Top EM Articles Come From Many Sources

ACEP News
December 2009

 

By Miriam E. Tucker
Elsevier Global Medical News

 BOSTON -- Top picks of articles for emergency physicians can run the gamut from infectious disease to seizure meds to resuscitation.

 Some advice for reading the medical literature: "If it fits with what you know, skip it. If it doesn't, challenge it. And above all, enjoy what you read, and read what you enjoy," advised Dr. William K. Mallon, of the department of emergency medicine at the University of Southern California, Los Angeles, in an interview. He discussed his favorite recent emergency medicine journal articles at a presentation at the American College of Emergency Physicians Scientific Assembly.  

Among the articles and topics Dr. Mallon highlighted: 

  • A new TB tool: A new tuberculosis screening tool can tell with nearly 100% certainty that a patient with pneumonia does not have tuberculosis--and therefore does not need to be placed in respiratory isolation. This is important, he said, because isolation beds are at a premium at many hospitals and currently are overused.
     
    The new tool involves assessment of TB history, social status, weight change, and radiographic findings. It was derived from a study of more than 5,079 patients, of whom just 4.4% turned out to have TB (Ann. Emerg. Med. 2009;53:625-32). 

  • Seizure treatments: While the basic management of epilepsy remains the same, new drug choices offer a chance for improved seizure control in the ED. The best data are available for valproate, with one study in children showing that it controlled refractory status epilepticus as well as did diazepam but in a shorter period of time and with less need for ventilation. Valproate was not associated with need for ventilation or with hypotension, whereas those conditions occurred in at least half of patients treated with diazepam (J. Child Neurol. 2007;22:1191-7).
     
    Other new options for seizure management include carbamazepine and levetiracetam (brand name Keppra), a new anticonvulsive approved in 2006 for patients with epileptic seizures who are unable to take oral medication. One report showed the efficacy of levetiracetam in 18 episodes of benzodiazepine-refractory focal status epilepticus (SE) in 16 patients, with just 2 requiring further antiepileptic medications (J. Neurol. Neurosurg. Psychiatry 2008;79:588-9).
     
    Valproate, carbamazepine, and levetiracetam are all potential candidates to replace benzodiazepams as first-line epilepsy treatment, Dr. Mallon said. 
  • Gausche Redoux: In a landmark 2000 study, Dr. Marianne Gausche of the University of California, Los Angeles, and her colleagues published a controlled clinical trial of 820 children who required out-of-hospital airway management, showing that adding endotracheal intubation to bag-valve-mask ventilation to paramedics' scope of practice did not improve survival or neurologic outcomes (JAMA 2000;283:783-90). Not surprisingly, those in the emergency medical services field protested and refused to accept the conclusion.
     
    Now, a prospective, observational study from the Netherlands has produced the same result. It compared outcomes for 95 children requiring out-of-hospital intubation and found that EMS personnel actually misplaced endotracheal tubes in 37% and that survival was dramatically lower than when a helicopter-transported medical team arrived to do the intubation (Resuscitation 2008;79:225-9).

Reading relevant medical literature is challenging for emergency physicians, he remarked, because so much is published outside of the core emergency medicine journals. Scientific assemblies are a good way to keep up, Dr. Mallon added

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