UpToDate

Figure: ECMO, hypothermia, cardiac arrest, rewarming, survival, mechanical thrombectomy, ischemic core infarcts, MT, acute ischemic stroke, artery occlusion, trials, HFNC, oxygen therapy, acute hypoxemic respiratory failure, children, nasal cannula, AHRFUpToDate® 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. ECMO for severe hypothermia in adults (February 2023) In patients with cardiac arrest from severe hypothermia, extracorporeal life support (e.g., ECMO) provides rapid active internal rewarming and may improve survival. In a multicenter, prospective study (ICE-CRASH) that included 242 patients with severe hypothermia (mostly older adults with indoor-onset hypothermia), in the 57 patients with cardiac arrest, treatment with ECMO (24 patients) was associated with better 28-day survival (adjusted odds ratio [OR] 0.17) and favorable neurologic outcome (adjusted OR 0.22).1 In patients without cardiac arrest, treatment with ECMO (17 patients) was not associated with improved 28-day survival or favorable neurologic outcomes but was associated with more adverse events such as bleeding. These findings support our recommendation for using ECMO, when available, in patients with severe hypothermia and a nonperfusing cardiac rhythm. Mechanical thrombectomy for large ischemic core infarcts (February 2023) Mechanical thrombectomy (MT) for acute ischemic stroke due to a large artery occlusion in the anterior circulation has been limited to patients with a small- to moderate-sized core infarct at baseline. The exclusion of patients with large core infarcts was first challenged in 2022 by results from the RESCUE-Japan LIMIT trial. The recent SELECT2 and ANGEL-ASPECT trials now confirm that MT compared with medical treatment alone improves outcomes for patients with a large ischemic core infarct (defined by an Alberta Stroke Program Early CT Score [ASPECTS] <6 or a core volume ≥50 ml).2-3 As an example, the SELECT2 trial showed that functional independence for patients with large infarcts was more likely with MT than with medical care alone (20 versus seven percent).2 Based on these results, in addition to previously defined eligible groups, we now recommend MT for patients who have a large ischemic core infarct as defined in these trials and can start treatment within 24 hours of the time last known to be well. HFNC oxygen therapy for mild to moderate acute hypoxemic respiratory failure in children (February 2023) Evidence is limited regarding the role of high-flow nasal cannula (HFNC) oxygen therapy for children with mild to moderate acute hypoxemic respiratory failure (AHRF). In the multicenter PARIS-2 trial, over 1500 children hospitalized with AHRF defined as increased work of breathing, respiratory rate ≥35 per minute, and oxygen requirement to maintain pulse oximetry over 90 to 92 percent were randomized to HFNC or standard oxygen therapy; wheezing was present in approximately three-quarters of patients. Patients assigned to HFNC oxygen therapy, compared with standard oxygen therapy, had longer length of stay (1.77 versus 1.50 days) and more ICU admissions (12.5 versus 6.9 percent).4 Adverse events were low in both groups. These findings do not support the routine use of oxygen delivery by HFNC in young children with mild to moderate AHRF.

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