1. Yield of Routine Provocative Cardiac Testing Among
Patients in an ED–Based CP Unit
Hermann
LK, et al. JAMA Intern Med. 2013;173(12):1128-1133.
Importance The American Heart Association recommends
routine provocative cardiac testing in accelerated diagnostic protocols for
coronary ischemia. The diagnostic and therapeutic yield of this approach are
unknown.
Objective To assess the yield of routine provocative
cardiac testing in an emergency department–based chest pain unit.
Design
and Setting We examined a prospectively
collected database of patients evaluated for possible acute coronary syndrome
between March 4, 2004, and May 15, 2010, in the emergency department–based
chest pain unit of an urban academic tertiary care center.
Participants Patients with signs or symptoms of possible
acute coronary syndrome and without an ischemic electrocardiography result or a
positive biomarker were enrolled in the database.
Exposures All patients were evaluated by exercise
stress testing or myocardial perfusion imaging.
Main
Outcomes and Measures Demographic and
clinical features, results of routine provocative cardiac testing and
angiography, and therapeutic interventions were recorded. Diagnostic yield
(true-positive rate) was calculated, and the potential therapeutic yield of
invasive therapy was assessed through blinded, structured medical record review
using American Heart Association designations (class I, IIa, IIb, or lower) for
the potential benefit from percutaneous intervention.
Results In total, 4181 patients were enrolled in the
study. Chest pain was initially reported in 93.5%, most (73.2%) were at
intermediate risk for coronary artery disease, and 37.6% were male. Routine
provocative cardiac testing was positive for coronary ischemia in 470 (11.2%),
of whom 123 underwent coronary angiography. Obstructive disease was confirmed
in 63 of 123 (51.2% true positive), and 28 (0.7% overall) had findings
consistent with the potential benefit from revascularization (American Heart
Association class I or IIa).
Conclusions
and Relevance In an emergency department–based
chest pain unit, routine provocative cardiac testing generated a small
therapeutic yield, new diagnoses of coronary artery disease were uncommon, and
false-positive results were common.
2. Prophylactic Lidocaine after Resuscitation: What's Old
Is New Again
Recurrent
cardiac arrest from ventricular fibrillation/ventricular tachycardia was less
likely in patients who received lidocaine.
Years
ago, lidocaine was routinely administered for arrhythmia prophylaxis after
acute myocardial infarction, but this practice was abandoned after an
association with excess mortality was identified. Researchers in King County,
Washington (excluding Seattle), retrospectively analyzed data for adult
patients with witnessed non-traumatic out-of-hospital cardiac arrest with
ventricular fibrillation/ventricular tachycardia (VF/VT) as the initial rhythm,
and who had transient or sustained return of spontaneous circulation (ROSC) at
any time during resuscitation. Lidocaine was the first-line anti-arrhythmic for
treatment of shock-refractory VF/VT; its use for arrhythmia prophylaxis after
ROSC was discretionary.
Of
1721 patients with VF/VT arrest during the 17-year study period, 425 received
prophylactic lidocaine after first ROSC. Recurrent VF/VT arrest occurred in
significantly fewer lidocaine recipients than non-recipients (16.7% vs. 37.4%).
Lidocaine recipients were significantly more likely to survive to hospital
admission (93.5% vs. 84.9%) and to hospital discharge (62.4% vs. 44.5%) than
non-recipients. There was no evidence of harm associated with post-ROSC
lidocaine use.
Comment:
In this study, administration of post-resuscitation prophylactic lidocaine in
patients with initial VF/VT cardiac arrest reduced recurrent VF/VT, but this
treatment's effect on long-term mortality or neurological status is not clear.
Nevertheless, refibrillation has been associated with worsened survival, and
this study showed no evidence of harm from lidocaine use — unlike prior studies
that showed a possible association with bradycardia and asystole. While
intriguing, this study is not a call to change practice but rather suggests
that post-arrest lidocaine warrants evaluation in a randomized trial.
—
Kristi L. Koenig, MD, FACEP, FIFEM. Published in Journal Watch Emergency
Medicine June 14, 2013. Citation: Kudenchuk PJ et al. Resuscitation 2013 Jun 3;
[e-pub ahead of print].
3. NAC Plus IV Fluids Versus IV Fluids Alone to
Prevent Contrast-Induced Nephropathy in Emergency CT
Traub
SJ, et al. Ann Emerg Med. 2013 June 17. [Epub ahead of print]
Study
objective: We test the hypothesis that N-acetylcysteine plus normal saline
solution is more effective than normal saline solution alone in the prevention
of contrast-induced nephropathy.
Methods:
The design was a randomized, double blind, 2-center, placebo-controlled
interventional trial. Inclusion criteria were patients undergoing chest,
abdominal, or pelvic computed tomography (CT) scan with intravenous contrast,
older than 18 years, and at least one contrast-induced nephropathy risk factor.
Exclusion criteria were end-stage renal disease, pregnancy, N-acetylcysteine
allergy, or clinical instability. Intervention for the treatment group was
N-acetylcysteine 3 g in 500 mL normal saline solution as an intravenous bolus
and then 200 mg/hour (67 mL/hour) for up to 24 hours; and for the placebo group
was 500 mL normal saline solution and then 67 mL/hour for up to 24 hours. The
primary outcome was contrast-induced nephropathy, defined as an increase in
creatinine level of 25% or 0.5 mg/dL, measured 48 to 72 hours after CT.
Results:
The data safety and monitoring board terminated the study early for futility.
Of 399 patients enrolled, 357 (89%) completed follow-up and were included. The
N-acetylcysteine plus saline solution group contrast-induced nephropathy rate
was 14 of 185 (7.6%) versus 12 of 172 (7.0%) in the normal saline solution only
group (absolute risk difference 0.6%; 95% confidence interval −4.8% to 6.0%).
The contrast-induced nephropathy rate in patients receiving less than 1 L
intravenous fluids in the emergency department (ED) was 19 of 147 (12.9%)
versus 7 of 210 (3.3%) for greater than 1 L intravenous fluids (difference
9.6%; 95% confidence interval 3.7% to 15.5%), a 69% risk reduction (odds ratio
0.41; 95% confidence interval 0.21 to 0.80) per liter of intravenous fluids.
Conclusion:
We did not find evidence of a benefit for N-acetylcysteine administration to
our ED patients undergoing contrast-enhanced CT. However, we did find a
significant association between volume of intravenous fluids administered and
reduction in contrast-induced nephropathy.
4. In non-obese patients, duration of action of rocuronium
is directly correlated with BMI
Fujimoto
M, et al. Can J Anaesth. 2013 Jun;60(6):552-556.
BACKGROUND:
Administration of neuromuscular blocking agents using a dose calculated on
actual body weight carries a risk of prolonged duration of action in obese
patients whose body mass index (BMI) is greater than 30 kg·m-2. In the present
study, we hypothesized that there could be a correlation between BMI and the
duration of action of rocuronium administered according to actual body weight
in non-obese patients, in particular, overweight (BMI 25-30 kg·m-2) and
underweight patients (BMI below 18.5 kg·m-2).
METHODS:
Sixteen female patients (BMI 15-30 kg·m-2, aged 45-60 yr) scheduled for
elective surgery under total intravenous anesthesia were included in this
study. Rocuronium 0.9 mg·kg-1 was administered, and adductor pollicis
train-of-four responses following ulnar nerve stimulation were monitored every
minute with acceleromyography. The times from the injection of rocuronium until
spontaneous recovery of first twitch to 5% (5% Duration) and 25% (25% Duration)
of baseline were measured, and the correlation with BMI was analyzed.
RESULTS:
A significant correlation between 5% Duration and BMI (r2 = 0.56; P less than
0.001) was found by linear regression analysis. A significant correlation was
also found between 25% Duration and BMI (r2 = 0.49; P = 0.003).
CONCLUSION:
In adult female patients with a BMI in the range of 15-30 kg·m-2, the duration
of action of rocuronium increases with BMI when the drug is administered on the
basis of mg per actual kg body weight.
5. Are EDs Appropriately Treating Adolescent PID?
Goyal
M, et al. JAMA Pediatr. 2013;167(7):672-673.
INTRODUCTION
Of the almost 1 million annually
diagnosed cases of pelvic inflammatory disease (PID), 20% occur among
adolescents.Because reproductive health complaints are the most
common reasons for emergency department (ED) visits among adolescent females,
it is critical that ED providers are knowledgeable about the diagnosis and
treatment of PID. The objective of this study was to evaluate adherence to the
Centers for Disease Control and Prevention (CDC) PID treatment guidelines among
a nationally representative sample of adolescent ED PID visits.
METHODS
We conducted a retrospective
cross-sectional analysis of the National Hospital Ambulatory Medical Care
Survey (NHAMCS) from 2000–2009. This study was considered exempt from formal
review by our institutional review board. The NHAMCS is an annual, national probability
sample survey of hospital EDs conducted by the National Center for Health
Statistics branch of the CDC. The eligible study
population included all sampled ED visits by females between 14 and 21 years
during 2000–2009 with the diagnosis of PID captured by the International
Classification of Diseases (ICD-9) codes. Our outcome measure was adherence to
CDC recommended PID treatment guidelines by evaluating whether patients were
prescribed antibiotics that were considered first or second line treatment for
PID for the respective year based on the published CDC Sexually Transmitted Disease
treatment guidelines for PID management. Given that the CDC
treatment guidelines changed in 2006, we also calculated the average proportion
of appropriately treated PID cases before and after the 2006 CDC treatment
guideline change. We used descriptive statistics and logistic regression with
appropriate weighting to account for the complex survey methodology to
calculate all estimates and perform all analyses.
RESULTS
During the study period, there were
an estimated 704,882 (95% CI 571,807, 837,957) PID cases in EDs. Among these,
only 37.1% (95% CI 30.6, 45.5) were prescribed antibiotics that adhered to the
CDC recommended treatment guidelines. Prior to 2006, only 30.7% (95% CI 9.2,
52.3) of PID cases received appropriate antibiotic therapy. This increased to
49.5% (95% CI 22.9, 76.6%) after the guideline change (p=0.01). The most common
antibiotic regimen found among inappropriately treated patients was the
combination of ceftriaxone and azithromycin (17.1%).
COMMENT
This analysis represents the first
population-based assessment of recent compliance with CDC recommended treatment
guidelines for adolescent ED patients diagnosed with PID. Only 37% of PID cases
were treated according to the CDC treatment guidelines in our study.
Furthermore, the common use of a third generation cephalosporin and
azithromycin suggests that clinicians may erroneously believe that PID
treatment is identical to cervicitis treatment and/or that patients are
incapable of adherence to doxycycline. This finding has substantial
implications as inadequate treatment of PID may lead to serious long-term sequelae
such as chronic pelvic pain or tubal infertility. Additionally, the lack of
adherence to the CDC guidelines suggests a need to further study strategies for
optimal diffusion and acceptance of the CDC guidelines.
Our finding of low adherence to the
CDC treatment guidelines is consistent with those of other single center
studies, and studies of adult populations. However, our study is the first to evaluate whether
treatment adherence had changed since the dissemination of the CDC 2006 STD
treatment guidelines. Even with the sizeable increase in the percent of
patients who were treated appropriately from prior to 2006 to afterwards, over
50% of patients are still not receiving treatment consistent with national
guidelines. Furthermore, these nationally representative data demonstrate the
need and potential high impact of utilizing the ED as a strategic setting to
further understand these issues and change clinical practice.
6. Aggressive Fluid and Sodium Restriction in Acute
Decompensated Heart Failure: A RCT
Aliti
GB, et al. JAMA Intern Med. 2013;173(12):1058-1064.
Importance The benefits of fluid and sodium restriction
in patients hospitalized with acute decompensated heart failure (ADHF) are
unclear.
Objective To compare the effects of a fluid-restricted
(maximum fluid intake, 800 mL/d) and sodium-restricted (maximum dietary intake,
800 mg/d) diet (intervention group [IG]) vs a diet with no such restrictions
(control group [CG]) on weight loss and clinical stability during a 3-day
period in patients hospitalized with ADHF.
Design Randomized, parallel-group clinical trial
with blinded outcome assessments.
Setting Emergency room, wards, and intensive care
unit.
Participants Adult inpatients with ADHF, systolic dysfunction,
and a length of stay of 36 hours or less.
Intervention Fluid restriction (maximum fluid intake, 800
mL/d) and additional sodium restriction (maximum dietary intake, 800 mg/d) were
carried out until the seventh hospital day or, in patients whose length of stay
was less than 7 days, until discharge. The CG received a standard hospital
diet, with liberal fluid and sodium intake.
Main
Outcomes and Measures Weight loss and
clinical stability at 3-day assessment, daily perception of thirst, and readmissions
within 30 days.
Results Seventy-five patients were enrolled (IG, 38;
CG, 37). Most were male; ischemic heart disease was the predominant cause of
heart failure (17 patients [23%]), and the mean (SD) left ventricular ejection
fraction was 26% (8.7%). The groups were homogeneous in terms of baseline
characteristics. Weight loss was similar in both groups (between-group
difference in variation of 0.25 kg [95% CI, −1.95 to 2.45]; P = .82) as well as
change in clinical congestion score (between-group difference in variation of
0.59 points [95% CI, −2.21 to 1.03]; P = .47) at 3 days. Thirst was
significantly worse in the IG (5.1 [2.9]) than the CG (3.44 [2.0]) at the end
of the study period (between-group difference, 1.66 points; time × group interaction;
P = .01). There were no significant between-group differences in the
readmission rate at 30 days (IG, 11 patients [29%]; CG, 7 patients [19%]; P =
.41).
Conclusions
and Relevance Aggressive fluid and
sodium restriction has no effect on weight loss or clinical stability at 3 days
and is associated with a significant increase in perceived thirst. We conclude
that sodium and water restriction in patients admitted for ADHF are
unnecessary.
7. Re-Evaluating the Diagnostic Accuracy of the Tongue
Blade Test: Still Useful as a Screening Tool for Mandibular Fractures? Yes!
Caputo
ND, et al. J Emerg Med. 2013;45:8-12.
Background:
Mandibular fractures are one of the most frequently seen injuries in trauma. In
terms of facial trauma, mandible fractures constitute 40%–62% of all facial
bone fractures. The tongue blade test (TBT) has been shown to be a sensitive
screening tool when compared with plain films. However, recent studies have
demonstrated that computed tomography (CT) scan is more sensitive for
determining mandible fractures than the traditionally used plain films.
Objective:
The purpose of the study was to determine the sensitivity and specificity of
the TBT as compared with the new gold standard of radiologic imaging, CT scan.
Methods:
Any patient suffering from facial trauma was prospectively enrolled during the
study period (August 1, 2010 to April 11, 2012) at a single urban, academic
Emergency Department. A TBT was performed by the resident physician and
confirmed by the supervising attending. CT facial bones were then obtained for
the ultimate diagnosis. Inter-rater reliability (κ) was calculated, along with
sensitivity, specificity, negative predictive value, and likelihood ratio (–) based
on a 2 × 2 contingency table generated.
Results:
During the study period, 190 patients were enrolled. Inter-rater reliability
was κ = 0.96 (95% confidence interval [CI] 0.93–0.99). The following parameters
were then calculated based on the contingency table: sensitivity 0.95 (95% CI
0.88–0.98), specificity 0.68 (95% CI 0.57–0.77), negative predictive value 0.92
(95% CI 0.82–0.97), and likelihood ratio (−) 0.07 (95% CI 0.03–0.18).
Conclusions:
Based on the test characteristics calculated (negative predictive value 0.92,
sensitivity 0.95, likelihood ratio −0.07), the TBT is a useful screening tool
to determine the need for radiologic imaging.
8. "Proning" Benefits Patients with Severe ARDS
Acute respiratory distress syndrome–associated
28-day mortality was halved in patients who spent most of the day face down.
Patients
with acute respiratory distress syndrome (ARDS) commonly develop consolidation
of the dependent lung regions. For many years, physicians have transitioned
severely hypoxemic patients from supine to prone position to improve aeration
of these areas and gas exchange. Small studies of "proning"
demonstrated improved oxygenation without affecting more important outcomes;
meta-analyses suggested proning could lower ARDS-associated mortality
(Intensive Care Med 2010; 36:585).
This
large French trial involved 466 patients with moderate-to-severe ARDS (ratio of
partial pressure of arterial oxygen to fraction of inspired oxygen [PaO2:FiO2] less
than 150, with FiO2 ≥0.6; positive end-expiratory pressure, ≥5 cm H2O). All
patients received low tidal-volume ventilation and were randomized to daily
prone positioning or to supine positioning only. Intervention patients were
placed in the prone position within 1 hour of randomization and underwent an
average of four sessions of proning (mean duration per daily session, 17.3
hours). At randomization, greater than 80% of patients were receiving
neuromuscular blockade, and approximately 40% were receiving glucocorticoids.
Mortality at 28 days was 16% in the prone group and 33% in the supine group.
Comment:
These results give new life to the practice of proning. Although this
intervention is not suitable for all patients with acute respiratory distress
syndrome (e.g., those with recent sternotomy or facial trauma), proning should
be considered early for most patients with severe disease. Almost all patients
in this study received neuromuscular blockade, which reinforces earlier
administering of short-term paralytics for severe hypoxemia. Patients in this
study were proned for prolonged periods. Delivering care safely to patients in
this position for most of the day will require additional training of nurses
and other providers.
—
Patricia Kritek, MD. Two videos that illustrate proning have been published
with this article and are available to New England Journal of Medicine
subscribers through the link given in the citation. Published in Journal Watch
General Medicine June 13, 2013. Citation: Guérin C et al. N Engl J Med 2013 Jun
6; 368:2159.
9. Images in Clinical Medicine
Hand
Pain After Fall
That's
Not An Abscess!
Eyelid
Swelling and Primary Sjögren's Syndrome
Sudden Unilateral Corneal Clouding in
an Infant
10. Sharp Increase in ED Visits for Mental Health
Disorders
Visits
related to mental health disorders increased at three times the rate of ED
visits overall.
Hakenewerth
AM, et al. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal
Wkly Rep 2013 Jun 14.
Results
(excerpt):
From
2008 to 2010, the annual number of ED visits in North Carolina increased by
5.1%, from 4,190,911 to 4,405,676, and Mental Health Disorders Diagnostic Code
(MHD-DC)-related ED visits increased by 17.7%, from 347,806 to 409,276 (Table
1). By 2010, ED visits with MHD-DCs accounted for 9.3% of all ED visits; 31.1%
of ED visits with MHC-DCs resulted in hospital admission, compared with 14.1%
of all ED visits.
11. Electrolyte Abnormalities in Children with
Hypertrophic Pyloric Stenosis
Most
children with hypertrophic pyloric stenosis had normal serum electrolytes at
time of diagnosis.
Tutay
GJ et al. Pediatr Emerg Care 2013; 29:465
OBJECTIVES:
Recent investigations have demonstrated that the classic hypochloremic,
hypokalemic, metabolic alkalosis of hypertrophic pyloric stenosis (HPS) is not
a common finding.Some have suggested a trend over time, but none has
investigated factors contributing to laboratory derangement, such as duration
of vomiting or patient age at presentation. We sought to determine the
proportion of patients with HPS with normal and abnormal laboratory findings as
a function of year of presentation, duration of vomiting, and patient age.
METHODS:
This is a retrospective chart review of 205 patients younger than 6 months with
operative diagnosis of HPS at a tertiary, regional pediatric center from 2000
to 2009. We examined the acid-base status and electrolyte levels (serum
bicarbonate [CO2], serum potassium [K], and serum chloride [Cl]) at the time of
the index visit to determine the proportion of normal, high, and low values for
each as a function of year of presentation, duration of vomiting, and patient
age.
RESULTS:
The proportion of HPS cases with normal CO2 was 62%; low serum CO2, 20%; and
high CO2, 18%. The proportion with normal serum K was 57%; low K, 8%; and high
K, 35%. The proportion with normal Cl was 69%; low Cl, 25%; and high Cl, 6%.
Logistic regression analysis demonstrated that the prevalence of metabolic
alkalosis increased across the decade, whereas the prevalence of metabolic
acidosis decreased and that advancing age was associated with the presence of
alkalosis.
CONCLUSIONS:
We observed that normal laboratory values are the most common finding in HPS
and that metabolic alkalosis was found more commonly in the latter part of the
decade and in older infants.
12. Continuous
neuromuscular blockade is associated with decreased mortality in post-cardiac
arrest patients.
Salciccioli JD, et al. Resuscitation. 2013 Jun 21. pii: S0300-9572(13)00331-6.
doi: 10.1016/j.resuscitation.2013.06.008. [Epub ahead of print]
AIM: Neuromuscular blockade may
improve outcome in patients with acute respiratory distress syndrome. In
post-cardiac arrest patients receiving therapeutic hypothermia, neuromuscular
blockade is often used to prevent shivering. Our objective was to determine
whether neuromuscular blockade is associated with improved outcomes after
out-of-hospital cardiac arrest.
METHODS: A post hoc analysis of a
prospective observational study of comatose adult (over 18 years) out-of-hospital cardiac arrest at 4 tertiary
cardiac arrest centers. The primary exposure of interest was neuromuscular
blockade for 24h following return of spontaneous circulation and primary
outcomes were in-hospital survival and neurologically intact survival.
Secondary outcomes were evolution of oxygenation (PaO2:FiO2), and change in
lactate. We tested the primary outcomes of in-hospital survival and
neurologically intact survival with multivariable logistic regression.
Secondary outcomes were tested with multivariable linear mixed-models.
RESULTS: A total of 111 patients were
analyzed. In patients with 24h of sustained neuromuscular blockade, the crude
survival rate was 14/18 (78%) compared to 38/93 (41%) in patients without
sustained neuromuscular blockade (p=0.004). After multivariable adjustment,
neuromuscular blockade was associated with survival (adjusted OR: 7.23, 95% CI:
1.56-33.38). There was a trend toward improved functional outcome with
neuromuscular blockade (50% versus 28%; p=0.07). Sustained neuromuscular
blockade was associated with improved lactate clearance (adjusted p=0.01).
CONCLUSIONS: We found that early
neuromuscular blockade for a 24-h period is associated with an increased
probability of survival. Secondarily, we found that early, sustained
neuromuscular blockade is associated with improved lactate clearance.
13. Value of Emergency Medicine: ACEP’s “Saving Millions”
PR Campaign
ACEP
NEWS, 06/13/13
In
addition to a press release issued at last month’s Leadership and Advocacy
Conference to highlight the RAND Corporation study, ACEP launched a public
relations campaign to highlight the value of emergency medicine. The theme is
"Saving Millions." The campaign is built around many of the following
key points:
• Four
in five people who called their family doctors about a sudden medical issue got
the same advice: Go to the emergency department (RAND report)
•
Primary care physicians increasingly depend on EDs to see their patients after
hours, perform complex diagnostic workups, and facilitate admissions of acutely
ill patients (RAND report)
•
Emergency physicians provide a disproportionate share of acute health care on
weekends, holidays and after regular business hours (CDC)
•
Ninety-two percent of patients who visit the emergency department each year
have the same condition – a real medical emergency (CDC)
•
According to the RAND Report, the 4 percent of America’s doctors who staff
hospital emergency departments provide/manage 11 percent of all outpatient care
in the United States, 28 percent of all acute care visits, half of the acute
care visits by Medicaid and CHIP beneficiaries and two-thirds of all acute care
for the uninsured
•
Emergency physicians can save money in the health care system because they are
key decision-makers in more than half of hospital admissions
•
Hospital admissions from the emergency department increased by 17 percent over
7 years (RAND)
•
Emergency physicians coordinate transitions of care every day in hospitals
across the country, filling the gaping holes in our health care system
• Lack
of access to follow-up care is a top concern that influences a physician’s
decision to admit patients to the hospital (RAND)
14. New Guidelines on tPA in Stroke:
Putting Out Fires With Gasoline?
Millard
WB, et al. Ann Emerg Med. 2013;62:A13-A18
Introduction
When a
joint panel representing the American College of Emergency Physicians (ACEP)
and the American Academy of Neurology (AAN) issued guidelines1 on the use of
recombinant tissue-type plasminogen activator (rt-PA, alteplase, or tPA) in
patients receiving a diagnosis of ischemic stroke, proponents of this treatment
may have heaved a sigh of relief.
Nearly
2 decades after tPA received Food and Drug Administration (FDA) approval for
this indication, the much-debated National Institute of Neurological Disorders
and Stroke trials2 appeared vindicated, with these influential organizations
elevating intravenous tPA treatment within 3 hours of symptom onset to a level
A recommendation. The actual wording specifies that “IV tPA should be offered,”
not that it must always be given, “to acute ischemic stroke patients who meet
National Institute of Neurological Disorders and Stroke (NINDS)
inclusion/exclusion criteria.” Thrombolysis proponents might infer that
entrenched resistance, particularly among emergency physicians,3 is likely to
dwindle. The only known acute treatment for stroke can reach more patients and
benefit most of them.
Not so
fast, say some observers of the controversy. Many things about tPA are
uncertain; its association with more intracranial hemorrhages is not one of
them. Whether the clot-busting treatment correlates with improved outcomes
clearly enough to outweigh that risk, particularly when the urgent time factor
(only treatment within the 3-hour window receives the ACEP/AAN level A
recommendation, whereas treatment within 4.5 hours gets a level B) adds
pressure to the uncertainties inherent in a diagnosis of exclusion, is a
settled question to some and an open question to others. At least 1 prominent
skeptic toward tPA views the available evidence as not only inconclusive at
best but also perhaps inconsistent with the proposed mechanism of action
altogether.
With widespread
reluctance to use tPA acknowledged by both proponents and skeptics, and with
shifting incentives affecting therapeutic policies, the new guidelines may
foster as much confusion and polarization as they resolve. Experience with tPA
can fit into either a narrative of progress and obstructionism or one of
earnest (albeit profit-enhanced) wishful thinking. The physician seeking a
definitive answer may be in the position of solitude and inescapable
responsibility that Jean-Paul Sartre described in a 1946 lecture: “[I]f you
seek counsel … at bottom you already knew, more or less, what [a given
counselor] would advise. In other words, to choose an adviser is nevertheless
to commit oneself by that choice.”4
15. Capnography Useful in Identifying Patients with DKA
In
this study, end tidal CO2 values greater than 24.5 mm Hg excluded DKA in most
hyperglycemic patients.
Soleimanpour
H et al. West J Emerg Med 2013 [Epub ahead of print]
Introduction:
Metabolic acidosis confirmed by arterial blood gas (ABG) analysis is one of the
diagnostic criteria for diabetic ketoacidosis (DKA). Given the direct
relationship between end-tidal carbon dioxide (ETco2), arterial carbon dioxide
(PaCO2) and metabolic acidosis, measuring
ETco2 may serve as a surrogate for ABG in the assessment of possible
DKA. The current study focuses on the predictive value of capnography in
diagnosing DKA in patients referring to the emergency department (ED) with
increased blood sugar levels and probable diagnosis of DKA.
Methods:
In a cross-sectional prospective descriptive-analytic study carried out in an
ED, we studied 181 patients older than 18 years old with blood sugar levels of
higher than 250 mg/dl and probable DKA. ABG and capnography were obtained from
all patients. To determine predictive value, sensitivity, specificity and
cut-off points, we developed receiver operating characteristic curves.
Results:
Sixty-two of 181 patients suffered from DKA. We observed significant
differences between both groups (DKA and non-DKA) regarding age, pH, blood
bicarbonate, PaCO2 and ETco2 values (P≤0.001). Finally, capnography values more
than 24.5 mmHg could rule out the DKA diagnosis with a sensitivity and
specificity of 0.90.
Conclusion:
Capnography values greater than 24.5 mmHg accurately allow the exclusion of DKA
in ED patients suspected of that diagnosis. Capnography levels lower that 24.5
mmHg were unable to differentiate between DKA and other disease entities.
Full-text
(free): http://www.escholarship.org/uc/item/5qz744fv
16. Vaccines Not Linked to Guillain-Barré, Asserts
13-Year Trial
Fran
Lowry. Jun 26, 2013. Medscape News.
In a
retrospective study spanning 13 years and more than 30 million person-years,
researchers found no evidence of an increased risk for Guillain-Barré Syndrome
(GBS) after vaccinations of any type, including influenza vaccination.
"If
there is a risk of Guillain-Barré syndrome following any vaccine, including
influenza vaccines, it is extremely low," lead author Roger Baxter, MD,
codirector of the Kaiser Permanente Vaccine Study Center, Oakland, California,
said in a Kaiser news release.
"GBS
is an acute inflammatory polyradiculoneuropathy affecting primarily motor
neurons, which in severe cases can progress to complete paralysis and even
death," write Dr. Baxter and colleagues in an article published online
April 11 and in the July 15 issue of Clinical Infectious Diseases.
"Estimates
of GBS incidence are in the range of 1-2 cases per 100,000 person-years
worldwide and increase with age," cite the authors. Causes of the syndrome
are unknown, but are thought to involve an autoimmune process triggered by antigenic
stimulation that results in demyelination and destruction of peripheral nerves,
the authors explain.
About
two thirds of cases are preceded by a gastrointestinal or respiratory
infection, with Campylobacter enteritis being the most common trigger. Also
implicated are influenza, cytomegalovirus, Epstein-Barr virus, HIV, and
Mycoplasma pneumonia.
Case
reports have linked a variety of vaccine types to GBS. The only clear
association, however, has been with the 1976 A/New Jersey swine influenza
vaccine, when a small but significant increase in the number of GBS cases was
seen 6 weeks after vaccination. Since that time, investigations have shown
either no risk or a very small attributable risk of GBS in roughly 1 case per
million doses. More recently, studies assessing the risk of GBS after the 2009
H1N1 monovalent influenza vaccines in the United States found a slightly higher
attributable risk ranging from 1 to 5 per million doses.
The
aim of the current study was to further evaluate the possible relationship
between GBS and vaccinations, using retrospective data from the Kaiser
Permanente of Northern California healthcare plan accumulated over many years.
Dr.
Baxter and colleagues identified 415 confirmed cases of GBS during the 13-year
period from 1994 to 2006. Most cases were male (58.6%), and the mean age was
48.5 years (range, 5 - 87 years).
The
researchers also found that 277 patients (66.7%) had a respiratory and/or
gastrointestinal illness in the 90 days preceding the onset of GBS.
Incidence
was significantly more likely to occur in the winter months (November - April),
with a relative risk of 1.5, compared with in the nonwinter months (P = .003),
peaking in March.
Among
the 415 patients with GBS, only 25 had received any vaccine in the 6 weeks
before onset of the disease. The vaccines that were received included trivalent
inactivated influenza vaccine (n = 18 patients), 23-valent polysaccharide
pneumococcal vaccine (n = 2), tetanus-diphtheria combination vaccines (n = 3),
hepatitis A (n = 2), and hepatitis B (n = 1).
The
other 390 patients with GBS received no vaccines in the 6 weeks before onset.
The
researchers also found no cases of GBS resulting from vaccines given mainly in
childhood, despite the large number of doses given. These included the oral
polio vaccine (1.2 million doses), measles-mumps-rubella (1.6 million),
conjugated pneumococcal (1.3 million), live attenuated influenza (69,000),
diphtheria-tetanus-acellular pertussis (1.9 million), varicella (764,000),
Haemophilus-diphtheria-tetanus-pertussis (525,000), and Haemophilus B vaccines
(1.2 million).
"For
rabies vaccine (13 000 doses), there was 1 case of GBS, 7.5 weeks after
vaccination," the authors add.
"Despite
many years of review of a very large captured population, we are unable to
exclude any [and all] possible association between vaccines and GBS," the
researchers note. This is in part because of the low power of the study, given
the infrequency with which GBS occurs.
Highlighting
another potential study limitation, the authors point out that their reviewer
was able to see whether medical providers thought that GBS was caused by a
vaccine, which "could have influenced the reviewer in some way."
Nonetheless,
"the low numbers of GBS cases that were temporally associated with
vaccination, coupled with our results, provide reassurance that the risk of GBS
following any vaccine, including influenza vaccines, is extremely low,"
conclude Dr. Baxter and colleagues.
17. Quick Lit Reviews
A. Is
SQ Sumatriptan an Effective Treatment for Adults Presenting to the ED with
Acute MHA?
Jones
S, et al. Ann Emerg Med. 2013;62:11-12.
Take-Home
Message: Subcutaneous sumatriptan provides effective treatment of migraine
headaches, quickly eliminating pain and associated symptoms; however, it has
yet to be proven as an optimal emergency department (ED) treatment modality
because of inadequate evidence of effectiveness in this setting, increased
self-limiting adverse events, and a high recurrence of pain within 24 hours.
B. Do
Fluids Facilitate Stone Passage in Acute Ureteral Colic?
Kirschner
J, et al. Ann Emerg Med. 2013;62:36-37.
Take-Home
Message: High-volume intravenous fluid therapy has not been shown to improve
ureteral stone passage, pain control, or need for surgical stone removal.
C. Do
Vasopressors Improve Outcomes in Patients With Cardiac Arrest?
Michiels
EA, et al. Ann Emerg Med. 2013;62:57-58.
Take-Home
Message: Research evidence is currently inadequate to either support or reject
the use of vasopressors in cardiac arrest.
D. Are
Benzodiazepines Effective for Alcohol Withdrawal?
Schaefer
TJ, et al. Ann Emerg Med. 2013;62:34-35.
Take-Home
Message: When compared with placebo, benzodiazepines offer significant benefit
in preventing alcohol withdrawal seizures.
E. Is
coronary CTA useful in diagnosing ACS in the ED?
Dipaola
F, et al. Intern Emerg Med 2013;8:345–346.
Clinical
Bottom Line: The study showed that early CCTA-based evaluation strategy in a
selected population without prior known coronary artery disease may improve the
efficacy of ED triage for patients with suspected ACS by reducing length of
hospital stay. However, this approach leads to increased diagnostic testing and
higher radiation exposure and no overall reduction in the cost of care. The net
benefit of this novel approach in the management of patients with suspected
acute coronary syndrome in ED is yet to be clarified.
18. EMCrit PodCast by Scot Weingart
A.Is
Lactate Clearance a Flawed Paradigm? (He says no)
B. Podcast
98 – Cyclic (Tricyclic) Antidepressant Overdose
C. The
Vortex Approach to AW Management
19. Metoclopramide plus Diphenhydramine Superior to Ketorolac
for Nonmigraine Headaches
A
randomized trial found better pain relief with the antiemetic combination than
with the NSAID.
Medications
recommended for headache treatment include nonsteroidal anti-inflammatory drugs
(NSAIDs), prochlorperazine, metoclopramide, and caffeine. These authors
compared two regimens in adult patients with recurrent headaches that did not
meet definitions for migraine or cluster headache. In a randomized,
double-blind study, 120 patients who presented to an academic emergency
department received either intravenous metoclopramide (20 mg) plus
diphenhydramine (25 mg), or intravenous ketorolac (30 mg).
After
1 hour, pain improvement was greater with the combination regimen (median
improvement on an 11-point scale, 5 vs. 3 points). The combination regimen was
also superior in sustained relief, requirement for rescue medications, and
patient desire to receive the same treatment again.
Comment:
This study joins a long list of prior studies that suggest that metoclopramide
and prochlorperazine are excellent agents for headache treatment. But it would
be unfortunate if we concluded from this study that there is any reason to
treat benign headaches with intravenous medications. There is also no reason to
use only one of these regimens. Common sense suggests that we simply treat
these benign conditions with oral ibuprofen, oral prochlorperazine or
metoclopramide, and perhaps also oral caffeine. Opioids and
barbiturate/analgesic combinations (e.g., Fiorinal) should not be used.
—
Daniel J. Pallin, MD, MPH. Published in Journal Watch Emergency Medicine June
21, 2013.
Citation:
Friedman BW et al. Ann Emerg Med 2013 Apr 8 [e-pub ahead of print].
20. Aspirin-clopidogrel combo may lower stroke recurrence
risk
Combining
clopidogrel and aspirin can lower the risk of a second stroke by almost
one-third compared with aspirin alone, according to a study in the New England
Journal of Medicine. Researchers tracked more than 5,000 patients who survived
a stroke or mini-stroke and found that 11.7% of those who took aspirin alone
suffered another stroke compared with 8.2% of those who received the
clopidogrel-aspirin combination. "Giving two drugs that block platelets
works a lot better than aspirin alone in people who have had a minor stroke or
TIA," a researcher said. An expert not involved in the study said
providers have been moving away from the combination due to risk of serious
bleeding.
21. ACEP Clinical Policy: Critical Issues in the
Evaluation and Management of Adult Patients in the ED with Asymptomatic
Elevated BP
Wolf
SJ, et al. Ann Emerg Med. 2013;62:59-68.
This
clinical policy from the American College of Emergency Physicians is the
revision of a 2006 policy on the evaluation and management of adult patients
with asymptomatic elevated blood pressure in the emergency department.1 A
writing subcommittee reviewed the literature to derive evidence-based
recommendations to help clinicians answer the following critical questions: (1)
In emergency department patients with asymptomatic elevated blood pressure,
does screening for target organ injury reduce rates of adverse outcomes? (2) In
patients with asymptomatic markedly elevated blood pressure, does emergency
department medical intervention reduce rates of adverse outcomes? A literature
search was performed, the evidence was graded, and recommendations were given
based on the strength of the available data in the medical literature.
22. An Absurdly Random, and Completely Blind, Review and
Prospective Validation of Mathematical Truisms in EM and Critical Care
Goodman
T, et al. Ann Emerg Med. 2013;62:95.
Study
Objective: We thought that in the darkest part of night shifts, when the diurnal
variation of our internal clocks is defunct and all organized neuronal
electrical activity in the cerebrum has ceased, that mathematical truisms might
be a valid tool in the assessment and treatment of the acutely ill, injured, or
merely crazy patients in the emergency department (ED). Therefore, in support
of evidence-based medicine, we sought to define and subsequently validate any
mathematical information that may be clinically useful at 3 am.
Methods:
The initial phase of this megatrial was a retrospective review by multiple EMS
personnel, nurses, and emergency physicians over a period of 10 years in Hawaii
and Arizona. Data collection occurred in fire stations, EDs, bars, boats, and
on surf breaks. The second phase of the trial was a prospective validation
series of the mathematical information by this same author over the subsequent
20 years of working in an ED. Interrater reliability was irrelevant.
Results:
1. Pulse
ox less than age=get an ETT or a DNR order fast
2. For
adults: Pulse greater than systolic BP=get the paddles
3. WBC
greater than Hct=culture every orifice and call infectious disease
4. Pulse
less than Hct=don't know what it means, but it's a bad thing
5. For
Peds: If the number of problems on their chart is greater than age, then it's
far too complicated to get involved; call Peds, but if chart weight is greater
than patient's weight=means it's a genetic defect kid, so get a dictionary …
then call Peds!
6. Bands
greater than Segs=bad, see 3
7. The
Tooth to Tattoo ratio … . If number of teeth still present less than tattoos=pt
has guaranteed immortality, don't sweat the resuscitation
8. Any
stab wound through a tattoo is guaranteed to be lethal, so start sweating now.
9. BUN
greater than Sodium=kidneys gone, call nephrology
10. Age
greater than Systolic BP=not a good sight on a triage note, immediately go to
dinner and let your partner get that chart
11. Allergies
greater than 4=drug seeker or psychosomatic … stay at dinner longer.
12. On
an ABG, if pO2 less than pCO2=the patient is either an anaerobe or needs a
great white snorkel in the lungs
13.100–Age=Percent
chance of going home from ED on any given visit
14. Respiratory
rate exceeds pulse=patient is either hyperventilating, on β-blockers, about to
be arrested, or needs the great white snorkel (ETT)
15. SED
rate is greater than HcT … . Hhhmmm????? Haven't a clue, but it will make some
internist happy for years figuring it out
16. Meds×10
exceeds age, or Number of Problems on problem list+meds exceeds age=automatic
admit
Conclusion:
Mathematical truism can be a helpful tool in our fight for sanity and sensible
decisions in the ED at all hours of the day and night. However, future studies
at posh hotels in exotic locations, and sponsored by hospitals or drug
companies, are definitely required.
23. Animal Behavior Books Altogether Unrelated to EM
These were both good reads: engaging, informative, well-written,
and easy to follow. You science-minded animal lovers will find these enjoyable.
A. Virginia Morell, Animalwise: The Thoughts and Emotions of our Fellow Creatures (New
York: Crown, 2013). http://www.amazon.com/dp/0307461440/
B. Frans de Waal, The Bonobo and the Atheist: In Search of Humanism Among the Primates
(New York: Norton, 2013). http://www.amazon.com/dp/0393073777/
24. Very Many Tib Bits
A. A
specific antidote for reversal of anticoagulation by direct and indirect
inhibitors of coagulation factor Xa.
Lu G,
et al. Nat Med. 2013 Apr;19(4):446-51.
B.
Exercise has positive effects on body fat, study finds
Exercising
regularly can cause the body to convert white fat into brown fat, which burns
calories and could help prevent weight gain, according to a study presented at
the American Diabetes Association's annual meeting. "Our results showed
that exercise doesn't just have beneficial effects on muscle, it also affects
fat," said researcher Kristin Stanford.
News
article: http://www.bloomberg.com/news/2013-06-21/exercise-turns-bad-fat-to-good-in-study-finding-benefits.html
C. Extended hours for PCPs may lead to fewer
child ED visits
Children's visits to emergency departments were reduced by
50% if their primary care doctors had evening office hours five or more days
per week, according to a study in the Journal of Pediatrics. Strategies such as
24-hour phone service, e-mail or patient portal communication, and same-day
sick visits did not result in reduced ED visits, researchers said.
D. Silent
MI Predictors
Silent
myocardial infarctions are more common than previously thought. In this study,
1 of 4 patients with suspected coronary artery disease had experienced a silent
myocardial infarction; the extent on average is 10% of the left ventricle, and
it is more common in diabetics.
E. 20%
of youths suffer from head trauma in their lifetime
Canadian
researchers surveyed 8,900 11- to 20-year-olds from Ontario and found that
about 20% had a serious head trauma at some point in their lives. Sports
injuries accounted for 56% of head trauma cases that happened in the last 12
months. Poor academic performance and frequent alcohol and cannabis use were
linked to increased traumatic brain injury risk, according to the study in the Journal
of the American Medical Association.
F. IOM
Report: Evidence Fails to Support Guidelines for Dietary Salt Reduction
A
report from the Institute of Medicine (IOM) finds no evidence that drastically
reducing salt, and the sodium it contains, in individuals' diets reduces the
risk of myocardial infarction, stroke, or death. The US Centers for Disease
Control and Prevention (CDC) and the American Heart Association (AHA) beg to
differ.
G.
Ciguatera Fish Poisoning
H.
More pedestrians land in EDs for using cellphones while walking
The
number of pedestrians who were taken to the emergency department for injuries
related to cellphone use increased from 1,055 in 2008 to 1,506 in 2010,
according to a study in the journal Accident Analysis and Prevention.
Researchers looked at a federal database of ED visits between 2004 and 2010 and
found that young adults sustained the most number of pedestrian injuries caused
by the use of cellphones while walking.
I. Why
Do I Think Better after I Exercise?
—Emily
Lenneville, Baltimore. Scientific American, June 23, 2013.
Justin
Rhodes, an associate professor of psychology at the University of Illinois at Urbana-Champaign,
responds:
After
being cooped up inside all day, your afternoon stroll may leave you feeling
clearheaded. This sensation is not just in your mind. A growing body of
evidence suggests we think and learn better when we walk or do another form of
exercise. The reason for this phenomenon, however, is not completely
understood.
Part
of the reason exercise enhances cognition has to do with blood flow. Research
shows that when we exercise, blood pressure and blood flow increase everywhere
in the body, including the brain. More blood means more energy and oxygen,
which makes our brain perform better.
Another
explanation for why working up a sweat enhances our mental capacity is that the
hippocampus, a part of the brain critical for learning and memory, is highly
active during exercise. When the neurons in this structure rev up, research
shows that our cognitive function improves. For instance, studies in mice have
revealed that running enhances spatial learning. Other recent work indicates
that aerobic exercise can actually reverse hippocampal shrinkage, which occurs
naturally with age, and consequently boost memory in older adults. Yet another
study found that students who exercise perform better on tests than their less
athletic peers.
The
big question of why we evolved to get a mental boost from a trip to the gym,
however, remains unanswered. When our ancestors worked up a sweat, they were
probably fleeing a predator or chasing their next meal. During such
emergencies, extra blood flow to the brain could have helped them react quickly
and cleverly to an impending threat or kill prey that was critical to their
survival.
So if
you are having a mental block, go for a jog or hike. The exercise might help
pull you out of your funk.
J. Patients’ attitudes about the use of placebo treatments:
telephone survey
Hull
SC, et al. BMJ 2013;347:f3757
Objective To examine the attitudes of
US patients about the use of placebo treatments in medical care.
Design One time telephone surveys.
Setting Northern California.
Participants 853 members of Kaiser
Permanente Northern California, aged 18-75, who had been seen by a primary care
provider for a chronic health problem at least once in the prior six months.
Results The response rate was 53.4%
(853/1598) of all members who were eligible to participate, and 73.2%
(853/1165) of all who could be reached by telephone. Most respondents (50-84%)
judged it acceptable for doctors to recommend placebo treatments under
conditions that varied according to doctors’ level of certainty about the
benefits and safety of the treatment, the purpose of the treatment, and the
transparency with which the treatment was described to patients. Only 21.9% of
respondents judged that it was never acceptable for doctors to recommend
placebo treatments. Respondents valued honesty by physicians regarding the use
of placebos and believed that non-transparent use could undermine the
relationship between patients and physicians.
Conclusions Most patients in this
survey seemed favorable to the idea of placebo treatments and valued honesty
and transparency in this context, suggesting that physicians should consider
engaging with patients to discuss their values and attitudes about the
appropriateness of using treatments aimed at promoting placebo responses in the
context of clinical decision making.
K. National Athletic Trainers’ Association, Inc releases new evidence-based guidelines on management of
ankle sprains
Kaminski
TW, et al. Journal of Athletic Training
2013;48(4):528–545
Full-text
(free): http://www.nata.org/sites/default/files/ankle-sprains.pdf
L. Science or Science Fiction? 12 Cutting-Edge Medical
Advances
M. 'I Can't Give You That Test': How to Tell Patients
Shelly Reese. Medscape Business of Medicine. Jun 26, 2013
Full-text
(free after one-time registration): http://www.medscape.com/viewarticle/806628
