JournalFeed 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: Cricoid Pressure For Pediatric Intubation

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Use of cricoid pressure did not decrease the risk of regurgitation during pediatric tracheal intubation.

Why does this matter?
Use of cricoid pressure has long been promoted as a standard of care to decrease the risk of regurgitation and tracheal aspiration during intubation. However, cricoid pressure is hard to apply correctly. Cricoid pressure often causes lateral displacement of the esophagus rather than compression. Laryngoscopy then applies counter pressure negating the effectiveness of even correctly applied cricoid pressure. Is there any evidence that cricoid pressure is effective?

Intubation is a no pressure situation.
Tracheal intubations were prospectively recorded in a database for 35 multinational PICUs. Among the 7,825 direct laryngoscopy intubations, 23% (n=1819) used cricoid pressure. There were 106 regurgitation occurrences. After multivariable adjustment, cricoid pressure had a trend towards increased regurgitation but was not statistically significant (adjusted OR, 1.57; 95% CI, 0.99—2.47; p=0.054). Propensity score matching of 1,194 matched pairs found no clinically meaningful increase in regurgitation with cricoid pressure (adjusted OR, 1.01; p=0.036). While the study is limited by risk for reporting bias and the possibility that cricoid pressure was not performed correctly by non-anesthesiologists, it provides further evidence that cricoid pressure does not offer benefit to clinical practice.

Cricoid Pressure During Induction for Tracheal Intubation in Critically Ill Children: A Report From National Emergency Airway Registry for Children.  Pediatr Crit Care Med. 2018 Jun;19(6):528-537. doi: 10.1097/PCC.0000000000001531.
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#2: Door to tPA Under 20 Minutes – Impressive or Dangerous?

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A door-to-tPA in under 20 minute protocol at this center with 1015 stroke alerts resulted in a misdiagnosis rate of 14.8% and 8 people being harmed.  The authors concluded this was safe.  I’m not so sure about that.
Guess who loved this article – Ryan Radecki, EM Lit of Note (just kidding).

Why does this matter?
If it is to do any good, the earlier a thrombolytic agent can be given in ischemic stroke, the better.  But prior to giving these agents with potential for serious harm, the diagnosis of stroke must be strongly suspected, contraindications assessed, and hemorrhage ruled out.  A large meta-analysis found the misdiagnosis rate in the ED was 9%.  Is it safe to rush giving tPA?

Door to danger in under 20 minutes
This was a retrospective review of 1015 patients at a single, neurologist-run stroke center that optimized processes to achieve door-to-tPA times under 20 minutes.  That’s pretty impressive, but was it safe?  Most of the time, they got the diagnosis of ischemic stroke correct, 91.1% (604/663).  But for stroke mimic, they only got the diagnosis correct in 61.5% (144/234).  In total, 14.8% (150/1015) were misdiagnosed.  Of these, 8.7% (13/150) received tPA.  Most of the misdiagnoses occurred in patients with milder stroke, NIHSS <8.  Eight people were harmed by a misdiagnosis, but no patients died as a result.  With a known number needed to harm (symptomatic ICH) for tPA of 20, it doesn’t take many misdiagnoses to hurt someone.  It’s difficult to agree with their conclusion: “Our findings support the safety of highly optimized door-to-needle times.”  In fact, it seems quite the opposite.  Their findings seem to indicate that perhaps they were moving a bit too fast to give tPA.  Bear in mind, this was a study of stroke neurologists.  Will administrators read this and expect a community ED doc with no neurologist on site to do the same?  Without a doubt, if tPA is to do any good, the processes for stroke alert activation need to be fine-tuned and efficient.  But there is such a thing as being hasty.

Diagnosing cerebral ischemia with door-to-thrombolysis times below 20 minutes.  Neurology. 2018 Jul 11. pii: 10.1212/WNL.0000000000005954. doi: 10.1212/WNL.0000000000005954. [Epub ahead of print]
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#3: Risk of Emergent Thoracotomy

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ED thoracotomy (EDT) was associated with a risk of exposure to blood or body fluid in 7.6% of the 305 cases and 1.6% of the 1360 participants.

Why does this matter?
EDT may be lifesaving but not often.  It is also associated with risk, namely occupational exposure to potentially infectious body fluid.  What is that risk specifically?

Let’s be careful out there…
This was a prospective study of 1360 surgeons performing 305 EDTs to determine the rate of accidental exposure to blood or body fluid.  Of the EDTs, 15 patients survived, 13 neurologically intact.  There were 22 exposures, mostly needlesticks.  This meant 7.6% of all EDTs were associated with an exposure and 1.6% of all participants had an exposure performing EDT.  Compliance with full personal protective equipment was only 46% among exposed providers.  Although the risk of exposure is low for an individual, this should factor into the decision to perform EDT.  The chance of surviving EDT is very low; in some cases we know EDT is futile, such as: CPR > 10 minutes, penetrating trauma patients with CPR > 15 minutes, or asystole without (clinical) tamponade.  I would add as well that bedside ultrasound with no pericardial fluid and no cardiac activity also means EDT is futile.

Occupational exposure during emergency department thoracotomy: A prospective, multi-institution study.  J Trauma Acute Care Surg. 2018 Jul;85(1):78-84. doi: 10.1097/TA.0000000000001940.
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Another Spoonful
See what the Trauma Pro says.  Here’s a taste, “How can anyone justify not wearing full PPE during an emergency thoracotomy?”


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