Top 5 Articles of 2019

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In this episode, we summarize some of our favorite articles from 2019.

Roc vs Sux: Guihard B et al. Effect of rocuronium vs succinylcholine on endotracheal intubation success rate among patients undergoing out-of-hospital rapid sequence intubation: A randomized clinical trial. JAMA 2019 Dec 17; 322:2303. (https://doi.org/10.1001/jama.2019.18254)

This trial may be difficult to interpret as non-inferiority trials operate under a different set of principles than typical superiority studies. An example of how the interpretation may differ had the results varied is seen below

Targeted Temperature Management after Cardiac Arrest: Lascarrou JB, Merdji H, Le gouge A, et al. Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. N Engl J Med. 2019.

Probability Adjusted D-Dimer in the Evaluation of PE: Kearon C, De wit K, Parpia S, et al. Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability. N Engl J Med. 2019;381(22):2125-2134. For more on this topic, see this review.

Pregnancy and Evaluation of PE van der pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 2019;380(12):1139-1149.

For more, see this review.

Righini M, Le gal G. Diagnosis of Pulmonary Embolism During Pregnancy. Ann Intern Med. 2019;171(2):148.

Additionally, Langlois E et al. retrospectively evaluated YEARS in their cohort of pregnant patients in the Righini study cohort and found a miss rate of 0%. Some have argued that the DiPEP study demonstrated that the D-dimer cannot be reliably used to exclude PE in pregnant patients (Goodacre. Diagnosis of Suspected Pulmonary Embolism in Pregnancy. Reply. N Engl J Med. 2019;380(25):e49). However, this study was significantly different. Over 60% of patients received empiric anticoagulation which may decrease the D-dimer results. Additionally, this likely reflects a different patient population (higher risk).

The CRASH-3 Trial Collaborators. Effects of Tranexamic Acid on Death, Disability, Vascular Occlusive Events and Other Morbidities in Patients with Acute Traumatic Brain Injury (CRASH-3): A Randomised, Placebo-Controlled Trial. Lancet 2019

VITAMINS Trials – Vitamin C + Hydrocortisone + Thiamine in Septic Shock

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In 2017, Dr. Paul Marik published astonishing results describing one center’s experience implementing the “metabolic cocktail” (Vitamin C 1.5 g q6 hours, hydrocortisone 50 mg q6 hours, thiamine 200 mg q12 hours) in patients with septic shock [1]. News outlets hailed this treatment as a miracle drug. However, this study was a before-and-after single-center study and this trial been discussed elsewhere, including on the Skeptics Guide to Emergency Medicine and Pulmcrit. Essentially all trials have predominantly assessed some variation of length of time on vasopressors as a primary outcome (or one of the primary outcomes), but several have reported on mortality. Now, we have the VITAMINS trial, as detailed below, the first rigorous study to evaluate metabolic resuscitation in a general septic shock population [2].

The authors published their protocol in advance (VITAMINS trial protocol) and appeared to follow it. Despite falling completely flat, this trial may not be sufficient for some individuals to give up belief in this treatment.The VICTAS trial (multicenter blinded RCT in the US) has enrolled ~500 of the 2000 estimated patients (VICTAS trial protocol.).

So, how does this compare in the landscape of Vitamin C? See the table below. Many of the historical studies are not RCTs and the ones that are, many these studies have unclear methods sections or significant design limitations, are small, and have discordant results [3-7].

  1. Marik PE et al. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229-1238.
  2. Fujii et al. Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock The VITAMINS Randomized Clinical Trial. JAMA. 2020: In Press.
  3. Fowler et al. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI Randomized Clinical Trial. JAMA. October 1, 2019.
  4. Shin TG, Kim YJ, Ryoo SM, et al. Early Vitamin C and Thiamine Administration to Patients with Septic Shock in Emergency Departments: Propensity Score-Based Analysis of a Before-and-After Cohort Study. J Clin Med. 2019;8(1)
  5. Zabet MH, Mohammadi M, Ramezani M, Khalili H. Effect of high-dose Ascorbic acid on vasopressor’s requirement in septic shock. J Res Pharm Pract. 2016;5(2):94-100.
  6. Habib et al. Early Adjuvant Intravenous Vitamin C Treatment in Septic Shock may Resolve the Vasopressor Dependence. International Journal of Microbiology & Advanced Immunology (IJMAI)j. 2017  05(1), 77-81.
  7. Fowler AA, Syed AA, Knowlson S, et al. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med. 2014;12:32.

Top Literature of 2019 – Mid Year Review

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Risk Stratification and D-dimer in Pregnant Patients With Suspected Pulmonary Embolism (PE)

Van der pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 2019;380(12):1139-1149.

Infectious Disease Society of America (IDSA) Guidelines for Asymptomatic

Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019.

Benzodiazepine dosing for seizures

Sathe AG, Tillman C, Coles LD, et al. Underdosing of benzodiazepines in patients with status epilepticus enrolled in Established Status Epilepticus Treatment Trial. Acad Emerg Med. 2019 Jun 4.

  • Outcomes after Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in Trauma Patients

Joseph B et al. Nationwide analysis of resuscitative endovascular balloon occlusion of the aorta in civilian trauma. JAMA Surg 2019. Mar 20.

Additional References:

  1. Brophy GM, Bell R, Claasen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17(1):3-13.
  2. Glauser T, Shinnar S, Gloss D, et al. American Epilepsy Society Guideline Evidence-Based Guideline: Treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61.

2017 Literature Review

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We review select articles from 2017 that are important or that got people talking.

Emergency Medicine LIterature of Note on this study

Review from The SGEM

References:

  1. Sadeghirad B et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ. 2017;358:j3887.
  2. Barniol et al.Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial. Ann Emerg Med. 2018;71(1):125-131.e1
  3. Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126-131.
  4. Hu et al  Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med. 2017 Sep 1. S0196-0644(17)31376-8
  5. Clattenburg et al Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: A prospective cohort study. Resuscitation. 2018;122:65-68.
  6. Hinson JS et al. Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Ann Emerg Med. 2017
  7. Healey CD et al. Asymptomatic cervical spine fractures: Current guidelines can fail older patients. J Trauma Acute Care Surg. 2017;83(1):119-125.
  8. Crowell et al. Accuracy of Computed Tomography Imaging Criteria in the Diagnosis of Adult Open Globe Injuries by Neuroradiology and Ophthalmology. Acad Emerg Med. 2017;24(9):1072-1079.
  9. Talan et al. Subgroup Analysis of Antibiotic Treatment for Skin Abscesses. Ann Emerg Med. 2018;71(1):21-30.