Background:
Early antibiotic administration is consistently linked to improved mortality outcomes in patients with sepsis. As a result, time-to-antibiotic delivery is a critical metric in hospital sepsis quality improvement initiatives. Empiric treatment often consists of a broad-spectrum beta-lactam to cover both gram-positive and gram-negative organisms, alongside vancomycin to ensure coverage of methicillin-resistant Staphylococcus aureus (MRSA). When multiple agents are indicated, they may be given simultaneously; however, factors such as limited intravenous (IV) access or drug incompatibilities can necessitate sequential administration. Administration of vancomycin first may delay the administration of a beta-lactam agent by at least 60-120 minutes due to its prolonged infusion time. This raises an important clinical question: Does the order in which antibiotics are administered influence outcomes in sepsis?
A 2022 retrospective study by Amoah et al. found that, among patients with confirmed bloodstream infections, a beta-lactam-first regimen was associated with a 52% reduction in the odds of short-term mortality compared to a vancomycin-first regimen. However, the generalizability of these findings to the broader population of patients with suspected sepsis, of whom only 15-20% ultimately have positive blood cultures, remains uncertain.
What's new?
A recent retrospective, multi-center, cohort study by Kondo et al. evaluated the impact of a beta-lactam-first antibiotic strategy compared to a vancomycin-first strategy on in-hospital mortality in patients with suspected sepsis. Of the 25,391 patients with sepsis who were screened, 21,449 (84.4%) received a beta-lactam first and 3,942 (15.6%) received vancomycin first. Patients who received vancomycin first had lower comorbidity burden, lower illness severity, more skin/musculoskeletal infections, and received beta lactams a median of 3.5 hours later relative to ED arrival compared to those who received a beta-lactam first. Although the overall rate of documented bloodstream infections was similar between groups, MRSA-positive cultures were more common in the vancomycin-first group, both in clinical cultures (4.5% vs. 3.2%) and in blood cultures (1.8 vs. 1.2%).
Beta-lactam administration prior to vancomycin was associated with an 11% reduction in the odds of in-hospital mortality (aOR: 0.89; 95% CI: 0.8-0.99; p=0.046). When the time-to-first antibiotic covariate was replaced with time-to-first beta-lactam, this association was no longer significant (aOR 0.93, 95% CI: 0.82-1.05, p=0.25), suggesting a possible link between time-to-first beta-lactam antibiotic and mortality. There was a trend toward lower in-hospital morality for the beta-lactam first regimen in several subgroups examined, including patients with positive blood cultures or positive MRSA cultures, and patients who received anti-pseudomonal beta-lactams; however, none reached statistical significance.
Bottom line:
Given the observed mortality benefit and absence of harm associated with a beta-lactam-first approach, even among patients with positive MRSA cultures, the findings of this study support the prioritization of beta-lactam therapy in patients with sepsis.
Pulse Checks in Cardiac Arrest: Your Fingers Are Not Reliable.
Summary: Whenever possible, use an ultrasound or an arterial line for pulse checks. Our fingers are not reliable.
Key points:
Multiple studies have demonstrated that manual pulse checks are not a reliable method to determine ROSC. Arterial lines and ultrasound are far more reliable methods. However, using more accurate measures of circulation lead to an additional dilemma: at what MAP, SBP, or ultrasound measured flow should we stop chest compressions? There is no agreed upon number, and as with most dilemmas in clinical medicine, the best answer is, “it depends”. However, a MAP > 50 or SBP > 60 for most patients is a reasonable choice to stop chest compressions. MAP < 50 or SBP < 60 are unlikely to provide adequate perfusion to the brain, and chest compressions should be resumed.
References:
Everyone clenches up when an imminent delivery shows up at the ED bay doors, even though most of these deliveries will not need intervention. Still, there are catastrophic ways delivery can go wrong, so today, let's talk about a new study on breech delivery.
The Study: Bogner et. al conducted a prospective single-center observational cohort study from 2006-2021 looking at breech deliveries in ~230 patients, with 92 of them being delivered in the traditional, supine way, while 140 of them delivered on all-fours. The only difference found between the two groups was that the all-fours group had heavier babies with bigger heads.
The Results: Over half (51.4%) of the patients in the all-fours position required no additional interventions from the provider compared to 11.9% of the supine group, and there were fewer perineal injuries. There was no increase in neonatal outcomes or NICU referrals in the all-fours group as compared to the supine group.
Limitations: Single center, no randomization, 11 patients started in all-fours and then had to switch to supine due to difficulty with delivery and prolonged second stage of labor, excluded footling breech
Takeaways: All-fours may be a position to consider for your patient with a breech delivery - especially if you haven't brushed up on your breech maneuvers recently.
Another case series of 3 resuscitative hysterotomies, all performed by obstetricians, reported 33% maternal and 67% neonate survival.(1).
The mechanics of the procedure are:
(3)
A literature search revealed very little evidence, however in 66 women and 68 neonates who underwent resuscitative hysterotomy for out of hospital cardiac arrest 4.5% of women and 45% of neonates survived to discharge. The longest down time was 29 minutes and 47 minutes for women and neonates respectively. While more evidence is needed, it appears this procedure should be performed as early as possible and may lead to some survival benefit.
Acute ischemic strokes involving the posterior circulation have significantly lower rates of hemorrhagic transformation after thrombolysis compared to anterior circulation strokes, a difference attributed to smaller infarct sizes and greater “ischemic tolerance” in the posterior circulation.
Given this lower hemorrhage risk, the EXPECTS trial evaluated the safety and efficacy of extending the thrombolysis window to 4.5–24 hours in patients with acute posterior circulation ischemic stroke who were not candidates for endovascular thrombectomy. This randomized controlled trial, conducted across 30 sites in China, enrolled 234 adults with mainly mild posterior circulation stroke (median NIHSS 3) and no evidence of extensive infarction on CT. Participants were randomized to receive either intravenous alteplase or standard medical care within the 4.5–24 hour window after symptom onset.
The primary outcome of functional independence at 90 days (modified Rankin Scale 0–2) was achieved in 89.6% of the alteplase group versus 72.6% of the standard care group. Rates of symptomatic intracranial hemorrhage were low and similar between groups (1.7% alteplase vs. 0.9% standard care), and 90-day mortality was lower in the alteplase group (5.2% vs. 8.5%).
These findings support extending the therapeutic window for intravenous thrombolysis in posterior circulation stroke beyond 4.5 hours when thrombectomy is not an option. However, the trial’s limitations, including a study population predominantly with mild strokes, exclusion of patients with extensive infarction, and enrollment limited to Chinese centers, warrant further investigation in larger and more diverse populations.
Bottom Line: Within limitations, emerging evidence supports an extended thrombolytic window beyond 4.5 hours for patients with posterior circulation strokes who are ineligible for thrombectomy.
The National Association of Emergency Medical Service Physicians reminds us that femur fractures rarely cause enough blood loss to cause hemodynamic instability (look for other sources), often have concomitant injuries in the pelvis or distal extremity, and can be effectively splinted either static or with traction (which has contraindications, complications, and technical hurdles).
A recent retrospective cohort study out of China investigated an escalating energy (200 > 300 > 360J) versus fixed energy (200 > 200 > 200 J) defibrillation strategy in OHCA with ventricular fibrillation requiring repeated defibrillations.
Notes:
Results:
Caveats:
An Australian retrospective study of 158 patients treated for nail gun injuries found those treated with operative debridement or with prophylactic antibiotics had no different 30 day infection rates compared to patients receiving no antibiotics.
Author: Matthew Jackson, MD
The Ket-Mid Study (1) is a recent RCT out of a tertiary center in a largely rural region of Egypt that evaluated combined ketamine (2 mg/kg) and midazolam (0.2 mg/kg) (ket-mid) to midazolam plus placebo (pla-mid) as the first line seizure abortive therapy. Children in the ket-mid group achieved 76% termination at 5 minutes compared to 21% of those in the pla-mid group (p<0.001). Adverse outcomes were rare, though the pla-mid group did have more hypotension.
Notably, the population included differed from that typically seen in the US. These kids were seizing for a long time, with a median seizure duration before IV meds of 34 minutes, and the benefit of ketamine on subgroup analysis seemed to shrink for those that were treated in less than 30 minutes. CNS infections were also much more common, accounting for the underlying pathology in 11% of cases. Important exclusion criteria also included trauma, inborn errors of metabolism, underlying CNS malignancy, and others not always known to EMS or ED clinicians at the time therapy begins.
This literature search from 1946-2023 looking at comparing selective use of CT scans vs whole body scans in geriatric trauma found no benefit of whole body CT in mortality, hospital length of stay or ED discharge. This study only included 15,000 pts over that very long time line. More robust, current work needs to be done on this important topic.
AI is probably already being used in your ED, like it or not…
This article is an excellent review of the ways that AI can be used in emergency medicine. (See blue boxes in the figure below for a visual representation of opportunities for AI to augment emergency care from start to finish.) The authors note that there will always be a role for human physicians in EDs; AI can serve as an adjunct rather than a replacement for physician care. Physicians should strive to be informed leaders in AI development to ensure it is performed in a cautious, thoughtful, patient-centered manner.
We have known that resuscitation with balanced crystalloids was associated with better outcomes, than normal saline. However, I have believed that in the early phase of resuscitation, volume of any crystalloids is still better than little volume. Thus, a couple of liters of normal saline (0.9% saline) would not hurt. However, the recent secondary analysis from the Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis (CLOVERS) trial might have changed my practice.
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Settings:
60 ICU in the United States between 2018 to 2022. This is the secondary analysis of the Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis (CLOVERS) trial population
Participants: Patients with sepsis-induced hypotension after receiving fluid resuscitation (from 1-3 litters). Participants who received lactate ringers (622 patients) were compared with patients who received normal saline (690 patients).
Outcome measurement:
Death before discharge home by day 90.
Hospital-free days at 28 days
Study Results:
Dead occurred in 12.2% of LR group (76/622) vs. 15.9% (110/690) patients of the NS group, Adjusted Hazard Ratio 0.71 (95% CI 0.51-0.99, p=0.043)
Patients receiving LR had more hospital-free days at 28 days than those receiving 0.9% saline (16.6 ± 10.8 vs. 15.4 ± 11.4 d, respectively). The mean difference was 1.6 days (95% CI, 0.4–2.8; p = 0.009).
Discussion:
This study confirms that not only early resuscitation is important, but the fluid choice during the early resuscitation phase is also important, especially in patients with signs and symptoms of sepsis.
Thus, even during pre-hospital phase and in the ED, clinicians should consider to use LR or other balanced solutions if available.
Conclusion:
Among patients with sepsis-induced hypotension, resuscitation with Lactate Ringer was associated with better outcomes than normal saline.
Typically Coccidioidomycosis is seen in the Southwestern US. The authors of this study, using climate modeling predict endemic areas will spread across the US to include Idaho, the Dakotas, Nebraska and Wyoming.
Clinically, “Patients with pulmonary Coccidioides infection frequently experience fever, cough, and shortness of breath. Chest radiographic imaging may demonstrate lobar, segmental, or multifocal consolidations; cavitary lesions; and lung nodules. Given these nonspecific findings, patients with coccidioidomycosis are often treated for community-acquired pneumonia. Coccidioidomycosis should be considered in patients not improving with antibiotic treatment or in those who have exposure to or reside in endemic areas. Up to 50% of patients with pulmonary coccidioidomycosis have erythema nodosum, approximately 25% to 30% have peripheral eosinophilia, and approximately 25% have arthralgias (particularly symmetric knee and ankle arthralgia). Up to 10% of patients diagnosed with coccidioidomycosis develop disseminated disease, including skin, central nervous system, and bone and joint infection.”
Distal Radius Fractures
One of the most common fracture locations seen in EM (1/6th of all fractures)
Surgical rates are approximately 15-20%
Bimodal injury distribution:
Younger patients (10-14yo)
Usually involved in sport and usually high energy mechanism
Sport associated injury: Artificial turf increase risk by 5x.
Increased risk with skiing and rugby
Increased risk with novice and intermediate snowboarders who don’t wear protective equipment.
Older patients (>50yo)
Associated with osteoporotic bone from low energy fall
Risk factors among older patients: Hx of recurrent falls, prior fragility fracture, decreased bone density, corticosteroid use, and also dementia when patient reaches age 75.
Encourage your older patients who sustain this injury to discuss bone density testing with their PCP. Patients at higher risk of hip fractures (which carries high morbidity and mortality)
Check and document median nerve function in all patients esp. in high energy injuries
Median nerve involved in up to 21-30%.
Check “A-OK sign” against resistance
Iatrogenic median nerve injury can also occur if patient splinted in position of flexion
Metformin, most widely used for type 2 diabetes, has shown promising early results in several different health outcomes.
A recent study, published in JAMA, investigated whether metformin could reduce knee pain in patients with symptomatic knee OA who were overweight or obese.
This was a small double-blind, placebo-controlled clinical trial involving 107 participants.
Background: There is some evidence (both preclinical and preliminary human) that metformin can reduce cartilage degradation and increase chondrocyte viability.
Intervention: Participants received metformin 2000 mg/day (n=54), or identical placebo (n=53) for 6 months.
Mean age, 58.8 [SD, 9.5] years. 68% female.
Patients had symptomatic radiologic knee OA and a body mass index > 25.
Adverse effects: Diarrhea (8 [15%] in the metformin group and 4 [8%] in the placebo group) and abdominal discomfort (7 [13%] in the metformin group and 5 [9%] in the placebo group).
Despite this, there were high levels of medication adherence.
The study found significant differences in primary and secondary outcome measures: Knee pain, stiffness and function.
There was some weight loss in both groups (mean change, 4 lbs in the metformin group and 2.6 lbs in the placebo group). Unlikely to explain outcome differences.
Conclusion: In patients with symptomatic knee osteoarthritis who were overweight or obese, metformin, had a moderate and statistically significant reduction in knee pain compared with placebo. Because of the small sample size, confirmation in a larger clinical trial is warranted.
How likely is your TIA pt to go on to have a stroke? This study in JAMA gives us some answers. While EM providers aren’t as interested in 5 and 10 year prediction, it provides more evidence TIAs need to be evaluated and are risk factors for future events.
“In this systematic review and meta-analysis of 171?068 patients with TIA or minor stroke from 38 studies, the risk of subsequent stroke was 5.9% within 1 year, 12.8% within 5 years, and 19.8% within 10 years.”
33 paramedics had a short course in thoracic point of care ultrasound. There was a pre and post test that included the history and physical exam for patient scenarios with COPD and CHF exacerbations. Paramedics were asked to select the appropriate treatments. The post test included ultrasound images. Diagnostic accuracy in the post test improved by 17% and appropriate treatment selection improved by 23%. Paramedics were also able to correctly identify ultrasound images 90% of the time.
Bottom line: Introducing thoracic ultrasound to paramedics can improve patient care.
DeMasi et al. published a review on the current evidence surrounding peri-intubation and intubation practices. While the actual approach and context to each patient will be different it is good to be aware of the actual evidence base for medical decision-making.
Preoxygenation
Between Induction and Laryngoscopy
During Laryngoscopy and Intubation of the Trachea
Medications
Interventions to Prevent Hypotension
When evaluating foreign bodies in soft tissue, an imaging interface- such as a standoff pad- can improve imaging of superficial structures.
Common image interfaces include gel, commercial standoff pads, saline bags, and water baths.
Water baths are primarily used for imaging the hands and feet, but a recent study explored a water-filled patient belongings bag as a novel alternative. This method gives the benefit of the same elevated standoff that water baths provide, while accommodating larger extremities that may not fit in traditional setups.
The study found no significant difference between the patient belonging bag and a water bath for identifying a FB in a porcine model. Saline bags had the lowest image quality.
