JournalFeed Weekly Wrap-Up
- Aug 4th, 2018
- Clay Smith
- categories:
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: PAMPer – Prehospital Plasma for Hemorrhagic Shock Saves Lives
Spoon Feed
Prehospital administration of 2 units of thawed plasma in adult trauma patients at risk for hemorrhagic shock reduced mortality compared to standard care, NNT = 10.
Why does this matter?
Damage control resuscitation, early use of blood products for hemorrhagic shock in preference to crystalloid, has been shown to improve outcome in trauma patients, as in the PROPPR trial. Would early intervention with plasma in the prehospital setting reduce coagulopathy, hemorrhage, and prevent worsening shock?
PAMPer your patients
This was a multi-center RCT of prehospital air transport administration of 2 units thawed plasma in 501 adult patients at risk for hemorrhagic shock. It was called PAMPer (Prehospital Air Medical Plasma trial). Most had blunt trauma, though 18% of cases were penetrating. Specifically, to be included, patients needed to have at least one SBP < 90 or heart rate >108 at any point or severe hypotension, SBP <70, at any time prior to trauma center arrival.
Groups were randomized and well matched; roughly half received 2 units of thawed plasma en route to the hospital, and the other half received standard care. The standard care group received about 400cc more crystalloid and more PRBC transfusions. For the primary outcome of 30-day mortality, the plasma group was far better: 23.2%, plasma vs. 33.0%, standard care; difference, −9.8% (95% CI, −18.6 to −1.0), NNT = 10. This held for almost all pre-planned subgroups as well. Important secondary outcomes were also better, such as 24-hour mortality, in-hospital mortality, need for transfusion, and INR (1.2 plasma; 1.3 standard care). Only INR remained significant after adjusting the p-value for multiple comparisons. There were no safety issues with the administration of plasma, such as ARDS, infection, or multi-organ failure.
Source
Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326. doi: 10.1056/NEJMoa1802345.
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#2: PARAMEDIC2 – Epinephrine in Arrest RCT
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Epinephrine for out-of-hospital cardiac arrest (OHCA) improved overall 30-day survival (3.2%, epi vs 2.4%, placebo) but did not improve survival to discharge with a good neurological outcome. In fact, more patients who received epinephrine and survived had severe neurological impairment than in the placebo group.
Why does this matter?
The literature has been back on forth on epinephrine. Studies suggest it improves return of spontaneous circulation (ROSC), but those who survive long-term are neurologically devastated. This RCT was designed to clear this up.
Epi – It depends on how you look at it
This was a large RCT from the UK with 8014 adult, non-pregnant people with OHCA who received standard resuscitation care and either epinephrine or saline as placebo. Groups were well matched. Those who made it to the hospital received standard ICU care, including targeted temperature management. For the primary outcome, epinephrine significantly improved 30-day survival over placebo: 3.2% vs 2.4%, respectively. Consistent with prior studies, ROSC was much higher in the epinephrine group vs placebo: 36% vs 12%, respectively. However, there was no improvement in survival to discharge with good neurological outcome (defined as modified Rankin scale [mRS] ≤3) with epinephrine vs placebo: each around 2% with no statistical difference. Survivors to hospital discharge with severe neurological injury (mRS 4 or 5) were more common in those who received epinephrine vs. placebo: 31% (39/126) vs 18% (16/90), respectively. See Figure.
Now we must debate if getting more survivors, at the cost of them being neurologically devastated, is the right thing to do. Prior to the study they assessed public opinion and found that patients, “identified survival with a favorable neurologic outcome to be a higher priority than survival alone.” Epi seems to be good for the heart but not the brain.
The authors also suggested we prioritize treatments with the most value in OHCA. The NNT was 112 for survival with epinephrine. Whereas for early defibrillation the NNT = 5 ; for early recognition of arrest, NNT = 11; for bystander CPR, NNT = 15.
Source
A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018 Jul 18. doi: 10.1056/NEJMoa1806842. [Epub ahead of print]. This is a free full text access article from NEJM.
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Another Spoonful
As you might have guessed, this blockbuster article already has garnered attention in the #FOAMed world.
- REBEL EM has a breakdown of the article and podcast.
- First 10EM has a great discussion of the issues.
- Rogue Medic weighs in as well.
- St. Emlyns has a thoughtful discussion of the pros and cons.
- emDocs has a nice summary of the literature evaluating epinephrine in cardiac arrest.
- EMNerd calls epi an ineffective therapeutic agent.
#3: Brain Injury in DKA; Fluid Rate or Type RCT by PECARN
Spoon Feed
Neither the fluid rate (fast or slow) or type (NS vs 1/2NS) altered the risk of brain injury with decline in GCS <14 in children with DKA.
Why does this matter?
Whether the type or rate of IV fluid used in DKA increases the risk of brain injury and subsequent cerebral edema has been a subject of intense and longstanding debate. This study helps clarify this question.
The fluid is not the culprit
This was a multi-center 2×2 factorial RCT in 1389 children with DKA, with NS given fast or slow or 1/2NS given fast or slow. Treatment groups were as per Table 1.
The primary outcome was decline in GCS <14, which occurred in 45 patients, evenly split among the 4 groups, with no statistical difference between them. Secondary outcomes looking at more subtle neurologic dysfunction (memory and IQ scores) were not affected by any of the tested variables. This tells us that it is not the type of fluid or infusion rate that causes brain injury in DKA.
Source
Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018 Jun 14;378(24):2275-2287. doi: 10.1056/NEJMoa1716816.
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- emDocs has a great summary of the literature evaluating myths concerning IV fluids, pediatric DKA, and cerebral edema.
