1. A Risk Scoring System to Identify ED Patients with HF at High Risk for Serious Adverse Events
Stiell IG, et al. Acad Emerg Med. 2013;20:17-26.
Objectives: There are no validated guidelines to guide
physicians with difficult disposition decisions for emergency department (ED)
patients with heart failure (HF). The authors sought to develop a risk scoring
system to identify HF patients at high risk for serious adverse events (SAEs).
Methods: This was a prospective cohort study at six large
Canadian EDS that enrolled adult patients who presented with acute
decompensated HF. Each patient was assessed for standardized clinical and
laboratory variables as well as for SAEs defined as death, intubation,
admission to a monitored unit, or relapse requiring admission. Adjusted odds
ratios for predictors of SAEs were calculated by stepwise logistic regression.
Results: In 559 visits, 38.1% resulted in patient admission.
Of 65 (11.6%) SAE cases, 31 (47.7%) occurred in patients not initially
admitted. The multivariate model and resultant Ottawa Heart Failure Risk Scale
consists of 10 elements, and the risk of SAEs varied from 2.8% to 89.0%, with
good calibration between observed and expected probabilities. Internal
validation showed the risk scores to be very accurate across 1,000 replications
using the bootstrap method. A threshold of 1, 2, or 3 total scores for
admission would be associated with sensitivities of 95.2, 80.6, or 64.5%,
respectively, all better than current practice.
Conclusions: Many HF patients are discharged
home from the ED and then suffer SAEs or death. The authors have developed an
accurate risk scoring system that could ultimately be used to stratify the risk
of poor outcomes and to enable rational and safe disposition decisions
Full-text (free): http://onlinelibrary.wiley.com/doi/10.1111/acem.12056/full
2. Videolaryngoscopy Versus Direct Laryngoscopy in
Simulated Pediatric Intubation
Donoghue AJ, et al. Ann Emerg Med. 2013;61:271-277.
Study objective: We determine whether videolaryngoscopy
results in a higher prevalence of first-attempt intubation success and improved
glottic visualization than direct laryngoscopy when performed by pediatric
emergency medicine providers in simulated patients.
Methods: This was a cross-sectional study at a single
institution. Fellows and faculty in pediatric emergency medicine were invited
to participate. Each subject performed intubations on 3 simulators (newborn,
infant, adult), using a videolaryngoscope; each simulator was intubated by each
subject with and without use of video. Primary outcome was first-attempt
intubation success; secondary outcome was percentage of glottic opening score
(POGO).
Results: Twenty-six participants performed 156 intubations;
complete data were available for 148 intubations. First-attempt success in the
neonate was 88%; in the infant, 79%; and in the adult, 60%. In the adult
simulator, videolaryngoscopy use showed a first-attempt success in 81% of subjects
compared with 39% with direct laryngoscopy (difference 43%; 95% confidence
interval [CI] 18% to 67%). There was no difference in first-attempt success
rates between videolaryngoscopy and direct laryngoscopy in the newborn or
infant simulators. Videolaryngoscopy use led to increased POGO scores in all 3
simulators, with a difference of 25% (95% CI 2% to 48%) in newborn simulators,
23% (95% CI 2% to 48%) in infant simulators, and 42% (95% CI 18% to 66%) in
adult simulators.
Conclusion: Videolaryngoscopy was associated with greater
first-attempt success during intubation by pediatric emergency physicians on an
adult simulator. POGO score was significantly improved in all 3 simulators with
videolaryngoscopy.
3. Cost and clinical effectiveness of MRI in occult
scaphoid fractures: a randomised controlled trial
Patel NK, et al. Emerg Med J
2013;30:202-207.
Background Clinical and radiographic diagnoses of scaphoid
fractures are often challenging at the time of injury. Patients are therefore
usually reassessed which has cost implications. Various investigations exist
but MRI has been suggested as effective in diagnosing these injuries early.
Aim To determine whether early MRI in suspected occult
scaphoid fractures is more clinically and cost effective than conventional
management with immobilisation and reassessment.
Methods All patients presenting to the Emergency Department
at a district general hospital with a suspected occult scaphoid fracture were
randomised into two groups, MRI (early scan of the wrist, discharged if no
injury) and control (reassessment in clinic).
Results 84 patients were randomised into MRI (45) and
control (39) groups. There were no baseline differences apart from greater
dominant hand injuries in the MRI group (62% (26) vs 36% (14), p=0.02). There
were three (6.7%) scaphoid fractures in the MRI group and four (10.3%) in the
control group (p=0.7). More fractures (15.6% (7) vs 5.1% (2), p=0.9) and other
injuries were detected in the MRI group who had fewer mean clinic appointments
(1.1±0.5 vs 2.3±0.8, p=0.001) and radiographs (1.2±0.8 vs 1.7±1.1, p=0.03).
Mean management costs were £504.13 (MRI) and £532.87 (control) (p=0.9). The MRI
group had better pain and satisfaction scores (not significant) with comparable
time off work and sporting activities.
Conclusion Early MRI in occult scaphoid fractures is
marginally cost saving compared with conventional management and may reduce
potentially large societal costs of unnecessary immobilisation. It enables
early detection and appropriate treatment of scaphoid and other injuries.
4. Physician E-mail and Telephone Contact After ED
Visit Improves Patient Satisfaction: A Crossover Trial
Patel PB, et al. Ann Emerg Med. 2013 February 27. [Epub
ahead of print].
Study objective: Enhancing emergency department (ED) patient
satisfaction has wide-ranging benefits. We seek to determine how postvisit
patient-physician contact by e-mail or telephone affects patients' satisfaction
with their emergency physician.
Methods: We undertook this crossover study from May 1, 2010,
to June 30, 2010, at 2 community EDs. Forty-two physicians either e-mailed or
telephoned their patients within 72 hours of the ED visit for 1 month; in the
alternate month, they provided no contact, serving as their own controls.
Patients received satisfaction surveys after their ED visit. Patient
satisfaction is reported as a percentage of those responding very good or
excellent on a 5-point Likert scale for 3 questions about their emergency
physician's skills, care, and communication. We calculated differences between
patient groups (noncontact versus contact) using an intention-to-treat
analysis.
Results: The mean patient satisfaction score was 79.4% for
the 1,002 patients in the noncontact group and 87.7% for the 348 patients in
the contact group (difference 8.3%; 95% confidence interval 4.0% to 12.6%).
Patient satisfaction scores were similar for e-mail and telephone contact:
89.3% for the e-mail group and 85.2% for the telephone group (difference 4.1%;
95% confidence interval −2.3% to 10.5%).
Conclusion: Patient satisfaction was higher when emergency
physicians contacted patients briefly after their visit, either by e-mail or by
telephone. Higher patient satisfaction was observed equally among patients
contacted by e-mail and those contacted by telephone. Postvisit patient-physician
contact could be a valuable practice to improve ED patient satisfaction.
Related news article: http://www.prnewswire.com/news-releases/call-me-maybe-er-patients-say-yes-please-193305391.html
Full-text (free at this posting 3-1-13): http://tinyurl.com/a5nbwuc
5. Randomized Clinical Trial of Efficacy and Safety
of a Single 2-mg IV Dose of Hydromorphone vs Usual Care in the Management of
Acute Pain
Chang AK, et al. Acad Emerg Med. 2013;20:185-192.
Objectives: The objective was to test the efficacy and
safety of 2 mg of intravenous (IV) hydromorphone (Dilaudid) against “usual
care” in emergency department (ED) patients with acute severe pain.
Methods: This was a randomized clinical trial. Patients
allocated to 2 mg of IV hydromorphone received their medication in a single
dose. Those randomized to usual care received any IV opioid, with type, dose,
and frequency chosen by the ED attending. All patients received 2 L/min. nasal cannula
oxygen. The primary outcome was the difference in the proportion of patients
who achieved clinically satisfactory analgesia by 30 minutes. This was defined
as the patient declining additional analgesia when asked the question, “Do you
want more pain medicine?” A 10% absolute difference was chosen a priori as the
minimum difference considered clinically significant.
Results: Of 175 subjects randomized to each group, 164 in
the 2 mg hydromorphone group and 161 in the usual care group had sufficient
data for analysis. Additional pain medication was declined by 77.4% of patients
in the 2 mg hydromorphone group at 30 minutes, compared to 65.8% in the usual
care group. This difference of 11.6% was statistically and clinically
significant (95% confidence interval [CI] = 1.8% to 21.1%). Safety profiles
were similar and no patient required naloxone. There was more pruritus in the
hydromorphone group (18.3% vs. 8.7%; difference = 9.6%, 95% CI = 2.6% to 16.6%).
Conclusions: Using a simple dichotomous patient-centered
endpoint in which a difference of 10% in proportion obtaining adequate
analgesia was considered clinically significant, 2 mg of hydromorphone in a
single IV dose is clinically and statistically more efficacious when compared
to usual care for acute pain management in the ED.
6. Ultrasound Research
A. Systematic Review:
ED Bedside US for Diagnosing Suspected AAA
Rubano E, et al. Acad Emerg Med 2013;20:128-138.
Background: The use of ultrasound (US) to diagnose an
abdominal aortic aneurysm (AAA) has been well studied in the radiology
literature, but has yet to be rigorously reviewed in the emergency medicine
arena.
Objectives: This was a systematic review of the literature
for the operating characteristics of emergency department (ED) ultrasonography
for AAA.
Methods: The authors searched PubMed and EMBASE databases
for trials from 1965 through November 2011 using a search strategy derived from
the following PICO formulation: Patients—patients (18+ years) suspected of AAA.
Intervention—bedside ED US to detect AAA. Comparator—reference standard for
diagnosing an AAA was a computed tomography (CT), magnetic resonance imaging
(MRI), aortography, official US performed by radiology, ED US reviewed by
radiology, exploratory laparotomy, or autopsy results. AAA was defined as ≥3 cm
dilation of the aorta. Outcome—operating characteristics (sensitivity,
specificity, and likelihood ratios [LR]) of ED abdominal US. The papers were
analyzed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)
guidelines.
Results: The initial search strategy identified 1,238
articles; application of inclusion/exclusion criteria resulted in seven studies
with 655 patients. The weighted average prevalence of AAA in symptomatic
patients over the age of 50 years is 23%. On history, 50% of AAA patients will
lack the classic triad of hypotension, back pain, and pulsatile abdominal mass.
The sensitivity of abdominal palpation for AAA increases as the diameter of the
AAA increases. The pooled operating characteristics of ED US for the detection
of AAA were sensitivity 99% (95% confidence interval [CI] = 96% to 100%) and
specificity 98% (95% CI = 97% to 99%).
Conclusions: Seven high-quality studies of the operating
characteristics of ED bedside US in diagnosing AAA were identified. All showed
excellent diagnostic performance for emergency bedside US to detect the
presence of AAA in symptomatic patients.
B. Check Both Sides
to Find the Bigger Vein before Central Line Insertion
An observational study of adult surgery patients finds
significant differences in contralateral infraclavicular axillary vein sizes
measured by bedside ultrasound.
Tan CO, et al. Crit Care Med. 2013 Feb;41(2):457-63.
OBJECTIVE: Vein size and use of dynamic ultrasound guidance
have been shown to be directly related to a reduction in insertion failure and
complication rates during subclavian vein catheterization. We hypothesized that
contralateral infraclavicular axillary vein sizes are significantly different
within the same patient. We also aimed to demonstrate the relationship of
subject's anthropomorphic indices with vein size and contralateral vein size
difference.
DESIGN: Prospective observational study.
SETTING: Operating theatre of a tertiary hospital.
PATIENTS: Fifty adult elective and emergency surgical
patients.
INTERVENTIONS: The largest dimensions of each patient's left
and right infraclavicular axillary veins were measured with two-dimensional
cross-sectional ultrasound examinations. The absolute difference between sides
in individual patients was calculated using a paired difference t test and the
relationship between hand dominance and vein size calculated by a paired
difference t test of dominant side vein size minus nondominant side vein size.
MEASUREMENTS AND MAIN RESULTS: Forty-five patients (90%) of
patients were right hand dominant. The mean proportional cross-sectional area
difference between left and right sides in individual patients was 59.7% (SEM
9.2%), with absolute cross-sectional area difference of 26.7 mm (SEM 2.8 mm).
All test statistics reached statistical significance at p less than 0.0001.
There was no relationship between right hand dominance and ipsilateral
infraclavicular axillary vein size (p = 1.0), nor was there any clinically
significant correlation between subject's anthropomorphic indices and
ipsilateral infraclavicular axillary vein size or contralateral vein size
difference (largest Pearson's r = 0.22).
CONCLUSIONS: Contralateral infraclavicular axillary vein
sizes within the same patient are significantly different in the adult surgical
population and bear no clear relation to patient hand dominance. The magnitude
of contralateral difference or absolute ipsilateral infraclavicular axillary
vein size cannot be predicted by a subject's anthropomorphic indices. All
patients in whom subclavian central line insertion is planned should have both
sides examined by ultrasound to determine which side has the largest vessel.
C. Diagnostic Accuracy
of History, PE, and Bedside US for Diagnosis of Extremity Fractures in the ED:
A Systematic Review
Joshi N, et al. Acad Emerg Med. 2013;20:1-15.
Objectives: Understanding history, physical examination, and
ultrasonography (US) to diagnose extremity fractures compared with radiography
has potential benefits of decreasing radiation exposure, costs, and pain and
improving emergency department (ED) resource management and triage time.
Methods: The authors performed two electronic searches using
PubMed and EMBASE databases for studies published between 1965 to 2012 using a
strategy based on the inclusion of any patient presenting with extremity
injuries suspicious for fracture who had history and physical examination and a
separate search for US performed by an emergency physician (EP) with subsequent
radiography. The primary outcome was operating characteristics of ED history,
physical examination, and US in diagnosing radiologically proven extremity
fractures. The methodologic quality of the studies was assessed using the
quality assessment of studies of diagnostic accuracy tool (QUADAS-2).
Results: Nine studies met the inclusion criteria for history
and physical examination, while eight studies met the inclusion criteria for
US. There was significant heterogeneity in the studies that prevented data
pooling. Data were organized into subgroups based on anatomic fracture
locations, but heterogeneity within the subgroups also prevented data pooling.
The prevalence of fracture varied among the studies from 22% to 70%. Upper
extremity physical examination tests have positive likelihood ratios (LRs)
ranging from 1.2 to infinity and negative LRs ranging from 0 to 0.8. US
sensitivities varied between 85% and 100%, specificities varied between 73% and
100%, positive LRs varied between 3.2 and 56.1, and negative LRs varied between
0 and 0.2.
Conclusions: Compared with radiography, EP US is an accurate
diagnostic test to rule in or rule out extremity fractures. The diagnostic
accuracy for history and physical examination are inconclusive. Future research
is needed to understand the accuracy of ED US when combined with history and
physical examination for upper and lower extremity fractures.
Full-text (free): http://onlinelibrary.wiley.com/doi/10.1111/acem.12058/full
D. Meta-Analysis
Finds US Guidance Superior to Landmark Technique for CVC Placement
In adults, use of the ultrasound approach lowered the risk
for cannulation failure and adverse events.
Wu SY, et al. Anesthesiology. 2013 Feb;118(2):361-75
BACKGROUND: Use of ultrasound-guided techniques to
facilitate central venous cannulation (CVC) may reduce the risk of misplacement
and complications. A meta-analysis was conducted to compare real-time
two-dimensional ultrasound (RTUS) guidance technique with anatomical landmark
technique for CVC to determine whether RTUS has any advantages.
METHODS: Randomized studies comparing outcomes in patients
undergoing CVC with either RTUS or landmark technique were retrieved from
PubMed, ISI Web of Knowledge, EMBASE, and OVID EBM Reviews from their inception
to March 2012.
RESULTS: Twenty-six studies involving 4,185 CVC procedures
met the inclusion criteria. Compared with landmark technique, patients with
RTUS had a pooled relative risk (RR) of 0.18 (95% CI: 0.10-0.32) for
cannulation failure, 0.25 (95% CI: 0.15-0.42) for arterial puncture, 0.30 (95%
CI: 0.19-0.46) for hematoma, 0.21 (95% CI: 0.06-0.73) for pneumothorax, and
0.10 (95% CI: 0.02-0.54) for hemothorax from random-effects models. However,
RTUS did not show a reduction in the risk of cannulation failure (RR = 0.26,
95% CI: 0.03-2.55), arterial puncture (RR = 0.34, 95% CI: 0.05-2.60), hematoma
(RR = 0.13, 95% CI: 0.01-2.42), pneumothorax (RR = 0.40, 95% CI: 0.02-9.61),
and hemothorax (RR = 0.40, 95% CI: 0.02-9.61) in children or infants when the
limited data were analyzed.
CONCLUSIONS: Among adults receiving CVC, RTUS was associated
with decreased risks of cannulation failure, arterial puncture, hematoma, and
hemothorax. Additional data of randomized studies are necessary to evaluate
these outcomes in pediatric patients.
7. Utility of point-of-care testing in ED triage
Soremekun OA, et al. Amer J Emerg Med. 2013;31:291-296.
Background: Triage systems are commonly used in emergency
departments (ED) to prioritize patients. Laboratory testing is not typically
used to help risk-stratify patients at triage.
Objectives: We studied the utility of point-of-care (POC)
testing at triage in ED patients with high-risk complaints.
Methods: We conducted a prospective observational study on a
convenience sample of ED patients at an urban academic hospital with 60,000
annual visits. Patients who were triaged to the waiting area with any of the
following criteria were approached for enrollment: (1) chest pain or shortness
of breath in patients older than 40 years, (2) possible infection in the
presence of two or more systemic inflammatory response system criteria in
patients older than 18 years, and (3) patients over 65 years with non-traumatic
complaints. A total of 300 subjects were enrolled. All enrolled patients
received POC testing that included a combination of Chem8+, hemoglobin,
troponin, B-type natriuretic peptide, and lactate. The triage nurse completed a
survey after receiving the results.
Results: POC results was reported to be helpful in 56% of
patients, changed the triage level in 15% of patients and led to 6% of patients
being brought back for rapid physician evaluation. Overall, 50% of patients had
one or more abnormal POC laboratory tests. There was no relationship between ED
census and the likelihood of being helpful, changing the triage level, changing
management, or bringing patients back any faster.
Conclusion: POC testing at triage is a helpful adjunct in
triage of patients with high-risk ED complaints.
8. Nationwide Improvement of Door-to-Balloon Times
in Patients with Acute STEMI Requiring Primary PCI with Out-of-Hospital 12-Lead
ECG Recording and Transmission
Ong MEH, et al. Ann Emerg Med. 2013;61:339-347.
Study objective: Reducing door-to-balloon times for acute
ST-segment elevation myocardial infarction (STEMI) patients has been shown to
improve long-term survival. We aim to reduce door-to-balloon time for STEMI
patients requiring primary percutaneous coronary intervention by adoption of
out-of-hospital 12-lead ECG transmission by Singapore's national ambulance
service.
Methods: This was a nationwide, before-after study of STEMI
patients who presented to the emergency departments (ED) and required
percutaneous coronary intervention. In the before phase, chest pain patients
received 12-lead ECGs in the ED. In the after phase, 12-lead ECGs were
performed by ambulance crews and transmitted from the field to the ED. Patients
whose ECG showed greater than or equal to 2 mm ST-segment elevation in anterior
or greater than or equal to 1 mm ST-segment elevation in inferior leads for 2
or more contiguous leads and symptom onset of less than 12 hours' duration were
eligible for percutaneous coronary intervention activation before arrival.
Results: ECGs (2,653) were transmitted by the ambulance
service; 180 (7%) were suspected STEMI. One hundred twenty-seven patients from
the before and 156 from the after phase met inclusion criteria for analysis.
Median door-to-balloon time was 75 minutes in the before and 51 minutes in the
after phase (median difference=23 minutes; 95% confidence interval 18 to 27
minutes). Median door-to-balloon times were significantly reduced regardless of
presentation hours. Overall, there was significant reduction in
door-to-activation, door-to-ECG, and door-to–cardiovascular laboratory times.
No significant difference was found pertaining to adverse events.
Conclusion: This study describes a nationwide implementation
of out-of-hospital ECG transmission resulting in reduced door-to-balloon times,
regardless of presentation hours. Out-of-hospital ECG transmission should be
adopted as best practice for management of chest pain.
9. The Importance of First Pass Success When
Performing Orotracheal Intubation in the ED
Sakles JC, et al. Acad Emerg Med. 2013;20:71-78.
Objectives: The goal of this study was to determine the
association of first pass success with the incidence of adverse events (AEs)
during emergency department (ED) intubations.
Methods: This was a retrospective analysis of prospectively
collected continuous quality improvement data based on orotracheal intubations
performed in an academic ED over a 4-year period. Following each intubation,
the operator completed a data form regarding multiple aspects of the
intubation, including patient and operator characteristics, method of
intubation, device used, the number of attempts required, and AEs. Numerous AEs
were tracked and included events such as witnessed aspiration, oxygen
desaturation, esophageal intubation, hypotension, dysrhythmia, and cardiac
arrest. Multivariable logistic regression was used to assess the relationship
between the primary predictor variable of interest, first pass success, and the
outcome variable, the presence of one or more AEs, after controlling for
various other potential risk factors and confounders.
Results: Over the 4-year study period, there were 1,828
orotracheal intubations. If the intubation was successful on the first attempt,
the incidence of one or more AEs was 14.2% (95% confidence interval [CI] =
12.4% to 16.2%). In cases requiring two attempts, the incidence of one or more
AEs was 47.2% (95% CI = 41.8% to 52.7%); in cases requiring three attempts, the
incidence of one or more AEs was 63.6% (95% CI = 53.7% to 72.6%); and in cases
requiring four or more attempts, the incidence of one or more AEs was 70.6% (95%
CI = 56.2.3% to 82.5%). Multivariable logistic regression showed that more than
one attempt at tracheal intubation was a significant predictor of one or more
AEs (adjusted odds ratio [aOR] = 7.52, 95% CI = 5.86 to 9.63).
Conclusions: When performing orotracheal intubation in the
ED, first pass success is associated with a relatively small incidence of AEs.
As the number of attempts increases, the incidence of AEs increases
substantially.
10. Patellar dislocation: cylinder cast, splint or
brace? An evidence-based review of the literature
van Gemert JP, et al. Internat J Emerg Med. 2012;5:45.
Patellar dislocations are a common injury in the emergency
department. The conservative management consists of immobilisation with a
cylinder cast, posterior splint or removable knee brace. No consensus seems to
exist on the most appropriate means of conservative treatment or the duration
of immobilisation.
Therefore the aims of this review were first to examine
whether immobilisation with a cylinder cast causes less redislocation and joint
movement restriction than a knee brace or posterior splint and second to
compare the redislocation rates after conservative treatment with surgical
treatment.
A systematic search of Pubmed, Embase and the Cochrane
Library was performed. We identified 470 articles. After applying the exclusion
and inclusion criteria, only one relevant study comparing conservative
treatment with a cylinder cast, brace and posterior splint remained (Mäenpää et
al.). In this study, the redislocation frequency per follow-up year was
significant higher in the brace group (0.29; p less than 0.05) than in the
cylinder cast group (0.12) and the posterior splint group (0.08). The
proportion of loss of flexion and extension was the highest in the cylinder
cast group and the lowest in the posterior splint group (not significant). The
evidence level remained low because of the small study population, difference
in duration of immobilisation between groups and use of old braces. Also, 12
studies comparing surgical with conservative treatment were assessed. Only one
study reported significantly different redislocation rates after surgical
treatment.
In conclusion, a posterior splint might be the best
therapeutic option because of the low redislocation rates and knee joint
restrictions. However, this recommendation is based on only one study with
significant limitations. Further investigation with modern braces and
standardisation of immobilisation time is needed to find the most appropriate
conservative treatment for patellar luxation. Furthermore, there is
insufficient evidence to confirm the added value of surgical management.
Full-text (available free): http://link.springer.com/article/10.1186/1865-1380-5-45
11. Intracranial Hemorrhage in Patients on
Bleed-prone Meds after Head Trauma and also after Lytics
A. Risk of traumatic ICH
in patients with head injury and preinjury warfarin or clopidogrel use.
Nishijima DK, and the KP CREST Network. Acad Emerg Med. 2013
Feb;20(2):140-5.
OBJECTIVES: Appropriate use of cranial computed tomography
(CT) scanning in patients with mild blunt head trauma and preinjury
anticoagulant or antiplatelet use is unknown. The objectives of this study
were: 1) to identify risk factors for immediate traumatic intracranial
hemorrhage (tICH) in patients with mild head trauma and preinjury warfarin or
clopidogrel use and 2) to derive a clinical prediction rule to identify
patients at low risk for immediate tICH.
METHODS: This was a prospective, observational study at two
trauma centers and four community hospitals that enrolled adult emergency
department (ED) patients with mild blunt head trauma (initial ED Glasgow Coma
Scale [GCS] score 13 to 15) and preinjury warfarin or clopidogrel use. The
primary outcome measure was immediate tICH, defined as the presence of ICH or
contusion on the initial cranial CT. Risk for immediate tICH was analyzed in 11
independent predictor variables. Clinical prediction rules were derived with
both binary recursive partitioning and multivariable logistic regression.
RESULTS: A total of 982 patients with a mean (± standard
deviation [SD]) age of 75.4 (±12.6) years were included in the analysis. Sixty
patients (6.1%; 95% confidence interval [CI] = 4.7% to 7.8%) had immediate
tICH. History of vomiting (relative risk [RR] = 3.53; 95% CI = 1.80 to 6.94),
abnormal mental status (RR = 2.85; 95% CI = 1.65 to 4.92), clopidogrel use (RR
= 2.52; 95% CI = 1.55 to 4.10), and headache (RR = 1.81; 95% CI = 1.11 to 2.96)
were associated with an increased risk for immediate tICH. Both binary
recursive partitioning and multivariable logistic regression were unable to
derive a clinical prediction model that identified a subset of patients at low
risk for immediate tICH.
CONCLUSIONS: While several risk factors for immediate tICH
were identified, the authors were unable to identify a subset of patients with
mild head trauma and preinjury warfarin or clopidogrel use who are at low risk
for immediate tICH. Thus, the recommendation is for urgent and liberal cranial
CT imaging in this patient population, even in the absence of clinical
findings.
B. Does Preexisting
Antiplatelet Treatment Influence Postthrombolysis Intracranial Hemorrhage in
Community-treated Ischemic Stroke Patients? An Observational Study
Meurer WJ, et al. Acad Emerg Med. 2013;20:146-154.
Objectives: Intracranial hemorrhage (ICH) after acute stroke
thrombolysis is associated with poor outcomes. Previous investigations of the
relationship between preexisting antiplatelet use and the safety of intravenous
(IV) thrombolysis have been limited by low event rates. The objective of this
study was to determine whether preexisting antiplatelet therapy increased the
risk of ICH following acute stroke thrombolysis. The primary hypothesis was
that antiplatelet use would not be associated with radiographic evidence of ICH
after controlling for relevant confounders.
Methods: Consecutive cases of thrombolysis patients treated
in the emergency department (ED) were identified using multiple methods.
Retrospective data were collected from four hospitals from 1996 to 2004 and 24
other hospitals from 2007 to 2010 as part of a cluster-randomized trial. The
same chart abstraction tool was used during both time periods, and data were
subjected to numerous quality control checks. Hemorrhages were classified using
a prespecified methodology: ICH was defined as presence of hemorrhage in
radiographic interpretations of follow-up imaging (primary outcome).
Symptomatic ICH (sICH) was defined as radiographic ICH with associated clinical
worsening. A multivariable logistic regression model was constructed to adjust
for clinical factors previously identified to be related to postthrombolysis
ICH. Sensitivity analyses were conducted where the unadjusted and adjusted
results from this study were combined with those of previously published
external studies on this topic via meta-analytic techniques.
Results: There were 830 patients included, with 47% having
documented preexisting antiplatelet treatment. The mean (± standard deviation
[SD]) age was 69 (±15) years, and the cohort was 53% male. The unadjusted
proportion of patients with any ICH was 15.1% without antiplatelet use and 19.3%
with antiplatelet use (absolute risk difference = 4.2%, 95% confidence interval
[CI] = −1.2% to 9.6%); for sICH this was 6.1% without antiplatelet use and 9%
with antiplatelet use (absolute risk difference = 3.1%, 95% CI = −1% to 6.7%).
After adjusting for confounders, antiplatelet use was not significantly
associated with radiographic ICH (odds ratio [OR] = 1.1, 95% CI = 0.8 to 1.7)
or sICH (OR = 1.3, 95% CI = 0.7 to 2.2). In patients 81 years and older, there
was a higher risk of radiographic ICH (absolute risk difference = 11.9%, 95% CI
= 0.1% to 23.6%). The meta-analyses combined the findings of this investigation
with previous similar work and found increased unadjusted risks of radiographic
ICH (absolute risk difference = 4.9%, 95% CI = 0.7% to 9%) and sICH (absolute
risk difference = 4%, 95% CI = 2.3% to 5.6%). The meta-analytic adjusted OR of
sICH for antiplatelet use was 1.6 (95% CI = 1.1 to 2.4).
Conclusions: The authors did not find that preexisting
antiplatelet use was associated with postthrombolysis ICH or sICH in this
cohort of community treated patients. Preexisting tobacco use, younger age, and
lower severity were associated with lower odds of sICH. The meta-analyses
demonstrated small, but statistically significant increases in the absolute
risk of radiographic ICH and sICH, along with increased odds of sICH in
patients with preexisting antiplatelet use.
12. Images in Clinical Medicine
Man with Facial Pain
Young Man With Fever and Cough
Torus Mandibularis
Pott's Disease of the Thoracic Spine
Lesions in the Oral Cavity
Mesenteric Abscess in Crohn's Disease
Syphilitic Chancres of the Lips
Virchow’s Node
13. Patient anxiety may influence the efficacy of ED
pain management
Craven P, et al. Amer J Emerg Med. 2013;31:313-318.
Objective: The aim of this study was to evaluate the
incidence of anxiety and rates of anxiety treatment in emergency department
(ED) patients presenting with pain-related complaints.
Methods: We prospectively evaluated patients in an urban
academic tertiary care hospital ED from 2000 through 2010. We enrolled a
convenience sample of adult patients presenting with pain and recorded patient
complaint, medication administration, satisfaction, and pain and anxiety scores
throughout their stay. We stratified patients into 4 different groups according
to anxiety score at presentation (0, none; 1-4, mild; 5-7, moderate; 8-10,
severe).
Results: We enrolled 10 664 ED patients presenting with
pain-related complaints. Patients reporting anxiety were as follows: 25.7%,
none; 26.1%, mild; 23.7%, moderate; and 24.5%, severe. Although 48% of patients
described moderate to severe anxiety at ED presentation and 60% were willing to
take a medication for anxiety, only 1% received anxiety treatment. Thirty-five
percent of patients still reported moderate/severe anxiety at discharge. Severe
anxiety at ED presentation was associated with increased demand for pain
medication (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.10-1.79) and
anxiety medication (OR, 4.34; 95% CI, 3.68-5.11) during the ED stay and
decreased satisfaction with the treatment of pain (β coefficient = −0.328; P less
than .001). After adjusting for age, sex, and presentation pain scores,
patients who reported severe anxiety were more likely to receive an analgesic
(OR, 1.33; 95% CI, 1.19-1.50) and an opioid (OR, 1.25; 95% CI, 1.11-1.41)
during the ED stay.
Conclusion: Anxiety may be underrecognized and undertreated
in patients presenting with pain-related complaints. Patients reporting severe
anxiety were less likely to report satisfaction with the treatment of their
pain, despite higher rates of analgesic administration.
14. Ann Emerg Med: Lit Review Bullets
A. Which Central Line
Insertion Site Is the Least Prone to Infection?
Akhter M, et al. Ann Emerg Med. 2013;61:362-363.
Take-Home Message: Although there are some differences in
catheter colonization rates, no central line insertion site has an increased
risk of catheter-related bloodstream infection. There are some differences in
thrombotic and mechanical complications; however, the clinical significance of
these other complications is uncertain.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01606-X/fulltext
B. Vasopressors for
Hypotensive Shock
Lampard JG, et al. Ann Emerg Med. 2013;61:351-352.
Take-Home Message: There is no significant difference in
mortality between norepinephrine and dopamine when investigated in
heterogeneous populations of hypotensive shock. Current research suggests that
norepinephrine confers mortality benefit in subgroup populations of cardiogenic
and septic shock.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01495-3/fulltext
C. Is Pronation Less
Painful and More Effective Than Supination for Reduction of a Radial Head
Subluxation?
Potis T, et al. Ann Emerg Med. 2013;61:291-292.
Take-Home Message: Evidence comparing pronation with
supination for reduction of nursemaid's elbow is limited in both quantity and
quality but suggests that pronation may be less painful and more likely to
succeed than supination.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01697-6/fulltext
D. In Infants Younger
than 24 Months Old and With Bronchiolitis, Does Nebulized Epinephrine Improve
Clinical Status?
Tudor GJ, et al. Ann Emerg Med. 2013;61:289-290.
Take-Home Message: Nebulized epinephrine decreases the risk
of hospitalization of infants younger than 24 months and with bronchiolitis
when presenting within the first 24 hours of illness.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01547-8/fulltext
15. Pediatric Abuse: Identifying Occult
Intra-Abdominal Injury
Among suspected victims of abuse, intra-abdominal injury was
five times more likely when hepatic transaminases were elevated.
Lindberg DM, et al. Pediatrics. 2013 Feb;131(2):268-75.
OBJECTIVE: Routine testing of hepatic transaminases,
amylase, and lipase has been recommended for all children evaluated for
physical abuse, but rates of screening are widely variable, even among abuse
specialists, and data for amylase and lipase testing are lacking. A previous
study of screening in centers that endorsed routine transaminase screening
suggested that using a transaminase threshold of 80 IU/L could improve injury
detection. Our objectives were to prospectively validate the test
characteristics of the 80-IU/L threshold and to determine the utility of
amylase and lipase to detect occult abdominal injury.
METHODS: This was a retrospective secondary analysis of the
Examining Siblings To Recognize Abuse research network, a multicenter study in
children younger than 10 years old who underwent subspecialty evaluation for
physical abuse. We determined rates of identified abdominal injuries and
results of transaminase, amylase, and lipase testing. Screening studies were
compared by using basic test characteristics (sensitivity, specificity) and the
area under the receiver operating characteristic curve.
RESULTS: Abdominal injuries were identified in 82 of 2890
subjects (2.8%; 95% confidence interval: 2.3%-3.5%). Hepatic transaminases were
obtained in 1538 (53%) subjects. Hepatic transaminases had an area under the
receiver operating characteristic curve of 0.87. A threshold of 80 IU/L yielded
sensitivity of 83.8% and specificity of 83.1%. The areas under the curve for
amylase and lipase were 0.67 and 0.72, respectively.
CONCLUSIONS: Children evaluated for physical abuse with
transaminase levels over 80 IU/L should undergo definitive testing for
abdominal injury.
16. Low-dose ketamine analgesia: patient and
physician experience in the ED
Richards JR and Rockford RE. Amer J Emerg Med.
2013;31:390-394.
Objective: Low-dose ketamine (LDK) may be useful for
treatment for opioid-tolerant patients. We conducted a survey of patients and
their treating clinicians regarding LDK for analgesia.
Methods: Survey data included the following: vital signs and
pain score before and after LDK, demographics, and adverse effects. Treating
physicians were queried about reasons for use of LDK and overall satisfaction.
Results: Twenty-four patients were enrolled: 21 received LDK
for analgesia, and 3 received LDK for sedation. Pain level on a visual analog
scale (range, 1-10) after LDK was significantly decreased from 8.9 ± 2.1 to 3.9
± 3.4 (P less than .0001). Change in vital signs after administration of LDK
was not statistically significant. Overall patient satisfaction with LDK was
55%, and overall physician satisfaction was 72%. Sixteen (67%) of patients
would prefer LDK again, and 23 (96%) of physicians would use LDK again for
analgesia. Four patients reported an adverse experience, but there were no
emergence reactions. Race subanalysis revealed no difference in pain reduction,
but whites were least satisfied compared with black and Hispanic patients (P =
.02). Physician reasons for using LDK included opioid failure (88%), concern
for respiratory depression (17%), concern for multiple opioid allergies (13%),
and concern for hypotension (8%). Most (96%) physicians believed that LDK is
underused.
Conclusion: Low-dose ketamine may decrease patients'
perception of pain. Most were satisfied with LDK for this purpose and would use
it again. Whites were least satisfied with the use of LDK for analgesia.
Physicians believed that ketamine is underused.
17. Targeted ᴅ-dimer Testing Best for DVT Diagnosis
Troy Brown, Medscape Medical News, Jan 14, 2013
It is best to base ᴅ-dimer testing on a patient's clinical
pretest probability (C-PTP) for deep vein thrombosis (DVT), rather than testing
all patients who present with symptoms of first DVT episode. This strategy can
exclude DVT in more patients without increasing missed diagnoses, according to
a randomized, multicenter, controlled trial in 1723 patients at 5 medical
centers in Canada.
Lori-Ann Linkins, MD, an assistant professor in the Division
of Hematology and Thromboembolism, Department of Medicine, McMaster University
in Hamilton, Ontario, Canada, and colleagues published their findings in the
January 15 issue of the Annals of Internal Medicine.
ᴅ-dimer testing is sensitive but not specific for
identifying DVT. Selectively testing ᴅ-dimer levels lowered the proportion of
patients who needed ultrasonography and decreased the percentage of patients
who required ᴅ-dimer testing by 21.8% (95% confidence interval [CI], 19.1% -
24.8%).
"In this trial comparing uniform with selective ᴅ-dimer
testing in patients with suspected first DVT, a selective strategy — which used
a higher ᴅ-dimer threshold to exclude first acute DVT in outpatients with low
C-PTP and omitted ᴅ-dimer testing in outpatients with high C-PTP and all
inpatients — was as safe as and more efficient than the uniform testing
strategy, which used the same threshold to exclude DVT in all patients,"
the authors write.
Patients were randomly assigned to the selective testing (n
= 860) or uniform testing (n = 863) groups on presentation for suspected first
DVT episode. Of the study participants, 1542 (89%) were outpatients and 181
(11%) were inpatients.
All patients in the uniform testing group underwent ᴅ-dimer
testing. Levels less than 0.5 μg/mL were considered negative, and levels of 0.5
μg/mL or higher were considered positive. For patients with positive results,
ultrasonography of the proximal veins in the symptomatic legs was conducted;
patients with normal ultrasonogram and high C-PTP had ultrasonography repeated
on the same legs 6 to 8 days later.
Patients in the selective testing group only underwent
ᴅ-dimer testing if they were outpatients and had low or moderate C-PTP.
Outpatients with high C-PTP and all inpatients underwent ultrasonography only.
ᴅ-dimer levels in the low C-PTP group were considered negative if they were
below 1.0 μg/mL and positive if they were 1.0 μg/mL or above.
For patients in the moderate C-PTP group, ᴅ-dimer levels
were considered negative if they were below 0.5 μg/mL and positive if they were
0.5 μg/mL or above. Patients with positive results had ultrasonography, and patients
with normal ultrasonogram and moderate or high C-PTP had ultrasonography
repeated 6 to 8 days later.
Of the patients in the uniform testing group, 859 (99.5%)
had ᴅ-dimer testing, 505 (58.5%) had initial ultrasonography, and 334 (38.7%)
had ultrasonography repeated after 6 to 8 days.
Positive ᴅ-dimer results were found in 506 patients (418
outpatients and 88 inpatients), and negative results were found in 353 patients
(351 outpatients and 2 inpatients). Four patients had no test. DVT was diagnosed
by initial ultrasonography in 56 ᴅ-dimer-positive patients (11.1% of the 506
ᴅ-dimer-positive patients and 6.5% of 863 patients in the uniform testing
group). None of the 81 patients with low C-PTP and a ᴅ-dimer level between 0.5
and 1.0 µg/mL had DVT on ultrasonography.
18. Primary Closure of Cutaneous Abscesses after
Incision and Drainage
Compared with traditional management, primary closure
yielded similar outcomes in this small study.
Primary Versus Secondary Closure of Cutaneous Abscesses in
the Emergency Department: A Randomized Controlled Trial. Singer AJ, et al. Acad
Emerg Med. 2013;20:27-32.
Objectives: Cutaneous abscesses have traditionally been
treated with incision and drainage (I&D) and left to heal by secondary
closure. The objective was to compare the healing rates of cutaneous abscesses
following I&D after primary or secondary closure.
Methods: This was a randomized, controlled, trial, balanced
by center, with blocked randomization created by a random-number generator. One
urban and one suburban academic emergency department (ED) participated.
Subjects were randomized to primary or secondary wound closure following
I&D of the abscess. Main outcome measures were the percentage of healed
wounds (wound was completely closed by visual inspection; a 40% difference in
wound healing was sought) and overall failure rate (need for additional
intervention including suture removal, additional drainage, antibiotics, or
admission within 7 days after drainage).
Results: Fifty-six adult patients with simple localized
cutaneous abscesses were included; 29 were randomized to primary closure, and
27 were randomized to secondary closure. Healing rates at 7 days were similar
between the primary and secondary closure groups (69.6%, 95% confidence
interval [CI] = 49.1% to 84.4% vs. 59.3%, 95% CI = 40.7% to 75.5%; difference
10.3%, 95% CI = −15.8% to 34.1%). Overall failure rates at 7 days were also
similar between the primary and secondary closure groups (30.4%, 95% CI = 15.6%
to 50.9% vs. 28.6%, 95% CI = 15.2% to 47.1%; difference 1.8%, 95% CI = −24.2%
to 28.8%).
Conclusions: The rates of wound healing and treatment
failure following I&D of simple abscesses in the ED are similar after
primary or secondary closure. The authors did not detect a difference of at
least 40% in healing rates between primary and secondary closure.
Full-text (free): http://onlinelibrary.wiley.com/doi/10.1111/acem.12053/full
19. Bright Screens Could Delay Bedtime
Using a tablet or computer in the late evening disrupts the
body's melatonin production
By Stephani Sutherland, Scientific American. February, 2013.
If you have trouble sleeping, laptop or tablet use at
bedtime might be to blame, new research suggests. Mariana Figueiro of the
Lighting Research Center at Rensselaer Polytechnic Institute and her team
showed that two hours of iPad use at maximum brightness was enough to suppress
people's normal nighttime release of melatonin, a key hormone in the body's
clock, or circadian system. Melatonin tells your body that it is night, helping
to make you sleepy. If you delay that signal, Figueiro says, you could delay
sleep. Other research indicates that “if you do that chronically, for many
years, it can lead to disruption of the circadian system,” sometimes with
serious health consequences, she explains.
The dose of light is important, Figueiro says; the
brightness and exposure time, as well as the wavelength, determine whether it
affects melatonin. Light in the blue-and-white range emitted by today's tablets
can do the trick—as can laptops and desktop computers, which emit even more of
the disrupting light but are usually positioned farther from the eyes, which
ameliorates the light's effects. The team designed light-detector goggles and
had subjects wear them during late-evening tablet use. The light dose
measurements from the goggles correlated with hampered melatonin production.
On the bright side, a morning shot of screen time could be
used as light therapy for seasonal affective disorder and other light-based
problems. Figueiro hopes manufacturers will “get creative” with tomorrow's
tablets, making them more “circadian friendly,” perhaps even switching to white
text on a black screen at night to minimize the light dose. Until then, do your
sleep schedule a favor and turn down the brightness of your glowing screens
before bed—or switch back to good old-fashioned books.
20. Other Interesting Research
A. Ondansetron Safe
in Pregnancy in NEJM
B. Medicinal Use of
Marijuana in NEJM
Currently, 18 states allow the medicinal use of marijuana,
but it remains controversial among physicians. This Clinical Decisions presents
both sides of the heated debate.
C. Opioid Pain Meds
Culprits in Majority of Overdose Deaths in JAMA
Opioid analgesics are the primary culprits in the vast majority
of US overdose deaths, new research shows. An analysis conducted by
investigators at the Centers for Disease Control and Prevention (CDC) in
Atlanta, Georgia, showed that 75.2% of pharmaceutical deaths involved opioids,
either alone or in combination with other drugs.
·
Medscape essay: http://www.medscape.com/viewarticle/779528
D. New Push For Early
Testing, Treatment for Dementia in WSJ
E. AAP Issues New
Otitis Media Guidelines
Watchful Waiting Best for Ear Infections http://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3488.full.pdf+html
F. Choosing Wisely:
More Tests Physicians Should Avoid
G. CDC: Give Tdap
During Every Pregnancy
H. FDA: Codeine use
after tonsillectomy can be fatal to children in WSJ
I. Cannabis-related
Stroke
J. Aspirin No Help for
Stroke Outcomes
http://stroke.ahajournals.org/content/44/2/432.abstract
K. There is
insufficient evidence either in favor of or against an early invasive approach
in the NSTE-ACS population.
