Journal Feed Weekly Wrap-Up
- Jun 12th, 2020
- Clay Smith
- categories:
We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter.
Originally published at JournalFeed, a site that provides daily or weekly literature updates.
Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.
#1: How Effective Is the Epley Maneuver?
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The Epley maneuver increased the likelihood of symptom resolution in benign paroxysmal positional vertigo (BPPV) by 35% compared to control or sham maneuver (OR 4.4, 95% CI 2.6-7.4) for a NNT of 3. This is a safe and easy maneuver to perform that can improve symptoms in your patients.
Why does this matter?
BPPV is a very common cause of vertigo and is a source of a significant distress for many patients. As providers, we prescribe anti-emetics and vestibular suppressants to help patients deal with the vertigo and nausea. However, these medicines are not without side effects, especially in the older patients who may be fall risks and have other co-morbidities. The Epley maneuver (or manoeuvre in British-speak) is safe and can improve symptoms without the side effects seen in other common treatments.
Playas Gon’ Epley – 3LW
This paper looked at a Cochrane review and another recent randomized trial set in 6 EDs. For the Cochrane review, this paper specifically looks at a primary outcome of complete symptom resolution in the intervention group (Epley) compared to the sham maneuver or control group (medication only, no maneuver). Compared to the sham/control groups, Epley maneuver increased likelihood of symptom resolution (56% vs 21%, OR 4.4, ARD 35%) for a NNT of 3. There were no reported serious complications of the treatments. Nausea was the most commonly reported symptom but was not significantly different between groups.
Part of my neuro exam for “dizzy” or vertiginous patients involves a Dix-Hallpike maneuver. This works out because if it is positive, they are already in the correct position to initiate the Epley maneuver. It takes me a few minutes to complete it and if I can improve symptoms in 1 out of 3 patients without any medications, that is a win-win. Also, it seems to get patients out faster, and they tend to feel like you did something. Of course, take caution in patients with any sign of cervical spine issues, concerns for carotid/vertebral artery dissection, and atlantoaxial joint issues. Also, older patients with significant co-morbidities for stroke should still get the appropriate workup for posterior circulation issues.
Source
Epley Maneuver (canalith repositioning) for Benign Positional Vertigo. Acad Emerg Med. 2020 Apr 13. doi: 10.1111/acem.13985. [Epub ahead of print]
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#2: Anaphylaxis Guidelines for 2020
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Epinephrine is the key drug for anaphylaxis. Give it early in suspected cases. Antihistamines and glucocorticoids are permissible but not very helpful and certainly should not supersede epinephrine.
Why does this matter?
Anaphylaxis is dangerous and common, with lifetime prevalence of 1.6-5.1%. Thankfully, it is rarely fatal, 0.47-0.69 per million. Medication and stinging insects are the most common causes in adults; foods and stinging insects in children. This review answers some important questions regarding anaphylaxis.
Epi is the stuff
Here are the most important takeaways. The quality of evidence for most of these recommendations was low.
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Biphasic anaphylaxis is likely real but rare. Patients with severe anaphylaxis and those requiring more than one epinephrine dose are at higher risk of biphasic reaction and need longer observation.
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Epinephrine is the critical intervention for anaphylaxis.
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Recommended dose is 0.01 mg/kg of a 1:1000 [1 mg/mL] solution to a maximum of 0.5 mg in adults and 0.3 mg in children.
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It is often underutilized and should be the first-line treatment.
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Do not delay administration in suspected cases.
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Antihistamines and glucocorticoids are not helpful in preventing a biphasic reaction, but they have a role in pre-treatment prior to certain chemotherapy regimens and aeroallergen immunotherapies.
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Authors suggest against routine use of antihistamines and glucocorticoids in preventing radiocontrast medium anaphylaxis.
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Patients should be observed until symptoms are fully resolved. At discharge, they should receive, “education about anaphylaxis, risk of recurrence, trigger avoidance, self-injectable epinephrine, and thresholds for further care, and they should be referred to an allergist for follow-up evaluation.”
What’s new and important? First, a higher dose than 0.3mg is recommended in adults, max 0.5mg IM. The importance of early epinephrine is reemphasized. Risk of biphasic reaction is probably greater with more severe cases and those needing >1 dose of epinephrine. Use of antihistamines and steroids is deemphasized; notably, premedication prior to IV contrast is not recommended.
Source
Anaphylaxis-a 2020 Practice Parameter Update, Systematic Review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Analysis. J Allergy Clin Immunol. 2020 Apr;145(4):1082-1123. doi: 10.1016/j.jaci.2020.01.017. Epub 2020 Jan 28.
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#3: Early ECG Warnings of RV Strain Before PEA Arrest
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Nearly half of inpatient PEA/asystole arrest patients had acute right ventricular strain (RVS) pattern on continuous ECG just prior to the event
Why does this matter?
What if several minutes prior to a patient going into PEA or asystole, you had an indicator that it was about to happen? That’s what this study tells us. With AI and deep machine learning, this is a very real possibility.
Sudden RV strain…then arrest
This was a retrospective analysis of 140 adult inpatients with continuous ECG monitoring prior to PEA/asystole arrest. Patients with pulmonary hypertension, LVAD, or on ECMO were excluded. Acute signs of RV strain (RVS)* on ECG preceded arrest in almost half (47%). This was caused by PE in just 4%. Most were due to worsening respiratory illness, such as pneumonia or ARDS. For patients with RVS prior to arrest who had ROSC, echocardiogram showed new RV dysfunction in 41%. The median time RVS was initially manifest prior to arrest was 7.2 minutes. Presence of RVS prior to PEA/asystole was highly suggestive of a hypoxic/respiratory cause.
From cited article. Note, the full text article erroneously stated ECG C when they meant B. I confirmed this was in error with lead author Dr. Duc Do. He has notified the journal. The version I have written below is correct.
ECG A is an 83 year old with pneumonia prior to arrest. Notice the subtle ST elevation in V1 30-60 minutes prior to arrest and the tiny notch in V1 at 20 minutes that moves rightward in the QRS complex until it becomes an R’ wave. This is from dilation of the RV with progressive hypoxic injury to the right bundle, with ever later depolarization of the RV, eventually manifesting as a RBBB pattern (as occurred in 67% of patients in this study). The ECG also shows increasing rightward axis deviation and rightward-directed ST elevation (lead III > lead II).
ECG C (at 100mm/s tracing speed) is the same patient as ECG A (at standard 25mm/s) but stretched out to make the waves easier to see. The intrinsicoid deflection (or R wave peak time) is marked with purple. The delayed RV depolarization is marked with orange. Note how there is progressively delayed RV depolarization as the patient nears arrest.
ECG B is a 63 year old with adrenal carcinoma with pneumonia and worsening hypoxia. It shows a notch in the S wave, loss of S wave amplitude, and ST elevation 10 minutes prior to arrest. This notch also indicates delayed RV depolarization and eventually becomes a terminal R wave that merges with the ST elevation and looks very much like Brugada type 1.
ECG D is the same patient as ECG B (with a 100mm/s tracing speed) and is intended to demonstrate the morphology change in V1 with progressive RV depolarization delay, similar to ECG C.
* Definite RVS was defined as morphological changes in lead V1, consisting of progressively delayed RV depolarization. This might include a notch in the S wave, progression to an RSR’ pattern, incomplete RBBB, or RBBB. PLUS at least 2 supporting signs of either RV ischemia or right axis deviation:
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ST elevation V1
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Rightward directed ST elevation vector in limb leads (i.e. towards lead III) or
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Right axis deviation in limb leads
Possible RVS was determined if V1 showed delayed RV depolarization and only one of the three supporting criteria were met.
Source
Electrocardiographic Right Ventricular Strain Precedes Hypoxic Pulseless Electrical Activity Cardiac Arrests: Looking Beyond Pulmonary Embolism. Resuscitation. 2020 Apr 29;151:127-134. doi: 10.1016/j.resuscitation.2020.04.024. Online ahead of print.
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