1. Thrombolytic Therapy in Unstable Patients with Acute PE: Saves Lives but Underused
Stein PD, et al. Amer J Med 2012;125:465-470.
Introduction: Since the first clinical report of the use of
a thrombolytic agent (streptokinase) in patients with pulmonary embolism by
Browse and James in 1964, several randomized controlled trials, beginning with
the Urokinase Pulmonary Embolism Trial, showed more rapid lysis of pulmonary
thromboemboli with thrombolytic agents than with anticoagulants alone. Among
symptomatic patients with pulmonary embolism who were not in shock, randomized
controlled trials showed that case fatality rate was comparable in those
treated with thrombolytic agents and those treated with anticoagulants alone. A
meta-analysis of patients not in shock showed no benefit of thrombolytic agents
compared with anticoagulants in terms of recurrent pulmonary embolism or death.
Clinical Significance: Thrombolytic therapy would seem
appropriate in patients in shock; however, data are sparse and inconsistent.
Among patients in shock in the Urokinase Pulmonary Embolism Trial, 2-week case
fatality rate among those treated with urokinase was 2 of 2 (100%) versus 1 of
1 (100%) in those treated with anticoagulants. In a trial of patients with
massive pulmonary embolism in shock, case fatality rate was 0 of 4 (0%) in
patients randomized to streptokinase and 4 of 4 (100%) among patients
randomized to heparin alone (P=.02).13 Among hypotensive patients with
pulmonary embolism in the International Cooperative Pulmonary Embolism Registry
(ICOPER), 90-day case fatality rate was similar in 33 patients who received
thrombolytic therapy and in 73 patients who did not (46% vs 55%). Meta-analysis
of 5 trials that included patients with unstable pulmonary embolism and
patients who were not unstable showed a lower end point of death or recurrent
pulmonary embolism in patients treated with thrombolytic agents (9.4% vs
19.0%).
There are no definitive trials that prove the value of
thrombolytic therapy in unstable patients with pulmonary embolism. It is
extremely remote that a randomized controlled trial will be performed in the
future. We therefore analyzed the database of the Nationwide Inpatient Sample
to test the hypothesis that thrombolytic therapy reduces case fatality rate in
unstable patients with acute pulmonary embolism.
Abstract
Background: Data are sparse and inconsistent regarding
whether thrombolytic therapy reduces case fatality rate in unstable patients
with acute pulmonary embolism. We tested the hypothesis that thrombolytic
therapy reduces case fatality rate in such patients.
Methods: In-hospital all-cause case fatality rate according
to treatment was determined in unstable patients with pulmonary embolism who
were discharged from short-stay hospitals throughout the United States from
1999 to 2008 by using data from the Nationwide Inpatient Sample. Unstable
patients were in shock or ventilator dependent.
Results: Among unstable patients with pulmonary embolism,
21,390 of 72,230 (30%) received thrombolytic therapy. In-hospital all-cause
case fatality rate in unstable patients with thrombolytic therapy was 3105 of
21,390 (15%) versus 23,820 of 50,840 (47%) without thrombolytic therapy (P less
than .0001). All-cause case fatality rate in unstable patients with
thrombolytic therapy plus a vena cava filter was 505 of 6630 (7.6%) versus 4260
of 12,850 (33%) with a filter alone (P less than .0001). Case fatality rate
attributable to pulmonary embolism in unstable patients was 820 of 9810 (8.4%)
with thrombolytic therapy versus 1080 of 2600 (42%) with no thrombolytic
therapy (P less than .0001). Case fatality rate attributable to pulmonary
embolism in unstable patients with thrombolytic therapy plus vena cava filter
was 70 of 2590 (2.7%) versus 160 of 600 (27%) with a filter alone (P less than .0001).
Conclusion: In-hospital all-cause case fatality rate and
case fatality rate attributable to pulmonary embolism in unstable patients was
lower in those who received thrombolytic therapy. Thrombolytic therapy resulted
in a lower case fatality rate than using vena cava filters alone, and the
combination resulted in an even lower case fatality rate. Thrombolytic therapy
in combination with a vena cava filter in unstable patients with acute
pulmonary embolism seems indicated.
See also: Stein PD, et al. Case Fatality Rate with Pulmonary
Embolectomy for Acute Pulmonary Embolism. Amer J Med. 2012;125:471-477.
Full-text (free): http://www.amjmed.com/article/PIIS0002934311010254/fulltext
Stein PD, et al. Impact of Vena Cava Filters on In-hospital
Case Fatality Rate from Pulmonary Embolism. Amer J Med. 2012;125:478-484.
Dalen JE. Thrombolytics and Vena Cava Filters Decrease
Mortality in Patients with Unstable Pulmonary Embolism. Amer J Med. 2012;125:429-430.
Full-text (free): http://www.amjmed.com/article/S0002-9343(11)00948-X/fulltext
2. Hospital
Strategies for Reducing Risk-Standardized Mortality Rates in AMI
Bradley EH, et al. Ann
Intern Med. 2012;156:618-626.
Mortality after acute myocardial infarction (AMI) varies
greatly between U.S. hospitals, even accounting for patient factors. This
cross-sectional survey of 537 U.S. hospitals identified several hospital
strategies associated with lower mortality after AMI: a culture that encouraged
physicians to solve problems creatively, physicians and nurses acting as
quality-of-care champions, hospital and emergency department clinicians meeting
at least monthly to review care, cardiologists always being present in the
hospital, and not cross-training nurses to work in both intensive care and
cardiac catheterization settings. However, less than 10% of hospitals reported
using at least 4 of the 5 strategies.
3. Variation in Head CT Use for ED Trauma
Patients and Physician Risk Tolerance
Andruchow JE, at al. Arch Intern Med. 2012;172(8):660-661.
Introduction: Physician risk intolerance and malpractice
fear have been implicated as leading to defensive behaviors and increased use
of health care resources. In the emergency department (ED), physician risk
aversion has been associated with higher rates of testing and hospitalization
for low-risk patients with chest pain, greater use of diagnostic imaging for
patients with abdominal pain,4 and an increased likelihood of performing head
computed tomography (CT) in scenarios involving pediatric patients with minor head
injury.
In this study, we explore predictors of head CT use for ED
trauma patients, including assessing the impact of physician risk intolerance
and malpractice fear. Patients with trauma were chosen because (1) the most
common indication for head CT in the ED is trauma, (2) head CT can definitively
exclude life-threatening injuries, and (3) missed diagnoses can have dire
consequences for both patients and physicians. Furthermore, because emergency
physicians overestimate the likelihood of clinically significant findings on
head CT and the medicolegal risk of not obtaining diagnostic imaging, head CT
use may be associated with defensive practice. We hypothesized that variation
exists in head CT use and is predicted by physician risk intolerance and malpractice
fear…
Excerpts from the rest of the article
Head CT use was associated with increasing patient age (P less
than .001), male sex (P = .001), higher triage acuity (P less than .001), and
time of presentation (overnight greater than evening or day) (P less than .008)
(Table).
Physician demographic characteristics and risk taking (P = .32), stress from
uncertainty (P = .30), and malpractice fear (P = .26) were not predictive of
head CT use. Even after controlling for the patient factors, physician identity
was still strongly associated with head CT use (P less than .001), suggesting
that significant variation in head CT use exists among physicians.
We found significant variation in head CT use for ED trauma
patients that was not explained by patient factors and was not associated with
physician risk tolerance or malpractice fear. Variation in head CT use by ED
physicians has been demonstrated previously, but not specifically for ED trauma
patients. Because well-validated decision rules are available to guide imaging
for patients with mild traumatic brain injury, this suggests that an
opportunity for quality improvement exists.
The lack of association between physician risk tolerance and
head CT use contrasts with prior findings of physician risk aversion being
associated with increased use of diagnostic imaging and health care resources.
One reason for this discrepancy may be the shared decision making involved in
the care of ED patients at our academic center, which, at a minimum, includes
either a resident physician or physician assistant in addition to the attending
physician. For patients with trauma team activation, the surgical trauma service
and possibly other consulting services may be involved. Because this study
measured only the risk tolerance of ED attending physicians, its impact on use
may have been diluted by the influence of other decision makers. Initiatives to
reduce variation and inappropriate imaging for ED trauma patients should
consider all decision makers involved in patient care and might ultimately
require institution-level support for clinical decision rules or
appropriateness measures.
4. Low-Dose Abdominal
CT as Good of High-Dose for Evaluating Suspected Appendicitis
Kim K, et al. N Engl J Med 2012; 366:1596-1605.
Background: Computed tomography (CT) has become the
predominant test for diagnosing acute appendicitis in adults. In children and
young adults, exposure to CT radiation is of particular concern. We evaluated
the rate of negative (unnecessary) appendectomy after low-dose versus
standard-dose abdominal CT in young adults with suspected appendicitis.
Methods: In this single-institution, single-blind,
noninferiority trial, we randomly assigned 891 patients with suspected
appendicitis to either low-dose CT (444 patients) or standard-dose CT (447
patients). The median radiation dose in terms of dose–length product was 116
mGy·cm in the low-dose group and 521 mGy·cm in the standard-dose group. The
primary end point was the percentage of negative appendectomies among all
nonincidental appendectomies, with a noninferiority margin of 5.5 percentage
points. Secondary end points included the appendiceal perforation rate and the
proportion of patients with suspected appendicitis who required additional
imaging.
Results: The negative appendectomy rate was 3.5% (6 of 172
patients) in the low-dose CT group and 3.2% (6 of 186 patients) in the
standard-dose CT group (difference, 0.3 percentage points; 95% confidence
interval, −3.8 to 4.6). The two groups did not differ significantly in terms of
the appendiceal perforation rate (26.5% with low-dose CT and 23.3% with
standard-dose CT, P=0.46) or the proportion of patients who needed additional
imaging tests (3.2% and 1.6%, respectively; P=0.09).
Conclusions: Low-dose CT was noninferior to standard-dose CT
with respect to negative appendectomy rates in young adults with suspected
appendicitis. (Funded by GE Healthcare Medical Diagnostics and others;
ClinicalTrials.gov number, NCT00913380.)
5. Eradication of
Community-Associated Staphylococcus
aureus Is Effective in Only Half of Cases
But a larger reduction in subsequent skin and soft-tissue
infections was seen when the entire household was treated.
Fritz SA, et al. Household versus individual approaches to
eradication of community-associated Staphylococcus aureus in children: a
randomized trial. Clin Infect Dis. 2012 Mar;54(6):743-51.
BACKGROUND: Community-associated Staphylococcus aureus
infections often affect multiple members of a household. We compared 2
approaches to S. aureus eradication: decolonizing the entire household versus
decolonizing the index case alone.
METHODS: An open-label, randomized trial enrolled 183
pediatric patients (cases) with community-onset S. aureus skin abscesses and
colonization of anterior nares, axillae, or inguinal folds from 2008 to 2009 at
primary and tertiary centers. Participants were randomized to decolonization of
the case alone (index group) or of all household members (household group). The
5-day regimen included hygiene education, twice-daily intranasal mupirocin, and
daily chlorhexidine body washes. Colonization of cases and subsequent skin and
soft tissue infection (SSTI) in cases and household contacts were ascertained
at 1, 3, 6, and 12 months.
RESULTS: Among 147 cases with 1-month colonization data,
modified intention-to-treat analysis revealed S. aureus eradication in 50% of
cases in the index group and 51% in the household group (P = 1.00). Among 126
cases completing 12-month follow-up, S. aureus was eradicated from 54% of the
index group versus 66% of the household group (P = .28). Over 12 months,
recurrent SSTI was reported in 72% of cases in the index group and 52% in the
household group (P = .02). SSTI incidence in household contacts was
significantly lower in the household versus index group during the first 6
months; this trend continued at 12 months.
CONCLUSIONS: Household decolonization was not more effective
than individual decolonization in eradicating community-associated S. aureus
carriage from cases. However, household decolonization reduced the incidence of
subsequent SSTI in cases and their household contacts.
6. Health Insurance
Status Change and ED Use among US Adults
Ginde AA, et al. Arch Intern Med. 2012;172(8):642-647.
Background: Recent
events have increased the instability of health insurance coverage. We compared
emergency department (ED) use by newly insured vs continuously insured adults
and by newly uninsured vs continuously uninsured adults.
Methods: We analyzed
159 934 adult respondents to the 2004 through 2009 National Health Interview
Survey. Health insurance status was categorized as newly insured (currently
insured but lacked health insurance at some point during the prior 12 months)
vs continuously insured and as newly uninsured (currently uninsured but had
health insurance at some point during the prior 12 months) vs continuously
uninsured. We analyzed the number of ED visits during the prior 12 months using
multivariable Poisson regression.
Results: Overall,
20.7% of insured adults and 20.0% of uninsured adults had at least 1 ED visit.
However, 29.5% of newly insured adults compared with 20.2% of continuously
insured adults had at least 1 ED visit. Similarly, 25.7% of newly uninsured
adults compared with 18.6% of continuously uninsured adults had at least 1 ED
visit. After adjusting for demographics, socioeconomic status, and health
status, recent health insurance status change was independently associated with
greater ED use for newly insured adults (incidence rate ratio [IRR], 1.32; 95%
CI, 1.22-1.42 vs continuously insured adults) and for newly uninsured adults
(IRR, 1.39; 95% CI, 1.26-1.54 vs continuously uninsured adults). Among newly
insured adults, this association was strongest for Medicaid beneficiaries (IRR,
1.45) but was attenuated for those with private insurance (IRR, 1.24) (P less
than .001 for interaction).
Conclusions: Recent
changes in health insurance status for newly insured adults and for newly
uninsured adults were associated with greater ED use. As policy and economic
forces create disruptions in health insurance status, new surges in ED use
should be anticipated.
7. Patients with Rib
Fractures Do Not Develop Delayed Pneumonia: A Prospective, Multicenter Cohort
Study of Minor Thoracic Injury
Chauny JM, et al. Ann Emerg Med. 2012 Apr 26. [Epub ahead of print]
Study objective: Patients admitted to emergency departments
(EDs) for minor thoracic injuries are possibly at risk of delayed pneumonia. We
aimed to evaluate the incidence of delayed pneumonia post–minor thoracic injury
and the associated risk factors.
Methods: A prospective, multicenter cohort study was
conducted in 4 Canadian EDs, from November 2006 to November 2010. All
consecutive patients aged 16 years and older with minor thoracic injury who
were discharged from the ED were screened for eligibility. Uniform clinical and
radiologic evaluations were performed on the initial ED visit and were repeated
at weeks 1 and 2. Relative risk analyses quantified incidence with comparison
by age, sex, smoking status, alcohol intoxication, pulmonary comorbidity,
ability to cough atelectasis, pain level, and number of rib fractures.
Results: Of the 1,057 participants recruited, 347 (32.8%)
had at least 1 rib fracture, 87 (8.2%) had asthma, and 36 (3.4%) had chronic
obstructive pulmonary disease. Only 6 patients (0.6%; 95% confidence interval
0.24% to 1.17%) developed pneumonia during the follow-up period. The relative
risk for patients with preexistent pulmonary disease and radiologically proven
rib fractures was 8.6 (P=.045; 95% confidence interval 1.05 to 70.9). Sex,
smoking habit, initial atelectasis, ability to cough, and alcohol intoxication
were not significantly associated with delayed pneumonia.
Conclusion: This prospective cohort study of nonhospitalized
patients with minor thoracic injuries revealed a low incidence of delayed
pneumonia. Nonetheless, our results support tailored follow-up for asthmatic or
chronic obstructive pulmonary disease patients with rib fracture.
8. Clostridium difficile Infection
Incidence, Costs Reach Historic Highs
Community-onset Cases More Likely to Require Colectomy,
Study Finds
AAFP. 04/30/2012
-- Clostridium difficile
infection (CDI) took center stage in a report recently published in Morbidity
and Mortality Weekly Report (MMWR) that stated "the incidence, deaths, and
excess health care costs resulting from CDIs in hospitalized patients are all
at historic highs."
According to the March 9 MMWR Vital Signs report, which
analyzed population-based surveillance data from the CDC's Emerging Infections
Program and other sources, hospital stays directly tied to CDIs tripled in the
past decade and the number of hospitalized patients with any CDI discharge
diagnosis more than doubled -- from about 139,000 to 336,600.
The rest of the article full-text (free): http://www.aafp.org/online/en/home/publications/news/news-now/health-of-the-public/20120430community-onsetcdi.html
MMWR full-text (free): http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm
9. Diagnostic value
of single complete compression US in pregnant and postpartum women with
suspected DVT: prospective study
Le Gal G, et al. BMJ 2012;344:e2635
Introduction: Because pregnancy is known to be a risk factor
for venous thromboembolism and pregnant women often experience symptoms
compatible with deep vein thrombosis (pain, tenderness, and swelling of the
legs), the threshold for clinical suspicion and the accuracy of clinical
examination are reduced. Misdiagnoses during pregnancy, however, should be
avoided as much as possible—for example, false positive test results lead to
inappropriate anticoagulant treatment, which increases the risk of bleeding and
requires daily heparin injections during the pregnancy. In contrast, false
negative test results may lead to a life threatening thromboembolic event. Thus
the accuracy of diagnostic methods used in pregnant women is crucial.
Phlebography remains the reference method for the diagnosis of deep vein
thrombosis, but it is invasive and costly and exposes the fetus to radiation.
Serial impedance plethysmography is the only non-invasive test that has been
formally proved, in a prospective study, to be safe during pregnancy. This test
is no longer in use, however, mainly because it has been shown to be less
accurate than compression ultrasonography in non-pregnant patients.4 In such
patients, assessment of clinical probability combined with D-dimer measurement
is a well validated step for ruling out deep venous thrombosis. D-dimer levels,
however, tend to increase steadily with pregnancy stage and to decrease slowly
during the first weeks after delivery. As a result, the clinical
usefulness—that is, the proportion of women with D-dimer levels below the
diagnostic cut-off—is reduced. Moreover, the safety of ruling out deep vein
thrombosis on the basis of D-dimer levels and clinical probability has never
been prospectively validated in an outcome study of management during
pregnancy.
In recent years, real time compression ultrasonography has
become the main diagnostic test for suspected deep vein thrombosis. In
non-pregnant patients with suspected deep vein thrombosis, a negative single
complete compression ultrasonography result allows the diagnosis to be safely
ruled out. Indeed, the rate of thromboembolic events in the three months after
a negative single complete compression ultrasonography result has been shown to
be about 1%, a figure comparable to the 1.3% (95% confidence interval 0.3% to
4.4%) thromboembolic rate observed after a negative phlebography test result.
Although compression ultrasonography is widely used, it has
not been prospectively evaluated in pregnancy and post-partum. Its accuracy may
be lower for several reasons. Firstly, pregnant women often present with
conditions that make visualisation of the veins difficult, such as leg oedema or
a gravid uterus, and that interfere with the visualisation of the proximal
veins. Secondly, isolated iliac venous thromboses, which may be encountered
more often in pregnancy, are more difficult to be diagnosed by compression
ultrasonography, as the usual accepted criterion for deep vein thrombosis—lack
of compressibility of the veins—may be difficult to evaluate at the iliac level
in pregnant women. Thirdly, pregnancy is associated with changes in the anatomy
and physiology of veins—namely, an increased vessel diameter and reduced flow
velocity. These physiological changes are associated with technical
difficulties for the ultrasound examination, and they persist for days or weeks
after delivery.
Nevertheless, a retrospective study suggested that single complete
compression ultrasonography may safely exclude deep vein thrombosis during
pregnancy and post partum. We assessed the safety of ruling out the diagnosis
of deep vein thrombosis in pregnant or early postpartum women using single
compression ultrasonography.
Abstract
Objective: To assess the safety of using single complete
compression ultrasonography in pregnant and postpartum women to rule out deep
vein thrombosis.
Design: Prospective outcome study.
Setting: Two tertiary care centres and 18 private practices
specialising in vascular medicine in France and Switzerland.
Participants: 226 pregnant and postpartum women referred for
suspected deep vein thrombosis.
Methods: A single proximal and distal compression
ultrasonography was performed. All women with a negative complete compression
ultrasonography result did not receive anticoagulant therapy and were followed
up for a three month period.
Main outcome measures: Symptoms of venous thromboembolism,
second compression ultrasonography or chest imaging, a thromboembolic event,
and anticoagulant treatment.
Results: 16 women were excluded, mainly because of
associated suspected pulmonary embolism. Deep vein thrombosis was diagnosed in
22 out of the 210 included women (10.5%). 10 patients received full dose
anticoagulation despite a negative test result during follow-up. Of the 177
patients without deep vein thrombosis and who did not receive full dose
anticoagulant therapy, two (1.1%, 95% confidence interval 0.3% to 4.0%) had an
objectively confirmed deep vein thrombosis during follow-up.
Conclusions: The rate of venous thromboembolic events after
single complete compression ultrasonography in pregnant and postpartum women
seems to be within the range of that observed in studies in the non-pregnant population.
These data suggest that a negative single complete compression ultrasonography
result may safely exclude the diagnosis of deep vein thrombosis in this
setting.
Full-text (free): http://www.bmj.com/content/344/bmj.e2635
10. Images in
Clinical Medicine
Torsion of Undescended Testis
Pneumoperitoneum
Man with Oropharyngeal Trauma
Infant with Head Injury
A Woman with Painless Swelling in the Right Lower Abdominal
Quadrant
11. Ultrasound-Guided
Peripheral IV Training Reduces Central Line Placement
Nancy A. Melville. Medscape Medical News. April 27, 2012
(Phoenix, Arizona) — The rate of inappropriately placed central venous
catheters (CVCs) substantially declines when residents and emergency department
(ED) technicians are trained to perform ultrasound-guided peripheral
intravenous access (USPIV), according to a study presented here at the American
Institute of Ultrasound in Medicine (AIUM) 2012 Annual Convention.
A research team led by Hamid Shokoohi, MD, from The George
Washington University (GWU) Medical Center in Washington, DC, evaluated the
monthly rate of CVC placement in high- and low-acuity patients from 2006 to
2010.
In 2008, administrators at the GWU Medical Center
implemented a program to train residents and ED technicians to use USPIV.
Whereas the ED saw an increase in patients over the study
period, from 60,239 in 2006 to 71,431 in 2010, the number of CVCs placed was
reduced by nearly 65%, from 426 in 2006 to 152 in 2010.
"In 2006, nearly 13% of patients who received CVC had
the line removed and it turned out the patient could be sent home," Dr.
Shokoohi reported. "This number dropped to just 1% in 2010."
In addition, most patients who did receive a CVC were
admitted to the intensive care unit (ICU).
"This is very important because we assume the people
who go to the ICU are the most severe patients who need the CVC for reasons
other than simply poor peripheral IV access," said Dr. Shokoohi. "In
2006, only about a third [33.2%] of patients who got CVC were admitted to the
ICU; by 2010, this number went up to 82%."
The findings underscore the association between USPIV and
CVC reduction in low-acuity patients who need IV access but not central line
access, Dr. Shokoohi noted.
"The study demonstrates that the best outcome can be
achieved using ultrasound first and replacing an unnecessary invasive CVC
procedure with a safe and successful method of obtaining IV access in
low-acuity patients with difficult IV access."
Michael Blaivas, MD, FACEP, professor of emergency medicine
in the Department of Emergency Medicine at Northside Hospital Forsyth, in
Cumming, Georgia, said the findings support the sentiment of many physicians
that CVC, and its potential for complications, can be avoided more often than
many realize.
"This is a really important study," said Dr.
Blaivas, who moderated the session and is chair of the AIUM Emergency and
Critical Care Ultrasound Section.
"It's amazing how many of us, over the years, have had
the gestalt that the central line is often unnecessary, and documenting that is
critical."
USPIV is "simple and extremely effective because it can
help you avoid the central line completely. Obviously, many central lines do
need to be placed, but as the study indicated, you can avoid it in as many as a
third of cases."
Although there is a bit of a learning curve for USPIV, Dr.
Blaivas said the training isn't too difficult. "In general, we've found
that training can be accomplished with a 2-hour course, lectures, some
demonstrations, practice on a phantom, and then trying it out on about 5
patients in a proper setting with the oversight of an expert."
USPIV is used at nearly all academic medical centers in the
United States, but its use in other settings needs to be increased, he said.
"The community healthcare providers tend to pick this
up less, so they are the next big battleground," Dr. Blaivas said.
"The Emergency Nurses Association has put out a statement endorsing this,
and I think you will start seeing more and more implementation."
12. Association
between Repeated Intubation Attempts and Adverse Events in EDs: An Analysis of
a Multicenter Prospective Observational Study
Hasegawa K, et al. Ann Emerg Med. 2012 Apr 27 [Epub ahead of
print]
Study objective: Although repeated intubation attempts are
believed to contribute to patient morbidity, only limited data characterize the
association between the number of emergency department (ED) laryngoscopic
attempts and adverse events. We seek to determine whether multiple ED
intubation attempts are associated with an increased risk of adverse events.
Methods: We conducted an analysis of a multicenter
prospective registry of 11 Japanese EDs between April 2010 and September 2011.
All patients undergoing emergency intubation with direct laryngoscopy as the
initial device were included. The primary exposure was multiple intubation
attempts, defined as intubation efforts requiring greater than or equal to 3
laryngoscopies. The primary outcome measure was the occurrence of
intubation-related adverse events in the ED, including cardiac arrest,
dysrhythmia, hypotension, hypoxemia, unrecognized esophageal intubation,
regurgitation, airway trauma, dental or lip trauma, and mainstem bronchus
intubation.
Results: Of 2,616 patients, 280 (11%) required greater than
or equal to 3 intubation attempts. Compared with patients requiring 2 or fewer
intubation attempts, patients undergoing multiple attempts exhibited a higher
adverse event rate (35% versus 9%). After adjusting for age, sex, principal
indication, method, medication, and operator characteristics, intubations
requiring multiple attempts were associated with an increased odds of adverse
events (odds ratio 4.5; 95% confidence interval 3.4 to 6.1).
Conclusion: In this large Japanese multicenter study of ED patients
undergoing intubation, we found that multiple intubation attempts were
independently associated with increased adverse events.
13. Mild Therapeutic
Hypothermia May Benefit Patients with Post-arrest Cardiogenic Shock
Mild hypothermia reduced need for vasopressors and inotropes
in patients with cardiogenic shock after out-of-hospital cardiac arrest.
Zobel C, et al. Crit Care Med. 2012 Apr 6. [Epub ahead of
print]
OBJECTIVE: Mortality in patients with cardiogenic shock
after out-of-hospital cardiac arrest remains high despite advances in
resuscitation and early revascularization strategies. Recent studies suggest a
reduced mortality in survivors of cardiac arrest subjected to mild therapeutic
hypothermia, but the underlying mechanisms are not yet clear. Because positive
hemodynamic effects of mild therapeutic hypothermia have been suggested, we
aimed at testing the hypothesis that patients in cardiogenic shock might
benefit from mild therapeutic hypothermia.
METHODS: Hemodynamic effects of mild therapeutic hypothermia
in 20 consecutive patients admitted in cardiogenic shock after successful
resuscitation from out-of-hospital cardiac arrest were investigated. A historic
normothermic control group was matched (one-to-one) by means of a propensity score.
Patients were cooled to 33°C for 24 hrs using an endovascular cooling device
and hemodynamic variables were continuously recorded by means of pulse contour
analysis. Cardiac performance was determined by echocardiography.
RESULTS: Mild therapeutic hypothermia induced a significant
decrease in heart rate from 74 to 64 beats per minute. Despite the reduction in
heart rate, cardiac index remained unchanged under mild therapeutic hypothermia
likely due to an increase in ejection fraction from 43 ± 4% to 55 ± 4%. Mean
arterial pressure increased rapidly from 75 ± 2 mm Hg to 84 ± 3 mm Hg (p =
.001) upon induction of hypothermia paralleled by an initial increase in
systemic vascular resistance. Accordingly, patients with mild therapeutic
hypothermia required lower cumulative doses of vasopressors and inotropes.
CONCLUSIONS: We conclude that in cardiogenic shock mild
therapeutic hypothermia provides circulatory support and an increase in
systemic vascular resistance that leads to reduced vasopressor use and may result
in lower oxygen consumption. These findings suggest that mild therapeutic
hypothermia could be a therapeutic option in hemodynamically unstable patients
independent of cardiac arrest and further randomized clinical studies are
needed.
14. Red Flags in
Electrocardiogram for Emergency Physicians: Remembering Wellens’ Syndrome and
Upright T wave in V1
Ünlüer EE, et al. West J Emerg Med. 2012;13(2):160–162.
We present a case of Wellens’ syndrome together with upright
T wave in lead V1 in a man presenting with atypical chest pain, and we discuss
the significance of its prompt recognition by the emergency physicians who are
involved in the evaluation of patients with coronary artery disease in
emergency departments.
Full-text (free): http://www.escholarship.org/uc/item/41b501j3#page-1
15. Taser Voltage
Enough to Kill
A shock to the chest from a stun gun can cause sudden
cardiac arrest and death. How so? The threshold for automated external
defibrillators is the output of the TASER X26.
By Chris Kaiser, Cardiology Editor, MedPage Today. May 02,
2012.
A shock to the chest from a stun gun can cause sudden
cardiac arrest and death, a small study suggested.
In eight cases of stun-gun induced loss of consciousness,
the first recorded rhythms were ventricular tachycardia/fibrillation in six and
asystole (after about 30 minutes of nonresponsiveness) in one, according to the
first clinical study of taser effects published in a peer reviewed journal.
An external defibrillator reported a shockable rhythm in one
case, but no recording was made, Douglas P. Zipes, MD, from Indiana University
School of Medicine in Indianapolis, reported online in Circulation: Journal of
the American Heart Association.
Given the animal and clinical data, Zipes concluded that
shocks from stun guns can cause ventricular fibrillation, which can lead to
death.
Stun guns, also known as tasers, are classified as nonlethal
weapons. They are not considered firearms and, therefore, are not regulated by
the Bureau of Alcohol, Tobacco, Firearms, and Explosives, Zipes noted.
However, they are capable of delivering an initial shock of
50,000 volts, followed by shorter 1,200-volt shocks that the user can stop,
repeat, or sustain longer.
The safety of stun guns has been questioned, particularly by
Amnesty International, which reported more than 500 deaths in the U.S.
following shocks from stun guns since 2001.
Of the cases studied, about 60 deaths have been directly
linked to the stun gun, either as a cause or contributing factor, according to
Amnesty International.
Zipes traced the first documented case of stun-gun death in
the literature to 2005. Animal studies, as well as a few human studies, have
shown that shocking the chest with the TASER X26 (the model preferred by law
enforcement) or a new prototype causes cardiac electrical capture, which is the
ability of the electrical impulse to initiate a cardiac response. Some animal
studies have shown that the shock could provoke rapid ventricular fibrillation.
In fact, the "concept of cardiac capture by
transthoracic electrical impulses in humans ... is now a standard part of
resuscitative equipment," Zipes wrote. He added that the threshold for
automated external defibrillators is the output of the TASER X26.
With this as background, Zipes said he wanted to determine
whether tasers can cause an electrical response and whether that could lead to
an arrhythmia and subsequent death.
He analyzed eight cases that were part of litigation
associated with taser shock (one from 2006, four from 2008, and three from
2009). In each case, the device used was the TASER X26. All but one individual
died.
When such information was available, Zipes used records from
police, hospitals, and emergency response teams; as well as data from stun
guns, automated external defibrillators, ECG strips, depositions, and autopsy
results.
All eight men had previously been clinically healthy, he
noted. All received shocks in the anterior chest near or over the heart. And
all lost consciousness during or immediately after the shock.
One of the potential mechanisms of ventricular fibrillation
from a taser shock could come from a sudden loss of blood pressure from an
initial shock-induced increase in heart rate, which is exacerbated by repeated
shocks, potentially causing ischemia and provoking ventricular fibrillation,
Zipes wrote.
He admitted that not all deaths following taser shocks can
be linked to the shock itself. However, when loss of consciousness happens
during or immediately after the shock "and the subsequent rhythm is VT/VF
... it becomes difficult to exonerate the effects of the shock," he wrote.
Zipes stressed that the report is not intended to condemn
the use of stun guns by trained ofessionals.
In that vein, he offered several suggestions:
·
Avoid chest shocks if possible
·
Monitor the person following a shock
·
Suspect the possibility of an arrhythmia in
those who lose consciousness
·
Be prepared to resuscitate, including the use of
an automated external defibrillator
The study is limited by not having an ECG recording during
the application of the shock, Zipes said.
16. IMS 3 Trial of
Mechanical Embolectomy in Stroke Stopped
Pauline Anderson. From Medscape Medical News. April 27, 2012
(New Orleans, Louisiana) — The Interventional Management of Stroke 3 (IMS 3)
trial, which was comparing intravenous (IV) tissue plasminogen activator (tPA)
alone with combination tPA and intra-arterial (IA) therapy using intra-arterial
tPA or mechanical thrombectomy in stroke patients, has suspended enrollment
after crossing a prespecified interim analysis threshold.
That means that even if the study continued, it would not
produce the expected result — that combination therapy is superior to tPA
alone, said principal investigator Joseph P. Broderick, MD, professor and
chairman, neurology, University of Cincinnati, Ohio. "This is not what we
had hoped," he told Medscape Medical News.
However, he said, "we remain optimistic about
mechanical embolectomy technology; we just need to do a better job" of
proving that these devices improve patient outcome.
The IMS 3 is a phase 3, randomized, open-label trial that
was to enroll 900 patients with a National Institutes of Health Stroke Scale
score of 8 or greater treated within 3 hours. The aim of the study was to
examine whether a combined IV and IA approach to recanalization is superior to
standard IV recombinant (rt)-PA alone.
The primary outcome is a favorable outcome in terms of
functional independence as measured by a Modified Rankin Scale score of 0 to 2
at 3 months. The trial was designed to test whether there is an overall
absolute difference of at least 10% in the proportion of a favorable outcome
for patients treated with the combined IV/IA approach as compared to those
treated with the IV rt-PA only approach.
It's important to note that the study was not put on hold
because of safety concerns, said Dr. Broderick. He also emphasized that he and
the other investigators remain blinded to the study results and that patient
follow-up will continue.
American Academy of Neurology (AAN) 64th Annual Meeting
17. Ultrasound
Imaging Reveals Cervical Vascular Injury Signature
Nancy A. Melville. Medscape Medical News. April 24, 2012
(Phoenix, Arizona) — Transcranial Doppler ultrasound imaging is a potentially
useful tool to detect blood flow disruptions related to blunt cervical vascular
injury (BCVI) that might otherwise go undetected by computed tomography
angiography (CTA), according to research presented here at the American
Institute of Ultrasound in Medicine 2012 Annual Convention.
CTA, currently the gold standard in imaging for BCVI, has
disadvantages, including radiation exposure, contrast risk, false-positive
results as high as 35% to 40%, and the need for patients who have undergone
multiple traumas to move.
In addition, CTA can miss vascular injuries, explained lead
author Dianna Purvis, PhD, from the Department of Neuroscience, Electrical, and
Computer Engineering at George Mason University in Centreville, Virginia.
"When arteries supplying blood to the brain are injured
in some sort of blunt trauma, often a thrombus forms and can cause a subsequent
stroke; however, there is usually a silent period in which it is very hard to
detect," Dr. Purvis explained.
She noted that at her center, a 26-year-old female presented
who had been sent home twice from another emergency department with a clear
head computed tomography scan.
"She then presented at our trauma center with a
cerebellar stroke," she said. "This was a woman who had just
graduated from college and relatively was young."
The case underscores the need for bedside screening, Dr.
Purvis said. "Serial dynamics have not been well studied in response to
this cervical disruption of blood flow."
In an effort to better understand the dynamics and the value
of transcranial Doppler ultrasound in detecting or monitoring a cervical
disruption of blood flow, Dr. Purvis and her colleagues have been conducting an
ongoing prospective pilot study in which trauma patients with BCVI are screened
with CTA as well as transcranial Doppler ultrasound.
The aim of the study is to look for Doppler signatures that
are reliably characteristic of BCVIs.
"We are extracting Doppler indices from the Doppler
wave form to characterize alterations in flow, both in the local cervical
region and global cerebral region," she explained.
Specifically, these include mean flow velocity, pulsatility
indices, and side-to-side asymmetries, she said.
The researchers are also looking at patterns in the inverse
damping factor. "This is simply the ratio of the pulsatility distal to a
thrombus, or the proximal pulsatility," Dr. Purvis explained.
Preliminary findings include evaluations of 35 trauma
patients, 12 with BCVI. Among the BCVI patients, 4 had internal carotid artery
injuries; 4 had vertebral artery injuries, 2 had bilateral vertebral artery
injuries, and 2 had concurrent internal carotid artery and vertebral artery
injuries.
Evaluations of the patients showed that internal carotid
artery BCVI is characterized by more middle cerebral artery mean flow velocity
asymmetry of 25% or higher than patients without BCVI (75% vs 0%; P = .009).
Internal carotid artery BCVI also shows a lower mean middle cerebral artery
ipsilateral pulsatility index (0.57 vs 1.20; P = .007).
Patients with vertebral artery BCVI had more middle cerebral
artery mean flow velocity asymmetry of 25% or greater than patients with no
BCVI (100% vs 0%; P less than .001).
In patients with internal carotid artery BCVI, mean internal
carotid artery flow was significantly dampened, compared with patients with no
BCVI (0.44 vs 0.95; P less than .001). It was also dampened in those with
concurrent internal carotid artery and vertebral artery BCVI (0.58 vs 0.95; P =
.002).
Dr. Purvis noted that the small sample size is a limitation;
however, the research team has received funding to continue to enroll up to 100
patients.
"Even though the sample size is small, the findings
lead us to believe we might be seeing some converging patterns with different
types of vascular injuries in the cervical region," she concluded.
"This may in fact be a viable method to not only screen
these injuries, but to follow their progress and assess hemodynamics throughout
the injury progression," she noted.
Other limitations include the fact that the there is no
assurance that all of the hemodynamic alterations observed were related to
BCVI; many of the patients had multiple injuries. Age and sex might also play a
role in different cerebral velocities, Dr. Purvis added.
Daniel B. Hoch, PhD, MD, assistant professor of neurology at
Harvard Medical School and neurologist in the Department of Neurology at
Massachusetts General Hospital in Boston, agreed that CTA, despite its value in
such cases, has its drawbacks.
"It takes time to get one, requires some transport of
the patient to the scanner, and the patient gets an intravenous contrast dose
that has to be cleared by the kidneys," said Dr. Hoch.
"If a highly sensitive test that is portable, fast, and
cheap can be provided to screen these patients, then our colleagues in trauma
management would be enthused."
He agrees, however, that larger studies are needed to better
evaluate the role of transcranial Doppler ultrasound in the trauma department.
"The study is encouraging. It's a very small number of
patients, though, and it's going to take a many more patients who get both CTA
and transcranial Doppler ultrasound before we know how sensitive this approach
really is," Dr. Hoch said.
"It's really important not to miss anyone, so the
false-negative rate has to be really low for this to be a helpful test."
Dr. Purvis and Dr. Hoch have disclosed no relevant financial
relationships.
American Institute of Ultrasound in Medicine (AIUM) 2012
Annual Convention. Abstract 1241283. Presented March 31, 2012.
18. Warfarin or
Aspirin in Patients with Heart Failure and Sinus Rhythm
Homma S, et al. N Engl J Med. 2012; May 2, 2012
(10.1056/NEJMoa1202299)
Background: It is unknown whether warfarin or aspirin
therapy is superior for patients with heart failure who are in sinus rhythm.
Methods: We designed this trial to determine whether
warfarin (with a target international normalized ratio of 2.0 to 3.5) or
aspirin (at a dose of 325 mg per day) is a better treatment for patients in
sinus rhythm who have a reduced left ventricular ejection fraction (LVEF). We
followed 2305 patients for up to 6 years (mean [±SD], 3.5±1.8). The primary
outcome was the time to the first event in a composite end point of ischemic
stroke, intracerebral hemorrhage, or death from any cause.
Results: The rates of the primary outcome were 7.47 events
per 100 patient-years in the warfarin group and 7.93 in the aspirin group
(hazard ratio with warfarin, 0.93; 95% confidence interval [CI], 0.79 to 1.10;
P=0.40). Thus, there was no significant overall difference between the two
treatments. In a time-varying analysis, the hazard ratio changed over time,
slightly favoring warfarin over aspirin by the fourth year of follow-up, but
this finding was only marginally significant (P=0.046). Warfarin, as compared
with aspirin, was associated with a significant reduction in the rate of
ischemic stroke throughout the follow-up period (0.72 events per 100
patient-years vs. 1.36 per 100 patient-years; hazard ratio, 0.52; 95% CI, 0.33
to 0.82; P=0.005). The rate of major hemorrhage was 1.78 events per 100
patient-years in the warfarin group as compared with 0.87 in the aspirin group
(P less than 0.001). The rates of intracerebral and intracranial hemorrhage did
not differ significantly between the two treatment groups (0.27 events per 100
patient-years with warfarin and 0.22 with aspirin, P=0.82).
Conclusions: Among patients with reduced LVEF who were in
sinus rhythm, there was no significant overall difference in the primary
outcome between treatment with warfarin and treatment with aspirin. A reduced
risk of ischemic stroke with warfarin was offset by an increased risk of major
hemorrhage. The choice between warfarin and aspirin should be individualized.
19. Mental Health
Issues Not a Priority in ED
By Charles Bankhead, Staff Writer, MedPage Today. May 05,
2012
Weiss AP, et al. Patient and practice-related determinants
of emergency department length of stay for patients with psychiatric illness.
Ann Emerg Med 2012 May 1. [Epub ahead of print]
Seeking psychiatric care in an emergency department led to a
wait of more than 11 hours, and the wait was even longer for older,
intoxicated, and uninsured patients, a study of five urban hospitals showed. The
median wait lasted 8.2 hours. Patients discharged to home had a wait on par
with the median, but a transfer outside a system of care almost doubled the
wait time for patients with psychiatric emergencies.
"The results of this study are important because they
highlight the interrelatedness of the various components of the mental health
system and provide objectively identified targets for quality
improvement," Anthony P. Weiss, MD, of Harvard and Massachusetts General
Hospital in Boston, and co-authors wrote in an article published online in
Annals of Emergency Medicine.
"Emergency departments (EDs) that are embedded within a
larger system of care and have ready access to various levels of after care
options ... are likely to be better positioned to more rapidly transition
patients through the ED," they added.
Several recent studies have shown that patients who go to
emergency departments for psychiatric care have substantially longer waits
compared with patients seeking other types of care. Data from the National
Center for Health Statistics showed that the average wait for mental health
services in an emergency department was 42% greater than the wait for nonmental
health issues (Psychiatr Ser 2010; 61: 678-684).
In a survey by the American College of Emergency Physicians,
40% of emergency department medical directors said psychiatric patients waited
more than 8 hours from disposition decision to discharge from the ED. In
contrast, 7% of the directors said medical patients had to wait that long.
Factors that contribute to the long wait times for mental
health services have received little attention in the literature. In an effort
to identify patient-related and clinical management factors associated with
longer ED waits, Weiss and colleagues conducted a prospective study involving
five Boston-area hospitals (two academic, three community).
Each hospital collected data on approximately 200
consecutive patients seeking psychiatric consultation in the hospital emergency
department. Relevant information was obtained from the emergency department,
mental health clinical staff, and patients' individual electronic medical
records.
The final analysis involved 1,092 patients. The median age
was 39 and there was even distribution between the sexes. The authors found
that non-Hispanic whites constituted 71% of the study sample; that two-thirds
of the patients had public insurance; and that 13% of the patients were
homeless.
The most common (37%) presenting complaint was subjective
mental distress (depressed or anxious), followed by suicidal ideation or
nonlethal self-harm (33%). In about 90% of cases, patients provided serum or
urine for a toxicology screen, which was uninformative 61% of the time. The
substance identified most often was alcohol (33% of total sample), with or
without other drugs.
The most common discharge diagnoses were mood disorder (69%)
and substance use disorder (41%). Subsequently, 299 patients were discharged to
home and 679 patients were admitted to the hospital or transferred to a
psychiatric unit. The remaining 114 patients had a heterogeneous make-up.
In summarizing the key findings, the authors reported the
following average wait times and average added times:
·
Transfer outside the care system, 15 hours
·
Transfer within the system, 12.9 hours
·
Transfer to psychiatric unit in hospital, 11
hours
·
Older age: 12.6 hours for ages 60 and older,
11.9 hours for ages 41 to 59, 10.7 hours for ages 18 to 40
·
Positive screen for alcohol, +6.2 hours (14-hour
average)
·
Diagnostic imaging, +3.2 hours
·
Use of a restraint, +4.2 hours
·
Uninsured, +4 hours
The extended time associated with admission or transfer
resulted from an additional 3.3 to 7.4 hours added to the time from decision
disposition to the end of the emergency department visit.
"The need for inpatient admission was the factor
associated with the greatest influence on length of stay, an effect that was
due to long wait times after the decision to pursue admission had been
made," the authors wrote.
"Approximately two-thirds of all patients receiving
emergency mental healthcare in this sample were either admitted or transferred
to a psychiatric unit," they added. "Although these hospitalized
patients tended to be seen and assessed more quickly than patients discharged
home, they had significantly longer overall length of stay because of the extended
wait time between the decision to admit and the ED discharge."
The study had some limitations including the reliance on
chart review, rather than direct observation, so there may have been incomplete
documentation of some patient-related factors. Also, the results may not apply
on a general level because the study was done at a single system of care within
on U.S. region.
However, the authors pointed out that the findings were
consisted across the five different hospitals, which ranged from a 150-bed
community hospital to a 900-bed academic tertiary care hospital.
20. The Long-Term
Effect of Premier Pay for Performance on Patient Outcomes
Jha AK, et al. N Engl J Med 2012; 366:1606-1615.
Background: Pay for performance has become a central
strategy in the drive to improve health care. We assessed the long-term effect
of the Medicare Premier Hospital Quality Incentive Demonstration (HQID) on
patient outcomes.
Methods: We used Medicare data to compare outcomes between
the 252 hospitals participating in the Premier HQID and 3363 control hospitals
participating in public reporting alone. We examined 30-day mortality among
more than 6 million patients who had acute myocardial infarction, congestive
heart failure, or pneumonia or who underwent coronary-artery bypass grafting
(CABG) between 2003 and 2009.
Results: At baseline, the composite 30-day mortality was
similar for Premier and non-Premier hospitals (12.33% and 12.40%, respectively;
difference, −0.07 percentage points; 95% confidence interval [CI], −0.40 to
0.26). The rates of decline in mortality per quarter at the two types of
hospitals were also similar (0.04% and 0.04%, respectively; difference, −0.01
percentage points; 95% CI, −0.02 to 0.01), and mortality remained similar after
6 years under the pay-for-performance system (11.82% for Premier hospitals and
11.74% for non-Premier hospitals; difference, 0.08 percentage points; 95% CI,
−0.30 to 0.46). We found that the effects of pay for performance on mortality
did not differ significantly among conditions for which outcomes were
explicitly linked to incentives (acute myocardial infarction and CABG) and
among conditions not linked to incentives (congestive heart failure and
pneumonia) (P=0.36 for interaction). Among hospitals that were poor performers
at baseline, mortality was similar in the two groups of hospitals at the start
of the study (15.12% and 14.73%; difference, 0.39 percentage points; 95% CI,
−0.36 to 1.15), with similar rates of improvement per quarter (0.10% and 0.07%;
difference, −0.03 percentage points; 95% CI, −0.08 to 0.02) and similar
mortality rates at the end of the study (13.37% and 13.21%; difference, 0.15
percentage points; 95% CI, −0.70 to 1.01).
Conclusions: We found no evidence that the largest
hospital-based pay-for-performance program led to a decrease in 30-day
mortality. Expectations of improved outcomes for programs modeled after Premier
HQID should therefore remain modest.
Full-text (free): http://www.nejm.org/doi/full/10.1056/NEJMsa1112351#t=article
21. Radiological and
biomechanical analysis of humeral fractures occurring during arm wrestling
Arm wrestling? Seriously? What, against Schwarzenegger?
Kruczyński J, et al. Med Sci Monit.
2012 Apr 23;18(5):CR303-307.
22. Accounting for
the Polarization of Politics: Recent Research in the Behavioral Sciences
Jonathan Haidt, social psychologist at the University of
Virginia, provides a fascinating sketch of human nature in The Righteous Mind: Why Good People Are Divided by Politics and
Religion (New York: Pantheon Books: 2012).
