Lit Bits: Feb 23, 2010

From the recent medical literature...

1. New Decision Rule Identifies Kids with Minor Head Trauma Who Need CT

Fran Lowry. February 12, 2010 — A new decision rule can identify children with minor head injury who need to undergo computed tomography (CT), thereby reducing the number of scans and saving children from unnecessary exposure to ionizing radiation, according to a new study published in the February 8 issue of the Canadian Medical Association Journal.

"Over the past decade the use of CT for minor head injury has become increasingly common, while its diagnostic yield has remained low," write Martin H. Osmond, MD, from the University of Ottawa, Canada, and colleagues for the Pediatric Emergency Research Canada Head Injury Study Group. "The increased use of CT adds substantially to health care costs and exposes a large number of children each year to potentially harmful effects of ionizing radiation."

At this time there are no widely accepted, evidence-based guidelines on the use of CT for children with minor head injury, the authors write. The aim of this prospective cohort study was to develop a sensitive clinical decision rule to guide physicians in determining whether a child with minor head trauma should receive a CT scan.

The study was conducted at 10 Canadian pediatric teaching hospitals and enrolled 3866 consecutive children aged up to 16 years (mean age, 9.2 years) who presented to the emergency department after sustaining an acute minor head injury within the past 24 hours.

A minor injury was defined as blunt trauma to the head resulting in witnessed loss of consciousness, definite amnesia, witnessed disorientation, persistent vomiting (2 or more distinct episodes of vomiting 15 minutes apart) or persistent irritability in the emergency department (for children younger than 2 years), and a score of 13 to 15 on the Glasgow Coma Scale.

After initial examination, the treating physician determined whether the patient should undergo CT of the head. The main outcome measures were need for neurologic intervention and presence of brain injury, as determined by CT.

Among the 3866 patients, 95 (2.5%) had a score of 13 on the Glasgow Coma Scale, 282 (7.3%) had a score of 14, and 3489 (90.2%) had a score of 15.

The CT scan revealed that 159 patients (4.1%) had a brain injury and 24 (0.6%) required neurologic intervention.

Results Used to Develop CATCH Rule

From these results, the investigators developed a decision rule for when to perform a CT of the head, which they called the Canadian Assessment of Tomography for Childhood Head injury (CATCH) rule.

This rule states that CT of the head is required only for children with minor head injury and any one of the following findings, which they divided into high risk, meaning the need for neurologic intervention, and medium risk, meaning brain injury on CT scan.

High risk
1. Failure to reach a score of 15 on the Glasgow Coma Scale within 2 hours
2. Suspected open or depressed skull fracture
3. History of worsening headache
4. Irritability on examination

Medium risk
1. Any sign of basal skull fracture
2. Large, boggy hematoma of the scalp
3. Dangerous mechanism of injury (eg, motor vehicle crash, fall from elevation above 3 feet [91 cm] or 5 stairs, fall from bicycle with no helmet)

The high-risk factors were 100.0% sensitive (95% confidence interval [CI], 86.2% - 100.0%) for predicting the need for neurologic intervention and would require that 30.2% of patients undergo CT.

The medium-risk factors were 98.1% sensitive (95% CI, 94.6% - 99.4%) for the prediction of brain injury by CT and would require that 52.0% of patients undergo CT, the study authors report.

"We derived the CATCH rule according to strict methodologic standards and using a large sample of patients," the authors write. "Nevertheless, we intend to prospectively and explicitly validate the rule at multiple sites."

The authors list potential limitations of their study. Not all enrolled children with minor head injury underwent CT, not all children with minor head injury seen at the study sites were enrolled in the study, and relatively few children younger than 2 years were enrolled. "Further prospective study of this subgroup is required, as children under two years of age may have more subtle presentations of head injury than older children," they write.

The authors conclude that the CATCH rule has the potential to standardize the need for CT, as well as to reduce the number of CT scans performed on children with minor head injury. "Further studies are required to prospectively validate this rule in other pediatric cohorts."

The study was supported by the Canadian Institutes of Health Research, the Emergency Health Services Branch of the Ontario Ministry of Health and Long-Term Care, and the Alberta Children's Hospital Foundation. The authors have disclosed no relevant financial relationships.

CMAJ. Published online February 8, 2010.

Full-text (free): http://www.cmaj.ca/cgi/rapidpdf/cmaj.091421v1?ijkey=933d2b6cfb9c0464f0f5b3b150c247a2dbc04876

2. Test Identifies Patients with Chest Pain Who Can Be Safely Discharged From ED

Fran Lowry. February 12, 2010 — A coronary artery calcium score (CACS) of 0 can identify patients with chest pain who can be safely discharged from the emergency department (ED) without the need for further cardiac testing, according to a prospective observational cohort study published online February 8 in the Annals of Emergency Medicine.

"The optimal strategy for evaluating chest pain in the [ED] remains a dilemma," write Faisal Nabi, MD, from the Methodist DeBakey Heart and Vascular Center, Methodist Hospital, Houston, Texas, and colleagues. "With more than 5 million annual hospital admissions, and at a cost of more than $10 billion, most patients (more than 60%) are found to have noncardiac chest pain."

CACS is a simple and readily available test for identifying coronary artery disease. The authors write that a CACS of 0 is rarely observed in patients with abnormal stress myocardial perfusion imaging (SPECT) or significant coronary artery disease or acute myocardial infarction.

The aim of this study was to determine whether a CACS of 0 would accurately identify low-risk patients among those with chest pain of unknown cause who could be sent home safely from the ED without needing further cardiac testing.

The study enrolled 1031 of 5066 patients who presented to the ED between September 2005 and February 2008. The enrolled patients all had a normal initial troponin level, nonischemic electrocardiogram, and no history of coronary artery disease. They underwent SPECT and CACS within 24 hours of admission to the ED.

The patients' mean age was 54 years (range, 41 - 67 years).

The investigators report that 61% of the patients in the study had a CACS of 0. The frequency of an abnormal SPECT ranged from 0.8% in patients with a CACS of 0 to 17% in patients with a CACS greater than 400.

Acute coronary syndrome events occurred in 28 patients during the index hospitalization and in 4 patients a mean of 7.4 months (range, 4.1 - 10.7 months) after hospital discharge.

Only 2 events occurred in 625 patients with a CACS of 0 (0.3%; 95% confidence interval [CI], 0.04% - 1.1%). In comparison, 30 events occurred in 406 patients with a CACS greater than 0 (7.4%; 95% CI, 5.0% - 10.4%).

The 2 patients with a CACS of 0 and a cardiac event both had abnormal troponin levels on their index admission (peak, 1.52 and 2.34 ng/dL, respectively), but had normal serial electrocardiogram and SPECT results. One patient, a 32-year-old man, had acute gastritis on upper endoscopy as a possible cause for his chest pain; the other, a 52-year-old woman, had chest pain that resolved spontaneously. Both were discharged and reported no cardiac events at 6-month follow-up, the study authors report.

In noting their study's limitations, the authors remind readers that it is a single-center study and that the results may not be applicable to the general population; in addition, the study population was at relatively low risk for acute coronary syndrome, which resulted in a very high negative predictive value for both a normal CACS and SPECT.

The authors also noted that a strict definition of acute coronary syndrome based on angiographic evidence of coronary artery disease was used in patients who did not meet criteria for myocardial infarction, but because all patients did not receive angiography, this could have biased the results. So could the fact that physicians were not blinded to the CACS results.

A final concern is that a CACS of 0 will miss noncalcified plaque that could result in acute coronary syndrome, the authors point out.

"There is a clear national mandate to improve health care utilization and reduce soaring costs," they write in their discussion and suggest that use of this simple, inexpensive test could save the healthcare system a considerable amount of money.

"A majority of patients with acute chest pain of uncertain cardiac cause have a CACS of 0, which predicts both a normal stress SPECT result and an excellent short-term outcome," the authors conclude. "If such a simple and straightforward testing strategy were widely adopted, it would streamline ED patient evaluation and might significantly reduce health care costs."

This is "a well-done study that makes an important observation," William Follansbee, MD, the master clinician professor of cardiovascular medicine and director of nuclear cardiology at the University of Pittsburgh Medical Center, Pennsylvania, commented to Medscape Emergency Medicine.

But a caveat is that a CACS of 0 implies that there is no significant atherosclerosis, but some patients in this category do have acute myocardial infarction when a minor plaque ruptures and sets off a cascade of events that result in a blocked artery. "A calcium score of zero does identify a population at very low risk, but not zero risk," he said.

The study excluded the higher-risk patients and ended up enrolling only about 20% of the patients who came to their ED, Dr. Follansbee pointed out. "Eighty percent of the patients who came in did not fit the criteria for the study. It is important when people apply these data to realize that you're applying it to that 20%, low-risk group, and not to everybody who comes in with chest pain. These results should not be generalized to all the patients who come in with chest pain."

He agrees with the study authors' assertions about the high cost of chest pain care and that the CACS might be of value in this setting.

"The point about the cost of chest pain care is quite legitimate, so even if you take 10% of the people who come in to the [ED] and do a simple test up front, you can identify them as low risk and send them home, and that still has some value and would then translate into some savings in healthcare dollars," Dr. Follansbee said. "But a lot of patients with chest pain do have some calcium in their arteries, and then the CACS is not going to be a useful marker."

The study was supported in part by a grant from the Methodist Hospital Foundation. The study authors have reported no other relevant financial relationships. Dr. Follansbee has reported no relevant financial relationships.

Nabi F, et al. Ann Emerg Med. Published online February 8, 2010. Abstract: http://www.annemergmed.com/article/S0196-0644(10)00040-5/abstract

3. Is It Always Wrong to Perform Futile CPR?

Truog RD. N Engl J Med. 2010;362:477-479.

Although there is currently much debate about the types of care to which patients are entitled, one thing on which everyone can agree is that nonbeneficial care should be eliminated. Although such care can be hard to define, in some circumstances experienced clinicians can be virtually certain that attempts at resuscitation will fail. In these cases, many argue that hospitals should adopt policies that allow physicians to refuse when families demand futile cardiopulmonary resuscitation (CPR).

Several years ago, I cared for a 2-year-old boy who had been born with a large frontal encephalocele. He survived surgical excision but was left neurologically devastated. The clinical team consistently counseled his parents that he would never have any meaningful neurologic development. We recommended redirecting his care toward comfort and palliation. The parents rejected all these suggestions. I came to know the family fairly well through the boy's multiple admissions to the intensive care unit (ICU) where I am a physician. Despite extensive and continual efforts by everyone involved to support the family and reach an agreement to limit aggressive treatment, the parents continued to insist that everything be done.

I vividly recall the evening when, a few minutes after a "code blue" was called over the hospital intercom, I watched this little boy being rolled in through the doors of the ICU. He appeared chalky and lifeless; I remember thinking that he might already be dead. Still, mindful of his father's unyielding refusal to consider a "do not resuscitate" order, I instructed the staff to attempt resuscitation. We ventilated the boy through his tracheostomy and made multiple unsuccessful attempts to place central venous and intraosseous lines. After perhaps 15 minutes, I asked the team to stop. I pronounced the boy dead. None of us felt good about what had just happened. One of the nurses later told me that it had been so upsetting she had had to fight back the urge to vomit.

I went to talk to the parents. They had arrived at the hospital a short time after the code blue was called and were holding their little boy. I fully expected to be on the receiving end of an angry tirade full of accusations about our failure to keep their son alive. Instead, the mood was remarkably quiet and somber, as they began the universal grieving of parents for a lost child. But what surprised me the most was when the father gently opened his son's shirt, revealing all the puncture wounds and bruises from our failed attempts to place a subclavian catheter. He looked up at me and said, "I want to thank you. I can see from this that you really tried; you didn't just give up and let him die."

There are many reasons why my decision to attempt resuscitation that evening might have been wrong. Our ethical obligations are to our patients, not to their families. Certainly we should never do anything harmful to a patient for the benefit of others. But that seems to be exactly what we did here — engaged in futile and brutal resuscitative efforts to placate a family that didn't accept reality as we saw it. Were our actions a form of child abuse?

This family's continued insistence on all life-sustaining treatments did not reflect our failure to properly counsel them about an appropriate plan of care for their child. We are as good at that as we are at resuscitation. So did we have an obligation to override their demands and withhold futile resuscitative efforts? Might not our acquiescence to their misguided demands have sent a wrong message to the community, implying that we are willing to compromise our medical standards and provide useless treatment when confronted by intransigent families?

Given the already heavy workloads of physicians and nurses, is it reasonable to pull some of the hospital's most senior and experienced clinicians away from their duties to engage in a "sham" procedure, potentially compromising the care of other patients? Did I fail in my leadership role within the ICU by contributing to the burnout that is becoming a plague in ICU medicine?

I have wondered about all these questions over the years. I know that I do not have convincing answers to most of them. I understand the arguments against what I did. Yet I still believe that, all things considered, we did the right thing for this patient and family on that evening.

Most families want their loved ones to be peaceful and comfortable when death is near. Some patients and families, however, do not share this vision of a "good death." For some, it is very important to believe that they fought until the very end. This may be particularly true for families who, like this one, may have to recount the story of their loved one's death to friends and relatives in parts of the world where modern ICU care is nonexistent, and for whom the idea of "giving up" despite the availability of such seemingly limitless technology would be deemed wrong and inconceivable.

Although the interests of the patient are always primary, at the end of life there are times when the interests of the patient begin to wane, while those of the family intensify. Family members may live for years with the psychological aftereffects and regrets of end-of-life decisions. In these situations, the interests of the surviving family members may take priority. At the time we began our resuscitation efforts, I believed that this child was beyond suffering, whereas the psychological needs of his parents were both clinically and ethically significant.

Are there any lessons to be learned from stories like these? Clinicians and hospitals are divided about the ethics of performing futile CPR for the benefit of family members. There is inconsistency even among the teaching hospitals of Harvard Medical School. Some have policies that permit clinicians to refuse to provide nonbeneficial CPR, whereas others explicitly reject this approach and insist on agreement between the clinicians and the patient or family before CPR is withheld.

On balance, either approach may be too limiting. Nonbeneficial CPR should never be performed when it would cause substantial suffering or when the demands of the family are clearly at odds with the interests of the patient. The diversion of hospital resources to nonbeneficial care should not occur if there is a credible threat to the health of other patients. Furthermore, as in all resuscitation attempts, clinicians should use their clinical judgment and discretion in deciding on the length and intensity of resuscitation efforts.

Decision making in medicine is likely to become even more complex as clinical practice becomes increasingly directed by guidelines, outcomes research, and comparative-effectiveness analyses. But actions surrounding the moment of death are highly symbolic and often of great significance to the surviving family. By sometimes agreeing to provide futile CPR, we send a message to our communities not that clinicians can be bullied into performing procedures that good medical judgment would oppose, but that our hospitals are invested in treating patients and families with respect and concern for their individual needs. The message to our medical and nursing colleagues is not that they can be forced to perform brutal and unnecessary procedures on their patients, but rather that — in a small number of cases — providing nonbeneficial CPR can be an act of sincere caring and compassion. Futile CPR has a limited but legitimate place in the practice of medicine.

4. Standardization of Severe Sepsis Management: A Survey of Methodologies in Academic and Community Settings

Nguyen HB, et al. J Emerg Med. 2010;38:122-132.

Background: Evidence-based therapies for severe sepsis include early antibiotics, early goal-directed therapy, corticosteroids, recombinant human activated protein C, glucose control, and lung protective strategies.

Objective: The objective of this study was to analyze methods, challenges, and outcomes observed by hospitals that implemented a hospital-wide sepsis management protocol incorporating evidence-based therapies.

Methods: In a cross-sectional multi-center telephone survey over a 4-month period, clinicians (participants) responsible for developing a hospital sepsis protocol were questioned regarding its development and outcomes.

Results: Participants completing surveys represented 40 hospitals (20 academic and 20 community). Twenty-seven percent of protocol champions were Emergency physicians or nurses. Sixty-three percent reported protocol development time of 6–12 months. Eighty-eight percent of participants reported protocol initiation in the Emergency Department. Three participants reported hiring a nurse educator to implement the protocol. Ninety-five percent of participants measure lactate as part of patient screening. Protocol therapies reported included early antibiotics (98%), early goal directed-therapy (EGDT) (98%), corticosteroids (80%), and activated protein C (73%). Contributions to success included having a protocol champion (85%) and sepsis education program (65%). Twenty-one participants had recorded patient-level data, totaling 2319 protocol patients, compared to 1719 non-protocol patients, with in-hospital mortality of 23% and 44%, respectively.

Conclusions: Implementation of a sepsis management protocol incorporating evidence-based therapies can be accomplished in both academic and community hospitals, with minimal additional staffing. The presence of a protocol champion and education program is crucial to success, and may result in improved patient outcome.

5. Intraosseous Access Devices: How to Choose?

No clinically meaningful differences were detected in prehospital use of three intraosseous access devices.

Intraosseous needles can be used for emergency administration of fluids, blood, and medications in both the in-hospital and out-of-hospital setting. In a single-blind, prospective randomized trial, investigators in the Netherlands compared use of three intraosseous devices by helicopter emergency medical services nurses during a 3-year period. The nurses, who received special training, used the devices after intravenous catheter insertion failed. Patients aged 14 years were randomized to the Jamshidi 15G, First Access for Shock and Trauma 1 (FAST1), or Bone Injection Gun (BIG) 15G devices. Patients aged 1 to 13 years were randomized to the Jamshidi 15G or BIG 18G devices.

Among 65 patients aged 14 years, median insertion times for the Jamshidi, BIG 15G, and FAST1 devices were 37, 49, and 62 seconds, respectively; insertion was significantly faster for the Jamshidi than for the FAST1 device. The successful placement rate was significantly lower with the BIG 15G (59%) than with the Jamshidi (92%) and FAST1 (89%) devices. Among 22 patients aged 1 to 13 years, median insertion times for the Jamshidi and BIG 18G devices (43 and 48 seconds) were statistically similar, as were successful placement rates (100% and 70%). User satisfaction ratings were similar in all groups.

Comment: A 25-second reduction in insertion time — although statistically significant — is not clinically relevant. Cost, chain of supply, and user preference will guide selection of an intraosseous device in any particular medical system. Unfortunately, the researchers did not study the EZ-IO device (popular in North America and Europe) or delayed complications (e.g., osteomyelitis, fat embolism, fractures), but there is no reason to suspect that any delayed complication might be more likely with one device than another.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine February 12, 2010. Citation: Hartholt KA et al. Prehosp Emerg Care 2010;14:6.

6. Optimization of initial energy for cardioversion of atrial tachyarrhythmias with biphasic shocks

Reisinger J, et al. Amer J Emerg Med. 2010;28:159-165.

Objective
Recommendations for optimal first-shock energies with biphasic waveforms are conflicting. We evaluated prospectively the relation between type and duration of atrial tachyarrhythmias and the probability of successful cardioversion with a specific biphasic shock waveform to develop recommendations for the initial energy setting aiming at the lowest total cumulative energy with 2 or less consecutive shocks.

Methods
We analyzed 453 consecutive patients undergoing their first transthoracic electrical cardioversion, including 358 attempts for atrial fibrillation (AF) and 95 attempts for atrial flutter (AFL) or atrial tachycardia (AT). A step-up protocol with a truncated exponential biphasic waveform starting at 50 J was used. Total cumulative energies were estimated under the assumption of a 2-tiered escalating shock protocol with different initial energy settings and a “rescue shock” of 250 J for AFL/AT or 360 J for AF. The initial energy setting leading to the lowest total cumulative energy was regarded as the optimal first-shock level.

Results
Cardioversion was successful in 448 patients (cumulative efficacy, 99 %). In patients with AFL/AT, the lowest total cumulative energy was attained with an initial energy setting of 50 J. In patients with AF, lowest values were achieved with an initial energy of 100 J for arrhythmia durations of 2 days or less and an initial energy of 150 J for arrhythmia durations of more than 2 days.

Conclusion
We recommend an initial energy setting of 50 J in patients with AFL/AT, of 100 J in patients with AF 2 days or less, and of 150 J with AF more than 2 days.

7. Routine testing in (a subpopulation of high-risk) patients with asymptomatic elevated blood pressure in the ED

Nishijima DK, et al. Amer J Emerg Med. 2010;28:235-242.

Study Objective
There are no clear recommendations for the diagnostic evaluation of patients who present to the emergency department (ED) with asymptomatic elevated blood pressure. In patients presenting with asymptomatic elevated blood pressure in the ED, we measured the prevalence of abnormalities on a basic metabolic profile (BMP) that led to hospital admission as well as the prevalence of diminished renal function.

Methods
This is a cross-sectional study at 2 urban teaching EDs with a largely African American population. Adult patients (≥18 years) with a triage diastolic blood pressure (BP) 100 mm Hg or higher and without symptoms suggestive of acute end-organ damage were enrolled. All patients had a BMP sent. The primary outcome measured was abnormalities on the BMP that led to hospital admission. The secondary outcome measured was the prevalence of diminished renal function (glomerular filtration rate below 60 mL min−1 1.73 m−2).

Results
One hundred sixty-seven patients with asymptomatic elevated BP were studied. Twelve (7.2%; 95% confidence interval, 3%-11%) patients were admitted due to abnormal results on the BMP. Twenty-seven (16.2%; 95% confidence interval, 11%-21%) patients met the secondary outcome measure of diminished renal function (glomerular filtration rate below 60 mL min−1 1.73 m−2).

Conclusion
In a homogenous African American population presenting to the ED with asymptomatic elevated BP, there is a relatively high prevalence of abnormalities on the BMP that led to hospital admission. We suggest routine testing of a serum creatinine should be strongly considered in a largely African American patient population with asymptomatic elevated BP in the ED.

8. Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort

Newgard CD, et al. The Resuscitation Outcomes Consortium Investigators. Ann Emerg Med 2010;55:235-246.e4.

Study objective
The first hour after the onset of out-of-hospital traumatic injury is referred to as the “golden hour,” yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality.

Methods
This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged ≥15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was inhospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders.

Results
There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings.

Conclusion
In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

Full-text (free): http://www.annemergmed.com/article/PIIS0196064409012840/fulltext

See also associated editorial: Barrett TW, et al. Journal Club: Is the Golden Hour Tarnished? Registries and Multivariable Regression. Ann Emerg Med. 2010;55:247-248

Full-text (free): http://www.annemergmed.com/article/PIIS019606441000003X/fulltext

9. Pelvic examination is unnecessary in pregnant patients with a normal bedside ultrasound

Seymour A, et al. Amer J Emerg Med. 2010;28:213-216.

Objective
This study examines the necessity of a formal pelvic examination in patients with early pregnancy-related complaints and an intrauterine pregnancy on bedside ultrasound (US).

Methods
Data were prospectively collected on emergency department (ED) patients presenting with early pregnancy complaints and bedside US evidence of intrauterine pregnancy. All patients received a formal pelvic examination with cervical testing for sexually transmitted pathogens. Disposition decisions based on pelvic examination findings were compared with disposition decisions based on ultrasound findings alone.

Results
Over a 13-month period, 50 patients entered the study. Mean estimated gestational age was 8.6 (±0.4) weeks. Abnormal speculum examination findings included vaginal blood (19 [38%]) and cervical discharge (3 [6%]). Abnormal bimanual findings included adnexal tenderness (6 [12%]) and uterine tenderness (4 [8%]). One patient (2.5%) had a positive antigen test for Chlamydia trachomatis. Emergency department diagnoses were threatened abortion (30 [60%]), intrauterine pregnancy (11 [22]), abdominal pain (8 [16%]), and ovarian cyst (1 [2%]). Three patients (6%) had incidental urinary tract infections. All patients were discharged from the ED. No management changes were made based on the pelvic examination.

Conclusion
In patients with a US-documented viable pregnancy, the pelvic examination did not contribute to the patient's immediate obstetric treatment. Occult cervical pathogens may be present in these patients.

10. Teleradiology Interpretations of Emergency Department CT Scans

Platts-Mills TF, et al. J Emerg Med. 2010;38:188-195.

Background: Teleradiologist interpretation of radiographic studies during after-hours Emergency Department (ED) care has the potential to influence patient management. Study Objectives: We sought to characterize frequencies of discrepancies between teleradiology and in-house radiology interpretations for computed tomography (CT) scans.

Methods: We conducted a prospective observational study comparing teleradiologist and in-house radiologist interpretations of CT scans obtained between 7:00 p.m. and 7:00 a.m. from the ED at a Level I trauma center. For each scan, discrepancies were characterized as major, minor, or no discrepancy. Follow-up data were used to characterize major discrepancies.

Results: Of 787 studies sent to teleradiology, 550 were scans of the head, cervical spine, chest, or abdomen and pelvis. Major discrepancies were identified in 32 of 550 studies (5.8%; 95% confidence interval 4.1%–8.1%), including 7 of 160 head CT scans, 1 of 29 cervical spine CT scans, 3 of 64 chest CT scans, and 21 of 297 abdominopelvic CT scans. We attributed 8 of the 32 major discrepancies to a teleradiology misinterpretation, with one case leading to an adverse event.

Conclusions: We identified major discrepancies due to teleradiologist misinterpretation in 8 of 550 studies, with one patient suffering an adverse event. Our findings support the cautious use of teleradiology interpretations.

11. "Don’t Call Me ‘Mom’": How Parents Want to Be Greeted by Their Pediatrician

Amer A, et al. Clinical Pediatrics. 2009;48:720-722.

Background. Physician—patient interaction during the medical interview is essential in establishing the rapport necessary for a successful relationship. Physicians are generally encouraged to shake hands with patients, address patients by name, and identify themselves.

Objective. To define parents expectations for greetings by pediatricians and to determine the frequency with which these expectations are met.

Design and methods. A total of 100 parents visiting the General Pediatric Clinic at Childrens Hospital of Michigan were recruited. Parents were interviewed at the end of their medical encounter to determine expectations for greeting by their doctor. They were questioned about preferences for shaking hands, the doctors’ use of their names, and the way doctors should introduce themselves. They were then asked if the experience at this visit conformed to these expectations.

Results. Overall, 81% of the parents were the childrens mother and 86% were African-American. Over 80% of parents expected physicians to shake hands; 70% of residents and 66% of attendings did. 88% of parents wanted to be addressed by their names; only 14% of residents and 24% of attending physicians did so. All of the parents wanted the physicians to introduce themselves; 84% of residents and 93% of attendings did so.

Conclusions. Physicians neither shook hands with many parents who expected it, nor did they address parents by their last names. About 90% of physicians introduced themselves. These disappointingly low results may predispose to parent dissatisfaction. Attending physicians need to teach these small, but important features, and to model them as well.

12. Does End Tidal CO2 Monitoring During Emergency Department Procedural Sedation and Analgesia With Propofol Decrease the Incidence of Hypoxic Events? A Randomized, Controlled Trial

Deitch K, et al. Ann Emerg Med. 2010;55:258-264.

Study objective
We determine whether the use of capnography is associated with a decreased incidence of hypoxic events than standard monitoring alone during emergency department (ED) sedation with propofol.

Methods
Adults underwent ED propofol sedation with standard monitoring (pulse oximetry, cardiac and blood pressure) and capnography and were randomized into a group in which treating physicians had access to the capnography and a blinded group in which they did not. All patients received supplemental oxygen (3 L/minute) and opioids greater than 30 minutes before. Propofol was dosed at 1.0 mg/kg, followed by 0.5 mg/kg as needed. Capnographic and SpO2 data were recorded electronically every 5 seconds. Hypoxia was defined as SpO2 less than 93%; respiratory depression, as end tidal CO2 (etco2) greater than 50 mm Hg, etco2 change from baseline of 10%, or loss of the waveform.

Results
One hundred thirty-two subjects were evaluated and included in the final analysis. We observed hypoxia in 17 of 68 (25%) subjects with capnography and 27 of 64 (42%) with blinded capnography (P=.035; difference 17%; 95% confidence interval 1.3% to 33%). Capnography identified all cases of hypoxia before onset (sensitivity 100%; specificity 64%), with the median time from capnographic evidence of respiratory depression to hypoxia 60 seconds (range 5 to 240 seconds).

Conclusion
In adults receiving ED propofol sedation, the addition of capnography to standard monitoring reduced hypoxia and provided advance warning for all hypoxic events.

See related editorial: Green SM, et al. Should Capnographic Monitoring Be Standard Practice During Emergency Department Procedural Sedation and Analgesia? Pro and Con. Ann Emerg Med. 2010;55:265-267.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(09)01446-2/fulltext

13. Comparison of ultrarapid and rapid intravenous hydration in pediatric patients with dehydration

Nager AL, et al. Amer J Emerg Med. 2010;28:123-129.

Objective
The purpose of this study is to test the efficacy of ultrarapidly infused vs rapidly infused intravenous (IV) hydration in pediatric patients with acute gastroenteritis and moderate dehydration.

Methods
Patients 3 to 36 months, with vomiting and/or diarrhea and moderate dehydration, were eligible. Subjects were randomly assigned “ultra” (50 mL/kg normal saline for 1 hour) vs “standard” (50 mL/kg normal saline for 3 hours) after failing an oral fluid challenge. Subjects were weighed and had serum electrolyte testing, and urine was obtained before/after IV hydration. Input/output and vital signs were tabulated hourly during the study. Subjects were discharged after fulfilling specified criteria. A follow-up questionnaire was completed 24 hours after discharge. Comparison data included success and timing of rehydration, number of patients who returned and/or were admitted, output during the rehydration period, laboratory differences, and serious complications.

Results
Eighty-eight of 92 subjects completed the study: 45 ultra and 43 standard. Four patients failed treatment (1 ultra and 3 standard), were hospitalized, and excluded from the study. Groups were similar regarding sex, days of symptoms, episodes of vomiting/diarrhea before treatment, capillary refill time, tears, and vital signs and laboratory results. No subject had evidence of serious complications. Ninety-one percent of subjects completed the follow-up questionnaire. Seven ultra and 6 standard subjects returned. Six ultra subjects received oral fluid, one received IV fluid, and all were discharged. Five standard subjects received oral fluid, one received IV fluid, and all were discharged.

Conclusion
Based on this pilot study, ultrarapid hydration for 1 hour preliminarily appears to be an efficacious alternative to standard rapid hydration for 3 hours and improves emergency department throughput time.

14. Association between first-trimester vaginal bleeding and miscarriage.

Hasan R, et al. Obstet Gynecol. 2009;114:860-7.

OBJECTIVE: To estimate the strength of association between first-trimester bleeding and miscarriage, setting aside bleeding at time of loss.

METHODS: Women enrolled in a community-based pregnancy cohort study before or during early pregnancy. Detailed first-trimester bleeding data were collected by telephone interview. Bleeding episodes proximal to miscarriage (within 4 days) were excluded. We used discrete-time hazard models to evaluate the association between bleeding and miscarriage. Models were adjusted for maternal age, prior miscarriage, and smoking. Exploratory regression tree analysis was used to evaluate the relative importance of other bleeding characteristics (duration, associated pain, color, timing).

RESULTS: Of the 4,510 participants, 1,204 (27%) reported some first-trimester vaginal bleeding or spotting, and 517 miscarriages were observed. Eight percent of those with bleeding reported heavy bleeding episodes. When we evaluated any bleeding, including episodes of only spotting, the unadjusted relative odds ratio (OR) of miscarriage for women with bleeding (n=1,204) was 1.1 (95% confidence interval [CI] 0.9-1.3). However, women who reported heavy bleeding (n=97) had nearly three times the risk of miscarriage compared with women without bleeding during the first trimester (OR 3.0, 95% CI 1.9-4.6). Adjustment for covariates had little effect on estimates. Further analyses suggested that women with heavy bleeding accompanied by pain were the group accounting for most of the elevated risk.

CONCLUSION: Heavy bleeding in the first trimester, particularly when accompanied by pain, is associated with higher risk of miscarriage. Spotting and light episodes are not, especially if lasting only 1-2 days.

15. Should I Consider Treating Patients With Acute Cardiogenic Pulmonary Edema With Noninvasive Positive-Pressure Ventilation?

Seupaul RA. Ann Emerg Med. 2010;55:299-300.

Conclusion: Noninvasive positive-pressure ventilation in addition to standard medical therapy is safe and effective in the treatment of adults with acute cardiogenic pulmonary edema.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(09)01228-1/fulltext

16. The utility of serial peak flow measurements in the acute asthmatic being treated in the ED

Henderson SO, et al. Amer J Emerg Med. 2010;28:221-223.

Background
Peak flow is used extensively in emergency departments (EDs) to both assess asthma patient's status on arrival as well as to document clinical improvement during treatment. Many algorithms suggest serial peak expiratory flow (PEF) measurements during an ED stay.

Objective
The aim of the study was to assess the contribution of serial PEF in describing the overall improvement of asthmatics over the course of an ED visit for acute exacerbation of their asthma.
Methods
This was a prospective institutional review board–approved study of mild/moderate asthmatics presenting to an inner-city ED serving a large Latino population. Peak expiratory flow was measured before treatment (baseline PEF) and after each inhaled treatment (PEF post RX#1, PEF post RX#2, PEF post RX#3) while in the ED.

Results
One hundred consecutive patients made up this study cohort. The change from baseline PEF to PEF #1 represented 86% (95% confidence interval [CI], 76%-96%) of the total improvement experienced by these patients with asthma. The change from PEF post RX#1 to PEF post RX#2 represented 7.5% (95% CI, −4.2% to 26%) of the total improvement and PEF post RX#2 to PEF post RX#3 represented 8.6% (95% CI, −1% to 34%) of the total PEF improvement seen.

Limitation
No correlation between outcome and PEF% of predicted was made or implied.

Conclusion
The improvement in PEF seen after the first ED inhaled therapy appears to describe most of the total improvement seen in asthmatic patients. Subsequent PEFs provided little additional information.

17. Withholding Information from Patients — When Less Is More

Epstein RM, et al. N Engl J Med. 2010;362:380-381.

As clinicians who strongly value truth telling and active patient involvement in medical decision making, we have lately been reflecting on the circumstances in which physicians consciously (and sometimes unconsciously) withhold from patients information about their conditions, treatments, and outcomes. The ethical principle of autonomy would suggest that patients should always be fully informed, not only so that they can make the best possible decisions, but also because information helps them to make sense of and cope with illness. However, since information can sometimes increase patients' cognitive and emotional burden and lead to greater confusion rather than clarity, the right to autonomy must be balanced with the ethical obligations to do good for patients (beneficence) and not to harm them (nonmaleficence). Physicians routinely make judgments about whether time taken to provide information will detract from other important tasks, such as making decisions or promoting adherence to treatment regimens.

Clinicians and ethicists are generally comfortable with the idea of withholding information in several types of situations. If a patient lacks the cognitive capacity to understand the information, then it should be provided to a surrogate. If there is a need to intervene urgently (e.g., in the case of a ruptured aortic aneurysm), the potential benefits of early intervention often outweigh the potential harms of incomplete or delayed disclosure. If patients explicitly or implicitly (e.g., through silence or repeated changing of the subject) choose not to receive important clinical information, then a health care proxy should be kept informed while the reasoning behind patients' refusal of information is explored. But decisions to withhold information should be reconsidered if a patient asks directly for information, or if the perspectives of the patient and his or her family about the clinical situation appear to be discordant.

Still, there remains a gray zone — situations in which physicians (consciously or unconsciously) withhold information from patients who have the capacity to understand and have not articulated a desire not to be informed. In these situations, choices about providing or withholding information should be made in such a way as to maximize benefit and minimize psychological and cognitive and emotional burdens. When considering whether the information will be of any significant benefit to the patient, clinicians should assess both instrumental benefits — help in making decisions, in providing meaningful options, and in obtaining access to resources — and emotional or relational benefits — helping the patient to cope, find meaning, defuse shame or blame, and build trust.

The consideration of potential burdens of information is more complex. For example, cognitive overload from too much information may impair rather than facilitate understanding and decision making, especially when patients and families are under considerable emotional and physical duress. A recitation of an exhaustive litany of improbable side effects of a medication, for example, can not only obscure more relevant information but also distract patients and physicians from practical discussions about the purpose and logistics of treatment. Detailed discussions of incidental findings — a benign liver cyst, say, noted on the computed tomographic scan of a patient with a suspicious lung nodule — can derail exploration of the complexities of a serious illness and the relevant treatment options. Informing a patient with panic disorder about borderline prolongation of his QT interval might reinforce his fears about cardiac disorders and distract from educating him about his panic disorder and initiating treatment.

The emotional nature of some information that is irrelevant to prognosis or treatment choices may result in unnecessary distress. For example, in a child with leukemia, the finding of a single blast cell on a routine follow-up blood count may have no prognostic significance and will not affect decision making, yet the information may be very distressing to parents.

Providing every detail of clinical information also takes time and may crowd out more important discussions. Time taken to explain to a hospice patient that she now has five rather than three pulmonary metastases might be better used to discuss how to relieve her symptoms or how her family is coping. If a screening-mammography report contains language suggesting that the image was technically imperfect yet good enough not to warrant repeat imaging before the next scheduled screening, the time spent relaying that information might be better spent reinforcing other healthy behaviors.

Finally, clinicians should consider how the information might enhance or reduce patients' autonomy. If patients find information clarifying or empowering, they are better able to make decisions that are consistent with their values. However, more information is not always better. Dumping all available information on patients can be overwhelming and may paradoxically undermine their ability to choose wisely. Furthermore, patients' ability to acquire and use information and fully participate in their care does not depend solely on how much information they receive — it also depends on the nature of their relationships with their clinicians, their families, and others. If patients distrust their physicians, they tend to seek more information. If patients are left alone to sort out complex information, they may feel abandoned and less able to exercise control. The ideal goal may be "autonomy-in-relation," which entails collaboration among patients, their loved ones, and clinicians in seeking, interpreting, contextualizing, and acting on information.

Physicians regularly make tacit judgments about the amount of information that patients can reasonably assimilate, how to interpret and contextualize it, how it will affect patients' and families' ability to cope with the illness and make informed decisions, and how to avoid frightening or overwhelming patients with details. These judgments ideally take into account physicians' knowledge of the patient as a person, including the patient's cognitive capacity, level of literacy and numeracy, values, and desire for detailed medical information.

However, physicians need to guard against conscious or unconscious bias in their exercise of "clinical judgment" regarding withholding possibly relevant clinical information. Though most would disavow any prejudice, physicians, like all humans, exhibit bias in their behavior. For example, physicians tend to provide black patients with less information about their illnesses than they provide to white patients, even when educational level and socioeconomic status are taken into account. In time-pressured health care environments, clinical judgment may be used as a rationale for withholding information in order to avoid time-consuming or burdensome aspects of care. Our current financial incentives generally favor interventions and discourage informative conversations about the limits of treatments. Furthermore, some physicians might withhold information — omitting mention of alternative treatments or controversial aspects of care — simply to avoid conflict with potentially contentious patients or families.

Clinicians' everyday decisions about how much detail to share with patients require self-awareness and honesty. In our view, clinicians should withhold information that is likely to overwhelm and distress patients if their having the information would provide no obvious benefit and they don't ask for it; information overload — especially if the information is not clinically relevant — may render more important discussions impossible. There may be situations in which it is even appropriate to withhold information of potential significance (or to delay its disclosure), but they are exceptions. We propose some simple rules: If the patient asks, the clinician should tell. If the clinician is anxious about what would happen if a patient discovers that information has been withheld, then the decision to withhold should be reconsidered. Clinicians should scrutinize their tacit judgments by routinely asking themselves questions such as "What would a trusted peer say?," "Am I feeling uncomfortable?," or "Am I assuming that the patient's values are the same as mine?" Clinicians should overcome potential biases by getting to know each patient as an individual. And when uncertain, clinicians should discuss the decision to withhold information with a trusted member of the patient's inner circle, experienced colleagues, or both.

18. Images in Emergency Medicine

Man with Painful Skin Lesion
http://www.annemergmed.com/article/S0196-0644(09)00647-7/fulltext

19. Whole Bowel Irrigation and the Hemodynamically Unstable Calcium Channel Blocker Overdose: Primum Non Nocere

Cumpston KL, et al. J Emerg Med. 2010;38:171-174.

Sustained-release calcium channel blocker (CCB SR) overdoses are potentially life-threatening ingestions. These patients may not become hemodynamically unstable until many hours after ingestion. On theoretical grounds, some have suggested that whole bowel irrigation (WBI) with polyethylene glycol electrolyte lavage solution may be of value in the management of these cases.

We report two cases with poor outcome (including one fatality) that were complicated by the use of WBI. Both cases were treated with WBI beginning before and continuing after developing hypotension. WBI should be avoided in the setting of the hemodynamically unstable CCB SR overdose.

20. Circadian pattern of intubation rates in ED patients with congestive heart failure

Allegra JR, et al. Amer J Emerg Med. 2010;28:166-169.

Purpose
A previous study showed that pulmonary edema patients presenting between noon and 4 pm have the highest rates of myocardial infarction and death. We hypothesized that the highest intubation rates would also occur at these times.

Basic Procedures
We performed a retrospective cohort study of consecutive patients seen by emergency department physicians in 15 hospital emergency departments (1996-2003).

Main Findings
Of 3.6 million visits in the database, 39,795 (1.1%) patients had congestive heart failure. We found statistically significant circadian variations in intubation rates. Patients arriving between midnight and 4 am had the highest intubation rates (4.1%), and those arriving between noon and 4 pm had the lowest (1.2%) (difference, 2.9%; 95% confidence interval, 2.4%-3.4%; P less than .0001).

Conclusion
We found significant circadian variation in intubation rates, with a marked increase around midnight. Pathological mechanisms causing patients with congestive heart failure to require intubation may differ from those resulting in myocardial infarction or death.

21. A Fine Excision: ATLS Manual No Longer Defines Trauma as a Surgical Disease

Millard WB. Ann Emerg Med. 2010;55:A20-A24.

The new 8th edition of the Advanced Trauma Life Support (ATLS) course manual1 contains a small but significant change. The phrase, “trauma is a surgical disease,” long a point of contention with other specialties caring for trauma patients, has been removed.

Now used in over 50 countries as the basis for training in the initial assessment and management of trauma, this publication reflects the research and clinical experience of the American College of Surgeons (ACS) Committee on Trauma and expresses that organization's philosophy toward triage, diagnosis, and clinical care. Astute readers of the ATLS materials have noticed that a certain message is conspicuous by its absence. The preface to the 7th edition of the ATLS describes the ACS's role as follows: “In accordance with that role, and recognizing that trauma is a surgical disease, the ACS Committee on Trauma (COT) has worked to establish guidelines for the care of the trauma patient.”

The 8th edition includes a substantially similar sentence, minus the crucial phrase on trauma as a “surgical disease.” John B. Kortbeek, MD, FACS, professor of surgery and critical care at the University of Alberta and a member of the COT who was instrumental in the revision process for the manual, confirms that the deletion is intentional.

Dr. Kortbeek explains the change in historical terms. “The intent of making that statement,” he says, “was to emphasize that to have a successful trauma system and a successful trauma hospital, surgeons needed to be included in the management team and the care of the trauma patient. That remains true today. What changed over time is that that statement became a focal point and could be interpreted in varying ways, including in a negative, exclusive way, suggesting that only surgeons should be managing trauma patients, which is not correct and never was the intent of the statement.” The ATLS, he says, presents a “common language” for a safe and effective response to trauma, not a mandatory formula.

The rest of the essay: http://www.annemergmed.com/article/S0196-0644(10)00038-7/fulltext

Lit Bits: Feb 10, 2010

From the recent medical literature...

1. Nasogastric Aspiration and Lavage in Emergency Department Patients with Hematochezia or Melena Without Hematemesis

Palamidessi N, et al. Acad Emerg Med. 2010;17:126–132.

Objectives: The utility of nasogastric aspiration and lavage in the emergency management of patients with melena or hematochezia without hematemesis is controversial. This evidence-based emergency medicine review evaluates the following question: does nasogastric aspiration and lavage in patients with melena or hematochezia and no hematemesis differentiate an upper from lower source of gastrointestinal (GI) bleeding?

Methods: MEDLINE, EMBASE, the Cochrane Library, and other databases were searched. Studies were selected for inclusion in the review if the authors had performed nasogastric aspiration (with or without lavage) in all patients with hematochezia or melena and performed esophagogastroduodenal endoscopy (EGD) in all patients. Studies were excluded if they enrolled patients with history of esophageal varices or included patients with hematemesis or coffee ground emesis (unless the data for patients without hematemesis or coffee ground emesis could be separated out). The outcome was identifying upper GI hemorrhage (active bleeding or high-risk lesions potentially responsible for hemorrhage) and the rate of complications associated with the nasogastric tube insertion. Quality of the included studies was assessed using standard criteria for diagnostic accuracy studies.

Results: Three retrospective studies met our inclusion and exclusion criteria. The prevalence of an upper GI source for patients with melena or hematochezia without hematemesis was 32% to 74%. According to the included studies, the diagnostic performance of the nasogastric aspiration and lavage for predicting upper GI bleeding is poor. The sensitivity of this test ranged from 42% to 84%, the specificity from 54% to 91%, and negative likelihood ratios from 0.62 to 0.20. Only one study reported the rate complications associated with nasogastric aspiration and lavage (1.6%).

Conclusions: Nasogastric aspiration, with or without lavage, has a low sensitivity and poor negative likelihood ratio, which limits its utility in ruling out an upper GI source of bleeding in patients with melena or hematochezia without hematemesis.

2. Muscle Relaxant Adds No Benefit to Ibuprofen for Cervical Strain

Pain relief did not differ among patients who received ibuprofen, cyclobenzaprine, or both drugs.

Muscle relaxants often are prescribed for neck and back pain, despite the lack of evidence of benefit. Researchers evaluated the effect of cyclobenzaprine in a prospective, randomized, double-blind study in a convenience sample of 61 adult patients (mean age, 34; 58% women) who presented to a level I trauma center emergency department with acute cervical strain (87% caused by motor vehicle collisions). Patients received ibuprofen (800 mg), cyclobenzaprine (5 mg), or both drugs three times daily for up to 7 days, as needed for pain. All patients received an initial dose of 800 mg of ibuprofen in the ED.

Patients rated pain severity on a 100-mm visual analog scale 30 to 60 minutes after taking the morning dose of medication. Pain scores improved significantly over 7 days in all three groups and did not differ among groups. Adverse effects were minimal and included dizziness in four patients who received cyclobenzaprine alone or with ibuprofen and nausea in one patient who received ibuprofen alone.

Comment: A small dose of cyclobenzaprine was used in this study, perhaps to avoid the anticholinergic, antihistaminic, and sedative side effects of this drug, which is closely related chemically to tricyclic antidepressants. No convincing evidence supports the use of cyclobenzaprine in painful musculoskeletal conditions, and the drug's benefit-to-adverse effect profile therefore argues against prescribing it. Most patients with cervical strain will get better. Provide adequate analgesia as needed, and leave the cyclobenzaprine in the pharmacy.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine February 5, 2010. Citation: Khwaja SM et al. Comparison of ibuprofen, cyclobenzaprine or both in patients with acute cervical strain: A randomized controlled trial. CJEM 2010 Jan; 12:39.

3. Aspirin for the Primary Prevention of Stroke and Myocardial Infarction: Ineffective or Wrong Dose?

Dalen JE. Amer J Med. 2010;123:101-102.

The concluding paragraphs:

It is difficult to ignore the results of 7 consecutive randomized clinical trials. There are 2 possible conclusions. One conclusion is that the recommendations of aspirin for primary prevention by the organizations shown in Table 1 are incorrect because aspirin is ineffective. Millions of people throughout the world are taking aspirin for primary prevention. Should they be told to discontinue aspirin?

The other conclusion is that the recommended dose is insufficient; 7 clinical trials have documented that doses of 100 mg or less are ineffective. The US Physicians Health study reported a 44% reduction in myocardial infarction in physicians taking 325 mg every other day (162 mg/d). One might reasonably conclude that the recommended dosage should be increased to 162 mg per day. I will continue to recommend 162 mg per day to my patients.

Full-text (free): http://www.amjmed.com/article/S0002-9343(09)00976-0/fulltext

4. Spine Immobilization for Penetrating Trauma Can Be Harmful

Patients who underwent immobilization were twice as likely to die as those who did not.

Despite a lack of supportive evidence for the practice, prehospital providers often apply spine immobilization to patients who have penetrating trauma to the head, neck, or torso without neurological symptoms or deficit. These authors retrospectively assessed the effect of prehospital spine immobilization on mortality in patients with penetrating trauma using data from the American College of Surgeons National Trauma Data Bank between 2001 and 2004.

Of 45,284 patients (median age, 29), 4.3% received cervical collars, spinal backboards, or both. The overall mortality rate was 8.1%. Multiple logistic regression analysis that controlled for confounders, including Injury Severity Score and Revised Trauma Score, showed that immobilized patients had significantly increased mortality (odds ratio, 2.06); this finding held true in subgroups of patients with gunshot wounds (OR, 2.12), hypotension (OR, 2.42), and gunshot wounds and hypotension (OR, 3.19). Complete data on in-hospital procedures were available for about 31,000 patients. Only 30 patients (0.1%) underwent operative spine stabilizing procedures for incomplete spinal-cord injury. The number needed to treat with spine immobilization to potentially benefit 1 patient was 1032. The number needed to harm with spine immobilization to potentially contribute to 1 death was 66.

Comment: Increasing evidence indicates that limited intervention at the scene allows trauma patients to receive definitive care at a trauma center more rapidly. This study indicates that prehospital spine immobilization is associated with increased mortality in patients with penetrating trauma. Trying to assign cause and effect in a retrospective study is risky, but possibly increased scene time or interference with later care (e.g., intubation, radiography, examination of the patient's back) contribute to worse outcomes. Spine immobilization might be applied more wisely to patients with altered mental status, spine tenderness, or sensorimotor dysfunction.

— John A. Marx, MD, FAAEM. Published in Journal Watch Emergency Medicine January 29, 2010. Citation: Haut ER et al. Spine immobilization in penetrating trauma: More harm than good? J Trauma 2010 Jan; 68:115.

5. Placing Thoracic Central Lines in Coagulopathic Patients: A Sampling of the Lit

A. Low levels of prothrombin time (INR) and platelets do not increase the risk of significant bleeding when placing central venous catheters.

Weigand K, et al. Med Klin (Munich). 2009;104:331-5.

BACKGROUND AND PURPOSE: Central venous catheters are frequently placed in intensive care medicine for multiple indications. The risk of severe bleeding after cannulation is considered to be increased in patients with abnormal coagulation, common in critically ill patients. PATIENTS AND METHODS: This open prospective trial, performed at two medical intensive care units and one hematology intermediate care ward, investigated whether insertion of a central venous catheter in patients with coagulopathy (prothrombin time less than 50% [International Normalized Ratio, INR, 1.5 or greater] and/or platelets less than 50 x 10(9)/l) bears an increased risk of bleeding. RESULTS: In 196 patients with and without severe disorders of hemostasis, no significant difference in decrease of hemoglobin after catheter placement was observed. In addition, no correlation between a significant drop in hemoglobin and increased levels of creatinine or urea was seen. Mechanical complications were similar in frequency compared to previous publications. CONCLUSION: These findings demonstrate that coagulation disorders with altered prothrombin time (INR) or platelets do not increase the risk of significant bleeding when inserting a central venous catheter. Therefore, the prophylactic correction of coagulation by transfusion of blood products or coagulation factors is not necessary before central venous catheter insertion.

B. Central venous catheter placement in patients with disorders of hemostasis.

Mumtaz H, et al. Am J Surg. 2000;180:503-5; discussion 506.

BACKGROUND: Patients requiring central venous access frequently have disorders of hemostasis. The aim of this study was to identify factors predictive of bleeding complications after central venous catheterization in this group of patients. METHODS: A retrospective analysis of all central venous catheters placed over a 2-year period (1997 to 1999) at our institution were performed. The age, sex, clinical diagnosis, most recent platelet count, prothrombin international normalized ratio (INR), activated partial thromboplastin time (aPTT), catheter type, the number of passes to complete the procedure, and bleeding complications were retrieved from the medical records. RESULTS: In a 2-year period, 2,010 central venous catheters were placed in 1,825 patients. Three hundred and thirty placements were in patients with disorders of hemostasis. In 88 of the 330 patients, the underlying coagulopathy was not corrected before catheter placement. In these patients, there were 3 bleeding complications requiring placement of a purse string suture at the catheter entry site. In the remaining 242 patients, there was 1 bleeding complication. Of the variables analyzed, only a low platelet count (below 50 x 10(9)/L) was significantly associated with bleeding complications. CONCLUSION: Central venous access procedures can be safely performed in patients with underlying disorders of hemostasis. Even patients with low platelet counts have infrequent (3 of 88) bleeding complications, and these problems are easily managed.

C. Central venous catheter placement in patients with disorders of hemostasis.

Doerfler ME, et al. Chest. 1996;110:185-8.

OBJECTIVE: To define the incidence of bleeding complications from central venous access procedures performed by a critical care service in patients with disorders of hemostasis. DESIGN: Prospective, consecutive sample, collection of clinical data. SETTING: University teaching hospital. PATIENTS: Seventy-six consecutive patients with disorders of hemostasis who required central venous access for clinical management between October 1992 and October 1993. MEASUREMENTS: Age, sex, clinical diagnosis, most recent platelet count, prothrombin time (PT), and activated partial thromboplastin time (aPTT) were recorded from the medical record of patients with known coagulation or platelet abnormalities. The site of central venous catheter placement, the number of needle passes necessary to complete the procedure, and the occurrence of complications were reported by the critical care attending physician performing or supervising the procedure. RESULTS: One hundred four central venous access procedures were performed on 76 patients with disorders of hemostasis. Seventy-three percent of catheters were placed in patients with platelet counts less than 100,000/mL and 40% of catheters were placed in patients with abnormalities of PT, aPTT, or both. Thirteen percent of patients had abnormalities of both platelets and coagulation profile. There were no serious complications. Bleeding complicated 7 (6.5% of the procedures; 5 patients had bleeding from the skin (from the suture sites in four), and 2 patients developed small periosteal hematomas. All patients with bleeding complications had thrombocytopenia with mean platelet counts of 22,000/mL and a range of 6,000 to 37,000/mL. Most patients with platelet counts in this range did not have clinically evident bleeding. CONCLUSIONS: Central venous access procedures can be done safely in patients with disorders of hemostasis by skilled physicians who frequently perform these procedures. Patients most likely to experience bleeding from these procedures are patients with severe thrombocytopenia. In this series, only a single patient, with a platelet count of 6,000/mL, required therapeutic blood product administration.

D. Invasive line placement in critically ill patients: do hemostatic defects matter?

DeLoughery TG, et al. Transfusion. 1996;36:827-31.

BACKGROUND: Blood components are often given prophylactically before the placement of invasive lines in patients with coagulation defects. Little, however, is known about the epidemiology of defects in these patients. The purpose of this study is to ascertain what proportion of intensive care patients who receive invasive lines have hemostatic defects, what actions are taken by physicians to correct these abnormalities before invasive line insertion, and what the incidence is of bleeding complications after invasive line placement. STUDY DESIGN AND METHODS: Charts were retrospectively reviewed for 490 intensive care patients in whom 938 arterial, pulmonary artery, and central venous lines were placed. RESULTS: At least one defect in hemostasis was documented for 388 patients (41%) before line placement, with 253 (27%) of these patients evidencing severe abnormalities. Seventeen percent of patients had no preprocedure laboratory evaluation. Trauma patients showed the highest numbers of abnormalities in hemostatic testing, but medical patients had more-severe defects. The occurrence of isolated abnormal laboratory values did not predict bleeding, but a score derived from a consideration of multiple defects did. Correction of the abnormalities was attempted in 37 percent of patients with hemostatic defects. Sixteen patients had bleeding complications, but only two had complications that were life-threatening. None of the complications were fatal. CONCLUSION: Invasive lines are used frequently in patients with hemostatic defects, often without any attempt to correct the abnormalities. Nevertheless, rates of hemorrhage are low and appear to be closely related to the level of experience of the physician rather than to defects in hemostasis. These findings suggest that the use of blood components for preprocedure correction of hemostatic defects is not necessary, except in those patients who have the most severe hemostatic abnormalities.

6. Risk of Deep Vein Thrombosis Following a Single Negative Whole-Leg Compression Ultrasound: A Systematic Review and Meta-analysis

Johnson SA, et al. JAMA. 2010;303:438-445.

Context: In patients with suspected lower extremity deep vein thrombosis (DVT), compression ultrasound (CUS) is typically the initial test to confirm or exclude DVT. Patients with an initial negative CUS result often require repeat CUS after 5 to 7 days. Whole-leg CUS may exclude proximal and distal DVT in a single evaluation.

Objective To determine the risk of venous thromboembolism after withholding anticoagulation in patients with suspected lower extremity DVT following a single negative whole-leg CUS result.

Data Sources: MEDLINE, EMBASE, CINAHL, LILACS, Cochrane, and Health Technology Assessments databases were searched for articles published from January 1970 through November 2009. Supplemental searches were performed of Internet resources, reference lists, and by contacting content experts.

Study Selection: Included studies were randomized controlled trials and prospective cohort studies of patients with suspected DVT and a negative whole-leg CUS result who did not receive anticoagulant therapy, and were followed up at least 90 days for venous thromboembolism events.

Data Extraction: Two authors independently reviewed and extracted data regarding a single positive or negative whole-leg CUS result, occurrence of venous thromboembolism during follow-up, and study quality.

Results: Seven studies were included totaling 4731 patients with negative whole-leg CUS examinations who did not receive anticoagulation. Of these, up to 647 patients (13.7%) had active cancer and up to 725 patients (15.3%) recently underwent a major surgery. Most participants were identified from an ambulatory setting. Venous thromboembolism or suspected venous thromboembolism–related death occurred in 34 patients (0.7%), including 11 patients with distal DVT (32.4%); 7 patients with proximal DVT (20.6%); 7 patients with nonfatal pulmonary emboli (20.6%); and 9 patients (26.5%) who died, possibly related to venous thromboembolism. Using a random-effects model with inverse variance weighting, the combined venous thromboembolism event rate at 3 months was 0.57% (95% confidence interval, 0.25%-0.89%).

Conclusion: Withholding anticoagulation following a single negative whole-leg CUS result was associated with a low risk of venous thromboembolism during 3-month follow-up.

7. Red Flags May Help Identify Serious Infection in Children

Laurie Barclay, MD. February 5, 2010 — Rapid breathing, parental concern, and the clinician's instinct are among the red flags warning of serious infection in children in developed countries, according to the results of a systematic review reported online in the February 3 issue of The Lancet.

"Our aim was to identify which clinical features have value in confirming or excluding the possibility of serious infection in children presenting to ambulatory care settings in developed countries," write Ann Van den Bruel, MD, from Katholieke Universiteit in Leuven, Belgium, and colleagues from the European Research Network on Recognising Serious Infection investigators.

The reviewers searched electronic databases (Medline, Embase, DARE, CINAHL) and bibliographies of identified relevant studies. In addition, they asked experts to identify articles evaluating clinical characteristics of serious infection in children.

Inclusion criteria for studies were analysis of diagnostic accuracy or prediction rules, enrollment of otherwise healthy children aged 1 month to 18 years, ambulatory care setting, outcome measure of serious infection, features evaluable in the ambulatory care setting, and sufficient data reported.

Evaluation of study quality was based on Quality Assessment of Diagnostic Accuracy Studies criteria. For each clinical feature, the reviewers calculated likelihood ratios for the presence (positive likelihood ratio) or absence (negative likelihood ratio) of the outcome, as well as pretest and post-test probabilities.

Red flags, or warning signs for serious infection, were defined as clinical characteristics with a positive likelihood ratio of more than 5.0. Rule-out signs were defined as clinical characteristics with a negative likelihood ratio of less than 0.2.

Of 1939 potentially relevant studies identified, 30 studies met selection criteria and were included in the analysis. Red flags identified from several studies were cyanosis (positive likelihood ratio range, 2.66 - 52.20), rapid breathing (1.26 - 9.78), poor peripheral perfusion (2.39 - 38.80), and petechial rash (6.18 - 83.70). Factors identified as strong red flags in 1 primary care study were parental concern (positive likelihood ratio, 14.40; 95% confidence interval [CI], 9.30 - 22.10) and clinician instinct (positive likelihood ratio, 23.50; 95% CI, 16.80 - 32.70).

In settings with a low prevalence of serious infection, a temperature of 40°C or more had value as a red flag. Although no single clinical characteristic had rule-out value, some combinations were helpful in ruling out the possibility of serious infection. For example, if the child is not short of breath and there is no parental concern, pneumonia is very unlikely (negative likelihood ratio, 0.07; 95% CI, 0.01 - 0.46).

"The Yale Observation Scale had little value in confirming (positive likelihood ratio range 1.10–6.70) or excluding (negative likelihood ratio range 0.16–0.97) the possibility of serious infection," the study authors write. "The red flags for serious infection that we identified should be used routinely, but serious illness will still be missed without effective use of precautionary measures. We now need to identify the level of risk at which clinical action should be taken."

Limitations of this review are primarily those inherent in the included studies, such as reproducibility and poor interobserver agreement, and the paucity of studies from first-contact care settings.

"The main strength of this systematic review is that it highlights the nature and difficulty of the diagnostic task facing primary care and hospital clinicians responsible for identifying seriously ill children at initial presentation in countries where serious childhood illness is now rare," the study authors conclude. "Most of the red flags already recommended by WHO [World Health Organization] for use in developing countries can be used in the initial assessment of children presenting to ambulatory care settings in developed countries. There should be more emphasis on parental concern in the diagnostic process."

In an accompanying comment, Martin Dawes, MBBS, MD, from McGill University in Montreal, Canada, notes that how to effectively recognize or rule out severe disease in ill children is still unclear and that there is no cohesive national or global research strategy to address this problem.

"We need better-designed diagnostic and prognostic studies in primary care," Dr. Dawes writes. "Such studies require properly documented histories and examination as well as follow-up, but both are well within the scope of an organised practice and if centrally coordinated we could have ten times the evidence within a year or two. This research cannot be done without adequate funding and should be a priority for national and international research foundations."

Health Technology Assessment and National Institute for Health Research National School for Primary Care Research supported this study. The study authors and Dr. Dawes have disclosed no relevant financial relationships.

Lancet. Published online February 3, 2010.

8. Applying the Lean principles of the Toyota Production System to reduce wait times in the emergency department

Ng D, et al. CJEM 2010;12:50-57.

Objective: In recognition of patient wait times, and deteriorating patient and staff satisfaction, we set out to improve these measures in our emergency department (ED) without adding any new funding or beds.

Methods: In 2005 all staff in the ED at Hôtel Dieu Grace Hospital began a transformation, employing Toyota Lean manufacturing principles to improve ED wait times and quality of care. Lean techniques such as value stream mapping, just in time delivery techniques, workplace organization, reduction of systemic wastes, use of the worker as the source of quality improvement and ongoing refinement of our process steps formed the basis of our project.

Results: Our ED has achieved major improvements in depart mental flow without adding any additional ED or inpatient beds. The mean registration to physician time has decreased from 111 minutes to 78 minutes. The number of patients who left without being seen has decreased from 7.1% to 4.3%. The length of stay (LOS) for discharged patients has decreased from a mean of 3.6 to 2.8 hours, with the largest decrease seen in our patients triaged at levels 4 or 5 using the Canadian Emergency Department Triage and Acuity Scale. We noted an improvement in ED patient satisfaction scores following the implementation of Lean principles.

Conclusion: Lean manufacturing principles can improve the flow of patients through the ED, resulting in greater patient satisfaction along with reduced time spent by the patient in the ED.

9. Tachypnea Is a Poor Predictor of Pneumonia in Children

An elevated respiratory rate in children younger than 5 years is less than 50% sensitive for predicting pneumonia.

Shah S et al. Pediatr Infect Dis J 2009 Dec 21.

Background: The World Health Organization (WHO) recommends the use of tachypnea as a proxy to the diagnosis of pneumonia in resource poor settings.

Objective: To assess the relation between tachypnea and radiographic pneumonia among children evaluated in a pediatric emergency department (ED).

Methods: Prospective study of children less than 5 years of age undergoing chest radiography (CXR) for possible pneumonia was conducted in an academic pediatric ED. Tachypnea was defined using 3 different measurements: (1) mean triage respiratory rate (RR) by age group, (2) age-defined tachypnea based on WHO guidelines (less than 2 months [RR 60/min or greater], 2 to 12 months [RR 50 or greater], 1 to 5 years [RR 40 or greater]), and (3) physician-assessed tachypnea based on clinical impression assessed before CXR. The presence of pneumonia on CXR was determined by an attending radiologist.

Results: A total of 1622 patients were studied, of whom, 235 (14.5%) had radiographic pneumonia. Mean triage RR among children with pneumonia (RR = 39/min) did not differ from children without pneumonia (RR = 38/min). About 20% of children with tachypnea as defined by WHO age-specific cut-points had pneumonia, compared with 12% of children without tachypnea (P less than 0.001). About 17% of children who were assessed to be tachypneic by the treating physician had pneumonia, compared with 13% of children without tachypnea (P = 0.07).

Conclusion: Among an ED population of children who have a CXR performed to assess for pneumonia, RR alone, and subjective clinical impression of tachypnea did not discriminate children with and without radiographic pneumonia. However, children with tachypnea as defined by WHO RR thresholds were more likely to have pneumonia than children without tachypnea.

10. Standard Medical Care May Not Relieve Symptoms of Nonspecific Chest Pain

Laurie Barclay, MD. February 8, 2010 — Standard medical care may not relieve symptoms of nonspecific chest pain, according to the results of a prospective, general physician–based cohort study reported in the February 8 issue of the Archives of Internal Medicine.

"Nonspecific chest pain is common in primary care, yet knowledge is sparse about its course and outcome and how they relate to optimum health care usage," write Julia Anna Glombiewski, PhD, from Philipps-University of Marburg, Germany, and colleagues. "We investigated the following observations: (1) many patients who present with nonspecific chest pain in primary care show symptom persistence for 6 months, (2) many patients with nonspecific chest pain showed signs of overinvestigation, and (3) many patients with chronic chest pain were referred to mental health specialists."

From October 1, 2005, to July 31, 2006, approximately 190,000 consecutive patients visited their general physicians at 74 primary care offices in Hessen, Germany. An expert committee identified 807 of these patients as having nonspecific chest pain, with no underlying heart condition. Follow-ups were performed at 6 weeks and 6 months, with a dropout rate of 2.7%.

The primary study endpoints were persistent chest pain at 6-month follow-up and healthcare use at 6 months. Inappropriate healthcare use was defined as at least 2 visits to a cardiologist or at least 3 cardiac diagnostic investigations.

At 6-month follow-up, 55.5% of patients had persistent chest pain, 10.7% of patients had inappropriate healthcare use, and fewer than 2% were referred to mental health specialists. Most patients with persistent nonspecific chest pain were referred to a cardiologist.

"For most patients with nonspecific chest pain, standard medical care does not offer sufficient help for symptom relief," the study authors write. "One-tenth of patients with persistent chest pain underwent additional diagnostic testing of no known clinical benefit. Psychological referrals were rarely given...[which] is surprising because psychological factors are known to contribute to the development of chronic pain, and psychological consultations are covered by the health care system in Germany."

Limitations of this study include the low response rate of general practitioners approached to participate in the study, use of a proposed new cutoff for inappropriate healthcare use, limited generalizability, and use of an informal definition of nonspecific chest pain.

"Patients with psychologically caused non-specific chest pain showed more problematic health care–seeking behavior but were rarely referred to mental health professionals," the study authors conclude. "Patients, general practitioners or both seem to be hesitant to involve psychological interventions.... Future research should investigate the development of effective interventions for non-specific chest pain and their implementation within health care systems."

The German Federal Ministry of Education and Research supported this study. The study authors have disclosed no relevant financial relationships.

Arch Intern Med. 2010;170:251-255.

11. Images in Emergency Medicine

Adult Male with Altered Mental Status and New-Onset Seizures

http://www.annemergmed.com/article/S0196-0644(09)00644-1/fulltext

12. Accuracy of Very Low Pretest Probability Estimates for Pulmonary Embolism Using the Method of Attribute Matching Compared with the Wells Score

Kline JA, et al. Acad Emerg Med. 2010;17:133–141.

Objectives: Attribute matching matches an explicit clinical profile of a patient to a reference database to estimate the numeric value for the pretest probability of an acute disease. The authors tested the accuracy of this method for forecasting a very low probability of venous thromboembolism (VTE) in symptomatic emergency department (ED) patients.

Methods: The authors performed a secondary analysis of five data sets from 15 hospitals in three countries. All patients had data collected at the time of clinical evaluation for suspected pulmonary embolism (PE). The criterion standard to exclude VTE required no evidence of PE or deep venous thrombosis (DVT) within 45 days of enrollment. To estimate pretest probabilities, a computer program selected, from a large reference database of patients previously evaluated for PE, patients who matched 10 predictor variables recorded for each current test patient. The authors compared the outcome frequency of having VTE [VTE(+)] in patients with a pretest probability estimate of less than 2.5% by attribute matching, compared with a value of 0 from the Wells score.

Results: The five data sets included 10,734 patients, and 747 (7.0%, 95% confidence interval [CI] = 6.5% to 7.5%) were VTE(+) within 45 days. The pretest probability estimate for PE was less than 2.5% in 2,975 of 10,734 (27.7%) patients, and within this subset, the observed frequency of VTE(+) was 48 of 2,975 (1.6%, 95% CI = 1.2% to 2.1%). The lowest possible Wells score (0) was observed in 3,412 (31.7%) patients, and within this subset, the observed frequency of VTE(+) was 79 of 3,412 (2.3%, 95% CI = 1.8% to 2.9%) patients.

Conclusions: Attribute matching categorizes over one-quarter of patients tested for PE as having a pretest probability of less than 2.5%, and the observed rate of VTE within 45 days in this subset was less than 2.5%.

13. Kitchen Spoons Don't Work for Meds

The amount of medicine poured varies with the size of the spoon.

Many patients and parents use kitchen spoons to dose liquid medications, but the accuracy of spoon dosing is questionable. These authors conducted a simple study in 195 university students to examine the effect of spoon size on dosing of liquid medication.

Students were asked to pour a 5-mL (teaspoon) dose of cold medicine into a teaspoon, a medium-sized tablespoon, and a larger spoon. The amount of medicine poured varied with the size of the spoon: Participants underdosed by 8.4% (amount poured, 4.58 mL) with the medium-sized tablespoon and overdosed by 11.6% (amount poured, 5.58 mL) with the larger spoon. When asked to judge their dosing accuracy, participants had above average confidence that they had poured the correct dose into the medium and larger spoons.

Comment: Although the dosing errors demonstrated in this study might seem inconsequential for a cold medication, the cumulative effect of 20% variation in the delivery of medications could have considerable clinical impact for drugs with tighter risk-benefit profiles. Clearly, the size of the spoon is important when patients pour their medications. We should encourage parents to use accurate measures (e.g., measuring cap, dropper, or syringe) rather than convenient utensils for liquid-medication dosing.

— F. Bruder Stapleton, MD. Published in Journal Watch Pediatrics and Adolescent Medicine January 27, 2010. Citation: Wansink B and van Ittersum K. Spoons systematically bias dosing of liquid medicine. Ann Intern Med 2010 Jan 5; 152:66.

14. The Etiology and Prognostic Significance of Cardiac Troponin I Elevation in Unselected Emergency Department Patients

Ilva TJ, et al. J Emerg Med. 2010;38:1-5.

Background: Cardiac troponin elevations are associated not only with acute coronary syndromes (ACS) but also with multiple other cardiac and non-cardiac conditions. Study Objectives: To investigate the etiology and clinical significance of cardiac troponin I elevations in an unselected Emergency Department (ED) patient cohort.

Methods: The study population consisted of 991 consecutive troponin-positive patients admitted to the ED of a university hospital with ACS as the presumptive diagnosis. Cardiac troponin I was measured on admission and a follow-up sample was obtained at 6–12 h. Clinical diagnosis was ascertained retrospectively using all the available information including electrocardiogram, clinical data, laboratory tests, and available coronary angiograms.

Results: At admission, 805 (81.2%) patients were already troponin positive; of these, the troponin elevation was related to myocardial infarction (MI) in 654 (81.2%) patients. Finally, 83.0% of the troponin elevations were due to MI, 7.9% were related to other cardiac causes, and 9.1% to non-cardiac diseases. The leading non-cardiac causes were pulmonary embolism, renal failure, pneumonia, and sepsis. Non-cardiac patients with elevated troponin I at admission showed significantly higher in-hospital mortality (26.7% vs. 13.4%, p = 0.002) compared to cardiac patients.

Conclusion: Elevated troponin levels for reasons other than MI are common in the ED and are a marker of poor in-hospital prognosis.

15. Prehospital ECG Speeds STEMI Patients' Route to Cath Lab

January 27, 2010 (Southfield, Michigan) — Emergency medical services (EMS) evaluating suspected ST-elevation myocardial infarction (STEMI) patients in the field with a prehospital electrocardiogram (ECG) are able to get patients directly to a cath lab much faster than if they had to go through triage in the emergency room (ER), a study in Michigan shows.

A five-year study by Dr Anjani Rao (Providence Hospital, Southfield, MI) and colleagues found that the average door-to-balloon time of patients evaluated by EMS in the field with a 12-lead ECG was about one hour, compared with about 90 minutes for patients presenting to the emergency department without a prehospital ECG (p less than 0.0001). Furthermore, prehospital ECGs reduced the door-to-balloon time, regardless of what time of day the patient came to the hospital. Results of the study by Rao et al are published online January 21, 2010 in Catheterization and Cardiovascular Interventions.

"This study adds to the evidence that prehospital ECGs improve the door-to-balloon time," Dr Deepak Bhatt (Brigham and Women's Hospital, Boston, MA) told heartwire ."The data are now fairly consistent."

The study evaluated data from three hospitals in southeast Michigan from 2003 to 2008. At each center, EMS personnel obtained a 12-lead ECG during initial assessment in the field from patients with symptoms of STEMI and then transmitted that data to the emergency department by cellular link. If the emergency-department physicians determined that the ECG indicated STEMI, they would activate the cath lab immediately. A total of 108 STEMI patients were admitted with prehospital ECG in the study.

For the same period, similar data were collected for all patients who came to the emergency department by EMS or on their own without a prehospital ECG, a total of 241 patients.

The overall average door-to-balloon time for patients with in-hospital ECG only was 90.5 minutes, compared with 60.2 minutes in patients with prehospital ECG, and door-to-balloon time was also significantly lower for the prehospital ECG patients at each of the three hospitals. The median door-to-balloon time was also lower with prehospital ECG (62 vs 82 minutes), and more patients in the prehospital ECG group had door-to-balloon times under 90 minutes, the target set by ACC/AHA guidelines (97.4% vs 61.5%; p less than 0.001). There were no in-hospital deaths in the prehospital ECG group compared with seven (2%) in the control group.

Rao et al note that previous studies show that patients presenting to an emergency room with STEMI during normal working hours are almost twice as likely to have a door-to-balloon time under 90 minutes as patients presenting during off-hours. The southeast Michigan study had similar findings for the in-hospital ECG group, but 98% of the patients with prehospital ECG during off-hours had door-to-balloon times within 90 minutes.

The study did not show a mortality benefit, most likely because of the low total number of deaths, Rao et al observe, but they note that previous trials have shown that delays in reperfusion therapy, such as those encountered during off-hours, increase mortality in STEMI patients. "The use of the prehospital ECG is a way of overcoming the obstacle of delay in cath-lab activation during off-hours."

Bhatt agrees that further studies may show that prehospital ECG saves lives. "There is even some evidence to suggest an associated improvement in hard clinical outcomes, although more data in this regard would be useful."

Bhatt also points out that hospitals relying on prehospital ECG to bypass triage in the emergency department must be carefully managed to ensure there is no loss of diagnostic accuracy when shifting from an in-hospital to prehospital ECG protocol. "There still needs to be careful oversight of these programs to make sure that clinically ambiguous cases get triaged appropriately in the emergency department," he said.

16. Comparison of Antiarrhythmic Drug Therapy and Radiofrequency Catheter Ablation in Patients With Paroxysmal Atrial Fibrillation: A Randomized Controlled Trial

Wilber DJ, et al. JAMA. 2010;303:333-340.

Context: Antiarrhythmic drugs are commonly used for prevention of recurrent atrial fibrillation (AF) despite inconsistent efficacy and frequent adverse effects. Catheter ablation has been proposed as an alternative treatment for paroxysmal AF.

Objective: To determine the efficacy of catheter ablation compared with antiarrhythmic drug therapy (ADT) in treating symptomatic paroxysmal AF.

Design, Setting, and Participants: A prospective, multicenter, randomized (2:1), unblinded, Bayesian-designed study conducted at 19 hospitals of 167 patients who did not respond to at least 1 antiarrhythmic drug and who experienced at least 3 AF episodes within 6 months before randomization. Enrollment occurred between October 25, 2004, and October 11, 2007, with the last follow-up on January 19, 2009.

Intervention: Catheter ablation (n = 106) or ADT (n = 61), with assessment for effectiveness in a comparable 9-month follow-up period.

Main Outcome Measures: Time to protocol-defined treatment failure. The proportion of patients who experienced major treatment-related adverse events within 30 days of catheter ablation or ADT was also reported.

Results: At the end of the 9-month effectiveness evaluation period, 66% of patients in the catheter ablation group remained free from protocol-defined treatment failure compared with 16% of patients treated with ADT. The hazard ratio of catheter ablation to ADT was 0.30 (95% confidence interval, 0.19-0.47; P less than .001). Major 30-day treatment-related adverse events occurred in 5 of 57 patients (8.8%) treated with ADT and 5 of 103 patients (4.9%) treated with catheter ablation. Mean quality of life scores improved significantly in patients treated by catheter ablation compared with ADT at 3 months; improvement was maintained during the course of the study.

Conclusion: Among patients with paroxysmal AF who had not responded to at least 1 antiarrhythmic drug, the use of catheter ablation compared with ADT resulted in a longer time to treatment failure during the 9-month follow-up period.

17. New Guidance for In-Hospital Torsades De Pointes

Steve Stiles. February 9, 2010 (Dallas, Texas and Washington, DC) — Many common, useful drugs have the side effect of electrocardiographic QT-interval prolongation, which substantially increases the risk of sudden death from torsades de pointes, a polymorphic VT. A given QT-prolonging drug may more likely cause torsades in hospitalized patients than in the general population, as hospitalized patients "are often elderly people with underlying heart disease who may also have renal or hepatic dysfunction, electrolyte abnormalities, or bradycardia and to whom drugs may be administered rapidly via the intravenous route," observes a new scientific statement from the American Heart Association and American College of Cardiology. Those features, including advanced age, have confirmed or suspected associations with development of the malignant arrhythmia, the document states.

The document, also endorsed by the American Association of Critical-Care Nurses, describes the state of the art of how to identify the arrhythmia and its precursors on the ECG, drugs and patient features that promote it, strategies for prevention and monitoring, and acute management of both QT prolongation and the manifest arrhythmia. Dr Barbara J Drew (University of California, San Francisco) chaired its writing group.

The benefits of using QT-prolonging agents must be weighed against the risk in patients with increased susceptibility to torsades, it states. The susceptibility can include certain genetic mutations that, when such drugs are given, can promote the arrhythmia.

In such cases, continuous monitoring of the corrected QT (QTc) interval is recommended; "prompt action" is needed if the QTc exceeds 500 ms compared with an ECG obtained before drug administration; the QTc must be measured by the same method and/or device each time.

Responses can include drug withdrawal, correction of electrolyte abnormalities, temporary pacing, and "the ready availability of an external defibrillator."

Other ECG features can signal impending torsades, including distortions of the TU wave, visible T-wave alternans, new ventricular ectopic beats, and "couplets and nonsustained polymorphic ventricular tachycardia initiated in the beat after a pause."

Drugs that promote QTc prolongation and torsades, to different degrees, include the antiarrhythmics quinidine, disopyramide, procainamide, sotalol, dofetilide, and ibutilide as well as methadone, thioridazine, and haloperidol, according to the statement.

Still, it notes, "where benefit clearly outweighs risk, QT prolongation should not limit necessary therapy."

Drew BJ, et al. Prevention of torsade de pointes in hospital settings. A scientific statement from the American Heart Association and the American College of Cardiology Foundation. Circulation 2010; DOI: 10.1161/CIRCULATIONAHA.109.192704.

Full-text (free): http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.109.192704v1

18. Anticholinergics and Ketamine Sedation in Children: A Secondary Analysis of Atropine Versus Glycopyrrolate

Green SM, et al. Acad Emerg Med. 2010;17:157–162.
.
Objectives: Adjunctive anticholinergics are commonly administered during emergency department (ED) ketamine sedation in children under the presumption that drying oral secretions should decrease the likelihood of airway and respiratory adverse events. Pharmacologic considerations suggest that glycopyrrolate might exhibit a superior adverse effect profile to atropine. The authors contrasted the adverse events noted with use of each of these anticholinergics in a large multicenter observational database of ketamine sedations.

Methods: This was a secondary analysis of an observational database of 8,282 ED ketamine sedations assembled from 32 prior series. The authors compared the relative incidence of six adverse events (airway and respiratory adverse events, laryngospasm, apnea, emesis, recovery agitation, and clinically important recovery agitation) between children who received coadministered atropine, glycopyrrolate, or no anticholinergic. Multivariable analysis using the specific anticholinergic as a covariate was performed, while controlling for other known predictors.

Results: Atropine was associated with less vomiting (5.3%) than either glycopyrrolate (10.7%) or no anticholinergic (11.4%) in both unadjusted and multivariable analyses. Glycopyrrolate was associated with significantly more airway and respiratory adverse events (6.4%) than either atropine (3.3%) or no anticholinergic (3.0%) and similarly more clinically important recovery agitation (2.1% vs. 1.2 and 1.3%). There were, however, no differences noted in odds of laryngospasm and apnea.

Conclusions: This secondary analysis unexpectedly found that the coadministered anticholinergic atropine exhibited a superior adverse event profile to glycopyrrolate during ketamine sedation. Any such advantage requires confirmation in a separate trial; however, our data cast doubt on the traditional premise that glycopyrrolate might be superior. Further, neither anticholinergic showed efficacy in decreasing airway and respiratory adverse events.

19. A Prospective Case Series of Pediatric Procedural Sedation and Analgesia in the Emergency Department Using Single-syringe Ketamine–Propofol Combination (Ketofol)

Andolfatto G, et al. Acad Emerg Med. 2010;17:194–201.

Objectives: This study evaluated the effectiveness, recovery time, and adverse event profile of intravenous (IV) ketofol (mixed 1:1 ketamine–propofol) for emergency department (ED) procedural sedation and analgesia (PSA) in children.

Methods: Prospective data were collected on all PSA events in a trauma-receiving, community teaching hospital over a 3.5-year period, from which data on all patients under 21 years of age were studied. Patients receiving a single-syringe 1:1 mixture of 10 mg/mL ketamine and 10 mg/mL propofol (ketofol) were analyzed. Patients received ketofol in titrated aliquots at the discretion of the treating physician. Effectiveness, recovery time, caregiver and patient satisfaction, drug doses, physiologic data, and adverse events were recorded.

Results: Ketofol PSA was performed in 219 patients with a median age of 13 years (range = 1 to 20 years; interquartile range [IQR] = 8 to 16 years) for primarily orthopedic procedures. The median dose of medication administered was 0.8 mg/kg each of ketamine and propofol (range = 0.2 to 3.0 mg/kg; IQR = 0.7 to 1.0 mg/kg). Sedation was effective in all patients. Three patients (1.4%; 95% confidence interval [CI] = 0.0% to 3.0%) had airway events requiring intervention, of which one (0.4%; 95% CI = 0.0% to 1.2%) required positive pressure ventilation. Two patients (0.9%; 95% CI = 0.0% to 2.2%) had unpleasant emergence requiring treatment. All other adverse events were minor. Median recovery time was 14 minutes (range = 3 to 41 minutes; IQR = 11 to 18 minutes). Median staff satisfaction was 10 on a 1-to-10 scale.

Conclusions: Pediatric PSA using ketofol is highly effective. Recovery times were short; adverse events were few; and patients, caregivers, and staff were highly satisfied.

20. Adjunctive dexamethasone in bacterial meningitis: a meta-analysis of individual patient data

van de Beek D, et al. The Lancet Neurology. 2010; Early Online Publication, 4 February

Background
Dexamethasone improves outcome for some patients with bacterial meningitis, but not others. We aimed to identify which patients are most likely to benefit from dexamethasone treatment.

Methods
We did a meta-analysis of individual patient data from the randomised, double-blind, placebo-controlled trials of dexamethasone for bacterial meningitis in patients of all ages for which raw data were available. The pre-determined outcome measures were death at the time of first follow-up, death or severe neurological sequelae at 1 month follow-up, death or any neurological sequelae at first follow-up, and death or severe bilateral hearing loss at first follow-up. Combined odds ratios (ORs) and tests for heterogeneity were calculated using conventional Mantel-Haenszel statistics. We also did exploratory analysis of hearing loss among survivors and other exploratory subgroup analyses by use of logistic regression.

Findings
Data from 2029 patients from five trials were included in the analysis (833 [41•0%] aged less than 15 years). HIV infection was confirmed or likely in 580 (28•6%) patients and bacterial meningitis was confirmed in 1639 (80•8%). Dexamethasone was not associated with a significant reduction in death (270 of 1019 [26•5%] on dexamethasone vs 275 of 1010 [27•2%] on placebo; OR 0•97, 95% CI 0•79—1•19), death or severe neurological sequelae or bilateral severe deafness (42•3% vs 44•3%; 0•92, 0•76—1•11), death or any neurological sequelae or any hearing loss (54•2% vs 57•4%; 0•89, 0•74—1•07), or death or severe bilateral hearing loss (36•4% vs 38•9%; 0•89, 0•73—1•69). However, dexamethasone seemed to reduce hearing loss among survivors (24•1% vs 29•5%; 0•77, 0•60—0•99, p=0•04). Dexamethasone had no effect in any of the prespecified subgroups, including specific causative organisms, pre-dexamethasone antibiotic treatment, HIV status, or age. Pooling of the mortality data with those of all other published trials did not significantly change the results.

Interpretation
Adjunctive dexamethasone in the treatment of acute bacterial meningitis does not seem to significantly reduce death or neurological disability. There were no significant treatment effects in any of the prespecified subgroups. The benefit of adjunctive dexamethasone for all or any subgroup of patients with bacterial meningitis thus remains unproven.

21. Is there Anybody in There?

By Greg Miller. ScienceNOW Daily News. 3 February 2010

When a brain injury leaves a person unresponsive and unable to communicate, doctors and nurses must provide care without input from their patient, and families agonize over whether their loved one might still have--or someday recover--a flicker of consciousness. A new study provides hope that technology might open a line of communication with some such patients. Researchers report that a man with a severe brain injury can, by controlling his thoughts, influence scans of his brain activity and thereby answer simple questions.

The work builds on a 2006 Science paper by Adrian Owen, a neuroscientist at the Medical Research Council Cognition and Brain Sciences Unit in Cambridge, U.K., and colleagues. Using functional magnetic resonance imaging (fMRI), they tested a young woman diagnosed as being in a vegetative state following a car accident. Although she was unresponsive and apparently unaware of her surroundings, she exhibited distinct patterns of brain activity when asked to imagine herself playing tennis or walking through the rooms of her house. As in healthy volunteers, imagining tennis activated motor planning regions in the woman's brain, whereas picturing her house activated a brain region involved in recognizing familiar scenes.

In the new study, published today in the New England Journal of Medicine, Owen and several colleagues used similar methods to examine 53 additional people who were in a vegetative state or in the slightly less severe minimally conscious state, in which patients show occasional flashes of responsiveness. In four of these patients, the researchers found distinct patterns of brain activity during the tennis versus house imagination task, hinting at some level of awareness that could not be detected by observing their behavior, says co-author Steven Laureys, a neurologist at the University of Liège in Belgium.

In one patient, a 22-year-old man who'd been in a vegetative state for 5 years, the researchers took an additional step, asking him to answer six questions by imagining tennis to indicate "yes" or picturing his house to indicate "no." The questions all involved basic autobiographical details, such as the name of his father or whether he had any brothers or sisters. In a group of 16 healthy volunteers, this method worked 100% of the time, the researchers report. The vegetative state patient answered the first five questions correctly. The final question elicited virtually no activity in the brain regions of interest, and the researchers speculate that the man may have fallen asleep or simply decided not to answer.

"This is a major step forward," says Nicholas Schiff, a neurologist at Weill Cornell Medical College in New York City. The paper is important because it shows that the Science report was not an isolated case and that technology can be used to establish communication with some patients who show no outward signs of consciousness, Schiff says.

Laureys cautions, however, that the fMRI method is not ready for widespread use in hospitals. He and collaborators are now trying to adapt the imagination task to work with electroencephalography, a relatively low-tech alternative to fMRI that's less expensive and easier to operate. "Our mission now is to translate this to clinical reality," Laureys says.

If such methods do become more widely available, they are sure to raise a host of sticky clinical and ethical questions, says James Bernat, a neurologist at Dartmouth Medical School in Hanover, New Hampshire. For example, doctors would want to involve patients in decisions about their care. But, Bernat asks, would a system that allows only yes or no answers make a physician "confident that all the nuances have been dealt with ... that they're dealing with a rational wish of the person that has been thoughtfully considered?"