Journal Feed Weekly Wrap-up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: Electrical or Chemical-First Cardioversion of A-fib?

Spoon Feed
For new onset atrial fibrillation (a-fib), an electrical-first approach reduced ED length of stay compared to a chemical-first approach.

Why does this matter?
With RACE 7, one might ask if there is need to cardiovert anyone with new onset a-fib or rather take a wait-and-see approach, as most spontaneously convert to NSR. But, many patients are profoundly symptomatic with a-fib, and restoration of NSR is a reasonable goal. As such, is it faster to chemically or electrically provide rhythm control?

Get into the rhythm
This was a multi-center RCT comparing chemical first to electrical first management of new onset a-fib. In all, 84 patients were randomized. The electrical first group was discharged home in under 4 hours 67% of the time, compared to the chemical first (procainamide) group at 32%. Procainamide converted 54% (22 of 41), and all failures crossed over and were then successfully converted electrically. Electrical cardioversion converted 88% (38 of 43), with 4 of the 5 failures crossing over and converting with procainamide. Adverse events were the same in each group, as were 3 and 30-day outcomes.

A Multicenter Randomized Trial to Evaluate a Chemical-first or Electrical-first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation. Acad Emerg Med. 2019 Aug 19. doi: 10.1111/acem.13669. [Epub ahead of print]

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#2: Why Not Ramp All Intubations? New RCT Suggests We Should

Spoon Feed
Bed-up-head-elevated (BUHE, aka ramped) position improved glottic view with Mac direct laryngoscopy (DL) over sniffing position and was noninferior to the GlideScope (GS) laryngeal view.

Why does this matter?
The Check-UP RCT found no difference in lowest SpO2 using the ramped position. But there is concern they were ramping incorrectly, with excessive cervical hyperextension and worsened glottic view. A retrospective look at NEAR data also did not show improvement in first pass success when ramped, but the patients most likely to have a difficult airway were also most likely to be ramped. Ramping is most often used in obese patients or when a difficult airway is anticipated. What would prove best in a RCT of all-comers?

Heads up…
This was a single center RCT of 138 low risk OR patients that compared percent of glottic opening (POGO) score with BUHE position using DL with a Mac vs GS view and compared both to baseline sniffing position. Groups were well randomized and otherwise equal. BUHE/DL was noninferior to GS. POGO score with BUHE was 80.14%; GS was 86.45%; difference -6.3% (98% CI, -13.2% to 0.6%). Noninferiority was considered a difference of > -15% on the lower 98% confidence interval. Both were significantly better than sniffing position: BUHE had a 26% improvement in POGO score; GS had a 31% improvement. Since half of difficult intubations are unanticipated, why not position every patient to optimize the view every time? Check-UP ramped wrong. See image. Image A is the sniffing position. Image B was what Check-UP did per their supplemental material (photos). Image C is the correct way to do BUHE, aka ramped position.

#3: Cricoid Pressure – First Do No Harm

Spoon Feed
The evidence does not support routine use of cricoid pressure (CP) to prevent pulmonary aspiration during intubation.

Why does this matter?
Sellick proposed CP in a case series of 26 patients considered at risk for aspiration but had no control group. In fact, CP may be biomechanically impossible. There is also little compelling evidence that it is effective. IRIS found that sham vs real cricoid pressure was identical in terms of pulmonary aspiration (0.5% without; 0.6% with) and slightly increased time to intubation. In light of this controversy being reignited, the authors set out to compile the known evidence.

Under pressure…

Anatomy controversy

Aspiration is bad

  • Aspiration of gastric contents may be lethal.

  • The authors argue it should be defined as, “bilious secretions or particulate material in the tracheobronchial tree or a new infiltrate on a chest roentgenogram,” producing clinical effects, such as hypoxia rather than defined as micro-aspiration by pepsin-A measurement.

Airway management effects

Appropriate application

  • If done, it should be posterior pressure on the anterior cricoid with two fingers, 30N of force. It may be biomechanically impossible, as laryngoscopy provides direct counterforce.

  • Most agree it should be performed in pregnant women. Most agree it should not be used in known unstable c-spine fracture.


International views


  • There is little solid evidence for using CP. The RCT we have indicates it does not reduce aspiration.

  • “Using the best currently available techniques, the incidence of pulmonary aspiration is not zero. This fact should be universal knowledge and should be well explained in medico-legal situations.”

  • In my practice, I have largely abandoned use of CP. It doesn’t reduce aspiration and makes a difficult airway even more difficult. Why would I want to do that?

Another Spoonful
Don’t miss Dr. John Hinds delivering a brilliant demolition of cricoid pressure in airway management, at smaccGOLD. Thanks, Aaron!

The Clinical Use of Cricoid Pressure: First, Do No Harm. Anesth Analg. 2019 Aug 6. doi: 10.1213/ANE.0000000000004360. [Epub ahead of print]

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