A couple of months ago, EM physician Ashley Shreves, MD, and I collaborated on a lecture highlighting the top articles in the emergency medicine literature from the past year. The sheer volume of practice-changing literature was simply too great to condense into a concise presentation, but that didn’t stop us from trying.
Explore This IssueACEP Now: Vol 35 – No 08 – August 2016
So, in the same vein, consider this snapshot of practice-changing articles published within the last year a whirlwind tour of a very busy year. Here are a few of my favorites:
“A Randomized Controlled Noninferiority Trial of Single Dose of Oral Dexamethasone Versus 5 Days of Oral Prednisone in Acute Adult Asthma”1
While this is technically a negative trial, these data support, rather than refute, the use of a single dose of dexamethasone in the treatment of asthma with acute exacerbation. The statistical underpinnings of noninferiority trials mean there simply weren’t enough patients enrolled to meet their predefined criteria. The overall context of these data fits with other smaller samples, showing the choice of single-dose dexamethasone is likely as safe as the typical prednisone burst.
“Naproxen with Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial”2
The challenge of managing low back pain in the emergency department is an age-old struggle. This is a negative trial, showing no significant difference between good-old NSAIDs alone or NSAIDs combined with either narcotics or muscle relaxants. The truth underlying this trial, however, is probably more complex, as it applies only to the narrowest population of acute presentations, and patients receiving oxycodone/acetaminophen appeared to have more rapid pain resolution in the immediate post-visit period.
“Delivering Safe and Effective Analgesia for Management of Renal Colic in the Emergency Department: A Double-Blind, Multigroup, Randomised Controlled Trial”3
We’ve always known nonsteroidal analgesia is undersold in general and has particular usefulness in renal colic. However, this trial takes it a step further, showing that intramuscular diclofenac is just as effective, if not more so, as intravenous paracetamol (acetaminophen) or intravenous morphine. Study-specific quibbles aside, intramuscular NSAIDs are great options for rapid treatment of suspected renal colic.
“Medical Expulsive Therapy in Adults with Ureteric Colic: A Multicentre, Randomised, Placebo-Controlled Trial”4
This is the larger of two trials testing “medical expulsive therapy” for ureteral stones. Typically, this is understood to be the alpha-blocker tamsulosin but also includes calcium-channel blockers like nifedipine. The purported benefit of medical expulsive therapy all but vanishes in this large high-quality trial. However, there may be a small benefit for large (>5 mm) distal stones; it’s reasonable to offer an alpha-blocker to this subset of patients.
“Trimethoprim-Sulfamethoxazole Versus Placebo for Uncomplicated Skin Abscess”5
For a few stalwart holdouts, the oft-repeated mantra has always been “incision and drainage [I&D] is definitive care for uncomplicated abscesses.” This well-designed trial seems to show that patients receiving trimethoprim-sulfamethoxazole following I&D had substantial reduction in both initial treatment failure and abscess recurrence.
“Antibiotic Therapy Versus Appendectomy for Treatment of Uncomplicated Acute Appendicitis”6
Can you treat appendicitis with antibiotics? You certainly can, and even better, some of those patients will be clinical cures. Unfortunately, many of those cures seem to be only short-term, with a worrisome handful of recurrences during long-term follow-up. Furthermore, this study probably overstates the harms of surgery as a “straw man” comparator. Antibiotics can be offered as an alternative to surgery, but their effectiveness shouldn’t be oversold.
“Platelet Transfusion Versus Standard Care After Acute Stroke Due to Spontaneous Cerebral Haemorrhage Associated with Antiplatelet Therapy”7
Intracerebral hemorrhage, already a dire clinical scenario, is only made worse by the anticoagulant effects of antiplatelet therapy. Do platelet transfusions help? No—in fact, they may even make outcomes worse. Save your blood products for other uses.
“Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis”8
In the debate regarding the necessity of lumbar puncture (LP) for exclusion of subarachnoid hemorrhage, it’s clear the ultimate winner is destined to be the “no-LP” camp. As CT technology improves, the detection of clinically important hemorrhage is greater than 99 percent within six hours of headache onset. Owing to the inaccuracy of the lumbar puncture pathway, it’s reasonable to stop after a current-generation non-contrast CT.
“Idarucizumab for Dabigatran Reversal”9
Dabigatran has been decried during its many years on the market as having no reasonable reversal pathway. That has now changed with the advent of Praxbind (idarucizumab). This monoclonal antibody fragment irreversibly binds dabigatran and is marketed as the antidote. The evidence is much weaker than the marketing teams would have you believe, but it’s the only option available.
“Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity”10
The news isn’t as good regarding reversal of factor Xa inhibitors. Andexanet alfa does bind apixaban and rivaroxaban but only as long as the infusion is maintained. Once the infusion is discontinued, factor Xa inhibition returns, and the faucets will flow again. Prothrombin complex concentrates remain the best reversal option.
“Risk for Clinically Relevant Adverse Cardiac Events in Patients with Chest Pain at Hospital Admission”11
The “observation admission” for chest pain has become nearly so ubiquitous, it has spawned its own cottage industry of short-stay medicine. However, this study followed every patient admitted for chest pain and found that iatrogenic harms outnumbered true cardiac harms in low-risk patients. In patients with normal ECGs, negative biomarkers, and normal vital signs, there was no added value in hospitalization specifically for the purposes of observation.
“Postural Modification to the Standard Valsalva Manoeuvre for Emergency Treatment of Supraventricular Tachycardias”12
If you’ve been continually disappointed by the ineffectiveness of vagal maneuvers for terminating supraventricular tachycardias, this is the study for you. With a simple recumbent leg-raise position immediately following vagal stimulation, these authors boosted response to therapy from 17 percent to 43 percent. This is almost certainly worth trying as an alternative to using adenosine or calcium-channel blockers.
“Intravascular Complications of Central Line Venous Catheterization by Insertion Site”13
Choice of central line insertion site is frequently dogmatic. As it turns out in this study, each site has its pros and cons, making each one reasonable as dictated by circumstance. Femoral sites have the fewest procedural complications, subclavian sites cause the fewest venous thromboemboli, and internal jugular sites slot right in between. Infectious complications were highest in the femoral and internal jugular locations, while subclavian attempts resulted in a small number of pneumothoraces.
“Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department”14
When agitated delirium exceeds the capacity of basic antipsychotic management, there’s a real danger to patients and staff. This observational study reports on the use of intramuscular ketamine to control behavioral disturbance after initial treatment failure. In the setting of polypharmacy and intoxication, no agent can be presumed universally safe, but patients treated with high doses (greater than 200 mg) attained safe levels of treatment for agitation.
“An Age-Adjusted D-Dimer Threshold for Emergency Department Patients with Suspected Pulmonary Embolus: Accuracy and Clinical Implications”15
Baseline circulating D-dimer gradually increases with age, so why not increase the D-dimer threshold for rule-out pulmonary embolus with age? The large retrospective cohort examined by this study indicated the “age-adjusted” D-dimer improved specificity but at the expense of sensitivity. The net result was one small missed pulmonary embolism for every 100 CT scans prevented. This represents high-value change in practice.