Aug 17, 2018

Mixed results

The story

Shady evidence led the International Liaison Committee on Resuscitation to call for a big-time study on the role of epinephrine in cardiac arrest. And boy, like the rest of codes, the data is complicated.

The basics

Your interns have already accepted cracked ribs and mega codes as part of their standard workflow. The two big pillars of resuscitation – early CPR and rapid defibrillation – have strong supporting evidence, but all the meds you push are a bit more iffy. Previous trials have failed to show that epinephrine improves outcomes in out-of-hospital cardiac arrest. Physiologically, benefits like α-adrenergic mediated vasoconstriction contend with β-adrenergic mediated drawbacks like dysrhythmias and an an increase in myocardial oxygen demand.

The study

The headline for PARAMEDIC2, an RCT of 8,000 UK patients with out-of-hospital cardiac arrest, reads that administration of epinephrine increased 30-day survival and return of spontaneous circulation relative to placebo. But that's about the only good news. Overall survival was low in both groups (3.2% for epi vs. 2.4% for placebo), and there was no clear improvement in functional recovery for the epi group. Survivors in the epinephrine group had a significantly higher rate of severe neurologic impairment than placebo (31% vs. 18%).

The takeaway

Unless you're moonlighting as an EMT, these results don't directly inform in-hospital practice. But they do raise questions about whether the routine use of epinephrine in cardiac arrest leads to desirable patient outcomes. 

Say it on rounds

When you get a hand in walk-in clinic

The more the merrier. Persistent use of monotherapy is a big cause of inadequate blood pressure control, especially in low-resource settings where other meds may be too expensive or unavailable. An open-label trial of 700 hypertensive patients in Sri Lanka found that a cheap triple-drug combo pill decreased SBP at 6 months by 10 mmHg compared to usual care, allowing more patients in the combo group (70% vs. 55%) to achieve a BP target of < 140/90 mmHg. The pill was made from telmisartan, amlodipine, and chlorthalidone at half-standard doses.

When you write your note after midnight to spare one the next day

The less (human) work, the better. A prospective study of 800 patients undergoing colonoscopy in Japan found that real-time artificial intelligence could predict which diminutive polyps were noncancerous based on staining patterns and appearance. The technology, called computer-aided diagnosis (CAD), was used to examine 466 diminutive polyps and produced a negative predictive value of almost 95%. The results met a prespecified performance level for a 'diagnose and leave' strategy, which could save time in the endoscopy suite.

When you wake up dizzy with no idea where you are

Hospital naps can be disorienting, but we're not sure they're tied to neurologic outcomes. An analysis of data from the ongoing 12,000-patient Atherosclerotic Risk in Communities study found that orthostatic hypotension on initial exam was associated with a 50% increased risk of dementia and double the risk of ischemic stroke at 25-year follow-up. Patients with hypertension and diabetes were particularly vulnerable. The authors suggest the findings are related to repetitive hypoperfusion and hypoxia.

Brush up

Toxic shock syndrome

Toxic shock syndrome (TSS) extends beyond tampons. Inciting factors include burns, soft tissue injuries, postsurgical wounds, and others. Rapid diagnosis is key as infection spreads quickly. Look for fever, desquamating rash, and multiorgan damage (deranged LFTs, elevated creatinine, anemia). Treat with aggressive fluids, bug-directed therapy, and an anti-toxin agent such as rifampin, clindamycin, or linezolid. Make sure to establish adequate source control. 

What's the evidence

For adjunctive IVIG in TSS? Like other overwhelming bacterial infections, the disease wreaks havoc through a dysregulated immune response. In theory, intravenous immunoglobulin (IVIG) can block T-cell activation and inactivate TSS superantigens to decrease cytokine release, and a 2003 RCT of 21 TSS patients found that those treated with IVIG had a 28-day mortality rate of 10% vs. 36% with placebo. The trial was underpowered to detect a statistically significant difference between groups.

What your CT surgery friends are talking about

In what could be any trainee's nightmare, Ricardo Quarrie was falsely accused of lying to a patient to cover up a surgical mistake in 2015 while a CT surgery fellow at Yale. This week, the patient's attorney recanted the allegation, and Quarrie is working to restore his good name.

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