Zworth Reading
EMMax’s EM Weekly Update
Highlight of the Week
Antibiotic treatment of acute otitis media: has watchful waiting gone with the diagnosis?
CJEM · Health records review (LOE 4)
Health records review of 396 children aged ≥2 years discharged from a tertiary pediatric ED (CHEO, Ottawa) with acute otitis media in 2021, assessing adherence to the Canadian Paediatric Society position statement. Guideline non-adherence occurred in 62.6% (248/396, 95% CI 58-67%). Of the 214 children categorized as mildly ill and therefore eligible for watchful waiting, only 22% (48/214) actually got it. 78% (166/214) received a prescription. Prolonged duration (10 days without perforation) occurred in 6.6% and non-penicillin first-line choice in 4.3%.
Retrospective chart review, so the usual caveats apply. The authors are appropriately upfront that ED crowding, parental expectations, caregiver reliability, and diagnostic uncertainty were all unmeasured, and those are exactly the forces driving this behaviour. What I find most compelling here is the setting. This is a tertiary care children's ED. Best-case conditions for guideline adherence, and watchful waiting was used in barely a fifth of eligible kids. You can imagine how much worse the numbers look in community departments.
Bottom line: Antibiotics are massively overprescribed in children, and AOM is one of the biggest offenders. None of this is surprising. There are real pressures at play, and it is often easier to write the prescription than to sit down and explain why it isn't needed. But it is worth reviewing the guideline and interrogating your own practice. Reminder of what the Canadian Paediatric Society actually recommends: a watchful waiting approach without antibiotic therapy in mildly ill infants and children >2 years; an age-appropriate duration of antibiotics initiated at presentation in those who are moderately to severely unwell, have fever over 39°C, or have had symptoms for over 48 hours. Also worth remembering that if you can't document a bulging tympanic membrane and middle ear effusion, you haven't actually made the diagnosis.
FOAM Radar
Acute Valvular EmergenciesKnowledge translation
EMOttawa · LOE 5 — educational review synthesizing existing literature
Covers the undifferentiated presentation of acute valvular pathology: respiratory failure, pulmonary oedema, cardiogenic shock. Warns against the reflexive interventions (aggressive fluids, early intubation) that can be actively harmful in this context.
Bottom line: Good refresher on a low-frequency, high-stakes presentation, and the central teaching point is important: our usual resuscitation reflexes can kill these patients. In the patient with known valvular pathology who is in shock, it is worth taking a moment to choose your vasopressors and plan your resuscitation carefully. In aortic stenosis particularly, avoid tachycardia and reach for norepinephrine, phenylephrine, or vasopressin. A good article to bookmark as a reference for the next time one of these lands in your department.
Major Journals Scan
Classic Hodgkin Lymphoma: A ReviewLOE 5 (Narrative review)
JAMA
Why it matters to EPs: Classic Hodgkin lymphoma has a bimodal age distribution with a first peak at 15-35 years. This is a young, otherwise-well demographic that shows up in the ED with lymphadenopathy or B symptoms and gets worked up by us.
Median age at diagnosis 33. Most present with supradiaphragmatic lymphadenopathy (cervical, mediastinal, supraclavicular, or axillary); isolated infradiaphragmatic involvement in under 10%. B symptoms occur in 30-40%. Risk factors include EBV infection, immune dysregulation, and familial predisposition. Early-stage disease is treated with chemotherapy with or without consolidative radiotherapy; advanced-stage with chemotherapy alone, increasingly incorporating anti-PD-1 agents.
Standard JAMA clinical review. Comprehensive, but no new evidence, and most of the treatment detail sits outside our lane.
Bottom line: Good short review of an important haematologic malignancy. The ED-relevant piece is the presentation: a young adult with persistent painless supraclavicular or cervical lymphadenopathy, particularly with B symptoms, deserves more than reassurance and a return-if-worse.