No difference in mortality at 60/90/365 days (18-20%) or organ support
-       Bottom line:  Identify sepsis quickly, with early fluids and antibiotics. Management with ScvO2 monitoring, pressors or specific MAP targets still unproven (independently) to change mortality.

N Engl J Med 2014; 371(16): 1496–1506, doi:10.1056/NEJMoa1404380
-       51 sites, n= 1600, usual care compared to Goal directed therapy
-       Results: more fluids in 1st 6 hr + pressor in EGDT group, no mortality difference (18%),
-       Limitation: Hawthorne effect from EGDT team being present?
-       Bottom line: sepsis care has come a long way with lower mortality no need for SvO2 measurement, central line, transfusion or arterial line

Holst  N Engl J Med 2014; 371:1381-1391October 9, 2014 DOI: 10.1056/NEJMoa1406617
-       ICU study of transfusion trigger in randomized patients with septic shock comparing Hgb threshold at 70 or 90 g/L.  At 90 days there were no differences in mortality, ischemic events or critical interventions though the higher threshold patients had a median of three extra transfusions (of leukoreduced packed red cells). 
-       Bottom line: another study suggesting no benefit from aggressively transfusing patients to maintain hemoglobin >90 g/L[JF1] 

Asfar et al. N Engl J Med 2014; 370:1583-1593 Apr 24, 2014 doi: 10.1056/NEJMoa1312173
-       Randomized, open-label trial comparing 776 patients with septic shock treated to a MAP target of either 80-85 mm Hg or 65-70 mm Hg.
-       Results: No difference in mortality at either 28 or 90 days
-       Bottom line: No compelling evidence that higher BP resuscitation improves outcome[JF2] 

Chatterjee et al, JAMA. 2014; 311(23):2414-2421. doi:10.1001/jama.2014.5990
-       Systematic review on mortality benefits and bleeding risks with thrombolytic therapy vs anticoagulation, with subset of stable patients+RV dysfunction (Intermediate risk)
-       Results (16 studies): Thrombolytics associated with lower all cause mortality (OR 0.53; 95% CI 0.32-0.88; NNT = 59), higher major bleed (OR 2.73, NNH =18) including ICH

Meyer et al,N Engl J Med. 2014. 370(15):1402-1411.
-       1,005 patients with submassive PE (hemodynamic stability with RV strain and étroponins) given heparin (UFH) with either tenecteplase or placebo
-       Results: No mortality benefit at day 7/30 (less hemodynamic compromise [unsure clinical significance]- balanced out by increased rates of major extracranial bleeding at 7 days (6.3% vs. 1.2%; NNH 20) and strokes at 7 days (2.4% vs. 0.2%; NNH 45).
-       Limitations: Not powered to detect differences in mortality
-       Bottom line: Consider Lytic in <65 yo in stable submassive PE

Game Changing Plays

7.   Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol  
Than et al, Emergency Medicine Australasia 26, no. 1 (January 15, 2014): 34–44, doi:10.1111/1742-6723.12164.
-       Prospective development and validation of a clinical decision rule to safely rule out adult patients with at least 5 minutes of chest pain symptoms suggestive of ischemia.  Age, sex, risk factors, diaphoresis, and pain qualities were combined into a weighted rule, which in combination with EKG and 2 hour negative troponin, was able to safely identify 40–50% of patients presenting to the ED with possible cardiac chest pain as having low risk of short-term (30 day) complications.
-       Limitations: a moderately cumbersome rule, not validated outside of their setting
-       Bottom line: Their decision rule (EDACS-ADP: available at seems to be a quick and easy risk stratification tool for sending home low risk patients

Smith-Bindman R et al N Engl J Med 2014 Sep 18; 371:1100
-       2776 adult patients with flank or abdominal pain were randomized to US or CT (1/2 of ultrasounds were done at bedside by EP).  Initial US had less radiation than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events at 30 days, pain scores, return ED visits, or hospitalizations.
-       Bottom line: patients with low risk for non-renal pathology seem to do just as well with ultrasound as an initial screening tool – Emergency docs can do this safely with training.

9.   The loop technique: a novel incision and drainage technique in the treatment of skin abscesses in a pediatric ED 
Ladde et al,The American Journal of Emergency Medicine, October 16, 2014, doi:10.1016/j.ajem.2014.10.014.
-       Retrospective study comparing standard I/D vs. loop drainage in 142 patients )5 weeks – 18 yrs, 75% MRSA)(excluded: face, scalp, hands, feet), x 10 days + warm soaks, DC when no drainage/induration (x 1 follow up) Treatment failure:  16.5% I/D vs 4% LOOP
-       Highest failure in head and neck for I/D, buttock for LOOP
-       Limitations: those who had sedation had better outcome, some done in OR
-       Bottom line: Loop drainage should be considered a safe option to I& D of abscesses
(Related: Loop drainage of cutaneous abscesses using a modified sterile glove: a promising technique Thompson, The Journal of Emergency Medicine, June 10, 2014, doi:10.1016/j.jemermed.2014.04.035.)

10.   Delayed Sequence Intubation: A Prospective Observational Study 
Weingart et al, Annals Emerg Med, October 23, 2014, doi:10.1016/j.annemergmed.2014.09.025
-       3 sites, prospective, observational study
-       Ketamine IV 1mg/kg + 0.5mg/kg to dissociation, High-flow O2+ NRB/NIPPV x 3 min
-       Muscle relaxant + nasal cannula apneic oxygenation, and intubation 45-60 sec post
-       Results: 64 pts (2 excluded - no post DSI Sat, but both had 100% sat on ABG), Sat from a mean of 89.9% →98.8%, with an increase of 8.9% (95% CI 6-10%).
-       Limitations: not randomized, all MDs with extensive ketamine experience
-       Bottom line: Ketamine is an option for delayed intubation in experienced hands

11.   Management of the Bleeding Patient Receiving New Oral Anticoagulants: A Role for Prothrombin Complex Concentrates
Baumann Kreuziger et al, BioMed Research International Volume 2014, Article ID 583794, 
-       A nice summary of available human and animal data guiding selection of a PCC in the protocols for NOAC-associated hemorrhage.  A simple figure reviews an approach using PCC’s, transfusions, and possibly dialysis for dabigatran.
-       Limitations: “These protocols are based on limited human data”
-       Bottom line: See for up to date guidelines on NOAC bleeding

12.   Free Open access medical education (FOAM) for the emergency physician
Nickson and Cadogan, Emergency Medicine Australasia 26, no. 1 (February 4, 2014): 76–83, doi:10.1111/1742-6723.12191.
-       High-quality medical education resources and interactions should be free and accessible to all who care for patients.
-       Bottom line: Use Google FOAM as your search engine (but buyer beware)

13.   Alpha-blockers as medical expulsive therapy for ureteral stones.
Campschroer et al, Cochrane Database Syst Rev. 2014;4:CD008509.
-       Meta-analysis of 32 studies of alpha blockers in treatment for ureteral stones. 
-       Results: Stone expulsion time was 2.9 days shorter with the use of alpha blockers.  Also reduced the number of pain episodes, the need for other analgesic and hospitalization.
-       Bottom line: alpha-blockers results in a higher stone-free rate and a shorter time to stone expulsion

Trick Plays

14.   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 et al. Acad Emerg Med 2014 Apr; 21:374.
-       Prospective, double-blinded RCT of 116 patients with uncomplicated corneal abrasions - 1% tetracaine vs. saline q30 minutes prn pain for 24 hours
-       Limitations: poor blinding, underpowered, and poor follow-up
-       Bottom line:  Likely that tetracaine does not increase infections or delay healing when used for 24 hours and improves satisfaction

15.   Comparison of therapeutic effects of magnesium sulfate vs. Dexamethasone/metoclopramide on alleviating acute migraine headache
Ali Shahrami et al., J Emerg Med., 2014, doi:10.1016/j.jemermed.2014.06.055
-       Prospective RCT(n = 70) of 8mg dex +10mg metoclopramide vs. 1gm Mg over 15 min
-       Limitations: No NSAIDS in ‘conventional’ therapy, little details about pts
-       Results: Sig. decrease for Mg at 20 min (35% change), 1 hour (71%) and 2 hr (90%)
-       Bottom line: Consider Magnesium in your arsenal of migraine treatment

16.   Sedative Dosing of Propofol for Treatment of Migraine Headache in the Emergency Department: A Case Series 
Mosier et al, Western J Emerg Med 2013: 14, (6): 646–49, doi:10.5811/westjem.2013.7.18081.
-       Case series of 4 patients, using Propofol as slow infusion (1 minute) until pt fell asleep without change in end-tidal CO2 or a change in resp rate or O2 sat.
-       Mean LOS usually is 6.5 hours (95% CI 6.16-6.84) vs 3.1 hour (95% CI 2-4.8)
-       Limitation: Procedure (1: 1 RN, MD) and monitoring cost, propofol dependency
-       Bottom line: If failed all kinds of migraine meds, consider, but need ++ monitoring

17.   Lidocaine and Pain Management in the Emergency Department: A Review
EJ Golzari et al, Anesth Pain Med. 2014 February; 4(1): e15444. doi:  10.5812/aapm.15444
-       Commonly used in chronic pain management, the options for ED use of lidocaine are not as well recognized.   This review article summarizes the diverse options for lidocaine, including multiple routes in varied conditions.  Worth reconsidering in renal colic, headache, intractable, neuropathic, complex and chronic pain.
-       Bottom line:  Add lidocaine as a safe option into your pain management arsenal.

Beaudoin et al., Acad Emerg Med 2014: 21(11): 1193–1202, doi:10.1111/acem.12510.
-       A blinded RCT in patients given morphine0.1 mg/kg, then placebo or low dose ketamine (0.15 or 0.3 mg/kg)
-       Results: n = 69 (over 10 months!): lost 9 before drug
-       Pain scores decreased over time, but difference higher in ketamine group
-       Bottom line: Another tool to treat pain, particularly for pain refractory to opioids.

19.   Prehospital use of IM ketamine for sedation of violent and agitated patients.
West J Emerg Med 2014 Nov 11; 15:736. Scheppke KA et al. 
-       Florida study of 52 patients treated with ketamine by EMS with 4 mg/kg IM.  96% were sedate quickly, most within 2 minutes.
-       Limitations:  ½ of patients were given IM midazolam also, of which 3/52  needed bagging
-       Bottom line:  Ketamine is mostly safe in agitated delirium to quickly gain control


Fumbles and Interceptions 

20.   Prednisone for emergency department low back pain  
Eskin et al. J Emerg Med. 2014 Jul;47(1):65-70.doi: 10.1016/j.jemermed.2014.02.010.
-       Small RCT (n=79) comparing 5 days prednisone to placebo
-       Results: no statistically significant differences in pain, return to work or activities at Day 5 (limited by 15% of patients lost to follow-up)
-       Bottom line:  No evidence for use of steroids in uncomplicated minor back pain

Righini et al.  JAMA. 2014;311(11):1117-1124. doi:10.1001/jama.2014.2135.
Multicenter, prospective study (19 hospitals in 4 countries)of ED pts
-       Results: Failure rate of conventional (< 500): 3-mo VTE risk: 1/810 (0.1%, 95% CI, 0.0%-0.7%).
-       Failure rate adjusted cutoff: 1/331 (0.3% [95% CI, 0.1%-1.7%) (*? up to 7/331)
-       Limitations: Low risk cohort (only 13% have wells score> 4), 2 pretest assessments, 6 D-dimer assays. Not RCT
-       Bottom line: Not ready to be used

Egerton-Warburton et al. Ann Emerg Med. 2014 May 9. pii: S0196-0644(14)00223-6. doi: 10.1016/j.annemergmed.2014.03.017.
-       Double-blinded RCT comparing 4 mg IV ondansetron, 20 mg IV metoclopramide, or placebo in 258 undiffentiated ED patients with nausea or vomiting.
-       Results: no difference in symptoms by VAS change or satisfaction at 30 min in this group with mostly opiate induced nausea or gastroenteritis.
-       Limitations: only 3 pts per day, 30 minutes as end point, only moderate nausea
-       Bottom line:  Another small but convincing study that antiemetics in the ED have minimal effects on most patients – stick to fluids or treat for sedation if necessary.

23. Use of glucagon for oesophageal food bolus impaction
Lorrains, Emerg Med J 2015:32(1): 85–88, doi:10.1136/emermed-2014-204467.1.
-       Best evidence review, not new study. Only 1 multicentre RCT: no significant difference (underpowered), about 30% success (usual spontaneous resolution rate)
-       Bottom line: Do not use glucagon. Not a higher success rate and can cause vomiting

24.   Are Proton-Pump Inhibitors Effective Treatment for Acute Undifferentiated Upper Gastrointestinal Bleeding?  
Cabot and Shah, Ann Emerg Med, 2014:63(6) 6:759–760
-       Best evidence review. A summary of previous studies suggesting lack of proven efficacy in patient-oriented outcomes.
-       Bottom line: PPI does not change patient-oriented outcomes in acute UGI bleed

25.   The NOTA Study (Non Operative Treatment For Acute Appendicitis) Prospective Study On The Efficacy And Safety Of Antibiotics (Amoxicillin And Clavulanic Acid) For Treating Patients With Right Lower Quadrant Abdominal Pain And Long-Term Follow-Up Of Conservatively Treated Suspected Appendicitis.  
Di Saverio et al.  Ann Surg. 2014 Jul;260(1):109-17. doi: 10.1097/SLA.0000000000000560.
-       159 patients were admitted and treated with antibiotics, 12% required surgery in first week with mean length of stay of nonoperatively managed patients  of 0.4 days
-       Bottom line:  This non-operative approach, similar to diverticulitis, should be compared with morbidity and costs of simple laparoscopic appendectomy

 [JF1]The TRISS Trial (Transfusion Requirements in Septic Shock) enrolled just over 1,000 patients who were randomized to hemoglobin transfusion triggers of 7 vs. 9 g/dL. Patients in the 7 g/dL group received half as many RBC units, and had similar mortality at 90 days, similar use of life support (vasopressors, inotropes, mechanical ventilation and renal replacement therapy), as well as a similar number of days alive and out of the hospital. This study represents the 7th large randomized trial demonstrating that a liberal transfusion strategy based on a higher hemoglobin trigger does not improve outcome. We now have evidence in the following patient populations supporting this finding: 1) critically ill ICU patients, 2) critically ill pediatric ICU patients, 3) postoperative cardiac surgery patients, 4) gastrointestinal bleeding patients, 5) traumatic brain injury patients, 6) elderly orthopedic patients with cardiovascular disease, and 7) patients with septic shock. The TRISS Trial should be considered to be one of the landmark studies supporting the goals of patient blood management programs.

 [JF2]However, higher blood pressure led to a less frequent need for renal-replacement therapy in patients with chronic arterial hypertension.


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