Lit Bits: November 9, 2006

From the recent medical literature...

1. CT Scan Improves Chest-Pain Triage in ED

from Heartwire — a professional news service of WebMD. October 31, 2006 (Boston, MA) — Noninvasive assessment of coronary artery disease by coronary 64-slice multidetector computed tomography (MDCT) can be used for ruling out ACS in subjects presenting with chest pain to the emergency department and may be useful for improving early triage, a new study suggests.

The study, published online in Circulation on October 30, 2006, was conducted by a team led by Dr Udo Hoffman (Massachusetts General Hospital, Boston, MA). They explain that accurate triage of patients presenting with acute chest pain to the emergency department remains difficult because chest-pain history, a single set of biochemical markers for myocardial necrosis, and the initial 12-lead ECG, alone or in combination, cannot identify a group of patients who can be safely discharged without further diagnostic testing. As a consequence, more than 60% of patients with chest pain who are admitted to the hospital turn out not to have ACS. In addition, the rate of missed diagnosis of ACS remains unacceptably high (2% to 8%).

They point out that as coronary artery disease is the major underlying cause of ACS, a noninvasive method that quickly and accurately excludes the presence of CAD could substantially improve the ability to triage patients with chest pain and that MDCT could be the answer. This scan requires patients to be injected intravenously with a contrast agent and to hold their breath during the 15-second exam.

CT results matched eventual clinical diagnosis

In the current study, patients presenting with chest pain to the emergency department underwent MDCT for the assessment of coronary atherosclerotic plaque and significant coronary artery stenosis. An expert panel, blinded to the CT data, determined the presence or absence of ACS on the basis of all data accrued during the index hospitalization and five-month follow-up. Among 103 patients, only 14 patients were found to have ACS. The MDCT results correlated well with other methods of diagnosis. Both the absence of significant coronary artery stenosis and nonsignificant coronary atherosclerotic plaque on the CT scan accurately predicted the absence of ACS, with a negative predictive value of 100%. Multivariate logistic regression analyses demonstrated that adding the extent of plaque from a MDCT scan significantly improved the initial models containing only traditional risk factors or clinical estimates of the probability of ACS.

Hoffman commented to heartwire that this is the first study that has "very rigorously" looked at the role of MDCT in a cardiology clinical application. "MDCT is an emerging technology and is not used routinely yet, but it is probably used most in patients with stable angina to help decide whether to send them to angiography. We may do about 10 a day, and many private practices will offer this, but there is a reimbursement issue at the moment as it is not an established diagnostic modality yet," he explained.

But Hoffman believes that MDCT has great potential as a diagnostic aid in chest-pain patients presenting in the emergency room. "At present, just acting on the traditional risk factors and tests conducted in the emergency department, it can still be difficult to differentiate those patients with an ACS from those whose chest pain is not cardiac related. Many patients are admitted to the hospital for stress tests and angiography, but fewer than 40% of patients admitted after initially normal blood tests and ECG turn out to have symptoms related to heart disease. But if we add the CT information to those tests conducted in the emergency department, things become a lot clearer," he said.

Hoffman believes MDCT will be used to exclude ACS rather than to confirm it. "I am not suggesting that MDCT be used at present to decide whether patients need a stent or not— it's not ready for that yet—but it probably does have a role in helping to decide who needs to be sent to angiography and who can be sent home. MDCT does not give the level of knowledge necessary to know whether a stent is required—you need angiography for that—but it can tell you whether there is significant stenosis or not. The beauty of MDCT is that it is much easier to perform than angiography. It takes less time, requires less physician time, it is less invasive, has fewer complications, and is much less expensive. It's not going to replace angiography but it may enable fewer patients to be sent to angiography by ruling out ACS beforehand," he told heartwire.

For the remainder of the Heartwire article, click here. For the abstract, click here.

Hoffmann U, Nagurney JT, Moselewski F, et al. Coronary multidetector computed tomography in the assessment of patients with acute chest pain. Circulation 2006; DOI: 10.1161/CIRCULATIONAHA.106.634808.

2. Do opiates affect the clinical evaluation of patients with acute abdominal pain?

Ranji SR; Goldman LE; Simel DL; Shojania KG. JAMA. 2006; 296(14):1764-74 (ISSN: 1538-3598)

CONTEXT: Clinicians have traditionally withheld opiate analgesia from patients with acute abdominal pain until after evaluation by a surgeon, out of concern that analgesia may alter the physical findings and interfere with diagnosis.

OBJECTIVE: To determine the impact of opiate analgesics on the rational clinical examination and operative decision for patients with acute abdominal pain.

DATA SOURCES AND STUDY SELECTION: MEDLINE (through May 2006), EMBASE, and hand searches of article bibliographies to identify placebo-controlled randomized trials of opiate analgesia reporting changes in the history, physical examination findings, or diagnostic errors (those resulting in "management errors," defined as the performance of unnecessary surgery or failure to perform necessary surgery in a timely fashion).

DATA EXTRACTION: Two authors independently reviewed each study, abstracted data, and classified study quality. A third reviewer independently resolved discrepancies.

DATA SYNTHESIS: Studies both in adults (9 trials) and in children (3 trials) showed trends toward increased risks of altered findings on the abdominal examination due to opiate administration, with risk ratios for changes in the examination of 1.51 (95% confidence interval [CI], 0.85 to 2.69) and 2.11 (95% CI, 0.60 to 7.35), respectively. When the analysis was restricted to the 8 adult and pediatric trials that reported significantly greater analgesia for patients who received opiates compared with those who received placebo, the risk of physical examination changes became significant (risk ratio, 2.13; 95% CI, 1.14 to 3.98). These trials exhibited significant heterogeneity (I2 = 68.6%; P = .002), and only 2 trials distinguished clinically significant changes such as loss of peritoneal signs from all other changes; consequently, we analyzed risk of management errors as a marker for important changes in the physical examination.

Opiate administration had no significant association with management errors (+0.3% absolute increase; 95% CI, -4.1% to +4.7%). The 3 pediatric trials showed a nonsignificant absolute decrease in management errors (-0.8%; 95% CI, -8.6% to +6.9%). Across adult and pediatric trials with adequate analgesia, opiate administration was associated with a nonsignificant absolute decrease in the risk of management errors (-0.2%; 95% CI, -4.0% to +3.6%).

CONCLUSIONS: Opiate administration may alter the physical examination findings, but these changes result in no significant increase in management errors. The existing literature does not rule out a small increase in errors, but this error rate reflects a conservative definition in which surgeries labeled as either delayed or unnecessary may have met appropriate standards of care. In published research reports, no patient experienced major morbidity or mortality attributable to opiate administration.

3. Real-Time US-Guided IJ Vein Catheterization in the ED Increases Success Rates and Reduces Complications: A Randomized, Prospective Study

Leung J, Duffy M, Finckh A. Ann Emerg Med 2006 (Nov);48:540-547.

Study objective
We compare real-time ultrasonographic guidance and the traditional landmark technique for the insertion of internal jugular vein catheters in an emergency department (ED) setting.

Methods
This was a prospective, randomized, clinical study performed in a tertiary ED between August 2003 and May 2005 on patients requiring central venous access. Ultrasonographically guided catheters were inserted under real time using the Sonosite ultrasonographic system with a 10 to 5 MHz 38-mm linear array transducer. Standardized data were collected on operator experience, method of insertion, reason for central venous access, and comorbidities. Outcome measures included successful insertion of an internal jugular vein catheter, number of attempts, access times, and complications.

Results
One hundred thirty patients were enrolled. Cannulation of the internal jugular vein was successful in 61 of 65 patients (93.9%) using ultrasonography and in 51 of 65 patients (78.5%) using the landmark technique, a significant difference of 15.4% (P=.009, 95% confidence interval [CI] 3.8% to 27.0%). Fifty of 61 (82.0%) of the successful ultrasonographically guided catheters were inserted on the first attempt compared with 36 of 51 (70.6%) of the successful landmark catheters. Mean access times to venipuncture and successful insertion were 138 and 281 seconds by ultrasonographic guidance and 132 and 271 seconds by the landmark technique. There was a 10.8% complication rate, with 11 complications (16.9%) in the landmark group and 3 (4.6%) in the ultrasonographic group, a difference of 12.3% (95% CI 1.9% to 22.8%).

Conclusion
Ultrasonographically guided internal jugular vein catheterization in the ED setting was associated with a higher successful insertion rate and a lower complications rate.

4. Should Proton Pump Inhibitors Be Used for Acute Peptic Ulcer Bleeding?

Barnet Eskin, et al. Ann Emerg Med. 2006;48:624-626

Systematic review source
This is a systematic review abstract, a regular feature of the Annals’ Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area.

Conclusions
Proton pump inhibitor treatment in peptic ulcer bleeding reduces rebleeding and surgical and further endoscopic intervention rates in studies comparing treatment with placebo or H2RA; however, there is no evidence of an overall effect on mortality.

5. Emergency department visits continue to rise, AHA annual survey finds

Source: AHA News Now. Date: October 20, 2006

Hospitals treated more than 114 million patients in the emergency department in 2005, while inpatient visits remained constant at 35.2 million, according to the AHA's Annual Survey of Hospitals. ED visits have increased by about one-third since 1990 while the number of EDs has declined, increasing pressure on EDs that remain open. Worker shortages, challenges securing on-call coverage by specialty physicians, reduced behavioral health resources and ambulance diversions also posed challenges to hospital EDs. According to the survey, the financial state of hospitals remains fragile, with one-third of hospitals operating with negative margins. Medicare reimbursed 92 cents for every dollar hospitals spent caring for Medicare patients, while Medicaid reimbursement again dropped in 2005 to 87 cents on the dollar.

AHA President Dick Davidson said: "These are the numbers behind the reality that the women and men in America's hospitals face every day. Despite these many challenges, they manage to deliver the crucial services their communities need. The AHA and its member hospitals are committed to working with legislators and others to solve emergency room overcrowding, workforce shortages, Medicare and Medicaid reimbursement shortfalls and the many other issues that stand in the way of a better health care system." The survey data can be found in AHA Hospital Statistics - 2007.

6. CDC Committee Recommends Shingles Vaccine for Older Adults

The CDC's Advisory Committee on Immunization Practices voted unanimously Wednesday to recommend Zostavax, Merck's live attenuated zoster vaccine to prevent shingles in adults age 60 and older.

Zostavax was approved by the FDA in May. A clinical trial involving more than 38,000 volunteers found that the vaccine reduced the risk of developing shingles by about half during roughly 3 years of follow up. Among volunteers who developed shingles, those who were vaccinated were about 40% less likely to develop postherpetic neuralgia than those who did not receive vaccine. Side effects included headache and injection-site reactions. The vaccine is about 15 times more potent than regular chickenpox vaccine.

The single-dose vaccine costs about $150. A Merck official said some health plans already cover it, but the committee's recommendation is likely to increase coverage.

The advisory committee's specific recommendations are under review by the CDC and are expected to be published later in MMWR.

CDC Press Release.

7. SIDS Linked to Abnormalities in Brainstem Serotoninergic System

November 1, 2006 — Sudden infant death syndrome (SIDS) is linked to abnormalities in the brainstem serotoninergic system, according to the results of an autopsy study reported in the November 1 issue of JAMA. The findings suggest that medullary 5-hydroxytryptamine (5-HT) pathology in SIDS is more extensive than previously thought, pointing the way to future screening tests or interventions.

"This study confirms that there is a biological basis for SIDS, that it's not a mystery event that happens for no known reason," lead author David Paterson, PhD, an instructor in pathology at Children's Hospital in Boston, Massachusetts, told Medscape. "We don't know exactly what causes these abnormalities," Dr. Paterson said. "We believe that it's a developmental process that begins in utero, involving probably environmental as well as genetic factors. Finding out exactly what the pathogenesis is a big step toward trying to intervene and stop this."

The triple risk model suggests that sudden death results from a combination of an underlying vulnerability, an exogenous stressor such as prone sleep position or bed sharing, and the critical developmental period during the first 6 months of postnatal life, when the infant is at greatest risk for SIDS.

Until screening tests and potential interventions become available, Dr. Paterson recommends following the mandates of the national "Back to Sleep" campaign, which urges caregivers to put babies to bed on their backs. In fact, 65% of the SIDS cases in this study were sleeping prone or on their side at the time of death, indicating the need for continued public health messages on safe sleeping practices. Other recommended sleeping practices for infants are use of firm sleeping surfaces and avoidance of soft bedding, overheating, and exposure to prenatal and postnatal cigarette smoke.

"This study reinforces the risk reduction strategies that have been recommended, so parents and potential parents should follow those closely," Dr. Paterson said.

JAMA. 2006;296(17):2124-2132, 2143-2144.

8. It is Helpful to Add Atrovent to a Continuous Albuterol Neb?

A randomized, clinical trial comparing the efficacy of continuous nebulized albuterol (15 mg) versus continuous nebulized albuterol (15 mg) plus ipratropium bromide (2 mg) for the treatment of acute asthma

David Salo, MD, et al. J Emerg Med 2006 (Nov);31: 371-376

Multiple studies have examined adding nebulized ipratropium bromide to intermittent albuterol for the treatment of acute asthma. Although continuous nebulized treatments in themselves offer benefits; few data exist regarding the efficacy of adding ipratropium bromide to a continuous nebulized system. To compare continuous nebulized albuterol alone (A) vs. albuterol and ipratropium bromide (AI) in adult Emergency Department (ED) patients with acute asthma, a prospective, randomized, double-blind, controlled clinical trial was conducted on a convenience sample of patients (IRB approved). The setting was an urban ED.

Consenting patients greater than 18 years of age with peak expiratory flow rates (PEFR) less than 70% predicted, between October 15 and December 28, 1999, were randomized to albuterol (7.5 mg/h) + ipratropium bromide (1.0 mg/h), or albuterol alone via continuous nebulization using the Hope Nebulizer (B&B Technologies Inc., Orangevale, CA) for 2 h.

Main outcome measures were changed in mean improvement at 60 and 120 min PEFR compared to baseline (time 0). Secondary measures were admission rates. Data were analyzed using appropriate parametric and non-parametric tests. Sixty-two patients (30 women) completed enrollment: 32 in (AI) and (30) in (A). Four (A) and 2 (AI) patients are without 120 min data: 3 (A) and 1 (AI) were discharged after 60 min, whereas one each (A) and (AI) worsened and were admitted before 120 min. There were no statistically significant differences between treatment groups in age, sex, predicted or initial PEFR. Thirteen (19.4%) patients were admitted.

There was no statistically significant difference in improvement of mean PEFR at 60 min or 120 min compared to baseline, between groups, using repeated measures analysis of variance. There was no statistically significant difference in admission rates between groups: 5/30 (A) and 8/32 (AI) (p = 0.62). There were no significant differences in mean improvement of PEFR at either 60 or 120 min between ED patients with acute asthma receiving continuous albuterol alone vs. those receiving albuterol in combination with ipratropium bromide.

9. Shiga Toxin in Feces Now Reportable in California

The California Department of Health Services (CDHS) has made the detection of Shiga toxin (Stx) in feces reportable by healthcare providers and laboratories. This addition to California’s reportable disease list responds to a trend by clinical laboratories toward testing for Shiga toxin-producing E. coli (STEC) infections using enzyme immunosorbant assay (EIA) or other non-culture based methods, and the resulting need for timely and reliable notification of STEC infections that may not be culture-confirmed.

At CDHS, the Infectious Diseases Branch will be working with Laboratory Field Services and the Microbial Diseases Laboratory to alert clinical laboratories to the reporting change. We will also continue to work with clinical and public health laboratories to ensure that follow-up culture is performed on Shiga toxin positive specimens.

For now, please use the Case Report form used for cases of E.coli O157, HUS, and other STEC to follow up on patients with feces positive for Shiga toxin, marking on top of the form “Shiga toxin positive in feces.” We will update this form in the near future. For further questions on Stx testing or on the new regulation for reporting of Shiga toxin in stool, please contact Dr. Charlotte Wheeler by email at cwheeler@dhs.ca.gov or by phone at (510) 620-3434.

10. Popularity of Energy Drinks Sparks Worry

Nutritionists are warning parents about the dangers of caffeine-and-sugar-filled energy drinks, such as Red Bull, the Associated Press reports. About 7.6 million U.S. teens, or 31%, consume energy drinks, according to survey data cited by the AP.

Nutritionists warn that the drinks are just as likely as soda to contribute to obesity. In addition, energy drinks contain large doses of vitamins and other additives that may pose risks. Many teens consume several cans in rapid succession to get a high, which may lead to caffeine poisoning. A recent study at a Chicago poison control center found an increase in reports of caffeine overdose, about 12% of which required a trip to the hospital.

When consumed with alcohol the drinks may increase the risk of alcohol poisoning because they mask the symptoms of drunkenness, one study found.

What is the caffeine content of various sport drinks? Consult Wikipedia.

11. Feasibility of Forearm US-Guided Nerve Blocks of the Radial, Ulnar, and Median Nerves for Hand Procedures in the ED

Otto Liebmann, MDa, et al. Ann Emerg Med 2006;48: 558-562.

Study objective
We determine the feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves, performed by emergency physicians, to provide procedural anesthesia of the hand in the emergency department (ED).

Methods
This was a prospective study involving a convenience sample of 11 patients presenting to an adult ED with hand pathology requiring a procedural intervention. Adults 18 years and older who presented to the ED during the 3-month study period were eligible. Physicians performing the nerve blocks were attending physicians, ultrasonography fellows, or residents who had participated in a 1-hour training session. The participants underwent ultrasonography-guided nerve blocks in the forearm to provide anesthesia. Any additional anesthesia or analgesia required to perform the procedure in the anesthetized region was recorded.

Subjects rated their pain on a 100mm visual analog scale before the nerve block and 15 minutes after the nerve block. The primary outcomes for feasibility were the percentage of cases completed without rescue anesthesia or analgesia and the median reduction in pain on the visual analog scale after the nerve block. Secondary outcomes for feasibility included the median time to completion of the entire nerve block procedure for each subject (from initiation of ultrasonography to completion of the last injection) and the percentage of participants wishing to have the same procedure for similar injuries in the future. Other secondary outcomes included the percentage of participants with complications during the procedure and at 3 months.

Results
All procedures (100%) were completed without additional anesthesia or analgesia. The median reduction in visual analog scale score was 5.0 cm (interquartile range 3.0, 8.0; P=.003). The median time to completion of nerve blocks was 9 minutes per patient (interquartile range 6 minutes 30 seconds, 10 minutes 0 seconds), with a median of 2 blocks per patient. Ten of 11 patients (92%) stated they would wish to have the ultrasonography-guided nerve block in the future for similar injuries. There were no immediate complications and no complications reported at 3 months.

Conclusion
Attending physicians, fellows, and residents can perform forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves quickly, without additional anesthesia and with high patient satisfaction, after minimal training. Although pilot data are suggestive, randomized controlled trials are needed to determine efficacy and safety. Ultrasonography-guided nerve blocks to provide anesthesia for hand procedures appear to be feasible in the ED.

12. A Randomized, Controlled Trial of IV Versus IM Ketamine for Sedation of Pediatric Patients Receiving ED Orthopedic Procedures

Mark G. Roback, MD, et al. Ann Emerg Med 2006 (Nov); 48: 605-612.

Study objective
We compare adverse events, efficacy, and length of sedation of intravenous (IV) versus intramuscular (IM) ketamine procedural sedation and analgesia for orthopedic procedures in the emergency department (ED).

Methods
Pediatric patients receiving ketamine for orthopedic procedures were enrolled in a prospective, randomized, controlled trial in a children’s hospital ED. All patients were initially randomized to receive ketamine either 1 mg/kg IV or 4 mg/kg IM. Demographics, adverse events, sedation efficacy, and length of sedation were recorded.

Results
Two hundred twenty-five patients were randomized (116 IV, 109 IM). Two hundred eight patients, aged 14 months to 15 years, completed the study, 109 IV and 99 IM. Respiratory adverse events were similar between groups (IV 8.3% versus IM 4.0%; odds ratio [OR] 0.47; 95% confidence interval [CI] 0.14 to 1.6). Vomiting in the ED was more common in the IM group (26.3% versus 11.9%; OR 2.60; 95% CI 1.2 to 5.9).

Using the Faces Pain Scale, patients in the IM group reported significantly less pain from the procedure. Video observers reported significantly lower distress in the IM group during the painful procedure (Observation Score of Behavioral Distress scores 0.35 IM versus 0.74 IV; mean difference 0.38; 95% CI 0.04 to 0.72). Length of sedation was significantly longer in the IM group (median 129 versus 80 minutes). Satisfaction of sedation was high in parents and physicians, with no difference in reported satisfaction between groups. This study was terminated early because of nursing resistance based on the longer recovery times observed in patients receiving ketamine IM.

Conclusion
In this study of pediatric sedation for orthopedic procedures, we found that ketamine 4 mg/kg IM was more effective than 1 mg/kg IV but demonstrated significantly longer recovery times and more vomiting.

13. Improving Alertness and Performance in ED Physicians and Nurses: The Use of Planned Naps

Rebecca Smith-Coggins, MD, et al. Ann Emerg Med 2006;48: 596-604.e3.

Study objective
We examine whether a 40-minute nap opportunity at 3 am can improve cognitive and psychomotor performance in physicians and nurses working 12-hour night shifts.

Methods
This is a randomized controlled trial of 49 physicians and nurses working 3 consecutive night shifts in an academic emergency department. Subjects were randomized to a control group (no-nap condition=NONE) or nap intervention group (40-minute nap opportunity at 3 am=NAP). The main outcome measures were Psychomotor Vigilance Task, Probe Recall Memory Task, CathSim intravenous insertion virtual reality simulation, and Profile of Mood States, which were administered before (6:30 pm), during (4 am), and after (7:30 am) night shifts. A 40-minute driving simulation was administered at 8 am and videotaped for behavioral signs of sleepiness and driving accuracy. During the nap period, standard polysomnographic data were recorded.

Results
Polysomnographic data revealed that 90% of nap subjects were able to sleep for an average of 24.8 minutes (SD 11.1). At 7:30 am, the nap group had fewer performance lapses, reported more vigor, less fatigue, and less sleepiness. They tended to more quickly complete the intravenous insertion, exhibit less dangerous driving and display fewer behavioral signs of sleepiness during the driving simulation. Immediately after the nap (4 am), the subjects scored more poorly on Probed Recall Memory.

Conclusion
A nap at 3 am improved performance and subjective report in physicians and nurses at 7:30 am compared to a no-nap condition. Immediately after the nap, memory temporarily worsened. The nap group did not perform any better than the no-nap group during a simulated drive home after the night shift.

14. Patient perceptions of emergency physicians: The gender gap still exists

Louise A. Prince, MD, at al. J Emerg Med 2006 (Nov); 31: 361-364

This study examines whether female emergency physicians are less likely than male emergency physicians to be recognized by patients as physicians. A convenience sample of adult patients seen while a trained observer was on duty in an academic ED constituted the study population. After the first physician contact, the observer asked the patient if a physician had seen the patient yet. The observer recorded the physician’s sex, the patient’s response, sex, age, and race. The frequencies that male and female physicians were recognized as physicians were compared.

For the 184 physician-patient contacts evaluated, 98/105 (93.3%) of males were recognized as physicians and 62/79 (78.5%) of females were recognized as physicians. Females were significantly less likely than males to be recognized as physicians (chi-square, p = 0.003). Female emergency physicians are less likely than male emergency physicians to be recognized by patients as physicians.

15. Burst fracture of the first lumbar vertebra and conus-cauda syndrome complicating a single convulsive seizure: A challenge of diagnosis in the ED

Fereydoon Roohi, MD, Andrew Fox, MD. J Emerg Med 2006 (Nov); 31:381-385.

Fractures of the thoracic and lumbar vertebrae as a direct consequence of generalized epileptic convulsions are the most common non-traumatic type of fracture complicating epileptic seizures. The majority of these fractures are compression fractures that occur with minimal symptoms and virtually no permanent neurological sequela. Nevertheless, muscle contractions generated during generalized motor seizures can result in severe axial skeletal trauma and grave neurological complications.

We describe the case of a 35-year-old man who suffered a burst fracture of the first lumbar vertebral body and acute conus medullaris-cauda equina syndrome as a direct consequence of a single grand mal seizure. The aim of this report is to draw attention to this serious complication of generalized convulsive seizures and alert readers to epilepsy-related vertebral fractures. Diagnosis and management of acute cauda equina-conus medullaris syndrome caused by lumbar fracture are reviewed.

16. Thoracic and lumbar spine radiographs for walking trauma patients—is it necessary?

Eran Tamir, MD, et al. J Emerg Med; 2006 (Nov); 31:403-405

Numerous patients ambulating independently arrive in the Emergency Department complaining of back pain after being involved in a motor vehicle crash (MVC). We examined the yield of routine screening radiographs of the lumbar and thoracic spine in these patients. A retrospective review was carried out of the records of 3173 patients who were involved in a MVC during a 1-year period and presented to a single medical center. Radiographs of the lumbar spine, thoracic spine, or both were obtained in all patients complaining of back pain.

Of 3173 ambulating MVC trauma patients, 35% (1110 patients) complained of thoracic or lumbar back pain. None of the lumbar and thoracic spine radiographs that were obtained in these patients was positive for a fracture or dislocation. The current study suggests that the yield of the routine use of spinal radiographs is very low in patients ambulating independently and complaining of back pain after a MVC.

17. NSAID Use May Raise Risk of Hospitalization for Heart Failure

NEW YORK (Reuters Health) Nov 03 - Current NSAID use is associated with a slightly increased risk of a first hospitalization for heart failure, according to a report in the November issue of Heart. Similarly, NSAID use may worsen preexisting heart failure.

The new findings, which stem from a case-control analysis, agree with those of epidemiologic studies linking NSAID use with increased risks of incident heart failure, hospitalization for heart failure, and heart failure relapse. Researchers believe that by blocking prostaglandin synthesis, NSAIDs increase systemic resistance and decrease renal perfusion, both of which would be expected to increase the risk of heart failure.

After adjusting for various confounders, current NSAID use was associated with a 30% increased risk of first hospitalization for heart failure, the authors note. No dose or duration effects were noted.

Current NSAID users with preexisting heart failure were 8.6-times more likely to have a first hospitalization for heart failure than nonusers without this medical history.

"Heart failure is a common cause of morbidity and mortality in the elderly and even a small increase in the risk can translate into a significant disease burden in the general population," the investigators write. "Therefore, NSAIDs should be used with caution by patients with a high risk of hospital admission due to heart failure such as those with prior clinical heart failure, diabetes, renal failure or treatment with hypertension drugs."

Heart 2006;92:1610-1615.

18. STEMI Treatment Faster With Emergency Physician Initiation of PCI

October 18, 2006 (New Orleans) — Involvement of emergency medicine physicians in initiating treatment of or facilitating transfer for ST-segment elevation acute myocardial infarction (STEMI) patients were deemed cutting-edge topics in recent emergency research presented here at the American College of Emergency Medicine Scientific Assembly.

One Illinois study found that median "door-to-balloon" time (MDBT) in STEMI patients improved significantly when emergency physicians initiated 1% primary percutaneous coronary intervention (PCI) emergent angioplasty in patients rather than waiting for a cardiology consultation. In the study of 60 patients conducted by University of Chicago Hospitals researchers, MDBT decreased to 88 minutes from 114 minutes.

"We have long since realized that time is muscle and that emergency physicians can make that decision [about starting PCI] as quickly and effectively as cardiologists," said Arthur Kellermann, MD, professor and chair of the department of emergency medicine at Emory University in Atlanta, Georgia, a comoderator of the session at which the Illinois study was presented. Researchers found that no inappropriate activations of cardiac catheterization occurred.

Whether PCI is initiated by emergency physicians should depend not just on timing or cardiologist availability but primarily on the physician's ability to safely and competently start the treatment. That's no longer the issue it once was, according to Jerome Hoffman, MD, professor of medicine and emergency medicine at the University of California David Geffen School of Medicine in Los Angeles, who comoderated the research highlights session. "Of course competent emergency physicians are the best people to do these things...that other people have traditionally considered theirs. If it's good for patients we should do it," he said, adding that "the important issue is that we do it well and safely."

Dr. Hoffman, who is also a clinical epidemiologist and health services researcher, cautioned, however, that the issue of PCI in STEMI should also be viewed in the larger picture of when interventions warrant protocol status. "We have to look at what is appropriate and rational, and we have to remember that only a tiny percentage of patients seen by paramedics have STEMI — it's a reasonable guess that 1 in 100 chest pains in the field is a STEMI."

Despite that low incidence, Dr. Hoffman said that evidence supports that PCI is both efficacious and generally safe for patients with STEMI. "It is good if you can get it," he said, but he urged healthcare systems to look at the cost-benefit ratio, risks of both over- and undertriage, and the potential for other "lost opportunities" before making protocol changes.

A second study by Minnesota researchers found that most STEMI patients can be safely transferred from rural facilities and community hospitals without PCI capability to angioplasty centers without increasing transfer-associated morbidity and mortality. That study of 746 consecutive patients transferred from 28 rural and community hospitals to a Minneapolis cardiac tertiary care center showed that even unstable patients weathered the transfer well; no deaths occurred during transfer, despite the fact that 11.7% of the patients were in cardiogenic shock and 6.7% had experienced pretransfer arrest.

Those findings should offer some peace of mind to emergency physicians trying to decide which MI patients to transport and when, said Dr. Kellermann. "This study showed a very low mortality rate and high success and safety rates with transfer times of about 30 minutes — and that's an important issue out there," he said, for emergency physicians working in rural facilities and suburban centers.

Two thirds of patients were transported by air and one third by ground ambulance, with median transport times of 28 and 32 minutes, respectively. Endotracheal intubation was performed in 4.5% of patients pretransfer and in 0.7% during transport, and all 12 patients who experienced cardiopulmonary arrest during transport were returned to spontaneous circulation. Three patients died in hospital (2 during angioplasty and 1 due to anoxic brain injury). The remaining patients were neurologically intact at discharge. The use of the standardized protocol — which called for transfer of all STEMI patients to Abbott Northwestern Hospital —was initiated in 2003.

ACEP 37th Annual Scientific Assembly. Presented October 16, 2006.

19. Stroke Uncommon Among Patients With Dizziness Symptoms

NEW YORK (Reuters Health) Oct 27 - Less than 1% of patients who present to the ER with isolated dizziness symptoms, including vertigo and imbalance, have a stroke or TIA, according to a report in the October issue of Stroke.

However, because so many people present with these symptoms, the absolute number of stroke cases presenting in this fashion may be high, the authors note.

Findings from case reports and small series have shown that dizziness may be the principal or only complaint in stroke patients, but until now no large population-based study has investigated the frequency of stroke among patients seen in the ER for dizziness symptoms.

The current study involved all patients, older than 44 years of age, with dizziness symptoms who presented to an ER or were directly admitted to a hospital in Neuces County, Texas between January 1, 2000 and June 30, 2003.

Of the 1666 patients who had dizziness symptoms, 53 (3.2%) had a final diagnosis of stroke or TIA, senior author Dr. Lewis B. Morgenstern, from the University of Michigan Medical School in Ann Arbor, and colleagues report. Moreover, just 0.7% of patients with dizziness symptoms as the only presenting complaint had a stroke or TIA.

The average age of stroke/TIA patients was 69.3 years, significantly older than the 65.3 years noted in non-stroke/TIA patients, the report indicates. Male gender was linked to stroke/TIA, whereas isolated dizziness symptoms tended to support a non-stroke diagnosis.

Among the various dizziness symptoms, imbalance was a predictor of stroke/TIA, the report indicates.

"This study suggests that of the patients presenting with dizziness symptoms, those with other neurologic symptoms, who are older and male, are at the highest risk for a cerebrovascular etiology," the authors conclude. "More detailed population-based studies and prospective clinical studies on the relationship of stroke and dizziness symptoms are critically needed so that stroke can be rapidly identified."

Stroke 2006;37:2484-2487.

20. Heart Failure with Preserved EF Also Has High Mortality

Heart failure with or without preserved left ventricular function is equally common and deadly, report two studies in the November 8 issue of JAMA.

Bursi and colleagues, studying 556 heart failure patients from a Minnesota community, found that 55% had preserved ejection fraction. Mortality at six months was high (16%) in both reduced and preserved EF groups. Ejection fraction aside, isolated diastolic dysfunction was present in 44% of patients.

Gheorghiade and colleagues also found preserved systolic function in about half of 41,267 patients hospitalized with heart failure. Regardless of EF, patients with higher systolic blood pressure at admission had lower mortality in-hospital and post-discharge.

For the full-text of the Bursi study, click here.