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: Fluoroquinolones and Aortic Dissection – Again

Spoon Feed
Use of fluoroquinolones (FQ) was associated with a 2.5-fold increase in risk of hospitalization for aortic aneurysm (AA) or aortic dissection (AD).

Why does this matter?
Fluoroquinolones are known to have effects on connective tissue. A prior study in BMJ showed increased risk of aortic dissection in patients with recent use. These drugs can chelate ions involved in type 1 collagen synthesis and reduce expression of metalloproteinases. So, it’s plausible that they could increase risk for aortic aneurysm or dissection.

Take this pill, and your aorta explodes.
This was a unique case-crossover and case-time-design approach from a detailed Taiwanese nationwide database (see figure). They identified 1,213 inpatient cases of aortic aneurysm (AA) or aortic dissection (AD) from 2000-2011. Unlike the usual case-control, in the case-crossover the patient acted as his or her own control for the 60-day time period just before the AA/AD event compared to an earlier 60-day earlier time period. They hypothesized that the odds of exposure to a FQ in the 60-days prior to the AA/AD event would be greater than the odds of exposure in a randomly selected prior 60-day period. Turns out, that was correct. In the 60-day period just before the AA/AD event, 1.6% of patients were taking a FQ compared to just 0.6% in a random 60-day prior period of time, which means a 270% greater odds of taking a FQ just prior to their aorta exploding, (odds ratio 2.71; 95%CI 1.14–6.46). They performed additional analysis to make sure the increase in FQ use wasn’t confounded by a general population trend of increased FQ use. It wasn’t. They also found the longer the duration of FQ treatment, the greater the risk. Assuming this association is correct, the authors estimate the number needed to harm to be about 10,000. With over 25 million prescriptions for FQ in the US in 2012, that would mean an additional 2,500 cases per year of AA or AD. They estimated a NNH of around 500 in patients >65.

Source
Oral Fluoroquinolone and the Risk of Aortic Dissection. J Am Coll Cardiol. 2018 Sep 18;72(12):1369-1378. doi: 10.1016/j.jacc.2018.06.067.

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#2: Pediatric TBI Guidelines from the CDC

Spoon Feed
Taking care of children with mild traumatic brain injury (mTBI) is not easy. This guideline states clearly, based on compiled evidence, what you should and should not do.  It’s helpful.

Why does this matter?
So much is being written on mTBI in children.  What should we do to take care of these kids?  Should we CT or observe?  Should we have them rest or resume light activity?  Here are the guidelines.

The CDC Guidelines can help
Each statement was listed as a level of obligation: “must,” “should,” or “may” based on the level and quality of the evidence.

Diagnosis

  • “Health care professionals (HCP) should not routinely obtain head CT for diagnostic purposes in children with mTBI [this also includes MRI and SPECT].”  Rather, they should use clinical decision instruments, such as PECARN, to guide imaging decisions and discuss the risk/benefit with families.  Level B evidence
  • “Skull radiographs should not be used in the diagnosis of pediatric mTBI.”  Level B evidence
  • “HCPs should use an age appropriate, validated symptom rating scale as a component of the diagnostic evaluation in children seen with acute mTBI,” such as the Graded Symptom Checklist.  They may use computerized testing and should not use the Standardized Assessment of Concussion. Level B evidence
  • “HCPs should not use biomarkers outside of a research setting for the diagnosis of children with mTBI.”  Level R evidence (R = only in research setting).

Prognosis

  • “HCPs should counsel patients and families that most (70%-80%) children with mTBI do not show significant difficulties that last more than 1 to 3 months after injury” and “each child’s recovery from mTBI is unique.” Level B
  • “HCPs should assess the premorbid history of children either before injury as a part of preparticipation athletic examinations or as soon as possible after injury in children with mTBI to assist in determining prognosis.”  They should screen kids for known risk factors and use validated tools to assess recovery.  Kids with more cognitive or learning comorbidities or prior mTBI do worse in recovery and need to be monitored more closely. There are several recovery assessment tools. Level B.

Management and Treatment

  • Give anticipatory guidance: “Warning signs of more serious injury; Description of injury and expected course of symptoms and recovery; Instructions on how to monitor postconcussive symptoms; Prevention of further injury; Management of cognitive and physical activity/rest; Instructions regarding return to play/recreation and school; Clear clinician follow-up instructions.”
  • Injured children should rest more in the days after mTBI, though complete rest is not helpful.  They should gradually resume activity and have supervised return to contact play.  Level B
  • Injured children also may need emotional support (Level C) and should have gradual return to school and academics (Level B).
  • “Children undergoing observation periods for headache with acutely worsening symptoms should undergo emergent neuroimaging.” Level B.  Ibuprofen or acetaminophen should be used for headache.  Level B.  They should not get 3% saline for mTBI (who is doing this?).  Level B.
  • Children may need referral for persistent vestibulooculomotor dysfunction after mTBI.  Level C
  • HCPs should instruct on, “proper sleep hygiene methods to facilitate recovery from pediatric mTBI” and should pursue treatment for persistent cognitive dysfunction after mTBI.  Level B

Another Spoonful
The CDC has created a website to house all this information, called HEADS UP, so you can find and reference the latest mTBI guidelines.

Source
Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children.  JAMA Pediatr. 2018 Sep 4:e182853. doi: 10.1001/jamapediatrics.2018.2853. [Epub ahead of print]

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#3: Prehospital Airway Management

In light of the important recent prehospital airway management articles, I thought it might be helpful to go into more depth on the topic of prehospital airway management. Using the JF search tools, I found all these posts in under a minute.

Maybe Intubation is Worse In Arrest?
These two studies were not in the prehospital setting but are relevant to the discussion of intubation during arrest. In late 2016, a retrospective study of pediatric in-hospital arrest in JAMA found that survival to discharge was 36% in those intubated during the resuscitation vs 41% in those who were not. Then in early 2017, JAMA published a similar article of adult in-hospital arrest, which found survival with a good neurological outcome was better in patients not intubated in the first 15 minutes of arrest, NNT = 33.

VL or DL?
Now we get into some prehospital studies. Among less experienced, non-physician intubators, first-pass success for ETT passage almost doubled when video laryngoscopy was used compared to direct laryngoscopy.

Reason for Concern
This meta-analysis of 21 studies in mid-2017 raised concern about prehospital intubation of trauma patients. There was a marked increase in mortality among patient intubated in the prehospital setting vs those intubated in the ED, 48% vs 29%. However, almost all the included studies were retrospective. The only RCT included found no difference in mortality, a trend toward improved mortality, and improved neurological outcome with PHI, though it was not powered for these outcomes.

However…
Later in 2017, a post-hoc look at the PROTECT III dataset (originally a multi-center RCT of progesterone in TBI patients that showed no benefit) found that, to the authors’ surprise, there may have been benefit to prehospital intubation. More patients with PHI had a favorable neurological outcome than those who were not intubated, 57.3% vs. 46.0%, p = 0.003, respectively, and “odds of dying for those with prehospital intubation were 47% lower than for those that were not intubated.”  But the groups were not well matched when stratified by PHI (rather than the initial study intent, progesterone vs placebo).  80% of those with PHI came by air; 91% without PHI came by ground.  So what this study may be measuring is the beneficial effect of prehospital airway management in TBI by highly trained and skilled aeromedical personnel.

What about SGAs?
Also in mid-2017, a small retrospective study showed improved mortality and good neurological outcome of arrest patients who had a SGA placed, despite earlier concerns that SGAs might worsen outcome in arrest patients.

Just Bag ‘Em
In early 2018, JAMA published results of a RCT of bag-mask ventilation vs ETT in arrest. They found survival with a good neurological outcome at 28-days was the same in each group, 4.3% and 4.2% for BMV and ETT, respectively.

PART and AIRWAYS-2
This week, we covered PART and AIRWAYS-2. Both were prehospital EMS studies in OHCA arrest patients. PART showed improved 72-hour survival for the laryngeal tube over ETT (18.3% vs 15.4%; P = 0.04; RR 1.19) and also showed improved secondary outcomes of ROSC (27.9% vs 24.3%; P = 0.03), hospital survival (10.8% vs 8.1%; P = 0.01), and favorable neurological status at discharge (7.1% vs 5.0%; P = 0.02). AIRWAYS-2 was larger and showed no difference in good neurological recovery after non-traumatic out-of-hospital cardiac arrest (OHCA) at 30 days with use of an i-gel SGA compared to ETT. An important finding in both studies was that paramedics seemed to prefer to use a SGA first-line and often avoided advanced airway management at all when they were randomized to place an ETT. The conclusion or the main editorial was that for those in, “settings with limited exposure to advanced airway management should reconsider the routine use of endotracheal intubation as the first-line strategy for airway management in out-of-hospital cardiac arrest.”

Tube or Not?
Prehospital intubation is an infrequent EMS procedure and difficult skillset to maintain, though it has a role in prehospital care. However, it may be harmful if attempted by those with less experience and seems best in the hands of those who perform more frequent intubation, which is often helicopter EMS crews. VL may improve success in the prehospital setting. For OHCA, PART and AIRWAYS-2 have convinced me that placing either a LT or other SGA is the best prehospital advanced airway for cardiac arrest patients. There may be other scenarios in which prehospital intubation is the right course and may be life saving, but I think it should remain infrequent. I welcome your thoughts in the comments section on the website.

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