Friday, April 20, 2018

Lit Bits: April 20, 2018

From the recent medical literature...

1. Syncope Management

A. European Society of Cardiology Issues New Guidelines On How To Stratify Syncope Patients In ED.

Written by whom? “The most important aspect characterizing this document is the composition of the Task Force, which is truly multidisciplinary. Cardiologists form a minority of the panel; experts in emergency medicine, internal medicine and physiology, neurology and autonomic diseases, geriatric medicine, and nursing cover all aspects of management of the various forms of syncope and transient loss of consciousness (TLOC).”

New Syncope Guidelines Take Aim at ED Bottleneck

Patrice Wendling. Medscape, March 23, 2018

BARCELONA, Spain  — About half of all people will have an episode of syncope in their lifetime, and up until now, an equal number in any part of the world will have been admitted to the hospital, even if risk for recurrence is low.

New 2018 European Society of Cardiology (ESC) syncope guidelines provide for the first time an algorithm to stratify these patients in the emergency department (ED) and discharge those at low risk.

"I think this is a major advance of this guideline because it goes beyond the individual management of the patient but has organizational and financial implications because it provides a completely different organizational structure of the hospital," task force chair, Michele Brignole, MD, from Ospedali Del Tigullio, Lavagna, Italy, told | Medscape Cardiology.

He observed that, "Seventy-five percent of the cost of syncope is hospitalization; so if you cut hospitalization, you cut 75% of the cost."

Following an initial syncope examination in the ED, including medical history, physical exam with resting and supine blood pressure, and electrocardiography, for all patients, the guidelines recommend that:

  • Patients with low-risk features only, likely to have reflex, situational, or orthostatic syncope, be discharged directly from the ED;
  • Patients with high-risk features should not be discharged but receive an intensive diagnostic evaluation in a syncope unit or ED observation unit, or hospitalized; and
  • Patients with neither high- nor low-risk features should be observed in the ED or in a syncope unit instead of being hospitalized. 
The document includes several tables listing high-risk features, such as severe structural or coronary artery disease, syncope during exertion or when supine, and sudden-onset palpitation immediately followed by syncope. It also has criteria for patients with high-risk features favoring initial management in an ED observational unit and/or fast-tracking to a syncope unit vs hospital admission….

The essay (registration required):

B. Syncope Prognosis Based on Emergency Department Diagnosis: A Prospective Cohort Study.

Toarta C, et al. Acad Emerg Med. 2018 Apr;25(4):388-396. doi: 10.1111/acem.13346. Epub 2018 Jan 11.

OBJECTIVE: Relatively little is known about outcomes after disposition among syncope patients assigned various diagnostic categories during emergency department (ED) evaluation. We sought to measure the outcomes among these groups within 30 days of the initial ED visit.

METHODS: We prospectively enrolled adult syncope patients at six EDs and excluded patients with presyncope, persistent mental status changes, intoxication, seizure, and major trauma. Patient characteristics, ED management, diagnostic impression (presumed vasovagal, orthostatic, cardiac, or other/unknown) at the end of the ED visit, and physicians' confidence in assigning the etiology were collected. Serious outcomes at 30 days included death, arrhythmia, myocardial infarction, structural heart disease, pulmonary embolism, and hemorrhage.

RESULTS: A total of 5,010 patients (mean ± SD age = 53.4 ± 23.0 years; 54.8% females) were enrolled; 3.5% suffered serious outcomes-deaths (0.3%), arrhythmias (1.8%), nonarrhythmic cardiac (0.5%), and noncardiac (0.9%) including pulmonary embolism (0.2%). The cause of syncope was presumed as vasovagal among 53.3% and cardiac in 5.4% of patients. The proportion of patients with ED investigations (p less than 0.001) and short-term serious outcomes (p less than 0.01) increased in each diagnostic category in the following order: presumed vasovagal, orthostatic hypotension, other/unknown cause, and cardiac. No deaths occurred in patients with presumed vasovagal syncope. A higher proportion of all serious outcomes occurred among patients suspected of cardiac syncope in the ED (p less than 0.01). Confidence was highest among physicians for a presumed vasovagal syncope diagnosis and lowest when the cause was other/unknown.

CONCLUSION: Short-term serious outcomes strongly correlated with the etiology assigned in the ED visit. The importance of the physician's clinical judgment should be further studied to determine if it should become incorporated in risk-stratification tools for prognostication and safe management of ED syncope patients.

C. Development of a Patient Decision Aid for Syncope in the Emergency Department: the SynDA Tool.

Probst MA, et al. Acad Emerg Med. 2018 Apr;25(4):425-433.

OBJECTIVES: The objective was to develop a patient decision aid (DA) to promote shared decision making (SDM) for stable, alert patients who present to the emergency department (ED) with syncope.

METHODS: Using input from patients, clinicians, and experts in the field of syncope, health care design, and SDM, we created a prototype of a paper-based DA to engage patients in the disposition decision (admission vs. discharge) after an unremarkable ED evaluation for syncope. In phase 1, we conducted one-on-one semistructured exploratory interviews with 10 emergency physicians and 10 ED syncope patients. In phase 2, we conducted one-on-one directed interviews with 15 emergency care clinicians, five cardiologists, and 12 ED syncope patients to get detailed feedback on DA content and design. We iteratively modified the aid using feedback from each interviewee until clarity and usability had been optimized.

RESULTS: The 11 × 17-inch, paper-based DA, titled SynDA, includes four sections: 1) explanation of syncope, 2) explanation of future risks, 3) personalized 30-day risk estimate, and 4) disposition options. The personalized risk estimate is calculated using a recently published syncope risk-stratification tool. This risk estimate is stated in natural frequency and graphically displayed using a 100-person color-coded pictogram. Patient-oriented questions are included to stimulate dialogue between patient and clinician. At the end of the development process, patient and physician participants expressed satisfaction with the clarity and usability of the DA.

CONCLUSIONS: We iteratively developed an evidence-based DA to facilitate SDM for alert syncope patients after an unremarkable ED evaluation. Further testing is required to determine its effects on patient care. This DA has the potential to improve care for syncope patients and promote patient-centered care in emergency medicine.

2. Prognosis After ED Intubation to Inform Shared Decision‐Making

Ouchi K, et al. J Am Geriatr Soc. 2018 Mar 15 [Epub ahead of print].

OBJECTIVES: To inform the shared decision-making process between clinicians and older adults and their surrogates regarding emergency intubation.

DESIGN: Retrospective cohort study.

SETTING: Multicenter, emergency department (ED)-based cohort.

PARTICIPANTS: Adults aged 65 and older intubated in the ED from 2008 to 2015 from 262 hospitals across the United States (greater than 95% of U.S. nonprofit academic medical centers).

MEASUREMENTS: Our primary outcome was age-specific in-hospital mortality. Secondary outcomes were age-specific odds of death after adjusting for race, comorbid conditions, admission diagnosis, hospital disposition, and geographic region.

RESULTS: We identified 41,463 ED intubation encounters and included 35,036 in the final analysis. Sixty-four percent were in non-Hispanic whites and 54% in women. Overall in-hospital mortality was 33% (95% confidence interval (CI)=34-35%). Twenty-four percent (95% CI=24-25%) of subjects were discharged to home, and 41% (95% CI=40-42%) were discharged to a location other than home. Mortality was 29% (95% CI=28-29%) for individuals aged 65 to 74, 34% (95% CI=33-35%) for those aged 75 to 79, 40% (95% CI=39-41%) for those aged 80 to 84, 43% (95% CI=41-44%) for those aged 85 to 89, and 50% (95% CI=48-51%) for those aged 90 and older.

CONCLUSION: After emergency intubation, 33% percent of older adults die during the index hospitalization. Only 24% of survivors are discharged to home. Simple, graphic representations of this information, in combination with an experienced clinician's overall clinical assessment, will support shared decision-making regarding unplanned intubation.

3. The Effect of Door-to-Diuretic Time on Clinical Outcomes in Patients with Acute Heart Failure

Park JJ, et al. JACC 2018;6(4):

Objectives This study sought to examine the impact of door-to-diuretic (D2D) time on mortality in patients with acute heart failure (AHF) who were presenting to an emergency department (ED).

Background Most patients with AHF present with congestion. Early decongestion with diuretic agents could improve their clinical outcomes.

Methods The Korea Acute Heart Failure registry enrolled 5,625 consecutive patients hospitalized for AHF. For this analysis, the study included patients who received intravenous diuretic agents within 24 h after ED arrival. Early and delayed groups were defined as D2D time ≤60 min and D2D time over 60 min, respectively. The primary outcomes were in-hospital death and post-discharge death at 1 month and 1 year on the basis of D2D time.

Results A total of 2,761 patients met the inclusion criteria. The median D2D time was 128 min (interquartile range: 63 to 243 min), and 663 (24%) patients belonged to the early group. The baseline characteristics were similar between the groups. The rate of in-hospital death did not differ between the groups (5.0% vs. 5.1%; p greater than 0.999), nor did the post-discharge 1-month (4.0% vs. 3.0%; log-rank p = 0.246) and 1-year (20.6% vs. 19.3%; log-rank p = 0.458) mortality rates. Get With the Guidelines-Heart Failure risk score was calculated for each patient. In multivariate analyses with adjustment for Get With the Guidelines-Heart Failure risk score and other significant clinical covariates and propensity-matched analyses, D2D time was not associated with clinical outcomes.

Conclusions The D2D time was not associated with clinical outcomes in a large prospective cohort of patients with AHF who were presenting to an ED.

4. Diphenhydramine should be co-administered with IV prochlorperazine to prevent akathisia.

Vinson DR, Friedman BW. Emerg Med J. 2018 Feb 25.

We commend Dr D’Souza et al for their systematic review of the effects of prophylactic diphenhydramine in the reduction of akathisia induced by intravenous dopamine D2 antagonist antiemetics.1 Akathisia is a dysphoric feeling of restlessness that ranges from mild to severe, the more severe expressions of which can be quite distressing to patients.2 Attention to its prevention is welcome. We took particular interest in the systematic review because we led three of the four studies included in the meta-analysis.2-4

The authors conclude that adjunct diphenhydramine reduces akathisia when dopamine D2 antagonist antiemetics are administered over 2 minutes, but diphenhydramine fails to augment the reduction in akathisia achieved by simply slowing the antiemetic infusion to 15 minutes. They report moderately high heterogeneity among the four included studies (I2 =43%).5 This reveals an inconsistency in results between studies that precludes a one-size-fits-all recommendation on the use of prophylactic diphenhydramine. Such an elevated I2 requires explanation. The authors attribute this heterogeneity to rates of infusion and determine that a 15-minute infusion is less likely to cause akathisia.

But another explanation for the heterogeneity is at hand that the authors did not explore: prochlorperazine and metoclopramide behave differently when it comes to akathisia prevention. Their systematic review assumes a drug-class consistency that is absent in the clinical trials. The meta-analysis includes three studies of metoclopramide and one of prochlorperazine.1 This combination at first appears reasonable: both medications are dopamine D2 antagonists and both are effective in the treatment of migraine and vomiting. However, these two drugs may not respond the same way to interventions aimed at akathisia prevention.

Slower infusion rates of metoclopramide are associated with a reduction in akathisia, as multiple studies have shown.2,6,7 The 15-minute infusion of metoclopramide is sufficiently effective to render adjunct diphenhydramine redundant: “Routine prophylaxis with diphenhydramine to prevent akathisia is unwarranted when intravenous metoclopramide is administered over 15 minutes.”2

One might think that slowing the infusion rate of prochlorperazine would have a similar akathisia-reducing effect. The authors mention that “some studies have shown a lower [extra-pyramidal symptom] incidence with [slower] infusion dosing,”1 then reference two studies.6,7 Interestingly, both references are studies of metoclopramide, not prochlorperazine. There are randomized trials of prochlorperazine that compare slow infusion (15 minutes) with more rapid administration (2 minutes), but these were not mentioned in the systematic review.8,9 These studies found that slow infusion of prochlorperazine failed to reduce akathisia. Such results undermine the conclusion of D’Souza et al that slow infusion rates reduce akathisia for all dopamine D2 antagonists across the board. Though a slower infusion rate seems an ineffective method to reduce prochlorperazine-induced akathisia, prophylactic intravenous diphenhydramine is effective.10

Until further studies challenge these unexpected differences between prochlorperazine and metoclopramide, we advocate the following: when administering intravenous prochlorperazine, co-administer diphenhydramine to reduce akathisia; slow infusion is not beneficial. When administering intravenous metoclopramide, infuse it over 15 minutes; adjunct diphenhydramine is not necessary. This approach is in sync with the evidence to date and avoids the drug-class assumption that besets the otherwise helpful review by D’Souza et al.1 

The original review: Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis.

5. Defer Urgent Noninvasive Testing in Low-Risk CP Patients

Sun BC. Ann Emerg Med. 2018;71(4):465-6.

To minimize missed acute coronary syndrome, the American Heart Association endorses noninvasive cardiac testing (eg, treadmill ECG, stress echocardiogram, stress myocardial perfusion, coronary computed tomography [CT] angiogram) before discharge or within 72 hours after discharge, after acute myocardial infarction has been excluded by serial biomarker tests (Class 2A recommendation).1 The fundamental assumption is that early identification of obstructive coronary artery disease may lead to coronary revascularization, with a subsequent reduction in acute myocardial infarction and cardiac death.

Despite decades of clinical practice, millions of patients, and billions of health care dollars, there is no evidence that this approach improves clinical outcomes. Previous randomized comparisons of testing strategies did not include a “no-test” arm and were powered on nonclinical outcomes such as health resource use. The existing literature suggests that physicians collectively overtest patients,2, 3 resulting in false-positive results that in turn lead to higher-risk tests (eg, invasive coronary angiography) and revascularization procedures, without evidence of improved clinical outcomes.

Let us focus specifically on the patient with “low” pretest risk of acute coronary syndrome, in which the rationale for urgent noninvasive testing seems to be particularly poor. For the purposes of this argument, I define “low risk” as less than 3%; this is the pooled prevalence of 30-day death or major cardiac events in several cohorts of emergency department (ED) chest pain patients, who were ruled out for acute myocardial infarction with biomarkers and received noninvasive cardiac testing. This population correlates with low-risk strata of published risk scores (eg, HEART [history, electrocardiogram, age, risk factors and troponin] 0 to 3; TIMI [thrombolysis in myocardial infarction] 0 to 1). In such patients, Bayes’s theorem suggests minimal information gain with a “normal” test result—that is, the posttest risk of disease—changes from approximately 3% to somewhat less than 3%. Conversely, an “abnormal” result is much more likely to represent a false-positive than a true-positive finding. In a classic article published in 1979, Diamond and Forrester4 predicted that for young women with a 3% pretest risk of obstructive coronary artery disease, an abnormal treadmill test result would be falsely positive 24 times for each true-positive result.

A large and consistent observational experience from ED chest pain cohorts supports Bayesian predictions. I summarize 4 studies that are representative of this literature.5, 6, 7, 8 These pooled cohorts included 7,642 ED patients with chest pain who received urgent noninvasive cardiac stress testing. There were 915 patients (12%) who had an abnormal stress test result, 233 (3%) who received invasive coronary angiogram, and 72 (0.9%) who received a cardiac revascularization procedure. These data highlight several important points. First, a significant proportion of patients had abnormal noninvasive test results. Second, only one quarter of abnormal results were followed up with coronary angiogram, which raises the question, what was the purpose of performing the other three quarters of noninvasive tests if there was no intent to perform confirmatory testing? Third, only a tiny proportion of this population received cardiac revascularization. Although the abnormal test result to revascularization ratio is “only” 13:1, better than predicted, there is no information about the appropriateness of revascularization or whether these procedures resulted in reduced rates of acute myocardial infarction or death.

Several studies have examined the link between noninvasive testing and clinical outcomes. In an analysis (which I led) of 895 patients who received early stress testing matched with 1,790 similar patients without testing, no association was found between early testing and 30-day death or major cardiac events (odds ratio 1.0; 95% confidence interval 0.6 to 1.7).9 At 224 hospitals, higher rates of noninvasive testing were correlated with increasing odds of admission, invasive angiograms, and revascularization without reducing acute myocardial infarction risk.2 In a retrospective cohort of 421,774 privately insured patients, stress ECG, stress myocardial perfusion, and coronary CT angiogram were associated with increased rates of invasive coronary angiograms and revascularization without reduction in acute myocardial infarction risk, compared with no testing.3 Of course, there will always be concerns about hidden confounding in observational data, but the lack of any signal suggesting benefit is striking.

A single randomized trial provides additional evidence that urgent noninvasive testing can be deferred for low-risk patients.10 This study randomized 282 ED patients with suspected acute coronary syndrome to usual care versus a structured decision aid to identify low-risk patients (ie, low-risk HEART score and normal serial troponin levels) who could defer subsequent stress testing or angiography. Despite a 20% physician noncompliance rate in the intervention group (ie, testing ordered despite protocol recommendation), the intervention reduced objective testing by 12.1% (P=.048) and length of stay by 12 hours (P=.013). No patients identified for early discharge experienced serious cardiac outcomes at 30 days.

Bottom line: rule out acute myocardial infarction with biomarkers in low-risk patients and send them home without further testing.

6. Helpful Only When Elevated: Initial Serum Lactate in Stable ED Patients with Sepsis Is Specific, but Not Sensitive for Future Deterioration

Fernando SM, et al. J Emerg Med. 2018 Mar 13 [Epub ahead of print].

Helpful Only When Elevated: Initial Serum Lactate in Stable ED Patients with Sepsis Is Specific, but Not Sensitive for Future Deterioration.

Background: Early emergency department (ED) identification of septic patients at risk of deterioration is critical. Lactate is associated with 28-day mortality in admitted patients, but little evidence exists on its use in predicting short-term deterioration.

Objective: Our aim was to determine the role of initial serum lactate for prediction of short-term deterioration in stable ED patients with suspected sepsis.

Methods: We conducted a prospective cohort study of adult ED sepsis patients. Venous lactate was obtained within 2 h of ED arrival. Main outcome was subsequent deterioration (defined as any of the following: death, intensive care admission over 24 h, intubation, vasoactive medications for over 1 h, or noninvasive positive pressure ventilation for over 1 h) within 72 h. Patients meeting any endpoint within 1 h of arrival were excluded.

Results: Nine hundred and eighty-five patients were enrolled, of whom 84 (8.5%) met the primary outcome of deterioration. Initial lactate ≥ 4.0 mmol/L had a specificity of 97% (95% confidence interval [CI] 94-100%), but a sensitivity of 27% (95% CI 18-37%) for predicting deterioration, with positive and negative likelihood ratios of 10.7 (95% CI 6.3-18.3) and 0.8 (95% CI 0.7-0.9), respectively. A lower threshold of lactate (≥2.0 mmol/L) had a sensitivity of 67% (95% CI 55-76%) and specificity of 66% (95% CI 63-69%), with corresponding positive and negative likelihood ratios of 2.0 (95% CI 1.7-2.3) and 0.5 (95% CI 0.4-0.7).

Conclusions: High ED lactate is predictive of subsequent deterioration from sepsis within 72 h, and may be useful in determining disposition, but low lactate is not effective in screening stable patients at risk of deterioration.

7. Essays from ACEP Now

A. How the Surviving Sepsis Campaign Got Almost Everything Wrong

Talan DA. ACEP Now. March 13, 2018

B. ACEP Battles Anthem BlueCross BlueShield Policy That Jeopardizes Prudent Layperson Standard

Wooster L. ACEP Now. March 14, 2018

Since early summer, ACEP has been working hard on behalf of its members to protect the prudent…

8. Pneumonia with Negative Chest X-Ray but Positive CT Scan

Allan S. Brett, MD, Journal Watch, reviewing Upchurch CP et al. Chest 2018 Mar.

These cases appear to be clinically similar to those in which both x-ray and computed tomography show pneumonia.

Patients who present with suspected pneumonia sometimes undergo both chest x-ray (CXR) and computed tomography (CT). Occasionally, CXR is negative but CT suggests pneumonia. In this study, researchers compared clinical characteristics of CXR-negative, CT-positive patients and patients in whom pneumonia was visualized by both modalities. The data were obtained from a previously published study of patients with community-acquired pneumonia who were admitted to five U.S. hospitals; severely immunosuppressed patients were excluded (NEJM JW Gen Med Sep 1 2015 and N Engl J Med 2015; 373:415).

All 2251 patients underwent CXR, and one third of them also underwent CT. Among the 748 patients who underwent both CXR and CT, 87% had pneumonia on both imaging studies, 9% had pneumonia only on CT, and 4% had pneumonia only on CXR. Patients with CT-only pneumonia, compared with those with pneumonia on both imaging studies, had a similar distribution of bacterial and viral pathogens, similar rates of requiring intensive care, and similar hospital lengths of stay. In contrast, in patients who were CXR positive but CT negative for pneumonia, CT depicted nonpneumonia abnormalities in all cases.

This study suggests that patients with CXR-negative, CT-positive community-acquired pneumonia and patients in whom both CXR and CT are positive should be managed similarly, given that clinical characteristics appear to be similar in the two groups. An editorialist advocates wider use of lung ultrasound for CXR-negative patients in whom pneumonia still is suspected clinically — but expertise in lung ultrasound is not available routinely in many clinical settings.

9. Aortic Dissection Corner

A. Clinical Examination for Acute Aortic Dissection: A Systematic Review and Meta-analysis.

Ohle R, et al. Acad Emerg Med. 2018 Apr;25(4):397-412.

OBJECTIVES: Acute aortic dissection is a life-threatening condition due to a tear in the aortic wall. It is difficult to diagnose and if missed carries a significant mortality.

METHODS: We conducted a librarian-assisted systematic review of PubMed, MEDLINE, Embase, and the Cochrane database from 1968 to July 2016. Titles and abstracts were reviewed and data were extracted by two independent reviewers (agreement measured by kappa). Studies were combined if low clinical and statistical heterogeneity (I2 less than 30%). Study quality was assessed using the QUADAS-2 tool. Bivariate random effects meta analyses using Revman 5 and SAS 9.3 were performed.

RESULTS: We identified 792 records: 60 were selected for full text review, nine studies with 2,400 participants were included (QUADAS-2 low risk of bias, κ = 0.89 [for full-text review]). Prevalence of aortic dissection ranged from 21.9% to 76.1% (mean ± SD = 39.1% ± 17.1%). The clinical findings increasing probability of aortic dissection were 1) neurologic deficit (n = 3, specificity = 95%, positive likelihood ratio [LR+] = 4.4, 95% confidence interval [CI] = 3.3-5.7, I2  = 0%) and 2) hypotension (n = 4, specificity = 95%, LR+ = 2.9 95% CI = 1.8-4.6, I2  = 42%), and decreasing probability were the absence of a widened mediastinum (n = 4, sensitivity = 76%-95%, negative likelihood ratio [LR-] = 0.14-0.60, I2  = 93%) and an American Heart Association aortic dissection detection (AHA ADD) risk score less than 1 (n = 1, sensitivity = 91%, LR- = 0.22, 95% CI = 0.15-0.33).

CONCLUSIONS: Suspicion for acute aortic dissection should be raised with hypotension, pulse, or neurologic deficit. Conversely, a low AHA ADD score decreases suspicion. Clinical gestalt informed by high- and low-risk features together with an absence of an alternative diagnosis should drive investigation for acute aortic dissection.

B. High Risk Clinical Features for Acute Aortic Dissection: A Case-Control Study.

Ohle R, et al. Acad Emerg Med. 2018 Apr;25(4):378-387.

BACKGROUND: Acute aortic dissection (AAD) is a rare condition with a high mortality that is often missed. The objective of our study was to assess the diagnostic accuracy of clinical and laboratory findings for AAD, in confirmed cases of AAD and in a low-risk control group.

METHODS: This was a historical matched case-control study: participants were adults over 18 years old presenting to two tertiary care emergency departments (EDs) or one regional cardiac referral center. Cases were patients with new ED or in-hospital diagnosis of nontraumatic AAD confirmed by computed tomography or echocardiography. Controls were patients with a triage diagnosis of truncal pain (less than 14 days) and an absence of a clear diagnosis on basic investigation. Cases and controls were matched in a 1:4 ratio by sex and age. A sample size of 165 cases and 660 controls was calculated based on 80% power and confidence interval of 95% to detect an odds ratio of greater than 2.

RESULTS: Data were collected from 2002 to 2014 yielding 194 cases of AAD and 776 controls (mean ± SD age = 65 ± 14.1 years; 66.7% male). Absence of abrupt-onset pain (sensitivity = 95.9%, negative likelihood ratio = 0.07 [0.03-0.14]) can help rule out AAD. Presence of tearing/ripping pain (specificity = 99.7%, positive likelihood ratio [LR+] = 42.1 [9.9-177.5]), aortic aneurysm (specificity = 97.8%, LR+ = 6.35 [3.54-11.42]), hypotension (specificity = 98.7%, LR+ = 17.2 [8.8-33.6]), pulse deficit (specificity = 99.3, LR+ = 31.1 [11.2-86.6]), neurologic deficits (specificity = 96.9%, LR+ = 5.26 [2.9-9.3]), and a new murmur (specificity = 97.8%, LR+ = 9.4 [5.5-16.2]) can help rule in the diagnosis of AAD.

CONCLUSIONS: Patients with one or more high-risk feature should be considered high risk, whereas patients with no high-risk and multiple low-risk features are at low risk for AAD.

C. Editorial: Acute Aortic Dissection: Is There Something Better than Physician Gestalt?

Smith LM, et al. Acad Emerg Med. 2018 Apr;25(4):464-466.

Acute aortic dissection (AAD) represents a high profile example of a rare, deadly, and expensive to diagnose conditions. It is a disease that every emergency physician (EP) considers on a daily basis, but encounters only a handful during a career. Considerable attention has been given to this disease after the American Heart Association, American College of Cardiology, and 10 cosponsoring professional societies published the 2010 thoracic aortic disease guidelines to improve the missed or delayed treatment of AAD.1 The American College of Emergency Physicians followed suit in 2015 with a clinical policy for the evaluation and management of suspected AAD, although no clear guidance of when AAD should be suspected was provided.2 Driving our profession's conservative approach to the condition is a number of high‐profile lawsuits and the fact that more than a quarter of patients presenting with AAD will leave the ED misdiagnosed to suffer catastrophic consequences.1, 3 Still, a growing scrutiny on resource utilization from third‐party payers and a legitimate concern for harm in overtesting has some in our profession wondering what degree of diagnostic error is tolerable for AAD. In other words, is it acceptable that one‐third of patients with a missed diagnosis of AAD will suffer a bad outcome so long as those missed had atypical presentations? Will we harm more patients not having the disease if we lower our threshold for diagnostic workups to catch those exceedingly rare atypical presentations of AAD. Better yet, will there ever be a validated decision rule to help us rule out the diagnosis while simultaneously decreasing our resource utilization? To answer these questions we must first come to a consensus on what constitutes typical and atypical presentations of AAD and to what extent atypical presentations are driving our miss rate. Only then will we be able to determine if realistic, cost‐effective improvements in accuracy are possible.

We commend Ohle et al.4 on a well‐designed study that provides and improved vantage point of AAD's clinical presentation to North American EDs. Previous studies have likely misstated the importance of certain high‐risk features due to a reliance on populations with a high prevalence of AAD. It appears that this study has successfully narrowed our focus on the actual patient population that we see on a daily basis. The authors have reaffirmed much of what we already knew, identified some new high‐risk features, and perhaps redirected our focus on more specific presentations. For example, AAD is classically associated with features such as hypertension, migrating pain, and neurologic deficits, but the authors found that patients with abrupt onset of pain or hypotension had a higher odds of having the disease. However, this becomes a bit problematic when our new definition of typical features for AAD increases the overlap with lethal diagnostic mimics. Would a reasonable EP be more worried about venous thromboembolism when confronted with a hypotensive patient with abrupt chest pain instead of the far less common AAD? When contemplating that question we were not comforted by the authors' finding that 5% of patients with AAD presented with flank pain, and a similar percentage of missed AADs were assigned an incorrect diagnosis of renal colic. The author's findings illustrate a frequently unappreciated and significant overlap of AAD presentations with more common, and often more benign, diagnoses. Therefore, we stress the need for realistic expectations for the performance of a decision aid derived from this study.

Complicating this problem is a lack of clinical features that effectively rule out AAD. Features previously seen as atypical for AAD such as palpable tenderness and resolving pain did not significantly lower the odds of AAD. In fact, the condition most associated with reduced odds of AAD, a history of ischemic heart disease, is likely a statistical effect from an alternative diagnosis rather than a protective factor that will assist clinicians in their decision making. The same can be said for a history of diabetes, which also significantly lowered the odds of AAD but is unlikely to reassure EPs facing a mixed clinical picture. In other words, the authors have done an excellent job of describing the features that are high risk for AAD; these data are less effective at identifying useful features that rule out the disease.

The authors hint that the logical next step is the development of a validated decision tool to assist in the risk stratification of AAD. We agree to the extent that an effective tool must balance increased diagnostic yield with increased overtesting. Aside from the difficulties in recruiting patients with an exceedingly rare disease for a prospective trial, this study suggests significant challenges in selecting a combination of clinical features and screening tests that improve our ability to detect atypical presentations. After all, a decision tool that only reaffirms physician gestalt for high‐risk presentations is not helpful if it fails to identify the 20% to 30% atypical presentations that are missed. The challenge will be to catch the 20% to 30% with atypical presentations without causing harm from increased costs and radiation exposure. A previous attempt at a decision rule, the Aortic Dissection Detection Risk Score (AAD‐RS), was derived from retrospective data on high‐risk patients and failed as a useful tool due to poor specificity and because patients with low scores still had a 5% chance of AAD.5, 6 The addition of a chest radiograph seeking mediastinal widening did not improve the performance of the AAD‐RS. We are unsure how a decision tool derived from the current study, using a lower‐risk population, would improve on the AAD‐RS as there is considerable overlap in the high‐risk features such as abrupt onset, tearing or ripping pain, and hypotension.

The authors have mentioned a combination of historical features and selective use of D‐dimer testing to rule out low‐risk populations despite lacking the power to accurately assess this test's performance in AAD. Our concern with this approach is twofold

10. Images in Clinical Practice

Scleral Discoloration from Minocycline Treatment

ECG Pattern Associated with Left Anterior Descending Coronary Artery Occlusion

Embolization of Struts from an Inferior Vena Cava Filter

Bouveret’s Syndrome (a variety of gallstone ileus)

Hand, Foot, and Mouth Disease in an Adult

Appendiceal Pinworms

Cutaneous Diphtheria

11. Pediatric Corner

A. Children with Isolated Vomiting After Head Injury Are Unlikely to Have Intracranial Injuries

Only 0.2% of such children had intracranial injuries.

Borland ML, et al. Vomiting With Head Trauma and Risk of Traumatic Brain Injury. Pediatrics. 2018 Apr;141(4).

OBJECTIVES: To determine the prevalence of traumatic brain injuries in children who vomit after head injury and identify variables from published clinical decision rules (CDRs) that predict increased risk.

METHODS: Secondary analysis of the Australasian Paediatric Head Injury Rule Study. Vomiting characteristics were assessed and correlated with CDR predictors and the presence of clinically important traumatic brain injury (ciTBI) or traumatic brain injury on computed tomography (TBI-CT). Isolated vomiting was defined as vomiting without other CDR predictors.

RESULTS: Of the 19 920 children enrolled, 3389 (17.0%) had any vomiting, with 2446 (72.2%) over 2 years of age. In 172 patients with ciTBI, 76 had vomiting (44.2%; 95% confidence interval [CI] 36.9%-51.7%), and in 285 with TBI-CT, 123 had vomiting (43.2%; 95% CI 37.5%-49.0%). With isolated vomiting, only 1 (0.3%; 95% CI 0.0%-0.9%) had ciTBI and 2 (0.6%; 95% CI 0.0%-1.4%) had TBI-CT. Predictors of increased risk of ciTBI with vomiting by using multivariate regression were as follows: signs of skull fracture (odds ratio [OR] 80.1; 95% CI 43.4-148.0), altered mental status (OR 2.4; 95% CI 1.0-5.5), headache (OR 2.3; 95% CI 1.3-4.1), and acting abnormally (OR 1.86; 95% CI 1.0-3.4). Additional features predicting TBI-CT were as follows: skull fracture (OR 112.96; 95% CI 66.76-191.14), nonaccidental injury concern (OR 6.75; 95% CI 1.54-29.69), headache (OR 2.55; 95% CI 1.52-4.27), and acting abnormally (OR 1.83; 95% CI 1.10-3.06).

CONCLUSIONS: TBI-CT and ciTBI are uncommon in children presenting with head injury with isolated vomiting, and a management strategy of observation without immediate computed tomography appears appropriate.

B. UTI Calculator Predicts Risk of Infant Urinary Tract Infection

Calculator reduces testing and decreases the number of urinary tract infections that were missed.

TUESDAY, April 17, 2018 (HealthDay News) -- The newly developed UTICalc calculator can be used to guide testing and treatment in children with suspected urinary tract infection (UTI), according to a study published online April 16 in JAMA Pediatrics.

In an effort to develop a calculator that can first estimate the probability of UTI based on clinical variables and then update that probability based on laboratory results, Nader Shaikh, M.D., M.P.H., from the Children's Hospital of Pittsburgh, analyzed electronic medical records from a training database of 1,686 febrile children (aged 2 to 23 months) presenting to the emergency department. The calculator was validated using a database of 384 patients.

The researchers found that, compared with the American Academy of Pediatrics algorithm, the clinical model in UTICalc reduced testing by 8.1 percent and decreased the number of UTIs that were missed from three cases to none. The dipstick model in UTICalc would have reduced the number of treatment delays by 10.6 percent compared with empirically treating all children with a leukocyte esterase test result of ≥1.

"Accurate diagnosis of UTI is important to reduce the delay in diagnosis and to avoid unnecessary treatment with antimicrobial drugs," the authors write. "The approach advocated here tailors testing and treatment to the risk factors present in the child being assessed, thus offering the potential to improve outcomes for children with UTI."

12. A Predictive Model Facilitates Early Recognition of Spinal Epidural Abscess in Adults.

Artenstein AW, et al. West J Emerg Med. 2018 Mar;19(2):276-281.

INTRODUCTION: Spinal epidural abscess (SEA), a highly morbid and potentially lethal deep tissue infection of the central nervous system has more than tripled in incidence over the past decade. Early recognition at the point of initial clinical presentation may prevent irreversible neurologic injury or other serious, adverse outcomes. To facilitate early recognition of SEA, we developed a predictive scoring model.

METHODS: Using data from a 10-year, retrospective, case-control study of adults presenting for care at a tertiary-care, regional, academic medical center, we used the Integrated Discrimination Improvement Index (IDI) to identify candidate discriminators and created a multivariable logistic regression model, refined based on p-value significance. We selected a cutpoint that optimized sensitivity and specificity.

RESULTS: The final multivariable logistic regression model based on five characteristics -patient age, fever and/or rigor, antimicrobial use within 30 days, back/neck pain, and injection drug use - shows excellent discrimination (AUC 0.88 [95% confidence interval {0.84, 0.92}]). We used the model's β coefficients to develop a scoring system in which a cutpoint of six correctly identifies cases 89% of the time. Bootstrapped validation measures suggest this model will perform well across samples drawn from this population.

CONCLUSION: Our predictive scoring model appears to reliably discriminate patients who require emergent spinal imaging upon clinical presentation to rule out SEA and should be used in conjunction with clinical judgment.

13. High Prevalence of Sterile Pyuria in the Setting of STI in Women Presenting to an ED

Shipman SB, et al. West J Emerg Med. 2018 Mar;19(2):282-286.

INTRODUCTION: The clinical presentations for sexually transmitted infections (STI) and urinary tract infections (UTI) often overlap, and symptoms of dysuria and urinary frequency/urgency occur with both STIs and UTIs. Abnormal urinalysis (UA) findings and pyuria are common in both UTIs and STIs, and confirmatory urine cultures are not available to emergency clinicians to aid in decision-making regarding prescribing antibiotics for UTIs. The objective of this study was to determine the frequency of sterile pyuria in women with confirmed STIs, as well as whether the absolute number of leukocytes on microscopy or nitrite on urine dipstick correlated with positive urine cultures in patients with confirmed STIs. We also sought to determine how many patients with STIs were inappropriately prescribed a UTI antibiotic.

METHODS: We performed a retrospective chart review of patients aged 18-50 who had a urinalysis and pelvic examination in the emergency department (including cervical cultures), and tested positive for Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis. Descriptive statistics were obtained for all variables, and associations between various findings were sought using the Fisher's exact test for categorical variables. We calculated comparison of proportions using the N-1 chi-squared analysis.

RESULTS: A total of 1,052 female patients tested positive for Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis and were entered into the database. The prevalence of pyuria in all cases was 394/1,052, 37% (95% confidence interval [CI] [0.34-0.40]). Of the cases with pyuria, 293/394, 74% (95% CI [0.70-0.78]) had sterile pyuria with negative urine cultures. The prevalence of positive urine cultures in our study population was 101/1,052, 9.6% (95% CI [0.08-0.11]). Culture positive urines had a mean of 34 leukocytes per high-power field, and culture negative urines had a mean of 24 leukocytes per high-power field, with a difference of 10, (95% CI [3.46-16.15]), which was statistically significant (p=0.003). Only 123 cases tested positive for nitrite on the urinalysis dipstick; 50/123, 41% (95% CI [0.32-0.49]) had positive urine cultures, and 73/123, 59% (95% CI [0.51-0.68]) had negative urine cultures. Nitrite-positive urines were actually 18% more likely to be associated with negative urine cultures in the setting of positive STI cases, (95% CI [4.95-30.42], p=0.0048). Antibiotics were prescribed for 295 patients with suspected UTI. Of these, 195/295, 66% (95% CI [0.61-0.71]) had negative urine cultures, and 100/295, 34% (0.33, 95% CI [0.28-0.39]) had positive urine cultures. Chi-square analysis yielded a difference of these proportions of 32% (95% CI [23.92-39.62], p less than 0.0001).

CONCLUSION: This study demonstrated that in female patients with STIs who have pyuria, there is a high prevalence of sterile pyuria. Our results suggest that reliance on pyuria or positive nitrite for the decision to add antimicrobial therapy empirically for a presumed urinary tract infection in cases in which an STI is confirmed or highly suspected is likely to result in substantial over-treatment.

14. SCAD: The Heart Attack That Strikes Young Women

By Jennifer Clopton. WebMD. March 19, 2018

Christine Shockey suspected she was having a heart attack when she awoke at 2 a.m. with excruciating pain shooting down her left arm. But it took medical professionals 5 days to figure it out -- a delay that changed her health forever.

Shockey went to the ER to have her pain checked out and told the doctors that 8 days earlier, her 43-year-old sister had a type of heart attack called spontaneous coronary artery dissection, or SCAD.

The mother of two living in Council Bluffs, IA, was 42 at the time, a runner with no known health or heart problems. Doctors did an electrocardiogram (EKG) on Shockey, and the results came back slightly abnormal. A blood test also found some proteins called troponins in her blood that are released when heart muscle is damaged during a heart attack.

Despite this, she says doctors diagnosed her with gastric reflux and anxiety. While they kept her for 2 days, they refused repeated requests by her family to do an angiogram to get a better look at her heart.

A SCAD heart attack starts with a tear in the wall of an otherwise normal artery. She was still having arm pain when she was released, so Shockey went to her primary care doctor. He diagnosed her with shingles -- even though she didn’t have a rash.

With the pain still not going away, Shockey was able to get an appointment with a doctor the next day at the University of Nebraska Medical Center at Omaha, just across the Missouri River from Council Bluffs. When he did an EKG, he immediately announced she was having a heart attack and said she’d been having it for the last 5 days -- since her symptoms started.

He handed her his personal cellphone before rushing her into surgery. “He told me to call my husband and tell him goodbye because he wasn’t sure he could save me,” Shockey says. Her heart was damaged so much, it couldn't pump the way it should. The main artery to her heart was torn from the top of her heart to the bottom. Although doctors restored blood flow to it by using a stent, her heart never fully recovered.

That was in 2015. Two-and-a-half years later, she is back to work and a fairly normal life, although she still has unexplained chest pain, takes heart medication, and must avoid vigorous activities that could put too much pressure on her heart.

“I have had to make some peace with the experience, but certainly I am angry because I think in my mind, I was simply too young, too fit, and too female for all of those doctors to recognize what was happening to me,” Shockey says. “There is no way that if I was a man and I had come in with those symptoms that I would have been turned away and told you just have anxiety. I think if I was a man, I would have been taken seriously.”

What Is SCAD?
Unlike a more typical heart attack caused by a rupture of plaque in the arteries, a SCAD heart attack starts with a tear in the wall of an otherwise normal artery. The tear tunnels within the wall of the artery, and its effect blocks the artery and blood flow to the heart muscles, leading to a heart attack. 

Although SCAD causes a small percentage of heart attacks overall, it’s responsible for 40% of heart attacks in women under the age of 50. And it mostly happens to women -- more than 90% of SCAD patients are female.

“This is an important cause of heart attacks among younger people, and it has really only been in the past 4 or 5 years that our thinking on it has changed. For the past 100 years, we had been missing it,” says Sharonne N. Hayes, MD, of the Mayo Clinic in Minnesota -- a renowned SCAD researcher.

Many researchers have been rushing to learn more about SCAD and are starting to better understand how it works and how to treat it. The American Heart Association released the first scientific statement about the condition in February. The 35-page document reviews relevant research and says, among other things, that conservative treatment is generally best. There isn’t yet enough high-quality evidence on the condition to write guidelines for treatment…

Hayes SN, et al; SCAD: Current State of the Science: A Scientific Statement From the AHA.
Circulation. 2018 Feb 22 [Epub ahead of print]. (select “Download pdf”

15. ED Management Issues

A. A Novel Approach to Addressing an Unintended Consequence of Direct to Room: The Delay of Initial Vital Signs

Basile J, et al. West J Emerg Med. 2018 Mar;19(2):254-258.

INTRODUCTION: The concept of "direct to room" (DTR) and "immediate bedding" has been described in the literature as a mechanism to improve front-end, emergency department (ED) processing. The process allows for an expedited clinician-patient encounter. An unintended consequence of DTR was a time delay in obtaining the initial set of vital signs upon patient arrival.

METHODS: This retrospective cohort study was conducted at a single, academic, tertiary-care facility with an annual census of 94,000 patient visits. Inclusion criteria were all patients who entered the ED from 11/1/15 to 5/1/16 and between the hours of 7 am to 11 pm. During the implementation period, a vital signs station was created and a personal care assistant was assigned to the waiting area with the designated job of obtaining vital signs on all patients upon arrival to the ED and prior to leaving the waiting area. Time to first vital sign documented (TTVS) was defined as the time from quick registration to first vital sign documented.

RESULTS: The pre-implementation period, mean TTVS was 15.3 minutes (N= 37,900). The post-implementation period, mean TTVS was 9.8 minutes (N= 39,392). The implementation yielded a 35% decrease and an absolute reduction in the average TTVS of 5.5 minutes (p less than 0.0001).

CONCLUSION: This study demonstrated that the coupling of registration and a vital signs station was successful at overcoming delays in obtaining the time to initial vital signs.

B. Is ED hallway care dangerous? An observational study

Rixe J, et al. Amer J Emerg Med. 2018 April 6 [Epub ahead of print].

In response to crowding the use of hallway beds has become an increasingly prevalent practice in Emergency Departments (EDs). There is limited research on whether caring for patients in hallways (HP) is associated with adverse outcomes. The goal of this study was to examine the effects of HP triage on 30 day outcomes for ED return, readmission, and mortality.

We performed a retrospective cohort study at an urban, academic ED comparing HPs (defined as HP for ≥30 min) to matched controls triaged to standard ED beds from 9/30/14 to 10/1/15. We analyzed data from the hospital's clinical data warehouse. Matched controls were selected by gender, age, ethnicity, and language. We used McNemar's test to assess the association between triage location and 30 day study outcomes. We also examined adverse outcomes by triage severity using McNemar's test.

A total of 10,608 HPs were matched to control patients. Compared to controls, HPs had 2.0 times the odds of returning to the ED in 30 days (95% CI: 1.8–2.1), 1.6 times the odds of inpatient readmission (95% CI: 1.4–1.9), and 1.7 times the odds of readmission to observation (95% CI: 1.4–2.0). The odds ratio for mortality in HPs versus controls was 0.80, (95% CI: 0.50–1.3).

Patients initially triaged to the hallway have an increased odds of 30 day return to the ED, observation and inpatient admission. After adjusting for ESI, the increased odds for return remained similar. The small sample size precluded testing effects of HP status on mortality.

16. Use an As-Needed Antivenom Dosing Strategy for Rattlesnake Bites

It saves antivenom and leads to shorter hospital stays

Spyres MB et al. Crit Care Med 2018 Mar 7

Objectives: This study compares maintenance with clinical- and laboratory-triggered (as-needed [PRN]) antivenom dosing strategies with regard to patient-centered outcomes after rattlesnake envenomation.

Design: This is a retrospective cohort study of adult rattlesnake envenomations treated at a regional toxicology center. Data on demographics, envenomation details, antivenom administration, length of stay, and laboratory and clinical outcomes were compared between the PRN and maintenance groups. Primary outcomes were hospital length of stay and total antivenom used, with a hypothesis of no difference between the two dosing strategies.

Setting: A single regional toxicology center

Patients: Three-hundred ten adult patients envenomated by rattlesnakes between 2007 and 2014 were included. Patients were excluded if no antivenom was administered or for receiving an antivenom other than Crofab (BTG International, West Conshohocken, PA).

Interventions: This is a retrospective study of rattlesnake envenomations treated with and without maintenance antivenom dosing.

Main Results: One-hundred forty-eight in the maintenance group and 162 in the PRN group were included. There was no difference in demographics or baseline envenomation severity or hemotoxicity (32.7% vs 40.5%; respectively; p = 0.158) between the two groups. Comparing the PRN with the maintenance group, less antivenom was used (8 [interquartile range, 6–12] vs 16 [interquartile range, 12–18] vials, respectively; p less than 0.001), and hospital length of stay was shorter (27 hr [interquartile range, 20–44 hr] vs 34 hr [interquartile range, 24–43 hr], respectively; p = 0.014). There were no differences in follow-up outcomes of readmission, retreatment, or bleeding and surgical complications.

Conclusions: Hospital length of stay was shorter, and less antivenom was used in patients receiving a PRN antivenom dosing strategy after rattlesnake envenomation.

17. Oral Nitroglycerin Solution May Be Effective for Esophageal Food Impaction.

Willenbring BA, et al. J Emerg Med. 2018 Mar 5 [Epub ahead of print].

BACKGROUND: Esophageal food impaction is a common illness presenting to emergency departments (ED), and is frequently resistant to pharmacologic therapy. Several medications have been promoted for this indication, but so far have not proven effective. Endoscopic removal is frequently required to resolve the impaction, resulting in risks from anesthesia and the physical procedure, and in prolonged hospital stay for recovery. Oral nitroglycerin solution was recently used in two such cases and may represent a new therapeutic option.

CASE REPORTS: A 49-year-old man presented to an ED with dysphagia 30 min after eating steak. He was given 0.4 mg nitroglycerin dissolved in 10 mL tap water orally, and obtained complete relief of symptoms within 2 min. A 43-year-old man with eosinophilic esophagitis and two prior food impaction episodes presented to a community ED with dysphagia and epigastric discomfort 110 min after eating steak. Five hours after symptom onset and after failure of intravenous glucagon, he was given 0.4 mg nitroglycerin sublingually, which resulted in headache but no relief in dysphagia. Twenty-nine minutes later he received 0.4 mg nitroglycerin solution, as above, with symptom resolution within 2 min.

WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The cases presented above demonstrate close temporal relationships between administration of oral nitroglycerin solution and symptom relief. Oral nitroglycerin solution for esophageal food impaction seemed effective in these cases, but further research on this therapeutic option is warranted.

18. Facing the Shortage of IV Fluids — A Hospital-Based Oral Rehydration Strategy

Patiño AM, et al. N Engl J Med 2018 Apr 19;378(16):1475-1477.

Puerto Rico produces 44% of the intravenous (IV) fluid bags used in the United States.1 On September 20, 2017, Hurricane Maria struck the island, causing a humanitarian crisis and widespread devastation that escalated a critical shortage of IV fluids throughout the United States. Initially, small-volume bags — 50- and 100-ml bags used to dilute medications — became scarce. Today, the larger 500- and 1000-ml IV-fluid bags are also in short supply. U.S. hospitals are scrambling to develop strategies for rationing IV fluids to ensure availability for the patients who need them most.

Hurricane Maria is only the latest challenge to the U.S. IV-fluid supply. Since 2014, U.S. hospitals have faced varying degrees of IV-fluid shortages, whose causes were multifactorial. IV-fluid production is complex and highly regulated in order to ensure quality and safety, which makes it expensive for hospitals and compounding pharmacies to produce their own. Most of the IV fluid used in the United States is produced by only three manufacturers, so availability is vulnerable to even small fluctuations in supply. In addition, hospitals buy IV fluids through large group-purchasing organizations representing hundreds of hospitals so that they can negotiate with manufacturers for lower prices or better access to scarce resources. Some observers argue that these organizations’ market power keeps prices so low that they create a disincentive for manufacturers to increase production or for small producers to enter the market.2

Given these supply-side constraints, the U.S. IV-fluid supply will be vulnerable for the foreseeable future. It is therefore critical for U.S. hospitals to develop both short- and long-term alternatives to IV-fluid use.

Emergency departments (EDs) are substantial consumers of IV fluids in the United States. The 59-bed ED at Brigham and Women’s Hospital treats more than 62,000 adult patients each year and, in the 5 months from September 2017 through January 2018, used 8519 liters of IV fluids — nearly 30% of the hospital’s total consumption. As the current IV-fluid shortage worsened, the team in the Division of International Emergency Medicine and Humanitarian Programs of the Department of Emergency Medicine was asked to develop an oral rehydration protocol for ED patients with mild dehydration. The protocol outlined in the box has since been adopted hospital-wide.

Use for patients with mild dehydration — in general, patients with the following conditions:

• Acute gastroenteritis
• Pregnancy-related hyperemesis
• Mild viral upper respiratory infection or pharyngitis

Exclusion Criteria:
• Moderate or severe dehydration
• Inability to receive oral intake for another reason

Protocol Steps:
Order oral rehydration fluids in the electronic health record (EHR); add antiemetic, pain control, or both if needed. Consider benzocaine or menthol lozenges in addition to acetaminophen or ibuprofen for pharyngitis. If there is significant nausea or pain, wait 20 min after medications to begin drinking (can start immediately otherwise).

The EHR order will direct the nurse to bring the patient two 500-ml pitchers of desired drink (flavored oral electrolyte solution or dilute sports drink or juice).
• Provide patient with straw as well as 30-ml medicine cup.
• Instruct patient to drink two large sips or 30 ml every 3–5 min. Use timers on cell phones or ask family to assist.
• Explain target hydration goals (see below) and provide a tracking sheet. Draw lines on pitcher for target volumes (e.g., “250 ml left”). Patient or family member should complete the tracking sheet.
• Return to reencourage oral intake as needed.

• If oral intake is insufficient, determine why and give additional antiemetic, pain control, or both as needed.
• If taste is a problem and dehydration mild (or not due to gastroenteritis), consider alternative liquid options, such as half-strength sports drink, dilute juice, or ginger ale.
For pregnancy-related hyperemesis, oral intake can often help. Encourage patients to try to eat a few crackers if possible.

Target Hydration Goals*:
Target times are given for the amount of liquid remaining at 2 sips or 30 ml every 3 min (or every 5 min)
• 1000 ml remaining: 0 min (0 min)
• 750 ml remaining: 25 min (40 min)
• 500 ml remaining: 50 min (1 hr 20 min)
• 250 ml remaining: 1 hr 15 min (2 hr)
• 0 ml remaining: 1 hr 40 min (2 hr 40 min)
* Patients with vomiting should be encouraged to maintain a slower rate of intake until they tolerate the fluid well. Patients without vomiting can drink faster, as tolerated. After an intake of 250 ml has been successfully completed without vomiting, and if nausea is well controlled, intake can increase to four sips or 60 ml every 3–5 min…

We share this protocol as a replicable model for other U.S. hospitals looking for strategies during the IV-fluid shortage. Experience in low-resource settings worldwide has proven the efficacy of oral rehydration therapy, and vulnerabilities of the U.S. IV-fluid supply chain are expected to continue. We believe that widespread use of oral rehydration protocols would therefore be a rational practice change and a mainstream model for use in the United States even after the current IV-fluid shortage crisis ends.

19. Clinical decision support increases diagnostic yield of CT for suspected PE

Mills AM, et al. Am J Emerg Med. 2018;36(4):540-44.

OBJECTIVE: Determine effects of evidence-based clinical decision support (CDS) on the use and yield of computed tomographic pulmonary angiography for suspected pulmonary embolism (CTPE) in Emergency Department (ED) patients.

METHODS: This multi-site prospective quality improvement intervention conducted in three urban EDs used a pre/post design. For ED patients aged 18+years with suspected PE, CTPE use and yield were compared 19months pre- and 32months post-implementation of CDS intervention based on the Wells criteria, provided at the time of CTPE order, deployed in April 2012. Primary outcome was the yield (percentage of studies positive for acute PE). Secondary outcome was utilization (number of studies/100 ED visits) of CTPE. Chi-square and statistical process control chart assessed pre- and post-intervention differences. An interrupted time series analysis was also performed.

RESULTS: Of 558,795 patients presenting October 2010-December 2014, 7987 (1.4%) underwent CTPE (mean age 52±17.5years, 66% female, 60.1% black); 34.7% of patients presented pre- and 65.3% post-CDS implementation. Overall CTPE diagnostic yield was 9.8% (779/7987 studies positive for PE). Yield increased a relative 30.8% after CDS implementation (8.1% vs. 10.6%; p=0.0003). There was no statistically significant change in CTPE utilization (1.4% pre- vs. 1.4% post-implementation; p=0.25). A statistical process control chart demonstrated immediate and sustained improvement in CTPE yield post-implementation. Interrupted time series analysis demonstrated the slope of PE findings versus time to be unchanged before and after the intervention (p=0.9). However, there was a trend that the intervention was associated with a 50% increased probability of PE finding (p=0.08), suggesting an immediate rather than gradual change after the intervention.

CONCLUSIONS: Implementing evidence-based CDS in the ED was associated with an immediate, significant and sustained increase in CTPE yield without a measurable decrease in CTPE utilization. Further studies will be needed to assess whether stronger interventions could further improve appropriate use of CTPE.

20. IV Continuous Infusion vs. Oral Immediate-release Diltiazem for Acute Heart Rate Control in AF

Means KN, et al. West J Emerg Med. 2018 Mar;19(2):417-422.

INTRODUCTION: Atrial fibrillation (AF) is a common diagnosis of patients presenting to the emergency department (ED). Intravenous (IV) diltiazem bolus is often the initial drug of choice for acute management of AF with rapid ventricular response (RVR). The route of diltiazem after the initial IV loading dose may influence the disposition of the patient from the ED. However, no studies exist comparing oral (PO) immediate release and IV continuous infusion diltiazem in the emergency setting. The objective of this study was to compare the incidence of treatment failure, defined as a heart rate (HR) of above 110 beats/min at four hours or conversion to another agent, between PO immediate release and IV continuous infusion diltiazem after an initial IV diltiazem loading dose in patients in AF with RVR.

METHODS: This was a single-center, observational, retrospective study conducted at a tertiary academic medical center. The study population included patients ≥18 years old who presented to the ED in AF with a HR above 110 beats/min and received an initial IV diltiazem loading dose. We used multivariate logistic regression to assess the association between routes of administration and treatment failure.

RESULTS: A total of 111 patients were included in this study. Twenty-seven percent (11/41) of the patients in the PO immediate-release group had treatment failure compared to 46% (32/70) in the IV continuous-infusion group. The unadjusted odds ratio (OR) of treatment failure with PO was less than IV at 0.4 (95% confidence interval [CI] [0.18, 0.99], p = 0.046). When we performed a multivariate analysis adjusted for race and initial HR, PO was still less likely to be associated with treatment failure than IV with an OR of 0.4 (95% CI [0.15, 0.94], p = 0.041). The median dose of PO diltiazem and IV continuous infusion diltiazem at four hours was 30 mg and 10 mg/h, respectively.

CONCLUSION: After a loading dose of IV diltiazem, PO immediate-release diltiazem was associated with a lower rate of treatment failure at four hours than IV continuous infusion in patients with AF with RVR.

21. Micro Bits

A. Film Shines Light on Deadly Errors in Medicine

Death toll in U.S. as high as 440,000 per year

by Ian Ingram, Deputy Managing Editor, MedPage Today. April 06, 2018

Can a film help shift the conversation on reducing deadly errors in medicine?

The documentary To Err Is Human, which is currently in previews and opens to wide release in the fall, attempts to answer that question, highlighting the obstacles, consequences, and attempts to address the myriad factors on both the institutional and individual level responsible for errors in medicine.

"It's a massive topic to address," said director Mike Eisenberg, following a recent screening of his film…

Between interviews with experts in the field of patient safety, To Err Is Human weaves in the story of Susan Sheridan, whose family's intersection with the healthcare system was met with two medical errors.

First, jaundice (a sign of too-high bilirubin) in her newborn son, Cal, was ignored and led to brain damage and development of cerebral palsy. Sheridan's experience led her to become a patient-safety advocate. Today hospitals routinely tests for elevated bilirubin.

Years later her husband Patrick was diagnosed with and treated for a benign brain tumor. Additional tests from pathology had revealed a malignant tumor, yet this was never communicated to Patrick's physician. Left untreated, the disease aggressively spread until it was too late. He died in 2002.

While the plan is for wide release in the fall, the trailer is now available online and various upcoming screenings have been scheduled in select cities -- including Cleveland on Monday, Tuesday and Wednesday next week, and Philadelphia on April 20. The latter will include a panel discussion.

B. Can Coffee Rev Up Your Workout? It May Depend on Your Genes

Author New York Times 2018 March 24

C. Federal Efforts To Control Rare And Deadly Bacteria Working

The CDC is trying to stop E. coli and other bacteria that have become resistant to antibiotics because they can cause a deadly infection.

D. SIGECAPS, SSRIs, and Silence — Life as a Depressed Med Student

E. Is chronic pain something more people should accept?

Amid the opioid crisis, the concept of “pain acceptance” is gaining credibility.

Clare Foran. April 4, 2018. The Outline.

Research dating back more than a decade suggests  that people with chronic pain may be able to improve their quality of life if they stop trying to avoid or get rid of their pain and instead learn to live as well as they can as the pain persists, a concept referred to in clinical settings as pain acceptance. Some psychologists and psychiatrists believe that pain acceptance might even help counteract opioid abuse in the United States, a problem so severe that it has contributed to a decline in American life expectancy. The idea that pain acceptance might serve as an effective alternative to opioids is an emerging area of research and not something that has been definitively established. As the idea attracts attention in the world of pain management and in the media, it has also generated controversy.

F. Meal Delivery Linked To Fewer Emergency Room Visits, Lower Monthly Medical Costs

Delivering meals, especially meals tailored to recipients’ medical needs, can reduce the use of costly health services among people eligible for both Medicare and Medicaid. With medical issues and poverty making them dually eligible for Medicare and Medicaid, this population is at high risk of experiencing food insecurity and its associated costs, according to a new study published in Health Affairs. 

G. Systematic review of presentation, management and prognosis idiopathic systemic capillary leak syndrome

The idiopathic systemic capillary leak syndrome is characterized by unexplained recurrent shock caused by capillary hyperpermeability. This systematic review of the literature analyzed clinical and laboratory data, treatment modalities, and mortality rate of patients. Two hundred sixty-three published cases were reviewed. Patients had hypotension (81.4%), edema (64.6%), and previous flu-like illness (34.2%). This disease was misdiagnosed as hypovolemic shock, septic shock, polycythemia vera, or angioedema. Twenty-three percent of cases were fatal. There were significant differences in the survival rates between patients who were treated with prophylactic beta-2 agonists, methylxanthines, and intravenous immunoglobulins versus those who were not. The estimated one-, five-, and 10-year survival rate of patients treated with intravenous immunoglobulins was 100%, 94%, and 94%, respectively.

H. Relationship between Clinic and Ambulatory Blood-Pressure Measurements and Mortality.

Conclusions Ambulatory blood-pressure measurements were a stronger predictor of all-cause and cardiovascular mortality than clinic blood-pressure measurements. White-coat hypertension was not benign, and masked hypertension was associated with a greater risk of death than sustained hypertension.

I. Some Caffeinated Beverages May Reduce Frequency Of Arrhythmias

HealthDay (4/16, Reinberg, 6K) reports that investigators analyzed data from eight studies. The researchers “found that, among more than 228,000 patients, drinking coffee cut the frequency of episodes of atrial fibrillation by 6 percent.” Meanwhile, “a further analysis of nearly 116,000 patients found a 13 percent risk reduction.” The investigators also “found that caffeine had no effect on abnormal heartbeats in the lower chambers of the heart, called ventricular arrhythmias.” The findings were published in JACC: Clinical Electrophysiology.

J. Physicians’ political preferences and the delivery of end of life care in the United States

This study provided no evidence that physician political affiliation is associated with the intensity of end of life care received by patients in hospital. Other treatments for politically polarised healthcare issues should be investigated.

K. Lidocaine patch for back pain? Not helpful.

Palmer TR. Am Fam Physician. 2017 Nov 15;96(10):online.

I appreciated the excellent review of vertebral compression fractures (VCFs) by Drs. McCarthy and Davis. The text of the article and Table 1 stated that lidocaine patches are an option for pain relief. However, the best evidence does not show any benefit from lidocaine 5% patches compared with placebo for somatic back pain.

There are no published randomized controlled trials (RCTs) of lidocaine patches for pain from VCFs. However, two unpublished RCTs showed no significant difference between placebo patches and lidocaine 5% patches for low back pain.1,2 Another RCT showed no significant difference between placebo and lidocaine patches for chronic low back pain.3 A final RCT showed no improvement in pain control with lidocaine patches vs. placebo for traumatic rib fractures.4

At a cost of $220 per month and with an over-the-counter lidocaine 4% patch now available, the lidocaine 5% patch is an expensive placebo for our patients.

L. Prolonged Zika Virus Shedding in Semen of Symptomatic Infected Men

M. Just 40% Of All Concussions In Children Result From Contact Sports, Researchers Say.

Medscape (4/11, Brooks, Subscription Publication, 304K) reports that “only 40% of all concussions in children” are “from contact sports, including football, soccer, basketball, and hockey,” researchers found. The findings, which were published online in the Journal of Pediatrics, suggest that “strategies to prevent such injuries in children will have to extend outside youth sports, the researchers say.”

N. Report: Ischemic heart disease top cause of death

A report in the Journal of the American Medical Association said ischemic heart disease was the leading cause of death in the US from 1990 to 2016, while the overall mortality rate decreased. There were wide disparities in disease burden, with increases in opioid use disorders and decreases in breast cancer mortality, while high blood pressure, blood glucose and body mass index, along with poor diet and alcohol and drug use, each accounted for more than 5% of risk-attributable disability-adjusted life years in 2016.

O. Seven tips for mastering the art of medicine

P. TXA Superior to Packing for Epistaxis, and Patients Like It Better.

Ballard DW, et al. Emerg Med News. 2018;40(4):1,32.

Q. Scientists Identify Interstitium As An Organ For First Time.

TIME (3/27, Park, 19.51M) reports scientists have proposed there is an organ called the interstitium “that may play a critical role in how many tissues and other organs do their jobs, as well as in some diseases.” The article explains that the interstitium “is a series of connected, fluid-filled spaces found under skin as well as throughout the gut, lungs, blood vessels and muscles.” Newsweek (3/27, Gander, 1.67M) reports the study, which was published in Scientific Reports, marks the “first time” that the interstitium “has been identified as an organ.”