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What's new in emergency medicine

What's new in emergency medicine
Authors:
Jonathan Grayzel, MD, FAAEM
James F Wiley, II, MD, MPH
Literature review current through: Feb 2022. | This topic last updated: Feb 18, 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.

ADULT RESUSCITATION

Rocuronium dosing for emergency rapid sequence intubation (February 2022)

Traditional rocuronium dosing for emergency rapid sequence intubation (RSI) in adults has been 1 to 1.2 mg/kg intravenously (IV), but the optimal dose is unclear. An observational study of data from the multicenter National Emergency Airway Registry (NEAR) evaluated over 8000 emergency department intubations of patients >14 years to determine whether a higher dose of rocuronium (≥1.4 mg/kg IV) during RSI would improve first-pass success rate [1]. Compared with three other dosing ranges (<1 mg/kg, 1 to 1.1 mg/kg, or 1.2 to 1.3 mg/kg), a dose of ≥1.4 mg/kg was associated with higher first-pass success rates when RSI was performed with direct laryngoscopy or in patients with pre-intubation hypotension. Across all doses, first-pass success was similar when video laryngoscopy was used. The frequency of peri-intubation adverse events did not significantly differ among the groups. These findings support our suggested rocuronium dose of 1.5 mg/kg IV when performing emergency RSI in adults. (See "Neuromuscular blocking agents (NMBAs) for rapid sequence intubation in adults outside of the operating room", section on 'Rocuronium'.)

Target temperature after sudden cardiac arrest in adults (December 2021)

For patients who survive sudden cardiac arrest (SCA) and have an indication for targeted temperature management (TTM), the optimal temperature is unknown. Two studies have recently addressed this issue:

In a network meta-analysis of 10 randomized trials (over 4200 patients) survival with good function was similar for patients regardless of targeted temperature after SCA, including deep hypothermia (31 to 32°C), moderate hypothermia (33 to 34°C), mild hypothermia (35 to 36°C), or normothermia (37 to 37.8°C) [2]. However, moderate and deep hypothermia were associated with a higher incidence of arrhythmia when compared with normothermia (OR 1.45, and OR 3.58, respectively).

In a randomized trial of over 700 patients, not included in the above meta-analysis, no survival benefit or difference in neurologic outcomes was reported when a temperature of either 31°C (deep hypothermia) or 34°C (moderate hypothermia) was targeted for 24 hours after SCA [3]. There were no differences among the groups for adverse events except for a higher rate of deep vein thrombosis in those receiving deep hypothermia (4 versus 8 percent). However, the study may have been underpowered to detect a difference between the groups.

These trials suggest that deep hypothermia may not be beneficial for patients with SCA, although patients with severe neurologic injury were excluded from these and other trials. Until data support select target temperatures for specific subgroups, we advise individualizing targets for patients with SCA between the range of 33 and 37.5°C. (See "Intensive care unit management of the intubated post-cardiac arrest adult patient", section on 'Setting the target temperature'.)

Fluid resuscitation with saline or a buffered crystalloid in adults (September 2021)

The choice between normal saline and a buffered crystalloid for initial fluid resuscitation in adults is debated. A recent two-by-two-factorial randomized trial of >11,000 critically ill patients (mostly surgical) treated with normal saline or a buffered crystalloid found that neither the fluid type nor the rate of administration had an impact on 90-day mortality or the incidence of acute kidney injury (AKI) [4,5]. However, the trial may have been underpowered, only small volumes of fluids were administered, and fluid was administered prior to randomization, all of which decrease confidence in the results. We suggest that the choice between fluids be individualized and re-evaluated following initial resuscitation. (See "Treatment of severe hypovolemia or hypovolemic shock in adults", section on 'Choosing between 0.9 percent saline and buffered crystalloid'.)

GENERAL ADULT EMERGENCY MEDICINE

Updated guidelines on venous thromboembolism management (January 2022)

Updated guidelines on the treatment of venous thromboembolism (VTE) were published by the American College of Chest Physicians (CHEST) [6]. Many recommendations are similar to those in the 2016 guideline but either expanded in scope or changed in strength of the recommendation. As new recommendations, for most patients with cancer-related VTE, CHEST suggests a direct oral anticoagulant (DOAC) rather than low molecular weight heparin. For select patients without cancer who require extended anticoagulation beyond the conventional period of three to six months, CHEST suggests low-intensity anticoagulation with a DOAC. While CHEST did not promote aspirin for VTE prevention, they suggest that it may reduce the risk of recurrence when compared with no therapy. (See "Overview of the treatment of lower extremity deep vein thrombosis (DVT)" and "Anticoagulation therapy for venous thromboembolism (lower extremity venous thrombosis and pulmonary embolism) in adult patients with malignancy" and "Selecting adult patients with lower extremity deep venous thrombosis and pulmonary embolism for indefinite anticoagulation".)

Comparison of protocols for the diagnosis of pulmonary embolism (January 2022)

The ideal strategy for diagnosing pulmonary embolism (PE) is unknown. One meta-analysis reported that protocols that used pretest probability (PTP) models, adjusted D-Dimer levels, and/or YEARs criteria excluded more cases of PE without imaging (high efficiency) [7]. However, they also had the highest failure rate (ie, more missed cases of VTE). In addition, such protocols did not perform uniformly across all subgroups, with the lowest efficiency observed in those who were 80 years of age or older and in patients with cancer. In patients with suspected PE, we prefer to use a conventional protocol that combines clinical PTP and unadjusted D-Dimer to direct imaging. Although this approach is associated with a higher rate of imaging, fewer cases of PE are missed and we value the role of imaging when looking for alternate causes of patients' symptoms. (See "Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism", section on 'Adjusted D-dimer'.)

YEARS plus age-adjusted D-Dimer to diagnose PE (December 2021)

In a recent randomized trial of over 1200 patients who were positive for pulmonary embolism (PE) rule out criteria (PERC) (table 1) and had a low or intermediate clinical probability of PE, further triage using YEARS criteria plus age-adjusted D-Dimer (intervention group) resulted in a 10 percent reduction in chest imaging and a 1.6-hour reduction in the emergency department (ED) stay without significantly impacting the three-month rate of venous thromboembolism (VTE) compared with age-adjusted D-Dimer alone (conventional group) [8]. While encouraging, the complexity of this protocol may not be practical in busy settings. We continue to use a simple protocol that uses the more conventional strategy of clinical pretest probability and unadjusted D-Dimer. Although this strategy leads to more imaging, we place value in chest imaging which can help explain patients' symptoms when PE is not found. (See "Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism", section on 'Adjusted D-dimer'.)

Updated Surviving Sepsis Campaign guidelines (November 2021)

Recent adult guidelines were issued by the Surviving Sepsis Campaign [9]. Major changes with the 2016 guidelines included a preference for balanced salt solutions as the initial resuscitation fluid, a recommendation to not delay vasopressors while waiting for central venous access, and the administration of intravenous hydrocortisone to patients with ongoing septic shock. Additional changes included a recommendation against the administration of vitamin C as well as support for the early identification and treatment of mental, emotional, and physical ailments in survivors of sepsis. (See "Evaluation and management of suspected sepsis and septic shock in adults".)

Updated sexually transmitted infections guidelines from CDC (October 2021)

In 2021, the United States Centers for Disease Control and Prevention (CDC) updated its guidelines on management of sexually transmitted infections [10]. Important changes include preferences for doxycycline over azithromycin for Chlamydia trachomatis infections and nongonococcal urethritis, routine anaerobic coverage for pelvic inflammatory disease, and a moxifloxacin-based regimen for Mycoplasma genitalium. The guidelines also affirmed previous recommendations to use a 500 mg dose of intramuscular ceftriaxone for gonococcal infections. Our approaches to sexually transmitted infections are largely consistent with these updated guidelines. (See "Pelvic inflammatory disease: Treatment in adults and adolescents" and "Mycoplasma genitalium infection in males and females" and "Treatment of uncomplicated Neisseria gonorrhoeae infections" and "Treatment of Chlamydia trachomatis infection", section on 'Doxycycline as preferred agent'.)

Sickle cell disease pain management in infusion centers (August 2021)

Hematology-oncology infusion centers or day hospitals staffed by clinicians familiar with sickle cell disease (SCD) can provide rapid evaluation and treatment of uncomplicated pain using a plan tailored to the individual's analgesic history. A study comparing pain management in nearly 500 adults with SCD who were treated in an infusion center or an emergency department (ED) found infusion center treatment was associated with better outcomes, including administration of pain medication nearly twice as fast, rapid reassessment nearly four times more likely, and rate of hospitalization nearly four-fold less [11]. These data reinforce the practice of managing acute SCD pain in hematology-oncology clinics or dedicated day hospitals rather than EDs. (See "Acute vaso-occlusive pain management in sickle cell disease", section on 'Day hospital/infusion center'.)

GENERAL PEDIATRIC EMERGENCY MEDICINE

Dose and duration of amoxicillin for community-acquired pneumonia (CAP) in young children (November 2021)

In a 2 x 2 factorial multicenter randomized trial, investigators randomly assigned nearly 600 children (median age 2.5 years) with clinically diagnosed CAP who were discharged from the emergency department to standard- or high-dose amoxicillin administered twice daily and to three or seven days of therapy [12]. Repeat antibiotics for respiratory infection within 28 days were required in 12.5 to 12.9 percent of children in the four groups with no significant differences by antibiotic dose or duration. None of the participants were colonized with penicillin-resistant pneumococci. These results support standard-dose amoxicillin (35 to 50 mg/kg per day) in areas with low levels of penicillin resistance, twice-daily administration, and, in children with mild disease and adequate follow-up, antibiotic duration for <7 days. However, they are not generalizable to other antibiotics, older children, or children who are hospitalized. Pending confirmation of these findings, our preferred regimen for immunized children one to five years of age with suspected bacterial pneumonia is amoxicillin 90 to 100 mg/kg per day divided into two or three doses for at least five days. (See "Community-acquired pneumonia in children: Outpatient treatment", section on 'Duration' and "Community-acquired pneumonia in children: Outpatient treatment", section on 'Suspected bacterial etiology'.)

Serum sodium changes not associated with cerebral injury during treatment of diabetic ketoacidosis in children (November 2021)

Prior retrospective studies in children with diabetic ketoacidosis (DKA) reported associations between declines in serum sodium levels during treatment and risk of cerebral injury. In a new prospective study involving over 1200 episodes of DKA in children, the frequencies of mental status changes and clinical markers of cerebral injury were no different in children who had declines in glucose-corrected sodium concentrations during treatment compared with those who did not [13]. Declines in serum sodium were associated with higher serum sodium and chloride levels at presentation, previously diagnosed diabetes mellitus, and treatment with half normal saline (versus normal saline). These data suggest that serum sodium declines during DKA treatment largely reflect differences in fluid and sodium balance at presentation and are not a cause of cerebral injury. (See "Diabetic ketoacidosis in children: Cerebral injury (cerebral edema)", section on 'Initial theories based on osmotic change'.)

AAP clinical practice guidelines for febrile infants 8 to 60 days old (August 2021)

The American Academy of Pediatrics (AAP) has published multidisciplinary, consensus guidelines for the evaluation and management of well-appearing, healthy febrile infants 8 to 60 days old at low risk for invasive bacterial infection (bacteremia or meningitis) (algorithm 1 and algorithm 2 and algorithm 3) [14]. Key changes from prior guidelines include the use of inflammatory markers to identify infants 29 to 60 days old in whom lumbar puncture (LP) need not be performed and neonates 22 to 28 days old who may not require LP and a recommendation against sending a urine culture in infants with normal a normal urinalysis. Febrile infants 29 to 60 days of age with normal inflammatory markers and urinalysis may be managed at home by reliable caregivers as long as close follow-up is assured. These guidelines are consistent with our approach, although sending a urine culture on all febrile young infants is reasonable in facilities where contamination rates are low. (See "The febrile infant (29 to 90 days of age): Outpatient evaluation", section on '29 to 60 days old' and "The febrile neonate (28 days of age or younger): Outpatient evaluation and initial management", section on '22 to 28 days old' and "The febrile infant (29 to 90 days of age): Management", section on 'Infants 29 to 60 days old'.)

PROCEDURES

Updated difficult airway guidelines for adults and children (December 2021)

The American Society of Anesthesiologists has updated its difficult airway guidelines for both adult and pediatric patients and created new algorithms (algorithm 4 and algorithm 5) and infographics. The new guidelines stress prioritizing oxygenation throughout airway management; confirming ventilation with end tidal CO2 regardless of the airway device used; and limiting attempts with each device or technique to three, with one more attempt by a more experienced operator [15]. The new guidelines also provide robust guidance for extubation. (See "Management of the difficult airway for general anesthesia in adults", section on 'Importance of an algorithmic approach'.)

TOXICOLOGY

New threshold for elevated blood lead in United States children (November 2021)

Detectable blood lead levels (BLLs) are associated with neurocognitive deficits in infants and children <6 years old, and targeted screening of at-risk children is recommended. The Centers for Disease Control and Prevention has lowered the blood lead level (BLL) threshold for action to 3.5 mcg/dL (0.17 micromol/L) from the previous level of 5.0 mcg/dL (0.24 micromol/L) [16,17]. At or above this threshold, specific interventions should be taken based upon the degree of BLL elevation (table 2). For children with BLLs below 3.5 mcg/dL, the limit of detection for lead varies by laboratory, and the actual blood lead value may be close to or above the threshold. Thus, some children may need to be retested depending upon age or other risk factors. (See "Childhood lead poisoning: Management", section on 'Approach'.)

Pediatric fatalities associated with over-the-counter cough and cold medications (November 2021)

Manufacturer labelling and US Food and Drug Administration recommendations strongly advise against the use of over-the-counter cough and cold medications (CCM) in young children. A new report describes fatalities identified by a United States surveillance system and associated with CCM ingestion in children <12 years of age from 2008 to 2016 [18]. During this period, there were 40 reported deaths; the majority occurred in children <2 years old and involved diphenhydramine. Root cause analysis determined that 13 deaths occurred after deliberate supratherapeutic administration by a caregiver with the goal of sedating or harming the child. Health care providers should continue to educate caregivers on the dangers of CCM in children and maintain a high index of suspicion for child abuse with a low threshold for toxicology testing in infants and young children with unexplained signs or symptoms compatible with drug toxicity. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Toxicology'.)

Cannabis edible product ingestion in US children (October 2021)

Concentrated edible cannabis (marijuana) products are popular for recreational use. Exploratory ingestions of these products in young children can cause severe toxicity including seizures, apnea, and coma. In a report from the United States National Poison Data System, cannabis edible product ingestions have significantly increased in children <5 years old, with over twice the rate of exposures from states where adult cannabis use is legal [19]. These findings indicate an urgent need for education of adult cannabis users regarding the dangers that edible cannabis products pose to young children and for legislative efforts to prohibit cannabis product packaging and advertising that target children. (See "Cannabis (marijuana): Acute intoxication", section on 'Recreational use'.)

Point-of-care lead testing kit recall (October 2021)

Certain lots of point-of-care capillary blood lead testing kits manufactured by Magellan Diagnostics, Inc (LeadCare II, LeadCare Plus, and LeadCare Ultra) and distributed after October 27, 2020 have been recalled by the manufacturer and the US Food and Drug Administration (FDA) because of a significant risk of falsely low results. Per the FDA, children and pregnant or breastfeeding individuals who had test results <3.5 mcg/dL (0.14 micromol/L) using either a recalled test kit or a test kit with an unknown lot number should be retested with a venous blood lead level, especially those with potential signs or symptoms of lead toxicity or who are at high risk for lead exposure [20,21]. Remaining recalled test kits should be quarantined and no longer used. (See "Childhood lead poisoning: Clinical manifestations and diagnosis", section on 'Lead levels'.)

REFERENCES

  1. Levin NM, Fix ML, April MD, et al. The association of rocuronium dosing and first-attempt intubation success in adult emergency department patients. CJEM 2021; 23:518.
  2. Fernando SM, Di Santo P, Sadeghirad B, et al. Targeted temperature management following out-of-hospital cardiac arrest: a systematic review and network meta-analysis of temperature targets. Intensive Care Med 2021; 47:1078.
  3. Le May M, Osborne C, Russo J, et al. Effect of Moderate vs Mild Therapeutic Hypothermia on Mortality and Neurologic Outcomes in Comatose Survivors of Out-of-Hospital Cardiac Arrest: The CAPITAL CHILL Randomized Clinical Trial. JAMA 2021; 326:1494.
  4. Zampieri FG, Machado FR, Biondi RS, et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021.
  5. Zampieri FG, Machado FR, Biondi RS, et al. Effect of Slower vs Faster Intravenous Fluid Bolus Rates on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021; 326:830.
  6. Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160:e545.
  7. Stals MAM, Takada T, Kraaijpoel N, et al. Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups : A Systematic Review and Individual-Patient Data Meta-analysis. Ann Intern Med 2022; 175:244.
  8. Freund Y, Chauvin A, Jimenez S, et al. Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial. JAMA 2021; 326:2141.
  9. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063.
  10. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70:1.
  11. Lanzkron S, Little J, Wang H, et al. Treatment of Acute Pain in Adults With Sickle Cell Disease in an Infusion Center Versus the Emergency Department : A Multicenter Prospective Cohort Study. Ann Intern Med 2021; 174:1207.
  12. Bielicki JA, Stöhr W, Barratt S, et al. Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia: The CAP-IT Randomized Clinical Trial. JAMA 2021; 326:1713.
  13. Glaser NS, Stoner MJ, Garro A, et al. Serum Sodium Concentration and Mental Status in Children With Diabetic Ketoacidosis. Pediatrics 2021; 148.
  14. Pantell RH, Roberts KB, Adams WG, et al. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics 2021; 148.
  15. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022; 136:31.
  16. Baum C, Hauptman M, Newman N, Woolf A. Recommendations on management of childhood lead exposure: A resource for health professionals. Pediatric Environmental Health Specialty Units and the American Academy of Pediatrics. https://www.pehsu.net/_Library/facts/PEHSU_Fact_Sheet_Lead_Management_Health_Professionals_Final.pdf (Accessed on November 08, 2021).
  17. Centers for Disease Control and Prevention. Recommended actions based on blood lead level: Summary of recommendationsfor follow-up and case management of children based on initial screening capillary and confirmed* venous blood lead levels. https://www.cdc.gov/nceh/lead/advisory/acclpp/actions-blls.htm (Accessed on November 08, 2021).
  18. Halmo LS, Wang GS, Reynolds KM, et al. Pediatric Fatalities Associated With Over-the-Counter Cough and Cold Medications. Pediatrics 2021; 148.
  19. Whitehill JM, Dilley JA, Brooks-Russell A, et al. Edible Cannabis Exposures Among Children: 2017-2019. Pediatrics 2021; 147.
  20. Recall of LeadCare Blood Lead Tests due to risk of falsely low results. Health Alert Network. Centers for Disease Control and Prevention. https://emergency.cdc.gov/han/2021/han00445.asp (Accessed on October 18, 2021).
  21. Update: Expansion of recall of LeadCare blood lead tests due to risk of falsely low results. Health Alert Network. Centers for Disease Control and Prevention. https://emergency.cdc.gov/han/2021/han00457.asp?ACSTrackingID=USCDC_511-DM69702&ACSTrackingLabel=HAN%20457%20-%20General%20Public&deliveryName=USCDC_511-DM69702 (Accessed on November 08, 2021).
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References

1 : The association of rocuronium dosing and first-attempt intubation success in adult emergency department patients.

2 : Targeted temperature management following out-of-hospital cardiac arrest: a systematic review and network meta-analysis of temperature targets.

3 : Effect of Moderate vs Mild Therapeutic Hypothermia on Mortality and Neurologic Outcomes in Comatose Survivors of Out-of-Hospital Cardiac Arrest: The CAPITAL CHILL Randomized Clinical Trial.

4 : Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial.

5 : Effect of Slower vs Faster Intravenous Fluid Bolus Rates on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial.

6 : Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report.

7 : Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups : A Systematic Review and Individual-Patient Data Meta-analysis.

8 : Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial.

9 : Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021.

10 : Sexually Transmitted Infections Treatment Guidelines, 2021.

11 : Treatment of Acute Pain in Adults With Sickle Cell Disease in an Infusion Center Versus the Emergency Department : A Multicenter Prospective Cohort Study.

12 : Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia: The CAP-IT Randomized Clinical Trial.

13 : Serum Sodium Concentration and Mental Status in Children With Diabetic Ketoacidosis.

14 : Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old.

15 : 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.

16 : 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.

17 : 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.

18 : Pediatric Fatalities Associated With Over-the-Counter Cough and Cold Medications.

19 : Edible Cannabis Exposures Among Children: 2017-2019.