Sandy Schneider, MD, FACEP
ACEP Associate Executive Director, Practice, Policy and Academic Affairs

ACEP would like to provide you with very brief synopses of the latest articles in Annals of Emergency Medicine. Some of these have not appeared in print. These synopses are not meant to be thorough analyses of the articles, simply brief introductions. Before incorporating into your practice, you should read the entire articles and interpret them for your specific patient population.

Allison MG, Schenkel SM. SEP-1: A sepsis measure in need of resuscitation? This editorial discusses a paper by Venkatesh and colleagues on the early institution of the sepsis bundle. This paper is an outgrowth of our EQUAL Sepsis Initiative (more information at https://www.acep.org/equal/) The authors found only 54% of patients received the full bundle within the appropriate time period. More importantly this editorial discusses the controversy around some of the components of the bundle. There is a growing evidence that the recommendation for 30mL/kg intravenous fluids may not be the best for all patients, particularly those with congestive failure. There is also controversy around the cutoff for lactate (2 vs 4). What we do know is that ‘standard’ care for sepsis is now much better than before the advent of early goal directed therapy. Tweaking the recommendations will be the focus of the future.

Zitek T, Gates M, Pitotti C, et al. A comparison of headache treatment in the emergency department: ProCholrperazine versus ketamine. Ketamine in small doses has been effective for acute pain. This study compared prochlorperazine/diphenhydramine and ketamine/ondansetron. In this study, which had significant limitations, prochlorperazine/diphenhydramine was superior.

Chau SC, Deng Y, Smart J, et al. Insurance status and access to urgent primary care follow-up after an emergency department visit in 2016. This study used a ‘secret shopper’ to try to make followup appointments at primary care offices within 7 days. Their ‘secret shoppers’ were able to get an appointment within the 7 days about 30% of the time. ‘Patients’ with commercial insurance were more likely to get an appointment. They conclude that individuals who do not have an established primary care provider have a difficult time finding followup care.

Levin M, Beuhler MC, Pizon A, et al. Assessing bleeding risk in patients with intentional overdoses of novel antiplatelet and anticoagulant medications. This is a retrospective study of patients who overdose on novel antiplatelet and anticoagulant medications. Surprisingly, there were few patients who actually had significant hemorrhage.

Ridderikhof ML, Lirk P, Goddijn H, et al. Acetaminophen or non-steroidal anti-inflammatory drugs in acute musculoskeletal trauma (PanAM): A multicenter, double-blind, randomized clinical trial. This study from the Netherlands compared acetaminophen to diclofenac to combination acetaminophen/diclofenac for acute blunt minor musculoskeletal trauma to an extremity. In this study acetaminophen was not inferior to diclofenac.

Jeffery MM, Hooten WM, Hess EP, et al. Opioid prescribing for opioid-naïve patients in emergency departments and other settings: characteristics of prescriptions and association with long-term use. In this study prescriptions written for opioid naïve patients in the ED aligned with CDC recommendations. Compared to non-ED settings, patients in the ED who received opioid prescriptions were less likely to progress to long-term use.

Powell EC, Mahajan PV, Roosevelt G, et al. Epidemiology of bacteremia in febrile infants 60 days of age and younger. This is a PECARN study of very young febrile infants. In this study, bacteremia and meningitis were more common in infants less than 29 days old (3%) which compared to those 29-60 days old (1%). The highest frequency was in those who were 8-14 days old. Most grew either E Coli or Group B Strep. About ½ of the group who were bacteremia or meningitis has concurrent urinary tract infections.

Talan DA, Moran GJ, Krishnadasan A, et al. Subgroup analysis of antibiotic treatment for skin abscesses. There has been a lot of controversy over whether or not to give antibiotics for abscesses. In fact, one of the Choosing Wisely recommendations (now under review) is not to give antibiotics after and I and D. In this study, which is a subgroup analysis of a larger study, trimethoprim-sulfamethoxazole was superior to placebo in a clinical cure (no new antibiotics prescribed) at 7-14 days after the end of treatment (93% vs 86%).

Klein L, Cole JB, Driver B, et al. Unsuspected critical illness among emergency department patients presenting for acute alcohol intoxication. Residents are often taught that patients who appear ‘just drunk’ may have underlying serious or even critical issues. In this paper form Minneapolis, the authors found that 1% of patient who presented for uncomplicated alcohol intoxication required critical care resources. Among the most common issues were hypoxic respiratory failure, alcohol withdrawal, sepsis/infection, and intracranial hemorrhage. Conditions that increased the risk of critical illness included hypoglycemia, hypotension, tachycardia, fever, hypoxia, hypothermia, and parenteral sedation.

Aycock RD, Westafer LM, Boxen JL, et al. Acute kidney injury following CT: a meta-analysis. There has long been concern for causing or worsening renal disease with the administration of contrast. This paper calls this in to question. This study is a meta-analysis of 28 studies and over 100,000 patients. Their suggest that CT contrast does not increase the risk of acute kidney injury, and that the cause for most patients is their underlying illness.