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.

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.

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).

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):

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):

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.


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):

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):
Full-text of the Uyttenboogaar article (free):
Abstract of the European tPA registry article:

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.


— 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.

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.

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.