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ERCAST


Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Mar 5, 2018

In the edition of the Ercast journal club

  • thrombectomy in pts with delayed stroke presentation shows promise
  • beware behavioral changes after procedural sedation
  • kids with isolated linear skull fractures have a good short term prognosis
  • procalcitonin may help decrease abx use in respiratory infections
  • steroids in mild sore throat help... a little

 

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The DAWN Trial

  • Nogueira, Raul G., et al. "Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct." New England Journal of Medicine 378.1 (2017). PMID:29129157
  • What happens when thrombectomy is done when last normal was over 6 hours ago?
  • 206 patients with occlusion of the intracranial internal carotid artery, middle cerebral artery, or both
  • these were patients excluded from TPA because of time from onset or they had persistent occlusion despite TPA
  • Pts had to get either perfusion CT or diffusion weighted MRI to see if there was salvageable brain (there had to be)
  • 107 got thrombectomy and 99 didn't.
  • 90 day functional independence: 49% thombectomy vs 13 % controls
  • No significant difference in symptomatic intracranial hemorrhage or 90 day mortality
  • Trial stopped early because of superiority of thrombectomy
  • Majority of patients were wake up strokes, a group we've had pretty much nothing to offer previously
  • Industry sponsored, many conflicts of interest

 

  • Rob's take-This trial uses salvageable brain as a determinant of treatment which makes sense as these are the patents who may actually benefit from reperfusion. This purports to speak for the patient 6-24 hours, but from what I can tell, treatment was heavily skewed toward those with time from last normal 16 hours and under, so it doesn't really tell us much about 24 hours. I will be consulting stroke centers with this patient cohort.
  • Adam's take- Impressive. I like that this is tissue based, not time based.

 

 

Skull Fractures in Kids

  • Bressan, Silvia, et al. "A Systematic Review and Meta-Analysis of the Management and Outcomes of Isolated Skull Fractures in Children." Annals of emergency medicine (2017). PMID: 29174834 
  • Are pediatric patients with isolated skull fractures at increased risk for short term adverse events?
  • Pool of 21 studies, over 6,000 kids with isolated skull fractures.
  • One required emergency neurosurgery, none died.
  • All kids had CT scan or MRI to exclude intracranial injury
  • 6 out of 570 had bleeding on a second scan and zero had surgery. The incidence of delayed hemorrhage is super low and even those with bleeding didn't need an intervention. Unless there is a change, you don't need to rescan.

 

  • Author take home: "Children with isolated skull fractures were at extremely low risk for emergency neurosurgery or death, but were frequently hospitalized. Clinically stable children with an isolated skull fracture may be considered for outpatient management in the absence of other clinical concerns."
  • Rob's take-An otherwise well appearing child with isolated skull fracture has an excellent short term neurosurgical prognosis and probably don't need hospitalization based on the skull fracture alone
  • Adam's take-Open and shut case. One kid out of over 6,000 is pretty good odds and that one patient got meningeal repair.

 

 

Procalcitonin is dead. Long live procalcitonin

  • Schuetz, Philipp, et al. "Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis." The Lancet Infectious Diseases 18.1 (2018): 95-107. PMID: 29037960
  • Over 6,000 patients with respiratory infections
  • Decision to give antibiotics based on procalcitioin level
  • Primary endpoints: Mortality, treatment failure
  • Secondary endpoints: Antibiotic use
  • No significant difference in death, treatment failure, ICU length of stay
  • Antitiocis initiated 86% controls, 70% procalcitonin guided and  shorter duration of abx using procalcitonin as the guide
  • Fewer Abx side effects with procalcitonin guided therapy

 

  • Adam's take-This is not a lifesaving study, this is a safety study. The point is, can you safely withhold antibiotics from people? This study says you can, based on procalc level in a patient with respiratory infection. The scenario I envision is someone with CHF, COPD, fever, and coughing. If the procalc is low, I don't have to add a horrendous quinolone to your 25 other meds, you can take tessalon perles and do better. I'm going to keep one more abx prescription out of the pool and it's not going to harm the patient. This is a noniferiory trial to me. Prescribing fewer antibiotics is a worthwhile goal to me. We know that using procalcitonin for that purpose works and this study says it is safe.

 

Steroids for sore throat

  • Little, Paul, et al. "Effect of oral Dexamethasone without immediate antibiotics vs placebo on acute sore throats in adults: a randomized clinical trial." JAMA 317.15 (2017): 1535-1543. PMID: 28418482
  • RCT of 576 adults with sore throat not requiring immediate abx. Treated with either steroid or placebo
  • Most afebrile and did not have pus on tonsils
  • Results: Symptoms better at 48 hours (but not 24) with dexamethasone

 

  • Rob's take- Set the expecation that it will take 48 hours to start feeling better if giving steroids. That being said,  I don't think that steroids are worth it in most mild sore throat patients. NSAIDS, tea, and time
  • Adam's take- A cofounder for me was that 14% of the dexamethasone and 19% of no dex group had strep, a confounder I don't like. Steroids probably work a little, they're probably safe, but they're not amazing

 

The Brain Does Not Love Ketamine as Much as You Do

  • Pearce, Jean I., et al. "Behavioral Changes in Children After Emergency Department Procedural Sedation." Academic Emergency Medicine (2017). PMID: 28992364 
  • 82 kids received ketamine for procedures in the ED
  • Most had forearm fracutres
  • Most had analgesia before procedure
  • 22% with negative behaviors changes after discharge. Anxiety, aggression, withdrawal, sleep anxiety, separation anxiety
  • Higher odd of this happening in kids anxious before procedure, nonwhite

 

  • Rob's take- ketamine is an excellent drug, but can have lasting effects. Also, it's not totally benign, one patient had over 30 seconds of apnea. Still one of our best options, but discuss with parents the post discharge behavioral changes that might occur
  • Adam's take- I don't think this is a study about ketamine at all. This says nothing about ketamine, this talks about procedural sedation. There is a long history of research about general anesthesia that shows a similar pattern- post op kids have behoaboiral disturbance a week after and the kids who come into the OR have worse outcomes, and if you treat the anxiety before the procedure, they have better outcomes.This could have been propofol nitrous, whatever. The kids who start out anxious pre-procduere have a much higher incidence of behavioral disturbance post procedure.In my opinion, this study shows that anxious kids are more likely to be disrupted by this experience than non-anxious kids. I am going to give a lot more versed. Maybe this is the versed indication that works with ketamine.