Sunday, October 27, 2013

Lit Bits: Oct 27, 2013

From the recent medical literature...

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. 


Earlier study by this group on the accelerated diagnostic protocol:  

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. 

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. 

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. 

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: 

5. HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness 

Newman-Toker DE, Acad Emerg Med 2013;20:986-996. 

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]). 

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. 

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. 

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.  

7. Intranasal Ketamine for Analgesia in the ED: A Prospective Observational Series 

Andolfatto G, et al. Acad Emerg Med. 2013;20:1050-1054.  

The objective was to examine the feasibility, effectiveness, and adverse effect profile of intranasal ketamine for analgesia in emergency department (ED) patients. 

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). 

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. 

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. 

Full-text of the article (free):

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


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 

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. 

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. 

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). 

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. 

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:  

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. 

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. 

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. 

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:  

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.  

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?