UpToDate
Emergency Medicine News · 2023
FigureUpToDate® and Emergency Medicine News are collaborating to present select content synopses on “What's New in Emergency Medicine.” UpToDate is an evidence-based, clinical support resource used worldwide by health care practitioners to make decisions at the point of care. For complete, current “What's New” content or to become a subscriber for full content access, go to www.uptodate.com. “What's New” abstract information is free for all medical professionals. Increased Use of Computed Tomographic Pulmonary Angiography (June 2023) Recent data suggest increased use of computed tomographic pulmonary angiography (CTPA), despite the publication of several well-validated protocols targeted at avoiding its overuse for the diagnosis of pulmonary embolism (PE). A retrospective analysis of almost 9000 CTPA studies performed for suspected PE reported an increase in CTPA use over the five-year period of the study (836 versus 1112 per 100,000 visits).1 More patients were diagnosed with low-risk PE and higher rates of ambulatory management were also noted. While these findings do not prove overuse of CTPA, more research is needed to determine the reasons for and potential clinical implications of its increased use. Type of Fluid for Resuscitation of Septic Shock in Children (June 2023) The type of fluid (balanced crystalloid solution [BCS] or normal saline [NS]) to use during the initial resuscitation of children with septic shock has been debated. In a multicenter, blinded randomized trial in more than 700 children treated for septic shock in India, patients assigned to fluid boluses with a multiple electrolyte solution (PlasmaLyte A) had a lower rate of new or progressive acute kidney injury within the first seven days of treatment compared with those assigned to fluid boluses with normal saline (21 versus 33 percent).2 The intensive care unit mortality rate was similar in both groups. Limitations include the lack of randomization of type of maintenance fluids during the study and potential lack of generalizability given the high mortality rate (approximately 33 percent). Nevertheless, these findings support our suggestion to use BCS during fluid resuscitation for children with septic shock, although NS is an acceptable alternative. Nalmefene Nasal Spray Approved for Acute Opioid Intoxication (June 2023) Nalmefene is an opioid antagonist with a longer duration of action compared with naloxone when administered at full reversing doses. A pre-filled, unit-dose intranasal formulation that delivers 2.7 mg nalmefene per spray was approved by the US Food and Drug Administration for use in adolescents and adults in May 2023 (parenteral nalmefene was previously approved for use in adults).3 We recommend against routine use in adults (intranasal or parenteral) given the extensive clinical experience with intranasal naloxone, lack of comparative trials, and concern for precipitating prolonged withdrawal. Nalmefene may have a role in a pediatric single opioid exposure or in an adolescent who does not experience withdrawal after a trial dose of naloxone.