An overdue selection of summaries of some recent publications that will hopefully be useful in your emergency medicine practice (from various sources).
Paul Atkinson, October 2023
Too much too soon? Extracorporeal versus conventional cardiopulmonary resuscitation
A recent randomized trial in 160 adults with witnessed out-of-hospital cardiac arrest found no significant difference in the rate of survival with good neurologic outcome at 30 days for ECPR compared with conventional CPR (20 percent versus 16 percent, respectively) [3]. A longer time to implementation or differences in practice among the participating centers may account for discrepancies with previous studies that reported improved outcomes with ECPR.
Suverein MM, et al. Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest. N Engl J Med. 2023 Jan 26;388(4):299-309. doi: 10.1056/NEJMoa2204511. PMID: 36720132. DOI: 10.1056/NEJMoa2204511
Skip the ER…Nursing home patients requiring X-ray
A retrospective analysis of all the visits to the emergency department (ED) and outpatient imaging departments in two hospitals in Saint John, New Brunswick, in 2020, that involved XR or CT investigations described the pattern of NH residents’ use of the ED for their imaging needs, supporting the creation of mobile XR policies to deliver more safe and efficient care in a Canadian medium population urban centre. The mobile program has now been approved for roll-out across New Brunswick.
Plant E, Mccloskey R, Shamputa IC, Chandra K, Atkinson P, Fraser J, Pishe T, Price P. Nursing Home Residents’ Use of Radiography in New Brunswick: A Case for Mobile Radiography? Health Policy. 2023 Feb;18(3):31-46. doi: 10.12927/hcpol.2023.27036. PMID: 36917452; PMCID: PMC10019512. DOI: 10.12927/hcpol.2023.27036
So that’s the problem…Pulmonary embolism in patients with severe COPD exacerbation
In a recent multicenter study, 1580 patients with COPD who were admitted to the hospital with acute worsening of respiratory symptoms were all screened for PE with computed tomography pulmonary angiogram within 48 hours of admission. PE was identified in 266 (17 percent), with 166 patients (11 percent) having PE involving the main or lobar pulmonary arteries. Purulent sputum production decreased the odds of PE by 60 percent. The authors suggest obtaining imaging for PE in patients requiring admission for COPD exacerbation who do not have evidence of other triggers (eg, infection or heart failure).
Jones CMP, etal. OPAL Investigators Coordinators. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet. 2023 Jul 22;402(10398):304-312. doi: 10.1016/S0140-6736(23)00404-X. Epub 2023 Jun 28. Erratum in: Lancet. 2023 Aug 19;402(10402):612. PMID: 37392748. DOI: 10.1016/S0140-6736(23)00404-X
What no ultrasound?…Lavage treatments for calcific rotator cuff tendinopathy
This important study challenges the clinical utility of a common intervention, ultrasound guided lavage, currently considered to be evidence driven and therefore best practice in the care of patients struggling with chronic symptomatic calcific rotator cuff tendinopathy. In this well conducted randomized controlled trial, representing one of the largest sample sizes to date (220 patients), Moosmayer and colleagues found no additional benefit of lavage over sham treatment at four and 24 months.
Moosmayer S, Ekeberg OM, Hallgren HB, Heier I, Kvalheim S, Juel NG, Blomquist J, Pripp AH, Brox JI. Ultrasound guided lavage with corticosteroid injection versus sham lavage with and without corticosteroid injection for calcific tendinopathy of shoulder: randomised double blinded multi-arm study. BMJ. 2023 Oct 11;383. doi: https://doi.org/10.1136/bmj-2023-076447
Stop the drop? Topical anesthetics for treatment of corneal abrasions
Topical anesthetics are helpful for the initial examination of a patient with a suspected corneal abrasion, but repeated use for the treatment of pain from a corneal abrasion is controversial. Prolonged use (ie, greater than 24 hours) may result in overuse or delayed corneal epithelial healing. A meta-analysis that included three trials in over 200 patients found that, compared with placebo, prolonged use of a topical anesthetic led to more eyes without complete resolution of epithelial defects by 24 to 48 hours (21 versus 15 percent), although the finding did not achieve statistical significance. Suggestion is to limit use of topical anesthetic drops to a maximum of 24 hours.
Sulewski M, Leslie L, Liu SH, Ifantides C, Cho K, Kuo IC. Topical ophthalmic anesthetics for corneal abrasions. Cochrane Database Syst Rev. 2023 Aug 9;8(8):CD015091. doi: 10.1002/14651858.CD015091.pub2. PMID: 37555621; PMCID: PMC10501323. DOI: 10.1002/14651858.CD015091.pub2
Be safe…No benefit of opioids for acute low back pain
In a randomized trial of 347 adults presenting to the emergency department or primary care clinic with acute, nonspecific low back pain, oxycodone (up to 20 mg daily for six weeks) was no more effective for pain relief or functional improvement than placebo. There was a higher risk of potential opioid misuse in patients in the oxycodone group at one-year follow-up (20 versus 10 percent). These results support recent guidelines that recommend against routine opioid use for acute low back pain, given the lack of benefit and potential for misuse.
Jones CMP, Day RO, Koes BW, Latimer J, Maher CG, McLachlan AJ, Billot L, Shan S, Lin CC; OPAL Investigators Coordinators. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet. 2023 Jul 22;402(10398):304-312. doi: 10.1016/S0140-6736(23)00404-X. Epub 2023 Jun 28. Erratum in: Lancet. 2023 Aug 19;402(10402):612. PMID: 37392748. DOI: 10.1016/S0140-6736(23)00404-X
Not really a SHoC…Use of IVC Pocus in undifferentiated hypotension
This post hoc secondary analysis of 129 patients from the SHOC-ED study data (a prospective randomized controlled trial investigating PoCUS in patients with undifferentiated hypotension), showed that IVC PoCUS is feasible in spontaneously breathing hypotensive adult ED patients, and demonstrates potential value as a predictor of a volume overloaded fluid status in patients with undifferentiated hypotension. IVC size (>2.5 cm) may be the preferred measure. The best overall performance utilized the combined parameters of a dilated IVC (> 2.5 cm) with minimal collapsibility (less than 50%) which had a sensitivity of 85.7% and specificity of 86.4% with an area under the curve (AOC) of 0.92 for predicting an volume overloaded fluid status.
Dunfield, R., Ross, P., Dutton, D., Chandra, K., Lewis, D., Scheuermeyer, F., … & Atkinson, P. SHoC-IVC: Does assessment of the inferior vena cava by point-of-care ultrasound independently predict fluid status in spontaneously breathing patients with undifferentiated hypotension?. Can J Emerg Med (2023). https://doi.org/10.1007/s43678-023-00584-1
Discussion and Comments
October 16, 2023 David Lewis
Thanks Paul
The shoulder study is interesting and fits with my take on steroid injections for almost all MSK inflammatory disorders. If the patient is stable, with chronic symptoms, a steroid injection will reduce pain for the first few weeks but because these conditions are usually self-limiting – the long term outcomes will be the same with or without steroid.
However, they didn’t include our specific EM patient group (In fact they were excluded) – “a sudden change in size or density of the deposit on ultrasonography together with an acute onset of extreme shoulder pain”. These are the patients that present with acute onset debilitating pain. US Guided L.A lavage is a very effective method of providing immediate relief from severe pain. While you are there, there is no harm in adding some steroid – this study confirms that pain scores are lower in first few weeks.
This study was focused on the chronic stable group. The intervention was performed 6 weeks after the diagnosis.
My conclusion:
- If we see a patient in ED with chronic shoulder pain and the have calcific deposits – shoulder lavage is unlikely to be beneficial
- If the patient presents with a sudden change in shoulder symptoms, with severe debilitating pain, and a prominent calcific deposit is identified – ultrasound guided lavage can provide immediate and short term benefit, but will not impact long term outcomes.
PS They provide a nice video of how to perform the procedure in another paper here – https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-017-1501-9