Saturday, January 31, 2009

Lit Bits: January 31, 2009

From the recent medical literature...

1. Greater Use of Reperfusion Therapy and Faster Reperfusion Times With Prehospital ECGs

Michael O'Riordan, from Heartwire — a professional news service of WebMD. January 7, 2008 (Boston, Massachusetts) — Only one in four patients transported to the hospital by emergency medical services (EMS) is receiving a prehospital electrocardiogram (ECG), a new study has shown [1]. Those who are screened with an ECG, however, are reperfused faster and more frequently than those who do not receive a prehospital ECG with first medical contact, report investigators.

"We hope the findings drive home the message that irrespective of reperfusion strategy, whether in an academic center that can do primary PCI 24/7 or a community hospital that utilizes fibrinolysis, an EMS system that transports patients who have chest pain and performs an ECG before arriving at the hospital improves our patients' outcomes and improves time to reperfusion," lead investigator Dr Deborah Diercks (University of California Davis Medical Center, Sacramento) told heartwire.

In August 2008, the American Heart Association (AHA) issued a scientific statement on the use of prehospital ECGs to improve the quality of care delivered to STEMI patients. The AHA guidelines, as well as other consensus and scientific statements, recommend the acquisition and use of prehospital ECGs by EMS for the evaluation of patients with suspected acute coronary syndrome. The current recommendation is class 2a with a B level of evidence.

In this recent study, Diercks and colleagues evaluated patients with STEMI in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment and Intervention Outcomes Network (ACTION) over a one-year period in 2007.

In total, 7098 patients utilized the EMS, and of these patients, just 27.4% received a prehospital ECG. Within this EMS transport population, 92% of those who received a prehospital ECG underwent primary PCI compared with 86% of those who received an ECG in the hospital. Also, more patients receiving an ECG in the ambulance were treated with fibrinolytic therapy compared with those who received one in the hospital.

Reperfusion times among STEMI patients screened with an ECG by EMS personnel were also shorter compared with those who received an ECG in the hospital. Similarly, more patients who received a prehospital ECG met the AHA door-to-balloon time recommendations of less than 90 minutes for PCI and the door-to-needle time of less than 30 minutes for fibrinolysis.

"I think what really improves the quality of care with the prehospital ECG is the time it takes to activate the system," said Diercks. "The prehospital ECG allows institutions to open up the lab, get their personnel ready, so that when the patient arrives the machine is started--the patient can get to where they need to go in a more prompt fashion."

Just one in four patients receiving an ECG prior to arriving at the hospital is a surprising finding, said Diercks. She added, however, that this study comes on the heels of the latest recommendations for prehospital ECG screening, so there might be insufficient time to see changes in the system. Increasing funding, training for EMS personnel to develop skills to interpret the ECG, and improvements in data transmission will hopefully result in an increase in utilization, she said.

In addition to improvements in reperfusion, investigators observed a trend toward improved clinical outcomes among patients who received a prehospital ECG. There were trends toward lower mortality, less congestive heart failure, and less cardiogenic shock among STEMI patients screened with an ECG by the EMS personnel. Although it failed to reach statistical significance, the risk of death was reduced 20% among those who received an ECG with first medical contact.

"The findings fall in line with what we know," said Diercks. "The faster we're able to reperfuse these people, the better their outcomes are. A reduction in mortality is very much in line with the reduced time to reperfusion with the prehospital ECG."

Diercks DB, Kontos MC, Chen AY, et al. Utilization and impact of prehospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction. J Am Coll Cardiol 2009; 53:161-166. Abstract:

2. Direct Paramedic Transport of Acute Myocardial Infarction Patients to Percutaneous Coronary Intervention Centers: A Decision Analysis

Wang HE, et al. Ann Emerg Med. 2009;53:233-240.e5

Study objective
One potential strategy in the emergency medical services (EMS) care of acute ST-segment elevation myocardial infarction (STEMI) is to bypass the nearest community hospital in favor of a more distant specialty center able to perform primary percutaneous coronary intervention. We seek to determine whether EMS transport of out-of-hospital STEMI patients directly to more distant specialty percutaneous coronary intervention centers will alter 30-day survival compared with transport to the nearest community hospital fibrinolytic therapy.

This decision analysis used parameter values and ranges from meta-analyses and North American clinical studies of STEMI and chest pain care published after 2001. The primary hypothetical interventions were primary percutaneous coronary intervention versus community hospital–delivered fibrinolytic therapy. We defined total STEMI treatment time as the sum of symptom duration, EMS response time, EMS scene time, EMS transport time to the nearest community hospital, additional EMS transport time to a more distant percutaneous coronary intervention center, and door-to-drug or door-to-balloon time. We related total STEMI treatment time to the primary outcome 30-day post-STEMI survival. We assumed that the closest specialty percutaneous coronary intervention centers were located farther than the nearest community hospital and that patients would receive primary percutaneous coronary intervention at specialty centers and fibrinolytic therapy at community hospitals. We assumed the use of ground transportation only and excluded situations with fibrinolytic therapy contraindications. We examined standard risk and best-case scenarios for each intervention, as well as changes in predicted risk with parameter value variations.

Baseline total treatment times (chest pain onset to intervention) were percutaneous coronary intervention 188 minutes (range 41 to 447 minutes) and community hospital fibrinolytic therapy 118 minutes (range 51 to 267 minutes). Thirty-day survival was higher for standard percutaneous coronary intervention than standard community hospital fibrinolytic therapy (95.8% versus 93.8%; relative risk [RR] 1.021; number needed to treat 50) but lower when compared to best-case community hospital fibrinolytic therapy (95.8% versus 97.8%; RR 0.980; number needed to harm 50). Best-case percutaneous coronary intervention was equivalent to best-case community hospital fibrinolytic therapy (RR 1.000). In 1-way sensitivity analyses, best-case community hospital fibrinolytic therapy versus standard percutaneous coronary intervention was sensitive to treatment time parameter variations. Probabilistic sensitivity analysis favored standard percutaneous coronary intervention over standard community hospital fibrinolytic therapy (RR=1.020; 95% probability range 1.002 to 1.045) but did not indicate a favored strategy for the other scenarios.

In select out-of-hospital STEMI care scenarios, EMS transport of acute STEMI patients directly to percutaneous coronary intervention centers may offer small but uncertain survival benefits over nearest community hospital fibrinolytic therapy.

3. A Mysterious Link Between Sleeplessness and Heart Disease

December 24, 2008. By RONI CARYN RABIN. People who don’t get much sleep are more likely than those who do to develop calcium deposits in their coronary arteries, possibly raising their risk for heart disease, a new study has found.

The 495 participants in the study filled out sleep questionnaires and kept a log of their hours in bed. At night they also wore motion-sensing devices around their wrists that estimate the number of hours of actual sleep. At the beginning, none of the participants, who were ages 35 to 47, had evidence of coronary artery calcification.

Five years later, 27 percent of those who were sleeping less than five hours a night on average had developed coronary artery calcification for the first time, while only 6 percent of those who were sleeping seven hours or more had developed it. Among those who were sleeping between five and seven hours a night, 11 percent had developed coronary artery calcification, the study found.

After accounting for various other causes, the researchers concluded that one hour more of sleep per night was associated with a 33 percent decrease in the odds of calcification, comparable to the heart benefit gained by lowering one’s systolic blood pressure by 17 millimeters of mercury.

The study was published on Tuesday in the Journal of the American Medical Association. The data were drawn from the ongoing Coronary Artery Risk Development In Young Adults study.

Senior author Diane S. Lauderdale cautioned that the new report does not prove a cause-and-effect relationship between a lack of sleep and heart disease.

“It’s important to say that this is the first report and this does not yet prove the association is causal,” said Dr. Lauderdale, an associate professor of health studies at the University of Chicago Medical Center. “Until we know what the mechanism is -- that it’s really a direct or a causal relationship -- there is no point in making recommendations based on this.”

Although a number of studies have suggested that people who sleep less are at greater risk of heart disease and death, this is the first investigation to measure how much its subjects actually are sleeping, said Dr. Sanjay Patel, assistant professor of medicine at Case Western Reserve University and expert in sleep medicine. Patients’ own self-assessments can be very inaccurate, he added.

What isn’t clear is whether reduced sleep triggers physiological changes that increase heart disease risk, or whether a third, unrelated factor causes both changes, he said.

“It’s possible, for example, that people who are under more stress may be both sleeping less and at higher risk of heart disease,” Dr. Patel said.

If so, he added, “If we got those people to sleep more but they still were under a lot of stress, it wouldn’t change their risk of heart disease.”

Higher education levels are also associated with both a lower risk of heart disease and a tendency to get more sleep, said Dr. Lauderdale.

But it is also possible that lack of sleep leads to certain changes, like increasing blood levels of the stress hormone cortisol, which can raise the risk of coronary artery disease over time, Dr. Lauderdale said.

Another possible mechanism could be through the effect that sleep has on average blood pressure levels over a 24-hour period. Blood pressure usually dips when people are asleep, which could provide health benefits for those who get more sleep, Dr. Lauderdale suggested.

4. Full extension (nearly) rules out elbow fracture

Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children

Appelboam A, et al. BMJ 2008;337:a2428

Objective: To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury.
Design Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care.

Setting: Five emergency departments in southwest England.

Participants: 2127 adults and children presenting to the emergency department with acute elbow injury.

Intervention: Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children.

Main outcome measures: Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days.

Results: Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children.

Conclusion: The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.


For similar findings, cf. Darracq MA, Vinson DR, Panacek EA. Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture. Am J Emerg Med. 2008;26:779-82. Abstract:

5. Data indicate amount of free hospital care continues to skyrocket.

Source: The Orlando Business Journal (
Date: December 19, 2008

The Orlando Business Journal reports that data indicate that the "amount of free hospital care provided to needy patients locally skyrocketed by 41.6 percent in the past three years, from a combined $431.1 million in 2005 to a whopping $610.4 million in 2007." Nationally, "the amount of charity hospital care provided grew by eight percent in third-quarter 2008 when compared to the same period last year." Hospital officials "expect the situation to worsen in 2009 as the recession deepens and unemployment grows."

In fact, "every one percentage point increase in unemployment leads to a loss of employer-sponsored health coverage for an estimated 2.5 million employees and dependents," according to an American Hospital Association report. Moreover, "many people lacking health insurance turn to the emergency [department] as a last resort," and to "make matters worse, uncompensated care costs typically get shifted to the amount billed to private insurers, which drives up insurance premiums for employers and their workers." The culmination of all these events can put "the squeeze on hospitals, which are looking for a variety of ways to cut costs."

6. First Simple Febrile Seizure in Some Young Children Not Likely Bacterial Meningitis

Laurie Barclay, MD. January 14, 2009 — Lumbar puncture may not be necessary for a first simple febrile seizure at ages 6 to 18 months because the risk for bacterial meningitis is very low, according to the results of a retrospective cohort review in the January issue of Pediatrics.

"American Academy of Pediatrics consensus statement recommendations are to consider strongly for infants 6 to 12 months of age with a first simple febrile seizure and to consider for children 12 to 18 months of age with a first simple febrile seizure lumbar puncture for cerebrospinal fluid analysis," write Amir A. Kimia, MD, from Children's Hospital Boston in Massachusetts, and colleagues. "Our aims were to determine compliance with these recommendations and to assess the rate of bacterial meningitis detected among these children."

The investigators reviewed records for patients aged 6 to 18 months who were seen in a pediatric emergency department between October 1995 and October 2006 for a first simple febrile seizure. This presenting complaint accounted for 1% of all emergency department visits for children of this age during this period (704 cases of children among 71,234 eligible visits).

Of the first simple febrile seizure visits, 188 (27%) were for infants aged 6 to 12 months, and 516 (73%) were for infants aged 12 to 18 months; in total, 271 (38%) had lumbar puncture. Of 188 children aged 6 to 12 months, 131 (70%) had available samples, as did 129 (25%) of 516 children aged 12 to 18 months. In both age groups, rates of lumbar puncture decreased significantly with time.

Ten cases (3.8%) had elevated cerebrospinal fluid white blood cell count, but all results of cerebrospinal fluid cultures were negative for pathogens. Although 10 (3.8%) of cultures were positive for a contaminant, no patients were diagnosed with bacterial meningitis.

"The risk of bacterial meningitis presenting as first simple febrile seizure at ages 6 to 18 months is very low," the study authors write. "Current American Academy of Pediatrics recommendations should be reconsidered."

Limitations of the study include lack of generalizability to patients with complex febrile seizures, ill-appearing patients, or those with an underlying illness; lack of complete follow-up of patients who did not have lumbar puncture; and pretreatment of 68 patients with antibiotics before their visit to the emergency department.

"Sound clinical judgment should always prevail, and clinicians should err on the side of caution (including performing an LP [lumbar puncture]) when evaluating any febrile child for whom the presence of bacterial meningitis is being considered," the study authors conclude.

Kimia AA ,et al. Pediatrics. 2009;123:6-12.

7. Is Subcutaneous Administration of Rapid-Acting Insulin as Effective as Intravenous Insulin for Treating Diabetic Ketoacidosis?

Mazer M, et al. Ann Emerg Med. 2009;53:259-263.

Diabetes mellitus, second only to hypertension as the most common chronic condition of emergency department (ED) patients, can cause acute hyperglycemia and ketoacidosis, responsible for more than 1 million ED visits in 2005. Traditionally (and more recently endorsed by the American Diabetes Association), the treatment of diabetic ketoacidosis is accomplished by the administration of a low dose intravenous infusion of regular insulin that is initiated in the ED and continued in an ICU3 setting for frequent insulin/fluid adjustments, glucose monitoring, and electrolyte assessment.

Although insulin administration by any route is effective for treating diabetic ketoacidosis, intravenous insulin is preferred over subcutaneous and intramuscular insulin because it provides rapid, titratable glycemic control. For example, subcutaneous regular insulin has an onset of action within 1 hour, peaks within 1 to 5 hours, and may last for 6 to 10 hours, whereas intravenous insulin acts within minutes and has a half-life of 9 minutes. Within the past decade, rapid-acting insulin analogues (lispro [Humalog, Eli Lilly and Company, Indianapolis, IN], aspart [Novolog, Novo Nordisk Inc, Princeton, NJ], and glulisine [Apidra, Sanofi-Aventis, Bridgewater, NJ]) have been adopted preferentially for the inpatient treatment of hyperglycemia because of their more favorable pharmacokinetic profiles. When administered subcutaneously, these analogs have an onset of action within 10 to 20 minutes, peak within 30 to 90 minutes, and last approximately 3 to 4 hours.

Because intravenous insulin infusion requires ICU admission in some institutions and higher equipment (infusion pumps, additional intravenous access) and nursing costs, we searched the literature to determine whether intermittent subcutaneous use of these rapid-acting analogs might be as effective as intravenous insulin infusions in treating uncomplicated diabetic ketoacidosis.

To determine whether intermittent subcutaneous administration of rapid-acting insulin is as effective as intravenous infusion of regular insulin for treating uncomplicated diabetic ketoacidosis, we performed a MEDLINE, EMBASE, and Cochrane Library search…

The Bottom Line
According to this review of the available data (Table), subcutaneous administration of rapid-acting insulin analogues such as lispro every hour (0.3 U/kg bolus; then 0.1 U/kg) or 2 hours (0.3 U/kg bolus; then 0.2 U/kg) may be a reasonable alternative to intravenous regular insulin infusion for treating uncomplicated diabetic ketoacidosis. Insulin analogues are as effective as intravenous insulin at normalizing glucose levels and other acid-base characteristics, with similar rates of hypoglycemia. Moreover, patients receiving subcutaneous insulin may be treated on the medical floors or in step-down units, which may provide an overall cost savings and improve ED patient flow when ICU beds are scarce.

Finally, although the data provided support for our conclusions, they are based on a few small studies (with slightly different inclusion and exclusion criteria and definitions for resolution of diabetic ketoacidosis), focused on one particular analogue (lispro), and assume that intravenous insulin infusions require monitoring in intensive care settings. More important, the majority are manufacturer-sponsored studies, thereby introducing the potential for a conflict of interest. Despite these limitations, we conclude that it would be safe and effective to treat uncomplicated diabetic ketoacidosis with a subcutaneously administered rapid-acting insulin analogue.

8. Use of the Emergency Department for Severe Headache. A Population-Based Study

Friedman BF, et al. Headache 2009;49:21-30.

Background.—Although headache is a common emergency department (ED) chief complaint, the role of the ED in the management of primary headache disorders has rarely been assessed from a population perspective. We determined frequency of ED use and risk factors for use among patients suffering severe headache.

Methods.—As part of the American Migraine Prevalence and Prevention study, a validated self-administered questionnaire was mailed to 24,000 severe headache sufferers, who were randomly drawn from a larger sample constructed to be sociodemographically representative of the US population. Participants were asked a series of questions on headache management, healthcare system use, sociodemographic features, and number of ED visits for management of headache in the previous 12 months. In keeping with the work of others, "frequent" ED use was defined as a particpant's report of 4 or more visits to the ED for treatment of a headache in the previous 12 months. Headaches were categorized into specific diagnoses using a validated methodology.

Results.—Of 24,000 surveys, 18,514 were returned, and 13,451 (56%) provided complete data on ED use. Sociodemographic characteristics did not differ substantially between responders and nonresponders. Among the 13,451 responders, over the course of the previous year, 12,592 (94%) did not visit the ED at all, 415 (3%) visited the ED once, and 444 (3%) visited the ED more than once. Patients with severe episodic tension-type headache were less likely to use the ED than patients with severe episodic migraine (OR 0.4 [95% CI: 0.3, 0.6]). Frequent ED use was reported by 1% of the total sample or 19% (95% CI: 17%, 22%) of subjects who used the ED in the previous year, although frequent users accounted for 51% (95% CI: 49%, 53%) of all ED visits. Predictors of ED use included markers of disease severity, elevated depression scores, low socioeconomic status, and a predilection for ED use for conditions other than headache.

Conclusions.—Most individuals suffering severe headaches do not use the ED over the course of a single year. The majority of ED visits for severe headache are accounted for by a small subset of all ED users. Increasing disease severity and depression are the most readily addressable factors associated with ED use.

9. Images in Emergency Medicine

a. Woman With Low Back Pain

b. Limp in an 11-Year-Old Male

10. Impact of an Internet-Based Emergency Department Appointment System to Access Primary Care at Safety Net Community Clinics

Chan TC, et al. Ann Emerg Med 2009; in press.

Study objective
We evaluate the effect of an Internet-based, electronic referral system (termed IMPACT-ED for Improving Medical home and Primary care Access to the Community clinics Through the ED) on access and follow-up at primary care community clinics for safety net emergency department (ED) patients.

We conducted a nonblinded interventional trial at an urban, safety net, hospital ED with a census of 39,000 annually. IMPACT-ED identified patients who had no source of regular care and lived in a 15-ZIP-code low-income area served by 3 community clinics. Emergency physicians received an automated notification through the electronic medical record to access an imbedded software program for scheduling follow-up clinic appointments. Patients who would benefit from a follow-up clinic visit within 2 weeks as determined by the emergency physician received a computer-generated appointment time and clinic map with bus routes as part of their discharge instructions, and the clinics received an electronic notification of the appointment. We compared frequency of follow-up for a 6-month period before implementation when patients received written instructions to call the clinic on their own (pre-IMPACT) and 6 months after implementation (post-IMPACT). Statistical analysis was conducted with χ2 testing, and corresponding 95% confidence intervals are presented.

There were 326 patients who received an appointment (post-IMPACT), of whom 81 followed up at the clinic as directed (24.8%), compared with 399 patients who received a referral (pre-IMPACT), of whom 4 followed up as directed (1.0%), for an absolute improvement of 23.8% (95% confidence interval 19.1% to 28.6%).

Although most patients still failed to follow up at the community clinics as directed, the use of an Internet-based scheduling program linking a safety net ED with local community clinics significantly improved the frequency of follow-up for patients without primary care.

11. Sleep and the Common Cold

Adults who slept fewer than 7 hours per night were almost three times more likely than longer sleepers to develop a cold after rhinovirus exposure.

Sleep deprivation can adversely affect immune function, and one study has suggested a link between poor sleep habits and increased risk for common colds (JAMA 1997; 277:1940). Researchers now report results from a prospective study of sleep habits and rhinovirus susceptibility.

Participants were interviewed daily for 14 days to assess sleep duration and "sleep efficiency" (the proportion of time in bed spent asleep). Information on several other variables (e.g., rhinoviral antibody titers, age, body-mass index, race, income, sex, smoking) was also collected to allow control for potential confounders. After this assessment, participants were placed in quarantine, exposed to an experimental rhinovirus (RV-39), and monitored for 5 days for signs and symptoms of illness. The outcome (a cold) was defined as infection (recovery of RV-39 from nasal lavage fluid or a 4-fold rise in RV-39 antibody titer) plus the presence of signs (mucus weight 10 g or nasal clearance time 35 minutes) or symptoms of a cold.

Of 153 individuals enrolled, 135 (88%) became infected, but only 54 (35%) and 66 (43%) developed a cold as determined by signs and by symptoms, respectively. Participants who averaged less than 7 hours of sleep per night had the highest risk for colds as determined by signs (odds ratio, compared with participants sleeping 8 hours/night, 2.9; 95% confidence interval, 1.2–7.3). Similarly, those with "sleep efficiency" less than 85% had the highest risk for colds after RV-39 exposure (OR, compared with the rest of the sample, 5.4; 95% CI, 1.5–19.1).

Comment: To the many benefits of good sleep we can now add protection from symptomatic rhinovirus infection. Data from this prospective investigation, combined with other study findings linking sleep duration to mortality and to heart disease morbidity, support a recommendation for 7–8 hours of sleep nightly. Further study of the link between sleep habits and disease susceptibility is warranted.

— Daniel J. Diekema, MD, MS. Published in Journal Watch Infectious Diseases January 21, 2009. Citation: Cohen S et al. Sleep habits and susceptibility to the common cold. Arch Intern Med 2009;169:62.

12. MI Reduction After Smoking Ban Is Sustained Over Long Term

from Heartwire — a professional news service of WebMD. Sue Hughes. January 7, 2009 (Pueblo, Colorado) — The reduction in MI hospitalizations observed after a smoke-free law takes effect appears to be sustained over an extended period, according to a new study from Pueblo, CO.

The study, reported in the January 2, 2009 issue of the Center for Disease Control and Prevention's (CDC's) Morbidity and Mortality Weekly Report, examined MI hospitalization rates before and after the implementation of a municipal law in the city of Pueblo making workplaces and public places smoke-free.

Results showed that MI hospitalizations for city residents decreased by 27% in the initial 18-month period (phase 1) after the smoke-free law came into effect on July 1, 2003. In addition, MI hospitalizations decreased by a further 19% during the following 18 months--through to June 30, 2006 (the phase 2 period).

No significant changes in MI hospitalizations were observed in two nearby comparison areas that did not have smoke-free laws in place before or during the study periods. "These findings suggest that smoke-free policies can result in reductions in AMI hospitalizations that are sustained over a three-year period and that these policies are important in preventing morbidity and mortality associated with heart disease," the CDC researchers write. "This effect likely is mediated through reduced second-hand-smoke exposure among nonsmokers and reduced smoking, with the former making the larger contribution," they add.


13. Raising the Threshold for Trauma Team Activation Decreases Workload Without Consequence

A change in criteria at a single trauma center reduced the incidence of trauma team activations, with no delays to surgery or increase in mortality.

A general tendency exists to over-triage patients to trauma centers and to activate trauma teams. Trauma team activation requires numerous personnel and the attending trauma surgeon to arrive within 20 minutes. In a retrospective observational study, researchers at a single level I trauma center determined whether changing criteria for trauma team activation from those recommended by the American College of Surgeons Committee on Trauma to more-aggressive indications affects patient outcomes. Criteria for trauma team activation were changed to decrease the systolic blood pressure cutoff (from less than 90 mm Hg to less than 80 mm Hg), decrease the respiratory rate cutoff (from less than 10 or greater than 28 to less than 8 or greater than 28 breaths per minute), eliminate the heart rate criterion, decrease the Glasgow Coma Scale score cutoff (from less than 14 to less than 9), and eliminate the following three anatomic criteria: pelvic fracture, flail chest, and 2 long bone fractures.

Researchers compared trauma registry data for 1955 patients who were admitted during an 18-month period before the criteria were changed and for 1844 patients who were admitted during an 18-month period after the change; 95% of patients had blunt injuries. After the change, the proportion of cases that led to trauma team activation was significantly lower overall (18% vs. 12%) and during nights and weekends (19% vs. 13%). The mean Injury Severity Score among cases that led to trauma team activation was significantly higher after the change (22.96 vs. 28.57), yet mortality did not change significantly. Among patients with systolic BP between 80 and 90 mm Hg, mortality decreased after the change (7 deaths among 23 patients vs. 0 deaths among 22 patients). The percentage of laparotomies that were performed more than 2 hours after arrival did not change.

Comment: As resources for trauma become increasingly limited, fewer physicians are opting to be trauma surgeons because of the high workload, the concentration of work on nights and weekends, and the risk for exposure to pathogens such as HIV (especially among victims of penetrating trauma). In this study, the changes in criteria for trauma team activation diminished the demand on resources and the workload for trauma surgeons, without compromising patient care.

— John A. Marx, MD. Published in Journal Watch Emerg Med January 30, 2009. Citation:
Shapiro MJ et al. Let the surgeon sleep: Trauma team activation for severe hypotension. J Trauma 2008;65:1245.

14. Oral Prednisolone May Not Be Helpful for Acute Virus-Induced Wheezing in Children

Laurie Barclay, MD. January 22, 2009 — Oral prednisolone is not superior to placebo in shortening hospitalization or improving other outcomes in preschool children with mild to moderate wheezing associated with a virus infection, according to the results of a randomized, double-blind, placebo-controlled trial reported in the January 22 issue of the New England Journal of Medicine.

"Attacks of wheezing induced by upper respiratory viral infections are common in preschool children between the ages of 10 months and 6 years," write Jayachandran Panickar, MD, MRCPCH, from University of Leicester, in Leicester, United Kingdom, and colleagues. "A short course of oral prednisolone is widely used to treat preschool children with wheezing who present to a hospital, but there is conflicting evidence regarding its efficacy in this age group."

In this study, 700 children aged 10 to 60 months who presented to 3 hospitals in England with an attack of wheezing associated with a virus infection were randomly assigned to a 5-day course of oral prednisolone (10 mg once a day for children aged 10 to 24 months and 20 mg once a day for older children) or placebo. Of 687 children included in the intent-to-treat analysis, 343 were in the prednisolone group and 344 in the placebo group. The main endpoint of the study was the duration of hospitalization, and secondary endpoints were the Preschool Respiratory Assessment Measure (PRAM) score, albuterol use, and a 7-day symptom score.

The placebo group and the prednisolone group were not significantly different in the duration of hospitalization (13.9 vs 11.0 hours; ratio of geometric means, 0.90; 95% confidence interval, 0.77 - 1.05), in the interval between hospital admission and signoff for discharge by a clinician, or in any of the secondary outcomes or the number of adverse events.

"In preschool children presenting to a hospital with mild-to-moderate wheezing associated with a viral infection, oral prednisolone was not superior to placebo," the study authors write. "We found no evidence that a short course of an oral corticosteroid significantly shortened the duration of hospitalization or significantly reduced markers of the severity of symptoms, as assessed by either physicians or parents," the study authors conclude. "Our results suggest that oral prednisolone should not be routinely given to preschool children presenting to the hospital with acute, mild-to-moderate virus-induced wheezing."

In an accompanying editorial, Andrew Bush, MD, from the Imperial School of Medicine at the National Heart and Lung Institute and the Royal Brompton Hospital, London, United Kingdom, notes that prednisolone should be administered to preschoolers only when they are severely ill in the hospital and that intermittent, high-dose inhaled corticosteroids should not be used.

"Also needed is follow-up of all preschool children enrolled in therapeutic trials to see who will go on to have persistent, atopic, multitrigger wheezing (true asthma)," Dr. Bush writes. "The data from the studies should be analyzed retrospectively to determine whether the response to treatment for acute episodes in preschoolers in whom true asthma develops differs from that in patients in whom symptoms subsequently regress. My suspicion is that there will be no difference."

N Engl J Med. 2009;360:329-338, 409-410.

15. Standard Needle for Pneumothorax Decompression Might Not Reach the Pleural Space

Chest wall thickness was greater than the length of a standard needle in half the patients in this small study.

Objective. Tension pneumothorax can lead to cardiovascular collapse and death. In the prehospital setting, needle thoracostomy for emergent decompression may be lifesaving. Taught throughout the United States to emergency medical technicians (EMTs) and physicians, the true efficacy of this procedure is unknown. Some question the utility of this procedure in the prehospital setting, doubting that the needle actually enters the pleural space. This study was designed to determine if needle decompression of a suspected tension pneumothorax would access the pleural cavity as predicted by chest computed tomography (CT).

Methods. We retrospectively reviewed consecutive adult trauma patients admitted to a level I trauma center between January and March 2005. We measured chest wall depth at the second intercostal space, midclavicular line on CT scans. Data on chest wall thickness were compared with the standard 4.4-cm angiocatheter used for needle decompression.

Results. Data from 110 patients were analyzed. The mean age of the patients was 43.5 years. The mean chest wall depth on the right was 4.5 cm (± 1.5 cm) and on the left was 4.1 cm (± 1.4 cm). Fifty-five of 110 patients had at least one side of the chest wall measuring greater than 4.4 cm.

Conclusions. The standard 4.4-cm angiocatheter is likely to be unsuccessful in 50% (95% confidence interval = 40.7-59.3%) of trauma patients on the basis of body habitus. In light of its low predicted success, the standard method for treatment of tension pneumothorax by prehospital personnel deserves further consideration.

Stevens RL, et al. Prehospital Emerg Care. 2009;13:14-17.

16. Teens’ Ability to “Text” indicates Full Post-Syncopal Recovery

Sinclair M, et al. BMJ 2008;337:a2723

Festival Medical Services is a charitable trust that provides music festivals throughout the United Kingdom with doctors, nurses, paramedics, first aiders, and other trained medical and administrative staff. One of the authors (MS) is the coordinator for the Festival Medical Services "pit crew." This team provides a resuscitation facility for the audience at the two main stages at Glastonbury and Reading festivals as well as a triage system to sort or treat people who need medical attention. The team follows the advice of the Third Annual Rock Concert Safety Survey Report published by Crowd Management Strategies in February 1995 (

Festival Medical Services has a small tent (3 m x 3 m) at the side of these stages, with resuscitation equipment as suggested by the Resuscitation Council UK’s recommended minimum equipment for inhospital adult resuscitation. A consultant anaesthetist, two nurses, an operating department practitioner, and at least two first aiders are present from when the first band appears on stage until the last band of the day finishes.

Three years ago we noticed that most of the patients with faint or panic attack were teenagers and as soon as they could they used their mobile phones to send an SMS (short message service) text message to their friends. SMS allows the interchange of short text messages between mobile phones. About 1.4 billion text messages are sent in the UK alone every week, according to the Mobile Data Association (

The ability to text, whether or not it actually makes sense, requires a Glasgow coma scale score of 15 (fully conscious), an adequately functioning "executive system" in the frontal lobes, and a high degree of manual dexterity and psychomotor coordination. It also shows a degree of common sense not always evident in teenagers.

Two years ago we decided to use this texting sign as an indication that patients had recovered from their faint or panic attack and were orientated and coordinated enough to be discharged back to the festival. At times of massive influx to the medical tent, when up to two patients a minute are triaged, this system seems to work well.

This year at the Reading festival we managed, with only one consultant anaesthetist, two accident and emergency nurses, one operating department practitioner, and two to four first aiders, to treat 142 patients in less than 60 minutes during the performance by Bloc Party and 130 patients over 90 minutes during the performance by Rage Against the Machine. The texting sign needs further investigation to determine whether it is a valid criterion for recovery after faint or panic attack at festivals as well as in busy accident and emergency departments.

17. Recurrence Common Following Emergency Treatment of Headache

NEW YORK (Reuters Health) Dec 30 - Headache patients treated at the emergency department frequently experience pain and functional impairment following discharge, regardless of type of primary headache disorder, according to a study reported in the December issue of the Annals of Emergency Medicine.

Headache is the fifth most common emergency department (ED) complaint. "Effective treatments for the acute headache exist, but patients often have a recurrence or persistence of the initial headache after ED discharge," write Dr. Benjamin W. Friedman and colleagues from Albert Einstein College of Medicine, Bronx, New York.

In a prospective cohort study, the researchers examined the frequency of moderate or severe headache during the first 24 hours after an ED visit for a primary headache disorder, and determined the burden of headache-related functional impairment during the 3 months after the ED visit.

The team enrolled 309 primary headache disorder patients during their initial ED visit over an 18-month period. The subjects were interviewed using a standardized questionnaire, and were followed by telephone 24 hours and 3 months after discharge. All headaches were classified according to the International Headache Society criteria by two emergency physicians.

The most common primary headache diagnoses were migraine, tension-type headache, and unclassifiable recurrent headache disorder. Ninety-four percent of patients were successfully followed-up at both time points.

Within 24 hours of ED discharge, 31% of migraine patients, 19% of tension-type headache patients, and 27% of the unclassifiable headache patients experienced moderate or severe headache.

Overall, 37% of migraine patients, 38% of tension-type headache patients, and 26% of the unclassifiable headache patients experienced headache-related functional impairment during the 3 months after discharge.

"Of the 2 hypothesized predictors of poor 24-hour outcome, duration of headache and discharge pain intensity, only duration of headache seemed an independent predictor of moderate or severe headache in the 24 hours after ED discharge," Dr. Friedman and colleagues report.

"Additional independent predictors of moderate or severe headache within 24 hours were severe baseline pain, presence of nausea, and a positive response to depression screening questions." The only independent predictor of poor 3-month outcomes was Medicaid insurance.

The team notes that the best treatment for postdischarge headache has not been determined. "Absent data," they advise, "it is reasonable practice to provide an oral agent with known efficacy in acute migraine or acute tension type headache, such as a triptan, a migraine-specific combination, an oral antiemetic combined with a nonsteroidal anti-inflammatory drug, or a nonspecific analgesic."

Ann Emerg Med 2008;52:696-704.

18. Preoxygenation for Emergency Intubation: Longer Is Not Better

Preoxygenation beyond 4 minutes adds no benefit.

Objective: To determine the effectiveness of increasing the preoxygenation period with 100% oxygen in the critically ill patient from 4 to 8 mins in preparation for emergency tracheal intubation.

Design: Nonrandomized, controlled trial.

Setting: Large, level one trauma center, tertiary care intensive care unit.

Patients: Critically ill patients failing noninvasive respiratory support techniques who required tracheal intubation followed by mechanical ventilation.

Interventions: A baseline arterial blood gas was obtained on noninvasive passive therapy and at 4, 6, and 8 mins of active preoxygenation efforts with 100% oxygen therapy with a noncollapsing resuscitator bag and mask. Best effort to achieve a tight fitting mask seal was pursued coupled with other mask ventilation maneuvers to optimize noninvasive oxygenation and ventilation.

Measurements and Main Results: Thirty-four patients consecutively intubated by the author during the 7-month study period were studied. The baseline Pao2 (mean ± sd) with concurrent noninvasive support was 61.9 ± 14.6 mm Hg (range: 44-109 mm Hg) and increased a mean of 22 mm Hg to 83.8 ± 51.5 mm Hg after 4 mins of preoxygenation (p less than 0.01). Continued preoxygenation efforts (6 mins) increased the Pao2 to 88.2 mm Hg ± 48.5 and after 8 mins to 92.7 mm Hg ± 55.2. At the 8-min mark, 5 of 34 patients achieved greater than 10% increase in their Pao2 and only two patients increased their 4-min Pao2 by 50 mm Hg or more after the additional 4 mins of preoxygenation. One quarter of the patients experienced a reduction in their Pao2 from the 4 to the 8-min time period. Nearly, 50% of the patients met the criteria for desaturation during the intubation procedure.

Conclusions: Extending the preoxygenation period from the customary 4 mins to either 6 or 8 min seems to be marginally effective in the majority of patient suffering from cardiopulmonary deterioration and such an extension may jeopardize oxygenation efforts in some patients.

Mort TC, et al. Critical Care Medicine 2009;37:68-71.

19. Recommendations for Prevention of Recurrent Stroke Reviewed

Laurie Barclay, MD. January 27, 2009 — Recommendations for prevention of recurrent stroke are reviewed in the January issue of Mayo Clinic Proceedings. In addition to control of modifiable risk factors, virtually all patients who have had ischemic stroke should be prescribed antiplatelet agents.

"Stroke is the leading cause of death and disability in the United States," writes Harold Adams Jr, MD, from the University of Iowa in Iowa City. "The economic consequences of stroke, including health care costs and lost economic productivity, are substantial. These are the reasons that stroke prevention, including treatment of underlying causes, are clearly of critical importance."

The leading cause of ischemic stroke is atherosclerotic vascular disease, which gives rise to occlusion or severe stenosis of major intracranial or extracranial arteries, as well as narrowing of small penetrating arteries of the brain.

Coronary artery disease, or atherosclerosis of the coronary arteries, may result in myocardial infarction, which in turn is an indirect cause of cardioembolic stroke. Atrial fibrillation and cardioembolic stroke may also complicate ischemic heart disease.
"Some risk factors associated with increased likelihood of advanced atherosclerosis and ischemic disease are not modifiable," Dr. Adams writes. "These risk factors include age, sex, ethnicity, family history and premature vascular disease. However, several conditions that augment the course of atherosclerosis can be effectively addressed across the continuum of care."

For patients with symptomatic ischemic cerebrovascular disease, a crucial aspect of treatment is prevention of recurrent stroke, myocardial infarction, and other ischemic events. This requires optimal control of modifiable risk factors that accelerate development of atherosclerosis, such as hypertension, hyperlipidemia, diabetes mellitus, and smoking.

Management of hypertension should aim to achieve a normal blood pressure for the patient, realizing that no single, specific antihypertensive regimen is ideal for all patients. When prescribing a blood pressure–lowering treatment plan, clinicians should consider a patient's history, while awaiting the results of ongoing and future studies.

Some evidence suggests that aggressive lowering of cholesterol levels may modestly increase the risk for hemorrhagic stroke. However, the benefits of statins to decrease the risk for recurrent ischemic stroke and other ischemic vascular events are thought to outweigh the risk of bleeding. In patients with diabetes mellitus, management should include aggressive control of blood pressure and lipid levels as well as of blood glucose levels.

More aggressive interventions may be required, such as carotid endarterectomy and endovascular treatment. In selected patients, carotid endarterectomy should be considered as complementary to use of antiplatelet agents and other medications. For other patients with atherosclerotic cerebrovascular disease, extracranial-intracranial bypass surgery and carotid artery stenting may be considered, pending the results of ongoing clinical trials.

The keystone of management to prevent recurrent stroke and other cardiovascular events in patients at risk continues to be administration of antiplatelet agents, which should be prescribed for virtually all patients who have had ischemic stroke. Therapeutic options include aspirin, aspirin plus extended-release dipyridamole, or clopidogrel. Specific choice among these should be guided by the patient's previous treatment and history of ischemic events as well as allergies or other potential contraindications.

Specific recommendations of the American Heart Association/American Stroke Association for antithrombotic therapy in patients with ischemic stroke of noncardioembolic origin (secondary prevention), and their accompanying levels of evidence, are as follows:

Antiplatelet agents are recommended vs oral anticoagulants (level of evidence, I, A).

Preferred options for initial treatment are aspirin (50 - 325 mg/day), a combination of aspirin and extended-release dipyridamole, or clopidogrel (level of evidence, I, A).

The combination of aspirin and extended-release dipyridamole may be preferred vs aspirin alone (level of evidence, I, B).

Instead of aspirin alone, clopidogrel may be considered (level of evidence, IIb, B).

Clopidogrel is a reasonable option for patients who are hypersensitive to aspirin (level of evidence, IIa, B).

Addition of aspirin to clopidogrel increases the risk for hemorrhage (level of evidence, III, A).

"Use of an integrated treatment approach involving risk-factor management, antiplatelet therapy and surgical procedure when indicated presents the opportunity to lower the risk of recurrent stroke and other ischemic events in patients with recent ischemic stroke," Dr. Adams concludes. "Future research may provide support for using new medications, clarify the role of currently available medications, and better define the appropriate role of surgery, particularly endovascular treatments."

In an accompanying editorial, James F. Meschia, MD, from the Mayo Clinic in Jacksonville, Florida, confirms that "after the immediate post-thrombolytic period, care needs to focus on secondary prevention."

"Patients with acute ischemic stroke are at high risk of recurrent stroke," Dr. Meschia writes. "If successful reperfusion therapy is like dodging a bullet, successful secondary prevention is like being caught in the line of fire again. [Dr. Adams'] review will be welcomed by clinicians seeking guidance beyond evidence-based guidelines."

Mayo Clin Proc. 2009;84:3-4,43-51.

20. Guidelines Issued for Field Triage of Injured Patients

Laurie Barclay, MD. January 27, 2009 — The National Expert Panel on Field Triage has issued guidelines for field triage of injured patients and has published the new recommendations in the January 23 issue of Morbidity and Mortality Weekly Report. Because not all patients require the services of a Level I trauma center (TC), those with less severe injuries may be transported to a closer emergency department (ED) capable of managing milder injuries.

"In the United States, injury is the leading cause of death for persons aged 1–44 years, and the approximately 800,000 emergency medical services (EMS) providers have a substantial impact on the care of injured persons and on public health," write Scott M. Sasser, MD, from the Division of Injury Response, National Center for Injury Prevention and Control, Atlanta, Georgia, and colleagues. "At an injury scene, EMS providers determine the severity of injury, initiate medical management, and identify the most appropriate facility to which to transport the patient through a process called 'field triage.'...Determining the appropriate facility to which an injured patient should be transported can have a profound impact on subsequent morbidity and mortality."

In addition to basic emergency services, which are generally available in all hospital EDs, designated TCs are those hospitals with additional expertise, resources, and equipment to treat severely injured patients.

Classification of TCs is based on the scope of resources and services available. Level I TCs provide the highest level of trauma care, Levels II and III are intermediate, and Level IV centers provide initial trauma care and transfer to a higher level of trauma care if needed.

Although the risk for death is 25% lower for a severely injured person treated at a Level I TC, not all patients need the level of services available at a Level I TC. The guidelines suggest that less severely injured patients might be better served by being transported to a closer ED capable of managing milder injuries and that transferring all injured patients to Level I TCs could place an unnecessary load on these centers, negatively affect patient outcomes, and reduce cost effectiveness.

The Field Triage Decision Scheme (Decision Scheme), first developed by the American College of Surgeons in 1986, serves as the basis for triage protocols for state and local EMS systems across the United States. To help determine the most appropriate destination facility within the local trauma care system, this algorithm guides EMS providers through 4 decision points: physiologic concerns, anatomic considerations, mechanism of injury, and special considerations.

The Decision Scheme has been revised 4 times since it was first published in 1986. To facilitate revision of the Decision Scheme, the US Centers for Disease Control and Prevention hosted a series of meetings of the National Expert Panel on Field Triage in 2005, with support from the National Highway Traffic Safety Administration.

The expert panel, which includes injury-care providers, public health professionals, automotive industry representatives, and officials from federal agencies, reviewed pertinent literature, presented its findings, and agreed on necessary revisions allowing publication of the revised Decision Scheme in 2006. The report published in the Morbidity and Mortality Weekly Report details the process and rationale used by the expert panel to revise the Decision Scheme.