Monday, October 31, 2011

Lit Bits: Oct 31, 2011

From the recent medical literature...

1. ROSC or Death: Some EMS Systems Stop Transporting Cardiac Arrest Patients, Perform CPR at Scene, Roadside, Ambulance Bay

Joanne Kenen, Ann Emerg Med. 2011;58:A17-A19.

The patient was alert and talking as the ambulance reached the Texas hospital. In the parking lot, he went into cardiac arrest. The paramedics started an aggressive attempt to restart his heart right there. He was then brought into the emergency department (ED), where efforts to resuscitate him continued, unsuccessfully. He died.

The initial effort to save him in the parking lot took place within view of the hospital ED itself, a foolproof recipe for miscommunication, misperception, misunderstanding. Yet ultimately the experience led to greater understanding of the boundaries and barriers—and bridges—between hospital and “out-of-hospital” care, of what the ever-evolving body of evidence now suggests may often be the best option for the patient, even if it runs counter to ingrained practices.

“If you looked out the window, you didn't understand the circumstances,” said Paul Hinchey, MD, MBA, who is the medical director of emergency services for Travis County, which includes Austin, and is also an attending emergency physician at South Austin Medical Center, where the parking lot incident occurred. “They didn't understand what was going on. All they saw was the [emergency medical services] EMS crew working a cardiac arrest in the parking lot. They didn't understand the patient had literally arrested right there.”

Eventually the tensions subsided after lots of discussions not just in that hospital but also in other hospitals in the larger community. And it led to an expanding appreciation that with out-of-hospital cardiac arrest seconds—not minutes, but seconds—count. It's not about on whose turf the patient's heart stopped but about how to improve the dismal odds of restarting it. If and when a similar situation arises in Austin, Dr. Hinchey said, the paramedics would again start aggressive care on the spot, even if the spot were a parking lot near the hospital. The difference is that next time emergency physicians may well come out and join them. Dr. Hinchey added that people inside the hospital often think it takes only seconds to move a patient from ambulance into the ED, but the EMS team knows the transition usually takes minutes.

The Bay Debate

“We discussed it extensively,” Dr. Hinchey said of his colleagues in the area hospitals. They came to understand and then re-examine the invisible but not unbreachable barrier between themselves and the patient outside their doors. “The whole point of EMS advanced care is to extend out to the field. But it's OK—not only OK but essential—for doctors to be part of the process,” added Dr. Hinchey, whose city is part of the “Take Heart America” demonstration project designed to show how cardiac arrest survival rates can be improved through state-of-the-art science partnered with interdisciplinary community approaches.

“It is the cooperative care that makes the difference. The focus should always be on the patient, and their outcome based on what we know in the science,” Dr. Hinchey later said in a follow-up e-mail. “EMS can never replace emergency department care, only supplement it. If done well, everyone benefits, most importantly our patients.”

Clifton W. Callaway, MD, PhD, Associate Professor, vice chair of the Department of Emergency Medicine, University of Pittsburgh, served on the advanced cardiac life support subcommittee when the American Heart Association updated its resuscitation guidelines. Dr. Callaway, who describes himself as “aggressive” when trying to resuscitate, appreciates why it might be better for ambulance crews that find themselves in a parking lot arrest situation to get to work right then and there.

But he likes the idea of having more ED staff, including physicians when practical and appropriate, to get out there and join them. If you can't get the patient to the ED, get the ED to the patient. Enough personnel on hand may also allow the patient to be transported inside while receiving good-quality compressions en route.

Two paramedics can't try resuscitation and move the patient. But 2 paramedics plus a couple of nurses, ED techs, and a physician may be able to. “That patient wants the maximum resources brought to bear if they are going to have a chance of survival,” Dr. Callaway said. “Leaving the paramedics to manage themselves when more experienced physicians or other resources are only a few meters away is not best for the patient.”

Improvement is sorely needed. According to the American Heart Association, EMS treat about 300,000 people with out-of-hospital cardiac arrest each year. Less than 8% survive.

In recent years, protocols have changed in communities across the country; not everyone is automatically rushed to the nearest hospital. For cardiac arrest, if the patient can't be resuscitated at the scene, there's usually no sense in rushing him or her to the hospital. (Several physicians interviewed observed that the exceptions would include cardiac arrest in a trauma victim, exsanguination, metabolic abnormalities, or a situation in which emergency vehicles were ill equipped and lacking defibrillators.)

Manually performed cardiopulmonary resuscitation (CPR) while a patient is in motion just doesn't work all that well, according to some studies. And CPR in the back of a speeding ambulance is dangerous to the patient, to the emergency medical technicians (EMTs) bouncing around unbelted while precariously perched over the patient's chest, and to the pedestrians and vehicles in the ambulance's path.

“The patient is at risk, and so is everyone else,” noted Brent Myers, MD, MPH, the medical director for the Wake County EMS System, whose community has also dealt with parking lot incidents near hospitals and who is also a strong advocate of treating the patient on site.

“I’ve done a lot of CPR in the back of moving vehicles for a long time. It's virtually impossible to do it well,” said Joseph P. Ornato, MD, chairman of emergency medicine at Virginia Commonwealth University Medical Center, as well as operational medical director of Richmond Ambulance Authority. With 37 years of experience working in hospitals, ambulances, helicopters, and fixed-wing aircraft, Dr. Ornato should know. He is also cardiac cochair for the National Institutes of Health–sponsored Resuscitation Outcomes Consortium, which performs large, randomized clinical trials on out-of-hospital cardiac arrest.

The rest of the article (free):

2. Scientific Support for Adrenaline’s (Temporary) Benefit in Cardiac Arrest

Adrenaline improves chance of return of spontaneous circulation but not survival to discharge.

Adrenaline has been used to treat patients with cardiac arrest for more than half a century but has not been evaluated in a placebo-controlled clinical trial in humans. Indeed, there is concern that it might have untoward effects on myocardial function and cerebral microcirculation in postcardiac arrest patients. In the first randomized, double-blind, placebo-controlled trial of adrenaline in cardiac-arrest patients, researchers in Australia randomized 534 adults (mean age, 65; 73% men) with out-of-hospital cardiac arrest from any cause to receive 1 mL of either adrenaline 1:1000 (i.e., 1 mg) or normal saline every 3 minutes to a maximum of 10 mL. No other resuscitation drugs were given. Paramedics were allowed to use other standard methods of cardiopulmonary resuscitation, including defibrillation.

Rates of survival to hospital discharge — the primary outcome — did not differ significantly between the adrenaline and control groups (4.0% and 1.9%; odds ratio, 2.2; 95% confidence interval 0.7-6.3). Patients receiving adrenaline had significantly higher likelihood of prehospital return of spontaneous circulation (ROSC) than placebo recipients (23.5% vs. 8.4%; OR, 3.4) and of admission to the hospital from the emergency department (25.4% vs. 13.0%; OR, 2.3).

Comment: This trial should diminish persistent speculation about the advantages of adrenaline in cardiac arrest. The finding that the more-than-doubled rate of survival to hospital discharge in adrenaline recipients failed to reach statistical significance might be explained by the fact that the trial was underpowered. The effect of the significantly higher rate of prehospital ROSC in the adrenaline group might be enhanced by use of post-ROSC hypothermic therapy, which has been shown to lower mortality and improve neurological outcomes at hospital discharge and thereafter.

— John A. Marx, MD, FAAEM. Published in Journal Watch Emergency Medicine October 14, 2011. Citation: Jacobs IG et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation 2011 Sep; 82:1138.

Medline abstract (free):

3. Anterior Versus Lateral Needle Decompression of Tension Pneumothorax: Comparison by CT Chest Wall Measurement

Sanchez LD, et al. Acad Emerg Med. 2011;18:1022-1026.

Objectives:  Recent research describes failed needle decompression in the anterior position. It has been hypothesized that a lateral approach may be more successful. The aim of this study was to identify the optimal site for needle decompression.

Methods:  A retrospective study was conducted of emergency department (ED) patients who underwent computed tomography (CT) of the chest as part of their evaluation for blunt trauma. A convenience sample of 159 patients was formed by reviewing consecutive scans of eligible patients. Six measurements from the skin surface to the pleural surface were made for each patient: anterior second intercostal space, lateral fourth intercostal space, and lateral fifth intercostal space on the left and right sides.

Results:  The distance from skin to pleura at the anterior second intercostal space averaged 46.3 mm on the right and 45.2 mm on the left. The distance at the midaxillary line in the fourth intercostal space was 63.7 mm on the right and 62.1 mm on the left. In the fifth intercostal space the distance was 53.8 mm on the right and 52.9 mm on the left. The distance of the anterior approach was statistically less when compared to both intercostal spaces (p less than 0.01).

Conclusions:  With commonly available angiocatheters, the lateral approach is less likely to be successful than the anterior approach. The anterior approach may fail in many patients as well. Longer angiocatheters may increase the chances of decompression, but would also carry a higher risk of damage to surrounding vital structures.

4. Screened and Examined: Placebo on the Brain

Ballard, Dustin MD. Emerg Med News. 2011;33.

I had placebo on the brain the other day. This occurred shortly after I took my morning glucosamine supplement (to ward off arthritis, of course) and right before I ordered two mg of morphine for a drug-seeking patient with chronic pain.

The principle of placebo is at work all the time in our daily and professional lives, and its power is undeniable. The medical literature has demonstrated it in dozens of studies, and the media have followed that lead. Last year, for instance, a Newsweek cover story examined the remarkable performance of the placebo arms in clinical trials evaluating new anti-depressants. ( Their performance was so robust that it's making it difficult for drug makers to demonstrate the superiority of their new medications over placebo.

Similarly, a recent Harvard study of asthmatics found 45 percent improvement in symptoms with a fake inhaler and 46 percent improvement with impostor acupuncture compared with 50 percent with an actual treatment (albuterol). Beyond just tricking the brain to feel better, placebo treatments seem capable of causing actual neurological and physiological changes. But the trickery has been somewhat of a sticking point for placebo. Many physicians consider using an impure placebo (a treatment with dubious physiological effect) for its psychological benefits, but would not go as far as prescribing fake pills. In fact, a survey-based study found that approximately 50 percent of U.S. doctors report using such impure treatments. I count myself among them. It was with great interest, then, that I read a recent study of patients with irritable bowel syndrome (IBS) that utilized an “open-label” placebo, a placebo treatment without deception.

In this investigation, which was led by Ted J. Kaptchuk and colleagues and published in December 2010 in PLos ONE, 80 IBS patients were given either no additional therapy or open-label placebo. This placebo treatment was described to patients as “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes.”

Both arms of the study received a counseling session from a physician and nurse that emphasized the importance of maintaining a positive mindset toward the therapy (suspending disbelief). Self-reported symptom scores were assessed at 0, 11, and 21 days. The results demonstrated significant improvements in symptom severity and relief in the placebo group at 11 and 21 days. These included an improvement in the global improvement scores of the placebo group of 5 points (vs. 3.9 for the control group, p=.002).

This study was a small one, with possible confounders such as unreliability in patient symptom reporting, but it certainly is provocative and promising. For years, physicians have struggled with placebo treatments because we've assumed that trickery was necessary for them to work. Trickery puts us in an uncomfortable position, having to choose between two ethical principles: beneficence and autonomy. But if the results of the IBS study are borne out in subsequent studies, the ramifications are tremendous. The placebo effect may not require deception at all. Perhaps it's been mischaracterized for decades. To prescribe placebo freely without the troublesome concealment component opens up a pathway for placebo treatments for many conditions: depression, asthma, chronic pain, IBS, addiction, hypertension, and more. And in the ED? Well, I see some obvious possibilities:

The Patient: Bonked Brenda who bumped her head on a kitchen cabinet last week, and today was reminded of the Natasha Richardson tragedy by a friend.

The Treatment: Trick O'Tomography. This happy-thought scanner is radiation- and risk-free! Who cares that it doesn't generate any pictures? They weren't needed to begin with.

The Patient: Snotty Scott with a touch of congestion, convinced that he has the sinusitis.

The Treatment: Placebiotics. Sweet-tasting and side effect-free, these pills help provide exactly what's needed: some harmless reassurance.

The Patient: Worried Wilma who is not happy with the past 48 hours of her life, and wants to let someone know it.

The Treatment: DeceptoTherapy. This is where your registration clerk can come in super-therapeutic. Rather than call in the psychiatrist in the middle of the night, send in someone qualified to provide the necessary treatment: a set of ears.

The Patient: Anxious Alejandro. A high-stress meeting at work has him breathing like a bunny and complaining of tingling in the hands and feet. He tells you he just can't catch his breath.

The Treatment: A dose of Ativan plus two puffs from the Placebo Pump. With this benzo/placebo cocktail, Alejandro will be ready to bolt back to the office before you can even begin to consider an alternative diagnosis.

These are, of course, tongue-in-cheek examples but perhaps not that farfetched. Could we use placebo to help with the expectant management of conditions like rule-out strep, bronchitis, and, yes, sinusitis? And could we use a simple strategy to improve mood and alleviate discomfort in certain segments of our patient population? Of course. We already do this in myriad ways.

Clearly, the physiologic possibilities for placebo have limits. We can't expect mind-over-matter to work with a bleeding limb, widely metastatic cancer, or a hardcore tweaker. In fact, a 2010 Cochrane review suggests that placebo may be ineffective beyond conditions with subjective symptoms (like pain and nausea). But in the ED, the sickest patients are not always the trickiest ones. Instead they are often the ones with subjective complaints and requests for treatment they don't need. For them, open-label placebo holds tremendous promise.

For more on Dr. Ballard,

5. The Public Lacks Knowledge about Automated External Defibrillators and Willingness to Use Them

In a survey of international travelers in the Netherlands, less than half could identify an AED and less than half were willing to use one.

To investigate attitudes and understanding about automated external defibrillators (AEDs) among the public, investigators conducted a cross-sectional survey of adults traveling through the Central Railway Station in Amsterdam, the Netherlands. Participants were asked a series of structured open-ended questions (e.g., did they recognize an AED, were they aware of public access AED programs, would they be willing to use an AED).

A total of 1018 individuals from 38 countries participated. When asked what they would do when first encountering a person with cardiac arrest, only 6% of respondents mentioned defibrillation or AEDs, 64% knew what a defibrillator is used for, and 43% were aware that defibrillators are often available for public access. When the interviewer pointed to an AED, only 47% of participants correctly identified it, 53% knew what an AED is used for, and 47% said they would be willing to use one.

Comment: Widespread placement of public-access AEDs is incomplete without the requisite public education or a method of ensuring ready availability of trained personnel (e.g., employees) in all locations. Both requirements are tall orders.

— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine October 7, 2011. Citation: Schober P et al. Public access defibrillation: Time to access the public. Ann Emerg Med 2011 Sep; 58:240.

6. Docs admit malpractice fears lead to overly aggressive care

Doctors admit to being part of the healthcare problem, fessing up that they provide too much medical care in a nationwide survey published in the Archives of Internal Medicine. They said malpractice concerns, current reimbursement structure, and quality measurement systems drove them to practice more aggressive healthcare.

Almost half (42 percent) of the 627 surveyed physicians said their patients "were receiving too much medical care" and another 28 percent said they had ordered more tests and made more referrals to specialists than they would like, reports the Los Angeles Times.

The doctors said fear of malpractice lawsuits (76 percent) and clinical performance measures (52 percent) were the most common drivers of their more aggressive practices. Another 40 percent don't spend enough time with their patients to figure out what's wrong, so they ordered tests and consultations to provide answers.

Eighty-three percent of the physicians said they could be sued if they didn't order a test that was indicated, whereas only 21 percent said they could be sued for ordering a test that wasn't indicated, according to the Wall Street Journal. The incentives, therefore, point toward "when in doubt, do more," says Brenda Sirovich, an author of the study and a staff physician and research associate in the Outcomes Group at the VA Medical Center in White River Junction, Vt.

The study also found that 40 percent of doctors thought other primary care physicians were driven by extra income that results from ordering more tests, although only 3 percent said financial considerations influenced their own practice style, Reuters reports.

"I'm not saying that physicians do tests in order to make money--there is a potential to be a real cynic here--but I think that the reimbursement model for most healthcare encourages utilization in a variety of ways," Sirovich said. "It's a time for us to reflect about what incentives we have built into our healthcare system, and what directions they are taking us in," she added.


7. Diagnostic accuracy of venous blood gas electrolytes for identifying diabetic ketoacidosis in the ED

Menchine M, Acad Emerg Med. 2011 Oct;18(10):1105-8.

Objectives: Diagnosing diabetic ketoacidosis (DKA) has traditionally required a venous blood gas (VBG) to obtain serum pH and a serum chemistry panel to obtain electrolyte values. Because newer blood gas analyzers have the ability to report electrolyte values and glucose in addition to pH, this diagnostic process could theoretically be condensed. However, neither the diagnostic accuracy of the VBG for DKA nor the agreement between the VBG electrolytes and the serum chemistry electrolytes, including sodium, chloride, and bicarbonate, has been evaluated in the context of acute hyperglycemia. The purpose of this study was to assess the accuracy of VBG electrolytes for diagnosing DKA using serum chemistry electrolytes measures as the criterion standard and to describe the correlation between VBG and serum chemistry electrolytes in a sample of hyperglycemic patients seen in the emergency department (ED).

Methods: The authors prospectively identified a convenience sample of ED patients with serum blood glucose ≥ 250 mg/dL and examined their paired VBG and serum chemistry electrolytes. The diagnosis of DKA was made by using American Diabetes Association (ADA) criteria including serum glucose ≥ 250 mg/dL, serum anion gap above 10 mEq/L, bicarbonate ≤ 18 mEq/L, serum pH ≤ 7.30, and presence of ketosis. Serum chemistry electrolyte values were considered to be the criterion standard. Diagnostic test characteristics of VBG electrolytes including sensitivity and specificity were compared against this standard. In addition, correlation coefficients for individual electrolytes and anion gap between VBG and chemistry electrolytes were calculated.

Results: Paired VBG and serum chemistry panels were available for 342 patients, of whom 46 (13.5%) had DKA. The sensitivity and specificity of the VBG electrolytes for diagnosing DKA was 97.8% (95% confidence interval [CI] = 88.5% to 99.9%) and 100% (95% CI = 98.8% to 100%), respectively. One case of DKA was missed by the VBG. Correlation coefficients between VBG and serum chemistry were 0.90, 0.73, 0.94, and 0.81 for sodium, chloride, bicarbonate, and anion gap, respectively.

Conclusions: The VBG electrolytes were 97.8% sensitive and 100% specific for the diagnosis of DKA in hyperglycemic patients. These preliminary findings support the use of VBG electrolytes in lieu of VBG along with serum chemistry analysis to rule in or rule out DKA.

8. A Decision Rule for Chest Imaging in Blunt Trauma

A combination of seven clinical criteria was 99% sensitive for detection of significant thoracic injury.

Rodriguez RM et al. J Trauma 2011 Sep; 71:549
BACKGROUND: To derive a decision instrument (DI) that identifies patients who have virtually no risk of significant intrathoracic injury (SITI) visible on chest radiography and, therefore, no need for chest imaging.

METHODS: This is a prospective observational study. At three Level 1 trauma centers, physicians caring for blunt trauma patients above 14 years were asked to record the presence or absence of 12 clinical criteria before viewing chest imaging results. SITI was defined as pneumothorax, hemothorax, aortic/great vessel injury, two or more rib fractures, ruptured diaphragm, sternal fracture, and pulmonary contusion on official radiograph readings. The κ (interrater reliability) and screening performance of individual criteria were determined. By using recursive partitioning, the most highly sensitive combination of criteria for SITI was derived.

RESULTS: Of the 2,628 subjects enrolled, 271 (10.3%) were diagnosed with a total of 462 SITIs, with rib fractures (73%), pneumothorax (38%), and pulmonary contusion (29%) as the most common injuries. Chest pain and chest wall tenderness had the highest sensitivity for SITI (65%). The DI of chest pain, distracting injury, chest wall tenderness, intoxication, age over 60 years, rapid deceleration, and altered alertness/mental status had the following screening performance: sensitivity 99.3% (95% confidence interval [CI], 97.4-99.8), specificity 14.0% (95% CI, 12.6-15.4), negative predictive value 99.4% (95% CI, 97.8-99.8), and positive predictive value 11.7% (95% CI, 10.5-13.1). All seven criteria in the DI met the predetermined cut off for acceptable κ (range, 0.51-0.81).

CONCLUSIONS: We derived a DI consisting of seven clinical criteria that can identify SITI in blunt trauma patients with extremely high sensitivity. If validated, this instrument will allow for safe, selective chest imaging with potential resource savings.

9. Diagnostic Blood Loss from Phlebotomy and Hospital-Acquired Anemia during AMI

Salisbury AC, et al. Arch Intern Med. 2011;171(18):1646-1653.

Background: Hospital-acquired anemia (HAA) during acute myocardial infarction (AMI) is associated with higher mortality and worse health status and often develops in the absence of recognized bleeding. The extent to which diagnostic phlebotomy, a modifiable process of care, contributes to HAA is unknown.

Methods: We studied 17 676 patients with AMI from 57 US hospitals included in a contemporary AMI database from January 1, 2000, through December 31, 2008, who were not anemic at admission but developed moderate to severe HAA (in which the hemoglobin level declined from normal to below 11 g/dL), a degree of HAA that has been shown to be prognostically important. Patients' total diagnostic blood loss was calculated by multiplying the number and types of blood tubes drawn by the standard volume for each tube type. Hierarchical modified Poisson regression was used to test the association between phlebotomy and moderate to severe HAA, after adjusting for site and potential confounders.

Results: Moderate to severe HAA developed in 3551 patients (20%). The mean (SD) phlebotomy volume was higher in patients with HAA (173.8 [139.3] mL) vs those without HAA (83.5 [52.0 mL]; P less than .001). There was significant variation in the mean diagnostic blood loss across hospitals (moderate to severe HAA: range, 119.1-246.0 mL; mild HAA or no HAA: 53.0-110.1 mL). For every 50 mL of blood drawn, the risk of moderate to severe HAA increased by 18% (relative risk [RR], 1.18; 95% confidence interval [CI], 1.13-1.22), which was only modestly attenuated after multivariable adjustment (RR, 1.15; 95% CI, 1.12-1.18).

Conclusions: Blood loss from greater use of phlebotomy is independently associated with the development of HAA. These findings suggest that HAA may be preventable by implementing strategies to limit blood loss from laboratory testing.

10. Droperidol Analgesia for Opioid-Tolerant Patients

Richards JR, et al. J Emerg Med. 2011;41:389-396.

Background: Patients with acute and chronic pain syndromes such as migraine headache, fibromyalgia, and sickle cell disease represent a significant portion of emergency department (ED) visits. Certain patients may have tolerance to opioid analgesics and often require large doses and prolonged time in the ED to achieve satisfactory pain mitigation. Droperidol is a unique drug that has been successfully used not only as an analgesic adjuvant for the past 30 years, but also for treatment of nausea/vomiting, psychosis, agitation, sedation, and vertigo.

Objectives: In this review, we examine the evidence supporting the use of droperidol for analgesia, adverse side effects, and controversial United States (US) Food and Drug Administration (FDA) black box warning.

Discussion: Droperidol has myriad pharmacologic properties that may explain its efficacy as an analgesic, including: dopamine D2 antagonist, dose-dependent GABA agonist/antagonist, α2 adrenoreceptor agonist, serotonin antagonist, histamine antagonist, muscarinic and nicotinic cholinergic antagonist, anticholinesterase activity, sodium channel blockade similar to lidocaine, and μ opiate receptor potentiation.

Conclusion: Droperidol is an important adjuvant for patients who are tolerant to opioid analgesics. The FDA black box warning does not apply to doses below 2.5mg.

11. An Algorithm for Minimizing Pelvic X-Rays in Blunt Trauma

Implementation of the algorithm reduced pelvic x-ray charges at the study institution by $207,000 over 6 months.

The current Advanced Trauma Life Support protocol recommends anteroposterior plain pelvic radiographs for blunt trauma patients. However, if patients are undergoing abdominal pelvic computed tomography (AP-CT), pelvic radiographs are less accurate and redundant. These authors developed an algorithm for obtaining pelvic radiographs and conducted a prospective observational study of its effects during a 6-month period at a single level I trauma center in California. The algorithm dictated that blunt trauma patients undergoing AP-CT would forgo pelvic radiographs unless systolic blood pressure was below 90 mm Hg, hemoglobin was below 8 mg/dL, hemoglobin fell more than 3 mg/dL in the emergency department (ED), and significant pelvic examination findings were present. The algorithm could be overridden by the attending physician.

Of 978 consecutive blunt trauma patients scheduled for AP-CT, 57 (6%) underwent pelvic radiography. Reasons for ordering radiographs were severe pelvic pain (61%), proximal fractures (25%), unexplained hypotension (9%), and hip dislocation (5%). Patients who underwent pelvic radiography were older (mean, 46 vs. 37), had higher mean Injury Severity Scores (12 vs. 7), and required more transfusions (10.5% vs. 1.6%). Pelvic radiographs changed management in two patients: One received an immediate blood transfusion despite normotension, and one had a pelvic binder placed before undergoing AP-CT. There were no complications, including hypotension in the ED, delayed administration of blood products or pelvic binder, or delay in contacting interventional radiology.

Comment: Healthcare imaging costs have risen from US$7 billion to $14 billion in 6 years in the U.S. Compared with abdominal pelvic CT scans, pelvic radiographs have a sensitivity of 55% for identifying pelvic fractures. This simple algorithm eliminated 94% of pelvic radiographs, with a projected annual reduction in charges of nearly $400,000 at a single hospital. Implementing the algorithm makes sense and saves cents.

— John A. Marx, MD, FAAEM. Published in Journal Watch Emergency Medicine October 21, 2011. Citation: Barleben A et al. Implementation of a cost-saving algorithm for pelvic radiographs in blunt trauma patients. J Trauma 2011 Sep; 71:582.


12. Blood cultures in the ED evaluation of childhood pneumonia.

Shah SS, et al. Pediatr Infect Dis J. 2011 Jun;30(6):475-9.

BACKGROUND: Blood cultures are frequently obtained in the emergency department (ED) evaluation of children with community-acquired pneumonia (CAP).

OBJECTIVES: To determine the prevalence of bacteremia in children presenting to the ED with CAP, identify subgroups at increased risk for bacteremia, and quantify the effect of positive blood cultures on management.

METHODS: This case-control study was nested within a cohort of children followed up at 35 pediatric practices. Patients from this cohort who were ≤18 years of age, evaluated in the ED in 2006-2007, and diagnosed with CAP were eligible. Cases were those with bacteremia. Controls included those with negative blood cultures and those without blood cultures performed.

RESULTS: A total of 877 (9.6%) of 9099 children with CAP were evaluated in the ED. The mean age was 3.6 years; 53% were male. Blood cultures were obtained from 291 children (33.2%). Overall, the prevalence of bacteremia was 2.1% (95% confidence interval [CI]: 0.8%-4.4%). Bacteremia occurred in 2.6% (95% CI: 1.0%-5.6%) with an infiltrate on chest radiograph and in 13.0% (95% CI: 2.8%-33.6%) with complicated pneumonia. Streptococcus pneumoniae accounted for 4 of the 6 cases of bacteremia. Blood culture results altered management in 5 of the 6 bacteremic patients; 1 had an appropriate broadening and 4 had an appropriate narrowing of coverage. The contamination rate was 1.0% (95% CI: 0.2%-3.0%).

CONCLUSION: Children presenting to the ED for evaluation of CAP are at low-risk for bacteremia. Although positive blood cultures frequently altered clinical management, the overall impact was small because of the low prevalence of bacteremia.

13. Early stroke risk and ABCD2 score performance in tissue- vs time-defined TIA: A multicenter study.

Giles MF, et al. Neurology. 2011 Sep 27;77(13):1222-8.

OBJECTIVES: Stroke risk immediately after TIA defined by time-based criteria is high, and prognostic scores (ABCD2 and ABCD3-I) have been developed to assist management. The American Stroke Association has proposed changing the criteria for the distinction between TIA and stroke from time-based to tissue-based. Research using these definitions is lacking. In a multicenter observational cohort study, we have investigated prognosis and performance of the ABCD2 score in TIA, subcategorized as tissue-positive or tissue-negative on diffusion-weighted imaging (DWI) or CT imaging according to the newly proposed criteria.

METHODS: Twelve centers provided data on ABCD2 scores, DWI or CT brain imaging, and follow-up in cohorts of patients with TIA diagnosed by time-based criteria. Stroke rates at 7 and 90 days were studied in relation to tissue-positive or tissue-negative subcategorization, according to the presence or absence of brain infarction. The predictive power of the ABCD2 score was determined using area under receiver operator characteristic curve (AUC) analyses.

RESULTS: A total of 4,574 patients were included. Among DWI patients (n = 3,206), recurrent stroke rates at 7 days were 7.1%(95% confidence interval 5.5-9.1) after tissue-positive and 0.4% (0.2-0.7) after tissue-negative events (p diff less than 0.0001). Corresponding rates in CT-imaged patients were 12.8% (9.3-17.4) and 3.0% (2.0-4.2), respectively (p diff less than 0.0001). The ABCD2 score had predictive value in tissue-positive and tissue-negative events (AUC = 0.68 [95% confidence interval 0.63-0.73] and 0.73 [0.67-0.80], respectively; p sig less than 0.0001 for both results, p diff = 0.17). Tissue-positive events with low ABCD2 scores and tissue-negative events with high ABCD2 scores had similar stroke risks, especially after a 90-day follow-up.

CONCLUSIONS: Our findings support the concept of a tissue-based definition of TIA and stroke, at least on prognostic grounds.

Context: The American Stroke Association has recently proposed revising the definitions from time-based to tissue-based criteria, advocating that stroke and TIA be distinguished by the presence or absence of brain infarction identified on diffusion-weighted MRI (DWI).

Cf: Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease Stroke 2009;40:2276–2293. Full-text (free):

Albers GW, Caplan LR, Easton JD, et al. Transient ischemic attack: proposal for a new definition. N Engl J Med 2002;347:1713–1716.

14. Morbidity related to emergency endotracheal intubation--a substudy of the KETAmine SEDation trial.

Jabre P, et al. Resuscitation. 2011;82(5):517-22.

OBJECTIVES: To evaluate the association between emergency tracheal intubation difficulty and the occurrence of immediate complications and mortality, when standardised airway management is performed by emergency physicians.

METHODS: The present study was a substudy of the KETAmine SEDation (KETASED) trial, which compared morbidity and mortality after randomisation to one of two techniques for rapid sequence intubation in an emergency setting. Intubation difficulty was measured using the intubation difficulty scale (IDS) score. Complications recognised within 5 min of endotracheal intubation were recorded. We used multivariate logistic regression analysis to determine the factors associated with the occurrence of complications. Finally, a Cox proportional hazards regression model was used to examine the association of difficult intubation with survival until 28 days.

RESULTS: A total of 650 patients were included, with mean age of 55 ± 19 years. Difficult intubation (IDS above 5) was recorded in 73 (11%) patients and a total of 248 complications occurred in 192 patients (30%). Patients with at least one complication had a significantly higher median IDS score than those without any complications. The occurrence of a complication was independently associated with intubation difficulty (odds ratio 5.9; 95% confidence interval (CI) [3.5;10.1], p less than 0.0001) after adjustment on other significant factors. There was a positive linear relationship between IDS score and complication rate (R(2) = 0.83; p less than 0.001). The Cox model for 28-day mortality indicated that difficult intubation (hazard ratio 1.59; 95%CI [1.04;2.42], p = 0.03) was a significant independent predictor of death.

CONCLUSION: Difficult intubation, measured by the IDS score, is associated with increased morbidity and mortality in patients managed under emergent conditions.

15. Emergency Airway Management: A Multi-Center Report of 8937 Emergency Department Intubations

Walls RM, et al. J Emerg Med. 2011;41:347-354.

Objective: Emergency department (ED) intubation personnel and practices have changed dramatically in recent decades, but have been described only in single-center studies. We sought to better describe ED intubations by using a multi-center registry.

Methods: We established a multi-center registry and initiated surveillance of a longitudinal, prospective convenience sample of intubations at 31 EDs. Clinicians filled out a data form after each intubation. Our main outcome measures were descriptive. We characterized indications, methods, medications, success rates, intubator characteristics, and associated event rates. We report proportions with 95% confidence intervals and chi-squared testing; p-values below 0.05 were considered significant.

Results: There were 8937 encounters recorded from September 1997 to June 2002. The intubation was performed for medical emergencies in 5951 encounters (67%) and for trauma in 2337 (26%); 649 (7%) did not have a recorded mechanism or indication. Rapid sequence intubation was the initial method chosen in 6138 of 8937 intubations (69%) and in 84% of encounters that involved any intubation medication. The first method chosen was successful in 95%, and intubation was ultimately successful in 99%. Emergency physicians performed 87% of intubations and anesthesiologists 3%. Several other specialties comprised the remaining 10%. One or more associated events were reported in 779 (9%) encounters, with an average of 12 per 100 encounters. No medication errors were reported in 6138 rapid sequence intubations. Surgical airways were performed in 0.84% of all cases and 1.7% of trauma cases.

Conclusion: Emergency physicians perform the vast majority of ED intubations. ED intubation is performed more commonly for medical than traumatic indications. Rapid sequence intubation is the most common method of ED intubation.

16. The “Million Hearts” Initiative — Preventing Heart Attacks and Strokes

Frieden TR, et al. N Engl J Med 2011; 365:e27

Each year, more than 2 million Americans have a heart attack or stroke, and more than 800,000 of them die; cardiovascular disease is the leading cause of death in the United States and the largest cause of lower life expectancy among blacks. Related medical costs and productivity losses approach $450 billion annually, and inflation-adjusted direct medical costs are projected to triple over the next two decades if present trends continue.1

To reduce this burden, the Department of Health and Human Services (DHHS), other federal, state, and local government agencies, and a broad range of private-sector partners are today launching a “Million Hearts” initiative to prevent 1 million heart attacks and strokes over the next 5 years by implementing proven, effective, inexpensive interventions (see tableThe Million Hearts Initiative: Principles and Examples of Interventions.).

Cardiovascular prevention works in two realms: the clinic and the community. Clinical and community interventions each contributed about equally to the 50% reduction in U.S. mortality due to heart attacks between 1980 and 2000.2 If used consistently, proven interventions could prevent more than half of heart attacks and strokes. It's time to take the next big step.

In the clinical realm, Million Hearts will improve management of the “ABCS” — aspirin for high-risk patients, blood-pressure control, cholesterol management, and smoking cessation. As for community-based prevention, the initiative will encourage efforts to reduce smoking, improve nutrition, and reduce blood pressure. It will implement the cardiovascular-disease–prevention priorities of the National Quality and National Prevention Strategies and help in meeting targets set by Healthy People 2020.

Improving management of the ABCS can prevent more deaths than other clinical preventive services.3 Patients reduce their risk of heart attack or stroke by taking aspirin as appropriate. Treating high blood pressure and high cholesterol substantially and quickly reduces mortality among high-risk patients. Even brief smoking-cessation advice from clinicians doubles the likelihood of a successful quit attempt, and the use of medications increases quit rates further.

Currently, less than half of people with ischemic heart disease take daily aspirin or another antiplatelet agent; less than half with hypertension have it adequately controlled; only a third with hyperlipidemia have adequate treatment; and less than a quarter of smokers who try to quit get counseling or medications. As a result, more than 100 million people — half of American adults — smoke or have uncontrolled high blood pressure or cholesterol; many have more than one of these cardiovascular risk factors. Increasing utilization of these simple interventions could save more than 100,000 lives a year.3 Measuring and monitoring can encourage providers to improve preventive care.4

The remainder of the essay (free):

17. Images in (Emergency) Medicine

A Woman with Unilateral Sudden Painless Vision Loss

Man with Back Pain

A Refractory Wart?

Human Papillomavirus Lesions of the Oral Cavity

Multiple Intracranial Tuberculomas

18. Most Long-Term Survivors of Out-of-Hospital Cardiac Arrest Have Positive Neurological Outcomes

Although some suffer long-term memory deficits

Long-term survival after out-of-hospital cardiac arrest (OHCA) has improved dramatically during the last several decades, due in large part to the "chain of survival" concept, which emphasizes cardiopulmonary resuscitation (CPR) and early defibrillation. In this prospective study, researchers assessed cognitive function in long-term (beyond 6 months) survivors of OHCA due to ventricular fibrillation (VF).

Of 332 patients with OHCA due to VF in one Minnesota county from 1990 to 2008, 140 patients survived to hospital discharge and 79 were alive in 2009. Of these, 47 patients (mean age, 61) agreed to participate in the study. The median time between OHCA and neurological and neuropsychological testing was 7.8 years. The median call to shock time was 5.6 minutes. Mean test results for the study population were compared to age-standardized normal population values in the same county. Overall, the study population had generally positive neurological outcomes (ability to live independently; mean Mini-Mental State Examination scores similar to standard values) and preserved cognitive ability. Patients suffered minor long-term memory deficits, but these did not affect their ability to live independently. Delayed time to defibrillation and older age at time of arrest were not independent predictors of neurological impairment.

Comment: These results reaffirm the importance of public education and the chain of survival, and they provide emergency physicians with valuable information for counseling patients and their family members.

— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine October 28, 2011. Citation: Mateen FJ et al. Long-term cognitive outcomes following out-of-hospital cardiac arrest: A population-based study. Neurology 2011 Oct 11; 77:1438.


19. Selective Use of CT Compared With Routine Whole Body Imaging in Patients with Blunt Trauma

Gupta M, et al. Ann Emerg Med. 2011;58:407-416.e15.

Study objective: Routine pan–computed tomography (CT, including of the head, neck, chest, abdomen/pelvis) has been advocated for evaluation of patients with blunt trauma based on the belief that early detection of clinically occult injuries will improve outcomes. We sought to determine whether selective imaging could decrease scan use without missing clinically important injuries.

Methods: This was a prospective observational study of 701 patients with blunt trauma at an academic trauma center. Before scanning, the most senior emergency physician and trauma surgeon independently indicated which components of pan-CT were necessary. We calculated the proportion of scans deemed unnecessary that: (a) were abnormal and resulted in a pre-defined critical action or (b) were abnormal.

Results: Pan-CT was performed in 600 of the patients; the remaining 101 underwent limited scanning. One or both physicians indicated a willingness to omit 35% of the individual scans. An abnormality was present in 18% of scans, including 22% of desired scans and 10% of undesired scans. Among the 95 patients who had one of the 102 undesired scans with abnormal results, 3 underwent a predefined critical action. There is disagreement among the authors about the clinical significance of the abnormalities found on the 99 undesired scans that did not lead to a critical action.

Conclusion: Selective scanning could reduce the number of scans, missing some injuries but few critical ones. The clinical importance of injuries missed on undesired scans was subject to individual interpretation, which varied substantially among authors. This difference of opinion serves as a microcosm of the larger debate on appropriate use of expensive medical technologies.

Full-text (free):

20. CMS Approves 10% Medi-Cal Provider Rate Cut

State Continues to Balance the Budget on the Backs of Patients & Physicians

Today, the Centers for Medicare & Medicaid Services (CMS) approved the State of California's 10% cut to provider reimbursement through the Medi-Cal program, which was approved as part of this year's budget deal to close another multi-billion dollar deficit.

The move will most certainly result in further access-to-care problems for Medi-Cal recipients, whose primary care providers may continue their exodus from the program. Provider rate cuts over the past five years have resulted in increased ED visits by Medi-Cal recipients - double digits in some counties - according to data compiled by California ACEP from the Office of Statewide Health Planning & Development.

California ACEP will explore all possible avenues to reverse this short-sighted move which is likely to further erode physician participation and faith in Medi-Cal, while exacerbating ED over-crowding in California.

21. CDC’s (!) Preparedness 101: Zombie Apocalypse

There are all kinds of emergencies out there that we can prepare for. Take a zombie apocalypse for example. That’s right, I said z-o-m-b-i-e a-p-o-c-a-l-y-p-s-e. You may laugh now, but when it happens you’ll be happy you read this, and hey, maybe you’ll even learn a thing or two about how to prepare for a real emergency.

A Brief History of Zombies
We’ve all seen at least one movie about flesh-eating zombies taking over (my personal favorite is Resident Evil), but where do zombies come from and why do they love eating brains so much? The word zombie comes from Haitian and New Orleans voodoo origins. Although its meaning has changed slightly over the years, it refers to a human corpse mysteriously reanimated to serve the undead. Through ancient voodoo and folk-lore traditions, shows like the Walking Dead were born.

In movies, shows, and literature, zombies are often depicted as being created by an infectious virus, which is passed on via bites and contact with bodily fluids. Harvard psychiatrist Steven Scholzman wrote a (fictional) medical paper on the zombies presented in Night of the Living Dead and refers to the condition as Ataxic Neurodegenerative Satiety Deficiency Syndrome caused by an infectious agent. The Zombie Survival Guide identifies the cause of zombies as a virus called solanum. Other zombie origins shown in films include radiation from a destroyed NASA Venus probe (as in Night of the Living Dead), as well as mutations of existing conditions such as prions, mad-cow disease, measles and rabies.

The rise of zombies in pop culture has given credence to the idea that a zombie apocalypse could happen. In such a scenario zombies would take over entire countries, roaming city streets eating anything living that got in their way. The proliferation of this idea has led many people to wonder “How do I prepare for a zombie apocalypse?”

Well, we’re here to answer that question for you, and hopefully share a few tips about preparing for real emergencies too!

Full-text (free) at the CDC: