Monday, August 19, 2013

Lit Bits: Aug 19, 2013

From the recent medical literature...

1. Does Size Really Matter? The Pathophysiology of ACS 

Amal Mattu, MD. Medscape Emergency Medicine, Jul 26, 2013. 

For many years, 2 axioms have ruled our thoughts and discussions of coronary atherosclerosis. The first axiom was that patients were at risk for acute coronary syndromes (ACS) if their coronary plaques were very large; more specifically, if the plaques produced a critical degree of luminal stenosis (eg, above 50%-75% occlusion). 

Large plaques were at highest risk for rupture by virtue of their size, and these were the plaques that produced subintimal bleeding, leading to platelet aggregation, thrombus formation, and myocardial infarction (MI). The second axiom was that these large, "risky" plaques would generally manifest with clinical symptoms prior to the MI by producing exertional angina via coronary flow limitation when myocardial oxygen demand increased. Therefore, stress testing could predict which patients were at risk of developing ACS and which patients were not. However, these axioms did not explain why seemingly fit people who exercised regularly or had negative stress tests would occasionally, without warning, drop dead of heart attacks. Despite this apparent paradox, for years we continued to believe that atherosclerosis and risk for MI were all about plaque size. 

Of note, pathologists have been saying for decades that plaque size is not the key determinant of MI. Histologic sections from patients who died revealed to them interesting information regarding atherogenesis that other physicians are only recently beginning to learn. A recent publication in the New England Journal of Medicine has finally brought to the forefront what had been common knowledge primarily only to the pathologists. (Libby P. Mechanisms of Acute Coronary Syndromes and Their Implications for Therapy. N Engl J Med 2013; 368:2004-2013). 

Study Summary
The traditional model of how atherosclerosis develops into ACS is that progressive stenosis eventually produces luminal occlusion and infarction. Dr. Libby, however, cites angiographic studies over the past 2 decades that have shown that in up to 50% of cases, the artery in which infarction occurs is often only mildly occluded prior to infarction. These relatively small occlusions are not sufficiently severe to limit flow and probably would result in a negative stress test if the test were done in the days or weeks prior to infarction. They could also allow a patient to perform routine cardio-type exercises (not to mention daily activities) without symptoms. A recent emergency department-based study confirmed what other studies and anecdotal experience have demonstrated: A recent negative stress test cannot reliably rule out ACS in a patient presenting with chest pain.[1] Does this mean that plaque size is truly irrelevant? 

To be fair, size does matter somewhat. Larger plaques are more likely to cause ACS, but it's important to distinguish size vs stenosis. We've traditionally assumed that as plaques grow, they grow inward from the vessel wall into the lumen, causing luminal stenosis. What is now understood, however, is that during the majority of the life of a plaque, growth occurs outward into the vessel wall, producing wall expansion and remodeling to accommodate the plaque. This remodeling process preserves the lumen patency. The result is that relatively large plaques may grow in a vessel but produce only mild stenosis. Significant stenosis may not develop until much later in the life of the plaque. Patients can therefore have significant disease, but because of preserved luminal flow, they lack exertional angina symptoms. These patients also are likely to have negative stress tests. 

So, size does matter to some extent, but how do we account for the fact that some patients with known large plaques do not go on to infarct? Recent data over the past 2 decades have highlighted the concept of plaque vulnerability. In other words, there are certain characteristics of the plaque that increase its vulnerability, or likelihood to rupture; and these are likely more important than total plaque size. Specifically, 3 factors play a major role in plaque vulnerability: the thickness and strength of the fibrous cap that overlies the plaque; the size of the lipid core of the plaque; and the plaque's content of inflammatory cells and macrophages. The New England Journal of Medicine article discusses these 3 factors in much greater physiologic detail than I will in this brief review. Suffice to say, however, that plaque composition appears to be far greater in importance than plaque size. 

I will, however, highlight a point regarding inflammation. Systemic inflammatory conditions produce accelerated atherogenesis and induce greater plaque instability. Such inflammatory conditions include systemic lupus erythematosus, chronic kidney disease, HIV, and so on. Patients with conditions that produce systemic inflammatory states should be considered to be at increased risk for both coronary atherosclerosis and ACS. 

The author also briefly discusses how this newer understanding of atherogenesis is influencing treatment strategies. Percutaneous coronary intervention (PCI) is focused on reducing luminal stenosis. However, if stenosis is less important than composition, it should be no surprise that studies have shown that medical therapies are as effective as PCI at preventing future cardiac events in patients with stable angina; PCI appears to only be superior in the treatment of acute coronary occlusions. The author also discusses the success of statins, which target plaque inflammation and lipid content and appear to have a stabilizing effect on plaques. 

What consequences does this information have for emergency physicians? First, it's important to realize the limitations of relying on recent negative stress tests when evaluating patients presenting with acute chest pain or angina equivalents. Second, it's important to remember that coronary angiography, which has long been considered the gold standard in the evaluation of coronary atherosclerotic disease, may actually be more of a tarnished bronze standard: Angiography provides information only regarding luminal stenosis, but it provides no information regarding artery remodeling or plaque composition. 

In the future, we may see the rise of other imaging technologies that provide more useful key information regarding plaque composition and intramural plaques. Finally, it's important to add systemic inflammatory conditions, including lupus and chronic kidney disease, to the list of independent risk factors for the development of premature atherosclerosis. As our understanding of atherogenesis and ACS evolves, we will, we hope, move beyond the myth of plaque size and appreciate the importance of plaque composition. 

2. Lactate Clearance for Assessing Response to Resuscitation in Severe Sepsis 

Jones AE. Acad Emerg Med. 2013;20:844-847. 

Severe sepsis remains a major public health problem both with a high hospital mortality rate and with staggering associated health care expenditures. The past decade has seen new insights into the early resuscitation of severe sepsis and this is an important, controversial, and constantly changing topic to emergency physicians.  

In this article, the recent support for lactate clearance as a measure of early sepsis resuscitation effectiveness is summarized, lactate-derived to oxygen-derived resuscitation variables are compared, and the shortcomings of lactate-derived variables are described. As summarized in this article, the best available experimental evidence suggests that lactate clearance of at least 10% at a minimum of 2 hours after resuscitation initiation is a valid way to assess initial response to resuscitation in severe sepsis. Associative data suggest that lactate normalization during resuscitation is a more powerful indicator of resuscitative adequacy; however, further research on the optimal lactate clearance parameters to use during resuscitation is needed, and many other important questions have yet to be answered. 

3. Blog Nuts Love ALiEM   

The ALiEM (Academic Life in EM) blog is one of the most popular free online EM educational sites. It encompasses a wide array of clinical and medical education topics in EM in this new era of open-access learning and collaboration. 

What is the site about?
The blog aims to disrupt how medical providers and trainees can gain public access to high-quality, educational content while also engaging in a dialogue about best-practices in Emergency Medicine and medical education. We strive to reshape medical education and academia in their evolution beyond the traditional classroom. We hope you join us in the FOAM movement (Free Open Access to Meducation). 

Editor-in-Chief: Michelle Lin, MD
Associate Professor of Emergency Medicine
University of California San Francisco (UCSF)
San Francisco General Hospital (SFGH) 

She writes: “I practice emergency medicine at SFGH with an academic niche in technology and how it can transform the landscape of medical education. I was a columnist for ACEP News on “Tricks of the Trade” for 4 years and am one of the founders of the Clerkship Directors of Emergency Medicine (CDEM). Through this blog, I hope to share some of my experiences and blunders, as well as introduce you to inspiring people whom I’ve met along the way, while navigating the academic and clinical waters of EM.” 

Best Of: The following are the best of the 1,000+ blog posts since 2009. 

Tricks of the Trade 

Nursemaid elbow reduction
Parents bring in their child because they pulled on their arm, and now the child is not using it. Parents are thoroughly convinced that the child’s arm is either broken or dislocated. We all recognize this as radial head subluxation or “nursemaid’s elbow” and immediately attempt to reduce it. The provider takes the injured arm, supinates at the wrist and flexes at the elbow. Does the child scream? What if nothing happens? Is there an alternative technique to reducing a nursemaid elbow?  

Peritonsillar abscess aspiration
When evaluating a patient with a sore throat and “hot potato voice,” peritonsillar abscess (PTA) is at the top of the differential diagnosis list. As with all abscesses, the definitive treatment involves drainage of pus. This can be done either by incision and drainage or, more commonly, by needle aspiration.  

Clinical Topic Review 

NG lavage: Indicated or outdated?
Nasogastric lavage (NGL) seems to be a logical procedure in the evaluation of patients with suspected upper GI bleeding, but does the evidence support the logic? Most studies state that endoscopy should occur within 24 hours of presentation, but the optimal timing within the first 24 hours is unclear… So what are the arguments for and against NGL?  

Is the 6-12-12 adenosine approach always correct?
The ACLS-recommended dosing strategy of 6 mg, 12 mg, and 12 mg for adenosine may not be appropriate in every situation. There are a few instances when lower or higher dosing should be considered.  

Medical Education 

Is it time to trash the stethoscope? The age of ultrasound
It is important to do and teach a thorough physical exam. I cautioned against the overreliance on diagnostic testing in lieu of a physical exam, which can be initially burdensome and prolonged. But perhaps our difficulty with the physical exam is not the exam itself, but the tools that we have at our disposal to perform an exam, rather than the exam itself.  

Top 10 reasons why Yoda would be a terrible mentor and teacher in Medicine
This is based on an article from GeekWire that lists the top ten reasons why Yoda would make a terrible teacher. Let’s see if I can make a derivation and convert these reasons as to why Yoda would make a terrible mentor/teacher in medicine.  

To read more, link here:   

4. A Sad Performance by the SADPERSONS Scale  

Diane M. Birnbaumer, MD, FACEP, Journal Watch Emerg Med 2013 

The scale, which is designed to evaluate potential self-harm patients, misses so many at-risk patients it may actually be harmful.  

To evaluate the performance of the SADPERSONS Scale for predicting whether self-harm patients would repeat self-harm, need hospitalization, or need referral for psychiatric care, researchers administered the scale to 126 consecutive self-harm patients presenting to a general hospital emergency department in the U.K. 

Of these patients, 25% repeated self-harm within 6 months, 4% were admitted to the hospital, and 55% were referred for psychiatric aftercare. While the scale was more than 90% specific for all three outcomes, sensitivity was very low, ranging from 2.0% (hospitalization) to 6.6% (repeated self-harm).  

Comment: The Joint Commission's Hospital National Patient Safety Goal 15 includes identifying patients at risk for suicide, and it applies to patients being treated for emotional or behavioral disorders in general hospitals. Using a simple tool such as the SADPERSONS Scale to assess risk is tempting. Unfortunately, this study shows that trying to distill a complex issue such as suicidality into to a scoring system may actually cause harm by missing many patients at risk. At this point, the best way to assess suicide risk is by listening to patients and their loved ones, seeking corroborative information, and then using your judgment.  

Citation(s): Saunders K et al. The sad truth about the SADPERSONS Scale: An evaluation of its clinical utility in self-harm patients. Emerg Med J 2013 Jul 29 [e-pub ahead of print].  

5. Efficacy of pain control with topical LET during lac repair with tissue adhesive in children: a RCT  

Harman S, et al. CMAJ 2013; July 29, 2013    

Background: Some children feel pain during wound closures using tissue adhesives. We sought to determine whether a topically applied analgesic solution of lidocaine-epinephrine-tetracaine would decrease pain during tissue adhesive repair.  

Methods: We conducted a randomized, placebo-controlled, blinded trial involving 221 children between the ages of 3 months and 17 years. Patients were enrolled between March 2011 and January 2012 when presenting to a tertiary-care pediatric emergency department with lacerations requiring closure with tissue adhesive. Patients received either lidocaine-epinephrine-tetracaine or placebo before undergoing wound closure. Our primary outcome was the pain rating of adhesive application according to the colour Visual Analogue Scale and the Faces Pain Scale - Revised. Our secondary outcomes were physician ratings of difficulty of wound closure and wound hemostasis, in addition to their prediction as to which treatment the patient had received.  

Results: Children who received the analgesic before wound closure reported less pain (median 0.5, interquartile range [IQR] 0.25- 1.50) than those who received placebo (median 1.00, IQR 0.38-2.50) as rated using the colour Visual Analogue Scale (p = 0.01) and Faces Pain Scale - Revised (median 0.00, IQR 0.00-2.00, for analgesic v. median 2.00, IQR 0.00-4.00, for placebo, p less than 0.01). Patients who received the analgesic were significantly more likely to report having or to appear to have a pain-free procedure (relative risk [RR] of pain 0.54, 95% confidence interval [CI] 0.37-0.80). Complete hemostasis of the wound was also more common among patients who received lidocaine-epinephrine-tetracaine than among those who received placebo (78.2% v. 59.3%, p = 0.008).  

Conclusion: Treating minor lacerations with lidocaine-epinephrine-tetracaine before wound closure with tissue adhesive reduced ratings of pain and increased the proportion of pain-free repairs among children aged 3 months to 17 years. This low-risk intervention may benefit children with lacerations requiring tissue adhesives instead of sutures. 

6. Diagnosing HF among acutely dyspneic patients with cardiac, IVC, and lung US 

Anderson KL, et al. Amer J Emerg Med 2013;31:1208-1214 

Rapid diagnosis (dx) of acutely decompensated heart failure (ADHF) may be challenging in the emergency department (ED). Point-of-care ultrasonography (US) allows rapid determination of cardiac function, intravascular volume status, and presence of pulmonary edema. We test the diagnostic test characteristics of these 3 parameters in making the dx of ADHF among acutely dyspneic patients in the ED. 

This was a prospective observational cohort study at an urban academic ED. Inclusion criteria were as follows: dyspneic patients, at least 18 years old and able to consent, whose differential dx included ADHF. Ultrasonography performed by emergency sonologists evaluated the heart for left ventricular ejection fraction (LVEF), the inferior vena cava for collapsibility index (IVC-CI), and the pleura sampled in each of 8 thoracic regions for presence of B-lines. Cutoff values for ADHF were LVEF less than 45%, IVC-CI less than 20%, and at least 10 B-lines. The US findings were compared with the final dx determined by 2 emergency physicians blinded to the US results. 

One hundred one participants were enrolled: 52% male, median age 62 (25%-75% interquartile, 53-91). Forty-four (44%) had a final dx of ADHF. Sensitivity and specificity (including 95% confidence interval) for the presence of ADHF were as follows: 74 (65-90) and 74 (62-85) using LVEF less than 45%, 52 (38-67) and 86 (77-95) using IVC-CI less than 20%, and 70 (52-80) and 75 (64-87) using B-lines at least 10. Using all 3 modalities together, the sensitivity and specificity were 36 (22-51) and 100 (95-100). As a comparison, the sensitivity and specificity of brain natriuretic peptide greater than 500 were 75 (55-89) and 83 (67-92). 

In this study, US was 100% specific for the dx of ADHF. 

7. US Confirms Tube Position During CPR 

In this small study, the positive predictive value of ultrasound to confirm endotracheal tube placement during active compressions was 98.8%. 

Chou HC, et al. Resuscitation. 2013 Jul 9 [Epub ahead of print] 

OBJECTIVE: This study aimed to evaluate the accuracy of tracheal ultrasonography for assessing endotracheal tube position during cardiopulmonary resuscitation (CPR). 

METHODS: We performed a prospective observational study of patients undergoing emergency intubation during CPR. Real-time tracheal ultrasonography was performed during the intubation with the transducer placed transversely just above the suprasternal notch, to assess for endotracheal tube positioning and exclude esophageal intubation. The position of trachea was identified by a hyperechoic air-mucosa (A-M) interface with posterior reverberation artifact (comet-tail artifact). The endotracheal tube position was defined as endotracheal if single A-M interface with comet-tail artifact was observed. Endotracheal tube position was defined as intraesophageal if a second A-M interface appeared, suggesting a false second airway (double tract sign). The gold standard of correct endotracheal intubation was the combination of clinical auscultation and quantitative waveform capnography. The main outcome was the accuracy of tracheal ultrasonography in assessing endotracheal tube position during CPR. 

RESULTS: Among the 89 patients enrolled, 7 (7.8%) had esophageal intubations. The sensitivity, specificity, positive predictive value, and negative predictive value of tracheal ultrasonography were 100% (95% confidence interval [CI]: 94.4-100%), 85.7% (95% CI: 42.0-99.2%), 98.8% (95% CI: 92.5-99.0%) and 100% (95% CI: 54.7-100%), respectively. Positive and negative likelihood ratios were 7.0 (95% CI: 1.1-43.0) and 0.0, respectively. 

CONCLUSIONS: Real-time tracheal ultrasonography is an accurate method for identifying endotracheal tube position during CPR without the need for interruption of chest compression. Tracheal ultrasonography in resuscitation management may serve as a powerful adjunct in trained hands. 

8. Emergency Physicians Monthly Ultrasound Tips 

A. Dead on Arrival: Post-Mortem Ultrasound  

by  Brady Pregerson, MD and Teresa S. Wu, MD on August 1, 2013 

Paramedics bring in a 60-year-old male who collapsed at work and remained unresponsive. They state that there was bystander CPR and a lot of freaking out by coworkers. The only past history they have was from a coworker who thought he had high blood pressure. There was also a witness who told them he was just walking, then doubled over and collapsed without saying a thing. No one knew if he had any symptoms earlier in the day. Paramedics state he was initially in a PEA rhythm at a rate of 120 bpm on the monitor. They started an IV, gave him a 500cc saline bolus, intubated him, and have given three rounds of epi. They estimate a 15 minute down time prior to their arrival and a 10 minute transport time with no return of spontaneous circulation. In fact, things are going in the opposite direction as he has been in asystole for the past five minutes. 

They move him onto the bed where your EMT takes over CPR. You note good and symmetric assisted breath sounds via the ET tube, but minimal palpable femoral pulse despite what appears to be good CPR to the tempo of the Bee Gees hit “Staying Alive”. On the monitor there is asystole in two leads. Pupils are fixed and dilated despite no atropine having been received. Things are not looking promising. 

You request saline wide open and a final round of epinephrine while you take a look for cardiac motion with the ultrasound machine. To minimize interruption of CPR you don’t have the EMT pause until you are completely ready to look. You also have the RT hold respirations to avoid any artifact. There is no cardiac motion. You verbalize this to your team. The heart does not appear dilated and there is no pericardial effusion. You ask aloud, “anyone have any other suggestions” prior to calling the time of death. 

Of course you next wonder what did him in: MI, PE, something else… His belly looks pretty protuberant, so you decide to take a quick look at his abdomen to check for free fluid. What you see is shown in the two images below. What do you think killed this gentleman? 

B. The Value of Repeat Studies  

by Teresa S. Wu, MD & Brady Pregerson, MD on June 20, 2013  

It’s busy. There are twenty-eight patients in the waiting room with the longest waiting 4 hours. The queue for CT scans is over 2 hours and the one for ultrasounds is even longer; a staggering 4 hours, plus another hour to get results. Lots of people are frustrated. Your next two patients are both pregnant females in their first trimester with vaginal bleeding. As you perform your H & P, you encounter more similarities between the two. Both have midline crampy pain like a period, with no fever, no vomiting, and no syncope. Both recently had ultrasounds done, one in your ED 3 days ago, and one with her obstetrician four days ago. You know why they are here. One reason – they want to see if their baby still has a heartbeat. You also know that repeating the ultrasound is not really medically indicated using the strict sense of the word. Sure it’s reasonable, even customary, but will it change management tonight? Can’t they just see their OB tomorrow? Is it really the right way to practice medicine to clog up your department even worse while simultaneously adding one more straw to the camel carrying the national healthcare budget? Who are you going to listen to? Press and Ganey? Barack Obama? Your conscience? What will the parents think and how will they react if you tell them, “Sorry, we can’t do an ultrasound tonight. You have to go home and make an appointment tomorrow to see your doctor.”? 

Vaginal bleeding in pregnancy, like many things in medicine, is both common and controversial. Do you really need to do a pelvic exam? Do you need to do another ultrasound if they already had one in this pregnancy that showed an IUP and they are not on fertility meds? Few patients will be disappointed if the pelvic exam is skipped, especially if is unlikely to have any important impact on their care, but if you don’t do the ultrasound it may require some explaining if you don’t want them to feel disappointed. But maybe there is a third option. Do a quick bedside ultrasound and show the mom the heartbeat (hopefully). She gets what she wants, you feel like you are doing the right thing, your ED throughput doesn’t take another hit, and you get to improve your ultrasound skills. If sold correctly to the patient and/or her husband, this can truly be a win-win approach. 

9. Incidence of Rash after Amox Treatment in Children with Infectious Mono 

Chovel-Sella A, et al. Pediatrics. 2013;131(5):e1424-7 

BACKGROUND: “Ampicillin rash,” a phenomenon unique to patients with Epstein-Barr virus acute infectious mononucleosis (AIM) treated with ampicillin, was first reported in the 1960s. The incidence was estimated as being between 80% and 100%, and the figures have not been reviewed since those first accounts. We sought to establish the current incidence of rash associated with antibiotic treatment among children with AIM.  

METHODS: A retrospective study of all hospitalized children diagnosed as having AIM based upon positive Epstein-Barr virus serology in 2 pediatric tertiary medical centers in Israel.  

RESULTS: Of the 238 children who met the study entry criteria during the study period, 173 were treated with antibiotics. Fifty-seven (32.9%) of the subjects treated with antibiotics had a rash during their illness compared with 15 (23.1%) in untreated patients (P = .156; not significant). Amoxicillin was associated with the highest incidence of antibiotic-induced rash occurrence (29.5%, 95% confidence interval: 18.52–42.57), but significantly lower than the 90% rate reported for ampicillin in past studies. Age, gender, ethnicity, and atopic or allergic history were not associated with the development of rash after antibiotic exposure. Among the laboratory data, only increased white blood cell counts were more prevalent among subjects who did not develop an antibiotic-induced rash.  

CONCLUSIONS: The incidence of rash in pediatric patients with AIM after treatment with the current oral aminopenicillin (amoxicillin) is much lower than originally reported. 

10. Images in Clinical Medicine 

Rubella Rash

Pellets in the Appendix

Uveoparotid Fever

Cutaneous Loxoscelism

Unblinded by the Lights

Quincke's Pulse

11. Neutral versus Retracted Shoulder Position for Infraclavicular Subclavian Vein Catheterization 

R. Eleanor Anderson, MD, Ron M. Walls, MD, FRCPC, FAAEM reviewing  Kim HJ et al. Br J Anaesth 2013 Aug.     

Surprisingly, there was no benefit to the retracted shoulder position. 

Traditional patient positioning for infraclavicular subclavian vein catheterization involves placing a rolled towel or saline bag longitudinally between the scapulae to create a retracted shoulder position; however, there is little scientific evidence to support this practice. 

In a noninferiority study, researchers in Korea compared neutral shoulder and retracted shoulder positions during anatomical-landmark–guided catheterization of the subclavian vein in 362 patients (age range, 16–82) undergoing elective surgery. Patients were randomized to a neutral position, with head elevated on a 5-cm headrest, or a retracted position, with a 1-L bag of normal saline placed between the scapulae and head elevated on a 9-cm headrest. The primary endpoint was successful catheterization (aspiration of venous blood). Two experienced anesthesiologists were each allowed three attempts, with arterial puncture or air aspiration counted as failures. 

The patients' average body mass index was 24.1. Catheterization success rates did not differ significantly between groups (about 96%). Complication rates also did not differ significantly (arterial puncture, about 2%; pneumothorax, 0.6%). Older age was an independent risk factor for failure. 

Comment: The retracted shoulder position is unnecessary when performing blind infraclavicular subclavian venous catheterization in patients with normal body mass index. Extra precautions, and perhaps visualization, may be valuable adjuncts in elderly or obese patients. 

Citation(s): Kim HJ et al. Comparison of the neutral and retracted shoulder positions for infraclavicular subclavian venous catheterization: A randomized, non-inferiority trial. Br J Anaesth 2013 Aug; 111:191.  

12. Traumatic Intracranial Injury in Intoxicated Patients with Minor Head Trauma 

Easter JS, et al. Acad Emerg Med 2013;20:753-760.  

Studies focusing on minor head injury in intoxicated patients report disparate prevalences of intracranial injury. It is unclear if the typical factors associated with intracranial injury in published clinical decision rules for computerized tomography (CT) acquisition are helpful in differentiating patients with and without intracranial injuries, as intoxication may obscure particular features of intracranial injury such as headache and mimic other signs of head injury such as altered mental status. This study aimed to estimate the prevalence of intracranial injury following minor head injury (Glasgow Coma Scale [GCS] score ≥14) in intoxicated patients and to assess the performance of established clinical decision rules in this population. 

This was a prospective cohort study of consecutive intoxicated adults presenting to the emergency department (ED) following minor head injury. Historical and physical examination features included those from the Canadian CT Head Rule, National Emergency X-Radiography Utilization Study (NEXUS), and New Orleans Criteria. All patients underwent head CT. 

A total of 283 patients were enrolled, with a median age of 40 years (interquartile range [IQR] = 28 to 48 years) and median alcohol concentration of 195 mmol/L (IQR = 154 to 256 mmol/L). A total of 238 of 283 (84%) were male, and 225 (80%) had GCS scores of 15. Clinically important injuries (injuries requiring admission to the hospital or neurosurgical follow-up) were identified in 23 patients (8%; 95% confidence interval [CI] = 5% to 12%); one required neurosurgical intervention (0.4%, 95% CI = 0% to 2%). Loss of consciousness and headache were associated with clinically important intracranial injury on CT. The Canadian CT Head Rule had a sensitivity of 70% (95% CI = 47% to 87%) and NEXUS criteria had a sensitivity of 83% (95% CI = 61% to 95%) for clinically important injury in intoxicated patients. 

In this study, the prevalence of clinically important injury in intoxicated patients with minor head injury was significant. While the presence of the common features associated with intracranial injury in nonintoxicated patients should raise clinical suspicion for intracranial injury in intoxicated patients, the Canadian CT Head Rule and NEXUS criteria do not have adequate sensitivity to be applied in intoxicated patients with minor head injury. 

13. Telemedicine consultations significantly improve pediatric care in rural ERs 

Telemedicine consultations with pediatric critical-care medicine physicians significantly improve the quality of care for seriously ill and injured children treated in remote rural emergency rooms, where pediatricians and pediatric specialists are scarce, a study by researchers at UC Davis Children's Hospital has found. 

The study also found that rural emergency room physicians are more likely to adjust their pediatric patients' diagnoses and course of treatment after a live, interactive videoconference with a specialist. Parents' satisfaction and perception of the quality of their child's care also are significantly improved when consultations are provided using telemedicine, rather than telephone, and aid emergency room treatment, the study found. The research is published earlier this month in Critical Care Medicine. 

"The bottom line is that this readily available technology can and should be used to improve the quality of care delivered to critically ill children when there are no pediatric specialists available in their own communities," said James Marcin, director of the UC Davis Children's Hospital Pediatric Telemedicine Program and the study's senior author. 

"People say a picture is worth a thousand words," said Marcin, professor in the Department of Pediatrics, "With medicine, video conferencing brings us right to the bedside, allowing us to see what's happening and collaborate with on-site doctors to provide the best possible care to our patients." 

The use of technology to link far-distant practitioners has been steadily increasing in American medicine, particularly as a tool to provide rural and underserved communities with access to specialty physicians. More recently, telemedicine has been used for consultations to emergency rooms, and is particularly recommended for use in the area of stroke care. 

Despite the expansion of telemedicine, studies of its effect on the quality of medical care remain scarce, with publications mostly limited to anecdotal reports or issues of technological feasibility and its potential to reduce health care costs. The researchers sought to measure the impact of telemedicine consultations compared to other modes of treatment, such as telephone consultations, or treatment without consultations.  

The study involved 320 seriously ill or injured patients 17 years old and younger. The patients were treated at five rural Northern California emergency departments between 2003 and 2007. The rural hospitals' emergency departments were equipped with videoconferencing units to facilitate telemedicine consultations. The interactive audiovisual communications involved the rural emergency room physicians, pediatric critical-care medicine specialists at UC Davis Children's Hospital, nurses, the patients and their parents. 

Fifty-eight consultations were conducted using telemedicine consultations and 63 consultations were conducted using telephone; 199 participants did not receive specialist consultations. The researchers compared the quality of care, accuracy of diagnosis and course of treatment, and overall satisfaction for all of the patients included in the study. Quality of care was evaluated using medical record review by two independent, unbiased emergency medicine physician experts. 

Overall, cases involving a telemedicine consultation received significantly higher quality-of-care scores than did those involving a telephone consultation or no consultation. In addition, rural emergency room physicians were far more likely to change their diagnosis and treatment plans when consultations were provided using telemedicine, rather than telephone. Parents' satisfaction and perception of the quality of care also were significantly greater when telemedicine was used, compared to telephone guidance. 

Madan Dharmar, assistant research professor in the pediatric telemedicine program and lead author of the study, said the results underscore the important role telemedicine can play in rural emergency departments, which often lack specialists and tools needed to treat pediatric patients, such as specially sized pediatric ventilators, to treat critically ill children. While 21 percent of children in the United States live in rural areas, only 3 percent of pediatric critical-care medicine specialists practice in such areas, Dharmar said. 

"This research is important," Dharmar said, "because it is one of the first published studies that has evaluated the value of telemedicine against the current standards of care from three different viewpoints—the emergency room physician; the parents of the patients; and the actual quality of care and patient outcome." 

He noted that future research efforts will focus on how telemedicine can affect patient safety and cut health care costs, by reducing the numbers of children unnecessarily transported to tertiary care hospitals in metropolitan areas. 

Founded under Marcin's leadership, the UC Davis pediatric critical-care telemedicine program is the first of its kind in the United States. He said that, in partnership with the UC Davis Center for Health and Technology, more than 5,500 pediatric telemedicine consultations have been provided to rural hospitals throughout Northern California. 

14. Blood Culture Results Do Not Affect Treatment in Complicated Cellulitis 

Paolo WF, et al. J Emerg Med. 2013;45:163-167.  

Cellulitis, a frequently encountered complaint in the Emergency Department, is typically managed with antibiotics. There is some debate as to whether obtaining blood cultures and knowing their results would change the management of cellulitis, although most authors argue that information from blood cultures does not change the empirical management of uncomplicated cellulitis. However, for complicated cellulitis (as defined by the presence of significant comorbidity), there is considerable disagreement and lack of evidence as to the utility of blood cultures. 

Our aim was to determine the role of blood cultures in the management of complicated cellulitis. 

This retrospective chart review assessed the utility of obtaining blood cultures in complicated cellulitis (as defined by active chemotherapy, dialysis, human immunodeficiency virus/acquired immune deficiency syndrome, diabetes, or organ transplantation) vs. a cohort of individuals without medical comorbidity. 

Six hundred and thirty-nine patients were identified, 314 of which were deemed cases and 325 controls. Within the cases, 29 of 314 returned as positive blood cultures vs. 17 of 325 positive blood culture controls within the cases (p = 0.05; odds ratio = 1.84; 95% confidence interval 0.99–3.43). A clinically significant change in management (a change in the class of antibiotic) was found in 6 of 314 cases vs. 4 of 325 controls (p = 0.578; odds ratio = 1.5525; 95% confidence interval 0.434–5.5541). 

Within this cohort of patients with complicated cellulitis, blood cultures rarely changed management from empirical coverage. 

15. Frequent Neurological Assessment Alone May Justify Intensive Care for ICH 

Maas MB, et al. Surveillance neuroimaging and neurologic examinations affect care for intracerebral hemorrhage. Neurology. 2013;81(2):107-12. 

OBJECTIVE: We tested the hypothesis that surveillance neuroimaging and neurologic examinations identified changes requiring emergent surgical interventions in patients with intracerebral hemorrhage (ICH). 

METHODS: Patients with primary ICH were enrolled into a prospective registry between December 2006 and July 2012. Patients were managed in a neuroscience intensive care unit with a protocol that included serial neuroimaging at 6, 24, and 48 hours, and hourly neurologic examinations using the Glasgow Coma Scale and NIH Stroke Scale. We evaluated all cases of craniotomy and ventriculostomy to determine whether the procedure was part of the initial management plan or occurred subsequently. For those that occurred subsequently, we determined whether worsening on neurologic examination or worsened neuroimaging findings initiated the process leading to intervention. 

RESULTS: There were 88 surgical interventions in 84 (35%) of the 239 patients studied, including ventriculostomy in 52 (59%), craniotomy in 21 (24%), and both in 11 (13%). Of the 88 interventions, 24 (27%) occurred subsequently and distinctly from initial management, a median of 15.9 hours (8.9-27.0 hours) after symptom onset. Thirteen (54%) were instigated by findings on neurologic examination and 11 (46%) by neuroimaging. Demographics, severity of hemorrhage, and hemorrhage location were not associated with delayed intervention. 

CONCLUSIONS: More than 25% of surgical interventions performed after ICH were prompted by delayed imaging or clinical findings. Serial neurologic examinations and neuroimaging are important and effective surveillance techniques for monitoring patients with ICH. 

16. CT c IV Contrast Alone: The Role of Intra-abdominal Fat on the Ability to Visualize the Normal Appendix in Children 

Garcia M, et al. for the Pediatric Emergency Care Applied Research Network (PECARN). Acad Emerg Med. 2013;20:795-800. 

Computed tomography (CT) with enteric contrast is frequently used to evaluate children with suspected appendicitis. The use of CT with intravenous (IV) contrast alone (CT IV) may be sufficient, however, particularly in patients with adequate intra-abdominal fat (IAF).

The authors aimed 1) to determine the ability of radiologists to visualize the normal (nondiseased) appendix with CT IV in children and to assess whether IAF adequacy affects this ability and 2) to assess the association between IAF adequacy and patient characteristics. 

This was a retrospective 16-center study using a preexisting database of abdominal CT scans. Children 3 to 18 years who had CT IV scan and measured weights and for whom appendectomy history was known from medical record review were included. The sample was chosen based on age to yield a sample with and without adequate IAF. Radiologists at each center reread their site's CT IV scans to assess appendix visualization and IAF adequacy. IAF was categorized as “adequate” if there was any amount of fat completely surrounding the cecum and “inadequate” if otherwise. 

A total of 280 patients were included, with mean age of 10.6 years (range = 3.1 to 17.9 years). All 280 had no history of prior appendectomy; therefore, each patient had a presumed normal appendix. A total of 102 patients (36.4%) had adequate IAF. The proportion of normal appendices visualized with CT IV was 72.9% (95% confidence interval [CI] = 67.2% to 78.0%); the proportions were 89% (95% CI = 81.5% to 94.5%) and 63% (95% CI = 56.0% to 70.6%) in those with and without adequate IAF (95% CI for difference of proportions = 16% to 36%). Greater weight and older age were strongly associated with IAF adequacy (p less than 0.001), with weight appearing to be a stronger predictor, particularly in females. Although statistically associated, there was noted overlap in the weights and ages of those with and without adequate IAF. 

Protocols using CT with IV contrast alone to visualize the appendix can reasonably include weight, age, or both as considerations for determining when this approach is appropriate. However, although IAF will more frequently be adequate in older, heavier patients, highly accurate prediction of IAF adequacy appears challenging solely based on age and weight. 

17. Why is ED Holding Still an Issue?  

by Richard Bukata, MD. EP Monthly, July 30, 2013  

Boarding admitted patients in the ED is as bad for patient care as it is for the hospital’s bottom line. So why aren’t more CEOs bringing this pervasive problem to an end?  

I think if you ask most emergency physicians who work in dysfunctional emergency departments (many) what is the greatest source of their angst, they would say it is the holding of admitted patients. 

The literature on this subject is very extensive (reflecting how serious a problem holding is). All manner of solutions have been suggested yet holding continues to cripple the ED.

Holding of ED patients is a widespread problem and is likely to get worse when the EDs are flooded by newly insured individuals as the result of the Affordable Care Act coupled with the graying of America and the transition of the baby boomers into large consumers of healthcare.
 Why does this problem still exist? Is holding an insoluble problem? Hard to conceive that it is. We have solved all sorts of more difficult problems than ED holding. How about smart phones, air travel, robotic surgery, cars that drive themselves, solar power airplanes, man on the moon. So what’s the big deal about ED holding?

The case to fix ED holding is compelling. Holding patient in the ED consumes nurse and physician time and precludes the ability to see more patients due to the blocking of an ED bed. Decreasing the ability to see and treat patients is costly (assuming there are patients waiting to be seen).  

Conservatively, every new patient who is discharged (representing about 80% of patients in most EDs), generates about $600 -- $100 for the physician and $500 for the hospital. See 2.5 patients per hour and it is $1500.  Hold a patient for six hours and it’s $9,000 in hard cash (not billings but actual collections). Hold multiple patients and there’s a lot more patients who can’t be efficiently treated in the ED (better hope there is no urgent care center in the area). If you can’t see the patients someone else will be happy to. There are about 9,000 urgent care centers in the country and the number is rising rapidly. 

Patients held in the ED generate essentially no additional money after the work-up and initial treatment are over and the patient is just tying up an ED bed – but they do take up nursing and to a lesser extent, physician time. That is assuming the patient is stable. If the patient being held is an ICU patient there is likely substantially more nursing and physician work. 

18. CT Scans Still Common in Pediatric HA Evaluation 

F. Bruder Stapleton, MD. Journal Watch Emerg Med 2013   

Despite current practice guidelines, CT scans are still ordered in emergency departments and pediatric practices. 

The American Academy of Pediatrics, among other professional societies, recommends against the use of computed tomography (CT) scans in the evaluation of childhood headache. To determine the frequency of CT scans used to diagnose pediatric headache, investigators retrospectively analyzed U.S. insurance claims data for 15,836 children (age range, 3–17 years) with at least two claims for headaches in 2007 through 2008. 

CT scans were performed in 25% of the children, typically in the month following the initial evaluation. The initial diagnostic categorization of the type of headache did not appear to influence whether CT was ordered, and the pre- and post-CT diagnostic headache category did not change for most patients. Among practitioners, neurologists were less likely and family practitioners were more likely to order CT scans. Evaluation in an emergency department (ED) increased the likelihood of CT evaluation for headache; however, two thirds of the children who underwent CT scans in this cohort had not been evaluated in an ED for headache 

Radiation from computed tomography increases risk for cancer in children (NEJM JW Pediatr Adolesc Med Jul 2 2013). CT scans are seldom helpful or necessary in the evaluation of children with headache; by limiting CT scans for evaluation of childhood headache, we can make a large contribution to efforts to reduce radiation exposure by eliminating unnecessary CT scans. 

Citation(s): DeVries A et al. CT scan utilization patterns in pediatric patients with recurrent headache. Pediatrics 2013 Jul; 132:e1.  

19. What is the clinical significance of chest CT when the CXR result is normal in patients with blunt trauma? 

Kea B, et al. Amer J Emerg Med. 2013;31:1268-73. 

Computed tomography (CT) has been shown to detect more injuries than plain radiography in patients with blunt trauma, but it is unclear whether these injuries are clinically significant. 

Study Objectives
This study aimed to determine the proportion of patients with normal chest x-ray (CXR) result and injury seen on CT and abnormal initial CXR result and no injury on CT and to characterize the clinical significance of injuries seen on CT as determined by a trauma expert panel. 

Patients with blunt trauma older than 14 years who received emergency department chest imaging as part of their evaluation at 2 urban level I trauma centers were enrolled. An expert trauma panel a priori classified thoracic injuries and subsequent interventions as major, minor, or no clinical significance. 

Of 3639 participants, 2848 (78.3%) had CXR alone and 791 (21.7%) had CXR and chest CT. Of 589 patients who had chest CT after a normal CXR result, 483 (82.0% [95% confidence interval [CI], 78.7-84.9%]) had normal CT results, and 106 (18.0% [95% CI, 15.1%-21.3%]) had CTs diagnosing injuries—primarily rib fractures, pulmonary contusion, and incidental pneumothorax. Twelve patients had injuries classified as clinically major (2.0% [95% CI, 1.2%-3.5%]), 78 were clinically minor (13.2% [95% CI, 10.7%-16.2%]), and 16 were clinically insignificant (2.7% (95% CI, 1.7%-4.4%]). Of 202 patients with CXRs suggesting injury, 177 (87.6% [95% CI, 82.4%-91.5%]) had chest CTs confirming injury and 25 (12.4% [95% CI, 8.5%-17.6%]) had no injury on CT.

Chest CT after a normal CXR result in patients with blunt trauma detects injuries, but most do not lead to changes in patient management. 

20. Heart Disease Overlooked in Women   

Coronary artery disease continues to be neglected in women, despite it killing at least as many women as men, researchers found.  

By Chris Kaiser, Cardiology Editor, MedPage Today. Jul 28, 2013  

Coronary artery disease (CAD) continues to be neglected in women, despite it killing at least as many women as men, a state-of-the-art review found. In addition, women are less likely to receive preventive therapies, such as lipid-lowering therapies and lifestyle advice compared with men at a similar risk level, according to Martha Gulati, MD, and Kavita Sharma, MD, from The Ohio State University in Columbus. 

"CAD is a leading cause of death of women and men worldwide. Yet CAD's impact on women traditionally has been underappreciated due to higher rates at younger ages in men," they wrote. Women are disproportionately affected by microvascular coronary disease and they have unique risk factors for CAD, including those related to pregnancy and autoimmune disease, they wrote in a review in this month's edition of Global Heart, the journal of the World Heart Federation. 

In their review, the authors summarized "the current state of knowledge about women and CAD," including risk assessment, unique sex-specific CAD characteristics, and management strategies in 2013. CT scans and other imaging techniques show that women have narrower coronary arteries than do men, and are more likely to suffer CAD due to microvascular disease. So while appearing not to have major coronary artery obstructions, women suffer symptoms due to blockages of these smaller vessels. 

Women without obstructive CAD suffer repeated hospitalizations and testing due to symptoms of ischemia. In contrast, obstructive CAD is more commonly found in men who are symptomatic and can be treated with aggressive medical therapy or stenting. This type of CAD is less frequently seen in women. Pooled estimates from multiple countries revealed that women, both pre- and postmenopausal, are also 20% more likely to suffer angina than men (pooled sex ratio of angina prevalence 1.20, 95% CI 1.14-1.28, P less than 0.0001). 

"Trial data indicate that CAD should be managed differently in women," they said. Specifically, more women than men die of CAD, and more women have died of CAD than of cancer, including breast cancer, chronic lower respiratory disease, Alzheimer's's disease, and accidents combined. 

Overall, rates of CAD have declined by 30% in the last decade, but rates have actually increased in women younger than 55, researchers said. Despite these known facts, women are still less likely to receive preventive recommendations, such as lipid-lowering therapy, aspirin, and lifestyle advice, than are men at a similar risk level, Gulati and Sharma pointed out. In terms of coronary artery bypass grafting (CABG), female sex is an independent risk factor for morbidity and mortality, the authors also noted. "Women have a higher risk of morbidity and mortality and they experience less relief from angina than do men after CABG, despite comprising less than 30% of the CABG population," they explained, adding that this sex discrepancy seems to be reduced when an off-pump CABG is performed. 

Traditional risk factors such as age, family history of CAD, hypertension, diabetes, dyslipidemia, smoking, and physical inactivity are important predictors of risk in women. Yet, women tend to a dramatic increase in CAD after the age of 60, in contrast to men who tend to have a more linear increase in CAD as they age. This difference in the development of CAD creates a situation where the disease isn't identified until much later in the course of the disease. 

There also are risk factors that appear to affect men and women differently. Obesity, for example, increases the risk of CAD by 64% in women but by only 46% in men. Younger women (less than 50 years) who experience a CAD-related myocardial infarction (MI) are twice as likely to die as men in similar circumstances, researchers noted. And as women age, they continue to have notably different risk factors than men. Women over the age of 65 are more likely to die within the first year after an MI compared with men (42% versus 24%). Women are also more likely than men to suffer autoimmune diseases, raising their risk of CAD, as well as polycystic ovary syndrome, pre-eclampsia, and gestational diabetes, which can also ultimately increase risk of CAD in women. 

Another risk factor is breast cancer treatment, which has improved survival for this disease in its early stages, but "the gains are being attenuated by increasing CAD risk. Whether the increased CAD risk is due to the breast cancer therapies or to the disease itself -- which is associated with some of the same risk factors for CAD -- remains unknown," Gulati and Sharma wrote. 

Women unable to carry out basic physical fitness tests are three times more likely to develop CAD than fitter women. "Increasing physical activity is a key component of the World Heart Federation's 'Make a Healthy Heart Your Goal' campaign, running in partnership with this month's Women's European Football Championships, researchers pointed out. 

Such awareness is greatly needed, f0r women and healthcare providers alike, the researchers said. In 1997, only 30% of American women surveyed were aware that the leading cause of death in women is CAD; this increased to 54% in 2009. But in a survey performed in 2004, fewer than one in five physicians recognized that more women than men die each year from CAD. Furthermore, cardiac rehabilitation after heart attacks is underused, particularly in women, as demonstrated in numerous national studies. Women are 55% less likely to participate in cardiac rehabilitation than men are. 

"Increasing data demonstrate that some treatment strategies have sex-specific effectiveness," the investigators concluded. "Further research regarding the pathophysiology of CAD in women, diagnosis, and treatment strategies specific to women is required. CAD is not a 'man's only' disease, and we eagerly await future studies that examine its unique presence in women." 

21. Doctors Tell Why They Got Sued

In this exclusive report, Medscape gives physicians an inside look at the experience of being sued for malpractice. Sample of key insights uncovered in this report:
·         74% of physicians were surprised they were sued
·         93% of physicians felt that saying 'I'm sorry' would not have helped
·         29% of physicians treat patients differently after going through a lawsuit 

22. Very Many Tib Bits 

A. New Guidelines: HIV Exposure at Work, Treat ASAP   

Healthcare workers exposed to HIV at work should immediately begin four weeks of post-exposure prophylaxis with three antiretroviral drugs, according to new recommendations.  

B. Hard Candy Not Always So Sweet for Kids     

Hard candy is a major cause of choking for children, according to the first multiyear, nationally representative study of food-related nonfatal choking injuries to kids.

C. Metoclopramide Risky for Kids?

Metoclopramide should be avoided whenever possible in children because of the drug’s neurological toxicity, the European Medicines Agency said.  

D. Landmark medical liability cap survives court challenge 

Physicians cheered a California appeals court ruling that upholds the constitutionality of the state’s Medical Injury Compensation Reform Act, reaffirming what physicians nationwide consider the gold standard among tort reforms. 

E. Elevated glucose elevates risk for dementia 

Our results suggest that higher glucose levels may be a risk factor for dementia, even among persons without diabetes. 

F. Changing Antibiotic Prescribing Practices through an Online Course 

Internet training achieved important reductions in antibiotic prescribing for respiratory-tract infections across language and cultural boundaries. 

G. Survey: Physician satisfaction depends on cultural attributes 

Data from a Physician Wellness Services/Cejka Search Organizational Culture Survey showed cultural fit affects physician satisfaction, recruitment and retention. Respectful and transparent communication and a focus on patient-centered care and teamwork were among the top cultural attributes ranked by physicians   

H. Opinions on Medical Marijuana 

2. Dr Sanjay Gupta
CNN's chief medical expert Sanjay Gupta announced [earlier this month] that he has reversed his blanket opposition to marijuana use. 

I. Predictors of severe H1N1 infection in children presenting within Pediatric Emergency Research 

Dalziel SR, et al. Networks (PERN): retrospective case-control study. BMJ 2013;347:f4836.  

J. Probiotics Do Not Reduce Diarrhea Risk in Large Trial 

Probiotic supplements did not prevent antibiotic-associated diarrhea (AAD) or Clostridium difficile diarrhea (CDD) in a large randomized, double-blind, placebo-controlled trial. 

K. Docs don't follow guidelines for treating back pain 

Many physicians don't adhere to treatment guidelines for patients with back pain, according to a study published in JAMA Internal Medicine. Researchers looked at data from almost 24,000 medical visits in the U.S. from 1999 to 2010 and found that the proportion of back pain patients given potentially addictive narcotics and screened with CT or MRI increased during the period. 

L. One Quarter of MIs Are Type 2, by Novel Criteria 

NEW YORK (Reuters Health) Jul 26 - One fourth of all myocardial infarctions are secondary to ischemia due to either increased oxygen demand or decreased supply (type 2), when diagnosed by the use of novel clinical criteria developed by Danish cardiologists. 

Dr. Lotte Saaby from the cardiology department at Odense University Hospital and colleagues say common mechanisms causing type 2 MI are anemia, respiratory failure, and tachyarrhythmias. And roughly 50% of patients with type 2 MI [which equates to 1/8 of all AMIs] have no significant coronary artery disease.