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: ACS Championship Preview

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T-MACS and EDACS outperformed HEART and TIMI in a head-to-head comparison of decision aids used to rule out acute coronary syndrome.

Why does this matter?
The literature is cluttered with different decision aids: HEART, TIMI, GRACE, EDACS, and T-MACS.  In the United States, the HEART score has been almost universally adopted by emergency physicians and has received the most first-place votes in the EP poll.  This study finally lets the top 4 scoring systems to go head-to-head in the 2020 ACS Playoffs. However, just like in the college football BCS Championship era, one team always gets left out of the finals—sorry GRACE.

The winning score in tonight’s ACS Championship is…
This was a nested study that prospectively collected data from 999 patients who presented to one of 14 emergency departments in England with symptoms concerning for ACS.  The study used a single troponin test (hs-cTnI, Siemens ADVIA Centaur) on initial ED presentation to evaluate an early rule-out strategy.  The authors compared four decision aids to a blinded and adjudicated diagnosis of type I AMI.  The reference standard was serial troponin measurement as prescribed by the third universal definition of myocardial infarction. 13.2% of patients had AMI.  T-MACS had the highest sensitivity and NPV (99.2% and 99.8%, respectively) although it was not statistically different from EDACS (sensitivity 96.2% , NPV 99.3%).  Both T-MACS and EDACS identified the highest percentage of patients for early discharge (46% and 48%, respectively).  The HEART score performed the worst in terms of sensitivity (91.8%) which was statistically significant compared to T-MACS (p=0.004).  Furthermore, the HEART score only identified 35% of patients for early discharge.  Be aware that this study was led by Rick Body, the super smart creator of T-MACS, so there is some risk of bias. Nonetheless, given prior literature comparing the HEART score to EDACS, my vote is for the HEART score to lose its #1 seed.

Source
Comparison of four decision aids for the early diagnosis of acute coronary syndromes in the emergency department. Emerg Med J. 2020 Jan;37(1):8-13. doi: 10.1136/emermed-2019-208898. Epub 2019 Nov 25.

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#2: Droperidol – Is It Safe?

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This is yet another study with thousands of patients that found no increased risk of death using droperidol at usual, low doses.

Why does this matter?
Droperidol is effective and has antiemetic, sedative, and analgesic effects, as well as a 30-year track record of safety. But in 2001, the FDA effectively ended its use, with an iffy black box warning for QT prolongation and torsades risk. Some suspect GlaxoSmithKline may have had something to do with it, as ondansetron sales soared after droperidol was effectively nudged out of usage. You need to read this Academic EM exposé on the questionable circumstances surrounding the black-box warning for droperidol.

Droperidol – safe wonder-drug?
This was a retrospective study of 6,353 visits in which patients received droperidol. There were no deaths within 24 hours and no arrhythmias. As a secondary outcome, over 90% of patients required no rescue medications when it was used for headache or other pain, though this was based on manual review of 10% of charts. This study was focused more on safety and less on efficacy. The gist is droperidol is safe when given in usual lower doses: 0.625 to 2.5mg.

Source
Effectiveness and safety of droperidol in a United States emergency department. Am J Emerg Med. 2019 Nov 25. pii: S0735-6757(19)30612-6. doi: 10.1016/j.ajem.2019.09.007. [Epub ahead of print]

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Fore more, see this emDocs post by David Cisewski.

#3: How Good Is CT Active Extravasation for Pelvic Fracture Arterial Injury?

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CT with contrast was 80% sensitive for detecting arterial injury with contrast extravasation. Subgroup analysis considering 64-slice scanners or better found sensitivity was 94%, specificity 89%.

Why does this matter?
Angiographic embolization (AE) is an early approach to stop arterial hemorrhage from pelvic fractures. Active extravasation of IV contrast on CT is one indication that arterial injury is present. The other cause of massive hemorrhage from pelvic fractures is oozing from the pelvic venous plexus. Venous bleeding tends to improve with reduction of pelvic volume and external fixation. Arterial injury benefits from AE. How accurate is CT for picking up active extravasation and need for AE?

“My broken relationship with the pelvis makes me blush.” External Pudendal Artery
This was a meta-analysis of 23 studies to determine the diagnostic accuracy of CT with contrast to detect extravasation of contrast in the setting of pelvic fractures compared with the gold standard of arterial bleeding on subsequent angiography and need for AE. Studies went back to 1996. Twelve had <64-slice scanners. Taking all studies into account, sensitivity was 80%, specificity 95%. The authors performed several subgroup analyses. In the subgroup of studies with 64-slice or better CT scanners (7 studies), the sensitivity was 94% (95%CI 86 to 97%); specificity 89% (95%CI 81 to 93%). Multiphasic vs monophasic (single scan) sequences improved the diagnostic accuracy for all studies. Of course, multiphasic means more time and radiation exposure as well. In short, CT with contrast in current generation scanners is a good test to determine if AE will be needed in trauma patients with pelvic fractures.

Source
Diagnostic value of CT contrast extravasation for major arterial injury after pelvic fracture: A meta-analysis. Am J Emerg Med. 2019 Nov 28. pii: S0735-6757(19)30777-6. doi: 10.1016/j.ajem.2019.11.038. [Epub ahead of print]

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#4: Arrest from PE – Do Lytics Help?

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For patients with out-of-hospital cardiac arrest (OHCA) and PE, 30-day survival was greater in those who received thrombolytic therapy than those who did not, but there was no significant improvement in neurologically intact survival.

Why does this matter?
PE is a rare cause of OHCA, around 2.5%. Determining when to use thrombolytic agents in arrest is challenging. Prior history of DVT/PE and non-shockable rhythm are known risks, though these two variables are not sensitive for PE as a cause of arrest. Bedside echo is very helpful in such cases and is recommended by the AHA and ERC. If we suspect PE caused arrest, does it make a difference in outcome to give a thrombolytic during CPR?

More survive…but not intact
This was a retrospective review of 246 patients with OHCA confirmed to have PE. Of these, 58 received thrombolysis during CPR. Tenecteplase was the most commonly used agent. Overall, 30-day survival was better in those who received thrombolysis vs. those who did not: 16% vs 6%, p = 0.005, respectively; but no improvement in neurologically intact survival: 10% vs 5%; adjusted relative risk, 1.97; 95% CI, 0.70-5.56. Groups were very similar except the lytic patients had longer down time, higher epinephrine dosing, and fewer patients with initial rhythm of asystole. Death from hemorrhage was not greater in the lytic cohort. The study was undoubtedly limited by confounding, being non-randomized and having occasional missing data in the arrest registry. At this point, it is a judgment call whether to give lytics or not for OHCA and suspected PE.

Source
Thrombolysis During Resuscitation for Out-of-Hospital Cardiac Arrest Caused by Pulmonary Embolism Increases 30-Day Survival: Findings From the French National Cardiac Arrest Registry. Chest. 2019 Dec;156(6):1167-1175. doi: 10.1016/j.chest.2019.07.015. Epub 2019 Aug 2.

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