1. A 2-Hour Diagnostic Protocol
for Possible Cardiac CP in the ED: A RCT
Than M, et al. JAMA Intern Med 2013. October 07, 2013 [Epub ahead of print]
Importance
Patients with chest pain represent a high health care burden, but it may
be possible to identify a patient group with a low short-term risk of adverse
cardiac events who are suitable for early discharge.
Objective
To compare the effectiveness of a rapid diagnostic pathway with a
standard-care diagnostic pathway for the assessment of patients with possible
cardiac chest pain in a usual clinical practice setting.
Design, Setting, and Participants A single-center, randomized parallel-group
trial with blinded outcome assessments was conducted in an academic general and
tertiary hospital. Participants included adults with acute chest pain
consistent with acute coronary syndrome for whom the attending physician
planned further observation and troponin testing. Patient recruitment occurred
from October 11, 2010, to July 4, 2012, with a 30-day follow-up.
Interventions
An experimental pathway using an accelerated diagnostic protocol
(Thrombolysis in Myocardial Infarction score, 0; electrocardiography; and 0-
and 2-hour troponin tests) or a standard-care pathway (troponin test on arrival
at hospital, prolonged observation, and a second troponin test 6-12 hours after
onset of pain) serving as the control.
Main Outcomes and Measures Discharge from the hospital within 6 hours
without a major adverse cardiac event occurring within 30 days.
Results
Fifty-two of 270 patients in the experimental group were successfully
discharged within 6 hours compared with 30 of 272 patients in the control group
(19.3% vs 11.0%; odds ratio, 1.92; 95% CI, 1.18-3.13; P = .008). It required 20
hours to discharge the same proportion of patients from the control group as
achieved in the experimental group within 6 hours. In the experimental group,
35 additional patients (12.9%) were classified as low risk but admitted to an
inpatient ward for cardiac investigation. None of the 35 patients received a
diagnosis of acute coronary syndrome after inpatient evaluation.
Conclusions and Relevance Using the accelerated diagnostic protocol in
the experimental pathway almost doubled the proportion of patients with chest
pain discharged early. Clinicians could discharge approximately 1 of 5 patients
with chest pain to outpatient follow-up monitoring in less than 6 hours. This diagnostic
strategy could be easily replicated in other centers because no extra resources
are required.
Addenda
Earlier study by this group on the accelerated
diagnostic protocol: http://www.ncbi.nlm.nih.gov/pubmed/22578923
Editor’s note: Patients deemed low-risk by
the ADP and eligible for expedited ED discharge were “required to return for a
confirmatory stress test, generally within 24 hours, as a separate visit.”
Replication of these results will require both arms of the intervention: ED
assessment and reliable timely outpatient testing.
2. Rapid Evaluation of CP in the ED
(Editorial on Than study above)
Rahko PS. JAMA Intern Med 2013. October 07, 2013 [Epub ahead of print]
Chest pain is responsible for more than 8
million visits to emergency departments (EDs) each year in the United States.
This diagnosis presents a large burden on the ED, acute care hospitals, and
overall resources dedicated to medical care. In this era of shrinking
resources, increased efficiency of initial evaluation and safe discharge
directly from the ED of patients at very low risk has the potential of reducing
unnecessary admissions, thereby reducing significant costs.1 Inadvertent
discharge of patients presenting with chest pain is a constant fear of ED
physicians, and the dire consequences of an acute coronary event drives the
desire for substantial testing to achieve a high level of certainty for a
negative diagnosis.
Current guidelines2 emphasize (1) rapid
determination of the likelihood that the presentation represents acute coronary
artery disease and (2) rapid assessment of the immediate risk for a major
adverse cardiac event (MACE). The cornerstone of treatment is a rapid history,
focused physical examination, 12-lead electrocardiogram (ECG), and laboratory
tests for biomarkers. This strategy quickly detects ongoing ST-elevation
myocardial infarction, for which highly sophisticated triage and intervention
systems exist, and ongoing non–ST-elevation myocardial infarction presenting
with ECG signatures of ischemia and/or immediately positive biomarkers. These
are the straightforward cases; unfortunately, they may account for only 25% of
acute chest pain presentations to EDs.3
The dilemma is what to do with the other 75%
of acute chest pain presentations. Contemporary studies1 have shown that many
patients at very low risk (less than 5% probability of MACE) who are
identifiable by symptoms, physical examination, and an ECG demonstrating no
abnormalities can be safely discharged from the ED and continue their
evaluation as outpatients, with an expected risk of MACE of 2.5% over 30 days.
Patients perceived to be at intermediate risk require more intensive scrutiny.
Current guidelines4 suggest that these patients are candidates for ongoing
observation in chest pain units or hospital admission to rule out myocardial
infarction. The guidelines are based on use of fourth-generation troponin T
levels, which when used alone seem to work just as well as troponin T levels
combined with older markers, such as the myocardial band isoenzyme of creatine
kinase and myoglobin. It is suggested that patients who present to the ED
within 6 hours of the onset of symptoms be placed in observation until at least
8 to 12 hours from the onset of initial symptoms, when a follow-up ECG and
biomarker tests can be obtained to maximize the chance that the test results
became positive. This strategy is then followed at the end of the observation
period with some type of confirmatory stress test, the purpose being to lower
the risk to a level at which it is safe to discharge the patient. Although very
safe, the strategy is time and resource intensive. This has led to a search for
alternative strategies to speed the evaluation and care of patients with chest
pain while maintaining the same level of patient safety from MACE.
Investigators from Christchurch, New Zealand,
report a randomized clinical trial of an accelerated 2-hour diagnostic protocol
(ADP) for evaluation of possible cardiac chest pain. This study is a natural
continuation of information acquired in the 2-Hour Accelerated Diagnostic
Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary
Troponins as the Only Biomarker (ADAPT) trial.5 The ADAPT was a prospective
observational study of 1975 patients that used the modified Thrombolysis in
Myocardial Infarction score to help risk stratify the history, a 12-lead ECG at
0 and 2 hours, and troponin levels at 0 and 2 hours. Patients were monitored
for 30 days for MACE. The protocol identified 392 patients as low risk, and
only 1 individual had a MACE during the next 30 days, for a negative predictive
value of 99.7%. However, this was an observational study; the investigators
could not control interventions, and 74% of the experimental group had further
diagnostic testing, with some having therapeutic (18.3%) or procedural (2.0%)
interventions during the follow-up. The authors hypothesized that their ADP
could rapidly triage perhaps 20% of patients presenting to EDs with chest pain,
avoiding hospitalization or prolonged observation.
The present study6 used a similar strategy.
The investigators identified patients with a modified Thrombolysis in
Myocardial Infarction score of 0 and used immediate and 2-hour ECGs and
laboratory troponin I levels for their ADP. Patients were randomized to the ADP
or conventional guideline-driven therapy of more prolonged observation and a
second ECG and troponin 6 to 12 hours after symptom onset. Criteria for success
were discharging the patient home within 6 hours of presentation and no MACE
for the next 30 days. Of a total of 542 randomized patients, 19.3% of the ADP
group and 11.0% of the standard-care group were discharged within 6 hours.
Interestingly, an additional 35 patients in the ADP group were classified as
low risk and could have been discharged but were admitted to the hospital by
their attending physician (who apparently did not trust the ADP). None of these
patients had a MACE. A unique part of this trial was that patients were
required to return for a confirmatory stress test, generally within 24 hours,
as a separate visit. One patient in the ADP group and no patients in the
standard-care group developed a MACE over the next 30 days. The patient who
developed a MACE should have been identified by the protocol as higher risk but
was not because of a clinical error.
Taken together, the ADAPT observational trial
and the present trial suggest that a successful strategy can be devised to
rapidly identify and process patients at low risk for an acute coronary
syndrome. If followed, this strategy might empower more clinicians to discharge
low-risk patients home rapidly from the ED. In my institution, the ADP would
reduce charges by 50% compared with a conventional 1-day admission to rule out
myocardial infarction. Can this particular ADP be applied widely? Yes, because
it uses commonly and readily available infrastructure, it could be initiated
immediately. Can this protocol be further improved? Yes, the current
infrastructure of many medical centers and their EDs are already set up to
allow immediate confirmatory stress testing with or without imaging or,
alternatively in selected patients, computed tomography angiography. This makes
rapid testing more practical and easier for all concerned. It also gives the ED
physician a higher level of confidence for discharge by lowering the risk of
MACEs to less than 5%.
Can an even more rapid ADP be devised?
Probably, because biomarkers under investigation hold promise for immediate
diagnosis of cardiac ischemia. New data suggest that a single blood sample of
high-sensitivity troponin and a new biomarker copeptin obtained at entry into
the ED might allow immediate triage of patients, further reducing the number of
patients needing prolonged observation or admission.4,7 However, with increased
sensitivity comes reduced specificity. We may see a further increase in ED
visits by patients with minute elevations of biomarkers yet no evidence of
coronary heart disease. More challenges are clearly ahead for evaluating
patients with chest pain in the ED.
3. The Diagnostic Yield of Cardiac Catheterization
in Low-Risk Troponinemia
Stripe B, et al. JAMA Intern Med 2013. October 07, 2013 [Epub ahead of print]
Serum cardiac troponin I (cTnI) is a
sensitive indicator of myocardial necrosis.1 However, many disease states can
result in an elevated cTnI level without clinical evidence of myocardial
infarction,2 resulting in possible misdiagnosis of epicardial coronary artery
disease (CAD).3 In the present study, we investigated the prevalence of CAD and
associated patient characteristics in patients with mildly elevated cTnI levels
without clinical evidence of acute coronary syndrome.
Methods
This was a single center, retrospective
cohort study that examined patients 18 years or older who presented with a peak
cTnI level between 0.05 ng/mL (above 99th percentile of normal population) and
2 ng/mL (nanograms per milliliter to micrograms per liter is a 1-to1
conversion) within 30 days prior to coronary angiography. Patients were
excluded if they had chest pain with cardiac features, a history of known CAD,
or ischemic changes on electrocardiography or stress test.
Baseline characteristics recorded included
age, sex, history of heart failure, diabetes, dyslipidemia, peripheral vascular
disease, lung disease, smoking, kidney disease, hypertension, and pulmonary
hypertension, as well as data related to the index episode such as level of
peak troponin, B-type natriuretic peptide (BNP) level, left ventricular
ejection fraction, and hemoglobin and serum creatinine levels.
The primary end point was the presence of
significant CAD, defined as 50% or greater left main stenosis, 70% or greater
stenosis of another epicardial coronary artery, or fractional flow reserve of
less than 0.8. Secondary end points were revascularization by percutaneous
coronary intervention or coronary artery bypass grafting. The final presumed
cause of elevated troponin level was also assessed.
Results
Of 140 patients, 16 (11%) were found to have
significant CAD. Of these patients, 12 underwent revascularization, 10 with
percutaneous coronary intervention and 2 via coronary artery bypass grafting.
Patients with CAD were older (P = .006), with none younger than 49 years.
Patients with CAD were more likely to have a presenting symptom of syncope
(P = .02) or have evidence of a new arrhythmia (P = .003 by univariate analysis
and P = .03 after multiple regression analysis) (Table 1). Patients with
diabetes were more likely to have CAD (P = .01) by univariate analysis. A
history of stroke was associated with CAD, but only after multiple regression
analysis (P = .04). Notably, factors such as sex, smoking history, heart
failure, dyslipidemia, and hypertension were not associated with CAD.
The majority of patients (58.9%) without
significant CAD had an elevated troponin level associated with heart failure
(Table 2). Fluid or pressure overload states—including heart failure,
hypertensive emergency, pulmonary hypertension, hypertrophic cardiomyopathy, or
significant aortic valve disease—accounted for 81.5% of the patients without
CAD. Other causes of “troponinemia” included increased oxygen demand due to
infection, tachycardia, or sympathomimetic abuse such as cocaine or
methamphetamine.
Discussion
The use of sensitive biomarkers such as cTnI
is becoming more widespread, with as many as 50% of hospitalized patients
having a troponin test ordered during their hospitalization.4 Given the need to
limit ineffective medical testing and associated costs and risks of cardiac
catheterization (estimated at a complication rate of approximately 1.7%5 and
$5000 for an outpatient procedure6), it is imperative to appropriately triage
patients with low-level elevations of troponin in the absence of clinical acute
coronary syndrome. Some of the risk factors identified by this study were
diabetes, age, chronic kidney disease, and disease of other vascular beds;
however, in this population, other risk factors such as syncope and
supraventricular tachyarrhythmia appear to confer increased risk as well.
Appropriate management of patients with low-level elevations of troponin should
consider the pretest probability of CAD and the likelihood that most patients
in this population do not have significant CAD.
4. Gunshot Wounds to the Brain: Improving
Survival
A new resuscitation policy was associated
with a survival increase from 10% to 46% at a single trauma center.
Cheryl Lynn Horton, MD, Journal Watch,
Emergency Medicine, October 7, 2013.
Gunshot wounds to the brain are usually
fatal, with reported survival rates of 7% to 15%. In 2008, a trauma center in
Arizona instituted a new aggressive resuscitation policy that involved treating
all patients with gunshot wounds to the brain with one or more of blood
products (1:1 red blood cells to fresh frozen plasma), hyperosmolar therapy,
and vasopressors, prothrombin complex concentrate, or both, to correct
coagulopathy.
To determine if survival rates improved,
researchers retrospectively reviewed 132 records for 132 patients between 2007
and 2011.The overall survival rate was 30%, with rates increasing yearly from
10% in 2008 to 46% in 2011. Survivors had higher initial systolic blood
pressures (mean, 110 vs. 79 mm Hg), higher Glasgow Coma Scale (GCS) scores
(median, 8 vs. 3), and more unihemispheric injuries (60% vs. 17%). Survivors
had lower Injury Severity Scores (median, 16 vs. 23), head Abbreviated Injury
Scale scores (median, 4 vs. 5), and international normalized ratios (mean, 1.4
vs. 1.6). Aggressive management with blood products, hyperosmolar therapy, and
operative neurosurgical intervention were each independent predictors of
survival. At discharge, 20% of patients had GCS scores ≥13 and 58% had scores
≥9. Of survivors presenting with a GCS score between 3 and 5, 18% were
discharged with a GCS score above 8. Of the nonsurvivors, the number of organs
procured per donor increased from 1.3 to 2.8.
Comment: This single-center study
demonstrated improved survival rates with a blood product–focused resuscitation
policy for patients with gunshot wounds to the brain. While we await
multicenter studies for confirmation of these promising results, limiting use
of crystalloid in favor of red blood cells and fresh frozen plasma, using
hypertonic saline to reduce intracranial pressure, reversing coagulopathy, and
obtaining early neurosurgical consultation are all prudent measures when caring
for patients with gunshot wounds to the brain.
Citation(s): Joseph B et al. Improving
survival rates after civilian gunshot wounds to the brain. J Am Coll Surg 2013
Sep 18; [e-pub ahead of print]. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/24055384
5. HINTS Outperforms ABCD2 to Screen for
Stroke in Acute Continuous Vertigo and Dizziness
Newman-Toker DE, Acad Emerg Med
2013;20:986-996.
Objectives
Dizziness and vertigo account for about 4
million emergency department (ED) visits annually in the United States, and
some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke
diagnosis in ED patients with vertigo/dizziness is challenging because the
majority have no obvious focal neurologic signs at initial presentation. The
authors sought to compare the accuracy of two previously published approaches
purported to be useful in bedside screening for possible stroke in dizziness: a
clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and
a risk stratification rule (age, blood pressure, clinical features, duration of
symptoms, diabetes [ABCD2]).
Methods
This was a cross-sectional study of high-risk
patients (more than one stroke risk factor) with acute vestibular syndrome
(AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or
vomiting, head motion intolerance, and new gait unsteadiness) at a single
academic center. All underwent neurootologic examination, neuroimaging (97.4%
by magnetic resonance imaging [MRI]), and follow-up. ABCD2 risk scores (0–7
points), using the recommended cutoff of ≥4 for stroke, were compared to a
three-component eye movement battery (HINTS). Sensitivity, specificity, and
positive and negative likelihood ratios (LR+, LR–) were assessed for stroke and
other central causes, and the results were stratified by age. False-negative
initial neuroimaging was also assessed.
Results
A total of 190 adult AVS patients were
assessed (1999–2012). Median age was 60.5 years (range = 18 to 92 years;
interquartile range [IQR] = 52.0 to 70.0 years); 60.5% were men. Final
diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105
infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2
was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 4 for stroke had
sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR– of 0.62;
sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke
sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR– was 0.04
and did not vary by age. For any central lesion, sensitivity was 96.8%,
specificity was 98.5%, LR+ was 63.9, and LR– was 0.03 for HINTS, and
sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR– was 0.01
for HINTS “plus” (any new hearing loss added to HINTS). Initial MRIs were
falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained
before 48 hours after onset, and all were confirmed by delayed MRI.
Conclusions
HINTS substantially outperforms ABCD2 for
stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained
within the first 2 days after symptom onset. While HINTS testing has
traditionally been performed by specialists, methods for empowering emergency
physicians (EPs) to leverage this approach for stroke screening in dizziness
should be investigated.
6. Predicting Depth of Pediatric Central
Lines
Practical and easy to remember formulas
correctly predict catheter insertion depth in children.
Katherine Bakes, MD, Journal Watch Emergency Medicine, October 23,
2013
To develop simple formulas to predict optimal
insertion depth for left thoracic central venous catheters in children,
investigators retrospectively measured left internal jugular and subclavian
veins in 257 children (less than 13 years; median, 20 months) who underwent
chest computed tomography angiography.
Vein lengths were measured along the path of
standard central line placement, to the junction of the superior vena cava and
the right atrium (the optimum termination point for the catheter tip); the left
internal jugular vein was measured from the superior border of the left
clavicle, the left subclavian vein from the anterior border of the left
clavicle.
Based on these measurements, the
investigators derived formulas for optimal insertion depth: 0.07 × height (cm)
for the left internal jugular vein and 0.08 × height (cm) for the left
subclavian vein. These formulas predicted correct vein lengths in 99% and 94%
of the children, respectively. Optimal catheter depth for the right internal
jugular vein was measured from the anterior border of the right clavicle,
yielding a formula of 0.06 × height (cm), although this was not validated.
Comment These formulas are practical and easy to remember for predicting
optimal pediatric central line depths. The authors note that the distance from
the catheter insertion point to the clavicle should be added to the length
generated by the formulas.
Citation(s): Kim H et al. Predicting the
optimal depth of left-sided central venous catheters in children. Anaesthesia
2013 Oct; 68:1033. http://www.ncbi.nlm.nih.gov/pubmed/23889075
7. Intranasal Ketamine for Analgesia in the
ED: A Prospective Observational Series
Andolfatto G, et al. Acad Emerg Med.
2013;20:1050-1054.
Objectives
The objective was to examine the feasibility,
effectiveness, and adverse effect profile of intranasal ketamine for analgesia
in emergency department (ED) patients.
Methods
This was a prospective observational study
examining a convenience sample of patients aged older than 6 years experiencing
moderate or severe pain, defined as a visual analog scale (VAS) score of 50 mm
or greater. Patients received 0.5 to 0.75 mg/kg intranasal ketamine. Pain
scores were recorded on a standard 100-mm VAS by trained investigators at
baseline, then every 5 minutes for 30 minutes, and then every 10 minutes for an
additional 30 minutes. The primary outcome was the number and proportion of
patients experiencing clinically significant reductions in VAS pain scores,
defined as VAS reductions of 13 mm or more, within 30 minutes. Secondary
outcomes included the median reduction in VAS, the median time required to
achieve a 13 mm reduction in VAS, vital sign changes, and adverse events.
Continuous data are reported with medians and interquartile ranges (IQRs). The
Wilcoxon signed-ranks test was used to assess changes in VAS scores. Adverse
effects are reported with proportions and 95% confidence intervals (CIs).
Results
Forty patients were enrolled with a median age
of 47 years (IQR = 36 to 57 years; range = 11 to 79 years) for primarily
orthopedic injuries. A reduction in VAS of 13 mm or more within 30 minutes was
achieved in 35 patients (88%). The median change in VAS at 30 minutes was 34 mm
(44%). Median time required to achieve a 13 mm VAS reduction was 9.5 minutes
(IQR = 5 to 13 minutes; range = 5 to 25 minutes). No serious adverse effects
occurred. Minor adverse effects included dizziness (21 patients, 53%; 95% CI =
38% to 67%), feeling of unreality (14 patients, 35%; 95% CI = 22% to 50%),
nausea (four patients, 10%; 95% CI = 4% to 23%), mood change (three patients,
8%; 95% CI = 3% to 20%), and changes in hearing (one patient, 3%; 95% CI = 0%
to 13%). All adverse effects were transient and none required intervention.
There were no changes in vital signs requiring clinical intervention.
Conclusions
Intranasal ketamine reduced VAS pain scores
to a clinically significant degree in 88% of ED patients in this series.
Adverse effects were minor and transient. Intranasal ketamine may have a role
in the provision of effective, expeditious analgesia to ED patients.
8. A Curious Case of Chest Pain:
Interactive Case at NEJM
Aday AW, et al. N Engl J Med 2013; 369:e21
Interactive Case
A 67-year-old man presented to the emergency
department with chest pain. He had presented to the emergency department at
another hospital 10 days earlier with an episode of periumbilical discomfort,
nausea, and nonbloody emesis. At that time, laboratory tests revealed minor
thrombocytosis, and an abdominal computed tomographic (CT) scan, obtained after
the intravenous . . .
9. ED Pregnancy Testing for Adolescents
Pregnancy testing was performed in only 45%
of adolescent females presenting with potentially reproductive-related
complaints.
Katherine Bakes, MD, Journal Watch Emergency
Medicine, October 24, 2013
Investigators used a national survey of
hospital emergency departments (EDs) to determine frequency and patterns of
pregnancy testing in adolescents from 2005 to 2009. Of 11,431 visits identified
(representing 41 million U.S. ED visits for females ages 14 to 21 years), 21%
had pregnancy testing. Pregnancy testing was performed in only 45% of
adolescents with potential reproductive health complaints (lower abdominal,
pelvic, or genital pain; vaginal discharge or bleeding; or dysuria), and in
only 37% of adolescents exposed to teratogenic radiation from computed
tomography. Among visits for potential reproductive health complaints,
pregnancy testing was less likely in Hispanic than non-Hispanic black/African
American patients (adjusted odds ratio, 0.71), in admitted than discharged
patients (AOR, 0.35), and in the Northeast than the Midwest (AOR 0.56).
Comment: As the authors point out, there are
almost one million U.S. teen pregnancies annually, and more than 80% are
unintended. All post-pubertal female adolescents presenting to the emergency
department with symptoms that could be either explained or affected by
pregnancy should be tested.
Citation(s): Goyal M et al. Frequency of
pregnancy testing among adolescent emergency department visits. Acad Emerg Med
2013 Aug; 20:816.
10. Are We Caring for Trauma Patients in
the Wrong Place? Or in the Wrong Way?
The Cost of Overtriage: More than One-Third
Of Low-Risk Injured Patients Were Taken To Major Trauma Centers
Newgard CD, et al. Health Aff 2013;32:1591-1599.
Regionalized trauma care has been widely
implemented in the United States, with field triage by emergency medical
services (EMS) playing an important role in identifying seriously injured
patients for transport to major trauma centers.
In this study we estimated hospital-level
differences in the adjusted cost of acute care for injured patients transported
by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury
severity. Among 301,214 patients, the average adjusted per episode cost of care
was $5,590 higher in a level 1 trauma center than in a nontrauma hospital.
We found hospital-level differences in cost
among patients with minor, moderate, and serious injuries. Of the 248,342
low-risk patients—those who did not meet field triage guidelines for transport
to trauma centers—85,155 (34.3 percent) were still transported to major trauma
centers, accounting for up to 40 percent of acute injury costs. Adhering to
field triage guidelines that minimize the overtriage of low-risk injured
patients to major trauma centers could save up to $136.7 million annually in
the seven regions we studied.
11. Nation's Emergency Physicians Announce
List of Tests and Procedures To Question As Part of Choosing Wisely Campaign
SEATTLE, Oct. 14, 2013 /PRNewswire-USNewswire/
-- Dedicated to reducing health care costs and improving patient care, the
American College of Emergency Physicians (ACEP) today announced a list of five
tests and procedures that may not be cost effective in some situations and
should prompt discussion with patients in order to both educate them and gain
their agreement regarding avoidance of such tests and procedures, when
appropriate. These recommendations are
part of ACEP's participation in the ABIM Foundation's Choosing Wisely® campaign
and were made to more than 1,000 emergency physicians attending the Opening
Session of the organization's annual meeting in Seattle.
"Emergency physicians are dedicated to
improving emergency care and to reducing health care costs," said Alex
Rosenau, DO, FACEP, president of ACEP.
"These recommendations are evidence-based and developed with
significant input from experts."
The mission of "Choosing Wisely" —
a multi-year effort of the ABIM Foundation — is to promote conversations among
physicians and patients about using appropriate tests and treatments and
avoiding care when harm may outweigh benefits.
Since launching in April of 2012, more than 80 national, regional and
state medical specialty societies and consumer groups have become
"Choosing Wisely" partners.
ACEP officially joined the campaign in February.
ACEP's five recommendations were developed
through a multi-step process that included research and input from an expert
panel of emergency physicians and the ACEP Board of Directors. In 2012, ACEP appointed a Cost Effectiveness
Task Force, chaired by Dr. David Ross, an emergency physician in Colorado and
medical director for more than 50 EMS agencies in Colorado Springs. To develop the recommendations, the task
force conducted a survey of all ACEP members.
ACEP previously declined to participate in
the campaign because of potential conflicts of this approach with the unique
nature of emergency medicine as compared with office-based practices, and
because of concerns that advocacy for medical liability reform is missing from
the campaign.
"Overuse of medical tests is a serious
problem, and health care reform is incomplete without medical liability
reform," said Dr. Rosenau.
"Millions of dollars in defensive medicine are driving up the costs
of health care for everyone. We will
continue to encourage the ABIM Foundation and its many partners in this
campaign to lend their influential voices to the need for medical liability
reform."
"ACEP needed a strategy to determine
what emergency physicians could do to improve efficiency and reduce cost
without affecting the quality of care we deliver," said Dr. Ross. "The challenge also was to identify real
cost savings, but also to develop consensus among emergency physicians. Thanks to the participation of leaders in the
research community, such as Dr. Jeremiah Schuur, chair of the Delphi Panel, we
were able to accomplish this task."
The following are the five "Choosing
Wisely" recommendations approved by ACEP's Board of Directors:
1. Avoid
computed tomography (CT) scans of the head in emergency department patients
with minor head injury who are at low risk based on validated decision
rules. Minor head injury is a common
reason for visiting an emergency department.
The majority of minor head injuries do not lead to skull fractures or
bleeding in the brain — which would need to be diagnosed by a CT scan.
2. Avoid
placing indwelling urinary catheters in the emergency department for either
urine output monitoring in stable patients who can urinate on their own, or for
patient or staff convenience. These
catheters are used to assist when patients cannot urinate, to monitor how much
they urinate, or for patient comfort.
3. Don't
delay engaging available palliative and hospice care services in the emergency
department for patients likely to benefit.
This is medical care that provides comfort and relief for patients who
have chronic or incurable diseases.
Early referral from the emergency department to hospice or palliative
care services can benefit patients, resulting in both improved quality and
quantity of life.
4. Avoid
antibiotics and wound cultures in emergency department patients with
uncomplicated skin and soft tissue abscesses after successful incision and
drainage and with adequate medical follow-up.
Skin and soft tissue infections are a frequent reason for visiting an
emergency department. Some infections,
called abscesses, become walled off under the skin. Opening and draining the abscess is the
appropriate treatment; antibiotics offer no benefit.
5. Avoid
instituting intravenous IV fluids before doing a trail of oral rehydration
therapy in uncomplicated emergency department cases of mild to moderate
dehydration of children. Many children
who come to the emergency department with dehydration require fluids. To avoid pain and potential complications,
it's preferable to give these fluids by mouth instead of the use of an IV.
12. Clinical Images
Gingival Melanoma
Müller's Sign (this is cool)
Respiratory Diphtheria
Pronator Drift
Dental Implant in the Ethmoid Sinus
Raynaud’s
Man with Dizziness and Vomiting
13. It's Official: IABP Does Not Improve
Mortality in AMI Patients with Shock
One-year findings from the IABP-SHOCK II
trial confirm that use of the device should not be routine in patients who
undergo early revascularization.
Beat J. Meyer, MD; Journal Watch, Emergency
Medicine, October 4, 2013
Short-term data from the IABP-SHOCK II trial
(NEJM 2012) showed no survival benefit with intra-aortic balloon
counterpulsation (IABP) in patients with acute myocardial infarction (MI)
complicated by shock, leading to an adjustment of American and European
guideline recommendations from Class I to Class IIa and IIb, respectively.
However, in a previous trial, early revascularization in cardiogenic shock, a
significant mortality benefit emerged only at extended follow-up (NEJM JW
Cardiol Mar 16 2001).
Therefore, the, the IABP-SHOCK II researchers
now present 12-month follow-up data.More than 99% of the cohort completed
12-month follow-up. Death rates were similar in the IABP and control groups
(52% and 51%, respectively). Rates of reinfarction, repeat revascularization,
and stroke did not differ significantly between the two groups, nor did
quality-of-life scores including mobility, self-care, usual activities, pain or
discomfort, and anxiety or depression. Of note, baseline serum lactate — an
easily obtained measure of the severity of end-organ hypoxia — was one of the
strongest predictors of long-term mortality.
Comment: These results validate the
downgrading of intra-aortic balloon counterpulsation therapy in the current
guidelines. In patients with acute myocardial infarction complicated by shock,
IABP may be considered in select circumstances but should not be used in
patients with high lactate levels. Given the high overall mortality in these
patients, further research should focus on novel therapeutic options.
Citation(s): Thiele H et al. Intra-aortic
balloon counterpulsation in acute myocardial infarction complicated by
cardiogenic shock (IABP-SHOCK II): Final 12 month results of a randomised,
open-label trial. Lancet 2013 Sep 3; [e-pub ahead of print].
14. Clinical score and rapid antigen
detection test to guide antibiotic use for sore throats: RCT of PRISM (primary
care streptococcal management)
Little P, et al. BMJ 2013;347:f5806
Objective To determine the effect of clinical
scores that predict streptococcal infection or rapid streptococcal antigen
detection tests compared with delayed antibiotic prescribing.
Design Open adaptive pragmatic parallel group
randomised controlled trial.
Setting Primary care in United Kingdom.
Patients Patients aged ≥3 with acute sore
throat.
Intervention An internet programme randomised
patients to targeted antibiotic use according to: delayed antibiotics (the
comparator group for analyses), clinical score, or antigen test used according
to clinical score. During the trial a preliminary streptococcal score (score 1,
n=1129) was replaced by a more consistent score (score 2, n=631; features:
fever during previous 24 hours; purulence; attends rapidly (within three days
after onset of symptoms); inflamed tonsils; no cough/coryza (acronym
FeverPAIN).
Outcomes Symptom severity reported by
patients on a 7 point Likert scale (mean severity of sore throat/difficulty
swallowing for days two to four after the consultation (primary outcome)),
duration of symptoms, use of antibiotics.
Results For score 1 there were no significant
differences between groups. For score 2, symptom severity was documented in 80%
(168/207 (81%) in delayed antibiotics group; 168/211 (80%) in clinical score
group; 166/213 (78%) in antigen test group). Reported severity of symptoms was
lower in the clinical score group (−0.33, 95% confidence interval −0.64 to
−0.02; P=0.04), equivalent to one in three rating sore throat a slight versus
moderate problem, with a similar reduction for the antigen test group (−0.30,
−0.61 to −0.00; P=0.05). Symptoms rated moderately bad or worse resolved
significantly faster in the clinical score group (hazard ratio 1.30, 95%
confidence interval 1.03 to 1.63) but not the antigen test group (1.11, 0.88 to
1.40). In the delayed antibiotics group, 75/164 (46%) used antibiotics. Use of
antibiotics in the clinical score group (60/161) was 29% lower (adjusted risk
ratio 0.71, 95% confidence interval 0.50 to 0.95; P=0.02) and in the antigen
test group (58/164) was 27% lower (0.73, 0.52 to 0.98; P=0.03). There were no
significant differences in complications or reconsultations.
Conclusion Targeted use of antibiotics for
acute sore throat with a clinical score improves reported symptoms and reduces
antibiotic use. Antigen tests used according to a clinical score provide
similar benefits but with no clear advantages over a clinical score alone.
15. “Sick” or “not-sick”: accuracy of
System 1 diagnostic reasoning for the prediction of disposition and acuity in
patients presenting to an academic ED
Wiswell J, et al. Amer J Emerg Med. 2013;31:1448-1452
Objective
System 1 decision-making is fast, resource
economic, and intuitive (eg, “your gut feeling”) and System 2 is slow, resource
intensive, and analytic (eg, “hypothetico-deductive”). We evaluated the
performance of disposition and acuity prediction by emergency physicians (EPs)
using a System 1 decision-making process.
Methods
We conducted a prospective observational
study of attending EPs and emergency medicine residents. Physicians were
provided patient demographics, chief complaint, and vital sign data and made
two assessments on initial presentation: (1) likely disposition (discharge vs
admission) and (2) “sick” vs “not-sick”. A patient was adjudicated as sick if
he/she had a disease process that was potentially life or limb threatening
based on pre-defined operational, financial, or educationally derived criteria.
Results
We obtained 266 observations in 178 different
patients. Physicians predicted patient disposition with the following
performance: sensitivity 87.7% (95% CI 81.4-92.1), specificity 65.0% (95% CI
56.1-72.9), LR+ 2.51 (95% CI 1.95-3.22), LR− 0.19 (95% CI 0.12-0.30). For the
sick vs not-sick assessment, providers had the following performance:
sensitivity 66.2% (95% CI 55.1-75.8), specificity 88.4% (95% CI 83.0-92.2), LR+
5.69 (95% CI 3.72-8.69), LR− 0.38 (95% CI 0.28-0.53).
Conclusion
EPs are able to accurately predict the
disposition of ED patients using system 1 diagnostic reasoning based on minimal
available information. However, the prognostic accuracy of acuity prediction
was limited.
16. Rethink the Salter-Harris I Fracture
by David H. Newman, MD; Emergency Physicians
Monthly, October 15, 2013
The last 50 years of pediatric fracture
management may have included a substantial misunderstanding of Salter and
Harris’s original findings.
In a recent issue of SMART EM we went under
the evidence sea and into the depths of pediatric orthopedics, where there is a
question trainees (and parents) with overdeveloped common sense have been
asking for a half century: why do we immobilize bones that are clinically and
radiographically normal?
The infamous Salter-Harris type I fracture
has, in many settings, become the most common type of pediatric ‘fracture’. And
yet the diagnosis is, in the overwhelming majority of cases, provisional…
preliminary... potential. That is because Salter-Harris I fractures are
typically diagnosed in the setting of normal x-rays and subjective bony
tenderness at a growth plate. In other words, when there is no objective
evidence of fracture.
Turns out Drs. Robert Salter and Robert
Harris may have been thinking about something quite different. In the seminal
1963 publication outlining their classification system the two pediatric
orthopedists offer an explanation of type I fractures as “resulting from a
shearing or avulsion force”, and “most commonly associated with birth
injuries.” They go on to describe their management, saying “reduction is not
difficult.” The paper includes 12 reproduced radiographs and one illustration
of type I fractures. All of these include visually conspicuous separation of
the epiphysis from the metaphysis in the absence of bony fracture.
In other words Salter and Harris were
describing instances of conspicuous displacement and total separation of the
growth plate, and at no point do they mention or even suggest the possibility
of radiographically negative variants.
Of course, it is always possible that the
authors meant for the management of this type of injury to be extended and
extrapolated to non-displaced growth plate injuries. If so, this would have
been an attempt to prevent growth disturbances and, ultimately, functional or
esthetic sequelae, since this was the intent of their classification system.
Which led us to another question of evidence: how often does a pediatric bone
injury result in functional or cosmetic sequelae when nondisplaced,
radiographically negative growth plate injuries are not immobilized?
The answer to this question was mercifully
unambiguous: never. At least, to our knowledge, no such instance has ever been
reported in the medical literature. In contrast, a number of studies have now
documented the management of presumed Salter-Harris type I injuries with early
mobilization, functional splinting, or as-desired orthopedic supports. In all
cases outcomes are excellent, while revisits and splint complications are
essentially vanquished.
The bottom line is that we were able to find
no literature to suggest that immobilization is beneficial for Salter-Harris
type I fractures. Therefore particularly in the case of those that appear to
show no signs of clinical injury that would benefit from immobilization
(minimal swelling, no deformity, able to weight bear, etc.), there seems to be
no benefit to splinting or casting.
Perhaps, then, the last fifty years of
Salter-Harris type I fracture management has really just been a
misunderstanding. Have a listen, see what you think. Maybe those trainees and
parents, with their silly common sense, have a point after all.
17. Criteria for Diagnosing Early Pregnancy
Failure
New consensus-based guidance allows better determination of location and
viability of pregnancy.
Andrew M. Kaunitz, MD; Journal
Watch, Emergency Medicine, October 9, 2013.
Transvaginal ultrasound (TVUS) and serial measurement of serum human
chorionic gonadotropin (hCG) have transformed the assessment of pregnant women
with early pain and/or bleeding or with other risk factors for ectopic
pregnancy (EP) or nonviable intrauterine pregnancy (IUP). With widespread use
of these diagnostic modalities, clinicians in obstetrics and gynecology,
radiology, emergency medicine, and primary care increasingly encounter early
pregnancies of uncertain viability and unknown location — but interpreting the
test results to determine appropriate interventions remains challenging.
Accordingly, experts in radiology and obstetrics and gynecology have developed
a consensus statement from the Society of Radiologists in Ultrasound based on
current published data.
The panel states that definitive pregnancy failure can be diagnosed in a
woman with an IUP of uncertain viability when TVUS reveals any of the
following:
·
Embryonic crown-rump length ≥7 mm and no heartbeat.
·
Mean gestational sac diameter ≥25 mm and no embryo present.
·
No embryo with heartbeat ≥2 weeks after TVUS showed a gestational sac
without a yolk sac.
·
No embryo with heartbeat ≥11 days after TVUS showed a gestational sac
with a yolk sac.
For evaluation and management of a woman with pregnancy of unknown
location when TVUS reveals no intrauterine fluid and no obvious adnexal
abnormalities:
·
A single hCG assessment, regardless of level, does not reliably determine
a pregnancy's location or viability (this is because hCG levels in women with
nonviable IUPs, viable IUPs, and EPs overlap substantially).
·
A single hCG level less than 3000 mIU/mL should not elicit treatment for presumed EP.
·
A single hCG ≥3000 mIU/mL indicates that viable IUP is possible but
unlikely. At least one additional hCG level should be measured before
initiating treatment for EP.
For pregnant women in whom TVUS has not been performed:
·
Clinicians should recognize that hCG levels in women with EP are highly
variable (but often less than 1000 mIU/mL), and that hCG level does not predict probability of EP
rupture. For high clinical suspicion of EP, TVUS should be performed even if
hCG level is low.
Comment: Incorrectly diagnosing an early pregnancy of uncertain viability
or location has led some clinicians to prescribe methotrexate for suspected
ectopic pregnancy in women later found to have viable intrauterine pregnancies.
The authors emphasize that, in hemodynamically stable women, the risk
associated with collecting additional data for several more days is limited and
will likely allow definitive diagnosis of pregnancy location and viability
using the criteria in these guidelines.
Citation(s): Doubilet PM et al. Diagnostic criteria for nonviable
pregnancy early in the first trimester. N Engl J Med 2013 Oct 10; 369:1443
18. Epi-pen needles too short for heavier patients?
By Kathryn Doyle. Reuters Health. New York. Oct
17, 2013
(Reuters Health) - People with serious
allergies who are obese may find out in a moment of crisis their epinephrine
injection needles aren't long enough to be effective, according to a new study.
"Epinephrine works best when injected
into the muscle," lead author Dr. Mary Colleen Bhalla said. "When it
is injected into the fat layer of the skin it takes longer to reach the blood
stream."
"When a person is having a severe
allergic reaction they need the medicine to work as soon as possible," she
told Reuters Health.
In an allergy attack, airways constrict and
may make breathing impossible. While waiting for emergency responders to arrive
on the scene, the victim or a friend may use an autoinjector to deliver
epinephrine, or adrenaline - a hormone that constricts blood vessels and
relaxes airway muscles - into the thigh.
If the injector needle is not long enough to
reach muscle tissue, the extra time the drugs take to get into the bloodstream
could be the difference between life and death for people with severe allergic
reactions, Bhalla, of the Summa Akron City Hospital in Ohio, said.
"A bee sting can cause death in 15
minutes," she said. "One study found that the epinephrine got in the
bloodstream in an average of 8 minutes when given in the muscle, but an average
of 34 minutes when given in the fat layer of the skin."
In an indirect investigation of the problem,
Bhalla's team decided to measure the thickness of fat around the thighs of a
random sample of patients in an emergency room and compare the measurements to
the length of the longest available needle. At the time, the longest needle
available was about 16 millimeters, or about two-thirds of an inch.
Of 120 emergency room patients, 31 percent
had layers of fat thicker than 16 millimeters around the thigh, the usual
epinephrine needle injection point. Five percent of men and 54 percent of women
in the sample fell into this category, according to the researchers' report in
the American Journal of Emergency Medicine.
More than half of the people studied were
obese.
The results are still hypothetical, since the
researchers didn't go as far as trying the injectors on people having allergy
attacks to see if they would be effective.
An injector with a 25 millimeter needle -
about an inch - has been approved and will be available in late 2013 in the UK,
Germany and Sweden, which would help solve the problem in the U.S., Bhalla
said.
"In our study we found that we would
need a needle length of 18mm to get the drug in the muscle in 95 percent of
men, however we found that we would need a needle length of 35mm to get the
drug in the muscle of 95 percent of women," she said.
But 35 millimeter needles would hit bone for
some people and could be dangerous. A wider variety of needle sizes or an
autoinjector that automatically adjusts needle length on insertion might be the
best solution, she said.
Patients should always keep their injector close
and use it s soon as they realize they have been exposed to an allergen, and
call emergency medical services as soon as possible, she said. Professionals
have better ways of delivering the necessary drugs.
"This study and several others suggest
that the needle length of the autoinjectors may be too short to reach muscle in
people with more body fat in the leg," Dr. Scott Sicherer said. "This
is an important concern."
Sicherer is a professor of pediatrics and a
researcher at the Jaffe Food Allergy Institute at Mount Sinai in New York, and
was not involved in the study.
"Since the injectors forcefully spray
the medicine beyond the tip of the needle, and there are insufficient direct
studies of how the medications behave in people of different body sizes, the
studies like this one looking simply at the anatomy of the leg have practical
limitations," he said. "However, an important question is being
raised that warrants more study."
19. Clinicians tend to stick to long-held
practice patterns, physician writes
While patients often seem reluctant to change
their behaviors, physicians also tend to retain established clinical habits
even if they are ineffective or contrary to medical recommendations, such as
those advanced in the Choosing Wisely campaign, writes Danielle Ofri, associate
professor at New York University School of Medicine. "If we doctors can
recognize that impulse in ourselves, it will give us a dose of empathy for our
patients, who are struggling with the same challenges when it comes to changing
behavior," Ofri says.
Essay
RECENTLY I was talking with a patient about
her glucose levels, which have been inching their way toward diabetes. She was
honest that she was eating too much junk and knew perfectly well that her diet
was not doing her health any favors.
We talked about the circumstances of her
daily life, and together came up with the plan: she would try to eat one fruit
or vegetable every day, while cutting out one serving of junk food. It was a
modest goal, but seemed obtainable. A perfect example of shared decision
making.
But after she left, I glanced back at my
previous notes and saw that we’d negotiated the exact same compromise during
her last appointment. Scrolling back, I could see that at every visit we
covered the same nutritional territory, and each time I must have congratulated
myself on the excellent patient-centered care.
Unfortunately, it wasn’t getting us anywhere.
Her diet hadn’t budged.
We doctors constantly lament how difficult it
is get our patients to change their behavior. We rant about those who won’t
take their meds, who won’t quit smoking, who never exercise. But the truth is,
we are equally intransigent when it comes to changing our own behaviors as
caregivers.
Clinical practice guidelines are a common way
of summarizing the standard recommendations for medical conditions. There are
thousands of guidelines, for everything from genetic screening to bedsore
prevention. Most doctors and nurses think that well-researched guidelines are
an excellent idea. Most agree with their recommendations.
The problem is, most of us are just like our
patients — we often ignore good advice when it conflicts with what we’ve always
done.
I thought about this as I read the latest
recommendations from the Choosing Wisely campaign — a project led by the
American Board of Internal Medicine to inform doctors and patients about
overused and ineffective tests and treatments. Medical groups were asked to
list five things in their field that are often overutilized but don’t offer
much benefit.
Last month, my specialty group — the Society
of General Internal Medicine — released its Choosing Wisely recommendations.
No. 2 was: “Don’t perform routine general health checks for asymptomatic
adults.”
This runs counter to a basic pillar in
medicine that doctors and patients remain strongly attached to: the annual
checkup. This is our chance to do screening tests and vaccinations and to
discuss a healthy lifestyle. Anecdotally, we all can cite examples of checkups
that uncovered serious illness. But the scientific evidence shows that on
balance, the harm of annual visits — overdiagnosis, overtreatment, excess costs
— can outweigh the benefits.
Yet, I still do them. Each time I see a
healthy patient, I close the visit by saying, “See you in a year.” It’s a
reflex.
After the research was initially published
last year, I grappled with the evidence, or lack thereof, reaching a conclusion
that I mainly still supported the annual visit, if only because it establishes
a solid doctor-patient relationship. But seeing these new, strongly worded
recommendations, I may have to re-evaluate. At the very least, I should take a
moment to think before I reflexively recommend the annual visit. But I know
that I might still end up doing the same thing, despite the evidence.
Humans are creatures of habit. Our default is
to continue on the path we’ve always trod. If we doctors can recognize that
impulse in ourselves, it will give us a dose of empathy for our patients, who
are struggling with the same challenges when it comes to changing
behavior.
Danielle Ofri is an associate professor at
New York University School of Medicine, the editor of the Bellevue Literary
Review and the author of “What Doctors Feel: How Emotions Affect the Practice
of Medicine.” Amazon: http://www.amazon.com/dp/0807073326/
20. Effects of Fluid Resus with Colloids vs
Crystalloids on Mortality in Critically Ill Patients Presenting with
Hypovolemic Shock: The CRISTAL Randomized Trial
Annane A, et al. for the CRISTAL
Investigators. JAMA. Published online October 09, 2013.
Importance
Evidence supporting the choice of intravenous colloid vs crystalloid
solutions for management of hypovolemic shock remains unclear.
Objective
To test whether use of colloids compared with crystalloids for fluid
resuscitation alters mortality in patients admitted to the intensive care unit
(ICU) with hypovolemic shock.
Design, Setting, and Participants A multicenter, randomized clinical trial
stratified by case mix (sepsis, trauma, or hypovolemic shock without sepsis or
trauma). Therapy in the Colloids Versus Crystalloids for the Resuscitation of
the Critically Ill (CRISTAL) trial was open label but outcome assessment was
blinded to treatment assignment. Recruitment began in February 2003 and ended
in August 2012 of 2857 sequential ICU patients treated at 57 ICUs in France,
Belgium, North Africa, and Canada; follow-up ended in November 2012.
Interventions
Colloids (n = 1414; gelatins, dextrans, hydroxyethyl starches, or 4% or
20% of albumin) or crystalloids (n = 1443; isotonic or hypertonic saline or
Ringer lactate solution) for all fluid interventions other than fluid
maintenance throughout the ICU stay.
Main Outcomes and Measures The primary outcome was death within 28 days.
Secondary outcomes included 90-day mortality; and days alive and not receiving
renal replacement therapy, mechanical ventilation, or vasopressor therapy.
Results
Within 28 days, there were 359 deaths (25.4%) in colloids group vs 390
deaths (27.0%) in crystalloids group (relative risk [RR], 0.96 [95% CI, 0.88 to
1.04]; P = .26). Within 90 days, there were 434 deaths (30.7%) in colloids
group vs 493 deaths (34.2%) in crystalloids group (RR, 0.92 [95% CI, 0.86 to 0.99];
P = .03). Renal replacement therapy was used in 156 (11.0%) in colloids group
vs 181 (12.5%) in crystalloids group (RR, 0.93 [95% CI, 0.83 to 1.03];
P = .19). There were more days alive without mechanical ventilation in the
colloids group vs the crystalloids group by 7 days (mean: 2.1 vs 1.8 days,
respectively; mean difference, 0.30 [95% CI, 0.09 to 0.48] days; P = .01) and
by 28 days (mean: 14.6 vs 13.5 days; mean difference, 1.10 [95% CI, 0.14 to
2.06] days; P = .01) and alive without vasopressor therapy by 7 days (mean: 5.0
vs 4.7 days; mean difference, 0.30 [95% CI, −0.03 to 0.50] days; P = .04) and
by 28 days (mean: 16.2 vs 15.2 days; mean difference, 1.04 [95% CI, −0.04 to
2.10] days; P = .03).
Conclusions and Relevance Among ICU patients with hypovolemia, the use
of colloids vs crystalloids did not result in a significant difference in
28-day mortality. Although 90-day mortality was lower among patients receiving
colloids, this finding should be considered exploratory and requires further
study before reaching conclusions about efficacy.
21. Sepsis: Guideline Changes Highlighted
for ED Clinicians
Steven Fox, Medscape, Oct 07, 2013
Updated guidelines for managing severe sepsis
and septic shock have direct implications for personnel working in emergency
departments, according to a review published online September 25 in the Annals
of Emergency Medicine.
The Surviving Sepsis Campaign, launched in
2002, is a joint effort of the Society of Critical Care Medicine and the
European Society of Intensive Care Medicine. The campaign updated sepsis
guidelines in 2012 to reflect knowledge gained since the previous update in
2008.
In the current review, Alan E. Jones, MD,
from the Department of Emergency Medicine, University of Mississippi Medical
Center, Jackson, and colleagues, highlight information in the guideline that is
essential for emergency department clinicians.
"The goal of this review is to provide
the emergency practitioner a synopsis of the recent changes in guidelines, with
a particular emphasis on those that may have direct implications for ED
assessment and management of early sepsis."
The review also provides brief discussions of
the various studies that prompted the guideline revision.
The 2012 update for the Surviving Sepsis
Campaign introduced several important changes in recommendations relevant for
treating severe sepsis and septic shock in emergency departments. They include:
·
use of
protocolized quantitative resuscitation with specific physiologic targets,
·
preferential
use of crystalloids (with or without albumin) for volume resuscitation,
·
preferential
use of norepinephrine,
·
addition of
lactate clearance as a marker of tissue hypoperfusion, and
·
decreased
emphasis on the use of corticosteroids.
One section of the updated guidelines
provides what is referred to as a "sepsis care bundle," which
specifies interventions that should be completed within 3 or 6 hours of triage.
The guidelines recommend that within 3 hours
of triage, lactate levels be measured, blood cultures be obtained,
broad-spectrum antibiotics be administered as indicated, and crystalloid or
lactate be administered for hypotension.
Within 6 hours, the guidelines recommend that
vasopressors be used to control hypotension that has remained unresponsive to
fluid resuscitation. If arterial hypotension persists despite volume
resuscitation or initial administration of lactate, the guidelines advise
measuring central venous pressure and central venous oxygen saturation. They
also recommend remeasuring lactate if initial lactate levels were elevated.
22. N-Acetylcysteine Plus IVF Versus IVF
Alone to Prevent Contrast-Induced Nephropathy in Emergency CT
Traub SJ, et al. Ann Emerg Med.
2013;62:511-520.e25
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.
23. Is the Addition of Vasopressin to
Norepinephrine Beneficial for the Treatment of Septic Shock?
Sandifer JP, et al. Ann Emerg Med.
2013;62:534-535.
Take-Home Message: The addition of low-dose
vasopressin to norepinephrine may not significantly reduce mortality in adult
patients with septic shock.
24. Tid Bits
Z. Highlights from the Lit Bits 2012-2013
I was recently asked to quickly review
several highlights/trends of the EM literature over the last year or two. The handout
and the slides from that national KP presentation have been posted: http://medicine.drvinson.net/lectures
A. Coldplay meets evidence-based medicine
You trendy alternative rock fans will
recognize the tune. You academics will appreciate the lyrics.
B. Winners of the 2013 IgNobel Prizes
1. Are cows more likely to lie down the
longer they stand?
Tolkamp BJ, et al. Applied Animal Behaviour
Science 2010;124:1:1-10
The longer a cow has been lying down, the
more likely that cow will soon stand up. Once a cow stands up, you cannot
easily predict how soon that cow will lie down again.
Abstract: http://www.journals.elsevierhealth.com/periodicals/applan/article/S0168-1591(10)00054-7/abstract
2. Does opera improve the peripheral immune
sufficiently to prolong allograft survival?
Uchiyama M, et al. J Cardiothorac Surg. 2012
Mar 23;7:26.
C. Beta-Blocker May Help in Septic Shock
Controlling heart rate with intravenous
infusion of the beta-blocker esmolol improved outcomes in patients with severe
septic shock, an open-label, randomized study showed.
D. Hypothermia Has No Benefit in
Meningitis
Patients with severe bacterial meningitis
were not helped by induced hypothermia in a randomized trial and may actually
have been harmed, researchers said.
E. Association of coffee consumption with
all-cause and cardiovascular disease mortality.
Liu J, et al. Mayo Clin Proc. 2013 Aug 15.
[Epub ahead of print]
F. Bugs Still Get Through Despite Gloves,
Gowns
SAN FRANCISCO -- Having intensive care
workers wear gloves and gowns during all patient contacts did not reduce the
risk of transmission of two major multidrug-resistant pathogens, a researcher
said.
G. Why I decided not to run marathons
Marathon Running Harms the Heart, But Effect
Is Fleeting
Marathon runners show adverse cardiac changes
in the 2 days following a race, with the most pronounced effects among the
least fit athletes, although everything returns to normal within 30 days,
according to a study in the Canadian Journal of Cardiology.
Previous studies have shown that strenuous
exercise is associated with increased cardiac risk during the activity,
especially in less fit individuals. Valerie Gaudreault, MD, of Laval University
in Quebec City, and colleagues explored possible mechanisms among 20 recreational
marathon runners, ages 18 to 60, who were free from known cardiovascular
disease. They were assessed while they were training for the marathon, within
48 hours after running the race, and 3 months after the race.
The post-race evaluation showed that global
left ventricular and right ventricular ejection fraction declined by more than
5% in half of the runners. Those runners did not run as far during their peak
training, did not train as long per week, and had a lower maximal oxygen
consumption compared with the others. Overall, 36% of left ventricular segments
developed edema, 53% had function drop by more than 5%, and 59% had decreased
perfusion. Three months after the marathon, however, all measures returned to
baseline levels.
"Although reversible, these changes
might contribute to the transient increase in cardiac risk reported during
sustained vigorous exercise," the authors wrote.
H. Esmolol drip may reduce mortality in pts
with septic shock
Morelli A, et al. Effect of Heart Rate
Control With Esmolol on Hemodynamic and Clinical Outcomes in Patients With
Septic Shock: A Randomized Clinical Trial. JAMA. 2013;310(16):1683
I. Intranasal Oxytocin Enhances Placebo
Analgesic Effect
J. Sleep Empties the Brain’s Dumpster
Studies in mice indicate that sleep’s
critical function is to allow metabolic waste products to be cleared from the
brain, which apparently cannot occur during waking hours, researchers said.
K. Does anything work for symptoms of acute
respiratory tract infections?
