From the recent medical literature...
1. ICU admissions reduce mortality among patients
with STEMI: retrospective cohort study.
Valley
TS, et al. BMJ. 2019 Jun 4;365:l1927.
OBJECTIVE:
To
evaluate the effect of intensive care unit (ICU) admission on mortality among
patients with ST elevation myocardial infarction (STEMI).
DESIGN:
Retrospective
cohort study.
SETTING:
1727
acute care hospitals in the United States.
PARTICIPANTS:
Medicare
beneficiaries (aged 65 years or older) admitted with STEMI to either an ICU or
a non-ICU unit (general/telemetry ward or intermediate care) between January
2014 and October 2015.
MAIN
OUTCOME MEASURE:
30
day mortality. An instrumental variable analysis was done to account for
confounding, using as an instrument the additional distance that a patient with
STEMI would need to travel beyond the closest hospital to arrive at a hospital
in the top quarter of ICU admission rates for STEMI.
RESULTS:
The
analysis included 109 375 patients admitted to hospital with STEMI. Hospitals
in the top quarter of ICU admission rates admitted 85% or more of STEMI
patients to an ICU. Among patients who received ICU care dependent on their
proximity to a hospital in the top quarter of ICU admission rates, ICU
admission was associated with lower 30 day mortality than non-ICU admission
(absolute decrease 6.1 (95% confidence interval -11.9 to -0.3) percentage
points). In a separate analysis among patients with non-STEMI, a group for whom
evidence suggests that routine ICU care does not improve outcomes, ICU
admission was not associated with differences in mortality (absolute increase
1.3 (-0.9 to 3.4) percentage points).
CONCLUSIONS:
ICU
care for STEMI is associated with improved mortality among patients who could
be treated in an ICU or non-ICU unit. An urgent need exists to identify which patients
with STEMI benefit from ICU admission and what about ICU care is beneficial.
2. Derivation, Validation, and Potential Treatment
Implications of Novel Clinical Phenotypes for Sepsis
Seymour
CW, et al. JAMA. 2019;321(20):2003-2017.
Key
Points
Question Are clinical sepsis phenotypes identifiable
at hospital presentation correlated with the biomarkers of host response and
clinical outcomes and relevant for understanding the heterogeneity of treatment
effects?
Findings In this retrospective analysis using data
from 63 858 patients in 3 observational cohorts, 4 novel sepsis phenotypes (α,
β, γ, and δ) with different demographics, laboratory values, and patterns of
organ dysfunction were derived, validated, and shown to correlate with
biomarkers and mortality. In the simulations using data from 3 randomized
clinical trials involving 4737 patients, the outcomes related to the treatments
were sensitive to changes in the distribution of these phenotypes.
Meaning Four novel clinical phenotypes of sepsis were
identified that correlated with host-response patterns and clinical outcomes
and may help inform the design and interpretation of clinical trials.
IMPORTANCE:
Sepsis
is a heterogeneous syndrome. Identification of distinct clinical phenotypes may
allow more precise therapy and improve care.
OBJECTIVE:
To
derive sepsis phenotypes from clinical data, determine their reproducibility
and correlation with host-response biomarkers and clinical outcomes, and assess
the potential causal relationship with results from randomized clinical trials
(RCTs).
DESIGN,
SETTINGS, AND PARTICIPANTS:
Retrospective
analysis of data sets using statistical, machine learning, and simulation
tools. Phenotypes were derived among 20 189 total patients (16 552 unique
patients) who met Sepsis-3 criteria within 6 hours of hospital presentation at
12 Pennsylvania hospitals (2010-2012) using consensus k means clustering
applied to 29 variables. Reproducibility and correlation with biological
parameters and clinical outcomes were assessed in a second database (2013-2014;
n = 43 086 total patients and n = 31 160 unique patients), in a prospective cohort
study of sepsis due to pneumonia (n = 583), and in 3 sepsis RCTs (n = 4737).
EXPOSURES:
All
clinical and laboratory variables in the electronic health record.
MAIN
OUTCOMES AND MEASURES:
Derived
phenotype (α, β, γ, and δ) frequency, host-response biomarkers, 28-day and
365-day mortality, and RCT simulation outputs.
RESULTS:
The
derivation cohort included 20 189 patients with sepsis (mean age, 64 [SD, 17]
years; 10 022 [50%] male; mean maximum 24-hour Sequential Organ Failure
Assessment [SOFA] score, 3.9 [SD, 2.4]). The validation cohort included 43 086
patients (mean age, 67 [SD, 17] years; 21 993 [51%] male; mean maximum 24-hour
SOFA score, 3.6 [SD, 2.0]). Of the 4 derived phenotypes, the α phenotype was
the most common (n = 6625; 33%) and included patients with the lowest
administration of a vasopressor; in the β phenotype (n = 5512; 27%), patients
were older and had more chronic illness and renal dysfunction; in the γ
phenotype (n = 5385; 27%), patients had more inflammation and pulmonary
dysfunction; and in the δ phenotype (n = 2667; 13%), patients had more liver
dysfunction and septic shock. Phenotype distributions were similar in the
validation cohort. There were consistent differences in biomarker patterns by
phenotype. In the derivation cohort, cumulative 28-day mortality was 287 deaths
of 5691 unique patients (5%) for the α phenotype; 561 of 4420 (13%) for the β
phenotype; 1031 of 4318 (24%) for the γ phenotype; and 897 of 2223 (40%) for
the δ phenotype. Across all cohorts and trials, 28-day and 365-day mortality
were highest among the δ phenotype vs the other 3 phenotypes (P less than .001).
In simulation models, the proportion of RCTs reporting benefit, harm, or no
effect changed considerably (eg, varying the phenotype frequencies within an
RCT of early goal-directed therapy changed the results from more than 33%
chance of benefit to more than 60%
chance of harm).
CONCLUSIONS
AND RELEVANCE:
In
this retrospective analysis of data sets from patients with sepsis, 4 clinical
phenotypes were identified that correlated with host-response patterns and
clinical outcomes, and simulations suggested these phenotypes may help in
understanding heterogeneity of treatment effects. Further research is needed to
determine the utility of these phenotypes in clinical care and for informing
trial design and interpretation.
3. Ketamine Corner
A. Subdissociative‐dose Ketamine Is Effective for Treating Acute
Exacerbations of Chronic Pain
Lumanauw
DD, et al. Acad Emerg Med. 2019 Mar 22 [Epub ahead of print]
BACKGROUND:
Subdissociative-dose
ketamine (SDDK) is used to treat acute pain. We sought to determine if SDDK is
effective in relieving acute exacerbations of chronic pain.
METHODS:
This
study was a randomized double-blind placebo-controlled trial conducted May 2017
to June 2018 at a public teaching hospital (ClinicalTrials.gov #NCT02920528).
The primary endpoint was a 20-mm decrease on a 100-mm visual analog scale (VAS)
at 60 minutes. Power analysis using three groups (0.5 mg/kg ketamine, 0.25
mg/kg ketamine, or placebo infused over 20 minutes) estimated that 96 subjects
were needed for 90% power. Inclusion criteria included age over 18 years, chronic
pain over 3 months, and acute exacerbation (VAS ≥ 70 mm). Pain, agitation, and
sedation were assessed by VAS at baseline and 20, 40, and 60 minutes after
initiation of study drug. Telephone follow-up at 24 to 48 hours used a 10-point
numeric rating scale for pain.
RESULTS:
A
total of 106 subjects were recruited, with three excluded for baseline pain less
than 70 mm. After randomization, 35 received 0.5 mg/kg ketamine, 36 received
0.25 mg/kg ketamine, and 35 received placebo. Three subjects receiving 0.5
mg/kg withdrew during the infusion due to adverse effects, and one subject in
each group had incomplete data, leaving 97 for analysis. Initial pain scores
(91.9 ± 8.9 mm), age (46.5 ± 12.6 years), sex distribution, and types of pain
reported were similar. Primary endpoint analysis found that 25 of 30 (83%)
improved with 0.5 mg/kg ketamine, 28 of 35 (80%) with 0.25 mg/kg ketamine, and
13 of 32 (41%) with placebo (p = 0.001). More adverse effects occurred in the
ketamine groups with one subject in the 0.25 mg/kg group requiring a restraint
code for agitation. A total of 89% of subjects were contacted at 24 to 48
hours, and no difference in pain level was detected between groups.
CONCLUSION:
Ketamine
infusions at both 0.5 and 0.25 mg/kg over 20 minutes were effective in treating
acute exacerbations of chronic pain but resulted in more adverse effects
compared to placebo. Ketamine did not demonstrate longer-term pain control over
the next 24 to 48 hours.
B. Psychiatric Outcomes of Patients With Severe Agitation
Following Administration of Prehospital Ketamine
Lebin
JA, et al. Acad Emerg Med. 2019 Mar 15 [Epub ahead of print]
BACKGROUND:
Ketamine
is an emerging drug used in the management of undifferentiated, severe
agitation in the prehospital setting. However, prior work has indicated that
ketamine may exacerbate psychotic symptoms in patients with schizophrenia. The
objective of this study was to describe psychiatric outcomes in patients who
receive prehospital ketamine for severe agitation.
METHODS:
This
is a retrospective cohort study, conducted at two tertiary academic medical
centers, utilizing chart review of patients requiring prehospital sedation for
severe agitation from January 1, 2014, to June 30, 2016. Patients received
either intramuscular (IM) versus intravenous (IV) ketamine or IM versus IV
benzodiazepine. The primary outcome was psychiatric inpatient admission with
secondary outcomes including ED psychiatric evaluation and nonpsychiatric
inpatient admission. Generalized estimating equations and Fisher's exact tests
were used to compare cohorts.
RESULTS:
During
the study period, 141 patient encounters met inclusion with 59 (42%) receiving
prehospital ketamine. There were no statistically significant differences
between the ketamine and benzodiazepine cohorts for psychiatric inpatient
admission (6.8% vs. 2.4%, difference = 4.3%, 95% CI = -2% to 12%, p = 0.23) or
ED psychiatric evaluation (8.6% vs. 15%, difference = -6.8%, 95% CI = -18% to
5%, p = 0.23). Patients with schizophrenia who received ketamine did not
require psychiatric inpatient admission (17% vs. 10%, difference = 6.7%, 95% CI
= -46% to 79%, p = 0.63) or ED psychiatric evaluation (17% vs. 50%, difference
= -33%, 95% CI = -100% to 33%, p = 0.55) significantly more than those who
received benzodiazepines, although the subgroup was small (n = 16). While there
was no significant difference in the nonpsychiatric admission rate between the
ketamine and benzodiazepine cohorts (35% vs. 51%, p = 0.082), nonpsychiatric
admissions in the benzodiazepine cohort were largely driven by intubation (63%
vs. 3.8%, difference = 59%, 95% CI = 38% to 79%, p less than 0.001).
CONCLUSIONS:
Administration
of prehospital ketamine for severe agitation was not associated with an
increase in the rate of psychiatric evaluation in the emergency department or
psychiatric inpatient admission when compared with benzodiazepine treatment,
regardless of the patient's psychiatric history.
4. We do extraordinary things for our patients in
what we think are ordinary shifts
“Any
job where we do our best and use our skills to care for those we love and
provide a service to others is a societal good.”
“A
job in which we actually help people survive illness and injury, actually guide
them through difficult social situations, one in which we ease suffering and
make death less terrifying is worth celebrating. That's a gift to our patients
and to ourselves.”
Leap
E. Life in Emergistan: Just Another Day in the ED, Saving Lives. Emerg Med
News 2019;41(5):5.
5. Severe Hypertension in Pregnancy Demands Prompt
Treatment
Maternal
deaths associated with preeclampsia and subsequent stroke can be averted with
rapid administration of antihypertensives.
Judy
AE, et al. Systolic Hypertension, Preeclampsia-Related Mortality, and Stroke in
California. Obstet Gynecol. 2019 Jun;133(6):1151-1159.
OBJECTIVE:
To
describe the clinical characteristics of stroke and opportunities to improve
care in a cohort of preeclampsia-related maternal mortalities in California.
METHODS:
The
California Pregnancy-Associated Mortality Review retrospectively examined a
cohort of preeclampsia pregnancy-related deaths in California from 2002 to
2007. Stroke cases were identified among preeclampsia deaths, and case
summaries were reviewed with attention to clinical variables, particularly
hypertension. Health care provider- and patient-related contributing factors
were also examined.
RESULTS:
Among
54 preeclampsia pregnancy-related deaths that occurred in California from 2002
to 2007, 33 were attributed to stroke. Systolic blood pressure exceeded 160 mm
Hg in 96% of cases, and diastolic blood pressure was 110 or higher in 65% of
cases. Hemolysis, elevated liver enzymes, and low platelet count syndrome was
present in 38% (9/24) of cases with available laboratory data; eclampsia
occurred in 36% of cases. Headache was the most frequent symptom (87%)
preceding stroke. Elevated liver transaminases were the most common laboratory
abnormality (71%). Only 48% of women received antihypertensive treatment. A
good-to-strong chance to alter outcome was identified in stroke cases 66%
(21/32), with delayed response to clinical warning signs in 91% (30/33) of
cases and ineffective treatment in 76% (25/33) cases being the most common
areas for improvement.
CONCLUSION:
Stroke
is the major cause of maternal mortality associated with preeclampsia or
eclampsia. All but one patient in this series of strokes demonstrated severe
elevation of systolic blood pressure, whereas other variables were less
consistently observed. Antihypertensive treatment was not implemented in the
majority of cases. Opportunities for care improvement exist and may
significantly affect maternal mortality.
6. Evaluating Effectiveness of Nasal Compression with
Tranexamic Acid Compared with Simple Nasal Compression and Merocel Packing: A RCT
Akkan
S, et al. Ann Emerg Med. 2019 May 9 [Epub ahead of print]
STUDY
OBJECTIVE: The primary objective of this study is to compare the effectiveness
of 3 treatment protocols to stop anterior epistaxis: classic compression, nasal
packing, and local application of tranexamic acid. It also aims to determine
the frequency of rebleeding after each of these protocols.
METHODS:
This single-center, prospective, randomized controlled study was conducted with
patients who had spontaneous anterior epistaxis. The study compared the effect
of 3 treatment options, tranexamic acid with compression but without nasal
packing, nasal packing (Merocel), and simple nasal external compression, on the
primary outcome of stopping anterior epistaxis bleeding within 15 minutes.
RESULTS:
Among the 135 patients enrolled, the median age was 60 years (interquartile
range 25% to 75%: 48 to 72 years) and 70 patients (51.9%) were women. The
success rate in the compression with tranexamic acid group was 91.1% (41 of 45
patients); in the nasal packing group, 93.3% (42 of 45 patients); and in the
compression with saline solution group, 71.1% (32 of 45 patients). There was an
overall statistically significant difference among the 3 treatment groups but
no significant difference in pairwise comparison between the compression with
tranexamic acid and nasal packing groups. In regard to rebleeding within 24
hours, the study found rates of 86.7% in the tranexamic acid group, 74% in the
nasal packing group, and 60% in the compression with saline solution group.
CONCLUSION:
Applying external compression after administering tranexamic acid through the
nostrils by atomizer stops bleeding as effectively as anterior nasal packing
using Merocel. In addition, the tranexamic acid approach is superior to Merocel
in terms of decreasing rebleeding rates.
7. Brief Reviews from Ann Emerg Med
A.
Among Low-Risk Patients, Does Functional Testing Decrease Referrals for
Invasive Coronary Angiography Compared With Coronary Computed Tomographic
Angiography?
Take-Home
Message
Functional
testing in patients with symptoms suggestive of low risk for acute coronary
syndrome is associated with decreased invasive coronary angiography compared
with coronary computed tomography (CT) angiography.
B. Do Mechanical Chest Compression Devices Compared With
High-Quality Manual Chest Compressions Improve Neurologically Intact Survival
of Patients Who Experience Cardiac Arrest?
Take-Home
Message
Mechanical
chest compression devices are not superior to conventional, high-quality manual
chest compressions in improving survival to hospital discharge with good
neurologic function.
C. Do Colloids Improve Mortality Compared With
Crystalloids for Resuscitation of Critical Patients?
Take-Home
Message
When
used as an intravenous resuscitation fluid in critically ill adult and
pediatric patients, colloids, including starches, dextrans, albumin, fresh frozen
plasma, and gelatins, do not improve mortality compared with crystalloids.
D. Can Acute Uncomplicated Diverticulitis Be Safely
Treated Without Antibiotics?
Take-Home
Message
Antibiotic
use in patients with acute uncomplicated diverticulitis is associated with an
increased length of hospital stay but does not reduce overall or individual
complication rates.
8. Treat Adolescents with STIs Before Discharging
Them from the ED
This
retrospective study found that almost half of adolescents prescribed outpatient
antibiotics for pelvic inflammatory disease or chlamydia did not fill their
prescriptions.
Lieberman
A et al. Frequency of Prescription Filling Among Adolescents Prescribed
Treatment for Sexually Transmitted Infections in the Emergency Department. JAMA
Pediatr 2019 May 28 [Epub ahead of print]
Opening
paragraph of study: Adolescents are disproportionately affected by sexually
transmitted infections (STIs), making up nearly half of all diagnosed STIs
annually,1 and are frequently diagnosed in the emergency department (ED)
setting.2 Many STIs, such as gonorrhea and chlamydia, can be treated
effectively with antibiotics. However, untreated, these infections can lead to
serious morbidity. Although adolescents are often prescribed antibiotics to
treat STIs, how often such prescriptions are actually filled by patients after
ED discharge is unknown. We sought to fill this gap by investigating
prescription filling for the treatment of STIs among adolescents in a real-world
clinical setting.
9. A Promising Clinical Score for Identifying Low-Risk
Febrile Infants in the ED
A
score that includes age, highest temperature recorded in the ED, urinalysis,
and absolute neutrophil count was highly sensitive for identifying infants with
low probability of invasive bacterial infection.
Aronson
PL, et al. Febrile Young Infant Research Collaborative. A Prediction Model to
Identify Febrile Infants ≤60 Days at Low Risk of Invasive Bacterial Infection. Pediatrics.
2019 Jun 5 [Epub ahead of print]
OBJECTIVES:
To
derive and internally validate a prediction model for the identification of
febrile infants ≤60 days old at low probability of invasive bacterial infection
(IBI).
METHODS:
We
conducted a case-control study of febrile infants ≤60 days old who presented to
the emergency departments of 11 hospitals between July 1, 2011 and June 30,
2016. Infants with IBI, defined by growth of a pathogen in blood (bacteremia)
and/or cerebrospinal fluid (bacterial meningitis), were matched by hospital and
date of visit to 2 control patients without IBI. Ill-appearing infants and
those with complex chronic conditions were excluded. Predictors of IBI were
identified with multiple logistic regression and internally validated with
10-fold cross-validation, and an IBI score was calculated.
RESULTS:
We
included 181 infants with IBI (155 [85.6%] with bacteremia without meningitis
and 26 [14.4%] with bacterial meningitis) and 362 control patients.
Twenty-three infants with IBI (12.7%) and 138 control patients (38.1%) had
fever by history only. Four predictors of IBI were identified (area under the
curve 0.83 [95% confidence interval (CI): 0.79-0.86]) and incorporated into an
IBI score: age less than 21 days (1 point), highest temperature recorded in the
emergency department 38.0-38.4°C (2 points) or ≥38.5°C (4 points), absolute
neutrophil count ≥5185 cells per μL (2 points), and abnormal urinalysis results
(3 points). The sensitivity and specificity of a score ≥2 were 98.8% (95% CI:
95.7%-99.9%) and 31.3% (95% CI: 26.3%-36.6%), respectively. All 26 infants with
meningitis had scores ≥2.
CONCLUSIONS:
Infants
≤60 days old with fever by history only, a normal urinalysis result, and an
absolute neutrophil count less than 5185 cells per μL have a low probability of
IBI.
10. Images in Clinical Practice
Thigh
Pain Associated With Diarrhea
Woman
With Red Eyes
Woman
With Cirrhosis and Shortness of Breath
Man
With Finger Pain and Swelling
Man
With Chronic Back Pain
Young
Male With Scrotal Pain
11. Ultrasound Corner
A. How to Perform an Ultrasound-Guided Transversus Abdominis Plane
(TAP) Block for Appendicitis Pain
Nagdev
A, et al. ACEP Now. May 17, 2019
Over
the past few years, emergency physicians have begun implementing multimodal
strategies for acute pain, reducing the use of opioids. Ultrasound-guided
single-injection nerve blocks have slowly become accepted for targeted pain
relief over the past decade in the emergency department for hip fractures, rib
fractures, deltoid abscess drainage, and other conditions.1–3 Currently,
point-of-care ultrasound (POCUS) fellowships require ultrasound-guided nerve
blocks as part of the training curriculum to ensure future leaders will provide
the next generation of emergency physicians the knowledge to offer optimal pain
management.4,5
Over
the past decade, our group has been fortunate to work in a hospital that values
interdepartmental collaboration to optimize patient care. More often than not,
long delays for patients admitted for surgical pathology (such as acute appendicitis)
lead to repeated rounds of intravenous opioid analgesics that ultimately fail
to achieve adequate pain control and feature side effects. This led our group
to think of alternative methods for pain control in this population rather than
standard intravenous opioid regimens.
The
ultrasound-guided transversus abdominis plane (TAP) block is a well-established
regional anesthetic block used by anesthesiologists for perioperative pain
control of the anterior abdominal wall.6,7 At our center, after computed
tomography (CT) confirmation of appendicitis, ED-performed TAP blocks have been
instituted as an alternative analgesic option for alleviating pain from this
common diagnosis. This additive analgesic (in addition to other intravenous
agents) has proved effective in our small cohort of patients, who have
demonstrated reduced pain scores and need for additional pain medications while
awaiting definitive surgical intervention.8
B. TEE During CPR Is Associated With
Shorter Compression Pauses Compared With Transthoracic Echocardiography.
Fair
J 3rd, et al. Ann Emerg Med. 2019 Jun;73(6):610-616.
Editor’s
Capsule Summary
What
is already known on this topic
Bedside
ultrasonography can be helpful to identify some reversible conditions in the
setting of cardiac arrest, and transesophageal echocardiography can be used to
assess real-time adequacy of chest compressions.
What
question this study addressed
This
retrospective case series of 25 patients addressed whether transesophageal
echocardiography is associated with briefer pulse check interruptions of chest
compressions compared with transthoracic echocardiography or no bedside
ultrasonography during cardiac arrest resuscitation.
What
this study adds to our knowledge
Transesophageal
echocardiography is associated with briefer pauses during pulse checks than
transthoracic echocardiography or no echocardiography.
How
this is relevant to clinical practice
There
is the unproven possibility that transesophageal echocardiography may benefit
resuscitation of cardiac arrest because of briefer pulse checks’ possibly
leading to less neurologic compromise in cardiac arrest survivors.
STUDY
OBJECTIVE:
Point-of-care
ultrasonography provides diagnostic information in addition to visual pulse
checks during cardiopulmonary resuscitation (CPR). The most commonly used
modality, transthoracic echocardiography, has unfortunately been repeatedly
associated with prolonged pauses in chest compressions, which correlate with
worsened neurologic outcomes. Unlike transthoracic echocardiography,
transesophageal echocardiography does not require cessation of compressions for
adequate imaging and provides the diagnostic benefit of point-of-care
ultrasonography. To assess a benefit of transesophageal echocardiography, we
compare the duration of chest compression pauses between transesophageal
echocardiography, transthoracic echocardiography, and manual pulse checks on
video recordings of cardiac arrest resuscitations.
METHODS:
We
analyzed 139 pulse check CPR pauses among 25 patients during cardiac arrest.
RESULTS:
Transesophageal
echocardiography provided the shortest mean pulse check duration (9 seconds
[95% confidence interval {CI} 5 to 12 seconds]). Mean pulse check duration with
transthoracic echocardiography was 19 seconds (95% CI 16 to 22 seconds), and it
was 11 seconds (95% CI 8 to 14 seconds) with manual checks. Intraclass
correlation coefficient between abstractors for a portion of individual and
average times was 0.99 and 0.99, respectively (P less than .001 for both).
CONCLUSION:
Our
study suggests that pulse check times with transesophageal echocardiography are
shorter versus with transthoracic echocardiography for ED point-of-care
ultrasonography during cardiac arrest resuscitations, and further emphasizes
the need for careful attention to compression pause duration when using
transthoracic echocardiography for point-of-care ultrasonography during ED
cardiac arrest resuscitations.
C. High-Yield Ocular Ultrasound Applications in the ED from ACEP
Now
12. RBC transfusions for ED patients with GI
bleeding within an integrated health system
Mark
DG, et al. Am J Emerg Med 2019 June 10 [Epub ahead of print]
Study
objective: To assess trends over time in red blood cell (RBC) transfusion
practice among emergency department (ED) patients with gastrointestinal (GI)
bleeding within an integrated healthcare system, inclusive of 21 EDs.
Methods:
Retrospective cohort of ED patients diagnosed with GI bleeding between July
1st, 2012 and September 30th, 2016. The primary outcome was receipt of an RBC
transfusion in the ED. Secondary outcomes included 90-day rates of RBC
transfusion, repeat ED visits, rehospitalization, and all-cause mortality.
Logistic regression was used to obtain confounder-adjusted outcome rates.
Results:
A total of 24,868 unique patient encounters were used for the primary analysis.
The median hemoglobin level in the ED prior to RBC transfusion decreased from
7.5 g/dl to 6.9 g/dl in the first versus last twelve months of the study period
(p less than 0.0001). A small trend was observed in the overall adjusted rate
of ED RBC transfusion (absolute quarterly change of −0.1%, R2=0.18, p=0.0001)
largely attributable to the subgroup of patients with hemoglobin nadirs between
7.0 and 9.9 g/dl (absolute quarterly change of −0.4%, R2=0.38,
p less
than 0.0001). Rates of RBC transfusions through 90days likewise decreased
(absolute quarterly change of −0.4%, R2=0.85, p less than 0.0001) with stable
to decreased corresponding rates of repeat ED visits, rehospitalizations and
mortality.
Conclusion:
Rates of ED RBC transfusion decreased over time among patients with GI
bleeding, particularly in those with hemoglobin nadirs between 7.0 and 9.9
g/dl. These findings suggest that ED providers are willing to adopt evidence-based
restrictive RBC transfusion recommendations for patients with GI bleeding.
13. Opioid Corner
A. Opioids Prescribed in 1 of 6 ED Visits by Young People
By
Kelly Young. Journal Watch. May 28, 2019
One
in six emergency department visits by adolescents and young adults resulted in
an opioid prescription, according to a Pediatrics study.
Using
2005 to 2015 data from two national health surveys, researchers examined 47,000
visits to emergency departments and 31,000 visits to outpatient clinics among
patients aged 13 to 22. Among the findings:
Nearly
15% of emergency department visits and 3% of clinic visits resulted in an
opioid prescription.
Opioid
prescriptions in the ED decreased slightly over time.
The
prescribing rate surpassed 40% for dental problems in all ages and clavicle
fracture in adolescents.
A
commentator writes: "This study's findings reflect many of the unique
attributes of health care use by young adults. ... Young adults seek care for
acute conditions and injuries, chronic conditions, and reproductive care and
receive a greater proportion of their care at emergency departments than any
age group except for the elderly."
B. Factors Predicting Risk for Opioid Use Disorder
Patients
with previous personality, somatoform, or psychotic disorders had a higher
likelihood of developing opioid use disorder.
Klimas
J et al. Strategies to Identify Patient Risks of Prescription Opioid Addiction
When Initiating Opioids for Pain: A Systematic Review. JAMA Netw Open 2019 May
3 [Epub ahead of print]
IMPORTANCE:
Although
prescription opioid use disorder is associated with substantial harms,
strategies to identify patients with pain among whom prescription opioids can
be safely prescribed have not been systematically reviewed.
OBJECTIVE:
To
review the evidence examining factors associated with opioid addiction and
screening tools for identifying adult patients at high vs low risk of
developing symptoms of prescription opioid addiction when initiating
prescription opioids for pain.
DATA
SOURCES:
MEDLINE
and Embase (January 1946 to November 2018) were searched for articles
investigating risks of prescription opioid addiction.
STUDY
SELECTION:
Original
studies that were included compared symptoms, signs, risk factors, and
screening tools among patients who developed prescription opioid addiction and
those who did not.
DATA
EXTRACTION AND SYNTHESIS:
Two
investigators independently assessed quality to exclude biased or unreliable
study designs and extracted data from higher quality studies. The Preferred
Reporting Items for Systematic Reviews and Meta-analyses of Diagnostic Accuracy
Studies (PRISMA-DTA) reporting guideline was followed.
MAIN
OUTCOMES AND MEASURES:
Likelihood
ratios (LRs) for risk factors and screening tools were calculated.
RESULTS:
Of
1287 identified studies, 6 high-quality studies were included in the
qualitative synthesis and 4 were included in the quantitative synthesis. The 4
high-quality studies included in the quantitative synthesis were all
retrospective studies including a total of 2 888 346 patients with 4470 cases
that met the authors' definitions of prescription opioid addiction. A history of
opioid use disorder (LR range, 17-22) or other substance use disorder (LR
range, 4.2-17), certain mental health diagnoses (eg, personality disorder: LR,
27; 95% CI, 18-41), and concomitant prescription of certain psychiatric
medications (eg, atypical antipsychotics: LR, 17; 95% CI, 15-18) appeared
useful for identifying patients at high risk of opioid addiction. Among
individual findings, only the absence of a mood disorder (negative LR, 0.50;
95% CI, 0.45-0.52) was associated with a lower risk of opioid addiction.
Despite their widespread use, most screening tools involving combinations of
questions were based on low-quality studies or, when diagnostic performance was
assessed among high-quality studies, demonstrated poor performance in helping
to identify patients at high vs low risk.
CONCLUSIONS
AND RELEVANCE:
While
a history of substance use disorder, certain mental health diagnoses, and
concomitant prescription of certain psychiatric medications appeared useful for
identifying patients at higher risk, few quality studies were available and no
symptoms, signs, or screening tools were particularly useful for identifying
those at lower risk.
14. Drug Order in Rapid Sequence Intubation: Does it
Matter?
Driver BE, et al. Acad Emerg Med. 2019 Mar 4 [Epub ahead of print]
BACKGROUND:
The
optimal order of drug administration (sedative first vs. neuromuscular blocking
agent first) in rapid sequence intubation (RSI) is debated.
OBJECTIVE:
We
sought to determine if RSI drug order was associated with the time elapsed from
administration of the first RSI drug to the end of a successful first
intubation attempt.
METHODS:
We
conducted a planned secondary analysis of a randomized trial of adult ED
patients undergoing emergency orotracheal intubation that demonstrated higher
first-attempt success with bougie use compared to a tracheal tube + stylet.
Drug choice, dose, and the order of sedative and neuromuscular blocking agent
were not stipulated. We analyzed trial patients who received both a sedative
and a neuromuscular blocking agent within 30 seconds of each other who were
intubated successfully on the first attempt. The primary outcome was the time
elapsed from complete administration of the first RSI drug to the end of the
first intubation attempt, a surrogate outcome for apnea time. We performed a
multivariable analysis using a mixed-effects generalized linear model.
RESULTS:
Of
757 original trial patients, 562 patients (74%) met criteria for analysis; 153
received the sedative agent first, and 409 received the neuromuscular blocking
agent first. Administration of the neuromuscular blocking agent before the
sedative agent was associated with a reduction in time from RSI administration
to the end of intubation attempt of 6 seconds (95% confidence interval = 0 to
11 sec).
CONCLUSION:
Administration
of either the neuromuscular blocking or the sedative agent first are both
acceptable. Administering the neuromuscular blocking agent first may result in
modestly faster time to intubation. For now, it is reasonable for physicians to
continue performing RSI in the way they are most comfortable with. If future
research determines that the order of medication administration is not
associated with awareness of neuromuscular blockade, administration of the
neuromuscular blocking agent first may be a logical default administration
method to attempt to minimize apnea time during intubation.
15. ECG alterations suggestive of hyperkalemia in
normokalemic versus hyperkalemic patients
Varga
C, et al. BMC Emergency Medicine 2019;19:33
BACKGROUND:
In
periarrest situations and during resuscitation it is essential to rule out
reversible causes. Hyperkalemia is one of the most common, reversible causes of
periarrest situations. Typical electrocardiogram (ECG) alterations may indicate
hyperkalemia. The aim of our study was to compare the prevalence of ECG alterations
suggestive of hyperkalemia in normokalemic and hyperkalemic patients.
METHODS:
170
patients with normal potassium (K+) levels and 135 patients with moderate
(serum K+ = 6.0-7.0 mmol/l) or severe (K+ over 7.0 mmol/l) hyperkalemia,
admitted to the Department of Emergency Medicine at the Somogy County Kaposi
Mór General Hospital, were selected for this retrospective, cross-sectional
study. ECG obtained upon admission were analyzed by two emergency physicians,
independently, blinded to the objectives of the study. Statistical analysis was
performed using SPSS22 software. χ2 test and Fischer exact tests were applied.
RESULTS:
24%
of normokalemic patients and 46% of patients with elevated potassium levels had
some kind of ECG alteration suggestive of hyperkalemia. Wide QRS (31.6%),
peaked T-waves (18.4%), Ist degree AV-block (18.4%) and bradycardia (18.4%)
were the most common and significantly more frequent ECG alterations suggestive
of hyperkalemia in severely hyperkalemic patients compared with normokalemic
patients (8.2, 4.7, 7.1 and 6.5%, respectively). There was no significant
difference between the frequency of ECG alterations suggestive of hyperkalemia
in normokalemic and moderately hyperkalemic patients. Upon examining ECG alterations
not typically associated with hyperkalemia, we found that prolonged QTc was the
only ECG alteration which was significantly more prevalent in both patients
with moderate (17.5%) and severe hyperkalemia (21.1%) compared to patients with
normokalemia (5.3%).
CONCLUSIONS:
A
minority of patients with normal potassium levels may also exhibit ECG
alterations considered to be suggestive of hyperkalemia, while more than half
of the patients with hyperkalemia do not have ECG alterations suggesting
hyperkalemia. These results imply that treatment of hyperkalemia in the
prehospital setting should be initiated with caution. Multiple ECG alterations,
however, should draw attention to potentially life threatening conditions.
16. Choosing Wisely Hepatology, Eh?
Ryan
Radecki’s EM Lits of Note Blog. June 12, 2019
The
Choosing Wisely campaign is quite popular in theory, if not in practice –
ranging widely across the specialties from Pediatric Hospital Medicine to our
own, beloved, Emergency Medicine.
This
list is from the Canadian Association for the Study of the Liver, and two of
their five recommendations are somewhat relevant to EM. Without further ado:
A. Statement
1: Don’t order serum ammonia to diagnose or manage hepatic encephalopathy
This
was their most highly ranked recommendation when members were surveyed at their
annual meeting. They cite multiple confounders regarding ammonia levels,
factors affecting accuracy of the measurement, and state “elevated ammonia
levels do not add any diagnostic, staging, or prognostic value.” The diagnosis,
they feel, ought to be made based on clinical history and response to therapy
alone.
B. Statement
2: Don’t routinely transfuse fresh frozen plasma, vitamin K, or platelets to
reverse abnormal tests of coagulation in patients with cirrhosis prior to
abdominal paracentesis, endoscopic variceal band ligation, or any other minor
invasive procedures
This
is another one of my favorite pet topics – transfusion intended to “restore
normal hemostasis” in a dysfunctional, but somewhat already rebalanced
coagulation system. As they say, “Routine tests of coagulation do not reflect
bleeding risk in patients with cirrhosis and bleeding complications of these
procedures are rare.” In fact, I’ve seen several articles approaching even
liver resection in the context of elevated coagulation parameters absent any
major bleeding complications – so this ought certainly apply to minor
procedures, including those in the Emergency Department.
No
doubt the uptake of these recommendations will be highly variable among
hospitals and specialty groups, but lists like these are great tools with which
to start the conversation.
17. Minor Blunt Thoracic Trauma in the ED:
Sensitivity and Specificity of Chest Ultralow-Dose CT Compared With
Conventional Radiography.
Macri
F, et al. Ann Emerg Med. 2019 Jun;73(6):665-670.
STUDY
OBJECTIVE:
To
evaluate the diagnostic performance of chest ultralow-dose computed tomography
(CT) compared with chest radiograph for minor blunt thoracic trauma.
METHODS:
One
hundred sixty patients with minor blunt thoracic trauma were evaluated first by
chest radiograph and subsequently with a double-acquisition nonenhanced chest
CT protocol: reference CT and ultralow-dose CT with iterative reconstruction.
Two study radiologists independently assessed injuries with a structured report
and subjective image quality and calculated certainty of diagnostic confidence
level.
RESULTS:
Ultralow-dose
CT had a sensitivity and specificity of 100% compared with reference CT in the
detection of injuries (187 lesions) in 104 patients. Chest radiograph detected
abnormalities in 82 patients (79% of the population), with lower sensitivity
and specificity compared with ultralow-dose CT (P less than .05). Despite an
only fair interobserver agreement for ultralow-dose CT image quality (κ=0.26),
the diagnostic confidence level was certain for 95.6% of patients (chest
radiograph=79.3%). Ultralow-dose CT effective dose (0.203 mSv [SD 0.029 mSv])
was similar (P=.14) to that of chest radiograph (0.175 mSv [SD 0.155 mSv]) and
significantly less (P less than .001) than that of reference CT (1.193 mSv [SD
0.459 mSv]).
CONCLUSION:
Ultralow-dose
CT with iterative reconstruction conveyed a radiation dose similar to that of
chest radiograph and was more reliable than a radiographic study for minor
blunt thoracic trauma assessment. Radiologists, regardless of experience with
ultralow-dose CT, were more confident with chest ultralow-dose CT than chest
radiograph.
18. Vital Signs = Vital
Ryan
Radecki. EM Lit of Note. June 3, 2019
That
is how the authors frame it, after all: “‘Vital signs are vital’ is a common
refrain in emergency medicine.”
And,
these authors add to the body of work further exploring this axiom. In this
simple, retrospective data analysis, they evaluate all adult visits to their
Emergency Department to determine the effect of abnormal vital signs at
disposition on short-term outcomes.
For
discharges, about 3% of their cohort returned to the same ED within 72 hours.
Only a handful – a little less than 15% – had any vital sign abnormalities at
discharge. And, yes, those with vital sign abnormalities were slightly more
likely to return than those who did not, with relative risk ratios centered
generally around 1.2. Then, a little more than a quarter of patients were
admitted on their return visit – and, again, vital sign abnormalities increased
the likelihood of subsequent admission by a small amount. In this case, fever
was more likely than the other abnormal vital signs to tip the scales towards
admission.
Similarly,
an analysis of inpatient visits and subsequent escalations in care noted vital
sign abnormalities exhibited a greater risk of upgrade, with RRs centered
around 2.
Overall,
however, the vast majority of patients who were either admitted or discharged
with abnormal vital signs did well. Abnormal vital signs are always worth
recognizing and dedicating a bit of cognitive effort, but the aren’t strong
enough predictors of subsequent outcomes to drive changes in management.
Hodgson
NR, et al. Association of Vital Signs and Process Outcomes in Emergency
Department Patients. West J Emerg Med. 2019 May; 20(3): 433–437.
19. How Quality Discharge May Reduce Return ED
Visits
Sabbatini
AK, et al. Capturing Emergency Department Discharge Quality With the Care
Transitions Measure: A Pilot Study. Acad Emerg Med. 2019 Jun;26(6):605-609.
BACKGROUND:
Recent
attention has been given to developing measures to capture the quality of ED
transitions of care. We examined the utility of a patient-reported measure of
transitional care, the Care Transitions Measure-3 (CTM-3), in the ED setting
and its association with outcomes of care after ED discharge.
METHODS:
A
telephone survey was conducted of a convenience sample of patients 14 days
after discharge from two emergency departments (EDs) in an academic health
system. Patients responded to three statements using a four-point agreement
scale (strongly disagree, disagree, agree, strongly agree): 1) "The
hospital staff took my preferences and those of my family or caregiver into
account when deciding what my health care needs would be"; 2) " When
I left the ER, I had a good understanding of the things I was responsible for
in managing my health"; and 3) "When I left the hospital, I clearly
understood the purpose for taking each of my medications." Patients were
also queried about outcomes after ED discharge that are known to be related to
ED care transitions including medication adherence, completion of recommended
follow-up, and return visits to the ED. Multivariable logistic regression was
used to determine the association between the CTM-3 score (on a 100-point
scale) and outcomes of interest.
RESULTS:
Among
1,832 patients called, 576 were reached by phone, and 410 consented and
completed our survey, representing a 22.4% response rate of patients we
attempted to call. A 10-point increase in the CTM-3 score (better care
experiences) was associated with a 12% decrease in the odds of having an ED
return visit (adjusted odds ratio [AOR] = 0.88, 95% confidence interval [CI] =
0.77-1.00) and a 45% increase in the odds of taking prescribed medications as
recommended (AOR = 1.45, 95% CI = 1.12-1.87). There was no association between
CTM-3 score and completion of follow-up.
CONCLUSIONS:
The
CTM-3 is associated with outcomes of care after an ED visit, including ED
return visits and medication adherence, and may have utility as a
patient-reported measure of ED transitions of care.
20. Challenge of immune-mediated adverse reactions
in the ED
Daniels
GA, et al. Emerg Med J. 2019 May 21 [Epub ahead of print]
Multiple
drugs of a new class of cancer treatments called immune checkpoint inhibitors,
which work by enabling the immune system to attack tumour cells, have been
approved for a variety of indications in recent years. Immune checkpoints, such
as cytotoxic T-lymphocyte antigen-4 and programmed death-1, are part of the
normal immune system and regulate immune activation. Treatment with inhibitors
of these checkpoints can significantly improve response rates, progression-free
survival and overall survival of patients with cancer; it can also result in
adverse reactions that present similarly to other conditions.
These
immune-mediated adverse reactions (IMARs) are most commonly gastrointestinal,
respiratory, endocrine or dermatologic. Although patients' presentations may
appear similar to other types of cancer therapy, the underlying causes, and
consequently their management, may differ. Prompt recognition is critical
because, with appropriate management, most IMARs resolve and patients can
continue receiving immune checkpoint inhibitor treatment. Rarely, these IMARs
may be life-threatening and escape detection from the usual evaluations in the
emergency environment. Given the unusual spectrum and mechanism of IMARs
arising from immune checkpoint inhibitors, emergency departmentED staff require
a clear understanding of the evaluation of IMARs to enable them to
appropriately assess and treat these patients. Treatment of IMARs, most often
with high-dose steroids, differs from chemotherapy-related adverse events and
when possible should be coordinated with the treating oncologist.
This
review summarises the ED presentation and management of IMARs arising from
immune checkpoint inhibitors and includes recommendations for tools and
resources for ED healthcare professionals.
21. The Diversity Snowball Effect: The Quest to
Increase Diversity in EM: A Case Study of Highland's EM Residency Program
Garrick
JF, et al. Ann Emerg Med. 2019 Jun;73(6):639-647.
Blacks,
Hispanics/Latinos, American Indians, Pacific Islanders, Alaska Natives, and
Native Hawaiians make up 33% of the US population. These same groups are
underrepresented in medicine. In 2013, the physician workforce was 4.1% black,
4.4% Hispanic/Latino, 0.4% American Indian or Alaska Native, 11.7% Asian, and
48.9% white. Only 9.9% of emergency physicians identify as underrepresented
minority (4.5% black, 4.8% Hispanic/Latino, and 0.6% American Indian/Alaska
Native).
Efforts
to increase the number of underrepresented minority physicians are important
because previous studies show improved outcomes when the patient and physician
share the same racial/ethnic background.
Starting
in 2006, the faculty at the Highland EM Residency Program in Oakland, CA, began
a diversification initiative to increase the number of underrepresented
minority residents. The goal was to closely mirror the US population and match
30% underrepresented minorities with each incoming class. After the initiative,
there was a 2-fold increase in the number of underrepresented minority
residents (from 12% to 27%). This article is a review of the strategies used to
diversify the Highland EM Residency Program. Most components can be applied
across emergency medicine programs to increase the number of underrepresented
minority residents and potentially improve health outcomes for diverse
populations.
22. Micro Bits
A.
Physician burnout costs US an average of $4.6B per year
A
study published online in the Annals of Internal Medicine estimates that
physician burnout costs the US an average of $4.6 billion per year. Researchers
developed a mathematical model to calculate the cost of turnover and shorter
hours linked to burnout and found that the issue costs health care
organizations $7,600 per doctor per year, meaning it "makes good business
sense" for institutions to address burnout, according to researcher Joel
Goh.
B. Overcoming
Barriers to Empathy in Health Care: How can we practice empathy when we feel
stressed, over-worked, and burned out?
C.
Acetaminophen
May Blunt Empathy
D. Seniors
who feel their life has purpose may live longer
E.
Study Links Patient Appointment Times, Cancer Screening Rates: 'Decision
Fatigue,' Lack of Time May Play a Role
F. How
great nursing improves doctors' performance
Harvard
Business Review
Every
physician can think of a time — probably many — when a nurse has saved the day.
And indeed, ample research shows that programs that foster a culture of
excellent nursing have sweeping impacts throughout health care organizations.
Hospitals participating in these initiatives see higher nurse satisfaction and
retention, improved patient experience and safety, decreased mortality,
increased revenues, and many other benefits. New research adds to this body of
work, showing a positive association between nursing excellence and physicians'
performance.
G.
Understanding the consequences of education inequality on cardiovascular
disease
H.
Will raising the minimum wage lower suicide rates?
This
study examined whether increases in state minimum wages have been associated
with changes in state suicide rates. In the period between 2006 and 2016, there
were approximately 432,000 suicide deaths. Authors found each one-dollar
increase in the real minimum wage was associated with a 1.9% decrease in the
annual state suicide rate on average, an association that was seen most
strongly in the years since 2011. Results indicate increasing the minimum wage
could be a valuable strategy for preventing suicide.
I. Was
It an Invisible Attack on U.S. Diplomats, or Something Stranger?
An
“unknown energy source” has been blamed for debilitating symptoms suffered by
Americans posted in Cuba. The real cause may be more surprising.
…
Dozens of
leading neurologists, psychiatrists and psychologists, meanwhile, have offered
an alternative narrative: that the diplomats’ symptoms are primarily
psychogenic — or “functional” — in nature. If true, it would mean that the
symptoms were caused not by a secret high-tech weapon but by the same confluence
of psychological and neurological processes — entirely subconscious yet
remarkably powerful — underlying hypnosis and the placebo effect. They are
disorders, in other words, not of the brain’s hardware but of its software; not
of objective injuries to the brain’s structure but of chronic alterations to
how the brain functions, typically following exposure to an illness, a physical
injury or stress. And the fact that the State Department and doctors the
government selected to treat the diplomats have dismissed this explanation out
of hand does not surprise these experts. After all, they say, functional
neurological disorders are among the most misunderstood, debilitating and
denigrated ailments known to medicine…
J.
Sleeping with the TV on? Don’t do it.
Association
of Exposure to Artificial Light at Night While Sleeping With Risk of Obesity in
Women
K. Feel
Free to Skip Breakfast Again and Again and Again: The Skeptical Cardiologist
tackles the "most important meal of the day"
L. 3
interventions could prevent 94.3M deaths globally
Research
published in the journal Circulation said increasing blood pressure treatment
coverage by 70%, reducing sodium intake by 30% and eliminating trans fat
consumption could prevent 94.3 million deaths globally by 2040. "Successful
global implementation would require increased investment in health care
capacity and quality of care in the primary health care sector, and increased
efforts to reduce sodium and eliminate trans fat intake through regulation and
health promotion campaigns as well," the authors wrote.
M. CDC Says Bats Are Main Source Of Human Rabies In US
N. Special Report: Stop Doing ‘Everything’
Doctors
systematically overestimate the benefits and underestimate the harm of
interventions to patients and their families.
