JournalFeed Weekly Wrap-Up

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: Time to Epi for Non-Shockable Rhythm Matters

Spoon Feed
Earlier epinephrine administration for non-shockable rhythm was associated with better overall survival to discharge and neurologically-intact survival.  Reducing EMS time to the scene, time to IV (or IO) access, and time to drug may improve survival in this group of patients.

Why does this matter?
The literature has been back and forth on epinephrine in arrest.  A study says sooner is better.  But another study says not too soon.  Yet another says we may be giving it too frequently.  What about the cohort of patients with non-shockable rhythms?  Does timely epinephrine matter?

Sooner was better
This was a registry study from the Resuscitation Outcomes Consortium network that included out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythm.  There were 32,101 patients included.  For every minute delay in epi administration, there was a 4% decrease in odds of survival to discharge, in both children and adults.  Not all patients had neurological status at discharge recorded.  For the 13,290 who had modified Rankin score assessment, odds of survival with modified Rankin Scale <3 (slight disability or better) were reduced 6% for each minute epi was delayed.  In this large, retrospective study, it appears earlier epi administration for non-shockable rhythm was associated with better overall survival and neurologically intact survival.  Any way we can reduce EMS arrival time, time to IV (or IO) access, and time to drug may improve survival in this group of patients.

Source
Time to Epinephrine Administration and Survival From Nonshockable Out-of-Hospital Cardiac Arrest Among Children and Adults.  Circulation. 2018 May 8;137(19):2032-2040. doi: 10.1161/CIRCULATIONAHA.117.033067. Epub 2018 Mar 6.

• For more on epinephrine in cardiac arrest, see this emDocs post.

#2: Syncope/Pre-syncope and Outcome in PE Patients

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Syncope or pre-syncope in patients with PE was associated with an increased risk for 30-day mortality (43% vs 6%) and was an independent predictor of 30-day mortality when accompanied by hemodynamic instability on admission.  Don’t try to treat them as an outpatient.

Why does this matter?
We recently learned that patients presenting with syncope had an unexpectedly high rate of concomitant PE in the PESIT study.  Subsequent lower quality studies have raised concern about whether or not this is true.  This study took a different approach: in patients with known PE who had pre-syncope or syncope as part of their presentation, did this portend a bad outcome?

DFO (“done fell out”) a bad sign in PE
This was a secondary analysis of the prospective Italian Pulmonary Embolism Registry (IPER). The original study enrolled 1716 patients, 458 (26.6%) of whom had pre-syncope or syncope.  Patients with syncope or pre-syncope had much higher 30-day mortality, 42.5% vs 6.2%.  There was a suggestion that pre-syncope was actually worse than syncope, but I am not sure about this.  Both were bad prognosticators.  Pre-syncope was also an independent risk factor for mortality at 30 days in patients with hemodynamic instability at admission (hazard ratio 2.13).  This was independent of RV dysfunction, age, or receipt of thrombolysis.  What this means for us is that patients with PE plus syncope or pre-syncope are not good candidates for outpatient management and with high short-term mortality risk, some may benefit from ICU-level care.

Source
Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism.  Eur J Intern Med. 2018 Apr 11. pii: S0953-6205(18)30141-9. doi: 10.1016/j.ejim.2018.04.004. [Epub ahead of print]

• For more on vascular syncope, see this emDocs post, and this post contains updated guidelines for syncope.

#3: NPO Status – No Correlation With Sedation Outcomes

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In this cohort of thousands of pediatric ED sedation patients who didn’t meet the American Society of Anesthesiologists (ASA) fasting guideline, none had aspiration nor was there any correlation of fasting time with any adverse events or vomiting.  It is time to change hospital NPO policies for the ED.

Why does this matter?
Children often have procedures delayed due to NPO status in the ED, but the overwhelming evidence suggests that NPO status does not correlate with aspiration risk in PED procedural sedation, even in the anesthesia literature.  ACEP guidelines also do not recommend following fasting guidelines for ED sedation.  This gives even more evidence.

Sedation without hesitation
In 6183 children who underwent ED sedation, 48% did not meet ASA fasting guidelines for solid food; 5% for liquids.  Yet there were no aspiration events.  There was no association with fasting time and any adverse event, serious adverse event, or vomiting.  Ketamine was most commonly used agent, with 62.2% receiving ketamine alone; 20.7% received ketamine plus another agent (3.2% + midazolam; 13.7% + propofol; 3.8% + fentanyl). Most hospitals still follow ASA fasting guidelines for the ED, but more evidence accrues that ED patients are categorically different than OR patients when it comes to NPO status.  It is time for our hospital policies to reflect the evidence.

Source
Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children.  JAMA Pediatr. 2018 May 7. doi: 10.1001/jamapediatrics.2018.0830. [Epub ahead of print]

Another Spoonful

• Justin Morgenstern’s, First 10EM masterful and comprehensive post on NPO for sedation is a must read.
• See this emDocs post for pearls on pediatric sedation.