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: Bilateral Clamshell or Left Anterolateral Thoracotomy?

Spoon Feed
The modified bilateral anterior clamshell thoracotomy (MCT) technique was as fast (faster for some) as the left anterolateral thoracotomy (LAT), resulted in fewer iatrogenic injuries, and was favored by emergency physicians.

Why does this matter?
Performing a resuscitative thoracotomy is one of the most dramatic procedures in EM. Usually it means a LAT – a slash down the left thorax, spreading the ribs, and gaining access to the heart by opening the pericardium, +/- cross clamping the aorta. An easier approach might be the MCT.

Trauma surgery for non-trauma surgeons
This was a randomized trial of 16 emergency physicians (about half senior residents, half attending) in the cadaver lab. They were trained in LAT and MCT and then randomized to perform one technique first, followed by the other, and timed on delivery of the heart from the pericardium plus 100% cross clamping of the thoracic aorta. There was no statistical difference in success: 67% MCT vs 40% LAT, difference -27% (95%CI -61% to 8%). The subset of emergency medicine staff (i.e. attending physicians) had significantly higher success with MCT vs LAT. 100% of the LAT trials resulted in some form of iatrogenic injury vs 67% of the MCT trials. Physicians overwhelmingly preferred MCT over LAT 87% vs 13%, difference 74% (95%CI 23-97%).

Prospective Randomized Trial of Standard Left Anterolateral Thoracotomy Versus Modified Bilateral Clamshell Thoracotomy Performed by Emergency Physicians. Ann Emerg Med. 2021 Mar;77(3):317-326. doi: 10.1016/j.annemergmed.2020.05.042. Epub 2020 Aug 15.

Another Spoonful
First, you must watch EMCrit’s Crack to Cure video. Next, the Thoracotomy Masterclass. Also, if you want to see how great Essentials of EM is, check out this video on performing a LAT!

#2: Best Antibiotic for Diverticulitis

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Amoxicillin-clavulanate (AC) compared to fluoroquinolone + metronidazole (FM) was not associated with worsened outcomes for outpatient treatment of diverticulitis and may reduce known harm related to the fluoroquinolone class of antibiotic.

Why does this matter?
There is some evidence that in select cases, antibiotics could be avoided for diverticulitis, though I remain skeptical. Usually, FM is prescribed for outpatient treatment of diverticulitis. Yet fluoroquinolones are associated with tendon rupture, hypoglycemia, altered mental status, possibly aortic dissection, QT prolongation, and possibly sudden death.

How to fix the tics
This was a retrospective study of a national claims database comparing FM to AC for outpatient treatment of uncomplicated diverticulitis. FM was used 82% of the time. There was no difference in hospital admission at one year, need for urgent surgery at one year, or risk of C. difficile colitis. In Medicare recipients (generally ≥65 years), the risk of C. difficile was slightly greater in the FM cohort, but the other outcomes were the same. I think this is a practice-changer for me.

Comparative Effectiveness and Harms of Antibiotics for Outpatient Diverticulitis : Two Nationwide Cohort Studies. Ann Intern Med. 2021 Feb 23. doi: 10.7326/M20-6315. Online ahead of print.

Spoon Feed
This literature review of crotalid envenomation answers 8 clinical questions for ED docs.

Why does this matter?
Crotalid envenomations account for about 10,000 ED visits per year, and we own the golden hour of treatment. CroFab improves limb disability and PRN dosing can lead to decreased hospital stay.

No snakes in these boots
The authors compiled 177 papers in an attempt to answer 8 clinical questions regarding crotalid envenomation.  Filtration of the papers through peer reviewed scoring criteria dwindled the field to 33, with many randomized-controlled, prospective, and retrospective trials filling the cohort.

Here’s the summary:

  1. How should patients with potential crotalid envenomation be assessed?

    • Own the ABCs

    • Extremity swelling and monitoring (take pictures)

    • Labs – CBC (thrombocytopenia/anemia), BMP (potassium/renal function), PT/fibrinogen (coagulopathy) and CK (rhabdomyolysis)

  2. What are the initial steps?

    • Pain control

    • Elevate extremity, monitor the extremity on regular intervals

    • Do not use tourniquets, local debridement, or cautery

    • Contact toxicology/poison control early

  3. Indications for antivenom?

    • Swelling extending beyond 1 major joint, significant necrosis as judged by clinician

    • PT >15, fibrinogen <150, platelets <150

    • Systemic toxicity – such as airway swelling, hypotension, neurological symptoms

  4. Dosing of Antivenom

    • CroFab is dosed in vials

    • 1st dose: 4-6 vials, repeat dosing as needed, maintenance dosing with 2-4 vials

    • Monitor for anaphylaxis

    • Same dosing in pediatric cases

    • Anavip is a formulation of antivenom but only covers rattlesnake envenomation that is now approved for all North American pit viper envenomations.
      (Correction on 4/7/2021: Anavip has recently been FDA approved for this broader indication. Thanks to the toxicologists who caught this error! Please see the comments.)

  5. Copperhead envenomations?

    • These should be managed the same as other crotalid envenomation

  6. Where should they be admitted?

    • Most can go to a medical floor

    • ICU is for neurovascular checks or severe systemic toxicity

  7. Antibiotics?

    • No antibiotics unless there is clinical suspicion of infection

  8. Indications for surgical consultation in the ED?

    • Rising compartment pressures despite appropriate antivenom treatment

    • Blebs and blisters are to be left intact

Spencer Greene et al. How Should Native Crotalid Envenomation Be Managed in the Emergency Department? J Emerg Med. 2021 Feb 20;S0736-4679(21)00029-9. doi: 10.1016/j.jemermed.2021.01.020. Online ahead of print.


Of note for the readers, there is an error in the citations that is currently in the process of being corrected. During the publishing process the third citation was accidentally omitted and all citations from 3-29 were shifted up one. If you have questions or concerns please read out to me, the corresponding author. Hopefully this will be corrected soon.

Thank you for featuring this article.

Garry Winkler MD

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