Reviewed by Rıdvan Atilla 30.06.2024
Effectiveness of introducer (bougie) for tracheal intubation (January 2024)
While the tracheal tube introducer (commonly referred to as a “bougie”) is widely considered an important tool for emergency intubation, high-quality evidence supporting its role has been limited. In a new systematic review and meta-analysis of 18 studies involving over 9000 adult patients, use of an introducer was associated with a higher overall rate of successful first-pass intubation compared with no introducer (in most cases an tracheal tube with a stylet). First-pass success rates were higher using an introducer regardless of the method of intubation (ie, direct versus video laryngoscopy) or where intubation was performed (eg, emergency department, intensive care unit, prehospital). The introducer was most effective in patients (n = 585 in five studies) with a Cormack-Lehane III or IV view. We consider the introducer an essential tool for difficult airway management that should be readily available in the emergency department.
Guidelines on management of acute respiratory distress syndrome (February 2024)
The American Thoracic Society recently updated their guidelines on the management of patients ventilated for acute respiratory distress syndrome (ARDS). Compared with previous recommendations, emphasis was placed on the value of systemic corticosteroid administration, early use of extracorporeal membrane oxygenation, and use of neuromuscular blockade, particularly in patients with severe ARDS. Recommendations also focus on the avoidance of recruitment maneuvers, especially prolonged maneuvers. We agree with these recommendations.
Multiple-dose activated charcoal for amatoxin-containing mushroom poisoning (March 2024)
Ingesting mushrooms that contain amatoxins can cause acute liver injury, liver and multisystem organ failure, and death. Multiple-dose activated charcoal (MDAC), which increases elimination of amatoxins by blocking enterohepatic recirculation, is a frequently used therapy, typically combined with other antidotes. A systematic review that included nearly 1200 patients (665 received MDAC, 2 received single-dose activated charcoal) with amatoxin-containing mushroom poisoning found that activated charcoal administration was associated with higher transplant-free survival (83 versus 75 percent). These findings support our recommendation to administer MDAC to patients with suspected amatoxin-containing mushroom ingestion.
ACEP consensus guidelines on topical anesthetics for simple corneal abrasions (April 2024)
Dispensing or prescribing a topical anesthetic for management of corneal abrasions in emergency department (ED) patients is generally discouraged because of concern of causing permanent corneal damage. The American College of Emergency Physicians (ACEP) published consensus guidelines recommending that in adult ED patients with simple corneal abrasions, prescribing or providing a commercial topical anesthetic for 24 hours (no more than 1.5 to 2 mL total) after presentation was safe and improved analgesia and patient satisfaction. Even though we agree that brief use of a topical anesthetic for a small, simple corneal abrasion is safe and provides superior analgesia, we disagree with these broader recommendations since errors in diagnosis of corneal abrasions are common and overuse is difficult to prevent because topical anesthetic is typically supplied in 4 to 15 mL bottles.
New guidelines for cannabinoid hyperemesis syndrome (May 2024)
Cannabinoid hyperemesis syndrome (CHS) causes severe abdominal pain and vomiting that occurs in a cyclical pattern associated with prolonged, regular cannabis use. Standard antiemetics (eg, ondansetron, metoclopramide) are typically ineffective. The Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4) from the Society for Academic Emergency Medicine suggest using dopamine antagonists such as droperidol or haloperidol in addition to usual care to manage symptoms of CHS in adult patients. Capsaicin cream may be used as an adjunct but is often less effective. We agree with these guidelines, but typically reserve capsaicin for second-line therapy.
ASTER Clinical Trail: Acetaminophen in sepsis-related organ failure (June 2024)
Preliminary data have suggested that acetaminophen may have potential benefits in patients with sepsis. A recent randomized trial of 447 patients with sepsis and respiratory or circulatory organ failure reported that patients treated with acetaminophen (1 g every six hours for five days) had a similar number of days alive and free of organ support compared with placebo. However, acetaminophen may have reduced the rate of acute respiratory distress syndrome (2 versus 9 percent). Further study is needed before acetaminophen can be routinely used in patients with sepsis and organ dysfunction.
