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. 

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#1: Epi vs. Norepi for Cardiogenic Shock

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Among patients with cardiogenic shock secondary to acute myocardial infarction (AMI), epinephrine led to a significantly increased rate of refractory shock compared to norepinephrine.

Why does this matter?
Acute coronary syndrome is the most common cause of cardiogenic shock. Recent AHA guidelines on cardiogenic shock identified norepinephrine as the likely preferred vasopressor based on the landmark SOAP II trial. This study compared norepinephrine to dopamine and found a mortality benefit among the cardiogenic shock subgroup treated with norepinephrine. However, the AHA guidelines expressed some reservations about the study’s vague definition of cardiogenic shock and the heterogenous subtypes of cardiogenic shock. This study addresses these concerns with a very focused RCT.

It’s been a rough month for epi
This was a double-blind RCT in 9 French ICUs that randomly assigned 57 patients to either epinephrine or norephinephrine for cardiogenic shock following percutaneous coronary intervention for AMI. The study was terminated early due to increased refractory shock among patients receiving epinephrine compared to those receiving norepinephrine (37% vs 7%, respectively, p = 0.008). Epinephrine was associated with a trend towards increased death on day 7 (p = 0.08). All patients had a pulmonary artery catheter. Many of these hemodynamic measures were no different between the two groups (e.g. cardiac index, mean arterial pressure, etc.)  However, epinephrine significantly increased tachycardia and affected several metabolic measures, such as increased lactate, metabolic acidosis, and cardiac double product—a surrogate marker myocardial oxygen consumption.

Epinephrine Versus Norepinephrine for Cardiogenic Shock After Acute Myocardial Infarction. J Am Coll Cardiol. 2018 Jul 10;72(2):173-182. doi: 10.1016/j.jacc.2018.04.051.

#2: Spinal Motion Restriction Guidelines

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The American College of Surgeons Committee on Trauma (ACS-COT), American College of Emergency Physicians (ACEP), and the National Association of EMS Physicians (NAEMSP) have offered a joint consensus statement on spinal motion restriction (SMR) in trauma patients.

Why does this matter?
Trauma patients with unstable spinal column injuries can suffer significant neurological injury due to excessive movement of the spine. The goal of SMR in the trauma patient is to minimize unwanted movement of the potentially injured spine. This is the first time these three groups have developed a joint statement on this topic.

Highlights of the Guidelines

  • SMR can be achieved with a backboard, scoop stretcher, vacuum splint, ambulance cot, or other similar device to which a patient is safely secured.
  • Indications for SMR following blunt trauma:
    • Acutely altered level of consciousness (e.g., GCS <15, evidence of intoxication)
    • Midline neck or back pain and/or tenderness
    • Focal neurologic signs and/or symptoms (e.g., numbness or motor weakness)
    • Anatomic deformity of the spine
    • Distracting circumstances or injury (e.g., long bone fracture, degloving, or crush injuries, large burns, emotional distress, communication barrier, etc.) or any similar injury that impairs the patient’s ability to contribute to a reliable examination
  • SMR should apply to the entire spine. This necessitates the use of an appropriately sized cervical collar.
  • Patients should be removed from a long backboard, scoop stretcher, or vacuum mattress as soon as possible after arrival at the hospital.
  • There is no role for SMR in penetrating trauma.
  • SMR in children should not be based on age alone despite possible communication barriers.
  • The rate of contiguous multilevel injury in children is extremely low at 1%. The rate of noncontiguous multilevel injury in children is thought to be equally as low.
  • Cervical collars should be applied in pediatric patients for the following findings:
    • Complaint of neck pain
    • Torticollis
    • Neurologic deficit
    • Altered mental status including GCS <15, intoxication, and other signs (agitation, apnea, hypopnea, somnolence, etc.)
    • Involvement in a high-risk motor vehicle collision, high impact diving injury, or substantial torso injury
  • Minimize time spent on backboards. Additional padding under the shoulders may be necessary in young children to avoid substantial cervical spine flexion due to the increased head size to body ratio compared to adults.

Spinal Motion Restriction in the Trauma Patient – A Joint Position Statement.  Prehosp Emerg Care. 2018 Aug 9:1-3. doi: 10.1080/10903127.2018.1481476. [Epub ahead of print]

Another Spoonful

#3: Outpatient Antibiotic for Pyelonephritis – Ciprofloxacin, TMP/SMX, or Cephalosporins?

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Outpatient treatment failure for pyelonephritis occurred more often in patients treated with fluoroquinolones or trimethoprim-sulfamethoxazole (TMP-SMX) than in patient treated with cephalosporins.*

Why does this matter?
The last IDSA guideline for treatment of uncomplicated pyelonephritis was published in 2011. First-line agents are fluoroquinolones and TMP-SMX. However, antibiotic resistance has continued to increase to these first-line agents since the guidelines were released. What other options might exist?

Bean Bug Battle
In this study, investigators performed a retrospective chart review of patients diagnosed with pyelonephritis in 6 community EDs between August 2017 and October 2017. Patients were excluded if they were male, were recently hospitalized, had kidney stones or recent catheterization, had received recent antibiotic use, were nursing home patients, or were immunocompromised. Treatment failure (defined as return within 30 days for relapsing symptoms or needing to change antibiotics based on cultures and sensitivities) occurred in 10 out of 43 patients (23%) treated with fluoroquinolones or TMP-SMX versus 0 out of 55 patients (0%) treated with cephalosporins (p<0.001).  Bacterial culture sensitivities showed significantly higher rates of resistance to TMP-SMX compared to the other antibiotic agents. Based on this study, oral cephalosporins may be a more appropriate antibiotic choice for uncomplicated pyelonephritis compared to current IDSA recommendations, with the caveat that local antibiograms may vary.

*Notable limitations of this study included lack of a standardized treatment regimen for pyelonephritis. 13 of 45 patients were prescribed an under-dosed regimen of a fluoroquinolone or TMP-SMX, as recommended by the IDSA. Additionally, more patients in the cephalosporin group received a dose of parenteral antimicrobial therapy before starting outpatient therapy (78% vs. 53%).

Pyelonephritis treatment in the community emergency department: Cephalosporins vs. first-lineagents. Am J Emerg Med. 2018 Aug 8. pii: S0735-6757(18)30652-1. doi: 10.1016/j.ajem.2018.08.016. [Epub ahead of print]

#4: COMBAT – Plasma First During Ground Transport

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Administration of plasma first for traumatic hemorrhagic shock when brought by ground did not change 28-day mortality.

Why does this matter?
Last month we covered PAMPer, that found improved survival when plasma was given first to patients with traumatic hemorrhagic shock who were brought by helicopter.  But does this work for ground crews with a much shorter transport time?

COMBAT – plasma doesn’t work on the ground
This was a single center RCT that used an as-treated analysis of 125 adult patients with traumatic hemorrhagic shock who were given plasma or saline.  Shock was defined as: SBP ≤70 mm Hg or 71-90 mm Hg plus heart rate ≥108.  About half were blunt trauma and half penetrating.  Plasma was frozen in a thin bag, and they used a rapid defrost (3 minutes) and special storage in the vehicle.  Mortality at 28 days was statistically the same: 15% plasma vs. 10% saline, p = 0.37.  Transport times were 19 minutes in the plasma group; 16 minutes for control (saline). Transport time was double this in PAMPer (median time 40-42 minutes), which may explain why the advantageous effect of plasma was seen in that study and not this one.  The study was stopped for futility after 144 of the planned 150 patients were enrolled.  There were no adverse events in either group.

Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial.  Lancet. 2018 Jul 28;392(10144):283-291. doi: 10.1016/S0140-6736(18)31553-8. Epub 2018 Jul 20.

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