5Topical Tetracaine in Corneal Abrasions 1: Topical tetracaine used for 24 hours is safe and rated highly effective by patients for the treatment of pain caused by corneal abrasions: a double-blind, randomized clinical trial. Waldman N, Densie IK, Herbison P. Acad Emerg Med Apr;21(4):374-82RCT of 122 patients with simple corneal abrasions on slit lampNo difference in healing (uptake of fluorescein on repeat exam)Similar pain scoring, but treatment group reported better “effectiveness of treatment”
6Topical Tetracaine in Corneal Abrasions Ready for primetime?Small studyNo contrary evidence of harmWhat do our colleagues say?
7Post-Arrest CoolingTargeted temperature management at 33°C versus 36°C after cardiac arrest. Nielsen N, Wetterslev J, Cronberg T et al. NEJM Dec 5;369(23):Multicentre RCT of 950 patients randomized to tight temperature control of 33°C versus 36°CPrimary outcome all cause mortality at six monthsSecondary outcome modified Rankin score >=4 at six monthsNo significant difference
8Post-Arrest CoolingPerhaps focus less on the number, more on the processCriticism of original data was lack of protocolization of care in control arm, poor fever controlAgain, what do our colleagues say?
9Age-Adjusted D-Dimer in PE Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. Righini M, Van Es J, Den Exter PL et al. JAMA Mar 19;311(11):Multicentre prospective validation of using age x 10 as a cut-off for ruling out PE in Wells Criteria low risk patients3346 patients enrolled over 3 years, of which 87% were low risk, of which 28% were <500, 11% were age-adjusted negative1/810 (0.1%) nonfatal PE in <500, 1/337 (0.3%) nonfatal PE in age-adjusted, 7/1481 (0.5%) still had PE or DVT with negative CTPA (!)
10Age-Adjusted D-Dimer in PE Authors felt most applicable to patients >75, as this group is most likely to have a false positive d-dimer at <500Application of age adjustment increased negative d-dimer from 6.6% to 29.7% with no additional misses in this group
11Etomidate and SepsisSingle-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database. McPhee LC, Badawi O, Fraser GL et al. Crit Care Med Mar;41(3):774-83Retrospective Database study of patientsSought out septic patients intubated in the ICU (not ED)N= 2,014: Single dose etomidate = 1,102 and no etomidate = 912Attempted matching age, comorbidities, but etomidate arm actually sickerNo difference in mortality
12Etomidate and Sepsis What do our colleagues say? Is this relevant to us?Why use instead of ketamine?What do our colleagues say?
13Tranexamic Acid and Epistaxis A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Zahed R, Moharamzadeh P, Alizadeharasi S et al. Am J Emerg Med Sep;31(9):N=216, 15 cm cotton pledget was soaked in the IV form of TXA (500mg in 5ml) and inserted in the bleeding nares (no formal packing) versus formal packing with pledgets soaked in epi and lidocaine71% of the TXA vs. 31% of the nasal packing group stopped bleeding by 10 minutes (OR 2.3, p<0.001)Rebleeding was less common in the TXA group (4.7% vs. 12.8% at 24 hours and 2.8% vs. 11.0% at 7 days)Time to discharge and ED complications also favored the TXA group
14Tranexamic Acid and Epistaxis Apples and Oranges?We use rapid rhino, not conventional packsConsider as adjunct?
15Preoxygenation and RSI Weingart, Scott D., and Richard M. Levitan. "Preoxygenation and prevention of desaturation during emergency airway management." Annals of emergency medicine 59.3 (2012):Preoxygenation: Adequate time on TRUE 100% O2CPAP masks or BVM with PEEP valve for patients unable to obtain sats greater than 93-95% by conventional meansIdeally should be >3 minutes or 8 deep breaths in awake patientsPatients should be in head-elevated position during pre-oxygenation (or reverse trendelenberg in the spinal patientControversial/not yet primetime: use of ketamine to allow NIPPV to preoxygenate in the combative patient with intact airway reflexes and respiratory effort – “Delayed Sequence Intubation”Maintenance of Oxygenation with Apneic Oxygenation via NP
16Preoxygenation and RSI Most of us have adopted high-flow NP oxygenationValue in establishing a common preoxygenation protocol/checklist for our RTs?Consider DSI in the “right” patient?
17The Dallas Protocol in Pediatric DKA Low morbidity and mortality in children with diabetic ketoacidosis treated with isotonic fluids. White PC1, Dickson BA. J Pediatr. 2013 Sep;163(3): doi: /j.jpeds Epub 2013 Mar 15.Compared a simplified 3 stage protocol of fluids to standard careGives overall more Na and H2O compared to conventional careShowed extremely low rates of death/disability compared to rates quoted by ADA (0.08% versus 0.3%)
22SSTI Uncomplicated cellulitis without evidence of abcess formation No evidence that adding Septra to treatment is beneficialTreat with Keflex alone
23SSTI Treatment of Abcess may change I+D Soon to released paper found that treatment with TMP/SMS is more effective than placebo93% vs 85.7% cure rateSecondary outcomes better as well – recurrence, need for hospital visits, infections in family membersStay tuned
24TAMIFLUIndications for use have not changed despite Cochrane review stating that it has limited efficacyMay lessen duration of symptoms by ½ dayNo change in mortalityReason for “no indication change” may be related to $1.3 billion US govt spent stockpiling this med?
25PROCESS TRIALEGDT is as good as “usual” sepsis care in terms of mortalityKeys to treatment are early fluids and antibiotics, measure lactate and use serial lactates…lactate clearance is still a reasonable marker.MAP 60 – 65 is reasonable goalAvoid pressors – increase mortalityNo need for blood transfusion unless Hb<7
26PEDIATRIC INFECTIONS Jerry and Rick Relationship between pediatric UTI and long term renal sequella is limited.Should be no need to catheterize febrile pediatric patients to obtain a urine
27PEDIATRIC INFECTIONS Duration of symptoms in children Croup – 2 days Sore throat – 7 daysBronchiolitis – 2 wksCommon cold / bronchitis – 25 days
32Optimal Positioning for LP in children evaluated by bedside U/S Pediatrics 2010; 125: e1149–e1153Goal: maximize interspinous space28 subjects, median age 5 years, u/s evaluation of interspinous space in 5 positionsUse of portable L3/L4, L4/L5 levels
33CONCLUSIONSThe interspinous space of the lumbar spine was maximally increased with children in the sitting position with flexed hipsIn the lateral recumbent position, neck flexion does not increase the interspinous space and may increase morbidity
34A New Technique For Fast and Safe Collection of Urine in Newborns A prospective feasibility and safety study conducted in the neonatal unit of University Infanta Sofía Hospital, Madrid A new technique based on bladder and lumbar stimulation manoeuvres was tested over a period of 4 months in 80 admitted patients aged less than 30 days The main variable was the success rate in obtaining a midstream urine sample within 5 minRESULTS This technique was successful in 86.3% of infants Median time to sample collection was 45 s (IQR 30) No complications other than controlled crying were observedArch Dis Child 2013; 98: 27-29
37ACEP PEARLSALL VF arrests should go for EARLY PCI, even w/o STEMI on EKG (increased survival to hospital discharge)hsTroponin (quickly becoming standard of care) dx AMI in 0-2 hrs (when will this come to Fraser Health?)
38ACEP PEARLSConsider lytics for Intermediate Risk PE (RV dysfnx, +trop)Mortality benefitCAUTION with pts >65 yrs (increased major bleeding and ICH)Consider using ½ dose of lyticsEvidence for NIPPV in Asthma, Chest Trauma and Procedural SedationRandom household toxins: Cinnamon acts as a caustic when swallowed in excess
39References for ACEP Pearls Therapeutic Hypothermia:Nielsen N, Wetterslev J, Cronberg T et al. Targeted Temperature Management at 33oC vs. 36oC after Cardiac Arrest. New Engl J Med 2013; 369:Kim F, Nichol G, Maynard C et al. Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurologic Status Among Adults with Cardiac Arrest A Randomized Clinical Trial. JAMA 2014; 311: 45-52PCI Post Cardiac Arrest:Hollenbeck RD, McPherson JA, Mooney MR et al. Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI. Resus 2014;85:88-95Callaway CW, Schmicker RH, Brown SP et al. Early coronary angiography and induced hypothermia are associated with survival and functional recovery after out-of-hospital cardiac arrest. Resus 2014;85:657-63HsTroponin:Bandstein N, Ljung R, Johansson M et al. Undetectable High Sensitivity Cardiac Troponin T Level in the Emergency Department and Risk of Myocardial Infarction. JACC 2014 (in press)Age-Adjusted D-Dimer:Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism The ADJUST-PE Study. JAMA 2014;311:Lytics in PEChatterjee S, Chakraborty A, Weinberg I et al. Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality, Major Bleeding and Intracranial Hemorrhage A Meta-analysis. JAMA 2014;311:Meyer G, Vicaut E, Danays T et al. Fibrinolysis for Patients with Intermediate-Risk Pulmonary Embolism. NEJM 2014;370:NIPPV:Ram FS, Wellington S, Rowe B et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev 2005(3):CD004360The safety and efficacy of noninvasive ventilation in patients with blunt chest trauma: a systematic review. Crit Care 2013;17:R142NIPPV for Procedural Sedation. Am J Emerg Med 2010;28:750Cinnamon Toxicity:Doctors warn teens about taking the “cinnamon challenge” in a new Report. Associated Press April 22, 2013 (Chicago)Grant-Alfieri A. Pediatrics 2013.
40(Let me know what you want to hear more of) Thanks!(Let me know what you want to hear more of)