Lit Bits: March 16, 2011

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

1. A Prospective Case Series of Single-syringe Ketamine–Propofol (Ketofol) for Emergency Department Procedural Sedation and Analgesia in Adults

Andolfatto G, et al. Acad Emerg Med. 2011;18:237–245.

Objectives: The objective was to evaluate the effectiveness, recovery time, and adverse event profile of intravenous (IV) mixed 1:1 ketamine–propofol (ketofol) for adult procedural sedation and analgesia (PSA) in the emergency department (ED).

Methods: Prospective data were collected on all PSA events over a 4.5-year period in a trauma-receiving suburban teaching hospital. PSAs using a 1:1 single-syringe mixture of 10 mg/mL ketamine and 10 mg/mL propofol in patients over 21 years of age were analyzed. Physiologic data, drug doses, adverse events, recovery time, patient satisfaction, and staff satisfaction were recorded.

Results: Ketofol PSA was used in 728 patients for primarily orthopedic procedures. Median patient age was 53 years (range = 21 to 99 years, interquartile range [IQR] = 36–70 years). The median dose of ketamine and propofol was 0.7 mg/kg each (range = 0.2 to 2.7 mg/kg, IQR = 0.5–0.9 mg/kg), and median recovery time was 14 minutes (range = 3 to 50 minutes, IQR = 10–17 minutes). PSA was effective in 717 cases (98%). Bag–mask ventilation occurred in 15 patients (2.1%; 95% confidence interval [CI] = 1.0% to 3.1%). Recovery agitation occurred in 26 patients (3.6%; 95% CI = 2.2% to 4.9%), of whom 13 (1.8%; 95% CI = 0.8% to 2.7%) required treatment. One patient experienced vomiting and one patient was admitted to the hospital for monitoring of transient dysrhythmia and hypotension. No sequelae were identified. The median staff satisfaction scores were 10 (IQR = 9–10) on a scale of 1 to 10, and 97% of patients would have chosen the same method of PSA in the future.

Conclusions: Ketofol is an effective PSA agent in adult ED patients. Recovery times are short and adverse events are few. Patients and ED staff were highly satisfied.

2. Diuretic Therapy for Acute Decompensated Heart Failure: Putting Practice to the Test

Continuous infusion or bolus? Low or high dose? A comparative effectiveness trial provides needed data.

The use of diuretics for decompensated heart failure (HF) is well established but largely unstudied. Researchers from the National Heart, Lung, and Blood Institute HF Clinical Research Network conducted the Diuretic Optimization Strategies Evaluation trial to evaluate common strategies for dose and mode of administration.

Eligible patients presented with acute decompensated HF within the previous 24 hours, had chronic HF, and had received outpatient diuretic treatment for at least the preceding month. According to the 2 x 2 factorial design, patients were randomized to receive furosemide at either a low dose (equal to their total daily oral dose) or a high dose (2.5 times their total daily dose) and by either intravenous bolus every 12 hours or continuous infusion. The primary efficacy endpoint was the patient's global assessment of symptoms at 72 hours. The primary safety endpoint was the 72-hour change in serum creatinine level.

At baseline, the 308 participants (average age, 66; about 75% men) had a mean ejection fraction of 35% and a mean creatinine level of 1.5 mg/dL. The primary endpoints did not differ significantly between the groups for either comparison (high vs. low dose or bolus vs. continuous infusion), although global improvement in symptoms was slightly greater in high-dose than in low-dose patients (P=0.06). However, more high-dose than low-dose patients had an increase in creatinine level of above 0.3 mg/dL (23% vs. 14%; P=0.04). The median length of hospital stay was similar in all groups, and readmission rates did not differ significantly among them.

Comment: This trial of diuretic therapy for HF is an important contribution to the evidence base. Continuous infusion, which has many advocates, was not superior to bolus administration. The results also suggest that compared with low doses, high doses confer some benefit with regard to diuresis and symptom relief but some harm with regard to renal function — although the primary endpoint did not differ between the dosage groups. An editorialist interpreted these findings as favoring the high-dose regimen. However, I believe that patients are generally better served by using less rather than more medication, unless the evidence clearly demonstrates benefit with more.

— Harlan M. Krumholz, MD, SM. Published in JW Cardiology March 2, 2011. Citation: Felker GM et al N Engl J Med 2011 Mar 3; 364:797.

Abstract: http://www.nejm.org/doi/full/10.1056/NEJMoa1005419

3. Vertigo…not Always a Benign Condition

Here’s a short informative online slide slow with little clinical vignettes, cool images, and interspersed board-type questions.

Medscape’s Multimedia: http://www.medscape.com/features/slideshow/vertigo

Don’t have access to Medscape? It’s free. Just register: https://profreg.medscape.com/px/registration.do?cid=med

4. Serum Lactate Is a Better Predictor of Short-Term Mortality When Stratified by CRP in Adult ED Patients Hospitalized for a Suspected Infection

Green JP, at al. Ann Emerg Med. 2011;57:291-295.

Study objective
We determine whether C-reactive protein (CRP) adds prognostic value to serum lactate levels when assessing mortality risk in emergency department (ED) patients admitted for a suspected infection.

Methods
This was an observational cohort of unique adult patients (≥21 years of age) who had lactate and CRP testing in the ED and were admitted for a suspected infection during a 1-year period. All data were collected through retrospective chart review. The study site is an urban teaching hospital with an approximate annual census of 95,000 patients. The endpoint was 28-day inpatient mortality.

Results
One thousand one hundred forty-three patients had lactate and CRP testing in the ED, an admitting diagnosis of infection, and complete records. Twenty-eight-day inpatient mortality for patients with both a lactate level greater than or equal to 4.0 mmol/L and CRP level greater than 10.0 mg/dL was 44.0% (95% confidence interval [CI] 32.5% to 55.5%), for lactate greater than or equal to 4.0 mmol/L and CRP less than or equal to 10.0 mg/dL, it was 9.7% (95% CI 2.7% to 16.7%), and for lactate level less than 4.0 mmol/L, it was 9.1% (95% CI 7.3% to 10.9%). In a logistic regression model that included patient demographics and Charlson score, as well as 4 separate dichotomous variables that were positive only in subjects with (1) serum lactate greater than or equal to 4.0 mmol/L and CRP level greater than 10.0 mg/dL, (2) lactate level greater than or equal to 4.0 mmol/L and CRP level less than or equal to 10.0 mg/dL, (3) lactate level less than 4.0 mmol/L and CRP level greater than 10.0 mg/dL, and (4) lactate level less than 4.0 mmol/L and CRP level less than or equal to 10.0 mg/dL (as reference), patients with both a lactate level greater than or equal to 4.0 mmol/L and CRP greater than 10 mg/dL had an increased risk of 28-day inpatient mortality (odds ratio 12.3; 95% CI 6.8 to 22.3).

Conclusion
In this cohort, patients with both an increased CRP level and hyperlactatemia had a higher mortality rate than patients with abnormalities of either laboratory test in isolation.

5. Daring to Practice Low-Cost Medicine in a High-Tech Era

Palfrey S. N Engl J Med. March 2, 2011

A child with chest pain or tics, a toddler who is limping, a 12-year-old girl with abdominal pain or headaches, an infant whose fever does not respond to antibiotics — these are age-old challenges that pediatricians face. I have been teaching pediatrics to residents and medical students for more than three decades, but over the past few years, as I’ve watched trainees at work, sitting at their computers, and ordering and monitoring tests, I’ve grown worried that the practice of medicine has tipped out of balance.

Recent advances in scientific knowledge and technology have resulted in the development of a vast array of new tests, new pharmacologic agents, and new diagnostic and therapeutic procedures. These are so accessible to us in the United States that few of us can resist using them at every opportunity. By being impatient, by mistrusting our hard-earned clinical skills and knowledge, and by giving in to the pressures and opportunities to test too much and treat too aggressively, we are bankrupting our health care system. Ironically, by practicing this way, we are perpetuating serious economic and racial disparities and have built a health care system that rates in the bottom tier among all developed countries in many categories of children’s health outcomes.

Most doctors are intensely risk-averse. We don’t tolerate uncertainty. Not wanting anything bad to happen, we reflexively overtest and overtreat in order to protect our patients — and ourselves. We feel judged by everyone — ourselves, our colleagues, our patients, the health care system, and the lawyers. The meaning of “first do no harm” has changed for us. We feel that “doing everything” is the best practice and the way to prevent harm, and we believe that it will shelter us from blame. We order tests and treatments because they are available to us, well before their importance has been established, their safety has been determined, and their cost–benefit ratio has been calculated.

The evaluation of a child with fever and cough is a good example. There are many possible causes, and we have a huge battery of available tests that might give us potentially relevant information. But why should we no longer trust our physical exam, our knowledge of the possible causes and their usual courses, and our clinical judgment? How much will we gain by seeing an x-ray, now, and how likely is it that the result will necessitate a change in our management? How dangerous would it be if we chose to perform certain tests later or not at all? Might our residents not learn more by thinking, waiting, and watching? Who is actually benefiting when we order a test — the patient, the laboratory, the drug company, the health plan administrators, or their investors? And who is losing health care as we spend these dollars? We need to ask these questions of ourselves and our residents at every step of the clinical process…

Remainder of the essay: http://healthpolicyandreform.nejm.org/?p=13874

6. Updated IDSA Guidelines for Neutropenic Patients with Cancer

The updated Infectious Diseases Society of America guidelines emphasize risk stratification and immediate empirical antibiotics.

Freifeld AG et al. Clin Infect Dis 2011 Feb 15;52:427.

Fever during chemotherapy-induced neutropenia may be the only indication of a severe underlying infection, because signs and symptoms of inflammation typically are attenuated. Physicians must be keenly aware of the infection risks, diagnostic methods, and antimicrobial therapies required for management of febrile patients through the neutropenic period. Accordingly, algorithmic approaches to fever and neutropenia, infection prophylaxis, diagnosis, and treatment have been established during the past 40 years, guided and modified by clinical evidence and experience over time.

The Infectious Diseases Society of America Fever and Neutropenia Guideline aims to provide a rational summation of these evolving algorithms. Summarized below are the recommendations made in the 2010 guideline update. A detailed description of the methods, background, and evidence summaries that support each of the recommendations can be found in the full text of the guideline.

Questions addressed include the following:

I. What Is the Role of Risk Assessment and What Distinguishes High-risk and Low-risk Patients with Fever and Neutropenia?

II. What Specific Tests and Cultures Should be Performed during the Initial Assessment?

III. In Febrile Patients With Neutropenia, What Empiric Antibiotic Therapy Is Appropriate and in What Venue?

IV. When and How Should Antimicrobials be Modified During the Course of Fever and Neutropenia?

V. How Long Should Empirical Antibiotic Therapy be Given?

VI. When Should Antibiotic Prophylaxis be Given, and With What Agents?

VII. What Is the Role of Empirical or Pre-emptive Antifungal Therapy and Which Antifungal Should be Used?

VIII. When Should Antifungal Prophylaxis be Given and With What Agents?

IX. What Is the Role of Antiviral Prophylaxis and What Virus Infections Require Antiviral Treatment?

X. What Is the Role of Hematopoietic Growth Factors (G-CSF or GM-CSF) in Managing Fever and Neutropenia?

XI. How are Catheter-Related Infections Diagnosed and Managed in Neutropenic Patients?

XII. What Environmental Precautions Should be Taken When Managing Febrile Neutropenic Patients?

Full-text (free): http://cid.oxfordjournals.org/content/52/4/e56.full

7. Hospice Care and the ED: Rules, Regulations, and Referrals

Lamba S, et al. Ann Emerg Med. 2011;57:282-290.

Emergency clinicians often care for patients with terminal illness who are receiving hospice care and many more patients who may be in need of such care.

Hospice care has been shown to successfully address the multidimensional aspects of the end-of-life concerns of terminally ill patients: dying with dignity, dying without pain, reducing the burden on family and caregivers, and achieving a home death, when desired. Traditional emergency medicine training may fail to address hospice as a system of care. When they are unfamiliar with the hospice model, emergency clinicians, patients, and caregivers may find it difficult to properly use and interact with these care services. Potential poor outcomes include the propagation of misleading or inaccurate information about the hospice system and the failure to guide appropriate patient referrals.

This article reviews the hospice care service model and benefits offered, who may qualify for hospice care, common emergency presentations in patients under hospice care, and a stepwise approach to initiating a hospice care referral in the emergency department.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)01202-3/fulltext

8. Unfractionated Heparin inferior to LMWH for the treatment of cerebral venous thrombosis

Coutinho JM, et al. Stroke. 2010 Nov;41(11):2575-80.

BACKGROUND AND PURPOSE: There is no consensus whether to use unfractionated heparin or low-molecular weight heparin for the treatment of cerebral venous thrombosis. We examined the effect on clinical outcome of each type of heparin.

METHODS: A nonrandomized comparison of a prospective cohort study (the International Study on Cerebral Vein and Dural Sinus Thrombosis) of 624 patients with cerebral venous thrombosis. Patients not treated with heparin (n = 107) and those who sequentially received both types of heparin (n = 99) were excluded from the primary analysis. The latter were included in a secondary analysis, allocated according to the type of heparin given first. The primary end point was functional independency at 6 months (modified Rankin scale score ≤ 2). Secondary end points were complete recovery (modified Rankin scale score 0 to 1), mortality, and new intracranial hemorrhages.

RESULTS: A total of 119 patients received low-molecular weight heparin (28%) and 302 received unfractionated heparin (72%). Significantly more patients treated with low-molecular weight heparin were functionally independent after 6 months, both in univariate analysis (odds ratio, 2.1; CI, 1.0 to 4.2) and after adjustment for prognostic factors and imbalances (odds ratio, 2.4; CI, 1.0 to 5.7). In the secondary analysis, there was a similar, nonsignificant trend (odds ratio, 1.7; CI, 0.80 to 3.6). Low-molecular weight heparin was associated with less new intracerebral hemorrhages (adjusted odds ratio, 0.29; CI, 0.07 to 1.3), especially in patients with intracerebral lesions at baseline (adjusted odds ratio, 0.19; CI, 0.04 to 0.99). There was no difference in complete recovery and mortality.

CONCLUSIONS: This nonrandomized study in patients with cerebral venous thrombosis suggests a better efficacy and safety of low-molecular weight heparin over unfractionated heparin. Low-molecular weight heparin seems preferable above unfractionated heparin for the initial treatment of cerebral venous thrombosis.

9. Emergency Physician–performed US to Diagnose Cholelithiasis: A Systematic Review

Ross M, et al. Acad Emerg Med. 2011;18:227–235.

Objectives:  The authors sought to determine the diagnostic test characteristics of bedside emergency physician (EP)-performed ultrasound (US) for cholelithiasis in symptomatic emergency department (ED) patients.

Methods:  A search was conducted of MEDLINE, EMBASE, the Cochrane Library, bibliographies of previous systematic reviews, and abstracts from major emergency medicine conference proceedings. We included studies that prospectively assessed the diagnostic accuracy of emergency US (EUS) for cholelithiasis, compared to a criterion reference standard of radiology-performed ultrasound (RADUS), computed tomography (CT), magnetic resonance imaging (MRI), or surgical findings. Two authors independently performed relevance screening of titles and abstracts, extracted data, and performed the quality analysis. Disagreements were resolved by conference between the two reviewers. EUS performance was assessed with summary receiver operator characteristics curve (SROC) analysis, with independently pooled sensitivity and specificity values across included studies.

Results:  The electronic search yielded 917 titles; eight studies met the inclusion criteria, yielding a sample of 710 subjects. All included studies used appropriate selection criteria and reference standards, but only one study reported uninterpretable or indeterminate results. The pooled estimates for sensitivity and specificity were 89.8% (95% confidence interval [CI] = 86.4% to 92.5%) and 88.0% (95% CI = 83.7% to 91.4%), respectively.

Conclusions:  This study suggests that in patients presenting to the ED with pain consistent with biliary colic, a positive EUS scan may be used to arrange for appropriate outpatient follow-up if symptoms have resolved. In patients with a low pretest probability, a negative EUS scan should prompt the clinician to consider an alternative diagnosis.

But watch out for some misleading images. See EP Monthly’s article “Mistaken Identity”
http://www.epmonthly.com/clinical-skills/ultrasound/mistaken-identity-/

10. Patients and Providers are Happier with Professional Translators

Examining Effectiveness of Medical Interpreters in Emergency Departments for Spanish-Speaking Patients with Limited English Proficiency: Results of a Randomized Controlled Trial

Bagchi AD, et al. Ann Emerg Med. 2011;57:248-256.e4.

Study objectives
This study examines whether availability of in-person professional interpreter services during emergency department (ED) visits affects satisfaction of limited English proficient patients and their health providers, using a randomized controlled trial.

Methods
We randomized time blocks during which in-person professional interpreters were available to Spanish-speaking patients in the EDs of 2 central New Jersey hospitals. We assessed the intervention's effects on patient and provider satisfaction through a multilevel regression model that accounted for the nesting of patients within time blocks and controlled for the patient's age and sex, hospital, and when the visit occurred (weekday or weekend).

Results
During the 7-month intake period, 242 patients were enrolled during 101 treatment time blocks and 205 patients were enrolled during 100 control time blocks. Regression-adjusted results indicate that 96% of treatment group patients were “very satisfied” (on a 5-point Likert scale) with their ability to communicate during the visit compared with 24% of control group patients (odds ratio=72; 95% confidence interval 31 to 167). (Among control group members who were not very satisfied, responses ranged from “very dissatisfied” to “somewhat satisfied.”) Similarly, physicians, triage nurses, and discharge nurses were more likely to be very satisfied with communication during treatment time blocks than during control time blocks. We did not assess acuity of illness or global measures of satisfaction.

Conclusion
Use of in-person, professionally trained medical interpreters significantly increases Spanish-speaking limited English proficient patients' and their health providers' satisfaction with communication during ED visits.

11. EM:RAP Tox Review: Overdoses that cause bradycardia and hypotension

Stuart Swadron: Part I: Calcium Channel Blockers and Beta Blockers (The Brady Bunch)

Brief Introductory Video by Mel Herbert: http://vimeo.com/20656995

Full article: http://www.epmonthly.com/clinical-skills/emrap/the-brady-bunch-/

12. Abdominal CT in Hypotensive Trauma Patients Delays Laparotomy and Increases Mortality

Authors urge caution in using this diagnostic tool for patients with blunt or penetrating trauma.

Neal MD et al. J Trauma 2011;70:278.

Background: Computed tomography (CT) has a high sensitivity and specificity for detecting abdominal injuries. Expeditious abdominal imaging in “quasi-stable” patients may prevent negative laparotomy. However, the significance of potential delay to laparotomy secondary to abdominal imaging remains unknown. We sought to analyze whether the use of abdominal CT (ABD CT) in patients with abdominal injury requiring laparotomy results in a significant delay and a higher risk of poor outcome.

Methods: A retrospective analysis of data from the National Trauma Data Bank (version 7.1) was performed. Inclusion criteria were adult patients (age over 14 years), a scene admission (nontransfer), hypotension on arrival (emergency department systolic blood pressure below 90 mm Hg), an abdominal Abbreviated Injury Scale (AIS) score over 3, and undergoing a laparotomy within 90 minutes of arrival. Patients with severe brain injury (head AIS score over 3) were excluded. The independent mortality risk associated with a preoperative ABD CT was determined using logistic regression after controlling important confounders.

Results: This cohort of patients (n = 3,218) was significantly injured with a median Injury Severity Score of 25 ([interquartile range, 16–34]). Patients who underwent ABD CT had similar Glasgow Coma Scale scores, a lower head AIS, longer time delays to the operating room, and a higher crude mortality (45% vs. 30%; p = 0.001). Logistic regression revealed that ABD CT was independently associated with more than a 70% higher risk of mortality (odds ratios, 1.71; 95% CI, 1.2–2.2; p less than 0.001). When stratified by injury mechanism, intubation status and whether or not a head CT was performed, the mortality risk remained significantly increased for each subgroup. When the laparotomy was able to occur within 30 minutes of arrival, an ABD CT was independently associated with more than a sevenfold higher risk of mortality (odds ratios, 7.6; p = 0.038).

Conclusion: Delay secondary to abdominal imaging in patients who require operative intervention results in an independent higher risk of mortality. ABD CT imaging is an important and useful tool after injury; however, these results suggest that delay caused by overreliance on ABD CT may result in poor outcome in specific patients. Clinicians who take care of critically injured patients should be aware of and understand these potential risks.

13. Evidence-based Lit Review in Annals (Feb 2011)

A. Succinylcholine Maximize Intubating Conditions Better Than Rocuronium for RSI
http://www.annemergmed.com/article/S0196-0644(10)01207-2/fulltext

B. The Clinical Diagnosis of Arrhythmias in Patients Presenting With Palpitations

Take Home: The history and physical examination may yield features suggesting cardiac arrhythmias to be more or less likely in patients with palpitations. The diagnosis will not typically be confirmed, however, without cardiac monitoring during symptoms.
http://www.annemergmed.com/article/S0196-0644(10)01402-2/fulltext

C. Update: Effect of Thrombolysis in Acute Ischemic Stroke
http://www.annemergmed.com/article/S0196-0644(10)01385-5/fulltext

14. CORTICUS Fuels Controversy Over Steroid Use for Sepsis

An Expert Interview with Michael Winters, MD, FAAEM at AAEM’s 2011 Scientific Assembly

Steven Fox. March 9, 2011 (Orlando, Florida) — Editor's note: Despite several recent studies, the debate surrounding the use of corticosteroids in the management of sepsis rages on. Questions about accurate patient selection and the optimal timing, dose, and duration of therapy remain.

Results from the Corticosteroid Therapy of Septic Shock (CORTICUS) study, a closely watched recent trial, were the focus of a session here at the American Academy of Emergency Medicine (AAEM) 17th Annual Scientific Assembly presented by Michael Winters, MD, FAAEM, assistant professor of emergency medicine at the University of Maryland School of Medicine in Baltimore.

Medscape Medical News spoke with Dr. Winters about the results of the CORTICUS study and how they will affect practice in the emergency department…

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Medscape’s Concluding Question: Given the findings of the CORTICUS study, as well as other research conducted to date, what recommendations do you have regarding the use of steroids in patients with sepsis?

Dr. Winters: I think patients receiving steroids for any existing medical disorder should continue to receive stress-dose steroids in the setting of septic shock. Hydrocortisone is the corticosteroid of choice; dexamethasone is no longer recommended.

The ACTH stimulation test is no longer recommended to select patients who may benefit from corticosteroids. Stress-dose steroids should also be administered to patients with septic shock that's refractory to intravenous fluids (at least 30 mL/kg) and vasopressor therapy.

Based on the results from the Annane study, I think steroids should be administered to these patients as soon as possible, preferably within 8 hours. Patients anticipated to receive short-term vasopressor infusion while receiving fluid resuscitation don't seem to benefit from corticosteroids.

There are a lot of questions that remain regarding the use of steroids in sepsis. Several trials are ongoing and will hopefully shed additional light on the topic.

Complete interview: http://www.medscape.com/viewarticle/738676

CORTICUS study full-text (free in NEJM): http://www.nejm.org/doi/full/10.1056/NEJMoa071366#

Annane study full-text (free in JAMA): http://jama.ama-assn.org/content/288/7/862.long

15. Images in Emergency Medicine

Adult Female with Malignant Pain
http://www.annemergmed.com/article/S0196-0644(10)00379-3/fulltext

Adult Female with Rash on Lower Extremities
http://www.annemergmed.com/article/S0196-0644(10)00462-2/fulltext

Woman with Hip Pain
http://www.annemergmed.com/article/S0196-0644(10)01356-9/fulltext

Giant Intracranial Aneurysm
http://www.nejm.org/doi/full/10.1056/NEJMicm1008509

Malignant Pericardial Effusion
http://www.nejm.org/doi/full/10.1056/NEJMicm1009066

The 2-Year-Old Itch
Saks M. EM News 2011;33:17,23

Sometimes nothing is more vexing on a busy ED shift than seeing a well-appearing child with a nondescript rash. The potential diagnosis (viral exanthem? allergic reaction? non-specific dermatitis? immunologic emergency?) and treatment (cultures? virologic testing? moisturizer? steroids? diphenhydramine?) seem endless.

Earlier in my career, I thought the solution would be to study a dermatology photo atlas or constantly refer to Google images. As it turns out, however, the answer was to become a father. As my family's recent run-in with parvovirus attests, I've gained far more experience distinguishing the numerous childhood rashes through fatherhood than I ever could have by reading a reference text…

Full-text (and image): http://journals.lww.com/em-news/Fulltext/2011/03000/ID_Rounds__The_2_Year_Old_Itch.11.aspx

16. Videos in Emergency Medicine

Successful Thrombolysis of Massive Pulmonary Embolism
http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2009.00659.x/full

Emergency Ultrasound Identification of Loculated Pericardial Effusion: The Importance of Multiple Cardiac Views
http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2010.00669.x/full

Emergency Ultrasound Identification of Pneumoperitoneum
http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2010.00671.x/full

17. Lean Thinking in Emergency Departments: A Critical Review

Holden RJ, et al. Ann Emerg Med. 2011;57:265-278.

Emergency departments (EDs) face problems with crowding, delays, cost containment, and patient safety. To address these and other problems, EDs increasingly implement an approach called Lean thinking.

This study critically reviewed 18 articles describing the implementation of Lean in 15 EDs in the United States, Australia, and Canada. An analytic framework based on human factors engineering and occupational research generated 6 core questions about the effects of Lean on ED work structures and processes, patient care, and employees, as well as the factors on which Lean's success is contingent. The review revealed numerous ED process changes, often involving separate patient streams, accompanied by structural changes such as new technologies, communication systems, staffing changes, and the reorganization of physical space.

Patient care usually improved after implementation of Lean, with many EDs reporting decreases in length of stay, waiting times, and proportion of patients leaving the ED without being seen. Few null or negative patient care effects were reported, and studies typically did not report patient quality or safety outcomes beyond patient satisfaction. The effects of Lean on employees were rarely discussed or measured systematically, but there were some indications of positive effects on employees and organizational culture. Success factors included employee involvement, management support, and preparedness for change.

Despite some methodological, practical, and theoretic concerns, Lean appears to offer significant improvement opportunities. Many questions remain about Lean's effects on patient health and employees and how Lean can be best implemented in health care.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)01322-3/fulltext

18. Identifying Neurocognitive Deficits in Adolescents Following Concussion

Thomas DG, et al. Acad Emerg Med. 2011;18:246–254.

Objectives: This study of concussed adolescents sought to determine if a [20-minute] computer-based neurocognitive assessment (Immediate Postconcussion Assessment and Cognitive Test [ImPACT]) performed on patients who present to the emergency department (ED) immediately following head injury would correlate with assessments performed 3 to 10 days postinjury and if ED neurocognitive testing would detect differences in concussion severity that clinical grading scales could not.

Methods: A prospective cohort sample of patients 11 to 17 years of age presenting to the ED within 12 hours of a head injury were evaluated using two traditional concussion grading scales and neurocognitive testing. ED neurocognitive scores were compared to follow-up scores obtained at least 3 days postinjury. Postconcussive symptoms, outcomes, and complications were assessed via telephone follow-up for all subjects.

Results: Sixty patients completed phone follow-up. Thirty-six patients (60%) completed follow-up testing a median of 6 days postinjury. Traditional concussion grading did not correlate with neurocognitive deficits detected in the ED or at follow-up. For the neurocognitive domains of verbal memory, processing speed, and reaction time, there was a significant correlation between ED and follow-up scores trending toward clinical improvement. By 2 weeks postinjury, 23 patients (41%) had not returned to normal activity. At 6 weeks, six patients (10%) still had not returned to normal activity.

Conclusions: Immediate assessment in the ED can predict neurocognitive deficits seen in follow-up and may be potentially useful to individualize management or test therapeutic interventions. Neurocognitive assessment in the ED detected deficits that clinical grading could not and correlated with deficits at follow-up.

More on the software: http://impacttest.com/about/background

19. Motivational Intervention May Reduce Adolescent Drinking

Laurie Barclay, MD. March 10, 2011 — In adolescents, motivational interventions positively affect short-term drinking outcomes after an alcohol-related emergency department visit, according to the results of a randomized controlled trial reported in the March issue of the Archives of Pediatrics & Adolescent Medicine.

"Primary health care settings have been the site of several efforts to reduce substance use among at-risk adolescent patients," write Anthony Spirito, PhD, from the Brown University Center for Alcohol and Addiction Studies in Providence, Rhode Island, and colleagues. "Studies have also targeted alcohol-abusing teenagers who present to the emergency department (ED), reasoning that the salience of an alcohol-related event may increase the adolescent's sense of vulnerability and, thereby, increase receptivity to an intervention by capitalizing on a teachable moment. Indeed, 1 study found that an individual motivational interview (IMI), which uses a nonconfrontational empathic therapeutic style, offers personalized feedback, and develops a discrepancy between current drinking behavior and current and long-term goals, to be effective in reducing alcohol-related problems in 18- to 19-year-old adolescents."

The goal of the study was to examine whether a brief IMI plus a family motivational interview (Family Check-Up; FCU) would decrease alcohol drinking in adolescents presenting to an emergency department after an alcohol-related event to a greater extent than an IMI only.

At an urban regional level I trauma center, 125 adolescents aged 13 to 17 years with a positive blood alcohol concentration test result using blood, breath, or saliva were randomly assigned to receive either an IMI or an IMI plus FCU. The primary study endpoints were drinking frequency (days per month), quantity (drinks per occasion), and frequency of high-volume drinking (≥ 5 drinks per occasion).

At all 3 follow-up points (3, 6, and 12 months), both groups had decreases in all drinking outcomes (P less than .001 for all), with the strongest effects at 3 and 6 months. Only for high-volume drinking days at 3-month follow-up, the group receiving the FCU plus the IMI had a somewhat better outcome than the group receiving only the IMI (14.6% vs 32.1%; P = .048; odds ratio, 2.76; 95% confidence interval, 0.99 - 7.75).

Limitations of this study include small sample size, limiting the power to detect differences; reliance on self-report without corroboration by a parent or peer; high refusal rate; generalizability limited to emergency department samples; dropout rate of approximately 20% in the FCU group; and lack of a standard care condition.

"Motivational interventions have a positive effect on drinking outcomes in the short term after an alcohol-related emergency department visit," the study authors write. "Adding the FCU to an IMI resulted in somewhat better effects on high-volume drinking at short-term follow-up than did an IMI only. The cost of extra sessions necessary to complete the FCU should be weighed against the potential benefit of reducing high-volume drinking when considering adding the FCU to an IMI for this population."

The National Institute on Alcohol Abuse and Alcoholism supported this study. The study authors have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2011;165:269-274

20. Former ER Exec Producer Reminisces About Show's Beginnings

“Dr. Greene. Dr. Greene. Patient for you, Dr. Greene.”

With those words, Mark Greene, Doug Ross, Peter Benton, Nurse Hathaway, and the rest of ER burst into American living rooms. They stayed for 15 years.

The characters may not have been real, but the writers and producers who created them included real physicians who had spent time in real emergency departments (EDs). Those real physicians changed television, they changed how television portrayed medicine, and they changed the way Americans perceived emergency medicine.

The September 1994 pilot still seems fresh enough after more than 16 years to have been written yesterday—except that today Dr. Greene's frustrated wife would probably call him on his cell, not leave a telephone message at the front desk. And there would be a lot more Purell. That and the fact that it was called ER, when today it might be ED.

“It was medicine from the doctors' point of view. Medicine that really was filtered through the doctors and the doctors in training, not necessarily through the patient,” said Neal Baer, MD, who was part of ER for the first 7 seasons as a writer and then as executive producer.

The rest of the essay: http://www.annemergmed.com/article/S0196-0644(11)00025-4/fulltext

21. The Role of Culturally-informed Unconscious Bias in Shaping Our Inadvertent Racism, Sexism, and Ageism

Research evidence is strong that health care providers often unwittingly share their culture’s predominant biases. Here is but one review applicable to emergency medicine: Heron SL, et al. Racial and ethnic disparities in the emergency department: a public health perspective. Emerg Med Clin North Am. 2006 Nov;24(4):905-23.

Many of us respond to this with both incredulity (Can that really be true? Certainly not with me!) and curiosity (Why is this so?). Studies in cognitive psychology are beginning to answer these questions. Cf. Project Implicit at Harvard: http://projectimplicit.net/generalinfo.php

One popular-level and enjoyable read on this topic is Shankar Vedantam’s The Hidden Brain: How Our Unconscious Minds Elect Presidents, Control Markets, Wage Wars, and Save Our Lives (New York: Spiegel & Grau, 2010). http://www.hiddenbrain.org/about-the-book Another fascinating collection of cognitive psychology studies discussed in an accessible fashion is the book by Christopher Chabris and Daniel Simons, The Invisible Gorilla: And Other Ways Our Intuitions Deceive Us (New York: Crown Publishers, 2010). http://www.theinvisiblegorilla.com/