Saturday, April 30, 2011

Lit Bits: April 30, 2011

From the recent medical literature...

1. Definition of a Boarded Patient

ACEP. Ann Emerg Med. 2011;57:548.

Many emergency departments (EDs) experience critical overcrowding and heavy emergency resource demand, which hampers the delivery of high-quality medical care and compromises patient safety.1

In order for EDs to continue to provide quality patient care and access to that care, the American College of Emergency Physicians (ACEP) believes a “boarded patient” is defined as a patient who remains in the ED after the patient has been admitted to the facility but has not been transferred to an inpatient unit.

The primary cause of overcrowding is boarding: the practice of holding patients in the ED after they have been admitted to the hospital, because no inpatient beds are available. This practice often results in a number of problems, including ambulance refusals, prolonged patient waiting times, and increased suffering for those who wait, lying on gurneys in ED corridors for hours, and even days, which affects not only their care and comfort but also the primary work of the ED staff taking care of ED patients. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may also be compromised.

Reducing the time that patients for whom an “admit” decision has been made remain in the ED can improve access to treatment and increase quality of care. ACEP agrees with the National Quality Forum deliberations noting the importance of examining the median time from admit decision time to time of departure from the ED for patients admitted to inpatient status:

A proxy for ED crowding includes the proportion and lengths of time patients remain in the ED after the decision to admit.2 Studies have shown that boarding patients in the ED can lead to greater hospital lengths of stay over prompt admissions.3, 4 Reducing this time potentially improves access to care specific to the patient condition and increases the capability of facilities to provide additional treatment.5

References available online (free):

2. 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.

3. More Physicians Say No to Endless Workdays

Gardiner Harris. New York Times. April 1, 2011. HONESDALE, Pa. — Even as a girl, Dr. Kate Dewar seemed destined to inherit the small-town medical practice of her grandfather and father. At 4, she could explain how to insert a pulmonary catheter. At 12, she could suture a gash. And when she entered medical school, she and her father talked eagerly about practicing together.

Dr. Kate Dewar in the emergency room at Lehigh Valley Hospital in Allentown, Pa. Work in the E.R. varies, but the hours are fixed.

But when she finishes residency this summer, Dr. Dewar, 31, will not be going home. Instead, she will take a job as a salaried emergency room doctor at a hospital in Elmira, N.Y., two hours away. An important reason is that she prefers the fast pace and interesting puzzles of emergency medicine, but another reason is that on Feb. 7 she gave birth to twins, and she cannot imagine raising them while working as hard as her father did.

“My father tried really hard to get home, but work always got in the way,” Dr. Dewar said. “Even on Christmas morning, we would have to wait to open our presents until Dad was done rounding at the hospital.”

Dr. Dewar’s change of heart demonstrates the significant changes in American medicine that are transforming the way patients get care.

For decades, medicine has been dominated by fiercely independent doctors who owned their practices, worked night and day, had comfortable incomes and rarely saw their families.

But with two babies, Dr. Dewar wants a life different from her father’s and grandfather’s. So instead of being an entrepreneur, she will become an employee of a large corporation working 36 hours a week — half the hours her father and grandfather worked.

Indeed, emergency room and critical-care doctors work fewer hours than any other specialty, according to a 2008 report from the federal Department of Health and Human Services.

Her decision is part of a sweeping cultural overhaul of medicine’s traditional ethos that along with wrenching changes in its economics is transforming the profession. Like Dr. Dewar, many other young doctors are taking salaried jobs, working fewer hours, often going part time and even choosing specialties based on family reasons. The beepers and cellphones that once leashed doctors to their patients and practices on nights, weekends and holidays are being abandoned. Metaphorically, medicine has gone from being an individual to a team sport.

For doctors, the changes mean more control of their personal lives but less of their professional ones; for patients, care that is less personal but, as studies have shown, more proficient….

The article is continued here:

For the experimental work detailing the ingredients associated with well-being and thriving, see Professor Jon Haidt’s The Happiness Hypothesis: Finding Modern Truth in Ancient Wisdom (New York: Basic Books, 2006).

4. Maternal treatment with opioid analgesics increases risk for birth defects

Broussard CS, et al. Amer J Obstet Gynecol, 2011;204:314.e1-314.e11.

Objective: We examined whether maternal opioid treatment between 1 month before pregnancy and the first trimester was associated with birth defects.

Study Design: The National Birth Defects Prevention Study (1997 through 2005) is an ongoing population-based case-control study. We estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIS) for birth defects categories with at least 200 case infants or at least 4 exposed case infants.

Results: Therapeutic opioid use was reported by 2.6% of 17,449 case mothers and 2.0% of 6701 control mothers. Treatment was statistically significantly associated with conoventricular septal defects (OR, 2.7; 95% CI, 1.1–6.3), atrioventricular septal defects (OR, 2.0; 95% CI, 1.2–3.6), hypoplastic left heart syndrome (OR, 2.4; 95% CI, 1.4–4.1), spina bifida (OR, 2.0; 95% CI, 1.3–3.2), or gastroschisis (OR, 1.8; 95% CI, 1.1–2.9) in infants.

Codeine and/or hydrocodone accounted for the majority of statistically significant findings from the main analysis, and oxycodone was only significantly associated with pulmonary valve stenosis (Table 3). However, given that the CIs for the effect estimates for each specific birth defect overlap, we cannot conclude whether one medication would be preferable to another in terms of risk for birth defects.

Conclusion: Consistent with some previous investigations, our study shows an association between early pregnancy maternal opioid analgesic treatment and certain birth defects. This information should be considered by women and their physicians who are making treatment decisions during pregnancy.

Full-text (free):

5. The 10 Most Prescribed Drugs

April 20, 2011 — The 10 most prescribed drugs in the U.S. aren't the drugs on which we spend the most, according to a report from the IMS Institute for Healthcare Informatics.

The institute is the public face of IMS, a pharmaceutical market intelligence firm. Its latest report provides a wealth of data on U.S. prescription drug use.

Continuing a major trend, IMS finds that 78% of the nearly 4 billion U.S. prescriptions written in 2010 were for generic drugs (both unbranded and those still sold under a brand name). In order of number of prescriptions written in 2010, the 10 most-prescribed drugs in the U.S. are:

• Hydrocodone (combined with acetaminophen) -- 131.2 million prescriptions

• Generic Zocor (simvastatin), a cholesterol-lowering statin drug -- 94.1 million prescriptions

• Lisinopril (brand names include Prinivil and Zestril), a blood pressure drug -- 87.4 million prescriptions

• Generic Synthroid (levothyroxine sodium), synthetic thyroid hormone -- 70.5 million prescriptions

• Generic Norvasc (amlodipine besylate), an angina/blood pressure drug -- 57.2 million prescriptions

• Generic Prilosec (omeprazole), an antacid drug -- 53.4 million prescriptions (does not include over-the-counter sales)

• Azithromycin (brand names include Z-Pak and Zithromax), an antibiotic -- 52.6 million prescriptions

• Amoxicillin (various brand names), an antibiotic -- 52.3 million prescriptions

• Generic Glucophage (metformin), a diabetes drug -- 48.3 million prescriptions

• Hydrochlorothiazide (various brand names), a water pill used to lower blood pressure -- 47.8 million prescriptions.

The 10 Best-Selling Drugs? See the rest of the essay:

IMS Institute for Healthcare Informatics: "The Use of Medicines in the United States: Review of 2010," April 2011.

6. Metoclopramide for Acute Migraine: A Dose-Finding Randomized Clinical Trial

--10 mg is all you need--

Friedman BW, et al. Ann Emerg Med. 2011;57:475-482.e1

Study objective: Intravenous metoclopramide is effective as primary therapy for acute migraine, but the optimal dose of this medication is not yet known. The objective of this study is to compare the efficacy and safety of 3 different doses of intravenous metoclopramide for the treatment of acute migraine.

Methods: This was a randomized, double-blind, dose-finding study conducted on patients who presented to our emergency department (ED) meeting International Classification of Headache Disorders criteria for migraine without aura. We randomized patients to 10, 20, or 40 mg of intravenous metoclopramide. We coadministered diphenhydramine to all patients to prevent extrapyramidal adverse effects. The primary outcome was improvement in pain on an 11-point numeric rating scale at 1 hour. Secondary outcomes included sustained pain freedom at 48 hours and adverse effects.

Results: In this study, 356 patients were randomized. Baseline demographics and headache features were comparable among the groups. At 1 hour, those who received 10 mg of intravenous metoclopramide improved by a mean of 4.7 numeric rating scale points (95% confidence interval [CI] 4.2 to 5.2 points); those who received 20 mg improved by 4.9 points (95% CI 4.4 to 5.4 points), and those who received 40 mg improved by 5.3 points (95% CI 4.8 to 5.9 points). Rates of 48-hour sustained pain freedom in the 10-, 20-, and 40-mg groups were 16% (95% CI 10% to 24%), 20% (95% CI 14% to 28%), and 21% (95% CI 15% to 29%), respectively. The most commonly occurring adverse event was drowsiness, which impaired function in 17% (95% CI 13% to 21%) of the overall study population. Akathisia developed in 33 patients. Both drowsiness and akathisia were evenly distributed across the 3 arms of the study. One month later, no patient had developed tardive dyskinesia.

Conclusion: Twenty milligrams or 40 mg of metoclopramide is no better for acute migraine than 10 mg of metoclopramide.

7. Symptoms: Swollen Cheek, Fever, Chills…Diagnosis? Mumps

Wiler, Jennifer L. MD, MBA. EM News. April 2011

A 23-year-old student presents with three days of swelling in his cheeks, more on his right than left. He complains of fevers, chills, malaise, headache, and decreased oral intake. He is a Russian immigrant, and unsure of his complete vaccination status. When asked to sit in a comfortable position, this is what you see.

Mumps is a highly contagious, self-limited, viral infection that causes painful swelling of the salivary glands. Humans serve as the only natural host for this single-stranded RNA paramyxovirus. Infection is spread by respiratory droplets, direct close contact, or fomites. (BMJ 2005;330[7500]:1132.) The incubation period is approximately 12 to 24 days, and can infect an unvaccinated person of any age (it is most common in ages 2 to 12, and rare in children under 1 because of maternal antibody transmission).

Prior to widespread vaccine use, mumps was the most common cause of viral meningitis and unilateral acquired deafness in children, with outbreaks typically in late winter and early spring. (Clin Infect Dis 2008;47[11]:1458.)

In 1967 a live, attenuated mumps vaccine was introduced, and it decreased infection rates by 95 percent to 99 percent. (MMWR CDC Surveill Summ 1995;44[3]:1.) A single vaccine is no longer available in the United States, but is part of the combined live MMR vaccine that includes measles, mumps, and rubella +/− varicella (MMRV). Initially a single dose of vaccine was recommended, but between 1989 and 1991, despite widespread vaccination programs, outbreaks of mumps in high schools, colleges, military quarters, summer camps, and hospitals were reported in previously vaccinated individuals.

Immunity does appear to improve with re-dosing, which the CDC recommends for school-aged children (K-12) and high-risk adults (health care or daycare workers, international travelers to endemic areas, and college students) who only received one dose. A first dose at 12 to 15 months and a second dose at ages 4 to 6 years is currently considered the standard. (MMWR 2006;55[22]:629.) Patients with a history of anaphylactic reaction to MMR/MMRV, pregnant women, immunocompromised individuals (including those on chronic steroid therapy) should not be given the (live) vaccine. The World Health Organization also has mumps vaccination guidelines (, but mumps-associated complications and deaths are still common in developing countries.

The classic description of an acute mumps infection is fever, headache, anorexia, malaise, myalgias, and referred ear pain followed by bilateral face pain and swelling (90% of cases) of the parotid glands (Nurs Times 2005;101[39]:53) in more than 60 percent of infections but 95 percent of symptomatic patients (Lancet 2008;371[9616]:932) within 48 hours of symptom onset. Other salivary glands are involved in 10 percent of cases. ( Subclinical infections, typically nonspecific respiratory infections, can occur, and are more likely in children.

A clinical diagnosis is often sufficient if the patient has a classic bilateral parotitis infection. Numerous viral and bacterial pathogens can cause parotitis, especially in the immunocompromised patient. Noninfectious etiologies of parotitis also include malignancy, salivary duct stone with secondary infection, and autoimmune conditions (Sjögren's syndrome). If laboratory testing is obtained, an elevated serum amylase is common. Depending on the organs involved, the mumps virus may be isolated from saliva, cerebrospinal fluid, or urine by polymerase chain reaction testing.

There is no specific treatment for mumps other than supportive care, including local application of ice or heat packs, hydration, analgesics and antipyretics, soft mechanical diet, and warm salt water gargles if needed. After infection, the patient is immunized for life.

Secondary mumps infection can occur in multiple organ systems resulting in viral meningitis (most common is nonsalivary gland complication in up to 10% of cases), deafness, pancreatitis, oophoritis (7% post-pubertal girls), and rarely encephalitis, labyrinthitis, Bell's palsy, Guillain-Barré syndrome, transverse myelitis, thyroiditis, myocarditis, interstitial nephritis, fetal death, and mono and polyarticular arthritis. These complications may occur without preceding parotids, and make the diagnosis of mumps associated complications challenging. Orchitis, sudden onset of fever, testicular mass and pain, and scrotal swelling [bilateral 30%]) are the most common complications in post-pubescent males (38%). (Urology 1990;36[4]:355.) Infertility (rare) and compromised fertility (10%-13%) are of concern for male patients who develop orchitis. (Medicine [Baltimore] 2010;89[2]:96; J Urol 1997;158[6]:2158.) Some have suggested a link between previous mumps orchitis infection and the subsequent development of testicular cancer (Br J Cancer 1987;55[1]:97), but a causal link has yet to be proven, and is controversial. (Urologe A 1980;19[5]:283.)

The most significant viral shedding and contagious period is typically three days before symptom onset. (MMWR 2006;55[14]:401.) Current guidelines recommend patient isolation for five days after symptom onset because viral shedding can occur for days. (MMWR 2008;57[40]:1103.) Vaccination is recommended for close contacts with no symptoms or only one dose of vaccine in the past. ( Although this does not prevent acute infection, it is recommended as a public health measure. There is no evidence of secondary transmission, so the vaccine can be administered to susceptible household members and health care workers with immunosuppressed patient contact. (Infect Control Hosp Epidemiol 2007;28[6]:702.)

This patient was admitted to the ED observation unit for intravenous fluid hydration, and had an uneventful course.

8. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis (Tdap) Vaccine from the Advisory Committee on Immunization Practices, 2010

CDC. Ann Emerg Med. 2011;57:505-508.

Full-text (free):

9. Overdoses that cause bradycardia and hypotension: Part II: Clonidine

by Stuart Swadron, MD. EP Monthly, EM:RAP, April 13, 2011

Over the past several months, we have featured a series of interviews with our resident toxicologist, Dr. Sean Nordt, on the common overdoses that cause bradycardia and hypotension: calcium channel blockers, beta blockers, clonidine and digoxin. All of these drugs can be fatal in overdose and all of them appear on the list of single tablets that can kill a child. Last month we discussed calcium channel blockers and beta blockers. This month we continue the discussion with clonidine.

Clonidine is very interesting. It is unlike any other antihypertensive medication because it is actually a receptor agonist. By stimulating pre-synaptic alpha-2 adrenergic receptors that are found in the medulla oblongata, clonidine causes a decrease in central sympathetic outflow throughout the body. Although its most familiar indication is as an antihypertensive, its central action has led to its use for a variety of behavioral indications, including attention deficit disorder, smoking cessation and opioid withdrawal. Not surprisingly, clonidine can be abused and clonidine tablets can be bought and sold on the street. Pediatric patients are of particular concern. Not only can dosing errors result in an overdose when children are prescribed clonidine for psychiatric conditions, but pediatric overdoses tend to be more severe.

The clinical picture of a clonidine overdose can be indistinguishable from that of an opioid overdose. Bradycardia, hypotension, respiratory depression, miosis and a decreased level of consciousness can all be seen. Although it may be a subtle finding, patients with clonidine overdose are more likely to respond transiently to painful stimuli before falling back to a state of unresponsiveness. Moreover, although patients may appear to respond to an opiate antagonist such as nalaxone, this response is only partial at best and often transient. Patients with an opiate-like toxidrome who fail to reverse with naloxone should raise one’s suspicion for a clonidine overdose.

The treatment of clonidine overdose is generally supportive. Airway protection via endotracheal intubation may be necessary in some cases. Volume infusion with crystalloid, atropine and dopamine can all be used to support the patient’s hemodynamic status. Clonidine is not dialyzable, so patients need to be supported through their toxidrome in the intensive care unit. GI decontamination is an option in the patient who presents early but once depression of consciousness occurs the risk of aspiration likely outweighs any benefit. In the intubated patient, activated charcoal may be given through a gastric tube.

Interestingly, many common over-the-counter eye drops and nasal sprays are closely related to clonidine. When used topically as directed, alpha agonists such as tetrahydrozoline (Visine®) and Oxymetazoline (Afrin®), stimulate alpha-1 receptors and result in vasoconstriction, decreasing eye redness and nasal congestion. However, if ingested, their action on the central alpha-2 receptors may predominate, and a syndrome resembling a clonidine overdose may occur.

Clonidine sustained release patches are relatively common and have also been implicated in overdose. Because these patches contain many times the amount of medication found in tablets, patch ingestion can cause a particularly prolonged and severe toxidrome. Whole bowel irrigation with polyethylene glycol is appropriate in these cases.

Finally, clonidine withdrawal is another common phenomenon that emergency physicians encounter. Clinically it can mimic alcohol withdrawal, with prominent hyperadrenergic features. It can similarly be treated with benzodiazepines.

In next month’s piece, we will finish our discussion with the last of the four cardinal agents causing bradycardia in overdose, digoxin.

In our March 16 issue of Lit Bits we covered the first installment of this tox series. If you missed Brady Bunch, part 1, link here:

10. Economic Impact of the Universal Definition of Acute Myocardial Infarction on an Inner City Teaching Hospital

Hatch J, et al. Amer J Cardiol 2011;107:1268-1269.

Measurement of cTnT or cTnI is a reproducible test that is readily done in clinical laboratories. This has become the preferred test for the diagnosis of AMI because of its high sensitivity and specificity.2, 3, 4, 5 As a result, the universal definition of myocardial infarction is based on the increase and decrease of cTn. Because of its superiority, cTn has been suggested as the only biomarker to be measured for the diagnosis of AMI, with a potential for cost savings.3, 4 Obviously, if additional laboratory testing is needed to generate a more specific diagnosis, then cost should not be an issue. With regard to CK-MB, there is no evidence for augmented information in the diagnosis of AMI compared to cTn and therefore should not be cost effective for institutions. Our experience shows a cost savings realized for the first 12 months by eliminating CK-MB from standard order sets of $82,894, and in the last 6 months, the average number of tests for CK-MB was 46 per month, which would increase the cost savings annualized at $86,786.

There has been reluctance at some centers to adopt cTn as the only biomarker for AMI. In our area, 75% of responding hospitals use CK-MB and cTn for the diagnosis of AMI. From a small survey of academic medical centers, nearly 60% of these hospitals use the 2 markers as well. Data were not available for the number of CK-MB tests ordered per month at each of these institutions. However, at large-volume hospitals in the Kansas City area with large numbers of cardiac admissions annually, the presumption is that a significant cost savings would be realized with the elimination of CK-MB from standardized order sets. Figure 1 shows the marked decrease in the frequency of CK-MB ordering for the 12 months this process was operational in our health care system. Implementation required organizational consensus, education, and changes in operational practices. Organizational communication strategies were essential to gain consensus among the care delivery teams. Presentation of the clinical evidence and revision of the standard order sets so the test panel was modified to eliminate CK-MB as an automated order were essential parts of the process to change the practice pattern at our institution. A monthly scorecard was developed to demonstrate progress and provide targeted intervention when appropriate.

There are a number of assay-related issues that can markedly affect the performance of cTn testing in everyday practice. Yet despite such limitations, cTnI has better sensitivity and specificity compared to CK-MB for AMI and can be used at a lower cost when it is the sole laboratory marker for AMI.5 We believe we are in the midst of a paradigm shift toward reliance on cTn. Recent work has focused on novel biomarkers with increased sensitivity and specificity earlier in the time course for the diagnosis of ACS. Such work has focused on the value of myocyte injury, vascular inflammation, and hemostatic and neurohormonal markers in the early diagnosis of ACS and risk stratification of patients with ACS, and this work appears promising.6 However, in this era of health care reform with increased scrutiny of cost-effectiveness, the adoption of a single marker, cTn, can result in a large cost savings with no detrimental effect on the quality of outcomes. If this approach were applied nationally, a large cost savings could be realized.

Full-text (free):

11. Postpartum Preeclampsia: Emergency Department Presentation and Management

Yancey LM, et al. J Emerg Med 2011;40:380-384.

Study Objective: Postpartum preeclampsia/eclampsia is the presence of hypertension and proteinuria, with or without seizures, occurring up to 4 weeks after delivery. We describe the Emergency Department (ED) presentation, signs and symptoms, results of diagnostic studies, management, and outcome in a cohort of patients diagnosed with postpartum preeclampsia/eclampsia at our institutions, and use this to review the diagnosis and management of postpartum preeclampsia/eclampsia.

Methods: A retrospective chart review was conducted at two urban teaching hospitals. Twenty-two cases were identified via ICD-9 (International Classification of Diseases, 9th revision) codes of discharge diagnoses over an 8-year period. Only those patients who initially presented to an ED in the postpartum period after hospital discharge were included. A standardized data tool was used to extract demographic data, signs and symptoms of preeclampsia/eclampsia, ancillary studies previously associated with eclamptic pathology, and outcome during admission.

Results: Of the 22 women, over half (55%) had not been diagnosed with preeclampsia in the ante- or peripartum period. Common prodromal symptoms and signs in the postpartum presentation included headache, visual changes, hypertension, edema, proteinuria, elevated uric acid, and elevated liver function tests. All 4 patients who seized had prodromal symptoms. Women presented from 3 to 10 days postpartum (median: 5 days). Only 10 women were primiparas. Nineteen women presented with diastolic blood pressures above 90 mm, and only 3 of these had diastolic blood pressures of 110 mm Hg or greater.

Conclusions: Postpartum preeclampsia/eclampsia often presents to the ED without a history of preeclampsia during the pregnancy. Further, not all women with this diagnosis who present to the ED in the postpartum period will have each of the “classic” features of this disease, including elevated blood pressure, edema, proteinuria, and hyperreflexia. This report is intended to inform emergency physicians of the presentation of preeclampsia/eclampsia in the postpartum period, including symptoms of headache, vision changes, elevated blood pressure, or seizure up to 4 weeks after delivery.

12. Who Owns Deep Sedation?

Green SM, et al. Ann Emerg Med. 2011;57:470-474.

Emergency physicians may be surprised to learn that their established deep sedation practice of past years is suddenly at risk because of an unusual privileging statement developed exclusively by anesthesiologists, wherein they propose to unilaterally regulate the deep sedation practice of all other specialties.1 This action capitalizes on recent confusing guidelines from the Center for Medicare & Medicaid Services (CMS).2 No new scientific evidence has triggered this controversial new chapter on deep sedation, and neither of the key documents are evidence based or cite any original research.1, 2 Physicians, hospital administrators, and regulators need to be clear on what CMS has actually specified (compared with the anesthesia interpretation) and the broad ramifications of this calculated effort by one specialty to unilaterally dictate the scope of practice in a field long considered multidisciplinary.

Anesthesiologists Granting Deep Sedation Privileges to “Nonanesthesiologists”

The new 9-page policy from the American Society of Anesthesiologists (ASA), titled “Statement of Granting Privileges for Deep Sedation to Non-Anesthesiologist Sedation Practitioners,”1 declares that “anesthesiologist participation in all deep sedation is the best means to achieve the safest care,” and proceeds to outline how anesthesia chiefs should exclusively regulate local deep sedation practice by all other specialties.1 For emergency physicians and other nonanesthesiologists to receive deep sedation privileges, the ASA would first require a formal training program that includes, among other things, a written “knowledge-based test” on ASA policies and guidelines, and supervised “clinical experience on no less than 35 patients” to demonstrate competency in airway management. Residency or fellowship training would excuse one from the formal training program only if completed within the last 2 years and if accompanied by a supporting letter from one's program director. Deep sedation privileges would then be granted on “a time-limited basis,” with ongoing maintenance requirements at the discretion of one's anesthesia service—but requiring periodic reassessment of competence in airway management and continuing medical education “in the delivery of anesthesia services.” And this is just to sedate adults; a separate credentialing mechanism would be required for children (again, with no evidence in support of such a change). Finally, they would require maintenance of advanced cardiac life support (ACLS) and pediatric advanced life support, or other such “certificate” attesting code skills.1 The ASA's cited motivation for this action is patient safety; however, they provide no evidence to support any contention that sedation is currently unsafe or that there exists a problem that requires solving.1

The ASA's credentialing requirements may be appropriate for practitioners with no experience or training in sedation but are unnecessary and counterproductive for a specialty already well qualified in the technique, such as emergency medicine. The sedation skills of the various specialties are far from homogenous, and the phrase “nonanesthesiologists” conveys the oversimplified and misleading message that anesthesiologists possess safe sedation skills, whereas all others do not. Emergency medicine residency and fellowship core curricula amply cover deep sedation's requisite skills of advanced airway management, rescue and resuscitation, monitoring, and sedation pharmacology. Deep sedation is performed as part of routine, daily emergency medicine practice to humanely facilitate a variety of painful or anxiety-inducing procedures, particularly in children. Emergency physicians have a superb and well-established track record of safe deep sedation3, 4, 5, 6 and are research leaders in this field.4, 5, 6, 7, 8, 9, 10, 11, 12, 13 There is no evidence to suggest that emergency physician–led deep sedation is anything other than exceedingly safe. As affirmed by CMS, “… emergency medicine–trained physicians have very specific skill sets to manage airways and ventilation that is [sic] necessary to provide patient rescue. Therefore, these practitioners are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general).”14 …

For the remainder of the essay, see full-text (free):

13. Emergency Physician–Administered Propofol Sedation: A Report on 25,433 Sedations from the Pediatric Sedation Research Consortium

Mallory MD, et al. Ann Emerg Med. 2011;57:462-468.e1

Study objective: We describe the adverse events observed in a large sample of children sedated with propofol by emergency physicians and identify patient and procedure characteristics predictive of more serious adverse events.

Methods: We identified sedations performed by emergency physicians using propofol as the primary sedative, included in the Pediatric Sedation Research Consortium database from July 2004 to September 2008. We describe the characteristics of the patients, procedures, location, adjunctive medications, and adverse events. We use a multivariable logistic regression model to identify predictors of more serious adverse events.

Results: Of 25,433 propofol sedations performed by emergency physicians, most (76%) were performed in a radiology department. More serious adverse events occurred in 581 sedations (2.28%; 95% confidence interval 2.1% to 2.5%). There were 2 instances of aspiration, 1 unplanned intubation, and 1 cardiac arrest. Significant predictors of serious adverse events were weight less than or equal to 5 kg, American Society of Anesthesiologists classification greater than 2, adjunctive medications (benzodiazepines, ketamine, opioids, or anticholinergics), nonpainful procedures, and primary diagnoses of upper respiratory illness or prematurity.

Conclusion: We observed a low adverse event prevalence in this largest series of propofol sedations by emergency physicians. Factors indicating greater risk of more serious adverse events are detailed.

14. A Randomized Controlled Trial of Ketamine/Propofol Versus Propofol Alone for Emergency Department Procedural Sedation

David H, et al. Ann Emerg Med. 2011;57:435-441.

Study objective: We compare the frequency of respiratory depression during emergency department procedural sedation with ketamine plus propofol versus propofol alone. Secondary outcomes are provider satisfaction, sedation quality, and total propofol dose.

Methods: In this randomized, double-blind, placebo-controlled trial, healthy children and adults undergoing procedural sedation were pretreated with intravenous fentanyl and then randomized to receive either intravenous ketamine 0.5 mg/kg or placebo. In both groups, this procedure was immediately followed by intravenous propofol 1 mg/kg, with repeated doses of 0.5 mg/kg as needed to achieve and maintain sedation. Respiratory depression was defined according to any of 5 predefined markers. Provider satisfaction was scored on a 5-point scale, sedation quality with the Colorado Behavioral Numerical Pain Scale, and propofol dose according to the total number of milligrams of propofol administered.

Results: The incidence of respiratory depression was similar between the ketamine/propofol (21/97; 22%) and propofol-alone (27/96; 28%) groups, difference 6% (95% confidence interval −6% to 18%). With ketamine/propofol compared with propofol alone, treating physicians and nurses were more satisfied, less propofol was administered, and there was a trend toward better sedation quality.

Conclusion: Compared with procedural sedation with propofol alone, the combination of ketamine and propofol did not reduce the incidence of respiratory depression but resulted in greater provider satisfaction, less propofol administration, and perhaps better sedation quality.

Full-text (free):

15. A Blinded, Randomized Controlled Trial to Evaluate Ketamine/Propofol Versus Ketamine Alone for Procedural Sedation in Children

Shah A, et al. Ann Emerg Med. 2011;57:425-433.e2

Study objective: The primary objective is to compare total sedation time when ketamine/propofol is used compared with ketamine alone for pediatric procedural sedation and analgesia. Secondary objectives include time to recovery, adverse events, efficacy, and satisfaction scores.

Methods: Children (aged 2 to 17 years) requiring procedural sedation and analgesia for management of an isolated orthopedic extremity injury were randomized to receive either ketamine/propofol or ketamine. Physicians, nurses, research assistants, and patients were blinded. Ketamine/propofol patients received an initial intravenous bolus dose of ketamine 0.5 mg/kg and propofol 0.5 mg/kg, followed by propofol 0.5 mg/kg and saline solution placebo every 2 minutes, titrated to deep sedation. Ketamine patients received an initial intravenous bolus dose of ketamine 1.0 mg/kg and Intralipid placebo, followed by ketamine 0.25 mg/kg and Intralipid placebo every 2 minutes, as required.

Results: One hundred thirty-six patients (67 ketamine/propofol, 69 ketamine) completed the trial. Median total sedation time was shorter (P=0.04) with ketamine/propofol (13 minutes) than with ketamine (16 minutes) alone (Δ –3 minutes; 95% confidence interval [CI] –5 to –2 minutes). Median recovery time was faster with ketamine/propofol (10 minutes) than with ketamine (12 minutes) alone (Δ –2 minutes; 95% CI –4 to –1 minute). There was less vomiting in the ketamine/propofol (2%) group compared with the ketamine (12%) group (Δ –10%; 95% CI –18% to –2%). All satisfaction scores were higher (P less than 0.05) with ketamine/propofol.

Conclusion: When compared with ketamine alone for pediatric orthopedic reductions, the combination of ketamine and propofol produced slightly faster recoveries while also demonstrating less vomiting, higher satisfaction scores, and similar efficacy and airway complications.

16. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update

Green SM, et al. Ann Emerg Med. 2011;57:449-461


The dissociative agent ketamine has been the single most popular agent to facilitate painful emergency department (ED) procedures in children for nearly 2 decades.1, 2, 3 Current ketamine protocols, including indications, contraindications, and dosing, are frequently based on a widely cited 2004 clinical practice guideline,1 which in turn was an update of a 1990 protocol.4 This latter article was cited in 1999 as an “example of compliance” by The Joint Commission.5 The 2004 guideline, however, is now substantially out of date and in need of revision because subsequent ketamine investigations have questioned, disproved, or refined several of its assertions and recommendations. During this same period, there has also been sufficient ED research in adults to support expansion of ketamine use beyond children. In addition, animal research describing neurotoxicity with ketamine raises important new questions that must be considered and further investigated in humans.

To describe the best available evidence and perspectives about optimal dissociative sedation practice, we reviewed the newer ketamine literature and updated the 2004 clinical practice guideline…

Full-text (free):

17. Images in Emerg Med

Woman with Painful Swelling in Fingers

Male with Facial Trauma

18. Sensitivity of Erythrocyte Sedimentation Rate and C-reactive Protein for the Exclusion of Septic Arthritis in Emergency Department Patients

Hariharan P, et al. J Emerg Med. 2011;40:428-431

Background: Previous studies in post-operative orthopedic and pediatric patients suggest that erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) testing may be helpful in ruling out septic arthritis. However, these tests have not been evaluated in a population of adult Emergency Department (ED) patients.

Study Objective: Determine the sensitivity of ESR and CRP in patients with septic arthritis.

Methods: Retrospective analysis of ED patients with septic arthritis from 2003 to 2008. Eligible patients had an International Classification of Diseases-Ninth Revision diagnosis of pyogenic arthritis (711.0x) plus: positive synovial fluid culture, positive synovial Gram stain, or operative irrigation. Patients were excluded if no ESR or CRP was performed within 24h. Sensitivity of ESR and CRP at various cutoffs was calculated with 95% confidence intervals (CI).

Results: We identified 167 patients with septic arthritis. We included 143 (86%) who had ESR (n=140, 84%) or CRP (n=96, 57%) performed. Mean age was 49 (± 22) years, and 85 (59%) were male. Race was: 125 (87%) white, 4 (3%) black, and 12 (8%) Hispanic. Thirty-five (24%) had infection of prosthetic joints. Synovial cultures were positive in 102 (71%). Sensitivity of ESR was: 98% (95% CI 94–100%) using a cutoff of≥10mm/h (n=134) and 94% (95% CI 88–97%) using a cutoff of≥15mm/h (n=131). The sensitivity of CRP was 92% (95% CI 84–96%) using a cutoff of≥20mg/L (n=88).

Conclusion: ESR and CRP have sensitivities of greater than 90% for septic arthritis, but only when low thresholds are used. Further study is required to determine the clinical usefulness of ESR and CRP testing.

19. HealthGrades lists top 10 cities for ED care

A HealthGrades quality report released in April ranked Cincinnati first on a "Top 10 Cities for Emergency Medicine" list, followed by Phoenix, Milwaukee and Dayton, Ohio. The cities on the list had the lowest mortality rates for Medicare patients admitted through emergency departments, and the report said patients treated at hospitals in those cities have a 40% lower risk of death than those at other facilities.

HealthGrades Report:

20. Emergency Department Visits Continue to Increase

Megan Brooks. April 28, 2011 — In a survey of US emergency physicians, more than 80% said emergency visits are increasing in their emergency department (ED), with roughly half reporting significant increases, and more than 90% expecting increases in the next year.

Nearly all of ED physicians (97%) reported treating patients on a daily basis who were referred by their primary care physician.

This is "one of the most interesting" findings in the survey, Sandra Schneider, MD, FACEP, president of the American College of Emergency Physicians (ACEP) noted in an interview with Medscape Medical News. It goes against the widely held belief that people are choosing to go to the ED instead of seeking primary care.

Why refer to the ED for nonurgent care? "Primary care physicians may not have room in their schedule to take another person," said Dr. Schneider, professor and chair emeritus, Department of Emergency Medicine, University of Rochester, New York.

"Or perhaps they are thinking if they send the patient with belly pain directly to the ED, they can get an ultrasound or blood test right away and know the results right away," she added.

A total of 1768 emergency physicians across the United States responded to the ACEP poll conducted between March 3 and March 11, 2011. The poll was released April 28 during a 1-day conference hosted by ACEP at Bellevue Hospital in New York City called "Crisis in the ER: Rx for the Future."

Insurance Does Not Guarantee Access

Nearly all of the emergency physicians polled (97%) also report that they treat Medicaid patients on a daily basis who could not find any other physician to accept their health insurance.

This reaffirms that "insurance coverage does not equal access to care," Dr. Schneider noted. "Medicaid patients, the uninsured, the underinsured, often can't get in to see their physician. In many cities, you call up, and if you're a Medicaid patient, they might see you in a month," she said.

Jesse Pines, MD, MBA, MSCE, FACEP, director of the Center for Health Care Quality and associate professor of emergency medicine and health policy at George Washington University in Washington, DC, who participated in the conference, told Medscape Medical News: "Being underinsured with Medicaid is really a major issue."

In a conference statement, ACEP warns that if the new healthcare reform legislation provides insurance coverage that reimburses physicians at Medicaid rates, this could exacerbate a lack of access to medical care.

Dr. Schneider made the point that emergency medicine provides lifesaving and critical care to millions of Americans every day, yet represents only 2% of the nation's healthcare costs.

"We've heard a lot about removing unnecessary ED visits, but even if we could remove all ED visits, we'd only save 2%, and the [US Centers for Disease Control and Prevention] has said that only 8% of ED visits are unnecessary. We're talking budget dust here," she said.

She believes EDs need more resources, not fewer, and said emergency physicians "must be prepared for increasing numbers of patients, not fewer, especially given our growing elderly population." At the same time, however, "hundreds of [EDs] have closed."

Of emergency physicians polled, 79% felt their departments use resources efficiently, 44% said the fear of being sued was the biggest challenge to cutting ED costs, and 53% said the fear of lawsuits is the main reason for ordering the tests that they do.

Medical liability reform would help reduce overall costs by reducing the need for "defensive medicine," Dr. Schneider said.

ACEP executive director Dean Wilkerson told Medscape Medical News it would help if the government and policymakers would acknowledge and publicize standards and best evidence-based approaches to practicing emergency care.

"In essence, this would tell the physician that it is not necessary to give every single individual that comes in a [computed tomography] scan, for example. Emergency physicians I talk to say they would order fewer tests if they didn't have to cover their butts all the time."

The authors have disclosed no relevant financial relationships. The conference, Crisis in the ER: Rx for the Future, held April 28, 2011, in New York City, was sponsored by the American College of Emergency Physicians.

21. What's the Optimal Insertion Angle for Lumbar Puncture in Children?

Ultrasound measurements show that the best needle insertion angle is about 50° for infants and 60° for older children.

Bruccoleri RE and Chen L. Pediatrics 2011 Apr; 127:e921

OBJECTIVE: The purpose of this study was to evaluate the angle for performing lumbar punctures in children aged 0 to 12 years. We hypothesized that the angle changes for different stages of development.

METHODS: Children aged 0 to 12 years who presented to the Yale–New Haven Children's Hospital at a low-acuity triage level, in need of a lumbar puncture, their accompanying siblings and authors' children were eligible for the study. Subjects in 3 age groups were recruited and grouped as follows: group 1, 0 to 12 months; group 2, 12 to 36 months; and group 3, 3 to 12 years. Ultrasound images of the L3-L4 and L4-L5 lumbar space were taken with subjects in the lateral recumbent and sitting positions. The angle from the interspinous space to the skin was measured.

RESULTS: Thirty-six subjects were included. The mean angles in the lateral recumbent and sitting positions were group 1, 47.8° (SD: 8.2) and 51.1° (SD: 8.5), respectively; group 2, 58.8° (SD: 6.8) and 59.6° (SD: 5.5); and group 3, 60.5° (SD: 6.6) and 61.9° (SD: 4.0). The results of group 1 were significantly different from those of groups 2 or 3 in both positions (lateral recumbent P = .00526 and 0.00160; sitting P = .0499 and .00282).

CONCLUSIONS: The angle for lumbar puncture was more acute for infants than for older children in this study. Future studies should assess the difference in success rates of lumbar punctures when clinicians have knowledge of these angles.