1. Marathon Day at Massachusetts General
Ann Intern Med. 2013 March 30 [Epub ahead of print]
Alasdair Conn, MD, Chief, Department of Emergency Medicine, MGH
We thought it would be a normal Marathon Monday at Massachusetts General Hospital (MGH). The Boston Marathon is always held on the third Monday in April and is a public holiday—Patriots Day. All state offices are closed, together with many businesses; but for hospitals, it is a regular working day. The MGH normally expects to receive about 15 to 20 marathon runners with hyponatremia and dehydration, many more are treated at the medical tents along the route of the marathon. For many this is a day that Bostonians look forward to each year as the unofficial start of spring.
It was not to be. At 2:50PM, an explosion rocked the area near the finish line, closely followed 11 seconds later by a second blast. Two minutes later, Boston EMS initiated a hospital ringdown; they contacted all of the Boston hospitals requesting disaster capability. Our answer is always the same; we have immediate capacity for 10 critical patients, 20 seriously injured, and we can accept unlimited “walking wounded.” I was paged as soon as the radio call came in; at this time we had no idea of the potential number of injured patients or of their severity. I looked at the current ED census—we were full and had one open stretcher bay in the entire department.
The first patient arrived without entry notification at 3:04PM by private vehicle; the patient was female and had sustained a traumatic amputation of one of her legs together with multiple other injuries. Two minutes later, a police van arrived with two additional patients—both also had traumatic lower extremity amputations, again there had been no time for entry notification. We activated our Hospital Incident Command System (HICS). Simultaneously, several hundred MGH staff received a phone call to their home and work, a message was also sent to their pagers, e-mail, and cell phone alerting them of the need to respond to disaster stations. The response from all staff was immediate and coordinated. Within minutes, the ED was vacated and rooms stocked in preparation for the arrival of further victims. Disaster packs, one for each expectant patient were opened, enabling us to identify patient by prearranged medical record numbers, preprinted wrist bands with the bar codes on them were attached to all disaster patients upon ED arrival. (We use scanned bar codes for patient identification.) Eight critical patients arrived to the hospital within 30 minutes of the explosion. Among the first was the patient who arrived pulseless; she had already exsanguinated. IVs were started; she was given four units of uncrossed blood and with her blood pressure restored transferred immediately to the operating room. Over the next few minutes five other patients—three with traumatic amputations—were also resuscitated and sent to the operating room; at that time we had positive identification on one of these six patients. More patients, albeit less severely injured, followed them to the OR over the next two to three hours. The MGH treated 31 patients that day; several more arrived over the subsequent 24 to 48 hours.
Unfortunately, three patients died at the scene of the explosions; miraculously all of the patients who were transferred to hospitals survived. There will be further debriefings over the next few weeks, several factors undoubtedly contributed to this remarkable survival rate. At the scene, there were many first responders who were immediately able to respond (despite the personal risk of further potential bomb blasts) and to control the hemorrhage from the multiple patients with lower extremity injuries. Stories abound of clothes being torn to make improvised tourniquets—this proved to be lifesaving. Staff in the medical tent close to the finish line changed their role from treating dehydration to controlling external hemorrhage and crystalloid resuscitation without missing a beat. Many ambulances were stationed near the finish line and could transport the most critically injured rapidly to the nearby hospitals. Boston EMS staff on scene performed an exemplary function in triaging the severely injured to the trauma centers, taking care not to overload the resources of any one hospital. Boston is fortunate to have a plethora of hospital resources—five Level I Adult Trauma Centers and three Level 1 Pediatric Trauma Centers are within three miles of the finish line; all hospitals received critical patients in roughly equal numbers.
The timing of the explosions was also opportune; the incident occurred at the change of shift. The morning shift was completing the 7am to 3pm shift; the 3 pm to 11 pm shift was already in house. On every unit in the hospital the medical, nursing, and support staff stayed to assist however they could – it was as though there was immediate double coverage. It was a Monday; the hospital was relatively open and had not yet filled with the elective cases that tend to occur early in the week. Being a state holiday the scheduled operating list was relatively light but because it was a normal working day the operating rooms were fully staffed; the ORs were also completing their operative schedules for the day. All of these factors contributed, but above all, it was the training and the repeated disaster drills that made the difference. Although we did not receive any patients from Ground Zero on that fateful day in September 2001, we realized that our hospital internal disaster plan was inadequate; we took the opportunity to thoroughly revise our response. We requested a consultation with Israeli emergency physicians—they let us know how they are able to respond to a bombing on a bus—they told us they experience this scenario every six weeks and are able to manage 70 to 80 patients arriving simultaneously. We worked with Boston EMS to hone our coordination and skills and performed numerous drills, often on a citywide basis. The simulated building collapse; the dirty bomb scenario at Logan airport and the repetitive activation of the MGH disaster response system—yes—on nights and weekends, all contributed to our learning and familiarity. This training and the iterative improvement in response by all involved made the difference on Marathon Monday. Our elected representatives who help fund these efforts have to be informed that this is money well-spent; this training made the difference and translated directly into lives saved.
Unfortunately, terrorism in today's world is a reality and even in the United States we now realize we are not immune. As a medical community we must be prepared to meet this challenge. In the ensuing months, I am sure we will be analyzing the Boston marathon response in more detail and we will surely find that there are more lessons to be learned. However, as a medical professional working that day, I feel an enormous sense of pride in being a member of a team of health care providers—both prehospital and in-hospital—all of whom functioned in a rehearsed, choreographed, and coordinated response. At the end of the day the system worked and lives were saved. I remain convinced that it was mostly this coordination of effort that contributed to the dramatic survival of the bombing victims. Or as one physician stated to an ad hoc debriefing about 48 hours after the event, “We all came together and worked as a team, and as a team we together saved lives” It was truly a day to remember.
Under the Medical Tent at the Boston Marathon: http://www.nejm.org/doi/full/10.1056/NEJMp1305299
Marathon Bombings: An EM Physician's First-Hand Account: http://www.medscape.com/viewarticle/802900
Lessons from Boston:
2. Do All Patients with Major Blunt Trauma Need C-Spine CT?
Clinical factors show promise for predicting fractures, but until they're validated, all such patients should undergo C-spine computed tomography.
Both the National Emergency X-Radiography Utilization Study (NEXUS) and Canadian cervical spine (C-spine) rules have demonstrated that clinical exam is sufficient to clear the cervical spine for certain trauma patients. However, the sensitivity and specificity of these rules for patients with major trauma are not adequate, and many centers perform C-spine computed tomography (CT) for all patients with major trauma. In this prospective single-site study, investigators evaluated the correlation between findings on C-spine CT and presence of any of 18 combined NEXUS and Canadian C-spine criteria in 5812 trauma patients.
All patients met criteria for major trauma requiring trauma team activation, which included Glasgow Coma Scale (GCS) score below 14, systolic blood pressure less than 90 mm Hg, respiratory rate below 10 or above 20 per minute, significant obvious anatomic injury (e.g., flail chest; two or more long-bone fractures; crushed, degloved, or mangled extremity; amputation; pelvic fractures; open or depressed skull fractures; paralysis), and significant mechanism of injury (e.g., falls greater than 20 feet, high-risk motor vehicle collision).
Fracture incidence was 6.3%. Clinical exam had 100% sensitivity and 0.62% specificity for detecting fractures. Seven NEXUS/Canadian C-spine criteria were independent predictors of fracture: midline tenderness, GCS score less than15, paresthesias, rollover motor vehicle collision, ejection from a motor vehicle, age ≥65, and not being able to sit up in the emergency department. Use of these seven factors increased specificity nearly 20-fold, to 11.6%.
Comment: Prospective multicenter validation of these factors is needed before practice changes. Until then, C-spine computed tomography should continue be the study of choice to evaluate patients with major trauma for possible cervical spine fracture.
— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine May 3, 2013
Citation: Duane TM et al. CT for all or selective approach? Who really needs a cervical spine CT after blunt trauma. J Trauma Acute Care Surg 2013 Apr; 74:1098.
3. Chest Pain: What Happens After the ED?
Patients who follow up with cardiologists do best.
Researchers examined patterns of follow-up care and outcomes in high-risk patients with chest pain who presented to Ontario emergency departments (EDs) from 2004 to 2010. High risk was defined as having a prior diagnosis of cardiovascular disease, diabetes, or both. The primary outcome was a composite of all-cause death and hospitalization for myocardial infarction within 1 year after the index visit.
Of nearly 57,000 patients, 17% followed up with a cardiologist (with or without a visit to primary care) within 30 days after ED discharge, 57% followed up with a primary care practitioner only, and 25% did not have a visit to a physician recorded. After adjustment for clinical, demographic, and hospital characteristics, the cardiologist group had a significantly lower hazard ratio for the composite outcome (HR, 0.79; P less than 0.001) than the no–follow-up group and the PCP-only group (HR, 0.85; P less than 0.001). PCP-only follow-up was significantly beneficial compared to no follow-up (HR, 0.93; P less than 0.023). Patients seen by cardiologists underwent more testing and received more evidence-based therapies within 100 days after discharge.
Comment: These robust results demonstrate that what happens after the emergency department visit is as important as what happens during the ED visit, and that postdischarge care for patients with high-risk chest pain should include timely assessment by a cardiologist.
— J. Stephen Bohan, MD, MS, FACP, FACEP. Published in Journal Watch Emergency Medicine April 19, 2013 .Citation: Czarnecki A et al. Association between physician follow-up and outcomes of care after chest pain assessment in high-risk patients. Circulation 2013 Apr 2; 127:1386-94.
4. Steroid-antiviral Treatment Improves the Recovery Rate in Patients with Severe Bell's Palsy
Lee HY, et al. Amer J Med. 2013;126:336-41.
Background: The extent of facial nerve damage is expected to be more severe in higher grades of facial palsy, and the outcome after applying different treatment methods may reveal obvious differences between severe Bell's palsy and mild to moderate palsy. This study aimed to systematically evaluate the effects of different treatment methods and related prognostic factors in severe to complete Bell's palsy.
Methods: This randomized, prospective study was performed in patients with severe to complete Bell's palsy. Patients were assigned randomly to treatment with a steroid or a combination of a steroid and an antiviral agent. We collected data about recovery and other prognostic factors.
Results: The steroid treatment group (S group) comprised 107 patients, and the combination treatment group (S+A group) comprised 99 patients. There were no significant intergroup differences in age, sex, accompanying disease, period from onset to treatment, or results of an electrophysiology test (P above .05). There was a significant difference in complete recovery between the 2 groups. The recovery (grades I and II) of the S group was 66.4% and that of the S+A group was 82.8% (P=.010). The S+A group showed a 2.6-times higher possibility of complete recovery than the S group, and patients with favorable electromyography showed a 2.2-times higher possibility of complete recovery.
Conclusions: Combined treatment with a steroid and an antiviral agent is more effective in treating severe to complete Bell's palsy than steroid treatment alone.
Full-text (free): http://www.amjmed.com/article/S0002-9343(12)00907-2/fulltext
5. A RCT of Cast vs. Splint for Distal Radial Buckle Fracture: An Evaluation of Satisfaction, Convenience, and Preference
Williams KG, et al. Pediatr Emerg Care. 2013;29:555-559.
Objectives: Buckle fractures are inherently stable and at low risk for displacement. These advantages allow for treatment options that may create confusion for the practitioner. Accepted immobilization methods include circumferential cast, plaster or prefabricated splint, and soft bandaging. Despite mounting evidence for splinting, the questions of pain, preference, satisfaction, and convenience offer a challenge to changing practice. The purposes of this study were (1) to compare cast versus splint for distal radial buckle fractures in terms of parental and patient satisfaction, convenience, and preference and (2) to compare pain reported for cast versus splint.
Methods: We conducted a prospective randomized trial of a convenience sample of patients 2 through 17 years with a radiologically confirmed distal radial buckle fracture. Subjects were randomly assigned to short-arm cast or prefabricated wrist splint. We assessed satisfaction, convenience, preference, and pain in the emergency department and at days 1, 3, 7, and 21 after immobilization.
Results: Ninety-four patients were enrolled. Compared with the cast group, those in the splint group reported higher levels of satisfaction, preference, and convenience on 10-point visual analog scale. Although pain scores were higher for those in the splint group, the difference was not statistically significant.
Conclusions: With the exception of pain reported in the emergency department being higher for the splinted group, all other measures, including convenience, satisfaction, and preference, showed a clear trend favoring splints at almost every time period in the study. This study provides additional evidence that splinting is preferable to casting for the treatment of distal radial buckle fractures.
6. Yield of Chest Radiography after Removal of Esophageal Foreign Bodies
Fisher J, et al. Pediatrics. 2013 Apr 22. [Epub ahead of print]
OBJECTIVES: The aim of this study was to determine the benefit of routine postoperative chest radiography after removal of esophageal foreign bodies in children.
METHODS: Medical records were reviewed of all patients evaluated with an esophageal foreign body at a single children’s hospital over 10 years. Operative records and imaging reports were reviewed for evidence of esophageal injury.
RESULTS: Of 803 records identified, 690 were included. All underwent rigid esophagoscopy and foreign body removal. The most common items removed were coins (94%), food boluses (3%), and batteries (2%). The rate of esophageal injury was 1.3% (9 patients). No injuries were identified on chest radiographs done as routine or for concern of injury. Patients with operative findings suggestive of an esophageal injury (n = 105) were significantly more likely to have an injury (8.6% vs 0%, P = .0001). Of the 585 children who did not have physical evidence of injury, 40% (n = 235) received a routine chest radiograph. Regardless of the indication, no injuries were identified on chest films.
CONCLUSIONS: We conclude that intraoperative findings during rigid esophagoscopy suggestive of an injury are predictive of esophageal perforation. Routine chest radiography is not warranted in children who do not meet this criterion. In patients with a concern for injury, we suggest that chest radiography should be deferred in favor of esophagram.
7. Bedside US Measurement of the IVC Does Not Predict Hydration Status in Children
IVC collapsibility index and IVC-to-aorta ratio did not correlate with central venous pressure ≤8 mm Hg.
In a prospective observational study at a pediatric critical care unit, investigators evaluated the correlation between two bedside ultrasound inferior vena cava (IVC) measurements and central venous pressure (CVP) indicative of dehydration (≤8 mm Hg). The two IVC measurements were percent decrease in IVC diameter between expiration and inspiration (IVC collapsibility index) above 0.5 and IVC-to-aorta ratio ≤0.8.
In a convenience sample of 51 patients less than 21 years (median age, 5 months) with central venous catheters, 67% were intubated, 65% had a femoral central line site, 47% were admitted for cardiac diagnoses, and 10% were admitted for intra-abdominal diagnoses. Overall, 43% had CVP ≤8 mm Hg. For predicting CVP ≤8 mm Hg, an IVC collapsibility index above 50% had a sensitivity of 14%, specificity of 83%, positive predictive value of 38%, and negative predictive value of 57%. Corresponding performance parameters of IVC-to-aorta ratio ≤0.8 were 18%, 81%, 38%, and 60%, respectively.
Comment: IVC collapsibility index has been shown to correlate well with CVP in adults (link below). The poor correlation between IVC measurements and CVP in the children in the current study may be secondary to the high incidences of intubation, with consequent alterations in intrathoracic pressure, and femoral central line sites, where soft tissue external pressure influences differ from those at other sites. However, until supportive evidence emerges, bedside ultrasound IVC measurements should not be relied on to estimate intravascular volume status in children.
— Katherine Bakes, MD. Published in Journal Watch Emergency Medicine April 26, 2013
Citation: Ng L et al. Does bedside sonographic measurement of the inferior vena cava diameter correlate with central venous pressure in the assessment of intravascular volume in children? Pediatr Emerg Care 2013 Mar; 29:337.
Peds abstract: http://www.ncbi.nlm.nih.gov/pubmed/23426248
In adults: Nagdev AD et al. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. Ann Emerg Med 2010 Mar; 55:290. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19556029
8. Focused Multiorgan Bedside Ultrasound in Patients with Nontraumatic Hypotension: A "Medical" FAST Scan?
In patients with nontraumatic hypotension of unclear etiology, immediate bedside ultrasound findings correlated well with final diagnoses.
Volpicelli G et al. Intensive Care Med 2013 Apr 13. [Epub ahead of print]
PURPOSE: We analyzed the efficacy of a point-of-care ultrasonographic protocol, based on a focused multiorgan examination, for the diagnostic process of symptomatic, non-traumatic hypotensive patients in the emergency department.
METHODS: We prospectively enrolled 108 adult patients complaining of non-traumatic symptomatic hypotension of uncertain etiology. Patients received immediate point-of-care ultrasonography to determine cardiac function and right/left ventricle diameter rate, inferior vena cava diameter and collapsibility, pulmonary congestion, consolidations and sliding, abdominal free fluid and aortic aneurysm, and leg vein thrombosis. The organ-oriented diagnoses were combined to formulate an ultrasonographic hypothesis of the cause of hemodynamic instability. The ultrasonographic diagnosis was then compared with a final clinical diagnosis obtained by agreement of three independent expert physicians who performed a retrospective hospital chart review of each case.
RESULTS: Considering the whole population, concordance between the point-of-care ultrasonography diagnosis and the final clinical diagnosis was interpreted as good, with Cohen's k = 0.710 (95 % CI, 0.614-0.806), p less than 0.0001 and raw agreement (Ra) = 0.768. By eliminating the 13 cases where the final clinical diagnosis was not agreed upon (indefinite), the concordance increased to almost perfect, with k = 0.971 (95 % CI, 0.932-1.000), p less than 0.0001 and Ra = 0.978.
CONCLUSIONS: Emergency diagnostic judgments guided by point-of-care multiorgan ultrasonography in patients presenting with undifferentiated hypotension significantly agreed with a final clinical diagnosis obtained by retrospective chart review. The integration of an ultrasonographic multiorgan protocol in the diagnostic process of undifferentiated hypotension has great potential in guiding the first-line therapeutic approach.
9. Evidence Reviews in Annals
A. Pediatric UTI: Does the Evidence Support Aggressively Pursuing the Diagnosis?
Newman DH, et al. Ann Emerg Med. 2013;61:559-565.
The epidemiology of pediatric fever has changed considerably during the past 2 decades with the development of vaccines against the most common bacterial pathogens causing bacteremia and meningitis. The decreasing incidence of these 2 conditions among vaccinated children has led to an emphasis on urinary tract infection as a remaining source of potentially hidden infections in febrile children. Emerging literature, however, has led to questions about both the degree and nature of the danger posed by urinary tract infection in nonverbal children, whereas the aggressive pursuit of the diagnosis consumes resources and leads to patient discomfort, medical risks, and potential overdiagnosis. We review both early and emerging literature to examine the utility and efficacy of early identification and treatment of urinary tract infection in children younger than 24 months. We conclude that in well children of this age, it may be reasonable to withhold or delay testing for urinary tract infection if signs of other sources are apparent or if the fever has been present for fewer than 4 to 5 days.
B. In Patients With Severe Sepsis, Does a Single Dose of Etomidate to Facilitate Intubation Increase Mortality?
Hunter BR, et al. Ann Emerg Med. 61:571-572.
Take-Home Message: Currently, single-dose etomidate has not been shown to cause increased mortality in septic patients requiring intubation; however, sufficiently powered randomized trials are required before definitive conclusions can be drawn.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01913-0/fulltext
C. Does Combination Treatment With Ibuprofen and Acetaminophen Improve Fever Control?
Malya RR, et al. Ann Emerg Med. 61:569-570.
Take-Home Message: Combination treatment with ibuprofen and acetaminophen is beneficial over either agent alone for sustained fever reduction in children older than 6 months.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01698-8/fulltext
10. Advertising ED Wait Times
Weiner SG. West J Emerg Med 2013;14(2):77-78.
Advertising emergency department (ED) wait times has become a common practice in the United States. Proponents of this practice state that it is a powerful marketing strategy that can help steer patients to the ED. Opponents worry about the risk to the public health that arises from a patient with an emergent condition self-triaging to a further hospital, problems with inaccuracy and lack of standard definition of the reported time, and directing lower acuity patients to the higher cost ED setting instead to primary care. Three sample cases demonstrating the pitfalls of advertising ED wait times are discussed. Given the lack of rigorous evidence supporting the practice and potential adverse effects to the public health, caution about its use is advised.
Full-text (free): http://www.escholarship.org/uc/item/0bt69906#
11. Images in Clinical Medicine
Healthy 51-Year-Old Male With Peritonsillar Swelling
Man With a Rash
Woman With Worsening Exertional Dyspnea
Levamisole-adulterated Cocaine Induced Vasculitis with Skin Ulcerations
Acute Vision Change in a 16-year-old Female
Perforation of Inferior Vena Cava by Inferior Vena Cava Filter
Neonatal Umbilical Mass
12. Cardiovascular Risks with Azithromycin and Other Antibacterial Drugs
Mosholder AD, et al. N Engl J Med 2013; 368:1665-1668.
In 2011, approximately 40.3 million people in the United States (roughly one eighth of the population) received an outpatient prescription for the macrolide azithromycin, according to IMS Health. During that year, we at the Food and Drug Administration (FDA) reviewed the labels of azithromycin and other approved macrolide antibacterials in view of cardiovascular risks that had become evident from published studies and reports emerging through postmarketing surveillance. On the basis of its review, the FDA approved revisions to azithromycin product labels regarding risks of QT-interval prolongation and the associated ventricular arrhythmia torsades de pointes. The revised labels advise against using azithromycin in patients with known risk factors such as QT-interval prolongation, hypokalemia, hypomagnesemia, bradycardia, or use of certain antiarrhythmic agents, including class IA (e.g., quinidine and procainamide) and class III (e.g., dofetilide, amiodarone, and sotalol) — drugs that can prolong the QT interval. In March 2013, the FDA announced that azithromycin labels had been further revised to reflect the results of a clinical study showing that azithromycin can prolong the corrected QT interval.
In a 2012 observational study involving Tennessee Medicaid patients, Ray et al.1 quantified the risk of death from cardiovascular causes associated with azithromycin as compared with other antibacterial drugs or nonuse. The study showed that the risks of death, both from any cause and from cardiovascular causes, associated with azithromycin were greater than those associated with amoxicillin. For every 21,000 outpatient prescriptions written for azithromycin, one cardiovascular death occurred in excess of those observed with the same number of amoxicillin prescriptions. The excess risk over amoxicillin varied considerably according to cardiovascular risk factors; the researchers estimated that there was one excess cardiovascular death per 4100 prescriptions among patients at high cardiovascular risk but less than one per 100,000 among patients with lower cardiovascular risk.
The study by Ray et al. has limitations that are intrinsic to observational, nonrandomized clinical studies. In particular, nonrandomized studies cannot exclude the possibility that patients receiving a drug under evaluation differ from control patients in some important but undetected way, causing bias in the results. Such confounding may bias comparisons not only between patients receiving antibacterial drugs and those receiving no antibacterials but also between patients receiving different antibacterials. Although Ray et al. used appropriate analytic methods to address potential confounding, we cannot know for certain whether these methods were fully successful. Replication of the authors' results, through analysis of a distinct data set, would provide more confidence in the finding of increased cardiovascular mortality among patients receiving azithromycin.
Despite such caveats, the results presented by Ray et al. warrant serious attention. A chief strength of the results is the time-limited pattern of the risk: the azithromycin-associated increase in the rates of death from any cause and from cardiovascular causes spanned days 1 through 5, reflecting the typical 5-day duration of azithromycin administration (e.g., Zithromax Z-Pak). On days 6 through 10, an elevated risk of death from cardiovascular causes was no longer detected. This pattern is consistent with the timing of peak plasma azithromycin concentrations and the concomitant risk of QT-interval prolongation. The elevated risk was statistically significant, regardless of whether azithromycin treatment was compared with amoxicillin or with nonuse of an antibacterial drug. Furthermore, the observed excess mortality was attributable solely to cardiovascular deaths and, in particular, to sudden cardiac death; although sudden cardiac death can result from causes other than arrhythmias, an increase in deaths in this category would be the pattern expected from an arrhythmogenic, QT-interval–prolonging drug. Also, the azithromycin-associated risk was higher among patients with cardiovascular disorders, which is consistent with a drug-related arrhythmia.
A new study by Svanström and colleagues (pages 1704–1712), using Danish national health care data, found no difference between azithromycin and penicillin V in the 5-day risk of cardiovascular death (relative risk, 0.93; 95% confidence interval [CI], 0.56 to 1.55). However, the upper bound of the 95% confidence interval does not exclude an increased risk of as much as 55%. As Svanström et al. point out, the population they studied differed from that studied by Ray et al. with respect to the baseline risk of death and cardiovascular risk factors. Overall, the Danish patients had better cardiovascular health than the Tennessee Medicaid patients. In a subgroup analysis of patients with a history of cardiovascular disease, the risk ratio for azithromycin versus penicillin V was greater than 1, though the difference was not statistically significant (relative risk, 1.35; 95% CI, 0.69 to 2.64). Svanström et al. conclude that their results do not conflict with those of Ray et al. Rather, the effect on cardiovascular mortality may be limited to patients with cardiovascular disease…
The remainder of the essay (free): http://www.nejm.org/doi/full/10.1056/NEJMp1302726
13. Brief ED Interventions for Youth Who Use Alcohol and Other Drugs: A Systematic Review
Newton AS, et al. Pediatr Emerg Care. 2013;29:673-684.
Objective: Brief intervention (BI) is recommended for use with youth who use alcohol and other drugs. Emergency departments (EDs) can provide BIs at a time directly linked to harmful and hazardous use. The objective of this systematic review was to determine the effectiveness of ED-based BIs.
Methods: We searched 14 electronic databases, a clinical trial registry, conference proceedings, and study references. We included randomized controlled trials with youth 21 years or younger. Two reviewers independently selected studies and assessed methodological quality. One reviewer extracted and a second verified data. We summarized findings qualitatively.
Results: Two trials with low risk of bias, 2 trials with unclear risk of bias, and 5 trials with high risk of bias were included. Trials evaluated targeted BIs for alcohol-positive (n = 3) and alcohol/other drug–positive youth (n = 1) and universal BIs for youth reporting recent alcohol (n = 4) or cannabis use (n = 1). Few differences were found in favor of ED-based BIs, and variation in outcome measurement and poor study quality precluded firm conclusions for many comparisons. Universal and targeted BIs did not significantly reduce alcohol use more than other care. In one targeted BI trial with high risk of bias, motivational interviewing (MI) that involved parents reduced drinking quantity per occasion and high-volume alcohol use compared with MI that was delivered to youth only. Another trial with high risk of bias reported an increase in abstinence and reduction in physical altercations when youth received peer-delivered universal MI for cannabis use. In 2 trials with unclear risk of bias, MI reduced drinking and driving and alcohol-related injuries after the ED visit. Computer-based MI delivered universally in 1 trial with low risk of bias reduced alcohol-related consequences 6 months after the ED visit.
Conclusions: Clear benefits of using ED-based BI to reduce alcohol and other drug use and associated injuries or high-risk behaviours remain inconclusive because of variation in assessing outcomes and poor study quality.
14. Lactate and Poor Lactate Clearance Predict Mortality in Trauma Patients
An elevated initial lactate may be an ominous sign, even in patients with normal initial blood pressure.
Odom SR et al. J Trauma Acute Care Surg 2013 Apr; 74:999-1004.
BACKGROUND: Initial serum lactate has been associated with mortality in trauma patients. It is not known if lactate clearance is predictive of death in a broad cohort of trauma patients.
METHODS: We enrolled 4,742 trauma patients who had an initial lactate measured during a 10-year period. Patients were identified via the trauma registry. Lactate clearance was calculated at 6 hours. Multivariable logistic regression was used to identify the independent contribution of both initial lactate and lactate clearance with mortality, after adjustment for severity of injury.
RESULTS: Initial lactate level was strongly correlated with mortality: when lactate was less than 2.5 mg/dL, 5.4% (95% confidence interval [CI], 4.5-6.2%) of patients died; with lactate 2.5 mg/dL to 4.0 mg/dL, mortality was 6.4% (95% CI, 5.1-7.8%); with lactate 4.0 mg/dL or greater, mortality was 18.8% (95% CI, 15.7-21.9%). After adjustment for age, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, heart rate, and blood pressure, initial lactate remained independently associated with increased mortality, with adjusted odds ratios of 1.0, 1.5 (95% CI, 1.1-2.0) and 3.8 (95% CI, 2.8-5.3), for lactate less than 2.5 mg/dL, 2.5 mg/dL to 4.0 mg/dL, and 4.0 mg/dL or greater, respectively. Among patients with an initially elevated lactate (≥4.0 mg/dL), lower lactate clearance at 6 hours strongly and independently predicted an increased risk of death. For lactate clearances of 60% or greater, 30% to 59%, and less than 30%, the adjusted odds ratio for death were 1.0, 3.5 (95% CI 1.2-10.4), and 4.3 (95% CI, 1.5-12.6), respectively.
CONCLUSION: Both initial lactate and lactate clearance at 6 hours independently predict death in trauma patients.
15. A Clinician’s Guide to the Diagnosis and Management of Gallbladder Volvulus
Pottorf BJ, et al. Perm J 2013 Spring; 17(2):80-83
Introduction: Gallbladder volvulus (GV), or torsion of the gallbladder, is an uncommon surgical emergency. This article reviews the world literature related to GV. We examine the history of gallbladder torsion and highlight the critical constellation of presenting signs and symptoms, which guide the acute care physician and surgeon to accurate and timely diagnosis of GV before surgical intervention.
Methods: A comprehensive review of all published cases of GV was performed using the National Library of Medicine (PubMed) database.
Results: Lists of typical symptoms and clinical presentations are provided to allow clinicians to establish an accurate preoperative diagnosis.
Conclusion: GV is frequently undiagnosed before surgical intervention. However, clinical presentation and associated radiographic findings can lead to an accurate diagnosis if the clinician is aware of this uncommon condition. When the diagnosis has been established before operative intervention, expeditious laparoscopic cholecystectomy can be performed safely. Delays in diagnosis may mandate open cholecystectomy if laparoscopic extraction is contraindicated because of undesirable sequelae of gallbladder necrosis, specifically perforation, bilious peritonitis, and hemodynamic instability.
Full-text (free): http://www.thepermanentejournal.org/issues/2013/spring/5107-gallbladder-volvulus.html
16. Variability of ICU Use in Adult Patients with Minor Traumatic Intracranial Hemorrhage
Nishijima DK, et al. Ann Emerg Med. 2013;61:509-517.e4.
Study objective: Patients with minor traumatic intracranial hemorrhage are frequently admitted to the ICU, although many never require critical care interventions. To describe ICU resource use in minor traumatic intracranial hemorrhage, we assess (1) the variability of ICU use in a cohort of patients with minor traumatic intracranial hemorrhage across multiple trauma centers, and (2) the proportion of adult patients with traumatic intracranial hemorrhage who are admitted to the ICU and never receive a critical care intervention during hospitalization. In addition, we evaluate the association between ICU admission and key independent variables.
Methods: A structured, historical cohort study of adult patients (aged 18 years and older) with minor traumatic intracranial hemorrhage was conducted within a consortium of 8 Level I trauma centers in the western United States from January 2005 to June 2010. The study population included patients with minor traumatic intracranial hemorrhage, defined as an emergency department (ED) Glasgow Coma Scale (GCS) score of 15 (normal mental status) and an Injury Severity Score less than 16 (no other major organ injury). The primary outcome measure was initial ICU admission. The secondary outcome measure was a critical care intervention during hospitalization. Critical care interventions included mechanical ventilation, neurosurgical intervention, transfusion of blood products, vasopressor or inotrope administration, and invasive hemodynamic monitoring. ED disposition and the proportion of ICU patients not receiving a critical care intervention were compared across sites with descriptive statistics. The association between ICU admission and predetermined independent variables was analyzed with multivariable regression.
Results: Among 11,240 adult patients with traumatic intracranial hemorrhage, 1,412 (13%) had minor traumatic intracranial hemorrhage and complete ED disposition data (mean age 48 years; SD 20 years). ICU use within this cohort across sites ranged from 50% to 97%. Overall, 847 of 888 patients (95%) with minor traumatic intracranial hemorrhage who were admitted to the ICU did not receive a critical care intervention during hospitalization (range between sites 80% to 100%). Three of 524 (0.6%) patients discharged home or admitted to the observation unit or ward received a critical care intervention. After controlling for severity of injury (age, blood pressure, and Injury Severity Score), study site was independently associated with ICU admission (odds ratios ranged from 1.5 to 30; overall effect P less than.001).
Conclusion: Across a consortium of trauma centers in the western United States, there was wide variability in ICU use within a cohort of patients with minor traumatic intracranial hemorrhage. Moreover, a large proportion of patients admitted to the ICU never required a critical care intervention, indicating the potential to improve use of critical care resources in patients with minor traumatic intracranial hemorrhage.
17. Clinical Impression and Ascites Appearance Do Not Rule Out Bacterial Peritonitis
Chinnock B, et al. J Emerg Med. 2013;44:903-909.
Background: Previous research has demonstrated that physician clinical suspicion, determined without assessing fluid appearance, is not adequate to rule out spontaneous bacterial peritonitis (SBP) without fluid testing.
Study Objective: To determine the sensitivity of physician clinical suspicion, including a bedside assessment of fluid appearance, in the detection of SBP in Emergency Department (ED) patients undergoing paracentesis.
Methods: We conducted a prospective, observational study of ED patients with ascites undergoing paracentesis at three academic facilities. The enrolling physician recorded the clinical suspicion of SBP (“none,” “low,” “moderate,” or “high”), and ascites appearance (“clear,” “hazy,” “cloudy,” or “bloody”). SBP was defined as an absolute neutrophil count ≥250 cells/mm3, or culture pathogen growth. We defined “clear” ascites fluid as negative for SBP, and “hazy,” “cloudy,” or “bloody” as positive. A physician clinical suspicion of “none” or “low” was considered negative for SBP, and an assessment of “moderate” or “high” was considered positive. The primary outcome measure was sensitivity of physician clinical impression and ascites appearance for SBP.
Results: There were 348 cases enrolled, with SBP diagnosed in 43 (12%). Physician clinical suspicion had a sensitivity of 42% (95% confidence interval [CI] 29–55%) for the detection of SBP. Fluid appearance had a sensitivity of 72% (95% CI 58–83%).
Conclusion: Physician clinical impression, which included an assessment of fluid appearance, had poor sensitivity for the detection of SBP and cannot be used to exclude the diagnosis. Routine laboratory fluid analysis is indicated after ED paracentesis, even in patients considered to have a low degree of suspicion for SBP.
18. Compartment Pressure Measurements Have Poor Specificity for Compartment Syndrome in the Traumatized Limb
Nelson JA. J Emerg Med. 2013;44:1039-1044.
Background: Osseofascial compartment syndrome is defined by ischemic necrosis of muscle caused by elevated pressure within fascial compartments. The diagnosis can be made either clinically or through compartment pressure measurements. Compartment pressure above 30 mm Hg was traditionally used as the threshold for diagnosis of compartment syndrome, but was challenged due to a high number of false-positive results. Perfusion pressure (diastolic blood pressure − compartment pressure) less than 30 mm Hg came to be promoted as a confirmatory diagnostic test.
Objective: The objective of this article is to review the specificity of perfusion pressure for compartment syndrome in the acutely traumatized limb.
Discussion: Perfusion pressure has been shown to generate false-positive results in 18–84% of patients with tibial fractures. Two studies showed that not a single patient with measurements qualifying for fasciotomy actually needed the procedure.
Conclusion: Both absolute compartment pressure and tissue perfusion pressure generate a high rate of false-positive results in the acutely traumatized limb. An alternative diagnostic test or process is needed to prevent overtreatment. In the meantime, emergency medicine and orthopedic surgery textbooks and guidelines should promote awareness of the limitations of the test.
19. Cool EM Educational Resources
A. EM CRIT
Podcast 94 – Has Video Laryngoscopy Killed the Direct Laryngoscope?
Paul Mayo and Scott Weingart have established a tradition of debating each other at the annual Greater NY Hospital Association Critical Care Controversies Conference.
The topic here: Should All Intubations be Performed with Video Laryngoscopy?
B. EM-RAP TV
143: STEMI vs. Pericarditis
Amal Mattu and his fantastic computer drawing machine return with this talk on STEMI vs. Pericarditis.
142: 20 y.o. with Syncope
The maestro of the 12 lead is back again. This time with a little latin flavor.
141: Hearts a Flutter
A case of a 63 Y.O. women with lightheadedness.
140: Irregularly irregular
Irregularly irregular? is that even a thing?
139: ST depressin in aVL
20. On Second Pass, ACEP Opts to Join “Choosing Wisely” Initiative
by Jay Schuur, MD & Jesse Pines MD. EP Monthly
In the name of high quality, cost-conscious care, ACEP has revised its stance on the Choosing Wisely campaign, voting to join the initiative in the fight against low value care.
… The American College of Emergency Physicians (ACEP) has started several initiatives to promote cost-effective care. Over the last eight months, ACEP has chartered a taskforce to develop recommendations. The taskforce began with an open survey of members soliciting ideas. In more than 150 responses, there were hundreds of specific actions that emergency physicians could take to reduce costs without harming quality.
Examples of individual actions were “not ordering brain natiuretic peptide (BNP) on patients with a clear clinical diagnosis of heart failure or previously elevated levels.” ED actions included interactions with other services, such as “not ordering routine pre-operative chest X-rays,” or “engaging palliative care for appropriate patients while in the ED.” Several suggestions would require formal policy action by government, such as “not routinely bringing public intoxicants to the ED for medical evaluation,” or “waiving the three-day Medicare rule for skilled nursing facility coverage.”
A diverse panel was assembled to review all of the recommendations and prioritize them based on their potential to reduce costs, benefit or harm patients, and actionability by emergency providers. After multiple rounds of review and revision, a large number of items remained that the panel supported.
The ACEP Board of Directors reviewed the recommendations and this ultimately led to their reconsidering the decision to not to join the Choosing Wisely campaign. Ultimately, they reversed the decision and decided to join the over 35 specialty societies involved in the campaign.
While the final Choosing Wisely “list” is still being developed and won’t be public until later this spring, when you see it, you probably won’t be too surprised. Many of the items are common sense, evidence-based practices that could improve care, reduce costs and make ED care safer. While some emergency providers are always practicing in a cost-conscious way, there is good evidence to suggest that all of us can probably do a little better.
What does this mean for you, the practicing emergency physician? As it is becoming part of our professional responsibility to be good stewards of health care dollars, we need to start working on how to make cost containment part of our daily work.
Some general considerations:
1. The Link Between (Over)testing and Length of Stay
Pressure to reduce length of stay can contribute to over testing, as ordering a wide panels of tests after a brief triage evaluation is generally thought to be quicker than ordering a small number of tests and adding on tests sequentially. But think again: indiscriminately adding extra tests that take a long time can be counterproductive. Ordering a marginal CT or lab test can add hours to a patients’ length of stay. By spending a bit more time carefully considering tests and using evidence-based clinical decision rules, we may actually help unclog our EDs.
2. The Paradox of Patient Satisfaction
On one hand, we are told to do less for patients; on the other hand we are told – even compelled – to make patients happy. Yet sometimes patients want us to order ankle X-rays when the Ottawa Ankle Rules say they have a sprain. Or they want a prescription for antibiotics for viral upper respiratory infections. While some patients will not be satisfied unless they get the test or treatment they want, what most patients want are careful exams and clear explanations: it is possible to talk most patients down off the cliff. Note to policymakers: it is equally important to understand this daily trade off and to not penalize us for taking the time to talk to patients and providing good, cost-conscious care.
3. Avoid Being the Vector for Low-Value Care
Some low value services come at the request of a primary care provider or an admitting physician. We need our EDs to work with the hospital and these services to implement evidence-based protocols, so you don’t have to order that meaningless pre-op chest x-ray, or coags in a healthy 22 year-old. But for the over 80% of ED patients nationwide who are discharged after their visit, we are largely responsible for the costs of their emergency care.
4. Don’t Wait for Liability Reform:
While this is a real issue, comprehensive federal medical liability reform in the near future is unlikely. Waiting for such reforms as a prerequisite for trying to reduce cost could leave us in the dust if today’s focus on cost-containment is truly here to stay. If we don’t define value in emergency medicine, the insurers, other specialties and government will. We need to control our destiny, not wait for it to happen to us…
Full-text (free): http://www.epmonthly.com/features/current-features/on-second-pass-acep-opts-to-join-choosing-wisely-initiative/
21. A Call to Action: Firearms, Public Health, and
Ranney ML, et al. Ann Emerg Med. 2013
At the time of this writing, it has been 2 months since Newtown. We have each mourned from a distance, imagining the heartbreak. We have asked ourselves what we would have done were this our community, our school, our child. We have formed opinions about what may or may not have stopped this tragedy. And we have each quietly recalled other tragedies that we have witnessed.
Now it is time, as individuals and as a specialty, to take action to decrease the likelihood of future deaths.
First, a review of the facts. Although mass shootings such as the Sandy Hook Elementary School massacre generate the greatest public attention, guns killed almost 32,000 American civilians in 2011 alone1 and seriously injured another 74,000.2 The rate of firearm-related deaths for children younger than 15 years is nearly 12 times higher in the United States than in other industrialized nations.3 Our overall firearm-related death rate is 7.5 times higher than in the world’s other 22 high-income countries.4,5 Case control and cohort studies show that the presence of a gun in the home is associated with a significantly increased risk of homicide, suicide, and accidental death.6-9 Firearm injuries cost the United States more than $70 billion a year in medical expenditures and lost productivity.10 As emergency physicians, we are often the first—and only—physicians to treat victims of gun violence. We are therefore acutely aware that victims of shootings have a higher mortality than those injured by other methods of assault or self-harm. We know that patients with gun-related injuries are unlikely to present anywhere other than the emergency department (except, perhaps, directly to the morgue). And we know that to reduce firearm-related deaths and injuries, we must prevent people from getting shot in the first place.11
We also know that emergency physicians can act collectively to prevent injuries. Emergency medicine has long been at the forefront of public health.12,13 As a specialty, we have identified domestic violence, child abuse, and vaccination, for instance, as just a few of the many public health issues that warrant our involvement and our intervention. The American College of Emergency Physicians (ACEP) has specific clinical care policies relating to these and other public health issues, including firearm injury prevention.14 Through well-designed research, advocacy campaigns, and public-private partnerships, emergency physicians have effected inspiring change. We have helped reduce drunk driving by supporting a shift in societal mores and implementation of “.08” per se laws throughout the nation; we have advocated for child-resistant caps on medications, leading to dramatic decreases in the rate of pediatric poisonings; and we continue to research more effective means of reducing injury from a variety of causes, ranging from suicide to opioid abuse to falls.
Emergency physicians are, of course, a diverse group that includes proud, responsible gun owners and non–gun owners alike. We have a history of advocating for public health and community well-being while respecting individuals’ rights. Our work in highway and auto safety, for instance, has helped to reduce US automobile fatalities by 31% without limiting access to automobiles. Scientific concerns for public health are free of agendas, and we are committed to finding solutions wherever they may lie.
The remainder of the essay (subscription only): http://www.annemergmed.com/article/S0196-0644(13)00137-6/fulltext
See also: ACEP Policy: Firearm Injury Prevention
Ann Emerg Med. 2013;61:602-603.
22. Some Additional Tidbits
A. Transvaginal Ultrasound Best to Find Ectopic Pregnancy
In women with abdominal pain or vaginal bleeding during early pregnancy, transvaginal sonography appears to be the single best diagnostic method for evaluating suspected ectopic pregnancy, a new meta-analysis found.
B. Diagnosis issues are most common medical errors
More than a quarter of U.S. medical malpractice claims analyzed in a study were associated with missed or wrong diagnoses, making them the most common, dangerous and expensive errors in the health care system. Mistakes in diagnosis were also linked to "death or disability almost twice as often as other error categories and accounted for the plurality of these outcomes," researchers reported in BMJ Quality & Safety.
C. Many parents give their children ineffective cold medicines
More than 40% of parents with children younger than age 4 reported giving their children multisymptom cough and cold medicines, according to the University of Michigan C.S. Mott Children's Hospital National Poll on Children's Health. Such medications are not effective for relieving cold symptoms in young children and could be harmful. The FDA has cautioned against their use in children under age 2.
Full-text (free): http://mottnpch.org/reports-surveys/parents-ignore-warning-labels-give-cough-cold-meds-young-kids
D. Meningitis in Kids May Mean Troubled Future
Childhood bacterial meningitis was linked to lower educational achievement and economic self-sufficiency later in life, researchers found.
E. Obesity in Physician and in Patients Impedes Care
1. Patients less inclined to trust overweight physicians
2. Doctors show less empathy for obese patients
F. Decline Facebook ‘Friend’ Appeals from Patients, Groups Say
Physicians should avoid making or accepting "friend" requests through social networking websites with past or current patients, a new policy statement advised.
G. New Warfarin-reversal Agent Approved
The FDA has approved Kcentra for the urgent reversal of vitamin K antagonist anticoagulation in adults with acute major bleeding, according to the agency.
H. ESC Provides Guidelines for Use of Novel Oral Anticoagulants for AF
I. 20% of U.S. adults get recommended amount of exercise
A CDC study revealed that just 20% of more than 450,000 adults met federal guidelines for both muscle-strengthening activity and aerobic exercise. Men and younger adults were more likely to meet the fitness recommendations than women and older adults, researchers wrote in the Morbidity and Mortality Weekly Report.