Lit Bits: Feb 21, 2012

From the recent medical literature...

1. Fleet Enemas: Causing More than Loose Stools

Fatalities and Severe Metabolic Disorders Associated With the Use of Sodium Phosphate Enemas: A Single Center's Experience

Ori Y, et al. Arch Intern Med. 2012;172(3):263-265.

We report our experience with severe complications of sodium phosphate enemas.

Eleven elderly patients received Fleet enemas for constipation. Three patients received 500 to 798 mL, and 8 received a standard 250-mL dose. Most presented within 24 hours with hypotension and volume depletion, extreme hyperphosphatemia (phosphorus level, 5.3-45.0 mg/dL), and severe hypocalcemia (calcium level, 2.0-8.7 mg/dL). Hypernatremia and hypokalemia were seen in most patients. Acute renal failure was present in all patients. Two patients required urgent hemodialysis. Five patients died (45%). One patient was autopsied. Calcium-phosphate deposition within the renal tubular lumens was found.

Following an educational campaign, the use of Fleet enemas was reduced in our hospital by 96%. Sodium phosphate enemas, even in standard doses, may lead to severe metabolic disorders associated with a high mortality and morbidity. Their use should be limited to low-risk patients only.

2. ED Neurologic Deterioration in Patients with Spontaneous Intracerebral Hemorrhage: Incidence, Predictors, and Prognostic Significance

Fan, J.-S., et al. Acad Emerg Med. 2012;19:133-138.

Objectives:  The objective was to explore the incidence, predictors, and prognostic significance of emergency department (ED) neurologic deterioration in patients with spontaneous intracerebral hemorrhage (SICH).

Methods:  This was a retrospective cohort study conducted at the ED, neurocritical care unit, and general intensive care unit of a university-affiliated medical center. Consecutive adult SICH patients treated in our ED from January 2002 through December 2009 were included, identified from the registered stroke data bank. These were cross-checked for coding with International Classification of Diseases, Ninth Revision, Clinical Modification 431 and 432.9. Enrolled patients had SICH with elapsed times of less than 12 hours and Glasgow Coma Scale (GCS) scores ≥ 13 on arrival. ED neurologic deterioration was defined as having a two-or-more-point decrease in consciousness noted in any GCS score assessment between ED presentation and admission. Comparisons of numerical data were performed using an unpaired t-test (parametric data) or Mann-Whitney U-test (nonparametric data). Comparisons of categorical data were done by chi-square tests. Variables with p below 0.1 in univariate analysis were further analyzed using multiple logistic regression. No variable automated or manual selection methods were used.

Results:  Among the 619 patients with SICH included in the study, 22.6% had ED neurologic deterioration. Independent predictors for ED neurologic deterioration included regular antiplatelet use, ictus to ED arrival time under 3 hours, initial body temperature ≥ 37.5°C, intraparenchymal hemorrhage associated with intraventricular hemorrhage (IVH), and presence of a midline shift of greater than 2 mm on computed tomography (CT). ED neurologic deterioration was associated with 1-week mortality, 30-day mortality, and poor neurologic outcome on discharge.

Conclusions:  Nearly one-quarter of SICH patients with an initial GCS of 13 to 15 had a two points or more deterioration of their GCS while in the ED. ED neurologic deterioration was associated with death and poor neurologic outcomes on discharge. Several risk factors that are available early in the patients’ courses appear to be associated with ED neurologic deterioration. By identifying patients at risk for early neurologic decline and intervening early, physicians may be able to improve patient outcomes.

3. Cardiac Telemetry Identifies A Fib in Cryptogenic Stroke

Caroline Helwick. Medscape Medical News. February 2, 2012 (New Orleans, Louisiana) — Outpatient cardiac telemetry over 21 days detects occult paroxysmal atrial fibrillation (PAF) in almost 20% of patients with cryptogenic cerebral ischemia, a new study shows.

Investigators from Henry Ford Hospital in Detroit, Michigan, reported their results here at the American Stroke Association’s International Stroke Conference 2012.

In one third of patients discharged with stroke or transient ischemic attack (TIA), the etiology of the event remains undetermined, the researchers note. While PAF is known to be a possible cause, factors predicting PAF have not been defined.

"Potentially, 1 in 3 stroke patients could be monitored with this technology," said lead author Daniel J. Miller, MD, at a press briefing. "The reason it is important to identify PAF is that it may change treatment." He explained that standard antiplatelet treatment would not be sufficient for this population, who would benefit instead from anticoagulation. Monitoring for 21 days detected PAF in 17%

Investigators hypothesized that mobile cardiac outpatient telemetry (MCOT), if continued for 21 days, would detect a high rate of PAF and that risk factors could be identified for predicting PAF.

The study was a retrospective analysis on 156 patients (mean age, 68.5 years) evaluated by MCOT monitoring within 6 months of a cryptogenic stroke or TIA. Almost all (97%) were not taking anticoagulation medication and 51% were not taking rate control medication.

Half the patients were women and half were African American; 79% of the index events were stroke, and 35% of patients had a history of prior stroke or TIA, with strokes being fairly mild (National Institutes of Health [NIH] Stroke Scale, 3.0). Hypertension was present in 87% but heart failure was seen in only 8%, Dr. Miller noted.

A multivariate analysis with survival regression analysis was performed using demographic, clinical, neuroimaging, and cardiac imaging characteristics to determine predictive risk factors for the detection of PAF on MCOT.

Twenty-seven of the patients (17.3%) were found to have PAF on monitoring. Two thirds of the episodes lasted less than 30 seconds; 26% lasted more than 30 seconds, and 7.5% of episodes were persistent, he reported.

The study also showed that as the duration of monitoring increased, so did the rate of detection of PAF.

PAF detection significantly increased from 3.8% in the initial 48 hours, to 9.2% at 7 days, to 15.1% at 14 days, and to 19.5% by 21 days (P less than .05).

"MCOT is a robust diagnostic tool for the identification of PAF in patients with cryptogenic stroke and TIA," Dr. Miller said. "Length of monitoring is strongly associated with the likelihood of detection of the condition."

In a multivariate Cox regression analysis, the strongest predictors of PAF were premature atrial complexes (PAC) on electrocardiography and female sex. Other significant factors were increase by 1 cm in left atrial diameter, decrease by 10% in left ventricular ejection fraction, and increase by 1 point in NIH Stroke Scale.

The study received no outside funding. CardioNet provided monitoring results and records at no charge. Dr. Miller and Dr. Biller have disclosed no relevant financial relationships.

International Stroke Conference (ISC) 2012: Abstract 150. Presented February 2, 2012.

4. Hypotension is Uncommon in Patients Presenting to the ED with Non-traumatic Cardiac Tamponade

Kapoor T, et al. J Emerg Med. 2012;42:220-226.

Background: Cardiac tamponade is a life-threatening disease in which hypotension is believed to be a common finding. Prior inpatient studies have described normotensive or hypertensive cases of tamponade; however, because the data were not collected from the Emergency Department (ED), the hemodynamic spectrum may differ from those presenting to the ED.

Objectives: We hypothesized that hypotension is uncommon in patients presenting to the ED with non-traumatic tamponade.

Methods: A retrospective chart review was conducted between January 2002 and December 2007 of patients presenting to our ED who were subsequently diagnosed with cardiac tamponade.

Results: A total of 34 patients were identified with a diagnosis of tamponade. The mean blood pressure on ED arrival was 131/79mm Hg. Upon initial presentation to the ED, 35% (n=12) of patients were hypertensive, 50% (n=17) were normotensive, and 15% (n=5) were hypotensive. Of the 5 patients who were hypotensive on ED arrival, only 2 (6% of all patients) remained hypotensive upon admission to the hospital and before a pericardiocentesis. An average of 995mL of fluid was removed from the pericardium. The chief complaint for the majority of patients in tamponade was shortness of breath (70%); 59% were tachycardic in the ED, and 72% had cardiomegaly on chest X-ray study.

Conclusions: Hypotension is uncommon in patients presenting to the ED with non-traumatic cardiac tamponade. The majority of patients are normotensive or even hypertensive. Thus, the emergency physician should not exclude the diagnosis of tamponade even in light of normotension or hypertension.

5. Preoxygenation and Prevention of Desaturation During Emergency Airway Management

Weingart SD, et al. Ann Emerg Med 2012;59: 165-175.e1

Patients requiring emergency airway management are at great risk of hypoxemic hypoxia because of primary lung pathology, high metabolic demands, anemia, insufficient respiratory drive, and inability to protect their airway against aspiration. Tracheal intubation is often required before the complete information needed to assess the risk of periprocedural hypoxia is acquired, such as an arterial blood gas level, hemoglobin value, or even a chest radiograph.

This article reviews preoxygenation and peri-intubation oxygenation techniques to minimize the risk of critical hypoxia and introduces a risk-stratification approach to emergency tracheal intubation. Techniques reviewed include positioning, preoxygenation and denitrogenation, positive end expiratory pressure devices, and passive apneic oxygenation.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(11)01667-2/fulltext

6. The iScore predicts poor functional outcomes early after hospitalization for an acute ischemic stroke.

Saposnik G, et al. Stroke. 2011 Dec;42(12):3421-8.

BACKGROUND AND PURPOSE: The iScore is a prediction tool originally developed to estimate the risk of death after hospitalization for an acute ischemic stroke. Our objective was to determine whether the iScore could also predict poor functional outcomes.

METHODS: We applied the iScore to patients presenting with an acute ischemic stroke at multiple hospitals in Ontario, Canada, between 2003 and 2008, who had been identified from the Registry of the Canadian Stroke Network regional stroke center database (n=3818) and from an external data set, the Registry of the Canadian Stroke Network Ontario Stroke Audit (n=4635). Patients were excluded if they were included in the sample used to develop and validate the initial iScore. Poor functional outcomes were defined as: (1) death at 30 days or disability at discharge, in which disability was defined as having a modified Rankin Scale 3 to 5; and (2) death at 30 days or institutionalization at discharge.

RESULTS: The prevalence of poor functional outcomes in the Registry of the Canadian Stroke Network and the Ontario Stroke Audit, respectively, were 55.7% and 44.1% for death at 30 days or disability at discharge and 16.9% and 16.2%, respectively, for death at 30 days or institutionalization at discharge. The iScore stratified the risk of poor outcomes in low- and high-risk individuals. Observed versus predicted outcomes showed high correlations: 0.988 and 0.940 for mortality or disability and 0.985 and 0.993 for mortality or institutionalization in the Registry of the Canadian Stroke Network and Ontario Stroke Audit cohorts.

CONCLUSIONS: The iScore can be used to estimate the risk of death or a poor functional outcome after an acute ischemic stroke.

7. GlideScope Versus Flexible Fiber Optic for Awake Upright Laryngoscopy

Silverton NA, et al. Ann Emerg Med. 2011;59:159-164.

Study objectives: We compare laryngoscopic quality and time to highest-grade view between a face-to-face approach with the GlideScope and traditional flexible fiber-optic laryngoscopy in awake, upright volunteers.

Methods: This was a prospective, randomized, crossover study in which we performed awake laryngoscopy under local anesthesia on 23 healthy volunteers, using both a GlideScope video laryngoscopy face-to-face technique with the blade held upside down and flexible fiber-optic laryngoscopy. Operator reports of Cormack-Lehane laryngoscopic views and video-reviewed time to highest-grade view, as well as number of attempts, were recorded.

Results: Ten women and 13 men participated. A grade II or better view was obtained with GlideScope video laryngoscopy in 22 of 23 (95.6%) participants and in 23 of 23 (100%) participants with flexible fiber-optic laryngoscopy (relative risk GlideScope video laryngoscopy versus flexible fiber-optic laryngoscopy 0.96; 95% confidence interval 0.88 to 1.04). Median time to highest-grade view for GlideScope video laryngoscopy was 16 seconds (interquartile range 9 to 34) versus 51 seconds (interquartile range 35 to 96) for flexible fiber-optic laryngoscopy. A distribution of interindividual differences demonstrated that GlideScope video laryngoscopy was, on average, 39 seconds faster than flexible fiber-optic laryngoscopy (95% confidence interval 0.2 to 76.9 seconds).

Conclusion: GlideScope video laryngoscopy can be used to obtain a Cormack-Lehane grade II or better view in the majority of awake, healthy volunteers when an upright face-to-face approach is used and was slightly faster than traditional flexible fiber-optic laryngoscopy. However, flexible fiber-optic laryngoscopy may be more reliable at obtaining high-grade views of the larynx. Awake, face-to-face GlideScope use may offer an alternative approach to the difficulty airway, particularly among providers uncomfortable with flexible fiber-optic laryngoscopy.

8. Comparison of Role of Early (Less Than Six Hours) to Later (More Than Six Hours) or No Cardiac Catheterization after Resuscitation From Out-of-Hospital Cardiac Arrest

Strote JA, et a. Amer J Cardiol. 2012;109:451-454.
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Despite reports of patients with resuscitated sudden cardiac arrest (rSCA) receiving acute cardiac catheterization, the efficacy of this strategy is largely unknown. We hypothesized that acute cardiac catheterization of patients with rSCA would improve survival to hospital discharge.

A retrospective cohort of 240 patients with out-of-hospital rSCA caused by ventricular tachycardia or fibrillation was identified from 11 institutions in Seattle, Washington from 1999 through 2002. Patients were grouped into those receiving acute catheterization within 6 hours (≤6-hour group, n = 61) and those with deferred catheterization beyond 6 hours or no catheterization during the index hospitalization (beyond 6-hour group, n = 179). Attention was directed to survival to hospital discharge, neurologic status, extent of coronary artery disease, presenting electrocardiographic findings, and symptoms before arrest. Propensity-score methods were used to adjust for the likelihood of receiving acute catheterization.

Survival was greater in patients who underwent acute catheterization (72% in the ≤6-hour group vs 49% in the beyond 6-hour group, p = 0.001). Percutaneous coronary intervention was performed in 38 of 61 patients (62%) in the ≤6-hour group and 13 of 170 patients (7%) in the beyond 6-hour group (p less than 0.0001). Neurologic status was similar in the 2 groups. A significantly larger percentage of patients in the acute catheterization group had symptoms before cardiac arrest and had ST-segment elevation on electrocardiogram after resuscitation.

Age, bystander cardiopulmonary resuscitation, daytime presentation, history of percutaneous coronary intervention or stroke, and acute ST-segment elevation were positively associated with receiving cardiac catheterization. In conclusion, in this series of patients who sustained out-of-hospital cardiac arrest, acute catheterization (less than 6 hours of presentation) was associated with improved survival.

9. Rapid Sequence Intubation from the Patient's Perspective

Kimball D, et al. West J Emerg Med. 2011 Nov;12(4):365-7.

INTRODUCTION: This study assesses the efficacy of the rapid sequence intubation (RSI) protocol in preventing patient recollection of resuscitative events and patient discomfort during intubation, as subjectively determined by the patient.

METHODS: This was a prospective study of all patients intubated at Los Angeles County, University of Southern California Medical Center from July 2009 to January 2010. Extubated patients were interviewed using a standard questionnaire and data collection tool.

RESULTS: Of 211 airway codes, 201 were excluded due to death before extubation, transfer, or persistent vegetative state, leaving 10 awake, alert subjects who were interviewed regarding their recollection of the RSI and resuscitation. Five had recollection of the event. Most patients recalling RSI described the event as painful or uncomfortable despite receiving the recommended doses of sedation/induction agents.

CONCLUSION: In this cohort of 10 patients intubated using typical agents, 5 remembered some details of their intubation and 2 described pain that was 10/10 on a verbal pain scale. Further work is indicated to ensure that the medications used during this procedure provide the appropriate sedation and amnesia.

Full-text (free): http://www.escholarship.org/uc/item/3wg7h4rg

10. The Medial-Transverse Approach for IJ Vein Cannulation: An Example of Lateral Thinking

Ho AM, et al. J Emerg Med. 2012;42:174-177.

Background: Cannulation of the internal jugular vein (IJV) is traditionally performed using the central-longitudinal approach. Pneumothorax, carotid artery puncture, and failure to cannulate are uncommon, but by no means rare, complications. Ultrasound (US) guidance for IJV cannulation has reduced but not eliminated such complications.

Technique: We herein introduce a new approach, coined the “medial-transverse approach” due to the perpendicular angle at which the introducer needle is advanced toward the IJV from the median to lateral direction.

Discussion: The direction of the introducer needle is not toward the lung, thus virtually eliminating the possibility of pneumothorax. The image of the entire needle is seen when the US probe is typically orientated for a short-axis view of the IJV and carotid artery, thus improving the chance of uncomplicated IJV puncture. We have used this technique with apparent success in thousands of cases over the past 20 years in two different institutions.

Conclusion: A modified IJV cannulation technique that seems to have unique advantages over traditional approaches has been described. This technique is compatible with the blind and US-guided approaches.

11. Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus

Silbergleit R, et al. for the NETT Investigators. N Engl J Med 2012; 366:591-600.

Background: Early termination of prolonged seizures with intravenous administration of benzodiazepines improves outcomes. For faster and more reliable administration, paramedics increasingly use an intramuscular route.

Methods: This double-blind, randomized, noninferiority trial compared the efficacy of intramuscular midazolam with that of intravenous lorazepam for children and adults in status epilepticus treated by paramedics. Subjects whose convulsions had persisted for more than 5 minutes and who were still convulsing after paramedics arrived were given the study medication by either intramuscular autoinjector or intravenous infusion. The primary outcome was absence of seizures at the time of arrival in the emergency department without the need for rescue therapy. Secondary outcomes included endotracheal intubation, recurrent seizures, and timing of treatment relative to the cessation of convulsive seizures. This trial tested the hypothesis that intramuscular midazolam was noninferior to intravenous lorazepam by a margin of 10 percentage points.

Results: At the time of arrival in the emergency department, seizures were absent without rescue therapy in 329 of 448 subjects (73.4%) in the intramuscular-midazolam group and in 282 of 445 (63.4%) in the intravenous-lorazepam group (absolute difference, 10 percentage points; 95% confidence interval, 4.0 to 16.1; P less than 0.001 for both noninferiority and superiority). The two treatment groups were similar with respect to need for endotracheal intubation (14.1% of subjects with intramuscular midazolam and 14.4% with intravenous lorazepam) and recurrence of seizures (11.4% and 10.6%, respectively). Among subjects whose seizures ceased before arrival in the emergency department, the median times to active treatment were 1.2 minutes in the intramuscular-midazolam group and 4.8 minutes in the intravenous-lorazepam group, with corresponding median times from active treatment to cessation of convulsions of 3.3 minutes and 1.6 minutes. Adverse-event rates were similar in the two groups.

Conclusions: For subjects in status epilepticus, intramuscular midazolam is at least as safe and effective as intravenous lorazepam for prehospital seizure cessation. (Funded by the National Institute of Neurological Disorders and Stroke and others; ClinicalTrials.gov number, ClinicalTrials.gov NCT00809146.)

12. Amoxicillin for Acute Rhinosinusitis: As Good as Placebo—but More Expensive

A Randomized Controlled Trial

Garbutt JM, et al. JAMA 2012; 307(7):685-692.

Context Evidence to support antibiotic treatment for acute rhinosinusitis is limited, yet antibiotics are commonly used.

Objective To determine the incremental effect of amoxicillin treatment over symptomatic treatments for adults with clinically diagnosed acute rhinosinusitis.

Design, Setting, and Participants A randomized, placebo-controlled trial of adults with uncomplicated, acute rhinosinusitis were recruited from 10 community practices in Missouri between November 1, 2006, and May 1, 2009.

Interventions Ten-day course of either amoxicillin (1500 mg/d) or placebo administered in 3 doses per day. All patients received a 5- to 7-day supply of symptomatic treatments for pain, fever, cough, and nasal congestion to use as needed.

Main Outcome Measures The primary outcome was improvement in disease-specific quality of life after 3 to 4 days of treatment assessed with the Sinonasal Outcome Test-16 (minimally important difference of 0.5 units on a 0-3 scale). Secondary outcomes included the patient's retrospective assessment of change in sinus symptoms and functional status, recurrence or relapse, and satisfaction with and adverse effects of treatment. Outcomes were assessed by telephone interview at days 3, 7, 10, and 28.

Results A total of 166 adults (36% male; 78% with white race) were randomized to amoxicillin (n = 85) or placebo (n = 81); 92% concurrently used 1 or more symptomatic treatments (94% for amoxicillin group vs 90% for control group; P = .34). The mean change in Sinonasal Outcome Test-16 scores was not significantly different between groups on day 3 (decrease of 0.59 in the amoxicillin group and 0.54 in the control group; mean difference between groups of 0.03 [95% CI, −0.12 to 0.19]) and on day 10 (mean difference between groups of 0.01 [95% CI, −0.13 to 0.15]), but differed at day 7 favoring amoxicillin (mean difference between groups of 0.19 [95% CI, 0.024 to 0.35]). There was no statistically significant difference in reported symptom improvement at day 3 (37% for amoxicillin group vs 34% for control group; P = .67) or at day 10 (78% vs 80%, respectively; P = .71), whereas at day 7 more participants treated with amoxicillin reported symptom improvement (74% vs 56%, respectively; P = .02). No between-group differences were found for any other secondary outcomes. No serious adverse events occurred.

Conclusion Among patients with acute rhinosinusitis, a 10-day course of amoxicillin compared with placebo did not reduce symptoms at day 3 of treatment.

13. Omental Infarction: Case Series and Review of the Literature

Park TU, et al. J Emerg Med. 2012;42:149-154.

Background: Omental infarction is a rare disease entity that can cause acute or subacute abdominal pain. In the past, it was thought that omental infarction mainly occurred on the right side because it was detected when surgery was performed on patients who complained of abdominal pain on the right side.

Objective: We present this case to demonstrate that omental infarction can occur at any site, including the epigastric area and the lower abdomen, and even on the left side where the greater omentum is located.

Case Report: Four patients with omental infarction presented to the Emergency Department with various clinical symptoms. All of them were diagnosed by computed tomography scan. Omental infarction occurred on the right side in 2 patients, at the epigastric area in 1 patient, and on the left side in 1 patient. Three were improved with supportive care. Laparoscopy was performed in 1 patient because his abdominal pain persisted despite conservative treatment.

Conclusion: Omental infarction should be included in the differential diagnosis list of acute abdominal pain because it can occur at any site. In addition, because this disease runs a self-limited course, conservative care is recommended. Thus, unnecessary operations can be avoided in cases where omental infarction is diagnosed by imaging studies.

14. Rates of Positive Blood, Urine, and CSF Cultures in Children Younger Than 60 Days during the Vaccination Era

Morley EJ, et al. Pedatr Emerg Care 2012;28:125-130.

Background: Fever is a common reason children present to the emergency department. The goal of this study was to determine the rates and the etiology of bacterial infection in children younger than 2 months during the vaccination era.

Methods: This is a retrospective chart review performed at a tertiary care hospital. Electronic medical records were used to identify patients who had a workup for fever/sepsis in the emergency department. The search was limited to identifying only children younger than 60 days.

Results: A total of 207 patients satisfied the inclusion/exclusion criteria. In children younger than 28 days, the blood culture–positive rate was 2.7% (range, 0.0%–6.4%), the urine culture–positive rate was 10.7% (range, 3.5%–17.8%), and the cerebrospinal fluid–positive rate (excluding enteroviral infections) was 0% (range, 0.0%–3.9%). In children 29 to 60 days, the blood culture–positive rate was 1.5% (range, 0.0%–3.6%), urine culture–positive rate was 8.5% (range, 3.7%–13.3%), and the cerebrospinal fluid–positive rate (excluding enteroviral infections) was 1.7% (range, 0.0%–5.0%). Urinary tract infections due to Escherichia coli were very common, whereas no cases of Haemophilus influenzae and one case of Streptococcus pneumoniae were detected.

Conclusions: Urinary tract infections due to E. coli are very common in this age group. The classic pathogens H. influenzae and S. pneumoniae were essentially nonexistent in this study possibly because of herd immunity obtained through current vaccination practices.

15. What’s New? Exuberance for Novelty Has Benefits

By JOHN TIERNEY. New York Times. Published: February 13, 2012

Do you make decisions quickly based on incomplete information? Do you lose your temper quickly? Are you easily bored? Do you thrive in conditions that seem chaotic to others, or do you like everything well organized?

Those are the kinds of questions used to measure novelty-seeking, a personality trait long associated with trouble. As researchers analyzed its genetic roots and relations to the brain’s dopamine system, they linked this trait with problems like attention deficit disorder, compulsive spending and gambling, alcoholism, drug abuse and criminal behavior.

Now, though, after extensively tracking novelty-seekers, researchers are seeing the upside. In the right combination with other traits, it’s a crucial predictor of well-being…

The remainder of the article: http://www.nytimes.com/2012/02/14/science/novelty-seeking-neophilia-can-be-a-predictor-of-well-being.html

16. Value of a rigid collar in addition to head blocks may be unnecessary

Holla M. Emerg Med J 2012;29:104-107.

Background All trauma patients with a cervical spinal column injury or with a mechanism of injury with the potential to cause cervical spinal injury should be immobilised until a spinal injury is excluded. Immobilisation of the entire patient with a rigid cervical collar, backboard, head blocks with tape or straps is recommended by the Advanced Trauma Life Support guidelines. However there is insufficient evidence to support these guidelines.

Objective To analyse the effects on the range of motion of the addition of a rigid collar to head blocks strapped on a backboard.

Method The active range of motion of the cervical spine was determined by computerised digital dual inclinometry, in 10 healthy volunteers with a rigid collar, head blocks strapped on a padded spine board and a combination of both. Maximal opening of the mouth with all types of immobiliser in place was also measured.

Results The addition of a rigid collar to head blocks strapped on a spine board did not result in extra immobilisation of the cervical spine. Opening of the mouth was significantly reduced in patients with a rigid collar.

Conclusion Based on this proof of principle study and other previous evidence of adverse effects of rigid collars, the addition of a rigid collar to head blocks is considered unnecessary and potentially dangerous. Therefore the use of this combination of cervical spine immobilisers must be reconsidered.

17. Reversal of warfarin-induced hemorrhage in the ED

Zareh M, et al. West J Emerg Med. 2011 Nov;12(4):386-92.

Warfarin, an oral vitamin K antagonist, is used to prevent arterial and venous thromboembolism in patients suffering from a multitude of diseases. In 2004, 31 million warfarin prescriptions were dispensed in the United States. Warfarin inhibits the activation of the vitamin K-dependent clotting factors (Factors II, VII, IX, and X) and regulatory proteins (proteins C, S, and Z). It is one of the leading drugs implicated in emergency room visits for adverse drug reactions. Annually the frequency of bleeding complications associated with overanticoagulation is 15% to 20%, with fatal bleeds measuring as high as 1% to 3%.

The most effective method of warfarin reversal involves the use of Four Factor Prothrombin Complex Concentrate (PCC), which is widely used throughout Europe but is unavailable in the United States. The current therapies available to emergency room physicians in the United States are fresh frozen plasma, recombinant Factor VIIa (rFVIIa), Factor Eight Inhibitory Bypassing Activity, or Three Factor PCC concomitantly administered with vitamin K. We review the advantages and disadvantages of these therapies and recommend Three Factor PCC with small doses of rFVIIa and with vitamin K in life-threatening situations if Four Factor PCC is unavailable.

Full-text (free): http://www.escholarship.org/uc/item/12f3z5c9#page-1

18. Images in Clinical Medicine

Post-Traumatic Herniated Cervical Disk
http://www.nejm.org/doi/full/10.1056/NEJMicm1111194

Deep Sulcus Sign
http://www.nejm.org/doi/full/10.1056/NEJMicm1105315

Pyogenic Granuloma of the Finger
http://www.nejm.org/doi/full/10.1056/NEJMicm1107409

‘Where am I?’ – An unusual stroke presentation
http://casereports.bmj.com/content/2012/bcr.12.2011.5296.full

Vernal Keratoconjunctivitis
http://www.nejm.org/doi/full/10.1056/NEJMicm1014624

Lingual Raynaud’s Phenomenon
http://www.nejm.org/doi/full/10.1056/NEJMicm1104140

Facial Swelling
http://www.annemergmed.com/article/S0196-0644(11)00715-3/fulltext

A Case of a Painful Swollen Leg
http://www.annemergmed.com/article/S0196-0644(11)00654-8/fulltext

19. Managing ED Patients with Recent-onset A Fib/Flutter: Cardioversion Safe and Effective

Vinson DR, et al. J Emerg Med. 2012;42(2):139-148.

BACKGROUND: The management of emergency department (ED) patients with presumed recent-onset atrial fibrillation or flutter less than 48h in duration varies widely.

OBJECTIVE AND METHOD: We conducted a prospective study across three affiliated community EDs within a large integrated health care delivery system to describe the management of patients with recent-onset atrial fibrillation or flutter, to determine the safety and effectiveness of ED cardioversion, and to measure the incidence of thromboembolism 30 days after discharge.

RESULTS: We enrolled 206 patients with convenience sampling between June 2005 and November 2007. Mean age was 64.0+/-14.4 years (range 21-96 years). Patients were grouped for analysis into four categories based on whether cardioversion was 1) spontaneous in the ED (59; 28.6%); 2) attempted with electrical or pharmacological means (115; 56.3%), with success in 110 (95.7%); 3) hoped for during a short stint of home observation (16; 7.8%, 11 of which spontaneously converted to sinus rhythm within 24h); or 4) contraindicated (16; 7.8%). Of the entire group, 183 (88.8%) patients were discharged home. Adverse events requiring ED interventions were reported in 6 (2.9%; 95% confidence interval [CI] 1.1-6.2%) patients, all of whom recovered. Two (1.0%; 95% CI 0.1-3.5%) patients were found to have an embolic event on 30-day follow-up.

CONCLUSIONS: Our approach to ED patients with presumed recent-onset atrial fibrillation or flutter seems to be safe and effective, with a high rate of cardioversion and discharge to home coupled with a low ED adverse event and 30-day thromboembolic event rate.

20. The Sufficiency of EM Physician Documentation of AMA Encounters

Monico EP. Emergency Medicine 2011, 1:e106. doi: 10.4172/egm.1000e106

A great deal of ambiguity exists among emergency medicine (EM) physicians regarding how to document against medical advice (AMA) encounters in the emergency department (ED) setting. In our own institution this ambiguity surfaces as inconsistent and eclectic documentation of patients terminating their evaluation and/ or treatment prematurely. This ambiguity suggests (EM) residency programs fail to educate EM physicians-in-training in the area of AMA encounters and the importance of this emergency patient population in the context of the extant EM climate. The Open Access Initiative provides an ideal venue to distribute information and supports efforts to establish uniformity in the provision of certain aspects of EM care, such as documentation of AMA encounters.

Emergency department overcrowding, healthcare manpower shortages, and lack of healthcare access have created novel quality and safety challenges not previously examined in US healthcare systems. Patients who leave before the conclusion of diagnostic and treatment modalities represent a failure of emergency healthcare [1]. These visits are used as a marker of ED crowding and have indirectly been linked to delays in treatment, [2-4] higher complication rates, [5] and increased mortality [6]. As such, the proportion of these visits has been proposed by the Joint Commission and Centers for Medicare and Medicaid Services (CMS) as hospital quality indicators [7]. Patients who leave the EM AMA represent a subset of this population and carry the same increased risk of morbidity and mortality [8,9].

In 2003, CMS mandated that the documentation of refusal to treat should include proof that patients had “been informed of the risks and benefits of the examination or treatment, or of both” [10]. The extent to which emergency physicians are aware of documentation requirements memorializing AMA encounters has never been formally addressed in the EM literature. Heretofore, the AMA literature focused on the identification of at-risk populations and demonstrated that middleage, impoverished, poorly–insured, males make up the lion share of this population.

A retrospective, year-long audit of ED AMA-encounters was conducted at our own institution between January 1 and December 31, 2010. During that time, four-hundred-and-eighteen patients left the ED AMA. The audit revealed 22.0% of EM-physicians documented patient capacity; (b) 34.9% documented extent or limitations of the evaluation; (c) 34.4% documented patient understanding of the diagnosis; (d) 43.1% documented physician concerns; (e) 66.7% documented the risks and benefits of leaving prematurely; (f) 5.8% documented alternative treatment or diagnostic options; (g) 97.8% explicitly documented that the patient left AMA; (h) 11.2% documented an opportunity to ask questions, 73.2% documented a follow-up care plan, and 68.9% documented that discharge instructions were received. In summary, we found that EM physicians sufficiently documented that patients left the ED AMA, but faired poorly in documenting other aspects of the encounter.

Critiques may argue that clinical demands prevent achieving the level of documentation suggested in our audit or that documentation advice aligns itself more closely with legal manoeuvres than with medical practice. However, these assertions, historically, do not tip scales in their favour when compared to the weight of federal mandates, standard of care requirements or professional liability threats. It remains unclear whether electronic medical records will facilitate AMA documentation compliance or further complicate the issue.

An effective and efficient standardization of the ED AMA encounter needs to be established to comport with federal and national documentation requirement. Future efforts in this area will include educating providers on AMA encounters, quality and safety risks, measuring the sufficiency of information received after this education, and comparing patient outcomes before and after these interventions.

Further multi-center studies are required to determine the extent of the problem, ascertain regional variations and attempt to uncover commonalities. If our audit forecasts the nature of AMA documentation in the U.S., these results demonstrate that physicians are not conducting AMA encounters according to quality and safety domains set forth by oversight institutions. Without appropriate documentation, it may be assumed that patients are ill-informed when deciding to leave the ED AMA.

Healthcare institutions should be cognisant of disparities between AMA documentation requirements enforced by oversight agencies and the documentation practices of EM physicians in their institution. Conformation to these requirements begins with the threshold determination of the sufficiency of extant documentation practices.

References (and full-text, free): http://omicsgroup.org/journals/EGM/EGM-1-e106.php

21. By the Sword: The Science (and Medical Complications) of Sword-Swallowing

By Jennifer Ouellette January 25, 2012 Scientific American

For all its long history, very few published reports exist of related injuries from the practice of shoving sharp steel blades down one’s throat — perhaps because there are only a little more than 100 sword swallowers worldwide, out of a population of some 6.6 billion people. That’s why Witcombe and Meyer set out to explore the various techniques and side effects of sword swallowing.

Forty-six Sword Swallowers Association International members participated in the study, having swallowed a combined 2000 swords over the prior three months. More than half (25) had swallowed more than one, five managed to swallow at least ten swords at a time, and one person achieved the whopping feat of swallowing 16 swords simultaneously.

A news release last December reported that Witcombe and Meyer found, “Sword swallowers are more likely to sustain an injury — such as a perforation of the esophagus — if they are distracted or are using multiple or unusual swords.”

Mostly, the respondents suffered from a sore throat (or as they call it, “sword throat,” such wags, those guys), generally from the multiple sword stunts, or swallowing odd-shaped blades such as curved sabers rather than straight ones. Lower chest pains were another common complaint — the only remedy being not swallowing any swords for a few days.

Sixteen had suffered some form of intestinal bleeding, and three had undergone surgery to repair injuries to their necks. One lacerated his pharynx, another slashed his esophagus — he claimed to have been distracted by a misbehaving macaw on his shoulder — and one unfortunate belly dancer suffered a major hemorrhage when three blades lodged in her esophagus unexpectedly “scissored,” after an appreciative bystander shoved some dollar bills in her belt. His donation didn’t come close to covering her medical expenses, which came close to $70,000. Not surprisingly, most sword swallowers have higher than average health care and medical costs. All it takes it one tiny slip-up, after all.

These injuries are quite real, and quite serious, because unlike many other sideshow novelty acts, sword swallowing is not a magician’s illusion — although there is a trick to it (more on that later). As the x-ray image above attests, sword swallowers really do maneuver that sharp metal blade down the hatch, past all kinds of vital organs…

The complete article (free): http://blogs.scientificamerican.com/cocktail-party-physics/2012/01/25/by-the-sword-the-science-of-sword-swallowing/

Lit Bits: Feb 4, 2012

From the recent medical literature...

1. Intracerebral Hemorrhage with Thrombolytic Therapy for Acute Pulmonary Embolism

Stein PD, et al. Amer J Med 2012;125:50-56.

Background: Intracranial hemorrhage is one of the dreaded complications of thrombolytic therapy for acute pulmonary embolism. We identified patients with pulmonary embolism who may be at relatively high risk of intracerebral hemorrhage from those selected for thrombolytic therapy by their physicians and presumably thought to be of reasonable risk.

Methods: The number of patients discharged from short-stay hospitals in the United States from 1998 to 2008 with pulmonary embolism who received thrombolytic therapy and the proportion with intracerebral hemorrhage were determined from the Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.

Results: From 1998 to 2008, 2,237,600 patients were discharged with a diagnosis of pulmonary embolism. Among patients who received thrombolytic therapy for pulmonary embolism, the prevalence of intracerebral hemorrhage was 430 of 49,500 (0.9%). The prevalence increased linearly with age more than 10 years. Intracerebral hemorrhage was less frequent in those with a primary diagnosis of pulmonary embolism (250/39,300 [0.6%]) than in those with a secondary diagnosis (180/10,300 [1.7%], P<.0001). The prevalence of intracerebral hemorrhage was lower in patients aged 65 years or less with no kidney disease (90/16,900 [0.5%]) than in patients aged more than 65 years or with kidney disease (290/20,900 [1.4%], P<.0001). The prevalence remained lower in those with a primary diagnosis (90/23,000 [0.4%] than in those with a secondary diagnosis (50/5700 [0.9%], P<.0001).

Conclusion: The cause of intracerebral hemorrhage in patients with pulmonary embolism who receive thrombolytic therapy seems to be multifactorial and related to comorbidity and age.

Full-text (free): http://www.amjmed.com/article/S0002-9343(11)00631-0/fulltext

2. Normalization of Vital Signs Does Not Reduce the Probability of Acute PE in Symptomatic ED Patients

Kline JA, et al. Acad Emerg Med 2012;19:11-17.

Objectives:  In a patient with symptoms of pulmonary embolism (PE), the presence of an elevated pulse, respiratory rate, shock index, or decreased pulse oximetry increases pretest probability of PE. The objective of this study was to evaluate if normalization of an initially abnormal vital sign can be used as evidence to lower the suspicion for PE.

Methods:  This was a prospective, noninterventional, single-center study of diagnostic accuracy conducted on adults presenting to an academic emergency department (ED), with at least one predefined symptom or sign of PE and one risk factor for PE. Clinical data, including the first four sets of vital signs, were recorded while the patient was in the ED. All patients underwent computed tomography pulmonary angiography (CTPA) and had 45-day follow-up as criterion standards. Diagnostic accuracy of each vital sign (pulse rate, respiratory rate, shock index, pulse oximetry) at each time was examined by the area under the receiver operating characteristic curve (AUC).

Results:  A total of 192 were enrolled, including 35 (18%) with PE. All patients had vital signs at triage, and 174 (91%), 135 (70%), and 106 (55%) had second to fourth sets of vital signs obtained, respectively. The initial pulse oximetry reading had the highest AUC (0.63, 95% confidence interval [CI] = 0.50 to 0.76) for predicting PE, and no other vital sign at any point had an AUC over 0.60. Among patients with an abnormal pulse rate, respiratory rate, shock index, or pulse oximetry at triage that subsequently normalized, the prevalences of PE were 18, 14, 19, and 33%, respectively.

Conclusions:  Clinicians should not use the observation of normalized vital signs as a reason to forego objective testing for symptomatic patients with a risk factor for PE.

3. Kaiser Permanente's performance improvement system, part 3: multisite improvements in care for patients with sepsis.

Whippy A, et al. Jt Comm J Qual Patient Saf. 2011 Nov;37(11):483-93.

BACKGROUND: In 2008, Kaiser Permanente Northern California implemented an initiative to improve sepsis care. Early detection and expedited implementation of sepsis treatment bundles that include early goal-directed therapy (EGDT) for patients with severe sepsis were implemented.

METHODS: In a top-down, bottom-up approach to performance improvement, teams at 21 medical centers independently decided how to implement treatment bundles, using a "playbook" developed by rapid cycle pilot testing at two sites and endorsed by a sepsis steering committee of regional and medical center clinical leaders. The playbook contained treatment algorithms, standardized order sets and flow charts, best practice alerts, and chart abstraction tools. Regional mentors and improvement advisers within the medical centers supported team-building and rapid implementation. Timely and actionable data allowed ongoing identification of improvement opportunities. A consistent approach to performance improvement propelled local rapid improvement cycles and joint problem solving across facilities.

RESULTS: The number of sepsis diagnoses per 1,000 admissions increased from a baseline value of 35.7 in July 2009 to 119.4 in May 2011. The percent of admitted patients who have blood cultures drawn who also have a serum lactate level drawn increased from a baseline of 27% to 97% in May 2011. The percent of patients receiving EGDT who had a second and lower lactate level within six hours increased from 52% at baseline to 92% in May 2011.

CONCLUSION: Twenty-one cross-functional frontline teams redesigned processes of care to provide regionally standardized, evidence-based treatment algorithms for sepsis, substantially increasing the identification and risk stratification of patients with suspected sepsis and the provision of a sepsis care bundle that included EGDT.

4. Paramedics Needn't Stand to Do CPR in a Moving Ambulance (thank goodness!)

By Rob Goodier. NEW YORK (Reuters Health) Jan 17 - Rescuers performing chest compressions in a moving ambulance should sit down instead of standing, experts now advise.

A recent trial showed that paramedics can do chest compressions comparably well in both positions, but they themselves are safer when they are seated with seat belts. Researchers had 14 emergency medical technicians and paramedics perform cardiopulmonary resuscitation (CPR) on a manikin in a moving ambulance, 150 chest compressions in both seated and standing positions.

While seated, the average compression depth was 1.97 inches at an average rate of 120 per minute, with 92% full chest recoil. While standing, the average compression depth was 2.18 inches at a rate of 123 per minute with 82% full recoil.

The differences in depth and recoil were not statistically significant, and the quality of the compressions was nearly equal, according to a presentation January 13 at the annual meeting of the National Association of EMS Physicians in Tucson, Arizona.

Chad Panke, a paramedic who led the study at American Medical Response in Los Angeles, told Reuters Health by email that participants "overwhelmingly preferred standing before the study," but after participating in the study (and before the results were known) they reported feeling safer and more controlled sitting down.

"The participants reported during turns they felt the standing position caused them to compress too deep and they felt more controlled seated," Panke said.

Dr. Jon Studnek, Director of Prehospital Research at Carolinas Medical Center in Charlotte, North Carolina, who was not involved in this study, told Reuters Health in an email, "Inherently in EMS there are tasks that are performed, such as CPR in the back of a moving ambulance, that place providers at greater risk of injury. This risk must be balanced with providing appropriate care to patients."

The results may have been limited by the small sample size and the short duration of the ambulance ride, the researchers write. More volunteers giving CPR over a longer time might have provided insight into how physical conditioning, height and weight can affect the compressions. Limitations notwithstanding, the results show how to strike the balance between risk to rescuers and quality care for patients, said Dr. Studnek, who also chairs the NAEMSP research committee.

"This abstract demonstrates how research in EMS can be utilized to both improve provider safety and maintain good patient care," he said.

Based on the results, American Medical Response is considering making changes to their ambulances to accommodate seated CPR. They may add an elevated seat that slides forward and has a harness-style seat belt, Panke says.

"This will allow the rescuer to remain seated and restrained in a manner that delivers quality chest compressions," Panke says. For now, he and his colleagues conclude, "When it is necessary to provide CPR in a moving vehicle, the ability to secure the rescuer in the sitting position makes it the preferred position."

5. Performance of the Canadian CT Head Rule and the New Orleans Criteria for Predicting Any Traumatic Intracranial Injury on Computed Tomography in a United States Level I Trauma Center

Papa L, Stiell IG, et al. Acad Emerg Med 2012;19:2-10.

Objectives:  This study compared the clinical performance of the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) for detecting any traumatic intracranial lesion on computed tomography (CT) in patients with a Glasgow Coma Scale (GCS) score of 15. Also assessed were ability to detect patients with “clinically important” brain injury and patients requiring neurosurgical intervention. Additionally, the performance of the CCHR was assessed in a larger cohort of those presenting with GCS of 13 to 15.

Methods:  This prospective cohort study was conducted in a U.S. Level I trauma center and enrolled a consecutive sample of mildly head-injured adults who presented to the emergency department (ED) with witnessed loss of consciousness, disorientation or amnesia, and GCS 13 to 15. The rules were compared in the group of patients with GCS 15. The primary outcome was prediction of “any traumatic intracranial injury” on CT. Secondary outcomes included “clinically important brain injury” on CT and need for neurosurgical intervention.

Results:  Among the 431 enrolled patients, 314 patients (73%) had a GCS of 15, and 22 of the 314 (7%) had evidence of a traumatic intracranial lesion on CT. There were 11 of 314 (3.5%) who had “clinically important” brain injury, and 3 of 314 (1.0%) required neurosurgical intervention. The NOC and CCHR both had 100% sensitivity (95% confidence interval [CI] = 82% to 100%), but the CCHR was more specific for detecting any traumatic intracranial lesion on CT, with a specificity of 36.3% (95% CI = 31% to 42%) versus 10.2% (95% CI = 7% to 14%) for NOC. For “clinically important” brain lesions, the CCHR and the NOC had similar sensitivity (both 100%; 95% CI = 68% to 100%), but the specificity was 35% (95% CI = 30% to 41%) for CCHR and 9.9% (95% CI = 7% to 14%) for NOC. When the rules were compared for predicting need for neurosurgical intervention, the sensitivity was equivalent at 100% (95% CI = 31% to 100%) but the CCHR had a higher specificity at 80.7% (95% CI = 76% to 85%) versus 9.6% (95% CI = 7% to 14%) for NOC. Among all 431 patients with a GCS score 13 to 15, the CCHR had sensitivities of 100% (95% CI = 84% to 100%) for 27 patients with clinically important brain injury and 100% (95% CI = 46% to 100%) for five patients requiring neurosurgical intervention.

Conclusions:  In a U.S. sample of mildly head-injured patients, the CCHR and the NOC had equivalently high sensitivities for detecting any traumatic intracranial lesion on CT, clinically important brain injury, and neurosurgical intervention, but the CCHR was more specific. A larger cohort will be needed to validate these findings.

6. Clot Busters May be OK for 'Wake-Up' Strokes

By Todd Neale, Senior Staff Writer, MedPage Today . Published: February 02, 2012

Manawadu D, et al "Thrombolysis in selected patients with wake-up stroke is feasible with similar safety as thrombolysis in 0 to 4.5 hours" American Stroke Association's International Stroke Conference 2012; Abstract 56.

This study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal. The study found that patients who wake up with stroke symptoms that weren't present when they fell asleep can safely receive thrombolytic treatment with tissue plasminogen activator (tPA), even though the stroke onset time is unknown. At 90 days, there were no between-group differences in rates of any intracerebral hemorrhage or symptomatic intracerebral hemorrhage.

NEW ORLEANS -- Patients who wake up with stroke symptoms that weren't present when they fell asleep can safely receive thrombolytic treatment with tissue plasminogen activator (tPA), even though the stroke onset time is unknown, a British study suggested.
In a non-randomized study, patients with a so-called "wake-up" stroke who had clinical signs and CT scans indicating only early ischemic changes had outcomes following thrombolysis similar to patients with a known symptom onset time, according to Dulka Manawadu, MD, of King's College London.

"I think the time is now right to prospectively randomize these patients with wake-up strokes into trials of thrombolysis," she reported at the American Stroke Association's International Stroke Conference here.

Steven Greenberg, MD, PhD, a neurologist at Harvard Medical School, said another approach, in addition to randomizing patients to tPA or no tPA, would be to use imaging to select patients who would most benefit from thrombolysis.

"It's exciting to think that one or the other will widen the pool of people who can benefit from clot-busting treatments," said Greenberg, who moderated a press briefing at which the results were presented.

Thrombolytic therapy has been shown to improve outcomes in patients with ischemic strokes when used within 4.5 hours of symptom onset, but use of tPA remains low. Partly explaining the low use is that for up to one-quarter of patients, the stroke onset time is not known, including for patients with wake-up strokes.

Clinicians are hesitant to use tPA outside the 4.5-hour window because of the possibility of increasing the risk of intracerebral hemorrhage without improving outcomes.

On the other hand, patients with wake-up strokes who are not treated have poor outcomes. Previous studies have shown that these patients have clinical and imaging characteristics similar to patients with a known stroke onset time and that about one-third would be eligible for tPA.

Manawadu and colleagues performed a retrospective study to examine whether tPA could be safely used in patients with wake-up stroke. They compared outcomes in 326 patients with a known symptom onset time who were treated within the recommended 4.5-hour window with 68 patients who woke up with stroke symptoms and were treated with tPA when CT scans revealed no or early ischemic changes.

At baseline, all of the patients had an NIH Stroke Scale (NIHSS) score of 5 or greater (mean 13.4 in the reference group and 12.6 in the wake-up group). The average age was about 73 in both groups. There was a greater proportion of men in the reference group, but the vascular risk profile was similar.

Within the first 24 hours, the NIHSS score improved to a greater extent in the wake-up group, resulting in a significantly lower score (7.2 versus 11.5, P=0.001). At 90 days, there were no between-group differences in rates of any intracerebral hemorrhage (20% in the reference group versus 22% in the wake-up group), symptomatic intracerebral hemorrhage (3.4% versus 2.9%), a modified Rankin Scale score of 0-1 (23.6% versus 16.2%), and a modified Rankin Scale score of 0-2 (38% versus 37%).

Mortality tended to be lower in the wake-up group (15% versus 26%, P=0.06), although Manawadu said that likely reflects inadvertent selection bias in the use of thrombolysis for those patients. The findings were similar in an analysis restricted to patients 80 and younger.

Lee Schwamm, MD, a neurologist at Massachusetts General Hospital in Boston and an American Heart Association spokesperson, said only a fraction of patients who receive thrombolytic therapy are treated outside of the 4.5-hour window, but that it is appropriate in certain situations, including when clinical and imaging characteristics indicate that a patient with a wake-up stroke has minimal ischemic damage.

"Physicians are allowed to use drugs in an off-label manner once they're FDA approved for a specific indication, and this seems like a very appropriate use," he said.

The assumption, he said, is that the stroke occurred shortly before the patient woke up. "That's why if all the other components are reassuring and its simply this question of an unobtainable time of onset then thrombolysis is reasonable." Still, Schwamm echoed Manawadu's call for randomized studies.

7. Propofol Saves Time for Orthopedic ED Procedures

And, it is as effective as midazolam/ketamine for procedural sedation in adults.

Uri O et al. J Bone Joint Surg Am 2011 Dec 21; 93:2255

Background: The use of procedural sedation and analgesia to allow painful orthopaedic manipulations in the emergency department has become a standard practice over the last decade. Both propofol and midazolam/ketamine are attractive sedative regimens for routine use in the emergency department. We hypothesized that sedation with propofol as compared with midazolam/ketamine will save time in the emergency department. The purpose of the present study was to compare the recovery time, the total sedation time, and the adverse events of procedural sedation and analgesia induced with propofol as compared with midazolam/ketamine.

Methods: This prospective randomized study was conducted in the emergency department of a tertiary care, university-affiliated medical center. All sedations and orthopaedic manipulations were performed by trained and approved orthopaedic residents assisted by a registered nurse according to the same protocol. Sedation time and adverse events were recorded in real time.

Results: Sixty adults (thirty-five men and twenty-five women) with a mean age (and standard deviation) of 45 ± 17 years were randomly enrolled in the study, with thirty patients being managed with each regimen. The average recovery time was 7.8 ± 3.7 minutes following sedation with propofol, compared with 30.7 ± 10.1 minutes following sedation with midazolam/ketamine (p < 0.001). The average total sedation time was 16.2 ± 3.8 minutes for the propofol group, compared with 41.6 ± 10.7 minutes for the midazolam/ketamine group (p < 0.001). The overall rate of respiratory and hemodynamic adverse events was 20% for the propofol group and 10% for the midazolam/ketamine group.

Conclusions: The use of propofol for an orthopaedic procedure requiring sedation in the emergency department expedites patient management and saves time in comparison with the use of midazolam/ketamine.

8. Symptoms May Say Sinusitis, but Scans Disagree

Infection and even inflammation were not reliably present in the scans of patients with classic sinusitis symptoms.

Ferguson BJ, et al. Prospective observational study of chronic rhinosinusitis: environmental triggers and antibiotic implications. Clin Infect Dis. 2012 Jan;54(1):62-8.

BACKGROUND: A prolonged course of antibiotic therapy is often initiated for chronic rhinosinusitis (CRS) based on symptomatology. We examined differences in clinical manifestations and underlying conditions in patients with symptoms typical for CRS. CT scan abnormality of the sinuses was the gold standard for diagnosis of CRS.

METHODS: We performed a prospective observational study of 125 adults with classic symptoms of CRS undergoing nasal endoscopy and sinus CT.

RESULTS: The patients were classified into 2 groups: (1) those with radiographic evidence of sinusitis by CT (Sx + CT) (75) and (2) those with normal CT scans of the sinus (Sx - CT) (50). Decreased smell was significantly more common in Sx + CT than in Sx - CT patients, (P = .003). Paradoxically, headache, facial pain, and sleep disturbance occurred significantly more frequently in patients with Sx - CT than in patients with Sx + CT (P < .05). The absence of mucopurulence on endoscopy proved to be highly specific for Sx - CT patients (100%). On the other hand, sensitivity was low; only 24% of Sx + CT patients demonstrated mucopurulence by endoscopy. Improvement in response to antibiotics was similar between both CRS categories.

CONCLUSIONS: Most symptoms considered to be typical for CRS proved to be nonspecific. Interestingly, symptoms that were more severe were significantly more likely to occur in younger patients who were Sx - CT. The efficacy of antibiotic therapy was uncertain. We suggest that objective evidence of mucopurulence assessed by endoscopy or CT should be obtained if antibiotics are to be given for prolonged duration. We recommend a moratorium for the widespread practice of a prolonged course of empiric antibiotics in patients with presumed CRS.

9. Association of ED Length of Stay with Safety-Net Status

Fee C, et al, JAMA 2012;307(5):476-482.

Context Performance measures, particularly pay for performance, may have unintended consequences for safety-net institutions caring for disproportionate shares of Medicaid or uninsured patients. Objective To describe emergency department (ED) compliance with proposed length-of-stay measures for admissions (8 hours or 480 minutes) and discharges, transfers, and observations (4 hours or 240 minutes) by safety-net status.

Design, Setting, and Participants The 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS) ED data were stratified by safety-net status (Centers for Disease Control and Prevention definition) and disposition (admission, discharge, observation, transfer). The 2008 NHAMCS is a national probability sample of 396 hospitals (90.2% unweighted response rate) and 34 134 patient records. Visits were excluded for patients younger than 18 years, missing length-of-stay data or dispositions of missing, other, left against medical advice, or dead on arrival. Median and 90th percentile ED lengths of stay were calculated for each disposition and admission/discharge subcategories (critical care, psychiatric, routine) stratified by safety-net status. Multivariable analyses determined associations with length-of-stay measure compliance.

Main Outcome Measures Emergency Department length-of-stay measure compliance by disposition and safety-net status.

Results Of the 72.1% ED visits (N = 24 719) included in the analysis, 42.3% were to safety-net EDs and 57.7% were to non–safety-net EDs. The median length of stay for safety-net was 269 minutes (interquartile range [IQR], 178-397 minutes) for admission vs 281 minutes (IQR, 178-401 minutes) for non–safety-net EDs; 156 minutes (IQR, 95-239 minutes) for discharge vs 148 minutes (IQR, 88-238 minutes); 355 minutes (IQR, 221-675 minutes) for observations vs 298 minutes (IQR, 195-440 minutes); and 235 minutes (IQR, 155-378 minutes) for transfers vs 239 minutes (IQR, 142-368 minutes). Safety-net status was not independently associated with compliance with ED length-of-stay measures; the odds ratio was 0.83 for admissions (95% CI, 0.52-1.34); 1.03 for discharges (95% CI, 0.83-1.27); 1.05 for observations (95% CI, 0.57-1.95), 1.30 for transfers (95% CI, 0.70-2.45]); or subcategories except for psychiatric discharges (1.67, [95% CI, 1.02-2.74]).

Conclusion Compliance with proposed ED length-of-stay measures for admissions, discharges, transfers, and observations did not differ significantly between safety-net and non–safety-net hospitals.

10. Development of a Clinical Prediction Rule for 30-Day Cardiac Events in Emergency Department Patients With Chest Pain and Possible Acute Coronary Syndrome

Hess EP, et al. Ann Emerg Med. 2012;59(2):115-125.e1.

Study objective: Evaluation of emergency department (ED) patients with chest pain who are at low risk for acute coronary syndrome is resource intensive and may lead to false-positive test results and unnecessary downstream procedures. We seek to identify patients at low short-term risk for a cardiac event for whom additional ED investigations might be unnecessary.

Methods: We prospectively enrolled patients older than 24 years and with a primary complaint of chest pain from 3 academic EDs. Physicians completed standardized data collection forms before diagnostic testing. The primary adjudicated outcome was acute myocardial infarction, revascularization, or death of cardiac or unknown cause within 30 days. We used recursive partitioning to derive the rule and validated the model with 5,000 bootstrap replications.

Results: Of 2,718 patients enrolled, 336 (12%) experienced a cardiac event within 30 days (6% acute myocardial infarction, 10% revascularization, 0.2% death). We developed a rule consisting of the absence of 5 predictors: ischemic ECG changes not known to be old, history of coronary artery disease, pain typical for acute coronary syndrome, initial or 6-hour troponin level greater than the 99th percentile, and age greater than 50 years. Patients aged 40 years or younger required only a single troponin evaluation. The rule was 100% sensitive (95% confidence interval 97.2% to 100.0%) and 20.9% specific (95% confidence interval 16.9% to 24.9%) for a cardiac event within 30 days.

Conclusion: This clinical prediction rule identifies ED chest pain patients at very low risk for a cardiac event who may be suitable for discharge. A prospective multicenter study is needed to validate the rule and determine its effect on practice.

11. Current methods of diagnosis and treatment of scaphoid fractures

Rhemrev SJ, et al. Internat J Emerg Med 2011;4:4 Open access

Fractures of the scaphoid bone mainly occur in young adults and constitute 2-7% of all fractures. The specific blood supply in combination with the demanding functional requirements can easily lead to disturbed fracture healing. Displaced scaphoid fractures are seen on radiographs.

The diagnostic strategy of suspected scaphoid fractures, however, is surrounded by controversy. Bone scintigraphy, magnetic resonance imaging and computed tomography have their shortcomings.

Early treatment leads to a better outcome. Scaphoid fractures can be treated conservatively and operatively. Proximal scaphoid fractures and displaced scaphoid fractures have a worse outcome and might be better off with an open or closed reduction and internal fixation. The incidence of scaphoid non-unions has been reported to be between 5 and 15%. Non-unions are mostly treated operatively by restoring the anatomy to avoid degenerative wrist arthritis.

Full-text (free): http://www.springerlink.com/content/x1k754879q244222/fulltext.pdf

12. Images in Medicine

Woman With Supposed Anaphylactic Reaction http://www.annemergmed.com/article/S0196-0644(11)00514-2/fulltext

Young Man With Fever and Eye Pain
http://www.annemergmed.com/article/S0196-0644(11)00613-5/fulltext

Man With Blurred Vision
http://www.annemergmed.com/article/S0196-0644(11)01405-3/fulltext

13. Admission and Repeat Head CT for Patients on Warfarin with Minor Head Injury?

This approach identifies most delayed intracranial bleeds, but whether it changes patient outcomes and justifies the increased resources is not clear.

Current U.S. guidelines recommend head computed tomography (CT) for all patients taking warfarin who experience minor head injury. In a prospective study at a single emergency department in Italy, researchers evaluated outcomes in 97 adults with minor head injury who were taking warfarin, had normal initial head CT scans, and were admitted for 24-hour observation and repeat head CT (consistent with European guidelines). Minor head injury was defined as any head trauma other than superficial face injuries and Glasgow Coma Scale score of 14–15 regardless of presence or absence of loss of consciousness. Ten patients declined the repeat CT scan (all were asymptomatic at 30 days).

Of the 87 remaining patients, 5 (6%) had lesions detected on repeat CT. Of these five patients, two were discharged because their lesions were considered inconsequential, and three were admitted, with one undergoing craniotomy for subdural hematoma. Only one of the five patients with positive repeat CT scans demonstrated new neurological symptoms during the observation period. Two patients who were discharged after normal repeat CT scans were readmitted with symptomatic (confusion, headache) delayed subdural hematoma; neither patient required surgery. Four of the five patients with positive repeat CT scans and both patients who were readmitted with delayed subdural hematoma had international normalized ratios (INRs) >3; however, the study was not powered to determine the statistical significance of predictors of intracranial hemorrhage (ICH).

Comment: Although the authors recommend that all patients who suffer minor head injury while taking warfarin be admitted and undergo repeat scanning, they did not demonstrate that doing so improves outcomes. If we assume that the 10 asymptomatic patients who declined the repeat CT scan did not have delayed consequential ICH, then the rate of delayed bleeding requiring surgery is 1% (1 of 97) and does not justify a change in practice. The compelling finding that most patients with delayed ICH had supratherapeutic INRs suggests that such patients warrant more observation and repeat imaging.

— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine February 3, 2012. Citations: Menditto VG et al. Management of minor head injury in patients receiving oral anticoagulant therapy: A prospective study of a 24-hour observation protocol. Ann Emerg Med 2012 Jan 13; [e-pub ahead of print].

See also: The Prevalence of Immediate and Delayed Intracranial Hemorrhage in Patients with Pre-injury Anticoagulant Use and Head Trauma

Nishijima DK, et al. Acad Emerg Med. 2011;18:S180, abstract 468.

Background: Patients on warfarin or clopidogrel are considered at increased risk for traumatic intracranial hemorrhage (tICH) following blunt head trauma. The rate of immediate and delayed tICH in these patients, however, is unknown.

Objectives: We hypothesized that the prevalence of immediate tICH is similar between patients on clopidogrel and warfarin and the rate of delayed tICH in both groups is < 1%. Methods: This is a prospective, observational, six center study (two trauma centers and four community hospitals) evaluating the prevalence of immediate and delayed tICH in adult patients on warfarin or clopidogrel. Delayed tICH was defined as tICH on cranial CT scan within two weeks after an initial normal CT scan in the absence of repeat head trauma. Patients were enrolled in the emergency department (ED) and followed up after two weeks by phone or medical record review if hospitalized. Measured outcomes included immediate and delayed tICH. Data were analyzed with descriptive statistics.

Results: Eight hundred and seventy patients with a median age of 78 years (IQR 70–85) were enrolled (capture rate of 83%). Anticoagulant use included warfarin (622 patients, 71%) and clopidogrel 248 patients, 29%). Both warfarin and clopidogrel groups had similar patient characteristics (see the Table). Of patients receiving a CT in the ED, the rate of immediate tICH on CT was higher in patients on clopidogrel (29/231, 13%; 95% CI 8.6–18%) than on warfarin (27/591, 4.6%; 95% CI 3.0–6.6%). Delayed tICH was identified in 4/563 (0.71%; 95% CI 0.19–1.8%) patients on warfarin and 0/201 (0%; 95% CI 0–1.8%) patients on clopidogrel.

Conclusion: Patients on clopidogrel had a significantly higher rate of tICH on CT scan as compared to those on warfarin. Routine cranial CT scanning is indicated in patients on clopidogrel with blunt head trauma. The rate of delayed tICH was very low and only occurred in patients on warfarin. Discharging these patients from the ED after a normal CT scan is safe but appropriate instructions are required as delayed ICH may occur.

14. Nonoperative Approach to Abdominal Wounds Gains Ground

Nancy A. Melville. January 6, 2012 — Trauma surgeons are increasingly taking a more conservative, nonsurgical approach in managing abdominal gunshot and stab wounds. However, caution should be used in selecting appropriate patients, according to a new study published online December 22, 2011, in the British Journal of Surgery.

Surgical approaches in the management of penetrating abdominal wounds have shifted over the past century from that of mandatory operative exploration to the more conservative selective nonoperative management (SNOM). The latter option has gained favor in recent decades as a safer, more efficient approach, and studies have supported the trend, indicating that as many as 30% of anterior abdominal gunshot wounds, and 67% of gunshot injuries to the back, can be managed safely without operative intervention, according to S. Nabeel Zafar, MBBS, MPH, from the Department of Surgery, Aga Khan University, Karachi, Pakistan, and colleagues.

"The ability to manage patients without having to perform an operation means not only fewer potential postoperative complications, but also decreased costs and resource use," they write.

The nonsurgical approach is not without its drawbacks, however. Current literature suggests that the nonsurgical approach to penetrating abdominal injuries has a 10% to 20% failure rate, and many surgeons still prefer an operative approach to make sure not to miss any injuries that could cause further morbidity or mortality. To better assess the trends of SNOM, and of associated mortality, researchers from the Johns Hopkins School of Medicine in Baltimore, Maryland, and the Aga Khan University reviewed data from the National Trauma Data Bank on nearly 26,000 patients with penetrating abdominal gunshot or stab injuries. The data, which spanned from 2002 to 2008, included 12,707 patients aged 16 years or older who had abdominal gunshot wounds, in addition to 13,030 patients with abdominal stab wounds.

The results showed that the nonsurgical approach was taken with 22.2% of gunshot wound patients and 33.9% of stab wound patients, and the trend increased with time (P < .001). All other patients received laparotomy surgery. The increase in the nonsurgical management approach, meanwhile, correlated with a decline in rates of nontherapeutic laparotomy (NTL; r = −0.70).

The failure of SNOM, defined as the patient requiring surgery more than 4 hours after admission, however, was independently associated with mortality for the gunshot and stab wound groups (odds ratio [OR], 4.48; 95% confidence interval [CI], 2.07 - 9.70; and OR, 9.83; 95% CI, 3.44 - 28.00, respectively). The leading factors predicting selective nonoperative failure included the need for blood transfusion (OR, 1.96; 95% CI, 1.11 - 3.46) and a higher injury score.

"The findings from the present study underscore the need for accurate patient selection and use of all modalities available to decrease SNOM failure rates further," the authors write. "Close attention should be paid to factors such as the need for blood transfusion and injury severity when selecting patients for SNOM, as the effects of failure are not inconsequential."

Improved technologies in diagnostic imaging, including computed tomography and angiography, have helped allow for more accurate patient selection for nonoperative management in recent years, the authors add. In addition, the payoff of declines in laparotomies is a welcome benefit of the approach, they say. "This decrease in NTL rates is advantageous, as NTL has been associated with complication rates of up to 41 per cent. Complications from NTL include small bowel obstruction, ileus, pneumothorax, wound infection, myocardial infarction, iatrogenic visceral injury and death."

They conclude: "When successful, SNOM does allow these consequences of NTL to be avoided, although the risks associated with SNOM failure must be recognized and balanced against these and other potential benefits."

The study was supported by the Age Kahn University-Johns Hopkins Trauma Research Outcomes Collaboration, Baltimore, Maryland. The authors have disclosed no relevant financial relationships. Br J Surg. Published online December 22, 2011.

15. TIA Clinics Might Be More Cost-Effective Than Hospitalization

However, developing such clinics for patients with transient ischemic attacks might not be feasible.

Joshi JK et al. Neurology 2011 Dec 13; 77:2082

OBJECTIVE: For patients presenting with TIA, a previous study concluded that hospitalization is cost-effective compared to discharge without treatment from the emergency department. We performed a cost-effectiveness analysis of hospitalization vs urgent clinic evaluation following TIA.

METHODS: Among a cohort of TIA patients, we created a decision tree model to compare the decision to hospitalize or refer to urgent-access specialty clinic. We estimated probabilities, utilities, and direct costs from the available literature and calculated incremental cost-effectiveness ratio (ICER). We assumed equal access to standard medical treatments between the 2 approaches; however, we estimated higher tissue plasminogen activator (tPA) utilization among hospitalized patients. We performed sensitivity analyses to assess all assumptions in our model.

RESULTS: In patients with TIA aged 65-74 years, hospitalization yielded additional 0.00026 quality-adjusted life-years (QALYs) at 1 year, but at an additional cost of $5,573 per patient compared to urgent clinic evaluation (ICER = $21,434,615/QALY). Over 30 years, the ICER was $3,473,125/QALY. These results were not sensitive to varying 48-hour stroke risk, length of stay, tPA utilization rate, QALYs saved per tPA treatment, and hospitalization and clinic costs, and cost saved per tPA treatment.

CONCLUSION: Despite increased access to tPA in the hospital, we found that hospitalization is not cost-effective compared to same-day clinic evaluation following TIA. A very small fraction of patients benefits from hospitalization if urgent-access TIA clinics are available. The widespread development of urgent-access TIA clinics is warranted.

16. Focused Echocardiography in the Field Is Feasible in Cardiac Arrest

Cardiac standstill predicted 100% mortality.

Aichinger G, et al. Cardiac Movement Identified on Prehospital Echocardiography Predicts Outcome in Cardiac Arrest Patients. Prehosp Emerg Care. 2012 Jan 11. [Epub ahead of print].

Introduction. The prognostic value of emergency echocardiography (EE) in the management of cardiac arrest patients has previously been studied in an in-hospital setting. These studies mainly included patients who underwent cardiopulmonary resuscitation (CPR) by emergency medicine technicians at the scene and who arrived at the emergency department (ED) still in a state of cardiac arrest. In most European countries, cardiac arrest patients are normally treated by physician-staffed emergency medical services (EMS) teams on scene. Transportation to the ED while undergoing CPR is uncommon.

Objective. To evaluate the ability of EE to predict outcome in cardiac arrest patients when it is performed by ultrasound-inexperienced emergency physicians on scene.

Methods. We performed a prospective, observational study of nonconsecutive, nontrauma, adult cardiac arrest patients who were treated by physician-staffed urban EMS teams on scene. Participating emergency physicians (EPs) received a two-hour course in EE during CPR. After initial procedures were accomplished, EE was performed during a rhythm and pulse check. A single subxiphoid, four-chamber view was required for study enrollment. We defined sonographic evidence of cardiac kinetic activity as any detected motion of the myocardium, ranging from visible ventricular fibrillation to coordinated ventricular contractions. The CPR had to be continued for at least 15 minutes after the initial echocardiography. No clinical decisions were made based on the results of EE.

Results. Forty-two patients were enrolled in the study. The heart could be visualized successfully in all patients. Five (11.9%) patients survived to hospital admission. Of the 32 patients who had cardiac standstill on initial EE, only one (3.1%) survived to hospital admission, whereas four out of 10 (40%) patients with cardiac movement on initial EE survived to hospital admission (p = 0.008). Neither asystole on initial electrocardiogram nor peak capnography value, age, bystander CPR, or downtime was a significant predictor of survival. Only cardiac movement was associated with survival, and cardiac standstill at any time during CPR resulted in a positive predictive value of 97.1% for death at the scene.

Conclusion. Our results support the idea of focused echocardiography as an additional criterion in the evaluation of outcome in CPR patients and demonstrate its feasibility in the prehospital setting.

17. Rhythm-Control Delays Development of Permanent Atrial Fibrillation in Unselected Patients

Camm AJ, et al. Real-life observations of clinical outcomes with rhythm- and rate-control therapies for atrial fibrillation RECORDAF (Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation). J Am Coll Cardiol. 2011;58(5):493-501.

OBJECTIVES: RECORDAF is the first worldwide, prospective, observational survey of management of atrial fibrillation (AF) in unselected, community-based patients.

BACKGROUND: Primary outcomes were therapeutic success and clinical outcomes associated with rhythm-control and rate-control strategies.

METHODS: Patients with recent-onset AF were included (n = 5,604). Treatment strategy (rhythm control or rate control) was noted at baseline. Follow-up was 12 months. Therapeutic success required that strategy was unchanged without clinical events. Further maintenance of sinus rhythm was required in the rhythm-control group, and heart rate ≤80 beats/min in the rate-control group.

RESULTS: Data from 5,171 patients were assessable. Therapeutic success was 54% overall (rhythm control 60% vs. rate control 47%), a result driven by control of AF: rhythm control, 81% vs. rate control, 74%. After adjustment for propensity score quintiles, the rhythm-control strategy was significantly related to superior therapeutic success (odds ratio: 1.34, 95% confidence interval: 1.15 to 1.55; p = 0.0002). Clinical events occurred in 18% of patients. The arrhythmia management strategy was not predictive of clinical events. The type (persistent), presence at baseline visit, and duration (>3 months) of AF, together with age older than 75 years and the presence of heart failure, predicted progression to permanent AF. The choice of rhythm control reduced the likelihood of AF progression (odds ratio: 0.20, 95% confidence interval: 0.17 to 0.25; p < 0.0001).

CONCLUSIONS: Clinical outcomes in AF patients were driven mainly by hospitalizations for arrhythmia/proarrhythmia and other cardiovascular causes, but not by the choice of rate or rhythm strategy. Rhythm-control patients progressed less rapidly to permanent AF.

18. Do Low-dose Corticosteroids Improve Mortality or Shock Reversal in Patients with Septic Shock? A Systematic Review and Position Statement Prepared for the American Academy of Emergency Medicine

Sherwin RL, et al. J Emerg Med. 2012; in press.

Background: The management of septic shock has undergone a significant evolution in the past decade. A number of trials have been published to evaluate the efficacy of low-dose corticosteroid administration in patients with septic shock.

Methods: The Sepsis Sub-committee of the American Academy of Emergency Medicine Clinical Practice Committee performed an extensive search of the contemporary literature and identified seven relevant trials.

Results: Six of the seven trials reported a mortality outcome of patients in septic shock. Analysis of the data revealed that the relative risk (RR) of 28-day all-cause mortality in septic shock patients who received low-dose corticosteroids was 0.92 (95% confidence interval [CI] 0.79–1.07). All seven trials reported data concerning shock reversal or the withdrawal of vasopressors. Pooled results revealed that the RR of shock reversal is 1.17 (95% CI 1.07–1.28), which suggests that there may be significant improvement in shock reversal after corticosteroid administration. It is important to understand that two of the seven studies reviewed were disproportionately represented and accounted for 799 of 1005 patients (80%) considered for this recommendation.

Conclusions: The evidence suggests that low-dose corticosteroids may reverse shock faster; however, mortality is not improved for the overall population.

19. Inappropriate Ventilation in Intubated Prehospital Patients on Arrival at the ED

In a study at a single emergency department, end-tidal CO2 values revealed inappropriate ventilation in nearly half the patients.

Holmes J et al. Prehosp Emerg Care 2012 Jan 4

Background. The utility of prehospital intubation is controversial, as uncontrolled studies in trauma patients suggest adverse outcomes with prehospital intubation, perhaps secondary to inappropriate ventilation once intubation is accomplished.

Objectives. The objectives were 1) to establish, immediately upon arrival to the emergency department (ED), the prevalence of abnormal end-tidal carbon dioxide (ETCO(2)) levels in patients with prehospital intubation and 2) to describe the relationship between abnormal ETCO(2) levels on ED arrival and mortality.

Methods. This was a prospective, observational cohort study of patients with prehospital intubation. Patients were excluded if they underwent prehospital cardiopulmonary resuscitation (CPR). On ED arrival, the initial ETCO(2) measurement from the patient's endotracheal tube was immediately obtained prior to purposeful intervention in the patient's ventilation by using an Oridion Surestream Sure VentLine H Set with a Welch Allyn Propaq CS monitor. For each patient, the treating physician documented the ETCO(2) measurement, patient demographics, and details of the transport. The primary outcome was an abnormal ETCO(2) value (<30 mmHg or >45 mmHg). The secondary outcome was mortality.

Results. One hundred eligible patients were enrolled, with a median age of 30 years (interquartile range [IQR] 15, 48 years). Esophageal intubations were identified in four cases, and those cases were excluded from further analysis. Mechanisms included trauma, 74; medical, 12; and burn, 10. The median ETCO(2) value was 32 mmHg (IQR 27, 38 mmHg), range 18-80 mmHg. Forty-six of 96 (48%, 95% confidence interval [CI] 38%, 58%) patients had abnormal ETCO(2) values, including 37 (39%, 95% CI 29%, 49%) with low ETCO(2) levels and nine (9%, 95% CI 4%, 17%) with high ETCO(2) levels. Death was higher in those trauma patients with abnormal ETCO(2) levels (10/33, 30%, 95% CI 16%, 49%) than in those with normal ETCO(2) levels (2/41, 5%, 95% CI 0.6%, 17%), relative risk = 6.2 (95% CI 1.5, 26.4), p = 0.004.

Conclusion. Nearly half of all patients transported by prehospital providers had abnormal ETCO(2) measurements on initial ED presentation, suggesting an area for potential improvement. Trauma patients with abnormal initial ETCO(2) levels were more likely to die.

20. Mandatory Pain Scoring at Triage Reduces Time to Analgesia

Vazirani J, et al. Ann Emerg Med. 2012;59(2):134-138.e2.

Study objective: We study whether mandatory triage pain scoring and an educational program reduces the time to initial analgesic treatment.

Methods: We performed a prospective interventional study in the emergency department (ED) of an adult tertiary referral hospital and major trauma center. After an observational assessment of baseline time to analgesic administration, we mandated the recording of triage pain scores through our computerized information system. In a second separate phase, we administered a staff educational package on the importance of timely analgesia. We measured time to initial analgesia after each phase and at 12-month follow-up.

Results: We studied 35,628 patients (8,743 baseline, 8,462 after mandating pain scoring, 9,043 after the educational program, and 9,380 at follow-up), with 12,925 patients (36.3%) overall receiving analgesics. At baseline, the median time to analgesia was 123 minutes (interquartile range [IQR] 58 to 231 minutes), which reduced with pain scoring (95 minutes; IQR 45 to 194 minutes) but no further with the educational package (98 minutes; IQR 45 to 191 minutes). At 12-month follow-up, the median time to analgesia was 78 minutes (IQR 45 to 143 minutes), 45 minutes (36.4%) faster than at baseline.

Conclusion; The simple act of altering our ED computerized information system to require pain scoring at triage led to substantially faster provision of initial analgesia, with the effect sustained at 12 months.

21. Head CT: EM physicians overestimate the pretest probability and legal risk of significant findings

Baskerville JR, et al. Amer J Emerg Med. 2012;30:367-370.

Objectives: This study focuses on clinically assigned prospective estimated pretest probability and pretest perception of legal risk as independent variables in the ordering of multidetector computed tomographic (MDCT) head scans. Our primary aim is to measure the association between pretest probability of a significant finding and pretest perception of legal risk. Secondarily, we measure the percentage of MDCT scans that physicians would not order if there was no legal risk.

Methods: This study is a prospective, cross-sectional, descriptive analysis of patients 18 years and older for whom emergency medicine physicians ordered a head MDCT.

Results: We collected a sample of 138 patients subjected to head MDCT scans. The prevalence of a significant finding in our population was 6%, yet the pretest probability expectation of a significant finding was 33%. The legal risk presumed was even more dramatic at 54%. These data support the hypothesis that physicians presume the legal risk to be significantly higher than the risk of a significant finding. A total of 21% or 15% patients (95% confidence interval, ±5.9%) would not have been subjected to MDCT if there was no legal risk.

Conclusions: Physicians overestimated the probability that the computed tomographic scan would yield a significant result and indicated an even greater perceived medicolegal risk if the scan was not obtained. Physician test-ordering behavior is complex, and our study queries pertinent aspects of MDCT testing. The magnification of legal risk vs the pretest probability of a significant finding is demonstrated. Physicians significantly overestimated pretest probability of a significant finding on head MDCT scans and presumed legal risk.