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.