Saturday, October 04, 2008

Lit Bits. Oct 5, 2008

From the recent medical literature...

1. Evaluation of a "Triple Rule-Out" Coronary CT Angiography Protocol: Use of 64-Section CT in Low-to-Moderate Risk ED Patients Suspected of Having ACS

Takakuwa KM, et al. Radiology 2008;248:438-446.

Purpose: To determine whether coronary computed tomographic (CT) angiography "triple rule-out" evaluation of emergency department (ED) patients presenting with symptoms suggestive of acute coronary syndrome (ACS) can help identify a subset of patients who can be discharged without adverse clinical outcomes within 30 days.

Materials and Methods: This protocol was approved by the university institutional review board. Each patient provided written informed consent prior to inclusion. Coronary CT angiography was performed in 201 consecutive low-to-moderate risk ACS patients. A triple rule-out protocol was used to evaluate for coronary disease, pulmonary embolism, aortic dissection, and other thoracic disease. Four patients were excluded because of technical problems. The remaining subjects underwent a 30-day follow-up.

Results: A disease process other than coronary atherosclerosis that explained the presenting symptoms was diagnosed in 22 (11%) of 197 patients. Clinically important noncoronary diagnoses that did not explain patient symptoms were identified in 27 (14%) of 197 additional patients. With respect to coronary artery disease, 10 patients had severe disease (greater than 70% stenosis), 12 had moderate disease (50%–70% stenosis), 46 had mild disease (up to 50% stenosis), and 129 had no disease. No further diagnostic testing was performed in 133 (76%) of 175 of patients with no to mild coronary disease. At 30-day follow-up, the negative predictive value of coronary CT angiography with no more than mild disease was 99.4%. There were no adverse outcomes at 30 days.

Conclusion: Triple rule-out coronary CT angiography evaluation of low-to-moderate risk ACS patients presenting to the ED provided a noncoronary diagnosis that explained the presenting complaint in 11% of patients, suggested the presence of significant moderate-to-severe coronary disease in 11% (22 of 197) of patients, and precluded additional diagnostic cardiac testing in the majority of patients with no adverse outcomes at 30-day follow-up.

2. ER top 5: a few thoughts on why I (generally) love my job

Murray H. CJEM 2008;10:396-7.

5. The colleagues
4. The team
3. The variety
2. The cool equipment
1. Making a difference


3. Prochlorperazine vs. Promethazine for Headache Treatment in the Emergency Department: A Randomized Controlled Trial

Callan JE, et al. J Emerg Med. 2008;35:247-253.

Headache is a very common medical complaint. Four to six percent of the population will have a debilitating headache in their lifetime; and 1–2% of all Emergency Department (ED) visits involve patients with headaches. Although promethazine is used frequently, it has never been studied as a single-agent treatment in undifferentiated headache. We hypothesized that promethazine would be superior to prochlorperazine in the treatment of headache.

We conducted a prospective, double-blinded, randomized, controlled trial on patients presenting to our ED between May and August 2005 with a chief complaint of headache. Each subject was randomized to receive either intravenous promethazine 25 mg or prochlorperazine 10 mg, and graded the intensity of their headache on serial 100-mm visual analog scales (VAS). Patients with dystonic reactions or akathisia were treated with diphenhydramine. Adequate pain relief was defined as an absolute decrease in VAS score of 25 mm. After discharge from the ED, patients were queried regarding the recurrence of headache symptoms, the need for additional pain medications, and the occurrence of any side effects since discharge.

Thirty-five patients were enrolled in each group. Both drugs were shown to be effective in treatment of headaches. Prochlorperazine provided a faster rate of pain resolution and less drowsiness when compared to promethazine. Both medications were individually effective as abortive therapy for headache.

Prochlorperazine was superior to promethazine in the rate of headache reduction and rate of home drowsiness, with similar rates of akathisia, nausea resolution, patient satisfaction, and headache recurrence within 5 days of discharge.

4. A Prospective, Randomized Trial of an ED Observation Unit for Acute Onset Atrial Fibrillation

Decker WW, et al. Ann Emerg Med. 2008;52:322-328.

Study objective
An emergency department (ED) observation unit protocol for the management of acute onset atrial fibrillation is compared with routine hospital admission and management.

Adult patients presenting to the ED with atrial fibrillation of less than 48 hours' duration without hemodynamic instability or other comorbid conditions requiring hospitalization were enrolled. Participants were randomized to either ED observation unit care or routine inpatient care. The ED observation unit protocol included pulse rate control, cardiac monitoring, reassessment, and electrical cardioversion if atrial fibrillation persisted. Patients who reverted to sinus rhythm were discharged with a cardiology follow-up within 3 days, whereas those still in atrial fibrillation were admitted. All cases were followed up for 6 months and adverse events recorded.

Of the 153 patients, 75 were randomized to the ED observation unit and 78 to routine inhospital care. Eighty-five percent of ED observation unit patients converted to sinus rhythm versus 73% in the routine care group (difference 12%; 95% confidence interval [CI] −1% to 25%]; P=.06). The median length of stay was 10.1 versus 25.2 hours (difference 15.1 hours; 95% CI 11.2 to 19.6; P less than .001) for ED observation unit and inhospital care respectively. Nine ED observation unit patients required inpatient admission. Eleven percent of the ED observation unit group had recurrence of atrial fibrillation during follow-up versus 10% of the routine inpatient care group (difference 1%; 95% CI −9% to 11%; P=.93). There was no significant difference between the groups in the frequency of hospitalization or the number of tests, and the number of adverse events during follow-up was similar in the 2 groups.

An ED observation unit protocol that includes electrical cardioversion is a feasible alternative to routine hospital admission for acute onset of atrial fibrillation and results in a shorter initial length of stay.

5. Regulator says hospitals need strict heparin rules

September 24, 2008. By LINDSEY TANNER, AP Medical Writer.CHICAGO - A regulatory group told hospitals Wednesday to adopt strict measures to prevent errors involving blood thinners including heparin — mistakes that have been made nearly 60,000 times and led to dozens of deaths in recent years.

The Joint Commission issued a safety alert saying hospitals need to adopt prevention measures that could include bar-coding technology for medicines or computerized drug orders. It advised hospitals to more closely monitor patients on these drugs and make sure that adult-strength heparin is stored nowhere near children's units.

The alert said 28 deaths are among 32 reports of drug errors involving blood thinners that it received between 1997 and last year.

"We know that there are many more (deaths) and ... that's the reason for issuing this alert," said Dr. Mark Chassin, president of the Oakbrook Terrace, Ill.-based commission.

Recent errors include accidental life-threatening heparin overdoses given to actor Dennis Quaid's newborn twins at a Los Angeles hospital last November. In July, 14 babies received accidental heparin overdoses at a hospital in Corpus Christi, Texas.

Commission investigators will make unannounced visits to make sure hospitals are adopting strict measures to prevent blood thinner errors, and those who fail to do so could see their accreditation revoked, Chassin said

The commission is a private group that sets hospital standards and accredits most of the nation's hospitals. Accreditation brings prestige and federal dollars.

A total of 59,316 medication errors involving blood thinners were reported between 2001 and 2006 to a database run by U.S. Pharmacopeia, a group that sets drug standards, the alert said. Nearly 3 percent, or roughly 1,700, resulted in patient harm or death, the commission said.

Blood thinners are particularly tricky to use because too much can cause hard-to-control bleeding internally and from every body opening; too little can result in life-threatening blood clots, Chassin said.

Heparin is usually given intravenously. Warfarin, another blood thinner cited in the alert, is available in pills patients can take at home but can cause bad reactions when mixed with other medicines.

The recommendations "absolutely" will make a difference and hospitals will pay attention, said James Conway, senior vice president of the nonprofit Institute for Healthcare Improvement in Cambridge, Mass.

6. CT Continues to Miss Hollow Viscus Injury

Free fluid without organ injury on CT scan might be a harbinger of hollow viscus pathology.

Diagnosis of Blunt Intestinal and Mesenteric Injury in the Era of Multidetector CT Technology--Are Results Better?

Ekeh AP, et al. J Trauma. 2008;65:354-359.

Background: Blunt Bowel and Mesenteric injuries (BBMI) can present diagnostic difficulties and are occasionally recognized in a delayed fashion. Most studies evaluating these injuries predate multidetector Computerized Tomography (CT) scan technology. We set out to analyze whether the current era of multislice CT scanning has led to changes in the incidence of missed injuries in BBMI or altered the patterns of diagnosis.

Methods: All patients with blunt small and large intestinal injury as well as mesenteric lacerations, recognized in the operating room (OR) between November 2000 and December 2006 were identified from the trauma registry. A 4 slice helical multidetector CT scanner was in use for abdominal CT scans during the first portion of the study (November 2000-July 2005) whereas a 16 slice scanner was in use in the second portion (July 2005-December 2006). Rectal injuries and serosal tears were excluded.

Results: Eighty-two patients were identified with BBMI. Twenty-five patients went directly to the OR for laparotomy after a positive Diagnostic Peritoneal Lavage, a positive Focused Abdominal Sonogram or other injury. Of the 57 patients who underwent CT, findings indicating possible BBMI were present in 46 patients (80.7%). These included free fluid without solid organ injury (50.9%), free air (10.5%), active mesenteric bleeding (10.5%), and bowel swelling (5.3%). Eleven patients (19.3%) had delayed bowel or mesenteric injury recognition with the diagnosis ultimately made by repeat CT or in the OR (range, 1-10 days).

Conclusion: Missed injuries remain common in BBMI even in the current era of multislice CT scanners. Free fluid w/o solid organ injury, though not specific, continues to be an important finding. Adjuncts to CT continue to be necessary for the optimal diagnosis of bowel injuries.

7. Pediatric myth: fever and petechiae

Klinkhammer MD, et al. CJEM 2008;10:479-82.

A child presenting with petechiae and fever is assumed to have meningococcemia or another form of bacterial sepsis and therefore to require antibiotics, blood cultures, cerebrospinal fluid analysis and hospital admission.

A review of the literature challenges this statement and suggests that a child presenting with purpura (or petechiae), an ill appearance and delayed capillary refill time or hypotension should be admitted and treated for meningococcal disease without delay.

Conversely, a child with a petechial rash, which is confined to the distribution of the superior vena cava, is unlikely to have meningococcal disease. Outpatient therapy in this context is appropriate.

In other children, a reasonable approach would be to draw blood for culture and C-reactive protein (CRP) while administering antibiotics. If the CRP is normal, these children could be discharged to follow-up in 1 day, whereas children with CRP values greater than 6 mg/L would be admitted.

Full-text (free):

8. Who Needs a Blood Culture? A Prospectively Derived and Validated Prediction Rule

Shapiro NI, et al. J Emerg Med. 2008;35:255-264

The study objective was to derive and validate a clinical decision rule for obtaining blood cultures in Emergency Department (ED) patients with suspected infection. This was a prospective, observational cohort study of consecutive adult ED patients with blood cultures obtained. The study ran from February 1, 2000 through February 1, 2001.

Patients were randomly assigned to derivation (2/3) or validation (1/3) sets. The outcome was “true bacteremia.” Features of the history, co-morbid illness, physical examination, and laboratory testing were used to create a clinical decision rule. Among 3901 patients, 3730 (96%) were enrolled with 305 (8.2%) episodes of true bacteremia. A decision rule was created with “major criteria” defined as: temperature above 39.5°C (103.0°F), indwelling vascular catheter, or clinical suspicion of endocarditis. “Minor criteria” were: temperature 38.3–39.4°C (101–102.9°F), age over 65 years, chills, vomiting, hypotension (systolic blood pressure below 90 mm Hg), neutrophil% greater than 80, white blood cell count over 18 k, bands more than 5%, platelets less than 150 k, and creatinine above 2.0.

A blood culture is indicated by the rule if at least one major criterion or two minor criteria are present. Otherwise, patients are classified as “low risk” and cultures may be omitted. Only 4 (0.6%) low-risk patients in the derivation set and 3 (0.9%) low-risk patients in the validation set had positive cultures. The sensitivity was 98% (95% confidence interval [CI] 96–100%) (derivation) and 97% (95% CI 94–100%) (validation). We developed and validated a promising clinical decision rule for predicting bacteremia in patients with suspected infection

9. Electrocardiographic Criteria for Detecting AMI in Patients With Left BBB: A Meta-analysis

Tabas JA, et al. Ann Emerg Med. 2008;52: 329-336.e1

Study objective
Numerous investigators have evaluated the ECG algorithm described by Sgarbossa et al to predict acute myocardial infarction in the presence of left bundle branch block and have arrived at divergent conclusions. To clarify the utility of the Sgarbossa ECG algorithm, we perform a systematic review and meta-analysis of these trials.

A structured search was applied to MEDLINE and Scopus databases, beginning with the year that the algorithm was derived (1996). Two reviewers independently screened citations, assessed for method quality, and extracted data (individual study characteristics, screening performance, and interobserver agreement) with a standardized extraction tool. We assessed qualifying studies for heterogeneity and generated summary estimates for the sensitivity, specificity, and positive and negative likelihood ratios with fixed-effect models.

We identified 11 studies with 2,100 patients that met criteria for at least 1 component of the analysis. Ten studies with 1,614 patients reported a Sgarbossa ECG algorithm score of greater than or equal to 3. These yielded a summary sensitivity of 20% (95% confidence interval [CI] 18% to 23%), specificity of 98% (95% CI 97% to 99%), a positive likelihood ratio of 7.9 (95% CI 4.5 to 13.8), and a negative likelihood ratio of 0.8 (95% CI 0.8 to 0.9). The summary diagnostic odds ratio revealed homogeneity. Seven studies with 1,213 patients reported a Sgarbossa ECG algorithm score of greater than or equal to 2. These yielded sensitivities ranging from 20% to 79% and specificities ranging from 61% to 100%. Positive likelihood ratios ranged from 0.7 to 6.6 and negative likelihood ratios ranged from 0.2 to 1.1. The summary diagnostic odds ratio revealed heterogeneity. Intra- and interobserver agreement was substantial. Sensitivity analysis using the highest-quality studies yielded similar results.

A Sgarbossa ECG algorithm score of greater than or equal to 3, representing greater than or equal to 1 mm of concordant ST elevation or greater than or equal to 1 mm ST depression in leads V1 to V3, is useful for diagnosing acute myocardial infarction in patients who present with left bundle branch block on ECG. The scoring system demonstrates good to excellent overall interobserver variability. A score of 2, representing 5 mm or more of discordant ST deviation, demonstrated ineffective positive likelihood ratios. A Sgarbossa ECG algorithm score of 0 is not useful in excluding acute myocardial infarction.

Full-text (free):

10. Poor Sign-Outs = Worse Outcomes and Wasted Time

A prospective observational study reveals that inadequate sign-outs are common and have a negative effect on patient care.

Horwitz LI, et al. Arch Intern Med. 2008;168:1755-1760.

Background: In case reports, transfers in the care of patients among health care providers have been linked to adverse events. However, little is known about the nature and frequency of these transfer-related problems.

Methods: We conducted a prospective audiotape study of 12 days of "sign-out" of clinical information among 8 internal medicine house-staff teams. Each day, postcall and night-float interns were asked to identify any sign-out–related problems occurring during the coverage period and to identify the associated sign-out inadequacies. We verified reported sign-out inadequacies by reviewing each corresponding oral and written sign-out. We then developed a taxonomy of types of errors and their consequences through an iterative coding process.

Results: Sign-out sessions (N = 88) included 503 patient sign-outs. A total of 184 patients were signed out twice in the same night. Thus, there were 319 unique patient-days in the data set. We interviewed intern recipients of 84 of 88 sign-out sessions (95%) about sign-out–related problems. Postcall interns identified 24 sign-out–related problems for which we could verify sign-out inadequacies. Five patients suffered delays in diagnosis or treatment, resulting in 1 intensive care unit transfer, and 4 patients had near misses. In addition, house staff experienced 15 inefficiencies or redundancies in work. Sign-outs omitted key information, such as the patient's clinical condition, recent or scheduled events, tasks to complete, anticipatory guidance, and a specific plan of action and rationale for assigned tasks.

Conclusion: Omission of key information during sign-out can have important adverse consequences for patients and health care providers.

11. Five Images (with case descriptions) in EM from the Annals

a. Right-eye Swelling

b. Proptosis of Left Eye

c. Shortness of Breath and Chest Pain in Two Females

d. Infant with Vomiting and Diarrhea

e. Eye Pain and Double Vision

12. Out-of-hospital cardiac arrest: Location is all

September 23, 2008. Lisa Nainggolan. Seattle, WA and Ann Arbor, MI - A new analysis of out-of-hospital cardiac arrest (OHCA) in 10 areas in North America has found a fivefold difference in survival rates [1]. Dr Graham Nichol (University of Washington, Seattle) and colleagues from the Resuscitation Outcomes Consortium (ROC) report their results in the September 24, 2008 issue of the Journal of the American Medical Association.

Nichol et al say more research is needed to understand why there is such variation but note that their study demonstrates that cardiac arrest is a treatable condition. "If survival after OHCA treated by emergency medical services [EMS] could be increased throughout North America from the study average of 7.9% to the maximum observed rate of 16.3%, an estimated 15 000 premature deaths would be prevented each year," they point out.

In a related paper in the same issue [2], Dr Comilla Sasson (University of Michigan, Ann Arbor) and colleagues say that to try to improve outcomes, attention should be focused on those patients most likely to survive OHCA, and they suggest certain rules should be adopted by EMS to decide when it is futile to continue resuscitation.

If survival after OHCA treated by EMS could be increased . . . from the study average . . . to the maximum observed rate, an estimated 15,000 premature deaths would be prevented each year. In an accompanying editorial [3], Drs Arthur B Sanders (University of Arizona Health Sciences Center, Tucson) and Karl B Kern (University of Arizona, Tucson) say that OHCA "has a dismal prognosis in many communities, [and] the magnitude of the problem in the US and Canada is such that even small improvements in survival translate into thousands of lives saved."

The study by Nichol et al illustrates that there is much room for improvement in the treatment of OHCA, they say, but they argue that applying rigid termination-of-resuscitation (TOR) criteria—as suggested by Sasson et al—is not necessarily the answer. Nichol agrees, telling heartwire: "Our point is more that there is a wide variation in care, so EMS agencies in [more poorly performing] cities need to try to improve their outcomes, rather than not resuscitating."

Location is all: 3% survive in Alabama compared with 16% in Seattle

In their prospective, observational ROC study, Nichol et al set out to determine whether cardiac-arrest incidence and outcome differed across geographic regions and included data on all OHCAs at seven US and three Canadian sites from May 2006 to April 30, 2007, followed up to hospital discharge and including data available as of June 28, 2008. The 10 sites were: Alabama; Dallas, TX; Iowa; Milwaukee, WI; Ottawa, ON; Pittsburgh, PA; Portland, OR; Seattle, WA; Toronto, ON; and Vancouver, BC.

Among the 10 sites, with a total population of 21.4 million, there were 20,520 cardiac arrests assessed by EMS personnel. Resuscitation was attempted in 11 898 cases (58.0% of the total); 2729 (22.9% of those treated) had initial rhythm of ventricular fibrillation (VF) or ventricular tachycardia or rhythms that were shockable by an automated external defibrillator (AED), but just 954 (4.6%) were discharged alive. Among those in whom resuscitation was attempted, 7.9% of all patients with cardiac arrest and 21% of those with VF survived to hospital discharge.

But there was huge variation in survival rates across the sites, ranging from 3.0% in Alabama to 16.3% in Seattle, the best-performing region for cardiac-arrest survival rates. For VF survival, the figures were 7.7% in Alabama and 39.9% in Seattle. Median survival for cardiac arrest was 8.4% and for VF 22%.

"These findings have implications for prehospital emergency care. The fivefold variation in survival after EMS-treated cardiac arrest and fivefold variation in survival after ventricular fibrillation demonstrate that cardiac arrest is a treatable condition," they write.

Nichol told heartwire: "We are doing further work to understand why these differences occur, but it's probably for several reasons, including differences in patient risk, community response, and EMS response. The key point is for every city to monitor outcomes and try to improve them."

The editorialists agree: "It is time to work to overcome barriers in each community, devote appropriate resources, and optimize survival of all patients so that location by city becomes a minor factor in survival of cardiac arrest."

The remainder of the article:

13. Adding More Beds to the ED or Reducing Admitted Patient Boarding Times: Which Has a More Significant Influence on Emergency Department Congestion?

Khare RK, et al. Ann Emerg Med. 2008;52:in press as of Sept 29

Study objective
We evaluate a computer simulation model designed to assess the effect on emergency department (ED) length of stay of varying the number of ED beds or altering the interval of admitted patient departure from the ED.

We created a computer simulation model (Med Model) based on institutional data and augmented by expert estimates and assumptions. We evaluated simulations of increasing the number of ED beds, increasing the admitted patient departure and increasing ED census, analyzing potential effects on overall ED length of stay. Multiple sensitivity analyses tested the robustness of the results to changes in model assumptions and institutional data.

With a constant ED departure rate at the base case and increasing ED beds, there is an increase in mean length of stay from 240 to 247 minutes (95% confidence interval [CI] 0.8 to 12.6 minutes). When keeping the number of beds constant at the base case and increasing the rate at which admitted patients depart the ED to their inpatient bed, the mean overall ED length of stay decreases from 240 to 218 minutes (95% CI 16.8 to 26.2 minutes). With a 15% increase in daily census, the trends are similar to the base case results. The sensitivity analyses reveal that despite a wide range of inputs, there are no differences from the base case.

Our computer simulation modeled that improving the rate at which admitted patients depart the ED produced an improvement in overall ED length of stay, whereas increasing the number of ED beds did not.

14. A Comparison of Observed Versus Documented Physician Assessment and Treatment of Pain: The Physician Record Does Not Reflect the Reality

Chisholm CD, et al. Ann Emerg Med. 2008;52:383-389.

Study objective
The Joint Commission requires “appropriate assessment” of patients presenting with painful conditions. Compliance is usually assessed through retrospective chart analysis. We investigate the discrepancy between observed physician pain assessment and that subsequently documented in the medical record.

This was an observational study using a trained investigator watching bedside interactions of emergency physicians. Using a priori definitions, the investigator recorded whether the patient volunteered the presence of pain, physician inquiry about pain, attempts to quantify the pain, treatment offered/rendered, and any assessment of the response to therapy. An independent investigator subsequently assessed the patient's chart for documentation of pain assessment, therapy rendered, and response to treatment. Children younger than 5 years and patients with major trauma, altered mental status, or nontraumatic chest pain were excluded. The institutional review board approved the protocol, the physicians agreed to participate in an “ergonomic study” without knowing the exact nature of data collection, and patients released their records.

The investigator observed 209 patient encounters. Physicians acknowledged the patients' pain 98.1% of the time but documented its presence in 91.7%. Physicians attempted to quantify the patient's pain in 61.5% of encounters but documented that attempt in only 38.9%. Treatment was offered in 79.9% and recorded in 31.7% of charts. When treatment was offered, the patient's response to the therapy was recorded only 28% of the time.

Physicians almost always assess and treat patient pain but infrequently record those efforts. The patient's chart is a poor surrogate marker for pain assessment and care by emergency physicians and may not be suitable for use as a compliance assessment tool. Research methodology using retrospective chart analysis may be affected by this phenomenon, suggesting the potential for underestimation of patient pain assessment and treatment by emergency physicians.

Full-text (free):

15. Ovarian Hyperstimulation Syndrome: A Potentially Fatal Complication of Early Pregnancy

Madill JJ, et al. J Emerg Med. 2008;35:283-286.

We present the case of a patient who presented to the Emergency Department (ED) 48 h after successful in vitro fertilization with abdominal pain, hypotension, and free fluid on an ED-focused abdominal sonogram for trauma study. This presentation is typical of Ovarian Hyperstimulation Syndrome (OHSS), a diagnosis that may be unfamiliar to many Emergency Physicians. With the increasing frequency of in vitro fertilization procedures, this disease process is becoming more common. Numerous complications can occur with OHSS, including third-space fluid accumulation, hemoconcentration, renal failure, and thromboembolic phenomena. Vigilance is required as these patients are at increased risk of ovarian torsion, ovarian rupture with internal hemorrhage, ectopic pregnancy, and infection. This case report provides an overview of clinical features and emergent management of OHSS.

16. Does a waiting room video about what to expect during an ED visit improve patient satisfaction?

Papa L, et al. CJEM 2008;10:347-54

Objective: We created an instructional waiting room video that explained what patients should expect during their emergency department (ED) visit and sought to determine whether preparing patients using this video would 1) improve satisfaction, 2) decrease perceived waiting room times and 3) increase calls to an outpatient referral line in an ambulatory population.

Methods: This serial cross-sectional study took place over a period of 2 months before (control) and 2 months after the introduction of an educational waiting room video that described a typical patient visit to our ED. We enrolled a convenience sample of adult patients or parents of pediatric patients who were triaged to the ED waiting room; a research assistant distributed and collected the surveys as patients were being discharged after treatment. Subjects were excluded if they were admitted. The primary outcome was overall satisfaction measured on a 5-point Likert scale, and secondary outcomes included perceived waiting room time, and the number of outpatient referral-line calls.

Results: There were 1132 subjects surveyed: 551 prevideo and 581 postvideo. The mean age was 38 years (standard deviation [SD] 18), 61% were female and the mean ED length of stay was 5.9 hours (SD 3.6). Satisfaction scores were significantly higher postvideo, with 65% of participants ranking their visit as either "excellent" or "very good", compared with 58.1% in the prevideo group (p = 0.019); however, perceived waiting room time was not significantly different between the groups (p = 0.24). Patient calls to our specialty outpatient clinic referral line increased from 1.5 per month (95% confidence interval [CI] 0.58-2.42) to 4.5 per month (95% CI 1.19-7.18) (p = 0.032). After adjusting for possible covariates, the most significant determinants of overall satisfaction were perceived waiting room time (odds ratio [OR] 0.41, 95% CI 0.34-0.48) and having seen the ED waiting room video (OR 1.41, 95% CI 1.06-1.86).

Conclusion: Preparing patients for their ED experience by describing the ED process of care through a waiting room video can improve ED patient satisfaction and the knowledge of outpatient clinic resources in an ambulatory population. Future studies should research the implementation of this educational intervention in a randomized fashion.


17. Regionalization of Care for ST-Segment Elevation Myocardial Infarction: Is It Too Soon?

Pottenger BC, et al. Ann Emerg Med. 2008;52:in press as of Sept 29

Interest in regionalization of the care of acute ST-segment elevation myocardial infarction (STEMI) has gained momentum recently. Optimal treatment of STEMI involves balancing time to treatment and reperfusion options. Primary percutaneous coronary intervention, when performed in a timely fashion, has been shown to be more effective than fibrinolysis. However, numerous practical barriers prevent many STEMI patients from receiving primary percutaneous coronary intervention. In an effort to increase beneficial primary percutaneous coronary intervention administration to STEMI patients, health care leaders have proposed regionalized STEMI care networks with advanced emergency medical services (EMS) involvement. Constructing regionalized STEMI networks presents a policy challenge because this shift in STEMI care would require changes in current EMS and emergency medicine practices.

Therefore, we present various perspectives and issues that decision-makers and system organizers must address properly before deciding whether to adopt this new model of care. Reorganizing STEMI care in a manner analogous to how trauma and stroke care are currently triaged and treated appeals intuitively; however, given the absence of evidence that STEMI regionalization actually improves patient outcomes and is cost-effective, more research is needed to determine whether STEMI regionalization is an efficient model for providing evidence-based care. The concept of STEMI regionalization represents an effort to inform policy according to evidence-based medicine, but real-world quality, geospatial, financial, cost, business, resource, and practice barriers present obstacles to implementing this concept efficiently and effectively.

18. A Randomized Trial of Diphenhydramine as Prophylaxis Against Metoclopramide-Induced Akathisia in Nauseated ED Patients

Friedman BW, et al. Ann Emerg Med. 2008;52:in press as of Sept 29

Study objective
Akathisia, an adverse effect observed at times after administration of parenteral metoclopramide, is an unpleasant symptom complex characterized by restlessness and agitation. Some try to limit the development of akathisia by coadministering diphenhydramine when using parenteral metoclopramide. The goal of this investigation is to determine whether concomitant administration of diphenhydramine 25 mg decreased the rate of development of akathisia after administration of 10 mg or 20 mg of intravenous metoclopramide.

This was a randomized, double-blind, factorial design trial. Patients who presented to our emergency department with a primary or secondary chief complaint of nausea were randomized to one of the following 4 groups: (1) metoclopramide 10 mg+diphenhydramine 25 mg; (2) metoclopramide 10 mg+placebo; (3) metoclopramide 20 mg+diphenhydramine 25 mg; (4) metoclopramide 20 mg+placebo. The medications were inserted into a 50-mL bag of normal saline solution and administered as an intravenous drip during 15 minutes. Primary outcome was development of akathisia within 60 minutes of medication administration, as measured by blinded assessors using a short akathisia instrument, or use of rescue medication for treatment of akathisia by blinded clinical staff. Patients were also asked at baseline and 30 minutes later whether they felt restless.

Two hundred eighty-nine patients were randomized and 286 patients were included in the final analysis. Within 1 hour of medication administration, 17 of 143 patients randomized to diphenhydramine (12%; 95% confidence interval [CI] 8% to 18%) and 17 of 143 (12%; 95% CI 8% to 18%) randomized to placebo developed akathisia (95% CI for difference of 0%: –8% to 8%). Thirteen of 143 patients randomized to metoclopramide 10 mg (9%; 95% CI 5% to 15%) and 21 of 143 randomized to metoclopramide 20 mg (15%; 95% CI 10% to 22%) developed akathisia (95% CI for difference of 6%: –2% to 14%). In those administered prophylactic diphenhydramine, odds of akathisia relative to placebo were 1.0 (95% CI 0.5 to 2.0). Odds of akathisia in those administered 20 mg of metoclopramide relative to the 10-mg dose were 1.7 (95% CI 0.8 to 3.6). Among patients who received 20 mg of metoclopramide, subjective restlessness was reported by 7 of 72 (9.7%) patients who received diphenhydramine and 14 of 71 (19.7%) patients who received placebo (95% CI for difference of 10%: –2% to 22%).

Routine prophylaxis with diphenhydramine to prevent akathisia is unwarranted when intravenous metoclopramide is administered over 15 minutes. For patients administered 20 mg of metoclopramide, prophylactic diphenhydramine may decrease subjective restlessness.

19. Elderly Patients May Be Less Likely to be Taken to a Trauma Center by EMS Personnel

Laurie Barclay, MD. August 24, 2008 — Emergency medical services (EMS) providers may be less likely to transport elderly patients to a trauma center, according to the results of a retrospective analysis reported in the August issue of Archives of Surgery.

"Evidence-based clinical practice guidelines strongly recommend that elderly trauma patients be treated as aggressively as non-elderly patients," write David C. Chang, PhD, MPH, MBA, from the Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and colleagues. "However, some studies have suggested that age bias may still exist in trauma care, even in the prehospital phase of that care."

The goal of this study was to assess whether age bias is a factor in triage errors. A retrospective analysis of 10 years of prospectively collected data (from 1995 to 2004) in the statewide Maryland Ambulance Information System was performed, followed by surveys of EMS personnel at regional EMS conferences and of trauma center personnel at level 1 trauma centers.

Trauma patients were defined as those who met criteria of the American College of Surgeons for physiology, injury, and/or mechanism and who were subjectively declared by EMS personnel to be priority 1 status (requiring immediate attention). The primary endpoint was undertriage, defined as failure to transport trauma patients to a state-designated trauma center.

Among 26,565 trauma patients identified by registry analysis, the undertriage rate was higher in patients aged 65 years or older than in younger patients (49.9% vs 17.8%; P less than .001). Multivariate analysis revealed that being age 50 years was also associated with a decrease in trauma center transports (odds ratio [OR], 0.67; 95% confidence interval [CI], 0.57 – 0.77), with an even more marked decrease at age 70 years (OR, 0.45; 95% CI, 0.39 – 0.53) in comparison with patients aged younger than 50 years.

Among 166 respondents (127 EMS personnel and 32 medical personnel, with 7 respondents refusing to identify their training background) who completed the follow-up surveys, the leading 3 factors responsible for this undertriage were given as insufficient training for managing elderly patients (25.3%), lack of familiarity with the protocol (12%), and possible age bias (13.4%).

"Even when trauma is recognized and acknowledged by EMS, providers are consistently less likely to consider transporting elderly patients to a trauma center," the study authors write. "Unconscious age bias, in both EMS in the field and receiving trauma center personnel, was identified as a possible cause."

Limitations of this study include unknown effect of this undertriage on patient outcomes and unsuccessful attempt to link the EMS data to Maryland hospital discharge data.

"The problem of age bias raised in this study may negate efforts to improve clinical care for elderly trauma patients within trauma centers if the system as a whole does not function properly and deliver patients appropriately to needed resources," the authors write. "It may be helpful to highlight the literature that now suggests that elderly trauma patients do, in fact, return to productive lives after their injury, which can eliminate the perception of futility of care that may be used consciously or subconsciously to justify age bias."

Chang DC, et al. Arch Surg. 2008;143:776–781.

20. The prognostic factors of hypotension after rapid sequence intubation

Lin C, et al. Amer J Emerg Med. 2008;26:845-851.

Rapid sequence intubation (RSI) has achieved high success and low complication rate in the ED. However, hypotension after RSI does occur. This study aimed to identify the prognostic factors of hypotension after RSI.

This study identified patients who needed emergency airway management and then divided them into 2 groups. Patients in the first group were the hypotension group, whose systolic blood pressure (SBP) was found to be greater than 90 mm Hg before RSI but less than 90 mm Hg after RSI. Patients in the second group were deemed as the control group whose pre-SBP and post-SBP were greater than 90 mm Hg. The following variables were measured in the study: age, sex, body weight, patients' underlying disease and ongoing disease, the initial vital signs, and laboratory tests. A prognostic model with multiple logistic regression was established based on significant findings from univariate analysis.

A total of 149 patients were recruited from the ED in this study, with 28 patients in the hypotension group and 121 patients in the control group. After univariate analysis, there were 6 factors identified as significant findings including chronic obstructive pulmonary disease, sepsis, albumin, lidocaine, low body weight (below 55 kg), and preintubation blood pressure of less than 140 mm Hg. Multiple logistic regression has demonstrated that patients' underlying diseases, anthropometric parameters, and drug medications were factors related to postintubation hypotension among ED patients.

Clinical practitioners in the ED should take a patient's predisposing factors into serious consideration before emergency intubation while a preplanned strategy is made.

21. Adenosine in the treatment of supraventricular tachycardia: 5 years of experience (2002-2006)

Riccardi A, et al. Amer J Emerg Med. 2008;26:879-882.

We report a retrospective analysis of 5 years of adenosine use in our emergency department (2002-2006). We treated 454 patients with an intravenous bolus of adenosine. The cohort was made up of 40.7% men and 59.3% women, with mean age of 47.32 years, mean heart rate of 162.48 beats per minute. Among them, 73% responded immediately to the 6-mg dose, 15% responded after the second 12-mg dose, and 11% responded to a further 12-mg dose, whereas 11% were unresponsive. We observed minor side effects in a high percentage of patients (ie, chest tightness 83%, flushing 39.4%, sense of impending death 7%). Only 1 major adverse effect was recorded, that is, administering 12 mg of adenosine induced a marked acceleration in the ventricular rate of a patient with an undiagnosed atrial flutter, caused by induction of atrioventricular conduction (1:1). Our results confirm that when patients are appropriately selected, adenosine is probably the best available drug to treat paroxysmal supraventricular tachycardias, especially in emergency situations.