Friday, November 24, 2017

Lit Bits: Nov 24, 2017

From the recent medical literature...

1. ED Headache Management Studies

A. IV Prochlorperazine/Diphenhydramine Beats IV Hydromorphone

Friedman BW, et al. Neurology 2017;89(20):2075-2082.

OBJECTIVE: To determine outcomes among patients with migraine in the emergency department (ED) who receive IV hydromorphone vs IV prochlorperazine + diphenhydramine.

METHODS: This study was conducted in 2 EDs in New York City. Patients who met international criteria for migraine were eligible for participation if they had not used an opioid within the previous month. Clinicians, participants, investigators, and research personnel were blinded to treatment. Patients were randomized in blocks of 4. Participants received hydromorphone 1 mg or prochlorperazine 10 mg + diphenhydramine 25 mg. Diphenhydramine was administered to prevent akathisia, a common side effect of IV prochlorperazine. The primary outcome was sustained headache relief, defined as achieving a headache level of mild or none within 2 hours of medication administration and maintaining that level for 48 hours without the requirement of rescue medication. A planned interim analysis was conducted once 48-hour data were available for 120 patients.

RESULTS: The trial was halted by the data monitoring committee after 127 patients had been enrolled. The primary outcome was achieved in the prochlorperazine arm by 37 of 62 (60%) participants and in the hydromorphone arm by 20 of 64 (31%) participants (difference 28%, 95% confidence interval 12-45, number needed to treat 4, 95% confidence interval 2-9).

CONCLUSIONS: IV hydromorphone is substantially less effective than IV prochlorperazine for the treatment of acute migraine in the ED and should not be used as first-line therapy.

From the AAN Press Release: “While this study demonstrates the overwhelming superiority of prochlorperazine over hydromorphone for initial treatment of acute migraine, the results do not suggest that treatment with IV opioids leads to long-term addiction,” Friedman said. “In addition, the results should not be used to avoid the use of opioids for people who have not responded well to anti-dopaminergic drugs.”

B. IV Prochlorperazine/Diphenhydramine Beats IV Ketamine/Ondansetron

Zitek T, et al. Ann Emerg Med 2017 Oct 13 [Epub ahead of print].

Study objective
Intravenous subdissociative-dose ketamine has been shown to be effective for pain management, but has not been specifically studied for headaches in the emergency department (ED). For this reason, we designed a study to compare standard treatment (prochlorperazine) with ketamine in patients with benign headaches in the ED.

This study was a multicenter, double-blind, randomized, controlled trial with a convenience sample of patients presenting to the ED with benign headaches. Patients were randomized to receive either prochlorperazine and diphenhydramine or ketamine and ondansetron. Patients' headache severity was measured on a 100-mm visual analog scale (VAS) at 0, 15, 30, 45, and 60 minutes. Nausea, vomiting, anxiety, and the need for rescue medications were also tracked. Patients were contacted at 24 to 48 hours posttreatment to rate their satisfaction and to determine whether they were still experiencing a headache.

There were a total of 54 subjects enrolled. Two patients in the ketamine group and one in the prochlorperazine group withdrew because of adverse effects of the medications. In regard to the primary outcome, at 60 minutes, the prochlorperazine group had a mean improvement in VAS pain scores of 63.5 mm compared with 43.5 mm in the ketamine group, corresponding to a between-groups difference of 20.0 mm (95% confidence interval [CI] 2.8 to 37.2 mm) and a P value of .026. At 45 minutes, the prochlorperazine group had a mean improvement in pain scores of 56.1 mm compared with 38.0 mm in the ketamine group, a difference of 18.1 mm (95% CI 1.0 to 35.2 mm). At 24- to 48-hour follow-up, the mean satisfaction score was 8.3 of 10 for prochlorperazine and 4.9 of 10 for ketamine, a difference of 3.4 (95% CI 1.2 to 5.6). There was not a statistically significant difference in the percentage of patients who had a headache at follow-up or in other secondary outcomes.

Prochlorperazine appears to be superior to ketamine for the treatment of benign headaches in the ED.

C. IV Sodium valproate ties IV Dexamethasone

Karimi N, et al. Clin Exp Emerg Med 2017; 4(3): 138-145.

OBJECTIVE: Migraine headache is a chronic and disabling condition in adults. Some studies have investigated the efficacy of sodium valproate in the treatment of acute migraine, but the effectiveness and tolerability of intravenous valproate as abortive therapy remains unclear. This study aimed to evaluate the effects of sodium valproate and dexamethasone in the treatment of acute migraine.

METHODS: We conducted a double-blind randomized clinical trial including 90 patients aged 18 to 65 years with acute migraine headache but no aura. Patients were randomized to receive intravenous dexamethasone (8 mg) or sodium valproate (400 mg) diluted into 4 mL of normal saline. The primary outcome measure was pain relief after 0.5, 1, 3, or 6 hours after administration. The secondary outcome criteria were the associated symptom recovery, rate of headache recurrence after 24 hours, and medication side effects. Pearson's chi square and the t-test were employed in the data analysis.

RESULTS: Of the 90 patients, 80 were investigated. The percentage of headache improvement at 0.5 hours after treatment was 55% and 67.5% in the sodium valproate and dexamethasone groups, respectively. Before-treatment and 0.5 hour after treatment pain severity visual analog scale scores were 9.05±0.90 and 3.8±3.09 in the sodium valproate group and 8.92±0.79 and 3.10±2.73 in the dexamethasone group, respectively. There were no significant intergroup differences.

CONCLUSION: This randomized clinical trial showed that the intravenous injection of sodium valproate 400 mg has similar effects to those of dexamethasone for improving acute migraine headache.

D. Influence of greater occipital nerve block on pain severity in migraine patients: A systematic review and meta-analysis.

Tang Y, et al. Am J Emerg Med. 2017 Nov;35(11):1750-1754.

AIMS: Greater occipital nerve (GON) block may be a promising approach to treat migraine. However, the results remained controversial. We conducted a systematic review and meta-analysis to explore the efficacy of GON block in migraine patients.

METHODS: PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the efficacy of GON block versus placebo in migraine patients were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. Meta-analysis was performed using the random-effect model.

RESULTS: Six RCTs were included in the meta-analysis. Overall, compared with control intervention in migraine patients, GON block intervention was found to significantly reduce pain score (Std. mean difference=-0.51; 95% CI=-0.81 to -0.21; P=0.0008), number of headache days (Std. mean difference=-0.68; 95% CI=-1.02 to -0.35; P less than 0.0001), and medication consumption (Std. mean difference=-0.35; 95% CI=-0.67 to -0.02; P=0.04), but demonstrated no influence on duration of headache per four weeks (Std. mean difference=-0.07; 95% CI=-0.41 to 0.27; P=0.70).

CONCLUSIONS: Compared to control intervention, GON block intervention can significantly alleviate pain, reduce the number of headache days and medication consumption, but have no significant influence on the duration of headache per four weeks for migraine patients.

E. Validation of the Ottawa SAH Rule in patients with acute headache.

However, with a specificity of only 13.6%, its impact on imaging and lumbar puncture rates may be low.

Perry JJ, et al. CMAJ. 2017 Nov 13;189(45):E1379-E1385.

BACKGROUND: We previously derived the Ottawa Subarachnoid Hemorrhage Rule to identify subarachnoid hemorrhage (SAH) in patients with acute headache. Our objective was to validate the rule in a new cohort of consecutive patients who visited an emergency department.

METHODS: We conducted a multicentre prospective cohort study at 6 university-affiliated tertiary-care hospital emergency departments in Canada from January 2010 to January 2014. We included alert, neurologically intact adult patients with a headache peaking within 1 hour of onset. Treating physicians in the emergency department explicitly scored the rule before investigations were started. We defined subarachnoid hemorrhage as detection of any of the following: subarachnoid blood visible upon computed tomography of the head (from the final report by the local radiologist); xanthochromia in the cerebrospinal fluid (by visual inspection); or the presence of erythrocytes (> 1 × 106/L) in the final tube of cerebrospinal fluid, with an aneurysm or arteriovenous malformation visible upon cerebral angiography. We calculated sensitivity and specificity of the Ottawa SAH Rule for detecting or ruling out subarachnoid hemorrhage.

RESULTS: Treating physicians enrolled 1153 of 1743 (66.2%) potentially eligible patients, including 67 with subarachnoid hemorrhage. The Ottawa SAH Rule had 100% sensitivity (95% confidence interval [CI] 94.6%-100%) with a specificity of 13.6% (95% CI 13.1%-15.8%), whereas neuroimaging rates remained similar (about 87%).

INTERPRETATION: We found that the Ottawa SAH Rule was sensitive for identifying subarachnoid hemorrhage in otherwise alert and neurologically intact patients. We believe that the Ottawa SAH Rule can be used to rule out this serious diagnosis, thereby decreasing the number of cases missed while constraining rates of neuroimaging.

Remind me, what is the Ottawa SAH Rule?

Ryan Radecki’s critique:

2. ED Analgesia Corner

A. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the ED: A Randomized Clinical Trial.

Chang AK, et al. JAMA. 2017 Nov 7;318(17):1661-1667.

IMPORTANCE: The choice of analgesic to treat acute pain in the emergency department (ED) lacks a clear evidence base. The combination of ibuprofen and acetaminophen (paracetamol) may represent a viable nonopioid alternative.

OBJECTIVES: To compare the efficacy of 4 oral analgesics.

DESIGN, SETTINGS, AND PARTICIPANTS: Randomized clinical trial conducted at 2 urban EDs in the Bronx, New York, that included 416 patients aged 21 to 64 years with moderate to severe acute extremity pain enrolled from July 2015 to August 2016.

INTERVENTIONS: Participants (104 per each combination analgesic group) received 400 mg of ibuprofen and 1000 mg of acetaminophen; 5 mg of oxycodone and 325 mg of acetaminophen; 5 mg of hydrocodone and 300 mg of acetaminophen; or 30 mg of codeine and 300 mg of acetaminophen.

MAIN OUTCOMES AND MEASURES: The primary outcome was the between-group difference in decline in pain 2 hours after ingestion. Pain intensity was assessed using an 11-point numerical rating scale (NRS), in which 0 indicates no pain and 10 indicates the worst possible pain. The predefined minimum clinically important difference was 1.3 on the NRS. Analysis of variance was used to test the overall between-group difference at P = .05 and 99.2% CIs adjusted for multiple pairwise comparisons.

RESULTS: Of 416 patients randomized, 411 were analyzed (mean [SD] age, 37 [12] years; 199 [48%] women; 247 [60%] Latino). The baseline mean NRS pain score was 8.7 (SD, 1.3). At 2 hours, the mean NRS pain score decreased by 4.3 (95% CI, 3.6 to 4.9) in the ibuprofen and acetaminophen group; by 4.4 (95% CI, 3.7 to 5.0) in the oxycodone and acetaminophen group; by 3.5 (95% CI, 2.9 to 4.2) in the hydrocodone and acetaminophen group; and by 3.9 (95% CI, 3.2 to 4.5) in the codeine and acetaminophen group (P = .053). The largest difference in decline in the NRS pain score from baseline to 2 hours was between the oxycodone and acetaminophen group and the hydrocodone and acetaminophen group (0.9; 99.2% CI, -0.1 to 1.8), which was less than the minimum clinically important difference in NRS pain score of 1.3. Adverse events were not assessed.

CONCLUSIONS AND RELEVANCE: For patients presenting to the ED with acute extremity pain, there were no statistically significant or clinically important differences in pain reduction at 2 hours among single-dose treatment with ibuprofen and acetaminophen or with 3 different opioid and acetaminophen combination analgesics. Further research to assess adverse events and other dosing may be warranted.

B. A Randomized, Double-Blind, Placebo-Controlled Trial of Naproxen With or Without Orphenadrine or Methocarbamol for Acute Low Back Pain.

Friedman BW, et al. Ann Emerg Med. 2017 Oct 28 [Epub ahead of print].

STUDY OBJECTIVE: In US emergency departments (EDs), patients with low back pain are often treated with nonsteroidal anti-inflammatory drugs and muscle relaxants. We compare functional outcomes among patients randomized to a 1-week course of naproxen+placebo versus naproxen+orphenadrine or naproxen+methocarbamol.

METHODS: This was a randomized, double-blind, comparative effectiveness trial conducted in 2 urban EDs. Patients presenting with acute, nontraumatic, nonradicular low back pain were enrolled. The primary outcome was improvement on the Roland-Morris Disability Questionnaire (RMDQ) between ED discharge and 1 week later. All patients were given 14 tablets of naproxen 500 mg, to be used twice a day, as needed for low back pain. Additionally, patients were randomized to receive a 1-week supply of orphenadrine 100 mg, to be used twice a day as needed, methocarbamol 750 mg, to be used as 1 or 2 tablets 3 times per day as needed, or placebo. All patients received a standardized 10-minute low back pain educational session before discharge.

RESULTS: Two hundred forty patients were randomized. Baseline demographic characteristics were comparable. The mean RMDQ score of patients randomized to naproxen+placebo improved by 10.9 points (95% confidence interval [CI] 8.9 to 12.9). The mean RMDQ score of patients randomized to naproxen+orphenadrine improved by 9.4 points (95% CI 7.4 to 11.5). The mean RMDQ score of patients randomized to naproxen+methocarbamol improved by 8.1 points (95% CI 6.1 to 10.1). None of the between-group differences surpassed our threshold for clinical significance. Adverse events were reported by 17% (95% CI 10% to 28%) of placebo patients, 9% (95% CI 4% to 19%) of orphenadrine patients, and 19% (95% CI 11% to 29%) of methocarbamol patients.

CONCLUSION: Among ED patients with acute, nontraumatic, nonradicular low back pain, combining naproxen with either orphenadrine or methocarbamol did not improve functional outcomes compared with naproxen+placebo.

C. Use of Prophylactic Ondansetron with IV Opioids in ED Patients: A Prospective Observational Pilot Study.

Culver MA, et al. J Emerg Med. 2017 Nov;53(5):629-634.

BACKGROUND: The current literature suggests that the prophylactic use of antiemetics is ineffective at preventing nausea or vomiting caused by opioids in the emergency department (ED). While there is no data evaluating ondansetron's efficacy for preventing opioid-induced nausea and vomiting, this practice remains common despite a lack of supporting evidence.

OBJECTIVES: This study aimed to identify if prophylactic ondansetron administered with intravenous (IV) opioids prevents opioid-induced nausea or vomiting.

METHODS: This prospective observational study was conducted in the ED at two academic medical institutions. Patients were eligible for enrollment if they were prescribed an IV opioid with or without IV ondansetron and absence of baseline nausea. Patients' level of nausea was evaluated at baseline, 5 min, and 30 min after an IV opioid was administered and then observed for 2 hours.

RESULTS: One hundred thirty-three patients were enrolled, with 90% of patients presenting with a chief complaint of pain. Sixty-four (48.1%) patients received an IV opioid alone and 69 (51.9%) patients received both IV ondansetron and an IV opioid. Twenty-three (17.3%) patients developed nausea caused by opioid administration. One (0.75%) patient had an emetic event and 3 (2.3%) patients required rescue antiemetics during their observation period. Rate of nausea was similar between treatment groups 5 min after the opioid was administered (p = 0.153). There was no statistical difference in emesis, rescue medication requirements, or nausea severity between treatment groups.

CONCLUSION: Our trial found that ondansetron did not appear to be effective at preventing opioid-induced nausea or vomiting. These findings and previous literature suggest prophylactic ondansetron should not be given to ED patients who are receiving IV opioids.

D. Codeine still prescribed after pediatric tonsil, adenoid removal despite warning

Although the rate of children who received codeine prescriptions after tonsil or adenoid removal significantly declined after the FDA issued a black box warning on the opioid in 2013, 5% continued to be prescribed codeine in 2015, researchers reported in Pediatrics. The findings, based on 2010 to 2015 private insurance claims data involving more than 360,000 youths across the US who underwent tonsillectomy, adenoidectomy or both, also showed higher pediatric hydrocodone and oxycodone prescriptions months after the FDA implemented its black box warning.

Getting Doctors to Stop Prescribing Codeine To Kids Has Taken Years

Greta Jochim. NPR, Nov 16, 2017.

For years the Food and Drug Administration has been trying to get doctors to quit prescribing codeine, an opioid painkiller, to children after getting their tonsils or adenoids out.

But it can be hard to get clinicians to change their prescribing habits, even when children have died and other less risky medications are available.

In 2013, the FDA told providers that "codeine should not be used for pain in children following these procedures." But in December 2015, nearly three years later, 5 percent of children were being prescribed the drug after surgery, according to a study published Thursday in Pediatrics.

Some children are "ultra-metabolizers" of codeine, causing their blood levels of medication to rise rapidly. That can depress breathing and be deadly.

It's hard to know how an individual metabolizes codeine, says Dr. Kao-Ping Chua, the paper's lead author and assistant professor in the University of Michigan department of pediatrics and communicable diseases. "You're basically rolling the dice when you prescribe codeine," he says. "Codeine in general for children ought to be a zero event."

3. Is Sepsis Incidence and Mortality Changing in U.S. Hospitals?

Robust clinical data show that sepsis incidence and sepsis-related mortality have remained stable.

Rhee C, et al. CDC Prevention Epicenter Program. Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014. JAMA. 2017 Oct 3;318(13):1241-1249.

Estimates from claims-based analyses suggest that the incidence of sepsis is increasing and mortality rates from sepsis are decreasing. However, estimates from claims data may lack clinical fidelity and can be affected by changing diagnosis and coding practices over time.

OBJECTIVE: To estimate the US national incidence of sepsis and trends using detailed clinical data from the electronic health record (EHR) systems of diverse hospitals.

DESIGN, SETTING, AND POPULATION: Retrospective cohort study of adult patients admitted to 409 academic, community, and federal hospitals from 2009-2014.

EXPOSURES: Sepsis was identified using clinical indicators of presumed infection and concurrent acute organ dysfunction, adapting Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria for objective and consistent EHR-based surveillance.

MAIN OUTCOMES AND MEASURES: Sepsis incidence, outcomes, and trends from 2009-2014 were calculated using regression models and compared with claims-based estimates using International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe sepsis or septic shock. Case-finding criteria were validated against Sepsis-3 criteria using medical record reviews.

RESULTS: A total of 173 690 sepsis cases (mean age, 66.5 [SD, 15.5] y; 77 660 [42.4%] women) were identified using clinical criteria among 2 901 019 adults admitted to study hospitals in 2014 (6.0% incidence). Of these, 26 061 (15.0%) died in the hospital and 10 731 (6.2%) were discharged to hospice. From 2009-2014, sepsis incidence using clinical criteria was stable (+0.6% relative change/y [95% CI, -2.3% to 3.5%], P = .67) whereas incidence per claims increased (+10.3%/y [95% CI, 7.2% to 13.3%], P less than .001). In-hospital mortality using clinical criteria declined (-3.3%/y [95% CI, -5.6% to -1.0%], P = .004), but there was no significant change in the combined outcome of death or discharge to hospice (-1.3%/y [95% CI, -3.2% to 0.6%], P = .19). In contrast, mortality using claims declined significantly (-7.0%/y [95% CI, -8.8% to -5.2%], P  less than .001), as did death or discharge to hospice (-4.5%/y [95% CI, -6.1% to -2.8%], P  less than .001). Clinical criteria were more sensitive in identifying sepsis than claims (69.7% [95% CI, 52.9% to 92.0%] vs 32.3% [95% CI, 24.4% to 43.0%], P less than .001), with comparable positive predictive value (70.4% [95% CI, 64.0% to 76.8%] vs 75.2% [95% CI, 69.8% to 80.6%], P = .23).

CONCLUSIONS AND RELEVANCE: In clinical data from 409 hospitals, sepsis was present in 6% of adult hospitalizations, and in contrast to claims-based analyses, neither the incidence of sepsis nor the combined outcome of death or discharge to hospice changed significantly between 2009-2014. The findings also suggest that EHR-based clinical data provide more objective estimates than claims-based data for sepsis surveillance.

4. Methemoglobinemia Due to Antifreeze Ingestion

Farkas AN, et al. N Engl J Med 2017; 377:1993-199.

Ingestion of antifreeze that contains ethylene glycol produces acidosis, nephropathy, coma, and cardiovascular collapse.1 Previously, minimal increases in methemoglobin levels (to as high as 6%; normal value, less than 1.0% or 1.5%, depending on the assay) after ingestion of antifreeze have been reported,2 with no known cause. We report a case of antifreeze ingestion that resulted in clinically significant methemoglobinemia caused by an identified agent.

Our patient, a 62-year-old man with a history of depression, presented to an emergency department 5 hours after ingesting antifreeze (Fleet Charge SCA Precharged Coolant/Antifreeze [Peak]). The bottle was recovered by paramedics. He had an arterial pH of 7.14 (normal range, 7.35 to 7.45), a serum bicarbonate level of 11 mmol per liter (normal range, 22 to 28), an osmolar gap of 167 mOsm per kilogram (normal value, less than 10), an anion gap of 17 mmol per liter (normal range, 3 to 11), and obtundation requiring intubation and mechanical ventilation. He was initially treated with intravenous sodium bicarbonate and fomepizole. Despite receiving mechanical ventilation, the patient had persistent pulse oximetry readings of 88% with the ventilator set to a fraction of inspired oxygen of 100% and a positive end-expiratory pressure of 15 cm of water. When his venous blood appeared brown in color despite an arterial partial pressure of oxygen of 502 mm Hg, the patient’s methemoglobin level was tested and found to be 32.2%. The methemoglobinemia was successfully treated with methylene blue, and hemodialysis resolved the ethylene glycol poisoning with a favorable outcome.

On the basis of the patient’s history and the results of urine gas chromatography–mass spectroscopy testing, no substance known to cause methemoglobinemia was present. The safety data sheet for the product that the patient ingested indicated a mixture of ethylene glycol (90 to 97%), diethylene glycol, water, and denatonium benzoate. Because only substances that comprise more than 1% of a given product are required by the Occupational Safety and Health Administration Hazard Communication Standard to be reported on the safety data sheet, a manufacturer’s representative was contacted directly for further information. He disclosed the presence of nitrite (0.27%) and nitrate (0.08%) in the product. Nitrites and nitrates are used as anticorrosion agents in antifreeze3 but are not universally included in all formulations, which may explain why methemoglobinemia has not been consistently observed after antifreeze ingestion.

On the basis of the concentration of ethylene glycol reported to be in the product, the patient’s serum level of ethylene glycol at 5 hours after ingestion (835 mg per deciliter), and the patient’s body weight (64 kg), we estimate that the ingested volume of antifreeze potentially exceeded 400 ml. This would contain the equivalent of 1.8 g of sodium nitrite, a toxic dose given that only 300 mg of medicinal sodium nitrite induces methemoglobinemia in the treatment of cyanide poisoning.4

In conclusion, methemoglobinemia should be considered after a massive ingestion of antifreeze. More importantly, clinicians should be aware of the fact that because of the reporting limits allowed by the law, clinically significant poisons may not be listed on safety data sheets.

5. Bacteremia in Febrile Infants Aged 60 Days and Younger.

A. Epidemiology of Bacteremia in Febrile Infants Aged 60 Days and Younger.

Powell EC, et al. Ann Emerg Med. 2017 Oct 6 [Epub ahead of print]

STUDY OBJECTIVE: To describe the current epidemiology of bacteremia in febrile infants 60 days of age and younger in the Pediatric Emergency Care Applied Research Network (PECARN).

METHODS: We conducted a planned secondary analysis of a prospective observational study of febrile infants 60 days of age and younger presenting to any of 26 PECARN emergency departments (2008 to 2013) who had blood cultures obtained. We excluded infants with significant comorbidities or critically ill appearance. The primary outcome was prevalence of bacteremia.

RESULTS: Of 7,335 screened infants, 4,778 (65.1%) had blood cultures and were enrolled. Of these patients, 84 had bacteremia (1.8%; 95% confidence interval [CI] 1.4% to 2.2%). The prevalence of bacteremia in infants aged 28 days or younger (47/1,515) was 3.1% (95% CI 2.3% to 4.1%); in infants aged 29 to 60 days (37/3,246), 1.1% (95% CI 0.8% to 1.6%). Prevalence differed by week of age for infants 28 days of age and younger (0 to 7 days: 4/156, 2.6%; 8 to 14 days: 19/356, 5.3%; 15 to 21 days: 15/449, 3.3%; and 22 to 28 days: 9/554, 1.6%). The most common pathogens were Escherichia coli (39.3%; 95% CI 29.5% to 50.0%) and group B streptococcus (23.8%; 95% CI 16.0% to 33.9%). Bacterial meningitis occurred in 19 of 1,515 infants 28 days of age and younger (1.3%; 95% CI 0.8% to 2.0%) and 5 of 3,246 infants aged 29 to 60 days (0.2%; 95% CI 0.1% to 0.4%). Of 84 infants with bacteremia, 36 (42.9%; 95% CI 32.8% to 53.5%) had urinary tract infections (E coli 83%); 11 (13.1%; 95% CI 7.5% to 21.9%) had bacterial meningitis.

CONCLUSION: The prevalence of bacteremia and meningitis among febrile infants 28 days of age and younger is high and exceeds that observed in infants aged 29 to 60 days. E coli and group B streptococcus are the most common bacterial pathogens.

B. Accuracy of CBC Counts to Identify Febrile Infants 60 Days or Younger With Invasive Bacterial Infections.

Cruz AT, et al. PECARN. JAMA Pediatr. 2017 Nov 6;171(11):e172927.

IMPORTANCE: Clinicians often risk stratify young febrile infants for invasive bacterial infections (IBIs), defined as bacteremia and/or bacterial meningitis, using complete blood cell count parameters.

OBJECTIVE: To estimate the accuracy of individual complete blood cell count parameters to identify febrile infants with IBIs.

DESIGN, SETTING, AND PARTICIPANTS: Planned secondary analysis of a prospective observational cohort study comprising 26 emergency departments in the Pediatric Emergency Care Applied Research Network from 2008 to 2013. We included febrile (≥38°C), previously healthy, full-term infants younger than 60 days for whom blood cultures were obtained. All infants had either cerebrospinal fluid cultures or 7-day follow-up.

MAIN OUTCOMES AND MEASURES: We tested the accuracy of the white blood cell count, absolute neutrophil count, and platelet count at commonly used thresholds for IBIs. We determined optimal thresholds using receiver operating characteristic curves.

RESULTS: Of 4313 enrolled infants, 1340 (31%; 95% CI, 30% to 32%) were aged 0 to 28 days, 2412 were boys (56%), and 2471 were white (57%). Ninety-seven (2.2%; 95% CI, 1.8% to 2.7%) had IBIs. Sensitivities were low for common complete blood cell count parameter thresholds: white blood cell count less than 5000/µL, 10% (95% CI, 4% to 16%) (to convert to 109 per liter, multiply by 0.001); white blood cell count ≥15 000/µL, 27% (95% CI, 18% to 36%); absolute neutrophil count ≥10 000/µL, 18% (95% CI, 10% to 25%) (to convert to  × 109 per liter, multiply by 0.001); and platelets less than 100  × 103/µL, 7% (95% CI, 2% to 12%) (to convert to × 109 per liter, multiply by 1). Optimal thresholds for white blood cell count (11 600/µL), absolute neutrophil count (4100/µL), and platelet count (362 × 103/µL) were identified in models that had areas under the receiver operating characteristic curves of 0.57 (95% CI, 0.50-0.63), 0.70 (95% CI, 0.64-0.76), and 0.61 (95% CI, 0.55-0.67), respectively.

CONCLUSIONS AND RELEVANCE: No complete blood cell count parameter at commonly used or optimal thresholds identified febrile infants 60 days or younger with IBIs with high accuracy. Better diagnostic tools are needed to risk stratify young febrile infants for IBIs.

6. ACEP Clinical Policy: ED Management of Patients Needing Reperfusion Therapy for Acute STEMI

Promes SB, et al. Ann Emerg Med 2017;70:724-39.

Ischemic heart disease is the leading cause of death in the world. More than half a million patients present to emergency departments across the United States each year with ST-segment elevation myocardial infarctions.1 Timely reperfusion is critical to saving myocardium at risk. Multiple studies have been conducted that demonstrate that improved care processes are linked to improved survival in patients having an acute myocardial infarction.

This clinical policy from the American College of Emergency Physicians addresses key issues in reperfusion for patients with acute ST-segment elevation myocardial infarction. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions:

(1) In adult patients having an ST-segment elevation myocardial infarction, are there patients for whom treatment with fibrinolytic therapy decreases the incidence of major adverse cardiac events when percutaneous coronary intervention is delayed?

(2) In adult patients having an ST-segment elevation myocardial infarction, does transfer to a percutaneous coronary intervention center decrease the incidence of major adverse cardiac events?

(3) In adult patients undergoing reperfusion therapy, should opioids be avoided to prevent adverse outcomes?

Evidence was graded and recommendations were made based on the strength of the available data.

7. ED Care Delivery

A. EDs deliver 47.7% of US medical care

Marcozzi D, et al. Trends in the Contribution of Emergency Departments to the Provision of Health Care in the USA. Int J Health Serv 2017 Oct 17 [Epub ahead of print].

Traditional approaches to assessing the health of populations focus on the use of primary care and the delivery of care through patient-centered homes, managed care resources, and accountable care organizations. The use of emergency departments (EDs) has largely not been given consideration in these models. Our study aimed to determine the contribution of EDs to the health care received by Americans between 1996 and 2010 and to compare it with the contribution of outpatient and inpatient services using National Ambulatory Medical Care Survey and National Hospital Discharge Survey databases. We found that EDs contributed an average of 47.7% of the medical care delivered in the United States, and this percentage increased steadily over the 14-year study period. EDs are a major source of medical care in the United States, especially for vulnerable populations, and this contribution increased throughout the study period. Including emergency care within health reform and population health efforts would prove valuable to supporting the health of the nation.

B. How one Las Vegas ED saved hundreds of lives after the worst mass shooting in U.S. history

The night that Stephen Paddock opened fire on thousands of people at a Las Vegas country music concert, nearby Sunrise Hospital received more than 200 penetrating gunshot wound victims. Dr. Kevin Menes was the attending in charge of the ED that night, and thanks to his experience supporting a local SWAT team, he'd thought ahead about how he might mobilize his department in the event of a mass casualty incident.

8. Comparing the success rates of standard and modified Valsalva maneuvers to terminate PSVT: A randomized controlled trial.

Çorbacıoğlu ŞK, et al. Am J Emerg Med. 2017 Nov;35(11):1662-1665.

PURPOSE: The study aimed to detect whether modified Valsalva maneuver (VM) is more effective than the standard VM in terminating paroxysmal supraventricular tachycardia (PSVT).

METHODOLOGY: This randomized controlled trial was conducted in the emergency department of a training and research hospital between Dec. 1, 2015 and Dec. 31, 2016. Participants were divided into two groups, randomly assigned standard VM or modified VM, as the first treatment with two-dimensional permutation blocks; in the order of arrival of the patients. In both groups; the determined procedure for standard or modified VM was repeated up to three times in patients whose PSVT did not convert to sinus rhythm. In both groups; if the maneuver was unsuccessful after three attempts, anti-arrhythmic medication was administered. The primary outcome was defined to compare the success rate of achieving sinus rhythm after standard VM or modified VM.

RESULTS: Fifty-six patients were randomized to modified or standard VM with 28 patients in each treatment arm. Three of 28 patients (10.7%) in VM group and 12 of 28 patients (42.9%) in modified VM group were returned to sinus rhythm after intervention (p=0.007). The number of patients who needed rescue treatment was lower in the modified VM group - 16 (57.1%) of 28 versus 25 (89.3%) of 28 in the standard VM group (p=0.007).

CONCLUSION: This study suggests that modified VM therapy was more effective than standard VM for terminating PSVT. The modified VM therapy also indirectly reduced the need for anti-arrhythmic medication and indirectly caused fewer side effects.

What is the modified Valsalva?

From the original study: “The modified Valsalva manoeuvre (intervention) was termed “lying down with leg lift Valsalva” (video). Participants performed the standardised strain in the same semi-recumbent position but immediately at the end of the strain, were laid flat and had their legs raised by a member of staff to 45° for 15 s. Participants were then returned to the semi-recumbent position for a further 45 s before re-assessment of cardiac rhythm, initially by 3-lead ECG. If sinus rhythm was not restored, participants were invited to undertake one further attempt at the allocated Valsalva manoeuvre.”

Appelboam A, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of SVT (REVERT): a RCT. Lancet 2015 Oct 31;386(10005):1747-53.

9. New International CPR Guidelines

Olasveengen TM et al. 2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.
Resuscitation 2017;121:201–214.

Journal Watch Summary
Quality cardiopulmonary resuscitation (CPR) has become the central factor in improving outcomes of cardiac arrest. ILCOR has moved from a 5-year cycle for releasing guidelines to a continuous process of conducting systematic reviews and annual publication of recent results. These guidelines focus on the key issue of when to give ventilations during CPR.

Although questions remain about the optimal role of ventilations in CPR, several things are clear: (1) Use a 30:2 ratio of compressions:ventilations when possible and appropriate; (2) don't withhold compressions if the rescuer can't or won't give rescue breaths; and (3) once an endotracheal tube is in place, don't pause to give breaths.

10. Images in Clinical Practice

Acute constipation and vomiting with the “coffee bean” sign

Decompression Sickness
A 42-year-old man presented to the emergency department with skin changes, arthralgias, and vomiting after scuba diving. He was treated for decompression sickness.

Takotsubo Cardiomyopathy
A 61-year-old woman with hypertension and hypothyroidism presented to the emergency department with acute onset of severe chest pain. She reported multiple recent stressors, including the death of her dog. An electrocardiogram showed ST-segment elevation in the anterolateral leads. Emergency coronary angiography revealed normal coronary arteries.

Molluscum Contagiosum in a Patient with Atopic Dermatitis

“Popeye” Sign

Falciform Ligament Sign

Compartment Syndrome

HIV Infection Manifesting as Proximal White Onychomycosis

Button Magnets in the Nasal Cavity

Congenital Diaphragmatic Hernia

Woman With Swelling of the Left Breast

Adolescent Male With Abdominal Pain

Newborn With a Rash

Woman With Headache and Neck Swelling

Elderly Woman With Chest Pain and Cough (Hampton’s Hump)

Man With Blunt Abdominal Trauma

Child With a Serpinginous Structure in the Bowel

You Traveled the World and All You Got Was Ascariasis

Seven-Year-Old Girl With Forehead Swelling

Female With Neck Pain

Male With Sudden Left Eye Vision Loss

Young Woman With a Blue, Painful and Swollen Arm

Male With Left Lower Quadrant Pain

Elderly Female With Dyspnea

Young Woman With Eye Pressure

Child With Generalized Weakness and Anorexia

Elderly Woman With Atrial Fibrillation

11. Lumbar Puncture Before CT in Patients with Bacterial Meningitis

Sweden’s LP-first strategy was associated with less mortality and more favorable outcomes.

Glimåker M, et al. Lumbar puncture performed promptly or after neuroimaging in adult bacterial meningitis: A prospective national cohort study evaluating different guidelines.
Clin Infect Dis. 2017 Sep 9 [Epub ahead of print].

INTRODUCTION: Acute bacterial meningitis (ABM) is a life-threatening disease. Despite modern treatment and intensive care, the mortality is still 10%–30%, and the risk of persistent neurologic or hearing deficit is high [1–3]. Early adequate treatment is pivotal to achieve a favorable outcome [1, 4]. Lumbar puncture (LP) is the basis of ABM diagnosis and, in clinical practice, LP and cerebrospinal fluid (CSF) analyses are often decisive to start correct antibiotics and corticosteroids in meningitis dosages [4, 5].

It is recommended that, in certain situations with suspected increased intracranial pressure (ICP) and cerebral mass lesion, the clinician should refrain from prompt LP and instead first perform computed tomography (CT) of the brain, as it is argued that LP may increase the risk of brain herniation [6–8]. However, firm evidence that LP may cause herniation is lacking, and the natural course of ABM or brain abscess may itself result in herniation [6, 9, 10]. Furthermore, it is shown that cerebral CT is poor at predicting the risk of herniation in ABM [11–13]. Guidelines differ as to when to perform neuroimaging before LP in patients with suspected bacterial meningitis. Table 1 shows the recommendations in the current Swedish, European Society for Clinical Microbiology and Infectious Diseases (ESCMID), and Infectious Diseases Society of America (IDSA) guidelines. The Swedish guidelines are the most liberal regarding prompt LP since impaired mental status and new-onset seizures were omitted as indications for CT before LP after the revision in 2009 [14]. The ESCMID guidelines were revised in 2016 when the level of consciousness indicating CT before LP was lowered from Glasgow Coma Scale score (GCS) less than 12 to less than 10 [8]. IDSA guidelines from 2004 are the most conservative regarding prompt LP by recommending CT before LP if abnormal mental status (GCS less than 15) is observed [7]. In contrast to the Swedish recommendations, both the ESCMID and IDSA guidelines recommend CT before LP in cases with severely immunocompromised state or new-onset seizures.

BACKGROUND: Early treatment is pivotal for favourable outcome in acute bacterial meningitis (ABM). Lumbar puncture (LP) is the diagnostic key. The aim was to evaluate the effect on outcome of adherence to European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Infectious Diseases Society of America (IDSA), and Swedish guidelines regarding neuroimaging before LP.

METHODS: The cohort comprised 815 adult ABM patients in Sweden registered prospectively between 2008-2015. Primary endpoint was in-hospital mortality and secondary endpoint was favorable outcome at 2-6 months follow-up.

RESULTS: Indications for neuroimaging before LP existed in 7%, 32% and 65% according to Swedish, ESCMID and IDSA guidelines, respectively. The adjusted odds ratio (aOR) was 0.48 (95% CI: 0.26-0.89) for mortality and 1.52 (1.08-2.12) for favorable outcome if Swedish guidelines were followed. ESCMID guideline adherence resulted in aOR of 0.68 (0.38-1.23) for mortality and 1.05 (0.75-1.47) for favorable outcome. Following IDSA recommendations resulted in aOR of 1.09 (0.61-1.95) for mortality and 0.59 (0.42-0.82) for favorable outcome. Performing prompt vs. neuroimaging preceded LP was associated with aOR of 0.37 (0.18-0.76) for mortality and 2.12 (CI: 1.49-3.03) for favorable outcome. The beneficial effect of prompt LP was observed regardless of mental status and immunosuppression.

CONCLUSION: Adherence to Swedish guidelines in ABM 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.

The Swedish Guidelines discussed here: Glimåker M , Johansson B , Bell M  et al.    Early lumbar puncture in adult bacterial meningitis—rationale for revised guidelines. Scand J Infect Dis 2013; 45:657–63.

12. Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline

Lapoint J, et al. West J Emerg Med 2017 Nov 8 [Epub ahead of print].

Introduction: Cannabinoid hyperemesis syndrome (CHS) is an entity associated with cannabinoid overuse. CHS typically presents with cyclical vomiting, diffuse abdominal pain, and relief with hot showers. Patients often present to the emergency department (ED) repeatedly and undergo extensive evaluations including laboratory examination, advanced imaging, and in some cases unnecessary procedures. They are exposed to an array of pharmacologic interventions including opioids that not only lack evidence, but may also be harmful.This paper presents a novel treatment guideline that highlights the identification and diagnosis of CHS and summarizes treatment strategies aimed at resolution of symptoms, avoidance of unnecessary opioids, and ensuring patient safety.

Methods: The San Diego Emergency Medicine Oversight Commission in collaboration with the County of San Diego Health and Human Services Agency and San Diego Kaiser Permanente Division of Medical Toxicology created an expert consensus panel to establish a guideline to unite the ED community in the treatment of CHS.

Results: Per the consensus guideline, treatment should focus on symptom relief and education on the need for cannabis cessation. Capsaicin is a readily available topical preparation that is reasonable to use as first-line treatment. Antipsychotics including haloperidol and olanzapine have been reported to provide complete symptom relief in limited case studies. Conventional antiemetics including antihistamines, serotonin antagonists, dopamine antagonists and benzodiazepines may have limited effectiveness. Emergency physicians should avoid opioids if the diagnosis of CHS is certain and educate patients that cannabis cessation is the only intervention that will provide complete symptom relief.

Conclusion: An expert consensus treatment guideline is provided to assist with diagnosis and appropriate treatment of CHS. Clinicians and public health officials should identity and treat CHS patients with strategies that decrease exposure to opioids, minimize use of healthcare resources, and maximize patient safety.

13. Annal Emerg Med Brief Reviews

A. What Elements of the History, Examination, Laboratory Testing, or Point-of-Care Ultrasonography Are Most Useful in the Diagnosis of Acute Appendicitis in Children?

Take-Home Message
In children with suspected appendicitis, history, physical examination, laboratory results, and the Pediatric Appendicitis Score cannot safely rule in or rule out the diagnosis. A positive ultrasonographic result, with sonography performed by a qualified provider, is diagnostic.

B. What Is the Utility of End-Tidal Capnography for Procedural Sedation and Analgesia in the ED?

Take-Home Message
The addition of capnography to standard monitoring in emergency department (ED) procedural sedation and analgesia does not appear to reduce the rate of clinically significant adverse events.

C. Are Nonsteroidal Anti-inflammatory Drugs Efficacious in Relieving Biliary Colic Pain?

Take-Home Message
Nonsteroidal anti-inflammatory drugs are beneficial in managing biliary colic pain compared with placebo. No difference was found in pain relief when nonsteroidal anti-inflammatory drugs were compared with opioids.

D. Is Antiplatelet Therapy an Independent Risk Factor for Traumatic ICH in Patients With Mild Traumatic Brain Injury?

Take-Home Message
Antiplatelet therapy appears to increase the risk for intracranial bleeding in patients with traumatic brain injury compared with those receiving warfarin or no antiplatelet therapy; however, this may not apply to aspirin monotherapy.

14. The Science of Performance Under Stress and of Wellness during Residency (and beyond)

A. Psychological Skills to Improve Emergency Care Providers' Performance Under Stress.

Lauria MJ, Weingart SD, et al. Ann Emerg Med. 2017 Dec;70(6):884-890.

Stress experienced by emergency medical providers during the resuscitation of critically ill or injured patients can cause cognitive and technical performance to deteriorate. Psychological skills training offers a reasonable and easily implemented solution to this problem. In this article, a specific set of 4 performance-enhancing psychological skills is introduced: breathe, talk, see, and focus. These skills comprise breathing techniques, positive self-talk, visualization or mental practice, and implementing a focus "trigger word." The evidence supporting these concepts in various domains is reviewed and specific methods for adapting them to the environment of resuscitation and emergency medicine are provided.

B. Strategies to Enhance Wellness in Emergency Medicine Residency Training Programs.

Ross S, et al. Ann Emerg Med. 2017 Dec;70(6):891-897.

Physician wellness is important at all stages of training, and resident depression and suicide has recently gained national attention as a critical problem in residencies across all specialties.9, 10 Despite this, many emergency medicine residencies have little to no devoted time to address wellness in their educational curricula. Residencies have begun to implement wellness activities, which range from rotations in wellness and leadership to wellness retreats, but so far those efforts have been insufficient to stave off the presence of depression and burnout in residency training.11, 12, 13 Here we discuss strategies to improve wellness during emergency medicine residency. Strategies include both interventions at the level of the individual resident and the emergency medicine residency training community.

15. OB/GYN Corner

A. Is the Pelvic Examination Still Crucial in Patients Presenting to the ED with Vaginal Bleeding or Abdominal Pain When an IUP Is Identified on US? A RCT

Linden JA, et al. Ann Emerg Med. 2017 Dec;70(6):825-834.

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.

Editor’s Capsule Summary
What is already known on this topic
It is unknown whether pelvic examinations enhance the management of first-trimester vaginal bleeding or lower abdominal pain.

What question this study addressed
This randomized controlled trial compared patient morbidity, satisfaction, and length of stay among 220 patients presenting to 2 emergency departments (EDs) with lower abdominal pain or vaginal bleeding and a confirmed first-trimester intrauterine pregnancy, who were randomized to no pelvic examination (versus standard care of a pelvic examination).

What this study adds to our knowledge
Although the study did not reach target recruitment numbers, it shows similar composite morbidity endpoints and substantially higher satisfaction among patients randomized to no pelvic examination compared with those receiving one.

How this is relevant to clinical practice
This study provides the best available evidence supporting omission of pelvic examinations from ED evaluation of women with confirmed intrauterine pregnancy and first-trimester bleeding or lower abdominal pain.

B. Update: UTI Diagnosis and Treatment

Gupta K, et al. Ann Intern Med. 2017;167:ITC49-ITC64.

This narrative review provides an update of the evidence regarding diagnosis and treatment of urinary tract infections (UTIs). Key points include:
  •      Clinicians should not screen for or treat asymptomatic bacteriuria, except in pregnant patients or those undergoing invasive urinary procedures that will induce mucosal bleeding (e.g., transurethral resection of the prostate).
  •      Although UTI can be diagnosed clinically, urine culture should be done in patients in whom the diagnosis is uncertain, in pregnant women, and in men with suspected UTI. Urine culture is also indicated when pyelonephritis or complicated infection is suspected and in cases of relapse or treatment failure.
  •      Antibiotic choice depends on the classification of the disease. Fluoroquinolones should not be used to treat uncomplicated cystitis based on safety and stewardship concerns but may be used to treat pyelonephritis and complicated infections (e.g., structural abnormalities of the urinary tract or immunocompromised host). Resistance is common in many areas.

Bonus: Symptomatic treatment of uncomplicated lower urinary tract infections in the ambulatory setting: randomised, double blind trial

C. What Antibiotic Regimen Is Most Efficacious in Treating Pelvic Inflammatory Disease?

Take-Home Message
Outcomes do not differ between the various antibiotics currently recommended by Centers for Disease Control and Prevention (CDC) guidelines for pelvic inflammatory disease, although most studies are at unclear or high risk of bias.

16. Does This Patient Have Acute Mountain Sickness? The Rational Clinical Examination Systematic Review

Meier D, et al. JAMA.  2017;318(18):1810-1819.

Key Points

Question  What is the best instrument to use for diagnosing acute mountain sickness (AMS)?

Findings  In a systematic review of studies assessing the accuracy of existing AMS diagnostic instruments, the visual analog scale for the overall feeling of sickness at altitude (VAS[O]) score, the Acute Mountain Sickness-Cerebral score (AMS-C), and the clinical functional score (CFS) had similar testing characteristics for diagnosing AMS as did a reference standard (the Lake Louise Questionnaire Score [LLQS] using ≥5 to indicate a positive test result).

Meaning  Although these instruments emphasize different clinical features, they all performed similarly for establishing a diagnosis of AMS. The clinical functional score is the simplest instrument to use for diagnosing AMS because it relies on a single question and emphasizes functional limitations resulting from AMS.

17. Oral Anticoagulant Corner

A. Dabigatran Reversal with Idarucizumab

Yip L, et al. N Engl J Med 2017; 377:1690-1692

Data provided by Pollack and colleagues (Aug. 3 issue)1 suggest a dissociation between the normalization of the coagulation profile and the establishment of effective hemostasis after the administration of idarucizumab in patients with uncontrolled bleeding. The median time to the cessation of bleeding was 2.5 hours among patients with nonintracranial hemorrhage. In analyses reported separately, the median time to the cessation of bleeding was 3.5 hours among patients with gastrointestinal bleeding and 4.5 hours among those with nonintracranial and nongastrointestinal bleeding.2 The median time to the cessation of bleeding was 11.4 hours when intracranial hemorrhage was included in the analysis involving patients with serious bleeding.3 Should clinicians rely solely on idarucizumab and hope that their patients do not die from uncontrolled hemorrhage while waiting for hemostasis to be established?

A reasonable approach would be to administer blood-component therapy (e.g., prothrombin complex concentrate and activated prothrombin complex concentrate) — a bridge between the normalization of the coagulation profile and the establishment of hemostasis, according to in vitro and preclinical data4,5 — in addition to idarucizumab. It can be reasonably argued that the establishment of effective hemostasis with blood-component and idarucizumab therapy outweighs the risk of thrombotic adverse events among patients with serious hemorrhaging. The effectiveness and need for further blood-component and idarucizumab therapy may be assessed by serial clinical assessments and a serial profile of clotting times.

B. OACs Tied to Less Dementia in Patients with Atrial Fibrillation

By Amy Orciari Herman. Journal Watch News.

Oral anticoagulation in patients with atrial fibrillation is associated with reduced risk for dementia, according to a retrospective study in the European Heart Journal.

Using data from Swedish health registries, researchers studied over 440,000 adults with diagnosed atrial fibrillation and no history of dementia. Over 40% of the patients were using vitamin K antagonists at baseline, and 3% were using novel oral anticoagulants (NOACs). During follow-up, about 6% of the cohort developed dementia (1.73 diagnoses per 100 patient-years).

In a matched cohort analysis, patients who'd received oral anticoagulants at baseline had a 29% lower risk for dementia than those who hadn't received oral anticoagulants. Earlier treatment initiation appeared more beneficial. The protective effect didn't seem to differ between NOACs and warfarin.

The researchers speculate that oral anticoagulation may "protect against small emboli which [cause] microinfarctions that eventually lead to cognitive deterioration." They conclude: "Our findings regarding dementia protection may provide a second argument for initiation of treatment among untreated AF-patients. Since the time from diagnosis to start of treatment appears to be an independent risk factor, early initiation of treatment is desirable in order to preserve cognitive function."

C. When Anticoagulants Become a Bloody Mess

Lai S, et al. Ann Emerg Med 2017;70:949–952.

Annals Case
Imagine just another busy day in your emergency department (ED) when an elderly gentleman presents with a simple, straightforward mechanical fall. Sounds easy. Subsequent head computed tomography shows a traumatic subdural hemorrhage and now his care is a little more complicated. Then you discover his history of atrial fibrillation and, as recommended by his CHA2DS2-VASc score,1 he is in fact receiving an oral anticoagulant. Of course he has no previous records or medication list on hand and cannot recall the name of his mystery anticoagulant. Now this simple case is very, very complicated. Anticoagulation reversal for his unknown anticoagulant is needed…and fast. Could he be receiving a non–vitamin K oral anticoagulant (NOAC)? How do we reverse these agents?

Helpful discussion section is located in this middle section (see full-text below)

Case Conclusion
Take 1: Fortunately for us and our patient, a family member shows up and reports he last took his dabigatran 6 hours ago. You cleverly order idarucizumab, and a concerned neurosurgeon takes the patient up to the ICU. After giving yourself a hearty and deserved pat on the back, on to the next patient!

Take 2: But what if this family member reported rivaroxaban taken 7 hours ago instead? Well, we are outside the 2-hour last ingestion window for activated charcoal, rivaroxaban does not currently have an antidote available, and it is not dialyzable. Here, you cleverly order PCC or aPCC and consider tranexamic acid, after which a concerned neurosurgeon takes the patient up to the ICU. Time for another hearty and deserved pat on the back, and on to the next patient!

D. ACEP Policy: Reversal of Non–Vitamin K Antagonist Oral Anticoagulants (NOACs) in the Presence of Major Life-Threatening Bleeding

This offers a helpful, up-to-date review.

E. A Crazy Case Report

Agosti S, et al. Successful Intravenous Thrombolysis for Ischemic Stroke After Reversal of Dabigatran Anticoagulation With Idarucizumab: A Case Report. J Med Case Rep. 2017; 11: 224.

18. Shared Decisionmaking in the ED: A Guiding Framework for Clinicians

Probst MA, et al. Ann Emerg Med. 2017;70:688–695.

Shared decisionmaking has been proposed as a method to promote active engagement of patients in emergency care decisions. Despite the recent attention shared decisionmaking has received in the emergency medicine community, including being the topic of the 2016 Academic Emergency Medicine Consensus Conference, misconceptions remain in regard to the precise meaning of the term, the process, and the conditions under which it is most likely to be valuable. With the help of a patient representative and an interaction designer, we developed a simple framework to illustrate how shared decisionmaking should be approached in clinical practice.

We believe it should be the preferred or default approach to decisionmaking, except in clinical situations in which 3 factors interfere. These 3 factors are lack of clinical uncertainty or equipoise, patient decisionmaking ability, and time, all of which can render shared decisionmaking infeasible. Clinical equipoise refers to scenarios in which there are 2 or more medically reasonable management options. Patient decisionmaking ability refers to a patient’s capacity and willingness to participate in his or her emergency care decisions. Time refers to the acuity of the clinical situation (which may require immediate action) and the time that the clinician has to devote to the shared decisionmaking conversation. In scenarios in which there is only one medically reasonable management option, informed consent is indicated, with compassionate persuasion used as appropriate. If time or patient capacity is lacking, physician-directed decisionmaking will occur. With this framework as the foundation, we discuss the process of shared decisionmaking and how it can be used in practice. Finally, we highlight 5 common misconceptions in regard to shared decisionmaking in the ED. With an improved understanding of shared decisionmaking, this approach should be used to facilitate the provision of high-quality, patient-centered emergency care.

19. Choking on a Foreign Body: A Physiological Study of the Effectiveness of Abdominal Thrust Manoeuvres to Increase Thoracic Pressure

Pavitt MJ, et al. Thorax. 2017;72(6):576-578.

The Heimlich manoeuvre is a well-known intervention for the management of choking due to foreign body airway occlusion, but the evidence base for guidance on this topic is limited and guidelines differ. We measured pressures during abdominal thrusts in healthy volunteers. The angle at which thrusts were performed (upthrust vs circumferential) did not affect intrathoracic pressure. Self-administered abdominal thrusts produced similar pressures to those performed by another person. Chair thrusts, where the subject pushed their upper abdomen against a chair back, produced higher pressures than other manoeuvres. Both approaches should be included in basic life support teaching….

The key to diagnosing complete airway obstruction is a conscious subject, in the process of eating, who is unable to breathe at all, nor to speak. Autoadministered thrusts appear as physiologically effective as first-aider-administered ones to generate expulsive intrathoracic pressures, and chair thrusts appear to be the most physiologically effective. We advise that everyone with complete airway obstruction should, in the first instance, either autoadminister abdominal thrusts or perform a chair thrust. The various manoeuvres should be more widely taught in schools, first aid courses, to staff in restaurants and publicised as widely as possible. We would like to see suitable notices in eating places.

20. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials

Sadeghirad B, et al. BMJ. 2017 Sep 20;358:j3887.

Objective To estimate the benefits and harms of using corticosteroids as an adjunct treatment for sore throat.

Design Systematic review and meta-analysis of randomised control trials.

Data sources Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), trial registries up to May 2017, reference lists of eligible trials, related reviews.

Study selection Randomised controlled trials of the addition of corticosteroids to standard clinical care for patients aged 5 or older in emergency department and primary care settings with clinical signs of acute tonsillitis, pharyngitis, or the clinical syndrome of sore throat. Trials were included irrespective of language or publication status.

Review methods Reviewers identified studies, extracted data, and assessed the quality of the evidence, independently and in duplicate. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including the selection of outcomes important to patients. Random effects model was used for meta-analyses. Quality of evidence was assessed with the GRADE approach.

Results 10 eligible trials enrolled 1426 individuals. Patients who received single low dose corticosteroids (the most common intervention was oral dexamethasone with a maximum dose of 10 mg) were twice as likely to experience pain relief after 24 hours (relative risk 2.2, 95% confidence interval 1.2 to 4.3; risk difference 12.4%; moderate quality evidence) and 1.5 times more likely to have no pain at 48 hours (1.5, 1.3 to 1.8; risk difference 18.3%; high quality). The mean time to onset of pain relief in patients treated with corticosteroids was 4.8 hours earlier (95% confidence interval −1.9 to −7.8; moderate quality) and the mean time to complete resolution of pain was 11.1 hours earlier (−0.4 to −21.8; low quality) than in those treated with placebo. The absolute pain reduction at 24 hours (visual analogue scale 0-10) was greater in patients treated with corticosteroids (mean difference 1.3, 95% confidence interval 0.7 to 1.9; moderate quality). Nine of the 10 trials sought information regarding adverse events. Six studies reported no adverse effects, and three studies reported few adverse events, which were mostly complications related to disease, with a similar incidence in both groups.

Conclusion Single low dose corticosteroids can provide pain relief in patients with sore throat, with no increase in serious adverse effects. Included trials did not assess the potential risks of larger cumulative doses in patients with recurrent episodes of acute sore throat.

21. 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; 377:2090-2091.

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.

Educate yourself. Read the background materials and proposals for sensible firearm legislation from health care professional organizations. Make a phone call and write a letter to your local, state, and federal legislators to tell them how you feel about gun control. Now. Don’t wait. And do it again at regular intervals. Attend public meetings with these officials and speak up loudly as a health care professional. Demand answers, commitments, and follow-up. Go to rallies. Join, volunteer for, or donate to organizations fighting for sensible firearm legislation. Ask candidates for public office where they stand and vote for those with stances that mitigate firearm-related injury.

Meet with the leaders at your own institutions to discuss how to leverage your organization’s influence with local, state, and federal governments. Don’t let concerns for perceived political consequences get in the way of advocating for the well-being of your patients and the public. Let your community know where your institution stands and what you are doing. Tell the press.

Educate yourself about gun safety. Ask your patients if there are guns at home. How are they stored? Are there children or others at risk for harming themselves or others? Direct them to resources to decrease the risk for firearm injury, just as you already do for other health risks. Ask if your patients believe having guns at home makes them safer, despite evidence that they increase the risk for homicide, suicide, and accidents.

Don’t be silent. We don’t need more moments of silence to honor the memory of those who have been killed. We need to honor their memory by preventing a need for such moments. As health care professionals, we don’t throw up our hands in defeat because a disease seems to be incurable. We work to incrementally and continuously reduce its burden. That’s our job.

Will yet another commentary about the ravages of firearm-related harm change anything? Probably not — our journals have published far too many following prior firearm-enabled catastrophes. The only thing that will change the world for the better is a group of people who believe that they can change the world. With regard to firearm-related injury and death, let’s each be part of that group.

22. Ultrasound in Emerg Med

A. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice.

Saugel B, et al. Crit Care. 2017 Aug 28;21(1):225. doi: 10.1186/s13054-017-1814-y.

The use of ultrasound (US) has been proposed to reduce the number of complications and to increase the safety and quality of central venous catheter (CVC) placement. In this review, we describe the rationale for the use of US during CVC placement, the basic principles of this technique, and the current evidence and existing guidelines for its use. In addition, we recommend a structured approach for US-guided central venous access for clinical practice. Static and real-time US can be used to visualize the anatomy and patency of the target vein in a short-axis and a long-axis view. US-guided needle advancement can be performed in an "out-of-plane" and an "in-plane" technique.

There is clear evidence that US offers gains in safety and quality during CVC placement in the internal jugular vein. For the subclavian and femoral veins, US offers small gains in safety and quality. Based on the available evidence from clinical studies, several guidelines from medical societies strongly recommend the use of US for CVC placement in the internal jugular vein. Data from survey studies show that there is still a gap between the existing evidence and guidelines and the use of US in clinical practice.

For clinical practice, we recommend a six-step systematic approach for US-guided central venous access that includes assessing the target vein (anatomy and vessel localization, vessel patency), using real-time US guidance for puncture of the vein, and confirming the correct needle, wire, and catheter position in the vein. To achieve the best skill level for CVC placement the knowledge from anatomic landmark techniques and the knowledge from US-guided CVC placement need to be combined and integrated.

B. The role for US in hypotension and in cardiac arrest

International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest

Atkinson P, et al. CJEM 2017 Nov;19(6):459-470.

The International Federation for Emergency Medicine (IFEM) Ultrasound Special Interest Group (USIG) was tasked with development of a hierarchical consensus approach to the use of point of care ultrasound (PoCUS) in patients with hypotension and cardiac arrest.
The IFEM USIG invited 24 recognized international leaders in PoCUS from emergency medicine and critical care to form an expert panel to develop the sonography in hypotension and cardiac arrest (SHoC) protocol. The panel was provided with reported disease incidence, along with a list of recommended PoCUS views from previously published protocols and guidelines. Using a modified Delphi methodology the panel was tasked with integrating the disease incidence, their clinical experience and their knowledge of the medical literature to evaluate what role each view should play in the proposed SHoC protocol.
Consensus on the SHoC protocols for hypotension and cardiac arrest was reached after three rounds of the modified Delphi process. The final SHoC protocol and operator checklist received over 80% consensus approval. The IFEM-approved final protocol, recommend Core, Supplementary, and Additional PoCUS views. SHoC-hypotension core views consist of cardiac, lung, and inferior vena vaca (IVC) views, with supplementary cardiac views, and additional views when clinically indicated. Subxiphoid or parasternal cardiac views, minimizing pauses in chest compressions, are recommended as core views for SHoC-cardiac arrest; supplementary views are lung and IVC, with additional views when clinically indicated. Both protocols recommend use of the “4 F” approach: fluid, form, function, filling.
An international consensus on sonography in hypotension and cardiac arrest is presented. Future prospective validation is required.

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23. Pushing Back on Push Dose Pressors?

Genes N. EP Monthly. Nov 20, 2017

A quick and easy life-saving solution, or an unjustifiable risk to patients?

As a resident, I was fortunate to regularly hear Scott Weingart speak at our Wednesday conference. So to me, bolus-dose vasopressors (or as Scott coined them, push-dose pressors) have just always been a useful thing to have nearby.

Say you have a crashing peri-intubation patient with a low MAP. Wouldn’t it be comforting to know that you can boost the blood pressure for your procedure quickly, albeit temporarily, while a drip is set up? We’ve had pre-filled syringes close at hand in our resuscitation bay for years, and push-dose pressors have bailed me out of at least a few tense situations. There are times when waiting for pressure-bagged fluids to exert an effect, or waiting for a drip to get set up isn’t in the patient’s best interest.

I just assumed that everyone else agreed. I didn’t realize that other specialties, and some of our own colleagues, would look upon EPs using push-dose pressors with suspicion – unnecessary at best, and too risky to recommend.

But that’s the perception that AJEM’s Letters to the Editor section gave this summer, with echoes across the EM social media world…

24. Micro Bits

A. Laptops in the Classroom Hinder Learning. Imagine their Effect during Meetings.

B. Regular Walking, Even if Minimal, Tied to Lower Death Risk

Researchers found that adults who did moderate-intensity walking for 120 minutes or less per week were at a reduced likelihood of dying prematurely from all causes, compared with inactive individuals, while higher levels of walking were tied to a 20% lower mortality risk. The findings in the American Journal of Preventive Medicine, based on data on more than 139,000 adults enrolled in the Cancer Prevention Study II Nutrition Cohort, showed that the age-standardized overall death rate among those who walked less than the recommended amount of physical activity was 2,851 per 100,000, compared with 4,293 per 100,000 among inactive participants.

C. Mood might influence vaccine efficacy among seniors, study suggests

Researchers who monitored the psychological and physical health of 138 people ages 65 to 85 found that those whose moods were more positive had higher serum levels of antibodies to H1N1 four and 16 weeks after vaccination than those whose moods were more negative. The findings -- reported in Brain, Behavior, and Immunity -- suggest that although many factors that could influence vaccine efficacy are out of patients' control, a positive outlook on the day of inoculation might benefit, health psychologist Kavita Vedhara said.

D. Pregnant Women Should Still Get The Flu Vaccine, Doctors Advise

E. Coffee consumption and health: umbrella review of meta-analyses of multiple health outcomes

Drinking three to four cups of coffee a day is associated with health benefits across a range of diseases and conditions. A review published in The BMJ this week identified 201 meta-analyses of observational research and 17 meta-analyses of interventional research and found that coffee consumption was more often associated with benefit than harm over various health outcomes

F. Thanks a Lot! New Reasons Not to Eat Cookie Dough

Spoiler alert.

If you are already elbow-deep in holiday cake and cookie batter, you may just want to take your chances and stop reading here.

But to become wiser and safer, though indisputably annoyed, step away from that bowl and read on.

Tasting uncooked foods made with flour can make you dangerously ill, according to a study published Wednesday in The New England Journal of Medicine. The report, which recounts the detective work that led to a recall of more than 10 million pounds of flour in the summer of 2016, confirms that a type of E. coli bacteria previously discovered lurking in wet environments like hamburger meat and leafy vegetables can also thrive in arid hosts.

“We’re not trying to ruin people’s holidays but we want them to be aware of the risks,” said Samuel J. Crowe, the lead author of the study and an epidemiologist…

G. Updated AHA guidelines lower threshold for hypertension

New guidelines from the American Heart Association and 10 other medical groups reduce the hypertension threshold from 140 mm Hg systolic over 90 mm Hg to 130 over 80, meaning 46% of US adults would be diagnosed with high blood pressure. The guidelines, published in the Journal of the American College of Cardiology and in Hypertension, call for patients already being treated for high blood pressure to work toward the lower goal and for adults to address early hypertension with lifestyle changes rather than medication.

A Visual Guide to the New Blood Pressure Guidelines : The ACC/AHA 2017 recommendations -- in color and by the numbers

What the new guidelines mean for Kaiser Permanente, and what can be learned

H. During Pregnancy, Side Sleeping Better For Baby (British Journal of Obstetrics and Gynaecology): Supine sleeping tied to stillbirth risk

I. FDA approves the first pill that can alert your doctor when you swallow it

The Food and Drug Administration has approved the first pill embedded with a sensor that can alert a patient’s physician or caregiver when it’s been ingested, the agency announced on Monday.

The Japanese drug maker Otsuka Pharmaceutical won the approval for an upgraded version of Abilify, the antipsychotic drug first approved 15 years ago to treat schizophrenia, bipolar disorder, and depression. Otsuka collaborated with Proteus Digital Health, the Silicon Valley company that designed the futuristic sensor technology.

The new product, which will be sold as Abilify MyCite, can be swallowed just like any other pill. When that happens, the ingestible sensor inside it sends a message to a patch worn by the patient, which then transmits the information to a mobile app that the patient can monitor. If a patient opts to allow it, the patient’s caregivers and doctor can access the data online, too…

J. Vegetarianism Linked to Depression : Maybe from Vit Deficiency ?

K. Readmission reduction program leads to higher mortality rates in HF Pts

The Hospital Readmissions Reduction Program has led to fewer patient readmissions but an increase in 30-day and one-year mortality rates for Medicare beneficiaries hospitalized with heart failure, researchers reported in JAMA Cardiology. Study co-author Gregg Fonarow, M.D., said while reducing preventable readmissions is important, it must be done in concert with "strong efforts to ensure patient safety and to reduce preventable deaths."

L. Offering Influenza Vaccine to All Pediatric Emergency Department Patients May Be Cost

In a computerized simulation, this strategy prevented an estimated 27 influenza cases per 1000 patients.

M. Does Acetaminophen Exposure In Utero Increase Risk for ADHD? FREE

Jenny Radesky, MD reviewing Ystrom E et al. Pediatrics 2017 Nov Wolraich ML. Pediatrics 2017 Nov

A large dataset analysis adjusted for multiple confounders indicates that acetaminophen use for ≥29 days during in pregnancy doubles the risk for ADHD in offspring.