UMEM Educational Pearls

In recent years, there has been an uptick in non-operative management of acute appendicitis. This study examins outcomes in older patients (>65 years old).

The study authors evaluated retrospective data and included 474845 patients in the US with acute uncomplicated appendicitis betwen 10/2021 and 04/2022. All participants survived at least 24 hours postoperatively and none carried a diagnosis of inflammatory bowel disease; there were 43,846 patients treated nonoperatively and 430,999 who underwent appendectomy. The primary outcome was incidence of post-treatment complications, with secondary outcomes of mortality, length of stay, and inpatient costs. 

In patients 65+, there was a 3.72% decrease in risk of complications, 1.82% increase in mortality, and increased LOS and costs. 

Ultimately, operative management of acute appendicits was associated with reduced mortality, length of stay, and costs across all adult patients. While nonoperative management remains an option in the treatment of acute appendicits, surgical management continues to be the accepted standard. 

 

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Category: Administration

Title: Weekend warriors and exercise concentration

Keywords: Exercise, health, cardiovascular mortality (PubMed Search)

Posted: 8/12/2023 by Brian Corwell, MD (Updated: 11/1/2024)
Click here to contact Brian Corwell, MD

The WHO and the US Department of Health and Human Services, among other groups, recommend between 150-300 minutes of moderate intensity or 75 to 150 minutes of vigorous intensity physical activity per week.

This could add up to almost 45 minutes a day!

Who has the time for that?

This is an extremely challenging goal with work and other life responsibilities.

Some recent studies asked whether routinely cramming the recommended weeks’ worth of physical activity into a couple of days, weekend warriors (WW), leads to the same life-extending benefits as distributing the exercise load throughout the week.

In a retrospective analysis of almost 90,000 individuals (56% women), providing a week of accelerometer-based physical activity data: Three activity patterns were compared: active weekend warrior (active WW, ≥150 minutes with ≥50% of total achieved in 1-2 days), active regular (≥150 minutes and not meeting active WW status), and inactive (<150 minutes).

A weekend warrior (WW) pattern of physical activity was associated with similarly lower risks of cardiovascular outcomes (incident atrial fibrillation, myocardial infarction, heart failure, and stroke) compared with more evenly distributed physical activity.

Another large prospective cohort study of over 350,000 US adults (51% women) did not find any significant difference in mortality rates between weekend warriors and regularly active participants. Compared with physically inactive participants, active participants (both weekend warrior and regularly active) had lower all-cause and cause-specific mortality rates.

Take home:  Any exercise is better than none. Adults who perform 150 minutes or more of moderate to vigorous physical activity (or 75 minutes of vigorous activity) per week may experience similar health benefits whether the sessions are spread throughout the week or concentrated in a weekend.

Note: Being a weekend warrior can increase the risk of MSK complications and injury..

Future studies should include the use of wearable devices and not rely on self-reporting exercise behavior.

 

 

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ACLS guidelines state that thrombolytics may be considered for suspected pulmonary embolism during cardiac arrest. There is limited data supporting the recommendation; however, it is noted that the benefits likely outweigh the risks. There is also no consensus on the appropriate thrombolytic timing, drug, or dose.

Our institution recently implemented the use of tenecteplase for acute ischemic stroke, ST-elevation myocardial infarction (STEMI), and pulmonary embolism (PE). When using tenecteplase for suspected PE during cardiac arrest, we use the same weight-based dose used for STEMIs. We include a label on the outside of the tenecteplase box that lists all the doses for the various indications.

 

 Tenecteplase Dose

<60 kg: 30 mg

≥60 to <70 kg: 35 mg

≥70 to <80 kg: 40 mg

≥80 to <90 kg: 45 mg

≥90 kg: 50 mg

 

The tenecteplase dose is administered as an IV bolus over 5 seconds.

There is also limited data for the duration of CPR after thrombolytic administration, with no recommendations being made in most literature. Our current institutional guidelines recommend to consider continuing CPR for 60-90 minutes before resuscitation efforts are terminated. The only guideline that makes any mention of duration of CPR is the European Resuscitation Council Guidelines 2021, which makes the same recommendation.

 

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Targeted Therapeutic Mild Hypercapnia after Resuscitated Cardiac Arrest (TAME)

Current guidelines recommend normocapnia for out-of-hospital cardiac arrest (OHCA), the TAME Study asked is mild hypercapnia better?

  • Smaller previous studies have shown some benefits for hypercapnia including some improved outcomes:
    • Increased likelihood of discharge home and better 12 month neurologic outcomes
  • The TAME study enrolled adults with OHCA with presumed cardiac or unknown cause within 3 hours of ROSC who were unconcious
  • Unwitnessed, asystolic, hypothermic, pregnant, or ICH patients were excluded.
    • ECMO and Severe COPD patients on home O2 also excluded
  • Randomization to either 24 hours of PaCO2:
    • Intervention arm:  50-55 mmHg
    • Control: 35-45 mmHg
  • Strong design with strong methodology, adequate power, and good protocol adherence (>65% of measurements in group limitations) 
  • Protocol violations in 8% of hypercapnia and 3% of normocapnia groups
  • Missing primary outcome data in 7% of patients.
  • Note: concurrent TTM trial (TTM2) was allowed to cross-enroll. Addressed with adequate statistical methodology
  • Primary outcome (Favorable neurological outcome (GOSE ≥ 5)
    • 43.5% (mild hypercapnia) vs 44.6% (normocapnia)
      • ARR 0.98 (95% CI 0.87 to 1.11)
  • Secondary outcomes: no differences

Conclusion: "In patients with coma who were resuscitated after out-of-hospital cardiac arrest, targeted mild hypercapnia did not lead to better neurologic outcomes at 6 months than targeted normocapnia."

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Category: Ophthamology

Title: Increase Your Gain for Ocular POCUS

Keywords: POCUS, Ocular, Posterior Chamber (PubMed Search)

Posted: 8/7/2023 by Alexis Salerno, MD
Click here to contact Alexis Salerno, MD

Prior research has shown that EPs can accurately detect ocular pathology using POCUS. 

A recent retrospective review looked at how ultrasound image gain levels impacted the accuracy of POCUS for detection of retinal detachment, retinal hemorrhage and posterior vitreous detachment.

They included 383 ED patients who received ocular POCUS and ophthalmology consultations. 

Conclusions: The authors found that increasing the gain for ocular POCUS images allowed for increased sensitivity.

Here is an example of a vitreous hemorrhage on ocular POCUS using low gain and high gain. 

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Category: Quality Assurance/Quality Improvement

Title: Do burned out physicians provide lower quality care?

Keywords: Physician Burnout, Quality of Care, Professionalism (PubMed Search)

Posted: 6/13/2023 by Brent King, MD (Emailed: 8/6/2023) (Updated: 6/19/2023)
Click here to contact Brent King, MD

Takeaways: Physicians who have symptoms of burnout as measured by standard burnout scales are more likely to be involved in patient safety incidents, more likely to be cited for poor professionalism, and more likely to have lower patient satisfaction scores. They are also more likely to leave their jobs, experience career regret, and experience job dissatisfaction/ The risk of burnout is highest among emergency physicians and intensivists. 

In this systematic review and meta analysis, the authors reviewed 170 qualitative and quantitative studies including 239,246 physicans to determine the impact of physician burnout on a variety of issues including, quality of care delivered, perception of professionalism, patient satisfaction, and career engagement.

As compared to physicians who did not report symptoms of burnout, burned-out physicians were about four times more likely to be unhappy in their jobs and three times more likely to regret their career decision and to express an intention to leave their jobs.Physician burnout doubled the likelihood of involvement in a patient safety incident and made it three times more likely that the physician would be cited for unprofessional behavior. Burned out physicians were also three times more likely to have low patient satisfaction scores.

Burned-out physicians in their 20's and 30's were particularly at risk for involvement in patient safety incidents and burned-out trainees were more often cited for poor professionalism than older physicians, especially those in their 50's and beyond.

The bottom line: Physican burnout is a serious and growing problem. It has numerous potentially serious consequences for both physicians and patients. Physicians working in high-pressure specialties like emergency medicine and critical care have the highest risk for burnout. 

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Category: EMS

Title: Is a Higher MAP Better for Patients with Out of Hospital Cardiac Arrest?

Keywords: Cardiac arrest, resuscitation, emergency medical services (PubMed Search)

Posted: 8/2/2023 by Ben Lawner, MS, DO
Click here to contact Ben Lawner, MS, DO

There is room for improvement with respect to rates of meaningful neurological survival in patients experiencing out of hospital cardiac arrest. Post resuscitation blood pressure goals remain a matter of debate. Though a MAP of >65 mm Hg is often cited as "desirable" in the post cardiac arrest setting, some experts have advocated for a higher MAP goal to increase cerebral perfusion pressure and improve outcomes. 

This study was a retrospective review and meta-analysis that examined post cardiac arrest patients with MAP goals < 70 mm Hg and > 70 mm Hg. Over 1000 patients were included in the final meta-analysis. The primary outcome was pooled mortality. Secondary outcomes included neurologically meaningful survival, dysrhythmia, and acute kidney injury. The study detected no statistically significant difference in survival. Neurological outcomes were also similar between the two groups of resuscitated patients with out of hospital cardiac arrest. However, the study revealed statistically significant decreases in ICU length of stay and mechanical ventilation time. 

As with any retrospective review, there are important limitations to consider. Among them: Few RCTs were included and all of them were conducted in European countries. Generalizability may be limited given the differences in emergency medical services systems and resuscitation protocols. 

Study authors recommend tailoring resuscitation goals to the individual patient since arrest physiology, comorbidities, and other factors influence a patient's post cardiac arrest course. 

Bottom line: 
There is insufficient evidence to recommend arbitrary MAP goals in patients resuscitated from out of hospital cardiac arrest. 

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Ectopic pregnancy ranges from 3 to 13% in symptomatic first-trimester ED patients. 

The discriminatory zone is defined as the level of Bhcg above which an intrauterine pregnancy can be reliably detected using ultrasound.  (1,500 mIU/mL for transvaginal ultrasound and 3,000 mIU/mL for transabdominal ultrasound)

One study found that an intrauterine pregnancy was visualized with as low as 1,440 mIU/mL and patients with an interdeterminate pelvic ultrasound who were found to have an ectopic pregnancy had a Bhcg greater than 3,000 mIU/mL only 35% of the time. 

 

Bottom Line: If you have a symptomatic patient with an empty uterus and a bhcg above the discriminatory zone, they have a higher risk for ectopic pregnancy. However, if your patient is symptomatic, they should still have further evaluation for ectopic pregnancy even if they have a bhcg lower than the discriminatory zone. 

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Category: Airway Management

Title: Anticipate the worst: major events peri-intubation

Keywords: major adverse event, airway, management, cardiovascular collapse (PubMed Search)

Posted: 7/30/2023 by Robert Flint, MD (Updated: 11/1/2024)
Click here to contact Robert Flint, MD

This systemic review and meta analysis looked at major adverses events (hypoxia, cardiovascular instability, or cardiac arrest) in patients intubated in emergency departments, ICU’s, or medical floors. They found nearly 1/3 of patents had an event. ICU intubation and patients with pre-existing hemodynamic compromise had the highest rate of adverse outcomes. This study gives further support to the concept of maximizing resuscitation pre-intubation and to anticipate a major event peri-intubation. Be prepared and don't be surprised when something doesn't go as planned.

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Category: Orthopedics

Title: Bohler Angle

Keywords: Ortho, bohler angle, fracture. (PubMed Search)

Posted: 7/27/2023 by Robert Flint, MD
Click here to contact Robert Flint, MD

"The normal value for the Böhler angle is between 25° and 40° 1. Although there is wide variation between individuals, there is relatively little variation between the left and right feet of a single individual 2. A reduced Böhler angle can be seen in displaced intra-articular calcaneal fractures. The degree of reduction in the Böhler angle is an indicator of the severity of calcaneal injury, and the degree to which the Böhler angle is restored at surgery is correlated with functional outcome 3."

 

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Category: Administration

Title: Workforce Attrition and Gender

Keywords: age, attrition, gender, workforce (PubMed Search)

Posted: 7/26/2023 by Mercedes Torres, MD
Click here to contact Mercedes Torres, MD

In a recent study of emergency physicians (EPs) who left the workforce between 2013 and 2020, authors sought to investigate their age and number of years since residency graduation for males and females.

A total of 25,839 (70.2%) male and 10,954 (29.8%) female EPs were included.

Female gender (adjusted odds ratio 2.30) was significantly associated with attrition from the workforce.

Of those who left the workforce, the median number of years after residency that males left was 17.5, as compared with only 10.5 years for females.

Furthermore, among those who exhibited attrition, one in 13 males and one in 10 females exited clinical practice within 5 years of residency graduation.

As authors emphasize, these data identify widespread gender-based disparities regarding EM workforce attrition that are critical to address to ensure stability, longevity, and diversity in the EP workforce.

 

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Category: Critical Care

Title: CT FIRST: Should we pan-CT everyone post-ROSC?

Keywords: OHCA, ROSC, cardiac arrest, resuscitation, CT, pan-scan, computed tomography (PubMed Search)

Posted: 7/25/2023 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

Background: Prior evidence1,2 has suggested that early “pan-scan” after ROSC provides clinically-relevant information that assists in the care of the patient in question, when the cause of OHCA is unclear.

The recent CT FIRST trial looked at patients pre- and post- implementation of a protocol for head-to-pelvis CT within 6 hours of ROSC for adult patients without known cause or evidence of possible cardiac etiology, stable enough for scan. *Patients with GFR <30 were excluded from assignment to CT, although were included in the post/CT cohort if their treating doctors ordered CT scans based on perceived clinical need. To balance this, a similar number of patients with GFR <30 were included in the pre/“standard of care” cohort.

  • Pre/SOC cohort (143 pts) vs. Post/SOC+CT cohort (104 pts)
  • CT protocol: Dry head CT, CTA chest, venous phase CT abd/pelvis
  • In pre/SOC group, CTs ordered by treating docs in 52% (one or mix of the above CTs)

Outcomes After Protocol (Pre- vs. Post-):

  • Increased identification of OHCA diagnosis (75% vs. 92%, p = 0.001)
    • In SOC + CT group, diagnosis only found by CT in 13%
    • In SOC group, diagnosis only found by CT in 17%
  • Faster OHCA diagnosis (14.1h vs. 3.1h, p= 0.0001)
     
  • Fewer delays in time-critical diagnoses* (62% vs. 12%, p= 0.001)  *both OHCA dx and resuscitation-related injury
     
  • No difference in ultimate diagnosis of time-critical diagnoses, rates of AKI, or survival to hospital discharge, allergic contrast reactions (0), scan complications (0), inappropriate treatments based on CT findings (0)

 

Bottom Line: Early pan-CT allows for earlier definitive diagnosis and stabilization without increase in adverse events. While this earlier diagnosis does not seem to yield better survival, earlier stabilization may provide some benefits in terms of resource allocation and disposition, a notable benefit during our current crisis of staffing shortages and ED boarding. 

 

CT FIRST

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Category: Trauma

Title: How much is too much? Imaging before transfer.

Keywords: radiology, transfer, trauma, imaging, rural (PubMed Search)

Posted: 7/23/2023 by Robert Flint, MD (Updated: 11/1/2024)
Click here to contact Robert Flint, MD

Evaluating trauma patients at Level 3 or 4 centers, rural hospitals, and non-trauma centers is difficult. Understanding the amount of work-up to perform prior to transfer is important. Summers, et al suggest less is more when it comes to imaging. The receiving facility often repeats imaging leading to time delays, additional radiation exposure, and increased costs. Chest X-ray and FAST exam may be all that is indicated in centers that do not have the resources to care for injures identified on CT imaging prior to transfer.

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Category: Orthopedics

Title: Evaluation of SLAP tears

Keywords: shoulder pain, labrum tear (PubMed Search)

Posted: 7/22/2023 by Brian Corwell, MD (Updated: 11/1/2024)
Click here to contact Brian Corwell, MD

SLAP tear/lesion – Superior labral tear oriented anterior to posterior

Glenoid labrum – A rim of fibrocartilaginous tissue surrounding the glenoid rim, deepening the “socket” joint.

Integral to shoulder stability.

https://aosm.in/storage/2019/05/ch-shoulder-slap.jpg

 

O’Brien’s test aka active compression test for superior labral pathology.

 

2 parts – generally performed with the patient standing.

 

The patient’s shoulder is raised to 90 degrees with full elbow extension and approximately 30 degrees of adduction across the midline.

Resistance is applied, using an isometric hold.

Test in both full internal and external rotation

         -This alters the position and rotation of the humerus against the glenoid

A positive test is when pain is elicited when the shoulder is in internal rotation with forearm pronation (thumb to floor) and much less or no pain when in external rotation (supination).

Note: AC joint pain may test similarly but will localize to different area of shoulder

The presence of similar, reproducible deep and diffuse glenohumeral joint pain is most indicative of a true positive test.

 

https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/03/f50-02-9780323287845.jpg?w=960

 

 

 



Substance use disorder is now known to be a function of brain disease and not a moral failure.  Patients with substance use disorder are highly complex and often use the ED at a higher frequency than those without the disorder.  However, these patients are also frequently the target of implicit bias and stigmatizing behavior from the healthcare team that can lead to worsened outcomes.  Add on top of that a racial disparity, and we can see how this group of patients can have really bad health outcomes.

This study looked at the length of time to treatment of patients with SUD, to see if there was a difference within this group based on racial or ethnic differences. It did find that black patients with SUD did wait on average 35% longer in the ED before being seen or treated.  This difference was statistically significant.

While this study wasn't designed to identify the causes of such a disparity, it does raise concern for implicit bias being in effect among not only the healthcare workers, but ingrained into the healthcare systems themselves.

Patient's with SUD are a vulnerable group of patients, and black patients with SUD are experiencing a disparity in time to treatment.  This should remind us all to seek out ways to remove these biases and disparities from the systems where we work.

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Category: Pediatrics

Title: Should blood cultures be drawn in a child with fever and lower extremity pain?

Keywords: fever, limp, bacteremia, osteomyelitis, septic joint (PubMed Search)

Posted: 7/21/2023 by Jenny Guyther, MD (Updated: 11/1/2024)
Click here to contact Jenny Guyther, MD

This was a cross sectional review of 698 patients ages 1 year to 18 years who presented to a tertiary care center with fever of at least 38 degrees centigrade and non traumatic acute lower extremity pain. This hospital was located in the North East of the United States. Lower extremity pain was defined as an antalgic gait by report or on exam, inability or refusal to bear weight or reported bone or joint pain in the verbal patient within the past 14 days.
Blood cultures were available for review in 510 patients.  Blood cultures were positive in 70 of them (13.7%).  Pathogens included MSSA, MRSA, Strep pyogenes and Salmonella.  Significant predictors of bacteremia included an elevated CRP and localizing exam findings.  
8 blood culture contaminants were identified.  6/8 of these patients had other testing and treatment consistent with osteomyelitis.  
The final diagnosis of the patients with bacteremia included osteomyelitis, septic arthritis, pyomyositis and toxic shock syndrome.
 
 
Bottom line: The prevalence of bacteremia, even in Lyme endemic areas, in healthy children presenting to the ED with fever AND lower extremity pain is high enough to strongly consider obtaining a blood culture with other lab work during the initial evaluation. 

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Category: Toxicology

Title: Fomepizole for acetaminophen overdose?

Keywords: acetaminophen overdose, fomepizole, NAC (PubMed Search)

Posted: 7/19/2023 by Natasha Tobarran, DO (Emailed: 7/20/2023) (Updated: 11/1/2024)
Click here to contact Natasha Tobarran, DO

Acetaminophen (APAP) is the leading cause of acute liver failure worldwide. Standard treatment for APAP overdose is with N-acetylcysteine (NAC), which is highly effective if given within 8 hours of ingestion.  However, in delayed presenters or massive ingestions patients can still develop hepatotoxicity. Adjunctive therapies can be considered in these cases including augmented NAC dosing, renal replacement, and fomepizole.

A small amount of APAP is metabolized to N-acetyl-p-benzoquinone imine (NAPQI) by cytochrome 2E1. In therapeutic doses, the body is able to detoxify the NAPQI using glutathione. In overdose, glutathione stores get depleted and NAPQI can cause hepatotoxicity. Mitochondrial damage in APAP overdose is mediated by the c-Jun-N-terminal Kinase (JNK) pathway. 

NAC works to replenish glutathione stores and detoxify NAPQI. In large overdoses, increased dosing of NAC may be necessary. Fomepizole is typically used for its alcohol dehydrogenase inhibitor property to treat methanol and ethylene glycol poisoning. Fomepizole is also a cytochrome 2E1 and JNK inhibitor and can be used in APAP overdose to block the formation of NAPQI and mitigate mitochondrial damage.  Dialysis can be used to eliminate APAP from the body completely in massive overdoses or if significant acidosis or renal failure. 

This study is a case series of 14 patients treated for APAP overdose between 2017 – 2021 at a tertiary hospital

  • Patients treated with standard NAC therapy
  • They also received IV fompeizole loading dose of 15 mg/kg followed by 10mg/kg every 12 hours at the discretion of the treating team
  • Most cases received only the loading dose
  • Some cases also received renal replacement therapies
  • Patients had “better than expected outcomes” based on initial presentation, APAP levels, liver function tests, and expected clinical course
  • No unfavorable outcomes
  • No side effects

Limitations of the study:

  • Patients were treated with NAC which is the standard of care
  • No formal protocol for the administration or identification of patients treated with fompeizole

In summary:

  • NAC is the standard of care in acetaminophen poisonings
  • Consider fomepizole as an adjunctive therapy in patients that are critically ill
  • Consult your poison center 1-800-222-1222 or friendly toxicologist for help in identifying these patients

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Category: EMS

Title: ED handoff of pediatric patients by EMS

Keywords: handoff, communication, adverse outcomes (PubMed Search)

Posted: 7/19/2023 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Ineffective handoff communications have been shown to occur in up to 80% of medical errors.  Previous studies have shown that up to 1/3 of pertinent information is lost during the handoff of trauma patients.  Interruptions, lack of listening and ED team preoccupation with their own patient assessment have been associated with adverse outcomes.
This study reviewed videotaped footage of pediatric critical care resuscitations and the handoff between the ED and EMS.  Inefficient communication occurred in 87% of handoffs, including 51% of cases with interruptions by staff, 40% with questions from the ED leader about information that had already been given and 65% requesting information that had not yet been communicated.
Bottom line: Allow for an uninterrupted hand off from EMS followed by closed loop communication and asking any additional questions.

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Category: Critical Care

Title: Platelet Transfusion before CVC Placement

Keywords: Central Lines, Platelets, Bleeding (PubMed Search)

Posted: 7/18/2023 by Mark Sutherland, MD (Updated: 11/1/2024)
Click here to contact Mark Sutherland, MD

Central Venous Catheter (CVC; aka central line) placement is a common procedure in both the ED and ICU, and while overall quite safe, does carry some risk.  In particular, many of us regularly are confronted with the challenge of placing a line in a patient with profound thrombocytopenia, which can result in significant bleeding.  In these cases, should we give platelets before we place the line?

Van Baarle et al published a randomized study in NEJM comparing an empiric 1u platelet transfusion vs no transfusion in patients with a platelet count of 10,000-50,000, prior to line placement.  The study included both HD and non-HD (e.g. TLC) lines, from all three major access sites, in patients in their ICU or hematology ward.  They found statistically fewer serious bleeding events in the transfusion group (4.8%) vs no transfusion group (11.9%).  The study wasn't powered to look at more patient oriented outcomes like mortality, but I'm sure we can all agree less bleeding is probably a good thing.  Also importantly, this study did not evaluate the risks/benefits of delaying line placement to obtain platelets when the line is urgently needed, so I would not recommend extending this to conclude platelets must be given before line placement if the line is needed for something highly time-sensitive (e.g. only available access to infuse pressors in a hypotensive patient).  

 

Bottom Line: It is probably beneficial and appropriate to provide prophylactic platelet transfusion prior to CVC placement in patients with a platelet count less than 50,000, assuming circumstances allow.  

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Category: Trauma

Title: Tme to Access: IO vs IV

Keywords: access, IO, IV, resucitation (PubMed Search)

Posted: 7/9/2023 by Robert Flint, MD (Emailed: 7/16/2023)
Click here to contact Robert Flint, MD

This study found that time to intraosseous was faster than time to peripheral IV. This lead to quicker resuscitation time. This was particularly true in pateints that arrived without a pre-hospital IV. 

 

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