March 8, 2021

Background: Though oxygen is fundamental for life, supra-physiological levels can be deleterious. Several randomized controlled trials and meta-analyses have been conducted in the critically ill to determine whether a conservative oxygenation approach compared to a liberal oxygenation approach is beneficial. The OXYGEN-ICU trial was one of the first trials to explore this issue in 2016. It was a small, single centered trial with 434 ICU patients that showed a significantly lower ICU mortality in the conservative oxygenation group with an ARR 8.6%1. ICU-ROX (Mechanically ventilated patients) and LOCO2 (ARDS patients) were two more randomized trials that explored critically ill patients in the ICU with conflicting evidence on oxygen targets. There was no mortality benefit or ventilator free days in either study2,3. Although in the LOCO2 trial there was a clinically relevant excess mortality in the conservative group of 14 percentage points higher than in the liberal group at 90 days (not statistically significant) Additionally, the LOCO2 trial found a higher rate of intestinal ischemia in patients with a conservative oxygenation strategy3. Based on these three trials it can be stated that both hyperoxia (SpO2 >97%) and hypoxemia (SpO2 <90%) should be avoided.  An SpO2 of 92 to 96% (PaO2 60 to 90) would be the ideal target in these patients. Until now, there has not been any good data regarding oxygenation parameters in patients with acute hypoxemic respiratory failure.

March 7, 2021

Background: Early observational studies led to the Emergency Use Authorization (EUA) for convalescent plasma therapy (CPT) in the US in August 2020 for the treatment of COVID-19. Data from the RECOVERY trial, the largest clinical trial on COVID-19 treatments was halted early and was communicated as a press release [2] in January 2021.  The preliminary report was based on data from ≈10,000 patients and indicated no significant association of benefit with CPT in reducing all-cause mortality compared with standard of care. Due to this press release the authors of this paper decided to perform a systematic review and meta-analysis to summarize the current literature on the topic.

March 6, 2021

Background: Epistaxis is a common Emergency Department (ED) complaint with over 450,000 visits per year and a lifetime incidence of 60% (Gifford 2008, Pallin 2005). Standard anterior epistaxis treatment consists of holding pressure, use of local vasoconstrictors, topical application of silver nitrate and placement of an anterior nasal pack. ED patients with epistaxis often fail conservative management and end up with anterior nasal packs which are uncomfortable. This is even more common in the group of patients who are taking antiplatelet agents or anticoagulants. In recent years, tranexamic acid (TXA) has been added to many physicians’ armamentarium based on small studies (REBEL EM). While topical TXA has minimal safety concerns and is relatively inexpensive, higher quality studies are needed to further evaluate this treatment approach.

March 4, 2021

Background:  Despite medical advances, survival after out of hospital cardiac arrest (OHCA) is still largely dependent on high-quality CPR. Many of these events are due to a primary cardiac event, likely coronary artery occlusion. Current guidelines recommend reperfusion therapy following cardiac arrest with signs of acute coronary occlusion on EKG. But this only applies when return of spontaneous circulation (ROSC) is achieved. What about those in refractory arrest? Is there a way to increase survival in those patients? Keeping in mind that achieving ROSC may be impossible without reperfusion and reperfusion will likely not occur without ROSC.

March 3, 2021

Background: One of the most common reasons for Emergency Department (ED) visits is chest pain. While most of these presentations are at a low risk for cardiac events, it is generally required to perform a full work-up to rule out an Acute Coronary Syndrome (ACS), including an Acute Myocardial Infarction (AMI), before being discharged responsibly. The biggest challenge for physicians is to not only identify patients who are likely to have ACS but also to identify low risk patients that can be safely discharged without prolonged stays for further investigation. The current standard of practice, including risk assessment protocols, recommend using serial troponin testing and detection of absolute changes in troponin levels to rule out AMI in the ED. Recent studies using high sensitivity troponin (hsTnT) have shown that if the initial troponin is very low, one troponin may be sufficient to safely discharge patients from the ED, especially when combined with the HEART score. In practice however, in countries where hsTnT is not generally available, some clinicians have adopted this strategy using conventional troponin. This particular practice of using single conventional troponin testing has not been studied well.