Emergency Medicine
Position Paper | Prehospital hemorrhage control and treatment by clinicians
27 Mar, 2023 | 13:20h | UTC
Guideline | Diagnosis and treatment of myocarditis
23 Mar, 2023 | 12:55h | UTCJCS 2023 Guideline on the Diagnosis and Treatment of Myocarditis – Circulation Journal (see PDF)
Guideline | Diagnosis and treatment of vasospastic angina and coronary microvascular dysfunction
23 Mar, 2023 | 12:53h | UTCJCS/CVIT/JCC 2023 Guideline Focused Update on Diagnosis and Treatment of Vasospastic Angina (Coronary Spastic Angina) and Coronary Microvascular Dysfunction – Circulation Journal (see PDF)
M-A | Efficacy of intraosseous access for trauma resuscitation
23 Mar, 2023 | 12:52h | UTC
RCT | Hydrocortisone reduces mortality in severe community-acquired pneumonia
22 Mar, 2023 | 13:44h | UTCSummary: Practice-changing! In a phase 3, multicenter, double-blind, randomized controlled trial involving 800 patients with severe community-acquired pneumonia admitted to the ICU, hydrocortisone treatment was found to reduce the risk of death by day 28 compared to a placebo group. The hydrocortisone group had a 6.2% death rate, while the placebo group had an 11.9% death rate.
Hydrocortisone also led to fewer endotracheal intubations among patients not on mechanical ventilation at baseline and reduced the need for vasopressor therapy in patients not receiving it at baseline. There was no significant difference in hospital-acquired infections or gastrointestinal bleeding between the two groups, but patients in the hydrocortisone group required higher daily doses of insulin during the first week of treatment.
Article: Hydrocortisone in Severe Community-Acquired Pneumonia – New England Journal of Medicine (link to abstract – $ for full-text)
Commentary: Steroid drug reduces death rate in severe pneumonia, study shows – STAT
Commentary on Twitter
In this randomized trial, hydrocortisone treatment decreased mortality among patients with severe community-acquire pneumonia in the ICU. https://t.co/DZadFMcA5o#ISICEM23 pic.twitter.com/yhkVCjBMWX
— NEJM (@NEJM) March 21, 2023
RCT | 4F-PCC fails to reduce blood product consumption and raises thromboembolic events in trauma patients
22 Mar, 2023 | 13:41h | UTCSummary: The PROCOAG Randomized Clinical Trial aimed to investigate the efficacy and safety of 4-factor prothrombin complex concentrate (4F-PCC) in trauma patients at risk of massive transfusion. Conducted in 12 French trauma centers, this double-blind, randomized, placebo-controlled superiority trial involved 324 patients. All patients were treated according to European traumatic hemorrhage guidelines and received early ratio-based transfusion (packed red blood cells:fresh frozen plasma ratio of 1:1 to 2:1). The primary outcome measured was 24-hour blood product consumption (efficacy), while arterial or venous thromboembolic events were assessed as a secondary outcome (safety).
The trial revealed no significant difference in 24-hour blood product consumption between the 4F-PCC and placebo groups, with median consumption of 12 units and 11 units, respectively. However, the study identified a statistically significant higher risk of thromboembolic events in the 4F-PCC group, with 35% of patients experiencing at least one event compared to 24% in the placebo group.
In conclusion, the study found no beneficial effect of incorporating 4F-PCC into a ratio-based transfusion strategy for patients with severe trauma at risk of massive transfusion. Furthermore, the higher rate of thromboembolic events in the 4F-PCC group indicated potential harm. The findings do not support the routine use of 4F-PCC in patients experiencing trauma who are at risk for extensive transfusion.
Article: Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial – JAMA (free for a limited period)
See also: Visual Abstract
M-A | Risk factors of hemorrhagic transformation in acute ischaemic stroke
22 Mar, 2023 | 13:21h | UTC
Pro-con debate | Should videolaryngoscopy be standard of care for tracheal intubation?
21 Mar, 2023 | 13:19h | UTCPro-Con Debate: Videolaryngoscopy Should Be Standard of Care for Tracheal Intubation – Anesthesia & Analgesia (free for a limited period)
RCT | Videolaryngoscopy improves first-pass tracheal intubation success compared with direct laryngoscopy
21 Mar, 2023 | 13:21h | UTC
Review | Surviving sepsis campaign
20 Mar, 2023 | 13:17h | UTCSurviving Sepsis Campaign – Critical Care Medicine
Review | Neurogenic shock: definition, identification, and management in the ED
20 Mar, 2023 | 13:09h | UTCNeurogenic Shock: Definition, Identification, and Management in the ED – emDocs
Cohort Study | COVID-19 outpatients mostly at low risk for VTE, but age, being male, and obesity are risk factors
17 Mar, 2023 | 13:11h | UTCSummary: The article discusses a cohort study that aimed to assess the risk of venous thromboembolism (VTE) among outpatients with COVID-19 and identify independent predictors of VTE.
The study used data from two integrated healthcare delivery systems in California and included 398.530 nonhospitalized adults aged 18 years or older with COVID-19 diagnosed between January 1, 2020, and January 31, 2021, with follow-up through February 28, 2021.
The results showed that the overall risk of VTE among outpatients with COVID-19 is low, but higher in the first 30 days after diagnosis. Factors associated with a higher risk of VTE in COVID-19 outpatients included:
- Age 55 years or older.
- Being male.
- history of VTE or thrombophilia.
- Body mass index greater than or equal to 30.0.
The study’s results could inform future randomized trials to explore targeted VTE preventive strategies and more intensive short-term surveillance for patients with COVID-19 who are at a higher risk of developing VTE.
Commentary: Venous blood clots rare among COVID-19 outpatients, study finds – CIDRAP
Commentary on Twitter
The rate of VTE was low in outpatients with #COVID19 in the first 30 days, and even lower >30 days. Factors associated with a higher risk of VTE in included age ≥55, male, prior VTE/thrombophilia, and BMI ≥30. https://t.co/3hwfDW88k4
— JAMA Network Open (@JAMANetworkOpen) March 13, 2023
Guidelines for the management of patients with substance intoxication presenting to the ED
17 Mar, 2023 | 13:09h | UTC
RCT | Pre-hospital rule-out of NSTE-ACS by ambulance paramedics with point-of-care troponin is feasible and cost-saving
16 Mar, 2023 | 13:27h | UTCSummary: Using a point-of-care (POC) troponin measurement, this randomized trial in the Netherlands assessed the safety and healthcare costs of a pre-hospital rule-out strategy for patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS).
The study included only patients considered at low risk with a HEAR (History, ECG, Age, Risk factors) score ≤3. A total of 863 low-risk participants were randomized to direct transfer to the ED or a pre-hospital rule-out strategy with POC troponin measurement.
The trial found that pre-hospital rule-out of NSTE-ACS in low-risk patients using a single POC troponin measurement is feasible, significantly reduces healthcare costs, and is associated with a low incidence of major adverse cardiac events.
The HEAR score, combined with a POC troponin measurement by ambulance paramedics, accurately identifies low-risk patients for whom ED evaluation is unnecessary. Implementing this pre-hospital rule-out strategy in low-risk patients could significantly reduce healthcare costs through more efficient use of ambulance services and fewer ED visits. It is worth noting, however, that further studies in other localities are necessary before the widespread use of this strategy can be implemented.
Commentaries:
JC: Can we rule out ACS by a single prehospital troponin measurement? – St. Emyln’s
Rule-Out of NSTE-ACS by a Prehospital Troponin Measurement – American College of Cardiology
Review | Improving vasopressor use in cardiac arrest
16 Mar, 2023 | 13:08h | UTCImproving vasopressor use in cardiac arrest – Critical Care
Out-of-hospital cardiac arrest – review of recent practice-informing trials
15 Mar, 2023 | 15:09h | UTCOut-of-hospital cardiac arrest – Intensive Care Medicine (if the link is paywalled, try this one)
Commentary on Twitter
#OHCA? 6 trials with potential to influence guidelines/practice:
💉 COCA: Calcium for #OHCA
⚡️ DOSE VF: double sequential external defib
🩸 INCEPTION: early #ECLS
💨 EXACT: ⬇️ O2
❄️ TTM2: targeted hypo vs normothermia
🩸 BOX: BP & O2 targets post #resus
🖇️ https://t.co/xtGmuYtXKF pic.twitter.com/3BOlfl5hRd— Intensive Care Medicine (@yourICM) March 13, 2023
Review | Approach to the patient with adrenal hemorrhage
15 Mar, 2023 | 15:03h | UTCApproach to the Patient With Adrenal Hemorrhage – The Journal of Clinical Endocrinology & Metabolism
Review | Prehospital stroke management and mobile stroke units
15 Mar, 2023 | 14:54h | UTCPrehospital stroke management and mobile stroke units – Current Opinion in Neurology
M-A | Pretest probability assessment and D-Dimer are preferred for the initial evaluation of suspected PE in pregnant women
15 Mar, 2023 | 14:50h | UTC
AHA Scientific Statement | Atrial fibrillation occurring during acute hospitalization
14 Mar, 2023 | 14:04h | UTC
Mortality rates and clinical manifestations of severe hypothyroidism in the ICU: a French multicenter cohort study
14 Mar, 2023 | 13:44h | UTCSummary: This article presents the findings of a retrospective multicenter cohort study conducted over 18 years in 32 French ICUs to investigate severe hypothyroidism (SH) requiring ICU admission.
The study included 82 patients with SH, with thyroiditis and thyroidectomy being the primary causes, and levothyroxine discontinuation, sepsis, and amiodarone-related hypothyroidism being the most frequent triggers.
Patients with SH presented with various clinical symptoms, including hypothermia, hemodynamic failure, and coma, with in-ICU and 6-month mortality rates being 26% and 39%, respectively. The study also found that patients with hemodynamic and respiratory failure on admission to the ICU had a higher likelihood of mortality.
Levothyroxine replacement was provided to all patients, but the administration route and loading dose varied. The authors recommend early diagnosis, prompt levothyroxine administration, and close monitoring of cardiac and hemodynamic parameters for SH patients admitted to the ICU.
Ultrasound-guided nerve blocks | Suggested procedural guidelines for emergency physicians
14 Mar, 2023 | 13:41h | UTC
Podcast and Brief Review | TIA/Stroke pearls for the hospitalist
14 Mar, 2023 | 13:36h | UTC#385 TIA/Stroke for the Hospitalist featuring Dr. Karima Benameur – The Curbsiders
Review | Guideline-based management of acute respiratory failure and acute respiratory distress syndrome
14 Mar, 2023 | 13:17h | UTC
RCT | Immediate complete revascularization non-inferior to staged approach in ACS patients with multivessel disease
13 Mar, 2023 | 15:10h | UTCSummary: Patients with an acute coronary syndrome and multivessel disease not presenting with cardiogenic shock usually benefit from complete revascularization by percutaneous coronary intervention (PCI). Complete revascularization involves treating all significant blockages in the coronary arteries, including those not causing symptoms (non-culprit lesions).
The BIOVASC randomized non-inferiority trial investigated whether patients with acute coronary syndrome and multivessel coronary disease should undergo immediate complete revascularization during the index procedure or undergo a staged approach with PCI of the culprit lesion only during the index procedure followed by another procedure within 6 weeks of all non-culprit lesions deemed to be clinically significant. The exclusion criteria were:
- Previous coronary artery bypass surgery.
- Cardiogenic shock.
- Single-vessel coronary disease.
- The presence of a chronic coronary total occlusion.
A total of 1525 patients with acute coronary syndrome and multivessel coronary disease were randomly assigned to either an immediate complete revascularization group (764 patients) or a staged complete revascularization group (761 patients). The primary outcome was a composite of all-cause mortality, myocardial infarction, unplanned ischemia-driven revascularization, or cerebrovascular events at 1 year after the index procedure. The study found that immediate complete revascularization was non-inferior to staged complete revascularization for the primary outcome.
Article: Immediate versus staged complete revascularisation in patients presenting with acute coronary syndrome and multivessel coronary disease (BIOVASC): a prospective, open-label, non-inferiority, randomised trial – The Lancet (free registration required)
Commentaries:
Revascularisation in acute coronary syndromes: change in practice? – The Lancet (free registration required)
No Downside to Immediate Complete Revascularization in ACS: BIOVASC – TCTMD
Immediate Complete Revascularization Non-Inferior to Staged Procedure in BIOVASC Trial – HCP Live
Related:
One-Year Outcomes after PCI Strategies in Cardiogenic Shock – New England Journal of Medicine