Monday, October 01, 2012

Lit Bits: Oct 1, 2012

From the recent medical literature...

1. IV Combos Work for Agitation in the ED 

By Todd Neale, Senior Staff Writer, MedPage Today. September 15, 2012 

For patients with acute agitation in the emergency department, adding either droperidol or olanzapine to midazolam reduces the time to sedation compared with midazolam alone, a randomized trial showed. 

The time to sedation was 10 minutes with midazolam alone (95% CI 4 to 25), 6 minutes with the droperidol combination (95% CI 3 to 10), and 5 minutes with the olanzapine combination (95% CI 3 to 10), according to David Taylor, MD, of Austin Health in Heidelberg, Australia, and colleagues. 

The differences between each of the antipsychotic combinations and midazolam alone were statistically significant, but the study was not designed to detect differences between the two groups receiving droperidol or olanzapine, the researchers reported online in Annals of Emergency Medicine. They noted, however, that "anecdotal evidence, current practice, and this study suggest their effects are similar." 

When patients come into the emergency department with acute agitation, parenteral benzodiazepines -- like midazolam -- and antipsychotics are often used when other strategies are not possible or don't work. Benzodiazepines and antipsychotics are sometimes used together, although there are insufficient data to support the use of such combinations. 

The current trial included 336 adult patients (median age 32 to 35) who required intravenous drug sedation for acute agitation in one of three large metropolitan emergency departments. They were randomized to one of three treatments:
·         An IV bolus of a saline solution representing placebo droperidol and placebo olanzapine
·         An IV bolus of droperidol 5 mg plus placebo olanzapine
·         An IV bolus of olanzapine 5 mg plus placebo droperidol 

In each group, the treatment was followed immediately by incremental IV midazolam boluses of 2.5 to 5 mg until sedation was achieved. Sedation was defined as a score of 2 or lower on a six-point sedation scale, indicating that the patients were mildly aroused, pacing, and willing to talk reasonably, were settled with minimal agitation, or were asleep. 

The time to sedation was significantly shorter in both of the antipsychotic groups, such that at any point patients in either the droperidol or olanzapine groups were more likely than those in the control group to be sedated. The hazard ratio for sedation was 1.61 (95% CI 1.23 to 2.11) for droperidol and 1.66 (95% CI 1.27 to 2.17) for olanzapine. 

In addition, patients in the two active treatment groups required less rescue therapy after sedation was initially achieved. 

Adverse events occurred in 15.7% of the control group, 10.7% of the droperidol group, and 8.3% of the olanzapine group. All were easily managed, according to the authors. Although the label for droperidol contains a boxed warning related to prolonged QT, patients receiving that drug had a corrected QT interval similar to that in the other groups. 

"Our findings do not support the Food and Drug Administration black box warning for droperidol ...," the researchers wrote. "However, firm conclusions cannot be made because the study was not powered to compare corrected QT intervals, not all patients had an ECG performed, and only single ECGs were performed." 

Taylor and colleagues acknowledged some limitations of the study, including possible selection bias because not all suitable patients were enrolled and possible observer bias in the use of the sedation scale.  

Chan E, et al. Intravenous droperidol or olanzapine as an adjunct to midazolam for the acutely agitated patient: a multicenter, randomized, double-blind, placebo-controlled clinical trial. Ann Emerg Med 2012; DOI: 10.1016/j.annemergmed.2012.07.118. 

 2. Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the ED 

Cantrill SV, et al. Ann Emerg Med. 2012;60:499-525. 

This clinical policy deals with critical issues in prescribing of opioids for adult patients treated in the emergency department (ED). This guideline is the result of the efforts of the American College of Emergency Physicians, in consultation with the Centers for Disease Control and Prevention, and the Food and Drug Administration. The critical questions addressed in this clinical policy are: (1) In the adult ED patient with noncancer pain for whom opioid prescriptions are considered, what is the utility of state prescription drug monitoring programs in identifying patients who are at high risk for opioid abuse? (2) In the adult ED patient with acute low back pain, are prescriptions for opioids more effective during the acute phase than other medications? (3) In the adult ED patient for whom opioid prescription is considered appropriate for treatment of new-onset acute pain, are short-acting schedule II opioids more effective than short-acting schedule III opioids? (4) In the adult ED patient with an acute exacerbation of noncancer chronic pain, do the benefits of prescribing opioids on discharge from the ED outweigh the potential harms? 

3. Small Strokes, TIA Can Be Disabling 

By Nancy Walsh, Staff Writer, MedPage Today. September 14, 2012 

A substantial 15% of patients who've had a transient ischemic attack (TIA) or minor stroke are disabled 3 months later, particularly if they had persistent symptoms and a high-risk phenotype seen on imaging, a Canadian prospective study found. 

The risk of disability was more than doubled in patients whose symptoms were ongoing during emergency department evaluation (OR 2.4, 95% CI 1.3 to 4.4, P=0.004), according to Shelagh B. Coutts, MD, and colleagues from the University of Calgary in Alberta. 

Similar high risks also were seen if CT or CT angiography revealed acute ischemic changes or more than 50% stenosis near the ischemic area (OR 2.4, 95% CI 1.4 to 4.0, P=0.001), the researchers reported online in Stroke: Journal of the American Heart Association. Risk assessment after minor stroke or TIA has traditionally focused on recurrence, not disability, yet studies have suggested that neurologic problems can worsen and standard evaluations may not identify certain deficits that can be disabling. Treatment for these patients also has been inadequate. 

"A common reason for patients to be excluded from thrombolysis is that [the events] are considered 'too mild'," the researchers noted. To explore the potential predictors of poor outcome after TIA or a minor stroke (less than 4 on the NIH Stroke Scale score), Coutts and colleagues analyzed data from a series of 499 patients referred to the Foothills Medical Center in Calgary who were previously not disabled. More than half were men, and median age was 69.  

A total of 61% had ongoing symptoms when seen in the emergency department, and the median time until CT was performed following symptom onset was about 5 hours. MRI also was successfully done in 82% of patients. 

Disability was defined as having a score of 2 or higher on the modified Rankin scale. Most of the 74 patients who had a disabled outcome had a modified Rankin score of 2 (42). Baseline characteristics associated with disability at 3 months included age older than 60, diabetes, higher baseline NIH Stroke Scale score (median baseline score was 1), high-risk CT findings, and positive findings on MR diffusion-weighted imaging. 

Aside from ongoing symptoms and high-risk CT findings, multivariate analysis found significant predictive ability for the following:
·         Diabetes, OR 2.3 (95% CI 1.2 to 4.3, P=0.009)
·         Female sex, OR 1.8 (95% CI 1.1 to 3, P=0.025)
·         Baseline NIH Stroke Scale score-per point, OR 1.49 (95% CI 1.2 to 1.9, P less than 0.001) 

The researchers also conducted an exploratory analysis in which they excluded patients who had recurrent cerebrovascular events and found similar results for high-risk CT findings (OR 2.02, 95% CI 1.1 to 3.6, P=0.017) and persistent symptoms in the emergency department (OR 2.2, 95% CI 1.2 to 4.3, P=0.017). 

Among the 74 patients who were disabled at 3 months, only 26% had had a recurrent event. But among those with a second event, 53% were disabled (RR 4.4, 95% CI 3.0 to 6.6, P less than 0.0001). Therefore, while most patients who became disabled had only the primary event, those who did have second events were at very high risk for adverse outcomes. "Recurrent events are therefore a very important surrogate for disability but numerically not the major factor in predicting a disabled outcome," Coutts and colleagues observed. These findings about the outcomes following minor strokes or TIAs were "surprising," they noted. 

"Our study is novel in that it emphasizes the need to examine disability even in minor strokes and brings together careful clinical assessments and imaging data to emphasize this point," they stated. 

Future research should explore the possible reasons for why certain individuals become disabled even after an apparently small stroke or TIA, and should examine more refined ways of measuring minor disabilities than were used in this study. The researchers concluded that patients with TIAs or minor strokes that have high-risk features should be considered for thrombolytic therapy and other treatments. "Furthermore, it is clear that the issue of disability after minor stroke requires much more careful consideration as the relevant outcome rather than simply recurrent stroke," they wrote. 

Coutts S, et al Stroke 2012; DOI: 10.1161/STROKEAHA.112.665141.

4. Lactate Level Correlates with Prognosis in Patients with Suspected Infection 

This large study identified a nearly linear relationship between lactate level and mortality. 

To analyze the relationship between blood lactate levels and mortality in patients with suspected infection, researchers reviewed charts from 2596 patients who were admitted from the emergency department (ED) with suspected infection (inferred from administration of antibiotics in the ED) and who had blood lactate levels measured in the ED. 

Overall in-hospital mortality was 14.4%, and the median initial lactate level was 2.1 mmol/L. The initial lactate level was over 4 mmol/L in 17.6% of patients. Mortality rose continuously across a continuum of incremental lactate elevations, ranging from 6% in patients with lactate levels less than 1.0 mmol/L to 39% in patients with levels of 19 to 20 mmol/L. 

Comment: We can draw two important conclusions from this study. First, patients with suspected infection who have lactate levels less than 4 mmol/L still are at risk of dying, so physicians should not base their evaluation of illness severity and patient risk solely on lactate level. Second, mortality risk increases with increasing lactate level, making resuscitation of patients with higher levels a priority. 

— Diane M. Birnbaumer, MD, FACEP. Published in Journal Watch Emergency Medicine September 14, 2012. Citation(s): Puskarich MA et al. Prognostic value of incremental lactate elevations in emergency department patients with suspected infection. Acad Emerg Med 2012 Aug; 19:983. 

5. New Strep Throat Guidelines Tackle Antibiotic Resistance 

Most sore throats are actually caused by viruses 

MONDAY, Sept. 10 (HealthDay News) -- Doctors need to accurately diagnose and treat strep throat in order to avoid inappropriate use of antibiotics that can lead to drug-resistant bacteria, according to updated guidelines from the Infectious Diseases Society of America. 

People often say they have strep throat. Most sore throats are caused by a virus, however, not by Streptococcus bacteria, and should not be treated with antibiotics, which are ineffective against viruses, noted an IDSA news release. 

Research shows that up to 15 million people in the United States go to the doctor for a sore throat every year. As many as 70 percent of patients receive antibiotics for a sore throat, but only 20 percent of those patients have strep throat, according to the IDSA. 

The guidelines also advised that when a strep infection is confirmed by testing, it should be treated with penicillin or amoxicillin -- if the patient does not have an allergy -- and not with an antibiotic such as cephalosporin. "We recommend penicillin or amoxicillin for treating strep because they are very effective and safe in those without penicillin allergy," lead author Dr. Stanford Shulman, chief of infectious diseases at the Ann & Robert H. Lurie Children's Hospital of Chicago, said in the news release. Other antibiotics more likely to lead to drug resistance also are more expensive, Shulman added. 

Children who have recurrent strep throat should not have their tonsils removed solely to reduce the frequency of throat infections, according to the guidelines. Patients with a sore throat do not need to be tested for strep throat if they have a cough, runny nose, hoarseness or mouth sores. These are strong signs of a viral infection. 

The guidelines, published online Sept. 10 and in the October issue of the journal Clinical Infectious Diseases, also outline what tests to conduct if strep throat is suspected and how to treat the condition. 

Shulman ST, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis 2012 September 9 [Epub ahead of print] doi: 10.1093/cid/cis629 

6. Sedation-assisted orthopedic reduction in emergency medicine: The safety and success of a one physician/one nurse model.  

Vinson DR, Hoehn C. West J Emerg Med. 2012 September [Epub ahead of print]  

Introduction: Much of the emergency medical research on sedation-assisted orthopedic reductions has been undertaken with two physicians—one dedicated to the sedation and one to the procedure. Clinical practice in community emergency departments (EDs), however, often involves only one physician, who both performs the procedure and simultaneously oversees the crendentialed registered nurse who administers the sedation medication and monitors the patient. Although the dual-physician model is advocated by some, evidence in support of its superiority is lacking. 

Methods: In this electronic health records review we describe sedation-assisted closed reductions of major joints and forearm fractures in three suburban community EDs. The type of procedure and sedation medication, need for specialty assistance, success rates, and intervention-requiring adverse events are reported. 

Results: During the 18-month study period, procedural sedation was performed 457 times on 442 patients undergoing closed reduction for shoulder dislocations (n=111), elbow dislocations (n=29), hip dislocations (n=101), and forearm fractures (n=201). In the vast majority of this cohort (98.4% [435/442]), a single emergency physician simultaneously managed both the procedural sedation and the initial orthopedic reduction without the assistance of a second physician. The reduction was successful or satisfactory in 96.6% (425/435; 95% confidence interval [CI], 95.8-98.8%) of these cases, with a low incidence of intervention-requiring adverse events (2.8% [12/435]; 95% CI, 1.5-4.8%).

Conclusion: Sedation-assisted closed reduction of major joint dislocations and forearm fractures can be performed effectively and safely in the ED using a one physician/one nurse model. A policy that requires a separate physician (or nurse anesthetist) to administer medications for all sedation-assisted ED procedures appears unwarranted. Further research is needed to determine which specific clinical scenarios might benefit from a dual-physician approach.  

7. Validation of a Clinical Prediction Model for Early Admission to the Intensive Care Unit of Patients with Pneumonia 

Labarère J, et al. Acad Emerg Med. 2012;19;993-1003.  

Objectives:  The Risk of Early Admission to the Intensive Care Unit (REA-ICU) index is a clinical prediction model that was derived based on 4,593 patients with community-acquired pneumonia (CAP) for predicting early admission to the intensive care unit (ICU; i.e., within 3 days following emergency department [ED] presentation). This study aimed to validate the REA-ICU index in an independent sample. 

Methods:  The authors retrospectively stratified 850 CAP patients enrolled in a multicenter prospective randomized trial conducted in Switzerland, using the REA-ICU index, alternate clinical prediction models of severe pneumonia (SMART-COP, CURXO-80, and the 2007 IDSA/ATS minor severity criteria), and pneumonia severity assessment tools (the Pneumonia Severity Index [PSI] and CURB-65). 

Results:  The rate of early ICU admission did not differ between the validation and derivation samples within each risk class of the REA-ICU index, ranging from 1.1% to 1.8% in risk class I to 27.1% to 27.6% in risk class IV. The areas under the receiver operating characteristic (ROC) curve were 0.76 (95% confidence interval [CI] = 0.70 to 0.83) and 0.80 (95% CI = 0.77 to 0.83) in the validation and derivation samples, respectively. In the validation sample, the REA-ICU index performed better than the pneumonia severity assessment tools, but failed to demonstrate an accuracy advantage over alternate prediction models in predicting ICU admission. 

Conclusions:  The REA-ICU index reliably stratifies CAP patients into four categories of increased risk for early ICU admission within 3 days following ED presentation. Further research is warranted to determine whether inflammatory biomarkers may improve the performance of this clinical prediction model. 

What’s the index? See their earlier work, available full-text free online. Renaud B, et al. Crit Care. 2009;13(2):R54.  

8. Images in Clinical Practice 

Battle’s Sign

A Tickling in the Ear [DRV note: viewer discretion advised]

Elderly Male with Respiratory Failure

A Suddenly Collapsed Man

Fever, Cough, and Weight Loss

9. Team Effort Cuts In-Hospital Blood Infections 

By Joyce Frieden, News Editor, MedPage Today. September 10, 2012 

A combination of best practices, improved safety culture, and a bigger focus on teamwork cut central-line-associated bloodstream infections (CLABSIs) in hospitals by 40%, the Agency for Healthcare Research and Quality (AHRQ) reported. 

In preliminary results from a project involving hospital teams at more than 1,100 intensive care units over a 4-year period, the rate of CLABSIs was reduced from 1.903 infections per 1,000 central line days to 1.137 infections per 1,000 line days, the agency said. Overall, more than 2,000 CLABSIs were prevented, more than 500 lives were saved, and more than $34 million in healthcare costs were avoided, according to AHRQ. 

"No patient should ever become sicker as result of care he or she receives," AHRQ Director Carolyn Clancy, MD, said at a press conference Monday. "Until recently, these infections were thought to be an [unavoidable] consequence of care. But they can be prevented." 

The program, known as CUSP, centered around four basic concepts, explained Michael Tooke, MD, chief medical officer at Memorial Hospital in Easton, Md., one of the participating facilities. He listed the "4 E's" of the program:
·         Engagement -- getting the entire staff involved
·         Education -- teaching the staff about best practices for preventing CLABSIs
·         Execution -- carrying out the program
·         Evaluation -- keeping track of the results and feeding them back to the staff 

"We also had another 'E' -- enthusiasm," Tooke said. "We acknowledged every victory – one month without infection, a whole year – and had a party for every one." 

Components of the program include a procedure checklist, educating staff members on best practices, and trying to change the culture so that infections are considered unacceptable, said Peter Pronovost, MD, PhD, senior vice-president for safety and quality at Johns Hopkins Medicine and one of the developers of the CUSP system. Pronovost explained that he was inspired to tackle the CLABSI problem after a pediatric patient at the hospital died from what he described as "a cascade of errors starting with a central line bloodstream infection." 

"We set out to change this – it worked," Pronovost said. "We virtually eliminated these infections at Hopkins." Since the program started, many hospitals now "have infection rates previously believed impossible." 

Theresa Hickman, RN, of Peterson Regional Medical Center in Kerrville, Texas, said one of the changes the program wrought at her hospital was making sure physicians washed their hands before inserting a line. "We made it so that if the nurse did not see a physician washing hands prior to the procedure, it was considered that the physician didn't wash his hands," she said.  

Hickman noted that her 125-bed rural hospital has not had a CLABSI in its entire facility for 31 months. "Before this, having CLABSIs was part of the price of doing business. Now we know that's not true, and we can keep patients from dying," she said. 

The key to the program is the toolkit provided by AHRQ, which is available to any hospital that wants it and can be adapted to any hospital's particular situation, Tooke said. "It's full of different things that apply to different situations." 

The speakers agreed that success in a program such as this one is very empowering. "Once [a facility] gets started, and they have those zeroes [for zero infections], they become extremely protective of those zeros," said Hickman. "Not too long ago, one nurse called and said, 'I think we have a CLABSI' and she was distraught. It turned out they did not. They become very proud of that." 

9. Public Health Concerns 

A. Commentary: Death on Our Nation's Roadways: Not Just for Cars 

Thoma T. Ann Emerg Med. 2012;60:496-498.  

“Motor vehicle accident.” The emergency medicine residents in our program run for cover when they hear the unsuspecting off-service intern use that term while presenting a case to me. They know that it is the trigger for a long diatribe explaining that motor vehicle crashes are not “accidents.” The unsuspecting physician hears a well-rehearsed lecture explaining that the whole premise of injury prevention is to assume that trauma is a preventable disease. I frequently use the example of a 17-year-old male adolescent driving on a country road at night at a high rate of speed, under the influence of alcohol and without a seat belt, who loses control and is involved in a rollover motor vehicle crash. Consequently, he is ejected and dies. I then ask the physician to explain to me how this young man experienced an unavoidable act of God or how it was just “an accident.” Close evaluation of this crash with the application of Haddon's matrix (a system for evaluating human, vehicle, and environmental factors contrasted to pre-event, event, and postevent phases) yields multiple points of intervention for prevention of this outcome. This young man was the victim of a “crash” or “collision” and the event was wholly avoidable. 

I firmly believe this tenet, but as emergency physicians we are well aware that in avoidable crashes there are often innocent victims. Take, for example, the unsuspecting mother with her children who is driving down the highway in a minivan and falls prey to a distracted driver who crosses the midline. Because of the nature of modern transportation, there are inherent risks. Today we are a much more mobile society compared with when I was a child. There are many more vehicles on the road, and we travel more miles each year. Each vehicle traveling down the road carries with it a large amount of kinetic energy by virtue of its motion, and even the smallest mistakes can result in high-kinetic-energy crashes and injuries. Therein lies the concern. 

The remainder of the essay (full-text free):  

B. The Bullet's Yaw: Reflections on violence, healing and an unforgettable stranger  

By Dustin W. Ballard, MD, MBE  

Jeffrey Mains was in shock. 

During a vengeful rampage, a deranged former security guard had fired a hollow point bullet into Mains’ truck. The bullet’s path through steel slowed its velocity, causing it to tumble sideways when it collided with Mains, a phenomenon that ballistics experts call the “bullet’s yaw.” The bullet’s impact and ensuing yaw were over in a blink, but the effects were profound. Mains’ bowel was pierced and leaking, his liver lacerated and one diaphragm ruptured. When the ambulance arrived, Jeffrey Mains was nearly unconscious; he was bleeding internally and desperately needed surgery. He was rushed, lights blazing and sirens calling, to the UC Davis Medical Center. This is where, several weeks and many complications later, he became my patient.  

During my three-year residency in emergency medicine I treated thousands of patients—strangers such as Jeffrey Mains. Most passed through my life swiftly and their illnesses left but a wisp in my memory. A handful of patients, however, marked me forever. The Bullet’s Yaw is the story of one of these unforgettable strangers and what he taught me about life, violence and healing. 

C. Half the Sky: Turning Oppression into Opportunity for Women Worldwide  

Women and girls across the globe face threats — trafficking, prostitution, violence, discrimination — every day of their lives. But hope endures. Brave men and women have developed innovative ways of helping those living in some of the most challenging conditions. 

A PBS Special (airing Oct 1-2), based on the book by Kristof and WuDunn.  

10. Restart Warfarin after GI Bleed, Study Suggests

Patients who have a gastrointestinal bleed while taking warfarin may do better if they either never stop or resume taking anticoagulation after the event, a retrospective study showed.  

11. Interventions to Improve Adherence to Self-administered Medications for Chronic Diseases in the United States: A Systematic Review  

Viswanathan M, et al. Ann Intern Med. 11 September 2012 [Epub ahead of print] 

Background: Suboptimum medication adherence is common in the United States and leads to serious negative health consequences but may respond to intervention. 

Purpose: To assess the comparative effectiveness of patient, provider, systems, and policy interventions that aim to improve medication adherence for chronic health conditions in the United States. 

Data Sources: Eligible peer-reviewed publications from MEDLINE and the Cochrane Library indexed through 4 June 2012 and additional studies from reference lists and technical experts. 

Study Selection: Randomized, controlled trials of patient, provider, or systems interventions to improve adherence to long-term medications and nonrandomized studies of policy interventions to improve medication adherence. 

Data Extraction: Two investigators independently selected, extracted data from, and rated the risk of bias of relevant studies. 

Data Synthesis: The evidence was synthesized separately for each clinical condition; within each condition, the type of intervention was synthesized. Two reviewers graded the strength of evidence by using established criteria. From 4124 eligible abstracts, 62 trials of patient-, provider-, or systems-level interventions evaluated 18 types of interventions; another 4 observational studies and 1 trial of policy interventions evaluated the effect of reduced medication copayments or improved prescription drug coverage. Clinical conditions amenable to multiple approaches to improving adherence include hypertension, heart failure, depression, and asthma. Interventions that improve adherence across multiple clinical conditions include policy interventions to reduce copayments or improve prescription drug coverage, systems interventions to offer case management, and patient-level educational interventions with behavioral support. 

Limitations: Studies were limited to adults with chronic conditions (excluding HIV, AIDS, severe mental illness, and substance abuse) in the United States. Clinical and methodological heterogeneity hindered quantitative data pooling. 

Conclusion: Reduced out-of-pocket expenses, case management, and patient education with behavioral support all improved medication adherence for more than 1 condition. Evidence is limited on whether these approaches are broadly applicable or affect long-term medication adherence and health outcomes. 

12. Needle Move Proposed for Tension Pneumothorax 

Damian McNamara. Medscape Medical News. September 18, 2012 — With trauma patients, it is traditional to decompress tension pneumothorax by quickly inserting a needle at the second intercostal space (ICS) in the midclavicular line. However, using computed tomography imaging, Kenji Inaba, MD, from the Department of Surgery, Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, and colleagues confirmed that a second site features significantly less chest wall thickness, which could mean more patients would benefit from the procedure. The researchers published the results of their retrospective study in the September issue of the Archives of Surgery. 

The chest wall at the fifth ICS in the anterior axillary line is significantly thinner at than the second ICS in the midclavicular line, thus increasing the likelihood a decompression needle will traverse it completely and enter the chest cavity. Computed tomography images from 120 trauma patients revealed a 12.9-mm shorter mean difference (95% confidence interval [CI], 11.0 - 14.8 mm; P less than .001) in chest wall thickness on the right side between the second ICS in the midclavicular line vs the fifth ICS on the anterior axillary line. On the left side of the patients, researchers found a similar, significant 13.4-mm shorter difference (95% CI, 11.4 - 15.3 mm; P less than .001). 

Standard 5-cm decompression needles were too short to reach the chest cavity through the second ICS/midclavicular line for 42.5% of patients and were too short for 16.7% of patients treated through the fifth ICS/anterior axillary line. 

Interestingly, sex and body mass index made a difference. Women had greater chest wall thickness at all sites compared with men. Therefore, women in particular could benefit from nontraditional needle placement and/or use of longer needles, the authors suggest. 

In addition, the investigators grouped patients by body mass index and found that chest wall thickness increased stepwise with each higher body mass index quartile. They proposed that the increasing proportion of overweight or obese patients also supports a switch to the alternative needle insertion site. 

Mean patient age was 41 years (range, 16 - 97 years), and 81.5% were men. Mean body mass index was 27.9 kg/m2 (range, 15.4 - 60.7 kg/m2), and mean injury severity score was 15.5. 

This clinical study included 120 patients randomly selected from a group of 680 trauma patients aged 16 years and older who were treated at the Los Angeles County University of Southern California Medical Center between January 2009 and January 2010. The findings confirm previous research from the same institution comparing the 2 insertion sites in 20 cadavers. 

The authors of the current study found that 100% of 40 needles inserted through the fifth ICS entered the chest cavity compared with 57.5% of 40 needles placed through the second ICS. 

In an accompanying editorial, Martin A. Schreiber, MD, from the Department of Surgery at Oregon Health & Science University in Portland, described the study as being very well done. However, he writes, "These types of studies make one ask: How could we have done it so wrong for so long?" He also questioned the need to perform the clinical study, given the previous cadaver findings. 

Dr. Schreiber outlined several shortcomings. For example, because no patient actually underwent needle thoracostomy, a clinical correlation could not be made between chest wall thickness and procedure success rate. "They also have not addressed the potential complications of using a longer needle or the devastating complication of cardiac injury if the fifth ICS at the [anterior axillary line] is used." In addition, "angiocatheters kink easily in transport and they can be displaced." 

The authors have disclosed no relevant financial relationships. 

Inaba K, et al. Arch Surg. 2012;147:813-818.  

13. NIPPV for CHF Works, ACLS Algorithms Do Not  

by David Newman, MD on September 26, 2012. Emergency Physicians Monthly 

A. Noninvasive ventilation 

Q: Does noninvasive positive pressure ventilation for CHF save lives? 

 a: Yes!

by Ashley E. Shreves, MD 

For every eight CHF patients you treat with NIPPV, one death is prevented

Side effects were minor, and the most common was gastric distension, then skin damage (20) and mask discomfort (30) 

Take Home Message: NIPPV for CHF appears to save lives, though the data only includes roughly 1000 subjects from both ICUs and EDs. 

B. The ACLS Algorithms 

Q: Do intravenous drugs, as recommended by ACLS algorithms, improve survival? 

a: Excellent studies say NO 

by David H. Newman, MD

NNT: For neurologically intact survival, there is NO BENEFIT. 

NNH: No medical harms were identified 

Take Home Message: Using the ACLS-recommended drug algorithm does not improve survival from cardiac arrest, though it does lead to more ICU admissions. 

14. Prehospital Point-of-Care Measurement of Troponin I Is Feasible 

Troponin I results did not differ when testing was performed in a moving ambulance or in the ED. 

Venturini JM et al. Prehosp Emerg Care 2012 Sep 6 

Background. Swift assessment of patients presenting with chest pain results in faster treatment and improved outcomes. Allowing ambulance crews to use point-of-care (POC) devices to measure cardiac troponin I levels during transport of patients to the emergency department (ED) may result in earlier diagnosis of acute myocardial infarction, particularly in those patients without ST-segment elevation. The ability of POC devices to measure cardiac troponin I levels reliably in a moving ambulance has not previously been tested.  

Objective. This study was conducted to determine whether POC devices operated in a moving ambulance reliably duplicate the measurement of cardiac troponin I levels obtained by POC devices in the ED.  

Methods. Blood samples were obtained in the ED and the hospital from patients reporting chest pain or other cardiac complaints. Troponin I assays were then performed in a moving ambulance using two POC devices. The POC devices were placed on flat surfaces in the rear of the ambulance. The ambulance driver was instructed to keep the ambulance moving in traffic while each assay was completed. A variety of routes were taken. Each set of two assays was completed entirely during a single simulated run. The results of the two assays performed in the moving ambulance were then compared with the results of the control assay, which was performed simultaneously in the ED on the same sample.  

Results. Forty-two whole-blood samples underwent troponin I assays in a moving ambulance. Thirteen (30.9%) assays were positive. One (2.4%) was excluded because of cartridge error. Two (4.8%) were excluded because of interfering substance. No significant difference in whole-blood troponin results was found between the assays performed in the moving ambulance and those performed in the ED (intraclass correlation coefficient 0.997; 95% confidence interval 0.994 to 0.998; p less than 0.005).  

Conclusions. When used in a moving ambulance, the POC device provided results of cardiac troponin I assays that were highly correlated to the results when the device was used in the ED. The feasibility, practicality, and clinical utility of prehospital use of POC devices must still be assessed. 

15. Clinical Corner from Emergency Physicians Monthly 

A. Has This Laceration Compromised the Joint?  

by Drs. Erik Adler, Samantha Mauck & Peter Pryor on May 23, 2012 

Use the methylene blue challenge to find out if there’s more damage beneath the surface. 

B. Coming Up Empty: The Blighted Ovum  

by Teresa S. Wu, MD & Brady Pregerson, MD on September 15, 2012 

C. Death by Interruption: Lessons in ED Efficiency 

By Michael Silverman, MD 

16. Physiologic Monitoring Practices during Pediatric Procedural Sedation: A Report from the Pediatric Sedation Research Consortium 

Langhan ML, et al. Arch Pediatr Adolesc Med. Published online September 10, 2012. doi:10.1001/archpediatrics.2012.1023 

Objectives  To describe the frequency of different physiologic monitoring modalities and combinations of modalities used during pediatric procedural sedation; to describe how physiologic monitoring varies among different classes of patients, health care providers (ie, ranging from anesthesiologists to emergency medicine physicians to nurse practitioners), procedures, and sedative medications employed; and to determine the proportion of sedations meeting published guidelines for physiologic monitoring. 

Design  This was a prospective, observational study from September 1, 2007, through March 31, 2011. 

Setting  Data were collected in areas outside of the operating room, such as intensive care units, radiology, emergency departments, and clinics. 

Participants  Thirty-seven institutions comprise the Pediatric Sedation Research Consortium that prospectively collects data on procedural sedation/anesthesia performed outside of the operating room in all children up to age 21 years. 

Main Outcome Measures  Data including demographics, procedure performed, provider level, adverse events, medications, and physiologic monitors used are entered into a web-based system. 

Results  Data from 114 855 subjects were collected and analyzed. The frequency of use of each physiologic monitoring modality by health care provider type, medication used, and procedure performed varied significantly. The largest difference in frequency of monitoring use was seen between providers using electrocardiography (13%-95%); the smallest overall differences were seen in monitoring use based on the American Society of Anesthesiologists classifications (1%-10%). Guidelines published by the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Society of Anesthesiologists for nonanesthesiologists were adhered to for 52% of subjects.

Conclusions  A large degree of variability exists in the use of physiologic monitoring modalities for pediatric procedural sedation. Differences in monitoring are evident between sedation providers, medications, procedures, and patient types. 

17. 'Gut Feelings' Matter in Diagnosis of Kids' Infections 

By Nancy Walsh, Staff Writer, MedPage Today. September 25, 2012.  

Physicians should pay attention to their "gut feeling" that something may be seriously wrong when assessing a child with an infectious disease -- even if the clinical appearance is reassuring -- an observational study suggested. 

Among 3,369 children whose primary care evaluation did not suggest a serious illness, six (0.2%) ultimately were admitted to the hospital with a severe infection, according to Ann Van den Bruel, MD, PhD, of the Radcliffe Observatory Quarter in Oxford, England, and colleagues. 

The clinician's gut feeling that the child was seriously ill considerably increased the chance that a severe infection was present, with a likelihood ratio of 25.5 (95% CI 7.9 to 82), and heeding the feeling might have prevented two cases from being overlooked (33%, 95% CI 0.95 to 1.75), the researchers reported online in BMJ. 

Considerable research has focused on developing tools for clinical prediction in acutely ill children, including symptoms, vital signs, and laboratory tests, but primary care physicians often see children before the full clinical picture has developed -- and sometimes report relying on intuition that a potentially serious problem exists even though they're unsure why. Moreover, a systematic review recently determined that such a gut feeling had considerable diagnostic significance. 

To clarify the usefulness of physicians' intuitive feelings as an addition to clinical impressions, Van den Bruel and colleagues recruited 3,890 acutely ill children presenting to primary care in Flanders, Belgium. 

For each child, the researchers reviewed the clinical features of the illness, including the physician's overall clinical impression of whether the illness was serious based on the physical examination, history, and observation. They also asked treating physicians for their gut feeling as to whether they suspected the illness was serious based on the appearance of the child or the attitude and behavior of the parent. Serious infections included pneumonia, sepsis, meningitis, pyelonephritis, cellulitis, osteomyelitis, and bacterial gastroenteritis requiring at least 1 day of hospitalization. 

A total of 21 children were hospitalized, with most ultimately being diagnosed with pneumonia or pyelonephritis. Among the children for whom the clinical impression was that the illness was nonserious, the two cases that weren't missed were accompanied by 44 "false alarms," giving a sensitivity of 33.3% and a specificity of 98.7% for the physicians' gut feelings. 

The researchers then looked at the clinical features that most often led to gut feelings that ran counter to the evidence, and found the strongest association for the child having a history of convulsions (OR 80.5, 95% CI 6.2 to 1,051). 

Parental impression that the illness was different from others also was very important (OR 26.93, 95% CI 9.02 to 80.41). 

Other features that led to physicians' gut feelings of serious illness, although less so than convulsions and parental concern, included:
·         Drowsiness, OR 3.49 (95% CI 1.04 to 11.75)
·         Changes in pattern of breathing, OR 4.88 (95% CI 1.38 to 17.26)
·         Weight loss, OR 16.83 (95% CI 3.29 to 85.96)
·         Urinary symptoms, OR 11.64 (95% CI 3.19 to 42.45) 

Temperature was not a significant factor, contrary to the expectations of the researchers. They noted that fever may have contributed to parental impressions of serious illness, however. 

"Nevertheless, it is important that primary care clinicians recognize the diagnostic value of fever in their clinical assessment -- for every 20 children with a temperature of 40° C [104° F) or more in a primary setting, one will have a serious infection," they cautioned. 

The presence of diarrhea also was not associated with gut feelings, which also concerned the researchers, who noted that diarrhea in a young child is not necessarily benign, because it can lead to dehydration and also could be an early symptom of sepsis. 

Among the 21 children who were hospitalized, nine were not admitted initially -- yet in four of those nine, the physician reported having a gut feeling that something was seriously wrong with the child. 

The researchers also considered the treating clinicians' years of experience, and found that the likelihood of their having gut feelings different from their clinical impression decreased by 5% each year. "This is presumably because the holistic clinical features that trigger gut feeling are gradually assimilated into clinical assessment," Van den Bruel and colleagues observed. 

They advised that medical training should emphasize the potential value of gut feelings, and suggested that any such feelings should warrant a "full and careful" examination, consulting with other more experienced clinicians or referral, and explanations to the parent of their need to observe the child diligently. 

"The observed association between gut feeling and clinical markers of serious infection means that by reflecting on the genesis of their gut feeling, clinicians should be able to hone their clinical skills," they concluded. 

The study was limited by its inclusion of only children in primary care, and a lack of power to analyze the specific details of clinicians' gut feelings. 

The study was supported by the Research Foundation-Flanders, Eurogenerics, and the National Institute for Health Research. The authors reported no financial conflicts. 

Van den Bruel A, et al. BMJ 2012; DOI: 10.1136/bmj.e6144.  

18. Utility of Emergency Cranial Computed Tomography in Patients without Trauma 

Narayanan V, et al. Acad Emerg Med. 2012;19:E1055-E1060.  

Objectives:  The objectives of this study were to determine, in patients admitted to the hospital from the emergency department (ED) without evidence of trauma, 1) the prevalence of clinically important abnormalities on cranial computed tomography (CCT) and 2) the frequency of emergent therapeutic interventions required because of these abnormalities. 

Methods:  The authors retrospectively reviewed the records of all patients from 2007 between the ages of 18 and 89 years who had CCT as part of their ED evaluations prior to hospitalization. Patients with any indication of trauma were excluded, as were those who had a lumbar puncture (LP). Chief complaint, results of the ED neurologic examination, tomogram findings, and whether patients had emergent interventions were recorded. Patients presenting with altered mental status (AMS) were analyzed separately. 

Results:  Of the 766 patients meeting inclusion criteria, 83 (11%) had focal neurologic findings, and 61 (8%) had clinically important abnormalities on computed tomography. Emergent interventions occurred in only 12 (1.6%), 11 (92%) of whom had focal neurologic findings. In the subgroup of 287 patients with AMS as their presenting problem, 14 (4.9%) had focal findings, six (2%) had clinically important abnormalities on tomography, and only two (0.7%) required emergent interventions, both of whom had focal findings. Patients presenting with AMS were less likely to have positive findings on tomography (odds ratio [OR] = 0.16, 95% confidence interval [CI] = 0.07 to 0.39). Patients presenting with motor weakness or speech abnormalities, or who were unresponsive, were more likely to have positive findings on tomography (OR = 4.7, 95% CI = 2.6 to 8.6; OR = 4.4, 95% CI = 1.5 to 2.7; and OR = 3.3, 95% CI = 1.6 to 7.1, respectively). 

Conclusions:  Of patients without evidence of trauma who receive CCT in the ED, the prevalence of focal neurologic findings and clinically important abnormalities on tomography is low, the need for emergent intervention is very low, and the large majority of patients requiring emergent intervention have focal findings. The yield of CCT was lower for patients presenting with AMS, and higher for patients presenting with motor weakness or speech abnormalities, and for those who were unresponsive. 

19. NSAIDs May Hike Long-Term CV Risk Post-MI 

By Chris Kaiser, Cardiology Editor, MedPage Today. September 11, 2012.  

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) may confer a long-term risk of adverse cardiovascular events, a Danish population study found. 

Of the nearly 100,000 patients with first-time myocardial infarction (MI) included in the analysis, those taking NSAIDs had a "persistent" increased risk of all-cause death at 1 year (HR 1.59, 95% CI 1.49 to 1.69) and at 5 years (HR 1.63, 95% CI 1.52 to 1.74), according to Anne-Marie Olsen, MD, a research fellow at Copenhagen University Hospital Gentofte in Hellerup, Denmark, and colleagues. 

In addition, those taking these anti-inflammatory drugs had a 41% increased risk of a second MI and a 30% increased risk of coronary death during the 5-year follow-up, they reported online in Circulation: Journal of the American Heart Association. 

While epidemiological studies such as this cannot establish causality, they said their results are further evidence of an association between COX-2 inhibitors and severe adverse cardiovascular events. "We advise long-term caution in using NSAIDs for patients after MI," they concluded. They also suggested that the availability of over-the-counter nonselective NSAIDS such as diclofenac and ibuprofen "should be reconsidered." 

Although taking any NSAID increased the risk compared with taking none, use of diclofenac was associated with the highest risk, they pointed out. Other NSAIDs evaluated in this study were rofecoxib (Vioxx), celecoxib (Celebrex), naproxen (Aleve, among other brand names), and others. At the time of the study, only ibuprofen (200 mg) was available over the counter in Denmark. 

Despite a focused update in 2007 from the American Heart Association cautioning against the use of NSAIDs for those with cardiovascular disease, many still receive these drugs, although for shorter periods (Circulation 2007; 115: 1634-1642), Olsen and colleagues wrote. 

Because the long-term effects of NSAIDs among those with a first MI were unclear, researchers analyzed data from 99,187 patients in the Danish National Patient Registry from 1997 to 2009. There were more men (64%) than women in the study, the mean age was 69, and 44% had filled at least one prescription of NSAIDs. 

Researchers found that the overall adverse risks associated with NSAIDs "remained virtually unchanged throughout all 5 years after discharge from hospital after the first MI." This is in contrast to the typical risk of cardiovascular mortality and morbidity following an MI, which declines as time passes, Olsen and colleagues noted. 

However, rofecoxib and diclofenac conferred a greater risk of death and the composite of recurrent MI and coronary death over time compared with other NSAIDs, especially naproxen, which had the lowest risk. Although it might be preferable to prescribe naproxen, researchers noted that the drug was associated with a higher risk of gastrointestinal bleeding than rofecoxib. They also found that those not taking anti-inflammatory drugs had a decreased risk of adverse events over the 5 years following the index MI. 

The study has several limitations, the authors noted, including its observational nature, some missing clinical data, no data on the use of over-the-counter aspirin, and no way to determine if patients adhered to their prescription. However, a strength of the study is that these data are from one country and are known to be accurate, they said. 

They concluded that their findings support previous results that suggest there is "no apparent safe treatment window" for NSAIDs among patients with MI. 

20. Emergency Cricothyroidotomy: A Randomized Crossover Trial Comparing Percutaneous Techniques: Classic Needle First Versus “Incision First” 

Kanji H, et al. Acad Emerg Med. 2012;19:E1061–E1067.  

Objectives:  Emergency cricothyroidotomy is potentially lifesaving in patients with airway compromise who cannot be intubated or ventilated by conventional means. The literature remains divided on the best insertion technique, namely, the open/surgical and percutaneous methods. The two are not mutually exclusive, and the study hypothesis was that an “incision-first” modification (IF) may improve the traditional needle-first (NF) percutaneous approach. This study assessed the IF technique compared to the NF method. 

Methods:  A randomized controlled crossover design with concealed allocation was completed for 180 simulated tracheal models. Attending and resident emergency physicians were enrolled. The primary outcome was time to successful cannulation; secondary outcomes included needle insertion(s), incision, and dilatation attempts. Finally, proportions of intratracheal insertion on the first attempt and subjective ease of insertion were compared. 

Results:  The IF technique was significantly faster than the standard NF technique (median = 53 seconds, interquartile range [IQR] = 45.0 to 86.4 seconds vs. median = 90 seconds, IQR = 55.2 to 108.6 seconds; p less than 0.001). The median number of needle insertions was significantly higher for the NF technique (p = 0.018); there was no significant difference in dilation or incision attempts. Intratracheal insertion on the first attempt was documented in 90 and 93% of the NF and IF techniques, respectively (p = 0.317). All the study participants found the IF hybrid approach easier. 

Conclusions:  The IF modification allows faster access, fewer complications, and more favorable clinician endorsement than the classic NF percutaneous technique in a validated model of cricothyroidotomy. We suggest therefore that the IF technique be considered as an improved method for insertion of an emergency cricothyroidotomy. 

21. AAP Reaffirms Position against Trampoline Use 

Larry Hand.  Medscape Medical News. September 24, 2012 — The American Academy of Pediatrics (AAP) has reaffirmed its position opposing recreational use of trampolines in a policy statement published online September 24 in Pediatrics. 

Coauthors Susannah Briskin, MD, and Michele LaBotz, MD, both pediatricians and sports medicine physicians, write, "Although trampoline injury rates have been decreasing since 2004, the potential for severe injury remains relatively high." 

They write that trampoline injury rates were 70 per 100,000 for 0- to 4-year-olds in 2009, increasing to 160 per 100,000 for 5- to 14-year-olds. Injury rates for those ages are similar for bicycling or playground equipment, as well as swimming pools. However, the authors write, population exposure is "significantly greater" for bicycling and playground equipment, and evidence-based safety advisories for swimming pools are broadly publicized, whereas such advisories for trampolines are not as well disseminated. 

Multiple Users, Smallest Jumpers Most Susceptible 

Most trampoline injuries occur when multiple people are using it at the same time, and the smallest individuals are up to 14 times more vulnerable to injury because of weight differences and their less-developed motor skills, according to the statement. Falling accounts for between 27% and 39% of injuries, and the risk for falling rises when the trampoline in use is on an uneven surface. 

Use of padding does not seem to abate the risk for injury, and a third to a half of all injuries occur under adult supervision, the authors write. Children younger than 6 years account for between 22% and 37% of injuries presenting to emergency departments. 

Although foot and ankle injuries, such as ankle sprain, are most common (more than 60% in one study), 10% to 17% of injuries affect the head or neck, "and 0.5% of all trampoline injuries resulted in permanent neurologic damage," the authors warn. 

Several recommendations are contained in the policy statement, including:
·         Pediatricians should advise against recreational trampoline use.
·         Homeowners should verify whether trampoline injuries are covered by their insurance policies.
·         Any trampoline use should be restricted to a single user at a time.
·         Adults familiar with safety guidelines should supervise any trampoline use.
·         Trampoline conditions should be inspected regularly, and trampolines in disrepair should be discarded. 

The policy statement also says that until further safety information is available on trampoline parks and structured trampoline sports programs, "the cautions outlined here" should be observed for those as well. 

The AAP previously issued policy statements on trampoline use in 1977, 1981, and 1999. Injury rates are based on injuries reported to the US Consumer Product Safety Commission's National Electronic Injury Surveillance System. However, no data source exists regarding injuries in structured trampoline sports programs. 

In summary, "Pediatricians need to actively discourage recreational trampoline use. Families need to know that many injuries occur on the mat itself, and current data do not appear to demonstrate that netting or padding significantly decrease the risk of injury," Dr. LaBotz said in a news release. 

The authors have disclosed no relevant financial relationships. 

AAP’s Council on Sports Medicine and Fitness. Pediatrics. Published online September 24, 2012. 

22. Wanna Get Your Video-addicted Kids Some Exercise?

Physiologic Responses and Energy Expenditure of Kinect Active Video Game Play in Schoolchildren 

Smallwood SR, et al. Arch Pediatr Adolesc Med. Published online September 24, 2012. doi:10.1001/archpediatrics.2012.1271 

Objective:  To evaluate the physiologic responses and energy expenditure of active video gaming using Kinect for the Xbox 360. 

Design:  Comparison study. 

Setting:  Kirkby Sports College Centre for Learning, Liverpool, England. 

Participants:  Eighteen schoolchildren (10 boys and 8 girls) aged 11 to 15 years. 

Main Exposure:  A comparison of a traditional sedentary video game and 2 Kinect activity-promoting video games, Dance Central and Kinect Sports Boxing, each played for 15 minutes. Physiologic responses and energy expenditure were measured using a metabolic analyzer. 

Main Outcome Measures:  Heart rate, oxygen uptake, and energy expenditure. 

Results:  Heart rate, oxygen uptake, and energy expenditure were considerably higher (P less than .05) during activity-promoting video game play compared with rest and sedentary video game play. The mean (SD) corresponding oxygen uptake values for the sedentary, dance, and boxing video games were 6.1 (1.3), 12.8 (3.3), and 17.7 (5.1) mL · min–1 · kg–1, respectively. Energy expenditures were 1.5 (0.3), 3.0 (1.0), and 4.4 (1.6) kcal · min–1, respectively.

Conclusions:  Dance Central and Kinect Sports Boxing increased energy expenditure by 150% and 263%, respectively, above resting values and were 103% and 194% higher than traditional video gaming. This equates to an increased energy expenditure of up to 172 kcal · h–1 compared with traditional sedentary video game play. Played regularly, active gaming using Kinect for the Xbox 360 could prove to be an effective means for increasing physical activity and energy expenditure in children.