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. 

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#1: Antiarrhythmics In Arrest – New ILCOR Update

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The European Resuscitation Council (ERC) International Liaison Committee on Resuscitation (ILCOR) 2018 guideline has made one minor change regarding antiarrhythmic drugs in arrest: lidocaine, in place of amiodarone, is now a viable, equally effective option in patients with VF/pVT refractory to defibrillation.

Why does this matter?
This is an update on the ERC ILCOR 2018 guidelines after the publication of the ALPS RCT. In ROC ALPS, the subgroup with witnessed arrest had improved survival to discharge with amiodarone or lidocaine vs. placebo.

Small changes
This was a systematic review of 14 RCTs on antiarrhythmic drugs for OHCA including ROC ALPS. Based on this, they made the following changes to the ERC 2018 Guidelines.

  • “We suggest the use of amiodarone or lidocaine in adults with shock-refractory VF/pVT (weak recommendation, low-certainty evidence).” The big change is the addition of lidocaine.
  • The recommendation against the routine use of magnesium in adults with shock-refractory VF/pVT is unchanged.
  • They still don’t recommend prophylactic antiarrhythmic drugs after ROSC.
  • “We suggest that amiodarone or lidocaine be used in the treatment of paediatric shock refractory VF/pVT (weak recommendation, very low certainty evidence).” Amiodarone dose is 5mg/kg for the first or second doses. Lidocaine dose is 1mg/kg, max 100mg, followed by 20–50 micrograms/kg/min infusion. No change here.

Of note, the ERC 2015 guidelines only recommend an antiarrhythmic drug in refractory VF/pVT. The 2015 guideline states, “amiodarone should be given after three defibrillation attempts irrespective of whether they are consecutive shocks, or interrupted by CPR, or for recurrent VF/pVT during cardiac arrest. Give amiodarone 300 mg intravenously; a further dose of 150 mg may be given after five defibrillation attempts.” The big change for 2018 is that lidocaine 100mg IV as the first dose and 50mg IV as needed for the second is a viable, equally effective choice that may be substituted for amiodarone.

European Resuscitation Council Guidelines for Resuscitation: 2018 Update – Antiarrhythmic drugs for cardiac arrest. Resuscitation. 2018 Nov 26. pii: S0300-9572(18)31096-7. doi: 10.1016/j.resuscitation.2018.11.018. [Epub ahead of print]

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#2: New Shoulder Reduction – The “Elbow” Technique

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The “elbow technique” is a simple and effective way to reduce anterior shoulder dislocations in this study.

Why does this matter?
Who doesn’t want another way to pop a shoulder back into place?

Add another shoulder reduction method to your arm-amentarium
In the study, 26 out of 26 emergency department patients with anterior shoulder reductions were successfully reduced with the elbow technique. The mean time for reduction was 5 seconds (range 3–69 s). No iatrogenic fractures or neurovascular injuries were reported after the reductions. 24 of the 26 patients received sedation prior to reduction with thiamylal sodium.

So how is it done?
The patient is placed in a supine position, and the operator stands on the side of the affected shoulder. The operator holds the wrist of the patient with his outer hand and applies a gentle traction force to keep the elbow straight (B, straight arrow), lifting to 45 degrees of forward flexion and abduction. With the lateral surface of the operator’s elbow, force is exerted on the midshaft of the patient’s humerus (D, straight arrow). By lengthening the lever arm (d), the force moment is increased, allowing the humeral head to glide back into the glenoid fossa more easily. (E) The reduction force pushes the humeral head posteriorly, superiorly, and laterally into the glenoid.

The Elbow Technique: A Novel Reduction Technique for Anterior Shoulder Dislocations. J Emerg Med. 2018 Dec 6. pii: S0736-4679(18)31044-8. doi: 10.1016/j.jemermed.2018.10.018. [Epub ahead of print]

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Reviewed by Clay Smith

#3: New IDSA Influenza Guidelines

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This is the IDSA influenza guideline, updated from 2009. It covers testing, treatment, complications, and more. This is long, but it’s less than the guideline’s 47 pages.

Why does this matter?
Most cases of influenza are self limited. However, each year, thousands of patients die from it, especially those with chronic heart and lung problems, immunocompromised patients, and pregnant/postpartum women.

It’s the most wonderful time of the year!

This IDSA clinical practice guideline helps us think through the flu by answering several key questions.

Who needs influenza testing?

During times of high influenza activity, test in high risk patients if it will change management. Otherwise, if symptoms are consistent with influenza and the patient warrants treatment, empiric therapy can be initiated. During times of low influenza prevalence, testing may be considered in high risk or immunocompromised patients with respiratory symptoms, but false positive rapid antigen tests are common.

Hospitalized patients with respiratory illness, especially those with chronic heart and lung disease or immunocompromise during times of high flu prevalence, should be tested. In times of low prevalence, test only if there is an epidemiological link to someone with influenza.

What specimen should be used?
Deep, mid-turbinate nasopharyngeal swabs, as early as possible in the illness, are preferred. In the hospital, endotracheal aspirates or BAL are options.

What influenza test should be used?
Nucleic acid amplification tests (NAATs) are preferred over rapid influenza diagnostic tests (RIDTs) in outpatients. Sensitivity for RIDTs ranges from the 60s-80s%, whereas the NAATs have mid to high 90% sensitivity and near 100% specificity. NAATs were impractical in many settings, such as small retail clinics, but now at least one available test is CLIA waived and can be run in under 15 minutes. NAATs or RT-PCR should be used in patients who are hospitalized or likely to be hospitalized.

Which patients should be treated for influenza?
Usually, treatment of patients without high risk of influenza complications is recommended within 2 days and should be with a neuraminidase inhibitor (NAI) like oseltamivir, inhaled zanamivir, or (not mentioned in this guideline) baloxivir. The benefit in such patients is small and may reduce the duration of the illness by a half day or so. They also mention benefit to treating symptomatic patients who are household contacts with people at high risk of flu complications, especially those with severe immunocompromise, and healthcare workers who contact patients at high risk. Treatment of low risk patients is fraught with conflict of interest and low quality evidence. See EM Lit of Note for more discussion.

This guideline emphasizes that there are several groups who benefit from NAI even if outside the 48h window, again with fairly low quality evidence:

  • All hospitalized patients
  • Outpatients with progressive or severe disease
  • Outpatients at high risk of complications from influenza, i.e. chronic medical conditions or immunocompromised patients
  • Children <2 years and adults ≥65 years
  • Pregnant women and those within 2 weeks postpartum

What drug, dose, and duration?
The four main drugs are oseltamivir, zanamivir, baloxivir (not mentioned in this IDSA iteration), and IV peramivir. Doses should be per FDA recommendations for each – look it up. Treatment with the first two is 5 days. The others are one-time doses.

When should bacterial co-infection be considered?

  • Severe disease – pneumonia, hypotension, etc.
  • Deterioration after initial improvement
  • Failure to improve in 3-5 days.

Should adjunctive medications be added?
Avoid steroids if at all possible unless there is a compelling indication (severe asthma exacerbation) and don’t give IVIG.

When should antiviral chemoprophylaxis be used?

  • In patients >3 months old at high risk of flu complications
  • It may also be used in outbreaks or to prevent outbreaks, especially in institutionalized patients.
  • The guideline goes on to discuss more on chemoprophylaxis and institutional outbreaks, which is outside the scope of the ED.

Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza. Clin Infect Dis. 2018 Dec 19. doi: 10.1093/cid/ciy866. [Epub ahead of print]

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#4: Tox Myth-Bust – Prehospital Exposure to Fentanyl Analogs

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  1. Concern for exposure should not delay treatment of patients.
  2. Responders are unlikely to have toxicity with incidental contact. Nitrile gloves are sufficient for most scenarios.
  3. Wash body surfaces that come in contact with fentanyl with water. Alcohol-based sanitizers may increase absorption.
  4. In the unlikely situation where there is concern for aerosolized fentanyl, a well-fitted N95 respirator should be sufficient.
  5. Give naloxone to those with signs of hypoventilation. Fentanyl analogs often respond to normal doses of naloxone. Titrate to response, up to 10mg.

Why does this matter?
As fentanyl and fentanyl analogs are becoming increasingly common, emergency responders are likely to come into contact with these substances in some form. There has been significant concern about occupational exposure and stories circulating about responders succumbing to the drug via incidental contact. This has led agencies such as the DEA and NIOSH to propose recommendations on personal protective equipment. While it is extremely important to protect our emergency responders, it also must balance limited resources and timely assistance for patients. This position statement by ACMT and AACT addresses specific concerns about occupational exposure to fentanyl with the literature that is currently available.

The facts on fentanyl

Transdermal exposure
While fentanyl is amenable to transdermal absorption due to its lipophilicity and low molecular weight, clinically significant absorption is dependent on multiple factors that are not present with incidental contact. Fentanyl patches are a common form of transdermal delivery device, and they require 3-13h to reach therapeutic levels and even longer to reach peak levels. That is the reason why fentanyl patches are not used in the management of acute pain. These patches are in constant close contact with the skin and provide a moist environment to increase absorption, whereas powdered drug and pills lack both of these characteristics. If a person covered both palms in fentanyl patches, it would require approximately 14 minutes to absorb 100mcg of fentanyl. The possibility of being knocked down instantly due to brushing fentanyl powder off with bare hands does not seem feasible. Using standard nitrile gloves and basic precautions such as washing body surfaces with water after contact are sufficient to minimize exposure. If there is the potential for heavy contamination where you will likely be exposed to a large amount of powdered drug or liquid drug, water-resistant coveralls can be used.

Inhalational exposure
While inhalational exposure has significant bioavailability, it is highly unlikely to be exposed to aerosolized fentanyl or analogs. Vapor pressure gives you an idea of how likely a liquid is to convert to the gas phase. Higher vapor pressure means the substance is more volatile and more likely to convert to a gas. At around room temperature, the vapor pressure of fentanyl is very low (4.6 x 10-6 Pa, compared to water which is 3173 Pa). This means that it is very unlikely for fentanyl found in solid or liquid form to evaporate under normal conditions. In the scenario where there are multiple people down and there is concern for possible weaponized fentanyl or fentanyl analogs, a N95 or P100 respirator should be sufficient to protect against exposure.

Naloxone administration
While it makes sense that something that has 50-100x (10,000x in certain analogs) the potency of morphine would require heroic doses of naloxone to reverse, there is scant literature to back this up. In our experience, the patients with confirmed illicit fentanyl exposure that we admit to our toxicology service (Banner University Medical Center – Phoenix) have, by and large, responded to standard doses of naloxone (0.4mg-2mg). While we have had patients require multiple repeat doses, we have not seen a significant difference in the bolus doses required to reverse hypoventilation. Until there is better data to guide naloxone administration, it is reasonable to give standard doses, titrated to effect up to 10mg. Just be aware that they may require additional doses.

Another Spoonful

ACMT and AACT position statement: preventing occupational fentanyl and fentanyl analog exposure to emergency responders. Clin Toxicol (Phila). 2018 Apr;56(4):297-300. doi: 10.1080/15563650.2017.1373782. Epub 2017 Sep 5.

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