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: CAPITAL CHILL RCT – Extreme Hypothermia in OHCA

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There was no benefit in 180-day mortality or neurological outcome in adults with out-of-hospital cardiac arrest (OHCA) when cooling to 31°C vs 34°C.

Why does this matter?
Therapeutic hypothermia is not better than normothermia, per the TTM trial. A range of temperatures, from 32-36°C, is acceptable according to the AHA and others. The authors note a pilot study and some animal studies that suggest the extreme hypothermia, 28-32°C may offer greater neuroprotection. Is this right?

How low can you go?
This was a single center RCT with 367 adults who were comatose after OHCA and were randomized to 31°C or 34°C. There was no difference in 180-day composite mortality and neurological outcome between the two temperatures; 48.4% at 31°C vs 45.4% at 34°C, RR 1.07 (95%CI, 0.86-1.33). No secondary outcomes were different, except ICU length of stay was longer in the 31°C group. There was no increase in adverse events in the cooler group. Take home: There is no benefit in going colder than 32°C.

Effect of Moderate vs Mild Therapeutic Hypothermia on Mortality and Neurologic Outcomes in Comatose Survivors of Out-of-Hospital Cardiac Arrest: The CAPITAL CHILL Randomized Clinical Trial. JAMA. 2021 Oct 19;326(15):1494-1503. doi: 10.1001/jama.2021.15703.

#2: Intradermal Sterile Water for Back Pain?

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For acute non-specific low back pain (LBP), intradermal sterile water injection (ISWI) + IV NSAID reduced pain and improved patient satisfaction vs IV NSAID alone.

Why does this matter?
Nonspecific low back pain can be quite unsatisfying to treat in the ED. Is there a way that we can decrease the patient’s pain with more than a shot of ketorolac? The authors investigate a new, simple procedure to decrease pain and increase patient satisfaction by injecting sterile water in the region of maximal pain.

Are you sure they are using just water?!
This was a prospective RCT with 112 patients equally split into 2 groups; everyone received an IV NSAID, but the intervention group received the ISWI. As for the details of the procedure, they used a 26-gauge, 0.5 inch insulin syringe to inject 0.1cc sterile water in a square pattern (each side was 3cm) around the area of maximal pain. Each injection created a small skin wheal, similar to a TB skin test. See image below from the article for reference. At 10 min post-ISWI, the patient’s pain was significantly improved, and the pain relief persisted for 24 hours (still statistically significant). Interestingly, the authors note that this procedure has been shown effective for other painful conditions of the back, such as kidney stones and LBP from labor. Finally, the authors state that other studies have shown less reduction in pain if the procedure was performed with sterile saline!

As for ED patient satisfaction? The ISWI group was highly satisfied 88% of the time, compared to the control group, which was highly satisfied only 16% of the time.

After reading this article, I feel like I don’t actually understand anything about pain. Although I still have a hard time accepting the results of this well-done study, this is a potentially practice-changing paper for me. Since this is an essentially risk-free intervention (with the exception of brief pain) with potential significant benefit, I will offer the ISWI procedure to nearly all my ED patients with acute lower back pain.

Pro tip: Many EDs stock vials of 10cc of sterile water that you can order. This is more practical than using a 1000cc bottle of sterile water and throwing away the unused 999.6cc.

From cited article

The effectiveness of intradermal sterile water injection for low back pain in the emergency department: A prospective, randomized controlled study. Am J Emerg Med. 2021 Apr;42:103-109. doi: 10.1016/j.ajem.2021.01.038. Epub 2021 Jan 20.

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Corticosteroid use for pediatric patients with retropharyngeal abscesses (RPAs) or parapharyngeal abscesses (PPAs) was associated with lower rate of surgical drainage, less frequent opioid use, and reduced hospital costs.

Why does this matter?
RPAs and PPAs are rare but potentially life-threatening diagnoses. They are most often diagnosed in children, and the incidence of these diseases has been increasing over the past 20 years. RPAs and PPAs can be treated with medical management alone (antibiotics, hydration, and analgesia) or in combination with surgical drainage. Would the addition of corticosteroids to medical management provide any benefit and possibly reduce the need for surgical drainage?

More meds = less scalpel?

Design: This was a multicenter, retrospective study of children aged 2 months to 8 years admitted to a PHIS participating hospital from January 2016 to December 2019 with a diagnosis of RPA or PPA. Children with complex chronic conditions or neck trauma were excluded. Included in the study were 2,259 patients with 1,677 (74.2%) in the non-corticosteroid group and 582 (25.8%) in the corticosteroid group.

Results: The primary outcome of surgical drainage occurred less often in the corticosteroid group compared to the non-corticosteroid group (22.2% vs 51.5%; P < .001). However, more patients who received corticosteroids had delayed surgery compared to the patients who did not receive corticosteroids (59.7% vs 29.4%; P < .001). Patients in the corticosteroid group had less frequent opioid medication use (45.2% vs 54.4%; P < .001), reduced length of stay (median 4 hours shorter; P = .02), and lower overall hospital costs (RR: 0.92; 95% CI: 0.88–0.97; P < .001). Patients in the corticosteroid group were 2.2-times more likely to have return ED visit within one week (95% CI: 1.24–4.05, P=.009) but rates of 30-day hospital readmission did not differ between the groups.

Limitations: The study had several limitations including its observational design, significant heterogeneity regarding corticosteroid and antibiotic use, and several potential confounders. In addition, information about the patient’s exam and diagnostic results (imaging findings) was not available.

Implications: This study suggests that including corticosteroids for medical management of RPAs and PPAs is associated with reduced need for surgical drainage, less opioid use, and lower hospital costs. I would like to see more data on corticosteroids (specifically an RCT), but based on this study, l will be giving my patients with RPAs and PPAs corticosteroids in the future.

Corticosteroids in the Treatment of Pediatric Retropharyngeal and Parapharyngeal Abscesses. Pediatrics. 2021 Nov;148(5):e2020037010. doi: 10.1542/peds.2020-037010. Epub 2021 Oct 25.

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