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/