EM Quick Hits 44 Fluids in Pancreatitis, Nasal Fractures, Delirium, DOSE VF, Intimate Partner Violence

Topics in this EM Quick Hits podcast Justin Morgenstern on fluids in acute pancreatitis - WATERFALL Trial (0:38) Leeor Sommer on nasal fractures in the emergency department (6:45) Christina Shenvi on acute delirium identification and workup (15:21) Sheldon Cheskes & Rohit Mohindra on the DOSE VF trial (25:23) Nour Khatib & Kari Sampsel on intimiate partner violence (61:13) Podcast content, production, editing and sound design by Anton Helman Podcast written summary & blog post by Raymond Cho; edited by Anton Helman Cite this podcast as: Helman, A. Morgenstern, J. Sommer, L. Shenvi, C. Cheskes, S. Mohindra, R. Khatib, N. Sampsel, K. EM Quick Hits 44 - Fluids in Pancreatitis, Nasal Fractures, Delirium, DOSE VF, Intimate Partner Violence. Emergency Medicine Cases. November, 2022. https://emergencymedicinecases.com/em-quick-hits-november-2022/. Accessed September 17, 2024. Fluids in Acute Pancreatitis - WATERFALL Trial * Background: ED management of acute pancreatitis has traditionally focused on aggressive fluid resuscitation; however, recent evidence suggests potential harm in this approach * Clinical question: Does moderate vs. aggressive fluid resuscitation in acute pancreatitis decrease progression to moderate/severe pancreatitis? * Methods/Outcomes: The WATERFALL trial is a randomized control trial of 249 patients with the control group receiving a ringer’s lactate (RL) bolus of 20 cc/kg followed by 3.0 cc/kg/hr, and the intervention group receiving 10 cc/kg bolus if hypovolemic or no bolus if euvolemic followed by 1.5 cc/kg/hr. Primary outcome was progression to moderate-to-severe acute pancreatitis, and primary safety endpoint was fluid overload. * Results: 17.3% in the moderate and 22.1% in the aggressive fluid group progressed to moderate/severe pancreatitis (aRR 1.30, 95% CI 0.78-2.18) * The trial was stopped early as interim analysis showed a high incidence of fluid overload in the aggressive fluid group (20.5% vs. 6.3%, aRR 2.85, 95%CI 1.36-5.94) * Author conclusions: Early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes * Commentary: In the fluid management of acute pancreatitis, less is more. Use small boluses (e.g., 500 cc RL), and reassess after each bolus; note that this trial applies only to patients with mild pancreatitis and ensure your patient meets this inclusion criteria before abandoning IV fluid resuscitation altogether. Expand to view reference list * de-Madaria E et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis (WATERFALL). NEJM 2022. https://www.nejm.org/doi/full/10.1056/NEJMoa2202884 * Morgenstern, J. (2022, November 1). Research roundup October 2022. First10EM. https://first10em.com/research-roundup-october-2022/ * Swaminathan, A. (2022, September 29). Less is more . . . Again: Speed of IV fluid administration in pancreatitis (Waterfall trial). REBEL EM - Emergency Medicine Blog. https://rebelem.com/less-is-more-again-speed-of-iv-fluid-administ...