Recent Literature Update for

Acute Care: 2013-14

Edward A. Panacek, MD, MPHUC Davis Medical Center

Big Sky conference, 2014

Disclosures: None No relevant financial relationships

pertaining to this lecture

The overwhelming amount of information in medicine

Each year:

� More than 3,000 biomedical journals are published

� The FDA approves more than 500 new or updated drugs and 3000 medical devices

Even if you only try to keep up with the relevant journals in your field and JAMA and the NEJM, you would have to read over 17 articles/day and 1,200 pages per month

To the rescue:

Panacek’s lit review lecture !

• I scan the literature for relevant articles

• Important articles and interesting *s#+%

Realistically, this lecture cannot overcome an entire year of not reading the medical literature

But we can make a dent in it

And have fun doing it…

Your job:commit yourself

It is questioned whether didactic lectures have an impact on clinical practice

That passive learning is not effective for adult learners…

In this talk, I am asking you to identify 2-3 things that will change your practice

Some caveats!

Do not hold your

questions to the end!

Audience participation and comments add to the talk

Respiratory-thoracic

Something you may already know

Issue: We treat tons of asthma

Context:

Which inhaled bronchodilator regimen works best?

Continuous vs intermittent albuterol to reduce hospital admissions in acute asthma

� Systematic review “snapshot” article

� 20 articles reviewed. 8 RCTs included

� Continuous nebulization:

� Clearly better in severe asthma

� Also better in moderate asthma (RR= 0.64)

� No benefit in mild asthma

� No increased side effects

� NNT in mod/severe = 7 (to save admission)

Gregory. AnnEmerMed.2012;60: 663

Take home points� NNT of 7 is very low to save something as

important as an admission.

� Continuous should become std care in all moderate/severe asthmatics in the ED

� Don’t bother in the mild cases

� But even if used in all ED asthmatics, NNT = 9-

12 to save an admission.

Critical Care

Get your sepsis fix now

Issue: Septic shock carries a 20-40%

mortality. Higher if not reversed quickly

Context:

Many pressor regimens still being used. Which is best?

Dopamine versus norepinephrine in the Tx of septic shock: Meta-analysis

� Individual studies show mixed results

� Meta of 11 studies ( 6 RCTS), 2768 pts

� Dopamine ���� increased risk death (OR 1.12)

� Little difference in ICU or hosp LOS

� More dysrhythmias with dopamine (RR= 2.34)

DeBacker, Vincent. CCM. 2012;240: 725

Take home points

� In 2012, dopamine should no longer be the first choice pressor for septic shock

� And maybe not for much else either

Old school:Levophed:

= leave them dead.

New school:

With Dopamine:

towards death will lean

Electricity: Some wonder how to use it

Issue: Cardiac arrest.

Shock first? CPR first?

Context:AHA CPR guidelines have flip-

flopped on this between the last 3 updated recommendations

Earlier vs. later rhythm analysis in pts with “out of hospital” cardiac arrest

� ROC group multicenter RCT. US & Canada

� 9,983 adults, nontraumatic, arrest

� 30-60 sec CPR then analyze and shock vs. 3 min of CPR before analysis

Results:

� Good neuro @ hosp D/C= 5.9% in each group

� Time to analysis: 42 sec vs 180 sec.

� No diff in 2nd outcomes (ROSC, survival, etc.)

Steill. NEJM. 2011; 365: 787

Take home points

� Early vs late rhythm analysis doesn’t matter

� But either way, do immediate CPR and continue CPR until ready for analysis and shock!

� BTW, the 2010 AHA-ILCOR guidelines noted inconsistent evidence

Infectious Diseases

Sometimes you can

use some help

Issue: STIs are an important public health

issue, with significant potential morbidity

Context:Anything the ED can do to better

treat and control?

Expedited partner Tx in management of GC & chlamydia by OB-Gyn

Professional ACOG comm recommendation:

� Tx of women with STIs should include Tx partners also

� Ideal to have partner seen, but not required

� Decreases prevalence of STI and recurrence

� Controversial legal issues

� Permissible in 32 states, illegal in 7, 11 unclear

� Supported by the CDC

� Produced a “toolkit” for implementation

Committee opinion. OB & Gyn. 2011; 118: 761

Take home points� STIs at epidemic rates in many

areas and subpopulations� 3x10^6 new chlamydia cases/yr, 700,000 GC

� Tx trend is growing nationally

� CDC supports it

� Legal in most states� Legal in CA

Sometimes you need

to improvise

a bit

Issue: Akathesia is rather commonCan limit use of antiemetics

Context:

We have few anti-emetics as it is, anything that we can do

about this?

Slow infusion of metoclopromide does not affect efficacy but reduces akasthesia and sedation

� 25% of pts can get akasthesia with reglan

� 140 adults, N/V, blinded RCT

� Reglan 10mg IV, over 2 min vs 15 minutes

Results:

� No difference between groups on N/V effect

� At 15 min or at 1 hr

� Much less complications with slow infusion

� Akasthesia much less (7% vs 26%)

� Sedation less (14.5% vs 27.5%)

Tura. EmergMedJ. 2012;29: 108

Take home points� You can seriously decrease the

problems of giving IV reglan by slow infusion (over 15 minutes)

� Works for many other similar medications also.

� Change your orders

� Change your practices

You want to do what!!!!!

Issue: Careful about epinephrine

injections and ischemia in selected vascular beds

Context:

Fingers, toes, penis, nose…

Really?

Six years of epinephrine digital injections: Absence of significant local or systemic effects

� Natural experiment : accidental epi-pen injections

� 6 poison centers, 6 yrs, 213 digital cases

� Mostly thumb injections, 127 with F/U

� 23% rec’d vasodilatory Tx, mostly just empiric

� 4 had evidence of ischemia, all improved with Tx

� None had significant systemic symptoms

� 100% had full recovery

Muck. AnnEmergMed. 2010;56: 275

Take home points� Concerns about use of epinephrine in

the hand are excessive.

� Hand surgeons routinely use lidocaine with epi in the hand

� Original prohibitions resulted from intra-arterial injections

� Avoid that and use in the hand is fine

Miscellaneous

Another myth… or fact ??

Topical anesthetics are toxic to the cornea !

Issue: Corneal abrasion.

Eye pain for 1-3 days

Context:Cycloplegics. Abx ointment.

Pt asks for that “stuff you put in my eye” for pain relief.

No way!.....…way?

Dilute proparacaine for management of acute corneal injuries in the ED

� CW: no D/C proparacaine to pts= eye toxic

� RCT, 15 adults, Canada

� 0.05% proparicaine vs placebo

� All ���� Ophthalmologist F/U

Results: Efficacious and safe

� Better pain relief

� higher satisfaction scores

� No complications or delayed eye healing

Ball. CJEM. 2010; 12: 389

Take home points� Dogma refuted !

� How does this compare to the proparicaine used in the ED?

� That is 0.5%

� This is 10 fold weaker: 0.05%

� Question: How do I do this?

� How do I dispense to the pt and document instructions?

Another myth… or fact ??

Topical anesthetics are toxic to the cornea?

Issue: Patient satisfaction scores

becoming increasingly common

Context:

What can be done to improve them?

Effect of sitting vs standing on perception of provider time at bedsie

� Surgeon on post-operative visits, 120 pts

� RCT to sit vs stand, rest of visit same

Results:

Position Actual time Perceived time

� Stand 1’ 28” 3’ 44”

� Sit 1’ 4” 5’ 14”

� Positive pt feelings: sit= 95%, Stand = 61%

Swayden. Patient Educ Couns. 2012; 86: 166.

Take home points� This one is a “no-brainer”

� Unless you can’t find a chair

� Want better pt satisfaction scores?

� Sit down instead of standing during the pt interview or meeting

As we near the end… a reminder

List a few things from this lecture that will change your

practice this year

Last article…..that won’t change your practice, but

more to entertain…… as time allows

Issue: Trends come and go

Context:

What is the latest bizarre medical trend that you have not

heard of?

Medical tattoos?

You are about to intubate and see…

Medical tattoos with vital information replacing bracelets for some

� Americans increasingly getting tattoos to warn about important medical conditions

� 80% relate to allergies, 10% to IDDM

� Simple, permanent, can’t lose or break

� Some MDs favor standardizing medical them

� Legal viability of “no CPR” tattoos questioned

CBS News. 2012 (Feb 27)

Dr. Friedlander, pathologist

Maybe instructions are better?

The end !

The end !