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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.
Apneic oxygenation in adults undergoing rapid sequence intubation in the emergency department (June 2016)
A number of techniques are used to prevent oxygen desaturation during rapid sequence intubation (RSI). One such technique involves giving oxygen passively via nasal cannula during the apneic phase of RSI. The results of a recent observational study of 635 patients being intubated in the emergency department suggest that this technique may have benefits beyond simply preventing hypoxia . According to this study, the rate of first pass successful intubation without hypoxia was greater in patients managed with apneic oxygenation (82 percent) compared with patients managed without this intervention (69 percent). The improvement was due to both an increase in the rate of first pass successful intubation and a decrease in the incidence of hypoxia. While further studies are needed to confirm this finding, apneic oxygenation is a simple, beneficial intervention that should be used whenever RSI is performed in the emergency department. (See "Rapid sequence intubation for adults outside the operating room", section on 'Preoxygenation'.)
Amiodarone versus lidocaine versus placebo for refractory out-of-hospital cardiac arrest (April 2016)
Out-of-hospital cardiac arrest is one of the leading causes of death worldwide. Antiarrhythmic therapy with amiodarone and lidocaine has been shown to increase survival to hospital arrival, but their effects on survival to hospital discharge and discharge with good neurologic function is unknown. In a randomized trial comparing amiodarone, lidocaine, and placebo in patients with pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF) refractory to defibrillation and initial vasopressor therapy, there was no difference in the primary outcome (survival to hospital discharge) between the three groups, although there was a suggestion of improved survival in both the amiodarone and lidocaine groups compared with placebo . These data are consistent with the 2015 American Heart Association (AHA) guideline approach to therapy, in which amiodarone and lidocaine "may be considered" for patients with VF or pulseless VT that is refractory to initial treatments. Further studies are needed to identify patients who are more likely to benefit from antiarrhythmic drug therapy. (See "Supportive data for advanced cardiac life support in adults with sudden cardiac arrest", section on 'Comparison of amiodarone and lidocaine'.)
GENERAL ADULT EMERGENCY MEDICINE
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'.)
Helmet-delivered noninvasive ventilation in acute respiratory distress syndrome (May 2016)
In patients with acute respiratory distress syndrome (ARDS), noninvasive ventilation (NIV) delivered with a face mask is often not sufficient to prevent intubation. Problems include patient discomfort and air leaks. Delivery of NIV using a helmet (ie, a transparent hood that covers the entire head, sealed with a rubber collar at the neck) may circumvent some of these issues. A preliminary trial compared the two approaches by randomly assigning patients with ARDS who required NIV to continue face mask NIV or switch to helmet–delivered NIV . Helmet-delivered NIV reduced the need for intubation (18 versus 62 percent) and increased ventilator-free days. It also reduced length of stay and 90-day mortality without additional adverse effects. While encouraging, early trial termination may have exaggerated the efficacy. In addition, general concerns regarding limited physician experience and unclear guidelines regarding patient selection, optimal ventilator settings, and monitoring need to be addressed before helmet-delivered NIV can be applied as a therapy for patients with ARDS. (See "Mechanical ventilation of adults in acute respiratory distress syndrome", section on 'Invasive versus noninvasive'.)
Nonoccupational postexposure prophylaxis to prevent HIV infection (April 2016)
A discrete course of antiretroviral therapy (ART) administered after a possible exposure to HIV may reduce the risk of HIV acquisition. The US Centers for Disease Control and Prevention (CDC) has issued updated guidelines on HIV prophylaxis following a nonoccupational exposure . A 28-day course of a three-drug regimen (eg, tenofovir disoproxil fumarate-emtricitabine plus either raltegravir or dolutegravir) should be offered to patients who present within 72 hours of a high-risk exposure (eg, condomless receptive or insertive vaginal or anal intercourse or a percutaneous exposure to blood or bloody body fluids) from a source who is HIV-infected or is at high risk for HIV infection. Exposed patients should be educated about the signs and symptoms of acute HIV infection, and have follow up HIV testing. (See "Nonoccupational exposure to HIV in adults".)
Adverse outcomes with lack of follow-up following emergency department visit for biliary colic (April 2016)
Proper follow-up of patients being discharged from the emergency department following an episode of symptomatic gallstones is important to avoid adverse outcomes. This was examined in a study of more than 11,000 Texas Medicare patients age 66 and older with symptomatic gallstones who were discharged from the emergency department without undergoing cholecystectomy . A quarter of the patients did not see a physician in follow-up. Subsequent emergency hospitalization was required in 78 percent of those patients (compared with 8 percent of those who saw a surgeon and 15 percent of those who saw a physician other than a surgeon). Of the patients with biliary colic, 17 percent required emergency cholecystectomy, with a complication rate of 41 percent (compared with a 19 percent complication rate for elective cholecystectomy). This study reinforces the importance of appropriate follow-up and management for patients with symptomatic gallstones. (See "Uncomplicated gallstone disease in adults", section on 'Cholecystectomy'.)
GENERAL PEDIATRIC EMERGENCY MEDICINE
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 [14-17]; 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'.)
Diluted apple juice for hydration in young children with mild gastroenteritis (May 2016)
Commercial oral rehydration solutions (ORS) are recommended for rehydration of children with gastroenteritis. More readily available household beverages, such as fruit juice, tea, sports drinks, and soft drinks, have not been recommended due to concerns that their lower sodium concentration and higher osmolarity could induce osmotic diarrhea, leading to hyponatremia. However, a randomized trial in children 6 to 60 months of age with mild gastroenteritis and no clinical signs of dehydration demonstrated that hydration with half-strength apple juice resulted in fewer episodes of treatment failure than ORS (17 versus 25 percent) . Treatment failure was defined as any of the following events occurring within seven days of enrollment: intravenous rehydration, hospitalization, subsequent unscheduled physician encounter, protracted symptoms, crossover to the other fluid, ≥3 percent weight loss, or signs of significant dehydration on a follow-up visit. Based on these findings, diluted apple juice followed by a permissive approach to fluid consumption is a reasonable alternative to ORS for hydration in young children with mild gastroenteritis and no clinical signs of dehydration. (See "Oral rehydration therapy", section on 'Common household beverages and fluids'.)
Fluid management in resource-limited countries for children with impaired circulation (May 2016)
The World Health Organization (WHO) has updated its emergency triage and treatment (ETAT) guidelines for fluid management in children with signs of circulatory impairment who are receiving treatment in resource-limited settings . Compared with the previous WHO ETAT guidelines, this guidance promotes less aggressive fluid resuscitation for children with shock, especially those with severe anemia or malnutrition. This update is based, in part, on a trial in a resource-limited setting showing higher mortality in children with severe febrile illness and impaired perfusion who received fluid boluses compared with those who did not . (See "Initial management of shock in children", section on 'Resource-limited settings'.)
PRIMARY CARE ORTHOPEDICS AND SPORTS MEDICINE
Ultrasound for the detection of distal forearm fractures in children (July 2016)
Distal forearm fractures are among the most common fractures in children. Plain radiographs of the forearm are considered the gold standard for definitive diagnosis. However, there is a growing interest in ultrasound diagnosis of distal forearm fracture due, in part, to the absence of exposure to radiation. In a metaanalysis of 12 studies (951 children 18 years of age and younger) comparing ultrasound with the reference standard of conventional radiography, ultrasound detected distal forearm fractures with a pooled sensitivity of 98 percent and a specificity of 96 percent . These findings correspond to an estimated 3 out of 100 distal forearm fractures missed by ultrasound. Detection of distal forearm fractures is a developing use of bedside ultrasound, especially when plain radiographs are not readily available. However, most centers still use plain radiographs for diagnosis of forearm fractures. (See "Distal forearm fractures in children: Diagnosis and assessment", section on 'Ultrasound'.)
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'.)
Nicotine poisoning from e-cigarette exposures in children (May 2016)
Since 2010, e-cigarette exposures (ingestion, dermal, inhalational, and ocular) have been rapidly increasing in the United States, from approximately 20 regional poison center calls per month in April 2012 to over 200 calls per month in April 2015 . Children younger than six years of age account for a majority of exposures, and ingestion is the most common route. Typical clinical features of poisoning are related to nicotine toxicity and include eye irritation, nausea and vomiting, tachycardia, and lethargy. Life-threatening effects consist of seizures, coma, apnea, and cardiac arrest. When compared with ingestions of cigarettes or other tobacco products, e-cigarette exposure is associated with a significantly increased risk of hospitalization or severe effects. Although the regulation of e-cigarettes varies by country, many of these devices do not yet have child safety features to prevent exposure. (See "Toxic plant ingestions and nicotine poisoning in children: Management", section on 'Electronic cigarettes' and "E-cigarettes", section on 'Regulatory status'.)
Simplified approach to acetylcysteine infusion for acetaminophen poisoning (April 2016)
The treatment of acetaminophen poisoning with acetylcysteine is sometimes complicated by nonallergic anaphylactic reactions (NAARs). The results of a large retrospective study, in addition to recent clinical experience, suggest that these reactions can be reduced by using a two-bag regimen instead of the traditional three-bag regimen described in the manufacturer’s package insert and most dosing references. In the study, NAARs occurred in 10 percent of the 389 patients treated with the standard regimen versus 4.3 percent of the 210 patients treated with a modified two-bag regimen . In both regimens, acetylcysteine was infused over 20 hours. While further study is needed to ensure the safety and effectiveness of this regimen, we believe this is a reasonable approach to treatment in adults and older adolescents with acetaminophen poisoning. (See "Acetaminophen (paracetamol) poisoning in adults: Treatment", section on 'Simplified 20 hour IV protocol'.)
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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