Atrial Fibrillation Guideline Update from the AHA

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The American Heart Association (AHA) released new clinical practice guidelines on atrial fibrillation (AF). This episode reviews the emergency medicine-related guidelines.

Ramesh T, Lee PYK, Mitta M, Allencherril J. Intravenous magnesium in the management of rapid atrial fibrillation: A systematic review and meta-analysis. J Cardiol. 2021 Nov;78(5):375-381. doi: 10.1016/j.jjcc.2021.06.001. Epub 2021 Jun 20. PMID: 34162502.
Bouida W, et al. Low-dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double-blind Study (LOMAGHI Study). Acad Emerg Med. 2019 Feb;26(2):183-191. PMID: 30025177.

Transfusion Updates: Restrictive vs Liberal Transfusion in Myocardial Infarction

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The Association for the Advancement of Blood & Biotherapies (AABB) released 2023 International Red Blood Cell Transfusion Guidelines. This podcast reviews the guidelines as well as a recently released trial evaluating restrictive versus liberal transfusion strategy in patients with myocardial infarction. Carson et al. Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia. NEJM 2023. DOI: 10.1056/NEJMoa2307983.

AABB Red Blood Cell Transfusion 2023 International Guidelines
Carson et al. Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia. NEJM 2023. DOI: 10.1056/NEJMoa2307983
Carson et al. Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia. NEJM 2023. DOI: 10.1056/NEJMoa2307983
Carson et al. Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia. NEJM 2023. DOI: 10.1056/NEJMoa2307983

ACEP Clinical Policy: Sedation of Severely Agitated Patients

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The American College of Emergency Physicians (ACEP) just released a clinical policy on the management of emergency department patients presenting with severe agitation. This podcast reviews the clinical policy. We previously covered parenteral agents and a small trial of ketamine in this podcast. The policy committee was unable to make any Level A recommendations due to limitations in included studies. The recommendations the clinical policy committee was able to make are based largely on class II studies. This field of research is limited by few direct, head-to-head comparisons of medications using similar doses via the same route, resulting in some indirect evidence and conclusions.

Disclosure: Lauren Westafer is a member of the ACEP Clinical Policy Committee but the views and opinions represented in this post/podcast are hers alone and do not represent those of the ACEP Clinical Policy Committee.

What’s new with REBOA in trauma?

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Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive way of providing resuscitative aortic occlusion in severe hemorrhage to gain temporary hemorrhage control as a bridge to definitive procedures. Despite initial enthusiasm for widespread use, there are minimal data suggesting significant mortality benefit. A joint statement from the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) states: “No current, high-grade evidence clearly demonstrates REBOA improves outcomes or survival compared to standard treatment of severe hemorrhage.” However, “REBOA is less invasive than resuscitative thoracotomy and in skilled hands may be more rapidly applied as compared with resuscitative thoracotomy.” As a result, Jansen et al. undertook a pragmatic RCT to investigate the use of REBOA in trauma. In this podcast we review the trial and contextualize the results as emergency physicians.

(JAMA. 2023 JAMA. Published online October 12, 2023. doi:10.1001/jama.2023.20850)
(JAMA. 2023 JAMA. Published online October 12, 2023. doi:10.1001/jama.2023.20850)
(JAMA. 2023 JAMA. Published online October 12, 2023. doi:10.1001/jama.2023.20850)

Naltrexone for Alcohol Use Disorder

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Alcohol-related emergency department (ED) visits are common – estimated to be comprise nearly 4% of all ED visits and up to 6% of hospitalizations. Historically, EDs have had little engagement in harm reduction around alcohol use disorder (AUD) and provision of medication for AUD. Often efforts to help patients with dangerous or harmful alcohol consumption have encouraged abstinence-only, or referral to detoxification centers. However, recent studies have demonstrated the feasibility of ED-initiated medication for AUD, specifically naltrexone (Anderson ES et al. Ann Emerg Med. 2021 Dec;78(6):752-758. PMID: 34353648. Murphy et al. Ann Emerg Med. 2023 Apr;81(4):440-449 PMID: 36328851).

Jonas DE et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014 May 14;311(18):1889-900. doi: 10.1001/jama.2014.3628. PMID: 24825644. Murphy CE 4th, Wang RC, Montoy JC, Whittaker E, Raven M. Effect of extended-release naltrexone on alcohol consumption: a systematic review and meta-analysis. Addiction. 2022 Feb;117(2):271-281. PMID: 34033183.

Example emergency department algorithm below, also see UCSF protocol

Anderson ES et al. Implementation of Oral and Extended-Release Naltrexone for the Treatment of Emergency Department Patients With Moderate to Severe Alcohol Use Disorder: Feasibility and Initial Outcomes. Ann Emerg Med. 2021 Dec;78(6):752-758. Aug 2. PMID: 34353648.

Steroids for Severe Community-Acquired Pneumonia

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The role of steroids in pneumonia is controversial. Steroids were found to reduce mortality in COVID-19 patients requiring at least supplemental oxygen but are not associated with a mortality benefit in influenza. In 2019, the Infectious Disease Society of America recommended against the routine use of steroids in hospitalized patients with community-acquired pneumonia (CAP) while the Society for Critical Care Medicine recommends steroids in these patients. Studies of steroids in pneumonia continue to have mixed results (e.g. ESCAPe found no benefit in their trial of a continuous infusion of methylprednisolone in severely ill patients with CAP). In this podcast episode, we review a new multicenter randomized trial of hydrocortisone in severe CAP.

References:

  1. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67.
  2. Pastores SM, Annane D, Rochwerg B; Corticosteroid Guideline Task Force of SCCM and ESICM. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part II): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive Care Med. 2018 Apr;44(4):474-477. doi: 10.1007/s00134-017-4951-5. Epub 2017 Oct 31. PMID: 29090327.
  3. Stern A, Skalsky K, Avni T, Carrara E, Leibovici L, Paul M. Corticosteroids for pneumonia. Cochrane Database Syst Rev. 2017 Dec 13;12(12):CD007720. doi: 10.1002/14651858.CD007720.pub3. PMID: 29236286; PMCID: PMC6486210.

CLOVERS Trial: Restricted vs Liberal Fluids in Sepsis-Induced Hypotension

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References:

  1. National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Clinical Trials Network, Shapiro NI, Douglas IS, et al. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. N Engl J Med. 2023;388(6):499-510.
  2. Surviving Sepsis Campaign guidelines 2021. Society of Critical Care Medicine (SCCM). Accessed February 14, 2023. https://www.sccm.org/Clinical-Resources/Guidelines/Guidelines/Surviving-Sepsis-Guidelines-2021
  3. PRISM Investigators, Rowan KM, Angus DC, et al. Early, Goal-Directed Therapy for Septic Shock – A Patient-Level Meta-Analysis. N Engl J Med. 2017;376(23):2223-2234.

Management of Acute, Uncomplicated Diverticulitis

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Although antibiotics have been the cornerstone of treatment of diverticulitis, recommendations have pivoted away from this routine practice. This episode reviews the literature and guideline recommendations for the treatment of acute, uncomplicated diverticulitis.

References:

  1. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology. 2015;149(7):1944-1949.
  2. Qaseem A, Etxeandia-Ikobaltzeta I, Lin JS, et al. Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2022;175(3):399-415.
  3. Hall J, Hardiman K, Lee S, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum. 2020;63(6):728-747.
  4. Fugazzola P, Ceresoli M, Coccolini F, et al. The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly. World J Emerg Surg. 2022;17(1):5.
  5. Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012 Apr;99(4):532-9. doi: 10.1002/bjs.8688. Epub 2012 Jan 30. PMID: 22290281.
  6. Daniels L, Ünlü Ç, de Korte N, van Dieren S, Stockmann HB, Vrouenraets BC, Consten EC, van der Hoeven JA, Eijsbouts QA, Faneyte IF, Bemelman WA, Dijkgraaf MG, Boermeester MA; Dutch Diverticular Disease (3D) Collaborative Study Group. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017 Jan;104(1):52-61. doi: 10.1002/bjs.10309. Epub 2016 Sep 30. PMID: 27686365.

The “Diamond of Death” in Trauma – Hypocalcemia

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References:

  1. Wray JP, Bridwell RE, Schauer SG, Shackelford SA, Bebarta VS, Wright FL, Bynum J, Long B. The diamond of death: Hypocalcemia in trauma and resuscitation. Am J Emerg Med. 2021 Mar;41:104-109. doi: 10.1016/j.ajem.2020.12.065. Epub 2020 Dec 28. PMID: 33421674.
  2. Giancarelli A, Birrer KL, Alban RF, Hobbs BP, Liu-DeRyke X. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016 May 1;202(1):182-7. doi: 10.1016/j.jss.2015.12.036. Epub 2015 Dec 30. PMID: 27083965.
  3. Webster S, Todd S, Redhead J, Wright C. Ionised calcium levels in major trauma patients who received blood in the Emergency Department. Emerg Med J. 2016 Aug;33(8):569-72. doi: 10.1136/emermed-2015-205096. Epub 2016 Feb 4. PMID: 26848163.