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We are going to try to bring you daily updates on COVID-19. There is a firehose of information and most of us are too busy to read and digest it all. 

Note: If you are listening to these more than a few days in the future, please beware that information may have changed and check subsequent episodes.

Shah, N. Higher co-infection rates in COVID19. https://medium.com/@nigam/higher-co-infection-rates-in-covid19-b24965088333

Dong Y, Mo X, Hu Y, et al. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. 2020; doi: 10.1542/peds.2020-0702 

Fang et al. Lancet March 11 wrote that ace-inhibitors should be avoided due to concern for worsening COVID-19 severity. This was immediately debunked by the European Society of Cardiology as without any evidence.

An article in the BMJ, mistaken in the news for a study (which it is not), in addition to comments by the Health Minister in France, created a viral panic to avoid ibuprofen for fever of severity. Initially reports stated the WHO recommended individuals avoid ibuprofen, however 3/18/20, the WHO reversed this statement.

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In this episode, we reivew the evaluation and management of community acquired pneumonia (CAP), including the 2019 guidelines from the Infectious Disease Society of America (IDSA) / American Thoracic Society (ATS) [1].

Regarding Biomarker Recommendation

Regarding the recommendation against using procalcitonin (PCT) to guide decision making to initiate antibiotics in CAP, the guidelines reference an older Cochrane review. The newer review (2017) claims a mortality benefit but combines trials from ICU/ED/primary care that use PCT to both initiate and/or guide antibiotic treatment. Amongst ED trials, the OR was 0.97 (95 CI 0.70,1.36) for 30-day mortality (I2=0%). For all trials combined, the forest plot demonstrates an OR 0.89 (95CI 0.78, 1.01). However, when adjusted this resulted in an aOR 0.83 (95CI 0.70 ,0.99) [2]. A meta-analysis recently published Ebell et al claims of C-reactive protein (CRP), PCT, and leukocytosis, CRP has promising utility in the diagnosis of CAP [3]. However, no single threshold had adequate operating characteristics (for any of the biomarkers), as the sensitivity/specificity trade-off was quite large. The ACEP draft clinical policy for CAP recommends against the use of biomarkers (Level C recommendation)

Regarding Pneumonia Severity Index (PSI) Recommendation

The IDSA/ATS guidelines recommend use of PSI or CURB-65 to identify patients who should be admitted or treated as outpatients. A draft of the American College of Emergency Physicians CAP clincial policy (not yet finalized) did not come to this same recommendation and had a more tempered recommendation – “Use the PSI or CURB-65 CAP mortality decision tools to help identify low-risk patients who may be appropriate for outpatient treatment.” The PSI is long and cumbersome. While it may identify a larger number of patients that can be treated as outpatient, we believe that not all of these test are necessary if you believe a patient can be treated as an outpatient.

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. Schuetz P, Wirz Y, Sager R, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev. 2017;10:CD007498.
3. Ebell MH, Bentivegna M, Cai X, Hulme C, Kearney M. Accuracy of Biomarkers for the Diagnosis of Adult Community-acquired Pneumonia: A Meta-analysis. Acad Emerg Med. 2020; In Press

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New recommendations for concussion evaluation in the emergency department from the writers of the ACEP clinical policies.

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Vaping associated lung injury (VALI) has become a frequent topic in the news in the United States (US). The Centers for Disease Control and Prevention (CDC) has released new guidance for clinicians that we review in this episode. We also discuss problems with widespread concern (potential over-screening and radiation exposure) as well as the available evidence on diagnosis and treatment of VALI.

References:

1. Morbidity and Mortality Weekly Report (MMWR). 2019; 68(40)
2. Layden JE, Ghinai I, Pray I, et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin – Preliminary Report. N Engl J Med. 2019; Sept 6.
3. Maddock SD, Cirulis MM, Callahan SJ, et al. Pulmonary Lipid-Laden Macrophages and Vaping. N Engl J Med. 2019;381:1488-1489.

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Insulin is a mainstay in the emergent treatment of hyperkalemia but comes at the cost of increased risk of hypoglycemia, which is quite common.

References:

1. Scott NL, Klein LR, Cales E, Driver BE. Hypoglycemia as a complication of intravenous insulin to treat hyperkalemia in the emergency department. Am J Emerg Med. 2019;37(2):209-213.
2. Apel J, Reutrakul S, Baldwin D. Hypoglycemia in the treatment of hyperkalemia with insulin in patients with end-stage renal disease. Clin Kidney J. 2014;7(3):248-50.
3. Coca A, Valencia AL, Bustamante J, Mendiluce A, Floege J. Hypoglycemia following intravenous insulin plus glucose for hyperkalemia in patients with impaired renal function. PLoS ONE. 2017;12(2):e0172961.
4. Larue HA, Peksa GD, Shah SC. A Comparison of Insulin Doses for the Treatment of Hyperkalemia in Patients with Renal Insufficiency. Pharmacotherapy. 2017;37(12):1516-1522.
5. Jacob BC, Peasah SK, Chan HL, Niculas D, Shogbonnwaesei A. Hypoglycemia Associated With Insulin Use During Treatment of Hyperkalemia Among Emergency Department Patients. Hosp Pharm. 2019;54(3):197-202.
6. Harel Z, Kamel KS. Optimal Dose and Method of Administration of Intravenous Insulin in the Management of Emergency Hyperkalemia: A Systematic Review. PLoS ONE. 2016;11(5):e0154963.
7. Pierce DA, Russell G, Pirkle JL. Incidence of Hypoglycemia in Patients With Low eGFR Treated With Insulin and Dextrose for Hyperkalemia. Ann Pharmacother. 2015;49(12):1322-6.

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Droperidol received a black box warning from the US Food & Drug Administration (FDA) in 2001.

 

More on droperidol
Taming the SRU
The Short Coat

References:

1. Khokhar MA, Rathbone J. Droperidol for psychosis-induced aggression or agitation. Cochrane Database Syst Rev. 2016;12:CD002830.
2. Calver L, Drinkwater V, Gupta R, Page CB, Isbister GK. Droperidol v. haloperidol for sedation of aggressive behaviour in acute mental health: randomised controlled trial. Br J Psychiatry. 2015;206(3):223-8.
3. Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010;56(4):392-401.e1.
4. Braude D, Soliz T, Crandall C, Hendey G, Andrews J, Weichenthal L. Antiemetics in the ED: a randomized controlled trial comparing 3 common agents. Am J Emerg Med. 2006;24(2):177-82.
5. Meek R, Mee MJ, Egerton-warburton D, et al. Randomized Placebo-controlled Trial of Droperidol and Ondansetron for Adult Emergency Department Patients With Nausea. Acad Emerg Med. 2019;26(8):867-877.
6. Honkaniemi J, Liimatainen S, Rainesalo S, Sulavuori S. Haloperidol in the acute treatment of migraine: a randomized, double-blind, placebo-controlled study. Headache. 2006;46(5):781-7.
7. Gaffigan ME, Bruner DI, Wason C, Pritchard A, Frumkin K. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015;49(3):326-34.
8. Leong LB, Kelly AM. Are butyrophenones effective for the treatment of primary headache in the emergency department?. CJEM. 2011;13(2):96-104.
9. Calver L, Page CB, Downes MA, et al. The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2015;66(3):230-238.e1.
10. Jackson CW, Sheehan AH, Reddan JG. Evidence-based review of the black-box warning for droperidol. Am J Health Syst Pharm. 2007;64(11):1174-86.
11. Habib AS, Gan TJ. Pro: The Food and Drug Administration Black box warning on droperidol is not justified. Anesth Analg. 2008;106(5):1414-7.
12. Rappaport BA. FDA response to droperidol black box warning editorials. Anesth Analg. 2008;106(5):1585.
13. Perkins J, Ho JD, Vilke GM, DeMers G. American Academy of Emergency Medicine Position Statement: Safety of Droperidol Use in the Emergency Department. J Emerg Med. 2015;49(1):91–7.

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The Free Open Access Medical Education (FOAM) world is often obsessed with magnesium. There are two situations that get unequivocal, high recommendations to give intravenous (IV) magnesium – eclampsia and polymorphic ventricular tachycardia. In this show we address the use of magnesium for various applications.

Magnesium for Acute Atrial Fibrillation with Rapid Ventricular Response (RVR)

1. Bouida et al. LOw dose MAGnesium sulfate versus HIgh dose in the early management of rapid atrial fibrillation: randomised controlled double blind study. Acad Emerg Med. 2018 Jul 19.
2. Ho KM, Sheridan DJ, Paterson T. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta-analysis. Heart. 2007;93(11):1433-40.
3. Davey MJ, Teubner D. A randomized controlled trial of magnesium sulfate, in addition to usual care, for rate control in atrial fibrillation. Ann Emerg Med. 2005;45(4):347-53.

Magnesium for Migraine

1. Corbo J, Esses D, Bijur PE, Iannaccone R, Gallagher EJ. Randomized clinical trial of intravenous magnesium sulfate as an adjunctive medication for emergency department treatment of migraine headache. Ann Emerg Med. 2001;38(6):621–7.
2. Bigal ME, Bordini CA, Tepper SJ, Speciali JG. Intravenous magnesium sulphate in the acute treatment of migraine without aura and migraine with aura. A randomized, double-blind, placebo-controlled study. Cephalalgia. 2002;22(5):345-53.
3. 1Cete Y, Dora B, Ertan C, Ozdemir C, Oktay C. A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the Emergency Department. Cephalalgia. 2005;25(3):199–204.
4. Shahrami A, Assarzadegan F, Hatamabadi HR, Asgarzadeh M, Sarehbandi B, Asgarzadeh S. Comparison of therapeutic effects of magnesium sulfate vs. dexamethasone/metoclopramide on alleviating acute migraine headache. J Emerg Med. 2015;48(1):69–76.
5. Orr SL, Friedman BW, Christie S, Minen MT, Bamford C, Kelley NE, et al. Management of Adults with Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache. 2016;56(6):911–40.

Magnesium for Acute Asthma Exacerbation

Griffiths B, Kew KM. Intravenous magnesium sulfate for treating children with acute asthma in the emergency department. Cochrane Database Syst Rev. 2016;4:CD011050.
Kew KM, Kirtchuk L, Michell CI. Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department. Cochrane Database Syst Rev. 2014;(5):CD010909.

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In this episode we highlight key articles in Emergency Medicine that came out, thus far, in 2018.

D’souza et al. Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis Emerg Med J. 2018;35(5):325-331.

Driver et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179-2189.Atkinson PR, Milne J, Diegelmann L, et al. Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators. Ann Emerg Med. 2018; In press.

Perkins GD et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med 2018; 379:711-721

Meltzer et al. Effect of Tamsulosin on Passage of Symptomatic Ureteral Stones: A Randomized Clinical Trial. JAMA Intern Med. 2018 Aug 1;178(8):1051-1057

Kabrhel et al Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism. Acad Emerg Med. 2018;25(9):987-994

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We are in San Diego for the American College of Emergency Physicians (ACEP) Scientific Assembly and are bringing you daily pearls from the lectures.

References

1. Chen F, Shen YH, Zhu XQ, Zheng J, Wu FJ. Comparison between CT and MRI in the assessment of pulmonary embolism: A meta-analysis. Medicine. 2017;96(52):e8935.
2. Akhter M et al. Ruling out Pulmonary Embolism in Patients with High Pretest Probability. Western Journal of Emergency Medicine. 2018; (18)3.
3. Hogg K, Brown G, Dunning J, et al. Diagnosis of pulmonary embolism with CT pulmonary angiography: a systematic review. Emerg Med J. 2006;23(3):172-8.
4. Mccrindle BW, Rowley AH, Newburger JW, et al. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association. Circulation. 2017;135(17):e927-e999.
5. Schwartz RH, Kim D, Martin M, Pichichero ME. A Reappraisal of the Minimum Duration of Antibiotic Treatment Before Approval of Return to School for Children With Streptococcal Pharyngitis. Pediatr Infect Dis J. 2015;34(12):1302-4.

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We are in San Diego for the American College of Emergency Physicians (ACEP) Scientific Assembly and are bringing you daily pearls from the lectures.

We cover a lecture by Nathan Schlicher on problems with CYA medicine including admissions (which can be harmful), imaging (also can be harmful), and polypharmacy.

We also cover a lecture by Haney Mallemat on the utility of common biomarkers.