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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.
Determining the futility of resuscitation following cardiac arrest (December 2016)
Based on data from almost 7000 out-of-hospital cardiac arrest patients from two large registries (Paris, France and King County, Washington State) and a major multicenter randomized trial, researchers identified three criteria (arrest not witnessed by emergency medical services personnel, non-shockable initial cardiac rhythm, and no return of spontaneous circulation prior to administration of third 1 mg dose of epinephrine) that, if all criteria were met, had a specificity and positive predictive value of essentially 100 percent for death prior to hospital discharge . Of the 2800 patients evaluated who met all three criteria, only one survived. Early identification of patients with no chance for survival may be helpful in family decisions about organ donation. (See "Advanced cardiac life support (ACLS) in adults", section on 'Termination of resuscitative efforts'.)
Iloprost therapy for severe frostbite (December 2016)
For years, no effective therapy was available to prevent tissue necrosis and subsequent amputation in patients with severe frostbite, but an increasing body of evidence suggests that treatment with iloprost, a prostacyclin analog (IV formulation not available in the United States) can prevent such injury in appropriately selected patients. According to one open-label randomized trial , a growing number of case reports , and revised management recommendations from wilderness medicine experts , treatment with iloprost is effective and safe. We suggest treatment with iloprost (where available), with or without tPA, for patients with severe frostbite (Grade 2-4) if given within 48 hours of the initial insult. (See "Frostbite", section on 'Prostacyclin therapy for severe injury presenting within 48 hours'.)
GENERAL ADULT EMERGENCY MEDICINE
Outcomes in severe asymptomatic hypertension (hypertensive urgency) (November 2016)
There is no proven benefit from rapid reduction of blood pressure in patients with severe asymptomatic hypertension (systolic blood pressure ≥180 mmHg and/or diastolic blood pressure ≥110 mmHg). In one retrospective study of over 59,000 patients who presented in the ambulatory setting with severe asymptomatic hypertension, there was no difference in major adverse cardiovascular events, or prevalence of uncontrolled hypertension six months later, for patients sent to the emergency department or sent home from the office for outpatient blood pressure management . Hospitalization rates were higher for those sent to the emergency department. This cohort study suggests that most patients with asymptomatic hypertensive urgency who present in the ambulatory setting can be managed as outpatients. (See "Management of severe asymptomatic hypertension (hypertensive urgencies) in adults", section on 'Rapidity of blood pressure lowering'.)
Syncope and pulmonary embolus (October 2016)
While pulmonary embolus (PE) has generally been considered to be a relatively rare cause of syncope, a recent study reported a 17 percent prevalence of PE among patients admitted to hospital with syncope, and a 25 percent prevalence among those without an alternative etiology for syncope . Two-thirds of patients with syncope secondary to PE had thrombus located in the mainstem or lobar arteries, suggesting that syncope may indicate a high burden of thrombus. The study underscores the importance of syncope as a presenting manifestation of clinically significant PE. (See "Clinical presentation, evaluation, and diagnosis of the adult with suspected acute pulmonary embolism", section on 'History and examination'.)
Corticosteroids not beneficial in severe sepsis without shock (October 2016)
The administration of corticosteroids to patients with sepsis is generally reserved for those with septic shock. A recent randomized trial of nearly 400 adults examined the efficacy of corticosteroids in patients with severe sepsis who did not have shock . Compared with placebo, an infusion of hydrocortisone (200 mg daily for five days followed by tapering until day 11) had no effect on mortality or progression to shock. This trial supports our current recommendation that corticosteroids not be routinely administered to septic patients without shock. (See "Glucocorticoid therapy in septic shock", section on 'HYPRESS'.)
Oxygenation goals in critically ill patients (October 2016)
The optimal level of oxygenation in mechanically ventilated patients is unknown. A recent randomized trial reported that, compared with a conventional approach to oxygenation (partial arterial pressure of oxygen [PaO2] up to 150 mmHg or peripheral arterial oxygen saturation [SpO2] 97 to 100 percent), a conservative approach (PaO2 70 to 100 mmHg or SpO2 94 to 98 percent) resulted in lower mortality and fewer episodes of shock, liver failure, and bacteremia . However, these preliminary results should be confirmed by a larger multicenter trial before a conservative approach to oxygenation should be routinely adopted for mechanically ventilated patients. (See "Overview of mechanical ventilation", section on 'Fraction of inspired oxygen'.)
Safety of magnetic resonance imaging and gadolinium in pregnancy (September 2016)
Magnetic resonance imaging (MRI) may be used for diagnostic imaging in pregnancy when ultrasound examination is inadequate; however, fetal safety has not been conclusively established. Recently, the largest study of MRI in pregnancy (over 1700 exposed and 1.4 million unexposed births) reported that first-trimester MRI was not associated with significantly increased risks for stillbirth, neonatal death, congenital anomaly, neoplasm, or vision or hearing loss in children followed up to age four years, when adjustments were made for differences between exposure groups . The study also found that gadolinium exposure at any time during pregnancy was associated with an increased risk for stillbirth and neonatal death. Children exposed in utero were at increased risk for rheumatological, inflammatory, or infiltrative skin conditions, but not congenital anomalies or nephrogenic systemic fibrosis (NSF). This study is a major addition to the body of evidence supporting the safety of MRI in pregnancy when medically indicated. It also provides the first data supporting existing recommendations to avoid use of gadolinium-based contrast agents in pregnant women, when possible. (See "Diagnostic imaging procedures during pregnancy", section on 'Magnetic resonance imaging'.)
New guidelines for the management of Stevens-Johnson/toxic epidermal necrolysis syndrome (August 2016)
The British Association of Dermatologists released new guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), a severe and potentially fatal mucocutaneous drug reaction . The guidelines provide evidence-based recommendations for the diagnosis, severity assessment, and management of SJS/TEN. Specific areas covered include initial management, supportive care, and therapies intended to reduce mortality, such as intravenous immune globulins, systemic corticosteroids, and cyclosporine. The treatment of eye involvement, including systemic therapies and amniotic membrane transplantation to prevent permanent ocular sequelae, as well as the management of oral, urogenital, and airway mucosal involvement are also addressed. (See "Stevens-Johnson syndrome and toxic epidermal necrolysis: Management, prognosis, and long-term sequelae", section on 'General principles'.)
Early benefit of aspirin after TIA or ischemic stroke (July 2016)
The risk of recurrent ischemic stroke is highest in the first days and weeks after a transient ischemic attack (TIA) or ischemic stroke, but the benefit of aspirin in this time period has not been well studied. In a recent pooled analysis of data from over 15,000 subjects in 12 trials evaluating aspirin for secondary prevention, the benefit of aspirin was strongest in the early weeks after TIA or ischemic stroke . Compared with control (mostly placebo), aspirin reduced the relative risk of recurrent ischemic stroke within the first six weeks by 58 percent (1 versus 2.4 percent, absolute risk reduction 1.4 percent). The benefit of aspirin in this time frame was greatest for the subgroup of patients with TIA or minor stroke. These findings emphasize that aspirin should be started as early as possible after the diagnosis of TIA or ischemic stroke is confirmed. (See "Antiplatelet therapy for secondary prevention of stroke", section on 'Aspirin'.)
GENERAL PEDIATRIC EMERGENCY MEDICINE
FDA issues warning about anesthesia for pregnant patients and children under three years of age (December 2016)
The US Food and Drug Administration has warned about potential negative effects on the developing brain from administration of anesthetics and sedatives to pregnant women and children under age three, especially for repeated exposures or procedures lasting more than three hours . However, the degree of risk remains unclear. A single, brief exposure to anesthesia probably does not cause neurotoxicity in healthy young children. Further study is required to determine the effects of prolonged or repeated anesthetics, variability among anesthetic agents and combinations of drugs, and patient factors that may confer vulnerability to anesthetic neurotoxicity. At present, there is no compelling evidence that any specific anesthetic agent should be avoided during pregnancy or in young children, or that necessary surgery should be delayed because of concerns about neurotoxicity. (See "Management of the pregnant patient undergoing nonobstetric surgery", section on 'Fetal brain development'.)
Bag urine specimen testing to determine the need for urine culture in children (October 2016)
A bag urine specimen for a screening urine dipstick and/or urinalysis may prevent the need for a catheterized urine culture in selected patients older than 6 months of age at low risk for a urinary tract infection (UTI). In an observational study of over 800 previously healthy, well-appearing children 6 to 24 months of age presenting to a pediatric emergency department for evaluation of fever, screening of urine obtained by a bag specimen reduced the number of subsequent urine cultures obtained by bladder catheterization from 63 to 30 percent without prolonging the length of stay or increasing rates of revisits or missed UTI . Although potentially helpful for urine screening tests, bag urine samples should not be routinely used to obtain urine samples for culture, especially in situations where contamination of the specimen will complicate further management (eg, young infants or ill-appearing patients who warrant empiric parenteral antibiotics). (See "Urine collection techniques in infants and children with suspected urinary tract infection", section on 'Specimen for urine dipstick or urinalysis'.)
Multidisciplinary approach to children and adolescents with persistent concussion symptoms (September 2016)
For patients with prolonged post-concussion symptoms, a multidisciplinary approach that includes mental health care by a psychologist or psychiatrist is associated with better outcomes. In a randomized trial of 49 children and adolescents (11 to 17 years of age) with persistent symptoms for one month or longer after a sports-related concussion, collaborative treatment consisting of care management, cognitive-behavioral therapy, and, when needed, psychopharmacologic consultation was associated with significant reductions in postconcussive and depression symptoms at six months when compared to usual treatment . (See "Concussion in children and adolescents: Management", section on 'Persistent symptoms'.)
Extended- versus narrower-spectrum antibiotics for prophylaxis of appendicitis in children (September 2016)
Prophylactic antibiotics in children undergoing surgery for appendicitis reduce postoperative complications. The optimal regimen (extended-spectrum antibiotics [eg, piperacillin and tazobactam] versus other narrower-spectrum antibiotics [eg, cefoxitin or ceftriaxone and metronidazole]) is unclear, although extended-spectrum antibiotics are favored by the American Pediatric Surgical Association for treatment of complicated appendicitis. In an observational study of almost 25,000 children with appendicitis, there was no benefit shown for empiric use of extended- over narrower-spectrum antibiotics . Among the 18,000 children with uncomplicated appendicitis, of whom one-third received extended-spectrum antibiotics (primarily piperacillin and tazobactam), treatment failure, defined as readmission within 30 days related to a complication of appendicitis, occurred in approximately 1 percent of the patients and was not reduced with use of extended-spectrum antibiotics. Among the 7000 children with complicated appendicitis, of whom two-thirds received extended-spectrum antibiotics, treatment failure occurred in approximately 6 percent of patients and was increased with use of extended-spectrum antibiotics. It is uncertain from the observational study design whether this association was due to confounding; sicker children may have received the extended-spectrum antibiotics, although the investigators attempted to adjust for this propensity. Clinical trials are needed to determine the best antibiotic regimen for children undergoing surgery for appendicitis. (See "Acute appendicitis in children: Management".)
Clinical prediction rule for abusive head trauma in well-appearing infants (August 2016)
Detection of abusive head trauma (AHT) is challenging in well-appearing infants who typically present with an unrelated complaint and no history of trauma. High-risk complaints include apnea or acute life-threatening event, seizure, vomiting without diarrhea, soft-tissue scalp swelling, bruising, lethargy, fussiness, or poor feeding. In a prospective multicenter validation of a clinical prediction rule in over 1000 well-appearing infants younger than one year of age (109 with abuse) who presented with high-risk complaints for possible abuse, a score of two or more had high sensitivity for an abnormality on computed tomography (CT) of the head . This rule, which assigns points based upon age, head circumference, skin examination, and serum hemoglobin, has significant potential for assisting the clinician with decisions about neuroimaging in well-appearing infants with equivocal findings for abuse. Magnetic resonance imaging is preferred to CT in such patients if there is timely availability of the study and interpretation by a pediatric neuroradiologist. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Well-appearing infants'.)
Inactivated influenza vaccine for 2016-2017 season in the northern hemisphere (August 2016)
The effectiveness of seasonal influenza vaccines varies from season to season and is determined by a number of factors, including the match between circulating influenza strains and influenza strains in the vaccine. During the 2015-2016 influenza season, data from the United States Influenza Vaccine Effectiveness Network indicated that inactivated influenza vaccine (IIV) was 63 percent effective in preventing influenza in children, but live attenuated influenza vaccine (LAIV) was not effective . Findings of poor or lower than expected LAIV effectiveness were also noted during the 2013-2014 and 2014-2015 seasons in the United States. These findings are inconsistent with studies sponsored by the manufacturer and studies from other countries that found LAIV was effective (ranging from 46 to 58 percent) during the 2015-2016 season [18-21]; however, LAIV was less effective than IIV in all of these studies . In August 2016, the United States Centers for Disease Control and Prevention recommended that LAIV not be used during the 2016-2017 influenza season . While some countries have elected to continue using LAIV , we suggest IIV rather than LAIV for the 2016-2017 influenza season in the northern hemisphere. (See "Seasonal influenza in children: Prevention with vaccines", section on 'IIV versus LAIV' and "Seasonal influenza vaccination in adults", section on 'Choice of vaccine formulation'.)
Tracheal intubation and survival following in-hospital pediatric cardiac arrest (November 2016)
In a retrospective observational study of over 2200 United States children younger than 18 years of age with in-hospital cardiac arrest reported to a centralized registry from 2000 to 2014, tracheal intubation during cardiac arrest was associated with a significantly lower adjusted survival to hospital discharge compared with a propensity-matched cohort of patients who were not intubated (36 versus 41 percent, respectively) . There was no significant difference in return of spontaneous circulation or favorable neurologic outcome between the groups. Although confounding cannot be fully excluded given the study design, this evidence suggests that the emphasis on early tracheal intubation during pediatric in-hospital cardiac arrest warrants re-examination and further study. (See "Pediatric basic life support for healthcare providers", section on 'Epidemiology and survival'.)
Ketofol versus propofol for procedural sedation (December 2016)
Ketofol, a combination of ketamine and propofol, is purported to provide good conditions while reducing harmful side effects during procedural sedation and analgesia (PSA) performed outside the operating room, but studies to date have failed to identify clinically significant differences between ketofol and propofol alone. These findings were confirmed in a randomized, multicenter trial involving over 500 patients receiving PSA that reported no significant differences in the rate of adverse respiratory events (oxygen desaturation, apnea, or hypoventilation) between those managed with ketofol or propofol . While multiple studies confirm that ketofol is safe and effective, there is no convincing evidence that it improves clinically significant outcomes or reduces important (albeit rare) complications during PSA compared with propofol. (See "Procedural sedation in adults outside the operating room", section on 'Ketamine and propofol (ketofol)'.)
Clinical manifestations of severe synthetic cannabinoid toxicity (July 2016)
Synthetic cannabinoids consist of a heterogeneous group of chemical compounds that act as agonists at cannabinoid receptors with 2 to 800 times the potency of delta-9 tetrahydrocannabinol (THC), the active component of cannabis (marijuana). They have emerged as a popular recreational drug in the United States and Europe. In an observational study of a multicenter, hospital-based registry of medical toxicology consultations, over two-thirds of 277 patients with single-agent exposure to synthetic cannabinoids had altered mental status including severe agitation, toxic psychosis, hallucinations, seizures, and coma . Rhabdomyolysis and acute kidney injury were present in approximately 5 percent of these patients. There were three deaths, including a 17-year-old adolescent with sudden death after first-time inhalational use. Thus, unlike cannabis, synthetic cannabinoids have significant potential to cause serious and life-threatening toxicity among recreational users. (See "Synthetic cannabinoids: Acute intoxication", section on 'Clinical manifestations'.)
Early physical activity following acute concussion in children and adolescents (January 2017)
Although physical rest is routinely recommended after concussion, there are few data to determine whether avoidance of physical activity hastens recovery. In a prospective, multicenter cohort study of over 2400 children who were diagnosed with an acute concussion during an emergency department visit, early physical activity (within seven days of injury) compared with physical rest was associated with a significantly reduced risk of persistent postconcussive symptoms (PPCS) at 28 days . However, the difference in PPCS may be the result of confounding, and clinical trials are needed to confirm this result. We suggest that children and adolescents with concussions adhere to full physical rest until they have no symptoms of concussion (table 1) and normal balance or return to baseline on standardized testing. In the minority of patients with prolonged symptoms beyond seven days after injury, we introduce light, subsymptom threshold aerobic exercise (eg, light stationary bicycling), which can often be tolerated and may improve symptoms. (See "Concussion in children and adolescents: Management", section on 'Physical rest'.)
Outpatient management of children with isolated basilar skull fractures (October 2016)
Children with isolated basilar skull fractures typically do well. In a study of over 250 children with isolated basilar skull fractures on computed tomography (CT) of the head and normal neurologic status during emergency department evaluation for head injury, none died or went on to need neurosurgical or intensive care intervention . These findings support outpatient management of children with CT evidence of isolated basilar skull fractures, a normal neurologic examination, and no progression of symptoms during emergency department observation as long as they have a reliable caregiver and ensured follow-up with a neurosurgeon. (See "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fractures'.)
Whole body CT and adult trauma (August 2016)
Multidetector computed tomography (CT) has transformed trauma care by improving the speed and accuracy with which internal injuries are diagnosed. However, whether severely injured patients should be studied with whole body CT scanning or selective imaging based on the most likely sites of injury remains a source of controversy. In an international, multi-center trial, adult trauma patients with evidence of severe injury were randomly assigned to either whole body CT (n = 541) or conventional imaging supplemented by selective CT imaging (n = 542) . In-hospital mortality did not differ between groups (whole body CT 86 [16 percent] versus selective CT 85 [16 percent]), nor did it differ significantly among patients with polytrauma or brain injury. While further research is needed, we believe that whole body CT should not be performed indiscriminately given its associated risks. (See "Initial management of trauma in adults", section on 'Computed tomography, including total body CT'.)
Thromboelastography-guided transfusion in trauma patients (July 2016)
Coagulopathy associated with trauma is evident in 25 to 35 percent of severely injured civilian patients and is associated with increased morbidity and mortality. Thromboelastography (TEG) is a point-of-care testing method that rapidly provides information on the properties of clot formation, detects hyperfibrinolysis, and may offer an advantage over standard coagulation assays. The results of a randomized trial are consistent with observations suggesting that TEG-parameter-guided resuscitation may improve outcomes . Following initial transfusion triggered by activation of a massive transfusion protocol, 111 injured patients were randomly assigned to subsequent transfusions based upon TEG parameters or conventional coagulation assays. Mortality rates were significantly lower for the TEG group compared with the conventional group at 6 hours and 28 days (7.1 versus 21.8 percent, and 19.6 versus 36.4 percent, respectively). Although there were no differences in the overall volume of transfusion at 24 hours, the standard assay group received more plasma and platelets during the first several hours of resuscitation. Where TEG is available, we suggest TEG-based goal-directed resuscitation for trauma patients requiring massive transfusion. (See "Coagulopathy associated with trauma", section on 'Thromboelastography-based transfusion'.)
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