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What's new in emergency medicine

What's new in emergency medicine
Literature review current through: Jan 2024.
This topic last updated: Feb 01, 2024.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

ADULT RESUSCITATION

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) [1]. 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. (See "Endotracheal tube introducers (gum elastic bougie) for emergency intubation", section on 'Evidence of effectiveness'.)

Extracorporeal cardiopulmonary resuscitation (December 2023)

Extracorporeal cardiopulmonary resuscitation (ECPR) is being increasingly used, but data are limited and the benefits are uncertain. In a recent meta-analysis of 11 studies (10,000 patients) who underwent CPR, compared with standard CPR, ECPR was associated with decreased in-hospital mortality and increased long-term favorable neurologic outcome and survival at one year [2]. The benefit of ECPR was confined to patients with in-hospital cardiac arrest. These data support the growing practice of ECPR in select patients likely to benefit. (See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Sudden cardiac arrest (extracorporeal cardiopulmonary resuscitation)'.)

Heart rate control in septic shock (December 2023)

Beta blockade has the potential to limit harm from the adrenergic overdrive that occurs in septic shock. However, data to support heart rate control in patients with septic shock are limited. In a recent, unblinded randomized trial of 126 patients with septic shock-related tachycardia (heart rate ≥95/min) who were receiving norepinephrine, the beta blocker landiolol did not reduce organ failure as measured by the sequential organ failure assessment score [3]. Furthermore, landiolol was associated with increased 28-day mortality compared with standard care (37 versus 25 percent). We continue to avoid the routine use of beta blockers in patients with septic shock. (See "Investigational and ineffective pharmacologic therapies for sepsis", section on 'Heart rate control'.)

Aerosol generation during noninvasive respiratory support modalities (October 2023)

Studies have reported conflicting data as to whether high levels of aerosols are generated when noninvasive ventilation (NIV) or high-flow nasal oxygen (HFNO) is used. In a 2023 systematic review including 12 studies in patients with respiratory infections and 15 studies in healthy volunteers, use of NIV or HFNO was not associated with increased generation of pathogen-laden aerosols compared with controls with unsupported normal or labored breathing, low-flow nasal oxygen, or oxygen or nonrebreather mask [4]. Inconsistency among studies may reflect differences in sampling and detection methodologies and operating room ventilation. Notably, the National Health Service in the United Kingdom has removed mask ventilation, intubation, and extubation from its list of aerosol-generating procedures. (See "Overview of infection control during anesthetic care", section on 'Considerations during aerosol-generating procedures'.)

No benefit of routine V-A ECMO in patients with AMI-related cardiogenic shock (September 2023)

Venoarterial extracorporeal membrane oxygenation (V-A ECMO) can increase survival for patients with refractory cardiogenic shock caused by a variety of conditions. However, benefit from the routine use of V-A ECMO for cardiogenic shock due to acute myocardial infarction (AMI) is unproven. In a meta-analysis of four randomized trials (nearly 570 patients with AMI-related cardiogenic shock), routine V-A ECMO use showed no mortality benefit and increased rates of both major bleeding and peripheral vascular ischemia compared with medical care alone [5]. Limitations of this meta-analysis include crossover between groups and a low rate of active left ventricular uploading during ECMO therapy, which may have biased the study in favor of the control group. These findings suggest no meaningful benefit for the routine use of V-A ECMO for patients with AMI-related cardiogenic shock but does not preclude benefit in selected patients who are candidates for salvage procedures such as heart transplant. (See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Refractory cardiogenic shock'.)

GENERAL ADULT EMERGENCY MEDICINE

Time window to start dual antiplatelet therapy for high-risk TIA or minor ischemic stroke (January 2024)

There is evidence from several randomized trials that early initiation of short-term dual antiplatelet therapy (DAPT) for select patients with high-risk transient ischemic attack (TIA) or minor ischemic stroke reduces the risk of recurrent ischemic stroke. The evidence comes from trials that started DAPT within 12 to 24 hours of symptom onset. Results from the recent INSPIRES trial suggest that DAPT is still beneficial when started up to 72 hours after symptom onset [6]. Although the time window is extended by the results from INSPIRES, we start DAPT as soon as possible for patients with high-risk TIA or minor ischemic stroke. (See "Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack", section on 'High-risk TIA and minor ischemic stroke'.)

Guidelines for primary spontaneous pneumothorax (December 2023)

The British Thoracic Society (BTS) has recently issued new guidelines for the management of primary spontaneous pneumothorax (PSP) [7]. Major changes since 2010 include a symptom- rather than size-based approach. For patients with mild symptoms who are stable following adequate analgesia, monitored observation is preferred, while those with significant dyspnea should undergo a drainage procedure (eg, aspiration or catheter/chest tube thoracostomy). Also promoted was ambulatory management in select patients with adequate outpatient support. We agree with these recommendations. (See "Treatment of primary spontaneous pneumothorax in adults", section on 'Initial evaluation and management'.)

Timing of appendectomy for uncomplicated appendicitis (November 2023)

Appendectomy is traditionally performed urgently to reduce the risk of perforation. However, a large randomized trial showed that patients with uncomplicated appendicitis (including those with appendicolith on computed tomography) who had an in-hospital delay of up to 24 hours before surgery had no increased risk of perforation or other complications compared with those who underwent surgery within 8 hours [8]. Given these data and general acceptance of antibiotic management of these patients, we suggest performing appendectomy within 24 hours of presentation in patients with uncomplicated appendicitis who elect to undergo surgery. (See "Management of acute appendicitis in adults", section on 'Timing of appendectomy'.)

Low-dose dexamethasone for severe migraine in adults (October 2023)

Parenteral dexamethasone is used along with short-acting abortive therapies to reduce migraine recurrence for patients with severe symptoms, but optimal dosing is uncertain. Prior trials have reported benefit at doses ranging from 8 to 24 mg. In a recent trial of 209 adults with moderate to severe migraine presenting to the emergency department treated with metoclopramide and intravenous (IV) dexamethasone, rates of sustained relief at 48 hours were similar between groups randomly assigned to 4 versus 16 mg of dexamethasone [9]. Rates of immediate headache relief and medication use in the week following discharge were also similar. These results support our preference for adjunctive dexamethasone at a dose of 4 mg IV to reduce migraine recurrence. (See "Acute treatment of migraine in adults", section on 'Abortive therapy plus parenteral dexamethasone'.)

Pulmonary embolism in patients with severe COPD exacerbation (September 2023)

Pulmonary embolism (PE) is an important potential trigger for COPD exacerbation. In a recent multicenter study, 1580 patients with COPD who were admitted to the hospital with acute worsening of respiratory symptoms were all screened for PE with computed tomography pulmonary angiogram within 48 hours of admission [10]. PE was identified in 266 (17 percent), with 166 patients (11 percent) having PE involving the main or lobar pulmonary arteries. Purulent sputum production decreased the odds of PE by 60 percent. We suggest obtaining imaging for PE in patients requiring admission for COPD exacerbation who do not have evidence of other triggers (eg, infection or heart failure). (See "COPD exacerbations: Clinical manifestations and evaluation", section on 'Triggers' and "COPD exacerbations: Clinical manifestations and evaluation", section on 'Additional testing'.)

Topical anesthetics not recommended for treatment of corneal abrasions (September 2023)

Topical anesthetics are helpful for the initial examination of a patient with a suspected corneal abrasion, but repeated use for the treatment of pain from a corneal abrasion is controversial. Prolonged use (ie, greater than 24 hours) may result in overuse or delayed corneal epithelial healing. A meta-analysis that included three trials in over 200 patients found that, compared with placebo, prolonged use of a topical anesthetic led to more eyes without complete resolution of epithelial defects by 24 to 48 hours (21 versus 15 percent), although the finding did not achieve statistical significance [11]. This supports our recommendation to not dispense or prescribe topical anesthetics for the treatment of corneal abrasions. (See "Corneal abrasions and corneal foreign bodies: Management", section on 'Pain control'.)

No benefit of opioids for acute low back pain (August 2023)

Opioid analgesics are often used to treat acute low back pain despite limited supporting evidence. In a randomized trial of 347 adults presenting to the emergency department or primary care clinic with acute, nonspecific low back pain, oxycodone (up to 20 mg daily for six weeks) was no more effective for pain relief or functional improvement than placebo [12]. There was a higher risk of potential opioid misuse in patients in the oxycodone group at one-year follow-up (20 versus 10 percent). These results support our recommendation against routine opioid use for acute low back pain, given the lack of benefit and potential for misuse. (See "Treatment of acute low back pain", section on 'Opioids'.)

Direct oral anticoagulants for cancer-related venous thromboembolism (August 2023)

In patients with cancer-related venous thromboembolism (VTE), accumulating evidence suggests that direct oral anticoagulants (DOACs) and subcutaneous low molecular weight heparin (LMWH) have similar efficacy and safety. In a recent randomized trial of over 670 patients with cancer-related VTE, there were no significant differences between rates at six months for recurrent VTE (6.1 [DOACs] versus 8.8 percent [LMWH]) and major bleeding (5.2 [DOACs] versus 5.6 percent [LMWH]) [13]. Despite limitations such as lack of blinding, late randomization, and poor adherence rates with LMWH, these data are in keeping with previous evidence and support our suggestion for DOACs rather than LMWH in patients with cancer-associated VTE. (See "Anticoagulation therapy for venous thromboembolism (lower extremity venous thrombosis and pulmonary embolism) in adult patients with malignancy", section on 'Direct oral anticoagulant mono- or dual therapy'.)

High-flow oxygen for acute hypoxemic respiratory failure (August 2023)

In adult patients with acute nonhypercapnic hypoxemic respiratory failure, the benefits of high-flow oxygen delivered via nasal cannulae (HFNC) compared with conventional low-flow oxygen (COT) are unclear. A recent meta-analysis of six trials (over 2700 patients with acute hypoxemic respiratory failure) reported that while HFNC did not reduce 28-day mortality compared with COT, it did significantly reduce the rate of reintubation (relative risk 0.89, 95% CI 0.81-0.97) [14]. These data support the use of HFNC in patients with acute hypoxemic respiratory failure who have escalating oxygen needs. (See "Evaluation and management of the nonventilated, hospitalized adult patient with acute hypoxemia", section on 'Humidified, high-flow oxygen delivered via nasal cannulae (HFNC)'.)

Using head CT alone to exclude aneurysmal subarachnoid hemorrhage (July 2023)

Diagnosing aneurysmal subarachnoid hemorrhage (SAH) can be challenging in patients with isolated headache whose initial bleeding is minor because head computed tomography (CT) can miss small bleeds. Morbidity and mortality risk associated with misdiagnosis causes many centers to perform a follow-up lumbar puncture to assess for blood in the cerebrospinal fluid in patients with no evidence of bleeding on CT. However, the sensitivity of high-quality head CT ranges from 95.5 to 100 percent among patients with isolated headache when performed within six hours of the onset of symptoms, potentially rendering a follow-up lumbar puncture unnecessary. Updated guidelines from the American Heart Association now endorse use of head CT to exclude SAH for selected patients when imaging performed within six hours of symptom onset is normal [15]. For properly selected patients (table 1), we agree with using head CT alone when performed within six hours of headache onset to exclude SAH. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Need for lumbar puncture when early CT is negative'.)

GENERAL PEDIATRIC EMERGENCY MEDICINE

Invasive bacterial illness in febrile young infants with COVID-19 (July 2023)

Evidence is limited for the risk of invasive bacterial illness (IBI) in febrile young infants <60 days old with SARS-CoV-2 infection. In one cohort study of 163 well-appearing febrile infants ≤60 days old (36 neonates) who were diagnosed with COVID-19 by multiplex viral panel testing, none had IBI compared with 0.5 percent of 448 infants with other viral infection (none had meningitis) and 1.3 percent of 320 infants with no viral infection on testing (one with meningitis) [16]. For well-appearing febrile infants ≤60 days old with a positive test for SARS-CoV-2, the risk of IBI appears to be low. For well-appearing infants 29 to 60 days, we suggest, at minimum, urinalysis and urine culture. It is also reasonable to obtain additional studies according to the American Academy of Pediatric Clinical Practice Guideline (algorithm 1). Evidence is insufficient to change the recommended evaluation for well-appearing neonates. (See "The febrile infant (29 to 90 days of age): Outpatient evaluation", section on 'COVID-19' and "The febrile neonate (28 days of age or younger): Outpatient evaluation and initial management", section on 'Well-appearing'.)

PRIMARY CARE ORTHOPEDICS AND SPORTS MEDICINE

Avulsion fractures of hip and pelvis in children (October 2023)

There are few large-scale studies of pelvic avulsion fractures in children. A retrospective review of over 700 children with pelvic or hip avulsion fractures from a single tertiary care hospital reported the average patient age was just over 14 years and nearly 80 percent were sustained by males [17]. The anterior-superior and inferior iliac spines and ischial tuberosity were the most common sites, accounting for over 80 percent of fractures. Most injuries were sustained while the patient was running or kicking during sport, most often football (soccer). The incidence of avulsion fracture rose substantially during the study period, 2005 to 2020. (See "Pelvic trauma: Initial evaluation and management", section on 'Epidemiology and mechanism'.)

PROCEDURES

New guidelines for airway management in infants (January 2024)

Very young children are at higher risk of complications of airway management than children in older age groups; however, guidelines for infants have been lacking. In 2024, the European Society of Anesthesiology and Intensive Care and the British Journal of Anesthesia published joint guidelines for airway management in neonates and infants [18]. A summary of their recommendations appears in the following table (table 2). (See "Airway management for pediatric anesthesia", section on 'Pediatric airway management guidelines'.)

Videolaryngoscopy for endotracheal intubation in critically ill children (January 2024)

Use of videolaryngoscopy (VL) for emergency endotracheal intubation (ETI) in children provides a shared view of the procedure that permits an experienced physician observer to give assistance to the proceduralist. In a multicenter quality study of VL implementation during ETI in pediatric intensive care units with standardized coaching by an attending, over 3500 ETIs were performed with VL, and use of VL increased from 30 percent to 89 percent of ETIs over four years [19]. Compared with direct laryngoscopy, VL was associated with lower adverse events (9 versus 15 percent). The majority of proceduralists were residents or fellows. These findings and prior studies confirm the safety of VL during emergency ETI in children and demonstrate the value of standardized coaching during the procedure for less experienced clinicians. (See "Technique of emergency endotracheal intubation in children", section on 'Video versus direct laryngoscopy'.)

Ultrasound guidance for lumbar puncture in children (August 2023)

Previous studies suggest that ultrasound guidance for lumbar puncture (LP) in children increases the chance of success. In a meta-analysis of seven randomized trials (over 700 infants and children), overall LP success rate was higher with ultrasound guidance compared with the use of external landmarks and palpation alone, but the difference was not significant [20]. Subgroup analysis of five studies (over 520 children) demonstrated significantly higher first attempt success in infants undergoing ultrasound guidance, but not in older children. The overall quality of the evidence was considered low. Based on these findings, when performed by a trained provider, ultrasound guidance prior to LP may be useful in infants. Ultrasound guidance in older children is also reasonable, but evidence of benefit in these patients is lacking. (See "Lumbar puncture in children", section on 'Ultrasound guidance'.)

TOXICOLOGY

Photobiomodulation therapy for local tissue damage from snake envenoming (January 2024)

Photobiomodulation therapy (also called low-level laser therapy [LLLT]) may decrease inflammation and enhance healing following envenoming by snake species that cause local tissue damage or myonecrosis. In a trial of 60 patients with Bothrops snakebites all of whom received antivenom, LLLT decreased pain intensity scores, extent of edema, and extremity circumference compared with no LLLT [21]. LLLT is a promising adjunct to antivenom, but more trials and access to equipment are needed before it can be recommended for routine use. (See "Snakebites worldwide: Management", section on 'Photobiomodulation'.)

National practice guidelines not associated with increased MOUD prescribing in the ED (January 2024)

In emergency department (ED) patients who survive an opioid overdose, initiation of medications for opioid use disorder (MOUD) is associated with decreased one-year mortality (approximately 5 percent without MOUD). However, prescribing rates are low and multiple barriers exist. A study of more than 20,000 ED visits for opioid toxicity in Canada found that even though MOUD prescribing increased between 2013 and 2020, it was still relatively low (<6 percent) and was not improved by the publication of Canadian clinical practice guidelines in 2018 [22]. These findings suggest that EDs and health systems need to make systematic efforts to implement and maintain MOUD-initiation programs that directly engage clinicians to overcome barriers and increase rates of prescribing. (See "Acute opioid intoxication in adults", section on 'Prevention of recurrent opioid overdose'.)

Methemoglobinemia in infants due to contaminated hospital water supply (January 2024)

Methemoglobinemia is a potentially life-threatening condition in which heme iron becomes oxidized, preventing oxygen delivery. A report from a hospital in Japan described methemoglobinemia in 10 neonates who were fed infant formula prepared with tap water from the general hospital water supply [23]. The cause was identified as high levels of nitrites, and the source was traced to contamination by an anticorrosion agent from the heating system that entered the water supply due to a malfunctioning valve. All 10 survived, although 3 required methylene blue therapy. Infants are especially susceptible to methemoglobinemia because they have lower baseline levels of the enzyme that converts heme iron back to its normal state. (See "Methemoglobinemia", section on 'Nitrates and nitrites (from foods, drugs, preservatives, and chemicals)'.)

Avoiding intubation in acutely poisoned but stable, unresponsive adults (December 2023)

In unresponsive patients with trauma or undifferentiated coma, tracheal intubation is generally recommended to protect the airway and prevent aspiration. However, the benefit of intubation is unclear in stable poisoned patients who have decreased level of consciousness but are oxygenating and ventilating adequately. In a randomized trial of 225 adults with acute poisoning and coma (GCS score ≤8), compared with airway management at the physician’s discretion, individuals not intubated unless hypoxia, seizure, vomiting, or hypotension developed had a lower likelihood of mechanical ventilation (18 versus 60 percent), intensive care unit admission (40 versus 66 percent), or adverse events from intubation (6 versus 15 percent); they also had a lower risk of pneumonia [24]. These findings support avoiding intubation solely for a GCS score ≤8 in stable, unresponsive poisoned patients who are expected not to deteriorate based upon the suspected poison (eg, ingestion of a short-acting sedative such as ethanol). (See "Initial management of the critically ill adult with an unknown overdose", section on '"A": Airway stabilization'.)

High blood lead levels in US children after eating cinnamon applesauce pouches (November 2023)

The Centers for Disease Control and Prevention have issued a health alert following reports of high blood lead levels from several states for a total of 22 children who were fed cinnamon-containing applesauce pouches that were subsequently found to contain extremely high concentrations of lead [25]. Children who have eaten a recalled product should undergo blood lead testing. Clinicians should advise parents, primary caregivers, and guardians to not buy specific cinnamon-containing apple puree or applesauce products named in the US Food and Drug Administration announcement and to discard any recalled products that they have purchased. (See "Childhood lead poisoning: Exposure and prevention", section on 'Food' and "Childhood lead poisoning: Clinical manifestations and diagnosis", section on 'Laboratory evaluation' and "Childhood lead poisoning: Management".)

Validation of an enzymatic assay for ethylene glycol poisoning in humans (November 2023)

Serum ethylene glycol (EG) concentrations are usually measured by gas chromatography, which is not widely offered by hospital clinical laboratories, leading to diagnostic uncertainty, need for empiric treatment, and delays in confirmation. Some hospitals have adopted an EG enzyme-based glycerol dehydrogenase (GDH) assay modified from a veterinary assay and run on automated chemistry analyzers. A study of 118 patient blood samples found that using a 9 mg/dL threshold (well below a toxic concentration), the GDH assay had a 100 percent positive and negative predictive value compared with gas chromatography [26]. This assay may provide a screening tool for possible EG poisoning that is associated with reduced costs and time of diagnostic uncertainty. (See "Methanol and ethylene glycol poisoning: Pharmacology, clinical manifestations, and diagnosis", section on 'Testing for methanol and ethylene glycol'.)

Acetylcysteine dosing and stopping criteria for acetaminophen poisoning (November 2023)

An expert panel of toxicologists from the United States and Canada have published consensus guidelines for the management of acetaminophen poisoning [27]. Many acetylcysteine protocols exist; they recommend that whichever regimen is chosen, it should deliver at least 300 mg/kg acetylcysteine orally or intravenously during the first 20 to 24 hours. A patient with a reliable history of ingesting >30 g of acetaminophen should receive acetylcysteine as soon as possible. The panel also recommended that duration of acetylcysteine should be based on clinical endpoints rather than a predetermined time. All of the following criteria should be met before stopping acetylcysteine: a clinically well patient, acetaminophen concentration <10 mcg/mL, international normalized ratio <2, and AST/ALT normal or decreased 25 to 50 percent from their peak concentration. We agree with the panel's recommendations. (See "Acetaminophen (paracetamol) poisoning: Management in adults and children", section on 'Choice of protocol' and "Acetaminophen (paracetamol) poisoning: Management in adults and children", section on 'Duration of treatment (stopping criteria)'.)

Consensus statement on acetaminophen poisoning (August 2023)

An expert panel of toxicologists from the United States and Canada have published consensus guidelines for the management of acetaminophen poisoning [27]. The guidelines broadly cover treatment of acute or repeated supratherapeutic ingestions in adults and children including indications and administration of acetylcysteine therapy, laboratory assessment, monitoring, enhanced elimination techniques, and indications for consultation with a liver transplant team. The guidelines also cover special situations including ingestion of extended-release formulations, co-ingestion of anticholinergics or opioids, high-risk (ie, very large dose) ingestions, young children, pregnancy, elevated weight, and patients for whom the time of ingestion is unknown or unreliable. In addition, the statement introduces a revised Rumack-Matthew nomogram with a specific treatment line for high-risk ingestions. (See "Acetaminophen (paracetamol) poisoning in adults: Pathophysiology, presentation, and evaluation", section on 'Evaluation and diagnosis' and "Clinical manifestations and diagnosis of acetaminophen (paracetamol) poisoning in children and adolescents", section on 'Evaluation and diagnosis'.)

TRAUMA

Whole blood transfusion for severe traumatic hemorrhage (January 2024)

For severe traumatic hemorrhage, whole blood transfusion is an alternative to balanced component transfusion (1:1:1 ratio of packed red blood cells/plasma/platelets). In an observational study comparing these two approaches, low titer group O whole blood transfusion was associated with lower 24-hour mortality (8 versus 19 percent) and lower volume of blood products received at 72 hours (48 versus 82 mL/kg) [28]. The survival benefit was greatest in patients with shock or coagulopathy. While this study suggests improved outcomes for whole blood transfusion, randomized trials are needed to determine which transfusion strategy might be superior and which patients would benefit the most. (See "Ongoing assessment, monitoring, and resuscitation of the severely injured patient", section on 'Whole blood transfusion'.)

Impact of pediatric trauma centers on clinical outcomes (October 2023)

Level 1 pediatric trauma centers (PTC) (table 3) are the preferred sites for initial resuscitation and ongoing management of critically injured children. In a meta-analysis of 34 studies that evaluated children hospitalized for traumatic injury, treatment in a PTC was associated with lower mortality than in an adult trauma center (ATC, odds ratio 0.59) [29]. Compared with an ATC, care of children with blunt trauma in a PTC was also associated with a lower likelihood of computed tomography or operative management for blunt solid organ injury. For seriously injured infants, children, and adolescents, these findings support treatment in a PTC. When a level 1 PTC is not available, these children should receive care at a hospital that has the highest level of pediatric trauma expertise and resources. (See "Trauma management: Approach to the unstable child", section on 'Definitive care'.)

Intraosseous access in hypotensive adult trauma patients (August 2023)

Hypotensive trauma patients require rapid vascular access because any delay in resuscitation increases the odds of mortality; two large-bore peripheral intravenous lines (PIV) are recommended but placement may not be possible. In a prospective study of 1410 vascular access attempts in 581 hypotensive adult trauma patients, initial attempts with intraosseous cannula (IO) were associated with a significantly faster time to resuscitation (5.8 versus 6.7 minutes); this difference was more pronounced in patients without established prehospital access [30]. IO access had higher success rates compared with PIV or central venous catheter (CVC; 93 versus 67 versus 59 percent, respectively). These findings support IO access for hypotensive adult trauma patients as an option when PIV is difficult or not possible and either before or simultaneously with a CVC in patients without a peripheral IV. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient", section on 'Initial assessment and interventions'.)

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  30. Dumas RP, Vella MA, Maiga AW, et al. Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review. J Trauma Acute Care Surg 2023; 95:87.
Topic 8365 Version 12473.0

References

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