Lit Bits: April 12, 2011

From the recent medical literature... (due to formating issues, URLs are not enabled)

1. Hydrocortisone Therapy for Patients with Multiple Trauma: The Randomized Controlled HYPOLYTE Study

Roquilly A, et al. JAMA 2011;305(12):1201-1209.

Context: The role of stress-dose hydrocortisone in the management of trauma patients is currently unknown.

Objective: To test the efficacy of hydrocortisone therapy in trauma patients.

Design, Setting, and Patients: Multicenter, randomized, double-blind, placebo-controlled HYPOLYTE (Hydrocortisone Polytraumatise) study. From November 2006 to August 2009, 150 patients with severe trauma were included in 7 intensive care units in France.

Intervention: Patients were randomly assigned to a continuous intravenous infusion of either hydrocortisone (200 mg/d for 5 days, followed by 100 mg on day 6 and 50 mg on day 7) or placebo. The treatment was stopped if patients had an appropriate adrenal response.

Main Outcome Measure: Hospital-acquired pneumonia within 28 days. Secondary outcomes included the duration of mechanical ventilation, hyponatremia, and death.

Results: One patient withdrew consent. An intention-to-treat (ITT) analysis included the 149 patients, a modified ITT analysis included 113 patients with corticosteroid insufficiency. In the ITT analysis, 26 of 73 patients (35.6%) treated with hydrocortisone and 39 of 76 patients (51.3%) receiving placebo developed hospital-acquired pneumonia by day 28 (hazard ratio [HR], 0.51; 95% confidence interval [CI], 0.30-0.83; P = .007). In the modified ITT analysis, 20 of 56 patients (35.7%) in the hydrocortisone group and 31 of 57 patients (54.4%) in the placebo group developed hospital-acquired pneumonia by day 28 (HR, 0.47; 95% CI, 0.25-0.86; P = .01). Mechanical ventilation–free days increased with hydrocortisone by 4 days (95% CI, 2-7; P = .001) in the ITT analysis and 6 days (95% CI, 2-11; P less than .001) in the modified ITT analysis. Hyponatremia was observed in 7 of 76 (9.2%) in the placebo group vs none in the hydrocortisone group (absolute difference, −9%; 95% CI, −16% to −3%; P = .01). Four of 76 patients (5.3%) in the placebo group and 6 of 73 (8.2%) in the hydrocortisone group died (absolute difference, 3%; 95% CI, −5% to 11%; P = .44).

Conclusion: In intubated trauma patients, the use of an intravenous stress-dose of hydrocortisone, compared with placebo, resulted in a decreased risk of hospital-acquired pneumonia.

2. Highly Sensitive ED Protocol for Identifying Low-Risk Patients with Chest Pain

Implementation of a new accelerated diagnostic protocol could reduce emergency department length of stay and hospitalization rate.

Protocols to facilitate safe early discharge from the emergency department (ED) for low-risk patients with chest pain have limitations, including lack of validation and variable sensitivity. The prospective, observational, multinational Asia-Pacific Evaluation of Chest Pain Trial assessed a new, accelerated diagnostic protocol in consecutive adult ED patients who had at least 5 minutes of chest, neck, jaw, or arm pain or discomfort without obvious noncardiac cause and who did not have ST-segment-elevation myocardial infarction (STEMI).

The protocol included Thrombolysis In Myocardial Infarction (TIMI) score (see the table), electrocardiogram (ECG), and point-of-care biomarker testing (within 2 hours after arrival) for troponin I, creatine kinase MB, and myoglobin. Patients with TIMI scores of 0, no new ischemic changes on initial ECG, and normal biomarker panels were classified as low risk.

Among 3582 patients who completed 30-day follow-up, 421 (11.8%) had major adverse cardiac events within 30 days, most often non-STEMI (10.1%). Of 352 patients (9.8%) who were classified as low risk, 3 (0.9%) had major adverse cardiac events. The protocol had a sensitivity of 99.3% for identifying low-risk patients, a specificity of 11.0%, and a negative predictive value (NPV) of 99.1%. Had TIMI score not been included, NPV would have been 96.7%, and an additional 44 patients with major adverse cardiac events would have been missed.

Comment: This study demonstrates that the combination of no new ischemic changes on initial ECG, normal point-of-care biomarker panel within 2 hours, and low pretest probability (TIMI score of 0) identifies patients who can safely be discharged from the ED. However, several issues about use of the protocol remain to be addressed, including performance relative to other protocols, whether use of laboratory biomarker testing improves accuracy, effect on patient care costs and hospital stay, and malpractice risk.

— John A. Marx, MD, FAAEM. Published in Journal Watch Emergency Medicine March 25, 2011.

Citation: Than M et al. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): A prospective observational validation study. Lancet 2011 Mar 26; 377:107.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21435709

3. Trajectories of End-of-Life Care in the Emergency Department

Bailey C, et al. Ann Emerg Med. 2011;57:362-369

Study objective
The emergency department (ED) is the gateway to the hospital setting. Despite the intentions from the end-of-life care strategy in the UK to improve care provision, the ED has increasingly become the access site for end-of-life support. Little attention has been given to this aspect of the work of the ED, even as the quality of end-of-life care in hospitals has become the subject of increasing concerns. We explore end-of-life care in the ED and provide an understanding of how care is delivered to the dying, deceased and bereaved in the emergency setting.

Methods
Observation was carried out in a large urban ED during 12 months. This was complemented by detailed interviews with emergency staff, patients diagnosed with a terminal condition, who had visited the ED in the previous 6 months, and their relatives. Data were analyzed thematically, following the normal conventions of ethnographic research.

Results
Two distinct trajectories of end-of-life care were identified in the ED; the spectacular (applied to those who are candidates for intensive life-preserving treatment) and the subtacular (applied to those who are not). Patients and family members experiencing end-of-life care in the ED have distinctly different care because of the nature of these 2 trajectories, frequently resulting in dissatisfaction for staff and distress and frustration for patients and their relatives.

Conclusion
The ED is priority driven, focused on resuscitation and the prolongation of life. As a result of the consuming nature of the spectacular death, a reluctance to build relationships with the dying, and a lack of educational support, the care needs of patients in the subtacular trajectory are somewhat neglected. These trajectories can be used to identify the shortfalls in end-of-life care in the ED and raise serious concerns for policy in regard to staffing, resources, and professional development.

4. Is hypothermia after cardiac arrest effective in both shockable and nonshockable patients?: insights from a large registry.

Hypothermia improved neurological outcomes in patients with shockable arrest rhythms.

Dumas F, et al. Circulation. 2011 Mar 1;123(8):877-86.

BACKGROUND: Although the level of evidence of improvement is significant in cardiac arrest patients resuscitated from a shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia [VF/Vt]), the use of therapeutic mild hypothermia (TMH) is more controversial in nonshockable patients (pulseless electric activity or asystole [PEA/asystole]). We therefore assessed the prognostic value of hypothermia for neurological outcome at hospital discharge according to first-recorded cardiac rhythm in a large cohort.

METHODS AND RESULTS: Between January 2000 and December 2009, data from 1145 consecutive out-of-hospital cardiac arrest patients in whom a successful resuscitation had been achieved were prospectively collected. The association of TMH with a good neurological outcome at hospital discharge (cerebral performance categories level 1 or 2) was quantified by logistic regression analysis. TMH was induced in 457/708 patients (65%) in VF/Vt and in 261/437 patients (60%) in PEA/asystole. Overall, 342/1145 patients (30%) reached a favorable outcome (cerebral performance categories level 1 or 2) at hospital discharge, respectively 274/708 (39%) in VF/Vt and 68/437 (16%) in PEA/asystole (P less than 0.001). After adjustment, in VF/Vt patients, TMH was associated with increased odds of good neurological outcome (adjusted odds ratio, 1.90; 95% confidence interval, 1.18 to 3.06) whereas in PEA/asystole patients, TMH was not significantly associated with good neurological outcome (adjusted odds ratio, 0.71; 95% confidence interval, 0.37 to 1.36).

CONCLUSIONS: In this large cohort of cardiac arrest patients, hypothermia was independently associated with an improved outcome at hospital discharge in patients presenting with VF/Vt. By contrast, TMH was not associated with good outcome in nonshockable patients. Further investigations are needed to clarify this lack of efficiency in PEA/asystole.

5. Prospective Validation of Two Systems of Classification for the Diagnosis of Acute Appendicitis

Escribá A, et al. Pediatr Emerg Care. 27(3):165-169

Objectives: The objectives of this study were (1) to validate the Alvarado score and pediatric appendicitis score (PAS) in a prospectively identified pediatric cohort and (2) to assess abdominal ultrasonography (AUS) as a tool to increase the diagnostic reliability of both scores.

Patients and Methods: Prospective study conducted from January 10, 2008, to January 1, 2009. All patients attended at the emergency department with suspected acute appendicitis (AA) who had a blood sample collected were included. Items from both scores were recorded. The performance of an AUS, the decision to admit the patient, and the therapeutics were decided by the physician, disregarding the scores values. Nonadmitted patients were contacted by telephone.

Results: Ninety-nine patients were included. Mean age was 11 years, and 62.6% were males. Appendectomy was performed in 44.4% patients. The area under the receiver operating characteristic curve for the Alvarado score was 0.96 and that for PAS was 0.97. Not a single patient with an Alvarado score less than 5 or PAS less than 4 had AA. All patients with an Alvarado score greater than 8 or PAS greater than 7 had AA. For both scores, the optimum cutoff point was 6 (sensibility of 90.4% and specificity of 91.2% for the Alvarado score and sensibility of 88.1% and specificity of 98.2% for PAS). Abdominal ultrasonography was performed on 31 patients (sensibility of 84.6% and specificity of 94.4%). We studied the value of scores and AUS together. Assuming an Alvarado score from 1 to 4 and PAS from 1 to 3 as no AA, an Alvarado score from 9 to 10 and PAS from 8 to 9 as AA, and proceeding according to the AUS for intermediate values, a sensibility of 93.3% and 97.2% and a specificity of 100% and 97.6%, respectively, were obtained.

Conclusions: Both scores are a useful tool in the evaluation of children with possible AA. For extreme values of scores, the results really ensure their use in the emergency department. The AUS can help on decision making for intermediate values.

Need a reminder of what these scores measure?

Alvarado Score: http://en.wikipedia.org/wiki/Alvarado_score

10-point Pediatric Appendicitis Score (PAS):
(2 points) cough/percussion/hopping tenderness in the RLQ
(1 point) anorexia
(1 point) pyrexia
(1 point) nausea/emesis
(2 points) tenderness over the right iliac fossa
(1 point) leukocytosis
(1 point) polymorphonuclear neutrophilia
(1 point) migration of pain

Here’s how the PAS works: http://intranet.emergency.med.ufl.edu/med_students/peds_rotation/reading_assignment/Pediatric%20Appendicitis%20Score.pdf

6. Torticollis: Not Always the Usual Suspects

Agha BS, et al. Pediatr Emerg Care. 2011;27:32-33.

We describe the clinical presentation, radiographic findings, management, and outcome of nontraumatic spinal epidural hematoma in a 10-month-old male infant with severe hemophilia (less than 1% activity). This patient presented with torticollis, and the differential diagnosis included intramuscular hemorrhage, retropharyngeal abscess, muscle spasm, and epidural hematoma. A computed tomography scan revealed extensive spinal epidural hematoma from C1-L4. Because of prompt diagnosis, this infant was able to be managed conservatively with factor VIII and did not require surgical intervention. Unlike other cases previously published, this case demonstrates how prompt recognition, diagnosis, and treatment can prevent the development of neurological deficits.

Full-text (free): http://journals.lww.com/pec-online/Fulltext/2011/01000/Torticollis__Not_Always_the_Usual_Suspects.9.aspx

7. “Sign Right Here and You're Good to Go”: A Content Analysis of Audiotaped ED Discharge Instructions

Vashi A, et al. Ann Emerg Med. 2011;57:315-322.e1

Study objective
The goal of this study is to quantitatively and qualitatively assess the quality and content of verbal discharge instructions at 2 emergency departments (EDs).

Methods
This was a secondary data analysis of 844 ED audiotapes collected during a study of patient–emergency provider communication at 1 urban and 1 suburban ED. ED visits of nonemergency adult female patients were recorded with a digital audiotape. Of 844 recorded ED visits, 477 (57%) audiotapes captured audible discharge instructions suitable for analysis. Audiotapes were double coded for the following discharge content: (1) explanation of illness, (2) expected course, (3) self-care, (4) medication instructions, (5) symptoms prompting return to the ED, (6) time-specified for follow-up visit, (7) follow-up care instructions, (8) opportunities for questions, and (9) patient confirmation of understanding. Analysis included descriptive statistics, χ2 tests, 2-sample t tests, and logistic regression models.

Results
Four hundred seventy-seven of 871 (55%) patient tapes contained audible discharge instructions. The majority of discharges were conducted by the primary provider (emergency physician or nurse practitioner). Ninety-one percent of discharges included some opportunity to ask questions, although most of these were minimal. Only 22% of providers confirmed patients' understanding of instructions.

Conclusion
Verbal ED discharge instructions are often incomplete, and most patients are given only minimal opportunities to ask questions or confirm understanding.

8. Rapid Sequence Intubation for Esophageal Coin Removal in Kids?

Rapid sequence intubation by emergency physicians resulted in coin removal in 95% of patients, but 10% of procedures lasted longer than 30 minutes and half the patients had complications.

Esophageal coins pass spontaneously in children about 25% of the time, but most coins must be actively removed. Methods of removal in the emergency department (ED) include bougienage, Foley catheter, and Magill forceps. Endoscopy under general anesthesia typically is not performed in stable patients and, in stable patients, is delayed until patients have fasted and intubation can be performed in a more controlled setting than the ED. These authors report a 4-year retrospective review of 101 children (age range, 4 months–13 years) who underwent rapid sequence intubation (RSI; usually with succinylcholine and etomidate) for coin removal by emergency physicians at a pediatric ED in California.

Median time from ingestion to presentation was 5 hours. Coins were successfully retrieved in 96 patients, with Magill forceps alone (56 patients) or Magill forceps plus a Foley catheter (40 patients). Complications occurred in 46 patients and included minor bleeding (13 patients), lip lacerations (7), multiple attempts (5), hypoxia (2), accidental extubation (3), dental injuries (3), and bradycardia (2) despite pretreatment with atropine in 84 cases. Median ED length of stay was 5 hours (range, 1.5–45 hours), and median time from intubation to extubation was 15 minutes (range, 2–93 minutes); nine procedures lasted more than 30 minutes.

Comment: Even at this tertiary referral center, almost 10% of procedures lasted longer than 30 minutes and nearly half the patients had complications. Faster, safer, simpler, less-expensive, and less resource-intensive techniques are more appropriate for removal of esophageal coins in most children. Why this aggressive RSI approach was used in the children in the study is unclear; however, it should be reserved for difficult cases and performed in an area of the hospital with dedicated resources.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine April 1, 2011

Citation: Bhargava R and Brown L. Esophageal coin removal by emergency physicians: A continuous quality improvement project incorporating rapid sequence intubation. CJEM 2011 Jan; 13:28

9. Occult Metformin Toxicity in Three Patients with Profound Lactic Acidosis

Perrone J, et al. J Emerg Med. 2011;40:271-275.

Abstract
There are 20.8 million Americans with diabetes, and metformin is the most commonly prescribed oral diabetes agent. A review of our metformin experience highlights common pitfalls that lead to life-threatening or fatal poisonings. We describe 3 patients with metformin toxicity; 2 of 3 patients were prescribed metformin despite end-stage renal disease (ESRD).

Case 1: a 40-year-old woman presented after a polysubstance overdose. Within 8 h, vomiting and lethargy developed; a profound acidosis, pH 6.95, pCO2 26, pO2 195, and elevated serum lactate 21 mmol/L (ref 0.5–1.6 mmol/L) were noted. Further inquiry revealed that the patient had ingested metformin. She was intubated; bicarbonate therapy and hemodialysis were initiated; however, she became hypotensive and died. A metformin level was 150 μg/mL (therapeutic 1–2 μg/mL).

Case 2: a 69-year-old woman with non-insulin-dependent diabetes mellitus (NIDDM) and ESRD presented to the Emergency Department (ED), having missed dialysis. She was sluggish and complained of abdominal pain; an acidosis, pH 7.37, pCO2 20, pO2 171; anion gap 38, and elevated serum lactate18.9 mmol/L were noted. Hemodialysis was initiated when it was revealed that she took metformin daily. She improved rapidly and a metformin level was 27.4 μg/mL.

Case 3: a 57-year-old woman with a history of NIDDM and ESRD presented with dyspnea. Laboratory studies showed pH 7.03, pCO2 21, pO2 99; anion gap 36, and lactate 16 mmol/L. Bicarbonate therapy and hemodialysis were initiated after discovering that she had recently been prescribed metformin. She had a fatal cardiac arrest after dialysis was completed.

We describe 3 ED patients with occult metformin toxicity diagnosed after laboratory results showed an anion gap metabolic acidosis and elevated lactate levels. All patients had lethargy, vomiting, or abdominal pain, also suggesting sepsis or mesenteric infarction. Despite sodium bicarbonate therapy and hemodialysis, metformin-associated lactic acidosis was fatal in 2 of 3 patients. Emergency Physicians must be vigilant to recognize metformin toxicity in patients at high risk for metformin-associated lactic acidosis

10. A single dose of Ambien may impair driving the next morning in people older than 55

Bocca ML, et al. Zolpidem and zopiclone impair similarly monotonous driving performance after a single nighttime intake in aged subjects. Psychopharmacology (Berl). 2011 Apr;214(3):699-706.

RATIONALE: Although hypnotics are primarily used by older people, the residual effects the morning after a single nighttime intake of the two most commonly prescribed hypnotics, zolpidem (Zp) and zopiclone (Zc), on older middle-aged drivers have not been evaluated and compared.

METHODS: Sixteen healthy subjects, 55 to 65 years of age, participated in this double-blind, balanced, cross-over study. Zc (7.5 mg), Zp (10 mg) and flunitrazepam (Fln) (1 mg) or a placebo was administered at each subject's home at 11.00 pm. The next morning, at 9.00 am, the subjects had to drive in a simulated monotonous driving environment for 1 h. During each morning session, two blood samples were collected, and subjective feelings of alertness were completed three times.

RESULTS: In comparison to placebo, Zp and Zc equivalently and significantly impaired the standard deviation of lateral position, the standard deviation of speed and the number of road exits. Detectable blood concentrations were found with Zp in 11 subjects at 8.30 am and at 1.30 pm. The subjective alertness factor was significantly impaired with Zp.

CONCLUSIONS: This is the first study revealing residual effects of Zp on driving performance in ageing drivers which are similar to that of Zc. Studying the effects of medication in different age ranges appears useful to complete the studies on behavioural-pharmacological effects of medication. To reduce the incidence of driving accidents due to prescription drugs, patients should be warned at the time of treatment initiation that they should avoid driving.

11. The Presence of Outcome Bias in Emergency Physician Retrospective Judgments of the Quality of Care

Gupta M, et al. Ann Emerg Med. 2011;57:323-328.e9.

Study objective
In peer review and malpractice litigation, biased assessment of the quality of care can have a profound effect. We determine the effect of knowledge of outcome on emergency physicians' ability to assess care quality.

Methods
Emergency physicians completed a Web-based survey containing 6 case scenarios written to fall along a spectrum of quality of care. Participants were randomized to receive either no case outcomes or a mixture of good and bad outcomes. For each scenario, participants rated the quality of care categorically (poor, below average, average, good, outstanding) and on a 0- to 100-point scale. We examined how the scenario's outcome affected judgments about the quality of the process of care and whether certain individuals are more prone to outcome bias.

Results
Five hundred eighty-seven participants completed the survey. For each scenario, quality ratings were highest when the outcome was good and lowest when the outcome was bad. The difference between ratings for “good outcome” and “no outcome provided” was bigger than the difference between “no outcome provided” and “bad outcome.” In cases of intermediate quality, outcome bias shifts ratings by a magnitude equivalent to 1 qualitative step in quality (eg, from good to average). The outcome bias effect is smaller for scenarios for which care is unambiguously good or bad. We found no evidence that outcome bias was concentrated in individuals.

Conclusion
Emergency physicians demonstrate outcome bias in cases of intermediate quality more than in cases in which the quality of care is clear. Outcome bias tends to inflate ratings in the presence of a positive outcome more than it penalizes scenarios with negative ones.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)01643-4/fulltext

12. Which Tool Is Best for Syncope Evaluation?

William R. Mower, MD, PhD

Question: What is the best clinical decision tool to use in the emergency department when evaluating an adult patient with syncope?

Response from William R. Mower, MD, PhD, Professor of Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Ronald Reagan Medical Center, Los Angeles, California

Syncope, defined as a sudden transient loss of consciousness due to global cerebral hypoperfusion, is characterized by abrupt onset, brief duration, and complete spontaneous recovery.[1] The management of syncope patients can be challenging and is complicated by the fact that episodes of syncope may be infrequent and paroxysmal and present with minimal etiologic clues. The evaluation of syncope patients is complicated by the absence of a single gold-standard clinical test that defines etiologies or identifies at-risk patients. Furthermore, underlying causes range from benign self-limited conditions to severe life-threatening problems, and accurate diagnosis may require prolonged observation and monitoring, making it impossible to determine etiology and acuity on initial presentation.[1]

These difficulties have stimulated interest in identifying clinical criteria that could be used to guide the management of syncope patients and aid in determining which patients require further evaluation and hospitalization. Several research teams have responded to this challenge and attempted to develop syncope prediction tools, but the majority of these investigations involve small numbers of patients in special settings. These studies are predominately derivational in scope and require further study to determine their clinical utility.[2] To date, only 2 prediction tools have had their accuracy evaluated in large prospective studies that meet level 2 evidence criteria.[2,3]

The San Francisco Syncope Rule (SFSR) considers patients to be low-risk if they do not exhibit any of the following: history of congestive heart failure; hematocrit below 30%; abnormal ECG result (new changes or nonsinus rhythm); complaint of shortness of breath; or systolic blood pressure below 90 mm Hg during triage.[4]

The Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score assesses risk based on the following: age over 65 years; cardiovascular disease in clinical history; syncope without prodromes; and abnormal electrocardiogram. The OESIL score is calculated by a simple sum of the number of predictors present in a given patient, with a low-risk outcome defined by a score of 0 or 1.[5]

Independent evaluations indicate that these tools have limited sensitivity (86% for SFSR; 95% for OESIL), limited specificity (49% for SFSR; 31% for OESIL) and result in more admissions (40% for SFSR; 43% for OEDIL) than clinical judgment (sensitivity 77%, specificity 69%, admission rate 34%).[2,6] Neither of these prediction tools has been shown to change physician behavior or improve patient outcomes (level 1 evidence).[2,3]

Because of their limited prognostic accuracy, existing syncope rules lack the characteristics needed to reliably guide critical decisions and should not be used as the sole means of determining patient disposition. Clinicians should focus on conducting thorough and careful evaluations that are likely to identify causality in most patients with "unstable" syncope.[2,7] Other approaches may be needed to deal with challenges posed by "stable" patients, including asymptomatic elderly patients, in whom syncopal episodes are frequently due to transient arrhythmias or structural heart disease, the major causes of sudden cardiac death and overall mortality.[7]

References: See essay http://www.medscape.com/viewarticle/740160

13. Real-time Readings: Diagnostic Case Studies in Emergency Ultrasound

Courtesy of Emergency Physician Monthly

http://www.epmonthly.com/clinical-skills/ultrasound/

14. A Method to Detect Occult Pneumothorax with Chest Radiography

Matsumoto S, et al. Ann Emerg Med. 2011;57:378-381

Small pneumothoraces are often not visible on supine screening chest radiographs because they develop anteriorly to the lung. These pneumothoraces are termed occult. Occult pneumothoraces account for an astonishingly high 52% to 63% of all traumatic pneumothoraces.

A 19-year-old obese woman was involved in a head-on car accident. The admission anteroposterior chest radiographs were unremarkable. Because of the presence of right chest tenderness and an abrasion, we suspected the presence of a pneumothorax. Thus, we decided to take a supine oblique chest radiograph of the right side of the thorax, which clearly revealed a visceral pleural line, consistent with a diagnosis of traumatic pneumothorax.

A pneumothorax may be present when a supine chest radiograph reveals either an apparent deepening of the costophrenic angle (the “deep sulcus sign”) or the presence of 2 diaphragm-lung interfaces (the “double diaphragm sign”). However, in practice, supine chest radiographs have poor sensitivity for occult pneumothoraces.

Oblique chest radiograph is a useful and fast screening tool that should be considered for cases of blunt chest trauma, especially when transport of critically ill patients to the computed tomographic suite is dangerous or when imminent transfer to another hospital is being arranged and early diagnosis of an occult pneumothorax is essential.

15. Victorious on Jeopardy, IBM’s Supercomputer Watson Heads to Medical School

John C. Hayes. 04/08/2011.

Fresh from its Jeopardy! victories, Watson -- IBM's new supercomputer -- heads off to medical school to master a set of medical information and processes far more complex than those required to win a game show contest.

On Jeopardy! the knowledge that Watson needed to win was housed in 8 refrigerator-sized boxes managed by 3000 core processors. To tackle medicine, however, Watson's processors must handle a data sweep that is likely to include electronic medical records, medical databases, journals, textbooks, clinical cases, and even blogs accessed via the Internet. In contrast to the simple answers supplied on Jeopardy!, the medical Watson will need to generate hypotheses from incomplete or incorrect data for clinical problems that may not have a single correct answer. That, as much as anything else, distinguishes the Jeopardy! challenge from the challenge of turning Watson into a medical whiz.

Engineers for IBM have already found that by pointing Watson to high-level medical textbooks, the machine can answer many of the questions that come up in common patient encounters, said Herbert Chase, MD, Professor of Clinical Medicine in Biomedical Informatics at the College of Physicians and Surgeons, Columbia University, New York, NY.

The essay is continued here: http://www.medscape.com/viewarticle/740079

16. Persistent Concussive Symptoms Common in ED Patients Diagnosed with Minor Head Injury

Cunningham J, et al. J Emerg Med. 2011;40:262-266.

Background: Evidence-based protocols exist for Emergency Department (ED) patients diagnosed with minor head injury. These protocols focus on the need for acute intervention or in-hospital management. The frequency and nature of concussive symptoms experienced by patients discharged from the ED are not well understood.

Objectives: To examine the prevalence and nature of concussive symptoms, up to 1 month post-presentation, among ED patients diagnosed with minor head injury.

Methods: Eligible and consenting patients presenting to Kingston EDs with minor head injury (n = 94) were recruited for study. The Rivermead Post-Concussion Symptoms Questionnaire was administered at baseline and at 1 month post-injury to assess concussive symptoms. This analysis focused upon acute and ongoing symptoms.

Results: Proportions of patients reporting concussive symptoms were 68/94 (72%) at baseline and 59/94 (63%) at follow-up. Seventeen percent of patients (18/102) were investigated with computed tomography scanning during their ED encounter. The prevalence of somatic symptoms declined between baseline and follow-up, whereas some cognitive and emotional symptoms persisted.

Conclusion: The majority of patients who present to the ED with minor head injuries suffer from concussive symptoms that do not resolve quickly. This information should be incorporated into discharge planning for these patients.

17. Images in Emerg Med

Vulvar Lesions
http://www.annemergmed.com/article/S0196-0644(10)00479-8/fulltext

Swollen Hand
http://www.annemergmed.com/article/S0196-0644(10)00498-1/fulltext

Giant Syphilitic Aortic Aneurysm
http://www.nejm.org/doi/full/10.1056/NEJMicm1008124

Black Tongue (aka Lingua villosa nigra)
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60930-0/fulltext

Sudden atraumatic unilateral loss of visual acuity in healthy young adult
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60677-0/fulltext

18. Hypertonic Saline vs. Mannitol for Treating Elevated Intracranial Pressure

This small meta-analysis gives no reason to use hypertonic saline rather than mannitol.

Mannitol is standard treatment for suspected elevated intracranial pressure (ICP), but it has been implicated in undesirable reductions in mean arterial blood pressure. Researchers performed a meta-analysis of five unblinded randomized trials that compared equiosmolar doses of mannitol and hypertonic saline in a combined total of 112 adult patients with 184 quantitatively documented episodes of elevated ICP. None of the five trials individually identified statistically significant differences between the two agents.

Combining data from the five trials resulted in slight superiority of hypertonic saline over mannitol (relative risk for ICP reduction, 1.16). The difference in magnitude of ICP reduction with the two agents was not clinically significant.

Comment: This small meta-analysis of unblinded studies of patients with mixed etiologies of elevated intracranial pressure does not provide sufficient evidence to change therapy from mannitol to hypertonic saline.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine March 18, 2011

Citation: Kamel H et al. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: A meta-analysis of randomized clinical trials. Crit Care Med 2011 Mar; 39:554.

19. Subcutaneous Rehydration: Updating a Traditional Technique

Spandorfer P, et al. Pediatr Emerg Care 2011;27:230-236

Subcutaneous (SC) rehydration therapy (SCRT), originally referred to as "hypodermoclysis," shows promise as an alternative to intravenous (IV) fluid administration for treatment of dehydration. A simple, safe, and effective technique, SCRT is indicated for treatment of mild-to-moderate dehydration. Augmentation of SCRT with administration of a recombinant human formulation of the hyaluronidase enzyme at the infusion site gives rise to SC fluid administration rates up to 5-fold faster than those achieved without the enzyme, making the technique more clinically practical. Unlike older, animal-derived forms of hyaluronidase, recombinant human hyaluronidase has a lower chance of allergic reactions with repeated dosing.

Clinical trials have demonstrated that recombinant human hyaluronidase effectively and safely facilitates fluid delivery in adults and children and is well accepted by parents and clinicians. In the emergency department setting, SCRT may be an appropriate alternative to IV fluid administration in certain situations because it is less invasive and generally less painful, while still permitting administration of appropriate volumes of rehydration fluids. Subcutaneous rehydration therapy appears to be particularly useful in patients who present with mild-to-moderate dehydration and have had failed attempts at oral rehydration. The SC route also provides benefits in patients with small, collapsed, or difficult-to-visualize veins or in those who may be agitated or distressed by IV catheterization. Continued research will further clarify the role of recombinant human hyaluronidase-facilitated SCRT in the rehydration treatment algorithm.

For more on hypodermoclysis in the elderly: http://qjmed.oxfordjournals.org/content/97/11/765.full

And in children: http://www.medscape.com/viewarticle/714798

Emerg Med Journal Club Summary: http://www.emjournalclub.com/uploads/SubQhydration_Brodsky_2010.pdf

20. ACEP Clinical Policy: Critical Issues in the Evaluation of Adult Patients Presenting to the ED with Acute Blunt Abdominal Trauma

Diercks DB, et al. Ann Emerg Med. 2011;57:387-404.

Abstract
This clinical policy from the American College of Emergency Physicians is an update of the 2004 clinical policy on the critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma.1 A writing subcommittee reviewed the literature as part of the process to develop evidence-based recommendations to address 4 key critical questions: (1) In a hemodynamically unstable patient with blunt abdominal trauma is ultrasound the diagnostic modality of choice? (2) Does oral contrast improve the diagnostic performance of computed tomography (CT) in blunt abdominal trauma? (3) In a clinically stable patient with isolated blunt abdominal trauma, is it safe to discharge the patient after a negative abdominal CT scan result? (4) In patients with isolated blunt abdominal trauma, are there clinical predictors that allow the clinician to identify patients at low risk for adverse events who do not need an abdominal CT? Evidence was graded and recommendations were based on the available data in the medical literature related to the specific clinical question.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(11)00031-X/fulltext

21. Levaquin Knocks Off Achilles: Suit Results in 1.8M Payout

Johnson & Johnson must pay $1.1 million in punitive damages to an 82-year-old man who claimed it failed to properly warn of the risks of tendon damage linked to its antibiotic Levaquin, a Minnesota jury said.

The federal court jury in Minneapolis today also awarded compensatory damages of $700,000 in the case of John Schedin, who sued J&J and its Ortho-McNeil-Janssen Pharmaceuticals unit in 2008. Schedin, who said he ruptured both Achilles tendons after taking Levaquin, claimed the companies failed to warn doctors and patients of the drug’s association with tendon damage.

The trial was the first on more than 2,600 claims in U.S. courts alleging that Levaquin caused tendon damage in patients and that New Brunswick, New Jersey-based J&J failed to disclose the risk adequately. The jury today, in ordering punitive damages, found the company acted with deliberate disregard for the safety of others.

Remainder of the Bloomberg essay: http://www.bloomberg.com/news/2010-12-08/johnson-johnson-must-pay-1-1-million-in-punitive-damages-jury-says.html

Rick Bukata’s Impression

Six-minute Video: http://www.epmonthly.com/features/current-features/video-levaquin-discussion/

22. Interactive Games to Promote Behavior Change in Prevention and Treatment

Read L, et al. JAMA. Published online March 29, 2011

Anyone who has observed someone deeply absorbed in a video game can appreciate that use of these games is a uniquely powerful interaction. For the player, time stands still and self-consciousness disappears. Csikszentmihalyi described this state as “flow.”1 His concept was exemplified by mountain climbers living in the moment of ascent or surgeons lost in a delicate and demanding task. He could just as well have been describing what happens when individuals engage with some of today's interactive games.

Games are now a dominant form of media, even larger than the motion picture industry, and are enjoyed across gender, age, and cultural boundaries. Zynga Inc, a Facebook game developer, claims 215 million players worldwide among that social Web site's half-billion users.2 Games targeting healthy behaviors are also proliferating. For example, Web-based games offered by Humana, the large insurance company, are based on conventional objectives for diet and exercise. Other games are appearing on consoles, mobile phones, and less traditional platforms including toys, robots, and medical devices.

Such games deserve serious attention, because clinicians and policy makers will be confronted with decisions regarding their use. There is great promise in channeling these hours of engagement to address some of the most difficult and persistent challenges involving diet, exercise, and adherence to therapy. Sufficiently engaging games might enhance the effectiveness of health messaging, allowing individuals to practice useful thought patterns and behaviors and encouraging them to explore and learn from failure in safe virtual environments.

Full-text (free): http://jama.ama-assn.org/content/early/2011/03/25/jama.2011.408.full