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What's new in adult and pediatric emergency medicine

Official reprint from UpToDate www.uptodate.com 2013 UpToDate

What's new in adult and pediatric emergency medicine Authors Jonathan Grayzel, MD, FAAEM James F Wiley, II, MD, MPH Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: oct 25, 2013. The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection. ADULT RESUSCITATION Crystalloids versus colloids for hypovolemic shock In patients with hypovolemic shock not due to bleeding, resuscitation with colloid-containing solutions has been associated with an increased need for renal replacement therapy and death. As a result, crystalloid solutions have become the preferred solution for resuscitation in this population. This practice was challenged by an open-label, multicenter, nine-year, randomized trial (CRISTAL) that compared intravenous crystalloid or colloid solutions in nearly 3000 patients with hypovolemic shock and found no difference between the groups in 28-day mortality or need for renal replacement therapy. In addition, patients treated with colloids had more days free of mechanical ventilation and vasopressor therapy as well as a lower 90-day mortality [1]. However, the open-label design, lengthy study period, and heterogeneity of fluids used limits confidence in the findings. Validation of any potential benefit of colloids will be required before they can replace crystalloids as the preferred therapy for the resuscitation of patients with hypovolemic shock not due to bleeding. (See "Treatment of severe hypovolemia or hypovolemic shock in adults", section on 'Overview'.) Beta blockade as a therapy in septic shock Beta blockade may have potential benefit in limiting harmful effects associated with the adrenergic surge that occurs in patients with sepsis. An open-label, single center trial randomized 154 patients with septic shock to an infusion of esmolol (short-acting beta blocker) or standard therapy [2]. All patients on esmolol achieved the pre-set target heart rate of 80 to 94 beats/min without a significant drop in mean arterial pressure. Compared to patients on standard therapy, patients receiving esmolol had improvements in left ventricular stroke work index, markers of endorgan function (eg, glomerular filtration rate), and a reduced need for vasopressors that were associated with a mortality benefit at 28 days. Further validation of these findings is warranted before esmolol can be routinely recommended as a therapy in patients with septic shock. (See "Investigational and ineffective therapies for sepsis", section on 'Beta-blockade'.) GENERAL ADULT EMERGENCY MEDICINE Apixaban for the treatment of venous thromboembolism The factor Xa inhibitor apixaban is a fixed-dose oral anticoagulant that does not require routine laboratory monitoring or dose adjustments. The safety and efficacy of apixaban was studied in two large randomized trials for the treatment of acute venous thromboembolism (VTE) and prevention of recurrent VTE [3,4]. Compared to conventional anticoagulation (enoxaparin followed by warfarin for six months), apixaban resulted in a similar rate
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of recurrent symptomatic VTE and VTE-related death and fewer bleeding events [3]. Extended treatment with apixaban following 6 to 12 months of conventional anticoagulation at prophylactic or treatment doses was superior to placebo for the prevention of VTE and VTE-related death [4]. These studies suggest that apixaban is a safe and effective therapy for the treatment of acute VTE and prevention of recurrent VTE. Apixaban is not yet approved for use for this indication, and we await further data on the safety of apixaban before advocating its use. (See "Treatment of lower extremity deep vein thrombosis", section on 'Apixaban'.) Bypassing the ED for primary PCI of STEMI Time to onset of reperfusion is a critical determinant of outcome with primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI). In an observational study of 12,158 STEMI patients diagnosed with a prehospital electrocardiogram, 10.5 percent bypassed the ED and were taken directly to the cardiac catheterization laboratory [5]. ED bypass shortened the time from first medical contact to PPCI and there was a trend toward a lower adjusted mortality. We support the use of this approach when feasible. (See "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome", section on 'Direct transfer from the field'.) Time to treatment with intravenous thrombolysis for acute ischemic stroke The benefit of intravenous thrombolysis with tissue-type plasminogen activator (tPA) for acute ischemic stroke decreases continuously over time from symptom onset, as previously shown in a pooled analysis of randomized trial data. The time-dependent benefit of tPA has now been confirmed in a registry that analyzed data from over 58,000 patients treated with tPA within 4.5 hours of ischemic stroke symptom onset [6]. Earlier treatment was associated with increased rates of independent ambulation and discharge to home, and decreased rates of death and symptomatic intracranial hemorrhage. (See "Reperfusion therapy for acute ischemic stroke", section on 'Intravenous thrombolysis'.) Antidote to the anticoagulant dabigatran Oral agents that directly inhibit thrombin or factor Xa are attractive options for anticoagulation because, unlike heparin and warfarin, they are used at a fixed dose without monitoring. However, these drugs lack specific reversal agents to treat anticoagulant-associated bleeding. To address this limitation, an antidote for the direct thrombin inhibitor dabigatran was created using humanized dabigatran-specific antibody fragments [7]. In initial studies, the antidote (aDabi-Fab) bound dabigatran with an affinity 350-fold higher than thrombin. It neutralized dabigatran activity in vitro and normalized clotting parameters in a rat model. Studies to determine the efficacy and tolerability of this agent in patients are awaited. (See "Anticoagulation with direct thrombin inhibitors and factor Xa inhibitors", section on 'Dabigatran antidote'.) Four-factor prothrombin complex concentrate approved in the United States The treatment of bleeding in patients taking vitamin K antagonists requires administration of a reversal agent. Available options include vitamin K, fresh frozen plasma (FFP), and unactivated prothrombin complex concentrates (PCC). PCC products act within minutes, whereas vitamin K and FFP require up to a day to take effect. To be fully functional, the PCC must contain all four of the vitamin K dependent coagulation factors (ie, 4-factor PCC), and previously, only 3-factor PCCs were available in the United States. In April 2013, the US Food and Drug Administration approved Kcentra, a 4-factor PCC that is similar to Beriplex (available in other countries) [8]. PCC can increase the risk of thrombosis and should only be administered after a prolonged PT and/or elevated INR has been documented. (See "Management of warfarin-associated intracerebral hemorrhage", section on 'Unactivated prothrombin-complex concentrates'.) PRIMARY CARE ORTHOPEDICS AND SPORTS MEDICINE Low Risk Ankle Rule for radiography of pediatric ankle injuries Use of the Low Risk Ankle Rule (LRAR) in addition to routine physical examination for children three to 16 years of
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age with acute isolated ankle injuries has been shown to reliably identify serious fractures and may avoid the need for radiography in some patients. In a multicenter implementation study of the LRAR in six emergency departments, including community, general, and pediatric facilities, use of the LRAR reduced ankle radiography by 22 percent when compared to physical examination alone with no significant difference in missed high-risk fractures or patient satisfaction [9]. Children are considered low risk by the LRAR and not in need of radiography at initial presentation if physical examination demonstrates tenderness or swelling confined to the distal fibula and/or adjacent lateral ligaments distal to the anterior tibial joint line (figure 1) and no gross deformity, neurovascular compromise, or other serious and potentially distracting injury are present. Distal fibular avulsion and nondisplaced Salter-Harris I and II fractures are considered low-risk injuries by this rule and may be present in low-risk patients who do not undergo radiography. (See "Ankle fractures in children", section on 'Low Risk Ankle Rule'.) PROCEDURES Ultrasound guidance for difficult peripheral intravenous access Ultrasound guidance is useful for the placement of peripheral intravenous catheters in those with difficult access. A systematic review identified seven trials, including nearly 300 adults and children with difficult access, which evaluated ultrasound assistance in the placement of peripheral intravenous catheters [10]. Successful cannulation was more frequent with ultrasound guidance compared with no ultrasound guidance (79 versus 62 percent). There were no differences in time to successful cannulation, or number of percutaneous skin punctures. (See "Principles of ultrasound-guided venous access", section on 'Peripheral intravenous access'.) Bedside ultrasound prior to skin abscess drainage The role of bedside ultrasound to determine which patients undergo incision and drainage of a skin infection is not well defined. It may be most helpful when the presence of a skin abscess is not clinically evident (eg, patients with no drainage or fluctuance). As an example, in a prospective observational study of nearly 400 children with skin and soft tissue infections, bedside ultrasound had a much higher sensitivity and specificity than clinical examination for the 159 children in whom abscesses were not clinically evident (sensitivity 78 versus 44 percent, specificity 61 versus 42 percent, respectively) [11]. By contrast, bedside ultrasound did not significantly change the sensitivity and specificity for the detection of clinically evident abscesses when compared to physical examination (sensitivity 93 versus 95 percent and specificity 81 versus 84 percent, respectively). (See "Technique of incision and drainage for skin abscess", section on 'Evaluation for abscess'.) TOXICOLOGY Prevention of carbon monoxide poisoning Accidental carbon monoxide poisoning is a leading cause of death by poisoning. Although many states require carbon monoxide (CO) detectors in homes, some allow exemptions if there is no obvious source of CO. A recent study reported that CO is capable of diffusing rapidly through standard wallboard and floorboard materials, not only through vents and other open passages as some previously believed [12]. Therefore, we agree with the authors of the study who recommend that every home (even those without an obvious source of CO) be equipped with a CO monitor. (See "Carbon monoxide poisoning", section on 'Prevention'.) TRAUMA Knee dislocation due to low-energy trauma Knee (ie, tibiofemoral) dislocations are classically described as occurring from high-energy trauma (eg, motor vehicle collisions). However, a growing number of reviews and case series describe knee dislocation in obese individuals as a result of low-energy trauma, such as falls [13]. The possibility of associated limb-threatening neurovascular injury persists in dislocations due to low-energy trauma. (See "Knee (tibiofemoral) dislocation and reduction", section on 'Clinical presentation and mechanism of injury'.)

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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Annane D, Siami S, Jaber S, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA 2013; 310:1809. 2. Morelli A, Ertmer C, Westphal M, et al. Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock: a randomized clinical trial. JAMA 2013; 310:1683. 3. Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med 2013; 369:799. 4. Agnelli G, Buller HR, Cohen A, et al. Apixaban for extended treatment of venous thromboembolism. N Engl J Med 2013; 368:699. 5. Bagai A, Jollis JG, Dauerman HL, et al. Emergency department bypass for ST-Segment-elevation myocardial infarction patients identified with a prehospital electrocardiogram: a report from the American Heart Association Mission: Lifeline program. Circulation 2013; 128:352. 6. Saver JL, Fonarow GC, Smith EE, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA 2013; 309:2480. 7. Schiele F, van Ryn J, Canada K, et al. A specific antidote for dabigatran: functional and structural characterization. Blood 2013; 121:3554. 8. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm350026.htm (Accessed on May 07, 2013). 9. Boutis K, Grootendorst P, Willan A, et al. Effect of the Low Risk Ankle Rule on the frequency of radiography in children with ankle injuries. CMAJ 2013; 185:E731. 10. Egan G, Healy D, O'Neill H, et al. Ultrasound guidance for difficult peripheral venous access: systematic review and meta-analysis. Emerg Med J 2013; 30:521. 11. Marin JR, Dean AJ, Bilker WB, et al. Emergency ultrasound-assisted examination of skin and soft tissue infections in the pediatric emergency department. Acad Emerg Med 2013; 20:545. 12. Hampson NB, Courtney TG, Holm JR. Diffusion of carbon monoxide through gypsum wallboard. JAMA 2013; 310:745. 13. Georgiadis AG, Mohammad FH, Mizerik KT, et al. Changing presentation of knee dislocation and vascular injury from high-energy trauma to low-energy falls in the morbidly obese. J Vasc Surg 2013; 57:1196. Topic 8365 Version 2890.0

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GRAPHICS Low Risk Ankle Rule

The Low Risk Ankle Rule defines low risk injury of the ankle in a child when tenderness, swelling or both are isolated to the distal fibula and/or adjacent lateral ligaments distal to the tibial joint line (Regions A and B of the figure). Radiography may be omitted in such children. Low risk fractures by this rule include distal fibular avulsion and nondisplaced Salter-Harris I and Salter-Harris II fractures.

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