From the recent medical literature...
1. Emergency Department Visits Up Sharply From 1996 to 2006, CDC Says
Date: August 07, 2008. The number of ED visits in the U.S. increased by 36% to 119 million in 2006 from 90 million in 1996, according to a CDC report on hospital use released on Wednesday, the AP/Miami Herald reports. At the same time, the number of EDs nationwide declined from about 4,000 to about 3,800, contributing to an increase in ED treatment wait times.
The findings are based on a national survey of 362 hospital EDs.
According to the report, average ED wait time increased to about 56 minutes in 2006, compared with 38 minutes in 1997. However, the increasing ED wait time is misleading because urban EDs with waits longer than an hour boost the average, according to Catharine Burt of the National Center for Health Statistics at CDC. The report's lead author, Stephen Pitts of CDC, said that half of ED users had wait times of 31 minutes or less.
Billy Mallon, president of the California chapter of the American College of Emergency Physicians, said that California has the lowest percentage of EDs per capita, at 6.12 per one million residents.
ED Overcrowding
Several factors contribute to overcrowding in the nation's EDs. Pitts said that it is getting more difficult for U.S. residents to schedule primary care appointments, which contributes to the rise in ED use. He said this trend applies to Medicare and Medicaid beneficiaries in particular.
The report found that 82 of every 100 Medicaid beneficiaries used ED care in 2006, compared to 21 of every 100 people with private insurance.
Pitts said a limited number of inpatient beds also is contributing to ED overcrowding as patients wait in the ED to be admitted. As hospitals have reduced bed capacity, the "major solution over the past 10 years has been to allow these patients to sit in the hallways in the ER," Pitts said.
More than half of hospital admissions in 2006 were through EDs, a 38% increase since 1996, the report found.
According to the report, although the number of uninsured U.S. residents increased by more than 5 million since 1996 to about 47 million, the growing uninsured population did not account for higher ED use.
The report also found that the overall growth in population did not account for the trend. According to the report, about 40% of ED patients had private insurance; about 25% received health coverage through state programs for children; about 17% were Medicare beneficiaries; and about 17% were uninsured.
Other ED findings
The report also found that:
- ED use overall increased by 18%;
-About 13% of ED visits led to a hospital admission;
-Infants had the highest use of EDs of any age group;
-People older than 75 were the second-highest users of ED care; and
-ED or hospital outpatient department visits accounted for 38% of care used by blacks, compared with 17% for whites.
For more information, please visit:
http://www.californiahealthline.org/articles/2008/8/7/Emergency-Department-Visits-Up-Sharply-From-1996-to-2006-CDC-Says.aspx?topicID=47
The entire report can be found at this link:
http://www.cdc.gov/nchs/data/nhsr/nhsr008.pdf
2. Silver-Coated Endotracheal Tube Reduces Risk for Ventilator-Associated Pneumonia
Laurie Barclay, MD. August 19, 2008 — Use of a silver-coated endotracheal tube significantly reduces the incidence of microbiologically confirmed ventilator-associated pneumonia (VAP), according to the results of a large, randomized, multicenter study reported in the August 20 issue of the Journal of the American Medical Association.
"VAP causes substantial morbidity," write Marin H. Kollef, MD, from the Washington University School of Medicine in St. Louis, Missouri, and colleagues from the North American Silver-Coated Endotracheal Tube Investigation Group. "A silver-coated endotracheal tube has been designed to reduce VAP incidence by preventing bacterial colonization and biofilm formation."
The goal of this prospective, single-blind study conducted in 54 centers in North America was to evaluate whether use of a silver-coated endotracheal tube would reduce the incidence of microbiologically confirmed VAP.
Of 9417 adult patients aged 18 years or older who were screened between 2002 and 2006, a total of 2003 patients who were expected to need mechanical ventilation for at least 24 hours were randomly assigned to undergo intubation with 1 of 2 high-volume, low-pressure endotracheal tubes. These tubes were similar except that the experimental tube had a silver coating.
The main endpoint was incidence of VAP, diagnosed from quantitative bronchoalveolar lavage fluid culture with at least 104 colony-forming units/mL in patients intubated for at least 24 hours. Secondary endpoints were VAP incidence in all intubated patients, time to VAP onset, length of intubation and duration of intensive care unit and hospital stay, mortality rates, and adverse events.
Rates of microbiologically confirmed VAP in patients intubated for at least 24 hours were 4.8% (37/766 patients; 95% confidence interval [CI], 3.4% - 6.6%) in the group receiving the silver-coated tube and 7.5% (56/743; 95% CI, 5.7% - 9.7%; P = .03) in the group receiving the uncoated tube (relative risk reduction, 35.9%; 95% CI, 3.6% - 69.0%).
Rates of microbiologically confirmed VAP in all intubated patients were 3.8% (37/968; 95% CI, 2.7% - 5.2%) in the experimental group and 5.8% (56/964; 95% CI, 4.4% - 7.5%; P = .04) in the control group (relative risk reduction, 34.2%; 95% CI, 1.2% - 67.9%).
Use of the silver-coated endotracheal tube was associated with delayed occurrence of VAP (P = .005), but there were no statistically significant between-group differences in durations of intubation, intensive care unit stay, and hospital stay. Mortality rates and frequency and severity of adverse events were also similar in both groups.
"Patients receiving a silver-coated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube," the study authors write. "The silver-coated endotracheal tube appears to offer a unique approach because it is the first intervention that becomes user-independent after intubation, requiring no further action by the clinician."
Limitations of this study include single blinding rather than double blinding; use of a small, fixed block size stratified by center; other factors possibly contributing to between-group differences in VAP rates; study protocol not standardizing prevention strategies; and a protective effect of higher severity-of-illness scores against development of VAP.
In an accompanying editorial, Jean Chastre, MD, from Institut de Cardiologie, Groupe Hospitalier Pitié-Salpê trière in Paris, France, discusses the study limitations.
"Important uncertainties exist regarding the exact benefit of silver-coated endotracheal tubes," Dr. Chastre writes. "Consequently, silver coated tubes should not be viewed as the definitive answer for VAP prevention, and, until additional data confirm the clinical effectiveness and cost benefit of these devices, their use should be restricted to high-risk patients treated in ICUs [intensive care units] with benchmark value-based infection rates that remain above institutional goals despite implementation of a comprehensive strategy of usual preventive measures to prevent VAP."
CR Bard Inc supported this study and provided grant support to all of the study authors. Some of the study authors have disclosed various financial relationships with Kimberly Clark, Elan, Merck, Pfizer, Bayer, GlaxoSmithKline, Boehringer Ingelheim, KCI, sanofi-aventis, Johnson & Johnson, Easi, Hospira, Nomir Medical Technologies, Arpida, Cubist, Elan, Ortho-McNeil, Sanofi Pasteur, Wyeth, Bayer-Nektar, Nestle Clinical Nutrition, Lilly, Corbett Accel Healthcare, National Institutes of Health, Novartis, and/or Maquet. Dr. Chastre has received consulting and lecture fees from Pfizer, Brahms, Wyeth, Johnson & Johnson, Bayer-Nektar, and Arpida.
JAMA. 2008.300:805-813, 842-844.
3. Triage Pain Scores and the Desire for and Use of Analgesics
Singer AJ, et al. Ann Emerg Med. 2008; in press.
Study objective
Inadequate analgesia (oligoanalgesia) is a common phenomenon. In an effort to improve pain recognition and management, pain scores are mandated by The Joint Commission. When patients with pain do not receive analgesics, treatment is considered deficient. However, the mere presence of pain does not imply that all patients desire analgesics. We determine how often patients in pain desire and receive analgesics in the emergency department (ED). We hypothesize that many ED patients in pain do not desire analgesics and that most who want them receive them.
Methods
We conducted a prospective observational study of pain-related visits to an academic ED during the spring of 2007. Standardized collection of demographic and clinical data was performed, and patients rated their pain severity on a 0 to 10 numeric rating scale. The main outcome measures were the desire for and administration of analgesics during the ED visit. Univariate and multivariate logistic regression was used to identify factors associated with patient desire for and administration of analgesics.
Results
We enrolled 392 patients. Mean (SD) age was 39 years (19), 50% were female patients, 76% were white. Mean (SD) initial pain score was 7.1 (2). Of the 392 patients, 199 (51% [95% confidence interval (CI) 46% to 56%]) desired analgesics and 227 (58% [95% CI 53% to 63%]) received analgesics within 92 (SD 106) minutes. Of patients desiring analgesics, 162 (81% [95% CI 75% to 86%]) received them. Reasons for not wanting analgesics included pain tolerable (47%), analgesic taken at home (11%), and wanting to remain alert (7%). Pain scores were higher in those patients who wanted analgesics than in those patients who did not want analgesics (7.8 [95% CI 7.5 to 8.1] versus 6.4 [95% CI 6.1 to 6.7]; difference 1.4 [95% CI 0.9 to 1.8]). In multivariate analysis, pain scores (odds ratio [OR] 1.3 for every 1-point increase in pain score) and constant pain (OR 2.0) were significant factors that predicted wanting analgesics, whereas pain scores (OR 1.2) and desiring analgesics (OR 7.4) were significant predictors of receiving analgesics.
Conclusion
Nearly half of all ED patients in pain do not desire analgesics and most who desire analgesics receive them. Although the average pain score for patients not wanting analgesics was lower, it was often in the moderate to severe range. Patients should be asked whether they have pain and whether they want analgesics regardless of their pain scores.
4. Coronary Multidetector CT Cost-Effective for Triage of Acute Chest Pain Patients
NEW YORK (Reuters Health) Aug 18 - Compared with standard protocols for assessing acute chest pain in emergency department patients, the use of coronary multidetector CT (MDCT) is modestly more effective and offers cost savings in the case of women, according to a report in the August issue of the American Journal of Roentgenology.
"Coronary CT angiography may be a useful adjunct to care in the emergency department setting when patients present with acute chest pain," Dr. Joseph A. Ladapo with the Harvard Ph.D. Program in Health Policy, Cambridge, Massachusetts told Reuters Health. "I think this finding provides support for people who feel like this technology needs be studied further."
Dr. Ladapo and colleagues used a Monte Carlo microsimulation model to compare the standard of care with MDCT coronary angiography-based management in the triage of patients with low-risk chest pain who present to the emergency department.
For a 55 year-old man, coronary MDCT increased emergency department and hospital costs by $110 and raised total health care expenditures by $200, the authors report, but for a similarly aged woman, it decreased emergency department and hospital costs by $410 and decreased total health care expenditures by $380.
Small incremental improvements in unadjusted and quality-adjusted life expectancy were seen with coronary MDCT in both sexes, the report indicates.
The incremental cost-effectiveness of coronary MDCT management (compared with standard of care) was $6400 per quality-adjusted life-year in men, the researchers note. The strategy was cost-saving in women.
Most patients who were wrongfully discharged from the emergency department after being triaged with MDCT angiography faced a low risk of mortality from the missed diagnosis, the investigators say.
"Our results suggest that 64-MDCT coronary angiography may be a safe addition to the management of low-risk patients with acute chest pain and is likely to be cost-saving in women and marginally more expensive than the standard of care in men," the authors conclude.
"Because coronary CT angiography is so good at ruling out disease, women -- along with other patients with a low likelihood of disease -- are much more likely to avoid a costly admission," Dr. Ladapo explained. "I think there's a strong case for reimbursing this technology when it's used in women, but it's cost-effective and ought to be reimbursed in men, too."
He added, "I don't think emergency departments need to rush to start using the exam on their acute chest pain patients, but I do think that it's worth supporting clinical trials of its application."
Am J Roentgenol 2008;191:455-463.
5. AHA Publishes Statement on Integrating Prehospital ECGs Into Care for ACS Patients
A Scientific Statement From the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology
Michael O'Riordan. From Heartwire — a professional news service of WebMD
August 14, 2008 — The American Heart Association (AHA) has issued a scientific statement on the use of prehospital electrocardiograms (ECGs) to improve the quality of care delivered to patients with ST-segment-elevation MI (STEMI), published online August 13, 2008 in Circulation. The central challenge, say the authors, will not be in acquiring the ECG, but rather in using and integrating the diagnostic information obtained by emergency medical service (EMS) personnel into existing systems of care.
"First medical contact with a patient is usually with the EMS, and this is the next phase of coordination that we need to reach out to," said lead author Dr Henry Ting (Mayo Clinic, Rochester, MN). "We've coordinated the emergency department, the cath lab, and the cardiology group and have done well with reducing door-to-balloon times, but we've not truly engaged the prehospital phase of care. This is critically important."
The AHA national guidelines, as well as other consensus and scientific statements, recommend the acquisition and use of prehospital ECGs by EMS for the evaluation of patients with suspected acute coronary syndrome. The current recommendation is class 2a with a B level of evidence. Speaking with heartwire, Ting said that the technology is currently available, but that hospitals do not have protocols in place that allow prehospital ECGs to serve any useful purpose.
"For the past 10 years, this equipment has been available to many paramedics, but what is happening is that when they acquire the ECG it's not really utilized," said Ting. "It's acquired, then the patient is brought to the emergency department, and in hospitals without these systems of care, they're told this is a patient with chest pain, and we have an ECG, but then the patient is placed in a critical-care room and receives another ECG. Where's the value in that?"
Not a one-size-fits-all solution
In the scientific statement, the authors review the benefits of using prehospital ECGs and the barriers and challenges to routine use and recommend approaches for using the diagnostic information for improving quality of care. In terms of benefits, Ting said the Mayo Clinic has been incorporating the use of prehospital ECGs for one year, and in doing so, has reduced door-to-balloon times to consistently less than 30 minutes, with 25 minutes being the average.
Ting said there are many ways of interpreting the ECG once it has been obtained. Computer algorithms, paramedic interpretation, and wirelessly transmitting the data to a physician for interpretation are three ways to interpret the data. The diversity of the EMS providers and the differing sizes of cities they cover, as well as wireless coverage available to transmit data, are not likely to lead to a one-size-fits-all solution, he said.
A recent survey found that 90% of EMS systems serving the largest US cities have 12-lead ECG equipment, and there are prehospital ECG programs in Boston, Los Angeles County, and North Carolina, as well as in Ottawa, ON. Paramedics in Boston, for example, are allowed to bypass non–percutaneous coronary intervention (PCI) hospitals and have an emergency-department physician activate the cardiac cath lab. North Carolina, on the other hand, allows paramedics to occasionally divert some STEMI patients to PCI hospitals and activate the cath lab directly (or have it activated by an emergency-department physician). Paramedics in Ottawa can also activate the cath lab directly through a central operator. Los Angeles County paramedics use a computer algorithm to interpret the ECG, and the cath lab is activated by the emergency department based on this diagnosis.
Allowing paramedics to "do something downstream" with the information is critical, said Ting, as is changing when the paramedics perform the ECG. "If you truly want to coordinate things, you want to start the prehospital ECG as early as possible in the examination," he said. "Once you establish that the patient has stable vital signs and doesn't have a cardiac arrhythmia, you probably want to do a prehospital ECG at the scene, as early as possible. If you detect ST elevation, the next steps are very different from treating a patient who has chest pain but no ST elevation."
Implementing prehospital ECGs into existing systems of care has the potential to "change the ball game," said Ting. He noted that the focus should begin to move away from door-to-balloon times toward a measure that provides a gauge of quality and performance that is more patient centered. The national "Door to Balloon: An Alliance for Quality" campaign launched in 2006 has helped improve the timeliness of lifesaving therapy for myocardial infarction (MI) patients at all US hospitals that perform emergency angioplasty, but from a patient perspective, first medical contact to balloon is a more relevant measure of quality of care.
Ting added that too many patients still take themselves to the emergency department or are driven there by friends or family, a decision that affects the course of care because it's impossible to obtain a prehospital ECG and then activate all the necessary hospital teams.
"The public doesn't perceive EMS as transforming care," said Ting. "They view it as transportation with sirens. They think, 'If Uncle Joe can drive me there just as fast, then why do I need to call 911 and create all the hassle in the neighborhood?' But the prehospital ECG can really change the course of treatment, something that can't happen when you drive yourself or have a friend take you."
Dr. Ting has received research grants from the American College of Cardiology and the Mayo Foundation for Medical Education and Research. A complete list of disclosures is available in the original article.
Source: Ting HH, Krumholz HM, Bradley EH et al. Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome. Circulation. 2008;
Full-text (free for now): http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.108.190402v1.pdf
6. When Is it Appropriate to Use Methotrexate for Ectopic Pregnancy in the Emergency Department?
Noelle A. Rotondo, DO, Associate Professor, Penn State Hershey Medical Center, Hershey, Pennsylvania; Staff Physician, York Hospital, York, Pennsylvania
Read her reply: http://www.medscape.com/viewarticle/576935
7. I Won’t Believe You, but Tell Me the Prognosis Anyway
Physicians’ prognoses are desired and discounted at the same time.
Zier LS, et al. Critical Care Medicine. 2008;36:2341-2347.
Objectives: Although discussing a prognosis is a duty of physicians caring for critically ill patients, little is known about surrogate decision-makers' beliefs about physicians' ability to prognosticate. We sought to determine: 1) surrogates' beliefs about whether physicians can accurately prognosticate for critically ill patients; and 2) how individuals use prognostic information in their role as surrogate decision-makers.
Design, Setting, and Patients: Multicenter study in intensive care units of a public hospital, a tertiary care hospital, and a veterans' hospital. We conducted semistructured interviews with 50 surrogate decision-makers of critically ill patients. We analyzed the interview transcripts using grounded theory methods to inductively develop a framework to describe surrogates' beliefs about physicians' ability to prognosticate. Validation methods included triangulation by multidisciplinary analysis and member checking.
Measurements and Main Results: Overall, 88% (44 of 50) of surrogates expressed doubt about physicians' ability to prognosticate for critically ill patients. Four distinct themes emerged that explained surrogates' doubts about prognostic accuracy: a belief that God could alter the course of the illness, a belief that predicting the future is inherently uncertain, prior experiences where physicians' prognostications were inaccurate, and experiences with prognostication during the patient's intensive care unit stay. Participants also identified several factors that led to belief in physicians' prognostications, such as receiving similar prognostic estimates from multiple physicians and prior experiences with accurate prognostication. Surrogates' doubts about prognostic accuracy did not prevent them from wanting prognostic information. Instead, most surrogate decision-makers view physicians' prognostications as rough estimates that are valuable in informing decisions, but are not determinative. Surrogates identified the act of prognostic disclosure as a key step in preparing emotionally and practically for the possibility that a patient may not survive.
Conclusions: Although many surrogate decision-makers harbor some doubt about the accuracy of physicians' prognostications, they highly value discussions about prognosis and use the information for multiple purposes.
8. Furosemide for Emergency Management of Hypercalcemia: An Unproven yet Common Practice
LeGrand SB, et al. Ann Intern Med. 2008;149:259-263.
Although primary hyperparathyroidism is the most common cause of hypercalcemia, cancer is the most common cause requiring inpatient intervention. An estimated 10% to 20% of all patients with cancer have hypercalcemia at some point in their disease trajectory, particularly in advanced disease. Aggressive saline hydration and varying doses of furosemide continue to be the standard of care for emergency management.
However, a review of the evidence for the use of furosemide in the medical management of hypercalcemia yields only case reports published before the introduction of bisphosphonates, in contrast to multiple randomized, controlled trials supporting the use of bisphosphonates. The use of furosemide in the management of hypercalcemia should no longer be recommended.
Full-text (subscription required): http://www.annals.org/cgi/content/full/149/4/259
9. ED Patients Often Don't Understand Discharge Instructions
NEW YORK (Reuters Health) Jul 22 - Patients often fail to fully comprehend the treatment they receive during an emergency department visit or recall instructions for their care after they leave, new research suggests.
More often than not, these patients aren't even aware that they have not understood what transpired or remembered what they were told, the investigators note in the Annals of Emergency Medicine, published online July 7.
To shed light on the communication process that occurs in this setting, Dr. Kirsten G. Engel at Northwestern University in Chicago and colleagues interviewed 140 adult English-speaking patients or their primary caregivers after discharge from emergency departments at two teaching hospitals. Subjects were asked questions about four domains: their diagnosis and the cause of their symptoms, the care they received, discharge recommendations, and return instructions.
Results showed that 78% of patients or their caregivers demonstrated deficient comprehension in at least one domain, and 51% had deficits in two or more domains.
At 34%, the highest rate of mistakes involved after-care, "raising significant concerns about patients' ability to adhere to discharge instructions and recommendations after leaving the ED," the investigators note.
"Moreover," they add, "our study suggests that we cannot simply ask patients to identify their comprehension deficiencies because the majority did not report difficulties in areas in which deficits were objectively demonstrated."
Specifically, subjects were unaware of their comprehension deficits 80% of the time.
Dr. Engel's group recommends that clinicians test patients' understanding by asking them to repeat information in their own words. Improving content and organization of written discharge instructions may also be of benefit.
Engel KG, et al.Ann Emerg Med 2008. In press
10. Telemedicine for Stroke Patients
Telemedicine consultation with a stroke-certified neurologist might increase appropriate use of thrombolytic agents in stroke patients.
Many patients with ischemic stroke who are eligible for alteplase therapy do not receive it because the agent must be administered within 3 hours from onset of symptoms and because emergency physicians might want to involve stroke neurologists in primary decision making regarding the use of thrombolytics. Researchers evaluated whether remote consultation with a stroke neurologist could increase appropriate use of thrombolytic agents for stroke patients.
Patients with acute stroke symptoms who presented to one of four remote hospitals from 2004 to 2007 were randomized to telemedicine or telephone-only consultation by neurologists who were National Institute of Health Stroke Scale (NIHSS) certified. During the telemedicine consultation, the consultant took a medical history, performed a physical assessment, calculated the NIHSS score, and reviewed head computed tomography (CT) scans, in concert with the local EP. Telephone consultations differed in that the consultant could not speak directly with or view the patient and relied on the local radiologist’s interpretation of the CT scan. In both scenarios, the consultant made a decision about whether to administer thrombolytic agents. The correctness of the decision — the primary outcome measure — was determined by an independent committee of stroke specialists.
Of 222 patients, 104 in the telemedicine group and 103 in the telephone group completed the study. Mean NIHSS scores at presentation were significantly higher in the telemedicine group than in the telephone group (11.4 vs. 7.7). Correct decision making was significantly more likely in the telemedicine group than in the telephone group (98% vs. 82%; odds ratio, 10.9). However, no differences were noted between groups in any of the secondary outcome variables, including rate of alteplase administration (28% vs. 23%), 90-day functional outcomes, mortality, or rate of intracranial hemorrhage after alteplase administration (7% vs. 8%). The time from call to decision making was significantly longer in the telemedicine group than in the telephone group (65 vs. 55 minutes).
Comment: This study suggests that remote consultation with a stroke neurologist can obviate the need for an on-site neurologist and enable high and appropriate rates of thrombolytic administration for patients with ischemic stroke. Telemedicine, which is expensive and not routinely available, provided better decision making but no other derivative advantages.
— John A. Marx, MD, FAAEM, FACEP. Published in Journal Watch EM August 22, 2008.
Citation: Meyer BC et al. Lancet Neurol 2008 Sep; 7:787.
11. Staphylococcus aureus Community-Acquired Pneumonia During the 2006 to 2007 Influenza Season
Kallen AJ, et al. Ann Emerg Med. 2008; in press.
Study objective
Staphylococcus aureus is a cause of community-acquired pneumonia that can follow influenza infection. In response to a number of cases reported to public health authorities in early 2007, additional case reports were solicited nationwide to better define S aureus community-acquired pneumonia during the 2006 to 2007 influenza season.
Methods
Cases were defined as primary community-acquired pneumonia caused by S aureus occurring between November 1, 2006, and April 30, 2007. Case finding was conducted through an Emerging Infections Network survey and through contacts with state and local health departments.
Results
Overall, 51 cases were reported from 19 states; 37 (79%) of 47 with known susceptibilities involved infection with methicillin-resistant S aureus (MRSA). The median age of case patients was 16 years, and 44% had no known pertinent medical history. Twenty-two (47%) of 47 case patients with information about other illnesses were diagnosed with a concurrent or antecedent viral infection during their illness, and 11 of 33 (33%) who were tested had laboratory-confirmed influenza. Of the 37 patients with MRSA infection, 16 (43%) were empirically treated with antimicrobial agents recommended for MRSA community-acquired pneumonia. Twenty-four (51%) of 47 patients for whom final disposition was known died a median of 4 days after symptom onset.
Conclusion
S aureus continues to cause community-acquired pneumonia, with most reported cases caused by MRSA and many occurring with or after influenza. In this series, patients were often otherwise healthy young people and mortality rates were high. Further prospective investigation is warranted to clarify infection incidence, risk factors, and preventive measures.
12. In-Hospital Bed-to-Nurse Ratio Linked with Survival to Discharge After Out-of-Hospital Cardiac Arrest
Patients admitted to hospitals with a bed-to-nurse ratio less than 1 were 1.5 times more likely to survive to hospital discharge than those admitted to hospitals with higher ratios.
Background. Previous literature has identified patient and emergency medical services (EMS) system factors that are associated with survival of out-of-hospital cardiac arrest patients.
Objective. To determine variability in rates of survival to discharge of resuscitated adult out-of-hospital cardiac arrest patients and to identify hospital-related factors associated with survival.
Methods. This was a retrospective, observational study of all adult (21 years or older) out-of-hospital Utstein criteria cardiac-etiology arrests treated by Milwaukee County EMS during the period 1995-2005 and surviving to hospital intensive care unit admission. The primary outcome measure was survival to hospital discharge. Logistic regression analysis was used to compare the odds of survival between hospitals, patient factors, and hospital factors.
Results. 1,702 patients at eight receiving hospitals were included in the study analyses. Hospital survival rates ranged from 29% to 42%. Patient and case factors associated with increased survival included younger age, male gender, nonwhite race, witnessed arrest in a public location, bystander cardiopulmonary resuscitation (CPR), a modest number of defibrillations, and initial cardiac rhythm of ventricular tachycardia. The only hospital characteristic correlated with survival was the number of beds per nurse. Patients admitted to a hospital with a ratio of beds to nurse less than 1.0 were over 1.5 times more likely to survive.
Conclusions. Survival to discharge of resuscitated adult out-of-hospital cardiac arrest patients may vary by receiving hospital. A hospital's ratio of beds to nurse and several patient/case f actors are correlated with survival. Further research is warranted to investigate how this may affect resuscitation care, EMS transport policy, and research design.
Lui JM, et al. Prehospital Emerg Care. 2008;12:339–346.
13. Out-of-Hospital Continuous Positive Airway Pressure Ventilation Versus Usual Care in Acute Respiratory Failure: A Randomized Controlled Trial
Thompson J. Ann Emerg Med. 2008;52:232-241.e1
Study objective
Continuous positive airway pressure ventilation (CPAP) in appropriately selected patients with acute respiratory failure has been shown to reduce the need for tracheal intubation in hospital. Despite several case series, the effectiveness of out-of-hospital CPAP has not been rigorously studied. We performed a prospective, randomized, nonblinded, controlled trial to determine whether patients in severe respiratory distress treated with CPAP in the out-of-hospital setting have lower overall tracheal intubation rates than those treated with usual care.
Methods
Out-of-hospital patients in severe respiratory distress, with failing respiratory efforts, were eligible for the study. The study was approved under exception to informed consent guidelines. Patients were randomized to receive either usual care, including conventional medications plus oxygen by facemask, bag-valve-mask ventilation, or tracheal intubation, or conventional medications plus out-of-hospital CPAP. The primary outcome was need for tracheal intubation during the out-of-hospital/hospital episode of care. Mortality and length of stay were secondary outcomes of interest.
Results
In total, 71 patients were enrolled into the study, with 1 patient in each group lost to follow-up after refusing full consent. There were no important differences in baseline physiologic parameters, out-of-hospital scene times, or emergency department diagnosis between groups. In the usual care group, 17 of 34 (50%) patients were intubated versus 7 of 35 (20%) in the CPAP group (unadjusted odds ratio [OR] 0.25; 95% confidence interval [CI] 0.09 to 0.73; adjusted OR 0.16; 95% CI 0.04 to 0.7; number needed to treat 3; 95% CI 2 to 12). Mortality was 12 of 34 (35.3%) in the usual care versus 5 of 35 (14.3%) in the CPAP group (unadjusted OR 0.3; 95% CI 0.09 to 0.99).
Conclusion
Paramedics can be trained to use CPAP for patients in severe respiratory failure. There was an absolute reduction in tracheal intubation rate of 30% and an absolute reduction in mortality of 21% in appropriately selected out-of-hospital patients who received CPAP instead of usual care. Larger, multicenter studies are recommended to confirm this observed benefit seen in this relatively small trial.
Full-text (free): http://www.annemergmed.com/article/PIIS0196064408000322/fulltext
14. SMART-COP: A Better Pneumonia Stratification Score?
This new, simple-to-use score had high sensitivity for predicting need for intensive respiratory or vasopressor support among CAP patients.
Background. Existing severity assessment tools, such as the pneumonia severity index (PSI) and CURB-65 (tool based on confusion, urea level, respiratory rate, blood pressure, and age 65 years), predict 30-day mortality in community-acquired pneumonia (CAP) and have limited ability to predict which patients will require intensive respiratory or vasopressor support (IRVS).
Methods. The Australian CAP Study (ACAPS) was a prospective study of 882 episodes in which each patient had a detailed assessment of severity features, etiology, and treatment outcomes. Multivariate logistic regression was performed to identify features at initial assessment that were associated with receipt of IRVS. These results were converted into a simple points-based severity tool that was validated in 5 external databases, totaling 7464 patients.
Results. In ACAPS, 10.3% of patients received IRVS, and the 30-day mortality rate was 5.7%. The features statistically significantly associated with receipt of IRVS were low systolic blood pressure (2 points), multilobar chest radiography involvement (1 point), low albumin level (1 point), high respiratory rate (1 point), tachycardia (1 point), confusion (1 point), poor oxygenation (2 points), and low arterial pH (2 points): SMART-COP. A SMART-COP score of 3 points identified 92% of patients who received IRVS, including 84% of patients who did not need immediate admission to the intensive care unit. Accuracy was also high in the 5 validation databases. Sensitivities of PSI and CURB-65 for identifying the need for IRVS were 74% and 39%, respectively.
Conclusions. SMART-COP is a simple, practical clinical tool for accurately predicting the need for IRVS that is likely to assist clinicians in determining CAP severity.
Charles PGP, et al. Clinical Infectious Diseases 2008;47:375–384.
15. McCain and Obama on Emergency Care: The Candidates' Approach to Emergency Care
Berger E. Ann Emerg Med. 2008;52:265-267.
…In the turbulent arena of presidential politics, a roiling economy and unrest abroad there are no political certainties. But health care, behind only the economy, has risen to the top of domestic issues for both Senator Barack Obama, the Democratic nominee, as well as Senator John McCain, the Republican nominee. That's largely because health care has increasingly become a serious economic issue stinging the pocketbooks of voters. According to one recent study by Harvard University researchers, every 30 seconds someone files for bankruptcy in the aftermath of a serious health problem. It is fair to say, then, that at some point health care will reach the forefront of the next President's agenda…
To understand the specific views of Barack Obama and John McCain on emergency care, it is helpful to review their overall health care plans…
Full-text (free): http://www.annemergmed.com/article/S0196-0644(08)01492-3/fulltext
16. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study
Henschke N, et al. BMJ 2008;337:a171
Objective: To estimate the one year prognosis and identify prognostic factors in cases of recent onset low back pain managed in primary care.
Design: Cohort study with one year follow-up.
Setting: Primary care clinics in Sydney, Australia.
Participants: An inception cohort of 973 consecutive primary care patients (mean age 43.3, 54.8% men) with non-specific low back pain of less than two weeks’ duration recruited from the clinics of 170 general practitioners, physiotherapists, and chiropractors.
Main outcome measures: Participants completed a baseline questionnaire and were contacted six weeks, three months, and 12 months after the initial consultation. Recovery was assessed in terms of return to work, return to function, and resolution of pain. The association between potential prognostic factors and time to recovery was modelled with Cox regression.
Results: The follow-up rate over the 12 months was more than 97%. Half of those who reduced their work status at baseline had returned to previous work status within 14 days (95% confidence interval 11 to 17 days) and 83% had returned to previous work status by three months. Disability (median recovery time 31 days, 25 to 37 days) and pain (median 58 days, 52 to 63 days) took much longer to resolve. Only 72% of participants had completely recovered 12 months after the baseline consultation. Older age, compensation cases, higher pain intensity, longer duration of low back pain before consultation, more days of reduced activity because of lower back pain before consultation, feelings of depression, and a perceived risk of persistence were each associated with a longer time to recovery.
Conclusions: In this cohort of patients with acute low back pain in primary care, prognosis was not as favourable as claimed in clinical practice guidelines. Recovery was slow for most patients. Nearly a third of patients did not recover from the presenting episode within a year.
17. Antipsychotics Useful in Psychiatric Emergencies, Study Confirms
NEW YORK (Reuters Health) Aug 15 - Immediate control of aggressive and impulsive behavior in psychiatric emergencies can be achieved through administration of antipsychotic medications, findings from an observational study indicate, confirming the validity of current medication practices.
Dr. Stefan Wilhelm and two colleagues from the medical department of Lilly Deutschland GmbH, Bad Homburg, Germany evaluated the short-term effectiveness and tolerability of atypical and typical antipsychotic medications in the emergency treatment of acutely agitated adult patients.
Treatment over the first 5 days was classified according to whether olanzapine, risperidone, or haloperidol was administered, with or without benzodiazepine co-medication.
In the open-access online journal BMC Psychiatry, the investigators report that "clear improvements" in agitation and aggression scores were noted in all treatment groups within the short observation period (5 days).
Most of the 558 patients included in the study had a diagnosis of schizophrenia and large proportions had mental disorders due to psychoactive substance abuse, mood disorders, and adult personality disorders.
Dr. Wilhelm and colleagues also observed that more patients treated with olanzapine (73.8%) were fully alert and active at day 2 than patients treated with risperidone (57.1%) or haloperidol (58.0%). This may have been caused by less frequent use of concomitant benzodiazepines, "suggesting that olanzapine may achieve an effective immediate control of aggression without severe tranquilisation of the patient," they write.
Concomitant benzodiazepines were used in 68.7% of olanzapine-treated patients, versus 72.2% and 83.3% of risperidone- and haloperidol-treated patients, respectively.
Summing up, Dr. Wilhelm and colleagues say this study confirms that "current medication practices for immediate aggression control are effective with positive results present within a few days."
They conclude that "given the huge number of patients requiring emergency inpatient or outpatient treatment for aggressive or impulsive behaviour, the use of atypical antipsychotics such as olanzapine may have the potential to reduce the medical burden for patients with this psychiatric condition."
BMC Psychiatry 2008, 8:61 (22 July 2008)
Full-text (free): http://www.biomedcentral.com/1471-244X/8/61
18. Cardiac MR Can Screen for ACS in the Emergency Department
August 12, 2008 (Boston, MA) — Harvard researchers have come up with a new and improved cardiac MR protocol they say can be used in the emergency department to screen for ACS. While other MR protocols have been proposed for this setting in the past, Dr Ricardo C Cury (Harvard Medical School, Boston, MA) and colleagues says theirs has the added advantage of being able to differentiate between new and old MI, providing information over and above clinical assessment and traditional cardiac risk factors.
As Cury explained to heartwire, all imaging modalities that have been used to triage possible ACS patients in the emergency setting--MRI as well as cardiac CT and nuclear perfusion imaging--have struggled to distinguish acute from prior MI. For their study, Cury et al were interested specifically in patients with chest pain, negative cardiac biomarkers, and no ECG changes indicative of acute ischemia.
"The patients in this study were all patients who had been in the emergency department for at least 12 hours waiting for changes in cardiac enzymes and waiting for a stress test," he said. "So by doing MRI early on, we were able to detect myocardial injury before the rise of cardiac enzymes. There were some patients who had increased cardiac enzymes at a later stage, but we were able to detect both edema and necrosis before the increase in cardiac enzymes."
MR Protocol Includes Information on Edema, LV Wall Thinning
In their protocol, Cury et al used T2-weighted imaging to look for myocardial edema and assessment of left ventricular wall thickness to check for myocardial thinning, in addition to first pass perfusion, cine function, and delayed-enhancement MRI. "The beauty of this is the combination of delayed enhancement looking at myocardial necrosis and T2-weighted imaging looking at myocardial edema," Cury explained. "By combining this information, we can differentiate patients with acute vs old MI and which patients had unstable angina vs non-STEMI. Unstable angina is very difficult for different modalities to detect, and we were able to detect it in the great majority of cases," Cury said.
The entire cardiac MR protocol, on average, took just over 30 minutes per patient. A diagnosis of ACS was subsequently confirmed by chart review.
Out of 62 patients presenting with possible ACS symptoms, the new cardiac MR protocol increased the specificity, positive predictive value, and overall accuracy, as compared with the conventional cardiovascular magnetic resonance protocol (which did not include T2-weighted imaging or LV-wall assessment). Cury et al's protocol also significantly improved on information derived from clinical risk assessment alone or from clinical risk assessment combined with traditional cardiac risk factors.
"At this point, just using initial clinical risk assessment based on ECG and cardiac enzymes, we are not doing a great job, and that's why many physicians are just admitting patients for catheterization, or, in some cases, 2% to 4% of patients are discharged when they actually have ACS," he explained. "So we think this is really impressive: MRI remained a significant predictor above and beyond traditional cardiac risk factors and clinical risk assessment. Specifically, if you have a positive MRI, you have 120 times higher likelihood of having ACS as compared with patients with normal MR, after adjusting for traditional cardiac risk factors and clinical risk assessment."
How MR Might Fit In
So how would cardiac MR fit into emergency-room triage? Cury told heartwire that if a patient had a positive stress test, he or she would go directly to the cath lab. If not, the patient could undergo MRI and if this turned up myocardial edema or necrosis or a regional wall-motion abnormality, they, too, could go directly to the cath lab. But patients in whom there is no evidence of myocardial injury could likely be sent home or undergo later stress testing, although Cury emphasized that this proposed strategy would require further, prospective testing.
Cury also clarified that MR might carve out its own niche distinct from cardiac CT, which has increasingly been shown to play an important role in emergency-room triage.
"CT will, I think, be the first-line test in the acute chest pain setting for patients with low likelihood of having ACS, whereas MRI, I believe, will be used more in patients with intermediate likelihood of ACS," he said. "In the future, I can see the emergency physicians stratifying the patient as low, intermediate, or high risk based on risk factors and type of chest pain, etc, and patients with low risk would probably go to CT, whereas in patients with intermediate risk or even high risk but no diagnostic ECG and negative enzymes, MRI would be a better test."
At present, Cury acknowledged, most hospital emergency departments would not have easy access to MR, but down the road, newer acute chest pain and stroke centers might consider including dedicated MR machines.
Circulation, Aug 2008; 118: 837-844.
19. A Double-blind Randomized Clinical Trial Evaluating the Analgesic Efficacy of Ketorolac versus Butorphanol for Patients with Suspected Biliary Colic in the ED
Olsen JC, et al. Acad Emerg Med. 2008;15:718-722.
Objectives: Patients presenting to the emergency department (ED) with suspected biliary colic often require intravenous (IV) analgesia. The choice of IV analgesia typically includes opioids and ketorolac. Although ultrasound (US) is the initial diagnostic study in these patients, nondiagnostic scans and a high clinical suspicion may require the patient to undergo hepatobiliary scintigraphy (HIDA). Opioids such as morphine interfere with the HIDA scan and thus may limit its value as an analgesic in the ED for these patients. Analgesics that do not interfere with HIDA scanning include ketorolac and butorphanol, an opioid agonist–antagonist. This study evaluates the efficacy of IV ketorolac compared to butorphanol for the treatment of biliary colic pain in the ED.
Methods: Between June 2005 and February 2007, a convenience sample of patients presenting to the ED with abdominal pain suspected to be biliary colic were randomized to receive either 30 mg of IV ketorolac or 1 mg of IV butorphanol. Pain level was assessed using a 1 to 10 "faces" visual analog pain scale initially, as well as 15 and 30 minutes after medication infusion. Side effect profiles and the need for rescue analgesia were also assessed. Patients and clinicians were blinded to the study drug given.
Results: Forty-six patients were enrolled in the study. Both groups had similar demographics and baseline pain scores. The mean (±standard deviation [SD]) pain score in the butorphanol group decreased from 7.1 (±1.7) to 2.1 (±2.2) after 30 minutes. The mean (±SD) pain score in the ketorolac group decreased from 7.4 (±2.0) to 3.1 (±3.3) after 30 minutes. Both groups had similar needs for rescue analgesia. Side effects included dizziness and sedation with butorphanol and nausea with ketorolac.
Conclusions: Although limited by small sample size and convenience sample, this study demonstrates that both ketorolac and butorphanol provide pain relief in biliary colic. Both agents should be considered reasonable options in the ED treatment of biliary colic, especially in patients that may undergo HIDA.
20. Physician Clinical Impression Does Not Rule Out Spontaneous Bacterial Peritonitis in Patients Undergoing ED Paracentesis
Chinnock B, et al. Ann Emerg Med. 2008;52:268-273.
Study objective
We determine whether clinical characteristics and physician assessment are useful in the exclusion of spontaneous bacterial peritonitis in emergency department (ED) patients with ascites requiring paracentesis.
Methods
We conducted a prospective, observational study of ED patients with ascites undergoing paracentesis. Predefined clinical characteristics including historical features and ED vital signs were recorded. Each patient was assessed by 2 separate, blinded physicians for severity of abdominal tenderness and overall clinical suspicion for spontaneous bacterial peritonitis. The primary outcome measures were sensitivity, specificity, and likelihood ratios (LR) of the individual clinical characteristics and the physician assessments. Spontaneous bacterial peritonitis was defined by absolute neutrophil count greater than 250 cells/mm3 or positive fluid culture result.
Results
There were 285 separate physician assessments in 144 patients enrolled with complete data. Spontaneous bacterial peritonitis was diagnosed in 17 (11.8%) patients. Physician clinical impression had a sensitivity of 76% (95% confidence interval [CI] 62% to 91%) and specificity of 34% (95% CI 28% to 40%) for the detection of spontaneous bacterial peritonitis. The lowest negative LR was associated with the presence of any abdominal pain or tenderness (negative LR=0.4); however, the presence of pain/tenderness was also observed in 85% of patients without spontaneous bacterial peritonitis. Six patients (4.2%) with spontaneous bacterial peritonitis had at least 1 physician assessment of little to no risk for spontaneous bacterial peritonitis, and 3 of the 6 subsequently died during their hospitalization.
Conclusion
Clinical characteristics and physician assessment were insufficient in the diagnosis or exclusion of spontaneous bacterial peritonitis in the ED patient undergoing diagnostic or therapeutic paracentesis. This finding supports routine laboratory fluid analysis after ED paracentesis.
Thursday, August 28, 2008
Wednesday, August 06, 2008
Lit Bits: August 6, 2008
From the recent medical literature...
1. Are the Uninsured Responsible for the Increase in ED Visits in the US?
Weber EJ, et al. Ann Emerg Med. 2008;52:108-115.e1
Study objective
The rise in emergency department (ED) use in the United States is frequently attributed to increased visits by the uninsured. We determine whether insurance status is associated with the increase in ED visits.
Methods
Using the national Community Tracking Study Household Surveys from 1996 to 1997, 1998 to 1999, 2000 to 2001, and 2003 to 2004, we determined for each period the proportion of reported adult ED visits according to insurance status, family income, usual source of care, health status, and outpatient (non-ED) visits. Trends over time were tested for statistical significance.
Results
The proportion of adult ED visits by persons without insurance was stable across the decade. Uninsured individuals accounted for 15.5% of ED visits in 1996 to 1997, 16.1% in 1998 to 1999, 15.2% in 2000 to 2001, and 14.5% of visits in 2003 to 2004 (P for trend=.43). The proportion of visits by persons whose family income was greater than 400% of the federal poverty level increased from 21.9% to 29.0% (P=.002). The proportion of visits by those whose usual source of care was a physician's office increased from 52.4% in 1996 to 1997 to 59.0% in 2003 to 2004 (P=.002), whereas the proportion of visits by those without a usual source of care was essentially unchanged (9.7% of visits in 1996 to 1997 and 9.6% in 2003 to 2004; P=.74).
Conclusion
The rise in ED visits between 1996 and 2003 cannot be primarily attributed to the uninsured. Major contributors to increasing ED utilization appear to be disproportionate increases in use by nonpoor persons and by persons whose usual source of care is a physician's office.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(08)00365-X/fulltext
2. Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
Hirsh J, et al. Chest. 2008; 133:67S-968S.
There are many separate articles here on nearly every aspect of antithrombotics and thrombolytics.
Full-text (free): http://www.chestjournal.org/content/vol133/6_suppl/
3. $1,526,000 Awarded to Plantiff for IV Administration of Phenergan
On April 6, 2006, a 42-year-old truck driver without health insurance presented to an urban general hospital’s emergency department in Florida because of rectal bleeding. A gastroenterologist admitted him and made him n.p.o. for a colonoscopy the next morning. The admission orders included Phenergan p.o. or IV as needed for nausea. Several hours later, the nurse gave him 12.5 mg IV push through an IV on the dorsum of his right hand. He says the injection caused burning pain in his right hand and arm. He was discharged the next day, after the colonoscopy His right hand and wrist became swollen and more painful. He could not drive his truck and lost his job.
The hospital set him up with physical therapy and later referred him to a pain management specialist, but he still has pain and is unable to drive a truck. He sued the hospital for negligent administration of Phenergan.
At the trial, he claimed the nurse gave him the drug IV push too fast, over about 15 seconds. The
nurse did not remember this specific injection, but she testified she customarily diluted Phenergan properly and gave it IV over two minutes. The plaintiff also told the jury he complained of burning pain while she was giving the drug, and the nurse told him it was supposed to burn. The plaintiff’s experts testified he has complex regional pain syndrome and will require treatment in the future.
The defense expert disagreed. After five days of trial, the jury deliberated for 3 hours and found 6-0 in favor of the plaintiff. The $1,526,000 award included $282,000 for past and future medical expenses, $748,000 for past and future lost earnings, and $496,000 for past and future pain and suffering.
COMMENT: This is the largest award I’ve seen yet for local tissue damage from IV Phenergan. As discussed previously in PLN (Vol. 37, No. 5, September/October 2007), it is wise to avoid giving Phenergan through a peripheral IV. If oral or IM administration is not possible and a central line is not available, a different drug could be tried.
David Shapiro, Professional Liability Newsletter. 2008;38(2).
4. Psychiatric patients often ‘boarded’ in ED
Source: The American Hospital Association. Date: June 19, 2008
In a survey of 328 emergency department directors from across the country, almost 80% said that their hospital “boards” psychiatric patients in the ED, the American College of Emergency Physicians reported yesterday. According to the survey, more than 60% of psychiatric patients stayed in the ED more than four hours, 33% more than eight hours and 6% more than 24 hours, even after the decision to admit them had been made. The main reasons included a lack of inpatient psychiatric beds and an inability to transfer psychiatric patients to other facilities.
“Hospitals and physicians struggle daily to care for these patients, but society is not yet willing to treat psychiatric patients the same as patients with physical illness,” said Jim Bentley, AHA’s senior vice president for strategic policy planning. “The decline in inpatient psychiatric beds clearly reflects the inadequacy of hospital and physician payments to treat these patients, and the influence insurance plan subcontractors, or ‘carve-outs,’ have on behavioral health treatment.” Carve-outs are services insurance plans provide through a separate managed care contract.
Article: http://www.acep.org/pressroom.aspx?id=39170
5. The Management of Encephalitis: Clinical Practice Guidelines by the ID Society of America
Tunkel AR, et al. Clinical Infectious Diseases 2008;47:303–327
Guidelines for the diagnosis and treatment of patients with encephalitis were prepared by an Expert Panel of the Infectious Diseases Society of America. The guidelines are intended for use by health care providers who care for patients with encephalitis. The guideline includes data on the epidemiology, clinical features, diagnosis, and treatment of many viral, bacterial, fungal, protozoal, and helminthic etiologies of encephalitis and provides information on when specific etiologic agents should be considered in individual patients with encephalitis.
Full-text (free): http://www.journals.uchicago.edu/doi/full/10.1086/589747
6. HBOC-201: A Viable Alternative to Blood Transfusion
Use of hemoglobin-based oxygen carrier-201 avoided need for blood transfusion in nearly 60% of patients.
Despite strategies to conserve use of packed red blood cells (PRBCs), experts predict that availability will not meet the increasing demand by an aging population. Hemoglobin-based oxygen carrier-201 (HBOC-201) is a bovine–hemoglobin-based blood substitute that is approved in South Africa for clinical use. In a randomized, single-blind, controlled, multinational study, researchers (some of whom were affiliated with the manufacturer) assessed whether administration of HBOC-201 eliminates the need for PRBC transfusion in adult patients undergoing orthopedic surgery.
Overall, 688 patients (mean age, 61) with hemoglobin concentrations less than10.5 g/dL who required transfusions were randomized to treatment with HBOC-201 or PRBCs. Once treatment was initiated, subsequent transfusions were administered based on the presence of at least one of the following criteria: pulse 100 bpm, systolic blood pressure less than 90 mm Hg, electrocardiogram evidence of myocardial ischemia, base deficit 4, acute blood loss more than 7 mL/kg within 2 hours, oliguria, and significant weakness or dizziness. Patients in the HBOC group received a loading dose of 65 g of hemoglobin infused in 500 mL (a volume considered equivalent to 1 unit of PRBCs); additional doses were administered for up to 6 days to a maximum of 325 g (2500 mL), after which need for additional oxygen-carrying capacity was met by transfusion of PRBCs.
Overall, 59% of patients in the HBOC group did not require PRBC transfusion. The HBOC group had significantly higher rates of adverse events (e.g., elevated blood pressure) than the PRBC group (8.5 vs. 5.9 per patient) and serious adverse events (e.g., cardiac events and strokes; 0.34 vs. 0.25 per patient). Findings of a safety analysis led the authors to conclude that risk for adverse events from HBOC was greatest in patients who were older than 80, had volume overload, and were undertreated.
Comment: HBOC-201 does not require crossmatching and can be stored at room temperature for as long as 3 years. In this study, its use eliminated the need for transfusion of allogeneic PRBCs in 59% of patients. Its safety profile was inferior to that of PRBC transfusion, including a greater incidence of acute coronary syndromes and strokes, which the authors partially attributed to age older than 80, volume overload, and undertreatment. Overall, the authors suggest that patients younger than 80 with moderate clinical need for transfusion can be managed with up to 10 units of HBOC-201, thereby preserving the stockpile of PRBCs for other patients.
— John A. Marx, MD, FAAEM, FACEP. Published in Journal Watch EM, August 1, 2008. Citation: Jahr JS et al. J Trauma 2008; 64:1484.
7. Antiplatelet Therapy and the Risk of Intracranial Hemorrhage After Intravenous tPA Therapy for Acute Ischemic Stroke
Hallevi H, et al. Arch Neurol. 2008;65:575-576.
IV administration of tPA is currently the only approved therapy for acute ischemic stroke. The drug works by splitting plasminogen into plasmin, ultimately leading to fibrin degradation at the site of cerebral artery occlusion. Even today, more than 10 years after the drug was approved in the United States (and subsequently around the world), its use has been hampered by the fear of inducing symptomatic intracerebral hemorrhage (SICH). This adverse event was seen in 6% of patients treated in the original National Institute of Neurological Disorders and Stroke trial that led to tPA’s approval and was subsequently confirmed in multiple postmarketing studies. The predictors of SICH after tPA administration are well known: severe stroke (high National Institute of Health Stroke Scale score) and large hypodensity on the admission computed tomography.
Other possible predictors include advanced age, elevated blood glucose, a platelet count of less than 50 000/mL, and systolic blood pressure above 180 mm Hg. Previous works have examined the relationship between prior antiplatelet (AP) therapy and SICH after tPA administration. Notably, in the National Institute of Neurological Disorders and Stroke tPA trial, there was no association between prior aspirin therapy and SICH. Another multicenter stroke survey showed an association of SICH with aspirin therapy that was lost after controlling for clinical and laboratory variables. Contrary to that, in this issue of Archives, Uyttenboogaart et al report a surprisingly high rate of SICH after tPA administration in patients undergoing long-term AP therapy. In their cohort of 309 patients derived from a single center in the Netherlands, AP therapy (mostly aspirin or an aspirin and dipyridamole combination) before the stroke was associated with a 13.5% rate of SICH compared with 2.8% in patients without AP therapy. Drug compliance was not assessed in this study. As expected, patients undergoing AP therapy were older and had more vascular risk factors than patients not taking AP drugs. There were no differences in stroke severity, stroke subtype, blood pressure, blood glucose, or early changes on the admission computed tomographic scan. Despite the high rate of SICH, AP therapy was associated with an odds ratio of 2 for a favorable outcome. How does one settle these seemingly contradictory results and what lessons can we draw from this observation?....[middle section not included].
How should we proceed as clinicians given these new data? Acute stroke care is still wrought with uncertainties and we have an obligation to ensure patient safety while struggling to reduce stroke morbidity. Certainly, we need to monitor the rates of SICH and keep identifying modifiable predictors. One way to improve the quality of our data is to look at large multicenter cohorts. The recently reported European tPA registry of 6483 patients given tPA within 3 hours of symptom onset is an excellent example. Analysis of this cohort should generate reliable data regarding any possible association among AP therapy, SICH, and favorable outcomes. Patient reporting of prior medication use is often inaccurate and compliance is hard to determine, especially in acute settings. If prior AP therapy is indeed shown to be associated with an unacceptably high rate of SICH in a large cohort, it may be possible to better assess the risk using rapid platelet function testing. At the present time, we firmly believe that prior AP use should not discourage physicians from administering tPA to patients undergoing an acute stroke. The association of favorable outcomes with prior AP therapy makes good clinical sense and should encourage us in the effort to devise better recanalization strategies using additional manipulations of selected hemostatic components in addition to tPA. Fear of SICH is understandable but should not deprive stroke patients of effective therapy or a chance to recover from the devastating effects of an ischemic stroke.
Full-text of this editorial (subscription required): http://archneur.ama-assn.org/cgi/content/extract/65/5/575
Full-text of the Uyttenboogaar article (free): http://archneur.ama-assn.org/cgi/content/full/65/5/607
Abstract of the European tPA registry article: http://www.thelancet.com/journals/lancet/article/PIIS0140673607601494/abstract
8. Patient Perceptions Affect Ambulance Use in Acute Coronary Syndrome
NEW YORK (Reuters Health) Aug 01 - Only about half of patients with acute coronary syndrome (ACS) call for an ambulance, even though ambulance use and early reperfusion therapy is strongly recommended. A recent study, reported in the July issue of the American Heart Journal, has identified reasons why symptomatic patients with ACS avoid the potentially beneficial assistance of emergency medical services.
"National guidelines recommend activation of the emergency medical service by patients who have symptoms of ACS," Maria Thuresson, of Orebro University Hospital, Sweden, and colleagues write. "In spite of this, only 50% to 60% of persons with myocardial infarction initiate care by using the emergency medical service."
At intensive cardiac care units in 11 hospitals in Sweden, 1939 patients with ACS completed questionnaires within the first few days after admission. All had experienced symptom onset outside the hospital, but only half had been transported to the hospital by ambulance.
Factors associated with ambulance use included knowledge of the importance of quickly seeking medical care when experiencing chest pain (odds ratio [OR] 3.61), history of heart failure (OR 2.48), abrupt onset of pain reaching maximum intensity within minutes (OR 2.08), nausea or cold sweat (OR 2.02), distance to the hospital of more than 5 km (OR 2.00), and vertigo or near syncope (OR 1.63).
Patients who did not call for an ambulance thought self-transport would be faster and did not believe their symptoms were serious enough to warrant ambulance use.
Dr. Thuresson and colleagues advise, "The results in the present study should be considered when planning educational and information programs to increase ambulance use in ACS."
Am Heart J 2008;156:170-176.
9. Falls Due to Seizure-Induced Cardiac Asystole
Syncope due to ictal asystole should be considered as an explanation for seizure-related falls.
Although most seizures are associated with sinus tachycardia, a minority are associated with bradycardia and even asystole (which is usually defined as a sinus pause lasting at least 3 seconds). An increasing number of case reports and series have focused on this phenomenon in recent years. Now, researchers report on three patients with sudden falls that were found to be due to seizure-induced asystole and syncope.
In each case, simultaneous EEG and electrocardiogram recordings identified the cause of the falls. The cases, supplemented by video clips on the Neurology website, provide convincing demonstrations of falls associated with seizure-induced asystole.
Comment: As is noted in an editorial, sudden falls are potentially dangerous in themselves. Even though a connection has not been established between ictal bradycardia or asystole and the phenomenon of sudden unexpected death in epilepsy, patients with seizure-induced cardiac asystole probably should be treated not only with the best available antiepileptic therapy, but also with cardiac pacing. The report also highlights the complex interactions between cerebral and cardiovascular dysfunctions that contribute to episodic unconsciousness. Clinicians must keep in mind that the spectrum of episodic unconsciousness includes not only ictal asystole but also the more common phenomenon of convulsive syncope (convulsive movements due to cerebral hypoperfusion without an epileptic discharge) and very rare cases of hypoperfusion-induced acute symptomatic seizures.
Videos: http://www.neurology.org/cgi/content/full/01.wnl.0000289193.89796.83/DC1
— Edward B. Bromfield, MD, Chief, Division of Epilepsy and Sleep Neurology, Brigham and Women’s Hospital, Boston. Published in Journal Watch Neurology July 15, 2008. Citation:
Rubboli G et al. Neurology 2008 May 13; 70:1933.
10. EU OKs Drug to Reverse Neuromuscular Blockade
By Ransdell Pierson. NEW YORK (Reuters) Jul 30 - European regulators have approved a breakthrough new medication to help patients emerge far more quickly from anesthesia than existing treatments, the drug's maker Schering-Plough Corp said on Tuesday.
The drug, called Bridion, was approved by the European Commission, following a recommendation last month by an advisory panel in support of the drug, also known as sugammadex.
Bridion was approved for reversal of neuromuscular block induced by rocuronium and vecuronium.
The medicine is awaiting approval in the United States. An advisory panel to the U.S. Food and Drug Administration in March voted that it was safe and effective.
In a late stage clinical trial, Bridion reversed the effects neuromuscular blockade within a few minutes -- nine to 12 times faster than the standard reversal agent, neostigmine, according to researchers.
11. Do Your Patients Borrow, Lend, or Trade Medications?
Neither a borrower nor a lender be — but about one third of people in this community survey do not heed this advice.
Objectives. We sought to document the frequency, circumstances, and consequences of prescription medication–sharing behaviors and to use a medication-sharing impact framework to organize the resulting data regarding medication-loaning and -borrowing practices.
Methods. One-on-one interviews were conducted in 2006, and participants indicated (1) prescription medicine taken in the past year, (2) whether they had previously loaned or borrowed prescription medicine, (3) scenarios in which they would consider loaning or borrowing prescription medicine, and (4) the types of prescription medicines they had loaned or borrowed.
Results. Of the 700 participants, 22.9% reported having loaned their medications to someone else and 26.9% reported having borrowed someone else’s prescription. An even greater proportion of participants reported situations in which medication sharing was acceptable to them.
Conclusions. Sharing prescription medication places individuals at risk for diverse consequences, and further research regarding medication loaning and borrowing behaviors and their associated consequences is merited.
Goldsworthy RC, et al. Beyond Abuse and Exposure: Framing the Impact of Prescription-Medication Sharing. Am J Public Health 2008 98: 1115-1121.
12. CT Angiography Aids Decision Making for Penetrating Neck Trauma
Physical examination of patients with penetrating neck trauma is specific, but CT angiography improves sensitivity for identification of significant vascular, aerodigestive, and neurologic injury.
Background: Improvements in imaging technology, particularly computed tomographic angiography (CTA), have altered the management of patients with penetrating injuries in the neck. The purpose of this retrospective study is to evaluate our 5-year experience with the management of penetrating injuries to the neck, to the further elucidate the role of CTA in clinical decision making, and to assess treatment outcome.
Methods: Clinical variables were collected and evaluated on all patients with penetrating injuries to the neck presenting to the Legacy Emanuel Hospital Trauma Service from 2000 to 2005. For comparison, the patients were divided into two groups based upon whether the patient had received a CTA before operative intervention: group 1, CTA; group 2, no CTA. A statistical analysis using the Fisher exact test and t test was performed to analyze whether the rate of neck exploration or the findings at the time of neck dissection were significantly different between the groups.
Results: Of the 120 consecutive patients with penetrating injuries to the neck, 55 were excluded from the study because the injury was superficial, the patient died before operative intervention, or they underwent emergent neck exploration to control hemorrhage. Sixty-five patients with neck injuries penetrating the platysma were identified that met the criteria for inclusion in the study. Group 1 (CTA) consisted of 24 patients and group 2 (no CTA) had 41 patients. Group 1 (CTA) had significantly fewer formal neck explorations (N = 6) compared with group 2 (no CTA) (N = 27) (p less than 0.01). All six of the operations in the CTA group had clear indications for and positive findings on surgical exploration, and there were no clinically significant missed injuries. Of the 27 patients in group 2 who underwent neck exploration, only 14 had a positive finding, 4 of which were simply superficial bleeding vessels, yielding a rate of negative neck exploration of 48%, compared with 0% for group 1 (p less than 0.01). The number of adjunctive studies such as esophagography, angiography, and various endoscopic procedures were similar in both groups.
Conclusion: The management of stable patients with penetrating injuries to the neck that penetrate the platysma has evolved at our institution into selective surgical intervention based on clinical examination and CTA. The use of CTA has resulted in fewer formal neck explorations and virtual elimination of negative exploratory surgery.
Osborn T, et al. J Trauma 2008;64:1466-1471.
13. Characteristics of Women With Fetal Loss in Symptomatic First Trimester Pregnancies With Documented Fetal Cardiac Activity
Juliano M, et al. Ann Emerg Med. 2008;52:143-147.
Study objective
The purpose of this study is to determine fetal outcomes of women diagnosed with live intrauterine pregnancy after emergency department (ED) presentation for abdominopelvic pain or vaginal bleeding during the first trimester.
Methods
A retrospective medical record review of prospectively recorded data of consecutive ED charts from December 2005 to June 2006 was performed to identify patients diagnosed with live intrauterine pregnancy. Demographic data, obstetric/gynecologic history, and presenting symptoms were obtained. Outcomes were determined by computerized medical records. Fetal loss was diagnosed by decreasing β-Human chorionic gonadotropin or pathology specimen. Live birth was diagnosed by viable fetus at 20-week-gestation ultrasonography or delivery.
Results
A total of 837 patients were evaluated during the first trimester. Three hundred forty patients (41%) met inclusion criteria, with a diagnosis of live intrauterine pregnancy. Outcome data were obtained for 303 (89%) of these patients. Fetal loss occurred in 28 (9.2%) pregnancies (95% confidence interval [CI] 5.9% to 12.5%). Fetal loss incidence was 13.8% (95% CI 9.9% to 17.7%) in patients presenting with vaginal bleeding compared with 2.5% (95% CI 0.007% to 4.3%) in patients without bleeding (P less than 0.002). Twenty five of 28 (89%) patients with resulting fetal loss presented with vaginal bleeding. Vaginal bleeding was the most important predictor of fetal loss; risk ratio 5.6 (95% CI 1.7 to 18.2). Conclusion Fetal loss before 20 weeks occurs in 9.2% of patients with live intrauterine pregnancy diagnosed by ultrasonography. Vaginal bleeding carries a higher fetal loss rate of 13.8%. These data will assist the emergency physician in counseling women experiencing symptomatic first trimester pregnancy.
14. Oral Proton Pump Inhibitors May Be Adequate for Control of Bleeding Ulcers
NEW YORK (Reuters Health) Jul 14 - Proton pump inhibitor (PPI) therapy administered by intravenous bolus plus infusion acts only marginally more rapidly than oral administration, University of Southern California investigators report.
Dr. Loren Laine and colleagues suggest that the manpower, discomfort and expense involved with the currently recommended approach of intravenous administration of PPIs in this setting may be unnecessary in many cases of bleeding ulcers.
Sixty-six patients presenting to the USC Medical Center in Los Angeles with overt signs of gastric or duodenal bleeding ulcers underwent endoscopic hemostasis and then intragastric placement of pH probes.
Once bleeding was controlled, patients were randomized to a 90 mg bolus of lansoprazole followed by a 9 mg/hour infusion or to oral lansoprazole as a 120 mg loading dose followed by 30 mg every three hours for 24 hours. Stomach pH was recorded throughout the study period.
At 1 hour, mean pH for intravenous lansoprazole was 5.3 compared with a mean pH of 3.3 with oral lansoprazole. After 1.5 hours, there were no differences in pH between intravenous and oral administration, the investigators report in the June issue of Gastroenterology.
Mean pH rose above 6 after 2-3 hours of intravenous PPI and after 3-4 hours of oral PPI.
"Because the only known mechanism by which PPI therapy reduces ulcer rebleeding is via its effect on acid secretion, our results suggest that frequent oral PPI therapy may be able to replace bolus plus constant infusion intravenous PPI for patients with ulcer bleeding," Dr. Laine and colleagues write.
"However," the USC team cautions, "our end-points were surrogate pharmacodynamic end-points and not clinical end-points, which provide the most relevant information. The major pharmacodynamic benefit of the intravenous regimen was a more rapid elevation in intragastric pH."
"If reaching a target pH of 6 (or 5) an hour earlier is desired and felt to be clinically important, then intravenous PPI therapy would be preferred," Dr. Laine and colleagues conclude.
Gastroenterology 2008;134:1836-1841.
15. Evolving MIs Usually Detected in the ED
from Heartwire — a professional news service of WebMD. July 28, 2008 — Doctors are doing a good job identifying patients with evolving MI presenting to the emergency department with chest pain but without ST segment elevation or an initial positive troponin test, a new study suggests [reference below].
The study, published in the August 1, 2008 issue of Emergency Medicine Journal, was conducted by a group led by Dr Chadwick Miller (Wake Forest University Baptist Medical Center, Winston Salem, NC).
He explained to heartwire that some patients who are having an MI might not always show a positive troponin when first presenting because it can take six to eight hours for troponins to rise after the start of an MI. And there is concern that, among patients without ST elevation or a positive initial troponin test, those with evolving MI might not be identified and therefore might not be treated as aggressively as they should be.
To look at this further, the researchers conducted an observational study using data from the Internet Tracking Registry for Acute Coronary Syndromes, a registry of patients presenting with undifferentiated chest pain. This analysis included patients without ST segment elevation with at least two troponin assay results less than 12 hours apart. Patients were stratified into three groups: those with an initial negative but a second positive troponin assay (classified as evolving MI); those with an initial positive troponin assays (NSTEMI); and those with two negative troponin assays (no MI). Miller explained that the first two groups had similar conditions but different time frames; the first group was at an earlier stage in the course of their MI than the second group.
Of the 4136 patients studied, 5% were found to be having an evolving MI, 8% had NSTEMI, and 87% had no MI. Patients with evolving MI were more similar, with respect to demographic characteristics, presentation, admission patterns, and revascularization, to those with NSTEMI than to those with no MI, and 76% of the time, physicians' initial impressions suggested heightened concern for cardiac risk in the evolving MI patients.
"Our results show that, on the whole, emergency physicians are doing a good job in picking up the patients with evolving MI before conclusive troponin tests are in," Miller commented to heartwire. "It was hard to tell from this study which factors are the most important in identifying these patients. It was a combination of findings from the patient's history, clinical examination, and ECG. But what we have shown is that the emergency's doctor best guess is usually right in finding these patients."
One of the symptoms of interest was chest pain described as burning. "We showed a strong association between burning chest pain and evolving MI. Burning chest pain is often taken as a symptom of GI reflux, but I think one message from our study is that we should not be discounting burning pain as reflux, as actually there is quite a high likelihood that it could be an ACS," Miller commented to heartwire.
He added that these results have implications for how a chest pain triage system is managed. "There are places where the triage system could be improved. But on the whole, I am happy with what we saw here. It is reassuring to see that the admission patterns among the evolving MI patients were more aggressive than with the patients found not to be having an MI, even though in both these groups the initial troponin results were not elevated. This suggests that clinicians are not allowing the initial negative troponin results to overshadow their clinical impression,” he said.
Miller explained that one of the issues is that chest pain patients thought not to be having an MI are sometimes sent for stress tests to rule out further cardiac causes before the second troponin test is back, but this would not be advisable for a patient who is having an evolving MI because it could induce ventricular arrhythmias. "If patients with evolving MI are lumped in with this group, then we could have a problem. But our results suggest that this is relatively unlikely to happen. In our study, of 4136 patients, just 187 were found to be having an evolving MI on the basis of the second troponin test. Because 76% of these were initially thought to be having an MI, unstable angina, or high-risk chest pain, only about 40 of these patients were not flagged after the initial examination," he noted.
Miller CD, Fermann GJ, Lindsell CJ, et al. Initial risk stratification and presenting characteristics of patients with evolving myocardial infarctions. Emerg Med J. 2008; 25:492-497.
16. Are Powered Intraosseous Insertion Devices Safe and Effective in Children?
These devices are good alternatives to manual intraosseous needles.
Horton M, et al. Pediatr Emerg Care. 2008;24:347-350.
Objective: For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients.
Methods: We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications.
Results: There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 +/- 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 +/- 2.8, and mean infusion pain score was 3.2 +/- 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4.
Conclusions: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.
17. Early, Aggressive Treatment Warranted in Pediatric Status Epilepticus
July 22, 2008 — Convulsive status epilepticus (CSE) in children warrants early, aggressive treatment that includes rapid transport to the emergency department as well as very early prehospital treatment. In addition, the study supports first-line treatment in the emergency department with intravenous lorazepam.
Published in the August issue of Lancet Neurology, the study showed for each minute delay from onset of CSE to hospital arrival there was a 5% cumulative increase in the risk of the episode lasting more than 60 minutes.
Furthermore, prehospital treatment for CSE, usually with rectal diazepam, significantly reduced the incidence of prolonged seizures — that is, those lasting more than 60 minutes. Further treatment in the emergency room with intravenous lorazepam was associated with a 3.7 times greater likelihood of seizure termination compared with rectal diazepam.
These findings, say investigators warrant a change to existing guidelines and practice in the United Kingdom and other jurisdictions that do not yet include prehospital treatment for CSE.
"There is evidence that the longer a seizure lasts, the harder it is to stop, and the poorer the outcome. We need to ensure that prehospital treatment is administered and that all children are transported to the hospital as quickly as possible, because even if prehospital treatment is delivered, we can't predict which children will respond," principal investigator Richard F. M. Chin, PhD, from the Institute of Child Health, University College London, and the Great Ormond Street Hospital for Children National Health Service Trust, in London, United Kingdom, told Medscape Neurology & Neurosurgery.
No Standardized Treatment
According to Dr. Chin, although some CSE patients are treated before they reach the hospital, the practice is extremely variable and frequently depends on regulations governing attending emergency staff and emergency antiepileptic drugs.
Furthermore, he said, there is a paucity of data on the treatment of childhood CSE, and, as a result, there is variation in the treatment of CSE that starts in the community.
In what is the first population-based study of childhood CSE, the investigators examined the treatment of childhood CSE and factors affecting seizure duration.
Known as the North London Convulsive Status Epilepticus in Childhood Surveillance Study (NLSTEPSS), the study included data on ED treatment of all children in North London between the ages of 29 days and 15 years who had episodes of CSE between 2002 and 2004.
Investigators examined the data to identify factors associated with seizure termination after first-line therapy in the emergency department as well as those associated with seizure termination after second-line treatment in children who failed to respond to or did not receive first-line benzodiazepine therapy.
They also attempted to identify factors associated with seizures lasting more than 60 minutes and those that predict respiratory depression.
A total of 240 episodes of CSE were identified in 182 children. Of these, 69% occurred in children with preexisting neurological abnormalities, including epilepsy.
Treatment decisions were made by individual caregivers, paramedics, and treating physicians who enrolled patients in the study. Medication adequacy was determined by the 3rd edition of the Advanced Pediatric Life Support (APLS) guideline, which recommends 0.1 mg/kg for intravenous lorazepam; 0.5 mg/kg for rectal diazepam; 0.4 mL/kg for rectal paraldehyde; 18 mg/kg for intravenous phenytoin; and 15 to 20 mg/kg for intravenous phenobarbital.
Prehospital treatment was administered in 147 (61%) episodes — 93 (63%) by paramedics and 54 (37%) by caregivers. Among children who received prehospital treatment, 32 (22%) episodes were terminated.
Too Little, Too Late
Of the children who did receive prehospital treatment, 96% received rectal diazepam. However, of these, 141 episodes were given a dose that was lower than the APLS guideline recommendation.
"It was surprising that such a significant proportion of children did not receive prehospital treatment and that, when they were treated, the dose was too low. What this highlights to me is that we have a potentially life-threatening condition that requires early treatment, but a significant proportion of our patients may or may not receive it or, when they do, are being treated suboptimally," said Dr. Chin.
Adjusted analyses revealed treatment with intravenous lorazepam administered in the emergency department was associated with a 3.7 times greater likelihood of seizure termination compared with rectal diazepam.
Furthermore, intravenous phenytoin, when used as a second-line therapy, was associated with a 9 times greater likelihood of seizure termination than rectal paraldehyde.
The investigators also found that more than 2 doses of a benzodiazepine — whether it was lorazepam or diazepam — were associated with respiratory depression and a longer duration of seizure activity.
The investigators also found that continuous CSE was as common as intermittent CSE. However, the latter was not as well recognized, resulting in delays in calling emergency services, arrival at the emergency department, and treatment. As a result, children with intermittent CSE were more likely to experience seizures lasting more than 60 minutes.
Clear Message
According to Dr. Chin, the study's message is clear. "Our study highlights the importance of prehospital treatment [with intravenous lorazepam], and we need to find ways to develop and facilitate this. On arrival of the patient at the emergency department, the emphasis should be on administering intravenous medication promptly."
Based on the study results and all other available evidence on the treatment of childhoood CSE, Dr. Chin, along with coauthor Rod C. Scott, MRCPCH, both members of a national working party, will aim to help revise current CSE treatment guidelines and integrate the findings into everyday practice.
In an accompanying editorial, David M. Treiman, MD, from the Barrow Neurological Institute, in Phoenix, Arizona, writes that the "clear superiority of intravenous lorazepam over rectal diazepam as a first-line treatment and intravenous phenytoin over rectal paraldehyde as a second-line treatment provide a basis for a revision of the current management guidelines for the treatment of CSE in children."
The study was supported by an anonymous donor to the UCL Institute of Child Health; the Wellcome Trust; UK Department of Health National Institute for Health Research Biomedical Research Centres Funding Scheme; and the Medical Research Council. The authors have no disclosures.
Lancet Neurol. 2008;7:696-703.
18. Balloon Compression as Treatment for Refractory Vaginal Hemorrhage
Schlicher NR. Ann Emerg Med. 2008;52:148-150.
Severe vaginal hemorrhage is a rare presenting condition but serious life threat in the emergency department (ED). Initial management has historically been limited to vaginal packing, fluid resuscitation, and emergency surgical intervention. An alternative approach to therapy is presented that can be effectively deployed in the ED. In the present case, balloon compression of the vaginal mucosa was successful in arresting life-threatening hemorrhage. The patient survived subsequent hemodynamic stabilization and surgical intervention and was ultimately discharged home.
19. Direct Emergency Admission to Catheterization Lab Reduces Time to Intervention
NEW YORK (Reuters Health) Jul 22 - Direct ambulance admission to the cardiac catheterization laboratory significantly reduces the time to performance of primary percutaneous intervention (PCI), according to a report in the June issue of the American Heart Journal.
The aim of the American Heart Association/American College of Cardiology "Door-to-balloon: an alliance for quality" campaign is to increase the percentage of patients with ST-elevation myocardial infarction (STEMI) in whom infarct artery patency is achieved within 90 minutes of symptom onset, the authors explain.
Dr. Michael F. Dorsch and colleagues from Leeds General Infirmary, Leeds, UK investigated the impact of prehospital paramedic ECG diagnosis and subsequent direct transfer to the cardiac catheterization laboratory on door-to-balloon and call-to-balloon times in primary PCI.
Compared to patients admitted via the emergency room, the authors report, direct ambulance admission significantly reduced door-to-balloon times (from 105 minutes to 58 minutes) and call-to-balloon times (from 143 to 105 minutes).
Ninety-four percent of patients admitted directly from the ambulance met the 90-minute door-to-balloon time, the report indicates, compared with only 29% of patients referred from the emergency department.
Both door-to-balloon and call-to-balloon times were significantly longer outside normal working hours and in women compared with men, the researchers note.
Thirty-day and 12-month mortality were lower for patients admitted directly, the investigators say, but the differences were not statistically significant.
"Prehospital paramedic ECG diagnosis of STEMI and subsequent direct ambulance admission to the cardiac catheterization laboratory dramatically reduces door-to-balloon times in primary PCI, enabling almost all patients to be treated within the 90-minute target," the authors conclude. "We believe this approach should be a key element of any contemporary primary PCI service."
Am Heart J 2008;155:1054-1058.
20. Do Physicians Report Patients’ Lapses of Consciousness?
Most emergency physicians in California report only new-onset seizures, despite broader mandatory state regulations.
Turnipseed SD (UC Davis), et al. J Emerg Med. 2008; 35:15-21.
Physician reporting of lapses of consciousness (LOC) to the Department of Motor Vehicles is a controversial topic in medicine. The objective of this study was to describe current LOC reporting practices by emergency physicians (EPs) in a state with mandatory reporting requirements (California).
A questionnaire describing 14 different clinical scenarios involving LOC was distributed to a diverse sample of California EPs. Clinical scenarios included new seizure, hypoglycemia, atrial fibrillation/rapid heart rate, cerebrovascular accident, micturation syncope, vasovagal syncope, hepatic encephalopathy, alcohol intoxication, closed head injury, hyperosmolar coma, methamphetamine psychosis, dementia, hyperventilation syndrome, and hypercalcemia. Emergency physicians were asked how often they would report these LOC-related conditions to the state. Simple summary statistics were calculated.
The response rate was 207/340 (61%) of the forms distributed. The average number of years in Emergency Medicine practice among respondents was 12 (range 1–35), and 57% were Emergency Medicine trained. Of the 14 scenarios, only one (new-onset seizure) was reported frequently by EPs (89% reported “nearly always” or “most of the time”). The remaining 13 scenarios were rarely reported (mean of 86% for “occasionally” or “never”).
Although reporting of LOC, from any cause, is mandatory in California, only new-onset seizures are frequently reported by California EPs.
21. Effect of DKA on QTc Prolongation in Children Might Be Mediated by Ketosis, Not Electrolyte Abnormalities
Possible cardiac effects of ketosis make cardiac monitoring of children with DKA essential.
Ketotic conditions have been shown to be associated with prolonged QTc interval and sudden cardiac death. In an observational study, researchers examined whether QTc prolongation occurs during diabetic ketoacidosis (DKA) in children and whether it resolves when ketosis clears.
A convenience sample of 30 children (mean age, 11 years; 12% male) with DKA and not other risks for prolonged QTc interval underwent electrocardiography during DKA and after recovery. Patients were treated according to a standardized DKA protocol that included normal saline, insulin, glucose, and electrolyte replacement. A pediatric cardiologist who was blinded to clinical and biochemical data measured QTc intervals; measurements by a second cardiologist showed high interobserver agreement (=0.62). Prolonged QTc was defined as an interval of at least 450 milliseconds.
Initial electrocardiogram measurements were taken at a mean of 6 hours after initiation of DKA treatment. The QTc interval was significantly longer during DKA (mean, 450 ms; range, 378–539 ms) than after recovery (mean, 407 ms; range, 302–485 ms). Overall, QTc intervals were longer than 450 milliseconds in 47% of patients during DKA and in 13% after recovery; the interval eventually normalized in two of the four patients who continued to have prolonged intervals after recovery. At presentation, the anion gap was significantly higher in patients with QTc prolongation than in those without (27 vs. 22 mEq/L). QTc duration was significantly correlated with the anion gap during DKA but not with serum potassium, calcium, or magnesium values or heart rate.
Comment: Although no life-threatening arrhythmias were observed in this study, QTc prolongation can predispose to them. This study’s findings suggest that QTc prolongation in children with diabetic ketosis might occur even in the absence of significant electrolyte disturbances. Given the high incidence of QTc prolongation in children with DKA, cardiac monitoring is advisable until ketosis is clearly resolving.
— Jill M. Baren, MD, MBE, FACEP, FAAP. Published in Journal Watch EM. Citation:
Kuppermann N et al. Arch Pediatr Adolesc Med 2008 Jun; 162:544.
1. Are the Uninsured Responsible for the Increase in ED Visits in the US?
Weber EJ, et al. Ann Emerg Med. 2008;52:108-115.e1
Study objective
The rise in emergency department (ED) use in the United States is frequently attributed to increased visits by the uninsured. We determine whether insurance status is associated with the increase in ED visits.
Methods
Using the national Community Tracking Study Household Surveys from 1996 to 1997, 1998 to 1999, 2000 to 2001, and 2003 to 2004, we determined for each period the proportion of reported adult ED visits according to insurance status, family income, usual source of care, health status, and outpatient (non-ED) visits. Trends over time were tested for statistical significance.
Results
The proportion of adult ED visits by persons without insurance was stable across the decade. Uninsured individuals accounted for 15.5% of ED visits in 1996 to 1997, 16.1% in 1998 to 1999, 15.2% in 2000 to 2001, and 14.5% of visits in 2003 to 2004 (P for trend=.43). The proportion of visits by persons whose family income was greater than 400% of the federal poverty level increased from 21.9% to 29.0% (P=.002). The proportion of visits by those whose usual source of care was a physician's office increased from 52.4% in 1996 to 1997 to 59.0% in 2003 to 2004 (P=.002), whereas the proportion of visits by those without a usual source of care was essentially unchanged (9.7% of visits in 1996 to 1997 and 9.6% in 2003 to 2004; P=.74).
Conclusion
The rise in ED visits between 1996 and 2003 cannot be primarily attributed to the uninsured. Major contributors to increasing ED utilization appear to be disproportionate increases in use by nonpoor persons and by persons whose usual source of care is a physician's office.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(08)00365-X/fulltext
2. Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
Hirsh J, et al. Chest. 2008; 133:67S-968S.
There are many separate articles here on nearly every aspect of antithrombotics and thrombolytics.
Full-text (free): http://www.chestjournal.org/content/vol133/6_suppl/
3. $1,526,000 Awarded to Plantiff for IV Administration of Phenergan
On April 6, 2006, a 42-year-old truck driver without health insurance presented to an urban general hospital’s emergency department in Florida because of rectal bleeding. A gastroenterologist admitted him and made him n.p.o. for a colonoscopy the next morning. The admission orders included Phenergan p.o. or IV as needed for nausea. Several hours later, the nurse gave him 12.5 mg IV push through an IV on the dorsum of his right hand. He says the injection caused burning pain in his right hand and arm. He was discharged the next day, after the colonoscopy His right hand and wrist became swollen and more painful. He could not drive his truck and lost his job.
The hospital set him up with physical therapy and later referred him to a pain management specialist, but he still has pain and is unable to drive a truck. He sued the hospital for negligent administration of Phenergan.
At the trial, he claimed the nurse gave him the drug IV push too fast, over about 15 seconds. The
nurse did not remember this specific injection, but she testified she customarily diluted Phenergan properly and gave it IV over two minutes. The plaintiff also told the jury he complained of burning pain while she was giving the drug, and the nurse told him it was supposed to burn. The plaintiff’s experts testified he has complex regional pain syndrome and will require treatment in the future.
The defense expert disagreed. After five days of trial, the jury deliberated for 3 hours and found 6-0 in favor of the plaintiff. The $1,526,000 award included $282,000 for past and future medical expenses, $748,000 for past and future lost earnings, and $496,000 for past and future pain and suffering.
COMMENT: This is the largest award I’ve seen yet for local tissue damage from IV Phenergan. As discussed previously in PLN (Vol. 37, No. 5, September/October 2007), it is wise to avoid giving Phenergan through a peripheral IV. If oral or IM administration is not possible and a central line is not available, a different drug could be tried.
David Shapiro, Professional Liability Newsletter. 2008;38(2).
4. Psychiatric patients often ‘boarded’ in ED
Source: The American Hospital Association. Date: June 19, 2008
In a survey of 328 emergency department directors from across the country, almost 80% said that their hospital “boards” psychiatric patients in the ED, the American College of Emergency Physicians reported yesterday. According to the survey, more than 60% of psychiatric patients stayed in the ED more than four hours, 33% more than eight hours and 6% more than 24 hours, even after the decision to admit them had been made. The main reasons included a lack of inpatient psychiatric beds and an inability to transfer psychiatric patients to other facilities.
“Hospitals and physicians struggle daily to care for these patients, but society is not yet willing to treat psychiatric patients the same as patients with physical illness,” said Jim Bentley, AHA’s senior vice president for strategic policy planning. “The decline in inpatient psychiatric beds clearly reflects the inadequacy of hospital and physician payments to treat these patients, and the influence insurance plan subcontractors, or ‘carve-outs,’ have on behavioral health treatment.” Carve-outs are services insurance plans provide through a separate managed care contract.
Article: http://www.acep.org/pressroom.aspx?id=39170
5. The Management of Encephalitis: Clinical Practice Guidelines by the ID Society of America
Tunkel AR, et al. Clinical Infectious Diseases 2008;47:303–327
Guidelines for the diagnosis and treatment of patients with encephalitis were prepared by an Expert Panel of the Infectious Diseases Society of America. The guidelines are intended for use by health care providers who care for patients with encephalitis. The guideline includes data on the epidemiology, clinical features, diagnosis, and treatment of many viral, bacterial, fungal, protozoal, and helminthic etiologies of encephalitis and provides information on when specific etiologic agents should be considered in individual patients with encephalitis.
Full-text (free): http://www.journals.uchicago.edu/doi/full/10.1086/589747
6. HBOC-201: A Viable Alternative to Blood Transfusion
Use of hemoglobin-based oxygen carrier-201 avoided need for blood transfusion in nearly 60% of patients.
Despite strategies to conserve use of packed red blood cells (PRBCs), experts predict that availability will not meet the increasing demand by an aging population. Hemoglobin-based oxygen carrier-201 (HBOC-201) is a bovine–hemoglobin-based blood substitute that is approved in South Africa for clinical use. In a randomized, single-blind, controlled, multinational study, researchers (some of whom were affiliated with the manufacturer) assessed whether administration of HBOC-201 eliminates the need for PRBC transfusion in adult patients undergoing orthopedic surgery.
Overall, 688 patients (mean age, 61) with hemoglobin concentrations less than10.5 g/dL who required transfusions were randomized to treatment with HBOC-201 or PRBCs. Once treatment was initiated, subsequent transfusions were administered based on the presence of at least one of the following criteria: pulse 100 bpm, systolic blood pressure less than 90 mm Hg, electrocardiogram evidence of myocardial ischemia, base deficit 4, acute blood loss more than 7 mL/kg within 2 hours, oliguria, and significant weakness or dizziness. Patients in the HBOC group received a loading dose of 65 g of hemoglobin infused in 500 mL (a volume considered equivalent to 1 unit of PRBCs); additional doses were administered for up to 6 days to a maximum of 325 g (2500 mL), after which need for additional oxygen-carrying capacity was met by transfusion of PRBCs.
Overall, 59% of patients in the HBOC group did not require PRBC transfusion. The HBOC group had significantly higher rates of adverse events (e.g., elevated blood pressure) than the PRBC group (8.5 vs. 5.9 per patient) and serious adverse events (e.g., cardiac events and strokes; 0.34 vs. 0.25 per patient). Findings of a safety analysis led the authors to conclude that risk for adverse events from HBOC was greatest in patients who were older than 80, had volume overload, and were undertreated.
Comment: HBOC-201 does not require crossmatching and can be stored at room temperature for as long as 3 years. In this study, its use eliminated the need for transfusion of allogeneic PRBCs in 59% of patients. Its safety profile was inferior to that of PRBC transfusion, including a greater incidence of acute coronary syndromes and strokes, which the authors partially attributed to age older than 80, volume overload, and undertreatment. Overall, the authors suggest that patients younger than 80 with moderate clinical need for transfusion can be managed with up to 10 units of HBOC-201, thereby preserving the stockpile of PRBCs for other patients.
— John A. Marx, MD, FAAEM, FACEP. Published in Journal Watch EM, August 1, 2008. Citation: Jahr JS et al. J Trauma 2008; 64:1484.
7. Antiplatelet Therapy and the Risk of Intracranial Hemorrhage After Intravenous tPA Therapy for Acute Ischemic Stroke
Hallevi H, et al. Arch Neurol. 2008;65:575-576.
IV administration of tPA is currently the only approved therapy for acute ischemic stroke. The drug works by splitting plasminogen into plasmin, ultimately leading to fibrin degradation at the site of cerebral artery occlusion. Even today, more than 10 years after the drug was approved in the United States (and subsequently around the world), its use has been hampered by the fear of inducing symptomatic intracerebral hemorrhage (SICH). This adverse event was seen in 6% of patients treated in the original National Institute of Neurological Disorders and Stroke trial that led to tPA’s approval and was subsequently confirmed in multiple postmarketing studies. The predictors of SICH after tPA administration are well known: severe stroke (high National Institute of Health Stroke Scale score) and large hypodensity on the admission computed tomography.
Other possible predictors include advanced age, elevated blood glucose, a platelet count of less than 50 000/mL, and systolic blood pressure above 180 mm Hg. Previous works have examined the relationship between prior antiplatelet (AP) therapy and SICH after tPA administration. Notably, in the National Institute of Neurological Disorders and Stroke tPA trial, there was no association between prior aspirin therapy and SICH. Another multicenter stroke survey showed an association of SICH with aspirin therapy that was lost after controlling for clinical and laboratory variables. Contrary to that, in this issue of Archives, Uyttenboogaart et al report a surprisingly high rate of SICH after tPA administration in patients undergoing long-term AP therapy. In their cohort of 309 patients derived from a single center in the Netherlands, AP therapy (mostly aspirin or an aspirin and dipyridamole combination) before the stroke was associated with a 13.5% rate of SICH compared with 2.8% in patients without AP therapy. Drug compliance was not assessed in this study. As expected, patients undergoing AP therapy were older and had more vascular risk factors than patients not taking AP drugs. There were no differences in stroke severity, stroke subtype, blood pressure, blood glucose, or early changes on the admission computed tomographic scan. Despite the high rate of SICH, AP therapy was associated with an odds ratio of 2 for a favorable outcome. How does one settle these seemingly contradictory results and what lessons can we draw from this observation?....[middle section not included].
How should we proceed as clinicians given these new data? Acute stroke care is still wrought with uncertainties and we have an obligation to ensure patient safety while struggling to reduce stroke morbidity. Certainly, we need to monitor the rates of SICH and keep identifying modifiable predictors. One way to improve the quality of our data is to look at large multicenter cohorts. The recently reported European tPA registry of 6483 patients given tPA within 3 hours of symptom onset is an excellent example. Analysis of this cohort should generate reliable data regarding any possible association among AP therapy, SICH, and favorable outcomes. Patient reporting of prior medication use is often inaccurate and compliance is hard to determine, especially in acute settings. If prior AP therapy is indeed shown to be associated with an unacceptably high rate of SICH in a large cohort, it may be possible to better assess the risk using rapid platelet function testing. At the present time, we firmly believe that prior AP use should not discourage physicians from administering tPA to patients undergoing an acute stroke. The association of favorable outcomes with prior AP therapy makes good clinical sense and should encourage us in the effort to devise better recanalization strategies using additional manipulations of selected hemostatic components in addition to tPA. Fear of SICH is understandable but should not deprive stroke patients of effective therapy or a chance to recover from the devastating effects of an ischemic stroke.
Full-text of this editorial (subscription required): http://archneur.ama-assn.org/cgi/content/extract/65/5/575
Full-text of the Uyttenboogaar article (free): http://archneur.ama-assn.org/cgi/content/full/65/5/607
Abstract of the European tPA registry article: http://www.thelancet.com/journals/lancet/article/PIIS0140673607601494/abstract
8. Patient Perceptions Affect Ambulance Use in Acute Coronary Syndrome
NEW YORK (Reuters Health) Aug 01 - Only about half of patients with acute coronary syndrome (ACS) call for an ambulance, even though ambulance use and early reperfusion therapy is strongly recommended. A recent study, reported in the July issue of the American Heart Journal, has identified reasons why symptomatic patients with ACS avoid the potentially beneficial assistance of emergency medical services.
"National guidelines recommend activation of the emergency medical service by patients who have symptoms of ACS," Maria Thuresson, of Orebro University Hospital, Sweden, and colleagues write. "In spite of this, only 50% to 60% of persons with myocardial infarction initiate care by using the emergency medical service."
At intensive cardiac care units in 11 hospitals in Sweden, 1939 patients with ACS completed questionnaires within the first few days after admission. All had experienced symptom onset outside the hospital, but only half had been transported to the hospital by ambulance.
Factors associated with ambulance use included knowledge of the importance of quickly seeking medical care when experiencing chest pain (odds ratio [OR] 3.61), history of heart failure (OR 2.48), abrupt onset of pain reaching maximum intensity within minutes (OR 2.08), nausea or cold sweat (OR 2.02), distance to the hospital of more than 5 km (OR 2.00), and vertigo or near syncope (OR 1.63).
Patients who did not call for an ambulance thought self-transport would be faster and did not believe their symptoms were serious enough to warrant ambulance use.
Dr. Thuresson and colleagues advise, "The results in the present study should be considered when planning educational and information programs to increase ambulance use in ACS."
Am Heart J 2008;156:170-176.
9. Falls Due to Seizure-Induced Cardiac Asystole
Syncope due to ictal asystole should be considered as an explanation for seizure-related falls.
Although most seizures are associated with sinus tachycardia, a minority are associated with bradycardia and even asystole (which is usually defined as a sinus pause lasting at least 3 seconds). An increasing number of case reports and series have focused on this phenomenon in recent years. Now, researchers report on three patients with sudden falls that were found to be due to seizure-induced asystole and syncope.
In each case, simultaneous EEG and electrocardiogram recordings identified the cause of the falls. The cases, supplemented by video clips on the Neurology website, provide convincing demonstrations of falls associated with seizure-induced asystole.
Comment: As is noted in an editorial, sudden falls are potentially dangerous in themselves. Even though a connection has not been established between ictal bradycardia or asystole and the phenomenon of sudden unexpected death in epilepsy, patients with seizure-induced cardiac asystole probably should be treated not only with the best available antiepileptic therapy, but also with cardiac pacing. The report also highlights the complex interactions between cerebral and cardiovascular dysfunctions that contribute to episodic unconsciousness. Clinicians must keep in mind that the spectrum of episodic unconsciousness includes not only ictal asystole but also the more common phenomenon of convulsive syncope (convulsive movements due to cerebral hypoperfusion without an epileptic discharge) and very rare cases of hypoperfusion-induced acute symptomatic seizures.
Videos: http://www.neurology.org/cgi/content/full/01.wnl.0000289193.89796.83/DC1
— Edward B. Bromfield, MD, Chief, Division of Epilepsy and Sleep Neurology, Brigham and Women’s Hospital, Boston. Published in Journal Watch Neurology July 15, 2008. Citation:
Rubboli G et al. Neurology 2008 May 13; 70:1933.
10. EU OKs Drug to Reverse Neuromuscular Blockade
By Ransdell Pierson. NEW YORK (Reuters) Jul 30 - European regulators have approved a breakthrough new medication to help patients emerge far more quickly from anesthesia than existing treatments, the drug's maker Schering-Plough Corp said on Tuesday.
The drug, called Bridion, was approved by the European Commission, following a recommendation last month by an advisory panel in support of the drug, also known as sugammadex.
Bridion was approved for reversal of neuromuscular block induced by rocuronium and vecuronium.
The medicine is awaiting approval in the United States. An advisory panel to the U.S. Food and Drug Administration in March voted that it was safe and effective.
In a late stage clinical trial, Bridion reversed the effects neuromuscular blockade within a few minutes -- nine to 12 times faster than the standard reversal agent, neostigmine, according to researchers.
11. Do Your Patients Borrow, Lend, or Trade Medications?
Neither a borrower nor a lender be — but about one third of people in this community survey do not heed this advice.
Objectives. We sought to document the frequency, circumstances, and consequences of prescription medication–sharing behaviors and to use a medication-sharing impact framework to organize the resulting data regarding medication-loaning and -borrowing practices.
Methods. One-on-one interviews were conducted in 2006, and participants indicated (1) prescription medicine taken in the past year, (2) whether they had previously loaned or borrowed prescription medicine, (3) scenarios in which they would consider loaning or borrowing prescription medicine, and (4) the types of prescription medicines they had loaned or borrowed.
Results. Of the 700 participants, 22.9% reported having loaned their medications to someone else and 26.9% reported having borrowed someone else’s prescription. An even greater proportion of participants reported situations in which medication sharing was acceptable to them.
Conclusions. Sharing prescription medication places individuals at risk for diverse consequences, and further research regarding medication loaning and borrowing behaviors and their associated consequences is merited.
Goldsworthy RC, et al. Beyond Abuse and Exposure: Framing the Impact of Prescription-Medication Sharing. Am J Public Health 2008 98: 1115-1121.
12. CT Angiography Aids Decision Making for Penetrating Neck Trauma
Physical examination of patients with penetrating neck trauma is specific, but CT angiography improves sensitivity for identification of significant vascular, aerodigestive, and neurologic injury.
Background: Improvements in imaging technology, particularly computed tomographic angiography (CTA), have altered the management of patients with penetrating injuries in the neck. The purpose of this retrospective study is to evaluate our 5-year experience with the management of penetrating injuries to the neck, to the further elucidate the role of CTA in clinical decision making, and to assess treatment outcome.
Methods: Clinical variables were collected and evaluated on all patients with penetrating injuries to the neck presenting to the Legacy Emanuel Hospital Trauma Service from 2000 to 2005. For comparison, the patients were divided into two groups based upon whether the patient had received a CTA before operative intervention: group 1, CTA; group 2, no CTA. A statistical analysis using the Fisher exact test and t test was performed to analyze whether the rate of neck exploration or the findings at the time of neck dissection were significantly different between the groups.
Results: Of the 120 consecutive patients with penetrating injuries to the neck, 55 were excluded from the study because the injury was superficial, the patient died before operative intervention, or they underwent emergent neck exploration to control hemorrhage. Sixty-five patients with neck injuries penetrating the platysma were identified that met the criteria for inclusion in the study. Group 1 (CTA) consisted of 24 patients and group 2 (no CTA) had 41 patients. Group 1 (CTA) had significantly fewer formal neck explorations (N = 6) compared with group 2 (no CTA) (N = 27) (p less than 0.01). All six of the operations in the CTA group had clear indications for and positive findings on surgical exploration, and there were no clinically significant missed injuries. Of the 27 patients in group 2 who underwent neck exploration, only 14 had a positive finding, 4 of which were simply superficial bleeding vessels, yielding a rate of negative neck exploration of 48%, compared with 0% for group 1 (p less than 0.01). The number of adjunctive studies such as esophagography, angiography, and various endoscopic procedures were similar in both groups.
Conclusion: The management of stable patients with penetrating injuries to the neck that penetrate the platysma has evolved at our institution into selective surgical intervention based on clinical examination and CTA. The use of CTA has resulted in fewer formal neck explorations and virtual elimination of negative exploratory surgery.
Osborn T, et al. J Trauma 2008;64:1466-1471.
13. Characteristics of Women With Fetal Loss in Symptomatic First Trimester Pregnancies With Documented Fetal Cardiac Activity
Juliano M, et al. Ann Emerg Med. 2008;52:143-147.
Study objective
The purpose of this study is to determine fetal outcomes of women diagnosed with live intrauterine pregnancy after emergency department (ED) presentation for abdominopelvic pain or vaginal bleeding during the first trimester.
Methods
A retrospective medical record review of prospectively recorded data of consecutive ED charts from December 2005 to June 2006 was performed to identify patients diagnosed with live intrauterine pregnancy. Demographic data, obstetric/gynecologic history, and presenting symptoms were obtained. Outcomes were determined by computerized medical records. Fetal loss was diagnosed by decreasing β-Human chorionic gonadotropin or pathology specimen. Live birth was diagnosed by viable fetus at 20-week-gestation ultrasonography or delivery.
Results
A total of 837 patients were evaluated during the first trimester. Three hundred forty patients (41%) met inclusion criteria, with a diagnosis of live intrauterine pregnancy. Outcome data were obtained for 303 (89%) of these patients. Fetal loss occurred in 28 (9.2%) pregnancies (95% confidence interval [CI] 5.9% to 12.5%). Fetal loss incidence was 13.8% (95% CI 9.9% to 17.7%) in patients presenting with vaginal bleeding compared with 2.5% (95% CI 0.007% to 4.3%) in patients without bleeding (P less than 0.002). Twenty five of 28 (89%) patients with resulting fetal loss presented with vaginal bleeding. Vaginal bleeding was the most important predictor of fetal loss; risk ratio 5.6 (95% CI 1.7 to 18.2). Conclusion Fetal loss before 20 weeks occurs in 9.2% of patients with live intrauterine pregnancy diagnosed by ultrasonography. Vaginal bleeding carries a higher fetal loss rate of 13.8%. These data will assist the emergency physician in counseling women experiencing symptomatic first trimester pregnancy.
14. Oral Proton Pump Inhibitors May Be Adequate for Control of Bleeding Ulcers
NEW YORK (Reuters Health) Jul 14 - Proton pump inhibitor (PPI) therapy administered by intravenous bolus plus infusion acts only marginally more rapidly than oral administration, University of Southern California investigators report.
Dr. Loren Laine and colleagues suggest that the manpower, discomfort and expense involved with the currently recommended approach of intravenous administration of PPIs in this setting may be unnecessary in many cases of bleeding ulcers.
Sixty-six patients presenting to the USC Medical Center in Los Angeles with overt signs of gastric or duodenal bleeding ulcers underwent endoscopic hemostasis and then intragastric placement of pH probes.
Once bleeding was controlled, patients were randomized to a 90 mg bolus of lansoprazole followed by a 9 mg/hour infusion or to oral lansoprazole as a 120 mg loading dose followed by 30 mg every three hours for 24 hours. Stomach pH was recorded throughout the study period.
At 1 hour, mean pH for intravenous lansoprazole was 5.3 compared with a mean pH of 3.3 with oral lansoprazole. After 1.5 hours, there were no differences in pH between intravenous and oral administration, the investigators report in the June issue of Gastroenterology.
Mean pH rose above 6 after 2-3 hours of intravenous PPI and after 3-4 hours of oral PPI.
"Because the only known mechanism by which PPI therapy reduces ulcer rebleeding is via its effect on acid secretion, our results suggest that frequent oral PPI therapy may be able to replace bolus plus constant infusion intravenous PPI for patients with ulcer bleeding," Dr. Laine and colleagues write.
"However," the USC team cautions, "our end-points were surrogate pharmacodynamic end-points and not clinical end-points, which provide the most relevant information. The major pharmacodynamic benefit of the intravenous regimen was a more rapid elevation in intragastric pH."
"If reaching a target pH of 6 (or 5) an hour earlier is desired and felt to be clinically important, then intravenous PPI therapy would be preferred," Dr. Laine and colleagues conclude.
Gastroenterology 2008;134:1836-1841.
15. Evolving MIs Usually Detected in the ED
from Heartwire — a professional news service of WebMD. July 28, 2008 — Doctors are doing a good job identifying patients with evolving MI presenting to the emergency department with chest pain but without ST segment elevation or an initial positive troponin test, a new study suggests [reference below].
The study, published in the August 1, 2008 issue of Emergency Medicine Journal, was conducted by a group led by Dr Chadwick Miller (Wake Forest University Baptist Medical Center, Winston Salem, NC).
He explained to heartwire that some patients who are having an MI might not always show a positive troponin when first presenting because it can take six to eight hours for troponins to rise after the start of an MI. And there is concern that, among patients without ST elevation or a positive initial troponin test, those with evolving MI might not be identified and therefore might not be treated as aggressively as they should be.
To look at this further, the researchers conducted an observational study using data from the Internet Tracking Registry for Acute Coronary Syndromes, a registry of patients presenting with undifferentiated chest pain. This analysis included patients without ST segment elevation with at least two troponin assay results less than 12 hours apart. Patients were stratified into three groups: those with an initial negative but a second positive troponin assay (classified as evolving MI); those with an initial positive troponin assays (NSTEMI); and those with two negative troponin assays (no MI). Miller explained that the first two groups had similar conditions but different time frames; the first group was at an earlier stage in the course of their MI than the second group.
Of the 4136 patients studied, 5% were found to be having an evolving MI, 8% had NSTEMI, and 87% had no MI. Patients with evolving MI were more similar, with respect to demographic characteristics, presentation, admission patterns, and revascularization, to those with NSTEMI than to those with no MI, and 76% of the time, physicians' initial impressions suggested heightened concern for cardiac risk in the evolving MI patients.
"Our results show that, on the whole, emergency physicians are doing a good job in picking up the patients with evolving MI before conclusive troponin tests are in," Miller commented to heartwire. "It was hard to tell from this study which factors are the most important in identifying these patients. It was a combination of findings from the patient's history, clinical examination, and ECG. But what we have shown is that the emergency's doctor best guess is usually right in finding these patients."
One of the symptoms of interest was chest pain described as burning. "We showed a strong association between burning chest pain and evolving MI. Burning chest pain is often taken as a symptom of GI reflux, but I think one message from our study is that we should not be discounting burning pain as reflux, as actually there is quite a high likelihood that it could be an ACS," Miller commented to heartwire.
He added that these results have implications for how a chest pain triage system is managed. "There are places where the triage system could be improved. But on the whole, I am happy with what we saw here. It is reassuring to see that the admission patterns among the evolving MI patients were more aggressive than with the patients found not to be having an MI, even though in both these groups the initial troponin results were not elevated. This suggests that clinicians are not allowing the initial negative troponin results to overshadow their clinical impression,” he said.
Miller explained that one of the issues is that chest pain patients thought not to be having an MI are sometimes sent for stress tests to rule out further cardiac causes before the second troponin test is back, but this would not be advisable for a patient who is having an evolving MI because it could induce ventricular arrhythmias. "If patients with evolving MI are lumped in with this group, then we could have a problem. But our results suggest that this is relatively unlikely to happen. In our study, of 4136 patients, just 187 were found to be having an evolving MI on the basis of the second troponin test. Because 76% of these were initially thought to be having an MI, unstable angina, or high-risk chest pain, only about 40 of these patients were not flagged after the initial examination," he noted.
Miller CD, Fermann GJ, Lindsell CJ, et al. Initial risk stratification and presenting characteristics of patients with evolving myocardial infarctions. Emerg Med J. 2008; 25:492-497.
16. Are Powered Intraosseous Insertion Devices Safe and Effective in Children?
These devices are good alternatives to manual intraosseous needles.
Horton M, et al. Pediatr Emerg Care. 2008;24:347-350.
Objective: For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients.
Methods: We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications.
Results: There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 +/- 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 +/- 2.8, and mean infusion pain score was 3.2 +/- 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4.
Conclusions: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.
17. Early, Aggressive Treatment Warranted in Pediatric Status Epilepticus
July 22, 2008 — Convulsive status epilepticus (CSE) in children warrants early, aggressive treatment that includes rapid transport to the emergency department as well as very early prehospital treatment. In addition, the study supports first-line treatment in the emergency department with intravenous lorazepam.
Published in the August issue of Lancet Neurology, the study showed for each minute delay from onset of CSE to hospital arrival there was a 5% cumulative increase in the risk of the episode lasting more than 60 minutes.
Furthermore, prehospital treatment for CSE, usually with rectal diazepam, significantly reduced the incidence of prolonged seizures — that is, those lasting more than 60 minutes. Further treatment in the emergency room with intravenous lorazepam was associated with a 3.7 times greater likelihood of seizure termination compared with rectal diazepam.
These findings, say investigators warrant a change to existing guidelines and practice in the United Kingdom and other jurisdictions that do not yet include prehospital treatment for CSE.
"There is evidence that the longer a seizure lasts, the harder it is to stop, and the poorer the outcome. We need to ensure that prehospital treatment is administered and that all children are transported to the hospital as quickly as possible, because even if prehospital treatment is delivered, we can't predict which children will respond," principal investigator Richard F. M. Chin, PhD, from the Institute of Child Health, University College London, and the Great Ormond Street Hospital for Children National Health Service Trust, in London, United Kingdom, told Medscape Neurology & Neurosurgery.
No Standardized Treatment
According to Dr. Chin, although some CSE patients are treated before they reach the hospital, the practice is extremely variable and frequently depends on regulations governing attending emergency staff and emergency antiepileptic drugs.
Furthermore, he said, there is a paucity of data on the treatment of childhood CSE, and, as a result, there is variation in the treatment of CSE that starts in the community.
In what is the first population-based study of childhood CSE, the investigators examined the treatment of childhood CSE and factors affecting seizure duration.
Known as the North London Convulsive Status Epilepticus in Childhood Surveillance Study (NLSTEPSS), the study included data on ED treatment of all children in North London between the ages of 29 days and 15 years who had episodes of CSE between 2002 and 2004.
Investigators examined the data to identify factors associated with seizure termination after first-line therapy in the emergency department as well as those associated with seizure termination after second-line treatment in children who failed to respond to or did not receive first-line benzodiazepine therapy.
They also attempted to identify factors associated with seizures lasting more than 60 minutes and those that predict respiratory depression.
A total of 240 episodes of CSE were identified in 182 children. Of these, 69% occurred in children with preexisting neurological abnormalities, including epilepsy.
Treatment decisions were made by individual caregivers, paramedics, and treating physicians who enrolled patients in the study. Medication adequacy was determined by the 3rd edition of the Advanced Pediatric Life Support (APLS) guideline, which recommends 0.1 mg/kg for intravenous lorazepam; 0.5 mg/kg for rectal diazepam; 0.4 mL/kg for rectal paraldehyde; 18 mg/kg for intravenous phenytoin; and 15 to 20 mg/kg for intravenous phenobarbital.
Prehospital treatment was administered in 147 (61%) episodes — 93 (63%) by paramedics and 54 (37%) by caregivers. Among children who received prehospital treatment, 32 (22%) episodes were terminated.
Too Little, Too Late
Of the children who did receive prehospital treatment, 96% received rectal diazepam. However, of these, 141 episodes were given a dose that was lower than the APLS guideline recommendation.
"It was surprising that such a significant proportion of children did not receive prehospital treatment and that, when they were treated, the dose was too low. What this highlights to me is that we have a potentially life-threatening condition that requires early treatment, but a significant proportion of our patients may or may not receive it or, when they do, are being treated suboptimally," said Dr. Chin.
Adjusted analyses revealed treatment with intravenous lorazepam administered in the emergency department was associated with a 3.7 times greater likelihood of seizure termination compared with rectal diazepam.
Furthermore, intravenous phenytoin, when used as a second-line therapy, was associated with a 9 times greater likelihood of seizure termination than rectal paraldehyde.
The investigators also found that more than 2 doses of a benzodiazepine — whether it was lorazepam or diazepam — were associated with respiratory depression and a longer duration of seizure activity.
The investigators also found that continuous CSE was as common as intermittent CSE. However, the latter was not as well recognized, resulting in delays in calling emergency services, arrival at the emergency department, and treatment. As a result, children with intermittent CSE were more likely to experience seizures lasting more than 60 minutes.
Clear Message
According to Dr. Chin, the study's message is clear. "Our study highlights the importance of prehospital treatment [with intravenous lorazepam], and we need to find ways to develop and facilitate this. On arrival of the patient at the emergency department, the emphasis should be on administering intravenous medication promptly."
Based on the study results and all other available evidence on the treatment of childhoood CSE, Dr. Chin, along with coauthor Rod C. Scott, MRCPCH, both members of a national working party, will aim to help revise current CSE treatment guidelines and integrate the findings into everyday practice.
In an accompanying editorial, David M. Treiman, MD, from the Barrow Neurological Institute, in Phoenix, Arizona, writes that the "clear superiority of intravenous lorazepam over rectal diazepam as a first-line treatment and intravenous phenytoin over rectal paraldehyde as a second-line treatment provide a basis for a revision of the current management guidelines for the treatment of CSE in children."
The study was supported by an anonymous donor to the UCL Institute of Child Health; the Wellcome Trust; UK Department of Health National Institute for Health Research Biomedical Research Centres Funding Scheme; and the Medical Research Council. The authors have no disclosures.
Lancet Neurol. 2008;7:696-703.
18. Balloon Compression as Treatment for Refractory Vaginal Hemorrhage
Schlicher NR. Ann Emerg Med. 2008;52:148-150.
Severe vaginal hemorrhage is a rare presenting condition but serious life threat in the emergency department (ED). Initial management has historically been limited to vaginal packing, fluid resuscitation, and emergency surgical intervention. An alternative approach to therapy is presented that can be effectively deployed in the ED. In the present case, balloon compression of the vaginal mucosa was successful in arresting life-threatening hemorrhage. The patient survived subsequent hemodynamic stabilization and surgical intervention and was ultimately discharged home.
19. Direct Emergency Admission to Catheterization Lab Reduces Time to Intervention
NEW YORK (Reuters Health) Jul 22 - Direct ambulance admission to the cardiac catheterization laboratory significantly reduces the time to performance of primary percutaneous intervention (PCI), according to a report in the June issue of the American Heart Journal.
The aim of the American Heart Association/American College of Cardiology "Door-to-balloon: an alliance for quality" campaign is to increase the percentage of patients with ST-elevation myocardial infarction (STEMI) in whom infarct artery patency is achieved within 90 minutes of symptom onset, the authors explain.
Dr. Michael F. Dorsch and colleagues from Leeds General Infirmary, Leeds, UK investigated the impact of prehospital paramedic ECG diagnosis and subsequent direct transfer to the cardiac catheterization laboratory on door-to-balloon and call-to-balloon times in primary PCI.
Compared to patients admitted via the emergency room, the authors report, direct ambulance admission significantly reduced door-to-balloon times (from 105 minutes to 58 minutes) and call-to-balloon times (from 143 to 105 minutes).
Ninety-four percent of patients admitted directly from the ambulance met the 90-minute door-to-balloon time, the report indicates, compared with only 29% of patients referred from the emergency department.
Both door-to-balloon and call-to-balloon times were significantly longer outside normal working hours and in women compared with men, the researchers note.
Thirty-day and 12-month mortality were lower for patients admitted directly, the investigators say, but the differences were not statistically significant.
"Prehospital paramedic ECG diagnosis of STEMI and subsequent direct ambulance admission to the cardiac catheterization laboratory dramatically reduces door-to-balloon times in primary PCI, enabling almost all patients to be treated within the 90-minute target," the authors conclude. "We believe this approach should be a key element of any contemporary primary PCI service."
Am Heart J 2008;155:1054-1058.
20. Do Physicians Report Patients’ Lapses of Consciousness?
Most emergency physicians in California report only new-onset seizures, despite broader mandatory state regulations.
Turnipseed SD (UC Davis), et al. J Emerg Med. 2008; 35:15-21.
Physician reporting of lapses of consciousness (LOC) to the Department of Motor Vehicles is a controversial topic in medicine. The objective of this study was to describe current LOC reporting practices by emergency physicians (EPs) in a state with mandatory reporting requirements (California).
A questionnaire describing 14 different clinical scenarios involving LOC was distributed to a diverse sample of California EPs. Clinical scenarios included new seizure, hypoglycemia, atrial fibrillation/rapid heart rate, cerebrovascular accident, micturation syncope, vasovagal syncope, hepatic encephalopathy, alcohol intoxication, closed head injury, hyperosmolar coma, methamphetamine psychosis, dementia, hyperventilation syndrome, and hypercalcemia. Emergency physicians were asked how often they would report these LOC-related conditions to the state. Simple summary statistics were calculated.
The response rate was 207/340 (61%) of the forms distributed. The average number of years in Emergency Medicine practice among respondents was 12 (range 1–35), and 57% were Emergency Medicine trained. Of the 14 scenarios, only one (new-onset seizure) was reported frequently by EPs (89% reported “nearly always” or “most of the time”). The remaining 13 scenarios were rarely reported (mean of 86% for “occasionally” or “never”).
Although reporting of LOC, from any cause, is mandatory in California, only new-onset seizures are frequently reported by California EPs.
21. Effect of DKA on QTc Prolongation in Children Might Be Mediated by Ketosis, Not Electrolyte Abnormalities
Possible cardiac effects of ketosis make cardiac monitoring of children with DKA essential.
Ketotic conditions have been shown to be associated with prolonged QTc interval and sudden cardiac death. In an observational study, researchers examined whether QTc prolongation occurs during diabetic ketoacidosis (DKA) in children and whether it resolves when ketosis clears.
A convenience sample of 30 children (mean age, 11 years; 12% male) with DKA and not other risks for prolonged QTc interval underwent electrocardiography during DKA and after recovery. Patients were treated according to a standardized DKA protocol that included normal saline, insulin, glucose, and electrolyte replacement. A pediatric cardiologist who was blinded to clinical and biochemical data measured QTc intervals; measurements by a second cardiologist showed high interobserver agreement (=0.62). Prolonged QTc was defined as an interval of at least 450 milliseconds.
Initial electrocardiogram measurements were taken at a mean of 6 hours after initiation of DKA treatment. The QTc interval was significantly longer during DKA (mean, 450 ms; range, 378–539 ms) than after recovery (mean, 407 ms; range, 302–485 ms). Overall, QTc intervals were longer than 450 milliseconds in 47% of patients during DKA and in 13% after recovery; the interval eventually normalized in two of the four patients who continued to have prolonged intervals after recovery. At presentation, the anion gap was significantly higher in patients with QTc prolongation than in those without (27 vs. 22 mEq/L). QTc duration was significantly correlated with the anion gap during DKA but not with serum potassium, calcium, or magnesium values or heart rate.
Comment: Although no life-threatening arrhythmias were observed in this study, QTc prolongation can predispose to them. This study’s findings suggest that QTc prolongation in children with diabetic ketosis might occur even in the absence of significant electrolyte disturbances. Given the high incidence of QTc prolongation in children with DKA, cardiac monitoring is advisable until ketosis is clearly resolving.
— Jill M. Baren, MD, MBE, FACEP, FAAP. Published in Journal Watch EM. Citation:
Kuppermann N et al. Arch Pediatr Adolesc Med 2008 Jun; 162:544.
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