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Department of Emergency Medicine

Department of Emergency Medicine

2011- September R3 Journal Review

Montalescot G, Zeymer U, Silvain J, Boulanger B, Cohen M, Goldstein P, et al.  Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomised open-label ATOLL trial.  Lancet. 2011 Aug 20;378(9792):693-703.
This international multicenter, randomized, open-label trial study looked at intravenous enoxaparin (bolus of 0.5 mg/kg) versus unfractionated heparin before primary PCI for ST-elevation MI.  Included: patients with STEMI or new LBBB, >17 years old, and had indication for primary PCI within 12 hours of onset of symptoms, or 12-24 hours if persistent ischemic symptoms and/or persistent/recurrent ST elevation EKG changes.  Excluded: patients who received anticoagulant of any type before randomization, administration of thrombolytic agents, short life expectancy, childbearing potential, known contraindications to treatment with aspirin, thienopyridines, or heparins.  Patients were randomly assigned in a 1:1 ratio.  All patients received aspirin (75–500 mg/day), thienopyridines, and glycoprotein IIb/IIIa inhibitors according to local practice.  A total of 450 patients received enoxaparin, and a total of 460 patients received heparin before primary PCI.  Patient characteristics were well matched.  The primary endpoint was 30-day incidence of death, complication of myocardial infarction, procedure failure, or major bleeding.  The data suggested fewer primary endpoint events with intravenous enoxaparin than with heparin, but the difference was not significant (28% and 34% respectively; p=0•063).  The main secondary endpoint was the composite of death, recurrent acute coronary syndrome, or urgent revascularization, which suggested a statistically significant decrease with the enoxaparin group versus the unfractionated heparin group (7% and 11% respectively; p=0.015).  The study concluded that enoxaparin had a net clinical benefit when compared to unfractionated heparin, since enoxaparin did reduce secondary endpoints of adverse ischemic events without a statistically significant difference in bleeding.  The major limitations of this study included that it was open-label, underpowered for low frequency events, and the use of concomitant drugs, including glycoprotein IIb/IIIa inhibitors, was at the discretion of the treating clinicians.  Another possible limitation is the fact that the only statistically significant difference in outcomes is in the composite secondary endpoints.  Although this study is applicable to our patient population, my overall impression is that it is not conclusive enough to change my clinical practice.

- Niedermeyer

Stuke, L. et al. Prehospital Spine Immobilization for Penetrating Trauma—Review and Recommendations From the Prehospital Trauma Life Support Executive Committee. Journal of Trauma; 2011 Sep;71(3):763-70.
Spine immobilization protocols, while a cornerstone of prehospital trauma care, do not typically distinguish between blunt and penetrating injury. The goal of immobilization is to prevent displacement of an unstable fracture that could damage an otherwise spared spinal cord. In blunt trauma, acceleration/deceleration injuries may lead to disruption of two of the three “columns”, which is by definition an unstable pattern.  However, evidence suggests that penetrating trauma does not create similar scenarios because most damage is done immediately by the missile (bullet) or associated concussive force, without ligamentous disruption. Meanwhile, spine immobilization is not benign. It delays transport time (~5.6min), may hinder assessment of the neck for edema, subcutaneous emphysema, hematoma development or expansion, and tracheal deviation, and significantly complicates airway management and intubation. A literature review was completed reviewing articles from 1989 to 2011 related to prehospital treatment of spinal cord injury in penetrating trauma patients. Twenty articles met inclusion criteria (addressing incidence and natural history of spinal cord injury in penetrating trauma and discussing need for spine immobilization in penetrating trauma).The results suggest that when the spinal cord is injured by penetrating trauma, “the damage has occurred at the moment of injury, is complete at the time of injury, and neurologic deterioration
does not occur.” The literature review found that among 45,000 patients, twice as many patients died from penetrating trauma when immobilized in the field. Studies also suggested only 0.01 to 0.03% of patients with partial cord injuries, or who were neurologically intact, eventually went on to have operative fixation. A small military study found 22% of casualties had life threatening neck injury that was only diagnosed after C-collar removal, while a large review of Vietnam-era military injuries found only 1.4% of casualties eligible for immobilization could have actually benefited from such care. These data suggest that especially in a hazardous or conflict environment, immobilization has questionable utility. The study concludes that there are no data to support routine spine immobilization in patients with penetrating trauma to the head, neck or torso. It may be performed if a focal deficit is noted on exam, though there is little evidence of benefit even in these cases. One limitation of the study is that it does not distinguish between outcomes in the immobilized vs. non-immobilized groups of penetrating trauma patients. It is possible that the number of complications would have been higher if transport and/or intubation had taken place without spine precautions.

- Vu

Kravitz et al.  Two Days of Dexamethasone Versus 5 Days of Prednisone in the Treatment of Acute Asthma: A randomized Controlled Trial.  Ann Emerg Med. 2011 Aug;58(2):200-4. 
Systemic steroid administration is a standard asthma exacerbation therapy in the ED, but there is little literature comparing effectiveness of different steroids.  Dexamethasone has equivalent oral and IV bioavailability to prednisone, but a longer half-life (up to 72 hours) and therefore may allow shorter duration of treatment and better patient compliance.
This was a prospective, randomized, double-blind study at two urban EDs (Albert Einstein and Temple University Hospitals) in Philadelphia, PA between 2004 and 2007.  It attempted to compare the time needed to return to normal activity, and the frequency of relapse, after treatment of an acute asthma exacerbation with either 2 days of oral dexamethasone or 5 days of oral prednisone.  They included all patients age 18-45, asthma diagnosis for at least 6 months, and peak expiratory flow rate (PEFR) less than 80% of predicted.  Exclusion criteria included oral steroid use in the last 4 weeks; known COPD, CHF, Pneumonia, or sarcoidosis; pregnant/breastfeeding; hx of corticosteroid allergy, tuberculosis, systemic fungal disease, gastritis, or diabetes; or if they were admitted to the hospital.
There were 104 in the Dexamethasone group and 96 in the prednisone group.  For the primary outcome measure, 91 (90%) of the dexamethasone group had return to normal activity within 3 days, compared with 72 (80%) in the prednisone group (95% CI 0 to 20, P=0.049).  For secondary outcomes, there was a similar frequency of relapse (11% in dexamethasone, 13% in prednisone group) and similar number of albuterol doses needed during the day (median 2 doses per day for each).  Numbers of subsequent hospital admissions, ED visits, and primary care visits were similar as well.
Therefore, using a 2 day course of Dexamethasone instead of 5 days prednisone may be a worthwhile change.  It is also a compelling option in the pediatric population, due to the bad taste associated with prednisone.  The study was limited by lack of a formal score to determine effectiveness of therapy; only a follow-up phone call 2 weeks after therapy asking the patient to remember how quickly they returned to “normal,” or if there were any follow-up appointments/ED visits.  It was also limited by a loss of 22% of patients to follow-up.  Even so, this article is potentially applicable to our ED.  Dexamethasone is also available on the Target/Walmart $4 prescription list.

- Naylor