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What's new in adult and pediatric emergency medicine

Last literature review version 18.2: May 2010 | This topic last updated: June 15, 2010 (More)

The following represent additions to UpToDate since the last version that were considered by the authors and editors to be of particular interest. The new material described below represents a small subset of the updating that has been performed, since approximately 40 percent of the topic reviews are updated during each four-month cycle.

ADULT RESUSCITATION

Vasopressors for shock — Patients who receive a dopamine infusion during the treatment of shock are more likely than patients who receive a norepinephrine infusion to have arrhythmias. A multicenter trial that randomly assigned 1679 patients with shock to receive either dopamine or norepinephrine as the initial vasopressor found that the patients who received dopamine were more likely to have arrhythmias [1]. There was no difference in mortality. (See "Use of vasopressors and inotropes", section on 'Dysrhythmias'.)

ADULT TRAUMA

Imaging blunt abdominal trauma — Multidetector computed tomography (MDCT) is used frequently to assess patients with blunt abdominal trauma. Although MDCT is a valuable tool, it may be used excessively in some instances, thereby increasing costs and exposing patients to radiation unnecessarily. Two prospective observational studies identified traits that made abdominal injury unlikely, obviating the need for MDCT [2,3]. These traits included:

• Glasgow coma scale ≥14
• No hypotension (SBP <90 mmHg)
• No abdominal or costal margin tenderness
• No abnormalities on chest radiograph
• No femur or pelvic fracture
• Hematocrit ≥30 percent
• No hematuria (<25 red blood cells/high powered field)

(See "General approach to blunt abdominal trauma in adults", section on 'Computed tomography'.)

Spinal immobilization in penetrating trauma — In selected cases, spinal immobilization may increase mortality among patients with penetrating trauma [4]. This finding was reported in a large retrospective study using the United States National Trauma Data Bank. First responders and emergency clinicians must remain cautious when they consider removing spinal immobilization in this setting because victims of penetrating trauma may simultaneously sustain blunt head or neck trauma during an assault. (See "Diagnosis and acute management of spinal column injuries in adults", section on 'Spinal immobilization'.)

Imaging cervical ligamentous injury — A systematic review of 11 prospective and retrospective studies found that MRI identified 182 cervical spine abnormalities, of which 96 led to substantial changes in management, among 1550 trauma patients whose initial CT scan of the cervical spine was negative [5]. No randomized trials that directly compared CT and MRI to CT alone were included. (See "Diagnosis and acute management of spinal column injuries in adults", section on 'Approach to ligamentous injury and SCIWORA'.)

Detecting acute compartment syndrome — A study using fresh cadavers found that palpation of leg compartments was neither sensitive nor specific for detecting substantial elevations in compartment pressures [6]. This study reemphasizes the importance of measuring compartment pressures whenever the diagnosis of acute compartment syndrome is suspected. (See "Acute compartment syndrome", section on 'Clinical features'.)

Control of severe hemorrhage from pelvic fractures — A case series describes 13 patients with life-threatening hemorrhage from pelvic fractures that was controlled initially by the placement of an intraaortic balloon [7]. Twelve of the 13 patients stabilized sufficiently for transfer to angiography for definitive care; of these, six survived. Temporary control of life-threatening pelvic hemorrhage may be achieved using intraaortic balloon occlusion. (See "Adult pelvic trauma", section on 'Initial stabilization and approach'.)

ANAPHYLAXIS

Epinephrine autoinjectors — New epinephrine autoinjector products are available in the United States, and some of these differ significantly from products available to date [8-10]. We advise designating the specific name and description of the product intended to be dispensed on the prescription order and providing patient education that is specific to that product. (See "Prescribing epinephrine for anaphylaxis self-treatment", section on 'Available autoinjectors'.)

BASIC LIFE SUPPORT

Conventional versus compression-only CPR — Compression-only cardiopulmonary resuscitation (COO-CPR) for bystanders is suggested in limited situations in adults with cardiac arrest. (See "Basic life support (BLS) in adults", section on 'Compression-only CPR'.)

However, this recommendation does not apply to children, because cardiac arrest is more commonly due to respiratory causes. An observational study of 5158 children ≤17 years of age, who had an out-of-hospital arrest, found that those who received conventional CPR were significantly more likely to have favorable neurologic outcomes at one month than those who received COO-CPR [11]. (See "Overview of basic life support in infants and children", section on 'Conventional versus compression-only CPR'.)

CARDIOLOGY

Acute decompensated heart failure — A systematic review suggested that noninvasive positive pressure ventilation may reduce mortality in patients with an acute decompensation of heart failure [12]. (See "Noninvasive positive pressure ventilation in acute respiratory failure in adults", section on 'Cardiogenic pulmonary edema'.)

Early repolarization — Early repolarization on an electrocardiogram has been considered a benign finding. However, a study of over 10,000 healthy, middle aged individuals found that early repolarization in the inferior or lateral leads was associated with an increased risk of cardiac death [13]. (See "ECG tutorial: Miscellaneous diagnoses".)

CHILD ABUSE

Abusive head injury — Unenhanced computed tomography (CT), with brain and bone windows, is the preferred imaging modality for the initial evaluation of cases of suspected abusive head injury. Mixed density subdural hemorrhages are more characteristic of inflicted, rather than unintentional head injury. Subcortical abnormalities on head CT may also be a strong marker for child abuse. In one prospective, multicenter observational study of 54 children under three years of age, a head CT with findings at the subcortical level, including swelling, hypoxic-ischemic changes, brain shift, or hernia was highly associated with abusive head injury [14]. (See "Evaluation and diagnosis of abusive head injury in infants and children", section on 'Computed tomography'.)

FEBRILE INFANT

Outpatient management — A systematic review of 21 observational studies evaluated low risk criteria for serious bacterial illness in infants between 0 and 90 days of age. The estimated incidence of serious bacterial infection (SBI) among infants categorized as low risk after a full evaluation was 2.2 percent (range, 0 to 6.3 percent) [15]. When limited to studies in which clinicians prospectively identified infants at low risk of SBI and performed outpatient observation with no antibiotics, the frequency of SBI was lower (0.7 percent), demonstrating the safety of treating a select population of young infants as outpatients. (See "Strategies for the evaluation of fever in neonates and infants (less than three months of age)", section on 'Traditional strategies'.)

INFECTIOUS DISEASE

Severe sepsis — Clinical outcomes are similar regardless of whether resuscitation during severe sepsis is guided by lactate clearance or central venous oxyhemoglobin saturation (ScvO2). A trial that randomly assigned 300 patients with severe sepsis to undergo resuscitation targeting either a lactate clearance ≥10 percent or an ScvO2 ≥70 percent found no differences in hospital mortality, ventilator-free days, or the incidence of multiorgan failure [16]. (See "Management of severe sepsis and septic shock in adults", section on 'Restore perfusion'.)

Urinary tract infection — Among patients age 66 and above taking warfarin who require antimicrobial therapy for treatment of urinary tract infection, trimethoprim-sulfamethoxazole and ciprofloxacin appear to be associated with increased risk of upper gastrointestinal tract bleeding [17]. (See "Therapeutic use of warfarin", section on 'Antibiotics'.)

PEDIATRIC SIGNS AND SYMPTOMS

Treatment of vomiting with ondansetron — A large retrospective study from two pediatric emergency departments showed the use of oral ondansetron to reduce vomiting in children with presumed gastroenteritis does not increase the risk of missing other serious alternate causes of vomiting [18]. Alternate diagnoses included appendicitis, intussusception, bacteremia, pyelonephritis, small bowel obstruction, and intracranial tumor. This study also confirmed previous observations that ondansetron therapy reduced the rate of hospital admissions for gastroenteritis. (See "Oral rehydration therapy", section on 'Vomiting and ondansetron'.)

PROCEDURAL SEDATION AND ANALGESIA

Ketofol in children — Propofol can be used safely in children as a 1:1 mixture with ketamine within the same syringe (10 mg/mL of ketamine and 10 mg/mL of propofol, also called ketofol). In an observational study of 219 patients, age 1 to 20 years, ketofol effectively sedated all patients with an average sedating dose of 0.8 mg/kg for both agents and a median recovery time of 14 minutes [19]. Airway intervention was necessary in three patients (1.4 percent), including one patient who needed bag-mask ventilation for laryngospasm. No patients required endotracheal intubation. (See "Procedural sedation and analgesia in children", section on 'Propofol'.)

Oral sucrose or glucose for analgesia in infants — A meta-analysis of randomized controlled trials that studied the use of sucrose or glucose for control of pain prior to immunization in infants, one to 12 months, found significant reductions in the incidence and duration of crying when compared to water or no treatment [20]. (See "Procedural sedation and analgesia in children", section on 'Sucrose'.)

TOXICOLOGY

Button battery ingestion — The number of severe and/or fatal button battery ingestions has increased almost seven-fold since 1985 with serious sequelae or death occurring in 2.7 percent of all button battery ingestions [21]. Ingestion of large diameter (≥20 mm) lithium cell batteries is strongly associated with major outcomes (eg, esophageal burn, perforation, or fistula) and death. (See "Button battery ingestion", section on 'Epidemiology'.)

Ingested batteries should be localized with prompt radiographs that provide AP and lateral views of the gastrointestinal tract from the mouth to the anus in all children ≤12 years of age, in all patients who have ingested a button battery that is ≥12 mm in diameter, or in patients for whom the diameter of the battery is not known. Batteries that are impacted in the esophagus require emergent removal. (See "Button battery ingestion", section on 'Management'.)

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