A collection of assorted summaries, highlights, and abstracts from the recent medical literature.
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
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
·An IV bolus of a saline solution representing
placebo droperidol and placebo olanzapine
·An IV bolus of droperidol 5 mg plus placebo
·An IV bolus of olanzapine 5 mg plus placebo
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?
By Nancy Walsh, Staff Writer, MedPage Today. September 14,
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,
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:
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,
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
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
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
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
By Joyce Frieden, News Editor, MedPage Today. September 10,
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
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,"
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."
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.
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.
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
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
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
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
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
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
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
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
Use the methylene blue challenge to find out if there’s more
damage beneath the surface.
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
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.
DesignThis was a
prospective, observational study from September 1, 2007, through March 31,
collected in areas outside of the operating room, such as intensive care units,
radiology, emergency departments, and clinics.
ParticipantsThirty-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 MeasuresData including demographics, procedure performed, provider level,
adverse events, medications, and physiologic monitors used are entered into a
ResultsData 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.
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,
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
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'
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,
·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
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
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
The use of nonsteroidal anti-inflammatory drugs (NSAIDs) may
confer a long-term risk of adverse cardiovascular events, a Danish population
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
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
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.
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
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
·Pediatricians should advise against recreational
·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
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
The authors have disclosed no relevant financial
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
evaluate the physiologic responses and energy expenditure of active video
gaming using Kinect for the Xbox 360.
Sports College Centre for Learning, Liverpool, England.
Participants:Eighteen schoolchildren (10 boys and 8 girls) aged 11 to 15 years.
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.
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.
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