Annals of Emergency Medicine

April 2018

Prehospital Stroke Assessment for Large Vessel Occlusions: A Systematic Review
William Krebs , DO, Travis P. Sharkey-Toppen , MD, PhD, Fern Cheek , AMLS, Eric Cortez , MD, Ashley Larrimore , MD, David Keseg , MD & show all
Abstract
Background and Objective: Stroke is the leading cause of disability in the United States and new evidence shows interventional procedures provide better outcomes for large vessel occlusions (LVO). We performed a systematic review of the literature on prehospital stroke scales used to identify LVOs comparing the scales with analysis of the sensitivity, specificity, and predictive values. The goal was to determine if emergency medical services (EMS) are able to accurately identify LVO in the field.
Methods: In this systematic review, multiple databases were searched for articles that addressed our goal. The identified studies were evaluated for their statistical performance of various stroke scales. In addition, we assessed biases that may explain the varying results reported.
Results: Eight studies encompassing 6787 patients were included in our systematic review. Of the 8 studies, 6 were retrospective studies, 1 was a prospective cohort, and 1 was a prospective observational study. Sensitivities of the studies ranged from 49% to 91% while specificity of the studies varied from 40% to 94%.
Conclusion: At this time, further evaluations must be done in the prehospital setting to determine the ease of use and true sensitivity and specificity of these scales in identifying LVOs.

Hypoxemia, Does Oxygen Therapy Improve Outcomes Compared With No Supplemental Oxygen?
Brit Long, MD (EBEM Commentator), Michael D. April, MD, DPhil (EBEM Commentator). Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX

Oxygen therapy does not reduce the risk of all-cause mortality, recurrent ischemia or myocardial infarction, heart failure, or arrhythmias compared with no supplemental oxygen therapy for patients with acute myocardial infarction and normal oxygen saturation.

NDLR : Encore un mythe qui disparait

Getting Inside the Expert’s Head: An Analysis of Physician Cognitive Processes During Trauma Resuscitations
Matthew R. White, MD, MSc, Heather Braund, MEd, Daniel Howes, MD, FRCPC, Rylan Egan, PhD, Andreas Gegenfurtner, PhD, Jeroen J.G. van Merrienboer, PhD, Adam Szulewski, MD, FRCPC
aszulewski@qmed.ca

Study objective
Crisis resource management skills are integral to leading the resuscitation of a critically ill patient. Despite their importance, crisis resource management skills (and their associated cognitive processes) have traditionally been difficult to study in the real world. The objective of this study was to derive key cognitive processes underpinning expert performance in resuscitation medicine, using a new eye-tracking–based video capture method during clinical cases.
Methods: During an 18-month period, a sample of 10 trauma resuscitations led by 4 expert trauma team leaders was analyzed. The physician team leaders were outfitted with mobile eye-tracking glasses for each case. After each resuscitation, participants were debriefed with a modified cognitive task analysis, based on a cued-recall protocol, augmented by viewing their own first-person perspective eye-tracking video from the clinical encounter.
Results: Eye-tracking technology was successfully applied as a tool to aid in the qualitative analysis of expert performance in a clinical setting. All participants stated that using these methods helped uncover previously unconscious aspects of their cognition. Overall, 5 major themes were derived from the interviews: logistic awareness, managing uncertainty, visual fixation behaviors, selective attendance to information, and anticipatory behaviors.
Conclusion: The novel approach of cognitive task analysis augmented by eye tracking allowed the derivation of 5 unique cognitive processes underpinning expert performance in leading a resuscitation. An understanding of these cognitive processes has the potential to enhance educational methods and to create new assessment modalities of these previously tacit aspects of expertise in this field.

Update: Is Needle Aspiration Better Than Chest Tube Placement for
the Management of Primary Spontaneous Pneumothorax?
Keegan Tupchong, MD, RDMS (EBEM Commentator)
Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
Take-Home Message
Chest tube placement is successful more often than needle aspiration in the treatment of primary spontaneous pneumothorax, yet is associated with longer hospital length of stay and potentially more adverse events. Therefore, both needle aspiration and chest tube placement are reasonable first-line options, depending on individual patient preferences and circumstances.

Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study
Michael D. April, MD, DPhil, et al.
D.April@post.harvard.edu

Study objective: Although both succinylcholine and rocuronium are used to facilitate emergency department (ED) rapid sequence intubation, the difference in intubation success rate between them is unknown. We compare first-pass intubation success between ED rapid sequence intubation facilitated by succinylcholine versus rocuronium.
Methods: We analyzed prospectively collected data from the National Emergency Airway Registry, a multicenter registry collecting data on all intubations performed in 22 EDs. We included intubations of patients older than 14 years who received succinylcholine or rocuronium during 2016. We compared the first-pass intubation success between patients receiving succinylcholine and those receiving rocuronium. We also compared the incidence of adverse events (cardiac arrest, dental trauma, direct airway injury, dysrhythmias, epistaxis, esophageal intubation, hypotension, hypoxia, iatrogenic bleeding, laryngoscope failure, laryngospasm, lip laceration, main-stem bronchus intubation, malignant hyperthermia, medication error, pharyngeal laceration, pneumothorax, endotracheal tube cuff failure, and vomiting). We conducted subgroup analyses stratified by paralytic weight-based dose.
Results: There were 2,275 rapid sequence intubations facilitated by succinylcholine and 1,800 by rocuronium. Patients receiving succinylcholine were younger and more likely to undergo intubation with video laryngoscopy and by more experienced providers. First-pass intubation success rate was 87.0% with succinylcholine versus 87.5% with rocuronium (adjusted odds ratio 0.9; 95% confidence interval 0.6 to 1.3). The incidence of any adverse event was also comparable between these agents: 14.7% for succinylcholine versus 14.8% for rocuronium (adjusted odds ratio 1.1; 95% confidence interval 0.9 to 1.3). We observed similar results when they were stratified by paralytic weight-based dose.
Conclusion: In this large observational series, we did not detect an association between paralytic choice and first-pass rapid sequence intubation success or peri-intubation adverse events.

May 2018

Accès Intra-osseux versus IV dans la prise en charge des arrêts cardiaques
Takahisa Kawano, et al. Vancouver. takahisa.kawano@ubc.ca
Sur un panel de 13000 patients ayant présenté un arrêt cardiaque extra-hospitalier, les auteurs ont déterminé un sous groupe de 660 sujets ayant été pris en charge par pose d’une voie intra-osseuse. Le taux de survie avec un état neurologique correct a été de 1,5% dans ce sous-groupe versus 7,6% dans le groupe général traité avec accès veineux classique.

Facteurs associés à la survie d’un arrêt cardiaque dans le groupe d’étude Pan-Asian (PAROS)
Marcus Ong, et al.Tokyo. marcus.ong.e.h@sgh.com.sg
Plus de 60 000 patients ont été inclus dans l’étude PAROS. L’action initiale d’un témoin, un temps de réponse des secours inférieur à 8 minutes, une défibrillation précoce sont des facteurs favorables. Une gestion avancée des voies aériennes est, par contre, liée à une évolution plus défavorable.

Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department
Lauren R. Klein, MD, MS
Correspondence information about the author MD, MS Lauren R. Klein
lauren.klein@hcmed.org
Brian E. Driver, MD, James R. Miner, MD, Marc L. Martel, MD, Michelle Hessel, PharmD, Jacob D. Collins, BS, Gabriella B. Horton, Erik Fagerstrom, BS, Rajesh Satpathy, BA, Jon B. Cole, MD
Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis,
Study objective:Agitation in the emergency department (ED) can pose a threat to patient and provider safety; therefore, treatment is indicated. The purpose of this study is to compare haloperidol, olanzapine, midazolam, and ziprasidone to treat agitation.
Methods: This was a prospective observational study of consecutive patients receiving intramuscular medication to treat agitation in the ED. Medications were administered according to an a priori protocol in which the initial medication given was predetermined in the following 3-week blocks: haloperidol 5 mg, ziprasidone 20 mg, olanzapine 10 mg, midazolam 5 mg, and haloperidol 10 mg. The primary outcome was the proportion of patients adequately sedated at 15 minutes, assessed with the Altered Mental Status Scale.
Results: Seven hundred thirty-seven patients were enrolled (median age 40 years; 72% men). At 15 minutes, midazolam resulted in a greater proportion of patients adequately sedated (Altered Mental Status Scale <1) compared with ziprasidone (difference 18%; 95% confidence interval [CI] 6% to 29%), haloperidol 5 mg (difference 30%; 95% CI 19% to 41%), haloperidol 10 mg (difference 28%; 95% CI 17% to 39%), and olanzapine (difference 9%; 95% CI –1% to 20%). Olanzapine resulted in a greater proportion of patients adequately sedated at 15 minutes compared with haloperidol 5 mg (difference 20%; 95% CI 10% to 31%), haloperidol 10 mg (difference 18%; 95% CI 7% to 29%), and ziprasidone (difference 8%; 95% CI –3% to 19%). Adverse events were uncommon: cardiac arrest (0), extrapyramidal adverse effects (2; 0.3%), hypotension (5; 0.5%), hypoxemia (10; 1%), and intubation (4; 0.5%), and occurred at similar rates in each group.
Conclusion: Intramuscular midazolam achieved more effective sedation in agitated ED patients at 15 minutes than haloperidol, ziprasidone, and perhaps olanzapine. Olanzapine provided more effective sedation than haloperidol. No differences in adverse events were identified.

June 2018

Echelle verbale numérique chez l’enfant
Daniel S. Tsze, et al. Columbia. dst2141@columbia.edu
L’échelle verbale numérique est largement utilisée pour évaluer l’intensité d’une douleur chez l’enfant. Les auteurs ont souhaité en valider la pertinence sur un panel d’enfants âgés de 4 à 17 ans. Elle ne s’avère fidèle qu’à partir de l’âge de 6 ans. En dessous, il vaut mieux se fier à l’utilisation des 6 faces schématiques allant du sourire à la grimace.

Modification du niveau de lactates après hémodialyse chez les insuffisants rénaux
Justin J. Hourmozdi, et al. Michigan. jhourmoz@icloud.com
La prévalence d’un niveau de lactate supérieur à 1.8 mmol/L est de 17% avant dialyse. Elle diminue de 30% environ après la dernière séance. Ceci peut induire en erreur (faux négatif) le clinicien, si le patient souffre aussi d’un sepsis.

La prescription de Tétracaïne comme topique pour abrasion de cornée est elle sûre ?
Neil Waldam, et al. NouvelleZélande. neil.waldman@southerndhb.govt.nz
A l’analyse d’une cohorte de plus de 1 000 patients suivis 24h après administration de Tétracaïne sur la cornée, pour traiter la douleur, les auteurs avancent que cette prescription ne présente aucun effet secondaire notable.

Take home message
Existe t-il des signes cliniques spécifiques pour diagnostiquer une pneumonie chez l’enfant ?
Michael Gottlieb. Scott Heinrich. Recherche sur EMBASE.
Chez les enfants de moins de 5 ans, il n’existe pas de signes cliniques permettant de différencier une pneumonie d’autres pathologies respiratoires.

Update: Topical Anesthetics for Pain Control During Repair of Dermal Laceration
Melody Milliron, DO (EBEM Commentator), Olga Lembersky, DO (EBEM Commentator)
Department of Emergency Medicine, Saint Vincent Hospital, Erie, PA

Take-Home Message
Although further high-quality studies are needed, low-quality evidence supports cocaine-free over cocaine-containing topical agents for superficial dermal laceration anesthesia.

Data Sources: The search was conducted to identify studies evaluating topical anesthetics for repair of dermal lacerations. An updated search for a previous 2011 systematic review used the following databases through December 2016: Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and MEDLINE. The authors e-mailed selected journals and reviewed meta-registers of ongoing trials. Authors also contacted selected manufacturers, societies, and researchers deemed appropriate by the reviewers.
Jump to SectionResultsCommentaryReferences

Study Selection: Randomized controlled trials evaluating topical anesthetic efficacy and safety for repair of dermal laceration were selected. Studies were included only if they evaluated efficacy of topical local anesthetics for pain control during dermal laceration repair. Both amide- and ester-containing agents were included, as were multicomponent agents with vasoconstrictors. Studies were excluded if iontophoresis was used, agents were applied to mucus membranes, the laceration was closed with tape or tissue adhesive, a procedure for an infected wound was used, the wound was a complex or deep laceration, or systemic analgesics or sedatives were used before closure.
Jump to SectionResultsCommentaryReferences

Data Extraction and Analysis: Two authors independently analyzed the quality of trials for inclusion and reviewed study data. If any questions arose, the study authors of the original studies were contacted for further information. The Grading of Recommendations Assessment, Development and Evaluation approach was used to evaluate each study for methodological risk of bias and to assess the evidence quality. Because of the heterogeneity of the data and outcome measures, the authors could analyze the data only for pain intensity and a meta-analysis was unable to be performed.

Results: The authors included 25 randomized controlled trials with a total of 3,278 adult and pediatric patients. They found that various topical cocaine-free agents provided adequate analgesia; however, comparison of specific agents was not possible because of high risk of bias among comparison studies. In 2 pooled studies, self-reported improvement in visual analog scale scores (0 to 100 mm), the improvement was greater for topical prilocaine-phenylephrine compared with topical tetracaine-epinephrine-cocaine, with a difference of 5.6 points.

Commentary: Dermal lacerations are a common presenting complaint in US emergency departments, with more than 8 million lacerations per year.1 Traditionally, local infiltration has been the technique of choice for wound anesthesia, but topical anesthetics may be preferable in pediatric and needle-averse patients.2 Introduction of tetracaine-epinephrine-cocaine in 1980 appeared to be a step forward; however, concerns arose about the use of cocaine-containing agents. As cocaine became more recognized as a street drug of abuse, stricter administrative standards lessened its clinical appeal. Eventually, newer cocaine-free agents began to penetrate the market. It is not clear whether they have specific clinical advantages that would encourage their use.
Although these results suggest the benefit of cocaine-free agents, this study has several limitations. Of 5,453 search results, all but 25 were excluded. Of these, only 2 studies could be pooled that evaluated self-reported pain scales, and multiple studies included in this review had significant bias. The pain scales were not standardized across studies. Inclusion of studies with only superficial, noncomplex, 1- to 10-cm dermal lacerations may limit the applicability. Inclusion of only noninfected wounds with locations on the face, scalp, extremities, or trunk and allowing closure with only sutures or staples also limited the applicability. The authors could not separate adult or pediatric cases to determine whether there was a differential effect based on age. Despite these limitations and the overall low quality of clinical evidence, there is little evidence to support the use of cocaine-containing topical agents when cocaine-free agents are readily available.

References
1 Mattu A, Chanmugam A, Swadron S, et al. Keep it clean: pitfalls in traumatic wound irrigation. In: Marcucci L, series ed. Avoiding Common Errors in the Emergency Department. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:889.
2 Osmond MH. Wound repair and tissue adhesives. In: Moyer VA, Elliot EJ, Davis RL, et al, eds. Evidence Based Pediatrics and Child Health. London, England: BMJ Books; 2000.

Is Low-Dose Ketamine an Effective Alternative to Opioids for the Treatment of Acute Pain in the Emergency Department?
Michael Gottlieb, MD (EBEM Commentator), Kelly W. Ryan, MD (EBEM Commentator), Christine Binkley, MD, MPH (EBEM Commentator)
Department of Emergency Medicine, Rush University Medical Center, Chicago, IL

Take-Home Message
According to limited evidence, low-dose ketamine and morphine appear to provide similar levels of pain relief at 30 minutes; however, low-dose ketamine is associated with a higher rate of self-limited neuropsychological adverse events.

Methods: Allied and Complementary Medicine Database, the Cumulative Index of Nursing and Allied Health, PubMed, the Cochrane Controlled Trial Registry, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov were searched from inception through February 2015 for relevant studies. Manual searches of abstracts presented at selected emergency medicine and anesthesia conferences from 2012 to 2014 were also performed. The investigators reviewed the bibliographies of included articles and contacted the authors for additional relevant references. The search strategy was limited to randomized controlled trials and observational studies of human subjects published in English.

Study Selection: The authors asked the following question, using the formatting population, intervention, control, outcome (PICO): “In adult patients requiring acute pain management in the emergency department (ED) (P), does the use of low-dose ketamine as an adjunct or alone (I), compared with using opioids (C), offer improved pain control, decrease the need for opioid analgesics, or decrease the occurrence of adverse events (O)?” Eligible studies compared participants receiving low-dose ketamine regardless of route or dose regimen with any opioid analgesic among adult patients (>18 years) requiring acute pain management for any condition in the ED. Initial study selection was assessed by 2 independent reviewers, with articles being included for full-text review according to title and abstract or if there was disagreement or uncertainty about article content. Final article inclusion was determined by one reviewer using standardized and piloted selection criteria. Equivocal decisions for final inclusion were resolved by consensus among all of the investigators.

Data Extraction and Synthesis: Two investigators extracted data with a predesigned form that included variables such as year, country, study design, clinical setting, low-dose ketamine and comparator dose or route or need for redosing, pain scores, and adverse outcomes. Study strength was determined with the Grading of Recommendations Assessment, Development, and Evaluation criteria.1 Risk of bias was assessed with the Cochrane Collaboration Risk of Bias tool.2 Meta-analysis was planned but not performed because of significant heterogeneity with respect to outcomes, methods, and indications for low-dose ketamine among the included studies.

Results: The search identified 1,396 articles, of which 44 were deemed eligible for full-text review. Of these, a total of 8 articles (n=609 patients) were included in the final qualitative analysis. The review included 6 randomized controlled trials and 2 observational studies. Five studies were conducted in the United States, with the remainder conducted in France, India, and Iran. Most of the randomized controlled trials used low-dose ketamine, with doses ranging from 0.1 to 0.5 mg/kg given intravenously; however, one study followed the initial intravenous dose with a subcutaneous infusion at 0.1 mg/kg per hour.3 Another study that used a dose of 0.5 mg/kg gave patients concomitant midazolam at 0.3 mg/kg in the treatment group only.4 The comparator group included intravenous morphine at 0.05 to 0.1 mg/kg in all 6 of the included randomized controlled trials. In terms of analgesic effect, the 6 randomized controlled trials were rated as moderate quality, whereas the 2 observational studies were rated as very low quality.
Overall, moderate-quality studies did not demonstrate a significant difference in pain scores between the low-dose ketamine and opioids. There was insufficient evidence to determine whether low-dose ketamine reduced the need for rescue analgesia because of limitations of the data from the 3 studies assessing this outcome. There was an increased risk of adverse effects in the low-dose ketamine group compared with the morphine group (15.4% versus 4.4%). Adverse effects included agitation, hallucinations, dysphoria, and confusion; however, they were self-limited and there were no significant differences in rates of respiratory depression.

Commentary: Ketamine is a well-known agent used for procedural sedation in the ED, most commonly used in pediatric patients.5 Compared with other agents, ketamine offers the advantage of providing analgesia while protecting the respiratory drive.5 More recently, investigators have explored the use of subdissociative doses of ketamine (ie, low-dose ketamine) for acute pain management.6 Low-dose ketamine is typically considered to be doses of less than 1 mg/kg, although most studies use 0.1 to 0.3 mg/kg.7 Although there have been a number of studies performed in the postoperative setting that demonstrate evidence of a morphine-sparing effect,6 the evidence in the ED setting is limited.
This systematic review provides a qualitative analysis of 8 studies assessing the use of ketamine to treat acute pain in the ED setting. Although the results suggest that ketamine has efficacy similar to that of morphine, with a low rate of self-limited neuropsychiatric adverse effects, it is important to consider several limitations. First, the number of studies (N=4) and patients (n=225) assessing the ability of ketamine to reduce opioid use was small. Moreover, there were variations in the patient populations with respect to baseline characteristics and type of pain. There were also differences in the routes and doses of ketamine, as well as the use of adjuvant benzodiazepines and opioids. Furthermore, the outcome criteria varied significantly between trials, with differences in primary outcomes and methods of pain scale assessment (eg, numeric rating scale, visual analog scale, summed pain intensity difference). Finally, the definitions of adverse events were different between trials, with some providing empiric benzodiazepines to reduce the risk of emergence reactions.
Although this review provides preliminary evidence that low-dose ketamine may be used as an alternative to opioids for acute pain in the ED setting, studies with larger sample sizes and more rigorous methodology are needed to establish patient selection criteria and the best dosing strategy.

References
3 Balshem, H., Helfand, M., Schünemann, H.J. et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011; 64: 401–406
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5 Gurnani, A., Sharma, P.K., Rautela, R.S. et al. Analgesia for acute musculoskeletal trauma: low-dose subcutaneous infusion of ketamine. Anaesth Int Care. 1996; 24: 32–36
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