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What's new in emergency medicine

What's new in emergency medicine
Michael Ganetsky, MD
Jonathan Grayzel, MD, FAAEM
James F Wiley, II, MD, MPH
Literature review current through: Nov 2022. | This topic last updated: Dec 15, 2022.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.


Blood pressure and oxygen targets following sudden cardiac arrest (September 2022)

Supporting data to guide specific blood pressure and oxygen targets after sudden cardiac arrest (SCA) are limited, and practice is variable. In a recent open-label, two-by-two factorial trial, 789 patients with SCA were randomly assigned to a high versus low mean arterial pressure (MAP) target (77 versus 63 mmHg) as well as a restrictive versus liberal arterial oxygen tension (PaO2) target (68 to 75 versus 98 to 105 mmHg) [1,2]. At 90 days, rates of death or severe disability/coma at discharge were similar across all groups. Although the trial had limitations and confidence intervals were wide, these results do not support aggressive MAP goals or overly restrictive oxygenation in the care of patients after cardiac arrest, pending future studies. (See "Intensive care unit management of the intubated post-cardiac arrest adult patient", section on 'Hemodynamic monitoring and goals'.)

De-escalation of fluid therapy in sepsis (June 2022)

In patients with sepsis, there is little guidance regarding when and how intravenous fluids (IVF) should be de-escalated following initial resuscitation. In a recent trial of over 1500 adults with sepsis who had received at least 1 liter of fluid and were within 12 hours of the onset of shock, individuals assigned to restrictive IVF strategy (ie, infusion stopped; small boluses given when needed for organ perfusion, low urine output, or insensible losses) compared with a standard IVF strategy had similar 90-day mortality and adverse effects [3]. These data support the safety of a restrictive approach to fluid de-escalation. However, the volume of fluid in both groups was lower than that previously reported in early resuscitation sepsis studies suggesting that practice has evolved toward a de-escalation approach that is restrictive. More studies are needed to further guide postresuscitation fluid therapy in patients with sepsis. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'De-escalation fluids'.)

Vitamin C alone not effective in sepsis (June 2022)

Early observational evidence suggested a possible mortality benefit from intravenous (IV) vitamin C in combination with thiamine and hydrocortisone in patients with sepsis. However, several randomized trials have since reported a lack of benefit from this combination. A recent trial of 872 patients with septic shock (and on a vasopressor) has reported that IV vitamin C alone also had no effect on 28-day mortality (35 versus 32 percent) or persistent organ dysfunction (9 versus 7 percent) [4]. One patient had severe hypoglycemia and another had anaphylaxis in response to vitamin C. We continue to recommend against the routine use of vitamin C alone or in combination with thiamine or hydrocortisone. (See "Investigational and ineffective therapies for sepsis", section on 'Vitamin C'.)

Routine preintubation fluid bolus does not prevent cardiovascular collapse in critically ill adults (June 2022)

Hypotension occurs in up to 50 percent of critically ill patients during and after intubation, and can cause cardiac arrest. If time permits, preintubation hemodynamic optimization is recommended, including correction of hypovolemia. However, in a randomized multicenter trial in >1000 critically ill adults, routine administration of a 500 mL intravenous (IV) fluid bolus prior to intubation did not reduce the incidence of cardiovascular collapse compared with no fluid bolus [5], consistent with a previous smaller trial. Methods to reduce peri-intubation hypotension should be individualized and may include use of etomidate or ketamine for induction, use of vasopressors, and IV fluid if necessary. (See "Complications of airway management in adults", section on 'Hemodynamic changes'.)


CDC updates opioid prescribing guidelines (November 2022)

The United States Centers for Disease Control and Prevention (CDC) has published a new guideline for prescribing opioids for acute, subacute, and chronic pain, updating their 2016 guideline (table 1). The guideline is intended for clinicians who prescribe opioids to outpatients ≥18 years of age and does not apply to pain related to sickle cell disease, cancer, palliative care, or end of life care [6]. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Opioid therapy in the context of the opioid epidemic'.)

Complications of physician burnout (September 2022)

Physician burnout appears to adversely affect career engagement and patient care. A meta-analysis that included 170 observational studies with >230,000 physician participants found that physicians with burnout were more than three times as likely to be dissatisfied with their career, regret their career choice, and think about leaving their job [7]. In addition, physicians with burnout were twice as likely to be involved in patient safety incidents, have low professionalism, and to receive low patient satisfaction ratings. Interventions to mitigate burnout should be implemented. (See "Unipolar depression in adults: Assessment and diagnosis", section on 'Burnout'.)

Intravenous magnesium in severe COPD exacerbation (August 2022)

Intravenous magnesium has short-acting bronchodilator activity that is helpful for severe asthma attacks, but it has not previously been recommended for chronic obstructive pulmonary disease (COPD). A new systematic review and meta-analysis found a decrease in hospitalization rates with emergency department intravenous magnesium administration compared with placebo [8]. The effect size is similar to or better than that seen in the setting of asthma exacerbation. Based on these data, we now suggest intravenous magnesium for patients with severe COPD exacerbations who are not improving with inhaled bronchodilator therapy. (See "COPD exacerbations: Management", section on 'Magnesium sulfate'.)

Levonorgestrel dose for emergency contraception in individuals with obesity (June 2022)

Because levonorgestrel (LNG) emergency contraception (EC) appears to be less effective in individuals with obesity, doubling the LNG EC dose has been proposed to improve efficacy in this population. However, in a randomized pharmacodynamic trial comparing usual (1.5 mg) versus double-dose (3 mg) LNG EC in 70 individuals with obesity and a dominant follicle ≥15 mm on ultrasound, the proportion of individuals that achieved at least five days with no evidence of rupture was not significantly different between groups, and the time to follicle rupture was also similar for both groups [9]. As there was no clear reduction or delay in ovulation, we use the 1.5 mg LNG EC dose for all individuals but counsel those with obesity that other options (eg, copper intrauterine device) are more effective. (See "Emergency contraception", section on 'Impact of body weight'.)

International validation of the Canadian Syncope Risk Score (June 2022)

Multiple risk stratification tools have been developed to avoid expensive unnecessary admissions for syncope, but none are universally accepted. The Canadian Syncope Risk Score (CSRS) has been validated in several sites across Canada and recently validated in an international, multicenter cohort that included over 2200 adults who presented to an emergency department (ED) with syncope [10]. In nearly 1400 patients classified as low-risk by the CSRS, only 1 percent had a serious clinical event or required a procedure at 30 days. A multivariate regression analysis of the nine individual items of the CSRS found that ED clinician gestalt for the classification of syncope (eg, cardiac syncope, vasovagal syncope, or other) had similar accuracy compared with the entire CSRS. This supports our recommendation that risk stratification tools should be used to assist clinical judgment but cannot replace it. (See "Approach to the adult patient with syncope in the emergency department", section on 'Risk stratification'.)


Risk of meningitis in febrile young infants with a positive urinalysis (October 2022)

Existing American Academy of Pediatrics guidelines suggest that cerebrospinal fluid (CSF) studies be obtained in otherwise low-risk febrile young infants (29 to 60 days old) with elevated blood inflammatory markers (IMs) (table 2), independent of urinalysis (UA) results. However, prior studies have found that for these infants, the risk of meningitis is low. In a secondary analysis of a prospective cohort study of nearly 700 well-appearing, previously healthy, febrile young infants (29 to 60 days old) with a positive UA, none had bacterial meningitis, including the 204 individuals with elevated procalcitonin or absolute neutrophil count [11]. Based on these findings, for otherwise low-risk febrile young infants 29 to 60 days old with elevated IMs and a positive UA, we no longer suggest obtaining CSF studies. Our practice is unchanged with regard to febrile infants in this age group who have elevated IMs and a negative UA (CSF recommended) or normal IMs and a positive UA (CSF not recommended). (See "The febrile infant (29 to 90 days of age): Outpatient evaluation", section on '29 to 60 days old'.)

Sexual abuse of children in health care settings (September 2022)

The American Academy of Pediatrics has released a new policy to assist health care professionals and organizations in efforts to prevent sexual abuse of children in health care settings and to ensure an appropriate institutional response to allegations of sexual abuse perpetrated by a health care provider [12]. Key actions that health care organizations should take to protect children include pre-employment screening of all personnel who have access to children in a health care setting; education of all employees regarding staff-patient boundary setting, chaperone use during examination of sensitive body regions (ie, perineum and, in adolescent females, breast examination), and the individual responsibility to report concern for sexual abuse by other health care providers to the proper authorities; and policies that ensure all patient, parent/caregiver, or staff allegations of sexual abuse perpetrated by a health care receive prompt documentation, timely investigation, and, when there is sufficient suspicion for sexual abuse, adherence to mandated reporting, if not already performed. (See "Management and sequelae of sexual abuse in children and adolescents", section on 'Sexual abuse in health care settings'.)

Frequency of transfusion reactions in children and adults (August 2022)

Transfusion reactions range from bothersome to life threatening. A new meta-analysis of >1.3 million transfusion reactions has documented a nearly twofold higher frequency of acute transfusion reactions in children than in adults [13]. Children were more likely than adults to have reactions to red blood cells and platelets, but not to plasma. Allergic and febrile nonhemolytic transfusion reactions were most common. The only type of reactions seen more frequently in adults were delayed hemolytic and delayed serologic reactions. Early signs and symptoms may not distinguish between benign and more serious events, and all acute transfusion reactions must be considered potentially serious until fully evaluated. (See "Approach to the patient with a suspected acute transfusion reaction", section on 'Frequency of reactions'.)

Visual and vestibular assessments in children with concussion (August 2022)

The American Academy of Pediatrics has released a new policy that highlights vision symptoms in children and adolescents with concussion [14]. The policy provides guidance on the components of a complete evaluation of the visual system after concussion (movie 1 and table 3). It also reviews the importance of identifying visual and vestibular deficits during assessment of concussion to confirm the diagnosis and to identify patients at risk for prolonged symptoms who may benefit from specific academic adjustments or specialist referral. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Physical examination'.)


Calcium administration during CPR in children with heart disease (November 2022)

According to the American Heart Association (AHA) guidelines, the use of calcium during pediatric cardiopulmonary resuscitation (CPR) is limited to specific indications (ie, hypocalcemia, hyperkalemia, hypermagnesemia, or calcium channel blocker overdose). However, calcium administration remains common during CPR in children with heart disease. In a retrospective study of the AHA resuscitation registry that included over 4500 children with heart disease and in-hospital cardiac arrest, 44 percent of patients received calcium [15]. In a propensity-matched cohort of over 1300 patients, calcium administration versus no calcium administration was associated with lower survival to hospital discharge (39.4 versus 45.6 percent) and lower survival to hospital discharge with favorable neurologic outcome (27.8 versus 34. 2 percent). These findings confirm prior observational studies regarding the detrimental effects of calcium during CPR. For children with cardiac arrest and heart disease, calcium administration should be confined to indications recommended by the AHA. (See "Primary drugs in pediatric resuscitation", section on 'Calcium'.)

Sodium bicarbonate administration during pediatric CPR (October 2022)

According to the American Heart Association guidelines, the use of sodium bicarbonate during pediatric cardiopulmonary resuscitation (CPR) is limited to specific indications (ie, hyperkalemia, hypermagnesemia, and overdose with prolonged QRS duration or tachyarrhythmias). In a propensity-matched cohort study of infants and children (1100 children, median age 0.6 years) who received CPR in a pediatric intensive care unit, sodium bicarbonate was given to 528 individuals who had no approved indications and was associated with lower survival to hospital discharge with favorable neurologic outcome compared with matched controls (adjusted odds ratio 0.69) [16]. These findings confirm prior observational studies. For children with cardiac arrest who do not have the above conditions, the routine use of sodium bicarbonate is not recommended. (See "Primary drugs in pediatric resuscitation", section on 'Sodium bicarbonate'.)

Administration of vasoactive therapy by peripheral IV in children with shock (October 2022)

For children with shock who require vasoactive therapy, central venous access is preferred. However, delivery of vasoactive therapy by peripheral intravenous (PIV) access may be used during initial resuscitation while central venous access is obtained. In a recent retrospective cohort study of over 750 critically ill children receiving vasoactive infusions for shock, of 231 children who initially received vasoactive therapy by PIV (93 patients with septic shock), extravasation occurred in 4 patients (1.7 percent, all hand vein sites) with no long-term complications; 46 percent of these patients ultimately did not require central venous access and had full recovery [17]. These findings confirm prior data that the delivery of dilute vasoactive medications by the most proximal peripheral vein in selected children with shock is safe. The decision and timing of central venous catheter placement depends on the expected severity and trajectory of shock, as well as other clinical needs that may require central venous access. (See "Septic shock in children: Rapid recognition and initial resuscitation (first hour)", section on 'Indications for vasoactive agents'.)

New guidance for pediatric advanced life support in patients with confirmed or suspected COVID-19 (August 2022)

The American Academy of Pediatrics (AAP) has released specific guidance for advanced life support of children with suspected or confirmed COVID-19 that supplements the previously released 2022 guidance provided by the American Heart Association [18]. Among the key changes from prior guidance, modifications to in-hospital pediatric resuscitation no longer emphasize endotracheal intubation as a priority procedure to reduce aerosol exposure during pediatric cardiopulmonary resuscitation (CPR). Other changes focus on ventilated children who arrest: They should have the advanced airway checked to ensure that it is connected, patent, and in proper position and then remain connected to a closed ventilator system with an inline high efficiency particulate air filter. If they are prone at the time of arrest, they should initially receive compressions with the hand centered over the T7 to T10 vertebral bodies and then be safely turned to the supine position to continue CPR. The AAP guidance also provides initial ventilator settings to use during pediatric CPR. (See "Pediatric advanced life support (PALS)", section on 'COVID-19 patients (suspected or confirmed)'.)

Noninvasive respiratory support for acutely ill infants and young children (June 2022)

The best approach to noninvasive respiratory support (high-flow nasal cannula oxygen therapy [HFNC] or continuous positive airway pressure [CPAP]) in critically ill infants and children is unclear. A recent unblinded, randomized, multicenter trial compared HFNC with CPAP in more than 570 critically ill infants and children (approximately 50 percent with bronchiolitis; 20 to 25 percent with asthma or other respiratory illness; and others with illnesses such as sepsis) [19]. The duration of noninvasive respiratory support and the proportion requiring endotracheal intubation were similar in both groups. Patients assigned to HFNC required less sedation and had a shorter duration of critical care and hospitalization. These findings suggest that HFNC is at least as good as CPAP for noninvasive support of critically ill children and may provide better patient comfort. (See "High-flow nasal cannula oxygen therapy in children", section on 'Comparison with other modes of oxygen delivery' and "Bronchiolitis in infants and children: Treatment, outcome, and prevention", section on 'HFNC and CPAP'.)


Management of pediatric torus (buckle) fractures of the wrist (July 2022)

Torus fractures of the wrist are stable compression fractures that are located at the distal metaphysis or the radius or ulna, where the bone is most porous (image 1); treatment is aimed at pain relief and comfort. Immobilization with a splint is the typical approach. In a large multicenter randomized trial (nearly 1000 children 4 to 15 years old), pain at three days was similar for patients assigned to a soft elastic bandage versus splint immobilization and remained equivalent through 42 days of follow-up [20]. Functional recovery was also similar in the two groups. However, 11 percent of children assigned to a soft bandage returned to receive splint immobilization because of pain. Based upon these findings, either a soft elastic bandage or a short-arm splint provides adequate treatment for torus fractures, and the choice of treatment should be in accordance with patient/caregiver preference. Regardless of chosen treatment, clear instructions on pain management are required. (See "Distal forearm fractures in children: Initial management", section on 'Torus (buckle) fracture'.)


Role of wound packing after drainage of perianal and perirectal abscess (September 2022)

After incision and drainage of a perianal or perirectal abscess, it is common practice to pack the wound, under the assumption that this will facilitate further drainage by wicking and prevent premature skin closure. In the PPAC2 trial of 443 patients with a primary perianal abscess, nonpacking, compared with packing, resulted in similar rates of fistula formation (11 versus 15 percent) and abscess recurrence (6 versus 3 percent), differences that were not statistically significant [21]. However, the nonpacking group had lower average pain scores (28 versus 38 on a 100-point visual analog scale). Given these and similar findings from two earlier small trials, we now suggest not packing the wound after drainage of perianal or perirectal abscess. (See "Perianal and perirectal abscess", section on 'Role of wound packing'.)

Prehospital pediatric airway management (September 2022)

For children with respiratory compromise, the role of prehospital endotracheal intubation (ETI) or supraglottic airway (SGA; eg, laryngeal mask airway) placement is unclear. In a systematic review of eight studies of prehospital airway management (one trial and seven observational studies), four studies found no additional benefit for children undergoing ETI and four studies found increased mortality compared with bag-mask ventilation (BVM) or SGA [22]. In two retrospective cohort studies, prehospital SGA was also associated with higher mortality compared with BVM. Current evidence does not support prehospital advanced airway management (ETI or SGA) over BVM for children with respiratory compromise. Medical control physicians should emphasize basic airway maneuvers (head tilt-chin lift or jaw thrust) and BVM for these patients. (See "Pediatric considerations in prehospital care", section on 'Pediatric procedures'.)

Laryngospasm during pediatric sedation outside of the operating room (August 2022)

Laryngospasm during pediatric procedural sedation is rare but serious, and a better understanding of risk factors may help guide care. In the largest study to date, which included over 275,000 sedations in children performed outside of the operating room, the unadjusted prevalence of laryngospasm was 3.3 per 1,000 cases [23]. On adjusted analysis, risk factors for laryngospasm included concurrent upper respiratory infection (odds ratio [OR] 3.9), airway procedures (OR 3.7), and, compared with propofol alone, use of propofol with ketamine (OR 2.5) or with dexmedetomidine (OR 2.1). Risks associated with ketamine and propofol as single agents were similar. These findings provide a strong rationale for appropriate airway expertise for all providers of pediatric sedation and identify important factors to consider when determining sedation regimens for children. (See "Procedural sedation in children outside of the operating room", section on 'Adverse outcomes'.)

Ultrasound- versus landmark-guided technique for joint aspirations (July 2022)

Although some joint aspirations may be performed using anatomic landmarks, the use of ultrasound guidance has been shown to improve accuracy of needle placement in previous studies. In a randomized trial including 44 patients presenting to an emergency department with a suspected moderate-size joint effusion involving the elbow, wrist, or ankle, a greater number of successful aspirations were performed with ultrasound guidance compared with landmark-guided aspirations (94 versus 60 percent) [24]. Notably, of the 14 landmark-guided aspirations for which arthrocentesis was initially unsuccessful, 8 of the patients had no effusion when subsequently evaluated with ultrasonography. This small study supports the use of ultrasound guidance to improve the success rates of arthrocentesis of medium-sized joints. (See "Musculoskeletal ultrasonography: Guided injection and aspiration of joints and related structures", section on 'Accuracy of needle placement'.)

Ultrasound guidance for peripheral intravenous line placement in children (June 2022)

In children, ultrasound guidance is well established for central venous access, but its role for placement of peripheral intravenous (PIV) lines is less clear. A new meta-analysis including five randomized trials performed in children with difficult intravenous access (DIVA) found improved rates of first attempt success (odds ratio 4.6) and overall success (odds ratio 3.3) for ultrasound-guided compared with standard (landmark) techniques during PIV line placement [25]. Based on these data, we suggest using ultrasound-guidance as the initial approach for placing PIV lines in children (but not neonates) with high DIVA scores. (See "Principles of ultrasound-guided venous access", section on 'Children with difficult access'.)


Xylazine adulteration of illicit drugs (December 2022)

Xylazine is an alpha-2 agonist and a chemical analogue of clonidine that is used in veterinary medicine for sedation and analgesia. In humans, xylazine overdose has caused major toxicity consisting of coma, apnea, bradycardia, and hypotension as well as severe, necrotic skin ulcerations after repeated parenteral use. Xylazine is increasingly found as an adulterant in illicit drugs, especially heroin and fentanyl, with rising reports of serious side effects. As a result, the US Food and Drug Administration has issued an alert to health care professionals and a letter to stakeholders [26]. Xylazine poisoning is on the differential diagnosis for patients with suspected opioid overdose that does not respond to naloxone administration. Treatment consists of supportive care. There is no rapid diagnostic testing for xylazine poisoning or safe antidote. (See "Clonidine and related imidazoline poisoning", section on 'Imidazoline agents'.)

Severe complications of button battery ingestion in children (October 2022)

Button battery (BB) ingestion with esophageal impaction in children is a true emergency that can cause life-threatening complications. In a systematic review of 361 pediatric cases of BB ingestion resulting in severe complications (95 percent with esophageal impaction), death occurred in 19 percent of patients [27]. Hemorrhage from vascular injuries, primarily aortoesophageal fistulae, was the most common cause of death. Among patients with vascular injuries, those who died had a longer duration of impaction than those who survived (median 144 versus 11 hours, respectively). These findings highlight the importance of timely recognition of BB ingestion with esophageal impaction and emergency BB removal. (See "Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management", section on 'Complications'.)


Nail bed laceration repair does not prevent nail deformity (October 2022)

When a nail bed laceration is suspected because of subungual hematoma >50 percent and/or coexistent distal phalanx fracture, the traditional treatment has been to remove the nail and repair the nail bed laceration to prevent a permanent nail deformity. However, in a retrospective study of 78 adults with suspected nail bed laceration (without frank nail disruption or nail fold laceration), patients treated conservatively (including trephination and/or splinting as appropriate) appeared to have similar rates of nail deformity and hand disability scores compared with those who underwent nail bed laceration repair [28]. These findings support our practice of not removing the nail to repair the nail bed in patients with closed nail bed injuries. (See "Evaluation and management of fingertip injuries", section on 'Choice of procedure'.)

Firearms are the leading cause of death in children in the United States (June 2022)

Firearm injury (homicide, suicide, or unintentional) is a major cause of morbidity and mortality in the United States. In 2019, firearms surpassed motor vehicle crashes (MVC) as the leading cause of death in children and adolescents (age 1 to 19 years) [29-31]. This finding highlights the increasing numbers of firearm deaths, driven largely by homicides in adolescents, as well as the success of interventions to prevent MVC deaths such as car seats, booster seats, side airbags, rear facing cameras, and lane departure warnings. (See "Firearm injuries in children: Prevention", section on 'Firearm injuries'.)

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