Warrior Medicine



Practice Changing Articles – 2019 Adult LiteratureBrit Long, MD, FACEPStudy 1 - Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. N Engl J Med. 2019 Oct 2. doi: 10.1056/NEJMoa1906661. [Epub ahead of print]Takeaway – This RCT included patients > 18 years of age with ROSC after nonshockable rhythm. Patients were randomized 1:1 to 32.5-33.5 C vs 36.5-37.5 C. The primary outcome was 90-day survival with a favorable neurologic outcome, defined as a CPC score of 1 or 2. They found 10.2% of the hypothermia protocol patients had a good neurologic outcome versus only 5.7% in the normothermia group (absolute difference 4.5%, 95% CI 0.1% - 8.9%, p = 0.04). However, there are multiple issues based on timing of hypothermia, sedation, and fragility index of 1.Study 2 - Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomised controlled trial. Lancet Respir Med. 2019 Oct 1. pii: S2213-2600(19)30246-2. doi: 10.1016/S2213-2600(19)30246-2. [Epub ahead of print]Takeaway – This RCT included patients > 18 years of age undergoing intubation in the ICU or ED setting. Patients were randomized to receive 500 mL fluid bolus just prior to and during intubation versus no bolus. There was no difference between the groups in the primary composite outcome of CV collapse (hypotension - SBP ≤65, new or increased vasopressor within 2 minutes of intubation, or cardiac arrest/death within an hour of intubation). There was no difference in adverse events. There are many issues with this study, and keep in mind that when it comes to fluid, one size does not fit all.Study 3 - Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg.?2019 Sep 27. doi: 10.1213/ANE.0000000000004445. [Epub ahead of print]Takeaway – This retrospective cohort study evaluated peripheral norepinephrine during elective surgery in patients > 18 years of age, with primary outcome adverse drug events, including extravasation. 14,385 patients who received norepinephrine in the OR were included. Drug extravasation occurred in 5 patients (5/14,385 = 0.035%). The 95% confidence interval (CI) for infusion extravasation was 0.011%-0.081%, indicating an estimated risk of 1-8 events per every 10,000 patients. Most IV’s were placed in the antecubital fossa, 18 G, and left in place for < 20 minutes. If using peripheral pressors, use a well-placed, proximal IV and monitor the IV site. Study 4 - Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache: Approved by the ACEP Board of Directors June 26, 2019 Clinical Policy Endorsed by the Emergency Nurses Association (July 31, 2019). Ann Emerg Med.?2019 Oct;74(4):e41-e74. doi: 10.1016/j.annemergmed.2019.07.009.Takeaway –1. In the adult ED patient presenting with acute headache, are there risk-stratification strategies that reliably identify the need for emergent neuroimaging?The Ottawa Subarachnoid Hemorrhage Rule is the only risk stratification tool that has been validated and identifies the need for neuroimaging in acute headache. It has a high sensitivity but lacks specificity for SAH.Patients with a normal neurologic examination and peak headache intensity within 1 hour of pain onset require investigation if one or more of the following is present: Symptoms of neck pain or stiffness, Age ≥40 years old, Witnessed loss of consciousness, Onset during exertion, Thunderclap headache (peak intensity immediately), Limited neck flexion on exam. Level B recommendation.2. In the adult ED patient treated for acute primary headache, are nonopioids preferred to opioid medications?Nonopioid medications are strongly preferred for treatment of acute primary headaches in the ED patients. Level A recommendation.?3. In the adult ED patient presenting with acute headache, does a normal noncontrast head CT scan performed within 6 hours of headache onset preclude the need for further diagnostic workup for SAH?A normal noncontrast head CT performed within 6 hours of symptom onset in an ED headache patient with a normal neurologic exam can be used to rule out a nontraumatic SAH without performing an LP. Level B recommendation.4. In the adult ED patient who is still considered to be at risk for SAH after a negative noncontrast head CT, is CTA of the head as effective as LP to safely rule out SAH?In patients considered to be at risk for SAH after negative noncontrast head CT, CTA is a reasonable alternative to LP for safely ruling out SAH. ACEP recommends using shared decision making to select the best diagnostic test with regard to pros and cons of CT/LP versus CT/CTA.Lumbar puncture is a time-intensive procedure with a low diagnostic yield, a high rate of traumatic taps, high rate of uninterpretable test results, and a risk of post-LP headache.CTA avoids many of the negative aspects of performing an LP. However, it may identify incidental cerebral aneurysms leading to unnecessary invasive procedures, is associated with a higher radiation dose, and risks missing an alternative diagnosis through LP.Level C recommendation.Study 5 - Evaluation and management of cauda equina syndrome in the emergency department. Am J Emerg Med. 2019 Aug 20:158402. doi: 10.1016/j.ajem.2019.158402. [Epub ahead of print]Takeaway – Cauda equina is a devastating disease that causes significant patient morbidity. It also requires significant resources to diagnose. This article is here to tell you that your history and physical exam findings may not be enough to rule this out, and you should be moving towards MRI when you are concerned.History and physical exam in isolation had poor sensitivity for the identification of cauda equina syndrome (CES).Risk factors include: obesity, female gender, pre-existing spinal disease (e.g. spinal stenosis, thickened ligamentum flavum).One study found that 89% of patients with CES had acute worsening within the past 24h; however, it may present gradually over weeks as well.CES is most commonly caused by a large central disk herniation/prolapse at L4-5 or L5-S1.Exam findings consistent with CES included: bilateral sciatica, reduced perineal sensation, urinary retention, loss of anal tone, loss of sexual function, motor/sensory changes in lower extremities, and diminished patellar and Achilles reflexes.Post-void residual > 500ml had OR of 4.0, which increased to 48.0 when combined with two of the three following symptoms: bilateral sciatica, subjective urinary retention, or rectal incontinence.The gold standard for diagnosis is MRI. CT myelography may be used when MRI is contraindicated.Management requires emergent neurosurgical evaluation.High-risk features include bladder dysfunction and rapid onset.Study 6 - Underdosing of Benzodiazepines in Patients With Status Epilepticus Enrolled in Established Status Epilepticus Treatment Trial. Acad Emerg Med.?2019 Aug;26(8):940-943. doi: 10.1111/acem.13811. Epub 2019 Jul 18.Takeaway – This research letter found we underdose benzodiazepines in the ED for patients with refractory status epilepticus. The first dose of lorazepam was correct in 14.7% of patients, and for midazolam, 15.4% of patients when administered in the ED. Overall, 29.8% of first doses met minimum recommendations per guidelines. Remember your benzodiazepine dosing for seizures: IM MDZ - 10 mg vs. 5mg, IV LZP - 0.1 mg/kg/dose, IV DZP - 0.15-0.2 mg/kg/dose. If refractory X2, strongly consider sedation and intubation.Study 7 - Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. doi: 10.1164/rccm.201908-1581ST.Takeaway – This update for community-acquired pneumonia (CAP) provides some must know information for ED clinicians.Question 1: In adults with CAP, should gram stain and culture of lower respiratory secretions be obtained at the time of diagnosis?Not in outpatients; only if severe inpatient (or intubated), if starting empiric anti-pseudomonal or MRSA coverage, prior history of pseudomonas/MRSA, or prior hospitalization in the past 90-days.Question 2: In adults with CAP, should blood cultures be obtained at the time of diagnosis?Not in outpatients or milder severity inpatients; yes if severe inpatient (or intubated), if starting empiric anti-pseudomonal or MRSA coverage, prior history of pseudomonas/MRSA, or prior hospitalization in the past 90-days.Question 4: In adults with CAP, should a respiratory sample be tested for influenza virus at the time of diagnosis?Yes at times of high flu prevalence, and they recommend using a molecular assay rather than antigen test.Question 5: In adults with CAP, should serum procalcitonin plus clinical judgment versus clinical judgment alone be used to withhold Initiation of antibiotic treatment?If clinically suspected and radiographically confirmed, forget about procalcitonin.Question 6: Should a clinical prediction rule for prognosis plus clinical judgment versus clinical judgment alone be used to determine inpatient versus outpatient treatment location for adults with CAP?They recommend clinical judgment plus the Pneumonia Severity Index, which is preferred over CURB-65.Question 7: Should a clinical prediction rule for prognosis plus clinical judgment versus clinical judgment alone be used to determine inpatient general medical versus higher levels of inpatient treatment intensity (ICU, step-down, or telemetry unit) for adults with CAP?Of course, hypotension on vasopressors and intubated patients need the ICU. Otherwise, they recommend clinical judgment plus the 2007 IDSA/ATS minor severity criteria.Question 8: In the outpatient setting, which antibiotics are recommended for empiric treatment of CAP in adults?Previously healthy with low risk for resistance: amoxicillin 1g TID; doxycycline 100mg BID; or azithromycin (macrolides assuming low community pneumococcal resistance, <25%).With comorbid diseases of heart, lung, liver, kidney, malignancy, or asplenia: amoxicillin/clavulanate + macrolide or doxycycline; another option is cepodoxime or cefuroxime + macrolide or doxycycline; OR monotherapy with a respiratory fluoroquinolone. See dangers of fluoroquinolones.Question 9: In the inpatient setting, which antibiotic regimens are recommended for empiric treatment of CAP in adults without risk factors for MRSA and P. aeruginosa?See Inpatient Treatment of CAP table below.Question 10: In the inpatient setting, should patients with suspected aspiration pneumonia receive additional anaerobic coverage beyond standard empiric treatment for CAP?Not unless lung abscess or empyema is suspectedQuestion 11: In the inpatient setting, should adults with CAP and risk factors for MRSA or P. aeruginosa be treated with extended-spectrum antibiotic therapy instead of standard CAP regimens?Healthcare associated pneumonia (HCAP) should be abandoned. Use of broader spectrum antibiotics for supposed HCAP did not improve outcomes. Only treat with extended spectrum antibiotics as above if locally validated risk factors for MRSA or pseudomonas are present.Question 12: In the inpatient setting, should adults with CAP be treated with corticosteroids?Do not use steroids in non-severe, severe, or influenza PNA. The literature has been back and forth on this. Steroids probably don’t help.Question 13: In adults with CAP who test positive for influenza, should the treatment regimen include antiviral therapy?Yes, oseltamivir should be used in outpatients or inpatients with CAP who test positive for influenza regardless of duration of illness.Question 14: In adults with CAP who test positive for influenza, should the treatment regimen include antibacterial therapy?Yes, bacterial pneumonia may exist along with viral pneumonia.Question 15: In outpatient and inpatient adults with CAP who are improving, what is the appropriate duration of antibiotic treatment?Antibiotics should be continued until vitals stabilize, oral intake is good, mental status normal, and no less than 5 days.Question 16: In adults with CAP who are improving, should follow-up chest imaging be obtained?If improving within 5-7 days, there is no need. ................
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