Use of Bones

Although the topic hardly rises to the level of serious controversy, the best protocol for vascular access in the context of out-of-hospital cardiac arrest is an ongoing unanswered question. Proponents of the intraosseous route highlight the ease of rapid access. In contrast, concerns remain over the relative efficacy of drugs infused through intraosseous sites, contraindications, and the cost of devices.

Two trials were published together on this topic, PARAMEDIC-3 and IVIO.^10,11 The primary outcomes of these trials differed: survival at 30 days in PARAMEDIC-3 and sustained return of spontaneous circulation in IVIO; however, despite differences in both primary outcomes and study procedures, neither access strategy separated itself from its peer. There will always be individual circumstances and clinical indications in which one access strategy may be preferable, but the net result was a wash.

Potpourri!

An amusingly named SENIOR-RITA trial tested whether elderly patients suffering non-ST segment myocardial infarction ought to undergo an invasive strategy versus a conservative, medical management strategy.¹² Although this question may seem a bit odd to some in the U.S., baseline frailty and life expectancy are common considerations during acute care in many health systems. In the frail elderly enrolled in this trial, invasive strategies reduced downstream nonfatal myocardial infarction, but had no effect on cardiovascular death or the overall composite outcome.

The glib dogma “GCS 8, intubate” may seem the perfect combination of clinical indication and clever rhyme, but the Glasgow Coma Scale (GCS) was never designed to predict airway complications in the heterogenous population of patients with diminished levels of consciousness. As it turns out, common sense likely rules the day when presented with patients whose low GCS is the result of a self-limited overdose toxidrome. In a randomized trial of initial preferred management of, primarily, alcohol-and benzodiazepine-intoxicated patients, fewer required mechanical ventilation or intensive care unit admission when an observation-first strategy was employed.¹³ Although intubation certainly has its place, it should not be considered a benign intervention and must be weighed against the risks of the specific presenting syndrome, rather than a blanket rule based on GCS.

In a setting where the ED is frequently described as the “front door” to the hospital, a very reasonable question to ask is: Why? If an inpatient ward is the ultimate intended endpoint, an ED encounter may not add any value, while contributing to long wait times and increased patient costs. The alternative would be direct admission, bypassing the ED, and it sounds so sensible that it rather boggles the mind that it isn’t more robustly utilized. Authors of one study clearly felt the same way and implemented a direct admission program across three pediatric health systems.¹⁴ Uptake was uncommon, but in those who were directly admitted to the ward, no adverse consequences occurred, and appropriate treatment was initiated more quickly. From a patient-oriented standpoint, the advantages of direct admission should encourage health systems to expand such appropriate offerings when the resources of an ED are not acutely required.