1. Evolving Considerations in the Management of Patients with Left BBB and Suspected MI
Neeland IJ, et al. J Amer Coll Cardiol 2012 Jul
10;60(2):96-105.
Patients with a suspected acute coronary syndrome and left
bundle branch block (LBBB) present a unique diagnostic and therapeutic
challenge to the clinician. Although current guidelines recommend that patients
with new or presumed new LBBB undergo early reperfusion therapy, data suggest
that only a minority of patients with LBBB are ultimately diagnosed with acute
myocardial infarction, regardless of LBBB chronicity, and that a significant
proportion of patients will not have an occluded culprit artery at cardiac
catheterization.
The current treatment approach exposes a significant
proportion of patients to the risks of fibrinolytic therapy without the
likelihood of significant benefit and leads to increased rates of
false-positive cardiac catheterization laboratory activation, unnecessary
risks, and costs. Therefore, alternative strategies to those for patients with
ST-segment elevation myocardial infarction are needed to guide selection of
appropriate patients with a suspected acute coronary syndrome and LBBB for
urgent reperfusion therapy. In this article, we describe the evolving
epidemiology of LBBB in acute coronary syndromes and discuss controversies
related to current clinical practice. We propose a more judicious diagnostic
approach among clinically stable patients with LBBB who do not have
electrocardiographic findings highly specific for ST-segment elevation
myocardial infarction.
Full-text (free): http://content.onlinejacc.org/article.aspx?articleid=1212260
2. Poor Prognosis in
Warfarin-Associated Intracranial Hemorrhage despite Anticoagulation Reversal
Dowlatshahi D, et al. Stroke 2012;43:1812-1817.
Background and Purpose Anticoagulant-associated intracranial
hemorrhage (aaICH) presents with larger hematoma volumes, higher risk of
hematoma expansion, and worse outcome than spontaneous intracranial hemorrhage.
Prothrombin complex concentrates (PCCs) are indicated for urgent reversal of
anticoagulation after aaICH. Given the lack of randomized controlled trial
evidence of efficacy, and the potential for thrombotic complications, we aimed
to determine outcomes in patients with aaICH treated with PCC.
Methods We conducted a prospective multicenter registry of
patients treated with PCC for aaICH in Canada. Patients were identified by
local blood banks after the release of PCC. A chart review abstracted clinical,
imaging, and laboratory data, including thrombotic events after therapy.
Hematoma volumes were measured on brain CT scans and primary outcomes were
modified Rankin Scale at discharge and in-hospital mortality.
Results Between 2008 and 2010, 141 patients received PCC for
aaICH (71 intraparenchymal hemorrhages). The median age was 78 years
(interquartile range, 14), 59.6% were male, and median Glasgow Coma Scale was
14. Median international normalized ratio was 2.6 (interquartile range, 2.0)
and median parenchymal hematoma volume was 15.8 mL (interquartile range, 31.8).
Median post-PCC therapy international normalized ratio was 1.4: 79.5% of
patients had international normalized ratio correction (<1.5) within 1 hour
of PCC therapy. Patients with intraparenchymal hemorrhage had an in-hospital
mortality rate of 42.3% with median modified Rankin Scale of 5. Significant
hematoma expansion occurred in 45.5%. There were 3 confirmed thrombotic
complications within 7 days of PCC therapy.
Conclusions PCC therapy rapidly corrected international
normalized ratio in the majority of patients, yet mortality and morbidity rates
remained high. Rapid international normalized ratio correction alone may not be
sufficient to alter prognosis after aaICH.
3. Adapted PECARN
Head Injury Rule Is Safe and Effective
A modified PECARN head injury rule had good staff adherence
and identified all patients with clinically important brain injuries.
Bressan S, et al. Acad Emerg Med 2012;19:801-807.
Objectives: Of the currently published clinical decision
rules for the management of minor head injury (MHI) in children, the Pediatric
Emergency Care Applied Research Network (PECARN) rule, derived and validated in
a large multicenter prospective study cohort, with high methodologic standards,
appears to be the best clinical decision rule to accurately identify children
at very low risk of clinically important traumatic brain injuries (ciTBI) in
the pediatric emergency department (PED). This study describes the
implementation of an adapted version of the PECARN rule in a tertiary care academic
PED in Italy and evaluates implementation success, in terms of medical staff
adherence and satisfaction, as well as its effects on clinical practice.
Methods: The adapted PECARN decision rule algorithms for
children (one for those younger than 2 years and one for those older than 2
years) were actively implemented in the PED of Padova, Italy, for a 6-month
testing period. Adherence and satisfaction of medical staff to the new rule
were calculated. Data from 356 visits for MHI during PECARN rule implementation
and those of 288 patients attending the PED for MHI in the previous 6 months
were compared for changes in computed tomography (CT) scan rate, ciTBI rate
(defined as death, neurosurgery, intubation for longer than 24 hours, or
hospital admission at least for two nights associated with TBI) and return
visits for symptoms or signs potentially related to MHI. The safety and
efficacy of the adapted PECARN rule in clinical practice were also calculated.
Results: Adherence to the adapted PECARN rule was 93.5%.
The percentage of medical staff satisfied with the new rule, in terms of
usefulness and ease of use for rapid decision-making, was significantly higher
(96% vs. 51%, p < 0.0001) compared to the previous, more complex, internal
guideline. CT scan was performed in 30 patients (8.4%, 95% confidence interval
[CI] = 6% to 11.8%) in the implementation period versus 21 patients (7.3%, 95%
CI = 4.8% to 10.9%) before implementation. A ciTBI occurred in three children
(0.8%, 95% CI = 0.3 to 2.5) during the implementation period and in two
children (0.7%, 95% CI = 0.2 to 2.5) in the prior 6 months. There were five
return visits (1.4%) postimplementation and seven (2.4%) before implementation
(p = 0.506). The safety of use of the adapted PECARN rule in clinical practice
was 100% (95% CI = 36.8 to 100; three of three patients with ciTBI who received
CT scan at first evaluation), while efficacy was 92.3% (95% CI = 89 to 95; 326
of 353 patients without ciTBI who did not receive a CT scan).
Conclusions: The adapted PECARN rule was successfully
implemented in an Italian tertiary care academic PED, achieving high adherence
and satisfaction of medical staff. Its use determined a low CT scan rate that
was unchanged compared to previous clinical practice and showed an optimal
safety and high efficacy profile. Strict monitoring is mandatory to evaluate
the long-lasting benefit in patient care and/or resource utilization.
4. Coronary CT Speeds
Triage of Chest Pain, Yet…
By Crystal Phend, Senior Staff Writer, MedPage Today.
Published: July 25, 2012
Action Points
·
A coronary CT angiography scan early in the
course of chest pain evaluation safely speeds emergency department discharge
for low-to-intermediate-risk patients.
·
Note that although early coronary CT angiography
didn't alter mean cost of care, it did increase further diagnostic testing and
radiation exposure.
A coronary CT angiography scan early in the course of chest
pain evaluation safely speeds emergency department discharge for
low-to-intermediate-risk patients, a randomized trial showed.
The strategy cut hospital length of stay by a mean 7.6 hours
compared with standard evaluation (23 versus 31 hours, P<0.001), and didn't
result in any missed acute coronary syndromes, Udo Hoffmann, MD, MPH, of
Massachusetts General Hospital in Boston, and colleagues found.
Although early coronary CT angiography didn't alter mean
cost of care, at $4,289 versus $4,060 (P=0.65), it did increase further
diagnostic testing and radiation exposure, they reported in the July 26 issue
of the New England Journal of Medicine.
These ROMICAT-II trial findings matched those reported in
March at the American College of Cardiology meeting.
Two other studies reported over the past year have also
supported coronary CT for lower-risk patients in the emergency department:
·
ACRIN PA showing earlier discharge and no events
compared with usual evaluation
·
CT STAT showing faster discharge with no
increase in major adverse cardiac events compared with SPECT myocardial
perfusion imaging
These results are important given the pressures on emergency
departments, J. Jeffrey Marshall, MD, of the Northeast Georgia Heart Center in
Atlanta and president of the Society for Cardiovascular Angiography and
Interventions, commented in an interview with MedPage Today.
"The doctors on the front lines have very little time
to sift through a thousand patients to find the eight that have heart disease
that could kill them," he said. "Our emergency rooms are flooded,
overrunning with people. In the real world, you're going to have to do tests on
these patients."
However, an editorial accompanying the NEJM paper challenged
that perspective. "In short, the question is not which test leads to
faster discharge of patients from the emergency department, but whether a test
is needed at all," Rita F. Redberg, MD, of the University of California
San Francisco, wrote.
There is no evidence that CT angiography or any other test
improves outcomes for low-to-intermediate-risk patients, she argued, citing the
Choosing Wisely campaign against unnecessary testing.
In ROMICAT-II, the rate of acute coronary syndromes was 8%
among the 1,000 patients presenting to the emergency department with a possible
ACS but no ischemic signs on electrocardiography and an initial negative troponin
test.
Randomization to early coronary CT imaging didn't
significantly impact major adverse cardiac event rates over 28-day follow-up
compared with standard evaluation (exercise, echocardiography, or SPECT at
physician's discretion) in the emergency department.
Four myocardial infarctions and two cases of unstable angina
pectoris requiring stenting occurred in the standard evaluation group compared
with one MI and one case of unstable angina requiring stenting (P=0.18).
Those low rates made it impossible to tell whether the CT
angiography group got any benefit from the early imaging in terms of preventing
events by treating disease found on the imaging, Redberg noted.
Marshall agreed that the study was probably too small to
have found a significant difference in rates in the safety analysis but called
the threefold difference meaningful on a population scale.
While the benefits were arguable, the risks were clear.
Cumulative radiation exposure was nearly tripled in the
early CT angiography group, at a mean of 14 mSv versus 5 mSv in the standard
group (P<0.001). Redberg noted that 10 mSv of radiation would kill one
patient from cancer in every 2,000 exposed.
Another downside was more downstream diagnostic and
functional testing in the early coronary CT imaging group (both P<0.001).
While Marshall noted that more tests are not always a bad
thing, Redberg cited risk of serious complications and added the risk of
nephrotoxicity and adverse reactions from the CT contrast dye to the list.
"The decision regarding the need for diagnostic testing
in these patients usually can be safely deferred to outpatient follow-up within
a few weeks after the visit to the emergency department," she concluded.
"I believe judicious clinical follow-up is safer and in the best interests
of the majority of these patients."
Regardless, the trial is unlikely to substantially boost
early CT use in emergency departments around the country, Marshall predicted.
"I don't actually think many places will take all
comers and put them in CT scanners," he told MedPage Today, suggesting
that use would be limited to the population with some risk factors and
histories that are difficult to untangle.
The study was supported by grants from the National Heart,
Lung, and Blood Institute and the National Institutes of Health. Hoffmann
reported receiving grant support from the American College of Radiology Imaging
Network, Bracco Diagnostics, Genentech, and Siemens Healthcare on behalf of his
institution. Redberg reported being a member of the coronary angiography
assessment forum as a part of the FDA cardiovascular expert device panel.
Marshall reported having no conflicts of interest to disclose.
Hoffmann U, et al. N Engl J Med 2012; 367:299-308. Study
abstract: http://www.nejm.org/doi/full/10.1056/NEJMoa1201161
Redberg RF. N Engl J Med 2012;367:375-376. Editorial
(subscription only): http://www.nejm.org/doi/full/10.1056/NEJMe1206040
From the American Heart Association: 2010 Expert Consensus
Document on Coronary CT Angiography. Full-text (free): http://my.americanheart.org/professional/General/Coronary-CT-Angiography_UCM_423991_Article.jsp
5. A Novel Approach
to Identifying Targets for Cost Reduction in the Emergency Department.
Smulowitz PB, et al. Ann Emerg Med. 2012 Jul 12. [Epub ahead
of print]
This article introduces a novel framework that classifies
emergency department (ED) visits according to broad categories of severity,
identifying those categories of visits that present the most potential for
reducing costs associated with the ED. Although cost savings directly
attributable to the ED are apt to be an important emphasis of organizations
operating under reformed payment systems, our framework suggests that a focus
on diverting low-acuity visits away from the ED would result in far less
savings compared with strategies aimed at reducing admissions and to a lesser
extent improving the efficiency of ED care for intermediate or complex
conditions. We conclude that targeting these categories, rather than minor
injuries/illnesses, should be the primary focus of cost-reduction strategies
from the ED. Given this understanding, we then discuss the implications of
these findings on the financing of an emergency care system that needs to
account for the required fixed costs of "stand-by capacity" of the ED
and explore ways in which the ED can be better integrated into a
patient-centered health care system.
Associated Medscape Essay: http://www.medscape.com/viewarticle/767537
6. Challenges in
Clinical Electrocardiography
ECG Findings in a Young Man With Tachycardia and Hypotension
Parikh VN, et al. Arch Intern Med. 2012;():1-1.
doi:10.1001/archinternmed.2012.2727
A 25-year-old man presented to the emergency department
complaining of shortness of breath, cough, and malaise, which had progressed
over the preceding several weeks. He had a 7-year history of daily
methamphetamine use. He had presented to the emergency department 3 times in
the previous month complaining of similar symptoms and had been discharged with
treatment for an upper respiratory infection; there was no evidence of
hemodynamic instability. At this presentation, however, his blood pressure was
95/60 mm Hg, his heart rate was 114 beats/min, and his oxygen saturation was
98% on room air..
Physical examination revealed a jugular venous pressure of
15 cm H2O, bilateral pulmonary rales, an inferolaterally displaced point of
maximal impulse, and an S3 gallop, all of which were new findings compared with
those of previous examinations. A chest x-ray film revealed bibasilar pulmonary
infiltrates, consistent with pulmonary edema, and an enlarged cardiac
silhouette. An electrocardiogram (ECG) was obtained (Figure 1).
Questions: What are the critical findings on this ECG and
what is the cause?
For the rest of the article, including ECG tracings, link
here: http://archinte.jamanetwork.com/article.aspx?articleid=1217211
For the answer, link here: http://archinte.jamanetwork.com/article.aspx?articleid=1217212
7. A Clinical
Decision Rule to Identify Infants with Apparent Life-Threatening Event Who Can
Be Safely Discharged From the ED
Mittal M, et al. Pediatr Emerg Care 2012;28:599-605.
Objective: This study aimed to formulate a clinical decision
rule (CDR) to identify infants with apparent-life threatening event (ALTE) who
are at low risk of adverse outcome and can be discharged home safely from the
emergency department (ED).
Methods: This is a prospective cohort study of infants with
an ED diagnosis of ALTE at an urban children’s hospital. Admission was
considered warranted if the infant required significant intervention during the
hospital stay. Logistic regression and recursive partitioning were used to
develop a CDR identifying patients at low risk of significant intervention and
thus suitable for discharge from the ED.
Results: A total of 300 infants were enrolled; 228 (76%)
were admitted; 37 (12%) required significant intervention. None died during
hospital stay or within 72 hours of discharge or were diagnosed with serious
bacterial infection. Logistic regression identified prematurity, abnormal
result in the physical examination, color change to cyanosis, absence of
symptoms of upper respiratory tract infection, and absence of choking as
predictors for significant intervention. These variables were used to create a
CDR, based on which, 184 infants (64%) could be discharged home safely from the
ED, reducing the hospitalization rate to 102 (36%). The model has a negative
predictive value of 96.2% (92%–98.3%).
Conclusions: Only 12% of infants presenting to the ED with
ALTE had a significant intervention warranting hospital admission. We created a
CDR that would have decreased the admission rate safely by 40%.
8. Therapy and
outcomes in massive pulmonary embolism from the Emergency Medicine Pulmonary
Embolism in the Real World Registry.
Lin BW, et al. Am J Emerg Med. 2012 May 23. [Epub ahead of
print]
STUDY AIM: Clinical guidelines recommend fibrinolysis or
embolectomy for acute massive pulmonary embolism (PE) (MPE). However, actual
therapy and outcomes of emergency department (ED) patients with MPE have not
previously been reported. We characterize the current management of ED patients
with MPE in a US registry.
METHODS: A prospective, observational, multicenter registry
of ED patients with confirmed PE was conducted from 2006 to 2008. Massive PE
was defined as PE with an initial systolic blood pressure less than 90 mm Hg.
We compared inpatient and 30-day mortality, bleeding complications, and
recurrent venous thromboembolism.
RESULTS: Of 1875 patients enrolled, 58 (3.1%) had MPE. There
was no difference in frequency of parenteral anticoagulation (98.3% [95%
confidence interval {CI}, 90.5-101.6] vs 98.5% [95% CI, 97.9-99.1], P = .902)
between patients with and without MPE. Fibrinolytic therapy and embolectomy
were infrequently used but were used more in patients with MPE than in patients
without MPE (12.1% [95% CI, 3.7-20.5] vs 2.4% [95% CI, 1.7-3.1], P < .001,
and 3.4% [95% CI, 0.0-8.1] vs 0.7% [95% CI, 0.3-1.1], P = .022, respectively).
Comparison of outcomes revealed higher all-cause inpatient mortality (13.8%
[95% CI, 4.9-22.7] vs 3.0% [95% CI, 2.2-3.8], P < .001), higher risk of
inpatient bleeding complications (10.3% [95% CI, 2.5-18.1] vs 3.5% [95% CI,
2.7-4.3], P = .007), and a higher 30-day mortality (14.0% [95% CI, 4.4-23.6] vs
1.8% [95% CI, 1.2-2.4], P < .001) for patients with MPE.
CONCLUSIONS: In a contemporary registry of ED patients, MPE
mortality was 4-fold higher than patients without MPE, yet only 12% of the MPE
cohort received fibrinolytic therapy. Variability exists between the treatment
of MPE and current recommendations.
9. Smartphones May
Aid Eye Diagnoses in the ED
Lamirel C, et al. Arch Ophthalmol. 2012;130(7):939-940.
If smartphones can be used to transit successfully
fundoscopic images (what emergency physicians are able to take those images??),
imagine what other images could be routed to specialists.
By Genevra Pittman. NEW YORK (Reuters Health) Jul 11 -
Sending patient images to ophthalmologists via smartphone may be an option for
emergency [physicians] looking to make a quick eye-related diagnosis, a new
study suggests.
Two ophthalmologists gave higher quality ratings to
inner-eye photos when they looked at the images on an iPhone as compared to a
desktop computer, according to results published online Monday in the Archives
of Ophthalmology.
That may mean the phones can be used to diagnose and plan
treatment for more obvious eye conditions -- even when an ophthalmologist isn't
available at the hospital, researchers noted.
"Not every hospital in the country in the ER has access
to an eye doctor always," said Dr. Rohit Krishna, an ophthalmologist from
the University of Missouri-Kansas City School of Medicine, who wasn't involved
in the new study.
Non-eye doctors, Dr. Krishna added, "don't always feel
really comfortable with eye care. So having tools in your pocket that enable
you to do ophthalmologic examination elements are a great asset."
He said smartphones could be used to take and send pictures
of damage to the eyelid or the front of the eye. When it comes to complicated,
inner-eye photos, using a more advanced camera to take a photo -- and then
sending it to an ophthalmologist via smartphone for diagnosis -- is also a good
option, he told Reuters Health.
For the new study, Dr. Valerie Biousse from Emory University
in Atlanta and her colleagues collected information on 350 patients with a
headache, changes in eyesight and other signs of vision problems who came to
the ER for treatment. Emergency staff took photos of the interior of their
eyes, including the retina, using an ocular camera.
Two ophthalmologists looked at those photos and rated their
quality on a typical desktop computer, and later assessed 100 of the images on
an iPhone.
Both reviewers consistently rated the phone images as the
same or higher quality on a one-to-five scale than the same photos viewed on
the computer.
One ophthalmologist said 53 of the photos were the same
quality, 46 were better on an iPhone and one was better on the desktop. The
other ophthalmologist rated the photos equally 56 times, the iPhone images
better 42 times and chose the desktop photos twice.
Consulting electronically with an ophthalmologist can give
ER staff a better idea of what a patient's prognosis will be, Dr. Krishna said,
as well as the severity of the eye injury.
"Using (an) iPhone to transmit images to colleagues as
a help with patient triage in the ER is a new concept," Dr. Biousse told
Reuters Health in an email.
"ER departments are working at improving acute patient
care by developing ways to access specialty consultations such as
ophthalmology."
The next step, Dr. Biousse said, is to show whether or not
"the triage and acute patient care are expedited and ophthalmologic
consultations can be obtained faster and more accurately" when photos are
sent from the ER to an ophthalmologist's smartphone.
Dr. Charles Wykoff, an ophthalmologist from Retina
Consultants of Houston, said his one worry would be doctors using smartphone
pictures to rule out all eye problems and then having a patient sent home.
"The concern for me is possibly false reassurance when
there's a normal picture," he told Reuters Health. "I don't think it
replaces the need for a complete eye exam."
But if using a smartphone does help ER patients get faster
and accurate diagnoses, Dr. Wykoff, who wasn't involved in the new study, said
he'd be all for it.
Full-text (free): http://archopht.jamanetwork.com/article.aspx?articleid=1214797
10. Adult
Intussusception: Presentation, Management, and Outcomes of 148 Patients
Lindor RA, et al. J Emerg Med 2012;43:1-6.
Background: Intussusception is a predominantly pediatric
diagnosis that is not well characterized among adults. Undiagnosed cases can
result in significant morbidity, making early recognition important for
clinicians.
Study Objectives: We describe the presentation, clinical
management, disposition, and outcome of adult patients diagnosed with
intussusception during a 13-year period.
Methods: A retrospective study of consecutive adult patients
diagnosed with intussusception at a tertiary academic center was carried out
from 1996 to 2008. Cases were identified using International Classification of
Diseases, 9th Revision codes and a document search engine. Data were abstracted
in duplicate by two independent authors.
Results: Among 148 patients included in the study, the most
common symptoms at presentation were abdominal pain (72%), nausea (49%), and
vomiting (36%). Twenty percent were asymptomatic. Sixty percent of cases had an
identifiable lead point. Patients presenting to the emergency department (ED)
(31%) had higher rates of abdominal pain (relative risk [RR] 5.7) and vomiting
(RR 3.4), and were more likely to undergo surgical intervention (RR 1.8) than
patients diagnosed elsewhere. There were 77 patients who underwent surgery
within 1 month; patients presenting with abdominal pain (RR 2.2), nausea (RR
1.7), vomiting (RR 1.4), and bloody stool (RR 1.9) were more likely to undergo
surgery.
Conclusions: Adult intussusception commonly presents with
abdominal pain, nausea, and vomiting; however, approximately 20% of cases are
asymptomatic and seem to be diagnosed by incidental radiologic findings.
Patients presenting to an ED with intussusception due to a mass as a lead point
or in an ileocolonic location are likely to undergo surgical intervention.
11. Images in
Clinical Medicine
A Scalp Nevus
Retinoblastoma
Traumatic Abducens Nerve Palsy
Denervation Atrophy of the Tongue after Hypoglossal-Nerve
Injury
Man with Nausea and Vomiting
Young Man with Left Thoracic Pain
12. Does This
Fracture Need to Be Reduced? ED management of distal radial fractures in
children
by Karen Serrano, MD on July 20, 2012. Emergency Physicians
Monthly
Distal radial fractures are among the most common fractures
in childhood, and are a frequent presenting complaint in the emergency
department. Traditionally, ED management of displaced distal radial fractures
in children has included closed reduction and splinting of displaced fractures,
usually under sedation. While generally safe when proper monitoring is used,
procedural sedation nonetheless carries risks of respiratory depression,
hypoxia, hypotension, vomiting, and emergence reactions.1 In addition,
procedural sedation is time- and labor-intensive, resulting in longer lengths
of stay for patients and sequestering physicians and nursing staff away from
seeing other patients, which can backlog even the most efficiently run ED.
Therefore if a fracture can be managed effectively without procedural sedation,
it would be welcome news both for patients and busy emergency departments
everywhere.
Data suggests that many displaced and angulated distal
radial fractures in children do not require anatomic reduction to achieve good
outcomes. Children have tremendous remodeling potential in their bones, with younger
age and proximity to growth plates corresponding to greater degree of
remodeling. Because growth plates begin to close at puberty, young children
with more years of bone growth ahead of them exhibit greater remodeling
potential than do older children. In addition, the distal forearm is a
particularly “forgiving” area for fractures, and greater degrees of
displacement and angulation can be tolerated. This is due to its proximity to
the highly biologically active growth plates of the distal radius and ulna,
which are responsible for 75% and 81% of the longitudinal growth of each bone,
respectively.2…
For the remainder of the essay, along with images and
references, link here: http://www.epmonthly.com/clinical-skills/films-and-scans/does-this-fracture-need-to-be-reduced-/
13. Do Low-dose
Corticosteroids Improve Mortality or Shock Reversal in Patients with Septic
Shock? A Systematic Review and Position Statement Prepared for the AAEM
Sherwin RL, et al. J Emerg Med 2012;43:7-12.
Background: The management of septic shock has undergone a
significant evolution in the past decade. A number of trials have been
published to evaluate the efficacy of low-dose corticosteroid administration in
patients with septic shock.
Methods: The Sepsis Sub-committee of the American Academy of
Emergency Medicine Clinical Practice Committee performed an extensive search of
the contemporary literature and identified seven relevant trials.
Results: Six of the seven trials reported a mortality
outcome of patients in septic shock. Analysis of the data revealed that the
relative risk (RR) of 28-day all-cause mortality in septic shock patients who
received low-dose corticosteroids was 0.92 (95% confidence interval [CI]
0.79–1.07). All seven trials reported data concerning shock reversal or the
withdrawal of vasopressors. Pooled results revealed that the RR of shock
reversal is 1.17 (95% CI 1.07–1.28), which suggests that there may be
significant improvement in shock reversal after corticosteroid administration.
It is important to understand that two of the seven studies reviewed were
disproportionately represented and accounted for 799 of 1005 patients (80%)
considered for this recommendation.
Conclusions: The evidence suggests that low-dose
corticosteroids may reverse shock faster; however, mortality is not improved
for the overall population.
14. Stroke Mimics and
Intravenous Thrombolysis (Maybe Not So Safe)
Durston W. Ann Emerg Med. 2012;60:246.
To the Editor:
In their report on stroke mimics and intravenous
thrombolysis, Artto et al1 conclude that patients with stroke mimics were
infrequent in their study and that none of the 14 patients with diagnoses of
stroke mimic was harmed by receiving tissue plasminogen activator (tPA).1 They
acknowledge a potential bias in their study, though, toward misclassifying
stroke mimics as actual strokes, noting that “…the diagnosis might have been
biased toward ischemic stroke because making an alternative diagnosis after
applying intravenous thrombolysis may have been difficult.” Artto et al1 state
in the introduction to their article that 5 other small studies, including a
total of 145 stroke mimic cases treated with tPA, also reported no symptomatic
intracranial hemorrhage in such patients. Artto et al1 fail to note, though,
that the other 5 studies also used the same retrospective methodology and are
subject to the same bias toward misclassifying stroke mimics as actual strokes.
Such a bias is even more likely in patients who develop intracranial hemorrhage
after receiving tPA. As difficult as it might be to recognize and acknowledge
that a patient who improves after receiving tPA actually had a stroke mimic, it
is undoubtedly more difficult to recognize and acknowledge that a patient who
deteriorates because of an intracranial hemorrhage shortly after receiving tPA
was not actually having a stroke when he or she initially presented.
Large studies of administration of tPA for acute myocardial
infarction have reported that about 1% of patients develop clinically
symptomatic intracranial hemorrhage.2, 3 One might reasonably expect a similar
incidence in patients with stroke mimics who receive tPA.
The greatest bias in the report by Artto et al,1 though, is
in the sweeping statement in the introduction: “Intravenous thrombolysis is an
effective and safe treatment for acute ischemic stroke when current guidelines
are followed properly.”1 As a reference for this statement, the authors cite a
report of a pooled analysis of data from the Alteplase Thrombolysis for Acute
Noninterventional Therapy in Ischemic Stroke, European Cooperative Acute Stroke
Study, and National Institute of Neurological Disorders and Stroke studies.4 In
the disclosures of the funding sources, affiliations, and potential conflicts
of interests for the participants in the original studies and the pooled
analysis, the names “Genentech” and “Boehringer Ingelheim” (the US and European
manufacturers of tPA, respectively) occur a combined 25 times. One of the
coauthors in the study by Artto et al1 also reports receiving honoraria and
consulting fees from Boehringer Ingelheim.1
A graphic reanalysis of the NINDS data by Hoffman and
Schriger5 has been published in this journal. This reanalysis showed that there
was no significant difference between tPA patients and controls in the degree
of improvement at 90 days when baseline differences in stroke severity were
taken into account. Physicians who treat patients with strokelike symptoms
should not be reassured by the results reported by Artto et al1 that it is safe
to administer tPA to patients with stroke mimics, and they should remain
skeptical of the claim repeated by Artto et al1 that tPA has been shown to be
safe and effective in treating patients who actually do have acute ischemic
strokes.
15. Effective
Discharge Communication in the Emergency Department
Samuels-Kalow ME, et al. Ann Emerg Med. 2012;60:152-159.
Communication at discharge is an important part of
high-quality emergency department (ED) care. This review describes the existing
literature on patient understanding and implementation of discharge
instructions, discusses previous interventions aimed at improving the discharge
process, and recommends best practices and future research. MEDLINE and
Cochrane databases were searched, using combinations of key terms. Literature
from both the adult and pediatric ED populations was reviewed. Multiple reports
have shown deficient comprehension at discharge, with patients or parents
frequently unable to report their diagnosis, management plan, or reasons to
return. Interventions to improve discharge communication have been, at best,
moderately successful. Patients need structured content, presented verbally,
with written and visual cues to enhance recall. Written instructions need to be
provided in the patient's language and at an appropriate reading level.
Understanding should be confirmed before the patient leaves the ED. Further
research is needed to describe the optimal content, channel, and timing for the
ED discharge process and the relationship between discharge process and
outcomes.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(11)01762-8/fulltext
16. Consider Emergent
Angiography for Exsanguinating Pelvic Fracture
Angioembolization reduced mortality from exsanguination
compared with conventional treatment for hemorrhage control.
Hauschild O et al. J Trauma Acute Care Surg. 2012 Jun 14.
[Epub ahead of print]
BACKGROUND: Hemorrhage from pelvic vessels is a potentially
lethal complication of pelvic fractures. There is ongoing controversy on the
ideal treatment strategy for patients with pelvic hemorrhage. The aim of the
study was to analyze the role of angiography and subsequent embolization in
patients with pelvic fractures and computed tomography scan-proven vascular
injuries.
METHODS: The data from the prospective multicenter German
pelvic injury registry were analyzed. Of 5,040 patients with pelvic fractures,
152 patients with associated vascular injuries were identified. Patients
undergoing angioembolization (n = 17) were compared with those undergoing
conventional measures for hemorrhage control (n = 135) with regard to
demographic and physiologic parameters, fracture type distribution, and
treatment measures. Outcome measures were mortality, requirement for blood
transfusions, complications, and hospital length of stay.
RESULTS: Embolization and nonembolization groups were
comparable with regard to age, sex, Injury Severity Score, Hannover Polytrauma
Score, initial hemoglobin levels, blood pressure, fracture distribution, and
conventional measures. Blood transfusion requirement was significantly
prolonged in the embolization group. This resulted in a higher adult
respiratory distress syndrome incidence and a tendency toward increased
multiple organ failure rate in this group. There was no significant difference
in overall mortality rate when compared with the nonembolization group (17.6%
vs. 32.6%, respectively; p = 0.27). None of the patients undergoing
embolization died from exsanguination when compared with 20.6% in the
nonembolization group (p = 0.038).
CONCLUSION: Angioembolization alongside with conventional
measures is an effective complementary means for hemorrhage control in patients
sustaining pelvic fracture-related vascular lesions. It might prove even more
effective when performed early enough to avoid prolonged blood transfusion
requirement. Further studies without the mentioned limitations of the study are
desired.
17. Hypotension after
Medical Termination of Pregnancy: Think Outside of the Uterus
Butt S, et al. J Emerg Med. 2012;43:50-53.
Background: Under usual circumstances, an ectopic pregnancy
would not be generally considered in the initial differential diagnosis of
shock after voluntary termination of pregnancy.
Objective: To present a rare case of a young woman with
shock after voluntary termination of pregnancy due to undiagnosed ectopic
pregnancy with concealed hemorrhage.
Case Report: A 37-year-old woman presented to the Emergency
Department (ED) 3 days after termination of pregnancy with clinical features of
shock. The patient had some evidence of infection and was initially managed as
a case of septic shock secondary to possible complication of recent termination
of pregnancy. Subsequent work-up led to suspicion of internal bleeding, and
ruptured ectopic pregnancy was confirmed and managed successfully.
Conclusion: Ruptured ectopic pregnancy can present with a
wide range of symptoms and under variable circumstances. Recognition of subtle
signs of hemorrhage and consideration of the diagnosis of ruptured pregnancy in
the ED will lead to early diagnosis and appropriate management.
18. The LVAD:
Walking, Talking … and Pulseless
by Stuart Swadron, MD on July 10, 2012. Emergency Physicians
Monthly
Sharp Memorial’s Dr. Zach Shinar explains how to manage the
care of the patient with a left ventricular assist device (LVAD)
You walk into your next code and it’s a man in his 60s who
collapsed on his way to his cardiologist’s office. His wife insists that he
doesn’t need CPR because he has a kind of artificial heart, an LVAD. No one in
the department has ever seen a patient with one of these before…
For me, I will always associate the LVAD with former vice-president
Dick Cheney. I remember the television interview that he did in 2010 where he
showed the whole nation his LVAD and the extra batteries that he carried in his
fishing vest. After almost two years on the LVAD, he received a heart
transplant and is doing well.
So, who qualifies for an LVAD?...
For the remainder of the essay with pictures, link here: http://www.epmonthly.com/clinical-skills/emrap/the-lvad-walking-talking-and-pulseless/
19. What Primary Care
Providers Need to Know About Preexposure Prophylaxis for HIV Prevention: A
Narrative Review
Krakower D, et al. Ann Intern Med. 22 July 2012. Online
First
As HIV prevalence climbs globally, including more than 50
000 new infections per year in the United States, we need more effective HIV
prevention strategies. The use of antiretrovirals for preexposure prophylaxis
(PrEP) among high-risk persons without HIV is emerging as 1 such strategy. Randomized,
controlled trials have demonstrated that once-daily oral PrEP decreased HIV
incidence among at-risk men who have sex with men and African heterosexuals,
including serodiscordant couples. An additional randomized, controlled trial of
a topical pericoital antiretroviral microbicide gel decreased HIV incidence
among at-risk heterosexual South African women. Two other studies in African
women did not demonstrate the efficacy of oral or topical PrEP, raising
concerns about adherence patterns and efficacy in this population.
The U.S. Food and Drug Administration (FDA) Antiviral Drugs
Advisory Committee reviewed these studies and additional data in May 2012 and
voted to advise the approval of oral tenofovir–emtricitabine for PrEP in
high-risk populations. On 16 July 2012, the FDA recommended that this
combination medication be approved for use as PrEP in high-risk persons without
HIV. Patients may seek PrEP from their primary care providers, and those
receiving PrEP require monitoring. Thus, primary care providers should become
familiar with PrEP. This review outlines current knowledge about PrEP as it
pertains to primary care, including identifying persons likely to benefit from
PrEP; counseling to maximize adherence and reduce potential increases in risky behavior;
and monitoring for potential drug toxicities, HIV acquisition, and
antiretroviral drug resistance. Issues related to cost and insurance coverage
are also discussed. Recent data suggest that PrEP, combined with other
prevention strategies, holds promise in helping to curtail the HIV epidemic.
Human immunodeficiency virus continues to spread, with more
than 2 million new infections globally (1) and 50 000 new infections in the
United States per year (2). Thus, more effective HIV prevention strategies are
urgently needed. Administration of antiretroviral medications to uninfected
persons at high risk to protect against HIV acquisition, known as preexposure
prophylaxis (PrEP), has recently emerged as a promising prevention strategy.
Over the past 2 years, randomized, controlled trials have
demonstrated that PrEP can decrease HIV incidence in high-risk populations (3 -
6). With the FDA's approval of oral tenofovir–emtricitabine for PrEP in
high-risk populations (7), clinicians can now prescribe PrEP to prevent HIV
acquisition in their at-risk patients. Thus, it is important that practicing
physicians understand this new evidence and its implications.
Full-text (free for now): http://annals.org/article.aspx?articleid=1221642
20. “Cool down”
before Lap Chole in Gallstone Pancreatitis May Not be Best
Falor AE, et al. Early Laparoscopic Cholecystectomy for Mild
Gallstone Pancreatitis: Time for a Paradigm Shift. Arch Surg. 2012;():1-5.
[Epub date] doi:10.1001/archsurg.2012.1473
Intro
Acute biliary pancreatitis is a common clinical scenario
encountered by the general surgeon. The etiology can be explained by the
“common channel” theory, in which the ampulla of Vater is transiently
obstructed by a gallstone, leading to pancreatic inflammation and
autodigestion.1 Because most of the offending stones are passed into the feces,
the ensuing pancreatitis is generally mild and can often be managed
supportively.2 To prevent further episodes, elective laparoscopic
cholecystectomy (LC) is routinely performed during the same hospital admission
to remove the source of calculi. The time to surgery after admission, however,
is still greatly debated..
Historically, the symptomatic management of gallstone pancreatitis
involved the delay of a cholecystectomy until the normalization of laboratory
values and the resolution of abdominal pain.3 Ranson's earlier articles3 - 4 in
the era of the open cholecystectomy investigated the timing of biliary surgery
in mild (<3 Ranson signs) and severe (≥3 Ranson signs) pancreatitis. He
concluded that “definitive correction of cholelithiasis should usually be
carried out as soon as evidence of acute pancreatitis has resolved”4 (p661) to
avoid exacerbating the severity or recurrence of disease. Recent evidence, with
the introduction of laparoscopic surgery, has suggested that patients with mild
gallstone pancreatitis, which comprises 80% to 90% of all patients with
gallstone pancreatitis, may be better served with earlier intervention.5 .
Two previous studies5 - 6 from our institution demonstrated
that, in patients with mild gallstone pancreatitis, an LC could be safely
performed within 48 hours of admission regardless of resolution of abdominal
pain or normalization of serum enzyme levels. This approach resulted in a
significant decrease in length of hospitalization without increasing
complications.5 - 6 There remains continued concern, however, that prediction
of mild pancreatitis is uncertain and that some patients may incur an
exacerbation of their disease as a result of early operative intervention..
To further address these concerns and to minimize the
possible bias of a single-institution study, we set out to expand our database
by collecting patient data from 2 university-affiliated urban medical centers
during a 5-year period, with the goal of reaffirming the results of our
previous, more limited investigations. Hospital lengths of stay, perioperative
complications, and readmission rates were examined to determine the efficacy
and safety of an early LC in patients with mild gallstone pancreatitis.
Abstract
Hypothesis Patients
with mild gallstone pancreatitis may undergo an early laparoscopic
cholecystectomy (LC) within 48 hours of hospital admission without awaiting the
normalization of pancreatic and liver enzyme levels. This may decrease the
hospital stay without increasing morbidity or mortality and may minimize the
unnecessary use of endoscopic retrograde cholangiopancreatography.
Design A
retrospective review.
Setting Two
university-affiliated urban medical centers.
Patients A total of
303 patients with mild gallstone pancreatitis, of whom 117 underwent an early
LC and 186 underwent a delayed LC.
Main Outcome Measures
Hospital length of stay, morbidity and mortality rates, and the use of
endoscopic retrograde cholangiopancreatography.
Results Similar
hospital admission variables were observed in the early and delayed LC groups,
although the delayed group was older (P = .006). The median hospital length of
stay was significantly less for the early group than for the delayed group (3
vs 6 days; P < .001). There were no patients who died, and the complication
rates were similar for both groups. However, the patients who underwent an
early LC were less likely than patients who underwent a delayed LC to undergo
endoscopic retrograde cholangiopancreatography (P = .02).
Conclusions An early
LC may be safely performed for patients with mild gallstone pancreatitis,
without concern for increased morbidity and mortality, resulting in shortened
hospital stays and a decrease in the use of endoscopic retrograde
cholangiopancreatography. The practice of delaying an LC until normalization of
laboratory values appears to be unnecessary.
Full-text (free): http://archsurg.jamanetwork.com/article.aspx?articleid=1216541
.
21. ER vs. ED: A
Comparison of Televised and Real-life Emergency Medicine
Primack BA, et al. J Emerg Med 2012; in press.
Background: Although accurate health-related representations
of medical situations on television can be valuable, inaccurate portrayals can
engender misinformation.
Objective: The purpose of this study was to compare
sociodemographic and medical characteristics of patients depicted on television
vs. actual United States (US) Emergency Department (ED) patients.
Methods: Two independently working coders analyzed all 22
programs in one complete year of the popular “emergency room” drama ER.
Inter-rater reliability was excellent, and all initial coding differences were
easily adjudicated. Actual health data were obtained from the National Heath
and Ambulatory Medical Care Survey from the same year. Chi-squared
goodness-of-fit tests were used to compare televised vs. real distribution
across key sociodemographic and medical variables.
Results: Ages at the extremes of age (i.e., ≤ 4 and≥45
years) were less commonly represented on television compared with reality.
Characters on television vs. reality were less commonly women (31.2% vs. 52.9%,
respectively), African-American (12.7% vs. 20.3%), or Hispanic (7.1% vs.
12.5%). The two most common acuity categories for television were the extreme
categories “non-urgent” and “emergent,” whereas the two most common categories
for reality were the middle categories “semi-urgent” and “urgent.” Televised
visits compared with reality were most commonly due to injury (63.5% vs. 37.0%,
respectively), and televised injuries were less commonly work-related (4.2% vs.
14.8%, respectively).
Conclusions: Comparison of represented and actual
characteristics of ED patients may be valuable in helping us determine what
types of patient misperceptions may exist, as well as what types of
interventions may be beneficial in correcting that potential misinformation.
