Sunday, October 15, 2017

Lit Bits: Oct 15, 2017

From the recent medical literature...

1. Does How We Administer Oxygen Matter? Studies on Cardiogenic Pulmonary Edema and on Intubation

A. High-Flow Nasal Cannula Versus Conventional Oxygen Therapy in ED Patients with Cardiogenic Pulmonary Edema: A RCT

Makdee O, et al. Ann Emerg Med. 2017 Oct;70(4):465-472.e2.

Many patients present to the emergency department (ED) with cardiogenic pulmonary edema. In addition to reversing the specific underlying causes, conventional approaches to oxygen and ventilation therapy for these patients include nasal cannula oxygen, or face mask oxygen, noninvasive ventilation, and intubation.

A novel approach to oxygen and ventilation therapy is high-flow nasal cannula oxygen, which delivers oxygenated air up to 60 L/min. High-flow nasal cannula is reported to achieve FiO2 ranging from 21% to 100%. The flow levels are high enough to generate positive airway pressure, potentially decreasing entrapment of ambient air and providing support to reduce the work of breathing. Because high-flow oxygen can be uncomfortable, modern high-flow nasal cannula systems integrate oxygen warming and humidification to enhance patient comfort.

There have been previous studies of high-flow nasal cannula in both adult volunteers and critically ill patients with hypoxemic respiratory failure, with results generally supporting its efficacy in reducing respiratory rate and improving oxygenation. Most of these studies have involved cases of pneumonia in the ICU. Few studies and no randomized controlled trials, to our knowledge, have investigated the use of high-flow nasal cannula for the treatment of cardiogenic pulmonary edema in the ED setting. Because dyspnea rescue therapy often begins in the ED, evaluation of high-flow nasal cannula application in the ED setting is important.

Goals of This Investigation
The aim of this randomized study was to compare the effectiveness of high-flow nasal cannula with conventional oxygen therapy in ED patients with cardiogenic pulmonary edema.

STUDY OBJECTIVE: High-flow nasal cannula is a new method for delivering high-flow supplemental oxygen for victims of respiratory failure. This randomized controlled trial compares high-flow nasal cannula with conventional oxygen therapy in emergency department (ED) patients with cardiogenic pulmonary edema.

METHODS: We conducted an open-label randomized controlled trial in the ED of Siriraj Hospital, Bangkok, Thailand. Patients aged 18 years or older with cardiogenic pulmonary edema were randomly assigned to receive either conventional oxygen therapy or high-flow nasal cannula. The primary outcome was the respiratory rate 60 minutes postintervention.

RESULTS: We enrolled 128 participants (65 in the conventional oxygen therapy and 63 in the high-flow nasal cannula groups). Baseline high-flow nasal cannula and conventional oxygen therapy mean respiratory rates were 28.7 breaths/min (SD 3.2) and 28.6 breaths/min (SD 3.5). Mean respiratory rates at 60 minutes postintervention were lower in the high-flow nasal cannula group (21.8 versus 25.1 breaths/min; difference 3.3; 95% confidence interval 1.9 to 4.6). No significant differences were found in the admission rate, ED and hospital lengths of stay, noninvasive ventilation, intubation, or mortality.

CONCLUSION: In patients with cardiogenic pulmonary edema in the ED, high-flow nasal cannula therapy may decrease the severity of dyspnea during the first hour of treatment.

B. Two Systematic Reviews of Apneic Oxygenation

B1. Effectiveness of Apneic Oxygenation During Intubation: A Systematic Review and Meta-Analysis

Oliveira J E Silva L, et al. Ann Emerg Med. 2017 Oct;70(4):483-494.e11.

Apneic oxygenation consists in the administration of oxygen during the apneic period of the intubation procedure to extend the safe apnea time beyond that which can be achieved by preoxygenation alone. This concept was first introduced in the operating room setting,6 and more recently its use has been rapidly adopted during airway management in the emergency department (ED) and ICU. The rationale for apneic oxygenation revolves around the physiologic capacity of continuous oxygen capture by alveoli through a passive process without providing ventilation. During laryngoscopy, apneic oxygenation may be provided as continuous oxygen delivery throughout the intubation with nasal cannulas, nasopharyngeal catheters, and modified laryngoscopes.

Airway management is commonly performed by anesthesiologists, emergency physicians, and critical care providers as part of their daily practice. Most intubations are performed in the operating room under controlled, often ideal situations. However, out-of-operating-room intubations have been associated with higher risks of adverse events because they are frequently performed urgently in critically ill patients, for whom the rates of severe complications can be as high as 28%. Hypoxemia is an adverse effect that can occur during intubation. If oxygen were administered through the pharynx during the apneic period, one could increase the uptake of oxygen into the bloodstream, thus reducing occurrences of potentially harmful oxygen desaturation events.

Goals of This investigation
The use of apneic oxygenation has been recommended by experts for management of high-risk airway situations, including emergency intubations in the ED, and for patients at risk for difficult laryngoscopy and intubation in the operating room; however, the evidence supporting apneic oxygenation is still not well established. The objective of this systematic review and meta-analysis was to evaluate the effectiveness of apneic oxygenation on hypoxemia, first-pass success, and lowest oxygen saturation during emergency intubation.

STUDY OBJECTIVE: We conduct a systematic review and meta-analysis to evaluate the effectiveness of apneic oxygenation during emergency intubation.

METHODS: We searched Ovid MEDLINE, Ovid EMBASE, Ovid CENTRAL, and Scopus databases for randomized controlled trials and observational studies from 2006 until July 2016, without language restrictions. Gray literature,, and reference lists of articles were hand searched. We conducted a meta-analysis with random-effects models to evaluate first-pass success rates, incidence of hypoxemia, and lowest peri-intubation SpO2 between apneic oxygenation and standard oxygenation cases.

RESULTS: A total of 1,386 studies were screened and 77 selected for full-text review. A total of 14 studies were included for qualitative analysis, and 8 studies (1,837 patients) underwent quantitative analysis. In the meta-analysis of 8 studies (1,837 patients), apneic oxygenation was associated with decreased hypoxemia (odds ratio [OR] 0.66; 95% confidence interval [CI] 0.52 to 0.84), but was not associated with decreased severe hypoxemia (6 studies; 1,043 patients; OR 0.86; 95% CI 0.47 to 1.57) or life-threatening hypoxemia (5 studies; 1,003 patients; OR 0.90; 95% CI 0.52 to 1.55). Apneic oxygenation was associated with increased first-pass success rate (6 studies; 1,658 patients; OR 1.59; 95% CI 1.04 to 2.44) and increased lowest peri-intubation SpO2 (6 studies; 1,043 patients; weighted mean difference 2.2%; 95% CI 0.8% to 3.6%).

CONCLUSION: In this meta-analysis, apneic oxygenation was associated with increased peri-intubation oxygen saturation, decreased rates of hypoxemia, and increased first-pass intubation success.

B2. Apneic oxygenation during intubation in the ED and during retrieval: A systematic review and meta-analysis

Binks MJ, et al. Am J Emerg Med. 2017;35:1542-6.

Hypoxemia increases the risk of intubation markedly. Such concerns are multiplied in the emergency department (ED) and during retrieval where patients may be unstable, preparation or preoxygenation time limited and the environment uncontrolled. Apneic oxygenation is a promising means of preventing hypoxemia in this setting.

To test the hypothesis that apnoeic oxygenation reduces the incidence of hypoxemia during endotracheal intubation in the ED and during retrieval.

We undertook a systematic review of six databases for all relevant studies published up to November 2016. Included studies evaluated apneic oxygenation during intubation in the ED and during retrieval. There were no exemptions based on study design. All studies were assessed for level of evidence and risk of bias. The Review Manager 5.3 software was used to perform meta-analysis of the pooled data.

Six trials and a total 1822 cases were included for analysis. The study found a significant reduction in the incidence of desaturation (RR = 0.76, p = 0.002) and critical desaturation (RR = 0.51, p = 0.01) when apneic oxygenation was implemented. There was also a significant improvement in first pass intubation success rate (RR = 1.09, p = 0.004).

Apneic oxygenation may reduce patient hypoxemia during intubation performed in the ED and during retrieval. It also improves intubation first-pass success rate in this setting.

C. ED use of Apneic Oxygenation Vs Usual Care During Rapid Sequence Intubation: A RCT (The ENDAO Trial)

Caputo N, et al. Acad Emerg Med 2017 Aug 9 [Epub ahead of print]

OBJECTIVES: Desaturation leading to hypoxemia may occur during rapid sequence intubation (RSI). Apneic oxygenation (AO) was developed to prevent the occurrence of oxygen desaturation during the apnea period. The purpose of this study was to determine if the application of AO increases the average lowest oxygen saturation during RSI when compared to usual care (UC) in the emergency setting.

METHODS: A randomized controlled trial was conducted at an academic, urban, Level I trauma center. All patients requiring intubation were included. Exclusion criteria were patients in cardiac or traumatic arrest or if preoxygenation was not performed. An observer, blinded to study outcomes and who was not involved in the procedure, recorded all times, while all saturations were recorded in real time by monitors on a secured server. Two-hundred patients were allocated to receive AO (n = 100) or UC (n = 100) by predetermined randomization in a 1:1 ratio.

RESULTS: A total of 206 patients were enrolled. There was no difference in lowest mean oxygen saturation between the two groups (92, 95% confidence interval [CI] = 91 to 93 in AO vs. 93, 95% CI = 92 to 94 in UC; p = 0.11).

CONCLUSION: There was no difference in lowest mean oxygen saturation between the two groups. The application of AO during RSI did not prevent desaturation of patients in this study population.

Wait a minute? Two systematic reviews concluded that apneic oxygenation works, yet this RCT says it doesn’t. What’s up?

Sakles JC. Maintenance of Oxygenation During RSI in the ED. Acad Emerg Med. 2017 October 13 [Epub ahead of print]

At first glance, these results may seem surprising, but close analysis of the data reveals the reason why no benefit was seen: most of the patients in this trial were intubated very rapidly. The mean apnea time was 58 seconds in the control group and 64 seconds in the apneic oxygenation group. Ninety percent of the patients were intubated in less than 100 seconds; all were intubated by 3.3 minutes. We know from physiologic modeling experiments and human studies that with complete preoxygenation several minutes of safe apnea time can be expected in adults.[57-59] Since most of the patients in this study were intubated within a couple of minutes, the preoxygenation alone likely would have provided an adequate oxygen reservoir to prevent desaturation. Apneic oxygenation would only be beneficial in those patients who have exhausted their oxygen reserves, for example, patients who had prolonged laryngoscopies. This study illustrates the problem of studying apneic oxygenation in the critically ill—the necessity of rapid intubation and restoration of alveolar oxygen delivery precludes evaluation of the outcome measure of interest—an extended safe apnea time….

…Emergent tracheal intubation is one of the most critical, yet risky procedures an emergency physician can perform. Desaturation during RSI in the ED is common and, when severe, can result in life-threatening complications. The risk of desaturation can be substantially reduced with meticulous attention to preoxygenation, using the most appropriate method for the given clinical circumstances. Portable oxygen analyzers are now available and may be helpful in maximizing preoxygenation before emergent intubation. Apneic oxygenation is a simple intervention that may help reduce the risk of desaturation, but it will not rescue poor preoxygenation. An emphasis on the maintenance of oxygenation during RSI in the ED is necessary to improve the safety of this lifesaving procedure.

2. 2017 Update on Medical Overuse: A Systematic Review

Morgan DJ, et al. JAMA Intern Med. 2017 October 2 [Epub ahead of print].

IMPORTANCE: Overuse of medical care is a well-recognized problem.

OBJECTIVE: To identify and highlight original research articles published in 2016 that are most relevant to understanding medical overuse or strategies to reduce it.

EVIDENCE REVIEW: A structured review of English-language articles on PubMed published in 2016 coupled with examination of tables of contents of high-impact journals to identify articles related to medical overuse in adults. These articles were appraised for their importance to medicine.

FINDINGS: This study considered 2252 articles, 1224 of which addressed medical overuse. Of these, 122 were deemed most relevant based on originality, methodologic quality, and number of patients potentially affected. The 10 most influential articles were selected by author consensus. Select findings from the studies include the lack of benefit of transesophageal echocardiography in the workup of cryptogenic stroke, increasing use of computed tomography in the emergency department from 2.2% to 9.4% from 2001 to 2010, and carotid ultrasonography and revascularization being performed for uncertain or inappropriate indications with 95% frequency. Likewise, services for which harms are likely to outweigh benefits include treatment for early-stage prostate cancer, which provides no mortality benefit but increases absolute risk of erectile dysfunction by 10% to 30%, oxygen for patients with moderate chronic obstructive pulmonary disease, surgery for meniscal tear with mechanical symptoms, and nutritional interventions for inpatients with malnutrition. This review highlights 2 methods for reducing overuse: clinician audit and feedback with peer comparison for antibiotic use (reduction in inappropriate antibiotic use from 20% to 4%) and a practical and sensible shared decision-making tool for low-risk chest pain (reduction in emergency department workup from 52% to 37%).

CONCLUSIONS AND RELEVANCE: The body of empirical work continues to expand related to medical services that are provided for inappropriate or uncertain indications. Engaging patients in conversations aimed at shared decision making and giving practitioners feedback about their performance relative to peers appear to be useful in reducing overuse.

Studies applicable to emergency medicine include:

Computed Tomography Pulmonary Angiography (CTPA). The use of this test in emergency departments has increased markedly in recent years. The researchers found that the test is overused compared with less risky tests. Overuse of CTPA is likely to result in delays, higher costs, and patient harm from unnecessary exposure to radiation and contrast dye.

Strategies to Reduce Overuse of Antibiotics: Up to half of all antibiotic use is inappropriate. The researchers examined several methods to reduce the rate of antibiotic prescriptions by doctors. The most effective approach was to show doctors comparisons to their peers who prescribed correctly. In this group, inappropriate prescriptions dropped from nearly 20% to less than 4%. In this context, peer pressure can be effective, it appears.

Cardiac Imaging. Advanced cardiac imaging for patients with chest pain has more than tripled over the past decade. Many low-risk patients may receive noninvasive testing that could lead to unnecessary hospitalisation and intervention. A study in which doctors and patients shared decision-making over whether or not to test found that this approach reduced the number of tests.

3. Sepsis Corner: Definitions, Antibiotic Timing, Fluid Timing, and Antipyresis

A. An ED Validation of the SEP-3 Sepsis and Septic Shock Definitions and Comparison With 1992 Consensus Definitions

Henning DJ, et al. Ann Emerg Med 2017;70(4): 544–552.e5.

In 1992, Bone et al1 published consensus definitions for sepsis, revolving around the systemic inflammatory response syndrome (SIRS) criteria. The SIRS construct helped to identify an inflammatory response, which in the presence of an infection defined “sepsis.” This unified communication in both the clinical and research settings. However, criticism arose around the definitions’ being overly sensitive and nonspecific. For example, a young adult with routine streptococcal pharyngitis may exhibit fever and tachycardia, meeting the definition of sepsis; this patient often has no increased risk of severe short-term adverse effects from the infection. During the last 2 decades, many individuals have noted the limitations of SIRS criteria, prompting calls to revisit the definition of sepsis.

The Third International Consensus Definitions Task Force (SEP-3) revisited the sepsis definitions and published a set of revised definitions. To aid the effort, research using 2 large data sets guided derivation of criteria to risk-stratify patients with infection according to the likelihood of inhospital mortality. The quick Sequential Organ Failure Assessment (qSOFA) score emerged as a tool to identify septic patients at higher risk of short-term death, drawing observations from initial features in the emergency department (ED) and other settings. The qSOFA score targets easy bedside application and uses 3 clinical criteria, with each receiving 1 point if present: respiratory rate greater than or equal to 22 breaths/min, altered mental status, and hypotension defined by a systolic blood pressure less than or equal to 100 mm Hg. A qSOFA score of 2 or greater was associated with an increased risk of mortality. The definitions group proposed using a suspected infection plus a qSOFA score greater than or equal to 2 to help identify patients with potential sepsis in the non-ICU setting. The SEP-3 authors state that qSOFA score greater than or equal to 2 should prompt clinicians to investigate for organ dysfunction because these patients may be septic.

The SEP-3 group redefined septic shock as patients with hypotension requiring vasopressor support to maintain a mean arterial pressure of 65 mm Hg and a lactate level greater than 2.0 mmol/L after adequate resuscitation. This definition sought to select patients with a higher acuity by including vasopressors as a criterion along with a biochemical response. This enhances specificity for the most ill septic patients, although the overall effect on care across the sepsis spectrum is unknown.

The SEP-3 authors acknowledge that these new definitions require validation in specific clinical settings, including the ED. We sought to evaluate the performance of the SEP-3 qSOFA criteria and revised septic shock definition in predicting mortality in ED patients with a suspected infection, and to compare the performance of the SEP-3 definitions to the previous 1992 consensus criteria of sepsis, severe sepsis, and septic shock.

STUDY OBJECTIVE: The Third International Consensus Definitions Task Force (SEP-3) proposed revised criteria defining sepsis and septic shock. We seek to evaluate the performance of the SEP-3 definitions for prediction of inhospital mortality in an emergency department (ED) population and compare the performance of the SEP-3 definitions to that of the previous definitions.

METHODS: This was a secondary analysis of 3 prospectively collected, observational cohorts of infected ED subjects aged 18 years or older. The primary outcome was all-cause inhospital mortality. In accordance with the SEP-3 definitions, we calculated test characteristics of sepsis (quick Sequential Organ Failure Assessment [qSOFA] score ≥2) and septic shock (vasopressor dependence plus lactate level over 2.0 mmol/L) for mortality and compared them to the original 1992 consensus definitions.

RESULTS: We identified 7,754 ED patients with suspected infection overall; 117 had no documented mental status evaluation, leaving 7,637 patients included in the analysis. The mortality rate for the overall population was 4.4% (95% confidence interval [CI] 3.9% to 4.9%). The mortality rate for patients with qSOFA score greater than or equal to 2 was 14.2% (95% CI 12.2% to 16.2%), with a sensitivity of 52% (95% CI 46% to 57%) and specificity of 86% (95% CI 85% to 87%) to predict mortality. The original systemic inflammatory response syndrome-based 1992 consensus sepsis definition had a 6.8% (95% CI 6.0% to 7.7%) mortality rate, sensitivity of 83% (95% CI 79% to 87%), and specificity of 50% (95% CI 49% to 51%). The SEP-3 septic shock mortality was 23% (95% CI 16% to 30%), with a sensitivity of 12% (95% CI 11% to 13%) and specificity of 98.4% (95% CI 98.1% to 98.7%). The original 1992 septic shock definition had a 22% (95% CI 17% to 27%) mortality rate, sensitivity of 23% (95% CI 18% to 28%), and specificity of 96.6% (95% CI 96.2% to 97.0%).

CONCLUSION: Both the new SEP-3 and original sepsis definitions stratify ED patients at risk for mortality, albeit with differing performances. In terms of mortality prediction, the SEP-3 definitions had improved specificity, but at the cost of sensitivity. Use of either approach requires a clearly intended target: more sensitivity versus specificity.

Letters to the editor:
Prognostic Accuracy of Quick Sequential Organ Failure Assessment Among Emergency Department Patients Admitted to an ICU:

B. The Timing of Early Antibiotics and Hospital Mortality in Sepsis.

Liu VX, et al. Am J Respir Crit Care Med. 2017 Oct 1;196(7):856-863

RATIONALE: Prior sepsis studies evaluating antibiotic timing have shown mixed results.

OBJECTIVE: To evaluate the association between antibiotic timing and mortality among sepsis patients receiving antibiotics within 6 hours of emergency department registration.

METHODS AND MEASUREMENTS: Retrospective study of 35,000 randomly selected sepsis inpatients treated at 21 emergency departments between 2010 and 2013 in Northern California. The primary exposure was antibiotics given within six hours of emergency department registration. The primary outcome was adjusted in-hospital mortality. We used detailed physiologic data to quantify severity of illness within 1 hour of registration and logistic regression to estimate the odds of hospital mortality based on antibiotic timing and patient factors.

MAIN RESULTS: The median time to antibiotic administration was 2.1 hours (interquartile range: 1.4-3.1 hours). The adjusted odds ratio for hospital mortality based on each hour of delay in antibiotics after registration was 1.09 (95% CI, 1.05-1.13) for each elapsed hour between registration and antibiotic administration. The increase in absolute mortality associated with an hours delay in antibiotic administration was: 0.3% (95% CI, 0.01%-0.6%; p=0.04) for sepsis; 0.4% (95% CI, 0.1%-0.8%; p=0.02) for severe sepsis; and 1.8% (95% CI, 0.8%-3.0%; p=0.001) for shock.

CONCLUSIONS: In a large, contemporary, and multicenter sample of sepsis patients in the emergency department, hourly delays in antibiotic administration were associated with increased odds of hospital mortality even among patients all of whom received antibiotics within 6 hours. The odds increased within each sepsis severity strata and the increased odds of mortality were greatest in septic shock.

Is it time to implement door-to-needle time for “infection attacks”?

Laupland KB, et al. Intensive Care Medicine. 2017;43(11):1712–1713.

Despite decades of research investigation, efforts to increase awareness and quality improvement initiatives efforts, morbidity and mortality due to severe sepsis and septic shock remains unacceptably high [1]. There has been an extensive search for novel adjunctive therapies and treatment strategies not limited to an array of immune-modulatory agents, anti-coagulants, and supportive treatments involving glucose control, fluid therapy, and vasopressor, inotropic, and organ support [2]. While gains in general associated with the outcomes of critical illness have been achieved, improvement in outcomes associated specifically with severe sepsis and septic shock management in recent years has been at best modest.

Antibiotic therapy has been a central aspect of sepsis and septic shock management in the modern era. A substantial body of observational studies has shown that delay in the time to receipt of antibiotics is associated with adverse outcome among patients with severe sepsis and septic shock [3 (Liu VX, et al. above), 4]. While guidelines recommend that antibiotics be administered within 1 h, it must be recognized that this has not been proven in a randomized trial and that controversy still exists as to what may define a clinically significant delay or threshold for antibiotic initiation [5, 6].

In a recent article in this journal, Bloos et al. report the results of a cluster randomized trial within 40 German ICUs comparing a multi-faceted enhanced educational and feedback program with a control group receiving standard education surrounding antibiotic therapy of sepsis and septic shock for the primary outcome of 28-day mortality [7]. The multi-faceted intervention resulted in neither a significant reduction in mortality nor a reduced time to receipt of antimicrobial therapy. However, the overall finding was that each 1-h delay in antibiotic therapy or source control was associated with a 2 or 1% increase in mortality, respectively.

While not demonstrating that the study intervention reduces time to antibiotic therapy (and thus in turn mortality), this study does provide further evidence to add to the evolving body of literature supporting the importance of early antibiotic therapy on improved sepsis outcome. Indeed, to definitively prove that early therapy improves outcome, the best experimental method would be to randomize patients to early compared to late therapy. Obviously, ethical considerations would preclude such a study. Bloos et al. are praised for their efforts to attempt to address this question though an indirect, but ethically appropriate, design. Although not conclusively proven, as a result of the large and increasing body of observational evidence, clinical plausibility, and feasibility, the recommendation for early therapy in sepsis and septic shock in our opinion remains prudent [1]…

The remainder of the editorial (free):

C. Patterns and Outcomes Associated with Timeliness of Initial Crystalloid Resuscitation in a Prospective Sepsis and Septic Shock Cohort.

Leisman DE, et al. Crit Care Med. 2017 Oct;45(10):1596-1606.

OBJECTIVES: The objectives of this study were to 1) assess patterns of early crystalloid resuscitation provided to sepsis and septic shock patients at initial presentation and 2) determine the association between time to initial crystalloid resuscitation with hospital mortality, mechanical ventilation, ICU utilization, and length of stay.

DESIGN: Consecutive-sample observational cohort.

SETTING: Nine tertiary and community hospitals over 1.5 years.

PATIENTS: Adult sepsis and septic shock patients captured in a prospective quality improvement database inclusion criteria: suspected or confirmed infection, greater than or equal to two systemic inflammatory response criteria, greater than or equal to one organ-dysfunction criteria.

INTERVENTIONS: The primary exposure was crystalloid initiation within 30 minutes or lesser, 31-120 minutes, or more than 120 minutes from sepsis identification.

MEASUREMENTS AND MAIN RESULTS: We identified 11,182 patients. Crystalloid initiation was faster for emergency department patients (β, -141 min; CI, -159 to -125; p less than 0.001), baseline hypotension (β, -39 min; CI, -48 to -32; p less than 0.001), fever, urinary or skin/soft-tissue source of infection. Initiation was slower with heart failure (β, 20 min; CI, 14-25; p less than 0.001), and renal failure (β, 16 min; CI, 10-22; p less than 0.001). Five thousand three hundred thirty-six patients (48%) had crystalloid initiated in 30 minutes or lesser versus 2,388 (21%) in 31-120 minutes, and 3,458 (31%) in more than 120 minutes. The patients receiving fluids within 30 minutes had lowest mortality (949 [17.8%]) versus 31-120 minutes (446 [18.7%]) and more than 120 minutes (846 [24.5%]). Compared with more than 120 minutes, the adjusted odds ratio for mortality was 0.76 (CI, 0.64-0.90; p = 0.002) for 30 minutes or lesser and 0.76 (CI, 0.62-0.92; p = 0.004) for 31-120 minutes. When assessed continuously, mortality odds increased by 1.09 with each hour to initiation (CI, 1.03-1.16; p = 0.002). We observed similar patterns for mechanical ventilation, ICU utilization, and length of stay. We did not observe significant interaction for mortality risk between initiation time and baseline heart failure, renal failure, hypotension, acute kidney injury, altered gas exchange, or emergency department (vs inpatient) presentation.

CONCLUSIONS: Crystalloid was initiated significantly later with comorbid heart failure and renal failure, with absence of fever or hypotension, and in inpatient-presenting sepsis. Earlier crystalloid initiation was associated with decreased mortality. Comorbidities and severity did not modify this effect.

We did not observe significant interaction effects between time to fluid initiation and mortality by the phenotypes tested. This may be particularly important for patients with preexisting heart or renal failure, as physicians frequently employ more conservative volume expansion strategies for resuscitation in these patients. This subset of our cohort had longer time to initiation and lower initial volumes administered. Our results are consistent with another population level investigation that found that sepsis bundle application was associated with improved survival in these populations (13) and suggest these patients benefit equally from rapid administration of initial fluid resuscitation. This—likely generalizable—pattern may provide an arena for improvement.

Reference 13: Liu VX, et al. Am J Respir Crit Care Med. 2016;193(11):1264-70.

D. Does Antipyresis Improve Mortality in Critically Ill Septic Patients?

Long B, et al. Ann Emerg Med 2017;70(4):573-5.

Take-Home Message
Antipyretic therapy through pharmacologic and physical cooling decreases body temperature but does not reduce 28-day or inhospital mortality in adult patients with sepsis.

4. Effect of patient weight on first pass success and neuromuscular blocking agent dosing for rapid sequence intubation in the ED

Patanwala AE, et al. Emerg Med J 16 August 2017 [Epub ahead of print]

Objectives The primary objective of this study was to determine the association between patient weight and first pass success (FPS) during rapid sequence intubation (RSI) in the ED. The secondary objective was to evaluate the association between patient weight and neuromuscular blocking agent (NMBA) dosing.

Methods This was a retrospective cohort study conducted in a tertiary care academic ED. Consecutive adult patients who underwent RSI in the ED between January 2014 and June 2016 were included. Data were collected on patient, operator and procedural characteristics. The cohort was categorised into the following weight strata: less than 80 kg, 80 to 100 kg, 100 to 120 kg and ≥120 kg. The primary outcome of interest was FPS. A multivariable logistic regression analysis was conducted to evaluate the relationship between patient weight category and FPS. NMBA dosing was reported descriptively.

Results The sample included 891 patients. FPS for each weight category was as follows: less than 80 kg (91%), 80 to 100 kg (90%), 100 to 120 kg (91%) and ≥120 kg (76%). After adjusting for potential confounders, the heaviest weight category was associated with decreased odds of FPS (OR 0.2, 95% CI 0.1 to 0.5, p less than 0.001). Median doses for succinylcholine (based on total body weight) decreased as weight increased: less than 80 kg (1.5 mg/kg), 80 to 100 kg (1.3 mg/kg), 100 to 120 kg (1.2 mg/kg) and ≥120 kg (1.0 mg/kg). Median doses for rocuronium (based on ideal body weight) were similar across weight categories: less than 80 kg (1.3 mg/kg), 80 to 100 kg (1.4 mg/kg), 100 to 120 kg (1.3 mg/kg) and ≥120 kg (1.4 mg/kg).

Conclusions Very heavy patients (over 120 kg) undergoing RSI in the ED had a reduced FPS, and succinylcholine was more commonly underdosed than rocuronium in the heavier weight group.

5. CT Before LP for Possible Meningitis?

A. Emerg Med Myths: CT of the Head Prior to LP in Adults with Suspected Bacterial Meningitis – Due Diligence or Antiquated Practice?

April MD, et al. J Emerg Med 2017;53:313-321.

Various sources purport an association between lumbar puncture and brainstem herniation in patients with intracranial mass effect lesions. Several organizations and texts recommend head computed tomography (CT) prior to lumbar puncture in selected patients.

To review the evidence regarding the utility of obtaining head CT prior to lumbar puncture in adults with suspected bacterial meningitis.

Observational studies report a risk of post-lumbar puncture brainstem herniation in the presence of intracranial mass effect (1.5%) that is significantly lower than that reported among all patients with bacterial meningitis (up to 13.3%). It is unclear from existing literature whether identifying patients with intracranial mass effect decreases herniation risk. Up to 80% of patients with bacterial meningitis experiencing herniation have no CT abnormalities, and approximately half of patients with intracranial mass effect not undergoing lumbar puncture herniate. Decision rules to selectively perform CT on only those individuals most likely to have intracranial mass effect lesions have not undergone validation. Despite recommendations for immediate antimicrobial therapy prior to imaging, data indicate an association between pre-lumbar puncture CT and antibiotic delays. Recent data demonstrate shortened door-to-antibiotic times and lower mortality from bacterial meningitis after implementation of new national guidelines, which restricted generally accepted CT indications by removing impaired mental status as imaging criterion.

Data supporting routine head CT prior to lumbar puncture are limited. Physicians should consider selective CT for those patients at risk for intracranial mass effect lesions based on decision rules or clinical gestalt. Patients undergoing head CT must receive immediate antibiotic therapy.

B. CT (Almost) Never Before LP

Ryan Radecki. EM Lit on Note. October 12, 2017

The guidelines describing the patients with suspected bacterial meningitis for whom neuroimaging is indicated prior to lumbar puncture are quite broad. The Infectious Disease Society of America includes virtually every imaginable mental status or immune system impairment, and guidelines in Europe are similar. The anachronistic concern: cerebral herniation in the setting of increased intracranial pressure leading to an otherwise potentially avoidable death. But, guidelines in Sweden are different. In Sweden, their neuroimaging guidelines suggest only those virtually comatose or with focal neurologic signs should undergo CT prior to LP.

In this review of patients with acute bacterial meningitis from a Swedish registry, the authors attempt to parse out whether a decision to perform CT is not only unnecessary – but also potentially harmful. They analyze 815 patients ultimately diagnosed with bacterial meningitis and stratify them by those who received LP without CT, LP before CT, and CT before LP. Presenting features and comorbid medical conditions were abstracted retrospectively, and the results were analyzed with respect to the varying guideline recommendations, mortality, and functional outcomes.

The clear winner: CT rarely before LP, as in Sweden. By their guidelines, only ~7% of those ultimately diagnosed with bacterial meningitis had indication for CT prior to LP – but, unfortunately, 52% of patients underwent imaging anyway. The reason for “winning” if adherent to the Swedish strategy, however, was not just reduced resource utilization – it was mortality and functional outcomes. Mortality was almost halved in those for whom Swedish guidelines were followed, only rarely CT prior to LP. The authors attribute the signals for the underlying mortality difference to a greater percentage of patients receiving antibiotics within 1 hour or 2 hours when no CT was performed.

This probably overstates the magnitude of harm relating to CT use, as delays in antibiotics are probably more accurately delays in diagnosis, rather than logistics impacting timely delivery of antibiotics. After all, even in those with LP prior to CT, only 41% received steroids plus adequate antibiotics, so I expect the magnitude of effect seen here likely ties more reliably to confounding individual patient factors not easily adjusted for in a retrospective analysis.

That said, I do think the Swedes are doing the right thing – the vast majority of CTs were unhelpful. Their guidelines for neuroimaging – deep coma and/or lateralizing neurologic signs – will probably pick up any relevant findings (like the subdural empyema in this series), and reduce waste while obviating any possible delays in care.

Their Conclusion: Adherence to Swedish guidelines in ABM (acute bacterial meningitis) is associated with decreased mortality and increased favorable outcome in contrast to adherence to ESCMID or IDSA recommendations. Our findings support that impaired mental status and immunocompromised state should not be considered indications for neuroimaging before LP in patients with suspected ABM.

6. Ibutilide effectiveness and safety in the cardioversion of AF and AFL in the community ED setting.

Vinson DR, et al, for the Pharm CAFÉ investigators of the CREST Network. Ann Emerg Med. 2017 Sept 29 [Epub ahead of print].

Background and Importance
Restoration of sinus rhythm in patients with atrial fibrillation (AF) reduces rhythm-related symptoms and functional impairment and improves exercise tolerance and quality of life.1-3 Sinus restoration also has been shown to improve left ventricular function and may delay the onset of persistent atrial dysrhythmia.4-8 Moreover, cardioversion of atrial fibrillation and atrial flutter (AFL; combined, AF/FL) in the emergency department (ED) is associated with increased patient satisfaction and reduced hospitalization and costs.9-11 Pharmacological cardioversion, though less effective than electrical cardioversion (roughly 50% vs 90% successful), avoids the need for procedural sedation and is thereby less resource intensive. Some medical centers begin with a pharmacological approach and proceed to electrical cardioversion only as needed,12 a practice also used in the community emergency setting.13

Ibutilide is among the leading recommended pharmacological agents for the cardioversion of presumed recent-onset AF/FL,14-17 and it is particularly useful in the ED because of its rapid effect and minimal impact on hemodynamics.18-21 Like other class III antidysrhythmics, however, ibutilide prolongs the QTc interval, increasing risk for ventricular tachycardia (VT). The incidence of VT in the trial data is concerning: up to 5% for sustained monomorphic VT and 4% for polymorphic VT, although most of the latter is unsustained.22, 23 This risk generated a black box warning and is the reason that the standard ibutilide dose of 2 mgs is divided into two half-doses of 1 mg each (or 0.01 mg/kg for patients less than 60 kg), separated by 10 minutes. The brief observation period between half-doses allows for the assessment of both early cardioversion and VT, which contraindicate the second half-dose.19, 20 VT nearly always occurs during or within 45 minutes of infusion,23 but given the half-life of ibutilide, U.S. and European cardiology societies recommend continuous electrocardiographic (ECG) monitoring during and for 4 hours following administration.14, 16

The risk of ibutilide-induced VT can be reduced by excluding patients with high-risk conditions, particularly congestive heart failure.20, 22, 24 Risk-reducing patient selection criteria have been integrated into trial protocols to various degrees. Early trials included patients with significant systolic dysfunction,20, 22, 25 but entry criteria have become stricter over time.26-28 Excluding patients with hypokalemia, hypomagnesemia, and prolonged QTc is nearly universal.20, 21, 25, 26, 28-39 It is unclear, however, how commonly such patient selection criteria are applied in unscripted community emergency medicine practice. The few studies that have evaluated ibutilide in the ED have limited generalizability, being single-center European studies, most of which are hampered by small sample sizes.30, 35, 36, 40 This is one of the first multicenter studies to describe ibutilide use and patient outcomes among U.S. community-based EDs.

Goals of this Investigation
We undertook this multicenter retrospective cohort study to improve understanding of ibutilide use in the real-world community ED setting. Our aims were (1) to characterize patient selection; (2) to describe cardioversion effectiveness of ibutilide at 90-minutes and 4-hours; (3) to analyze the association of candidate predictor variables with cardioversion success; and (4) to describe the 4-hour incidence of VT and other adverse events. The results of this first report of the Pharm CAFÉ (Pharmacological Cardioversion of Atrial Fibrillation/Flutter Effectiveness) Study may help inform the ED management of AF/FL patients eligible for cardioversion.

Study objective: Little is known about the use of ibutilide for cardioversion in atrial fibrillation and flutter outside of clinical trials. We seek to describe patient characteristics, ibutilide administration patterns, cardioversion rates, and adverse outcomes in the community emergency department (ED) setting. We also evaluate potential predictors of cardioversion success.

Methods: Using a retrospective cohort of adults who received ibutilide in 21 community EDs between January 2009 and June 2015, we gathered demographic and clinical variables from electronic health records and structured manual chart review. We calculated rates of cardioversion and frequency of ventricular tachycardia within 4 hours and estimated adjusted odds ratios (aOR) in a multivariate regression model for potential predictors of cardioversion.

Results: Among 361 patients, the median age was 61 years (interquartile range 53 to 71 years) and most had recent-onset atrial fibrillation and flutter (98.1%). Five percent of the cohort had a history of heart failure. The initial QTc interval was prolonged (over 480 ms) in 29.4% of patients, and 3.1% were hypokalemic (less than 3.5 mEq/L). The mean ibutilide dose was 1.5 mg (SD 0.5 mg) and the rate of ibutilide-related cardioversion within 4 hours was 54.8% (95% confidence interval [CI] 49.6% to 60.1%), 50.5% for atrial fibrillation and 75.0% for atrial flutter. Two patients experienced ventricular tachycardia (0.6%), both during their second ibutilide infusion. Age (in decades) (aOR 1.3; 95% CI 1.1 to 1.5), atrial flutter (versus atrial fibrillation) (aOR 2.7; 95% CI 1.4 to 5.1), and no history of atrial fibrillation and flutter (aOR 2.0; 95% CI 1.2 to 3.1) were associated with cardioversion.

Conclusion: The effectiveness and safety of ibutilide in this community ED setting were consistent with clinical trial results despite less stringent patient selection criteria.

Figure E2. Clinical decision aid for the use of ibutilide for the cardioversion of atrial fibrillation or flutter.

Full-text available upon request.

7. Angioedema in the ED: a practical guide to differential diagnosis and management.

Bernstein JA, et al. Int J Emerg Med. 2017 Dec;10(1):15.

BACKGROUND: Angioedema is a common presentation in the emergency department (ED). Airway angioedema can be fatal; therefore, prompt diagnosis and correct treatment are vital.

OBJECTIVE OF THE REVIEW: Based on the findings of two expert panels attended by international experts in angioedema and emergency medicine, this review aims to provide practical guidance on the diagnosis, differentiation, and management of histamine- and bradykinin-mediated angioedema in the ED.

REVIEW: The most common pathophysiology underlying angioedema is mediated by histamine; however, ED staff must be alert for the less common bradykinin-mediated forms of angioedema. Crucially, bradykinin-mediated angioedema does not respond to the same treatment as histamine-mediated angioedema. Bradykinin-mediated angioedema can result from many causes, including hereditary defects in C1 esterase inhibitor (C1-INH), side effects of angiotensin-converting enzyme inhibitors (ACEis), or acquired deficiency in C1-INH. The increased use of ACEis in recent decades has resulted in more frequent encounters with ACEi-induced angioedema in the ED; however, surveys have shown that many ED staff may not know how to recognize or manage bradykinin-mediated angioedema, and hospitals may not have specific medications or protocols in place.

CONCLUSION: ED physicians must be aware of the different pathophysiologic pathways that lead to angioedema in order to efficiently and effectively manage these potentially fatal conditions.

8. On Healthcare Delivery

A. The Best Health Care System in the World: Which One Would You Pick?

By AARON E. CARROLL and AUSTIN FRAKT. New York Times. SEPT. 18, 2017

To better understand one of the most heated U.S. policy debates, we created a tournament to judge which of these nations has the best health system: Canada, Britain, Singapore, Germany, Switzerland, France, Australia and the U.S.

“Medicare for all,” or “single-payer,” is becoming a rallying cry for Democrats.

This is often accompanied by calls to match the health care coverage of "the rest of the world." But this overlooks a crucial fact: The “rest of the world” is not all alike.

The commonality is universal coverage, but wealthy nations have taken varying approaches to it, some relying heavily on the government (as with single-payer); some relying more on private insurers; others in between.

Experts don’t agree on which is best; a lot depends on perspective. But we thought it would be fun to stage a small tournament.

We selected eight countries, representing a range of health care systems, and established a bracket by randomly assigning seeds.

To select the winner of each matchup, we gathered a small judging panel, which includes us:

Aaron Carroll, a health services researcher and professor of pediatrics at Indiana University School of Medicine

Austin Frakt, director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health

and three economists and physician experts in health care systems:

Craig Garthwaite, a health economist with Northwestern University’s Kellogg School of Management

Uwe Reinhardt, a health economist with Princeton University’s Woodrow Wilson School of Public and International Affairs

Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health and the director of the Harvard Global Health Institute

A summary of our worldviews on health care is at bottom.

So that you can play along at home and make your own picks, we’ll describe each system along with our choices (the experts' selections will decide who advances). When we cite hard data, they come from the Commonwealth Fund’s International Country Comparison in 2017.

But enough talk. Let’s play….

The remainder of the essay (full-text free) is here:

B. The Key to Reducing Doctors’ Misdiagnoses: Researchers are finding new ways to make sure physicians make the right call

By Laura Landro. The Wall Street Journal · September 12, 2017

Doctors are developing novel solutions to make sure they come up with the right diagnoses.

A flood of new initiatives by researchers, physicians, health-care systems, nonprofits and malpractice insurers is yielding new insights and approaches. These include sophisticated computer programs, some that use artificial intelligence to help analyze and diagnose tough cases, and others that scan records for errors such as missed test results and appointments. Advanced technologies aren’t just bringing the processing power of big data and machine learning to bear. They are also allowing more doctors to share their knowledge—including lessons they’ve learned from their own diagnostic mistakes.

Misdiagnoses are a leading cause of medical malpractice suits in the U.S., and they don’t have simple causes or solutions. Most people will experience at least one diagnostic error in their lifetime, sometimes with “devastating consequences,” according to a landmark 2015 report by the National Academies of Sciences, Engineering and Medicine.

For decades, inaccurate or delayed diagnosis has been “a blind spot in the delivery of quality care,” said the report, which is broadly credited in scientific circles with inspiring the recent multipronged push for improvements.

“There is a huge opportunity to put knowledge and tools into the hands of clinicians to help them make a better or more timely and accurate diagnosis,” says Janet Corrigan, head of the patient-care program at the nonprofit Gordon and Betty Moore Foundation, which is funding several projects to improve the accuracy of medical diagnoses.

Here are some of the most promising efforts:

Spotting Mistakes
A Pennsylvania hospital is experimenting with the first formal computerized program to track, measure and analyze doctors’ diagnostic mistakes—sometimes as they are happening. The Safer Dx Learning Lab is being implemented at Geisinger Medical Center, the flagship of Geisinger Health System, based in Danville, Pa., which has 13 hospitals, a health plan and a medical school. The project is funded by a Moore Foundation grant and is led by Hardeep Singh, chief of health policy, quality and informatics at the Michael E. DeBakey VA Medical Center and an associate professor at Baylor College of Medicine in Houston.

Once fully installed, the system will scan electronic medical records to identify patients who are experiencing potential or actual diagnostic mistakes or delays, based on certain clinical criteria, such as abnormal chest X-rays or CT scans for which there is no documented follow-up. Flagged records will then be reviewed for confirmation, analysis and further action.

For example, Geisinger will look at patients who return to the ER unexpectedly within 48 hours after discharge, or a hospital patient who was unexpectedly transferred to an intensive-care unit to see what happened and why.

“Knowledge from systematically analyzing missed opportunities in correct or timely diagnosis will inform improvements and create a learning health system for diagnosis,” Dr. Singh says.

Dr. Singh’s research suggests doctors often miss common conditions with significant potential for harm….

The remainder of the essay (full-text free) is here:

9. Video Laryngoscopy Helps Even Experienced Intubators

This systematic review finds that video laryngoscopy improves outcomes, even for experts.

Pieters BMA, et al. Videolaryngoscopy vs. direct laryngoscopy use by experienced anaesthetists in patients with known difficult airways: a systematic review and meta-analysis. Anaesthesia. 2017 Sep 22 [Epub ahead of print].

Experienced anaesthetists can be confronted with difficult or failed tracheal intubations. We performed a systematic review and meta-analysis to ascertain if the literature indicated if videolaryngoscopy conferred an advantage when used by experienced anaesthetists managing patients with a known difficult airway.

We searched PubMed, MEDLINE, Embase and the Cochrane central register of controlled trials up to 1 January 2017. Outcome parameters extracted from studies were: first-attempt success of tracheal intubation; time to successful intubation; number of intubation attempts; Cormack and Lehane grade; use of airway adjuncts (e.g. stylet, gum elastic bougie); and complications (e.g. mucosal and dental trauma).

Nine studies, including 1329 patients, fulfilled the inclusion criteria. First-attempt success was greater for all videolaryngoscopes (OR 0.34 (95%CI 0.18-0.66); p = 0.001). Use of videolaryngoscopy was associated with a significantly better view of the glottis (Cormack and Lehane grades 1 and 2 vs. 3-4, OR 0.04 (95%CI 0.01-0.15); p less than 0.00001). Mucosal trauma occurred less with the use of videolaryngoscopy (OR 0.16 (95%CI 0.04-0.75); p = 0.02).

Videolaryngoscopy has added value for the experienced anaesthetist, improving first-time success, the view of the glottis and reducing mucosal trauma.

10. Images in Clinical Practice

Calcium Oxalate Crystals in Ethylene Glycol Toxicity

Acute Esophageal Necrosis

“Acrobatic” Lice

Pulmonary Foreign-Body Granulomatosis

Intraocular Infection with a Trematode

Middle-Aged Male With Right Neck Pain

Young Woman With Ankle Pain

Woman With Headache and Vertigo

Elderly Man With Bullous Eruption on the Feet

Elderly Man in Respiratory Arrest

Young Girl With Abdominal Pain

Child With Cough and Fever

Yellow Palms and Soles: Look Beyond the Eyes and Think Beyond Hyperbilirubinemia

Small-Bowel Intussusception in a Pregnant Woman: A Case Report

11. Comparison of outcomes for pediatric paraphimosis reduction using topical anesthetic versus intravenous procedural sedation

Burstein B, et al. Am J Emerg Med. 2017;35:1391–1395.

Paraphimosis is an acute urologic emergency requiring urgent manual reduction, frequently necessitating procedural sedation (PS) in the pediatric population. The present study sought to compare outcomes among pediatric patients undergoing paraphimosis reduction using a novel topical anesthetic (TA) technique versus PS.

We performed a retrospective analysis of all patients less than 18 years old, presenting to a tertiary pediatric ED requiring analgesia for paraphimosis reduction between October 2013 and September 2016. The primary outcome was reduction first attempt success; secondary outcomes included Emergency Department length of stay (ED LOS), adverse events and return visits. Dichotomous outcomes were analyzed by Chi-square testing and multivariate linear regression was used to compare continuous variables.

Forty-six patients were included; 35 underwent reduction using TA, 11 by PS. Patient age and duration of paraphimosis at ED presentation did not differ between groups. There was no difference in first attempt success between TA (32/35, 91.4%) and PS groups (9/11, 81.8%; p = 0.37). Mean ED LOS was 209 min shorter for TA patients (148 min vs. 357 min, p = 0.001) and remained significantly shorter after controlling for age and duration of paraphimosis (adjusted mean difference −198 min, p = 0.003). There were no return visits or major adverse events in either group, however, among successful reduction attempts, PS patients more frequently experienced minor adverse events (7/9 vs. 0/32, p  less than  0.001).

Paraphimosis reduction using TA was safe and effective. Compared to PS, TA was associated with a reduced ED LOS and fewer adverse events. TA could potentially allow more timely reduction with improved patient experience and resource utilization.

12. Prevalence of PE in patients presenting with syncope. A systematic review and meta-analysis.

Oqab Z, et al. Am J Emerg Med. 2017 Sep 14 [Epub ahead of print]

BACKGROUND: Syncope is a common clinical presentation and establishing an etiology is often challenging. Pulmonary embolism (PE) has been thought to be an uncommon cause but a recent report suggested otherwise.

OBJECTIVE: To establish the prevalence of PE in patients presenting with syncope to the emergency department (ED) and in hospitalized patients.

METHODS: We systematically searched Medline, CINAHL, EMBASE, LILACS and Web of Science with relevant keywords and MeSH headings for syncope and PE. Inclusion criteria were patients presenting with syncope to ED or hospitalized due to syncope, and etiologies including PE.

RESULTS: Of 1329 titles and abstracts, 12 (other than Prandoni et al.) met inclusion criteria. Nine studies included 6608 ED patients and 3 included 975 hospitalized patients. The mean age was 62 (95% CI 54-69) for ED patients and 67 (95% CI 64-70) for hospitalized. The pooled estimate of PE prevalence in ED syncope patients was 0.8% (95% CI 0.5-1.3%, I2=0%). The pooled estimate of PE prevalence in hospitalized patients was 1.0% (95% CI 0.5-1.9%, I2=0). In contrast, the prevalence of PE in Prandoni et al. were 3.8% and 17.3% for ED and hospitalized patients respectively, both significantly higher than in other relevant studies (p less than 0.0001).

CONCLUSION: The estimated prevalence of PE in patients presenting with syncope is low. The Prandoni et al. estimates are significantly higher, suggesting a possible site effect, accrual bias, or investigation strategy. These and the prognostic impact of higher PE prevalence require understanding before changes in practice.

13. Firearm-Related Injury and Death — A U.S. Health Care Crisis in Need of Health Care Professionals

Taichman DB, et al. N Engl J Med 2017 October 9 [Epub ahead of print].

What would happen if on one day more than 50 people died and over 10 times that many were harmed by an infectious disease in the United States? Likely, our nation’s esteemed and highly capable public health infrastructure would gear up to care for those harmed and study the problem. There would be a rush to identify the cause, develop interventions, and refine them continually until the threat is eliminated or at least contained. In light of the risks to public health (after all, over 500 people have been harmed already!), health care professionals would sound the alarm. We would demand funding. We would go to conferences to learn what is known and what we should do. We would form committees at our institutions to plan local responses to protect our communities. The United States would spend millions or more in short order to assure public safety, and no elected officials would conceive of getting in the way. Rather, they would compete to be calling the loudest for the funds and focus required to protect our people. Americans should be proud of our prowess at and commitment to addressing public health crises.

Yet, here we are again with another editorial about the public health crisis of firearm-related injury and death following what used to be unthinkable, this time a mass murder and casualties at a concert in Las Vegas. We’ve written it all before. The staggering numbers killed annually. The numbers left permanently disabled. The families left to cope with the loss of loved ones or to care for those broken but not killed by a bullet. As health care professionals, we seem powerless. This public health crisis seems beyond the reach of our tools.

Is there really nothing health care professionals can do? We think there is a lot. We need to each ask ourselves what we have done to apply our knowledge and skills to help address the problem since the moment of silence that followed the last mass shooting. More silence is not the answer. Have we demanded funding to adequately study the problem and test solutions? Have we participated in such studies? Have we mobilized forces at our institutions to plan strategies to lower the risks in our communities? Have we talked to our patients about gun safety and effectively challenged policies that would enforce our silence on this matter? Some of our colleagues have. We should be proud of them, but they need all of our help. And so do our patients.

Here’s a short list of how health care professionals can use our skills and voices to fight the threat that firearms present to health in the United States…

The remainder of the essay here:

14. Henry Ford HEART Score Randomized Trial: Rapid Discharge of Patients Evaluated for Possible MI

Frisoli TM, et al. Circ Cardiovasc Qual Outcomes. 2017 Oct;10(10).

BACKGROUND: Hospital evaluation of patients with chest pain is common and costly. The HEART score risk stratification tool that merges troponin testing into a clinical risk model for evaluation emergency department patients with possible acute myocardial infarction (AMI) has been shown to effectively identify a substantial low-risk subset of patients possibly safe for early discharge without stress testing, a strategy that could have tremendous healthcare savings implications.

METHOD AND RESULTS: A total of 105 patients evaluated for AMI in the emergency departments of 2 teaching hospitals in the Henry Ford Health System (Detroit and West Bloomfield, MI), between February 2014 and May 2015, with a modified HEART score ≤3 (which includes cardiac troponin I less than 0.04 ng/mL at 0 and 3 hours) were randomized to immediate discharge (n=53) versus management in an observation unit with stress testing (n=52). The primary end points were 30-day total charges and length of stay. Secondary end points were all-cause death, nonfatal AMI, rehospitalization for evaluation of possible AMI, and coronary revascularization at 30 days. Patients randomized to early discharge, compared with those who were admitted for observation and cardiac testing, spent less time in the hospital (median 6.3 hours versus 25.9 hours; P less than 0.001) with an associated reduction in median total charges of care ($2953 versus $9616; P less than 0.001). There were no deaths, AMIs, or coronary revascularizations in either group. One patient in each group was lost to follow-up.

CONCLUSIONS: Among patients evaluated for possible AMI in the emergency department with a modified HEART score ≤3, early discharge without stress testing as compared with transfer to an observation unit for stress testing was associated with significant reductions in length of stay and total charges, a finding that has tremendous potential national healthcare expenditure implications.

15. Point-of-care US in the ED

A. Diagnostic Accuracy of US for Identifying Shoulder Dislocations and Reductions: A Systematic Review of the Literature.

Gottlieb M, et al. West J Emerg Med. 2017 Aug;18(5):937-942.

INTRODUCTION: Patients with shoulder dislocations commonly present to the emergency department. Ultrasound has the potential to save time, radiation exposure, healthcare costs, and possible need for re-sedation. We conducted this systematic review to compare the diagnostic accuracy of ultrasound compared with plain radiography in the assessment of shoulder dislocations.

METHODS: We searched PubMed, Scopus, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials for relevant trials. Primary data and test characteristics were obtained for all included studies. We used QUADAS-2 to assess study quality. Meta-analysis was not performed due to significant heterogeneity.

RESULTS: Four studies met our inclusion criteria, comprising 531 assessments with 202 dislocations. Most studies had a sensitivity of 100% for identifying dislocations. One study demonstrated a sensitivity of 54%, and another had only one dislocation that was misidentified. All studies were 100% specific for detecting dislocation.

CONCLUSION: Ultrasound may be considered as an alternative diagnostic method for the detection of shoulder dislocation and reduction, but further studies are necessary before routine use.

B. ED point-of-care ultrasonography improves time to pericardiocentesis for clinically significant effusions

Alpert EA, et al. Clin Exp Emerg Med 2017; 4(3): 128-132.

Our objective was to determine the utility of point-of-care ultrasound (POCUS) to identify and guide treatment of tamponade or clinically significant pericardial effusions in the emergency department (ED).

This was a retrospective cohort study of non-trauma patients who were diagnosed with large pericardial effusions or tamponade by the ED physician using POCUS. The control group was composed of those patients later diagnosed on the medical wards or incidentally in the ED by other means such as a computed tomography. The following data were abstracted from the patient’s file: demographics, medical background, electrocardiogram results, chest radiograph readings, echocardiogram results, and patient outcomes.

There were 18 patients in the POCUS arm and 55 in the control group. The POCUS arm had a decreased time to pericardiocentesis (11.3 vs. 70.2 hours, P=0.055) as well as a shorter length of stay (5.1 vs. 7.0 days, P=0.222). A decreased volume of pericardial fluid was drained (661 vs. 826 mL, P=0.139) in the group diagnosed by POCUS.

This study suggests that POCUS may effectively identify pericardial effusions and guide appropriate treatment, leading to a decreased time to pericardiocentesis and decreased length of hospital stay. Pericardial tamponade or a large pericardial effusion should be considered in all patients presenting to the ED with clinical, radiographic, or electrocardiographic signs of cardiovascular compromise.

C. Annals Lit Reviews on ED Ultrasound

C1. What Is the Utility of Ultrasonography for the Identification of Skin and Soft Tissue Infections in the ED?

Take-Home Message
Point-of-care ultrasonographic examination of skin and soft tissue infections enhances the ability to differentiate abscesses from cellulitis.

C2. Can Abdominal US Be Used to Accurately Diagnose Acute Appendicitis?

Take-Home Message
Although abdominal ultrasonography alone may not identify all cases of acute appendicitis, it still has a place in the diagnostic algorithm, especially when patient and sonographer characteristics are favorable.

C3. Is Bedside Ultrasonography Rapid and Accurate for Confirmation of Central Venous Catheter Position and Exclusion of Pneumothorax Compared with Chest Radiograph?

Take-Home Message
Ultrasonography is faster than chest radiography for confirming correct central venous catheter placement and ruling out pneumothorax. However, it is less accurate for ruling out malposition, and chest radiography should be obtained in cases of suspected malposition.

16. Alcohol, marijuana, and opioid use disorders: 5-Year patterns and characteristics of ED encounters.

Bahorik AL, et al. Subst Abus. 2017 Jul 19 [Epub ahead of print]

BACKGROUND: Changes in substance use patterns stemming from opioid misuse, ongoing drinking problems, and marijuana legalization may result in new populations of patients with substance use disorders (SUDs) using emergency department (ED) resources. This study examined ED admission trends in a large sample of patients with alcohol, marijuana, and opioid use disorders in an integrated health system.

METHODS: In a retrospective design, electronic health record (EHR) data identified patients with ≥1 of 3 common SUDs in 2010 (n = 17,574; alcohol, marijuana, or opioid use disorder) and patients without SUD (n = 17,574). Logistic regressions determined odds of ED use between patients with SUD versus controls (2010-2014); mixed-effect models examined 5-year differences in utilization; moderator models identified subsamples for which patients with SUD may have a greater impact on ED resources.

RESULTS: Odds of ED use were higher at each time point (2010-2014) for patients with alcohol (odds ratio [OR] range: 5.31-2.13, Ps less than .001), marijuana (OR range: 5.45-1.97, Ps less than .001), and opioid (OR range: 7.63-4.19, Ps less than .001) use disorders compared with controls; odds decreased over time (Ps less than .001). Patients with opioid use disorder were at risk of high ED utilization; patients were 7.63 times more likely to have an ED visit in 2010 compared with controls and remained 5.00 (average) times more likely to use ED services. ED use increased at greater rates for patients with alcohol and opioid use disorders with medical comorbidities relative to controls (Ps less than .045).

CONCLUSIONS: ED use is frequent in patients with SUDs who have access to private insurance coverage and integrated medical services. ED settings provide important opportunities in health systems to identify patients with SUDs, particularly patients with opioid use disorder, to initiate treatment and facilitate ongoing care, which may be effective for reducing excess medical emergencies and ED encounters.

17. Pelvic Exam for Vaginal Bleeding or Abdominal Pain in Early Pregnancy

A two-center, randomized study suggests that this common practice adds no benefit.

Linden JA, et al. Is the Pelvic Examination Still Crucial in Patients Presenting to the Emergency Department With Vaginal Bleeding or Abdominal Pain When an Intrauterine Pregnancy Is Identified on Ultrasonography? A Randomized Controlled Trial. Ann Emerg Med. 2017 Sep 19 [Epub ahead of print].

STUDY OBJECTIVE: We determine whether omitting the pelvic examination in emergency department (ED) evaluation of vaginal bleeding or lower abdominal pain in ultrasonographically confirmed early intrauterine pregnancy is equivalent to performing the examination.

METHODS: We conducted a prospective, open-label, randomized, equivalence trial in pregnant patients presenting to the ED from February 2011 to November 2015. Patients were randomized to no pelvic examination versus pelvic examination. Inclusion criteria were aged 18 years or older, English speaking, vaginal bleeding or lower abdominal pain, positive β-human chorionic gonadotropin result, and less than 16-week intrauterine pregnancy by ultrasonography. Thirty-day record review and follow-up call assessed for composite morbidity endpoints (unscheduled return, subsequent admission, emergency procedure, transfusion, infection, and alternate source of symptoms). Wilcoxon rank sum tests were used to assess patient satisfaction and throughput times.

RESULTS: Only 202 (of a planned 720) patients were enrolled, despite extension of the study enrollment period. The composite morbidity outcome was experienced at similar rates in the intervention (no pelvic examination) and control (pelvic examination) groups (19.6% versus 22.0%; difference -2.4%; 90% confidence interval [CI] -11.8% to 7.1%). Patients in the intervention group were less likely to report feeling uncomfortable or very uncomfortable during the visit (11.2% versus 23.7%; difference -12.5; 95% CI -23.0% to -2.0%).

CONCLUSION: Although there was only a small difference between the percentage of patients experiencing the composite morbidity endpoint in the 2 study groups (2.4%), the resulting 90% CI was too wide to conclude equivalence. This may have been due to insufficient power. Patients assigned to the pelvic examination group reported feeling uncomfortable more frequently.

18. Loperamide-Induced Torsades de Pointes: A Case Series

Katz KD, et al. J Emerg Med 2017;53:339-44.

Loperamide is an over-the-counter, inexpensive, antidiarrheal opioid that can produce life-threatening toxicity at high concentrations.

Case Report 1
A 28-year-old man with a history of depression and substance abuse disorder (SUD) presented to the emergency department (ED) with shortness of breath and lightheadedness. He ingested large amounts of loperamide daily. The patient's initial electrocardiogram (ECG) demonstrated sinus rhythm, right axis deviation, undetectable PR interval, QRS 168 ms, and QTc 693 ms. He was administered intravenous sodium bicarbonate and magnesium sulfate and admitted to the intensive care unit, eventually developing Torsades de Pointes (TdP). He was given lidocaine and isoproterenol infusions, and an external pacemaker was placed. He was discharged in stable condition on hospital day (HD) 16.

Case Report 2
A 39-year-old woman with a history of hepatitis C, depression, and SUD was transported to the ED after reported seizure-like activity. The patient experienced TdP in the ED and admitted to ingesting large amount of loperamide daily. An ECG demonstrated sinus rhythm, right axis deviation, PR interval 208 ms, QRS interval 142 ms, and QTc 687 ms. She was administered intravenous magnesium, sodium bicarbonate, and isoproterenol. After intensive care unit admission, the patient experienced no further TdP and was discharged on HD 6.

Why Should an Emergency Physician Be Aware of This?
Emergency physicians should proceed with caution when treating patients with loperamide toxicity. Even in asymptomatic patients and drug discontinuance, obtain consultation with a medical toxicologist, promptly treat ECG abnormalities aggressively, and admit all patients for further monitoring.

19. On Falls in the Elderly

One out of three adults ages 65 and older falls at least once a year, which can lead to moderate to severe injuries, including fractures, decreased mobility and even death. 

A. Revisit, Subsequent Hospitalization, Recurrent Fall, and Death Within 6 Months After a Fall Among Elderly ED Pts

Sri-On J, et al. Ann Emerg Med. 2017 Oct;70(4):516-521.e2.

Fall and fall-related injuries are a major public health problem and a leading cause of morbidity and mortality among elderly patients.1 Fall-related death rates have increased among older persons worldwide. Furthermore, serious injuries after a fall, such as hip fractures, subdural hematomas, serious soft tissue injury, and head injury, occur in 5% to 11% of older individuals.2

The emergency department (ED) is often the first place where patients with fall-related injuries receive care. Approximately 2.4 million older adults visit the ED each year, and more than 28% of these patients are admitted to the hospital.3 Overall, 16% of elderly ED patients experience adverse events within 30 days of discharge, and 27% experience adverse events within 90 days.4 One study found that indoor falls, hospital admissions, and a Barthel Index of activities of daily living less than or equal to 18 were associated with increased 1- and 3-year mortality rates after patients visited the ED.5 A recently published large database study identified that male sex and comorbidities increased ED revisit and death within 1 year.6 However, to our knowledge there is no ED-based study that examines how risk factors according to recent geriatric ED guidelines predict recurrent falls, as well as subsequent ED visits, subsequent hospitalizations, and death, after a visit to the ED for a fall among older adult patients.

Goals of This Investigation
The objective of this study was to determine the risk during 6 months and specific risk factors for recurrent falls, ED revisits, subsequent hospitalizations, and death within 6 months after an older adult ED fall visit.

STUDY OBJECTIVE: We seek to describe the risk during 6 months and specific risk factors for recurrent falls, emergency department (ED) revisits, subsequent hospitalizations, and death within 6 months after a fall-related ED presentation.

METHODS: This was a secondary analysis of a retrospective cohort of elderly fall patients who presented to the ED from one urban teaching hospital. We included patients aged 65 years and older who had an ED fall visit in 2012. We examined the frequency and risk factors of adverse events (composite of recurrent falls, ED revisits, subsequent hospitalization, and death, selected a priori) at 6 months.

RESULTS: Our study included 350 older adults. Adverse events steadily increased, from 7.7% at 7 days, 21.4% at 30 days, and 50.3% at 6 months. Within 6 months, 22.6% of patients had at least one recurrent fall, 42.6% revisited the ED, 31.1% had subsequent hospitalizations, and 2.6% died. In multivariable logistic regression analysis, psychological or sedative drug use predicted recurrent falls, ED revisits, subsequent hospitalizations, and adverse events.

CONCLUSION: More than half of fall patients had an adverse event within 6 months of presenting to the ED after a fall. The risk during 6 months of these adverse events increased with psychological or sedative drug use. Larger future studies should confirm this association and investigate methods to minimize recurrent falls through management of such medications.

B. Task force draft recommendations cover falls, fractures

A US Preventive Services Task Force draft recommendation statement gave a "B" recommendation to using exercise to prevent falls in community-dwelling older adults and said physicians may selectively offer multifactorial interventions based on individual patient assessments.

20. NEJM Interactive Case: 26-year-old ED pt with one week of worsening pleuritic CP

Solomon CG, et al. N Engl J Med 2017; 377:e1

A 26-year-old woman presented to the emergency department with a 1-week history of worsening pleuritic chest pain. She recalled the development of a dull, substernal ache several days after a 5-hour flight home from Puerto Rico, where she had spent 3 weeks hiking in national parks and exploring several caves.

The ache progressed over the ensuing days to a constant, stabbing pain that worsened with deep inspiration and coughing. She had not taken any medication for the pain. The patient reported no fevers, chills, shortness of breath, wheezing, sputum production, hemoptysis, weight loss, night sweats, leg swelling, or diarrhea and no changes in appetite or urinary habits. She had no history of venous thromboembolism, cancer, or environmental or drug allergies and did not use oral contraceptives…

Because of the patient’s pleurisy and recent long-distance air travel, emergency department physicians considered the possibility that she may have a pulmonary embolism. Which one of the following tests should be performed to evaluate for pulmonary embolism?

The rest of the interactive is available (free) here:

21. Micro Bits

A. Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival.

Bodai BI, et al. Perm J. 2018;22:17-025.

B. Reversing the New Oral Anticoagulants Not as Complicated as You Think

Rodos A, et al. Emerg Med New 2017;39(10):14-15.

Youths who took ibuprofen for pain relief after undergoing minor outpatient orthopedic surgery had similarly reduced pain scores but significantly fewer adverse effects such as drowsiness, nausea, dizziness, vomiting and constipation compared with those who took oral morphine, according to a study in the Canadian Medical Association Journal. However, the findings showed that neither drug provided complete pain relief, prompting researchers to suggest further studies on better treatments.

D. Coordination Program Reduced Acute Care Use And Increased Primary Care Visits Among Frequent Emergency Care Users

E. CDC finds suicide rates on the rise, particularly in rural areas

CDC researchers found that suicide rates in the US rose by over 20% from 2001 to 2015, translating to 500,000 lost lives during that period, and suicide rates were higher in rural areas than urban areas. Suicide was the 10th leading cause of death by 2015, men were five times more likely to commit suicide than women, and risk was highest among working-age adults.

F. Survey: 87.3% of patients want to avoid antibiotic for RTI

A study in the Journal of the American Board of Family Medicine found 87.3% of patients surveyed wanted to avoid taking antibiotics for respiratory tract infections, but 64% who saw a physician for an RTI received one. The survey of 737 adult patients showed 63.1% were very or somewhat willing to have venous blood drawn and 79% were very or somewhat willing to have a point-of-care fingerstick test to determine if they needed an antibiotic.

G. The Importance of Breakfast in Atherosclerosis Disease: Insights From the PESA Study

Conclusion Skipping breakfast is associated with an increased odds of prevalent noncoronary and generalized atherosclerosis independently of the presence of conventional CV risk factors.

H. Bed bugs love your stinky laundry. Here’s how to keep them away

On the surface, bed bugs seem ill-equipped for world domination: They can’t fly, jump, or swim; they can survive only on blood; and the world’s foremost apex predators—humans—want them all dead. Yet the parasitic arthropods have recently undergone what scientists are calling a “rapid global expansion,” taking over new territories and growing in number and range. And according to a new study, their globetrotting is made possible in part by an unusual form of transportation: our stinky laundry.

I. Physicians see more fulfillment in work than retirement

A growing number of physicians nearing retirement age are choosing not to step back. According to a CompHealth survey, they believe they can find more fulfillment with the social interactions of their practice and continuing to help patients.

J. CDC reports record high STD cases in the US in 2016

New cases of sexually transmitted diseases such as chlamydia, gonorrhea and syphilis in the US reached a record high of more than 2 million in 2016, more than 1.6 million of which were from chlamydia, according to a CDC report. Data also showed that syphilis prevalence among newborns increased by 28% between 2015 and 2016.

K. Youth football may boost behavioral, cognitive problems in adulthood

Children who played tackle football before age 12 were two times more likely to develop problems with behavioral regulation, executive function and apathy, and had an increased likelihood of elevated depression scores in adulthood, compared with those who played at age 12 or older, researchers reported in Nature's Translational Psychiatry. The findings also showed similar health risks for those who gave up the sport before high school and those who continued in high school and college.

L. Global Causes of Death, By the Numbers

Cardiovascular disease reigns; U.S life expectancy flatlines