Lit Bits: Feb 26, 2011

From the recent medical literature...

1. Treatment of Acute Otitis Media in Infants and Young Children

Do these two studies end the debate?

Currently, no consensus exists about whether young children with acute otitis media (AOM) should be treated with antibiotics. Two new double-blind, placebo-controlled, randomized trials might end the debate. In both studies, AOM was defined by acute onset and presence of middle-ear effusion, bulging tympanic membrane, and otalgia or erythema of the tympanic membrane.

Researchers in Finland randomized 319 children (age range, 6–35 months) with AOM to receive amoxicillin-clavulanate or placebo for 7 days. Treatment failure (no overall improvement by day 3, worsening condition, no improvement in otoscopic signs, perforation, severe infection requiring antimicrobial treatment, or stopping the study drug for any reason) was significantly less common in the antibiotic group than in the placebo group (18.6% vs. 44.9%; number needed to treat, 3.8). Children who received antibiotics were significantly more likely to develop diarrhea (47.8% vs. 26.6%).

Researchers in Pittsburgh randomized 291 children (age range, 6–23 months) with AOM to receive amoxicillin-clavulanate or placebo for 10 days. Children who received amoxicillin-clavulanate achieved symptom resolution more quickly than children in the placebo group (35% vs. 28% on day 2; 61% vs. 54% on day 4; 74% vs. 54% on day 7). Results were similar for sustained resolution of symptoms. Children who received antibiotics were significantly more likely to develop diarrhea (24% vs. 1%) and diaper-area dermatitis (47% vs. 4%).

A General Pediatrician's Perspective
Both studies overcome the flaws of previous studies and provide the best data to date. Jerry Klein, a leading AOM expert, believes that these studies end the debate about treatment of AOM in young children. He states, "More young children with a certain diagnosis of acute otitis media recover more quickly when they are treated with an appropriate antimicrobial agent." Because most cases of AOM are caused by bacteria sensitive to amoxicillin-clavulanate, it's my belief that the issue isn't whether young children with AOM benefit from antibiotics, but whether the diagnosis of AOM is accurate. Both trials highlight the well-known adverse effects associated with use of antibiotics but do not address serious complications such as mastoiditis. Together, they do suggest that young children with AOM get better faster if they are treated with antibiotics, but treatment decisions must be balanced against the risk for adverse effects, particularly diarrhea.
— Howard Bauchner, MD

A Pediatric Infectious Disease Specialist's Perspective

I doubt that our readers were surprised to see additional documentation that antibiotics work for AOM. To me, the question that remains is "When do we need to treat and when can we watch and wait?" Placebo was a successful option for more than half the children in both studies. For children who look well, are old enough to easily evaluate, and can be comforted with supportive care (e.g., Tylenol and TLC), watchful waiting remains in my armamentarium. Parental wishes, history of prior infections, concerns about excess antibiotic use, and adverse effects still factor into my decision. Finally, although amoxicillin-clavulanate was used in these two studies, amoxicillin alone is still first-line therapy for many children.
— Peggy Sue Weintrub, MD

Published in Journal Watch Pediatrics and Adolescent Medicine February 2, 2011. Citation(s):
Tähtinen PA et al. A placebo-controlled trial of antimicrobial treatment for acute otitis media. N Engl J Med 2011 Jan 13; 364:116. Hoberman A et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med 2011 Jan 13; 364:105. Klein JO. Is acute otitis media a treatable disease? N Engl J Med 2011 Jan 13; 364:168.

See also recent JAMA review: http://jama.ama-assn.org/content/304/19/2161.abstract

2. A randomized, placebo-controlled trial of ondansetron, metoclopramide, and promethazine in adults

Barrett TW, et al. Amer J Emerg Med. 2011;29:247-255.

Objectives
The objective of the study was to assess whether ondansetron has superior nausea reduction compared with metoclopramide, promethazine, or saline placebo in emergency department (ED) adults.

Methods
This randomized, placebo-controlled, double-blinded superiority trial was intended to enroll a convenience sample of 600 patients. Nausea was evaluated on a 100-mm visual analog scale (VAS) at baseline and 30 minutes after treatment. Patients with a minimum preenrollment VAS of 40 mm were randomized to intravenous ondansetron 4 mg, metoclopramide 10 mg, promethazine 12.5 mg, or saline placebo. A 12-mm VAS improvement in nausea severity was deemed clinically important. We measured potential drug adverse effects at baseline and 30 minutes. Patients received approximately 500 mL of saline hydration during the initial 30 minutes.

Results
Of 180 subjects who consented, 163 completed the study. The median age was 32 years (interquartile range, 23-47), and 68% were female. The median 30-minute VAS reductions (95% confidence intervals) and saline volume given for ondansetron, metoclopramide, promethazine, and saline were −22 (−32 to −15), −30 (−38 to −25.5), −29 (−40 to −21), and −16 (−25 to −3), and 500, 500, 500, and 450, respectively. The median 30-minute VAS differences (95% confidence intervals) between ondansetron and metoclopramide, promethazine, and saline were −8 (−18.5 to 3), −7 (−21 to −5.5), and 6 (−7 to 20), respectively. We compared the antiemetic efficacy across all treatments with the Kruskal-Wallis test (P = .16).

Conclusions
Our study shows no evidence that ondansetron is superior to metoclopramide and promethazine in reducing nausea in ED adults. Early study termination may have limited detection of ondansetron's superior nausea reduction over saline.

3. Two Days of Dexamethasone Versus 5 Days of Prednisone in the Treatment of Acute Asthma: A Randomized Controlled Trial

Kravitz J, et al. Ann Emerg Med. 2011; in press

Study objective
Dexamethasone has a longer half-life than prednisone and is well tolerated orally. We compare the time needed to return to normal activity and the frequency of relapse after acute exacerbation in adults receiving either 5 days of prednisone or 2 days of dexamethasone.

Methods
We randomized adult emergency department patients (aged 18 to 45 years) with acute exacerbations of asthma (peak expiratory flow rate less than 80% of ideal) to receive either 50 mg of daily oral prednisone for 5 days or 16 mg of daily oral dexamethasone for 2 days. Outcomes were assessed by telephone follow-up.

Results
Ninety-six prednisone and 104 dexamethasone subjects completed the study regimen and follow-up. More patients in the dexamethasone group reported a return to normal activities within 3 days compared with the prednisone group (90% versus 80%; difference 10%; 95% confidence interval 0% to 20%; P=.049). Relapse was similar between groups (13% versus 11%; difference 2%; 95% confidence interval –7% to 11%, P=.67).

Conclusion
In acute exacerbations of asthma in adults, 2 days of oral dexamethasone is at least as effective as 5 days of oral prednisone in returning patients to their normal level of activity and preventing relapse.

4. New Consensus Statement on Cardiac Ultrasound Released

ACEP News. January 2011

By Jeffrey S. Eisenberg. Elsevier Global Medical News

ST. LOUIS - Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient's bedside - allowing for earlier, possibly lifesaving interventions - and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the consensus statement (see full-text link below). FOCUS also can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The consensus statement also outlines the following specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient's bedside.

Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure. FOCUS can also determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. In addition, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

Dyspnea/shortness of breath. In cases of dyspnea, FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease, according to the statement.

Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (A diameter greater than 4 cm is suspicious for type A dissection.) However, the authors caution, a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

FOCUS training should include positive and negative cases of various cardiac pathologies, and any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses, the statement said.

Labovitz et al. J. Am. Soc. Echocardiogr. 2010;23:1225-30.
Full-text (free): http://www.asecho.org/files/EchoinES.pdf

5. Effect of Routine Sterile Gloving on Contamination Rates in Blood Culture: A Cluster Randomized Trial

Nak-Hyun Kim N, et al. Ann Intern Med 2011;154:145-151

Background: Blood culture contamination leads to inappropriate or unnecessary antibiotic use. However, practical guidelines are inconsistent about the routine use of sterile gloving in collection of blood for culture.

Objective: To determine whether the routine use of sterile gloving before venipuncture reduces blood culture contamination rates.

Design: Cluster randomized, assessor-blinded, crossover trial (ClinicalTrials.gov registration number: NCT00973063).

Setting: Single-center trial involving medical wards and the intensive care unit.

Participants: 64 interns in charge of collection of blood for culture were randomly assigned to routine-to-optional or optional-to-routine sterile gloving groups for 1854 adult patients who needed blood cultures.

Intervention: During routine sterile gloving, the interns wore sterile gloves every time before venipuncture, but during optional sterile gloving, sterile gloves were worn only if needed.

Measurements: Isolates from single positive blood cultures were classified as likely contaminant, possible contaminant, or true pathogen. Contamination rates were compared by using generalized mixed models.

Results: A total of 10 520 blood cultures were analyzed: 5265 from the routine sterile gloving period and 5255 from the optional sterile gloving period. When possible contaminants were included, the contamination rate was 0.6% in routine sterile gloving and 1.1% in optional sterile gloving (adjusted odds ratio, 0.57 [95% CI, 0.37 to 0.87]; P = 0.009). When only likely contaminants were included, the contamination rate was 0.5% in routine sterile gloving and 0.9% in optional sterile gloving (adjusted odds ratio, 0.51 [CI, 0.31 to 0.83]; P = 0.007).

Limitation: Blood cultures from the emergency department, surgical wards, and pediatric wards were not assessed.

Conclusion: Routine sterile gloving before venipuncture may reduce blood culture contamination.

Full-text (free): http://www.annals.org/content/154/3/145.full.pdf+html

6. Outcomes associated with small changes in normal-range cardiac markers

McMullin N, et al. Amer J Emerg Med. 2011;29:162-167.

Introduction
Troponin concentrations rising above an institutional cutpoint are used to define acute myocardial necrosis, yet it is uncertain what outcomes are associated with fluctuations in troponin that do not exceed this level. We evaluate the association between troponin fluctuations below an institutional upper limit of normal and acute coronary syndrome (ACS).

Materials and methods
This was a post hoc analysis of the Internet tracking registry of ACS (i*trACS), which describes patients presenting to emergency departments (EDs) with suspected ACS across the spectrum of risk. Patients were included in this registry if they were at least 18 years old and had suspected ACS at the time of their ED visit. Inclusions in this analysis required that patients had at least 1 cardiac marker (creatine kinase-MB [CK-MB], troponin T, or troponin I) drawn twice within 6 hours of presentation, with both measures being below the institution's upper limit of normal. A marker change was defined as either an increase or decrease that exceeded 15% of the institutional upper limit of normal. Acute coronary syndrome was defined as a positive stress test, documented myocardial infarction, coronary revascularization, or death within 30 days of their ED admission.

Results
Of 17 713 patient visits, 2162 met inclusion and exclusion criteria. There were 1872 patient visits with 2 troponin results and 1312 with 2 CK-MB results. Patient visits with increasing troponin had increased odds of ACS compared with those with stable troponin levels (odds ratio, 3.6; 95% confidence interval, 1.4-9.2). Changing CK-MB and decreasing troponin were not associated with increased odds of ACS.

Conclusions
Small increases in troponin concentration below the upper limit of normal are associated with increased odds of ACS.

7. Clinical Outcomes in Obese and Normal-weight Children Undergoing Ultrasound for Suspected Appendicitis

Sulowski C, et al. Acad Emerg Med 2011;18:167–173.

Background:  Obesity constitutes an independent predictor for a nondiagnostic screening ultrasound (US) in suspected appendicitis. Furthermore, the imaging route consisting of the screening US with a second US if necessary has a significantly lower diagnostic accuracy in the obese children (83%) than their lean counterparts (93%). However, the effect of this association on clinical outcomes in the obese population is unknown.

Objectives:  In children presenting to the emergency department (ED) undergoing US for suspected appendicitis, the objective was to examine if there is a significant difference in the proportions of those with a “desirable outcome” in the obese group versus their normal-weight counterparts.

Methods:  This was a reanalysis of a recent prospective cohort study conducted at a tertiary care pediatric ED. A consecutive sample of 263 previously healthy children 4–17 years of age undergoing screening US for suspected appendicitis was enrolled. Study patients were divided into obese (body mass index-for-age percentiles [BMI-FAP] ≥ 85%) and normal-weight groups. The main outcome was the proportion of children with the desirable outcome in the obese and normal-weight groups. Desirable outcomes for patients with a nondiagnostic screening US were defined as either 1) nonperforated appendicitis or alternate surgical diagnosis undergoing appropriate surgical procedure within 24 hours of assessment without a computed tomography (CT) scan or 2) no appendicitis, discharged from the ED within 24 hours without a CT scan. Secondary outcomes included hospitalization, CT imaging for any reason within 30 days of initial presentation, length of hospital stay, return visits, time to and length of surgery, and complications.

Results:  Of the 263 patients, 76 (28.9%) were obese, and 187 had a normal weight. Ninety-nine children (37.6%) had appendicitis (obese = 24, normal-weight = 75). The desirable outcome was achieved in 46 (64.5%) of the obese patients versus 137 (73.3%) of the normal-weight children (95% confidence interval [CI] for the difference = −0.21 to 0.04). Compared to the normal-weight children, the obese children had similar hospitalization rates (44.7% vs. 45.5%), median length of hospital stay (20.5 hours vs. 23.0 hours), and return ED visit rates (11.8% vs. 9.1%). The median time to surgery (obese = 10.5 hours, normal-weight = 9.0 hours), complications (obese = 25%, normal-weight = 21.3%), perforations (obese = 33%, normal-weight = 31%), and length of surgery (obese 80 [±37] minutes, normal-weight 67 [±25] minutes) were also similar. The rate of CT within 30 days of initial presentation was higher in the obese compared to the normal-weight group (13/76 or 17.1% vs. 13/187 or 6.9%, 95% CI = 0.02 to 0.23).

Conclusions:  Previously healthy obese children undergoing screening US for suspected appendicitis experienced comparable clinical outcomes to their normal-weight counterparts. However, they were three times more likely to receive a CT scan during their investigation. These results argue for continuing current practice of using the screening US in this population, followed by a CT if clinically warranted upon reexamination.

8. Etiology and Diagnosis of Systolic Murmurs in Adults

McGee S, Amer J Med. 2011;123:913-921.e1

Introduction

In his Treatise on the Diseases of the Heart and Great Vessels,1 published in 1832, just 11 years after Laennec's invention of the stethoscope, the British physician James Hope fully described the characteristics of systolic murmurs, attributing them to either abnormal forward flow over semilunar valves (eg, aortic or pulmonic valve) or regurgitation of blood from high pressure chambers into low pressure ones (eg, mitral or tricuspid regurgitation). His observations—along with those of Austin Flint (1812-1886), Graham Steell (1851-1942), and others using phonocardiography during the 1950s and 1960s—form virtually our entire knowledge base about systolic murmurs, including the classic teaching that pathologic systolic murmurs are identifiable by their location on the chest wall and by additional abnormalities of the neck veins, precordial pulsations, arteries, and heart tones.

During recent decades the diagnosis and treatment of heart disease have changed significantly, and it is unknown whether these classic tenets remain true. For example, original observations were mostly of young patients with rheumatic and congenital heart disease and normal ejection fractions; modern patients, in contrast, are frequently elderly and more often have ischemic, calcific, or degenerative heart disease with reduced ventricular function.

Echocardiography has been widely applied to modern cardiovascular diagnosis, yet few if any studies providing additional insights into systolic murmurs have appeared. The purpose of this study is to carefully examine a series of hospitalized patients and compare their physical findings to transthoracic echocardiography, thereby investigating both the etiology of systolic murmurs and the modern diagnostic value of the bedside examination.

Full-text (free): http://www.amjmed.com/article/S0002-9343(10)00501-2/fulltext

9. Erythromycin Infusion or Gastric Lavage for Upper Gastrointestinal Bleeding: A Multicenter Randomized Controlled Trial

Pateron D, et al. Ann Emerg Med. 2011; in press

Study objective
The quality of endoscopy depends on the quality of upper gastrointestinal tract preparation. We determine whether in acute upper gastrointestinal bleeding the frequency of satisfactory stomach visualization was different after intravenous erythromycin, a nasogastric tube with gastric lavage, or both.

Methods
We performed a prospective, randomized, multicenter (6 emergency departments) study in patients with acute upper gastrointestinal bleeding presenting with hematemesis or melena. The patients were randomized into 3 groups: (1) intravenous erythromycin infusion without nasogastric tube placement (erythromycin group), (2) nasogastric tube placement without erythromycin (nasogastric group), and (3) intravenous erythromycin infusion combined with nasogastric tube placement (nasogastric-erythromycin group). The main outcome measure was the proportion of satisfactory stomach visualization.

Results
Two hundred fifty-three patients (181 men, mean age 61 years [SD 15 years], 84 with cirrhosis) were randomized: 84 (erythromycin group), 85 (nasogastric group), and 84 (nasogastric-erythromycin group). Overall, there was 85% satisfactory stomach visualization; between-group differences were not significant: −4% (95% confidence interval [CI] −15% to 6%) for the erythromycin group and nasogastric-erythromycin group, 2% (95% CI −14% to 9%) for the erythromycin group and nasogastric group, and −6.5% (95% CI −17% to 4%) for the nasogastric group and nasogastric-erythromycin group. The duration of the endoscopic procedure, rebleeding frequency, the need for a second endoscopy, the number of transfused blood units, and mortality at days 2, 7, and 30 did not differ significantly between groups.

Conclusion
In acute upper gastrointestinal bleeding, administration of intravenous erythromycin provides satisfactory endoscopic conditions, without the need for a nasogastric tube and gastric lavage.

10. New Guidelines Released for Cerebral Venous Thrombosis

Allison Gandey. February 4, 2011 — The American Heart Association/American Stroke Association has unveiled its first scientific statement on cerebral venous thrombosis. The recommendations will help clinicians identify this uncommon cause of stroke that mostly affects young people.

"The diagnosis and management of cerebral venous thrombosis requires a high level of suspicion," committee chair Gustavo Saposnik, MD, from the University of Toronto in Ontario, Canada, told Medscape Medical News. "The guidelines are intended to improve awareness and recognition."

The committee includes a multidisciplinary group of experts from the United States, Canada, Mexico, Portugal, and Argentina. The guidelines were published online February 3 in the journal Stroke.
.
Cerebral venous thrombosis is caused by clots in the dural venous sinuses and accounts for 0.5% to 1% of all strokes. It disproportionally affects women who are pregnant or taking oral contraceptives and people 45 years and younger.

The incidence of cerebral venous thrombosis during pregnancy and post partum ranges from 1 in 2500 deliveries to 1 in 10,000 deliveries in Western countries, according to the guidelines. The greatest risk periods are during the third trimester and in the first 4 postpartum weeks. Up to 73% of cerebral venous thrombosis in women occurs during the time immediately after childbirth. However, the risk for complications during future pregnancies is low, report the guideline authors.

They recommend patients with suspected cerebral venous thrombosis undergo blood studies to see whether they have a prothrombotic factor, such as protein C or S, antithrombin deficiency, antiphospholipid syndrome, prothrombin G20210A mutation, and factor V Leiden.

"A predisposing condition to form clots or a direct cause is identified in about two-thirds of patients with cerebral venous thrombosis,” Dr. Saposnik said.

An estimated 30% to 40% of patients with cerebral venous thrombosis may develop an intracranial hemorrhage. "It’s important to distinguish a hemorrhage caused by rupture of a brain artery from those associated with cerebral venous thrombosis," he said. "The mechanisms — and treatment — of the bleeding are quite different."

The guidelines suggest that patients having a brain hemorrhage with an unclear cause undergo imaging of their cerebral veins.

Headache Most Common Symptom

According to the International Study on Cerebral Venous and Dural Sinuses Thrombosis, headache is the most common symptom and was recorded in about 90% of patients (Stroke. 2005;36:1720–1725).

"The usual appropriate acute treatment includes prevention of complications and anticoagulation therapy," Dr. Saposnik said. The guidelines emphasize that magnetic resonance imaging and magnetic resonance venography are the most sensitive and therefore recommended tests.

In the emergency department, computed tomography may be useful when magnetic resonance imaging is not readily available, Dr. Saposnik added.

For patients who develop a stroke, he emphasized the importance of care in an appropriate setting, such as a stroke unit, for the prevention and management of complications.

"Testing for prothrombotic conditions in the acute phase has limited value," he noted. "Thorough blood work should be completed later. And the duration of anticoagulation therapy should ultimately depend on the underlying etiology."

Dr. Saposnik pointed out to Medscape Medical News there is limited evidence regarding endovascular treatment or thrombolysis in patients with cerebral venous thrombosis. "Based on that, the current guidelines recommend this approach only in patients with progressive neurological deterioration despite the best medical treatment."

"As with any guideline," Dr. Saposnik said, "the current one provides a general approach analyzing the available evidence. It doesn't address individual situations."

Committee chair Dr. Saposnik has disclosed no relevant financial relationships.

Stroke. Published online February 3, 2011.

Full-text (free pdf): http://stroke.ahajournals.org/cgi/reprint/STR.0b013e31820a8364v1

11. Patient history and physician suspicion accurately exclude pregnancy

Minnerop MH, et al. Amer J Emerg Med. 2011;29:212-215.

Objectives
Reliance upon patient assessment in excluding pregnancy is questionable. Physicians are encouraged to obtain pregnancy tests in all women of childbearing age. We affirmed the accuracy of women and their physicians in predicting pregnancy.

Methods
This was a prospective, observational study performed in a suburban academic emergency department on adult women with an ordered pregnancy test. A standardized gynecologic history was obtained by trained research assistants. Subjects estimated their likelihood of pregnancy as impossible, possible, or definite. Emergency department physicians estimated the likelihood of pregnancy as high, moderate, or low. All women had either a serum or urine β-human chorionic antigen. The diagnostic characteristics of patient and physician predictions of pregnancy were calculated with 95% confidence intervals (CIs).

Results
We enrolled 377 subjects. Median age was 29 (interquartile range, 22-37) years. Twelve percent of the women were pregnant. Women's estimates of pregnancy were as follows: impossible, 64.7%; possible, 22.5%; and definite, 12.7%. The pregnancy rates among women with estimates of impossible, possible, and definite were 0% (95% CI, 0%-1.5%), 4.7% (95% CI, 1.9%-11.5%), and 89.6% (95% CI, 77.8%-95.5%) (P < .001). Physicians' suspicions of pregnancy were high (13.7%), moderate (11.3%), and low (75.1%). The rate of pregnancy among low, moderate, and high physician suspicion groups were 0% (95% CI, 0%-1.4%), 9.5% (95% CI, 3.8%-22%), and 84.3% (95% CI, 72%-92%) (P < .001). Conclusions There were no pregnancies among women who estimated pregnancy as impossible or whose physicians thought that the likelihood of pregnancy was low. Routine pregnancy testing before radiological imaging and medication administration may not be required in adult women of childbearing age.

12. Images in Emergency Medicine

Decreased Skin Turgor
http://www.nejm.org/doi/full/10.1056/NEJMicm1005144

Pseudomembranous Colitis
http://www.nejm.org/doi/full/10.1056/NEJMicm1004244

Secondary Syphilis
http://www.nejm.org/doi/full/10.1056/NEJMicm1005345

Diphenhydramine Poisoning
http://www.nejm.org/doi/full/10.1056/NEJMicm1002035

Tinea
http://www.nejm.org/doi/full/10.1056/NEJMicm1003685

Cutaneous cryptococcal infection as a manifestation of disseminated disease http://www.annemergmed.com/article/S0196-0644(10)00042-9/fulltext

Woman With Right-Sided Flank Pain
http://www.annemergmed.com/article/S0196-0644(10)00039-9/fulltext

13. Clinical Review: Approach to the Anticoagulated Patient with Spontaneous ICH

Roberts, JR. EM News. 2011;33:13-16.

Individuals with spontaneous intracranial hemorrhage (ICH) are common denizens of every ED. The public is relatively clueless about the nefarious and debilitating effects of brain hemorrhage, and often think patients who have had a hemorrhagic stroke can get back to normal through the prowess of highly skilled physicians, especially if everything is done correctly. While this might be somewhat true for a modicum of fortunate survivors, bleeding brains usually continue to bleed, and dead brain usually stays dead. Fortunately, rehabilitation of other areas of the brain and the body's remarkable reparative processes offer some respite from certain paralysis or a long-term vegetative existence. But exactly what doctors can do to help the acutely bleeding brain or enhance potential recovery is still quite a mystery.

… I will now embark on a review of the recent 2010 guidelines from the American Heart Association (AHA) and American Stroke Association (ASA) for treating ICH in patients with warfarin-induced coagulopathy, thrombocytopenia, and dysfunctional platelets.

The remainder of the essay: http://journals.lww.com/em-news/Fulltext/2011/02000/InFocus__Approach_to_the_Anticoagulated_Patient.5.aspx

The Guidelines (full-text free): http://stroke.ahajournals.org/cgi/content/full/41/9/2108

14. Prehospital Active Compression-Decompression CPR

ACD cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure during decompression was associated with a higher rate of neurologically functional survival than was standard CPR.

Active compression-decompression cardiopulmonary resuscitation (ACD-CPR) achieves greater negative intrathoracic pressure during the decompression phase than standard CPR. In a prospective industry-sponsored study that involved 46 U.S. emergency medical services (EMS) systems, 1653 adults with nontraumatic cardiac arrest were randomized to receive either standard CPR or ACD-CPR with augmentation of negative intrathoracic pressure during decompression via an impedance-threshold device attached to the face mask. ACD-CPR was performed with a hand-held suction cup device containing a metronome and force gauge to guide depth and timing of compressions.

The rate of survival to hospital discharge with modified Rankin scale score 3 (the primary outcome) was significantly higher in the ACD-CPR group than the standard-CPR group (9% vs. 6%). This difference persisted at 1 year. Disability rating scale scores and rates of major adverse events were similar between groups; however, pulmonary edema was more common in the ACD-CPR group (11% vs. 8%). Mean time from emergency call to start of professional rescuer CPR did not differ between groups (approximately 6.7 minutes); no patient met the primary endpoint when professional CPR was started more than 10 minutes after the call.

Comment: Active compression-decompression CPR augmented with a negative-pressure impedance device leads to a better rate of neurologically functional survival after out-of-hospital cardiac arrest and should be adopted by EMS systems. Whether this technique would also benefit victims of arrest in the hospital — where professional CPR likely would be started much sooner — is unclear.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine February 11, 2011. Citation: Aufderheide TP et al. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: A randomised trial. Lancet 2011 Jan 22; 377:301.

15. CSF Reference Values for Febrile Infants without Infection

Normal ranges for cerebrospinal fluid profiles in febrile infants should be revised.

Previous reference ranges for normal cerebrospinal fluid (CSF) values in infants are based on findings from small studies that did not exclude infants with viral disease. To better characterize normal values, investigators retrospectively evaluated CSF profiles of infants (age range, 1–90 days) at a pediatric medical center in Utah from 1996 to 2002 who met the following criteria: rectal temperature 38°C, negative bacterial cultures, negative enteroviral polymerase chain reaction testing, term birth (37 weeks' gestation), no antibiotics within 48 hours, and no herpes simplex virus infection.

Of 823 infants, 743 had atraumatic lumbar punctures (red blood cell count 1000/mm3). CSF white blood cell (WBC) counts above 14.5/ mm3 were considered statistical outliers (presumed due to unidentified viral infections) and were excluded. In the remaining 677 patients with atraumatic lumbar punctures, mean and median CSF WBC counts were 4.3/mm3 and 3.0/mm3, respectively (range, 0–12/mm3). Infants in the first month of life, compared to those in the second and third months of life, had significantly higher mean CSF WBC counts (6.1/mm3 vs. 3.1/mm3 and 3.0/mm3) and mean CSF protein concentrations (75.4 mg/dL vs. 58.9 and 39.2 mg/dL); mean CSF glucose concentrations were similar in the first and second months and significantly lower than in the third month (45.3 mg/dL, 48.0 mg/dL, and 57.7 mg/dL). Traumatic lumbar puncture did not significantly affect WBC count norms, with mean and median counts of 6.5/mm3 and 5.0/mm3, respectively (range, 0–16/mm3).

Comment: The authors appropriately call into question previously established normal values of infant cerebrospinal fluid. Moreover, they define new values that physicians should use when evaluating febrile infants for meningitis.

— Katherine Bakes, MD. Published in Journal Watch Emergency Medicine February 25, 2011.
Citation: Byington CL et al. Normative cerebrospinal fluid profiles in febrile infants. J Pediatr 2011 Jan; 158:130.

16. The Effect of Triage Diagnostic Standing Orders on Emergency Department Treatment Time

Retezar R, et al. Ann Emerg Med. 2011;89-99.e2

Study objective
Triage standing orders are used in emergency departments (EDs) to initiate evaluation when there is no bed available. This study evaluates the effect of diagnostic triage standing orders on ED treatment time of adult patients who presented with a chief complaint for which triage standing orders had been developed.

Methods
We conducted a retrospective nested cohort study of patients treated in one academic ED between January 2007 and August 2009. In this ED, triage nurses can initiate full or partial triage standing orders for patients with chest pain, shortness of breath, abdominal pain, or genitourinary complaints. We matched patients who received triage standing orders to those who received room orders with respect to clinical and temporal factors, using a propensity score. We compared the median treatment time of patients with triage standing orders (partial or full) to those with room orders, using multivariate linear regression.

Results
Of the 15,188 eligible patients, 25% received full triage standing orders, 56% partial triage standing orders, and 19% room orders. The unadjusted median ED treatment time for patients who did not receive triage standing orders was 282 minutes versus 230 minutes for those who received a partial triage standing order or full triage standing orders (18% decrease). Controlling for other factors, triage standing orders were associated with a 16% reduction (95% confidence interval −18% to −13%) in the median treatment time, regardless of chief complaint.

Conclusion
Diagnostic testing at triage was associated with a substantial reduction in ED treatment time for 4 common chief complaints. This intervention warrants further evaluation in other EDs and with different clinical conditions and tests.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)00486-5/fulltext

17. Ultrasound-Guided Needle Aspiration "Insufficient" for Skin Abscesses

By Megan Brooks. NEW YORK (Reuters Health) Jan 28 - For treatment of uncomplicated skin abscesses, ultrasound-guided needle aspiration is not on par with incision and drainage. It doesn't even come close, a new study shows.

In a nonblinded randomized trial of about 100 patients, the overall treatment failure rate was 74% with needle aspiration compared with 20% for incision and drainage.

Treatment failure after ultrasound-guided needle aspiration is "unacceptably high," Dr. Romolo Gaspari from University of Massachusetts Memorial Medical Center in Worcester, Massachusetts and colleagues report in the January 18 online issue of Annals of Emergency Medicine. They say their data don't support use of this drainage technique for skin and soft tissue infections.

"Needle aspiration of an abscess cavity, even with ultrasound guidance, is insufficient and should be abandoned," Dr. Gaspari told Reuters Health. "This is true for all patients but especially true for patients with methicillin-resistant Staphylococcus aureus (MRSA)."

It's also important to note, Dr. Gaspari said, that patients with MRSA "did worse regardless of the drainage procedure and independent of antibiotics, which is scary as a clinician."

Needle aspiration with ultrasound guidance has been advocated for superficial abscesses as a less invasive alternative to incision and drainage, which is considered the primary intervention.

Dr. Gaspari and colleagues randomly assigned 54 patients with uncomplicated superficial abscesses to incision and drainage with packing and 47 similar patients to ultrasound-guided needle aspiration. They defined successful treatment as a combination of sonographic resolution and clinical resolution of the signs and symptoms of ongoing infection at day 7.

According to the investigators, the overall success rate was 26% with needle aspiration compared with 80% for incision and drainage, a difference of 54%.

"I was very surprised by the results as I initially designed this trial thinking that ultrasound-guided needle aspiration would be equivalent to incision and drainage," Dr. Gaspari said. "We had seen some failures from needle aspiration but I assumed that this was because of a lack of ultrasound guidance."

Staphylococcus aureus was isolated in 64 of 101 patients (63%); 33 of the isolates (52%) were community-acquired MRSA. There was no difference in the percentage of MRSA in either group.

Overall success rates of both drainage methods were lower in patients with than without MRSA - 8% versus 55% for needle aspiration and 61% versus 89% for incision and drainage.

In a multivariate analysis comparing outcomes of MRSA and non-MRSA, failure of therapy was independent of drainage procedure, making MRSA an independent risk factor for failure of therapy.

Needle aspiration may continue to have limited clinical indications for abscesses for which immediate incision and drainage is less desirable, such as abscesses on the face, according to the researchers. They advise, based on their experience, that any needle aspiration be accompanied by ultrasound guidance.

Ann Emerg Med. Posted January 18, 2011.

18. Clinical Decision Rule for Intussusception in Children

A clinical decision rule identified low-risk patients who might not require further imaging beyond plain radiography.

Weihmiller SN, et al. Pediatrics 2011;127:e296.

CONTEXT: Intussusception is the most common cause of intestinal obstruction in young children, and delayed diagnosis may lead to bowel perforation.

OBJECTIVE: To determine predictive clinical criteria and develop a decision tree to risk-stratify children with possible intussusception.

DESIGN/METHODS: This is a prospective observational cohort study of children aged 1 month to 6 years who presented with possible intussusception. A data-collection form was completed before knowledge of any advanced imaging. Univariate analysis was performed, and decision trees were developed using recursive partitioning.

RESULTS: In the study, 310 patients were enrolled, including 38 (12.3%) with intussusception. The median age was 21.1 months and 61% were male. Univariate predictors of intussusception included age older than 6 months (P = 0.04), male gender (P = .007), history of lethargy (P = .001), and abnormal plain x-ray (P = .0001). Multivariate analysis through recursive partitioning identified decision trees (with and without the result of a plain abdominal x-ray) and allowed identification of patients at low risk. The decision tree based on the results of an abdominal x-ray (negative or positive), age (≤5 or >5 months), diarrhea (present or absent), and bilious emesis (present or absent) had the best test performance (sensitivity: 97% [95% confidence interval (CI): 86-100]; negative predictive value: 99% [95% CI: 93-100]; negative likelihood ratio: 0.08 [95% CI: 0.01-0.6]).

CONCLUSIONS: Among children who were being evaluated for intussusception, we prospectively determined clinical criteria and developed a decision tree to risk-stratify children with possible intussusception.

19. Ketamine with and without Midazolam for Emergency Department Sedation in Adults: A Randomized Controlled Trial

Senar S, et al. Ann Emerg Med. 2011;57:109-114.e2

Study objective
We assess whether midazolam reduces recovery agitation after ketamine administration in adult emergency department (ED) patients and also compared the incidence of adverse events (recovery agitation, respiratory, and nausea/vomiting) by the intravenous (IV) versus intramuscular (IM) route.

Methods
This prospective, double-blind, placebo−controlled, 2×2 factorial trial randomized consecutive ED patients aged 18 to 50 years to 4 groups: receiving either 0.03 mg/kg IV midazolam or placebo, and with ketamine administered either 1.5 mg/kg IV or 4 mg/kg IM. Adverse events and sedation characteristics were recorded.

Results
Of the 182 subjects, recovery agitation was less common in the midazolam cohorts (8% versus 25%; difference 17%; 95% confidence interval [CI] 6% to 28%; number needed to treat 6). When IV versus IM routes were compared, the incidences of adverse events were similar (recovery agitation 13% versus 17%, difference 4%, 95% CI –8% to 16%; respiratory events 0% versus 0%, difference 0%, 95% CI –2% to 2%; nausea/vomiting 28% versus 34%, difference 6%, 95% CI –8% to 20%).

Conclusion
Coadministered midazolam significantly reduces the incidence of recovery agitation after ketamine procedural sedation and analgesia in ED adults (number needed to treat 6). Adverse events occur at similar frequency by the IV or IM routes.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)01536-2/fulltext

20. Emergency, Primary Care Physicians Need More Teamwork

Robert Lowes. February 25, 2011 — Emergency department (ED) physicians and their primary care counterparts all too often work poorly together, and that spells trouble for patient care, say researchers at the Center for Studying Health System Change (HSC) in a new study.

In one common example of clinical uncoordination, a primary care physician (PCP) refers a patient to a hospital ED but fails to send along pertinent chart information. Or the material gets lost in transit. As a result, the patient arrives in the ED as a medical blank slate and announces to a physician, "My doctor told me to come over here," according to the study, conducted for the nonprofit National Institute for Health Care Reform.

Operating in the dark, an ED physician may duplicate tests and procedures already performed by a PCP.

But when PCPs brief ED physicians about why they are referring a patient, patient care can become more streamlined. "It probably gets you to manage the patient a little quicker," one ED physician told researchers.

The researchers write that better communication and coordination among PCPs and ED physicians are more important than ever since the nation’s new healthcare reform law will extend insurance coverage to more than 30 million additional Americans, who will be more likely to visit EDs as a result.

Barriers Are Personal, Technological, Financial

The HSC team last year interviewed 21 pairs of ED physicians and PCPs who practiced at the same hospital in 12 communities across the country. They uncovered numerous hindrances to teamwork, some of them reflective of structural changes in medicine.

With more hospitalists on the job, fewer and fewer PCPs round at the hospital; consequently, PCPs miss the opportunity to develop close working ties with ED physicians. At the same time, the shift to group practice means that ED physicians who seek information about a patient from his or her regular doctor may end up talking to a less knowledgeable cross-covering physician instead.

Other barriers to teamwork are technological in nature. Telephones trigger time-consuming phone-tag. Faxing records does not permit real-time dialogue, nor is it readily apparent that faxes arrive at their destination or get read. That uncertainty also characterizes email, although this medium at least enables an online conversation. ED physicians and PCPs may use electronic health record (EHR) systems that cannot talk to each other.

Then there is money. Discussions about follow-up care for a patient leaving the ED go unreimbursed and distract both ED physicians and PCPs from the crunch of patients and billable services in their respective workplaces, the HSC researchers write.

The authors recommend wide-ranging solutions to the problem of poor coordination of ED patients. Communitywide networks of interoperable EHRs among providers would allow an ED physician to easily view medical records maintained by a PCP. Federal incentives for meaningful use of EHRs could be revised to reward that kind of data sharing. And rewarding conglomerations of physicians and hospitals for controlling the utilization of services — and therefore costs — will motivate ED physicians and PCPs to work in tandem.

More cooperation also depends on medical liability reform. Right now, ED physicians tend to be the only ones sued for malpractice when they decide not to conduct a certain test or admit a patient because a PCP told them it was unnecessary — and then something goes wrong. This unequal risk discourages ED physicians from soliciting advice from PCPs in the first place. The HSC researchers recommend that states revise their medical liability laws to give EDs a "safe harbor" from malpractice claims if they coordinate patient care with their PCP colleagues.

Full-text (free): http://www.nihcr.org/ED-Coordination.html

21. Trial: Nesiritide Safe for Acute Heart Failure but of Limited Value

November 14, 2010 Steve Stiles. Chicago, IL - Designed to settle a debate that loomed over cardiology about five years ago, a randomized trial with >7000 patients has concluded that the IV vasodilator nesiritide (Natrecor, Scios/Johnson & Johnson) doesn't compromise renal function or increase mortality within a month of its use in acute decompensated heart failure (ADHF) [1].

Nor, of note, does it seem to have much more of an effect against acute dyspnea than can be currently achieved in ADHF with conventional diuretics and vasodilators, both of which are less expensive than nesiritide, a mass-production version of a native natriuretic peptide.

In the Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF), there was "no evidence for a major benefit" from nesiritide vs placebo on top of standard care, said Dr Robert Califf (Duke Clinical Research Institute, Durham, NC) at a presentation of the trial for the media.

Califf chairs the ASCEND-HF executive committee, which he said collectively concluded that physicians, based on the data, "can make their [own] decisions about the value of the effect of this drug on dyspnea."

He addressed the past controversy about whether nesiritide—once widely popular for what seemed to be a consistent, rapid benefit against dyspnea in ADHF—might worsen renal function and actually increase 30-day mortality, as suggested by two meta-analyses [2,3]. "We constantly put drugs on the market without doing the right outcome trials. If this outcome trial had been done earlier, clinicians and patients would have had a much better idea of the potentially very limited role of this treatment, but they also would have known that it was not harmful."

Nesiritide rode to widespread use on the basis of studies with designs that made them inconclusive, Califf observed for heartwire. "The effect of nesiritide on dyspnea was overestimated, partly because the original trial withheld other therapies for the first three hours," he said.

The remainder of the essay: http://www.theheart.org/article/1147999.do

Lit Bits: Feb 5, 2011

From the recent medical literature...

1. Updated Recommendations for Pediatric Resuscitation

These updated consensus recommendations are based on a thorough evaluation of the literature.

The 2010 International Liaison Committee on Resuscitation Pediatric Task Force has updated the 2005 treatment recommendations for pediatric resuscitation. Highlights include the following:

• Initiate cardiopulmonary resuscitation (CPR) if there are no signs of life and a pulse is not palpated within 10 seconds.

• Provide conventional CPR (chest compressions with rescue breathing).

• Compress at least one third of the anterior-posterior dimension of the chest.

• Consider using cuffed tracheal tubes in infants and young children; cuff pressure should not exceed 25 cm H2O. Appropriate sized tubes by age are as follows:

— 3 mm for age 1 year

— 3.5 mm for age 1–2 years

— Age in years/4 + 3.5 mm for age over 2 years

• Modify or discontinue cricoid pressure if it impedes preintubation ventilation or intubation.

• Monitor capnography to confirm endotracheal tube position, recognizing that end-tidal CO2 in infants and children might be below detectable limits for colorimetric devices (85% sensitivity and 100% specificity).

• Consider use of an esophageal detector device in children weighing more than 20 kg.

• Use capnography monitoring to assess effectiveness of chest compressions.

• Avoid excessive ventilation, which can decrease cerebral perfusion pressure, rates of return of spontaneous circulation (ROSC), and survival rates.

• After ROSC, titrate oxygen concentration to limit the risk for toxic oxygen byproducts.

•For pediatric septic shock, include therapy directed at normalizing central venous oxygen saturation to 70%.

• Do not routinely use bicarbonate or calcium for pediatric cardiac arrest: Both agents are associated with decreased survival.

Comment: These consensus recommendations are based on a thorough evaluation of the literature, and emergency physicians should know them.

— Katherine Bakes, MD. Published in Journal Watch Emergency Medicine January 21, 2011
Citation: Kleinman ME et al. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010 Nov; 126:e1261.

Full-text (free): http://pediatrics.aappublications.org/cgi/reprint/126/5/e1261.pdf

2. Psychiatric Patients Often Warehoused in EDs for a Week or More (!)

Reduction in Mental Health Beds Prevents Timely Transfers

Deborah Brauser. January 24, 2011 — A lack of inpatient facilities means mental health patients are often left lingering in hospital emergency departments (EDs) for up to a week or more, according to a nationwide survey of ED administrators.

In fact, 86% of the survey participants report their EDs were "sometimes" or "often" unable to transfer patients to an inpatient facility quickly, and 60% said these delays compromised patient care.

This problem is attributed to both a sharp decrease in beds at mental health facilities and an increased demand for mental health services, William Schumacher, MD, chief executive officer of Schumacher Group, the national ED management firm that conducted the survey and located in Lafayette, Louisiana, said in a release.

The mental health problem in America is being swept under the rug for hospital to deal with. We need a more proactive way to address this challenge. "The mental health problem in America is being swept under the rug for hospital [EDs] to deal with. We need a more proactive way to address this challenge," added Dr. Schumacher.

Anita Sowell, RN, MSN, CPHQ, chief of emergency services at Athens-Limestone Hospital in Athens, Alabama, and a participant in the survey, says the survey findings reflect her experience. "Fortunately, we have not had to board mental health patients for a week, but we have had to board them for quite a while. It is a problem in this rural area as it is everywhere else in the country," said Ms. Sowell.

The survey analyzed data on staffing and operational issues from 603 EDs across the country gathered via a mailed questionnaire. According to background information in the survey, approximately 120 million patients visit US hospital EDs every year.

"By virtue of the Emergency Medical Treatment and Labor Act, the federal law obliging hospital personnel to see all patients who present to the [ED], hospital [EDs] are the de facto healthcare safety net for millions of patients throughout the country," the survey states.

The results also showed the following:

• More than 70% reported boarding mental/behavioral patients for 24 hours or longer;

• 41% reported boarding times up to 2 days or longer;

• 10% reported boarding times of a week or more; and

• Only 29% reported boarding these patients for 12 hours or less.

"This poses risks to patients and underlines a growing crisis in mental healthcare in which hospital [EDs] must 'house' mental health patients who have few or no inpatient options. Long boarding times can lead to ED crowding, extended wait times, and hospital admission times for all patients," the survey authors write.

The remainder of the article: http://www.medscape.com/viewarticle/736187

The Emergency Department Challenges and Trends: 2010 Survey is available online.
http://schumachergroup.com/

3. Short-Acting Neuromuscular Blocking Agents Don't Impair Pupillary Response to Light

NEW YORK (Reuters Health) Jan 26 - The short-acting neuromuscular blocking agents succinylcholine and rocuronium don't inhibit pupillary response to light in most patients, according to a report in the January 8th online Annals of Emergency Medicine.

These agents could theoretically impair pupillary response, because pupillary response is mediated by ganglionic nicotinic receptors which are subject to inhibition by depolarizing and nondepolarizing neuromuscular blockers.

Sixty-one of 67 (91%) patients in the study receiving succinylcholine and all 27 patients receiving rocuronium had preserved pupillary responses to light after neuromuscular blockade.

Dr. David A. Caro and colleagues from University of Florida College of Medicine-Jacksonville, Jacksonville, Florida investigated whether succinylcholine or rocuronium affected pupillary response to light in 94 patients undergoing rapid sequence intubation.

Four succinylcholine patients didn't retain pupillary responsiveness, and rating physicians disagreed about pupillary response in the remaining two succinylcholine patients.

Study limitations noted by the authors included the lack of sample size or study design to investigate differences between the two neuromuscular blocking agents, the lack of randomization, and the lack of physician blinding to the medication used.

"Although replication of our study with a larger series may result in different inferences, the time-sensitive nature of the protocol and the short duration of succinylcholine pose logistic challenges to any evaluation" the investigators note.

"Our study supports the clinical utility of pupillary response after neuromuscular blockade with succinylcholine or rocuronium," the researchers conclude.

"Clinicians should verify the presence of pupillary response after rapid sequence intubation. The absence of pupillary response may indicate the presence of a significant neurologic lesion."

Caro DA, et al. Ann Emerg Med. Posted online January 8, 2011.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21220175

4. Effect of CPR with chest compression only not as good as conventional CPR for cardiopulmonary arrest out of hospital

Ogawa T, et al. BMJ 2011;342:c7106

In this large, nationwide, population based, observational study from Japan, conventional cardiopulmonary resuscitation was associated with better rates of overall survival and neurologically favourable survival at one month than chest compression only CPR in people who had an out of hospital cardiac arrest witnessed by a bystander. For non-cardiac cases and all cases combined, they found a significantly greater benefit of conventional CPR in younger people with non-cardiac events and in people in whom the start of CPR was delayed by up to 10 minutes after the event was witnessed. These findings could be important for developing new guidelines for bystander CPR, say the authors. Editorialist Ian G Jacobs points out that definitive evidence is lacking but either method is better than no CPR.

Full-text (free): http://www.bmj.com/content/342/bmj.c7106

5. Updated Guidelines Support Expansion of Ketamine Use in ED Setting

Emma Hitt, PhD. January 20, 2011 — Guidelines for use of ketamine in emergency department (ED) procedural sedation have been updated for the first time since 2004; the use of ketamine has been expanded to include adults and babies between 3 and 12 months of age, according to a new report.

The updated guidelines were published online January 20 in the Annals of Emergency Medicine.

Accompanying the guidelines was a report conveying the results of the first randomized, controlled trial of ketamine plus propofol vs propofol alone in the ED setting. Study authors Henry David, MD, and Joseph Shipp, PAC, from the Department of Emergency Medicine at the University of Missouri-Columbia found that the use of ketamine plus propofol improved outcomes compared with ketamine alone.

The randomized trial included healthy children and adults undergoing procedural sedation who were pretreated with intravenous fentanyl and then randomly assigned to receive intravenous ketamine, 0.5 mg/kg (n = 97), or placebo (n = 96). Both groups then immediately received intravenous propofol, 1 mg/kg, with additional doses of 0.5 mg/kg given as needed to achieve and maintain sedation.

The trial found that the incidence of respiratory depression was similar in the ketamine/propofol group (22%) and the propofol-alone group (28%). In addition, compared with propofol alone, for the group receiving ketamine/propofol, clinicians were more satisfied, less propofol was administered, and there appeared to be a trend toward better sedation quality.

"Addition of a subdissociative dose of ketamine to propofol did not significantly reduce respiratory depression," the authors conclude. "However, it did result in greater provider satisfaction, a decreased propofol requirement, and a trend toward more effective sedation."

According to the researchers, the "most striking" outcome was markedly greater provider satisfaction with ketamine/propofol. "This did not correlate with sedation scores and thus reflects features of sedation that transcend simple sedation depth," they suggest. "Possibilities include the more consistent sedation already described or the decreased need to titrate additional propofol."

Regarding the new guidelines, lead author of the guidelines, Steven M. Green, MD, from the Department of Emergency Medicine at Loma Linda University, California, noted, "It was time to update the clinical guidelines because substantial new research on the use of ketamine warranted it."

Since the guidelines were last updated, there has been "sufficient emergency department research in adults to support expansion of ketamine use beyond children," Dr. Green noted in a news release. He added that the body of research now supports the expansion of ketamine for use in children younger than previously recommended (ie, between 3 and 12 months of age). "We further recommend that emergency physicians administer ketamine intravenously instead of intra-muscularly whenever feasible, and that certain other medications not be routinely co-administered," he added.

Full-text (free) guidelines: http://www.annemergmed.com/webfiles/images/journals/ymem/smgreen.pdf

6. The Effect of Triage Diagnostic Standing Orders on ED Treatment Time

Retezar R, et al. Ann Emerg Med. 2011;89-99.e2

Study objective
Triage standing orders are used in emergency departments (EDs) to initiate evaluation when there is no bed available. This study evaluates the effect of diagnostic triage standing orders on ED treatment time of adult patients who presented with a chief complaint for which triage standing orders had been developed.

Methods
We conducted a retrospective nested cohort study of patients treated in one academic ED between January 2007 and August 2009. In this ED, triage nurses can initiate full or partial triage standing orders for patients with chest pain, shortness of breath, abdominal pain, or genitourinary complaints. We matched patients who received triage standing orders to those who received room orders with respect to clinical and temporal factors, using a propensity score. We compared the median treatment time of patients with triage standing orders (partial or full) to those with room orders, using multivariate linear regression.

Results
Of the 15,188 eligible patients, 25% received full triage standing orders, 56% partial triage standing orders, and 19% room orders. The unadjusted median ED treatment time for patients who did not receive triage standing orders was 282 minutes versus 230 minutes for those who received a partial triage standing order or full triage standing orders (18% decrease). Controlling for other factors, triage standing orders were associated with a 16% reduction (95% confidence interval −18% to −13%) in the median treatment time, regardless of chief complaint.

Conclusion
Diagnostic testing at triage was associated with a substantial reduction in ED treatment time for 4 common chief complaints. This intervention warrants further evaluation in other EDs and with different clinical conditions and tests.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)00486-5/fulltext

7. Drug-Induced Deaths More Common Than Alcohol- or Firearm-Related Fatalities

Deborah Brauser. January 28, 2011 — US deaths caused by drug use in 2007 were more common than either alcohol-induced or firearm-related deaths, according to a new report from the Centers for Disease Control and Prevention (CDC).

Although the report found that 38,371 drug-induced deaths occurred that year, the number was down slightly from those reported during the 2003-2006 period. However, the rates for males were significantly higher than for females during all years examined.

The information was published January 14 as part of the CDC's Morbidity and Mortality Weekly Report.

Increase in Prescription Drugs

Drug-induced deaths included those "attributable to acute poisoning by drugs (drug overdoses) and deaths from medical conditions resulting from chronic drug use," write Leonard J. Paulozzi, MD, from the Division of Unintentional Injury Prevention at the National Center for Injury Prevention and Control in El Paso, Texas, and colleagues.

The researchers assessed data on this type of death occurring between 2003 and 2007 from the National Vital Statistics System.

They found the following:

• The highest drug-induced group mortality rates for each year examined, and greatest rate increases, were for non-Hispanic white people;
• For males, non-Hispanic white or black males had the highest rates;
• Rates for non-Hispanic white males were 64% higher than for non-Hispanic white females in 2007;
• For females, American Indians/Alaskan natives had the highest rate for every year except 2006;
• Rates for Hispanics did not increase significantly year to year;
• The lowest group rates overall were found in Asian/Pacific Islanders; and
• Unintentional drug poisoning was the cause of most deaths, followed by suicidal drug poisoning and drug poisoning of undetermined intent.

The report notes that although most drug-induced deaths in the 1980s and 1990s were attributable to illicit drugs and the mortality rates were higher for blacks than for whites, that trend reversed beginning in 2002.

"This change occurred as prescription drugs, especially opioid painkillers and psychotherapeutic drugs, were prescribed more widely by physicians. Prescribed drugs eventually supplanted illicit drugs as the leading cause of drug-related overdose deaths," the study authors write.

They note that racial/ethnic minorities "are less likely to use prescription drugs and therefore might have been less likely to misuse such drugs."

On the basis of their findings, the report authors recommend that clinicians should be following "existing guidelines for cautious use" of prescription drugs.

"Regulations designed to prevent illicit use of prescription drugs need to be strengthened and enforced. Persons who misuse prescription drugs should be identified and receive a referral for substance abuse treatment," they conclude.

MMWR Morb Mortal Wkly Rep. 2011;60:60-61.

Full-text: http://www.cdc.gov/mmwr/pdf/other/su6001.pdf

8. Use of Ocular Ultrasound for the Evaluation of Retinal Detachment

Shinar Z, et al. J Emerg Med. 2011;40:53-57.

Background: Retinal detachment is an ocular emergency posing diagnostic difficulty for the emergency practitioner. Direct fundoscopy and visual field testing are difficult to perform and do not completely rule out retinal detachment. Ophthalmologists use ocular ultrasound to enhance their clinical acumen in detecting retinal detachments (RD), and bedside ultrasound capability is readily available to many emergency practitioners (EP).

Study Objective: Our study sought to assess whether ocular ultrasound would be a helpful adjunct for the diagnosis of RD for the practicing EP. Methods: This was a prospective observational study with a convenience sample of patients. As part of a general course on emergency ultrasonography, practitioners received a 30-min training session on ocular ultrasound before beginning the study. Trained practitioners submitted ultrasound scans with interpretation on patients with signs and symptoms consistent with retinal detachment.

Results: Thirty-one of the 72 practitioners trained submitted ocular ultrasound reports on patients presenting to the Emergency Department with concerns for retinal detachments. EPs achieved a 97% sensitivity (95% confidence interval [CI] 82–100%) and 92% specificity (95% CI 82–97%) on 92 examinations (29 retinal detachments). Disc edema and vitreous hemorrhage accounted for false positives, and a subacute retinal detachment accounted for the only false negative.

Conclusion: These data show that trained emergency practitioners can use ocular ultrasound as an adjunct to their clinical assessment for retinal detachment.

9. Encouraging Change in Behavior by Nudging

Marteau TM, et al. Judging nudging: can nudging improve population health? BMJ 2011;342:d228

If people didn’t smoke, drank less, ate healthier diets and were more active, the huge burden of chronic diseases such as cancer, heart disease, and type 2 diabetes would be much reduced.1 The prospect of being able to nudge populations into changing their behaviour has generated great interest among policymakers worldwide, including the UK government.2 We explore what nudging is and assess the prospect of nudging our way to a healthier population.

Understanding behaviour change
Most people value their health yet persist in behaving in ways that undermine it. This can reflect a deliberate act by individuals who happen at different moments in time to value other things in life more highly than their health. It can also reflect a non-deliberate act. This gap between values and behaviour can be understood by using a dual process model in which human behaviour is shaped by two systems.3 The first is a reflective, goal oriented system driven by our values and intentions. It requires cognitive capacity or thinking space, which is limited. Many traditional approaches to health promotion depend on engaging this system. Often based on providing information, they are designed to alter beliefs and attitudes, motivate people with the prospect of future benefits, or help them develop self regulatory skills. At best, these approaches have been modestly effective in changing behaviour.4

The second is an automatic, affective system that requires little or no cognitive engagement, being driven by immediate feelings and triggered by our environments. Despite wishing to lose weight, for example, we still buy the chocolate bar displayed by the checkout till. Such environmental cues combine with the power of immediate and certain pleasure over larger, less certain and more distant rewards to make unhealthy behaviour more likely. This suggests an approach to behaviour change that focuses on altering environmental cues to prompt healthier behaviour. Such an approach is readily embraced by advertisers and retailers and, increasingly, by public health specialists.5 Nudging mainly operates through this automatic, affective system.

What is nudging?
The term “nudge” was first used in a book of the same title to describe “any aspect of the choice architecture that alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives.”6 It is exemplified by a simple intervention that substantially increased the amount that people saved for their retirement: an opt-in system in which people had to make a positive choice to set aside savings from their salaries was replaced by an opt-out system in which savings were made by default.7

The original definition of nudging excludes legislation, regulation, and interventions that alter economic incentives. Aside from these exclusions, nudging could include a wide variety of approaches to altering social or physical environments to make certain behaviours more likely. These might include providing information about what others are doing (“social norm feedback”) framed to make healthy behaviours more salient, changing the defaults that surround the serving of food and drinks, or altering the layout of buildings to cue physical activity (table⇓). However, there is no precise, operational definition of nudging. This may reflect a reality—namely, that nudging is at best a fuzzy set8 intended to draw attention to the role of social and physical environments in shaping our behaviour and not to inform a scientific taxonomy of behaviour change interventions.

The remainder of the article: http://www.bmj.com/content/342/bmj.d228.full

10. CT Scans Not Needed Routinely for Head Trauma in Asymptomatic Kids with Bleeding Disorders

NEW YORK (Reuters Health) Jan 25 - For children with bleeding disorders who experience head trauma, cranial CT scans are usually not necessary if symptoms are absent, investigators report in The Journal of Pediatrics online January 14.

Dr. Lois K. Lee at Children's Hospital, Boston, Massachusetts, and colleagues note that intracranial hemorrhage (ICH) is a potentially life-threatening complication for children with congenital or acquired bleeding disorders.

"There is evidence that these children are at increased risk for sustaining ICH even after minor blunt head trauma."

To determine the rate of CT imaging after blunt head trauma in children with or without bleeding disorders, and the prevalence of ICH in these children, the authors analyzed data on 43,904 cases seen in 25 emergency departments. Among this cohort, 230 children had a bleeding disorder - 129 of them with hemophilia.

All of the patients with bleeding disorders and 98% of those without had apparently minor trauma indicated by a Glasgow coma scale score of 14 or 15.

Cranial CT scans were obtained for 80.9% of the children with bleeding disorders and 35.3% of those without, for a rate ratio of 2.29.

"Of the patients with GCS scores of 14 to 15 for whom a CT was obtained, an ICH was present in 2 of 186 children with bleeding disorders (1.1%) compared with 655 of 14, 969 children without bleeding disorders (4.4%)," Dr. Lee and colleagues report.

Both of the children with bleeding disorders and positive CT scans presented with signs and symptoms of ICH.

Given these results, the researchers conclude, "CT imaging may not routinely be needed in the evaluation of children with bleeding disorders after blunt head trauma, particularly in those without signs and symptoms suggestive of ICH."

J Pediatr. Posted online January 14, 2011.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21232760

11. Short-Term Outcomes after Fab Antivenom Therapy for Severe Crotaline Snakebite

Lavonas L, et al. Ann Emerg Med. 2011;57:128-137.e3

Study objectives
We seek to determine the short-term outcomes associated with the use of Crotalidae polyvalent immune Fab (ovine) (CroFab; FabAV) therapy for severe crotaline snake envenomation and to better define the incidence of hypersensitivity reactions associated with FabAV use.

Methods
We conducted a multicenter observational case series study of patients who received FabAV at 17 US hospitals in 2002 to 2004. A 7-point score incorporating local, systemic, and hematologic venom effects was used to grade envenomation severity before and after FabAV therapy. The primary outcome for response to therapy was the change in overall envenomation severity after FabAV administration. The primary safety outcomes were the rates of immediate hypersensitivity reactions and serum sickness.

Results
The outcome-evaluable population included 209 patients, of whom 28 had severe envenomation. All severely envenomated patients improved after receiving FabAV. The median severity scores of severely envenomated patients were 5 (interquartile range [IQR] 5 to 5) before FabAV, 1 (IQR 1 to 2) at the last FabAV loading dose, and 1 (IQR 0 to 1) at the last clinical observation. The proportion of patients with progressive pain, progressive swelling, cardiovascular effects, respiratory effects, neurologic effects, gastrointestinal effects, coagulopathy, and thrombocytopenia all improved after FabAV therapy. The safety population included 247 patients. Immediate hypersensitivity reactions were reported in 6.1% (95% confidence interval 3.4% to 9.8%) of patients. Serum sickness was reported in 5% (95% confidence interval 0.6% to 17%) of patients with a minimum of 6 days of follow-up after the last dose of FabAV.

Conclusion
FabAV therapy is associated with clinical improvement in severe crotaline snake envenomation. Immediate hypersensitivity and serum sickness rates may be less than described in the FabAV prescribing information.

12. Neurothrombectomy 'Intriguing' Option for Stroke but Questions Remain

January 18, 2011 — Currently available neurothrombectomy devices offer "intriguing" treatment options for acute ischemic stroke patients who present either outside the initial time window from symptom onset or who cannot receive traditional therapies, such as pharmacologic thrombolysis, conclude the authors of a new "State of the Evidence" review of the devices.

Results of the review, funded by the Agency for Healthcare Research and Quality, were published online January 17 in Annals of Internal Medicine and will appear in the February 15 print issue of the journal.

"Despite their availability, the clinical data are still evolving and many unanswered questions remain,” first author William L. Baker, PharmD, BCPS (AQ Cardiology), from the University of Connecticut School of Pharmacy & Medicine in Farmington, told Medscape Medical News. "Noncomparative studies have shown these devices to be effective in many patients, although risks do exist," he noted, and the comparative effectiveness of these devices remains unknown.

Ann Intern Med article (free): http://www.annals.org/content/early/2011/01/13/0003-4819-154-4-201102150-00306.full

13. Is Hyperbaric Oxygen Therapy Beneficial in Carbon Monoxide Poisoning?

HBO therapy did not add benefit to normobaric oxygen therapy in these studies.

Annane D, et al. Intensive Care Medicine 2010 Online First, December

Introduction: Although hyperbaric oxygen therapy (HBO) is broadly used for carbon monoxide (CO) poisoning, its efficacy and practical modalities remain controversial.

Objectives: To assess HBO in patients poisoned with CO.

Design: Two prospective randomized trial on two parallel groups.

Setting: Critical Care Unit, Raymond Poincaré Hospital, Garches, France.

Subjects: Three hundred eighty-five patients with acute domestic CO poisoning.

Intervention: Patients with transient loss of consciousness (trial A, n = 179) were randomized to either 6 h of normobaric oxygen therapy (NBO; arm A0, n = 86) or 4 h of NBO plus one HBO session (arm A1, n = 93). Patients with initial coma (trial B, n = 206) were randomized to either 4 h of NBO plus one HBO session (arm B1, n = 101) or 4 h of NBO plus two 2 HBO sessions (arm B2, n = 105).

Primary endpoint: Proportion of patients with complete recovery at 1 month.

Results: In trial A, there was no evidence for a difference in 1-month complete recovery rates with and without HBO [58% compared to 61%; unadjusted odds ratio, 0.90 (95% CI, 0.47–1.71)]. In trial B, complete recovery rates were significantly lower with two than with one HBO session [47% compared to 68%; unadjusted odds ratio, 0.42 (CI, 0.23–0.79)].

Conclusion: In patients with transient loss of consciousness, there was no evidence of superiority of HBO over NBO. In comatose patients, two HBO sessions were associated with worse outcomes than one HBO session.

14. Abdominal CT Scans Improve Diagnostic Certainty in the ED

John Otrompke. January 24, 2011 — A change in diagnosis and treatment was made in nearly half (49%) of adult patients presenting to an emergency department with nontraumatic abdominal pain after a computed tomography (CT) scan, according to a prospective study of 584 patients at the Massachusetts General Hospital in Boston between November 2006 and February 2008.

The results support the utility of CT scans, despite concerns about associated increases in cost and radiation exposure, researchers said.

Results of the study appear in the February 2011 issue of the American Journal of Roentgenology.

The use of CT scans was associated with a reduction in the number of patients admitted to the hospital by nearly half. In addition, the imaging technique was associated with an increase in the level of physician confidence in their diagnosis to 92.2%, up from 70.5%.

Prior to the CT scan, physicians planned to admit 75.3% of the patients evaluated (440 of 584 patients). After CT, the plan was changed to discharge with follow-up in 106 of 440 cases (24.1%), Hani H. Abujudeh, MD, and colleagues report. There was a 126% increase in the diagnosis of "no acute condition" after a CT.

Surgery was initially planned in 79 patients, but after CT, 20 patients (25.3%) were discharged.

The use of CT also reduced the number of patients for whom observation was planned by 44% (from 117 to 66 patients), and increased the number of patients discharged by 55% (from 142 to 220 patients).

Dr. Abujudeh and colleagues also found that treatment was upgraded to admission for some patients, even though the initial treatment plan was discharge. Prior to CT, physicians planned to discharge 142 patients, but the treatment plan was changed to admission in 29 patients (20.4%), they say. Overall, the use of CT reduced planned admission by 17.5%.

The researchers only analyzed data from adults who presented to the emergency department during the hours covered by the study coordinator, which varied between 3:00 PM and midnight Monday through Friday, and who underwent an abdominal CT scan as part of their work-up, the authors note. The patients had a mean age of 53.5 years.

The study was thought to be more powerful than some previous studies, which excluded conditions such as intraabdominal malignancies and inflammatory bowel disease, according to the authors. However, the study had weaknesses, they say. For instance, the research took place at a teaching hospital, so the findings might not be generalizable to other institutions.

AJR. 2011;196:238-243.

15. A Review of Emergent Inpatient Intubations

This large observational study reveals a 10% incidence of difficult intubation.

Martin LD et al. Anesthesiology 2011 Jan; 114:42.

BACKGROUND: There are limited outcome data regarding emergent nonoperative intubation. The current study was undertaken with a large observational dataset to evaluate the incidence of difficult intubation and complication rates and to determine predictors of complications in this setting.

METHODS: Adult nonoperating room emergent intubations at our tertiary care institution from December 5, 2001 to July 6, 2009 were reviewed. Prospectively defined data points included time of day, location, attending physician presence, number of attempts, direct laryngoscopy view, adjuvant use, medications, and complications. At our institution, a senior resident with at least 24 months of anesthesia training is the first responder for all emergent airway requests. The primary outcome was a composite airway complication variable that included aspiration, esophageal intubation, dental injury, or pneumothorax.

RESULTS: A total of 3,423 emergent nonoperating room airway management cases were identified. The incidence of difficult intubation was 10.3%. Complications occurred in 4.2%: aspiration, 2.8%; esophageal intubation, 1.3%; dental injury, 0.2%; and pneumothorax, 0.1%. A bougie introducer was used in 12.4% of cases. Among 2,284 intubations performed by residents, independent predictors of the composite complication outcome were as follows: three or more intubation attempts (odds ratio, 6.7; 95% CI, 3.2-14.2), grade III or IV view (odds ratio, 1.9; 95% CI, 1.1-3.5), general care floor location (odds ratio, 1.9; 95% CI, 1.2-3.0), and emergency department location (odds ratio, 4.7; 95% CI, 1.1-20.4).

CONCLUSIONS: During emergent nonoperative intubation, specific clinical situations are associated with an increased risk of airway complication and may provide a starting point for allocation of experienced first responders.

16. Ability of Physicians to Diagnose CHF Based on Chest X-Ray

Kennedy S, et al. J Emerg Med. 2011;40:47-52.

Background: Chest X-ray interpretation is an important skill in the diagnosis of congestive heart failure (CHF) by emergency physicians.

Objectives: This study evaluated the ability of emergency physicians to recognize CHF on chest X-ray and the effect of level of training and confidence upon accuracy of interpretation. Methods: This was a prospective, blinded study in which 24 patients with an elevated brain natriuretic peptide, low ejection fraction, and diagnosis of CHF were retrospectively identified. In addition, 31 patients without CHF were identified and used as controls. These 55 chest X-rays were presented to emergency attendings and housestaff and a radiologist. We calculated the accuracy of the raters' diagnoses, and measured their confidence in that diagnosis and their level of training.

Results: Physicians correctly identified the CHF chest X-rays 79% of the time (sensitivity 59%, specificity 96%; positive likelihood ratio 14.6, negative likelihood ratio 0.43). Accuracy ranged from a low of 78% among first-year residents to a high of 85% among attendings, and from 73% (confidence rating of 3/5) to 91% (confidence rating of 5/5). Increasing confidence was significantly correlated with accuracy across the spectrum (p = 0.001). An accuracy of 95% among radiologists suggests that a negative X-ray does not rule out CHF.

Conclusions: High specificity (96%) and low sensitivity (59%) suggest that emergency physicians are excellent at identifying CHF on X-ray when present, but under-call it frequently. Sensitivity may be much higher in real life given clinical correlation. Both increased level of training and higher confidence significantly improved accuracy.

17. Cardiac Arrest in Public vs. at Home

Weisfeldt ML, et al. N Engl J Med 2011; 364:313-321.

In a large U.S.–Canadian registry of out-of-hospital cardiac arrests, shockable rhythms were more common in public settings than in the home. This finding has important implications for resuscitation strategies, especially the use of automated external defibrillators.

Background
The incidence of ventricular fibrillation or pulseless ventricular tachycardia as the first recorded rhythm after out-of-hospital cardiac arrest has unexpectedly declined. The success of bystander-deployed automated external defibrillators (AEDs) in public settings suggests that this may be the more common initial rhythm when out-of-hospital cardiac arrest occurs in public. We conducted a study to determine whether the location of the arrest, the type of arrhythmia, and the probability of survival are associated.

Methods
Between 2005 and 2007, we conducted a prospective cohort study of out-of-hospital cardiac arrest in adults in 10 North American communities. We assessed the frequencies of ventricular fibrillation or pulseless ventricular tachycardia and of survival to hospital discharge for arrests at home as compared with arrests in public.

Results
Of 12,930 evaluated out-of-hospital cardiac arrests, 2042 occurred in public and 9564 at home. For cardiac arrests at home, the incidence of ventricular fibrillation or pulseless ventricular tachycardia was 25% when the arrest was witnessed by emergency-medical-services (EMS) personnel, 35% when it was witnessed by a bystander, and 36% when a bystander applied an AED. For cardiac arrests in public, the corresponding rates were 38%, 60%, and 79%. The adjusted odds ratio for initial ventricular fibrillation or pulseless ventricular tachycardia in public versus at home was 2.28 (95% confidence interval [CI], 1.96 to 2.66; P less than 0.001) for bystander-witnessed arrests and 4.48 (95% CI, 2.23 to 8.97; P less than 0.001) for arrests in which bystanders applied AEDs. The rate of survival to hospital discharge was 34% for arrests in public settings with AEDs applied by bystanders versus 12% for arrests at home (adjusted odds ratio, 2.49; 95% CI, 1.03 to 5.99; P=0.04).

Conclusions
Regardless of whether out-of-hospital cardiac arrests are witnessed by EMS personnel or bystanders and whether AEDs are applied by bystanders, the proportion of arrests with initial ventricular fibrillation or pulseless ventricular tachycardia is much greater in public settings than at home. The incremental value of resuscitation strategies, such as the ready availability of an AED, may be related to the place where the arrest occurs

Full-text (free): http://www.nejm.org/doi/full/10.1056/NEJMoa1010663

18. A Fighting Spirit Won’t Save Your Life

Richard P Sloan. New York Times, January 24, 2011

GABRIELLE GIFFORDS’S remarkable recovery from a bullet to her head has provided a heartening respite from a national calamity. Representative Giffords’s husband describes her as a “fighter,” and no doubt she is one. Whether her recovery has anything to do with a fighting spirit, however, is another matter entirely.

The idea that an individual has power over his health has a long history in American popular culture. The “mind cure” movements of the 1800s were based on the premise that we can control our well-being. In the middle of that century, Phineas Quimby, a philosopher and healer, popularized the view that illness was the product of mistaken beliefs, that it was possible to cure yourself by correcting your thoughts. Fifty years later, the New Thought movement, which the psychologist and philosopher William James called “the religion of the healthy minded,” expressed a very similar view: by focusing on positive thoughts and avoiding negative ones, people could banish illness.

The idea that people can control their own health has persisted through Norman Vincent Peale’s “Power of Positive Thinking,” in 1952, to a popular book today, “The Secret,” by Rhonda Byrne, which teaches that to achieve good health all we have to do is to direct our requests to the universe.

It’s true that in some respects we do have control over our health. By exercising, eating nutritious foods and not smoking, we reduce our risk of heart disease and cancer. But the belief that a fighting spirit helps us to recover from injury or illness goes beyond healthful behavior. It reflects the persistent view that personality or a way of thinking can raise or reduce the likelihood of illness…

The remainder of the essay: http://www.nytimes.com/2011/01/25/opinion/25sloan.html

19. Anticoagulant-associated intracerebral hemorrhage.

Semin Neurol. 2010 Nov;30(5):565-72. Epub 2011 Jan 4.

The incidence of anticoagulant-associated intracerebral hemorrhage (AAICH) quintupled during the 1990s, probably due to increased warfarin use for the treatment of atrial fibrillation. Anticoagulant-associated intracerebral hemorrhage now accounts for nearly 20% of all intracranial hemorrhage (ICH). Among patients using warfarin for atrial fibrillation, the annual risk of ICH in trials is 0.3 to 1.0%.

Predictors of potential anticoagulant-associated hemorrhage are increasing age, prior ischemic stroke, hypertension, leukoaraiosis, the early period of warfarin use, higher intensity anticoagulation, and antiplatelet use in addition to anticoagulation. Compared with other intracranial hemorrhage patients, anticoagulated patients have a greater risk of hematoma expansion, subsequent clinical deterioration and death, necessitating vigorous reversal of their coagulopathy.

Recommended methods of warfarin reversal are administration of intravenous vitamin K and either prothrombin complex concentrates or fresh frozen plasma. Reversal of unfractionated heparin is accomplished with intravenous protamine sulfate. Surgical treatment of intracranial hemorrhage may be life saving in select cases, but has not reduced morbidity or mortality in large randomized trials.

20. The “High” Risk of Energy Drinks

Arria AM, et al. JAMA 2011; online first

In this Commentary, we outline why regular (nonalcoholic) energy drinks might pose just as great a threat to individual and public health and safety. More research that can guide actions of regulatory agencies is needed. Until results from such research are available, the following should be seriously considered: health care professionals should inform their patients of the risks associated with the use of highly caffeinated energy drinks; the public should educate themselves about the risks of energy drink use, in particular the danger associated with mixing energy drinks and alcohol; and the alcohol and energy drink industries should voluntarily and actively caution consumers against mixing energy drinks with alcohol, both on their product labels and in their advertising materials.

Full-text (free): http://jama.ama-assn.org/content/early/2011/01/21/jama.2011.109.full

21. EMS Makes a Difference

A. Improved Clinical Outcomes and Downstream Healthcare Savings. A Position Statement of the National EMS Advisory Council

NHTSA. Ann Emerg Med. 2011;57:169.

The National Emergency Medical Services Advisory Council (NEMSAC) conducted a literature review to answer such questions as, do emergency medical services (EMS) make a difference? Do out-of-hospital interventions really improve patient outcomes? Can timely care provided in the out-of-hospital setting lead to reduced total health care expenditures?

The article summarizes the evidence base documenting improved patient outcomes resulting from out-of-hospital interventions and regionalized EMS systems. It documents the definitive relationship between EMS-related improvements in patient outcomes and financial savings to the health care system for specific conditions.

The strongest evidence demonstrating improved patient outcomes resulting from coordinated systems of out-of-hospital care was observed in the treatment of cardiovascular disease. Trained EMS providers are proficient in the capture and interpretation of 12-lead ECGs, and their participation in the triage decisionmaking process results in clinically meaningful reductions in the time to definitive care.

Strong evidence was also found to document the positive effect of out-of-hospital care and transport for patients experiencing stroke or respiratory distress. By providing advance notification to the receiving hospital and by transporting stroke patients to regional centers, out-of-hospital care providers significantly increase the percentage of stroke patients receiving thrombolysis within 2.5 hours of symptom onset. Patients in respiratory distress who received advanced life support (ALS) treatments show improved higher survival rates and higher functioning cerebral performance scores at discharge than patients receiving basic life support.

By providing appropriate triage and transport to regionalized trauma centers, EMS systems play an important role in improving survival for patients with severe injuries. Adherence to out-of-hospital protocols for the treatment of head injury and pediatric shock also contributes to improved outcomes.

The cost-effectiveness for out-of-hospital care has not received adequate scrutiny, but early studies indicate favorable lifetime cost savings per quality-adjusted life-year from treatments, including thrombolysis and continuous positive airway pressure in the out-of-hospital setting. The use of paramedic practitioners to treat acute minor medical emergencies has been shown to be cost-effective.

The NEMSAC believes that there is enough evidence to support the fact that EMS in general and certain interventions in the out-of-hospital care of patients positively affect the clinical outcome of the patient in the short and long term and have been shown to be cost-effective. Meaningful health reform cannot ignore the significant role of EMS in improving health outcomes and decreasing health care expenditures.

Copies of the 30-page report “EMS Makes a Difference: Improved Clinical Outcomes and Downstream Healthcare Savings. A Position Statement of the National EMS Advisory Council” can be downloaded from http://www.ems.gov/pdf/nemsac-dec2009.pdf. Questions about the information presented in this document can be directed to Cathy Gotschall at cathy.gotschall@dot.gov.

B. Commentary: Making a Difference in Emergency Medical Services

Kahn C. Ann Emerg Med. 2011;57:169-171.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)01724-5/fulltext