EM Quick Hits 35 – 10 Best Papers of 2021, Peripartum Cardiomyopathy, Crashing Asthmatic, Febrile Neutropenia, Anaphylaxis update

Topics in this EM Quick Hits podcast

Ken Milne on The 10 Best EM Papers of 2021 (00:40)

Brit Long on a careful structured approach to Febrile Neutropenia to improve outcomes (11:55)

Catherine Varner on how not to miss Peripartum Cardiomyopathy (20:35)

Joe Nemeth on Anaphylaxis Update (27:30)

Anand Swaminathan on his approach to The Crashing Asthmatic (38:54)



Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Kate Dillon and Joe Nemeth, edited by Anton Helman, January 2022

Cite this podcast as: Helman, A, Milne, K, Varner, C, Long, B, Nemeth, J, Swaminathan, A. EM Quick Hits 35 - 10 Best Papers of 2021, Peripartum Cardiomyopathy, Crashing Asthmatic, Febrile Neutropenia, Anaphylaxis update. January, 2022. https://emergencymedicinecases.com/em-quick-hits-january-2022/. Accessed [date].

10 Best EM Papers of 2021 from EM Cases Summit 2021

1. TTM2 - Therapeutic Hypothermia after Cardiac Arrest



* Population: adult patients with out of hospital cardiac arrest who were comatose

* Intervention: cooled to 33°C vs. maintaining normothermia

* Primary Outcome: all-cause mortality at 6 months

* Results: no statistical difference between groups (~50% in both groups)



Bottom line: no benefit to cooling patients after out of hospital cardiac arrest who are comatose

Deep dive: https://thesgem.com/2021/07/sgem336-you-cant-always-get-what-you-want-ttm2-trial/

Deep dive into worlds literature on therapeutic hypothermia: Journal Jam on Therapeutic Hypothermia after Cardiac Arrest

2. SALSA Trial - Hypertonic Saline to treat Hyponatremia



* Population: adult patients with sodium 38.3°C OR >38.0°C for 1h with neutropenia

* Neutropenia: most common 5-14 days after chemotherapy, defined as an absolute neutrophil count (ANC) < 0.50 × 109/L or < 1 × 109/L with expected decrease to < 0.50 × 109/L

* Patients not meeting diagnostic criteria (borderline): consult your oncologist/internist, these patients are still at risk for poor outcomes!







Identifying a Source:







* Most common sources: lung, urinary tract, GI, bloodstream, skin, but remember a reduced inflammatory response in neutropenic patients can mean the signs are subtle

* Be aware of atypical infections/sites seen in immunocompromised patients such as:



* ENT: mucositis, murcormycosis, malignant otitis externa

* Abdomen: necrotizing enterocolitis (typhlitis) – look for abdominal pain N/V/D, peritonitis

* Cardiac: endocarditis – look for a new murmur

* Vascular devices

* Perirectal: visually inspect the area





* Consider using the LUCCSASS mnemonic to remember occult sources of infection:









Antimicrobials: follow your local/institutional guidelines for antimicrobial coverage, but general principles can include:







* Pseudomonal coverage for all patients (monotherapy is as effective as dual therapy)

* Consider viral and/or fungal coverage (especially in typhlitis, or those who are still febrile despite 4 days of antibiotics)

* MRSA coverage isn’t required for all patients but should be considered if: known history of MRSA,