September 17, 2018

Background: The mis- and overuse of antibiotics continues to be a growing problem in medicine; the results of which are increased health-care costs, increased antibiotic resistance and, ultimately, patient harm. Unnecessary antibiotics are particularly prevalent in the treatment of lower respiratory tract infections (LRTIs) including asthma exacerbations and bronchitis. While it would be nice to simply stop using antibiotics when they’re not indicated, issues in stewardship abound. Amongst these are legitimate concerns by providers that the patient may have a bacterial infection causing their symptoms and, thus, benefit from a course of antibiotics.

Procalcitonin has been touted in recent years as a lab test that can help with this conundrum. Ideally, an elevated procalcitonin level would indicate the presence of a bacterial infection and, thus, suggest benefit from use of antibiotics while a low procalcitonin level would suggest a viral or non-bacterial etiology and suggest an absence of benefit from antibiotics. A recent Cochrane review showed potential for a procalcitonin approach but, there was minimal Emergency Department based evidence.

September 6, 2018

Background: Despite serious concerns about the role of alteplase in the management of acute ischemic stroke including, but not limited to, significant conflicts of interest, unbalanced baseline patient characteristics, systematic devaluation of contrary data, lack of reproduced benefit and low fragility index, it remains standard care for patients presenting with symptoms of acute ischemic stroke within 3 (or 4.5 depending on system) hours of onset of symptoms. Though the NINDS studies only showed benefit in a specific subgroup of patients, subsequent work has endeavored to expand the target group in a classic example of indication creep. Patients with minor CVA (NIHSS < 5 without disabling features or, essentially mRS 0-1) represent one such subgroup in which alteplase is often not employed due mainly in part to the perception of minimal benefit with continued potential for harm (i.e. anaphylaxis, intracranial hemorrhage). Alteplase supporters argue that minor stroke patients should still get the drug as it not only may reduce symptoms but can also prevent deterioration. The evidence for this viewpoint is both extremely limited and of poor methodologic quality.

September 3, 2018

EM Journal Update: Safety of Using Wells’ Clinical Model With D-Dimer To Manage Patients In The ED With Suspected Pulmonary Embolism

Background: In the US, pulmonary embolism (PE) kills 100,000 people each year and over 360,000 new cases of PE are diagnosed each year (Horlander 2003). Currently, the gold standard for diagnosing PE is the computed tomographic pulmonary angiography (CTPA). Patients with PE present with varying symptoms, from anxiety and tachycardia, to shortness of breath and syncope. Thus, it is difficult to exclude this life-threatening diagnosis and thus far there is no validated method to exclude PE. Prior work from this group derived and validated Wells’ criteria for calculating clinical probability of PE, and using it to determine which patients should get serial ultrasonography, venography, or angiography after an equivocal ventilation perfusion (VQ) scan (Wells 1998). Now, this group examines how the D-dimer assay, together with Wells’ clinical model can help manage PE patients.

August 30, 2018

Background: Venous thromboembolism (VTE) occurs frequently in patient with cancer. Treatment in this group entails a number of challenges including a higher rate of thrombosis recurrence and a higher risk of bleeding. Standard therapy at this time for both symptomatic and asymptomatic VTE is with low-molecular-weight heparin (LMWH) based on results from the CLOT trial (Lee 2003). In non-cancer patients, new oral anticoagulants (NOACs) like  rivaroxaban have been shown to be effective in treatment without increasing bleeding events. The NOACs also add ease of use for the patient. Though these agents are frequently used in the treatment of cancer-associated VTE, there is a dearth of evidence supporting this practice.

August 16, 2018

Background: Alcohol and drug intoxication is common in trauma patients and a significant proportion of cervical spine (c-spine) injuries occur in patients with intoxication. A standard approach to both intoxicated and sober patients with suspected c-spine injury in many trauma centers includes the placement of a rigid cervical collar for spinal immobilization until the c-spine can be “cleared.”  Even after a negative CT, intoxicated patients often are immobilized for prolonged periods of time until a reliable exam can be performed due to concern for missed findings on CT scan, specifically unstable ligamentous injuries.  This practice is less than ideal, as prolonged c-spine immobilization is associated with DVT, atelectasis, aspiration pneumonia, and elevated intracranial pressures.  In 2015, the Eastern Association for the Surgery of Trauma (EAST) demonstrated that CT imaging of obtunded patients due to any cause would miss approximately 9% of cervical spine injuries, most of which are clinically insignificant. They additionally found no benefit to prolonged immobilization.