The following represent additions to UpToDate since the last version of What’s New that were considered by the authors and editors to be of particular interest.
ADULT CARDIOLOGY
Coronary CT angiography — The value of coronary computed tomographic angiography (CCTA) as compared to traditional care for the management of low to intermediate risk patients with possible acute coronary syndrome presenting to the emergency department was evaluated in a multicenter randomized trial enrolling 1370 patients [1]. Lengths of stay were shorter, rates of discharge from the emergency department were higher and there was a higher rate of detection of coronary disease in patients undergoing CCTA. One percent of patients in each group had a myocardial infarction and there were no cardiac deaths within 30 days after presentation. (See "Noninvasive imaging and stress testing in patients with suspected acute coronary syndrome", section on 'Coronary computed tomographic angiography'.)
Chest pain severity and MI risk — Chest pain is a common complaint among patients presenting to the emergency department with a possible acute coronary syndrome. In a secondary analysis of a prospective observational study, researchers found that increased chest pain severity did not correlate with an increased likelihood of myocardial infarction (MI) [2]. (See "Initial evaluation and management of suspected acute coronary syndrome in the emergency department", section on 'Ischemic chest pain'.)
High sensitivity troponin assays in acute coronary syndromes — The role of high-sensitivity (hs) troponin assays in the evaluation of patients with possible acute coronary syndromes (ACS) continues to evolve. In a study of 413 patients who presented to emergency departments with symptoms suggestive of an ACS and were ultimately diagnosed with acute myocardial infarction (MI), the use of an hs troponin assay allowed for a “rule in” or ”rule out” of MI by three hours in over 98 percent of patients [3]. However, because of concerns about false positivity and lack of evidence for clear clinical benefit, additional data are needed before we suggest the routine use of high-sensitive troponin assays. (See "Troponins and creatine kinase as biomarkers of cardiac injury", section on 'Clinical considerations'.)
ADULT PROCEDURES
Intraosseous cannula placement in adults — Adults in cardiac arrest or with other life-threatening illness who do not have readily available intravenous (IV) access may benefit from intraosseous (IO) cannula placement. Potential sites for intraosseous placement in adults include the proximal tibia and the proximal humerus. In a trial of 183 adults undergoing prehospital vascular access for cardiac arrest that compared peripheral IV placement with IO placement in the tibia or humerus using a battery-powered device, tibial IO placement was significantly more likely to result in overall successful vascular access when compared to humeral IO or peripheral IV access (91 versus 53 and 41 percent, respectively) [4]. A battery-powered or impact driven device is typically required to accomplish IO placement in adult patients. (See "Intraosseous infusion", section on 'Sites of placement'.)
ADULT RESUSCITATION
Epinephrine for out-of-hospital cardiac arrest — Epinephrine is frequently used as a vasopressor in patients with out-of-hospital cardiac arrest, although data showing improved outcomes with epinephrine are sparse. In a prospective observational study of over 417,000 adults with out-of-hospital cardial arrest that compared return of spontaneous circulation (ROSC), survival, and neurologic outcome in patients who did (15,030 patients, 3.6 percent) or did not (402,158 patients, 96.4 percent) receive epinephrine, there was significantly greater ROSC in the epinephrine group [5]. However, this improvement in ROSC did not translate into improved survival, as patients receiving epinephrine had significantly lower rates of overall and neurologically intact survival. Although this study is limited by its observational nature, the results call into question the routine use of epinephrine in the treatment of out-of-hospital cardiac arrest and should serve as an impetus for randomized controlled trials of this issue. (See "Supportive data for advanced cardiac life support in adults with sudden cardiac arrest", section on 'VF or VT arrest and vasopressors'.)
Impedance threshold device — In a multicenter prospective trial of over 8000 cardiac arrest patients randomly assigned to receive CPR with an impedance threshold device (ITD) or a sham device, no significant difference was found between the groups in neurologically satisfactory survival (approximately 6 percent in both groups) [6]. It remains to be determined whether ITDs may benefit particular subgroups of cardiac arrest patients. (See "Therapies of uncertain benefit in basic and advanced cardiac life support", section on 'Inspiratory impedance threshold devices'.)
PEDIATRIC INFECTIOUS DISEASE
Fever without a source in infants and young children — A well-appearing child between the age of three and 36 months who has a fever without a source and who is completely immunized has a low risk of bacteremia but a substantial risk for a urinary tract infection (UTI) depending upon age, gender, and, in boys, circumcision status. Thus, urine testing and culture in such patients is frequently indicated. In contrast, measurement of complete blood count (CBC), obtaining blood cultures, and prescribing antibiotics are typically not warranted. However, in an observational study that reported national estimates of laboratory testing and antibiotic treatment based upon sampling from a national database of emergency department (ED) visits in the United States, ED clinicians did not perform urine testing in 60 percent of girls with high fever, obtained CBC measurements in 21 percent of visits, and prescribed antibiotics in 20 percent of patients in whom no testing was performed [7]. Thus, ED clinicians may not use laboratory testing or antibiotic therapy appropriately when caring for these patients. (See "Fever without a source in children 3 to 36 months of age", section on 'Immunization complete'.)
TOXICOLOGY
Education and dust control measures for pediatric lead poisoning — Families of children with elevated blood lead levels (BLLs) who are unwilling or unable to have their homes professionally abated should undergo education regarding ways to diminish their child's exposure to lead and to control dust in their household (table 1 and table 2 and table 3 and table 4). However, the benefits of these interventions are unclear. A meta-analysis of 14 studies (2656 children) did not show a significant impact on mean blood lead levels 6 to 18 months after initiation of household education, dust control measures, or both [8]. However, a subanalysis of four studies (520 children) that evaluated educational interventions alone did show a positive trend towards reduced numbers of children with a BLL ≥15 mcg/dL (0.72 micromol/L). (See "Childhood lead poisoning: Exposure and prevention", section on 'Education and dust control'.)
Iatrogenic IV acetaminophen overdose in children — Intravenous acetaminophen in a concentration of 10 mg/mL has been available in the United Kingdom since 2003 and was approved for use in the United States in 2010 [9]. Tenfold iatrogenic overdoses have been described in hospitalized young children receiving intravenous acetaminophen for pain relief [10]. The typical error occurs when the dose in mg is mistakenly given as the volume in mL. Other errors include human error when determining the volume to infuse by pump, duplicated doses, and intravenous injection of the oral suspension [9]. Treatment is controversial and consultation with a poison control center or medical toxicologist is strongly advised to guide management. (See "Clinical manifestations and diagnosis of acetaminophen (paracetamol) poisoning in children and adolescents", section on 'Iatrogenic IV overdose' and "Management of acetaminophen (paracetamol) poisoning in children and adolescents", section on 'Iatrogenic intravenous overdose'.)
Pressure immobilization in snake envenomation — The pressure immobilization technique to delay systemic absorption of snake venom has widespread use in Australia, where Elapid toxin primarily causes neurotoxicity without tissue necrosis and where there may be significant delays in transfer to medical facilities (figure 1). However, in the United States, Crotalinae species (eg, rattle snake, water moccasin, or copperhead) predominate and primarily cause serious local tissue toxicity and coagulopathy (table 5). According to an international consortium of toxicology societies, pressure immobilization for North American Crotalinae snake bites has not been shown to be efficacious in humans, may cause serious adverse effects, and should be avoided [11,12]. (See "Management of Crotalinae (rattlesnake, water moccasin [cottonmouth], or copperhead) bites in the United States", section on 'Pressure immobilization'.)
Symptoms of levamisole adulteration of cocaine — Levamisole is a common adulterant of cocaine that can cause agranulocytosis and other serious complications. However, symptoms and signs associated with levamisole toxicity in this setting are not well studied. A review of published cases of levamisole-related toxicity among cocaine users noted that 52 percent of these patients presented with oropharyngeal complaints, while 27 percent presented with soft tissue infections or purpura [13]. (See "Cocaine: Acute intoxication", section on 'Adulterants and their effects'.)
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.
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