Friday, March 01, 2013

March 1, 2013

From the recent medical literature...

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

The Ottawa Heart Failure Risk Scale (below) consists of 10 elements from history, examination, or investigations and has a maximum score of 15. We found that the risk of SAE varied from 2.8%, for a score of 0, to 89.0%, for a score of 9. 


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:   

Full-text (free at this posting 3-1-13):   

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. 

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. 

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. 

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. 

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. 

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. 

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. 

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:
·         CDC Report:  

D. New Push For Early Testing, Treatment for Dementia in WSJ

E. AAP Issues New Otitis Media Guidelines

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     

K. There is insufficient evidence either in favor of or against an early invasive approach in the NSTE-ACS population.