Ben's Top Ten

Ben Hunter, MD, reviews many publications to help him make the best decision in the emergency department. Here are his top ten publications from the past year that include essential take home messages to incorporate into clinical practice.

1A. Effect of Intravenous of Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial

Summary: 391 patient RCT of IV calcium vs placebo in patients being resuscitated from out of hospital cardiac arrest. Stopped early for concern for harm with calcium. Less ROSC (19% vs 27%, p = 0.09), less 30 day survival (5.2% vs. 9.1%, p = 0.17), less survival with good neurologic outcome (3.6% vs 7.6%, p = 0.12) among patients who got calcium.

Bottom Line: We should not use calcium during resuscitation unless there is a clear indication (hyperkalemia).

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1B. Calcium Administration During Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest in Children With Heart Disease Is Associated With Worse Survival – A Report From the American Heart Association’s Get With The Guidelines – Resuscitation (GTWT -R) Registry 

Summary: 4500 patient retrospective study of children with in hospital cardiac arrest. After propensity matching, calcium administration was associated with decreased survival to discharge (39% vs. 47%, p = 0.02).

Bottom Line: We should not use calcium during resuscitation unless there is a clear indication (hyperkalemia).

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2. Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial

Summary: 1200 patient cluster randomized study showing non-inferiority of risk adjusted D-Dimer (double standard threshold if YEARS negative) compared to standard use of D-Dimer. Using risk adjusted algorithm resulted in 10% fewer CT scans, no increase in misses. Only 1 patient ruled out by YEARS algorithm who had subsequent VTE at 3 months = 0.15%.

Bottom Line: Risk adjusted d-dimer is supported by multiple well done large studies and is now supported by guidelines. You should feel safe doing this in low risk patients (years negative or low risk wells).         

ESC Guidelines: see section 4.11

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3. Diagnostic Accuracy of Neuroimaging in Emergency Department Patients With Acute Vertigo or Dizziness: A Systematic Review and Meta-Analysis for the Guidelines for Reasonable and Appropriate Care in the Emergency Department

Summary: Systematic review and diagnostic meta-analysis of neuroimaging in acute dizziness or vertigo. Sensitivity for central cause: For Head CT 28.5%; Head CTA 14.3%; MRI 79.8%; MRA 60%. Specificity was high for all modalities. Note results are based on relatively small number of studies, some with significant risk of bias.

Bottom Line: Head CT, with or without CTA, should not be used to rule out central causes of vertigo or dizziness. MRI has only fair sensitivity and negative results should be interpreted in the context of pretest suspicion. Neurology consultation may be warranted in cases with high pretest suspicion even with negative MRI.

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4. Etomidate Versus Ketamine for Emergency Endotracheal Intubation: A Randomized Clinical Trial

Summary: 801 patient RCT of etomidate vs ketamine for RSI. Survival was higher with ketamine at 7 days (85% vs 77%), but not at 28 days (67% vs 64%). Hypotension/cardiovascular collapse was more common with ketamine.

Bottom Line: Don’t throw out etomidate yet, but worrisome signal that it may not be the ideal first line RSI sedative. Ketamine is actually less “hemodynamically stable” than etomidate.

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5. Restriction of Intravenous Fluid in ICU Patients with Septic Shock  

Summary: 1500 patient RCT of septic ICU patients. Randomized to restrictive IV fluids or usual care. Mortality was identical in the 2 groups. Note that randomization didn’t occur until ICU and after many patients had gotten some initial fluid boluses.

Bottom Line: This study was not ED-centric enough to tell us how to resuscitate septic patients early on, but is more evidence that unfettered fluid administration is unhelpful in general.

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6. Two-Day Versus Seven-Day Course of Levofloxacin in Acute COPD Exacerbation: A Randomized Controlled Trial 

Summary: 310 pt RCT of 2 vs 7 days of abx (levofloxacin) for acute COPD exacerbation without pneumonia diagnosis. Primary outcome was complete resolution without relapse at 30 days, and occurred in 79% in the 2 day group and 74% in the 7 day group (p = 0.28). No differences in other outcomes including death, ICU admission, relapse or time to relapse. Small study and most people (appropriately) don’t use quinolones for this, so extrapolation to more common drugs is questionable.

Bottom Line: According to Cochrane, there is inconsistent evidence of small benefits in COPD exacerbation unless ICU level of care. If using abx for this indication (fluoroquinolones not recommended first line), a shorter course makes sense, since it’s unclear that there’s any benefit at all. 

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7. Oral Tecovirimat for the Treatment of Smallpox  

Summary: Not a new study, but this is the evidence upon which the use of tecovirimat for monkeypox is based. Monkeys were given lethal dose of monkeypox. Tecovirimat or nothing was started when lesions developed. 1/20 monkeys survived without TCV. 19/20 survived if TCV was started early at high enough doses. If it was started day 6 or later, survival was 50%. TCV was well tolerated among 450 human volunteers.

Bottom Line: The decision to start tecovirimat for monkeypox will be made in conjunction with consultants, but the evidence to support its use is limited to a small study in non-human primates exposed to lethal doses of monkeypox.

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8. Balanced Multielectrolyte Solution Versus Saline in Critically Ill Adults 

Summary: 5000 patient DB RCT of plasmalyte vs saline in ICU patients. No differences in mortality (21.8% plasmalyte, 22.0% saline, p = 0.90), renal injury, dialysis, or anything else. Limitations include most patients in plasmalyte group got some saline outside of protocol.

Bottom Line: 2nd huge study showing no benefit with plasmalyte vs saline. The added cost of plasmalyte doesn’t seem justified. Since lactated ringers is the same cost as saline and there was suggestion of benefit with lr over saline in the smart trial, lr seems a reasonable alternative, but in most cases saline is probably just fine (note subgroup of head injured patients saline is likely preferable).

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9. Efficacy of Benzodiazepines or Antihistamines for Patients With Acute Vertigo: A Systematic Review and Meta-Analysis

Summary: Systematic review of antihistamines or benzodiazepines for acute vertigo treatment. All 4 studies that compared AH to BZD directly found AH provided more immediate relief (At 2 hours, 16 points more relief on 100 pt VAS in meta-analysis), with trends towards less side effects. No studies found any benefit with BZD compared to any other drug or placebo for any outcome. Compared to other drugs (prochlorperazine, ondansetron, droperidol, piracetam), AH provided similar relief. No drugs provided clear benefit with daily use at a week or a month.

Bottom Line: Benzodiazepines should not be first line treatment for vertigo, and probably shouldn’t be 2nd or 3rd line either. For patients with bppv, repositioning maneuvers are likely superior to any drug therapy and should be first line. Daily use of antihistamines or other drugs likely has minimal to no benefit.

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10. Major Adverse Cardiac Event Rates in Moderate-Risk Patients: Does Prior Coronary Disease Matter? 

Summary: Among 1717 moderate risk for ACS (HEART score 4-6 without positive troponin) patients from the original HEART score database, 30 d MACE was 1.4% in moderate risk patients with no previous hx of CAD, and 7.1% in moderate risk patients with a hx of CAD. Note no difference in death, MACE differences were driven by subsequent troponin elevation and revascularization.

Bottom Line: It may be relatively safe to discharge selected moderate risk patients with no hx of cad with close follow up. Moderate risk patients with a hx of CAD have a higher incidence of mace, and we might lean towards cardiology consultation or observation.

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Meet the Creator 

A true hoosier, Ben was born in Bloomington, IN, and stayed there for undergrad at IU where he was a 4 year swimmer and academic all-american. He stayed at IU for medical school, graduating in 2004 and immediately began his IUEM residency. After completing residency, Ben started as teaching faculty at Methodist, which he considers a dream job. 

Since joining the Methodist faculty, Ben has made a substantial impact on our department in several ways. He led our departmental journal clubs and M&M conferences for several years and is one of our department's most established and published experts in Evidence Based Medicine.  As of 2020, he serves as the departmental Director of Quality for IU Health's Adult Academic Health Center and he chairs the statewide IU Health ED Clinical Effectiveness Council. He has established a research niche in cardiac arrest, but has published on a number of topics. There is still nothing he likes more about his job, however, than clinical teaching and the camaraderie of working in a teaching emergency department. He has won the Methodist EM Faculty Teacher of the Year (as voted on by the EM residents) twice and was Methodist's inaugural winner of the Chisholm-Rodgers Teaching Award. He has also won teacher of the year for the transitional year residency program. In combining his affinity for teaching, science, and research, he accepted the role of "Scholar in Residence" for the department, helping mentor many of our junior researchers. 

When he's not working, Ben has many interests that keep him busy. He enjoys outdoor sports and games like volleyball, frisbee, running, scuba, and fishing. He has a serious fondness for good food (steak) and drink (scotch). He is the guy you are looking for if you like to throw a friendly wager on a sporting event or card game. He has two very awesome daughters, Kira and Haley, who are both competitive swimmers. 

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