From the recent medical literature...
1. Hold the Epi: No Advantage Seen With IV Drugs at Out-of-Hospital Cardiac Arrest
November 25, 2009 (Oslo, Norway) — Facing off with longstanding policy and tradition, a large randomized trial found that giving IV drugs like epinephrine and atropine in the setting of out-of-hospital cardiac arrest made it more likely that patients would be admitted to the hospital but little difference in whether they survived to discharge.
That outcome was in spite of their undergoing resuscitation longer and receiving more defibrillations, and more often reattaining a spontaneous circulation, compared with another group that didn't receive IV drugs during arrest, observe the authors, led by Dr Theresa M Olasveengen (Oslo University Hospital, Norway), in this week's Journal of the American Medical Association.
The trial is only the latest of several in recent years to reappraise the efficacy of major elements of conventional cardiopulmonary resuscitation.
For now, the cornerstones of optimal cardiac resuscitation include high-quality cardiopulmonary resuscitation with minimal interruptions for anything, including any drug administration, and early defibrillation.
"These researchers present important and compelling data, which challenge the efficacy of one of the most common procedures in cardiac resuscitation: the administration of intravenous epinephrine," said Dr Bentley J Bobrow (Arizona Department of Health Services, Phoenix) in an email to heartwire. Bobrow, who wasn't involved in the study, is medical director of his state's Bureau of Emergency Medical Services & Trauma System.
"While epinephrine administration has been part of the guidelines for resuscitation for many years, there has been very little evidence supporting its benefit and some convincing evidence suggesting worse outcomes with higher doses of epinephrine," he remarked.
"The message for emergency providers is that, for now, the cornerstones of optimal cardiac resuscitation include high-quality cardiopulmonary resuscitation with minimal interruptions for anything, including any drug administration, and early defibrillation."
Olasveengen et al randomized 851 consecutive adults with nontraumatic out-of-hospital cardiac arrest to management according to advanced-cardiac-life-support guidelines with or without access to IV drug administration. In the no-IV-access group, those who achieved "return to spontaneous circulation" could receive IV drugs five minutes later, if indicated.
Those treated with access to IV drugs fared significantly better at first, but didn't outdo those managed without IV drug access for the primary end point of survival to hospital discharge.
Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest: A Randomized Trial
Olasveengen TM, et al. JAMA. 2009;302(20):2222-2229.
Context: Intravenous access and drug administration are included in advanced cardiac life support (ACLS) guidelines despite a lack of evidence for improved outcomes. Epinephrine was an independent predictor of poor outcome in a large epidemiological study, possibly due to toxicity of the drug or cardiopulmonary resuscitation (CPR) interruptions secondary to establishing an intravenous line and drug administration.
Objective: To determine whether removing intravenous drug administration from an ACLS protocol would improve survival to hospital discharge after out-of-hospital cardiac arrest.
Design, Setting, and Patients: Prospective, randomized controlled trial of consecutive adult patients with out-of-hospital nontraumatic cardiac arrest treated within the emergency medical service system in Oslo, Norway, between May 1, 2003, and April 28, 2008.
Interventions: Advanced cardiac life support with intravenous drug administration or ACLS without access to intravenous drug administration.
Main Outcome Measures: The primary outcome was survival to hospital discharge. The secondary outcomes were 1-year survival, survival with favorable neurological outcome, hospital admission with return of spontaneous circulation, and quality of CPR (chest compression rate, pauses, and ventilation rate).
Results: Of 1183 patients for whom resuscitation was attempted, 851 were included; 418 patients were in the ACLS with intravenous drug administration group and 433 were in the ACLS with no access to intravenous drug administration group. The rate of survival to hospital discharge was 10.5% for the intravenous drug administration group and 9.2% for the no intravenous drug administration group (P = .61), 32% vs 21%, respectively, (P less than .001) for hospital admission with return of spontaneous circulation, 9.8% vs 8.1% (P = .45) for survival with favorable neurological outcome, and 10% vs 8% (P = .53) for survival at 1 year. The quality of CPR was comparable and within guideline recommendations for both groups. After adjustment for ventricular fibrillation, response interval, witnessed arrest, or arrest in a public location, there was no significant difference in survival to hospital discharge for the intravenous group vs the no intravenous group (adjusted odds ratio, 1.15; 95% confidence interval, 0.69-1.91).
Conclusion: Compared with patients who received ACLS without intravenous drug administration following out-of-hospital cardiac arrest, patients with intravenous access and drug administration had higher rates of short-term survival with no statistically significant improvement in survival to hospital discharge, quality of CPR, or long-term survival.
2. Occult Abdominal Trauma Common in Children With Suspected Physical Abuse
Will Boggs, MD. NEW YORK (Reuters Health) Nov 24 - Children with suspected physical abuse should be screened for abdominal trauma, according to a report from the University of Maryland School of Medicine, Baltimore.
"Children with injuries from physical abuse can have many occult injuries, including occult abdominal trauma, and physicians should consider this possibility when deciding what medical tests should be performed," lead author Dr. Wendy Gwirtzman Lane told Reuters Health.
Dr. Lane and colleagues conducted a retrospective study to examine the rate of occult abdominal trauma among 244 children with suspected physical abuse and to identify characteristics associated with screening practice.
Fifty-one of the children had at least one screening test for occult abdominal trauma, the authors report in the December Pediatrics, but only 9 of the 21 children with positive screening results had confirmatory testing with abdominal CT and/or ultrasonography.
Overall, 5 children (10% of those screened, 2% of the total sample) had injuries identified through abdominal CT and/or ultrasonography.
Four of 5 children with elevated ALT and/or AST levels had evidence of intra-abdominal injury on CT or ultrasound scans and 3 others had evidence of liver injury, yielding positive predictive values between 60% and 80%.
Children under 18 months of age were less likely to be screened than were older children, the researchers note, and children who presented in the evening were screened significantly less often than were children who presented at other times of day.
In multivariate analysis, the likelihood of occult abdominal trauma screening was higher for children presenting with probable abusive head trauma and for children evaluated in subspecialty consultation from the child protection team.
Regarding further studies, Dr. Lane said, "Our first step is to better elucidate which children should be screened. We are doing this by conducting a prospective multi-center study, in which we plan to screen all children with abusive injuries age 0-6. We anticipate that this data will allow us to make more specific screening recommendations; e.g., what age children should be screened, and with what injuries (e.g., bruises, burns, fractures, abusive head trauma). We can then look at how to improve screening rates among children who should be screened."
Pediatrics 2009;124:1595-1602.
3. Clinical Controversies: Initiation of Therapy for Asymptomatic Hypertension in the Emergency Department
Ann Emerg Med. 2009;54:791-3.
Do it: http://www.annemergmed.com/article/S0196-0644(09)00484-3/fulltext
Don’t bother: http://www.annemergmed.com/article/S0196-0644(09)01445-0/fulltext
4. Renal Stones, Pancreatitis Receive High Cumulative Radiation Doses in the ED
December 2, 2009 (Chicago, Illinois) — A study that looked at patterns of radiation exposure from computed tomography (CT) in the emergency department of a large urban level 1 trauma center found that patients who were diagnosed with renal stone disease and pancreatitis were the most likely to receive the highest exposure to radiation from CT scans.
Cumulative effective-dose data from imaging should become part of the patient's medical record, Amita Kamath, MD, from San Francisco General Hospital and the University of California at San Francisco, said here at the Radiological Society of North America 95th Scientific Assembly and Annual Meeting.
Dr. Kamath studied cumulative exposure to radiation from CT between October 2006 and March 2007 using effective-dose estimates to determine if certain patient populations were at risk for higher levels of imaging studies and radiation.
Focusing on a retrospective review of common emergency department diagnoses — altered mental status, pancreatitis, renal stone disease, and trauma, she found that renal stone disease and pancreatitis patients had the most repeat imaging and the highest radiation exposure (50 mSv or more).
Among the 10,382 patients reviewed, 91 patients were diagnosed with renal stone disease and 61 with pancreatitis.
Overall, 28% of the cohort (2890 patients) underwent at least 1 CT scan. This ranged from 20% to 22% of patients with trauma and altered mental states, to 70% of patients with pancreatitis, to 85% of patients with renal stone disease.
A mean of 2 CT scans were performed on each patient. That number ranged from 1.8 in patients with trauma and altered mental states, to 1.4 in patients with renal stone disease, to 2.7 in patients with pancreatitis.
Overall, 4% of patients received in excess of 50 mSv. The patients most likely to receive such a high dose were those with renal stone disease and pancreatitis, Dr. Kamath said.
Patients with renal stone disease were over 60 times more likely to undergo a CT scan (odds ratio [OR], 64.6; 95% confidence interval [CI], 8.5 - 493.1) than were patients with altered mental status, and those with pancreatitis were 20 times more likely to undergo a CT scan than those diagnosed with altered mental states (OR, 21.5; CI, 7.5 - 61.7). Patients with renal stone disease were nearly 8 times more likely (OR, 7.9; CI, 1.7 - 36.0) to receive more than 50 mSv over the study period, she reported.
"I think this is often because they develop complications, such as pseudocysts or necrosis, and they end up having to get repetitive imaging," she told Medscape Radiology.
Alternative imaging modalities, such as ultrasound and magnetic resonance imaging, should be considered when such patients require a follow-up study. Limiting the number of phases within the CT itself would also limit exposure, she said.
"We have known about the risks of CT radiation exposure for a while," session moderator, Larry DeWerd, PhD, from the University of Wisconsin, Madison, told Medscape Radiology. "Now we have numbers to tell us the scope of the problem."
Heightened awareness is a good thing, he added. "The more awareness there is among radiologists, the fewer repeat exams, or at least the fewer unnecessary exams, there will be. Hopefully, this could be one of the outcomes, but of course it will take time. It won't happen overnight."
Weighing in with his opinion, J. Louis Hinshaw, MD, from the University of Wisconsin Hospital and Clinics, Madison, added: "This was very interesting work and not surprising in my experience. The use of CT in the [emergency department] has been increasing dramatically, even more so over the past 5 years or so. One of the main indications that 'needs CT in the [emergency department]' is renal stones and, if positive, there is often at least 1 follow-up examination performed, sometimes leading to large cumulative radiation doses."
He endorsed the suggestion that radiation dose should become part of the medical record.
"That is an idea that certainly has merit. There are many obstacles to overcome in order to accomplish something like that, but a national electronic medical record could make something like that possible."
Dr. Kamath, Dr. DeWerd, and Dr. Hinshaw have disclosed no relevant financial relationships.
Radiological Society of North America (RSNA) 95th Scientific Assembly and Annual Meeting: Abstract SSE22-06. Presented November 30, 2009.
5. 600 mg Clopidogrel Loading Dose Bests 300 mg in Patients with STEMI
Patients with STEMI who underwent primary PCI had better clinical outcomes — and no greater risk for bleeding — with a 600-mg loading dose compared with 300 mg.
Dangas G et al. J Am Coll Cardiol. 2009;54:1438-46.
Objectives: Our aim was to determine whether a 600-mg loading dose of clopidogrel compared with 300 mg results in improved clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).
Background: A 600-mg loading dose of clopidogrel compared with 300 mg provides more rapid and potent inhibition of platelet activation.
Methods: In the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial, 3,602 patients with STEMI undergoing primary PCI were randomized to bivalirudin (n = 1,800) or unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor (n = 1,802). Randomization was stratified by thienopyridine loading dose, which was determined before random assignment.
Results: Patients in the 600-mg (n = 2,158) compared with the 300-mg (n = 1,153) clopidogrel loading dose group had significantly lower 30-day unadjusted rates of mortality (1.9% vs. 3.1%, p = 0.03), reinfarction (1.3% vs. 2.3%, p = 0.02), and definite or probable stent thrombosis (1.7% vs. 2.8%, p = 0.04), without higher bleeding rates. Compared with unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor, bivalirudin monotherapy resulted in similar reductions in net adverse cardiac event rates within the 300-mg (15.2% vs. 12.3%) and 600-mg (10.4% vs. 7.3%) clopidogrel loading dose subgroups (pinteraction = 0.41). By multivariable analysis, a 600-mg clopidogrel loading dose was an independent predictor of lower rates of 30-day major adverse cardiac events (hazard ratio: 0.72 [95% confidence interval: 0.53 to 0.98], p = 0.04).
Conclusions: In patients with STEMI undergoing primary PCI with contemporary anticoagulation regimens, a 600-mg loading dose of clopidogrel may safely reduce 30-day ischemic adverse event rates compared with a 300-mg loading dose.
6. Images in Emergency Medicine
Young Man With Fishing Injury
http://www.annemergmed.com/article/S0196-0644(09)00405-3/fulltext
Man With Painful Swelling in Neck
http://www.annemergmed.com/article/S0196-0644(09)00611-8/fulltext
7. NFL to manage concussions with the help of neurologists
By ALAN SCHWARZ. NY Times. Published: November 22, 2009.
In a shift in the National Football League’s approach to handling concussions, the league will soon require teams to receive advice from independent neurologists while treating players with brain injuries, several people with knowledge of the plan confirmed Sunday.
For generations, decisions on when players who sustain concussions should return to play have been made by doctors and trainers employed by the team, raising questions of possible conflicts of interest when coaches and owners want players to return more quickly than proper care would suggest.
As scientific studies and anecdotal evidence have found a heightened risk for brain damage, dementia and cognitive decline in retired players, the league has faced barbed criticism from outside experts and, more recently, from Congress over its policies on handling players with concussions.
The league and Commissioner Roger Goodell have insisted that the N.F.L.’s policies are safe and that no third-party involvement is necessary, pointing to research by its committee on concussions as proof. But after an embarrassing hearing on the issue before the House Judiciary Committee last month in which the league was compared to the tobacco industry, the N.F.L. seems to have begun to embrace the value of outside opinion.
Full-text: http://www.nytimes.com/2009/11/23/sports/football/23concussion.html
8. Diagnostic Accuracy of Noncontrast Computed Tomography for Appendicitis in Adults: A Systematic Review
Hlibczuk V, et al. Ann Emerg Med 2009; in press
Study objective
We seek to determine the diagnostic test characteristics of noncontrast computed tomography (CT) for appendicitis in the adult emergency department (ED) population.
Methods
We conducted a search of MEDLINE, EMBASE, the Cochrane Library, and the bibliographies of previous systematic reviews. Included studies assessed the diagnostic accuracy of noncontrast CT for acute appendicitis in adults by using the final diagnosis at surgery or follow-up at a minimum of 2 weeks as the reference standard. Studies were included only if the CT was completed using a multislice helical scanner. Two authors independently conducted the relevance screen of titles and abstracts, selected studies for the final inclusion, extracted data, and assessed study quality. Consensus was reached by conference, and any disagreements were adjudicated by a third reviewer. Unenhanced CT test performance was assessed with summary receiver operating characteristic curve analysis, with independently pooled sensitivity and specificity values across studies.
Results
The search yielded 1,258 publications; 7 studies met the inclusion criteria and provided a sample of 1,060 patients. The included studies were of high methodological quality with respect to appropriate patient spectrum and reference standard. Our pooled estimates for sensitivity and specificity were 92.7% (95% confidence interval 89.5% to 95.0%) and 96.1% (95% confidence interval 94.2% to 97.5%), respectively; the positive likelihood ratio=24 and the negative likelihood ratio=0.08.
Conclusion
We found the diagnostic accuracy of noncontrast CT for the diagnosis of acute appendicitis in the adult population to be adequate for clinical decisionmaking in the ED setting.
9. Dabigatran Non-inferior to Warfarin in the Treatment of Acute Venous Thromboembolism
Much Pricier yet without the Need for Lab Monitoring
Schulman S, et al. N Engl J Med. 2009;361:2342-2352
Background: The direct oral thrombin inhibitor dabigatran has a predictable anticoagulant effect and may be an alternative therapy to warfarin for patients who have acute venous thromboembolism.
Methods: In a randomized, double-blind, noninferiority trial involving patients with acute venous thromboembolism who were initially given parenteral anticoagulation therapy for a median of 9 days (interquartile range, 8 to 11), we compared oral dabigatran, administered at a dose of 150 mg twice daily, with warfarin that was dose-adjusted to achieve an international normalized ratio of 2.0 to 3.0. The primary outcome was the 6-month incidence of recurrent symptomatic, objectively confirmed venous thromboembolism and related deaths. Safety end points included bleeding events, acute coronary syndromes, other adverse events, and results of liver-function tests.
Results: A total of 30 of the 1274 patients randomly assigned to receive dabigatran (2.4%), as compared with 27 of the 1265 patients randomly assigned to warfarin (2.1%), had recurrent venous thromboembolism; the difference in risk was 0.4 percentage points (95% confidence interval [CI], –0.8 to 1.5; P less than 0.001 for the prespecified noninferiority margin). The hazard ratio with dabigatran was 1.10 (95% CI, 0.65 to 1.84). Major bleeding episodes occurred in 20 patients assigned to dabigatran (1.6%) and in 24 patients assigned to warfarin (1.9%) (hazard ratio with dabigatran, 0.82; 95% CI, 0.45 to 1.48), and episodes of any bleeding were observed in 205 patients assigned to dabigatran (16.1%) and 277 patients assigned to warfarin (21.9%; hazard ratio with dabigatran, 0.71; 95% CI, 0.59 to 0.85). The numbers of deaths, acute coronary syndromes, and abnormal liver-function tests were similar in the two groups. Adverse events leading to discontinuation of the study drug occurred in 9.0% of patients assigned to dabigatran and in 6.8% of patients assigned to warfarin (P=0.05).
Conclusions: For the treatment of acute venous thromboembolism, a fixed dose of dabigatran is as effective as warfarin, has a safety profile that is similar to that of warfarin, and does not require laboratory monitoring.
10. What Happens When Doctors Give Patients More Power?
Dec. 03, 2009. NEW YORK (Reuters Health) - When patients are given the responsibility for medical decisions, they may be less willing to try a potentially risky treatment, a study published Monday suggests.
The study, of 216 patients with arthritis and other similar diseases, tested patients' willingness to take a hypothetical "new" drug that carried important benefits but also a small risk of serious side effects.
It turned out that patients were less willing to try the drug when they were given complete power over the decision than when a doctor advised them to take the medication.
When given a choice rather than a doctor's order, the study found, patients appeared to give greater thought to the potential side effects of the drug.
The findings, published in the journal Arthritis Care & Research, have implications for the trend toward greater patient involvement in healthcare. Studies have shown that patients who are more active in their care tend to fare better. However, there has been less research into what happens when actual decision-making is shifted over to patients.
The current results "suggest that asking some patients to assume more responsibility for decisions involving their healthcare may have unanticipated consequences," lead researcher Dr. Liana Fraenkel, of the Yale University School of Medicine, told Reuters Health in an email.
For the study, Fraenkel and colleague Dr. Ellen Peters had patients view one of two videos. Each featured a doctor describing a hypothetical new medication for which the patients were candidates -- a pain drug or a drug designed to lower heart disease risk.
Each drug was described as "very effective" and generally safe, but with a small risk of a serious side effect: either a breakdown of tissue in the jaw, or a rare but often fatal infection that causes brain inflammation. (Both of those are side effects of drugs currently on the market.)
After seeing the video, patients rated their willingness to take the drug under two circumstances: in one, their doctor said they should take the drug and wrote a prescription; in the other, the decision was left completely to the patient.
Overall, the researchers found, patients were less open to taking the drug when the decision was theirs alone. They also expressed greater worries over side effects.
"The shift of responsibility from M.D. to patient may cause some patients to pay more attention to risks," Fraenkel explained.
She and Peters note that studies in other areas have suggested that when people have a choice about whether to take a potentially risky action, they consider those risks more carefully. For example, city dwellers who can opt to drive or take the bus are more likely to see driving as a risky endeavor than do rural residents -- who have no choice but to drive.
According to Fraenkel, the current findings suggest that to make the most informed decisions about medical treatments, patients need help in weighing the potential benefits against the risks.
"I would argue that these results highlight the need to ensure that patients have the proper support to be able to participate in decision making," she said.
SOURCE: Arthritis Care & Research, online November 30, 2009.
11. Predictors of 30-Day Serious Events in Older Patients With Syncope
Sun BC, et al. Ann Emerg Med. 2009;54:769-778.e5.
Study objective
We identify predictors of 30-day serious events after syncope in older adults.
Methods
We reviewed the medical records of older adults (age ≥60 years) who presented with syncope or near syncope to one of 3 emergency departments (EDs) between 2002 and 2005. Our primary outcome was occurrence of a predefined serious event within 30 days after ED evaluation. We used multivariable logistic regression to identify predictors of 30-day serious events.
Results
Of 3,727 potentially eligible patients, 2,871 (77%) met all eligibility criteria. We excluded an additional 287 patients who received a diagnosis of a serious clinical condition while in the ED. In the final study cohort (n=2,584), we identified 173 (7%) patients who experienced a 30-day serious event. High-risk predictors included age greater than 90 years, male sex, history of an arrhythmia, triage systolic blood pressure greater than 160 mm Hg, abnormal ECG result, and abnormal troponin I level. A low-risk predictor was a complaint of near syncope rather than syncope. A risk score, generated by summing high-risk predictors and subtracting the low-risk predictor, can stratify patients into low- (event rate 2.5%; 95% confidence interval [CI] 1.4% to 3.6%), intermediate- (event rate 6.3%; 95% CI 5.1% to 7.5%), and high-risk (event rate 20%; 95% CI 15% to 25%) groups.
Conclusion
We identified predictors of 30-day serious events after syncope in adults aged 60 years and greater. A simple score was able to stratify these patients into distinct risk groups and, if externally validated, might have the potential to aid ED decisionmaking.
12. Rapid Influenza Test Helps Identify Low-Risk Febrile Infants
A positive rapid influenza test result predicted low risk for serious bacterial infection in febrile infants younger than 3 months.
Strategies for evaluating febrile infants younger than 3 months commonly use laboratory markers to identify patients at low risk for serious bacterial illness (SBI). In a prospective multicenter study, investigators in Spain evaluated whether rapid influenza tests can help identify low-risk patients. During the 2003–2008 influenza seasons, the investigators enrolled 381 infants younger than 3 months (22% aged 28 days) with fever 38°C from an unknown source who were evaluated with blood culture and rapid influenza tests. Patients who had been treated previously with antibiotics were excluded.
Overall, 3 of 113 patients (2.6%) with positive rapid influenza test results had SBI, compared with 47 of 268 patients (17.5%) with negative results. All SBIs in the positive group were from a urinary source. Blood cultures were positive in 0% of patients with positive rapid influenza test results, compared with 8 patients (3%) with negative rapid influenza test results (Streptococcus agalactiae in 4 patients, Neisseria meningitidis in 2, Streptococcus pneumoniae in 1, and Staphylococcus aureus in 1).
Comment: Historically, febrile infants younger than 1 month have been the most difficult to risk stratify. Unfortunately, these authors did not analyze the results by age, making the generalizability of these findings to that higher-risk, youngest age group unclear. However, when these results are coupled with those from previous studies that have demonstrated a low risk for bacteremia in infants with an identifiable viral source of fever, incorporating rapid influenza tests into risk stratification algorithms seems reasonable. Although rapid influenza tests have variable sensitivity, for well-appearing infants between ages 1 and 3 months with positive rapid influenza test results, urine analysis and culture are sufficient to exclude bacteremia. Caution: These investigators looked at seasonal influenza and not 2009 pandemic H1N1 influenza, which has been associated with higher rates of concomitant bacterial pneumonia.
— Katherine Bakes, MD. Published in Journal Watch Emergency Medicine November 13, 2009. Citation: Mintegi S et al. Rapid influenza test in young febrile infants for the identification of low-risk patients. Pediatr Infect Dis J 2009 Nov; 28:1026.
13. Anxieties Over Acetaminophen: FDA Panel Recommends Reducing Doses, Discarding Combination Drugs In Light of Liver Failures
Ann Emerg Med. 2009;54:A13-A16.
Full-text: http://www.annemergmed.com/article/S0196-0644(09)01642-4/fulltext
14. To Sellick or Not to Sellick?
A study of magnetic resonance images demonstrates occlusion of the hypopharynx by Sellick maneuver but does not prove that the maneuver has clinical value.
Routine use of Sellick maneuver (posterior displacement of the cricoid cartilage to occlude the alimentary tract) during rapid sequence intubation is no longer recommended because of inadequate proof of benefit and evidence that it might make intubation or ventilation more difficult (JW Emerg Med Jun 1 2000 and JW Emerg Med Jun 29 2007). To determine whether and how the maneuver occludes the alimentary tract, researchers obtained magnetic resonance images of 24 nonsedated volunteers with and without Sellick maneuver in three head and neck positions (sniffing, head extended, neutral).
Axial images showed a reduction in diameter of the postcricoid hypopharynx from an average of 7.3 mm without the maneuver to 4.7 mm with the maneuver in each position. The compressed diameter was less than the estimated wall thickness (6.1 mm) of the hypopharynx at this level, indicating complete occlusion.
Comment: An earlier study showed that the esophagus often slips left or right when Sellick maneuver is applied, thus avoiding compression by the cricoid cartilage. This study shows that the hypopharynx behind the cricoid cartilage was effectively occluded in these nonsedated patients, regardless of whether lateral displacement occurred at other levels of the esophagus. This finding's clinical meaning is not clear, nor does it help us decide whether to use Sellick maneuver. Editorialists express divergent opinions regarding the merit of the maneuver. Sellick maneuver should be considered optional until we have outcome data that support its use. However, Sellick maneuver is probably worthwhile during bag-mask ventilation, because previous research has shown that it minimizes flow of gases to the stomach.
— Ron M. Walls, MD, FRCPC, FAAEM. Published in Journal Watch Emergency Medicine December 11, 2009. Citation: Rice MJ et al. Cricoid pressure results in compression of the postcricoid hypopharynx: The esophageal position is irrelevant. Anesth Analg 2009 Nov; 109:1546.
15. Acute Metformin Overdose: Examining Serum pH, Lactate Level, and Metformin Concentrations in Survivors Versus Nonsurvivors: A Systematic Review of the Literature
Dell'Aglio DM, et al. Ann Emerg Med. 2009;54:818-823.
Study objective
Metformin is known to cause potentially fatal metabolic acidosis with an increased lactate level in both overdose and therapeutic use. No association between mortality and serum pH, lactate level, or metformin concentrations, though intuitive, has yet been described. This systematic literature review is designed to evaluate the association between mortality and serum pH, lactate level, and metformin concentrations in acute metformin overdose.
Methods
We reviewed the literature by using the MEDLINE, EMBASE, CINAHL, and TOXNET databases for cases of metformin overdose with documented mortality data and values of serum pH, lactate level, and metformin concentrations. When available, patient age, patient sex, and whether patients received intravenous sodium bicarbonate therapy or hemodialysis were also analyzed. Cases meeting inclusion criteria were analyzed to determine whether a difference in distribution of nadir serum pH, peak serum lactate level, or peak serum metformin concentrations existed between overdose survivors and nonsurvivors.
Results
We identified 10 articles that had 1 or more cases meeting our inclusion criteria. In total, there were 22 cases of metformin overdose (5/22 died) that met inclusion criteria. No intentional overdose patients died whose serum pH nadir was greater than 6.9, maximum lactate concentration less than 25 mol/L, or maximum metformin concentration less than 50 μg/mL (therapeutic range 1 to 2 μg/mL). Intentional overdose patients with a nadir serum pH less than 6.9 had 83% mortality (5/6), those with lactate concentration greater than 25 mmol/L had 83% mortality (5/6), and those with metformin concentration greater than 50 μg/mL had 38% mortality (5/12). Nadir serum pH and peak serum lactate and metformin concentration distributions in survivors and nonsurvivors revealed that survivors had a median nadir pH of 7.30, interquartile range (IQR) 7.22, 7.36; nonsurvivors, a median nadir pH of 6.71, IQR 6.71, 6.73; survivors, a median peak lactate level of 10.8 mmol/L, IQR 4.2, 12.9; nonsurvivors, a median peak lactate level of 35.0 mmol/L, IQR 33.3, 39.0; survivors, a median peak metformin level of 42 μg/mL, IQR 6.6, 67.6; and nonsurvivors, a median peak metformin level of 110 μg/mL, IQR 110, 110.
Conclusion
No cases of acute metformin overdose meeting the study's inclusion criteria were found in which patients with a nadir serum pH greater than 6.9, peak serum lactate concentrations less than 25 mmol/L, or peak serum metformin concentrations less than 50 μg/mL died. Patients with acute metformin overdose who died had much lower serum pH nadirs and much higher peak serum lactate and metformin concentrations than those who survived.
16. Downwardly Mobile: The Accidental Cost of Being Uninsured
Uninsured adults are almost twice as likely as insured adults to die after blunt or penetrating trauma.
Rosen H et al. Arch Surg. 2009;144:1006-11.
Hypothesis: Given the pervasive evidence of disparities in screening, hospital admission, treatment, and outcomes due to insurance status, a disparity in outcomes in trauma patients (in-hospital death) among the uninsured may exist, despite preventive regulations (such as the Emergency Medical Treatment and Active Labor Act).
Design: Data were collected from the National Trauma Data Bank from January 1, 2002, through December 31, 2006 (version 7.0). We used multiple logistic regression to compare mortality rates by insurance status.
Setting: The National Trauma Data Bank contains information from 2.7 million patients admitted for traumatic injury to more than 900 US trauma centers, including demographic data, medical history, injury severity, outcomes, and charges.
Patients: Data from patients (age, 18 years; n = 687 091) with similar age, race, injury severity, sex, and injury mechanism were evaluated for differences in mortality by payer status.
Main Outcome Measure: In-hospital death after blunt or penetrating traumatic injury.
Results: Crude analysis revealed a higher mortality for uninsured patients (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.36-1.42; P less than .001). Controlling for sex, race, age, Injury Severity Score, Revised Trauma Score, and injury mechanism (adjusted for clustering on hospital), uninsured patients had the highest mortality (OR, 1.80; 95% CI, 1.61-2.02; P less than .001). Subgroup analysis of young patients unlikely to have comorbidities revealed higher mortality for uninsured patients (OR, 1.89; 95% CI, 1.66-2.15; P less than .001), as did subgroup analyses of patients with head injuries (OR, 1.65; 95% CI, 1.42-1.90; P less than .001) and patients with 1 or more comorbidities (OR, 1.52; 95% CI, 1.30-1.78; P less than .001).
Conclusions: Uninsured Americans have a higher adjusted mortality rate after trauma. Treatment delay, different care (via receipt of fewer diagnostic tests), and decreased health literacy are possible mechanisms.
17. CDC: 10,000 H1N1 Flu Deaths in US by mid-Nov
from WebMD. Daniel J. DeNoon. December 10, 2009 — H1N1 influenza killed 10,000 Americans, sent 213,000 to the hospital, and sickened 50 million — a sixth of the population — by mid-November, the US Centers for Disease Control and Prevention (CDC) estimates.
The CDC's new estimates reflect a flood of new cases from mid-October to mid-November, as the current wave of the US flu pandemic was climbing to its peak. The numbers represent the middle of a range of estimates made using statistical calculations to correct for underreporting of cases, hospitalizations, and deaths.
"Sadly, there were nearly 10,000 deaths: 1,100 in children and 7,500 among young adults," CDC director Thomas R. Frieden, MD, MPH, said at a news conference. "That is much higher than we would see in a usual flu season. This is a flu that is much harder on young people and that has largely spared the elderly."
The new estimates suggest that about 15% of the population — 1 in 6 Americans — has had the H1N1 flu.
"That leaves most Americans not infected or vaccinated and still susceptible to H1N1 flu," Frieden said. "Even if there were a lot of infections without symptoms and adding in those who have been vaccinated, that still leaves a lot of people unprotected. Only time will tell what the future will hold — but the more people who get vaccinated, the lower the probability of a third wave of the pandemic."
Full-text (free) at CDC: http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm
18. Exploring Emergency Physician–Hospitalist Handoff Interactions: Development of the Handoff Communication Assessment
Apker J, et al. Ann Emerg Med. 2009; in press.
Study objective
We develop and evaluate the Handoff Communication Assessment, using actual handoffs of patient transfers from emergency department to inpatient care.
Methods
This was an observational qualitative study. We derived a Handoff Communication Assessment tool, using categories from discourse coding described in physician-patient communication, previous handoff research in medicine, health communication, and health systems engineering and pilot data from 3 physician-hospitalist handoffs. The resulting tool consists of 2 typologies, content and language form. We applied the tool to a convenience sample of 15 emergency physician-to-hospitalist handoffs occurring at a community teaching hospital. Using discourse analysis, we assigned utterances into categories and determined the frequency of utterances in each category and by physician role.
Results
The tool contains 11 content categories reflecting topics of patient presentation, assessment, and professional environment and 11 language form categories representing information-seeking, information-giving, and information-verifying behaviors. The Handoff Communication Assessment showed good interrater reliability for content (kappa=0.71) and language form (κ=0.84). We analyzed 742 utterances, which provided the following preliminary findings: emergency physicians talked more during handoffs (67.7% of all utterances) compared with hospitalists (32.3% of all utterances). Content focused on patient presentation (43.6%), professional environment (36%), and assessment (20.3%). Form was mostly information-giving (90.7%) with periodic information-seeking utterances (8.8%) and rarely information-verifying utterances (0.4%). Questions accounted for less than 10% of all utterances.
Conclusion
We were able to develop and use the Handoff Communication Assessment to analyze content and structure of handoff communication between emergency physicians and hospitalists at a single center. In this preliminary application of the tool, we found that emergency physician–to-hospitalist handoffs primarily consist of information giving and are not geared toward question-and-answer events. This critical exchange may benefit from ongoing analysis and reformulation.
19. Price of Nonadherance to Antihypertensives
Mazzaglia G, et al. Circulation. 2009;120:1598-1605.
Introduction: High blood pressure (BP) is one of the most preventable causes of cardiovascular disease morbidity and mortality. The use of antihypertensive drug therapy (AHT) has been shown to reduce the risk of stroke and coronary heart disease by an estimated 34% and 21%, respectively, in long-term randomized controlled trials (RCTs). Generally, AHT should be maintained indefinitely. However, findings in clinical practice have raised concerns about the high extent of undertreatment and nonadherence to AHT, which hampers the effectiveness of these medications. In RCTs, antihypertensive drug discontinuation rates range from 5% to 10% per year, and rates up to 50% to 60% after 6 months have been reported in actual practice.
Adherence to AHT has been associated with improved BP, decreased hospitalizations rates, and lower medical care costs. A recent cohort study has also confirmed that the long-term survival advantages associated with improved adherence to AHT after acute myocardial infarction (AMI) appear to be class specific and correlated positively in a dose-response–type fashion. This evidence suggests that the benefits associated with adherence to evidence-based therapies are mediated by drug effects rather than the adoption of healthier lifestyles that often accompanies adherent behaviors (ie, healthy adherer effect).
To the best of our knowledge, less attention has been paid to understanding how nonadherence to AHT might affect the occurrence of cardiovascular events (CVEs) among patients who had not experienced any major cardiovascular outcome. The aim of the present study was to describe adherence to AHT and its association with concurrent drug use, comorbidities, and cardiovascular risk factors. Furthermore, we assessed the impact of adherence on the incidence of CVE among newly diagnosed hypertensive patients.
Methods and Results— Using data obtained from 400 Italian primary care physicians providing information to the Health Search/Thales Database, we selected 18 806 newly diagnosed hypertensive patients 35 years of age during the years 2000 to 2001. Subjects included were newly treated for hypertension and initially free of cardiovascular diseases. Patient adherence was subdivided a priori into 3 categories—high (proportion of days covered, 80%), intermediate (proportion of days covered, 40% to 79%), and low (proportion of days covered, 40%)—and compared with the long-term occurrence of acute cardiovascular events through the use of multivariable models adjusted for demographic factors, comorbidities, and concomitant drug use. At baseline (ie, 6 months after index diagnosis), 8.1%, 40.5%, and 51.4% of patients were classified as having high, intermediate, and low adherence levels, respectively. Multiple drug treatment (odds ratio, 1.62; 95% CI, 1.43 to 1.83), dyslipidemia (odds ratio, 1.52; 95% CI, 1.24 to 1.87), diabetes mellitus (odds ratio, 1.40; 95% CI, 1.15 to 1.71), obesity (odds ratio, 1.50; 95% CI, 1.26 to 1.78), and antihypertensive combination therapy (odds ratio, 1.29; 95% CI, 1.15 to 1.45) were significantly (P less than 0.001) associated with high adherence to antihypertensive treatment. Compared with their low-adherence counterparts, only high adherers reported a significantly decreased risk of acute cardiovascular events (hazard ratio, 0.62; 95% CI, 0.40 to 0.96; P=0.032).
Conclusions— The long-term reduction of acute cardiovascular events associated with high adherence to antihypertensive treatment underscores its importance in assessments of the beneficial effects of evidence-based therapies in the population. An effort focused on early antihypertensive treatment initiation and adherence is likely to provide major benefits.
Full-text (free): http://circ.ahajournals.org/cgi/content/full/120/16/1598
20. Serious Bacterial Infection in Recently Immunized Young Febrile Infants
Wolff M, et al. Acad Emerg Med. 2009;16:1284-1298.
Objective: The objective of this study was to investigate the prevalence of serious bacterial infection (SBI) in febrile infants without a source aged 6–12 weeks who have received immunizations in the preceding 72 hours.
Methods: The authors conducted a medical record review of infants aged 6–12 weeks with a fever of 38.0°C or higher presenting to the pediatric emergency department (ED) over 88 months. Infants were classified either as having received immunizations within the 72 hours preceding the ED visit (recent immunization [RI]) or as not having received immunizations during this time period (no recent immunization [NRI]). Primary outcome of an SBI was based on culture results; only patients with a minimum of blood and urine cultures were studied.
Results: A total of 1,978 febrile infants were studied, of whom 213 (10.8%) had received RIs. The overall prevalence of definite SBI was 6.6% (95% confidence interval [CI] = 5.5 to 7.7). The prevalence of definite SBI in NRI infants was 7.0% (95% CI = 5.9 to 8.3) compared to 2.8% (95% CI = 0.6 to 5.1) in the RI infants. The prevalence of definite SBI in febrile infants vaccinated in the preceding 24 hours decreased to 0.6% (95% CI = 0 to 1.9). The prevalence of definite SBI in febrile infants vaccinated greater than 24 hours prior to presentation was 8.9% (95 CI = 1.5 to 16.4). The relative risk of SBI with RI was 0.41 (95% CI = 0.19 to 0.90). All SBIs in the RI infants were urinary tract infections (UTI).
Conclusions: Among febrile infants, the prevalence of SBI is less in the initial 24 hours following immunizations. However, there is still a substantial risk of UTI. Therefore, urine testing should be considered in febrile infants who present within 24 hours of immunization. Infants who present greater than 24 hours after immunizations with fever should be managed similarly to infants without RIs.
21. Soft Tissue Infections and ED Disposition: Fever Predicts Need for Inpatient Admission
Sabbaj A, et al. Ann Emerg Med. 2009;16:1290-1297.
Objectives: Little empiric evidence exists to guide emergency department (ED) disposition of patients presenting with soft tissue infections. This study's objective was to generate a clinical decision rule to predict the need for greater than 24-hour hospital admission for patients presenting to the ED with soft tissue infection.
Methods: This was a retrospective cohort study of consecutive patients presenting to a tertiary care hospital ED with diagnosis of nonfacial soft tissue infection. Standardized chart review was used to collect 29 clinical variables. The primary outcome was >24-hour hospital admission (either general admission or ED observation unit), regardless of initial disposition. Patients initially discharged home and later admitted for more than 24 hours were included in the outcome. Data were analyzed using classification and regression tree (CART) analysis and multivariable logistic regression.
Results: A total of 846 patients presented to the ED with nonfacial soft tissue infection. After merging duplicate records, 674 patients remained, of which 81 (12%) required longer than 24-hour admission. Using CART, the strongest predictors of >24-hour admission were patient temperature at ED presentation and mechanism of infection. In the multivariable logistic regression model, initial patient temperature (odds ratio [OR] for each degree over 37°C = 2.91, 95% confidence interval [CI] = 1.65 to 5.12) and history of fever (OR = 3.02, 95% CI = 1.41 to 6.43) remained the strongest predictors of hospital admission. Despite these findings, there was no combination of factors that reliably identified more than 90% of target patients.
Conclusions: Although we were unable to generate a high-sensitivity decision rule to identify ED patients with soft tissue infection requiring >24-hour admission, the presence of a fever (either by initial ED vital signs or by history) was the strongest predictor of need for >24-hour hospital stay. These findings may help guide disposition of patients presenting to the ED with nonfacial soft tissue infections.
Friday, December 11, 2009
Sunday, November 22, 2009
Lit Bits: Nov 22, 2009
From the recent medical literature...
1. Induced Hypothermia After VF Cardiac Arrest Improves Outcomes
Hypothermia led to significantly better survival rates and neurological outcomes in patients with ventricular fibrillation but not in those with other initial rhythms.
Despite evidence that induced hypothermia therapy after cardiac arrest improves neurological outcomes and survival, cooling protocols have not been widely implemented. In a retrospective observational study, researchers compared outcomes in consecutive patients with out-of-hospital cardiac arrest who were resuscitated in the 2 years before (204 patients) and the 2 years after (287) implementation of a therapeutic hypothermia protocol at a teaching hospital in Seattle. Patients with severe infection, active bleeding, or nonintact skin from recent burns or who were in a persistent vegetative state prior to cardiac arrest were excluded.
Patients in the hypothermia group were cooled with ice packs, cooling blankets, or cooling pads and received intravenous vecuronium and diazepam. Temperature was measured with an esophageal probe; the goal of 32°C–34°C was achieved in 65% of patients. Passive rewarming commenced after 24 hours of cooling.
Rates of survival to hospital discharge were significantly higher in the hypothermia group than in the control group among patients with an initial rhythm of ventricular fibrillation (VF) (54% vs. 39%) but did not differ among patients with other rhythms. Similarly, the rate of favorable neurological outcomes was significantly higher in the hypothermia group than in the control group among patients with VF (35% vs. 15%).
Comment: Although a greater incidence of witnessed arrests in the hypothermia group (66%) than in the control group (57%) might have skewed the results, the findings suggest that cardiac arrest patients with an initial rhythm of VF might benefit from therapeutic cooling. Based on this and previous outcome studies and on other studies showing that induced hypothermia in the emergency department is feasible, it is time for EDs (and some emergency medical services systems) to implement hypothermia protocols for comatose survivors of cardiac arrest.
— Kristi L. Koenig, MD, FACEP. Published in Journal Watch EM November 6, 2009. Citation: Don CW et al. Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest: A retrospective before-and-after comparison in a single hospital. Crit Care Med 2009 Sep 16; [e-pub ahead of print]. (http://tinyurl.com/yht8qs7)
2. Capsule Endoscopy in ED Hastens Treatment of Upper GI Bleeding
By Anthony J. Brown, MD. NEW YORK (Reuters Health) Oct 26 - Use of real time capsule endoscopy in the emergency room can rapidly identify patients with upper gastrointestinal bleeding who require urgent treatment, according to study findings presented this week at the American College of Gastroenterology annual meeting in San Diego.
"A positive capsule endoscopy test, defined as visualization of a bleeding lesion, red blood or coffee grounds, (was) highly correlated with high-risk stigmata at endoscopy," senior researcher Dr. Moshe Rubin, from New York Hospital Queens, told Reuters Health. "We were surprised at the accuracy of capsule endoscopy in this small study."
Using capsule endoscopy, he added, "we may able to improve patient outcomes...by rapidly identifying those at high risk who need urgent endoscopic care."
The study featured 24 patients with a history of upper GI bleeding who were randomized to capsule endoscopy or standard clinical evaluation following admission to the emergency room.
Intravenous metoclopramide was given within 10 minutes after the capsule was swallowed. Images were evaluated in real-time at the bedside and then again later after download. Patients with positive findings received endoscopic treatment within 6 hours, whereas those without bleeding and control subjects underwent endoscopic assessment within 24 hours.
Seven of the 12 patients in the capsule endoscopy group had positive findings. In all, seven stigmata of bleeding were confirmed at endoscopy. In 6 of the 7, the actual lesion was identified either during bedside image viewing or upon download review, the researchers report.
Of the 5 patients with negative findings on capsule images, 4 had no bleeding stigmata at endoscopy and 1 had comorbidities that precluded endoscopy. Capsule endoscopy-positive patients had a significantly shorter time to endoscopy than did controls: 2.5 vs. 8.9 hours (p = 0.029).
No patient died, and blood transfusion requirements and length of stay were comparable in the two groups. A capsule was retained in one patient with a strictured esophagus, but it was retrieved with endoscopy.
"We need to validate these findings in a larger trial that we are planning," Dr. Rubin said. "In a follow up study, we will use capsule endoscopy to segregate high-risk patients who need urgent intervention from low-risk patients who can potentially be treated more conservatively, and then assess outcomes."
3. ED Waiting Times Increasing in US
Percentage of US Emergency Department Patients Seen Within the Recommended Triage Time: 1997 to 2006
Horwitz LI, et al. Arch Intern Med. 2009;169:1857-1865.
Background The wait time to see a physician in US emergency departments (EDs) is increasing and may differentially affect patients with varied insurance status and racial/ethnic backgrounds.
Methods Using a stratified random sampling of 151 999 visits, representing 539 million ED visits from 1997 to 2006, we examined trends in the percentage of patients seen within the triage target time by triage category (emergent, urgent, semiurgent, and nonurgent), payer type, and race/ethnicity.
Results The percentage of patients seen within the triage target time declined a mean of 0.8% per year, from 80.0% in 1997 to 75.9% in 2006 (P less than .001). The percentage of patients seen within the triage target time declined 2.3% per year for emergent patients (59.2% to 48.0%; P less than .001) compared with 0.7% per year for semiurgent patients (90.6% to 84.7%; P less than .001). In 2006, the adjusted odds of being seen within the triage target time were 30% lower than in 1997 (odds ratio, 0.70; 95% confidence interval, 0.55-0.89). The adjusted odds of being seen within the triage target time were 87% lower (odds ratio, 0.13; 95% confidence interval, 0.11-0.15) for emergent patients compared with semiurgent patients. Patients of each payment type experienced similar decreases in the percentage seen within the triage target over time (P for interaction = .24), as did patients of each racial/ethnic group (P = .05).
Conclusions The percentage of patients in the ED who are seen by a physician within the time recommended at triage has been steadily declining and is at its lowest point in at least 10 years. Of all patients in the ED, the most emergent are the least likely to be seen within the triage target time. Patients of all racial/ethnic backgrounds and payer types have been similarly affected.
4. Ultrasound Detects Central Line Placement and Postprocedure Pneumothorax
Chest x-ray missed 2 of 4 pneumothoraces and 1 of 25 misplaced catheter tips that were detected by bedside ultrasound.
Vezzani A et al. Crit Care Med 2009 Oct 12.
Objective: To determine the usefulness of ultrasound to evaluate central venous catheter misplacements and detection of pneumothorax, thus obviating postprocedural radiograph. After the insertion of a central venous catheter, chest radiograph is usually obtained to ensure correct positioning of the catheter tip and detect postprocedural complications.
Measurements and Main Results: A prospective study of 111 consecutive central venous catheter procedures, using a landmark technique, was conducted in an adult intensive care unit. At the end of the procedure, a B-mode ultrasonography was first performed to assess catheter position and detect pneumothorax. Then, contrast enhanced ultrasonography was used to facilitate visualization of catheter tip, avoiding unknown right atrium positioning or artifacts. A postprocedural chest radiograph was obtained for all patients and was considered as a reference technique. Right atrium positioning was detected in 19 patients by ultrasonography, and an additional six by contrast enhanced ultrasonography. Combining ultrasonography and contrast enhanced ultrasonography yielded a 96% sensitivity and 93% specificity in detecting catheter misplacement. Concordance was 95% and [kappa] value was 0.88 (p less than .001). Pneumothorax was detected in four patients by ultrasonography and in two by chest radiograph (concordance = 98%). The mean time required to perform ultrasonography plus contrast enhanced ultrasonography was 10 +/- 5 mins vs. 83 +/- 79 mins for chest radiograph (p less than .05).
Conclusions: The close concordance between ultrasonography plus contrast enhanced ultrasonography and chest radiograph justifies the use of sonography as a standard technique to ensure the correct positioning of the catheter tip and to detect pneumothorax after central venous catheter cannulation to optimize use of hospital resources and minimize time consumption and radiation. Chest radiograph will be necessary when sonographic examination is impossible to perform by technical limitations.
5. Updated Guidelines for the Care of Children in EDs
This joint policy statement provides a highly useful roadmap for standardizing emergency care of children in community EDs.
American Academy of Pediatrics et al. Pediatrics 2009;124:1233-1243.
Full-text (free): http://pediatrics.aappublications.org/cgi/content/full/124/4/1233
6. Cervical Collar, Physical Therapy, or "Wait and See" for Recent-Onset Cervical Radiculopathy?
Pain scores were significantly lower in the collar and physical therapy groups.
Kuijper B et al. BMJ 2009 Oct 7; 339:b3883.
Full-text: http://www.bmj.com/cgi/content/full/339/oct07_1/b3883
7. A Comparison of Parental and Nursing Assessments of Level of Illness or Injury in a Pediatric Emergency Department
Kestner V, et al., Pediatric Emergency Care. 2009;25:633-635.
Background: The 5-tier Emergency Severity Index (ESI) score is a well-accepted, validated triage tool with good interrater reliability. Parental perception of illness severity has not been compared to ESI score.
Objective: This study compares parental assessment of severity of illness to triage nurse acuity.
Design: Prospective and descriptive.
Setting: Large, urban pediatric emergency department (ED).
Participants: Parents/guardians of patients younger than 18 years.
Intervention: The triage nurse assigned an ESI score, and the parent/guardian assigned all patients a severity score on a scale of 1 to 5 (1, most sick and 5, least sick). Mean severity scores were compared between the groups.
Results: There were 142 participants with a mean patient age of 6.15 years. The mean participant and nurse severity scores were 3.01 and 3.35, respectively, with an intraclass correlation coefficient of 0.203 (P = 0.008). Most frequently, the parent/guardian and triage nurse assigned the same score (n = 44, 31%). Seventy-six percent of the parent/guardian scores were within 1 point of the triage nurse score.
Conclusions: Close agreement exists between parent/guardian and nurse ESI scores, illustrating objectivity in parent/guardian assessments. This study provides a springboard for future studies regarding ED use after educating families on ED triage.
8. Interobserver agreement in the interpretation of computed tomography in acute pulmonary embolism
Costantino G, Amer J Emerg Med. 2009;27:1109-1111.
Multidetector computed tomography (MDCT) is one of the best diagnostic tools for the diagnosis of pulmonary embolism (PE). However, differences in MDCT interpretation, depending on the operator personal expertise, is an important factor that could interfere with the right diagnosis and, consequently, with the more adequate and well-timed therapy.
The aim of the present study was to evaluate the interobserver agreement in the interpretation of MDCT for the diagnosis of acute PE.
On a blind basis, 4 radiologists with different expertise in CT interpretation evaluated 46 different MDCT executed for acute PE. They had to verify the presence or absence of PE and, in the positive case, localize (right-left) and quantify (massive, segmentarian or subsegmentarian) it. The interobserver concordance was expressed using the Cohen K statistic.
The mean concordance between the 4 operators was high (0.82; range, 0.68-0.95). Ruling out the massive PE cases, the mean concordance over the other cases was only moderate (0.47; range, 0.16-0.84).
We found a very good interobserver agreement in MDCT evaluation for the diagnosis of massive PE, whereas we observed a lower concordance in regard to segmentarian and subsegmentarian PE. In the case of negative or nonmassive PE diagnosis, a second evaluation of the CT performed by an expert CT radiologist would probably be effective to decrease the CT evaluation error.
9. Compress the Chest: Better CPR Improves Survival from Out-of-Hospital Cardiac Arrest
Implementation of the 2005 AHA CPR guidelines that focus on uninterrupted chest compressions nearly doubled the odds of survival among patients with out-of-hospital cardiac arrest.
In 2005, the American Heart Association (AHA) released updated evidence-based guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, but does adherence to the revised protocol improve outcomes? Investigators compared rates of survival from out-of-hospital cardiac arrest among 606 adult patients treated before and 1021 treated after implementation of the 2005 AHA guidelines in a single large emergency medical services system.
Review of a convenience sample of 69 electronic electrocardiogram recordings showed significant improvement in CPR quality after guideline implementation, including improvements in mean chest-compression rate, proportion of time that patients received chest compressions, and median preshock and postshock pause times for compressions. Unadjusted rates of survival to hospital discharge were significantly higher after implementation of the guidelines than before (9.4% vs. 6.1%). Among patients with witnessed arrest whose initial rhythm was ventricular fibrillation on EMS arrival, survival rates improved significantly from 24% (19 of 78) before implementation to 30% (34 of 112) after. Multivariate regression analysis that adjusted for initial rhythm, sex, arrest location, and witnessed arrest showed 1.8 greater odds of survival in the postintervention period.
Comment: The promising results of this large study suggest the AHA was on the right track with its renewed focus on basic CPR, including the importance of providing uninterrupted chest compressions.
— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine October 23, 2009. Citation: Sayre MR et al. Impact of the 2005 American Heart Association cardiopulmonary resuscitation and emergency cardiovascular care guidelines on out-of-hospital cardiac arrest survival. Prehosp Emerg Care 2009;13:469.
10. Methohexital Beats Pentobarbital for Head CT Sedation in Children
Chun TH et al. Pediatr Emerg Care 2009 Oct; 25:648.
Objectives: To determine if there are differences in the duration of sedation between pediatric emergency department (PED) patients receiving methohexital and PED patients receiving pentobarbital for the purpose of obtaining a head computed tomographic (CT) scan.
Methods: Retrospective cohort study of PED patients receiving either methohexital or pentobarbital for a sedated head CT. Data were collected on patient demographics and medical condition, indications for head CT, duration of sedation, medication dosage, and medication adverse events. Primary analyses investigated whether there were differences between the 2 groups. Secondary analysis determined whether the need for additional sedative doses contributed to observed differences between groups.
Results: The patients receiving methohexital completed their head CT more quickly and needed less total sedation monitoring than those receiving pentobarbital. The need for additional doses of medication does not appear to be responsible for the observed difference. Adverse medication events were minor and comparable between groups.
Conclusions: Methohexital may be superior to pentobarbital for the purpose of sedating PED patients for head CT.
11. Anticholinergic Drugs and Acute Urinary Retention
Risk is highest during the first several weeks of treatment.
Martín-Merino E et al. J Urol 2009 Oct; 182:1442.
Abstract: http://www.jurology.com/article/S0022-5347(09)01525-0/abstract
12. Doctors' Lack of Respect Weighs on the Obese
October 29, 2009 — Heavier patients get less respect from doctors, raising concerns about the impact on the quality of care, new research indicates.
Scientists reporting in the November issue of the Journal of General Internal Medicine say they found that the higher a patient’s body mass index (BMI), the less respect their doctors had for them.
Mary Margaret Huizinga, MD, MPH, of Johns Hopkins University School of Medicine and lead author of the study, says she came up with the idea for the research from her experiences working in a weight loss clinic.
She says that patients who'd visit would, by the time they left, “be in tears, saying 'no other physician talked with me like this before,'" and had failed to listen.
“Many patients felt like because they were overweight, they weren’t receiving the type of care other patients received,” she says in a news release.
She and colleagues looked at data on 238 patients and 40 physicians. The average BMI of the patients was 32.9.
A person with a BMI of 25 to 29.9 is considered overweight, and 30 or greater obese.
In the study, patients and physicians filled out questionnaires about a doctor’s visit. They were asked questions about their attitudes and perceptions of one another at the end of their encounter. Physicians were asked to rate the level of respect they had for each patient compared to “the average patient” on a 5-point scale.
The patients for whom doctors expressed low respect, on average, had a higher BMI than patients for whom the physicians had high respect, the researchers report. The researchers note that the findings don’t show a cause/effect relationship between BMI and physician respect. Their study also didn’t investigate patients’ health outcomes.
Huizinga writes that respect is critical because some patients may avoid the health care system altogether. In other research, physician respect has been linked to more information being provided by the physician during a patient visit. She says more research is needed “to really understand how physician attitudes toward obesity affect quality of care for those patients."
“If a doctor has a patient with obesity and has low respect for that person, is the doctor less likely to recommend certain types of weight loss programs or to send her for cancer screening?” Huizinger asks. “We need to understand these things better.”
SOURCES: News release, Johns Hopkins University School of Medicine.
Huizinga, M., Journal of General Internal Medicine, November 2009.
13. Divorce Risk Higher When Wife Gets Sick
By TARA PARKER-POPE. NY Times. Nov 12, 2009.
When Dr. Marc Chamberlain, a Seattle oncologist, was treating his brain cancer patients, he noticed an alarming pattern. His male patients were typically receiving much-needed support from their wives. But a number of his female patients were going it alone, ending up separated or divorced after receiving a brain tumor diagnosis.
Dr. Chamberlain, chief of the neuro-oncology division at the Fred Hutchinson Cancer Research Center, had heard similar stories from his colleagues. To find out if these observations were based in fact, he embarked on a study with Dr. Michael J. Glantz of the University of Utah Huntsman Cancer Institute and colleagues from three other institutions who began to collect data on 515 patients who received diagnoses of brain tumors or multiple sclerosis from 2001 through 2006.
The results were surprising. Women in the study who were told they had a serious illness were seven times as likely to become separated or divorced than men with similar health problems, according to the report published in the journal Cancer.
The remainder of the NY Times article: http://well.blogs.nytimes.com/2009/11/12/men-more-likely-to-leave-spouse-with-cancer/
The abstract of the study: http://www3.interscience.wiley.com/journal/122527377/abstract
14. Intranasal Naloxone Is Effective for Opioid Overdose
Time from patient contact to clinical response was the same with intranasal and intravenous naloxone.
Robertson TM, et al. Prehospital Emerg Care 2009;13:512-515.
Objective. To compare the prehospital time intervals from patient contact and medication administration to clinical response for intranasal (IN) versus intravenous (IV) naloxone in patients with suspected narcotic overdose.
Methods. This was a retrospective review of emergency medical services (EMS) and hospital records, before and after implementation of a protocol for administration of intranasal naloxone by the Central California EMS Agency. We included patients with suspected narcotic overdose treated in the prehospital setting over 17 months, between March 2003 and July 2004. Paramedics documented dose, route of administration, and positive response times using an electronic record. Clinical response was defined as an increase in respiratory rate (breaths/min) or Glasgow Coma Scale score of at least 6. Main outcome variables included time from medication to clinical response and time from patient contact to clinical response. Secondary variables included numbers of doses administered and rescue doses given by an alternate route. Between-group comparisons were accomplished using t-tests and chi-square tests as appropriate.
Results. One hundred fifty-four patients met the inclusion criteria, including 104 treated with IV and 50 treated with IN naloxone. Clinical response was noted in 33 (66%) and 58 (56%) of the IN and IV groups, respectively (p = 0.3). The mean time between naloxone administration and clinical response was longer for the IN group (12.9 vs. 8.1 min, p = 0.02). However, the mean times from patient contact to clinical response were not significantly different between the IN and IV groups (20.3 vs. 20.7 min, p = 0.9). More patients in the IN group received two doses of naloxone (34% vs. 18%, p = 0.05), and three patients in the IN group received a subsequent dose of IV or IM naloxone.
Conclusions. The time from dose administration to clinical response for naloxone was longer for the IN route, but the overall time from patient contact to response was the same for the IV and IN routes. Given the difficulty and potential hazards in obtaining IV access in many patients with narcotic overdose, IN naloxone appears to be a useful and potentially safer alternative.
15. Subarachnoid Hemorrhage Might Be a Common Cause of Out-of-Hospital Cardiac Arrest
In this Japanese study, 16% of survivors of out-of-hospital cardiac arrest had subarachnoid hemorrhage.
Inamasu J, et al. Resuscitation 2009;80:977-980.
Aim
Aneurysmal subarachnoid haemorrhage (SAH) is a relatively common cause of out-of-hospital cardiac arrest (OHCA). Early identification of SAH-induced OHCA with the use of brain computed tomography (CT) scan obtained immediately after resuscitation may help emergency physicians make therapeutic decision as quickly as they can.
Methods
During the 4-year observation period, brain CT scan was obtained prospectively in 142 witnessed non-traumatic OHCA survivors who remained haemodynamically stable after resuscitation. Demographics and clinical characteristics of SAH-induced OHCA survivors were compared with those with “negative” CT finding.
Results
Brain CT scan was feasible with an average door-to-CT time of 40.0min. SAH was found in 16.2% of the 142 OHCA survivors. Compared with 116 survivors who were negative for SAH, SAH-induced OHCA survivors were significantly more likely to be female, to have experienced a sudden headache, and trended to have achieved return of spontaneous circulation (ROSC) prior to arrival in the emergency department less frequently. Ventricular fibrillation (VF) was significantly less likely to be seen in SAH-induced than SAH-negative OHCA (OR, 0.06; 95% CI, 0.01–0.46). Similarly, Cardiac Trop-T assay was significantly less likely to be positive in SAH-induced OHCA (OR, 0.08; 95% CI, 0.01–0.61).
Conclusion
Aneurysmal SAH causes OHCA more frequently than had been believed. Immediate brain CT scan may particularly be useful in excluding SAH-induced OHCA from thrombolytic trial enrollment, for whom the use of thrombolytics is contraindicated. The low VF incidence suggests that VF by itself may not be a common cause of SAH-induced OHCA.
16. Combination of epinephrine and dexamethasone may reduce hospitalization in children with bronchiolitis
Frohna JG, et al. J Pediatrics 2009;155:761-762.
Commentary
Identifying effective treatments for children with bronchiolitis has proven elusive. In part, this is due to the heterogenous cause of wheezing, which can range from episodic wheezing (often caused by viral infections) to multifactorial wheezing that can be triggered by a variety of factors and often resulting in asthma. A meta-analysis showed limited short-term benefit from epinephrine, and it is well known that children with asthma respond to corticosteroids. Plint et al were surprised to find a synergistic effect between epinephrine and dexamethasone, which reduced the frequency of hospitalization for children in this study. In addition, there are likely many factors that influence the decision to hospitalize a child, such as the distance to the hospital, the ability of the parents to care for their ill child, and the availability of health care resources. While a number needed to treat of 11 to prevent 1 hospitalization might be appealing, there are several caveats to these results. First, the dose of corticosteroids used in this study is quite high, and there is still limited knowledge of potential risks associated with this treatment. Second, when the authors adjusted their results for the multiple comparisons that were made, the difference in hospitalization was no longer statistically significant. One area of future research would be to look at the subgroups of infants who respond better to corticosteroids and look for possible biomarkers that may even include virus identification techniques. Although we await follow-up studies to provide stronger evidence, it is prudent to provide supportive care and close monitoring for children with an initial episode of wheezing. Monitoring these infants in the general pediatrician's office does not require high-tech medicine—just some relatively straightforward clinical algorithims.
Full-text: http://www.jpeds.com/article/S0022-3476(09)00862-2/fulltext
17. The Oblique View: An Alternative Approach for Ultrasound-Guided Central Line Placement
Phelan M, et al. Amer J Emerg Med. 2009;37:403-408.
Background: Numerous studies have shown significant benefits of using real-time ultrasonography for central line intravenous access. Traditionally, the ultrasound probe is placed along the short axis of the vein to visualize and direct needle placement. This view has some limitations, particularly being able to visualize the needle tip. Some practitioners place the ultrasound probe in the long axis of the vessel to direct needle placement, allowing better visualization of the needle entering the vein, but this does not allow visualization of relevant anatomic structures.
Objectives: We describe an alternative means to obtain ultrasound-guided vascular access using an oblique axis rather than the traditional short-axis approach.
Discussion: This view allows better visualization of the needle shaft and tip but also offers the safety of being able to visualize all relevant anatomically significant structures at the same time and in the same plane. This orientation is halfway between the short and long axis of the vessel, allowing visualization of the needle as it enters the vessel. This capitalizes on the strengths of the long axis while optimizing short-axis visualization of important structures during intravenous line placement.
Conclusion: Ultrasound-guided vascular access can be obtained in a variety of ways. We describe a technique that is used by some experienced ultrasound users but that has never been fully described in the literature. This technique for obtaining ultrasound-guided vascular access offers another option for attempting ultrasound-guided vascular access that has the potential to improve success rates and minimize complications associated with intravenous access.
18. CT-STAT: CT Angiography Rules Out CAD Faster and Cheaper Than Standard Care
Michael O'Riordan. November 18, 2009 (Orlando, Florida) — The use of coronary computed tomography (CT) angiography in the emergency room can successfully triage at-risk chest-pain patients and can do so faster and less expensively than standard diagnostic testing, according to the results of a new study.
"I think the reassurance is that both strategies are very safe," said lead investigator Dr James Goldstein (William Beaumont Hospital, Royal Oak, MI). "We've chosen a chosen a low-risk population--we don't want anybody to go home with a heart attack. We already know that the standard of care is a very fine strategy, and we've gotten very good at evaluating chest pain, but it is cumbersome and expensive."
Although the use of CT to rule out coronary artery disease should not be used in all patients, especially those with manifest ischemia, electrocardiogram abnormalities, or elevations in enzymatic biomarkers, among low-risk patients, "wisely and prudently applied," CT angiography is a powerful addition to the armamentarium of clinicians, said Goldstein.
The results of the study, known as the Computed Tomographic Angiography for the Systematic Triage of Acute Chest Pain Patients to Treatment (CT-STAT) trial, were presented today at the American Heart Association 2009 Scientific Sessions.
The remainder of the essay: http://www.medscape.com/viewarticle/712673
19. Prophylactic Acetaminophen Blunts Immunogenicity of Childhood Vaccinations
Routine prophylactic use of acetaminophen at the time of childhood immunizations should be reconsidered.
Prymula R et al. Lancet 2009; 374:1339.
Abstract: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61208-3/abstract
20. Kubler-Ross’ Stages of Grief: Maybe Not so Cut-and-Dried
In 1969 the psychiatrist Elizabeth Kubler-Ross wrote one of the most influential books in the history of psychology, On Death and Dying. It exposed the heartless treatment of terminally-ill patients prevalent at the time. On the positive side, it altered the care and treatment of dying people. On the negative side, it postulated the now-infamous five stages of dying—Denial, Anger, Bargaining, Depression, and Acceptance (DABDA), so annealed in culture that most people can recite them by heart. The stages allegedly represent what a dying person might experience upon learning he or she had a terminal illness. “Might” is the operative word, because Kübler-Ross repeatedly stipulated that a dying person might not go through all five stages, nor would they necessarily go through them in sequence. It would be reasonable to ask: if these conditions are this arbitrary, can they truly be called stages?
Many people have contested the validity of the stages of dying, but here we are more concerned with the supposed stages of grief which derived from the stages of dying. As professional grief recovery specialists, we contend that the theory of the stages of grief has done more harm than good to grieving people. Having co-authored three books on the impact of death, divorce, and other losses, and having worked directly with over 100,000 grieving people during the past 30 years, our reasons for disputing the stages of grief theory are predicated on the horror stories we’ve heard from thousands of grieving people who’ve told us how they’d been harmed by them.
Friedman R, et al. The Myth of the Stages of Dying, Death and Grief. Skeptic. 2008;13:37-41.
Full-text: http://www.grief.net/Articles/Myth%20of%20Stages.pdf
1. Induced Hypothermia After VF Cardiac Arrest Improves Outcomes
Hypothermia led to significantly better survival rates and neurological outcomes in patients with ventricular fibrillation but not in those with other initial rhythms.
Despite evidence that induced hypothermia therapy after cardiac arrest improves neurological outcomes and survival, cooling protocols have not been widely implemented. In a retrospective observational study, researchers compared outcomes in consecutive patients with out-of-hospital cardiac arrest who were resuscitated in the 2 years before (204 patients) and the 2 years after (287) implementation of a therapeutic hypothermia protocol at a teaching hospital in Seattle. Patients with severe infection, active bleeding, or nonintact skin from recent burns or who were in a persistent vegetative state prior to cardiac arrest were excluded.
Patients in the hypothermia group were cooled with ice packs, cooling blankets, or cooling pads and received intravenous vecuronium and diazepam. Temperature was measured with an esophageal probe; the goal of 32°C–34°C was achieved in 65% of patients. Passive rewarming commenced after 24 hours of cooling.
Rates of survival to hospital discharge were significantly higher in the hypothermia group than in the control group among patients with an initial rhythm of ventricular fibrillation (VF) (54% vs. 39%) but did not differ among patients with other rhythms. Similarly, the rate of favorable neurological outcomes was significantly higher in the hypothermia group than in the control group among patients with VF (35% vs. 15%).
Comment: Although a greater incidence of witnessed arrests in the hypothermia group (66%) than in the control group (57%) might have skewed the results, the findings suggest that cardiac arrest patients with an initial rhythm of VF might benefit from therapeutic cooling. Based on this and previous outcome studies and on other studies showing that induced hypothermia in the emergency department is feasible, it is time for EDs (and some emergency medical services systems) to implement hypothermia protocols for comatose survivors of cardiac arrest.
— Kristi L. Koenig, MD, FACEP. Published in Journal Watch EM November 6, 2009. Citation: Don CW et al. Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest: A retrospective before-and-after comparison in a single hospital. Crit Care Med 2009 Sep 16; [e-pub ahead of print]. (http://tinyurl.com/yht8qs7)
2. Capsule Endoscopy in ED Hastens Treatment of Upper GI Bleeding
By Anthony J. Brown, MD. NEW YORK (Reuters Health) Oct 26 - Use of real time capsule endoscopy in the emergency room can rapidly identify patients with upper gastrointestinal bleeding who require urgent treatment, according to study findings presented this week at the American College of Gastroenterology annual meeting in San Diego.
"A positive capsule endoscopy test, defined as visualization of a bleeding lesion, red blood or coffee grounds, (was) highly correlated with high-risk stigmata at endoscopy," senior researcher Dr. Moshe Rubin, from New York Hospital Queens, told Reuters Health. "We were surprised at the accuracy of capsule endoscopy in this small study."
Using capsule endoscopy, he added, "we may able to improve patient outcomes...by rapidly identifying those at high risk who need urgent endoscopic care."
The study featured 24 patients with a history of upper GI bleeding who were randomized to capsule endoscopy or standard clinical evaluation following admission to the emergency room.
Intravenous metoclopramide was given within 10 minutes after the capsule was swallowed. Images were evaluated in real-time at the bedside and then again later after download. Patients with positive findings received endoscopic treatment within 6 hours, whereas those without bleeding and control subjects underwent endoscopic assessment within 24 hours.
Seven of the 12 patients in the capsule endoscopy group had positive findings. In all, seven stigmata of bleeding were confirmed at endoscopy. In 6 of the 7, the actual lesion was identified either during bedside image viewing or upon download review, the researchers report.
Of the 5 patients with negative findings on capsule images, 4 had no bleeding stigmata at endoscopy and 1 had comorbidities that precluded endoscopy. Capsule endoscopy-positive patients had a significantly shorter time to endoscopy than did controls: 2.5 vs. 8.9 hours (p = 0.029).
No patient died, and blood transfusion requirements and length of stay were comparable in the two groups. A capsule was retained in one patient with a strictured esophagus, but it was retrieved with endoscopy.
"We need to validate these findings in a larger trial that we are planning," Dr. Rubin said. "In a follow up study, we will use capsule endoscopy to segregate high-risk patients who need urgent intervention from low-risk patients who can potentially be treated more conservatively, and then assess outcomes."
3. ED Waiting Times Increasing in US
Percentage of US Emergency Department Patients Seen Within the Recommended Triage Time: 1997 to 2006
Horwitz LI, et al. Arch Intern Med. 2009;169:1857-1865.
Background The wait time to see a physician in US emergency departments (EDs) is increasing and may differentially affect patients with varied insurance status and racial/ethnic backgrounds.
Methods Using a stratified random sampling of 151 999 visits, representing 539 million ED visits from 1997 to 2006, we examined trends in the percentage of patients seen within the triage target time by triage category (emergent, urgent, semiurgent, and nonurgent), payer type, and race/ethnicity.
Results The percentage of patients seen within the triage target time declined a mean of 0.8% per year, from 80.0% in 1997 to 75.9% in 2006 (P less than .001). The percentage of patients seen within the triage target time declined 2.3% per year for emergent patients (59.2% to 48.0%; P less than .001) compared with 0.7% per year for semiurgent patients (90.6% to 84.7%; P less than .001). In 2006, the adjusted odds of being seen within the triage target time were 30% lower than in 1997 (odds ratio, 0.70; 95% confidence interval, 0.55-0.89). The adjusted odds of being seen within the triage target time were 87% lower (odds ratio, 0.13; 95% confidence interval, 0.11-0.15) for emergent patients compared with semiurgent patients. Patients of each payment type experienced similar decreases in the percentage seen within the triage target over time (P for interaction = .24), as did patients of each racial/ethnic group (P = .05).
Conclusions The percentage of patients in the ED who are seen by a physician within the time recommended at triage has been steadily declining and is at its lowest point in at least 10 years. Of all patients in the ED, the most emergent are the least likely to be seen within the triage target time. Patients of all racial/ethnic backgrounds and payer types have been similarly affected.
4. Ultrasound Detects Central Line Placement and Postprocedure Pneumothorax
Chest x-ray missed 2 of 4 pneumothoraces and 1 of 25 misplaced catheter tips that were detected by bedside ultrasound.
Vezzani A et al. Crit Care Med 2009 Oct 12.
Objective: To determine the usefulness of ultrasound to evaluate central venous catheter misplacements and detection of pneumothorax, thus obviating postprocedural radiograph. After the insertion of a central venous catheter, chest radiograph is usually obtained to ensure correct positioning of the catheter tip and detect postprocedural complications.
Measurements and Main Results: A prospective study of 111 consecutive central venous catheter procedures, using a landmark technique, was conducted in an adult intensive care unit. At the end of the procedure, a B-mode ultrasonography was first performed to assess catheter position and detect pneumothorax. Then, contrast enhanced ultrasonography was used to facilitate visualization of catheter tip, avoiding unknown right atrium positioning or artifacts. A postprocedural chest radiograph was obtained for all patients and was considered as a reference technique. Right atrium positioning was detected in 19 patients by ultrasonography, and an additional six by contrast enhanced ultrasonography. Combining ultrasonography and contrast enhanced ultrasonography yielded a 96% sensitivity and 93% specificity in detecting catheter misplacement. Concordance was 95% and [kappa] value was 0.88 (p less than .001). Pneumothorax was detected in four patients by ultrasonography and in two by chest radiograph (concordance = 98%). The mean time required to perform ultrasonography plus contrast enhanced ultrasonography was 10 +/- 5 mins vs. 83 +/- 79 mins for chest radiograph (p less than .05).
Conclusions: The close concordance between ultrasonography plus contrast enhanced ultrasonography and chest radiograph justifies the use of sonography as a standard technique to ensure the correct positioning of the catheter tip and to detect pneumothorax after central venous catheter cannulation to optimize use of hospital resources and minimize time consumption and radiation. Chest radiograph will be necessary when sonographic examination is impossible to perform by technical limitations.
5. Updated Guidelines for the Care of Children in EDs
This joint policy statement provides a highly useful roadmap for standardizing emergency care of children in community EDs.
American Academy of Pediatrics et al. Pediatrics 2009;124:1233-1243.
Full-text (free): http://pediatrics.aappublications.org/cgi/content/full/124/4/1233
6. Cervical Collar, Physical Therapy, or "Wait and See" for Recent-Onset Cervical Radiculopathy?
Pain scores were significantly lower in the collar and physical therapy groups.
Kuijper B et al. BMJ 2009 Oct 7; 339:b3883.
Full-text: http://www.bmj.com/cgi/content/full/339/oct07_1/b3883
7. A Comparison of Parental and Nursing Assessments of Level of Illness or Injury in a Pediatric Emergency Department
Kestner V, et al., Pediatric Emergency Care. 2009;25:633-635.
Background: The 5-tier Emergency Severity Index (ESI) score is a well-accepted, validated triage tool with good interrater reliability. Parental perception of illness severity has not been compared to ESI score.
Objective: This study compares parental assessment of severity of illness to triage nurse acuity.
Design: Prospective and descriptive.
Setting: Large, urban pediatric emergency department (ED).
Participants: Parents/guardians of patients younger than 18 years.
Intervention: The triage nurse assigned an ESI score, and the parent/guardian assigned all patients a severity score on a scale of 1 to 5 (1, most sick and 5, least sick). Mean severity scores were compared between the groups.
Results: There were 142 participants with a mean patient age of 6.15 years. The mean participant and nurse severity scores were 3.01 and 3.35, respectively, with an intraclass correlation coefficient of 0.203 (P = 0.008). Most frequently, the parent/guardian and triage nurse assigned the same score (n = 44, 31%). Seventy-six percent of the parent/guardian scores were within 1 point of the triage nurse score.
Conclusions: Close agreement exists between parent/guardian and nurse ESI scores, illustrating objectivity in parent/guardian assessments. This study provides a springboard for future studies regarding ED use after educating families on ED triage.
8. Interobserver agreement in the interpretation of computed tomography in acute pulmonary embolism
Costantino G, Amer J Emerg Med. 2009;27:1109-1111.
Multidetector computed tomography (MDCT) is one of the best diagnostic tools for the diagnosis of pulmonary embolism (PE). However, differences in MDCT interpretation, depending on the operator personal expertise, is an important factor that could interfere with the right diagnosis and, consequently, with the more adequate and well-timed therapy.
The aim of the present study was to evaluate the interobserver agreement in the interpretation of MDCT for the diagnosis of acute PE.
On a blind basis, 4 radiologists with different expertise in CT interpretation evaluated 46 different MDCT executed for acute PE. They had to verify the presence or absence of PE and, in the positive case, localize (right-left) and quantify (massive, segmentarian or subsegmentarian) it. The interobserver concordance was expressed using the Cohen K statistic.
The mean concordance between the 4 operators was high (0.82; range, 0.68-0.95). Ruling out the massive PE cases, the mean concordance over the other cases was only moderate (0.47; range, 0.16-0.84).
We found a very good interobserver agreement in MDCT evaluation for the diagnosis of massive PE, whereas we observed a lower concordance in regard to segmentarian and subsegmentarian PE. In the case of negative or nonmassive PE diagnosis, a second evaluation of the CT performed by an expert CT radiologist would probably be effective to decrease the CT evaluation error.
9. Compress the Chest: Better CPR Improves Survival from Out-of-Hospital Cardiac Arrest
Implementation of the 2005 AHA CPR guidelines that focus on uninterrupted chest compressions nearly doubled the odds of survival among patients with out-of-hospital cardiac arrest.
In 2005, the American Heart Association (AHA) released updated evidence-based guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, but does adherence to the revised protocol improve outcomes? Investigators compared rates of survival from out-of-hospital cardiac arrest among 606 adult patients treated before and 1021 treated after implementation of the 2005 AHA guidelines in a single large emergency medical services system.
Review of a convenience sample of 69 electronic electrocardiogram recordings showed significant improvement in CPR quality after guideline implementation, including improvements in mean chest-compression rate, proportion of time that patients received chest compressions, and median preshock and postshock pause times for compressions. Unadjusted rates of survival to hospital discharge were significantly higher after implementation of the guidelines than before (9.4% vs. 6.1%). Among patients with witnessed arrest whose initial rhythm was ventricular fibrillation on EMS arrival, survival rates improved significantly from 24% (19 of 78) before implementation to 30% (34 of 112) after. Multivariate regression analysis that adjusted for initial rhythm, sex, arrest location, and witnessed arrest showed 1.8 greater odds of survival in the postintervention period.
Comment: The promising results of this large study suggest the AHA was on the right track with its renewed focus on basic CPR, including the importance of providing uninterrupted chest compressions.
— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine October 23, 2009. Citation: Sayre MR et al. Impact of the 2005 American Heart Association cardiopulmonary resuscitation and emergency cardiovascular care guidelines on out-of-hospital cardiac arrest survival. Prehosp Emerg Care 2009;13:469.
10. Methohexital Beats Pentobarbital for Head CT Sedation in Children
Chun TH et al. Pediatr Emerg Care 2009 Oct; 25:648.
Objectives: To determine if there are differences in the duration of sedation between pediatric emergency department (PED) patients receiving methohexital and PED patients receiving pentobarbital for the purpose of obtaining a head computed tomographic (CT) scan.
Methods: Retrospective cohort study of PED patients receiving either methohexital or pentobarbital for a sedated head CT. Data were collected on patient demographics and medical condition, indications for head CT, duration of sedation, medication dosage, and medication adverse events. Primary analyses investigated whether there were differences between the 2 groups. Secondary analysis determined whether the need for additional sedative doses contributed to observed differences between groups.
Results: The patients receiving methohexital completed their head CT more quickly and needed less total sedation monitoring than those receiving pentobarbital. The need for additional doses of medication does not appear to be responsible for the observed difference. Adverse medication events were minor and comparable between groups.
Conclusions: Methohexital may be superior to pentobarbital for the purpose of sedating PED patients for head CT.
11. Anticholinergic Drugs and Acute Urinary Retention
Risk is highest during the first several weeks of treatment.
Martín-Merino E et al. J Urol 2009 Oct; 182:1442.
Abstract: http://www.jurology.com/article/S0022-5347(09)01525-0/abstract
12. Doctors' Lack of Respect Weighs on the Obese
October 29, 2009 — Heavier patients get less respect from doctors, raising concerns about the impact on the quality of care, new research indicates.
Scientists reporting in the November issue of the Journal of General Internal Medicine say they found that the higher a patient’s body mass index (BMI), the less respect their doctors had for them.
Mary Margaret Huizinga, MD, MPH, of Johns Hopkins University School of Medicine and lead author of the study, says she came up with the idea for the research from her experiences working in a weight loss clinic.
She says that patients who'd visit would, by the time they left, “be in tears, saying 'no other physician talked with me like this before,'" and had failed to listen.
“Many patients felt like because they were overweight, they weren’t receiving the type of care other patients received,” she says in a news release.
She and colleagues looked at data on 238 patients and 40 physicians. The average BMI of the patients was 32.9.
A person with a BMI of 25 to 29.9 is considered overweight, and 30 or greater obese.
In the study, patients and physicians filled out questionnaires about a doctor’s visit. They were asked questions about their attitudes and perceptions of one another at the end of their encounter. Physicians were asked to rate the level of respect they had for each patient compared to “the average patient” on a 5-point scale.
The patients for whom doctors expressed low respect, on average, had a higher BMI than patients for whom the physicians had high respect, the researchers report. The researchers note that the findings don’t show a cause/effect relationship between BMI and physician respect. Their study also didn’t investigate patients’ health outcomes.
Huizinga writes that respect is critical because some patients may avoid the health care system altogether. In other research, physician respect has been linked to more information being provided by the physician during a patient visit. She says more research is needed “to really understand how physician attitudes toward obesity affect quality of care for those patients."
“If a doctor has a patient with obesity and has low respect for that person, is the doctor less likely to recommend certain types of weight loss programs or to send her for cancer screening?” Huizinger asks. “We need to understand these things better.”
SOURCES: News release, Johns Hopkins University School of Medicine.
Huizinga, M., Journal of General Internal Medicine, November 2009.
13. Divorce Risk Higher When Wife Gets Sick
By TARA PARKER-POPE. NY Times. Nov 12, 2009.
When Dr. Marc Chamberlain, a Seattle oncologist, was treating his brain cancer patients, he noticed an alarming pattern. His male patients were typically receiving much-needed support from their wives. But a number of his female patients were going it alone, ending up separated or divorced after receiving a brain tumor diagnosis.
Dr. Chamberlain, chief of the neuro-oncology division at the Fred Hutchinson Cancer Research Center, had heard similar stories from his colleagues. To find out if these observations were based in fact, he embarked on a study with Dr. Michael J. Glantz of the University of Utah Huntsman Cancer Institute and colleagues from three other institutions who began to collect data on 515 patients who received diagnoses of brain tumors or multiple sclerosis from 2001 through 2006.
The results were surprising. Women in the study who were told they had a serious illness were seven times as likely to become separated or divorced than men with similar health problems, according to the report published in the journal Cancer.
The remainder of the NY Times article: http://well.blogs.nytimes.com/2009/11/12/men-more-likely-to-leave-spouse-with-cancer/
The abstract of the study: http://www3.interscience.wiley.com/journal/122527377/abstract
14. Intranasal Naloxone Is Effective for Opioid Overdose
Time from patient contact to clinical response was the same with intranasal and intravenous naloxone.
Robertson TM, et al. Prehospital Emerg Care 2009;13:512-515.
Objective. To compare the prehospital time intervals from patient contact and medication administration to clinical response for intranasal (IN) versus intravenous (IV) naloxone in patients with suspected narcotic overdose.
Methods. This was a retrospective review of emergency medical services (EMS) and hospital records, before and after implementation of a protocol for administration of intranasal naloxone by the Central California EMS Agency. We included patients with suspected narcotic overdose treated in the prehospital setting over 17 months, between March 2003 and July 2004. Paramedics documented dose, route of administration, and positive response times using an electronic record. Clinical response was defined as an increase in respiratory rate (breaths/min) or Glasgow Coma Scale score of at least 6. Main outcome variables included time from medication to clinical response and time from patient contact to clinical response. Secondary variables included numbers of doses administered and rescue doses given by an alternate route. Between-group comparisons were accomplished using t-tests and chi-square tests as appropriate.
Results. One hundred fifty-four patients met the inclusion criteria, including 104 treated with IV and 50 treated with IN naloxone. Clinical response was noted in 33 (66%) and 58 (56%) of the IN and IV groups, respectively (p = 0.3). The mean time between naloxone administration and clinical response was longer for the IN group (12.9 vs. 8.1 min, p = 0.02). However, the mean times from patient contact to clinical response were not significantly different between the IN and IV groups (20.3 vs. 20.7 min, p = 0.9). More patients in the IN group received two doses of naloxone (34% vs. 18%, p = 0.05), and three patients in the IN group received a subsequent dose of IV or IM naloxone.
Conclusions. The time from dose administration to clinical response for naloxone was longer for the IN route, but the overall time from patient contact to response was the same for the IV and IN routes. Given the difficulty and potential hazards in obtaining IV access in many patients with narcotic overdose, IN naloxone appears to be a useful and potentially safer alternative.
15. Subarachnoid Hemorrhage Might Be a Common Cause of Out-of-Hospital Cardiac Arrest
In this Japanese study, 16% of survivors of out-of-hospital cardiac arrest had subarachnoid hemorrhage.
Inamasu J, et al. Resuscitation 2009;80:977-980.
Aim
Aneurysmal subarachnoid haemorrhage (SAH) is a relatively common cause of out-of-hospital cardiac arrest (OHCA). Early identification of SAH-induced OHCA with the use of brain computed tomography (CT) scan obtained immediately after resuscitation may help emergency physicians make therapeutic decision as quickly as they can.
Methods
During the 4-year observation period, brain CT scan was obtained prospectively in 142 witnessed non-traumatic OHCA survivors who remained haemodynamically stable after resuscitation. Demographics and clinical characteristics of SAH-induced OHCA survivors were compared with those with “negative” CT finding.
Results
Brain CT scan was feasible with an average door-to-CT time of 40.0min. SAH was found in 16.2% of the 142 OHCA survivors. Compared with 116 survivors who were negative for SAH, SAH-induced OHCA survivors were significantly more likely to be female, to have experienced a sudden headache, and trended to have achieved return of spontaneous circulation (ROSC) prior to arrival in the emergency department less frequently. Ventricular fibrillation (VF) was significantly less likely to be seen in SAH-induced than SAH-negative OHCA (OR, 0.06; 95% CI, 0.01–0.46). Similarly, Cardiac Trop-T assay was significantly less likely to be positive in SAH-induced OHCA (OR, 0.08; 95% CI, 0.01–0.61).
Conclusion
Aneurysmal SAH causes OHCA more frequently than had been believed. Immediate brain CT scan may particularly be useful in excluding SAH-induced OHCA from thrombolytic trial enrollment, for whom the use of thrombolytics is contraindicated. The low VF incidence suggests that VF by itself may not be a common cause of SAH-induced OHCA.
16. Combination of epinephrine and dexamethasone may reduce hospitalization in children with bronchiolitis
Frohna JG, et al. J Pediatrics 2009;155:761-762.
Commentary
Identifying effective treatments for children with bronchiolitis has proven elusive. In part, this is due to the heterogenous cause of wheezing, which can range from episodic wheezing (often caused by viral infections) to multifactorial wheezing that can be triggered by a variety of factors and often resulting in asthma. A meta-analysis showed limited short-term benefit from epinephrine, and it is well known that children with asthma respond to corticosteroids. Plint et al were surprised to find a synergistic effect between epinephrine and dexamethasone, which reduced the frequency of hospitalization for children in this study. In addition, there are likely many factors that influence the decision to hospitalize a child, such as the distance to the hospital, the ability of the parents to care for their ill child, and the availability of health care resources. While a number needed to treat of 11 to prevent 1 hospitalization might be appealing, there are several caveats to these results. First, the dose of corticosteroids used in this study is quite high, and there is still limited knowledge of potential risks associated with this treatment. Second, when the authors adjusted their results for the multiple comparisons that were made, the difference in hospitalization was no longer statistically significant. One area of future research would be to look at the subgroups of infants who respond better to corticosteroids and look for possible biomarkers that may even include virus identification techniques. Although we await follow-up studies to provide stronger evidence, it is prudent to provide supportive care and close monitoring for children with an initial episode of wheezing. Monitoring these infants in the general pediatrician's office does not require high-tech medicine—just some relatively straightforward clinical algorithims.
Full-text: http://www.jpeds.com/article/S0022-3476(09)00862-2/fulltext
17. The Oblique View: An Alternative Approach for Ultrasound-Guided Central Line Placement
Phelan M, et al. Amer J Emerg Med. 2009;37:403-408.
Background: Numerous studies have shown significant benefits of using real-time ultrasonography for central line intravenous access. Traditionally, the ultrasound probe is placed along the short axis of the vein to visualize and direct needle placement. This view has some limitations, particularly being able to visualize the needle tip. Some practitioners place the ultrasound probe in the long axis of the vessel to direct needle placement, allowing better visualization of the needle entering the vein, but this does not allow visualization of relevant anatomic structures.
Objectives: We describe an alternative means to obtain ultrasound-guided vascular access using an oblique axis rather than the traditional short-axis approach.
Discussion: This view allows better visualization of the needle shaft and tip but also offers the safety of being able to visualize all relevant anatomically significant structures at the same time and in the same plane. This orientation is halfway between the short and long axis of the vessel, allowing visualization of the needle as it enters the vessel. This capitalizes on the strengths of the long axis while optimizing short-axis visualization of important structures during intravenous line placement.
Conclusion: Ultrasound-guided vascular access can be obtained in a variety of ways. We describe a technique that is used by some experienced ultrasound users but that has never been fully described in the literature. This technique for obtaining ultrasound-guided vascular access offers another option for attempting ultrasound-guided vascular access that has the potential to improve success rates and minimize complications associated with intravenous access.
18. CT-STAT: CT Angiography Rules Out CAD Faster and Cheaper Than Standard Care
Michael O'Riordan. November 18, 2009 (Orlando, Florida) — The use of coronary computed tomography (CT) angiography in the emergency room can successfully triage at-risk chest-pain patients and can do so faster and less expensively than standard diagnostic testing, according to the results of a new study.
"I think the reassurance is that both strategies are very safe," said lead investigator Dr James Goldstein (William Beaumont Hospital, Royal Oak, MI). "We've chosen a chosen a low-risk population--we don't want anybody to go home with a heart attack. We already know that the standard of care is a very fine strategy, and we've gotten very good at evaluating chest pain, but it is cumbersome and expensive."
Although the use of CT to rule out coronary artery disease should not be used in all patients, especially those with manifest ischemia, electrocardiogram abnormalities, or elevations in enzymatic biomarkers, among low-risk patients, "wisely and prudently applied," CT angiography is a powerful addition to the armamentarium of clinicians, said Goldstein.
The results of the study, known as the Computed Tomographic Angiography for the Systematic Triage of Acute Chest Pain Patients to Treatment (CT-STAT) trial, were presented today at the American Heart Association 2009 Scientific Sessions.
The remainder of the essay: http://www.medscape.com/viewarticle/712673
19. Prophylactic Acetaminophen Blunts Immunogenicity of Childhood Vaccinations
Routine prophylactic use of acetaminophen at the time of childhood immunizations should be reconsidered.
Prymula R et al. Lancet 2009; 374:1339.
Abstract: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61208-3/abstract
20. Kubler-Ross’ Stages of Grief: Maybe Not so Cut-and-Dried
In 1969 the psychiatrist Elizabeth Kubler-Ross wrote one of the most influential books in the history of psychology, On Death and Dying. It exposed the heartless treatment of terminally-ill patients prevalent at the time. On the positive side, it altered the care and treatment of dying people. On the negative side, it postulated the now-infamous five stages of dying—Denial, Anger, Bargaining, Depression, and Acceptance (DABDA), so annealed in culture that most people can recite them by heart. The stages allegedly represent what a dying person might experience upon learning he or she had a terminal illness. “Might” is the operative word, because Kübler-Ross repeatedly stipulated that a dying person might not go through all five stages, nor would they necessarily go through them in sequence. It would be reasonable to ask: if these conditions are this arbitrary, can they truly be called stages?
Many people have contested the validity of the stages of dying, but here we are more concerned with the supposed stages of grief which derived from the stages of dying. As professional grief recovery specialists, we contend that the theory of the stages of grief has done more harm than good to grieving people. Having co-authored three books on the impact of death, divorce, and other losses, and having worked directly with over 100,000 grieving people during the past 30 years, our reasons for disputing the stages of grief theory are predicated on the horror stories we’ve heard from thousands of grieving people who’ve told us how they’d been harmed by them.
Friedman R, et al. The Myth of the Stages of Dying, Death and Grief. Skeptic. 2008;13:37-41.
Full-text: http://www.grief.net/Articles/Myth%20of%20Stages.pdf
Wednesday, October 28, 2009
Lit Bits: Oct 28, 2009
From the recent medical literature...
1. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial
Jabre P, et al. Lancet. 2009;374(9686):293-300.
Introduction
Critically ill patients often require emergency orotracheal intubation for airway control. Rapid sequence intubation with administration of a sedative and a paralytic agent is common. Etomidate is the sedative-hypnotic drug that is most often used in rapid sequence intubation, but its use has been challenged because it can cause a reversible adrenal insufficiency by dose-dependent inhibition of 11β-hydroxylase.
Several studies have suggested an association between the use of etomidate and the occurrence of adrenal insufficiency and increased morbidity in critically ill or injured patients, particularly in those with sepsis. Because adrenal insufficiency when a patient is critically ill can increase the risk of death, several investigators have advised against the use of etomidate, even as a single bolus.9 However, no causal link has been established between its use and an increase in morbidity and mortality.
Etomidate's haemodynamic tolerance, even in patients with shock, and the excellent intubation conditions provided have to be weighed against potential adverse effects, including adrenal insufficiency. A possible alternative to etomidate is ketamine, which is not known to inhibit the adrenal axis. The aim of this randomised controlled study was to compare early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients.
Abstract
BACKGROUND: Critically ill patients often require emergency intubation. The use of etomidate as the sedative agent in this context has been challenged because it might cause a reversible adrenal insufficiency, potentially associated with increased in-hospital morbidity. We compared early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients.
METHODS: In this randomised, controlled, single-blind trial, 655 patients who needed sedation for emergency intubation were prospectively enrolled from 12 emergency medical services or emergency departments and 65 intensive care units in France. Patients were randomly assigned by a computerised random-number generator list to receive 0.3 mg/kg of etomidate (n=328) or 2 mg/kg of ketamine (n=327) for intubation. Only the emergency physician enrolling patients was aware of group assignment. The primary endpoint was the maximum score of the sequential organ failure assessment during the first 3 days in the intensive care unit. We excluded from the analysis patients who died before reaching the hospital or those discharged from the intensive care unit before 3 days (modified intention to treat). This trial is registered with ClinicalTrials.gov, number NCT00440102.
FINDINGS: 234 patients were analysed in the etomidate group and 235 in the ketamine group. The mean maximum SOFA score between the two groups did not differ significantly (10.3 [SD 3.7] for etomidate vs 9.6 [3.9] for ketamine; mean difference 0.7 [95% CI 0.0-1.4], p=0.056). Intubation conditions did not differ significantly between the two groups (median intubation difficulty score 1 [IQR 0-3] in both groups; p=0.70). The percentage of patients with adrenal insufficiency was significantly higher in the etomidate group than in the ketamine group (OR 6.7, 3.5-12.7). We recorded no serious adverse events with either study drug.
INTERPRETATION: Our results show that ketamine is a safe and valuable alternative to etomidate for endotracheal intubation in critically ill patients, and should be considered in those with sepsis.
FUNDING: French Ministry of Health.
Discussion
Our study shows that one etomidate bolus is not associated with a significant increase in morbidity or mortality compared with ketamine in patients admitted to the intensive care unit. The maximum SOFA score did not differ significantly between the two drugs in the subgroup of patients having sepsis or trauma. However, for the subgroup of septic patients (n=76), the small number of patients might account for the absence of significant difference. The mortality rate at day 28 in this subgroup did not differ between the treatment groups.
An association between the administration of etomidate and an increased mortality of patients with sepsis has been suggested previously. In a retrospective study of children with meningococcal sepsis or shock, mortality rate was 30% in patients who received etomidate versus 12% in those who did not, but the difference was not significant (OR 3•1 [95% CI 0•3–79•3]). In a post-hoc analysis of the Corticus study undertaken in patients with severe sepsis, the 28-day mortality rate was significantly higher in patients who received etomidate than in those who did not (p=0•03). The investigators, however, did not draw any cause and effect conclusion, presumably because of the lack of randomisation to sedative agents.
By contrast with the substantial increase in mortality reported by Ledingham and Watts, etomidate did not affect outcome in trauma patients in our study. This discrepancy between the two studies is probably related to the duration of etomidate administration: one bolus in our study versus prolonged sedation in Ledingham and Watts' study. Hildreth and co-workers reported increased use of blood products, ventilator days, and days in intensive care in trauma patients randomly assigned to etomidate (n=18) versus midazolam (n=12), but reported no difference in mortality. However, interpretation of this study is difficult because half of the eligible patients were excluded, with 11 of 31 patients having received etomidate.
Although adrenal axis dysfunction arises to some extent after etomidate use for rapid sequence intubation, the effect of such adrenal suppression on patients' outcome remains debated. Studies have reported increased mortality in non-responders to the adrenocorticotropin hormone stimulation test and in patients with adrenal insufficiency. One bolus of etomidate decreases cortisol secretion, which contributed to the increased morbidity and mortality reported in several studies. However, these findings have not been confirmed by other investigators. Clearly, the results of these studies could be biased owing to the presence of multiple confounding factors.
Our study confirms the finding of others that etomidate affects the adrenal axis: according to our criteria, more than four-fifths of etomidate recipients had adrenal insufficiency and were non-responders to the adrenocorticotropin hormone stimulation test. About half of patients given ketamine also had adrenal insufficiency, which emphasises that critical illness per se affects adrenal function. In one study, more than 30% of non-responders had not been exposed to etomidate, and in another, 51% of patients with septic shock who had not received etomidate were non-responders. Indeed, multiple mechanisms could account for adrenal insufficiency in critically ill patients. Adrenal insufficiency is probably associated with increased mortality in critically ill patients, including those with sepsis; however, whether the adrenal axis suppression and mortality are the result of some underlying process, or whether the adrenal axis suppression causes death, has never been established. Among established independent predictors of low cortisol response to adrenocorticotropin hormone stimulation are a low pH or bicarbonate and platelet count, disease severity, and organ failure. Fentanyl or sufentanil infusion can also modify cortisol concentrations. However, these factors should not affect the results of our study since both patient groups received the same type of continuous sedation (fentanyl or sufentanil combined with midazolam).
Etomidate is the sedative-hypnotic drug most often used by emergency physicians for rapid sequence intubation, and is the drug of choice for patients who are haemodynamically unstable. Use of ketamine instead of etomidate might have drawn attention to potential adverse effects of the use of ketamine during the intubation procedure. The most common side-effects of ketamine are psychodysleptic effects, but they could not be observed because, unlike in an operating theatre, patients are not awakened until several hours after intubation. We noted no difference between the sedative drugs tested in our study on the ease of intubation, probably because intubation conditions depend mostly on the muscle relaxant effects of succinylcholine. Accordingly, Sivilotti and Ducharme reported no significant difference in the overall successful intubation in a comparison of three hypnotic drugs.
With regard to the strengths and limitations of our study, we have confirmed the appropriateness of the choice of the maximum SOFA score as the primary endpoint. There is an established relation between the maximum SOFA score and Δ-SOFA score (from maximum to admission) and mortality in patients who are critically ill. Moreover, measurement of the SOFA score has good reliability and accuracy among intensivists. These scores have shown its usefulness in the assessment of in-hospital morbidity in seriously ill patients.
However, our study might not have had sufficient power to show a significant increase in morbidity related to the use of etomidate in patients with sepsis. Our failure to enroll and analyse a larger number of patients with sepsis could have led to a type-II error for this group. A future study should be based on patients with sepsis only, since the controversy regarding the use of etomidate focuses on these patients. We felt that patients admitted with trauma were important to study as well because of suggestions from recent reports that etomidate might be harmful to this group of patients. In conclusion, our results show that ketamine is a safe and valuable alternative to etomidate for intubation in critically ill patients, particularly in septic patients.
2. Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients
Chang AM, et al. Amer J Emerg Med. 2009;27:916-921.
Objective
Guidelines recommend treating patients with a new or presumed new left bundle-branch block (LBBB) similar to those with an acute ST-segment elevation myocardial infarction. It is often unclear which emergency department (ED) patients with potentially ischemic symptoms actually have an acute myocardial infarction (AMI), even in the setting of LBBB. Our null hypothesis was that in ED patients with potential AMI, the presence of a new or presumed new LBBB would not predict an increased likelihood of AMI.
Methods
This was an observational cohort study. Patients older than 30 years who presented with chest pain or other ischemic equivalent and had an electrocardiogram (ECG) to evaluate potential acute coronary syndrome (ACS) were enrolled. Data collected include demographics, history, ECG, and cardiac markers. Electrocardiograms were classified according to the standardized guidelines, including LBBB not known to be old (new or presumed new LBBB), LBBB known to be old, or no LBBB. The hospital course was followed, and 30-day follow-up was performed on all patients. Our main outcome was AMI.
Results
There were 7937 visits (mean age, 54.3 ± 15 years, 57% female, 68% black): 55 had new or presumed new LBBB, 136 had old LBBB, and 7746 had no LBBB. The rate of AMI was not significantly different between the 3 groups (7.3% vs 5.2% vs 6.1%; P = .75). Revascularization (7.8% vs old 5.2% vs 4.3%; P = .04) and coronary artery disease were more common in patients with new or presumed new LBBB (19.2% vs 11.9% vs 10.1%; P = .0004).
Conclusions
Despite guideline recommendations that patients with potential ACS and new or presumed new LBBB should be treated similar to STEMI, ED patients with a new or presumed new LBBB are not at increased risk of AMI. In fact, the presence of LBBB, whether new or old, did not predict AMI. Caution should be used in applying recommendations derived from patients with definite AMI to ED patients with potential ACS that may or may not be sustaining an AMI.
3. Recent-onset A Fibbers in the ED: Cardiovert?
Stead LG, et al. Rhythm Control With Electrocardioversion for Atrial Fibrillation and Flutter. Ann Emerg Med. 2009;54:745-747.
This review provides little evidence on which emergency physicians can base decisions about patients with acute atrial fibrillation. Because the majority of symptomatic patients encountered in the ED have atrial fibrillation of less than 48 hours’ duration and the risk of stroke and other complications in such patients is low, current practice remains cardioversion (electrical or medical) as soon as possible. In older patients with sustained atrial fibrillation, referral for cardioversion may be warranted for quality of life considerations; however, stroke prevention must be an integral
component of pre- and postcardioversion management to reduce the risk of embolic stroke.
Full-text (free): http://download.journals.elsevierhealth.com/pdfs/journals/0196-0644/PIIS0196064408020866.pdf
4. Arranging Follow-up Appointments for your Discharged Patients
Vinson DR, Patel PB. Facilitating follow-up after emergency care using an appointment assignment system. J Healthcare Quality. 2009; 31:18-24.
Many emergency department patients require urgent follow-up in primary care. The most effective way to help patients obtain their needed after-visit care is to secure the appointment on their behalf prior to their departure from the ED. This study describes the development, implementation, and outcomes of an appointment assignment system that facilitates patient follow-up at two community hospitals in an integrated healthcare system. This patient-centered system resulted in a high rate of compliance and a very low rate of unscheduled ED recidivism. Improving access in this manner will likely strengthen the continuum of care, improve quality, and increase patient satisfaction.
Full-text (free) available from the authors: drvinson@ucdavis.edu
5. Sleep-Deprived Attending Surgeons Have Higher Rates of Procedural Complications
Kathleen Louden. October 19, 2009 (Chicago, Illinois) — Attending surgeons who perform daytime surgical procedures within 6 hours of finishing an overnight shift have a nearly 3-fold higher rate of provider-related complications than when their opportunity for sleep between procedures exceeds 6 hours, a new study finds. The study was published in the October 14 issue of the Journal of the American Medical Association.
Until now, little was known about the effects of long work shifts and limited sleep opportunity on the performance of attending physicians, said lead author Jeffrey Rothschild, MD, MPH, a surgeon at Brigham and Women's Hospital and an assistant professor of medicine at Harvard Medical School in Boston, Massachusetts.
"Attendings who perform emergency overnight procedures . . . often perform elective procedures the next day," said Dr. Rothschild, who presented the results at a media briefing held to release new research on surgical care.
"Our data suggest that attending physicians, like residents and nurses, may be at increased risk of making errors when sleep-deprived or working extended shifts," he said.
The authors studied the outcomes of 919 "postnighttime" procedures performed by 86 attending surgeons over an 8-year period. The definition of a postnighttime procedure was one performed in the operating room the day after at least 1 operative case between midnight and 6 am. Dr. Rothschild's team compared outcomes of postnighttime procedures with those of 3552 control procedures, which were the same or similar procedures performed by the same 86 surgeons when they had not worked the previous night, within 12 months of the other procedures. Of the 86 surgeons, 32 were general surgeons. Their mean length of experience was 14 years.
Working Late Does Not Increase Next-Day Complications
Dr. Rothschild and colleagues found that the overall rate of complications — intraoperative adverse events likely attributable to the surgeon — did not significantly differ between postnighttime and control procedures. The complication rate was 7.5% in the postnighttime group and 7.8% in the control group. Likewise, the duration of the extended work shift did not have a statistically significant effect on the complication rate.
It was only when the investigators looked at the data by length of sleep opportunity — the time between the end of the last overnight case and the beginning of the first case later that day — that they observed a significant difference in the frequency of complications. When surgeons in the postnighttime group got 6 hours or less of sleep opportunity, there was a 2.7-fold increase in the rate of complications, compared with a longer time between shifts in the same group, Dr. Rothschild said. The difference between that 8.5% complication rate and the 3.1% rate for surgeons whose sleep opportunity was more than 6 hours was significant (P = .03), the authors write.
Actual sleep time was likely to be far shorter than sleep opportunity, owing to the need to change clothes and travel home, Dr. Rothschild noted.
Most of the complications that occurred were preventable, the authors report. The most frequent complications for both groups, according to Dr. Rothschild, were organ injury, bleeding, and infections.
Based on their findings, he said that "a limitless work week for attending physicians is not optimal for patient care."
Self-Regulation Needed
Unlike resident physicians, attending physicians in the United States have no restrictions on the number of hours they can work. Dr. Rothschild did not think that attendings' work hours would become federally regulated. Instead, he recommended strategies that surgeons can take to reduce complications due to fatigue.
"Surgeons can try to avoid scheduling elective surgeries the day after they take emergency call, or at least when risks are high for the elective procedure. And, if possible, they should use back-up personnel to assist when they are fatigued."
A limitation of the study, according to Dr. Rothschild, is that the investigators did not know the surgeons' sleep practices the night before control procedures. "Some physicians could have worked overnight at other hospitals," he explained. Also, the findings might not apply to nonteaching hospitals, he observed.
Although the study included data from only 1 center, it raised the profile of a common problem, said Phil Fontanarosa, MD, MBA, executive deputy editor of JAMA. "More awareness is needed about this problem among attending physicians, because all the focus [of fatigue contributing to medical errors] has been on residents," Dr. Fontanarosa told Medscape General Surgery.
JAMA. 2009;302:1565-1572.
6. Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment: U.S. Preventive Services Task Force Says “Don’t Bother”
Ann Intern Med. 2009;151:474-482.
The U.S. Preventive Services Task Force (USPSTF) has issued a recommendation statement on the use of 9 nontraditional risk factors (high-sensitivity C-reactive protein [CRP], ankle–brachial index, leukocyte count, fasting blood glucose level, periodontal disease, carotid intima–media thickness, coronary artery calcification on electron-beam computed tomography, homocysteine level, and lipoprotein[a] level) in assessing coronary heart disease (CHD) risk in asymptomatic persons. It concludes that the current evidence is insufficient to assess the balance of benefits and harms of using these nontraditional risk factors to screen asymptomatic men and women with no history of CHD to prevent CHD events (I statement).
Full-text (free): http://www.annals.org/cgi/content/full/151/7/474
7. Psychosocial Stress: Bad for your Heart
Milani RV, et al. Amer J Med. 2009;122:931-938.
Background
Exercise training reduces mortality in patients with coronary artery disease. Behavioral characteristics, including depression, hostility, and overall psychosocial stress, have been shown to be independent risk factors for recurrent myocardial infarction and death in these patients. Exercise training can reduce these high-risk behaviors, but it remains uncertain as to what extent the health benefits of exercise training can be attributed to improving these behaviors.
Methods
We evaluated the impact of exercise training during cardiac rehabilitation on mortality in 53 patients with coronary artery disease with high levels of psychosocial stress and in 469 patients with coronary artery disease with low levels of psychosocial stress and compared them with 27 control patients with high psychosocial stress who did not undergo formal cardiac rehabilitation and exercise training.
Results
Mortality was approximately 4-fold greater in patients with high psychosocial stress than in those with low psychosocial stress (22% vs 5%; P = .003). Exercise training decreased the prevalence of psychosocial stress from 10% to 4% (P less than .0001) and similarly improved peak oxygen uptake in patients with high and low psychosocial stress. Mortality in patients who improved exercise capacity by greater than 10% (high exercise change) was 60% lower than in patients who had less than 10% improvement in exercise capacity (low exercise change) (P=.009). Mortality was lower in patients with high psychosocial stress with high exercise change compared with patients with high psychosocial stress with low exercise change (0% vs 19%; P=.009). In contrast, there was no significant improvement in mortality in patients with high versus low exercise change with low psychosocial stress (4% vs 8%; P=.14).
Conclusion
Psychosocial stress is an independent risk factor for mortality in patients with coronary artery disease, and exercise training can effectively reduce its prevalence. Exercise training reduces mortality in patients with coronary artery disease, and this effect seems to be mediated in part because of the salutary effects of exercise on psychosocial stress.
Full-text: http://www.amjmed.com/article/PIIS0002934309004392/fulltext
8. Urinalysis (without culture) is not reliable to detect UTI in febrile ED infants
Reardon JM, et al. Amer J Emerg Med. 2009;27:930-932.
Objective
Urinary tract infections are a common source of serious bacterial infections in febrile infants younger than 2 years. Our objective was to compare urinalysis with urine culture in the emergency department evaluation of febrile infants.
Methods
A febrile infant registry was instituted at a tertiary care hospital treating an average of 55000 patients annually (27% children), from December 2002 to December 2003. Patients were eligible if they were younger than 3 months and had a temperature of at least 38°C or if they were between 3 and 24 months of age and had a temperature of at least 39°C. Data abstracted included age, sex, and temperature. Urinalysis (UA) and urine culture (UCx) results were obtained from electronic hospital archives.
Results
Nine hundred eighty-five patients were entered into the febrile infant registry. Male patients comprised 55%. The mean age of patients was 12.6 months; median was 12 months. Four hundred thirty-five (78% of eligible patients) had both a UA and UCx from the same specimen, and there were 45 (10.3%) positive UCx result. Females accounted for 33 (73%) of 45 positive results. The sensitivity of UA for predicting a positive UCx result was 64% (95% confidence interval [CI], 49%-78%), whereas the specificity was 91% (95% CI, 88%-94%). The positive predictive value was 46% (95% CI, 31%-53%), with a negative predictive value of 96% (95% CI, 93%-97%).
Conclusion
Urinalysis is not reliable for the detection of urinary tract infections in febrile infants when compared with urine cultures.
9. Crowding Delays Treatment and Lengthens Emergency Department Length of Stay, Even Among High-Acuity Patients
McCarthy ML, et al. Ann Emerg Med. 2009;54:492-503.e4.
Study objective
We determine the effect of crowding on emergency department (ED) waiting room, treatment, and boarding times across multiple sites and acuity groups.
Methods
This was a retrospective cohort study that included ED visit and inpatient medicine occupancy data for a 1-year period at 4 EDs. We measured crowding at 30-minute intervals throughout each patient's ED stay. We estimated the effect of crowding on waiting room time, treatment time, and boarding time separately, using discrete-time survival analysis with time-dependent crowding measures (ie, number waiting, number being treated, number boarding, and inpatient medicine occupancy rate), controlling for patient demographic and clinical characteristics.
Results
Crowding substantially delayed patients' waiting room and boarding times but not treatment time. During the day shift, when the number boarding increased from the 50th to the 90th percentile, the adjusted median waiting room time (range 26 to 70 minutes) increased by 6% to 78% (range 33 to 82 minutes), and the adjusted median boarding time (range 250 to 626 minutes) increased by 15% to 47% (range 288 to 921 minutes), depending on the site. Crowding delayed the care of high-acuity level 2 patients at all sites. During crowded periods (ie, 90%), the adjusted median waiting room times of high-acuity level 2 patients were 3% to 35% higher than during normal periods, depending on the site and crowding measure.
Conclusion
Using discrete-time survival analysis, we were able to dynamically measure crowding throughout each patient's ED visit and demonstrate its deleterious effect on the timeliness of emergency care, even for high-acuity patients.
Full-text (free): http://www.annemergmed.com/article/PIIS019606440900239X/fulltext
10. D-dimer Testing in Patients with Suspected Pulmonary Embolism and Impaired Renal Function: Still Useful
Karami-Djurabi R, et al. Amer J Med. 2009;122:1050-1053.
Background
Determination of pretest probability and D-dimer tests are the first diagnostic steps in patients with suspected pulmonary embolism, which can be ruled out when clinical probability is unlikely and D-dimer level is normal. We evaluated the utility of D-dimer testing in patients with impaired renal function.
Methods
D-dimer tests were performed in consecutive patients with suspected pulmonary embolism and an unlikely clinical probability. Creatinine levels were assessed as clinical routine. Glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula. Correlation between D-dimer level and renal function and proportions of patients with normal D-dimer in different categories of estimated glomerular filtration rate (eGFR) were assessed. Different categories of decreasing eGFR were defined as: normal renal function (eGFR over 89 mL/min), mild decrease in eGFR (eGFR 60-89 mL/min), and moderate decrease in eGFR (eGFR 30-59 mL/min).
Results
Creatinine levels were assessed in 351 of 385 patients (91%). D-dimer levels significantly increased in 3 categories of decreasing eGFR (P = .027 and P = .021 for moderate renal impairment compared with mild renal impairment and normal renal function, respectively). Normal D-dimer levels were found in 58% of patients with eGFR above 89 mL/min, in 54% with eGFR 60-89 mL/min, and in 28% with eGFR 30-59 mL/min.
Conclusions
The specificity of D-dimer testing in patients with suspected pulmonary embolism and decreased GFR is significantly decreased. Nonetheless, performing D-dimer tests is still useful because computed tomography scanning can be withheld in a significant proportion of these patients.
11. Pediatric myocarditis: presenting clinical characteristics
Durani Y, et al. Amer J Emerg Med. 2009;27:942-947.
Objective
The objective of the study was to characterize the clinical profiles of pediatric patients with acute myocarditis and dilated cardiomyopathy (DCM) before diagnosis.
Methods
A retrospective cross-sectional study was conducted to identify patients with myocarditis and DCM who presented over a 10-year span at 2 tertiary care pediatric hospitals. Patients were identified based on the International Classification of Diseases, Ninth Revision, diagnostic codes.
Results
A total of 693 charts were reviewed. Sixty-two patients were enrolled in the study. Twenty-four (39%) patients had a final diagnosis of myocarditis, and 38 (61%) had DCM. Of the 62 patients initially evaluated, 10 were diagnosed with myocarditis or DCM immediately, leaving 52 patients who required subsequent evaluation before a diagnosis was determined. Study patients had a mean age of 3.5 years, 47% were male, and 53% were female. Common primary complaints were shortness of breath, vomiting, poor feeding, upper respiratory infection (URI), and fever. Common examination findings were tachypnea, hepatomegaly, respiratory distress, fever, and abnormal lung examination result. Sixty-three percent had cardiomegaly on chest x-ray, and all had an abnormal electrocardiogram results.
Conclusions
These data suggest children with acute myocarditis and DCM most commonly present with difficulty breathing. Myocarditis and DCM may mimic other respiratory or viral illnesses, but hepatomegaly or the finding of cardiomegaly and an abnormal electrocardiogram result may help distinguish these diagnoses from other more common pediatric illnesses.
12. The Association between Transfer of ED Boarders to Inpatient Hallways and Mortality: A 4-Year Experience
Viccellio A, et al. Ann Emerg Med. 2009;54:487-491.
We posted this pre-publication abstract in our May Lit Bits, abstract #20. Since this article was published this month, the full-text is now available online for free: http://www.annemergmed.com/article/S0196-0644(09)00238-8/fulltext
13. New Analyses From ECASS 3 Support Use of tPA Up to 4.5 Hours After Stroke
Susan Jeffrey. October 20, 2009 (UPDATED October 21, 2009) — Secondary analyses of data from the third European Cooperative Acute Stroke Study (ECASS 3) trial appear to support the use of recombinant tissue plasminogen activator (rt-PA, alteplase) to treat stroke up to 4.5 hours after symptom onset in patients without exclusions for treatment, but who miss the approved time window of 0 to 3 hours.
"Almost all our additional outcome analyses strongly support the positive primary and secondary trial results of ECASS 3," the investigators, with lead author Werner Hacke, MD, PhD, professor and chairman of the Department of Neurology at Ruprecht-Karls-Universität, Germany, conclude.
Although not significant in every analysis, all additional efficacy endpoints showed "at least a clear pattern in favor of alteplase," the authors note, in particular confirming that treatment was effective in patients regardless of stroke severity.
However, Dr. Hacke told Medscape Neurology that in his view, the most critical point to make about ECASS 3, now supported by these subanalyses, is not that the time window for tPA can safely be extended to 4.5 hours.
"It is that the concept of thrombolytic therapy in acute ischemic stroke is supported now by a very straightforward, conservative, randomized clinical trial, a trial that is more than double the size of the National Institute of Neurological Disorders and Stroke trial that was positive for the 3-hour time window," he said.
Along with a collection of pooled and meta-analyses and data from a large European registry, he said, their results bolster the concept, still questioned by some, that thrombolysis as a valid therapy for stroke. "We have 2 independent randomized clinical trials that are positive with the primary outcome in favor of rtPA, so there is no reason any more to not accept this as a scientific fact," Dr. Hacke stressed.
This new report from ECASS 3 was published online October 21 and will appear in the December issue of Lancet Neurology. ECASS 3 was supported by Boehringer Ingelheim.
14. Images in EM
Traumatic Eye Swelling
http://www.annemergmed.com/article/S0196-0644(09)00365-5/fulltext
Psychotic Woman With Painful Abdominal Distension
http://www.annemergmed.com/article/S0196-0644(09)00373-4/fulltext
15. Facemasks and Hand Hygiene to Prevent Influenza Transmission in Households: A Cluster Randomized Trial
Cowling BJ, et al. Ann Intern Med. 2009;151:437-446
Few data are available on the effectiveness of nonpharmaceutical interventions for preventing influenza virus transmission. In this cluster randomized trial of 259 people with confirmed influenza virus infection and 794 household contacts, hand washing and facemasks seemed to prevent influenza virus transmission when healthy people started these measures within 36 hours of symptom onset in an infected family member. Although adherence to the interventions varied, these findings suggest that nonpharmaceutical interventions may help to mitigate pandemic and interpandemic influenza.
Abstract: http://www.annals.org/cgi/content/abstract/151/7/437
16. Validation of a Prediction Rule for the Identification of Children with Intra-abdominal Injuries After Blunt Torso Trauma
Holmes JF, et al. Ann Emerg Med. 2009;54:528-533.
Study objective
We validate the accuracy of a previously derived clinical prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma.
Methods
We conducted a prospective observational study of children with blunt torso trauma who were evaluated for intra-abdominal injury with abdominal computed tomography (CT), diagnostic laparoscopy, or laparotomy at a Level I trauma center during a 3-year period to validate a previously derived prediction rule. The emergency physician providing care documented history and physical examination findings on a standardized data collection form before knowledge of the results of diagnostic imaging. The clinical prediction rule being evaluated included 6 “high-risk” variables, the presence of any of which indicated that the child was not at low risk for intra-abdominal injury: low age-adjusted systolic blood pressure, abdominal tenderness, femur fracture, increased liver enzyme levels (serum aspartate aminotransferase concentration over 200 U/L or serum alanine aminotransferase concentration over 125 U/L), microscopic hematuria (urinalysis over 5 RBCs/high powered field), or an initial hematocrit level less than 30%.
Results
One thousand three hundred twenty-four children with blunt torso trauma were enrolled, and 1,119 (85%) patients had the variables in the decision rule documented by the emergency physician and therefore made up the study sample. The prediction rule had the following test characteristics: sensitivity=149 of 157, 94.9% (95% confidence interval [CI] 90.2% to 97.7%) and specificity=357 of 962, 37.1% (95% CI 34.0 to 40.3%). Three hundred sixty-five patients tested negative for the rule; thus, strict application would have resulted in a 33% reduction in abdominal CT scanning. Of the 8 patients with intra-abdominal injury not identified by the prediction rule, 1 underwent a laparotomy. This patient had a serosal tear and a mesenteric hematoma at laparotomy, neither of which required specific surgical intervention.
Conclusion
A clinical prediction rule consisting of 6 variables, easily available to clinicians in the ED, identifies most but not all children with intra-abdominal injury. Application of the prediction rule to this sample would have reduced the number of unnecessary abdominal CT scans performed but would have failed to identify 1 child undergoing (a nontherapeutic) laparotomy. Thus, further refinement of this prediction rule in a large, multicenter cohort is necessary before widespread implementation.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(09)00398-9/fulltext
17. Rapid Viral Testing Promising in Pediatric Emergencies
NEW YORK (Reuters Health) Oct 19 - In children with acute febrile respiratory illness, rapid viral testing techniques may save time and reduce demands on emergency department staff, according to a review published this month in the Cochrane Database of Systematic Reviews.
Nevertheless, lead investigator Dr. Quynh Doan said in a statement that "the existing evidence is not strong enough to prove that these tests help to reduce pressure on health systems, but it certainly does look promising."
Moreover, she told Reuters Health, "Rapid viral testing in a well defined context can provide physicians with very valuable information and potentially impact on management decision." However, "emphasis must be put on 'well defined context.'"
"We must remember," she added, "that only positive rapid viral testing adds any information, as these tests can only detect a specific virus -- commonly influenza -- and the absence of this virus in the sample is in no way indicative of what is causing the illness."
Dr. Doan of the British Columbia Children's Hospital in Vancouver, Canada, and colleagues studied data from 4 trials involving 759 children who underwent rapid testing and 829 who acted as controls.
Three of the studies employed influenza testing and the remaining study used a virus panel test encompassing influenza, parainfluenza, respiratory syncytial virus and adenovirus.
The team found that overall, viral testing reduced the use of chest X-rays (relative risk, 0.77) and that there was a trend toward less antibiotic usage (relative risk, 0.89) and fewer blood and urine investigations.
Dr. Doan also pointed out that "since the rate of positive rapid viral testing varied widely between 20 and 60% of tested subjects -- depending on which studies we look at -- perhaps we should be selective in the population to be tested in order to maximize its usefulness."
"In addition," she concluded, "it is important to note that all these studies were conducted before the H1N1 era. How rapid viral testing can contribute to managing the emergency department volume surges associated with the H1N1 pandemic can only be speculated."
Cochrane Database Syst Rev 2009.
18. The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics
Vaillancourt C, et al. Ann Emerg Med. 2009;54:663-671.e1
Study objective
We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting.
Methods
We conducted this prospective cohort study in 7 Canadian regions and involved alert (Glasgow Coma Scale score 15) and stable adult trauma patients at risk for neck injury. Advanced and basic care paramedics interpreted the Canadian C-Spine Rule status for all patients, who then underwent immobilization and assessment in the emergency department to determine the outcome, clinically important cervical spine injury.
Results
The 1,949 patients enrolled had these characteristics: median age 39.0 years (interquartile range 26 to 52 years), female patients 50.8%, motor vehicle crash 62.5%, fall 19.9%, admitted to the hospital 10.8%, clinically important cervical spine injury 0.6%, unimportant injury 0.3%, and internal fixation 0.3%. The paramedics classified patients for 12 important injuries with sensitivity 100% (95% confidence interval [CI] 74% to 100%) and specificity 37.7% (95% CI 36% to 40%). The κ value for paramedic interpretation of the Canadian C-Spine Rule (n=155) was 0.93 (95% CI 0.87 to 0.99). Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule.
Conclusion
This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.
Full-text (free): http://www.annemergmed.com/article/PIIS0196064409002418/fulltext
19. Serious Bacterial Infections Uncommon in Infants Who Have Experienced an Apparent Life-Threatening Event
Mittal MK, et al. Ann Emerg Med. 2009;54:523-527.
Study objective
We determine the incidence of serious bacterial infection in infants presenting to the emergency department (ED) with an apparent life-threatening event.
Methods
This was a prospective cohort study of infants younger than 12 months who were treated at an urban children's hospital ED during 1 year and who met standard criteria for an apparent life-threatening event. Sociodemographic data, presenting features, diagnostic testing, hospital course, and final diagnosis were collected. Follow-up information was obtained 4 weeks after the visit.
Results
Of the 198 infants enrolled, 44 (22.2%) had evaluation for serious bacterial infection: urine culture 36 (18%), blood culture 38 (19%) and cerebrospinal fluid culture 18 (9%). No infant (0/198; 95% confidence interval 0% to 1.8%) was found to have bacteremia, urinary tract infection, or bacterial meningitis, which was confirmed at the 4-week interview (99% ascertainment). Two infants were found to have enteroviral meningitis.
Conclusion
The incidence of serious bacterial infection in this cohort was extremely low. Infants presenting with an apparent life-threatening event need not be subjected to a full serious bacterial infection evaluation routinely.
20. Do Not Pardon the (CPR) Interruption
Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation
Wang HE, et al. Ann Emerg Med. 2009;54:645-652.e1
Emergency cardiac care guidelines emphasize treatment of cardiopulmonary arrest with continuous uninterrupted cardiopulmonary resuscitation (CPR) chest compressions. Paramedics in the United States perform endotracheal intubation on nearly all victims of out-of-hospital cardiopulmonary arrest. We quantified the frequency and duration of CPR chest compression interruptions associated with paramedic endotracheal intubation efforts during out-of-hospital cardiopulmonary arrest.
Methods
We studied adult out-of-hospital cardiopulmonary arrest treated by an urban and a rural emergency medical services agency from the Resuscitation Outcomes Consortium during November 2006 to June 2007. Cardiac monitors with compression sensors continuously recorded rescuer CPR chest compressions. A digital audio channel recorded all resuscitation events. We identified CPR interruptions related to endotracheal intubation efforts, including airway suctioning, laryngoscopy, endotracheal tube placement, confirmation and adjustment, securing the tube in place, bag-valve-mask ventilation between intubation attempts, and alternate airway insertion. We identified the number and duration of CPR interruptions associated with endotracheal intubation efforts.
Results
We included 100 of 182 out-of-hospital cardiopulmonary arrests in the analysis. The median number of endotracheal intubation–associated CPR interruption was 2 (interquartile range [IQR] 1 to 3; range 1 to 9). The median duration of the first endotracheal intubation–associated CPR interruption was 46.5 seconds (IQR 23.5 to 73 seconds; range 7 to 221 seconds); almost one third exceeded 1 minute. The median total duration of all endotracheal intubation–associated CPR interruptions was 109.5 seconds (IQR 54 to 198 seconds; range 13 to 446 seconds); one fourth exceeded 3 minutes. Endotracheal intubation–associated CPR pauses composed approximately 22.8% (IQR 12.6-36.5%; range 1.0% to 93.4%) of all CPR interruptions.
Conclusion
In this series, paramedic out-of-hospital endotracheal intubation efforts were associated with multiple and prolonged CPR interruptions.
Full-text (free): http://www.annemergmed.com/article/PIIS0196064409005344/fulltext
21. Abstracts from ACEP’s 2009 Scientific Assembly
A. ED Doctors Rarely Adjust Antibiotic Doses for Obese Patients
By Marilynn Larkin. NEW YORK (Reuters Health) Oct 07 - Emergency department physicians rarely adjust antimicrobial medication doses for obese patients, according to research reported Tuesday at the American College of Emergency Physicians annual meeting in Boston.
"We have a one-size-fits-all dose in our minds for most antibiotics, and we tend to give that dose regardless of size and other factors that should affect dosing, like age, renal function, and body mass index," study co-researcher Dr. Michael Mullins told Reuters Health.
Dr. Mullins and his colleagues, from Washington University School of Medicine, St. Louis, analyzed the rate at which their center's emergency physicians adhered to dose adjustment guidelines for selected antibiotics established by the university's antibiotic utilization review (AUR) committee.
They reviewed data for all emergency department patients treated over a 3-month period who weighed more than 100 kg, had a body mass index greater than 40 kg/m2, and were given cefazolin, cefepime, or ciprofloxacin.
Slightly more than a thousand patients met the study criteria. Overall, they were treated with 503 doses of cefepime, 293 doses of cefazolin, and 306 doses of ciprofloxacin. Thirty received more than one antibiotic.
Based on AUR guidelines, the initial dose for these patients should be 2 g IV for cefazolin or cefepime and 800 mg IV or 750 mg PO for ciprofloxacin.
These guidelines were followed for only 48 doses of cefepime (9.5%), 12 doses of cefazolin (4.1%), and 4 doses of ciprofloxacin (1.3%).
"Obesity is an epidemic in North America in particular, and unfortunately, we're seeing more people in the obese and severely obese range than we used to," Dr. Mullins observed. "I think this problem is under-recognized by emergency physicians and other specialists."
"If you give too low a dose," he cautioned, "you'll have treatment failure even if you pick the right antibiotic--and increase the likelihood that some of the bacteria you're trying to kill will form a mutation and become less sensitive to the drug."
B. Vast Increase in ED Visits for Head Injuries Seen After Natasha Richardson's Death
Fran Lowry. October 8, 2009 (Boston, Massachusetts) — Widespread media coverage of Natasha Richardson's death from a head injury on March 18, 2009 prompted a huge increase in emergency department (ED) visits, investigators reported here at the American College of Emergency Physicians 2009 Scientific Assembly.
The actress appeared well after she hit her head in a fall while skiing at Mont Tremblant, Quebec. She initially refused medical help, saying she felt fine, but died shortly afterward.
"We see this all the time in emergency rooms," Brian Walsh, MD, from Morristown Memorial Hospital in New Jersey, told Medscape Emergency Medicine. "Coverage about a certain disease, for instance meningitis deaths in young people, can cause a big bump in visits. We thought that the publicity surrounding her tragic death would do the same thing, and we wanted to quantify that."
Dr. Walsh and his colleagues compared the daily visits for head injury for the 10 days before and after March 18 in the EDs of 19 urban, suburban, and rural hospitals in New Jersey and New York. They classified patients as having head injury based on ICD9 codes.
They found that visits to the ED for head injury increased 73% (95% confidence interval, 53% - 94%; P less than .0001) for the 10 days after March 18 compared with the 10 days before. However, by March 31, the number of ED visits for head trauma was back to the pre–March 18 level.
According to Christina Campo-Ford, PA, from Morristown Memorial Hospital, who coauthored the study with Dr. Walsh, the media can cause quite a scare. "Good Morning America ran a spot a day after Natasha Richardson died about a little girl who was hit in the head with a softball and she was fine but then she went downhill. You can't show that on Good Morning America and not expect parents to bring their children in."
Pediatricians were telling concerned parents to bring their children who fell and hit their heads to the ED "just to be safe," she said. However, although the number of people who came to the ED for head trauma increased, the number of serious head injuries did not, nor did the percentage of computed tomography (CT) scans that were performed.
"We educated patients about the pros and cons of CTs and the radiation exposure risks and so on, and we did not do CTs unnecessarily," said Ms. Campo-Ford. "However, some patients insisted on having a CT, so we couldn't refuse them."
Ms. Campo-Ford believes that Ms. Richardson's death will continue to influence ED visits for head injury.
Media attention can definitely highlight issues, Debra Houry, MD, from Emory University in Atlanta, Georgia, told Medscape Emergency Medicine. "As emergency physicians, we need to make sure that we talk about injury prevention a well, such as helmet use, as this decreases the morbidity and mortality with a head injury."
Media reporting, which used headlines such as "Stand Up and Die" when reporting Ms. Richardson's death, fuels panic reactions on the part of the public, and encourages them to go to the ED even when such visits are not necessary. "The media called it "stand up and die," so why would you not come in if you hit your head," Ms. Campo-Ford noted.
Such reporting only compounds the already serious problem of ED overcrowding, said Dr. Walsh.
Physicians should educate their patients about head trauma and what symptoms to look for. But even when they do, some patients will insist on coming into the ED and having a CT scan anyway, Dr. Alexander M. Rosenau, DO, FACEP, from Lehigh Valley Hospital in Allentown, Pennsylvania, told Medscape Emergency Medicine. Dr. Rosenau is chair of the Emergency Medicine Foundation.
He pointed out how difficult it is to persuade patients that they don't need to come to the hospital after every head injury as a result of the publicity about Ms. Richardson. "A mother brought her daughter to the ED, insisting on a CT scan because the girl had fallen off her horse about 2 days prior and had hit her head. After taking a careful history and exam, we tried to reassure the mother that a CT was not necessary, but she was not convinced."
American College of Emergency Physicians 2009 Scientific Assembly. Abstract 156. Presented October 5, 2009.
C. Shorter Wait Times in the ED Mean More Patients Stay to See a Doctor
Marilynn Larkin. NEW YORK (Reuters Health) Oct 06 - Modest decreases in emergency department (ED) waiting times can have a big impact on whether a patient stays to see a doctor or leaves without being seen, investigators said Monday at the annual meeting of the American College of Emergency Physicians in Boston.
The research is based on an analysis of all visits to the George Washington Hospital ED from 2006-2008. Dr. Mehdi Sattarian and colleagues compared wait times for walk-in patients who left without being seen, either before or after nursing triage, to waiting times (from arrival to hospital bed) for people who arrived at the hospital at the same hour and stayed to see a doctor. They also recorded the total number of patients in the ED treatment area and lobby at the hour's end, and illness severity, Dr. Sattarian said at the Boston meeting.
During the study period, 187,663 patients came to the ED, 128,430 of whom were walk-ins. (The rest came by ambulance.) Of those, 5.2% left without being seen.
Further analysis revealed the proportion of walk-in patients who left without being seen fell from 5.5% in July-December 2006 to 3.5% in July-December 2008. During the same period, mean waiting times for walk-ins decreased from 61.4 to 52.6 minutes.
The drop in the number of patients who left without being seen occurred even while the total number of patients coming to the ED in a given hour increased (from 6.9 patients in 2006 to 7.5 patients in 2008), along with the number of patients left in the ED at the end of that hour (36.5 in 2006, 39.5 in 2008).
"We saw highly significant relationships between the number of people who left without being seen and both waiting times and the total number of patients in the emergency department," Dr. Sattarian told meeting attendees. In email to Reuters Health, he attributed improvements in "front-end processes" -- for example, streamlining registration and triage -- to the decreased waiting times and concomitant increase in the number of people who stayed to see a doctor.
Improving "back-end" processes -- what happens from the time a patient is seen by a doctor to the time they're either admitted or discharged -- could have "an even greater effect" on the number of people who stay to be seen by reducing the overall number of people in the ED, Dr. Sattarian observed.
Those strategies would include decreasing the amount of time it takes for seriously ill people to be moved to a hospital bed, and "improving laboratory and radiology turnaround times," he concluded.
D. Oxygen Therapy Relieves Headache Pain in the ED, Cuts Length of Stay, Drug Use
Marilyn Larkin. NEW YORK (Reuters Health) Oct 05 - Giving high-flow oxygen therapy for 15 minutes to emergency department patients with headaches provides rapid relief and reduces hospital stays, use of CT scans, and headache pharmacotherapy, according to a pilot study.
Dr. Boris Veysman of the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School reported the results on Monday at the annual meeting of the American College of Emergency Physicians in Boston.
"Very often, when a patient comes to the emergency department with one complaint being headache, they're uncomfortable and symptomatic and they have to wait for a workup before anyone can determine the cause. A diagnosis may not even be made in the emergency department," Dr. Veysman told Reuters Health. "So we approached it from a different perspective and asked, 'What if therapy were the first thing you did (for a headache) before attempting to find a cause?' And so we tried giving oxygen therapy, because it's so widespread and safe."
In the placebo-controlled study, 17 patients were randomized to 100% oxygen at 15 L/min for 15 minutes; 14 received high flow air for 15 minutes; and 17 received no intervention prior to standard treatment. Headache intensity was assessed using a 10-point visual analog scale.
Median times to relief were significantly shorter for patients treated with oxygen (40 minutes) compared with those treated with high flow air (110 minutes) or nothing (120 minutes). Median length of stay was also significantly shorter for patients treated with oxygen (57.5 minutes) than for those treated with air (210 minutes) or nothing (180 minutes).
In addition, CT scans were ordered less frequently: for four of 17 patients (24%) who received oxygen; 11 of 14 (79%) who received air; and eight of 17 (47%) who got nothing.
Medication was given to 29% of those who received oxygen, 86% of those who received air, and 82% of those who received no treatment.
Headache intensity was significantly reduced at both 15 minutes and 30 minutes after initiation of treatment, with patients treated with oxygen realizing the greatest reductions.
"It was a small study, and our results are preliminary," Dr. Veysman stressed. "But the medical community is starting to recognize that it's important to treat discomfort even when you don't know what's causing it, as long as you feel confident the treatment won't make the patient worse. In this case, we found more relief with oxygen than with placebo, although the fact that the headache goes away doesn't necessarily mean the patient can go home."
1. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial
Jabre P, et al. Lancet. 2009;374(9686):293-300.
Introduction
Critically ill patients often require emergency orotracheal intubation for airway control. Rapid sequence intubation with administration of a sedative and a paralytic agent is common. Etomidate is the sedative-hypnotic drug that is most often used in rapid sequence intubation, but its use has been challenged because it can cause a reversible adrenal insufficiency by dose-dependent inhibition of 11β-hydroxylase.
Several studies have suggested an association between the use of etomidate and the occurrence of adrenal insufficiency and increased morbidity in critically ill or injured patients, particularly in those with sepsis. Because adrenal insufficiency when a patient is critically ill can increase the risk of death, several investigators have advised against the use of etomidate, even as a single bolus.9 However, no causal link has been established between its use and an increase in morbidity and mortality.
Etomidate's haemodynamic tolerance, even in patients with shock, and the excellent intubation conditions provided have to be weighed against potential adverse effects, including adrenal insufficiency. A possible alternative to etomidate is ketamine, which is not known to inhibit the adrenal axis. The aim of this randomised controlled study was to compare early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients.
Abstract
BACKGROUND: Critically ill patients often require emergency intubation. The use of etomidate as the sedative agent in this context has been challenged because it might cause a reversible adrenal insufficiency, potentially associated with increased in-hospital morbidity. We compared early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients.
METHODS: In this randomised, controlled, single-blind trial, 655 patients who needed sedation for emergency intubation were prospectively enrolled from 12 emergency medical services or emergency departments and 65 intensive care units in France. Patients were randomly assigned by a computerised random-number generator list to receive 0.3 mg/kg of etomidate (n=328) or 2 mg/kg of ketamine (n=327) for intubation. Only the emergency physician enrolling patients was aware of group assignment. The primary endpoint was the maximum score of the sequential organ failure assessment during the first 3 days in the intensive care unit. We excluded from the analysis patients who died before reaching the hospital or those discharged from the intensive care unit before 3 days (modified intention to treat). This trial is registered with ClinicalTrials.gov, number NCT00440102.
FINDINGS: 234 patients were analysed in the etomidate group and 235 in the ketamine group. The mean maximum SOFA score between the two groups did not differ significantly (10.3 [SD 3.7] for etomidate vs 9.6 [3.9] for ketamine; mean difference 0.7 [95% CI 0.0-1.4], p=0.056). Intubation conditions did not differ significantly between the two groups (median intubation difficulty score 1 [IQR 0-3] in both groups; p=0.70). The percentage of patients with adrenal insufficiency was significantly higher in the etomidate group than in the ketamine group (OR 6.7, 3.5-12.7). We recorded no serious adverse events with either study drug.
INTERPRETATION: Our results show that ketamine is a safe and valuable alternative to etomidate for endotracheal intubation in critically ill patients, and should be considered in those with sepsis.
FUNDING: French Ministry of Health.
Discussion
Our study shows that one etomidate bolus is not associated with a significant increase in morbidity or mortality compared with ketamine in patients admitted to the intensive care unit. The maximum SOFA score did not differ significantly between the two drugs in the subgroup of patients having sepsis or trauma. However, for the subgroup of septic patients (n=76), the small number of patients might account for the absence of significant difference. The mortality rate at day 28 in this subgroup did not differ between the treatment groups.
An association between the administration of etomidate and an increased mortality of patients with sepsis has been suggested previously. In a retrospective study of children with meningococcal sepsis or shock, mortality rate was 30% in patients who received etomidate versus 12% in those who did not, but the difference was not significant (OR 3•1 [95% CI 0•3–79•3]). In a post-hoc analysis of the Corticus study undertaken in patients with severe sepsis, the 28-day mortality rate was significantly higher in patients who received etomidate than in those who did not (p=0•03). The investigators, however, did not draw any cause and effect conclusion, presumably because of the lack of randomisation to sedative agents.
By contrast with the substantial increase in mortality reported by Ledingham and Watts, etomidate did not affect outcome in trauma patients in our study. This discrepancy between the two studies is probably related to the duration of etomidate administration: one bolus in our study versus prolonged sedation in Ledingham and Watts' study. Hildreth and co-workers reported increased use of blood products, ventilator days, and days in intensive care in trauma patients randomly assigned to etomidate (n=18) versus midazolam (n=12), but reported no difference in mortality. However, interpretation of this study is difficult because half of the eligible patients were excluded, with 11 of 31 patients having received etomidate.
Although adrenal axis dysfunction arises to some extent after etomidate use for rapid sequence intubation, the effect of such adrenal suppression on patients' outcome remains debated. Studies have reported increased mortality in non-responders to the adrenocorticotropin hormone stimulation test and in patients with adrenal insufficiency. One bolus of etomidate decreases cortisol secretion, which contributed to the increased morbidity and mortality reported in several studies. However, these findings have not been confirmed by other investigators. Clearly, the results of these studies could be biased owing to the presence of multiple confounding factors.
Our study confirms the finding of others that etomidate affects the adrenal axis: according to our criteria, more than four-fifths of etomidate recipients had adrenal insufficiency and were non-responders to the adrenocorticotropin hormone stimulation test. About half of patients given ketamine also had adrenal insufficiency, which emphasises that critical illness per se affects adrenal function. In one study, more than 30% of non-responders had not been exposed to etomidate, and in another, 51% of patients with septic shock who had not received etomidate were non-responders. Indeed, multiple mechanisms could account for adrenal insufficiency in critically ill patients. Adrenal insufficiency is probably associated with increased mortality in critically ill patients, including those with sepsis; however, whether the adrenal axis suppression and mortality are the result of some underlying process, or whether the adrenal axis suppression causes death, has never been established. Among established independent predictors of low cortisol response to adrenocorticotropin hormone stimulation are a low pH or bicarbonate and platelet count, disease severity, and organ failure. Fentanyl or sufentanil infusion can also modify cortisol concentrations. However, these factors should not affect the results of our study since both patient groups received the same type of continuous sedation (fentanyl or sufentanil combined with midazolam).
Etomidate is the sedative-hypnotic drug most often used by emergency physicians for rapid sequence intubation, and is the drug of choice for patients who are haemodynamically unstable. Use of ketamine instead of etomidate might have drawn attention to potential adverse effects of the use of ketamine during the intubation procedure. The most common side-effects of ketamine are psychodysleptic effects, but they could not be observed because, unlike in an operating theatre, patients are not awakened until several hours after intubation. We noted no difference between the sedative drugs tested in our study on the ease of intubation, probably because intubation conditions depend mostly on the muscle relaxant effects of succinylcholine. Accordingly, Sivilotti and Ducharme reported no significant difference in the overall successful intubation in a comparison of three hypnotic drugs.
With regard to the strengths and limitations of our study, we have confirmed the appropriateness of the choice of the maximum SOFA score as the primary endpoint. There is an established relation between the maximum SOFA score and Δ-SOFA score (from maximum to admission) and mortality in patients who are critically ill. Moreover, measurement of the SOFA score has good reliability and accuracy among intensivists. These scores have shown its usefulness in the assessment of in-hospital morbidity in seriously ill patients.
However, our study might not have had sufficient power to show a significant increase in morbidity related to the use of etomidate in patients with sepsis. Our failure to enroll and analyse a larger number of patients with sepsis could have led to a type-II error for this group. A future study should be based on patients with sepsis only, since the controversy regarding the use of etomidate focuses on these patients. We felt that patients admitted with trauma were important to study as well because of suggestions from recent reports that etomidate might be harmful to this group of patients. In conclusion, our results show that ketamine is a safe and valuable alternative to etomidate for intubation in critically ill patients, particularly in septic patients.
2. Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients
Chang AM, et al. Amer J Emerg Med. 2009;27:916-921.
Objective
Guidelines recommend treating patients with a new or presumed new left bundle-branch block (LBBB) similar to those with an acute ST-segment elevation myocardial infarction. It is often unclear which emergency department (ED) patients with potentially ischemic symptoms actually have an acute myocardial infarction (AMI), even in the setting of LBBB. Our null hypothesis was that in ED patients with potential AMI, the presence of a new or presumed new LBBB would not predict an increased likelihood of AMI.
Methods
This was an observational cohort study. Patients older than 30 years who presented with chest pain or other ischemic equivalent and had an electrocardiogram (ECG) to evaluate potential acute coronary syndrome (ACS) were enrolled. Data collected include demographics, history, ECG, and cardiac markers. Electrocardiograms were classified according to the standardized guidelines, including LBBB not known to be old (new or presumed new LBBB), LBBB known to be old, or no LBBB. The hospital course was followed, and 30-day follow-up was performed on all patients. Our main outcome was AMI.
Results
There were 7937 visits (mean age, 54.3 ± 15 years, 57% female, 68% black): 55 had new or presumed new LBBB, 136 had old LBBB, and 7746 had no LBBB. The rate of AMI was not significantly different between the 3 groups (7.3% vs 5.2% vs 6.1%; P = .75). Revascularization (7.8% vs old 5.2% vs 4.3%; P = .04) and coronary artery disease were more common in patients with new or presumed new LBBB (19.2% vs 11.9% vs 10.1%; P = .0004).
Conclusions
Despite guideline recommendations that patients with potential ACS and new or presumed new LBBB should be treated similar to STEMI, ED patients with a new or presumed new LBBB are not at increased risk of AMI. In fact, the presence of LBBB, whether new or old, did not predict AMI. Caution should be used in applying recommendations derived from patients with definite AMI to ED patients with potential ACS that may or may not be sustaining an AMI.
3. Recent-onset A Fibbers in the ED: Cardiovert?
Stead LG, et al. Rhythm Control With Electrocardioversion for Atrial Fibrillation and Flutter. Ann Emerg Med. 2009;54:745-747.
This review provides little evidence on which emergency physicians can base decisions about patients with acute atrial fibrillation. Because the majority of symptomatic patients encountered in the ED have atrial fibrillation of less than 48 hours’ duration and the risk of stroke and other complications in such patients is low, current practice remains cardioversion (electrical or medical) as soon as possible. In older patients with sustained atrial fibrillation, referral for cardioversion may be warranted for quality of life considerations; however, stroke prevention must be an integral
component of pre- and postcardioversion management to reduce the risk of embolic stroke.
Full-text (free): http://download.journals.elsevierhealth.com/pdfs/journals/0196-0644/PIIS0196064408020866.pdf
4. Arranging Follow-up Appointments for your Discharged Patients
Vinson DR, Patel PB. Facilitating follow-up after emergency care using an appointment assignment system. J Healthcare Quality. 2009; 31:18-24.
Many emergency department patients require urgent follow-up in primary care. The most effective way to help patients obtain their needed after-visit care is to secure the appointment on their behalf prior to their departure from the ED. This study describes the development, implementation, and outcomes of an appointment assignment system that facilitates patient follow-up at two community hospitals in an integrated healthcare system. This patient-centered system resulted in a high rate of compliance and a very low rate of unscheduled ED recidivism. Improving access in this manner will likely strengthen the continuum of care, improve quality, and increase patient satisfaction.
Full-text (free) available from the authors: drvinson@ucdavis.edu
5. Sleep-Deprived Attending Surgeons Have Higher Rates of Procedural Complications
Kathleen Louden. October 19, 2009 (Chicago, Illinois) — Attending surgeons who perform daytime surgical procedures within 6 hours of finishing an overnight shift have a nearly 3-fold higher rate of provider-related complications than when their opportunity for sleep between procedures exceeds 6 hours, a new study finds. The study was published in the October 14 issue of the Journal of the American Medical Association.
Until now, little was known about the effects of long work shifts and limited sleep opportunity on the performance of attending physicians, said lead author Jeffrey Rothschild, MD, MPH, a surgeon at Brigham and Women's Hospital and an assistant professor of medicine at Harvard Medical School in Boston, Massachusetts.
"Attendings who perform emergency overnight procedures . . . often perform elective procedures the next day," said Dr. Rothschild, who presented the results at a media briefing held to release new research on surgical care.
"Our data suggest that attending physicians, like residents and nurses, may be at increased risk of making errors when sleep-deprived or working extended shifts," he said.
The authors studied the outcomes of 919 "postnighttime" procedures performed by 86 attending surgeons over an 8-year period. The definition of a postnighttime procedure was one performed in the operating room the day after at least 1 operative case between midnight and 6 am. Dr. Rothschild's team compared outcomes of postnighttime procedures with those of 3552 control procedures, which were the same or similar procedures performed by the same 86 surgeons when they had not worked the previous night, within 12 months of the other procedures. Of the 86 surgeons, 32 were general surgeons. Their mean length of experience was 14 years.
Working Late Does Not Increase Next-Day Complications
Dr. Rothschild and colleagues found that the overall rate of complications — intraoperative adverse events likely attributable to the surgeon — did not significantly differ between postnighttime and control procedures. The complication rate was 7.5% in the postnighttime group and 7.8% in the control group. Likewise, the duration of the extended work shift did not have a statistically significant effect on the complication rate.
It was only when the investigators looked at the data by length of sleep opportunity — the time between the end of the last overnight case and the beginning of the first case later that day — that they observed a significant difference in the frequency of complications. When surgeons in the postnighttime group got 6 hours or less of sleep opportunity, there was a 2.7-fold increase in the rate of complications, compared with a longer time between shifts in the same group, Dr. Rothschild said. The difference between that 8.5% complication rate and the 3.1% rate for surgeons whose sleep opportunity was more than 6 hours was significant (P = .03), the authors write.
Actual sleep time was likely to be far shorter than sleep opportunity, owing to the need to change clothes and travel home, Dr. Rothschild noted.
Most of the complications that occurred were preventable, the authors report. The most frequent complications for both groups, according to Dr. Rothschild, were organ injury, bleeding, and infections.
Based on their findings, he said that "a limitless work week for attending physicians is not optimal for patient care."
Self-Regulation Needed
Unlike resident physicians, attending physicians in the United States have no restrictions on the number of hours they can work. Dr. Rothschild did not think that attendings' work hours would become federally regulated. Instead, he recommended strategies that surgeons can take to reduce complications due to fatigue.
"Surgeons can try to avoid scheduling elective surgeries the day after they take emergency call, or at least when risks are high for the elective procedure. And, if possible, they should use back-up personnel to assist when they are fatigued."
A limitation of the study, according to Dr. Rothschild, is that the investigators did not know the surgeons' sleep practices the night before control procedures. "Some physicians could have worked overnight at other hospitals," he explained. Also, the findings might not apply to nonteaching hospitals, he observed.
Although the study included data from only 1 center, it raised the profile of a common problem, said Phil Fontanarosa, MD, MBA, executive deputy editor of JAMA. "More awareness is needed about this problem among attending physicians, because all the focus [of fatigue contributing to medical errors] has been on residents," Dr. Fontanarosa told Medscape General Surgery.
JAMA. 2009;302:1565-1572.
6. Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment: U.S. Preventive Services Task Force Says “Don’t Bother”
Ann Intern Med. 2009;151:474-482.
The U.S. Preventive Services Task Force (USPSTF) has issued a recommendation statement on the use of 9 nontraditional risk factors (high-sensitivity C-reactive protein [CRP], ankle–brachial index, leukocyte count, fasting blood glucose level, periodontal disease, carotid intima–media thickness, coronary artery calcification on electron-beam computed tomography, homocysteine level, and lipoprotein[a] level) in assessing coronary heart disease (CHD) risk in asymptomatic persons. It concludes that the current evidence is insufficient to assess the balance of benefits and harms of using these nontraditional risk factors to screen asymptomatic men and women with no history of CHD to prevent CHD events (I statement).
Full-text (free): http://www.annals.org/cgi/content/full/151/7/474
7. Psychosocial Stress: Bad for your Heart
Milani RV, et al. Amer J Med. 2009;122:931-938.
Background
Exercise training reduces mortality in patients with coronary artery disease. Behavioral characteristics, including depression, hostility, and overall psychosocial stress, have been shown to be independent risk factors for recurrent myocardial infarction and death in these patients. Exercise training can reduce these high-risk behaviors, but it remains uncertain as to what extent the health benefits of exercise training can be attributed to improving these behaviors.
Methods
We evaluated the impact of exercise training during cardiac rehabilitation on mortality in 53 patients with coronary artery disease with high levels of psychosocial stress and in 469 patients with coronary artery disease with low levels of psychosocial stress and compared them with 27 control patients with high psychosocial stress who did not undergo formal cardiac rehabilitation and exercise training.
Results
Mortality was approximately 4-fold greater in patients with high psychosocial stress than in those with low psychosocial stress (22% vs 5%; P = .003). Exercise training decreased the prevalence of psychosocial stress from 10% to 4% (P less than .0001) and similarly improved peak oxygen uptake in patients with high and low psychosocial stress. Mortality in patients who improved exercise capacity by greater than 10% (high exercise change) was 60% lower than in patients who had less than 10% improvement in exercise capacity (low exercise change) (P=.009). Mortality was lower in patients with high psychosocial stress with high exercise change compared with patients with high psychosocial stress with low exercise change (0% vs 19%; P=.009). In contrast, there was no significant improvement in mortality in patients with high versus low exercise change with low psychosocial stress (4% vs 8%; P=.14).
Conclusion
Psychosocial stress is an independent risk factor for mortality in patients with coronary artery disease, and exercise training can effectively reduce its prevalence. Exercise training reduces mortality in patients with coronary artery disease, and this effect seems to be mediated in part because of the salutary effects of exercise on psychosocial stress.
Full-text: http://www.amjmed.com/article/PIIS0002934309004392/fulltext
8. Urinalysis (without culture) is not reliable to detect UTI in febrile ED infants
Reardon JM, et al. Amer J Emerg Med. 2009;27:930-932.
Objective
Urinary tract infections are a common source of serious bacterial infections in febrile infants younger than 2 years. Our objective was to compare urinalysis with urine culture in the emergency department evaluation of febrile infants.
Methods
A febrile infant registry was instituted at a tertiary care hospital treating an average of 55000 patients annually (27% children), from December 2002 to December 2003. Patients were eligible if they were younger than 3 months and had a temperature of at least 38°C or if they were between 3 and 24 months of age and had a temperature of at least 39°C. Data abstracted included age, sex, and temperature. Urinalysis (UA) and urine culture (UCx) results were obtained from electronic hospital archives.
Results
Nine hundred eighty-five patients were entered into the febrile infant registry. Male patients comprised 55%. The mean age of patients was 12.6 months; median was 12 months. Four hundred thirty-five (78% of eligible patients) had both a UA and UCx from the same specimen, and there were 45 (10.3%) positive UCx result. Females accounted for 33 (73%) of 45 positive results. The sensitivity of UA for predicting a positive UCx result was 64% (95% confidence interval [CI], 49%-78%), whereas the specificity was 91% (95% CI, 88%-94%). The positive predictive value was 46% (95% CI, 31%-53%), with a negative predictive value of 96% (95% CI, 93%-97%).
Conclusion
Urinalysis is not reliable for the detection of urinary tract infections in febrile infants when compared with urine cultures.
9. Crowding Delays Treatment and Lengthens Emergency Department Length of Stay, Even Among High-Acuity Patients
McCarthy ML, et al. Ann Emerg Med. 2009;54:492-503.e4.
Study objective
We determine the effect of crowding on emergency department (ED) waiting room, treatment, and boarding times across multiple sites and acuity groups.
Methods
This was a retrospective cohort study that included ED visit and inpatient medicine occupancy data for a 1-year period at 4 EDs. We measured crowding at 30-minute intervals throughout each patient's ED stay. We estimated the effect of crowding on waiting room time, treatment time, and boarding time separately, using discrete-time survival analysis with time-dependent crowding measures (ie, number waiting, number being treated, number boarding, and inpatient medicine occupancy rate), controlling for patient demographic and clinical characteristics.
Results
Crowding substantially delayed patients' waiting room and boarding times but not treatment time. During the day shift, when the number boarding increased from the 50th to the 90th percentile, the adjusted median waiting room time (range 26 to 70 minutes) increased by 6% to 78% (range 33 to 82 minutes), and the adjusted median boarding time (range 250 to 626 minutes) increased by 15% to 47% (range 288 to 921 minutes), depending on the site. Crowding delayed the care of high-acuity level 2 patients at all sites. During crowded periods (ie, 90%), the adjusted median waiting room times of high-acuity level 2 patients were 3% to 35% higher than during normal periods, depending on the site and crowding measure.
Conclusion
Using discrete-time survival analysis, we were able to dynamically measure crowding throughout each patient's ED visit and demonstrate its deleterious effect on the timeliness of emergency care, even for high-acuity patients.
Full-text (free): http://www.annemergmed.com/article/PIIS019606440900239X/fulltext
10. D-dimer Testing in Patients with Suspected Pulmonary Embolism and Impaired Renal Function: Still Useful
Karami-Djurabi R, et al. Amer J Med. 2009;122:1050-1053.
Background
Determination of pretest probability and D-dimer tests are the first diagnostic steps in patients with suspected pulmonary embolism, which can be ruled out when clinical probability is unlikely and D-dimer level is normal. We evaluated the utility of D-dimer testing in patients with impaired renal function.
Methods
D-dimer tests were performed in consecutive patients with suspected pulmonary embolism and an unlikely clinical probability. Creatinine levels were assessed as clinical routine. Glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula. Correlation between D-dimer level and renal function and proportions of patients with normal D-dimer in different categories of estimated glomerular filtration rate (eGFR) were assessed. Different categories of decreasing eGFR were defined as: normal renal function (eGFR over 89 mL/min), mild decrease in eGFR (eGFR 60-89 mL/min), and moderate decrease in eGFR (eGFR 30-59 mL/min).
Results
Creatinine levels were assessed in 351 of 385 patients (91%). D-dimer levels significantly increased in 3 categories of decreasing eGFR (P = .027 and P = .021 for moderate renal impairment compared with mild renal impairment and normal renal function, respectively). Normal D-dimer levels were found in 58% of patients with eGFR above 89 mL/min, in 54% with eGFR 60-89 mL/min, and in 28% with eGFR 30-59 mL/min.
Conclusions
The specificity of D-dimer testing in patients with suspected pulmonary embolism and decreased GFR is significantly decreased. Nonetheless, performing D-dimer tests is still useful because computed tomography scanning can be withheld in a significant proportion of these patients.
11. Pediatric myocarditis: presenting clinical characteristics
Durani Y, et al. Amer J Emerg Med. 2009;27:942-947.
Objective
The objective of the study was to characterize the clinical profiles of pediatric patients with acute myocarditis and dilated cardiomyopathy (DCM) before diagnosis.
Methods
A retrospective cross-sectional study was conducted to identify patients with myocarditis and DCM who presented over a 10-year span at 2 tertiary care pediatric hospitals. Patients were identified based on the International Classification of Diseases, Ninth Revision, diagnostic codes.
Results
A total of 693 charts were reviewed. Sixty-two patients were enrolled in the study. Twenty-four (39%) patients had a final diagnosis of myocarditis, and 38 (61%) had DCM. Of the 62 patients initially evaluated, 10 were diagnosed with myocarditis or DCM immediately, leaving 52 patients who required subsequent evaluation before a diagnosis was determined. Study patients had a mean age of 3.5 years, 47% were male, and 53% were female. Common primary complaints were shortness of breath, vomiting, poor feeding, upper respiratory infection (URI), and fever. Common examination findings were tachypnea, hepatomegaly, respiratory distress, fever, and abnormal lung examination result. Sixty-three percent had cardiomegaly on chest x-ray, and all had an abnormal electrocardiogram results.
Conclusions
These data suggest children with acute myocarditis and DCM most commonly present with difficulty breathing. Myocarditis and DCM may mimic other respiratory or viral illnesses, but hepatomegaly or the finding of cardiomegaly and an abnormal electrocardiogram result may help distinguish these diagnoses from other more common pediatric illnesses.
12. The Association between Transfer of ED Boarders to Inpatient Hallways and Mortality: A 4-Year Experience
Viccellio A, et al. Ann Emerg Med. 2009;54:487-491.
We posted this pre-publication abstract in our May Lit Bits, abstract #20. Since this article was published this month, the full-text is now available online for free: http://www.annemergmed.com/article/S0196-0644(09)00238-8/fulltext
13. New Analyses From ECASS 3 Support Use of tPA Up to 4.5 Hours After Stroke
Susan Jeffrey. October 20, 2009 (UPDATED October 21, 2009) — Secondary analyses of data from the third European Cooperative Acute Stroke Study (ECASS 3) trial appear to support the use of recombinant tissue plasminogen activator (rt-PA, alteplase) to treat stroke up to 4.5 hours after symptom onset in patients without exclusions for treatment, but who miss the approved time window of 0 to 3 hours.
"Almost all our additional outcome analyses strongly support the positive primary and secondary trial results of ECASS 3," the investigators, with lead author Werner Hacke, MD, PhD, professor and chairman of the Department of Neurology at Ruprecht-Karls-Universität, Germany, conclude.
Although not significant in every analysis, all additional efficacy endpoints showed "at least a clear pattern in favor of alteplase," the authors note, in particular confirming that treatment was effective in patients regardless of stroke severity.
However, Dr. Hacke told Medscape Neurology that in his view, the most critical point to make about ECASS 3, now supported by these subanalyses, is not that the time window for tPA can safely be extended to 4.5 hours.
"It is that the concept of thrombolytic therapy in acute ischemic stroke is supported now by a very straightforward, conservative, randomized clinical trial, a trial that is more than double the size of the National Institute of Neurological Disorders and Stroke trial that was positive for the 3-hour time window," he said.
Along with a collection of pooled and meta-analyses and data from a large European registry, he said, their results bolster the concept, still questioned by some, that thrombolysis as a valid therapy for stroke. "We have 2 independent randomized clinical trials that are positive with the primary outcome in favor of rtPA, so there is no reason any more to not accept this as a scientific fact," Dr. Hacke stressed.
This new report from ECASS 3 was published online October 21 and will appear in the December issue of Lancet Neurology. ECASS 3 was supported by Boehringer Ingelheim.
14. Images in EM
Traumatic Eye Swelling
http://www.annemergmed.com/article/S0196-0644(09)00365-5/fulltext
Psychotic Woman With Painful Abdominal Distension
http://www.annemergmed.com/article/S0196-0644(09)00373-4/fulltext
15. Facemasks and Hand Hygiene to Prevent Influenza Transmission in Households: A Cluster Randomized Trial
Cowling BJ, et al. Ann Intern Med. 2009;151:437-446
Few data are available on the effectiveness of nonpharmaceutical interventions for preventing influenza virus transmission. In this cluster randomized trial of 259 people with confirmed influenza virus infection and 794 household contacts, hand washing and facemasks seemed to prevent influenza virus transmission when healthy people started these measures within 36 hours of symptom onset in an infected family member. Although adherence to the interventions varied, these findings suggest that nonpharmaceutical interventions may help to mitigate pandemic and interpandemic influenza.
Abstract: http://www.annals.org/cgi/content/abstract/151/7/437
16. Validation of a Prediction Rule for the Identification of Children with Intra-abdominal Injuries After Blunt Torso Trauma
Holmes JF, et al. Ann Emerg Med. 2009;54:528-533.
Study objective
We validate the accuracy of a previously derived clinical prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma.
Methods
We conducted a prospective observational study of children with blunt torso trauma who were evaluated for intra-abdominal injury with abdominal computed tomography (CT), diagnostic laparoscopy, or laparotomy at a Level I trauma center during a 3-year period to validate a previously derived prediction rule. The emergency physician providing care documented history and physical examination findings on a standardized data collection form before knowledge of the results of diagnostic imaging. The clinical prediction rule being evaluated included 6 “high-risk” variables, the presence of any of which indicated that the child was not at low risk for intra-abdominal injury: low age-adjusted systolic blood pressure, abdominal tenderness, femur fracture, increased liver enzyme levels (serum aspartate aminotransferase concentration over 200 U/L or serum alanine aminotransferase concentration over 125 U/L), microscopic hematuria (urinalysis over 5 RBCs/high powered field), or an initial hematocrit level less than 30%.
Results
One thousand three hundred twenty-four children with blunt torso trauma were enrolled, and 1,119 (85%) patients had the variables in the decision rule documented by the emergency physician and therefore made up the study sample. The prediction rule had the following test characteristics: sensitivity=149 of 157, 94.9% (95% confidence interval [CI] 90.2% to 97.7%) and specificity=357 of 962, 37.1% (95% CI 34.0 to 40.3%). Three hundred sixty-five patients tested negative for the rule; thus, strict application would have resulted in a 33% reduction in abdominal CT scanning. Of the 8 patients with intra-abdominal injury not identified by the prediction rule, 1 underwent a laparotomy. This patient had a serosal tear and a mesenteric hematoma at laparotomy, neither of which required specific surgical intervention.
Conclusion
A clinical prediction rule consisting of 6 variables, easily available to clinicians in the ED, identifies most but not all children with intra-abdominal injury. Application of the prediction rule to this sample would have reduced the number of unnecessary abdominal CT scans performed but would have failed to identify 1 child undergoing (a nontherapeutic) laparotomy. Thus, further refinement of this prediction rule in a large, multicenter cohort is necessary before widespread implementation.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(09)00398-9/fulltext
17. Rapid Viral Testing Promising in Pediatric Emergencies
NEW YORK (Reuters Health) Oct 19 - In children with acute febrile respiratory illness, rapid viral testing techniques may save time and reduce demands on emergency department staff, according to a review published this month in the Cochrane Database of Systematic Reviews.
Nevertheless, lead investigator Dr. Quynh Doan said in a statement that "the existing evidence is not strong enough to prove that these tests help to reduce pressure on health systems, but it certainly does look promising."
Moreover, she told Reuters Health, "Rapid viral testing in a well defined context can provide physicians with very valuable information and potentially impact on management decision." However, "emphasis must be put on 'well defined context.'"
"We must remember," she added, "that only positive rapid viral testing adds any information, as these tests can only detect a specific virus -- commonly influenza -- and the absence of this virus in the sample is in no way indicative of what is causing the illness."
Dr. Doan of the British Columbia Children's Hospital in Vancouver, Canada, and colleagues studied data from 4 trials involving 759 children who underwent rapid testing and 829 who acted as controls.
Three of the studies employed influenza testing and the remaining study used a virus panel test encompassing influenza, parainfluenza, respiratory syncytial virus and adenovirus.
The team found that overall, viral testing reduced the use of chest X-rays (relative risk, 0.77) and that there was a trend toward less antibiotic usage (relative risk, 0.89) and fewer blood and urine investigations.
Dr. Doan also pointed out that "since the rate of positive rapid viral testing varied widely between 20 and 60% of tested subjects -- depending on which studies we look at -- perhaps we should be selective in the population to be tested in order to maximize its usefulness."
"In addition," she concluded, "it is important to note that all these studies were conducted before the H1N1 era. How rapid viral testing can contribute to managing the emergency department volume surges associated with the H1N1 pandemic can only be speculated."
Cochrane Database Syst Rev 2009.
18. The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics
Vaillancourt C, et al. Ann Emerg Med. 2009;54:663-671.e1
Study objective
We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting.
Methods
We conducted this prospective cohort study in 7 Canadian regions and involved alert (Glasgow Coma Scale score 15) and stable adult trauma patients at risk for neck injury. Advanced and basic care paramedics interpreted the Canadian C-Spine Rule status for all patients, who then underwent immobilization and assessment in the emergency department to determine the outcome, clinically important cervical spine injury.
Results
The 1,949 patients enrolled had these characteristics: median age 39.0 years (interquartile range 26 to 52 years), female patients 50.8%, motor vehicle crash 62.5%, fall 19.9%, admitted to the hospital 10.8%, clinically important cervical spine injury 0.6%, unimportant injury 0.3%, and internal fixation 0.3%. The paramedics classified patients for 12 important injuries with sensitivity 100% (95% confidence interval [CI] 74% to 100%) and specificity 37.7% (95% CI 36% to 40%). The κ value for paramedic interpretation of the Canadian C-Spine Rule (n=155) was 0.93 (95% CI 0.87 to 0.99). Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule.
Conclusion
This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.
Full-text (free): http://www.annemergmed.com/article/PIIS0196064409002418/fulltext
19. Serious Bacterial Infections Uncommon in Infants Who Have Experienced an Apparent Life-Threatening Event
Mittal MK, et al. Ann Emerg Med. 2009;54:523-527.
Study objective
We determine the incidence of serious bacterial infection in infants presenting to the emergency department (ED) with an apparent life-threatening event.
Methods
This was a prospective cohort study of infants younger than 12 months who were treated at an urban children's hospital ED during 1 year and who met standard criteria for an apparent life-threatening event. Sociodemographic data, presenting features, diagnostic testing, hospital course, and final diagnosis were collected. Follow-up information was obtained 4 weeks after the visit.
Results
Of the 198 infants enrolled, 44 (22.2%) had evaluation for serious bacterial infection: urine culture 36 (18%), blood culture 38 (19%) and cerebrospinal fluid culture 18 (9%). No infant (0/198; 95% confidence interval 0% to 1.8%) was found to have bacteremia, urinary tract infection, or bacterial meningitis, which was confirmed at the 4-week interview (99% ascertainment). Two infants were found to have enteroviral meningitis.
Conclusion
The incidence of serious bacterial infection in this cohort was extremely low. Infants presenting with an apparent life-threatening event need not be subjected to a full serious bacterial infection evaluation routinely.
20. Do Not Pardon the (CPR) Interruption
Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation
Wang HE, et al. Ann Emerg Med. 2009;54:645-652.e1
Emergency cardiac care guidelines emphasize treatment of cardiopulmonary arrest with continuous uninterrupted cardiopulmonary resuscitation (CPR) chest compressions. Paramedics in the United States perform endotracheal intubation on nearly all victims of out-of-hospital cardiopulmonary arrest. We quantified the frequency and duration of CPR chest compression interruptions associated with paramedic endotracheal intubation efforts during out-of-hospital cardiopulmonary arrest.
Methods
We studied adult out-of-hospital cardiopulmonary arrest treated by an urban and a rural emergency medical services agency from the Resuscitation Outcomes Consortium during November 2006 to June 2007. Cardiac monitors with compression sensors continuously recorded rescuer CPR chest compressions. A digital audio channel recorded all resuscitation events. We identified CPR interruptions related to endotracheal intubation efforts, including airway suctioning, laryngoscopy, endotracheal tube placement, confirmation and adjustment, securing the tube in place, bag-valve-mask ventilation between intubation attempts, and alternate airway insertion. We identified the number and duration of CPR interruptions associated with endotracheal intubation efforts.
Results
We included 100 of 182 out-of-hospital cardiopulmonary arrests in the analysis. The median number of endotracheal intubation–associated CPR interruption was 2 (interquartile range [IQR] 1 to 3; range 1 to 9). The median duration of the first endotracheal intubation–associated CPR interruption was 46.5 seconds (IQR 23.5 to 73 seconds; range 7 to 221 seconds); almost one third exceeded 1 minute. The median total duration of all endotracheal intubation–associated CPR interruptions was 109.5 seconds (IQR 54 to 198 seconds; range 13 to 446 seconds); one fourth exceeded 3 minutes. Endotracheal intubation–associated CPR pauses composed approximately 22.8% (IQR 12.6-36.5%; range 1.0% to 93.4%) of all CPR interruptions.
Conclusion
In this series, paramedic out-of-hospital endotracheal intubation efforts were associated with multiple and prolonged CPR interruptions.
Full-text (free): http://www.annemergmed.com/article/PIIS0196064409005344/fulltext
21. Abstracts from ACEP’s 2009 Scientific Assembly
A. ED Doctors Rarely Adjust Antibiotic Doses for Obese Patients
By Marilynn Larkin. NEW YORK (Reuters Health) Oct 07 - Emergency department physicians rarely adjust antimicrobial medication doses for obese patients, according to research reported Tuesday at the American College of Emergency Physicians annual meeting in Boston.
"We have a one-size-fits-all dose in our minds for most antibiotics, and we tend to give that dose regardless of size and other factors that should affect dosing, like age, renal function, and body mass index," study co-researcher Dr. Michael Mullins told Reuters Health.
Dr. Mullins and his colleagues, from Washington University School of Medicine, St. Louis, analyzed the rate at which their center's emergency physicians adhered to dose adjustment guidelines for selected antibiotics established by the university's antibiotic utilization review (AUR) committee.
They reviewed data for all emergency department patients treated over a 3-month period who weighed more than 100 kg, had a body mass index greater than 40 kg/m2, and were given cefazolin, cefepime, or ciprofloxacin.
Slightly more than a thousand patients met the study criteria. Overall, they were treated with 503 doses of cefepime, 293 doses of cefazolin, and 306 doses of ciprofloxacin. Thirty received more than one antibiotic.
Based on AUR guidelines, the initial dose for these patients should be 2 g IV for cefazolin or cefepime and 800 mg IV or 750 mg PO for ciprofloxacin.
These guidelines were followed for only 48 doses of cefepime (9.5%), 12 doses of cefazolin (4.1%), and 4 doses of ciprofloxacin (1.3%).
"Obesity is an epidemic in North America in particular, and unfortunately, we're seeing more people in the obese and severely obese range than we used to," Dr. Mullins observed. "I think this problem is under-recognized by emergency physicians and other specialists."
"If you give too low a dose," he cautioned, "you'll have treatment failure even if you pick the right antibiotic--and increase the likelihood that some of the bacteria you're trying to kill will form a mutation and become less sensitive to the drug."
B. Vast Increase in ED Visits for Head Injuries Seen After Natasha Richardson's Death
Fran Lowry. October 8, 2009 (Boston, Massachusetts) — Widespread media coverage of Natasha Richardson's death from a head injury on March 18, 2009 prompted a huge increase in emergency department (ED) visits, investigators reported here at the American College of Emergency Physicians 2009 Scientific Assembly.
The actress appeared well after she hit her head in a fall while skiing at Mont Tremblant, Quebec. She initially refused medical help, saying she felt fine, but died shortly afterward.
"We see this all the time in emergency rooms," Brian Walsh, MD, from Morristown Memorial Hospital in New Jersey, told Medscape Emergency Medicine. "Coverage about a certain disease, for instance meningitis deaths in young people, can cause a big bump in visits. We thought that the publicity surrounding her tragic death would do the same thing, and we wanted to quantify that."
Dr. Walsh and his colleagues compared the daily visits for head injury for the 10 days before and after March 18 in the EDs of 19 urban, suburban, and rural hospitals in New Jersey and New York. They classified patients as having head injury based on ICD9 codes.
They found that visits to the ED for head injury increased 73% (95% confidence interval, 53% - 94%; P less than .0001) for the 10 days after March 18 compared with the 10 days before. However, by March 31, the number of ED visits for head trauma was back to the pre–March 18 level.
According to Christina Campo-Ford, PA, from Morristown Memorial Hospital, who coauthored the study with Dr. Walsh, the media can cause quite a scare. "Good Morning America ran a spot a day after Natasha Richardson died about a little girl who was hit in the head with a softball and she was fine but then she went downhill. You can't show that on Good Morning America and not expect parents to bring their children in."
Pediatricians were telling concerned parents to bring their children who fell and hit their heads to the ED "just to be safe," she said. However, although the number of people who came to the ED for head trauma increased, the number of serious head injuries did not, nor did the percentage of computed tomography (CT) scans that were performed.
"We educated patients about the pros and cons of CTs and the radiation exposure risks and so on, and we did not do CTs unnecessarily," said Ms. Campo-Ford. "However, some patients insisted on having a CT, so we couldn't refuse them."
Ms. Campo-Ford believes that Ms. Richardson's death will continue to influence ED visits for head injury.
Media attention can definitely highlight issues, Debra Houry, MD, from Emory University in Atlanta, Georgia, told Medscape Emergency Medicine. "As emergency physicians, we need to make sure that we talk about injury prevention a well, such as helmet use, as this decreases the morbidity and mortality with a head injury."
Media reporting, which used headlines such as "Stand Up and Die" when reporting Ms. Richardson's death, fuels panic reactions on the part of the public, and encourages them to go to the ED even when such visits are not necessary. "The media called it "stand up and die," so why would you not come in if you hit your head," Ms. Campo-Ford noted.
Such reporting only compounds the already serious problem of ED overcrowding, said Dr. Walsh.
Physicians should educate their patients about head trauma and what symptoms to look for. But even when they do, some patients will insist on coming into the ED and having a CT scan anyway, Dr. Alexander M. Rosenau, DO, FACEP, from Lehigh Valley Hospital in Allentown, Pennsylvania, told Medscape Emergency Medicine. Dr. Rosenau is chair of the Emergency Medicine Foundation.
He pointed out how difficult it is to persuade patients that they don't need to come to the hospital after every head injury as a result of the publicity about Ms. Richardson. "A mother brought her daughter to the ED, insisting on a CT scan because the girl had fallen off her horse about 2 days prior and had hit her head. After taking a careful history and exam, we tried to reassure the mother that a CT was not necessary, but she was not convinced."
American College of Emergency Physicians 2009 Scientific Assembly. Abstract 156. Presented October 5, 2009.
C. Shorter Wait Times in the ED Mean More Patients Stay to See a Doctor
Marilynn Larkin. NEW YORK (Reuters Health) Oct 06 - Modest decreases in emergency department (ED) waiting times can have a big impact on whether a patient stays to see a doctor or leaves without being seen, investigators said Monday at the annual meeting of the American College of Emergency Physicians in Boston.
The research is based on an analysis of all visits to the George Washington Hospital ED from 2006-2008. Dr. Mehdi Sattarian and colleagues compared wait times for walk-in patients who left without being seen, either before or after nursing triage, to waiting times (from arrival to hospital bed) for people who arrived at the hospital at the same hour and stayed to see a doctor. They also recorded the total number of patients in the ED treatment area and lobby at the hour's end, and illness severity, Dr. Sattarian said at the Boston meeting.
During the study period, 187,663 patients came to the ED, 128,430 of whom were walk-ins. (The rest came by ambulance.) Of those, 5.2% left without being seen.
Further analysis revealed the proportion of walk-in patients who left without being seen fell from 5.5% in July-December 2006 to 3.5% in July-December 2008. During the same period, mean waiting times for walk-ins decreased from 61.4 to 52.6 minutes.
The drop in the number of patients who left without being seen occurred even while the total number of patients coming to the ED in a given hour increased (from 6.9 patients in 2006 to 7.5 patients in 2008), along with the number of patients left in the ED at the end of that hour (36.5 in 2006, 39.5 in 2008).
"We saw highly significant relationships between the number of people who left without being seen and both waiting times and the total number of patients in the emergency department," Dr. Sattarian told meeting attendees. In email to Reuters Health, he attributed improvements in "front-end processes" -- for example, streamlining registration and triage -- to the decreased waiting times and concomitant increase in the number of people who stayed to see a doctor.
Improving "back-end" processes -- what happens from the time a patient is seen by a doctor to the time they're either admitted or discharged -- could have "an even greater effect" on the number of people who stay to be seen by reducing the overall number of people in the ED, Dr. Sattarian observed.
Those strategies would include decreasing the amount of time it takes for seriously ill people to be moved to a hospital bed, and "improving laboratory and radiology turnaround times," he concluded.
D. Oxygen Therapy Relieves Headache Pain in the ED, Cuts Length of Stay, Drug Use
Marilyn Larkin. NEW YORK (Reuters Health) Oct 05 - Giving high-flow oxygen therapy for 15 minutes to emergency department patients with headaches provides rapid relief and reduces hospital stays, use of CT scans, and headache pharmacotherapy, according to a pilot study.
Dr. Boris Veysman of the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School reported the results on Monday at the annual meeting of the American College of Emergency Physicians in Boston.
"Very often, when a patient comes to the emergency department with one complaint being headache, they're uncomfortable and symptomatic and they have to wait for a workup before anyone can determine the cause. A diagnosis may not even be made in the emergency department," Dr. Veysman told Reuters Health. "So we approached it from a different perspective and asked, 'What if therapy were the first thing you did (for a headache) before attempting to find a cause?' And so we tried giving oxygen therapy, because it's so widespread and safe."
In the placebo-controlled study, 17 patients were randomized to 100% oxygen at 15 L/min for 15 minutes; 14 received high flow air for 15 minutes; and 17 received no intervention prior to standard treatment. Headache intensity was assessed using a 10-point visual analog scale.
Median times to relief were significantly shorter for patients treated with oxygen (40 minutes) compared with those treated with high flow air (110 minutes) or nothing (120 minutes). Median length of stay was also significantly shorter for patients treated with oxygen (57.5 minutes) than for those treated with air (210 minutes) or nothing (180 minutes).
In addition, CT scans were ordered less frequently: for four of 17 patients (24%) who received oxygen; 11 of 14 (79%) who received air; and eight of 17 (47%) who got nothing.
Medication was given to 29% of those who received oxygen, 86% of those who received air, and 82% of those who received no treatment.
Headache intensity was significantly reduced at both 15 minutes and 30 minutes after initiation of treatment, with patients treated with oxygen realizing the greatest reductions.
"It was a small study, and our results are preliminary," Dr. Veysman stressed. "But the medical community is starting to recognize that it's important to treat discomfort even when you don't know what's causing it, as long as you feel confident the treatment won't make the patient worse. In this case, we found more relief with oxygen than with placebo, although the fact that the headache goes away doesn't necessarily mean the patient can go home."
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