1. New Guidelines Published on Sepsis, Stroke, and Immunizations
A. 2012 Sepsis
Guidelines
A
revised and updated edition of "Surviving Sepsis Campaign: International
Guidelines for Management of Severe Sepsis and Septic Shock: 2012" were
officially released at the Society of Critical Care Medicine's 42nd Congress in
San Juan on January 20. Thirty international professional organizations
supported the content of the new guidelines.
Dellinger RP, et al. Surviving Sepsis Campaign:
International Guidelines for Management of Severe Sepsis and Septic Shock:
2012. Crit Care Med. 2013 Feb;41(2):580-637.
OBJECTIVE: To provide an update to the "Surviving
Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic
Shock," last published in 2008.
DESIGN: A consensus committee of 68 international experts
representing 30 international organizations was convened. Nominal groups were
assembled at key international meetings (for those committee members attending
the conference). A formal conflict of interest policy was developed at the
onset of the process and enforced throughout. The entire guidelines process was
conducted independent of any industry funding. A stand-alone meeting was held
for all subgroup heads, co- and vice-chairs, and selected individuals.
Teleconferences and electronic-based discussion among subgroups and among the
entire committee served as an integral part of the development.
METHODS: The authors were advised to follow the principles
of the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) system to guide assessment of quality of evidence from high (A) to very
low (D) and to determine the strength of recommendations as strong (1) or weak
(2). The potential drawbacks of making strong recommendations in the presence
of low-quality evidence were emphasized. Some recommendations were ungraded
(UG). Recommendations were classified into three groups: 1) those directly
targeting severe sepsis; 2) those targeting general care of the critically ill
patient and considered high priority in severe sepsis; and 3) pediatric
considerations.
RESULTS: Key recommendations and suggestions, listed by
category, include…
Full-text (free): http://www.sccm.org/Documents/SSC-Guidelines.pdf
B. New American
Stroke Association Guidelines
By Chris Kaiser, Cardiology Editor, MedPage Today. January
31, 2013
Stroke treatment within 60 minutes, telestroke networks, and
expanded eligibility for clot-buster therapy are among the topics outlined in
the new stroke guidelines from the American Stroke Association published in
Stroke: Journal of the American Heart Association. Many of the so-called new
guidelines are a simple statement of accepted clinical practice, such as
treating eligible stroke patients with IV tissue plasminogen activator (tPA)
within 60 minutes of arriving at the hospital, Edward C. Jauch, MD, lead author
of the document, told MedPage Today.
But it has been 6 years since the last stroke treatment
guidelines were published and the new document contains 21 new recommendations
as well as 50 revisions of existing recommendations. Another 42 recommendations
remain unchanged. "The guidelines are a progression of what the stroke
community is learning and a nod toward the direction we're heading," said
Jauch, director of the division of emergency medicine at the Medical University
of South Carolina in Charleston.
One of the new recommendations states that tPA can be
administered to stroke patients where the treatment was previously
contraindicated. These include those with a minor stroke, a rapidly improving
stroke, recent major surgery, or a recent heart attack (class IIb, level of
evidence C).
"Several studies have now reported that approximately
one third of patients who are not treated with intravenous tPA because of mild
or rapidly improving stroke symptoms on hospital arrival have a poor final
stroke outcome," according to the guidelines. Guidelines also noted that
patients may have "potentially disabling symptoms even though their NIH
Stroke Scale score is just 2."
One of the biggest changes in stroke care is the involvement
of whole regions to offer coordinated care rather than relying on a single
hospital to do everything. "Different hospitals have different
capabilities for taking care of our sickest stroke patients," Andrew
Russman, DO, of the Cleveland Clinic, who was not on the writing committee,
told MedPage Today. "Some of the new guidelines suggest that we should
reroute patients from hospitals that have lesser capability to those that have
more capabilities."
Emergency medical personnel should be aware of the various
levels of stroke care offered in their community, including
·
Comprehensive stroke centers -- which offer
24/7, highly specialized treatment for all types of stroke
·
Primary stroke centers -- which provide 24/7
specialized care mainly for ischemic stroke
·
Acute stroke-ready hospitals -- which can
evaluate and treat most strokes but lack highly specialized capabilities
Also new is an emphasis on creation of acute stroke-ready
hospitals in regional systems of care (class IIa, level of evidence C). EMS
also need to be ready to bypass hospitals that may not offer certain
procedures, such as advanced CT or MRI imaging (which is recommended before IV
tPA [class I, level of evidence A]).
When none of these hospitals are available, the guidelines
state that telestroke consultation can be used to access stroke treatment
expertise (class IIa, level of evidence C). Along with telestroke, the
guidelines also recommend the use of teleradiology systems for fast and
accurate image interpretation.
During an acute stroke, physicians must quickly evaluate and
diagnose the patient as soon as possible to determine if patients are eligible
to receive tPA, which can be given within 4.5 hours of symptom onset. The FDA
has approved tPA to be given within a 3-hour window of symptom onset. In
Europe, the clot-busting drug is approved for up to 4.5 hours. Genentech, maker
of tPA, asked the FDA to approve the drug for the extended 4.5-hour time frame
and provided the agency with additional data. But the FDA last spring declined
the request. That move by the FDA interested the guideline writing committee
because it had endorsed the extended therapeutic window in 2009, Jauch told
MedPage Today. "We wanted to be sure we weren't advocating something for
our patients that would harm them."
A few members of the writing committee reviewed the
additional data with representatives of Genentech. Although the FDA gave no
reason for declining the request, the writing committee was satisfied the
reason was not based on safety concerns, Jauch said. "We felt we should
continue to maintain our recommendation that the administration of tPA could be
considered for up to 4.5 hours of symptom onset in select patients," he
said.
Other new recommendations:
·
Multidisciplinary quality improvement committees
should be created within hospitals to review and monitor stroke care quality
(class I, level of evidence B)
·
Recently introduced stent retrievers could
potentially remove large blood clots more completely and quickly than tPA.
Solitaire FR and Trevo are preferred for coil retrievers over the Merci device
when mechanical thrombectomy is used (class I, level of evidence A)
·
Patients already on statins when presenting with
stroke can continue taking them during the acute phase (class IIa, level of
evidence B)
·
The use tPA in patients taking direct thrombin
inhibitors, such as dabigatran (Pradaxa) or direct factor Xa inhibitors, such
as rivaroxaban (Xarelto) or apixaban (Eliquis) is not recommended unless
certain tests are conducted beforehand such as activated partial thromboplastin
time or ecarin clotting time (class III, level of evidence C)
"Time is brain when it comes to the onset of stroke
symptoms," Russman emphasized. "For each minute the brain goes
without blood flow, there are 1.9 million nerve cells that are dying, that
affect 14 billion nerve connections and 7.5 miles worth of never fibers.
"What this tells us is we should treat patients as quickly as possible to
reduce the likelihood they will have disability from a stroke."
C. ACEP Policy on tPA
for Stroke
ACEP/ANA. Clinical Policy: Use of Intravenous tPA for the
Management of Acute Ischemic Stroke in the ED. Ann Emerg Med 2013;61:225-243.
Critical Questions
1. Is IV tPA safe and effective for acute ischemic stroke
patients if given within 3 hours of symptom onset?
2. Is IV tPA safe and effective for acute ischemic stroke
patients treated between 3 to 4.5 hours after symptom onset?
Patient Management Recommendations
Level A recommendations
In order to improve functional outcomes, IV tPA should be
offered to acute ischemic stroke patients who meet National Institute of
Neurological Disorders and Stroke (NINDS) inclusion/exclusion criteria and can
be treated within 3 hours after symptom onset.
Level B recommendations
In order to improve functional outcomes, IV tPA should be
considered in acute ischemic stroke patients who meet European Cooperative
Acute Stroke Study (ECASS) III inclusion/exclusion criteria and can be treated
between 3 to 4.5 hours after symptom onset.
Note: Within any time window, once the decision is made to
administer IV tPA, the patient should be treated as rapidly as possible. As of
this writing, tPA for acute ischemic stroke in the 3- to 4.5-hour window is not
FDA approved.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01736-2/fulltext
D. New 2013
Immunization Guidelines
ACIP Issues 2013 Adult Immunization Schedule and Guidelines
AAP Issues 2013 Child/Adolescent Immunization Schedule
Pediatrics (full-text free): http://pediatrics.aappublications.org/content/early/2013/01/23/peds.2012-3706.full.pdf+html
2. Selective DVT Testing Called Safe, Efficient
By Charles Bankhead, Staff Writer, MedPage Today. January
15, 2013
Action Points
·
Clinically guided D-dimer testing for suspected
deep vein thrombosis (DVT) based on clinical pretest probability significantly
reduced testing frequency and use of confirmatory ultrasonography compared with
unselected testing.
·
Note that the 3-month DVT rate was identical in
patients who were selectively tested or universally tested by D-dimer testing.
·
Clinically guided D-dimer testing for suspected
deep vein thrombosis (DVT) significantly reduced testing frequency and use of
confirmatory ultrasonography compared with universal testing, a randomized
trial showed.
Selective testing led to a 21.8% absolute reduction in
testing frequency and a 7.6% absolute reduction in ultrasound use. The 3-month
DVT rate was identical in patients who were selectively tested or universally
tested, wrote Lori-Ann Linkins, MD, of McMaster University in Hamilton,
Ontario, and colleagues, in the Annals of Internal Medicine online.
"This study supports the use of a higher D-dimer
threshold to exclude first DVT in outpatients with low clinical pretest probability
(C-PTP) than that used in outpatients with moderate C-PTP and that D-dimer
testing should be avoided in outpatients with high C-PTP and in all
inpatients," they wrote. "Future studies to determine whether this
diagnostic strategy can be applied to patients who present with suspected
recurrence DVT or pulmonary embolism are required."
The 0.5 µg/mL cutoff for D-dimer test results has good
accuracy for excluding DVT, but a test value ≥0.5µg/mL mandates additional
workup, usually ultrasound, which often proves negative for DVT.
DVT is uncommon in patients with a low C-PTP, and a high C-PTP
is associated with a high rate of DVT. Most hospitalized patients have elevated
D-dimer levels, irrespective of C-PTP, usually because of comorbid conditions,
and D-dimer test results usually will be negative.
In an earlier retrospective study, Linkins and colleagues
showed that use of a higher D-dimer cutoff for patients with low C-PTP improved
specificity from 54% to 95% and maintained a negative predictive value of 98%
(J Thromb Haemost 2004; 2: 1256-1260).
The current study was a prospective, multicenter, randomized
trial involving patients with a suspected first acute DVT. By use of the
9-point Wells clinical prediction rule, patients were classified as having a
low, moderate, or high C-PTP of DVT.
All patients randomized to the control group underwent
D-dimer testing. A negative test ended the workup for DVT. A positive test was
followed by ultrasonography. Patients with a low C-PTP and normal ultrasound
results had no further workup. Patients with moderate or high C-PTP and normal
ultrasound had repeat ultrasound 6 to 8 days later. Patients with low or
moderate C-PTP underwent selective D-dimer testing and patients with a high
C-PTP underwent immediate ultrasonography without D-dimer measurement. For
patients with low C-PTP, a positive result was defined as a D-dimer level ≥1
µg/mL, whereas the cutoff for patients with moderate C-PTP was 0.5 µg/mL.
A negative result ended the workup and a positive result
triggered ultrasonography of the proximal veins of the symptomatic leg.
Negative ultrasonography ended the DVT workup in patients with low C-PTP, while
patients with moderate C-PTP had repeat ultrasound.
The primary outcome was the proportion of patients who
initially had a negative DVT workup but had objectively confirmed DVT within 90
days. Analysis of the primary outcome included 1,723 patients. Of 863 patients
assigned to uniform testing, 772 were outpatients (334 low C-PTP, 319 moderate,
and 119 high), and 91 were inpatients. D-dimer test results were positive in
506 patients, negative in 353 patients, and four patients did not have the
test.
Subsequently, 11.1% of the 506 patients with positive
D-dimer tests had DVT confirmed by ultrasound during the initial workup. Four
patients (0.8%) with negative D-dimer results and ultrasonography had confirmed
DVT during follow-up. Less than 1% of 798 patients who did not have DVT on
initial workup and remained in the study. No patient with a negative D-dimer
test developed DVT during follow-up.
The 860 patients randomized to selective testing comprised
770 outpatients (360 low C-PTP, 310 moderate, and 100 high) and 90 inpatients.
The low C-PTP subgroup had negative D-dimer results in 80% of cases and none
developed VTE during follow-up. Of the 72 patients with positive D-dimer
results, 11% had DVT confirmed by ultrasonography during the initial workup. No
patient with normal ultrasound findings developed DVT during follow-up.
The authors found that 176 patients with moderate C-PTP had
positive D-dimer test results, and 13% of those patients had DVT confirmed by
ultrasonography during the initial workup. One patient with negative D-dimer
results developed DVT during follow-up. Of 153 moderate C-PTP patients with a
positive D-dimer test and normal ultrasound, one developed DVT during
follow-up.
The results showed that 10.5% of the 190 high C-PTP
outpatients and inpatients had DVT confirmed during the initial workup. Two
patients with normal ultrasonography developed DVT during follow-up. Overall,
5.9% of 860 patients in the selective-testing group had DVT confirmed during
initial testing, and 0.5% who had negative results during the initial workup
subsequently developed DVT during follow-up.
"The selective strategy was more efficient insofar as
an absolute 21.8% fewer patients required D-dimer testing and 7.7% fewer
required ultrasonography compared with uniform testing," the authors
wrote.
"Using a D-dimer threshold of 1.0 µg/mL rather than 0.5
µg/mL to exclude DVT in outpatients with low C-PTP halved the number of those
who required ultrasonography," they continued. "This savings, which
corresponded to 10% of all patients in the selective group, accounted for the
overall reduction in ultrasonography in this randomly assigned group."
The study had some limitations. First, the results may not
be generalizable to patients with a history of DVT or to other D-dimer tests
(the MDA D-dimer assay and the STA-Liatest D-Di assay were used in this study).
Also, patients and study personnel were not blinded to trial interventions.
In Chinese: http://www.acponline.org/journals/annals/abstracts/china/0000605-201301150-00003_chinese.pdf
3. Eating a Larger Number of High-Salt Foods is Not
Associated with Short-Term Risk of Acute Decompensation in Patients with CHF
Borke JA, et al. J Emerg Med. 2013;44:36-45.
Background: Risk factors for exacerbation of congestive
heart failure have not been consistently validated.
Objective: Our objective was to examine the role of
short-term dietary sodium intake in acute decompensated heart failure.
Methods: Patients with chronic congestive heart failure
presenting to the Emergency Department for either acute decompensated heart
failure (cases) or for other reasons (controls) were included in a case-control
study. Cases and controls were compared with respect to age, smoking, recent
sodium intake, medication nonadherence, coronary artery disease, and
hypertension. A food frequency questionnaire was utilized to estimate recent
sodium intake, defined as the number of food types consumed in the previous 3
days from the 12 highest-sodium food categories.
Results: There were 182 patients enrolled. One patient was
excluded due to uncertainty about the primary diagnosis. When adjusted for age,
smoking, medication nonadherence, coronary artery disease, and hypertension,
acute decompensated heart failure was not associated with short-term dietary
sodium intake. The odds ratio for acute decompensated heart failure for each
increase in the number of high-sodium food types consumed was 1.1 (95%
confidence interval 0.9–1.3; p = 0.3). Acute decompensated heart failure was
associated with medication nonadherence, with an odds ratio for decompensation
of 2.5 (95% confidence interval 1.2–5.1; p = 0.01).
Conclusions: Patients with chronic congestive heart failure
who presented to the Emergency Department with acute decompensated heart
failure were no more likely to report consuming a greater number of high-sodium
foods in the 3 days before than were patients with chronic congestive heart
failure who presented with unrelated symptoms. On the other hand, those who
presented with acute decompensated heart failure were significantly more likely
to report nonadherence with medications.
4. Bouncing Back
A. ED Visits Common
After Hospital Stay
Vashi A, et al. Use of hospital-based acute care among
patients recently discharged from the hospital. JAMA 2013;309:364-371.
By John Gever, Senior Editor, MedPage Today. January 22,
2013
Among some 5 million hospitalizations, involving about 4
million unique patients in California, Florida, and Nebraska over a 15-month
period in 2008 and 2009, 17.9% (95% CI 17.9% to 18.0%) of discharges were
followed within 30 days by a "treat-and-release" ER visit or
readmission, according to Anita Vashi, MD, MPH, of Yale University, and
colleagues.
Treat-and-release ER visits accounted for 39.8% of the
follow-up care (95% CI 39.7% to 39.9%), the researchers reported in the Jan.
23/30 issue of the Journal of the American Medical Association.
Moreover, for the 10 most common medical and 10 most common
surgical conditions that were the basis for hospitalization, follow-up ER
visits "were always related to the index hospitalization," the
researchers wrote.
On the medical side, such conditions were led by vaginal
childbirth, psychosis, heart failure and shock, chest pain, and chronic
obstructive pulmonary disease. Common surgical conditions included cesarean
delivery, joint replacement, uterine and adnexa procedures for nonmalignancies,
complicated cesarean sections, and percutaneous interventions with stent
placement.
Vashi and colleagues argued that the current policy focus on
readmissions for judging hospital care quality may miss part of the problem, as
relatively minor ER visits after discharge "are another important
outcome," often representing uncoordinated follow-up care. "These
emergency department visits are likely to result in fragmented care following
discharge and consequently contribute to duplication of services, conflicting
care recommendations, medication errors, patient distress, or higher
costs," they wrote.
The study examined outcomes of 5,032,245 discharges from
acute care hospitals in the three states from July 2008 through September 2009,
as reflected in the Healthcare Cost and Utilization Project databases.
These databases included patient-level information on the
primary diagnoses for the index hospitalizations as well as the timing and
chief reasons for acute care rendered after discharge.
Besides tracking the number and type of post-discharge acute
care visits, Vashi and colleagues also calculated a "condition-specific ED
index" as a simple measure of the likelihood that a return visit was to
the emergency department versus readmission.
Conditions for which treat-and-release visits outnumbered
readmissions would receive a value greater than 1, whereas the index would be
less than 1 for those in which readmissions predominate. The analysis showed ED
index values of 2 or greater for vaginal childbirth, standard and complicated
cesarean delivery, and appendectomy. Values of 0.5 or less were calculated for
heart failure and shock, septicemia, stroke, and complicated hip and femoral
procedures.
Vashi and colleagues also reported the three top reasons for
treat-and-release ER visits for each of the 20 high-volume conditions
associated with the index hospitalizations. In every case, all three appeared
at least superficially related to the condition at original admission. For
example, the three most common reasons for ER visits following discharges of
septicemia patients were urinary tract infection, genitourinary symptoms, and
abdominal pain.
Likewise, patients who had undergone angioplasty with
stenting sought emergency treatment for complaints including nonspecific chest
pain, heart conditions including coronary atherosclerosis, and abdominal pain.
Rates of post-discharge ER visits ranged from 22.4 per 1,000
discharges (95% CI 4.6 to 65.4) involving breast cancer patients to 282.5 per
1,000 discharges (95% CI 209.7 to 372.4) of patients originally treated for
uncomplicated benign prostatic hypertrophy.
In an accompanying editorial, Mark Williams, MD, of
Northwestern University in Chicago, agreed that post-discharge ER visits are an
important outcome to track in addition to readmissions. "Developing care
process approaches that serve patients and ensure adequate coordinated care
should be the goal. Visits to the emergency department after hospitalization
should also be monitored and assessed as a quality measure to complement 30-day
readmissions," Williams wrote.
Study authors reported relationships with CMS, the Pew
Charitable Trusts, Medtronic (through Yale's Open Access project to analyze
Medtronic clinical trial data), and FAIR Health.
B. Diagnoses and
Timing of 30-Day Readmissions After Hospitalization for Heart Failure, AMI, or
Pneumonia
Dharmarajan K, et al. JAMA. 2013;309(4):355-363.
Importance To better
guide strategies intended to reduce high rates of 30-day readmission after
hospitalization for heart failure (HF), acute myocardial infarction (MI), or
pneumonia, further information is needed about readmission diagnoses,
readmission timing, and the relationship of both to patient age, sex, and race.
Objective To examine
readmission diagnoses and timing among Medicare beneficiaries readmitted within
30 days after hospitalization for HF, acute MI, or pneumonia.
Design, Setting, and Patients We analyzed 2007-2009 Medicare
fee-for-service claims data to identify patterns of 30-day readmission by
patient demographic characteristics and time after hospitalization for HF,
acute MI, or pneumonia. Readmission diagnoses were categorized using an
aggregated version of the Centers for Medicare & Medicaid Services'
Condition Categories. Readmission timing was determined by day after discharge.
Main Outcome Measures
We examined the percentage of 30-day readmissions occurring on each day
(0-30) after discharge; the most common readmission diagnoses occurring during
cumulative periods (days 0-3, 0-7, 0-15, and 0-30) and consecutive periods
(days 0-3, 4-7, 8-15, and 16-30) after hospitalization; median time to
readmission for common readmission diagnoses; and the relationship between
patient demographic characteristics and readmission diagnoses and timing.
Results From 2007 through
2009, we identified 329 308 30-day readmissions after 1 330 157 HF
hospitalizations (24.8% readmitted), 108 992 30-day readmissions after 548 834
acute MI hospitalizations (19.9% readmitted), and 214 239 30-day readmissions
after 1 168 624 pneumonia hospitalizations (18.3% readmitted). The proportion
of patients readmitted for the same condition was 35.2% after the index HF
hospitalization, 10.0% after the index acute MI hospitalization, and 22.4%
after the index pneumonia hospitalization. Of all readmissions within 30 days
of hospitalization, the majority occurred within 15 days of hospitalization:
61.0%, HF cohort; 67.6%, acute MI cohort; and 62.6%, pneumonia cohort. The
diverse spectrum of readmission diagnoses was largely similar in both cumulative
and consecutive periods after discharge. Median time to 30-day readmission was
12 days for patients initially hospitalized for HF, 10 days for patients
initially hospitalized for acute MI, and 12 days for patients initially
hospitalized for pneumonia and was comparable across common readmission
diagnoses. Neither readmission diagnoses nor timing substantively varied by
age, sex, or race.
Conclusion and Relevance
Among Medicare fee-for-service beneficiaries hospitalized for HF, acute
MI, or pneumonia, 30-day readmissions were frequent throughout the month after
hospitalization and resulted from a similar spectrum of readmission diagnoses
regardless of age, sex, race, or time after discharge.
Full-text (free): http://jama.jamanetwork.com/article.aspx?articleID=1558276&utm
5. Airway Devices May Not Help in Cardiac Arrest
By Todd Neale, Senior Staff Writer, MedPage Today, January
15, 2013
Action Points
·
Note that most emergency medical services
systems in prioritize the use of advanced airways (endotracheal intubation or a
supraglottic airway) but recent studies have challenged the survival benefit of
advanced airway management compared with conventional bag-valve-mask ventilation.
·
In this large observational study of adults with
out-of-hospital cardiac arrest in Japan, neurologically favorable survival was
higher among those who received bag-valve-mask ventilation alone compared with
those who received endotracheal intubation or supraglottic airway insertion.
Advanced airway management -- endotracheal intubation or the
use of supraglottic airway devices -- may not be beneficial to emergency
medical services personnel when trying to resuscitate patients who've had an
out-of-hospital cardiac arrest, an observational study suggested.
The percentage of patients with a favorable neurological
outcome 1 month after the arrest was significantly lower among those who
received advanced airway management than among those who received conventional
bag-valve-mask ventilation (1.1% versus 2.9%; OR 0.38, 95% CI 0.36 to 0.39),
according to Kohei Hasegawa, MD, MPH, of Massachusetts General Hospital in
Boston, and colleagues.
Similarly, use of advanced airway management was associated
with a lower likelihood of a return to spontaneous circulation (OR 0.67, 95% CI
0.66 to 0.69) and of surviving to 1 month (OR 0.73, 95% CI 0.71 to 0.75), the
researchers reported in the Jan. 15 issue of the Journal of the American
Medical Association.
"Our observations contradict the assumption that
aggressive airway intervention is associated with improved outcomes and provide
an opportunity to reconsider the approach to pre-hospital airway management in
this population," the authors wrote.
The findings are provocative and "at least suggestive
that this study should prompt further prospective randomized trials,"
Joseph Ornato, MD, chairman of the department of emergency medicine at VCU
Medical Center in Richmond, Va., said in an interview.
He noted that the Resuscitation Outcomes Consortium
sponsored by the National Institutes of Health is currently designing a trial
to explore the impact of advanced airway management on patient outcomes.
Although survival following out-of-hospital cardiac arrest
has improved in recent years, it remains low overall, at just 8% to 10%. "Better
survival has been associated with the improvement in early access to emergency
medical care, early cardiopulmonary resuscitation (CPR), rapid defibrillation,
and integrated post-cardiac arrest care," Hasegawa and colleagues wrote.
"Early advanced life support is often considered of benefit in that it
provides intravenous drug therapy and advanced airway management."
Recent studies, however, have raised questions about whether
advanced airway management actually improves outcomes. To explore the issue,
the researchers looked at data from the nationwide All-Japan Utstein Registry
of the Fire and Disaster Management Agency. The current analysis included
649,359 Japanese adults (mean age 73) who had an out-of-hospital cardiac arrest
and who had resuscitation attempted by emergency responders in the pre-hospital
setting from 2005 through 2010.
Most of the patients (57%) underwent bag-valve-mask
ventilation and 43% underwent advanced airway management, including 6% with
endotracheal intubation and 37% with supraglottic airways.
The primary outcome was a favorable neurological status,
defined as Glasgow-Pittsburgh cerebral performance category 1 (good
performance) or 2 (moderate disability), 1 month after the arrest. The poorer
outcomes among patients who received advanced airway management remained after
adjustment for numerous potential confounders, including age, sex, arrest
etiology, first documented rhythm, witnessed status, type of bystander CPR, use
of a public access automated external defibrillator, epinephrine
administration, and time intervals from the call to CPR initiation by EMS
personnel and to hospital arrival.
Although these observational data cannot establish a causal
relationship between advanced airway management and outcomes, there are some
plausible mechanisms tying them together, according to the researchers.
"It has been well documented that pre-hospital
intubation is a complex psychomotor task and that EMS personnel have difficulty
gaining and maintaining competency in this skill," they wrote, noting that
intubation by unskilled practitioners could lead to a variety of adverse events
such as unrecognized esophageal intubation, tube dislodgement, iatrogenic
hypoxemia, and bradycardia. The intubation process may also interfere with the
performance of effective chest compressions, they said.
Ornato pointed out that a variable that could have affected
the findings was the difference between the groups in the median time to a
return of spontaneous circulation (14 minutes with advanced airway management
versus 6 minutes with conventional ventilation).
"It could very well be that the group of patients who
restarted with a more prolonged resuscitation effort would in fact be expected
to have less of a survival and a neurologically intact outcome," he said.
"Some may view the results [of the current study] as
evidence to cease all emergency medical services endotracheal intubation or
supraglottic airway insertion in out-of- hospital cardiac arrest," Henry
Wang, MD, of the University of Alabama at Birmingham, and Donald Yealy, MD, of
the University of Pittsburgh, wrote in an accompanying editorial.
"However, this interpretation should be tempered by the limits and
potential biases of the study."
Hasegawa and colleagues acknowledged that the findings may
be limited by confounding by unmeasured factors, by the lack of information
about the intubation process, by concerns about data integrity and validity and
about ascertainment bias, and by the uncertain generalizability to other
countries besides Japan.
Because of those limitations, a randomized clinical trial is
the best way to explore the utility of advanced airway management in
out-of-hospital cardiac arrest, Wang and Yealy wrote, adding that such a study
could be difficult because the belief that the techniques work is entrenched in
current practice.
Without a commitment for a large clinical trial, "the
emergency medical services community risks turning a blind eye and embracing
ineffective or harmful airway interventions," they wrote. "Patients
with cardiac arrest and the out-of-hospital rescuers who care for them deserve
to know what is best."
6. Therapeutic Hypothermia after Cardiac Arrest
Scirica BM, et al, Circulation 2013;127:244-250.
Case 1
A 63-year-old man was at home watching television when his
roommate noticed him gurgle and lose consciousness. He started cardiopulmonary
resuscitation (CPR) and called emergency medical services. The initial rhythm
was ventricular fibrillation (VF). A perfusing rhythm was obtained within 15
minutes, but there were repeated episodes of VF requiring multiple
defibrillations and repeated episodes of cardiopulmonary resuscitation. With
restoration of circulation, he was not responsive. Initial ECG revealed
inferior ST-segment elevations. In the emergency department, he required
further defibrillations and was then taken for primary coronary intervention.
Emergency medical personnel started intravenous iced saline, and ice packs were
placed while he was in the emergency department and remained in place during
cardiac catheterization. A stent was placed in a thrombotic right coronary
artery. On arrival at the cardiac intensive care unit, surface cooling pads
were placed, and he received therapeutic hypothermia (TH) for 24 hours, at
which point he was rewarmed. He initially remained comatose, but by day 5, he
was awake, alert, and interactive. He was discharged home.
Case 2
A 54-year-old woman was found unresponsive by coworkers. It
was not clear how long she had been down. Cardiopulmonary resuscitation was
started, and an automated external defibrillator recommended no shock.
Emergency medical personnel identified asystole as the initial rhythm. After 25
minutes of advanced cardiac life support, a perfusing rhythm was obtained.
There were no ischemic changes on the ECG. She was unresponsive on arrival at the
emergency department. Computed tomographs of the head and pulmonary arteries
were normal. She received TH for 24 hours and, when rewarmed, had no change in
her mental status by day 5. Magnetic resonance imaging did not reveal any major
abnormalities, but she had incomplete recovery of brainstem reflexes and
bilaterally absent sensory stimulatory evoked potentials. After extensive
discussions with her family, continued support was withdrawn, and she expired.
Cardiac arrest (CA) remains one of the most unexpected,
dramatic, and life-threatening events in medicine. Survival and neurological
recovery vary widely, depending on whether an arrest was witnessed or
unwitnessed and the initial cardiac rhythm during resuscitation. Even among
patients with successful return of spontaneous circulation (ROSC) who are
admitted to an intensive care unit, survival until hospital discharge has
historically been less than 10%.1 Fortunately, recent data suggest a steady
trend toward improved survival. However, in 2009, mortality remained at almost
60%.2,3
Improvements in the survival and neurological outcomes of
patients with CA have focused on 2 principal areas of treatment. The first is
increased education to improve immediate post-CA perfusion via national efforts
promoting the 4 links in the chain of survival that include early access to
emergency medical care, early cardiopulmonary resuscitation, early
defibrillation, and early advanced cardiac life support.4
The second area is greater emphasis on postresuscitation
care, which includes optimizing oxygenation and ventilation, avoiding
hypotension (systolic blood pressure less than 90 mm Hg), treating immediate
precipitants of CA such as acute coronary ischemia, and initiating TH when
appropriate.5 The American Heart Association (Figure 1), the International
Liaison Committee of Resuscitation, and the European Resuscitation Council
recently published guidelines and recommendations covering the entire spectrum
of postresuscitation care.5–7 This review focuses on the practical aspects of
implementing TH, one of the key therapeutic procedures in postresuscitation
care…
Full-text (free): http://circ.ahajournals.org/content/127/2/244.full
7. Pediatric Corner
A. Management of the
Child after Enema-Reduced Intussusception: Hospital or Home?
Chien M, et al. J Emerg Med. 2013;44:53-57.
Background: Standard practice has been to admit children for
an observation period after enema-reduced intussusception. However, the utility
of such routine practice has not been clearly justified.
Study Objectives: The main objective was to determine the
rate and timing of recurrent intussusception after successful enema reduction
and describe any associated complications.
Methods: The study was a retrospective chart review
identifying children with enema-reduced intussusception during a 7-year period
from 2002 through 2008. Subjects were children ages 0 to 17 years presenting to
the Emergency Department (ED) of a tertiary care, free-standing children’s
hospital with confirmed and uncomplicated enema-reduced intussusception.
Results: During the study period there were 98 children with
successful enema reduction of intussusception. There were 10 episodes of
recurrence in 7 patients, for an overall recurrence rate of 7.1%. Three
patients had two recurrences each, and the remainder had single recurrences.
Two patients had early recurrences (less than 48h) at 3 and 5h, for an early
recurrence rate of 2.0%. The late recurrence rate (over 48h) was 5.1%. No
adverse events were noted in any of the recurrences.
Conclusions: Given the low early recurrence rate for
enema-reduced intussusception and the minimal risk of adverse outcomes, ED
observation for a 6-h period seems to be a safe alternative to inpatient
management. These results support previous work and suggest that these patients
can be managed on an outpatient basis.
B. Metabolic Syndrome
in 40s Linked to TV, Exercise at Age 16
Lisa Nainggolan, Medscape Medical News. Jan 25, 2013
Television viewing habits and leisure-time physical activity
at the age of 16 years independently predicts the metabolic syndrome at age 43,
according to the first prospective study to examine this.
The work "supports previous findings" and, for TV
viewing and subsequent metabolic risk, "provides new evidence that this
association may stretch over a considerable proportion of the lifespan: from
adolescence to mid-adulthood," say Patrik Wennberg, PhD, from Umeå
University, Sweden, and colleagues in their article published online January 22
in Diabetes Care.
The researchers also believe that separate mechanisms may be
at play here for TV-viewing and physical-activity habits, because these
activities were linked to different metabolic-syndrome components.
Nevertheless, the findings "suggest that reduced TV
viewing in adolescence, in addition to regular physical activity, may
contribute to cardiometabolic health later in life," they state…
8. Effectiveness of IV
Dexamethasone versus Propofol for pain relief in the migraine headache: A
prospective double blind RCT
Soleimanpour H, BMC Neurol. 2012 Sep 29;12:114.
BACKGROUND: There are many drugs recommended for pain relief
in patients with migraine headache.
METHODS: In a prospective double blind randomized clinical
trial, 90 patients (age 18 or older) presenting to Emergency medicine
Department with Migraine headache were enrolled in two equal groups. We used
intravenous propofol (10 mg every 5-10 minutes to a maximum of 80 mg, slowly)
and intravenous dexamethasone (0.15 mg/kg to a maximum of 16 mg, slowly), in
group I and II, respectively. Pain explained by patients, based on VAS (Visual
Analogue Scale) was recorded at the time of entrance to ED, and after injection.
Data were analyzed by paired samples t test, using SPSS 16. P less than 0.05
was considered to be statistically significant.
RESULTS: The mean of reported pain (VAS) was 8 ± 1.52 in
propofol group and 8.11 ± 1.31 in dexamethasone group at presenting time (P above 0.05).
The VAS in propofol group was obviously decreased to 3.08 ± 1.7, 1.87 ± 1.28
and 1.44 ± 1.63 after 10, 20 and 30 minutes of drug injection, respectively.
The VAS in dexamethasone group was 5.13 ± 1.47, 3.73 ± 1.81 and 3.06 ± 2 after
10, 20 and 30 minutes of drug injection, respectively. The mean of reported VAS
in propofol group was less than dexamethasone group at the above mentioned
times (P less than 0.05). The reduction of headache in propofol group, also,
was very faster than dexamethasone group (P less than 0.05). There were no
adverse side effects due to administration of both drugs.
CONCLUSIONS: Intravenous propofol is an efficacious and safe
treatment for patients presenting with Migraine headache to the emergency
department.
Full-text (free): http://www.biomedcentral.com/1471-2377/12/114
9. Point-of-Care US in
Assessing Fluid Responsiveness in Sepsis Patients: Sonographer Characteristics,
Noninferential Statistics, and Study Design: Answers to the September 2012
Journal Club Questions
Chiem A. Ann Emerg Med. 2013;61:244-250.
Below is a sampling of the questions answered in this
helpful review:
Q1.a Several articles have assessed probe positioning in
relation to IVC measurement and its correlation with CVP. Describe potential
patient-specific or operator-specific issues that might confound the accurate
measurement of the inferior vena cava in septic patients.
Q1.b Discuss the evidence for using bedside ultrasonographic
measurements of IVC variability to estimate fluid responsiveness. Are
ultrasonographic measurements a more accurate measure of fluid responsiveness
than CVP, urine output, jugular venous distention, or continuous pulse rate and
blood pressure monitoring? What is the criterion standard for measuring the
success of fluid resuscitation in patients with septic shock?
Q2.d How would you design a study that fully incorporates
the use of ultrasonography in managing sepsis patients? What is the unit of
analysis for an emergency department–based ultrasonographic research
investigation? How does one calculate the required sample size for such an
investigation?
Q3.a What sonographic measures of cardiac contractility
provide the best estimation of ejection fraction?
Q3.c How does the clinician apply various findings on
ultrasonography, such as IVC variation greater than 50% and normal ejection
fraction or IVC variation less than 50% and low ejection fraction, in septic
shock patients?
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01713-1/fulltext
10. The Association
between Self-reported Exercise Intensity and ACS in ED Chest Pain Patients
Singer AJ, et al. J Emerg Med. 2013;44:17-22.
Background: Regular exercise is thought to be protective
against coronary artery disease. As a result, some physicians believe that the
likelihood of acute coronary syndrome (ACS) in patients with acute chest pain
is reduced in those who exercise regularly. We studied the association between
self-reported frequency of exercising and the likelihood of ACS in patients
presenting to the Emergency Department (ED) with chest pain.
Methods: A multi-center prospective, descriptive, cohort
study design was used in ED patients to determine whether the risk of ACS was
reduced in patients who self-reported regular exercise.
Results: There were 1093 patients enrolled. Median
(interquartile range) age was 57 (48–67) years; 506 (45.7%) were female. ACS
was diagnosed in 248 (22.7%) patients. Patients who did not exercise at least
monthly were more likely to be diagnosed with ACS than those who did (129/466
[27.7%] vs. 119/627 [19.0%]; odds ratio 1.63, 95% CI 1.23–2.17). After
adjusting for age, gender, body mass index, smoking, and prior history, limited
exercise was still associated with ACS (adjusted odds ratio 1.52, 95% CI
1.10–2.10). There was no apparent association between frequency and intensity
of exercise and risk of ACS.
Conclusion: Although self-reported frequency of exercise was
significantly associated with a decrease in ACS in ED patients with chest pain,
it should not be used to exclude ACS in symptomatic ED patients.
11. Images in Clinical
Medicine
Bilateral Internuclear Ophthalmoplegia in Multiple Sclerosis
Young Man With Scratches on His Back
Woman With Right Lower Quadrant Pain
Hemifacial Flushing
Perioral Myokymia (for you tox-minded and wilderness
medicine docs)
12. How Long Does a
Cough Last? Comparing Patients’ Expectations with Data From a Systematic Review
of the Literature
Ebell MH, et al. Ann Fam Med 2013;11:5-13
PURPOSE We hypothesized that antibiotic overuse for acute
cough illness (ACI) is in part due to a mismatch between patients’ expectations
and the natural history of ACI.
METHODS We performed a population-based random digit dialing
survey of 493 adults in Georgia to determine their expectations regarding the
duration of ACI. We also performed a systematic review of observational studies
and the placebo or untreated control groups of randomized controlled trials to
determine the duration of ACI from the published medical literature. We
included studies of otherwise healthy adults with undifferentiated ACI, no
clear bacterial cause, data on at least 1 cough outcome, and at least 1 week of
follow-up.
RESULTS The mean duration of cough in the published
literature was 17.8 days. Survey respondents reported a median duration of 5 to
7 days and a mean duration of 7.2 to 9.3 days depending on the specific
scenario. Patients expecting a longer duration of illness were more likely to
be white, female, and have self-reported asthma or chronic lung disease.
Independent predictors of the belief that antibiotics are always helpful
included nonwhite race (OR = 1.82, 95% CI, 1.14–2.92), some college education
or less (OR = 2.08, 95% CI, 1.26–3.45), and previous antibiotics for ACI (OR =
2.20, 95% CI, 1.34–3.55).
CONCLUSIONS There is a mismatch between patients’
expectations regarding the duration of ACI and the actual duration based on the
best available evidence. Efforts to reduce inappropriate antibiotic use should
target this discrepancy.
Full-text (free): http://www.annfammed.org/content/11/1/5.full
13. The Future of
Antibiotics and Resistance
Spellberg B, et al. N Engl J Med 2013; 368:299-302
In its recent annual report on global risks, the World
Economic Forum (WEF) concluded that “arguably the greatest risk . . . to human
health comes in the form of antibiotic-resistant bacteria. We live in a
bacterial world where we will never be able to stay ahead of the mutation
curve. A test of our resilience is how far behind the curve we allow ourselves
to fall.”1
Traditional practices in infection control, antibiotic
stewardship, and new antibiotic development are cornerstones of society's
approach to combating resistance and must be continued. But the WEF report
underscores the facts that antibiotic resistance and the collapse of the
antibiotic research-and-development pipeline continue to worsen despite our
ongoing efforts on all these fronts. If we're to develop countermeasures that have
lasting effects, new ideas that complement traditional approaches will be
needed.
New ideas are often based on the recognition of old truths.
Prokaryotes (bacteria) “invented” antibiotics billions of years ago, and
resistance is primarily the result of bacterial adaptation to eons of
antibiotic exposure. What are the fundamental implications of this reality?
First, in addition to antibiotics' curative power, their use naturally selects
for preexisting resistant populations of bacteria in nature. Second, it is not
just “inappropriate” antibiotic use that selects for resistance. Rather, the
speed with which resistance spreads is driven by microbial exposure to all
antibiotics, whether appropriately prescribed or not. Thus, even if all
inappropriate antibiotic use were eliminated, antibiotic-resistant infections
would still occur (albeit at lower frequency).
Third, after billions of years of evolution, microbes have
most likely invented antibiotics against every biochemical target that can be
attacked — and, of necessity, developed resistance mechanisms to protect all
those biochemical targets. Indeed, widespread antibiotic resistance was
recently discovered among bacteria found in underground caves that had been
geologically isolated from the surface of the planet for 4 million years.2
Remarkably, resistance was found even to synthetic antibiotics that did not
exist on earth until the 20th century. These results underscore a critical
reality: antibiotic resistance already exists, widely disseminated in nature,
to drugs we have not yet invented.
Thus, from the microbial perspective, all antibiotic targets
are “old” targets. Yet since the early 1930s, when Gerhard Domagk and
colleagues discovered that chemical red dyes (the sulfonamides) can kill
bacteria, the singular arc of antibiotic research and development has been to
discover “new” targets to attack in order to kill the microbes. This strategy
has saved countless lives. Ironically, it has also driven the resistance that
threatens the very miracle of antibiotics. Ultimately, over centuries or
millennia of selective pressure, we will run out of targets, and resistance
mechanisms will become so prevalent as to preclude effective clinical
deployment of antibiotics…
The rest of the essay (full-text free): http://www.nejm.org/doi/full/10.1056/NEJMp1215093
See also Audio Interview Online with Dr. Robert Moellering on the
evolution of antibiotic resistance and strategies for combating it:.
14. EMS Triage and
Transport of Intoxicated Individuals to a Detoxification Facility Instead of an
ED
Ross DW, et al. Ann Emerg Med. 2013;61:175-184. .
Study objective: We evaluate the effectiveness and safety of
emergency medical services (EMS) provider use of a checklist to triage
alcohol-inebriated patients directly to a detoxification facility, rather than
an emergency department (ED).
Methods: A retrospective cohort study was conducted of all
patients evaluated during a 2-year period, from 2003 to 2005, by EMS providers
who used a detoxification evaluation checklist to aid in triage decisionmaking.
Patients who did not meet detoxification evaluation checklist criteria were
transported to an ED. Twelve-hour follow-up was solicited for patients taken to
the detoxification center. Hospital records of inebriated patients transported
to an ED were reviewed to assess ultimate need for ED care.
Results: Seven hundred eighteen patient encounters were
reviewed. One hundred thirty-eight of these patients (19.2%) were transported
to the detoxification facility, whereas 580 (80.8%) were transported to an ED;
339 patients transported to an ED were ultimately deemed to have required ED
care. The criteria that most commonly excluded transport to the detoxification
center were an inability to ambulate with minimal assistance (N=334) and an
unwillingness to cooperate with the physical examination (N=195). Low-acuity
adverse events were observed in 4 subjects (0.6%) initially transported to the
detoxification center who then required subsequent transport to an ED. No
high-acuity clinical complications were identified at any time. The use of the
detoxification evaluation checklist resulted in high sensitivity (99%; 95%
confidence interval 97% to 100%) and low specificity (42%; 95% confidence
interval 37% to 48%) in predicting need for ED care.
Conclusion: Our analysis suggests that field triage criteria
can be used effectively to safely divert inebriated patients to a
detoxification facility rather than an ED, with minimal adverse events. Use of
the detoxification evaluation checklist resulted in substantial ED overtriage,
and further refinement of the detoxification evaluation checklist criteria is
needed to reduce it.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01509-0/fulltext
15. A Normal ECG That
Should Have Been Frightening
Kyuhyun Wang, MD, Medscape Cardiology: ECG of the Week, Jan
11, 2013
A 58-year-old truck driver from out of town checked into a
hotel after a long day of driving. While resting in bed, he was suddenly seized
by a sharp jaw pain that felt like a "shock" and which soon spread to
the anterior chest. He had never had a similar pain before. It did not abate and
he reported to the emergency room at a nearby hospital. At the hospital he was
still in acute distress with chest pain. He was taking medicine for
hypertension but otherwise his medical history was unremarkable. His pulse was
90 beats/min and his blood pressure was 150/90 mm Hg; otherwise the physical
examination, chest x-ray, and blood tests, including troponin, were
unremarkable.
The ECG tracing (Figure 1) did not show any findings of
acute coronary syndrome (ACS).
Tracing and discussion: http://www.medscape.com/viewarticle/777280
16. Little Utility of
the Cardiac Component of FAST in Blunt Trauma
Press GM, et al. J Emerg Med. 2013;44:9-16.
Background: Focused assessment with sonography in trauma
(FAST) is widely used and endorsed by guidelines, but little evidence exists
regarding the utility of the cardiac portion in blunt trauma. The traditional
FAST includes the routine performance of cardiac sonography, regardless of risk
for hemopericardium.
Study Objectives: Our goal was to estimate the prevalence of
hemopericardium due to blunt trauma and determine the sensitivity of certain
variables for the presence of blunt hemopericardium.
Methods: We performed a retrospective chart review of two
institutional databases at a large urban Level I trauma center to determine the
prevalence of blunt hemopericardium and cardiac rupture and incidental or
insignificant effusions. We evaluated the sensitivity of major mechanism of
injury, hypotension, and emergent intubation for blunt hemopericardium and
cardiac rupture.
Results: Eighteen patients had hemopericardium and cardiac
rupture (14 and 4, respectively) out of 29,236 blunt trauma patients in the
Trauma Registry over an 8.5-year period. The prevalence was 0.06% (95%
confidence interval [CI] 0.04–0.09%). The prevalence of incidental or
insignificant effusions was 0.13% (95% CI 0.09–0.18%). One case of blunt
hemopericardium was identified in the emergency ultrasound database out of 777
cardiac ultrasounds over a 3-year period. No patient with blunt hemopericardium
or cardiac rupture presented without a major mechanism of injury, hypotension,
or emergent intubation.
Conclusion: Blunt hemopericardium is rare. High-acuity
variables may help guide the selective use of echocardiography in blunt trauma.
17. Implications of
new anticoagulants in primary practice.
Perez A, et al. Int J Clin Pract. 2013 Feb;67(2):139-56.
Background: Effective prophylaxis and treatment of
thromboembolic disorders remain suboptimal in many healthcare systems, partly
owing to limitations of traditional anticoagulants. New oral anticoagulants
have been developed and among these, rivaroxaban, apixaban and dabigatran
etexilate are in the most advanced stage of clinical development.
Method: A literature search using the PubMed and
ClinicalTrials.gov databases was performed to identify English-language
publications. The search was performed up to 31 December 2011 with the terms
rivaroxaban OR Xarelto, apixaban OR Eliquis and dabigatran OR Pradaxa. Ongoing,
completed and published phase III randomised controlled trials were selected as
the primary source of information for the clinical development programme of
each drug.
Results: The new oral agents demonstrate several advantages
over traditional anticoagulants, including administration at fixed doses and no
requirement for routine coagulation monitoring On the basis of phase III
clinical trials, rivaroxaban, apixaban and dabigatran etexilate have been
approved in many countries for the prevention of venous thromboembolism after
hip and knee replacement surgery. Dabigatran etexilate and rivaroxaban have
also been approved for the prevention of stroke and systemic embolism in
patients with non-valvular atrial fibrillation in Europe and the US. In
addition, rivaroxaban has been approved in Europe for the treatment of acute
deep vein thrombosis and prevention of recurrent venous thromboembolism. Approval
of these agents and postapproval monitoring of their safety and efficacy will
have implications for primary care.
Conclusion: Rivaroxaban, apixaban and dabigatran etexilate
offer the possibility of simplified prevention and treatment strategies for
thromboembolic disorders in the outpatient setting.
18. Extremely Low Risk
for Acquisition of a Respiratory Viral Infection in the ED of a Large Pediatric
Hospital during the Winter Season
Maltezou HC, et al. Influenza Resp Viruses. 2013;7(1):14-17.
The aim of this study was to investigate the rate of
transmission of respiratory viral infections to children visiting the emergency
room of a large pediatric hospital during winter. A total of 615 children were
prospectively studied. Twenty-two (3·6%) children developed at least one
symptom compatible with a respiratory viral infection within 1-7 days after the
visit, including cough (12 children), fever (8), rhinorrhea (7), and/or
respiratory distress (1). Three children (0·49%) developed an influenza-like
illness. These findings indicate that transmission of respiratory viral
infections to children visiting an emergency room during the winter season is
extremely low.
19. The Ultrasound-guided “Peripheral IJ”: Internal
Jugular Vein Catheterization using a Standard Intravenous Catheter
Teismann NA, et al. J Emerg Med. 2013;44:150-154.
Background: Obtaining vascular access is difficult in
certain patients. When routine peripheral venous catheterization is not
possible, several alternatives may be considered, each with its own strengths
and limitations.
Discussion: We describe a novel technique for establishing
vascular access in Emergency Department (ED) patients: the placement of a
standard catheter-over-needle device into the internal jugular vein using
real-time ultrasound guidance. We present a series of patients for whom this
procedure was performed after other attempts at vascular access were
unsuccessful. In all cases, the procedure was performed quickly and without
complications.
Conclusion: Although further study of this technique is required,
we believe this procedure may be a valuable option for ED patients requiring
rapid vascular access.
20. Medical Malpractice (Video Journalism on PBS)
·
Do no harm: Every year, one in 14 doctors in
America will be sued for malpractice. Most lawsuits will be dismissed, or
resolved in favor of the doctor; but the cost of insuring against such suits
can be huge.
·
The Danish option: A closer look at how medical
malpractice is handled in Denmark, by taking litigation out of the equation completely.
Supporters of the system say it makes it easier for doctors to practice
medicine, and for injured patients to get compensated quickly.
·
Prescriptive policies for medical malpractice:
Can the U.S. change its costly court-based way of dealing with medical
mistakes? Stuck between tort reform and
patient’s rights — see what some states are trying.
Video (23 minutes): http://www.pbs.org/wnet/need-to-know/video/need-to-know-january-25-2013/16105/
21. ED Imaging
Concerns Raised for Academic Medical Centers
Mitka M. JAMA. 2013;309(4):329-330.
Chicago—Academic medical centers are often considered the
top facilities for delivering health care, but some observers think the
majority of these institutions should do more to ensure expert radiology
coverage in the emergency department at all times. In most centers, coverage
during the off hours is usually provided by a radiology resident, who is more
likely than an experienced attending radiologist to make errors when assessing
imaging tests.
At the November meeting of the Radiology Society of North
America held here, Stephen M. Ledbetter, MD, MPH, an assistant professor of
radiology at the Harvard Medical School and chief of radiology at Brigham and
Women's Hospital in Boston, said that only 10% of academic medical centers have
24-hour coverage 7 days a week by attending radiologists (Hunter TB et al. J Am
Coll Radiol. 2007;4[10]:716-719). He called on his colleagues to establish such
comprehensive coverage of emergency departments…
Academic medical centers are urged to have an experienced
radiologist available for emergency department coverage at all times, rather
than relying on a radiology resident during off hours.
“If we talk about patient-centered care, the people who
argue for 24/7 coverage would say this is the highest form of care we can
deliver; the radiologist is always there, not just for interpreting studies but
also for bringing his or her expertise in overseeing the resident and
technologist to make sure the study was done properly with the least radiation
possible,” said Ledbetter in an interview. “For someone like me, an advocate
for establishing emergency radiology, the physical presence of a radiologist,
engaging with the emergency physician to provide emergency radiology, is the
right way to go.”
Ledbetter's call for comprehensive radiology coverage in
academic medical center emergency departments also resonates in the emergency
medicine community, including with Sandra M. Schneider, MD, a professor of
emergency medicine at the University of Rochester Medical Center's School of
Medicine and Dentistry in Rochester, NY, and past president of the American
College of Emergency Physicians. “Traditionally, academic medical centers used
residents and their judgment on emergency imaging tests during the off hours,”
Schneider said. “As an attending, I’m less comfortable with this, and as a
patient, I’d be even less comfortable with it.”
Given the significantly increased use of advanced radiologic
imaging in the emergency department in recent years, lacking full-time coverage
with radiologists in the emergency setting is a quality-of-care issue, agreed
Frederick K. Korley, MD, an assistant professor of emergency medicine at Johns
Hopkins Medical School in Baltimore. For example, the prevalence of computed
tomography or magnetic resonance imaging during emergency department visits for
injury-related conditions increased from 6% in 1998 to 15% in 2007 (Korley FK
et al. JAMA. 2010;304[13]:1465-1471).
“The emergency department never sleeps, so we're seeing
patients 24 hours a day, and they don't choose when they get sick and need
important imaging studies,” Korley said. “There have been some small radiology
studies looking at the discrepancy rate in reads between residents and
attendings that found the error rate is pretty low, but ‘low’ still means
someone's mother or father is being wrongly diagnosed. And even if the
condition is not life threatening, you may inconvenience the patient if he or
she needs to come back to the hospital.”…
The remainder of the essay (full-text free): http://jama.jamanetwork.com/article.aspx?articleID=1558274&utm
22. Patients Suffer if Hospitalists Overworked
Impact of Attending Physician Workload on Patient Care: A
Survey of Hospitalists
Michtalik HJ, et al.
JAMA Intern Med. 2013;():1-2. [Epub ahead of print]
Many attending physicians said they feel overburdened to the
point where it negatively impacts patient evaluations, satisfaction, and
possibly safety outcomes.
Point out that nearly one-quarter of hospitalists reported
that excess workload adversely impacted patient outcomes by preventing full discussion
of treatment options.
23. CDC: Produce
Biggest Player in Foodborne Illness
By Cole Petrochko, Staff Writer, MedPage
Today, January 30, 2013
Nearly half of all foodborne illnesses
are caused by tainted produce, but the greatest number of attributable deaths
are caused by poultry consumption, according to data released by the CDC.
Leafy vegetables were the source of the
most foodborne illnesses from 1998 to 2008 -- accounting for some 22% of
illnesses and 14% of hospitalizations -- and made up part of the 46% of
produce-based foodborne illnesses during that decade, according to John
Painter, PhD, of the CDC, and colleagues.
The analysis, released Tuesday, showed
that poultry was responsible for nearly one fifth of all foodborne illness-related
deaths (19.1%), mostly a result of contamination from Listeria monocytogenes or
Salmonella bacteria, they wrote online in Emerging Infectious Diseases.
The researchers noted that over an
estimated 9 million foodborne illnesses are acquired in the U.S. annually, but
that "preventing these illnesses is challenging because resources are
limited and linking individual illnesses to a particular food is rarely
possible except during an outbreak."
In order to establish this first national
estimate of foodborne illness, the CDC organized all state and local health
departments' foodborne disease outbreak reports from 1998 to 2008 under 17
"mutually exclusive" food categories, such as leafy vegetables, vine
vegetables, fruits and nuts, pork, fish, and eggs.
Reports contained information on whether
an agent was confirmed or suspected and how that agent was confirmed, such as
statistical evidence from an epidemiologic investigation, laboratory results, supporting
data, previous similar experience, or other types of data. The authors noted
that a "large proportion" of these reports were missing tests or
documentation.
Also included in reports were the number
of acquired illnesses, hospitalizations, and deaths based on published
estimated or available data.
Over the 10-year period, there were
13,352 foodborne disease outbreaks that caused 271,974 illnesses. Over
one-third of the outbreaks -- 4,589 -- were associated with nearly half of all
outbreak illnesses -- 120,321 -- and were sourced to a food vehicle with a
single etiology. These illnesses were caused by a total of 36 viruses or
bacteria.
Almost half of the included outbreaks
contained complex food agents (49%) -- food agents that contained ingredients
from more than one food group.
"Norovirus caused the most outbreaks
(1,419) and outbreak-associated illnesses (41,257)," they wrote, noting
that it was well above the median of all agents.
Outbreak data was used to form estimates
of the 9.6 million estimated food-based illnesses. The investigators attributed
4.9 million illnesses to plant sources, 4 million to land animal sources, and
600,000 to aquatic animal sources.
Nearly half of all illnesses were the
result of produce consumption -- sources from the fruits and nuts group as well
as five vegetable categories -- and meat and poultry illnesses accounted for
less than a quarter (22%). However, by individual category of food agent, dairy
was the second most common source of foodborne illness (14%) after leafy
vegetables.
"The high estimate for illnesses
attributable to leafy vegetables was many times higher than the low estimate,
which indicates that leafy vegetables were frequently found in complex
foods," they noted.
Most hospitalizations due to foodborne
illness were caused by dairy (16%), leafy vegetables (14%), poultry (12%), or
fruits and nuts (10%). Most deaths were due to poultry (19%), dairy (10%),
vine-grown vegetables (7%), fruits and nuts (6%), and leafy vegetables (6%).
Bacterial illnesses were most commonly
spread through dairy, poultry, and beef sources, while plant sources were the
most common source of viral pathogens.
The authors noted that overall illness
data was based on a number of assumptions, such as the assumption that using the
number of outbreak-associated illnesses "would enable better assignment of
illnesses to commodities," that outbreak illnesses represented all
illnesses, and that complex food-based outbreaks' agents of illness were
proportional to the frequency of illnesses tied to individual agents.
They also noted that additional data on
specific foods consumed would be needed to measure per-serving risks for
various foods, but added that even foods with low risks for pathogens can
result in large numbers of illnesses if consumed frequently enough.
"The risk for foodborne illness is
just one part of the risk-benefit equation for foods; other factors, such as
health benefits of consuming a diet high in fruits and vegetables, must be
considered," they concluded.
The authors said the study was limited by
the absence of outbreaks caused by some agents, such as some that cause fatal
illnesses. Other limitations included lack of credible intervals for estimated
illnesses, hospitalizations, and deaths; lack of data on chemical-based
illnesses; and absent quality and quantity of data in some reports.
The authors declared no conflicts of
interest.
Painter JA, et al. Attribution of
foodborne illnesses, hospitalizations, and deaths to food commodities by using
outbreak data, United States, 1998-2008. Emerg Infect Dis 2013; DOI:
10.3201/eid1903.1111866.
See
also: Major Foodborne Illness Outbreaks of 2012
Division of Foodborne, Waterborne, and Environmental
Diseases,
National Center for Emerging and Zoonotic Infectious
Diseases, CDC, January 29, 2013
