Friday, May 21, 2010

Lit Bits: May 21, 2010

From the recent medical literature...

1. Interruptions May Hamper ED Physicians' Ability to Provide Adequate Care

Nancy Fowler Larson. May 13, 2010 — Frequent interruptions leave nearly one fifth of emergency department (ED) tasks incomplete and may jeopardize physicians' ability to care for patients, according to an Australian study published online today in Quality and Safety in Health Care.

"Emergency physicians working in acute, pressurized settings have been shown to experience high rates of interruption and multitasking," write Johanna Westbrook, PhD, director, Health Informatics Research and Evaluation Unit, University of Sydney, Australia, and colleagues. "Their environment is dynamic, characterised by resource and time constraints, and has been identified to be at greater risk of errors than many other settings."

Quantifying the relationship between the rates of physicians' interruptions and the completion times and rates of tasks was the study's goal. To accomplish this, the investigators performed an observational time-and-motion study in a teaching hospital's 400-bed ED. The researchers observed 91% (n = 40) of the medical staff for 210.45 hours as they performed 9588 tasks on weekdays (ie, Monday through Friday) during a 6-month period from July 2006 until January 2007.

Controlling for length-biased sampling (the concept that the longer the time on task, the greater the risk for interruptions), researchers evaluated the time on task, the effect of interruptions on time on task, and the amount of time spent on specific categories of tasks. Key findings are as follows:

• Interruptions occurred 6.6 times an hour; 11% of tasks were interrupted, with 3.3% disrupted 2 times or more.
• Physicians did not revisit tasks 18.5% of the time (95% confidence interval [CI], 15.9% - 21.1%) after an interruption.
• The most frequently occurring interruptions were during documentation; 47% came while documenting discharges.
• An average 12.8% of physician time was spent multitasking.
• Professionals in all categories multitasked almost equally (physicians, 14.4%; registrars, 13.2%; residents, 12.3%; interns, 9.4%; P = .24).
• The average time on task declined as physician seniority increased in these categories: direct care (P less than .0001), indirect care (P less than .0001), and documentation (P = .0002); seniority made no difference during professional communication (P = .9826).
• The average uninterrupted time on task was 1 minute, 26 seconds (1:26; 95% CI, 1:23 - 1:29); 1 interruption doubled the mean time on task, and 3 or more interruptions increased time on task by 493% to 7:04.

Absent length-based sampling, the results showed that the fewer the interruptions, the less time it took to finish tasks. However, when adjusted for length-biased sampling, tasks were actually completed more quickly after interruptions occurred, with 1 interruption cutting completion time in half. The study authors could not pinpoint a reason but speculated that physicians make up for time lost to interruption by trying to finish tasks more quickly.

"This could be done by a faster work rate, reducing the effort spent on task elements, or even dropping task elements," the authors write. "Other possible explanations include that emergency clinicians are refusing interruptions for long or complex tasks, or it may be that shorter tasks are more likely to attract interruptions relative to longer tasks, for example because of the settings in which they occur, or the perceived availability of the clinician by others."

Two study limitations stated by the study authors included that the generalizability of the findings may be hindered because the research came from only 1 hospital setting, and that investigators observed physicians during the workweek. Important differences may exist during evenings or weekends.

The researchers said their findings support the likelihood that interruptions may hinder patient safety. Charlene Irvin, MD, FACEP, emergency physician, St. John Hospital and Medical Center, and associate clinical professor, Wayne State University School of Medicine, Detroit, Michigan, agreed that interruptions increase the potential for errors. In an interview with Medscape Emergency Medicine, Dr. Irvin called ED interruptions the "nature of the beast."

The majority of St. John's interruptions are related to constant requests for electrocardiogram interpretation. Because 95% of the electrocardiograms are not indicative of heart attack, Dr. Irvin noted, "It's easy to get into a habit of saying, 'Oh, sure, it's fine,' " without carefully looking at the test. Another common scenario is that of a physician completing a simple yet necessary task, such as writing a prescription, only to be interrupted by a crisis in the emergency room.

"At that very moment when you're deciding what medicine to give them and what dose, you have a gunshot to the chest coming in the door, and you may not either finish the order or may not carefully dose the medication," Dr. Irvin said.

When mistakes are made, patient harm is often averted as a result of questions raised by nurses or through inconsistencies in electronic records.

"You can't eliminate interruption," Dr. Irvin said. "What you have to do is train for it, be prepared for it, and put safety checks and balances in place so that any error that is occurring because of interruptions is minimized."

The Health and Medical Research Foundation and the National Health and Medical Research Council Program supported the study. The study authors have disclosed no relevant financial relationships.

Qual Saf Health Care. Published online May 13, 2010.

2. Emergency Department Visits Are on the Rise

Bill Hendrick. May 20, 2010 — Americans have been going to emergency rooms (EDs) for treatment in increasing numbers since 1996, with poor and uninsured people more likely to seek treatment than others, the CDC says.

The increase in emergency room visits has come at a time when the number of EDs has decreased, causing overcrowding, longer wait times, and rising health care costs, according to the CDC's National Center for Health Statistics.

"As national health care costs continue to rise and policymakers become increasingly interested in ways to make the health care system more efficient, it is important to understand the characteristics of those individuals who use EDs -- often in place of other sources of ambulatory care," the report states.

The CDC reports that:

• One in five people in the U.S. had one or more emergency room visits over a 12-month period in 2007.
• The uninsured between 45 and 64 were no more likely than those with private insurance to report at least one emergency room visit. The same was true for children.
• Among adults 18-44 the uninsured were more likely than those with private insurance to have at least one ER visit.
• Medicaid patients were more likely to have reported multiple ED visits than people with private insurance, as well as the uninsured.
• As family income increased, the likelihood of having visited an ED decreased. Income differences were more pronounced than those based on age, race, or ethnicity.
• Adults 75 and over were more likely to have reported at least one ED visit in a12-month period than younger people.
• Non-Hispanic black people were more likely to have reported one or more ED visits in a 12 month period than non-Hispanic whites or Hispanics.
• In 2007, 10% of ED visits by people under age 65 were considered nonurgent.
The numbers paint a clear picture, showing a strong correlation between income levels and a tendency to seek treatment in emergency departments, which is costly for hospitals, and causes costs to individuals to rise, as well as increases in health insurance premiums.

Also, the report states, adults in fair or poor health are much more likely to use emergency departments than people describing themselves as in very good or excellent health. Factors such as age, insurance status, perceived health status and race and ethnicity all play roles in ED visits.

"Future work should focus on untangling the complex interactions among the socio-demographic, health status and health care access factors that appear to be associated with visits to the ED (emergency department)," the CDC says.

Medicaid and ED Visits

The numbers also show an apparent tendency of Medicaid beneficiaries to go to emergency departments more often than others. The report says 15% of Medicaid beneficiaries under 65 had two or more ED visits, compared with 7% of the uninsured and 5% of people with private insurance.

The percentage of Medicaid beneficiaries under 65 with four or more ED visits over a 12-month period was highest at 5% compared to 2% among the uninsured and 1% of those with private insurance.

The report says that 10% of ED visits in 2007 by people under 65 were considered non-urgent.

People on Medicaid may seek emergency treatment more often than those with private insurance coverage or the uninsured because of higher rates of disability and chronic medical conditions, the CDC says.

National Center for Health Statistics: "NCHS Data Brief No. 38, May 2010."

Full-text (free):

3. Cricoid Pressure Benefit During Intubation Unclear

By Anne Harding. NEW YORK (Reuters Health) May 12 - Cricoid pressure, used for decades to prevent patients from regurgitating during intubation, may in some cases make the process more difficult, a new observational study shows.

The findings are "not enough to change practice, but we would say that we've got evidence that releasing cricoid pressure facilitates intubation," Dr. Tim Harris of the Royal London Hospital and London Air Ambulance in the UK, one of the study's authors, told Reuters Health.

Cricoid pressure was introduced after several pregnant women died under anesthesia due to aspiration in the 1950s, Dr. Harris said. The technique involves pressing on the cricoid ring during intubation to prevent material from passing from the esophagus into the pharynx and trachea. "It's a very neat and elegant idea," he said.

And cricoid pressure during emergency tracheal intubation of trauma patients is routine in many European countries, and recommended by both the American College of Emergency Physicians and the National Association of EMS Physicians, he and his colleagues note in their April 20 online publication in Resuscitation.

But the benefits and risks of applying cricoid pressure during intubation have never been tested in clinical trials, Dr. Harris said. On top of its unproven efficacy at reducing the incidence of aspiration or regurgitation, there's recently been evidence linking it to impaired laryngeal view and less effective bag mask ventilation, he and his colleagues write.

"The use of cricoid pressure in the pre-hospital trauma patient may make an already challenging environment more difficult, potentially worsening intubating conditions for little proven gain," the authors write.

In the current study, Dr. Harris and his team looked at the effects of cricoid pressure and laryngeal manipulation in a series of patients undergoing rapid sequence induction and tracheal intubation in their pre-hospital trauma service. They included 402 patients treated over 16 months. The physician-led trauma team intubated 98.8% of patients on the first or second try. In 22 cases, cricoid pressure was removed, improving laryngeal view in 11 patients. The researchers attempted bimanual laryngeal manipulation in 25 intubations, which improved visualization in 60%. During 14 intubations, "backwards upwards rightwards pressure" (BURP) was applied, resulting in an improved laryngeal view in 64%.

Two of the patients in whom cricoid pressure was removed regurgitated. Both had prolonged bag valve mask ventilation and difficult intubations.

While cricoid pressure can prevent regurgitation in certain patients, Dr. Harris and his team write, it can also worsen laryngeal view and make intubation more difficult. "Such risk:benefit analysis is best performed on a case-by-case basis. A randomized trial is required to determine whether cricoid pressure provides more benefit than harm."

The U.K. research team concludes: "Our data support our current approach to pre-hospital rapid-sequence induction -- cricoid pressure is performed routinely, but there is a low threshold for removal to improve laryngeal view and facilitate intubation."

Resuscitation 2010.

4. Randomized, Controlled Trial of Antibiotics in the Management of Community-Acquired Skin Abscesses in the Pediatric Patient

Duong M, et al. Ann Emerg Med 2010;55:401-407.

Study objective
Emergency department visits for skin and soft tissue infections are increasing with the discovery of community-acquired methicillin-resistant Staphylococcus aureus. Whether abscesses treated surgically also require antibiotics is controversial. There are no published pediatric randomized controlled trials evaluating the need for antibiotics in skin abscess management. We determine the benefits of antibiotics in surgically managed pediatric skin abscesses.

This was a double-blind, randomized, controlled trial. Pediatric patients were randomized to receive 10 days of placebo or trimethoprim-sulfamethoxazole after incision and draining. Follow-up consisted of a visit/call at 10 to 14 days and a call at 90 days. Primary outcome was treatment failure at the 10-day follow-up. Secondary outcome was new lesion development at the 10- and 90-day follow-ups. Noninferiority of placebo relative to trimethoprim-sulfamethoxazole for primary and secondary outcomes was assessed.

One hundred sixty-one patients were enrolled, with 12 lost to follow-up. The failure rates were 5.3% (n=4/76) and 4.1% (n=3/73) in the placebo and antibiotic groups, respectively, yielding a difference of 1.2%, with a 1-sided 95% confidence interval (CI) (−∞ to 6.8%). Noninferiority was established with an equivalence threshold of 7%. New lesions occurred at the 10-day follow-up: 19 on placebo (26.4%) and 9 on antibiotics (12.9%), yielding a difference of 13.5%, with 95% 1-sided CI (−∞ to 24.3%). At the 3-month follow-up, 15 of 52 (28.8%) in the placebo group and 13 of 46 (28.3%) in the antibiotic group developed new lesions. The difference was 0.5%, with 95% 1-sided CI (−∞ to 15.6%).

Antibiotics are not required for pediatric skin abscess resolution. Antibiotics may help prevent new lesions in the short term, but further studies are required.

Full-text (free):

5. Comparing Face Mask Ventilation Techniques in Edentulous Patients

Lower lip face mask placement outperformed standard face mask placement.

Face mask ventilation is often challenging in edentulous patients. Researchers in France compared standard face mask placement with a new technique, called "lower lip" placement, in edentulous patients who were undergoing general anesthesia for elective surgery. The lower lip ventilation technique is similar to standard face mask ventilation except that the caudal end of the mask is placed between the lower lip and the alveolar ridge.

Six experienced anesthesiologists performed two-handed face mask ventilation in 300 edentulous patients with oral airways. Standard face mask ventilation was performed first. If an air leak — defined as a difference of at least 33% between inspired and expired tidal volumes — persisted for five consecutive breaths, the mask was repositioned to lower lip placement.

Forty-nine patients (16%) had persistent air leaks with standard face mask placement. The median air leak was 400 mL, with median inspired and expired tidal volumes of 450 mL and 0 mL, respectively. After the mask was repositioned to lower lip placement, the median air leak decreased to 10 mL, with inspired and expired volumes of 450 mL and 400 mL, respectively.

Comment: The various techniques traditionally taught to assist with face mask ventilation in edentulous patients (e.g., leaving dentures in, packing the mouth with gauze) are associated with risk for aspiration. This study describes a simple, effective technique that should be considered a key tool when we are faced with this challenging clinical situation.

— Emily L. Brown, MD, and Ron M. Walls, MD, FRCPC, FAAEM. Published in Journal Watch Emergency Medicine May 7, 2010. Citation: Racine SX et al. Face mask ventilation in edentulous patients: A comparison of mandibular groove and lower lip placement. Anesthesiology 2010 May; 112:1190.

6. Ultrasound Diagnosis of Type A Aortic Dissection

Perkins AM, et al. J Emerg Med. 2010;38:490-493.

Background: An aortic dissection is a life-threatening process that must be diagnosed and treated expeditiously. Imaging modalities used for diagnosis in the emergency department include computed tomography, magnetic resonance imaging, and trans-esophageal echocardiography. There are significant limitations to these studies, including patient contraindications (intravenous contrast dye allergies, renal insufficiency, metal-containing implants, hemodynamic instability) and the length of time required for study completion and interpretation by a radiologist or cardiologist.

Objectives: A case is presented that demonstrates how emergency physicians can use trans-thoracic and abdominal bedside ultrasound to diagnose a type A aortic dissection.

Case Report: A 72-year-old woman presented with chest pain radiating to her neck and back that was concerning for aortic dissection. This was subsequently confirmed and further classified as a type A dissection by bedside emergency physician-performed ultrasound. The images showed a clear intimal flap in the abdominal aorta, a dilatated aortic root, and extension of the intimal flap into the left common carotid artery. With prompt diagnosis, the patient was able to have emergent surgical consultation, confirmatory imaging, and intervention before further complication occurred.

Conclusion: This case provides an example of how emergency trans-thoracic and abdominal ultrasound can be used to promptly diagnose a type A aortic dissection and expedite further consultation and prompt management.

7. Images in Emergency Medicine

Pregnant Woman With Gastric Pain

Woman with Left Facial Swelling

8. Slow Down That Ambulance for Better CPR

By Frederik Joelving. NEW YORK (Reuters Health) May 13 - Speeding ambulances might do more harm than good to patients receiving cardiopulmonary resuscitation (CPR), Korean doctors suggest.

Using a computerized mannequin called Resusci Anne, the researchers monitored how well EMTs performed as the ambulance - lights flashing, sirens squealing -- picked up speed.

Both depth and rate of chest compressions increased, but what made the researchers worry was that EMTs tended to spend less time doing CPR at high velocities. The exact reasons for the added hands-off time are unclear.

At 60 km/hr (37 mph) and faster, the extra "no-flow" time amounted to only a few seconds, compared to going 30 km/hr (19 mph) or slower. But the ambulance was driving on a straight expressway with no traffic lights, said Dr. Tae Nyoung Chung, an emergency physician at Yonsei University College of Medicine in Seoul, Korea, who led the study.

In real life, sharp turns, stops and bumpy roads would likely exaggerate the effects, he told Reuters Health in an e-mail.

Based on the findings, published online April 8 in Resuscitation, "there may be a threshold speed between 30 km/hour and 60 km/hour which doesn't increase the portion of hands-off interval while maintaining the speed of ambulance," he said. "This speed level can be suggested as a speed limit for the ambulance transport with ongoing CPR."

Dr. Dana Edelson, associate chair of the CPR Committee at the University of Chicago, urged caution before slowing down ambulances. While she said continuous CPR is paramount to survival, she noted that the effects found in the current study were "pretty small."

"The downside of slowing down your ambulance is that it takes longer to get to the hospital," she said. "We need to be looking for other ways to increase CPR quality."

One way to increase that quality, recommended by the American Heart Association, is for emergency personnel to attempt resuscitation where it happened, instead of rushing the victim off to the hospital.

"Trying to do CPR in the back of an ambulance is not terribly effective," said emergency physician Dr. Michael Sayre, a spokesman for the association.

Still, experts say it is common practice both in Korea and the US. Some patients go into cardiac arrest during transport, for instance, and others might not respond to CPR initially.

While a few emergency services do moderate ambulance speed when the EMT is doing chest compressions in the back, there are currently no official guidelines, said Jerry Johnston, a paramedic and the immediate past president of the National Association of Emergency Medical Technicians.

Mechanical devices that deliver chest compressions dependably already exist, but the price -- between $10,000 and $15,000 per ambulance -- is prohibitive, said Johnston.

"Right now the overarching recommendation is that the person driving the ambulance needs to be really cognizant about making the ride smooth so that quality CPR can be performed," he said.

Resuscitation 2010.

9. Repeat Computed Tomography Not Needed After Mild Head Injury in Patients on Warfarin

However, patients who experience loss of consciousness might be at greater risk for hemorrhage and warrant repeat CT scans 24 hours after injury.

Do anticoagulated patients with minor closed-head injury require repeat head computed tomography (CT) after in-hospital observation for 24 hours? Researchers prospectively studied 137 consecutive patients (mean age, 76) at a single hospital in Spain who were taking warfarin and had normal initial head CT scans after minor closed-head injury (defined as documented loss of consciousness [LOC] or evidence of post-traumatic amnesia and Glasgow Coma Scale score of 14–15 at presentation). Anticoagulation was continued, and patients underwent serial neurological examinations every 4 to 6 hours and second CT scans 20 to 24 hours after the first scan. Mean international normalized ratio was 3.8. Median time from injury to first CT was 3.2 hours.

Two patients (1.4%) with normal neurological examinations had hemorrhagic lesions on the second CT scan (a minimal intraventricular hemorrhage and a subarachnoid hemorrhage over the convexity of the right cerebral hemisphere); neither lesion was worse on 48-hour CT scan or required intervention. Both patients were taking aspirin and warfarin and experienced LOC. Abnormal results on the second CT scan were significantly more likely among patients who experienced LOC (2 of 14 patients) than among those who did not experience LOC (0 of 123).

Comment: These data suggest that patients with mild closed-head injury who are taking warfarin can be managed with initial computed tomography and close observation for 24 hours. Repeat CT 24 hours later can be reserved for patients who experience loss of consciousness. If this study's findings are confirmed in a prospective, large, randomized trial, implementing this strategy would reduce costs and radiation exposure and improve patient throughput.

— John A. Marx, MD, FAAEM. Published in Journal Watch Emergency Medicine May 14, 2010.
Citation: Kaen A et al. The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury. J Trauma 2010 Apr; 68:895.

10. An Evaluation of the Accuracy of Emergency Physician Activation of the Cardiac Catheterization Laboratory for Patients with Suspected ST-Segment Elevation Myocardial Infarction

Kontos MC, et al. Ann Emerg Med. 2010;55:423-430.

Study objective
Current recommendations indicate that emergency physicians should activate cardiac catheterization laboratory personnel by a single page for ST-segment elevation myocardial infarction (STEMI) patients. We assessed the accuracy of emergency physician cardiac catheterization laboratory activations, angiographic findings, outcomes, and treatment times among patients with and without STEMI.

We classified the appropriateness and outcomes of consecutive emergency physician STEMI pages between June 2006 and September 2008. Emergency physician activations of the cardiac catheterization laboratory were classified according to the findings of the initial ECG compared with cardiology interpretation for the presence of STEMI and presence of coronary disease.

During a 27-month period, emergency physician activation of the cardiac catheterization laboratory occurred 249 times. There were 188 (76%) patients with a true STEMI, of whom 13 did not receive emergency angiography. Of the 37 (15%) patients who had ECG findings meeting STEMI criteria and who ultimately did not have myocardial necrosis and underwent emergency angiography, 12 had significant disease and 5 had revascularization performed. Eleven patients had ECGs concerning for but not meeting STEMI criteria; all had emergency angiography (n=11) or received a diagnosis of non-STEMI (n=6). Only 13 patients were considered as having received unnecessary cardiac catheterization laboratory activations (5.2%) in which emergency angiography was not performed and myocardial infarction was excluded.

A significant number of emergency physician STEMI cardiac catheterization laboratory activations are for patients who did not meet standard STEMI criteria. However, most had ECG findings and symptoms that lead to emergency angiography, had significant disease, or were diagnosed with non-STEMI. Only a small percentage of patients received unnecessary cardiac catheterization laboratory activations. Our findings support current recommendations for emergency physician cardiac catheterization laboratory activation for potential STEMI patients.

11. Magnesium Infusion Might Improve Outcomes after Subarachnoid Hemorrhage

The incidences of delayed ischemic infarction and vasospasm were significantly reduced in patients treated with magnesium, compared with controls.

Westermaier T et al. Crit Care Med 2010 May; 38:1284

Objective: To examine whether the maintenance of elevated magnesium serum concentrations by intravenous administration of magnesium sulfate can reduce the occurrence of cerebral ischemic events after aneurysmal subarachnoid hemorrhage.

Design: Prospective, randomized, placebo-controlled study.

Setting: Neurosurgical intensive care unit of a University hospital.

Interventions: One hundred ten patients were randomized to receive intravenous magnesium sulfate or to serve as controls. Magnesium treatment was started with a bolus of 16 mmol, followed by continuous infusion of 8 mmol/hr. Serum concentrations were measured every 8 hrs, and infusion rates were adjusted to maintain target levels of 2.0-2.5 mmol/L. Intravenous administration was continued for 10 days or until signs of vasospasm had resolved. Thereafter, magnesium was administered orally and tapered over 12 days.

Measurements and Main Results: Delayed ischemic infarction (primary end point) was assessed by analyzing serial computed tomography scans. Transcranial Doppler sonography and digital subtraction angiography were used to detect vasospasm. Delayed ischemic neurologic deficit was determined by continuous detailed neurologic examinations; clinical outcome after 6 mos was assessed using the Glasgow outcome scale. Good outcome was defined as Glasgow outcome scale score 4 and 5.

The incidence of delayed ischemic infarction was significantly lower in magnesium-treated patients (22% vs. 51%; p = .002); 34 of 54 magnesium patients and 27 of 53 control patients reached good outcome (p = .209). Delayed ischemic neurologic deficit was nonsignificantly reduced (9/54 vs. 15/53 patients; p = .149) and transcranial Doppler-detected/angiographic vasospasm was significantly reduced in the magnesium group (36/54 vs. 45/53 patients; p = .028). Fewer patients with signs of vasospasm had delayed cerebral infarction.

Conclusion: These data indicate that high-dose intravenous magnesium can reduce cerebral ischemic events after aneurysmal subarachnoid hemorrhage by attenuating vasospasm and increasing the ischemic tolerance during critical hypoperfusion.

12. Are CT Scans Overused in Emergency Assessment of Pediatric Head Trauma?

Brian Hoyle. May 12, 2010 (Vancouver, British Columbia) — A pair of studies presented here at the Pediatric Academic Societies 2010 Annual Meeting indicates that the observation of children with blunt head trauma can, in many cases, reduce the need for a computed tomography (CT) scan without compromising outcome and without undue radiation exposure to the child.

CT scanning has been growing in popularity for the diagnosis of neurologic injury over the past 2 decades. However, CT use has been questioned, especially for young children in the time-critical atmosphere of the emergency department, because it can increase the risk for malignancy. This risk is greatest in the first 10 years of life.

The issue of whether to observe before using CT or to perform CT as the first course of action for a child with a head injury is debatable, and was the subject of a study by a team from Inova Fairfax Hospital for Children in Falls Church, Virginia.

"A significant number of children receiving CT scans . . . do not appear to have clinical justification for the procedure," poster presenter Rebecca S. Kriss, MD, from the Department of Pediatrics at Inova Fairfax Hospital for Children, said in an interview with Medscape Pediatrics.

In the study, electronic records were reviewed for 394 children, 1 month to 5 years of age, who received a head CT at a large suburban emergency department between February 2008 and February 2009. Child's age, chief complaint, history, results of physical examination, indication for and results of the CT scan, number of scans, and outcome were examined.

The historic data included a slew of "red flags" that heightened indication for a CT scan. These included loss of consciousness, altered mental state, signs of fracture, hematoma, seizure, pain upon awaking, suspected nonaccidental trauma, indication of increased intracranial pressure, and an abnormal neurologic exam.

Of the 236 patients who received a CT scan, abnormalities were evident in 89 (38%). Moreover, 20% of the 236 children received more than 1 CT scan; 6% received 6 to 20 scans. Overall, 40% of the children who received a CT scan lacked red flag indicators of head trauma.

Of the 236 head injuries evaluated by CT, 23 were judged to be significant. Only 3 cases required immediate action, all of which presented with red flag indicators.

The Virginia team's observations were supported by findings from a second study, presented by Lise E. Nigrovic, MD, MPH, from Children's Hospital Boston and assistant professor of pediatrics at Harvard Medical School, in Massachusetts, who announced the results of a subanalysis of a prospective observational study of children who had sustained a blunt head injury.

Dr. Nigrovic's team analyzed the records of 40,113 children with blunt head trauma. Presenting symptoms were compared in patients who were observed before receiving a CT scan (n = 5,433) and in those who were not observed before receiving a scan (n = 34,680). Observation led to a significantly lower CT rate without affecting patient outcome.

"A decision to do a CT scan is usually made quickly, sometimes as the patient is being transported to the hospital. A neurological consult is usually not even done before the [emergency department] physician orders a CT," Dr. Kriss told Medscape Pediatrics.

For some children, the prompt decision proves to be the correct one. But for a sizable number of children, a wait-and-see approach, with careful monitoring of symptoms, can be the best course.

"These are great data. There can be a big difference in the condition of a child at presentation and 24 or 48 hours later," said Russell T. Migita, MD, clinical director of emergency medicine at Seattle Childrens' Hospital in Washington.

The studies were funded by the Health Resources and Services Administration/Maternal and Child Health Bureau, the National Institute of Neurological Disorders and Stroke, and the Inova Fairfax Hospital for Children. The authors have disclosed no relevant financial relationships.

Pediatric Academic Societies (PAS) 2010 Annual Meeting: Poster sessions 4400.1 and 4400.33. Presented May 4, 2010.

13. Do Antiviral Medications Improve Recovery in Patients With Bell's Palsy?

Sherbino J. Ann Emerg Med. 2010;55:475-476.

In the treatment of Bell's palsy, antiviral medications alone do not decrease the risk of incomplete neurologic recovery.

Full-text (free):

14. Emergency Department Use of Droperidol Safe in Adolescents

Szwak K, Sacchetti A. Pediatr Emerg Care. 2010;26:248-250.

Introduction: Droperidol is a controversial drug with multiple clinical applications. This report examines the use of droperidol in pediatric emergency department (ED) patients.

Methods: An observational structured chart review was conducted of patients 21 years or younger receiving droperidol as part of their ED treatment.

Results: Over a 32-month period, 79 ED records were identified for review. Patients' ages ranged from 15 to 21 years with a mean age of 19.4 (+/-0.2) years. Indications for droperidol included agitation, 68 (86%); nausea/vomiting, 7 (9%); headache, 2 (3%); and other pain, 2 (3%). Droperidol was the initial therapy in 63 patients (80%) and the rescue medication in 16 (20%). In nonagitated patients, droperidol was 100% effective in controlling patient's symptoms, whereas in agitated patients, droperidol alone was 86.6% effective as a single agent. Within the agitated patients, 35 (51.5%) were positive for drugs, 15 (22.1%) were positive for drugs and alcohol, and 12 (17.6%) were positive for alcohol alone. All patients were placed on continuous cardiac monitoring immediately after administration of the drug and for the duration of their active ED visit. No cardiac arrhythmias were noted. Thirty-eight patients (48%) were discharged from the ED, 35 (44%) were transferred to the psychiatric crisis unit for evaluation, 5 (6%) were admitted, and in 1 patient with biliary colic, the disposition was not recorded. No admissions were for droperidol-associated complications.

Conclusions: Droperidol is a safe and effective medication in the adolescent and young adult population.

15. Hormone Spray Improves Male Sensitivity, German Research Finds

ScienceDaily (Apr. 29, 2010) — Many women have no doubt been waiting a long time for this: the neuropeptide oytocin enhances male empathy. This substance also increases sensitivity to so-called "social multipliers," such as approving or disapproving looks. This is revealed in a study conducted by scientists at Bonn University and the Babraham Institute of Cambridge, which has now appeared in the Journal of Neuroscience.

48 healthy males participated in the experiment. Half received an oxytocin nose spray at the start of the experiment, the other half a placebo. The researchers then showed their test subjects photos of emotionally charged situations in the form of a crying child, a girl hugging her cat, and a grieving man. The test subjects were then invited to express the depth of feeling they experienced for the persons shown.

In summary, Dr. René Hurlemann of Bonn University´s Clinic for Psychiatry was able to state that "significantly higher emotional empathy levels were recorded for the oxytocin group than for the placebo group," despite the fact that the participants in the placebo group were perfectly able to provide rational interpretations of the facial expressions displayed. The administration of oxytocin simply had the effect of enhancing the ability to experience fellow-feeling. The males under test achieved levels which would normally only be expected in women. Under normal circumstances, the "weak" sex enjoys a clear advantage when it comes to the subject of "empathy."

Nasal Spray improves Learning

In a second experiment, the participants had to use their computers to complete a simple observation test. Correct answers produced an approving face on the screen, wrong ones a disapproving one. Alternatively, the feedback appeared as green (correct) or red (false) circles. "In general, learning was better when the feedback was shown in the form of faces," states Dr. Keith Kendrick of the Cambridge Babraham Institute in England. "But, once again, the oxytocin group responded clearly better to the feedback in the form of facial expression than did the placebo group."

In this connection, the so-called amygdaloid nucleus appears to play an important role. This cerebral structure, known generally to doctors as the amygdala, is involved in the emotional evaluation of situations. Certain people suffer from an extremely rare hereditary disease which progressively affects the amygdala. "We were lucky to be able to include two femals patients in our study group who were suffering this defect of the amygdala," says Hurlemann. "Both women reacted markedly worse to approving or disapproving faces in the observation test than did other women in a control group. Moreover, their emotional empathy was also affected." Hence, the researchers suspect that the amygdala could bear some form of co-responsibility for the effect of the oxytocin.

One of the effects of the hormone oxytocin is that it triggers labour pains. It also strengthens the emotional bond between a mother and her new-born child. Oxytocin is released on a large scale during an orgasm, too. This neuropeptide is also associated with feelings such as love and trust. Our study has revealed for the first time that emotional empathy is modulated by oxytocin, and that this applies similarly to learning processes with social multipliers, says Hurlemann. This hormone might thus be useful as medication for diseases such as schizophrenia, which are frequently associated with reduced social approachability and social withdrawal.

16. Pregnancy Testing in Women of Reproductive Age in US Emergency Departments, 2002 to 2006: Assessment of a National Quality Measure

Schuur JD, et al. Ann Emerg Med. 2010;55:449-457.e2

Study objective
We assess performance and explore definitions for a new emergency department (ED) quality measure: the proportion of women aged 14 to 50 years who have abdominal pain and receive pregnancy testing (aimed at detecting ectopic pregnancy).

We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) (2002 to 2006) to test trends and predictors of the new measure, using both restrictive and broad definitions from the International Classification of Diseases, Ninth Revision (ICD-9) and reason-for-visit codes, and determine the proportion of women with ectopic pregnancy who had undergone pregnancy testing. For comparison, we conducted a detailed chart review in 4 US hospitals among patients who visited the ED in 2006.

Using a broad ICD-9 definition for inclusion in NHAMCS, 2.13 million women aged 14 to 50 years with abdominal pain visited an ED annually between 2002 and 2006. Of those, 33.0% (95% confidence interval [CI] 30.5% to 35.5%) received pregnancy testing. Testing rates were materially stable, regardless of the definition used (broad or restrictive ICD-9 or reason-for-visit code). Among women with an ICD-9 diagnosis of ectopic pregnancy, 55.6% (95% CI 43.7% to 67.6%) had a documented pregnancy test. In the chart review, among 200 women aged 14 to 50 years and with abdominal pain, 89.4% (95% CI 85.0% to 94.0%) were eligible for the measure; of those, 93.9% (95% CI 90.3% to 97.4%) received testing.

Analysis of national ED survey data demonstrated a large performance gap for a new pregnancy testing quality measure, whereas focused chart review at 4 sites showed a smaller gap. Given these discrepancies, additional study is recommended before the widespread implementation of the pregnancy testing measure as an assessment of ED performance.

Full-text (free):

17. Serotonin Syndrome Precipitated by Fentanyl During Procedural Sedation

Kirschner R, et al. J Emerg Med. 2010;38:477-480.

Fentanyl is frequently used for analgesia during emergency procedures.

We present the cases of 2 patients who developed agitation and delirium after intravenous fentanyl administration. These patients were chronically taking selective serotonin reuptake inhibitors (SSRIs). Both developed neuromuscular examinations consistent with serotonin syndrome, a diagnosis that must be established on the basis of clinical criteria. Although they required aggressive supportive care, including mechanical ventilation, both patients made a full recovery.

Use of fentanyl for procedural sedation may precipitate serotonin syndrome in patients taking SSRIs or other serotonergic drugs.

18. Few Would Call 911 Despite Recognizing Signs of Stroke

Fran Lowry. May 17, 2010 — Only a fraction of people said they would call 911 if they observed the warning signs of stroke in a family member or friend, according to the results of a new population-based survey published online May 13 in Stroke: Journal of the American Heart Association.

"The take-home message for the public from our study would be to first become aware of the warning signs associated with stroke and then to understand that if any of these warning signs are ever observed they should call 911 immediately," lead study author Chris Fussman, MS, an epidemiologist with the Michigan Department of Community Health in Lansing, told Medscape Neurology. "We are in control of our own destiny when it comes to acute stroke treatment."

Advantages of Emergency Medical Services (EMS) Transport

In their study, Fussman and colleagues estimated the proportion of adults in Michigan who would react appropriately and call 911 when they were presented with 3 different hypothetical stroke-related scenarios — sudden slurred speech, sudden numbness on one side of the body, or sudden blurry vision. They also examined the association between knowledge of warning signs and calling 911.

The participants were recruited through a random-digit telephone survey, and the researchers used the Michigan Behavioral Risk Factor Surveillance System (MiBRFSS) survey to record their answers.

Among 4841 adults surveyed, the researchers found that 27.6% (95% confidence interval [CI], 26.2% – 29.0%) had an adequate knowledge of the warning signs of stroke and that 14.0% (95% CI, 12.9% – 15.1%) reported they would call 911 for all 3 stroke-related scenarios. However, a greater proportion, 37%, reported that they would not call 911 for any of the stroke symptoms.

The study also found that knowledge of specific stroke warning signs was only modestly associated with calling 911 in response to scenarios that involved the same stroke symptom (odds ratio, 1.17 – 1.39). "Even among those with adequate knowledge of stroke warning signs, only 17.6% (95% CI, 15.5% – 20.0%) would call 911 for all 3 stroke scenarios," the study authors report.

The percentage of adults who appropriately said they would call 911 increased with age but was still less than 20% in all groups.

Instead, most respondents said they would take the patient to the emergency department.

"This shows us that there is a problem," Mr. Fussman said. "The public does not seem to be aware of the advantages of EMS transport and the fact that we recommend the use of emergency medical services over private transport. We need to improve education in this area."

There are very effective treatments for stroke, and getting to the hospital fast is the best way to get these treatments, he told Medscape Neurology. "Calling 911 gets you to the hospital fast and allows the paramedics to communicate with the hospital so they are prepared for your arrival."

For medical professionals, the message is to stress the importance of calling 911 in response to stroke-related events to the patients in their care. "They should reassure individuals that calling 911 will indeed lead to earlier arrival and quicker treatment upon arrival at the hospital."

Defining Barriers

In an accompanying editorial, Marlís González-Fernández, MD, PhD, from the Johns Hopkins University School of Medicine, Baltimore, Maryland, said that the study confirms that public recognition of stroke signs and symptoms has improved in recent years. Unfortunately, public awareness of the advantages of transport to the hospital by ambulance is still lacking.

Dr. González-Fernández writes that the study's most important accomplishment, “beyond the data presented, is raising questions that should inform and guide the next steps in research and public education.”

She calls for evaluation of the factors that influence the decision to use private transportation instead of calling 911 for ambulance transport to the hospital and suggests barriers to EMS access and financial concerns, among others, could have an impact on community action patterns.

"In the fight against time to save brain and to reduce mortality and disability after stroke, it is important to eliminate all the system and community barriers," she concludes. "Getting people to the [emergency department] on time is where it all starts."

Stroke. Published online May 13, 2010.

19. FDA Approves Nasal Formulation of Ketorolac for Short-Term Pain Management

Susan Jeffrey. May 17, 2010 — Roxro Pharma (Menlo Park, California) today announced that the US Food and Drug Administration has approved an intranasal formulation of ketorolac tromethamine (Sprix Nasal Spray) for the short-term management of moderate to moderately severe pain requiring analgesia at the opioid level.

The formulation can be used for up to 5 days in patients outside the hospital setting. Ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is most often given in the hospital setting as an intramuscular (IM) injection for short-term treatment of moderately severe pain, a statement from the company notes. The new formulation, given intranasally and absorbed through nasal mucosa, achieves peak blood levels as fast as an IM injection, the statement adds.

The new product "fills the need for a new non-opioid, non-injectable option for ambulatory pain control, because it minimizes the potential for abuse as well as the negative side effects associated with narcotic pain relievers while providing potent control of moderate to moderately severe pain at the opioid level," said Askomur Buvanendran, director of orthopedic anesthesia at Rush University Medical Centers in Chicago, Illinois, in the company release. "The convenient nasal spray formulation will also provide pain relief outside of the hospital setting."

The full prescribing information for the intranasal ketorolac formulation is available on the Roxro Pharma Website:

20. External (In)Validation of the San Francisco Syncope Rule in the Canadian Setting

Thiruganasambandamoorthy V, Stiell IG, et al. Ann Emerg Med. 2010;55:464-472.

Study objective
Syncope is a common disposition challenge for emergency physicians. Among the risk-stratification instruments available, only the San Francisco Syncope Rule is rigorously developed. We evaluate its performance in Canadian emergency department (ED) syncope patients.

This retrospective review included patients aged 16 years or older who fulfilled the definition of syncope (transient loss of consciousness with complete recovery) and presented to a tertiary care ED during an 18-month period. We excluded patients with ongoing altered mental status, alcohol/illicit drug use, seizure, and head and severe trauma. Patient characteristics, 5 predictors for the rule (history of congestive heart failure, hematocrit level below 30%, abnormal ECG characteristics, shortness of breath, and triage systolic blood pressure below 90 mm Hg), and outcomes (as per the original study) were extracted.

Of 915 visits screened, 505 were included. Forty-nine (9.7%) visits were associated with serious outcomes. The rule performed with a sensitivity of 90% (44/49 outcomes; 95% confidence interval [CI] 79% to 96%) and a specificity of 33% (95% CI 32% to 34%). Including monitor abnormalities in the ECG variable would improve sensitivity to 96% (47/49 outcomes; 95% CI 87% to 99%). Although physicians failed to predict 2 deaths, the rule would have predicted all 3 deaths that occurred after ED discharge. Implementing the rule in our setting would increase the admission rate from 12.3% to 69.5%.

In this retrospective Canadian study, the San Francisco Syncope Rule performed with comparable sensitivity but significantly poorer specificity than previously reported. Implementing the rule would significantly increase admission rates. Further studies to either refine the San Francisco Syncope Rule or develop a new rule are needed.

21. It's Not What Politicians Say but What We Hear

ScienceDaily (Apr. 30, 2010) — There is increasing evidence that individuals interpret the same election message in different ways, according to their personal political views, say experts in an editorial online in the British Medical Journal.

Martin McKee, from the London School of Hygiene and Tropical Medicine, and David Stuckler from the University of Oxford argue that "it is possible for two well-informed groups of people faced with the same evidence to reach completely different conclusions about what should be done."

They highlight a recent American study where three groups who described themselves as either Democrats, Republicans or Independents were randomly given four versions of an authoritative news story about diabetes. The stories were exactly the same apart from how they described the causes of diabetes -- one said nothing while the other three alluded to genetic factors, individual lifestyle choices and social determinants such as economic status.

Interestingly, the Democrats and Independents were far more likely to agree with the social determinants explanation but this had no effect on the Republicans. Furthermore, the Democrats were significantly more likely than the Republicans to support action to tackle diabetes, such as restrictions on junk food.

The authors also refer to a study on brain activity in Democrat and Republican research participants who were exposed to contradicting messages from both parties. They say: "Whereas those registered as Republicans clearly identified the contradictions voiced by Democrat politicians, they saw minimal contradiction in the statements by Republicans, and vice versa."

They conclude: "Politicians are often criticised for being all things to all people and for making promises that they then fail to keep. However … the problem may be less what the politicians are actually saying but rather how their words are heard and interpreted."

McKee M, et al. How cognitive biases affect our interpretation of political messages. BMJ 2010;340:c2276. Full-text:

Cf. also Farhad Manjoo, True Enough: Learning to Live in a Post-Fact Society (Wiley:2008).