Tuesday, February 23, 2010

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.

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.

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.

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.

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.

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).

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).

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.

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.

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.

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.

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).

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.

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

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.
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.

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.

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

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

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.

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).

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