Saturday, October 02, 2010

Lit Bits: Oct 2, 2010

From the recent medical literature (and conferences)...

2010 ACEP Scientific Assembly Highlights

Day 1:
Day 2:
Day 3:

1. Clinically Suspected Coagulopathy in Blunt Head Trauma? Get the CT

Medzon R, et al. J Emerg Med. 2010;39:399-405.

Patients with moderate to severe head injury and abnormal coagulation studies have a significantly higher risk of brain injury. The objective of this study was to determine the association of clinical suspicion of coagulopathy and intracranial injury (ICI) among patients sustaining blunt head trauma, including minor injuries.

As part of the NEXUS II blunt head injury study, enrolled patients were prospectively evaluated for ICI and suspicion of coagulopathy. We examined the relationship between suspicion of coagulopathy and the presence of any clinically significant or “therapeutically inconsequential” ICI based on head computed tomography (CT) scan results.

The NEXUS II study enrolled 13,728 patients, including 493 with suspicion of coagulopathy. Significant ICI was present in 46 (9.3%; 95% confidence interval [CI] 6.9–12.2) patients with suspected coagulopathy, and in 460 of 9863 (4.7%; 95% CI 4.3–5.1) patients without such suspicion. “Therapeutically inconsequential” findings were found on head CT scan in 74 patients, and 7 of these had suspected coagulopathy. Interventions including intubation, intracranial pressure monitoring, or craniotomy were performed in 5 of these 7 (71%; 95% CI 29–96) individuals, compared with only 3 of 67 (4%; 95% CI 1–12) patients without suspicion of coagulopathy.

Initial clinical suspicion of coagulopathy, independent of laboratory confirmation, is associated with a greater prevalence of significant ICI injury after blunt head trauma; it also substantially increases the risk of morbidity despite the presence of an apparent “therapeutically inconsequential” injury. CT scanning of the head should be performed initially based on clinical suspicion of coagulopathy.

2. Using Etomidate in Patients with Suspected Sepsis Does Not Increase LOS

Megan Brooks. September 24, 2010 — In a prospective, randomized study, patients with suspected sepsis who received a bolus of etomidate before rapid sequence intubation spent no more time in the hospital than similar patients who received a bolus of midazolam.

Etomidate, the researchers note, is ideal for rapid intubation in septic patients because of its "predictability in dosing, reliable hypnotic effect, rapid onset, and short duration of effects and because it has no effect on histamine release, which contributes to its hemodynamic stability." However, previous studies have found adverse outcomes from a single bolus dose of etomidate in septic patients.

But in this study, along with similar hospital stays, the two groups also spent similar amounts of time in intensive care and on a ventilator, according to a September 10th online paper in Annals of Emergency Medicine.

But the trial was underpowered to detect any differences in mortality, "which is the more meaningful clinical outcome," first author Dr. Karis L. Tekwani, from Advocate Christ Medical Center in Oak Lawn, Illinois, noted in an e-mail to Reuters Health.

"Our study found a non-significant 7% increase in mortality in patients given single bolus doses of etomidate," she said. "Another randomized controlled study comparing etomidate to ketamine for rapid sequence intubation by Jabre et al also found a similar non-significant 8% increase in mortality in patients with sepsis given single bolus doses of etomidate."

Therefore, Dr. Tekwani said, it is still possible that a larger study would detect a significant difference, "and hence we would urge clinicians to at least consider using alternative induction agents in the critically ill population at risk of adrenal suppression."

Dr. Tekwani and her colleagues had randomly assigned 122 critically ill patients with presumed sepsis to etomidate (0.3 mg/kg IV) or midazolam (0.1 mg/kg IV) before emergency department intubation at their hospital. The investigators were blinded to treatment assignment. Demographics and baseline characteristics were fairly similar between the two groups. The median patient age was 70 in the etomidate group, 73 in the midazolam group.

Two patients in the etomidate arm were lost to follow-up. In intention-to-treat analysis, the median number of days in the hospital (the primary outcome) was 7.3 in the etomidate group and 9.5 in the midazolam group.

There was also no significant difference in intent-to-treat analysis in the secondary outcome of ICU stay: 3.1 days in the etomidate arm vs 4.2 days in the midazolam arm. The same was true for number of ventilator days (median 2.1 with etomidate and 2.8 days with midazolam).

The in-hospital mortality rate was 43% (26 of 61) with etomidate and 36% (21 of 59) with midazolam. "Kaplan-Meier survival analysis likewise showed no statistically significant differences between groups (p = 0.22)," the authors note.

The decision to use steroids was left to the treating physician; 20 patients in the etomidate arm (33%) got steroids in the ED versus 28 (47%) in the midazolam arm. Overall, there were no significant effects from the use of steroids, "although trends toward increased mortality were evident with supplemental steroid use, irrespective of induction agent," they report.

Etomidate has been shown to cause "measurable adrenal suppression after a single bolus dose," the authors point out, although the clinical significance of this in patients with sepsis "remains controversial." The current study, however, was not designed to obtain quantitative measures of adrenal function.

Pulse oximetry results and systolic blood pressures were similar in the two groups, both before and after intubation; 25% of patients in each group had a systolic blood pressure below 90 mm Hg after intubation.

A per-protocol analysis of 45 etomidate- and 51 midazolam-treated subjects with confirmed sepsis yielded largely findings similar to the intention-to-treat analysis.

In their report, Dr. Tekwani and colleagues try to reconcile their findings with prior studies that hinted at increased harm with etomidate in patients with sepsis. They say, for instance, that to their knowledge theirs is the only randomized, double-blind comparison of etomidate to an alternative agent for intubation in patients with presumed sepsis.

And they cite several methodological problems with past studies. The current study, they say, "overcomes many of the limitations of previous observational studies and raises the possibility that previous findings were influenced by confounding variables."
Nevertheless, they admit, this study was relatively small. This, combined with the non-significant increase in mortality in the etomidate group, raises the possibility that there may be a clinically important difference in mortality after all.

Clearly, more study is needed, they conclude.

Ann Emerg Med. Published online September 10, 2010.


3. Risk Stratification for Hospitalization in Acute Asthma: the CHOP classification tree

Tsai C, et al. Amer J Emerg Med. 2010;28:803-808.

Simple risk stratification rules are limited in acute asthma. We developed and externally validated a classification tree for asthma hospitalization.

Data were obtained from 2 large, multicenter studies on acute asthma, the National Emergency Department Safety Study and the Multicenter Airway Research Collaboration cohorts. Both studies involved emergency department (ED) patients aged 18 to 54 years presenting to the ED with acute asthma. Clinical information was obtained from medical record review. The Classification and Regression Tree method was used to generate a simple decision tree. The tree was derived in the National Emergency Department Safety Study cohort and then was validated in the Multicenter Airway Research Collaboration cohort.

There were 1825 patients in the derivation cohort and 1335 in the validation cohort. Admission rates were 18% and 21% in the derivation and validation cohorts, respectively.

The Classification and Regression Tree method identified 4 important variables (CHOP): change [C] in peak expiratory flow severity category, ever hospitalization [H] for asthma, oxygen [O] saturation on room air, and initial peak expiratory flow [P]. In a simple 3-step process, the decision rule risk-stratified patients into 7 groups, with a risk of admission ranging from 9% to 48%. The classification tree performed satisfactorily on discrimination in both the derivation and validation cohorts, with an area under the receiver operating characteristic curve of 0.72 and 0.65, respectively.

We developed and externally validated a novel classification tree for hospitalization among ED patients with acute asthma. Use of this explicit risk stratification rule may aid decision making in the emergency care of acute asthma.

Fig. 1

Fuzzily shown here is Figure 1 which depicts the final tree generated by the CART analysis along with the admission rate for each terminal node of this tree. Overall, the CART method used 4 variables to stratify patients into 7 terminal nodes. “Ever hospitalization for asthma” was the best single discriminator, followed by room-air oxygen saturation (95% or greater vs less than 95%) and PEF severity category (severe/very severe vs mild/moderate) as the second-level discriminators. For the node of lower oxygen saturation, changes in PEF (improved vs unchanged/worsened) provided additional prognostic value. Overall, the tree resulted in 3 groups with an admission rate that was below the average (light gray boxes) and 4 groups with an admission rate that was above the average (dark gray boxes).

4. This Just In: You'll get Sued Eventually

AMA Study: EPs Rank 5th in Liability Claims Frequency

by Louise B. Andrew, MD, JD. Published in Emergency Physicians Monthly, Sept 2010

A just-released AMA study has revealed that more than 42% of physicians across all specialties has at some time been sued for malpractice, and more than 20% have been sued two or more times. Based on a 2007-2008 survey of a statistically valid sample (5285 physicians from 42 specialties randomly selected from the AMA physician masterfile) the survey asked whether the physician had ever been sued, and whether they had been named in a suit in the past year. The survey was jointly sponsored by the AMA, CMS, and 40 specialty societies, including ACEP.

Overall, 95 claims were reported ever filed for each 100 physicians, with approximately five physicians out of every 100 reporting claims in the preceding year. There was remarkable variability in the suit frequency between specialties, as well as age and gender disparities.

Surgeons and ObGyns experienced twice the overall average claims rate, followed closely by surgical subspecialists. Emergency physicians ranked fifth in claims frequency, just below radiologists, at 109 claims per 100 physicians. The lowest claims rates were experienced by psychiatrists and pediatricians.

Emergency physicians experienced an 8.7% claims rate in the year covered by the study. If this year was representative, this could approximate our annual claims rate.

Remainder of the essay:

AMA Study:

5. Bedside Ocular US for the Detection of Retinal Detachment in the ED

Yoonessi R, et al. Acad Emerg Med. 2010;17:913-917.

Objectives:  Acute retinal detachments (RD) can be difficult to diagnose and may require emergent intervention. This study was designed to assess the performance of emergency department ocular ultrasound (EOUS) for the diagnosis of RD.

Methods:  This was a prospective, observational study using a convenience sample of emergency department (ED) patients. Physicians performed EOUS for the diagnosis of RD prior to evaluation by an ophthalmologist. The criterion standard was the diagnosis of a RD by the ophthalmologist who was blinded to the results of EOUS.

Results:  Fifteen physicians evaluated 48 patients with acute visual changes. Eighteen patients (38%) had RDs and all were correctly identified (true positives). Of the 30 patients (62%) without RD, 25 patients were correctly identified (true negatives), and five patients with vitreous hemorrhages were misidentified as having RDs (false positives). Therefore, the sensitivity and specificity of EOUS for RD were 100% (95% confidence interval [CI] = 78% to 100%) and 83% (95% CI = 65% to 94%), respectively.

Conclusions:  Emergency department ocular ultrasound is sensitive for the diagnosis of RD and may have a role in excluding RD in patients presenting to the ED.

6. Rapid Diagnostic Testing for Seasonal Influenza: An Evidence-Based Review and Comparison with Unaided Clinical Diagnosis

Petrozzino JJ, et al. J Emerg Med. 2010;39:476-490.e1

Background: Worldwide, seasonal influenza imposes a considerable health and economic burden. Clinical diagnosis of influenza-like illness (ILI) is complicated by non-specific symptomatology. Rapid flu tests (RFTs) impact treatment decisions and may improve patient care; yet, recommendations for RFT use are broad, and the performance of unaided clinical diagnosis relative to RFTs is unclear.

Objectives: To determine age-stratified, overall sensitivities and specificities of the widely studied RFT, QuickVue® (Quidel Corporation, San Diego, CA), and clinical diagnosis of ILI by meta-analysis and to seek factors associated with poorer clinical diagnostic discrimination.

Methods: A systematic literature review was conducted using article selection criteria identifying studies indexed in PubMed/MEDLINE, the Cochrane Library, and other pertinent sources of studies reporting sensitivity, specificity, and effects of RFTs and clinical diagnosis on decision-making for patients with ILI.

Results: QuickVue's® diagnostic specificity exceeds that of unaided clinical diagnosis by 29–31%. False-positive results occur approximately 8.2 times more frequently by unaided clinical diagnosis than by the RFT alone. These findings were unaffected by seasonal variations in disease prevalence. RFTs reduce diagnostic testing, antibiotic use, and emergency department utilization while increasing antiviral prescription rates. No systematic relationship between the broadness of clinical diagnostic criteria for influenza and diagnostic performance was observed across studies included in this review.

Conclusions: Use of RFTs improves seasonal influenza diagnostic specificity above that based on unaided clinical diagnosis irrespective of the broadness of clinical diagnostic criteria, and affects clinical decision-making. These results provide an improved framework upon which to diagnose influenza, design future RFT studies, and modify existing recommendations for improved ILI patient management.

7. Prophylactic Intravenous Magnesium Sulfate for treatment of Aneurysmal Subarachnoid Hemorrhage: a Randomized, Placebo-controlled, Clinical Study

Westermaier T, et al. Crit Care Med. 2010;38:1284-90.

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 months 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 of 54 vs. 15 of 53 patients; p = .149) and transcranial Doppler-detected/angiographic vasospasm was significantly reduced in the magnesium group (36 of 54 vs. 45 of 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.

8. What to Do When the Nurses Can’t Get a Line

When the RNs can’t plant an IV, you might be more successful securing an US-guided peripheral line that going for the EJ.

Ultrasound-Guided Peripheral Venous Access vs. the External Jugular Vein as the Initial Approach to the Patient with Difficult Vascular Access

Costantino TG, et al. J Emerg Med. 2010;39:462-467.

Background: Traditionally, Emergency Physicians (EPs) have used the external jugular (EJ) vein to gain vascular access in patients who have failed nursing attempts at peripheral access. Recently, some EPs have used ultrasound (USIV) to gain peripheral access.

Study Objective: This study seeks to determine which initial approach by EPs would lead to greater success. Methods: This was a prospective, randomized study of all adult patients who presented to the Emergency Department (ED) between June and December 2007. Inclusion criteria were failed nursing attempts at peripheral access (at least three). EPs were 2nd- or 3rd-year residents who had previously performed more than five each of EJs and USIVs. Patients were randomized into either an initial EJ or USIV approach.

Results: Sixty patients were enrolled, 32 in the ultrasound group, 28 in the EJ group. Fifteen different EPs performed access. Initial Success: USIV 84% (95% confidence interval [CI] 68–93%) vs. EJ 50% (95% CI 33–67%), p = 0.006. Success if EJ visible: USIV 84% vs. EJ 66% (p = 0.18). Overall success, including data from the crossover pathway: a total of 41 lines were successfully placed by ultrasound out of 46 attempts (89%) vs. 18 out of 33 for EJ (55%), p = 0.001. In total, 59/60 patients (98%) had a peripheral i.v. successfully placed. The percentage of functioning lines when the patient left the ED was: USIV 89% (95% CI 72–96%) vs. EJ 93% (95% CI 68–98%), p = 0.88.

Conclusion: As an initial approach to all patients with difficult venous access, ultrasound-guided peripheral lines are superior to the EJ approach. However if the EJ was visible, there was no difference in success among the initial approaches. Both techniques, when used together, could achieve peripheral vascular access in 98% of difficult access patients.

9. Clinical Updates from EM:RAP

A New Look at Thyroid Emergencies by Stuart P. Swadron, MD

Part I: Myxedema Coma

On the EM:RAP program, Mel Herbert and I recently did a two-part series on two rare and exotic emergencies – myxedema coma and thyroid storm. Our expert for this segment was Dr. Jonathan LoPresti, a senior endocrinologist and thyroid researcher at LA County/USC Medical Center. I interviewed him on two occasions and, quite frankly, what he had to say was fascinating. In the first part of this series, we will discuss myxedema coma. Next month we will cover thyroid storm.

Myxedema coma is one of a long list of “misnomer” diagnoses in medicine; patients with the condition are rarely edematous or comatose. Dr. LoPresti prefers to use the term “decompensated hypothyroidism”. And it is decompensated hypothyroidism that we as ER Docs need to identify and treat in the emergency department.

Dr. LoPresti has a remarkably simple and useful way of explaining what decompensated hypothyroidism is all about. Basically, patients who are hypothyroid, and thus have a decreased metabolic rate, conserve heat by being in a constant state of vasoconstriction. That is why they feel cool to the touch. They also are in a relative state of volume depletion, and although their blood pressure may be mildly elevated, they have a reduced cardiac output.

Decompensation typically occurs with infection and sepsis. These patients, who are dependent on chronic vasoconstriction to get by, suddenly have the bottom pulled out from beneath them. They are now vasodilated, volume depleted, and unable to produce enough cardiac output to cope with it. Simply stated, decompensated hypothyroidism is cardiovascular collapse in a hypothyroid patient with sepsis.

So what do these patients look like? They are cold, their skin is dry, the recovery phase of their deep tendon reflexes are delayed, their sodium and white blood cell counts are low, and there is some precipitating event going on – usually an infection. Although the formal definition of myxedema coma involves some alteration of mental status, this can be subtle: Dr. LoPresti gave the example of a patient who lost their ability to speak in a second language.

The bottom line is that it doesn’t matter to us if they meet the formal definition. If in doubt, TREAT! Despite what a lot of us have been led to believe, we have far less to worry about if we don’t treat than if we do. The only issue is the way that you treat them…

The remainder of the essay:

Part II: Handling Thyroid Storm

…Patients with hyperthyroidism walk around every day in a state of vasodilatation. They are dependent on vasodilatation to get rid of the excess heat that they generate in their hypermetabolic state. Patients with thyroid storm are decompensated – no longer able to vasodilate sufficiently, their core temperature begins to rise. This occurs in response to any number of stressors that result in a release of catecholamines, to which the hyperthyroid patients are uniquely sensitive.

The diagnosis of thyroid storm is made on the basis of the following: characteristic clinical features, such as sweating, tremor, hyperreflexia and supraventricular tachycardias, elevated temperature, and some precipitating event, such as infection, surgery or trauma. Lastly, in order to make the formal diagnosis of storm, the patient must also have some degree of altered mental status, but this may be rather subtle and subjective.

The diagnosis is even more difficult in the elderly because they have a less dramatic response to the hyperthyroid state. Interestingly, even though the diagnosis is easier to make in younger people, thyroid storm is more dangerous for them because of their greater capacity to respond to the inappropriately high thyroid activity. This is something that seems quite counterintuitive to most EPs, but it makes sense when you think about it.

Because infection is such a common trigger of a decompensated hyperthyroid state, you should draw blood and urine cultures and initiate empiric antibiotic treatment when the diagnosis of storm is being entertained. To help confirm the diagnosis, a TSH and T4 should be sufficient. Other laboratory abnormalities that are typical include a mild normocytic anemia, low platelets, and hypocalcemia. White blood cell counts are typically, and misleadingly, low.

The thing that scares most EPs is pulling the trigger on thyroid-specific treatment, especially before results of thyroid laboratory studies are available. These patients are critically ill and we worry that treatment of the hyperthyroid state might blunt their ability to compensate for shock. Just like in decompensated hypothyroidism, the critical message here is that when in doubt, the EP should treat. If left untreated, thyroid storm is fatal. If you are wrong, a few doses of anti-thyroid medication is unlikely to harm the euthyroid patient…

The remainder of the essay:

10. Low-dose Ketamine for Analgesia in the ED: a retrospective case series

Lester L, et al. Amer J Emerg Med. 2010;28:820-827.

The aim of this study was to describe the use and effect of low-dose ketamine (LDK) for analgesia in the emergency department (ED).

A chart review was performed to identify all adult patients who received LDK for analgesia in our ED. Cases were identified by pharmacy record of ketamine administration. Low-dose ketamine was defined as the administration of 0.1 to 0.6 mg/kg of ketamine for pain control. Use of ketamine during procedural sedation was excluded. Data were analyzed descriptively.

Thirty-five cases in which patients received LDK in the ED for a 2-year period were identified. Doses ranged from 5 to 35 mg. Administration was intravenous in 30 (86%) of 35 cases and intramuscular in 5 (14%) of 35 cases. Opioids were administered before or coadministered with LDK in 32 (91%) of 35 cases, and in the remaining 3 cases, opioids were used before the patient came to the ED. Improvement in pain was observed in 19 (54%) of 35 cases in which patients received LDK. Pain scores did not improve in 8 (23%) of 35 cases. Insufficient data were available to determine LDK effect for 8 (23%) of 35 cases. No significant adverse events were identified in any of the 35 cases.

The administration of LDK in the ED may be a safe and effective adjunct for analgesia in some patients. However, prospective randomized controlled trials are needed before widespread use of LDK for analgesia in the ED can be recommended.

11. Delaying Appendectomy May Not Be Harmful for Adults with Acute Appendicitis

Laurie Barclay, MD. September 24, 2010 — Delaying appendectomy for 12 hours or more may not be harmful for adults with acute appendicitis, according to the results of a retrospective cohort study reported in the September issue of the Archives of Surgery.

"Appendectomy is the most common emergent surgical procedure performed worldwide, with appendicitis accounting for approximately 1 million hospital days annually," write Angela M. Ingraham, MD, MS, from the American College of Surgeons in Chicago, Illinois, and colleagues. "Increased time from onset of symptoms to operative intervention is associated with more advanced disease. Recent developments in imaging and antibiosis have afforded improved preoperative assessment and treatment, allowing for non-operative management of abscesses and phlegmons and potentially limiting the need for immediate operative intervention to halt disease progression."

The goal of the study was to determine the impact of delay from surgical admission for acute appendicitis to induction of anesthesia on outcomes after appendectomy in adults, using data from 32,782 patients submitted to the American College of Surgeons National Surgical Quality Improvement Program database from January 1, 2005, through December 31, 2008. The principal exposure was time to operation, and primary study endpoints were 30-day overall morbidity and serious morbidity or mortality. Probabilities of outcomes were adjusted for patient and surgical risk factors with use of regression models.

Appendectomy was performed within 6 hours of surgical admission in 24,647 patients (75.2%), from more than 6 through 12 hours in 4934 patients (15.1%), and more than 12 hours after surgical admission in 3201 patients (9.8%). Although there were statistically significant differences in operative duration (51, 50, and 55 minutes, respectively; P below .001), these were not clinically meaningful. Similarly, the difference in length of postoperative stay (2.2 days for the greater than 12-hour group vs 1.8 days for the remaining groups; P less than .001) was not clinically meaningful.

In regression models, duration from surgical admission to induction of anesthesia did not predict overall morbidity or serious morbidity or mortality. There were no significant differences in adjusted overall morbidity (5.5%, 5.4%, and 6.1%, respectively; P = .33) or serious morbidity or mortality (3.0%, 3.6%, and 3.0%, respectively; P = .17).

"In this retrospective study, delay of appendectomy for acute appendicitis in adults does not appear to adversely affect 30-day outcomes," the study authors write. "This information can guide the use of potentially limited operative and professional resources allocated for emergency care."

Limitations of this study include retrospective design, lack of randomization, possible differences in patient or organizational factors, and use of operative and diagnostic codes to identify appendicitis.

"Because of the growing issues surrounding access to emergency care and specialist coverage, care for emergency general surgery patients is increasingly the responsibility of acute care surgeons and specialized services, which cover the specialties of trauma, emergency general surgery and critical care," the study authors conclude. "...As the elderly population continues to increase, the medical needs of patients presenting for emergency general surgical care will become increasingly complex and will demand additional resources and attention. Because of potentially limited physical and professional staffing resources, an acute care surgeon may need to delay the operation of less critically ill patients to appropriately care for those requiring immediate attention."

Critique: Findings a "Win-Win-Win Situation"

In an accompanying invited critique, John G. Hunter, MD, from Oregon Health & Science University in Portland, notes that these findings validate the practice of treating acute appendicitis urgently rather than emergently.

"Financial savings without any evidence of adversity to the patient and the promise of a well-rested surgeon in the morning provide benefit sufficiently ample for me to embrace these recommendations," Dr. Hunter writes. "At the end of the day, it is clearly a win-win-win situation when the interests of the patient, the surgeon, and the hospital are in complete alignment around such a shift in surgical practice."

The study authors and Dr. Hunter have disclosed no relevant financial relationships.

Arch Surg. 2010;145:886-892. Abstract:

12. Bolus Dose of Ketamine Offers Fast-Acting Alleviation of Acute Depression in ED Setting

Nancy A. Melville. September 29, 2010 (Las Vegas, Nevada) — A single subanesthetic dose of intravenous ketamine administered to acutely depressed and suicidal patients presenting to the emergency department (ED) can rapidly alleviate depression and can alleviate suicidal thoughts for up to 10 days, according to a study presented here at the American College of Emergency Physicians 2010 Scientific Assembly.

The study involved 15 patients who presented to the ED with a primary complaint of depression and/or suicidal ideation. Results showed that all patients who were administered a single subanesthetic intravenous bolus of ketamine (0.20 mg/kg over 1 to 2 minutes) had decreased suicidal ideation at 40, 80, 120, and 240 minutes postinfusion. Suicidal ideation was completely resolved in 14 of the 15 subjects within 40 minutes, and was sustained at 10-day follow-up in 13 of the 14 patients.

Previous studies have looked at ketamine as a treatment for depression. Researchers from the Yale University School of Medicine's Department of Emergency Medicine, in New Haven, Connecticut, decided to evaluate the drug's fast-acting potential.

"Currently there is no good pharmacotherapy for the treatment of acute depression or suicide ideation. However, several studies have shown that ketamine may exert effects on patients who present with depression," said coauthor Robert Turelli, MD.

The study's findings, although preliminary, are promising, Dr. Turelli said. "Our study is the first to show that a reduction in depressive systems can be achieved with a rapid bolus, which is a more feasible application in a busy ED setting," he said.

"There was no sign of remission of any of the suicidal thoughts among patients who underwent the study in the 10 days of follow-up." Dr. Turelli added.

Patients' moods were evaluated at baseline on the Montgomery-├ůsberg Depression Rating Scale (MADRS) and the Beck Scale for Suicidal Ideation (SSI)

Scores were 42 (range, 38 to 47) for MADRS and 19 (range, 12 to 28) for Beck's SSI. Mean MADRS scores at baseline, and at 40, 80, 120, and 240 minutes postinfusion were 41.5,14.9, 13.6, 12.2, and 12.0, respectively (repeated-measures analysis of variance; P below .0001).

Mild positive psychotic-like symptoms or adverse effects were experienced, but all resolved within 40 minutes. Two patients experienced significant unpleasant dissociative symptoms, but those resolved within 30 minutes.

The patients did not have a significantly longer ED stay than 15 age- and diagnosis-matched control subjects who did not receive the drug.

The patients all endorsed the statement that "the benefits of receiving this medication outweigh any inconvenience, discomfort, or side effects."

The study's limitations include the small number of patients and the lack of a placebo group, but Dr. Turelli said the findings suggest a potentially important new use for the drug.

"Despite the small numbers, these results are dramatic and very impressive, suggesting that ketamine is feasible and possibly beneficial for the emergency setting."

According to Michael P. Wilson, MD, PhD, from the Department of Emergency Medicine at University of California at San Diego, the findings are significant in suggesting a potentially valuable, fast-acting use for the drug in depressed patients.

"The study is unique in showing that the drug can be given safely in the emergency department for depressed patients. The study authors also gave the drug rapidly, instead of at a low dose over a long period of time," Dr. Wilson said.

"You would expect that such a low dose wouldn't work for most patients, but the drug made people feel better — 100% of them — so it's really an interesting study and it seems that it might be a very exciting tool."

The study was supported by funding from the Connecticut College of Emergency Physicians. Dr. Turelli and Dr. Wilson have disclosed no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2010 Scientific Assembly: Abstract 157. Presented September 28, 2010.

13. At-Risk Populations and the Critically Ill Rely Disproportionately on Ambulance Transport to Emergency Departments

Squire BT. Ann Emerg Med. 2010;56:341-347.

Study objective
Emergency department (ED) crowding increases ambulance diversion. Ambulance diversion disproportionately affects individuals who rely on ambulance transport. The purpose of this study is to determine which populations rely most on ambulance transport.

We queried the National Hospital Ambulatory Medical Care Survey database for 1997 to 2000 and 2003 to 2005 for patients who arrived by ambulance or personal transport. We performed bivariate analysis to assess the extent to which all patients and a subset of critically ill patients use ambulance transport relative to self-transport.

In our sample, 30,455 (15%; 95% confidence interval [CI] 15% to 16%) patients arrived by ambulance and 162,091 (85%; 95% CI 84% to 85%) arrived by walk-in/self-transport. Overall, patients with Medicare insurance were more likely to rely on ambulance transport, at 34% (95% CI 33% to 35%), than the privately insured, at 11% (95% CI 10% to 11%). Among the critically ill, privately insured patients were less likely to rely on ambulance transport, at 47% (95% CI 42% to 52%), than those with Medicare insurance (61%; 95% CI 58% to 65%), the publicly insured (60%; 95% CI 52% to 67%), or the uninsured (57%; 95% CI 49% to 64%). Among the critically ill, patients aged 15 to 24 years and those older than 74 years were most likely to rely on ambulance transport, at 63% (95% CI 53% to 72%) and 67% (95% CI 62% to 71%), respectively. Fifty-seven percent (95% CI 54% to 59%) of the critically ill used ambulance versus 15% (95% CI 14% to 15%) of noncritical patients.

Patients with Medicare insurance or public insurance, the uninsured, the elderly, and the critically ill disproportionately rely on ambulance transport to the ED. Ambulance diversion may disproportionately affect these populations.

14. Decreasing Unplanned Return Visits in Children with Fever in the Emergency Department

Dunn AL, et al. Abstract Presented at the annual meeting of the Eastern Society for Pediatric Research 2010

BACKGROUND: Overcrowding in the emergency department (ED) is one of the most pressing issues in the national health care debate today. One of the many causes of ED overcrowding is unplanned return visits. Young febrile children frequently make unplanned return visits to the emergency department (ED). Specific discharge instructions were developed to address parental fears and provide proper antipyretic dosing to decrease unneccessary return visits to the ED for fever.

OBJECTIVE: To evaluate the association between receiving specific fever instructions and the rate of return to the ED within the subsequent 48 hours.

DESIGN/METHODS: This study is a retrospective case-control study of a sample of children aged 8 weeks to 5 years who presented to the ED with fever over a one-year time period. Demographic characteristics were compared along with receipt of specific fever instructions and the completeness of the instructions. Inclusion criteria were fever over 100.4 degrees F and age 8 weeks to 5 years. Exclusion criteria included: admission to the hospital, chronic medical conditions, returned to the ED for an unrelated complaint and patients that left without being seen.

RESULTS: 202 medical charts were audited. 120 (59.4%) did not return to the ED and 82 (40.6%) did return within 48 hours of index ED visit. 74.2% of children who did not return to the ED received specific instructions compared with 53.7% of patients that did return (p=0.003). Demographic characteristics of children who did and did not return within 48 hours were similar including age, gender, insurance, race, average temperature, and receipt of antipyretics in the ED. More patients in the 48-hour return group received instructions missing antipyretic dosing than children in the group that did not return (53.7% vs 40.8%).

CONCLUSIONS: Among children with fever seen in the ED, those who did not return within 48 hours were more likely to have received specifically designed instructions for fever. Specifically designed discharge instructions, may be helpful in decreasing unplanned return visits to the ED for common illnesses.

Associated essay in ACEP News:

Below are some highlights from their discharge instructions (courtesy of the PI):

-- Fever is not a disease. It is a normal way for your body to fight a possible infection.

-- Fever may be caused by an infection. But, sometimes other things like exercise, too much clothing, or hot weather may cause your child’s temperature to rise.

-- Many infections are caused by a virus. Antibiotics will not help when infections are caused by a virus. Your doctor will prescribe an antibiotic only if your child has an infection caused by bacteria.

-- Fever will often return as the medicine (that is, the antipyretic) wears off until the infection begins to get better.

--Call your doctor if your child has fever that is not gone away in 5-7 days.

15. K2/Spice: Much More than “Fake Marijuana”

by Evan Schwarz, MD. Published in Emergency Physicians Monthly, Sept 2010

Over the last six months, the drug K2 – or “spice” – has gained national attention both from the media and the medical community. This synthetic cannabinoid, which is completely legal in most states, is sending users to the ED with symptoms from hallucinations to seizures.
K2 is a tetrahydrocannabinol (THC) analogue, which is the psychoactive component of marijuana. Synthetic cannabinoids have been around since the 1980s, when scientists discovered receptors that bind cannabinoids and cause their effects. In fact, in search of a new analgesic, Pfizer developed their own line of synthetic cannabinoids known as the CP series. In 1994, Clemson professor John W. Huffman developed a series of synthetic cannabinoids. One of them, JWH-018, is thought to be the active ingredient in K2.

While many of us in the United States may be unfamiliar with K2, mention of the synthetic marijuana can be found on the internet dating back to 2006. The drug has gained notoriety in both Asia and Europe leading to Germany banning it in early 2009. However four weeks after it was outlawed in Germany, second-generation products were reported. In most places in the United States, K2 can be purchased over the internet or at any local head shop for about $30. A head shop is any local retail outlet that sells items such as pipes, rolling papers, or other products that can be used as drug paraphernalia. K2 is sold under many names including Spice, Spice Gold, and Spice Diamond. It is marketed as an incense or herbal preparation. In most cases the packaging states that the product is not for human use. Spice is a combination of different herbs that have been sprayed with a synthetic marijuana such as JWH-018. The user can then make it into a cigarette or place it into a bong to smoke just as they would with regular marijuana.

The average marijuana user can be envisioned as the college stoner sitting on his couch while eating junk food and laughing at children’s cartoons. Anyone that has ever treated a patient presenting after using Spice knows that they do not act like this. While undoubtedly some users have a similar experience when they use Spice as they have after smoking marijuana, an increasing amount of patients are not. While I can’t remember the last time a patient, assuming they weren’t being detained by the police or involved in a car accident, was brought to the ED because of marijuana intoxication, local poison center data do show a consistent climb in the number of calls originating from EDs regarding patients using K2. They can present drowsy and with hallucinations. However a number of them present with agitation, bad GI upset, tachycardia, hypertension, and even seizures. Marijuana used in large amounts or very high concentrations can cause some of these symptoms; but once again, when was the last time you saw multiple agitated patients after only using marijuana. Whether these symptoms are due to an inherent characteristic of K2 or just due to the concentration that is sprayed on the herbal product is unknown. Care generally involves symptomatic treatment with hydration and benzodiazepines for agitation. The standard urine drug test, while it can detect marijuana, will not detect K2. While there are some research laboratories that have equipment sensitive enough to detect K2, this technology is not available in a clinically useful manner. Little research has been conducted on possible long-term sequelae after using these drugs.

The drug has also gained the attention of law enforcement. In addition to not showing up on drug tests, part of the popularity of K2 is likely related to it being easily accessible. Its availability is a consequence of it being completely legal in most states. Kansas was the first state to outlaw K2. Missouri and Arkansas have since followed with similar legislation reported in Illinois, Louisiana, Michigan, New Jersey, New York and Texas.

16. Clinical Predictors for Testicular Torsion as Seen in the Pediatric ED

This Small Series Confirms What We Already Know

Beni-Israel T, et al. Amer J Emerg Med. 2010;28:786-789.

The aim of the study was to identify clinical findings associated with increased likelihood of testicular torsion (TT) in children.

This study used a retrospective case series of children with acute scrotum presenting to a pediatric emergency department (ED).

Five hundred twenty-three ED visits were analyzed. Mean patient age was 10 years 9 months. Seventeen (3.25%) patients had TT. Pain duration of less than 24 hours (odds ratio [OR], 6.66; 95% confidence interval [CI], 1.54-33.33), nausea and/or vomiting (OR, 8.87; 95% CI, 2.6-30.1), abnormal cremasteric reflex (OR, 27.77; 95% CI, 7.5-100), abdominal pain (OR, 3.19; 95% CI, 1.15-8.89), and high position of the testis (OR, 58.8; 95% CI, 19.2-166.6) were associated with increased likelihood of torsion.

Testicular torsion is uncommon among pediatric patients presenting to the ED with acute scrotum. Pain duration of less than 24 hours, nausea or vomiting, high position of the testicle, and abnormal cremasteric reflex are associated with higher likelihood of torsion.

17. Suggested Work-up of Pts with Postcholecystectomy Syndrome

Schofer JM, et al. J Emerg Med. 2010;39:406-410.

Background: The postcholecystectomy syndrome refers to the persistence of gastrointestinal symptoms after cholecystectomy; patients with this syndrome commonly seek treatment in the Emergency Department (ED). There are a multitude of biliary and non-biliary causes of postcholecystectomy syndrome.

Objectives: To review the biliary causes of postcholecystectomy syndrome and present a suggested diagnostic workup.

Discussion: A number of biliary causes are discussed, including choledocholithiasis, bile duct injury and biliary leaks, cystic duct and gallbladder remnants, sphincter of Oddi dysfunction, and biliary ascariasis. The ED workup should focus on differentiating biliary from non-biliary causes of the patient's symptoms.

Conclusion: A right upper quadrant abdominal ultrasound, liver transaminases, alkaline phosphatase, and serum bilirubin are the tests most useful in the ED for making this distinction and determining the most appropriate treatment and disposition of the patient. Computed tomography may be of use in the initial post-operative period.

18. A Discussion of Antiemetic Therapy for Nausea and Vomiting in the ED

Patanwala AE, et al. J Emerg Med. 2010;39:330-336.

Background: Antiemetic agents are among the most frequently prescribed medications in the emergency department (ED). Nevertheless, there are no widely accepted evidence-based guidelines to optimize the use of these medications for nausea or vomiting in this setting.

Objective: The objective of this article is to briefly review the evidence supporting the use of antiemetic agents for the treatment of nausea or vomiting for adults in the ED, and to provide recommendations to help guide therapy.

Discussion: The antiemetic agents studied include droperidol, promethazine, prochlorperazine, metoclopramide, and ondansetron. Droperidol was commonly used in the past, and is more effective than prochlorperazine or metoclopramide, but due to the US Food and Drug Administration black box warning regarding the potential for QT prolongation with this drug, its use is limited to refractory cases. Promethazine is more sedating than other comparative agents, and also has the potential for vascular damage upon intravenous administration. It may be a suitable option when sedation is desirable. Patients given prochlorperazine or metoclopramide must be monitored for akathisia that can develop at any time over 48 h post administration. Decreasing the infusion rate can reduce the incidence of this adverse effect, and the effect can be treated with intravenous diphenhydramine. Ondansetron is as effective as promethazine, and is not associated with sedation or akathisia.

Conclusion: Based on the safety and efficacy of ondansetron, it may be used as a first-line agent for relief of nausea or vomiting for most patient populations in the ED.

19. What Is the Appropriate Antibiotic Course for the Treatment of UTIs in Children?

Seupaul RA. Ann Emerg Med. 2010;56:300-301.

Data Sources

The authors searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE from 1966 to 2005, and EMBASE from 1988 to 2005, without language restriction.

Study Selection

Randomized and quasirandomized controlled trials comparing short-term (2 to 4 days) with standard (7 to 14 days) oral antibiotic therapy in children aged 3 months to 18 years, with culture-proven urinary tract infections.

Data Extraction and Synthesis

Two authors independently assessed study quality and extracted data from included trials. A random-effects model was used to analyze data. Only randomized controlled trials were included; only 2 clearly described allocation concealment, whereas none of the trials defined appropriate blinding or used an intention-to-treat analysis.

Take-Home Message

Short-course antibiotic therapy (2 to 4 days) is probably as effective as a standard duration of therapy (7 to 14 days) in treating children with their first lower urinary tract infection.


Lower urinary tract infection is a common occurrence in children, but unlike the generally benign course in adults, urinary tract infection in the pediatric population is well recognized as a cause of hypertension and renal insufficiency in adulthood.[1] Although antibiotics provide effective therapy, it is unclear what the appropriate duration of therapy should be. Shorter courses of antibiotics (less than 7 to 14 days) have the potential to reduce the rate of adverse events, decrease cost, and improve compliance but may place the patient at risk for relapse and long-term sequelae. The authors of this review pooled data to determine whether a short course of antibiotics is safe and as effective as a standard duration of therapy. The results indicate that there is no difference in the frequency of failed treatment or recurrence; however, there were insufficient data to estimate the effects on symptom resolution, development of bacterial resistance, adverse events, compliance, or cost savings.

Additionally, the authors analyzed the risk of relapse between children with recurrent urinary tract infection (a higher-risk group) and those with their first infection. Although there was not a large enough sample to reach a definitive conclusion, the data suggest that for this high-risk group, short-course antibiotic therapy is probably not appropriate. Current guidelines support the findings of this systematic review. They specify a 3-day course for uncomplicated urinary tract infection in children and a longer course with appropriate subspecialty evaluation for all others.

20. The Future of Emergency Medicine

Schneider SM, et al. Acad Emerg Med. 2010 Sep;17(9):998-1003.

Physician shortages are being projected for most medical specialties. The specialty of emergency medicine continues to experience a significant workforce shortage in the face of increasing demand for emergency care. The limited supply of emergency physicians, emergency nurses, and other resources is creating an urgent, untenable patient care problem.

In July 2009, representatives of the leading emergency medicine organizations met in Dallas for the Future of Emergency Medicine Summit. The organizations represented met specifically to address the issues facing the emergency care workforce. This consensus document, agreed to and co-written by all participating organizations, describes the substantive issues discussed and provides a foundation for the future of the specialty. There are other, non workforce issues that were not addressed that will also inevitably influence the future of emergency medicine.

Attendees at the Future of Emergency Medicine Summit agreed that:

1. Emergency medical care is an essential community service that should be available to all. Public expectations as well as federal law require the ready availability of emergency care. Resources, including funding, should be made available to meet this well-intended goal.

2. An insufficient emergency physician workforce also represents a potential threat to patient safety.

3. Accreditation Council for Graduate Medical Education/American Osteopathic Association (AOA)-accredited emergency medicine residency training and American Board of Medical Specialties/AOA emergency medicine board certification is the recognized standard for physician providers currently entering a career in emergency care. Physicians who enter the practice of emergency medicine in the 21st century without this training represent a potential threat to patient safety.

4. Physician supply shortages in all fields contribute to—and will continue to contribute to—a situation where providers with other levels of training may be a necessary part of the workforce for the foreseeable future. These providers include nurse practitioners, physician assistants, and physicians trained in fields other than emergency medicine.

5. A maldistribution of emergency medicine residency–trained physicians persists, with few pursuing practice in small or rural settings.

6. Assuring that the public receives high-quality emergency care while continuing to produce highly skilled emergency medicine specialists through emergency medicine training programs is the challenge for emergency medicine’s future.

7. It is important that all providers of emergency care receive continuing postgraduate education.

21. The Effect of Physician Risk Tolerance and the Presence of an Observation Unit on Decision Making for ED Patients with Chest Pain

Pines JM, et al. Amer J Emerg Med 2010;28:771-779.

We sought to determine whether risk tolerance as measured by scales (malpractice fear scale [MFS], risk-taking scale [RTS], and stress from uncertainty scale [SUS]) is associated with decisions to admit or use computed tomography (CT) coronary angiogram and decisions to order cardiac markers in emergency department (ED) patients with chest pain. We also studied if the opening of an ED-based observation unit affected the relationship between risk scales and admission decisions.

Data from a prospective study of ED patients 30 years or older with chest pain were used. Risk scales were administered to ED attending physicians who initially evaluated them. Physicians were divided into quartiles for each separate risk scale. Fisher's exact test and logistic regression were used for statistical analysis.

A total of 2872 patients were evaluated by 31 physicians. The most risk-averse quartile of RTS was associated with higher admission rates (78% vs 68%) and greater use of cardiac markers (83% vs 78%) vs the least risk-averse quartile. This was not true for MFS or SUS. Similar associations were observed in low-risk patients (Thrombolysis in Myocardial Infarction risk score of 0 or 1). The observation unit was not associated with a higher admission rate and did not modify the relationship between risk scales and admission rates.

The RTS was associated with the decision to admit or use computed tomography coronary angiogram, as well as the use of cardiac markers, whereas the MFS and SUS were not. The observation unit did not affect admission rates and nor did it affect how physician's risk tolerance affects admission decisions.

Wanna See How You Rank?

In each instrument, physicians were asked to respond to the questions using a 5- to 6-point Likert scale from “strongly disagree” to “strongly agree.”

Risk-taking scale (The RTS is a 6-item scale that is derived from the risk-taking subscale of the Jackson Personality Index.)

1. I enjoy taking risks.

2. I try to avoid situations that have uncertain outcomes.

3. Taking risks does not bother me if the gains involved are high.

4. I consider security and important element in every aspect of my life.

5. People have told me that I seem to enjoy taking chances.

6. I rarely, if ever, take risks when there is another alternative.

Stress from uncertainty scale (cf.

1. The uncertainty of patient care often troubles me.

2. Not being sure of what is best for a patient is one of the most stressful parts of being a physician.

3. I am tolerant of the uncertainties present in patient care.

4. I find the uncertainty involved in patient care disconcerting.

5. I usually feel anxious when I am not sure of a diagnosis.

6. When I am uncertain of a diagnosis, I imagine all sorts of bad scenarios—patient dies, patient sues, etc.

7. I am frustrated when I do not know a patient's diagnosis.

8. I fear being held accountable for the limits of my knowledge.

9. Uncertainty in patient care makes me uneasy.

10. I worry about malpractice when I do not know a patient's diagnosis.

11. The vastness of the information that physicians are expected to know overwhelms me.

12. I frequently wish I had gone into a specialty or subspecialty that would minimize the uncertainties of patient care.

13. I am quite comfortable with the uncertainty in patient care.

Fear of malpractice scale (cf.

1. I have had to make significant changes in my practice pattern because of recent legal developments concerning medical delivery.

2. I am concerned that I will be involved in a malpractice case sometime in the next 10 years.

3. I feel pressured in my day-to-day practice by the threat of malpractice litigation.

4. I order some tests or consultations simply to avoid the appearance of malpractice.

5. Sometimes, I ask for consultant opinions primarily to reduce my risk of being sued.

6. Relying on clinical judgment rather than on technology to make a diagnosis is becoming riskier from a medicolegal perspective.