COMMENTARY

Three Must-Read Emergency Medicine Articles of 2015

Amal Mattu, MD

Disclosures

January 07, 2016

Introduction

The past year has again been a fantastic year for the emergency medicine (EM) literature. Some new concepts for life-saving treatments have emerged and been espoused, whereas other long-held beliefs have been torn down. Many new guidelines were published, and old guidelines were updated. Original research has continued to flourish. The overall quality of the EM literature continues to excel.

As in recent years, I present here a few of my favorite articles of the past calendar year. Narrowing my selections was difficult, and I chose to avoid topics that I've covered in prior Viewpoints (eg, resuscitation updates, chest pain workup) or in the 2014 end-of-the-year review (eg, updates in sepsis, acute coronary syndrome [ACS] management). I'll make the usual disclaimer that these are not necessarily the best articles from a methodological standpoint, but they are practice-changing and focus on high-risk conditions where lives are at stake.

In particular, these are articles that I would strongly suggest that all emergency physicians should read, beyond my simple summaries, for the sake of the background knowledge they will impart. In the limited space here, I cannot possibly do them full justice. They are excellent, and worth your time to read!

Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient

Rab T, Kern KB, Tamis-Holland JE, et al; Interventional Council, American College of Cardiology
J Am Coll Cardiol. 2015;66:62-73

In 2013, the American College of Cardiology and the American Heart Association published their joint update of the guidelines for management of ST-segment elevation myocardial infarction (STEMI).[1] In that document, they assigned a class I recommendation for patients who have postarrest ST-segment elevation (STE) to be taken immediately for cardiac catheterization and potential percutaneous coronary intervention (PCI).

The publication of that new guideline made it much easier to send postarrest patients with STE for cardiac catheterization, but patients who did not manifest STE on the ECG after resuscitation were still a quandary. However, this past summer, the Interventional Council of the American College of Cardiology published a review of the literature and a proposed algorithm for how resuscitated postarrest patients that remain comatose and manifest a STEMI or non-STE-ACS pattern on the ECG should be treated.

The recommendations are as follows:

  • Patients with out-of-hospital cardiac arrest who have achieved return of spontaneous circulation but remain comatose should receive an immediate ECG. Targeted temperature management should be initiated. The guidelines do not specify whether the goal temperature should be 33°C or 36°C [91.4 or 96.8F].

  • Patients who manifest STE should be referred for urgent cardiac catheterization and possible PCI. Negative prognostic factors should be taken into account ("unfavorable resuscitation features," discussed further below), but the default clearly appears to be activation to the catheterization laboratory.

  • If the patient does not manifest STE, the recommendation is to consult with interventional cardiology and intensive care services and discuss the best course of action. In the absence of multiple unfavorable resuscitation features, strong consideration should be given to proceeding with urgent cardiac catheterization and possible PCI.

  • Patients with multiple unfavorable resuscitation features are less likely to benefit from urgent cardiac catheterization and are best managed initially with standard resuscitation of their hemodynamic, metabolic, and other underlying conditions (eg, sepsis). The Table shows unfavorable resuscitation features.

Table. Unfavorable Resuscitation Features

Unwitnessed arrests pH < 7.2
Initial rhythm nonventricular fibrillation Lactate level > 7
No bystander CPR Age > 85 yr
> 30 min to ROSC End-stage renal disease
Ongoing CPR Noncardiac causes (eg, sepsis, trauma)

CPR = cardiopulmonary resuscitation; ROSC = return of spontaneous circulation

The authors provide a nice review of the literature that justifies their recommendations. As a whole, this is an outstanding review and well worth the read.

After discussions between representatives from our medical center's EM department and division of cardiology, our own University of Maryland Network of hospitals has adopted this protocol. I suggest that other EM groups should meet with their cardiology colleagues as well in order to discuss plans for how to care for these patients, and consider adopting a similar protocol.

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