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: Rock Star Review of Critical Care Literature – 2018

Spoon Feed
This is a great reference list of critical care articles with EM relevance from the year 2018.

Why does this matter?
This is a group of authors we respect, and these are the critical care articles they thought were most important from the year 2018. JournalFeed covered ten of these in real time back in 2018. What were their picks?

The Lucky 13 CC from 2018

  1. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med. 2018; 379:711–21. Authors’ take: “30-day survival occurred in 3.2% of patients who received epinephrine compared to 2.4% of patients who received placebo. In survivors, severe neurologic impairment occurred in 31% of patients who received epinephrine compared to 17.8% of patients who received placebo.”
    JF Summary

  2. Effect of bag-mask ventilation vs endotracheal intubation during cardiopulmonary resuscitation on neurological outcome after out-of-hospital cardiopulmonary arrest. A randomized clinical trial. JAMA. 2018; 319:779–87. Authors’ take: “28-day survival with favorable neurologic outcome occurred in 4.3% of patients in the BMV group and in 4.2% of patients in the ETI group. There was no difference in the secondary outcomes of survival to hospital admission and 28-day survival between the two groups.”
    JF Summary

  3. Effect of a strategy of a supraglottic airway device vs tracheal intubation during out-of-hospital cardiac arrest on functional outcome: The AIRWAYS-2 randomized clinical trial. JAMA. 2018; 320:779–91. Authors’ take: “The primary outcome of neurologic outcome at hospital discharge or 30-days after OHCA occurred in 6.4% of patients randomized to an SGA and 6.8% of patients randomized to ETI. Initial successful insertion rates were greater in the SGA group without any increase in complications.”
    JF Summary

  4. Association between elevated mean arterial blood pressure and neurologic outcome after resuscitation from cardiac arrest: results from a multicenter prospective cohort study. Crit Care Med. 2018;47(1):93–100. Authors’ take: “Patients in the higher MAP group (MAP greater than 90 mmHg) had a higher incidence of good neurologic outcome when compared patients with a MAP between 70 and 90 mmHg. A MAP greater than 90 mmHg was found to be an independent predictor of good neurologic function at hospital discharge. The benefit of a higher MAP was greater in patients with a history of hypertension compared with those with no history of hypertension.”

  5. Association between early hyperoxia exposure after resuscitation from cardiac arrest and neurological disability: a prospective multi-center protocol-directed cohort study. Circulation 2018;137(20):2114–2124. Authors’ take: “Patients exposed to hyperoxia had a higher incidence of poor neurologic outcome at hospital discharge compared to patients not exposed to hyperoxia. Hyperoxia was found to be an independent predictor of poor neurologic outcome at hospital discharge.”
    JF Summary

  6. Adjunctive glucocorticoid therapy in patients with septic shock. N Engl J Med. 2018;378(9):797–808. Authors’ take: “No significant difference in the primary outcome of 90-day all-cause mortality in patients who received hydrocortisone compared to those who received placebo. Time to shock resolution, time to ICU discharge, and the duration of the initial episode of mechanical ventilation were all shorter in patients who received hydrocortisone.”
    JF Summary

  7. Hydrocortisone plus fludrocortisone for adults with septic shock. N Engl J Med. 2018;378: 809–18. Authors’ take: “The primary outcome of 90-day all-cause mortality occurred 43% of the hydrocortisone-fludrocortisone group compared with 49.1% in the placebo group. Those in the hydrocortisone-fludrocortisone group had a statistically significant difference in all-cause mortality at ICU discharge. Patients in the hydrocortisone-fludrocortisone group had a shorter time to cessation of mechanical ventilation and cessation of vasopressor therapy.”
    JF Summary

  8. Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: A randomized clinical trial. JAMA 2018; 319:2179–2189. Authors’ take: “The primary outcome of first attempt success in those with at least one characteristic of a difficult airway occurred in 96% of patients randomized to the bougie and 82% of patients randomized to the ETT plus stylet.”
    JF Summary

  9. Cardiac arrest and mortality related to intubation procedure in critically ill adult patients: A multicenter cohort study. Crit Care Med. 2018; 46:532. Authors’ take: “Patients who suffered an intubation-related cardiac arrest had a higher 28-day mortality rate compared with patients who did not have an intubation-related cardiac arrest. A systolic blood pressure <90 mm Hg prior to intubation, hypoxemia prior to intubation, the absence of preoxygenation, obesity, and age >75 years were associated with intubation– related cardiac arrest.”
    JF Summary

  10. Effect of a low vs intermediate tidal volume strategy on ventilator-free days in intensive care unit patients without ARDS. The PReVENT Trial. JAMA 2018; 320 (18):1872–1880. Authors’ take: “There was no significant difference in the primary outcome of ventilator free days and alive at day 28 between the low tidal volume ventilation group and the intermediate tidal volume ventilation group.”
    JF Summary

  11. Practice patterns and outcomes associated with early sedation depth in mechanically ventilated patients: A systematic review and meta-analysis. Crit Care Med 2018; 46 (3):471–479. Authors’ take: “A statistically significant decrease in mortality was found for patients who received an early, lighter level of sedation compared with patients who received early, deep sedation. Lighter sedation was also associated with significantly fewer days of mechanical ventilation and shorter ICU lengths of stay.”

  12. Balanced crystalloids versus saline in critically ill adults. N Engl J Med 2018;378(9): 829–39. Authors’ take: “The primary outcome of MAKE at 30 days occurred in 14.3% of the balanced crystalloid group compared with 15.4% of the 0.9% sodium chloride group.”
    JF Summary

  13. Sodium bicarbonate therapy for patients with severe metabolic acidemia in the intensive care unit (BICAR-ICU): a multicenter, open-label, randomized controlled, phase 3 trial. Lancet. 2018; 392:31–40. Authors’ take: “There was no significant difference in the primary outcome of all-cause 28-day mortality and failure of at least one organ system at seven days after randomization between patients in the intervention group and those in the control group.”

Source
Winters ME, Hu K, Martinez JP, Mallemat H, Brady WJ. The critical care literature 2018. Am J Emerg Med. 2019 Nov 28. pii: S0735-6757(19)30772-7. doi: 10.1016/j.ajem.2019.11.032. [Epub ahead of print]

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#2: Is It Time to Adjust D-dimer Thresholds to Our Clinical Pretest Probability?

Spoon Feed
Using the Wells Score to categorize patients as low, moderate, or high clinical pretest probability in conjunction with adjusted positive D-dimer thresholds at >1000 ng/mL for a low or >500 ng/mL for a moderate Wells Score, the authors reduced diagnostic chest imaging in the ED with no incidence of missed venous thromboembolism (VTE) at 90 days.

Why does this matter?
We can reduce imaging for PE by increasing the D-dimer threshold or by using the D-dimer test to rule out PE in more than just patients with a low pretest probability. Historically, age-adjusted D-dimer and the YEARS criteria are examples. Using clinical pre-test probability to adjust a D-dimer threshold has also been done. PEGeD is a prospective validation of this prior work.

“Dr. Wells or: How I learned to stop imaging and love the D-dimer”
This was a multicenter, prospective trial performed in Canada which enrolled 2,017 adult patients with signs or symptoms suggestive of PE.  Study outcomes were assessed at 90 days after initial diagnostic testing. When compared to a standard strategy of low clinical pretest probability and a D-dimer <500, there was a relative reduction of 34% in chest imaging using the PEGeD strategy (outlined in the Spoon Feed). Of the 1,970 patients that had low or moderate clinical pretest probability, 1,325 had negative D-dimers at the predefined thresholds and none of these patients had VTE during the 90 day follow-up. The majority of the benefit was found in the low pretest probability patients with D-dimers <1000, as only 11% patients had a moderate clinical pretest probability and only 18% of those had a negative D-dimer. The authors compared their D-dimer adjusted threshold criteria to both age-adjusted and YEARS criteria with the PEGeD strategy showing a larger reduction in imaging compared to both. Granted, this study used the Wells score to categorize patients’ pretest probability, and it is uncertain whether the same approach to D-dimer interpretation without using a clinical prediction tool would have the same result. One wonders…physician gestalt isn’t too bad.

Another Spoonful

Source
Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability. N Engl J Med. 2019 Nov 28;381(22):2125-2134. doi: 10.1056/NEJMoa1909159.

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#3: Lever Sign – A Better ACL Exam Technique

Spoon Feed
Compared to other clinical tests of anterior cruciate ligament (ACL) disruption, the lever sign is more accurate and sensitive in an ED setting.

Why does this matter?
Accurate initial diagnosis of ACL rupture can facilitate timely follow-up and repair. This study shows increased sensitivity for ACL rupture with the lever sign test and can be a helpful addition to the standard knee injury examination in the ED.

The power of a lever
This was a single-center implementation study in which emergency physicians were trained in performing the lever test. They enrolled 45 patients between the ages of 12 and 55 who presented to the ED with acute knee injuries. Patients were diagnosed as having ACL rupture or not with the lever sign test during the first 4.5 months of the study and either the anterior drawer or the Lachman test for the second 4.5 months of the study. Follow-up MRI imaging was used as the gold standard. The lever sign test was found to be 95% accurate and 100% sensitive for ACL rupture. Anterior drawer/Lachman testing was 88% accurate and 40% sensitive. Specificity was slightly higher for the anterior drawer/Lachman testing at 100% vs. 94% for the lever sign. Diagnostic confidence was slightly higher for the lever test and there did not appear to be any difference in accuracy based on training level of the provider.

Here is how to do it!

How to perform the lever sign test:

  1. The patient is placed supine with the knees fully extended on the examination table.

  2. The examiner places a closed fist under the tibial tuberosity of the affected knee. This causes the knee to flex slightly. (Pro tip – make sure your fist isn’t too close to the knee, or it won’t work.)

  3. With the other hand, the examiner applies moderate downward force to the distal femur. With this configuration, the patient’s leg acts as a lever over a fulcrum—the clinician’s fist.

Intact ACL = Patient’s foot will rise off the bed with the addition of downward force to the distal quadriceps.

Ruptured ACL = Patient’s foot will remain in contact with the bed with addition of downward force to the distal quadriceps.

Source
Implementing the Lever Sign in the Emergency Department: Does it Assist in Acute Anterior Cruciate Ligament Rupture Diagnosis? A Pilot Study. J Emerg Med. 2019 Dec;57(6):805-811. doi: 10.1016/j.jemermed.2019.09.003. Epub 2019 Nov 7.

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