Practice Changing Papers

In the time when I really started going through papers and hitting the books after residency, I noticed that, for whatever reason, a lot of the papers I was reading just really didn’t lead to a change in my practice. There were plenty of reasons for this, like selection bias (am I more likely to read a paper if I like the title and subconsciously feel “comfortable” with the topic?), my own developing personal threshold for what I consider a “practice changing” threshold to include in my, well, practice, my own ability to interpret and integrate the literature in a way that makes sense to me, the fact that many of my teachers in med school and residency were certified badasses (very likely), the fact that I’m a freaking nerd who likes reading papers outside of my own specialty of emergency medicine (I’m not likely to be the doctor inside someone’s abdomen; if I am, then many things have gone horribly wrong), or perhaps the fact that a lot of stuff that was published is just plain trash (unfortunately saw a lot of that in the early days of the covid-19 pandemic when not only were we all crapping ourselves in fear while wearing garbage bags as “PPE” but also certain unsavory actors were looking to make their career off of the corpses of millions and just firing off half-baked dumbass ideas to try and get their foot in the publishing door oh wait did I say that out loud).

At any rate, from the papers I’ve read, I decided to put the ones that led to a change in my practice down below. If you want to learn more about them, I highly recommend reading the papers yourselves and maybe glancing at my blog post about them. These are just the ones that have led to a change in my practice. People who have trained at different times than me, have had different teachers, and are at different stages in their career and education would obviously have different things that changed their practice. As my kung fu master says, though, hold no head above your own and don’t take my word for things. Seriously, read the papers yourselves. I’m just some dude on the internet.

Abdominal, Gastroenterology, and General Surgery

Nylund, et al. 2010. Bacterial Enteritis as a Risk Factor for Childhood Intussusception: A Retrospective Cohort Study. The Journal of Pediatrics, 156, 5, p761-765.

Cardiovascular

Budolfsen, et al. 2023. NT-proBNP cut-off value for ruling out heart failure in atrial fibrillation patients – a prospective clinical study. AJEM, 71, p18-24.

Cattaneo, et al. 2012. Why does ticagrelor induce dyspnea? Thromb Haemostasis, 108, 6.

  • https://pubmed.ncbi.nlm.nih.gov/23070079/
  • P2Y12 receptors are found on vagal C nerve tissue and when inhibited by ticagrelor can cause centrally mediated perception of dyspnea, without pulmonary function abnormalities, often within 2 hr of administration, but is a diagnosis of exclusion. Trial theophylline 200 mg IV slow infusion.

Guo, et al. 2022. High-dose tranexamic acid in patients underwent surgical repair of aortic dissection might reduce postoperative blood loss: a cohort analysis. Frontiers in Surgery, 9.

  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9237523/
  • High dose TXA (> 50 mg/kg) associated with less post op blood loss 3d after surgery for type A aortic dissection and not associated w an increase in thrombotic safety events compared to low dose TXA (< 50 mg/kg).

McCoy, et al. 2023. A Woman With Recurrent Torsade de Pointes. JAMA Cardiology, accessed June 29, 2023 online ahead of print.

Park, et al. 2022. The Man Who Mistook a Hat for His Wife: Case Report of Aortic Dissection Presenting With Acute Hyperfamiliarity for Faces. Annals of Emergency Medicine, 615.

Yin, et al. 2023. Fact or Artifact in Inferior ST Elevation—Avoiding Misdiagnosis and Missed Diagnosis. JAMA Internal Medicine, accessed June 29, 2023 online ahead of print.

Zhang, et al. 2023. Palpitations in a Young Woman With Breast Cancer. JAMA Internal Medicine, accessed June 29, 2023 online ahead of print.

Infectious Disease

Long, et al. 2023. Emergency medicine updates: Spontaneous bacterial peritonitis. AJEM, 70.

Marks, et al. 2023. Ultrasound for the diagnosis of necrotizing fasciitis: A systematic review of the literature. AJEM, 65, p31-35.

Pelletier, et al. 2023. High risk and low prevalence diseases: Orbital Cellulitis. AJEM, 68.

Shapiro, N, et al. 2023. Early restrictive or liberal fluid management for sepsis-induced hypotension. NEJM. Online ahead of print, accessed 2023 Feb 2.

  • https://www.nejm.org/doi/full/10.1056/NEJMoa2212663 
  • CLOVERS trial. In adults with sepsis induced hypotension there was no drastic difference in aggressive IV fluids versus restrictive fluids and early vasopressor support in mortality, organ replacement therapy, ventilation, days spent on pressors, in ICU, or other markers. 

Neurology & Sedation

Chen, et al. 2023. An evidence-based review of life-threatening secondary headaches in pediatric patients in the emergency department. Pediatric Emergency Medicine Practice, 20, 5.

Oh, et al. 2023. The use of andexanet alfa and 4-factor prothrombin complex concentrate in intracranial hemorrhage. AJEM, 64, p74-77.

  • AA and PCC show good hemostatic efficiency and mortality in pts taking Xa inhibitors with ICH < 60 mL and GCS 8 or greater and AA may serve as an alternate option if PCC is unavailable, though AA’s dosing is based on the timing of last dose of Xa, compared to single PCC dose of 50 mg/kg. 

Rached-d’Astous, et al. 2023. Intranasal ketamine for procedural sedation in children: An open-label multicenter clinical trial. AJEM, 67, p 10-16.

  • IN ketamine 6 mg/kg can be a potentially safe option for peds pts getting laceration repairs. 

In earlier 2023, there was a vigorous discussion amongst some of my emergency medicine colleagues on utility of digital rectal exam, bladder scans and post void residuals in the evaluation of cauda equina syndrome (CES) with many papers and citations being recommended. I decided to just put them all here in one section.

Alshahwani, A, et al. 2021. A Systematic Review of the Value of a Bladder Scan in Cauda Equina Syndrome Diagnosis. Cureus, 13, 4.

  • This is a review of 5 studies that look at DRE and PVR, again claiming that DRE is useless and PVR might be of utility.

Long, B, et al. 2020. Evaluation and management of cauda equina syndrome in the emergency department. AJEM, 38, 1, 143-148.

Tabrah, J, et al. 2022. Can digital rectal examination be used to detect cauda equina compression in people presenting with acute cauda equina syndrome? A systematic review and meta-analysis of diagnostic test accuracy studies. Musculoskeletal science & practice. 58. PMID: 35180641

Todd, T, et al. 2022. Post-void bladder ultrasound in suspected cauda equina syndrome—data from medicolegal cases and relevance to magnetic resonance imaging scanning. International Orthopaedics, 46, 6, 1375-1380.

Pulmonary

Giorno, et al. 2023. Point-of-care lung ultrasound score for predicting escalated care in children with respiratory distress. AJEM, 68.

  • https://www.sciencedirect.com/science/article/pii/S0735675723001031 
  • Lung US score can be used to predict chances of clinical deterioration and need for escalating cair (HFNC, NIV, MV). 6 zones in each lung (0: normal lung; 1: 3 or more B lines; 3: consolidation); Lung US score > 12 rec transfer/admission to unit skilled in peds airway mgmt.

Toxicology

Pourmand, et al. Evaluation of phenobarbital based approach in treating patient with alcohol withdrawal syndrome: A systematic review and meta-analysis. AJEM, 69, p65-75.

  • https://www.sciencedirect.com/science/article/pii/S0735675723001869 
  • Phenobarbital and BZD has simialr LOS and ICU admissions and rates of intubation. Phenobarbital dosing for AWS from Up to Date: IV 130-260 mg initial load, followed by 130 mg q15-30 min PRN until resolution of sx’s, the maintenance 130-260 mg IV divided across 2-3 doses/day for 3-5 days, then taper 10% per day.

Trauma and Musculoskeletal

Bokor-Billman, T., et al. 2015. Reduction of acute shoulder dislocations in a remote environment: a prospective multicenter observational study. Wilderness & Environmental medicine, 26, p 395-400.

  • https://pubmed.ncbi.nlm.nih.gov/25823603/
  • Bokor-Billman Technique: patient sits upright, shoulder flexed to 90 degree forward, elbow flexed to 90 deg. Elbow adducted to midline, then shoulder internally rotated until reduction is achieved. Only technique validated for use in the wilderness setting. 

Bukowski, J, et al. 2023. High risk and low prevalence diseases: Blast Injuries. AJEM, 70.

Sokoloff, W, et al. 2023. Emergency Department management of dangerous back pain in children. Pediatric Emergency Medicine Practice, EB Medicine, 20, 4.

  • https://www.ebmedicine.net/topics/musculoskeletal/pediatric-emergency-medicine-back-pain
  • young age (esp < 4 yo and < 10 yo worrisome for infection, oncology), nocturnal pain/pain awakens from sleep (esp oncology, rheum), competetive athlete (traumatic causes), neurologic symptoms incl radicular pain (spinal cord or nerve root compression), fever (infection, oncology), weight loss (oncology, inflammatory), persistent or constant pain > 4 wk (not specific to a cause, but itself a red flag). Red flags should get radiographs as initial imaging. If radiographs are neg and there are red flags, strongly consider get an MRI.

Urology

Choi, et al. 2023. Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study. AJEM, 68.