A collection of assorted summaries, highlights, and abstracts from the recent medical literature.
Saturday, November 30, 2013
Lit Bits: Nov 30, 2013
From the recent medical literature...
1. Therapeutic Hypothermia Articles
in Journal Watch Emerg Med
A. Post–Cardiac Arrest Cooling — Colder Is Not Better
Ali S. Raja, MD,
MBA, MPH, FACEP reviewing Nielsen N et al. N Engl J Med 2013 Nov 17.
recommend therapeutic hypothermia as a cornerstone of management for patients
who remain unconscious after cardiac arrest, as it has been demonstrated to
reduce mortality and improve neurologic function. However, the optimal target
temperature (typically between 32°C and 35°C) has been unclear. Researchers
randomized 950 patients in 36 European and Australian intensive care units to target
temperatures of either 33°C or 36°C, to determine which might be more
Of 939 patients
included in the primary intention-to-treat analysis, 460 had died by the end of
the trial (mean follow-up, 256 days). All-cause mortality was similar in the
33°C and 36°C groups (50% and 48%), as was the composite secondary outcome of
death or poor neurologic function at 180 days (54% and 52%, respectively).
Rates of serious adverse events also were similar in the two groups (93% and
Comment This eye-opening
and well-performed study convincingly argues against more-aggressive cooling
after cardiac arrest. However, outcomes in both groups were reportedly better
than historical outcomes without therapeutic hypothermia, and the underlying
benefits of active temperature regulation in these patients remain unchanged.
N et al. Targeted temperature management at 33°C versus 36°C after cardiac
arrest. N Engl J Med 2013 Nov 17; [e-pub ahead of print].
B. Prehospital Cooling After Cardiac Arrest Is Not Necessary
Ali S. Raja, MD,
MBA, MPH, FACEP reviewing Kim F et al. JAMA 2013 Nov 17
cooled by paramedics had similar outcomes to patients cooled only after
hypothermia is guideline-recommended for comatose patients after cardiac
arrest, but previous small studies of cooling prior to hospital arrival did not
demonstrate benefit. Researchers in Washington State randomized cardiac arrest
patients to standard care with or without paramedic-initiated cooling with
intravenous 4°C normal saline, to determine the effect of prehospital cooling
on survival and neurological status at hospital discharge.
Of 1359 patients,
583 had ventricular fibrillation and 776 did not. Mortality was similar in the
prehospital-cooled and control groups; in patients with ventricular
fibrillation (VF), 63% and 64% survived to discharge, while in patients without
VF, 19% and 16% survived. Similarly, there was no difference in neurological
outcomes; in patients with VF, 58% and 62% had full recovery or mild
impairment, while in patients without VF, 14% and 13% had full recovery or mild
impairment. Notably, patients whose cooling was initiated by paramedics
achieved the target temperature of 34°C about 1 hour faster than those whose
cooling was begun only after hospital arrival.
with the findings of earlier studies, initiating cooling before hospital
arrival does not benefit patients who survive cardiac arrest. Efforts in the
prehospital arena should continue to focus on rapid transport and treatment
using proven interventions. Perhaps the greater question is whether cooling
confers any real benefit at all, regardless of where it is initiated.
Citation(s): Kim F
et al. Effect of prehospital induction of mild hypothermia on survival and
neurological status among adults with cardiac arrest: A randomized clinical
trial. JAMA 2013 Nov 17; [e-pub ahead of print].
2. Sex-Specific CP Characteristics in the Early
Diagnosis of AMI
Gimenez MR, et al.
JAMA Intern Med. 2013 Nov 25. [Epub Ahead of Print]
ImportanceWhether sex-specific chest pain
characteristics (CPCs) would allow physicians in the emergency department to
differentiate women with acute myocardial infarction (AMI) from women with
other causes of acute chest pain more accurately remains unknown.
ObjectiveTo improve the management of suspected AMI in
women by exploring sex-specific CPCs.
Design, Setting, and
ParticipantsFrom April 21, 2006,
through August 12, 2012, we enrolled 2475 consecutive patients (796 women and
1679 men) presenting with acute chest pain to 9 emergency departments in a
prospective multicenter study. The final diagnosis of AMI was adjudicated by 2
InterventionsTreatment of AMI in the emergency department.
Main Outcomes and
performance of 34 predefined and uniformly recorded CPCs in the early diagnosis
ResultsAcute myocardial infarction was the
adjudicated final diagnosis in 143 women (18.0%) and 369 men (22.0%). Although
most CPCs were reported with similar frequency in women and men, several CPCs
were reported more frequently in women (P less than .05). The accuracy of most CPCs in the diagnosis of
AMI was low in women and men, with likelihood ratios close to 1. Thirty-one of
34 CPCs (91.2%) showed similar likelihood ratios for the diagnosis of AMI in
women and men, and only 3 CPCs (8.8%) seemed to have a sex-specific diagnostic
performance with P less than .05 for interaction. These CPCs were related to pain
duration (2-30 and over 30 minutes) and dynamics (decreasing pain intensity).
However, because their likelihood ratios were close to 1, the 3 CPCs did not
seem clinically helpful. Similar results were obtained when examining
combinations of CPCs (all interactions, P ≥ .05).
RelevanceDifferences in the
sex-specific diagnostic performance of CPCs are small and do not seem to
support the use of women-specific CPCs in the early diagnosis of AMI.
3. Predictors of suppurative
complications for acute sore throat in primary care: prospective clinical
Little P, et al. BMJ 2013;347:f6867
document whether elements of a structured history and examination predict
adverse outcome of acute sore throat.
measures Common suppurative complications (quinsy or peritonsillar abscess,
otitis media, sinusitis, impetigo or cellulitis) and reconsultation with new or
unresolving symptoms within one month.
Complications were assessed reliably (inter-rater κ=0.95). 1.3% (177/13 445) of
participants developed complications overall and 14.2% (1889/13 288)
reconsulted with new or unresolving symptoms. Independent predictors of complications
were severe tonsillar inflammation (documented among 13.0% (1652/12 717); odds
ratio 1.92, 95% confidence interval 1.28 to 2.89) and severe earache (5%
(667/13 323); 3.02, 1.91 to 4.76), but the model including both variables had
modest prognostic utility (bootstrapped area under the receiver operator curve
0.61, 0.57 to 0.65), and 70% of complications (124/177) occurred when neither
was present. Clinical prediction rules for bacterial infection (Centor criteria
and FeverPAIN) also predicted complications, but predictive values were also
poor and most complications occurred with low scores (67% (118/175) scoring ≤2
for Centor; 126/173 (73%) scoring ≤2 for FeverPAIN). Previous medical problems,
sex, temperature, and muscle aches were independently but weakly associated
with reconsultation with new or unresolving symptoms.
suppurative complications after an episode of acute sore throat in primary care
are uncommon. History and examination and scores to predict bacterial infection
cannot usefully identify those who will develop complications. Clinicians will
need to rely on strategies such as safety netting or delayed prescription in
managing the uncertainty and low risk of complications.
4. Missed Opportunities for Appropriate
Anticoagulation among ED Patients
With Uncomplicated A Fib or Flutter
Scheuermeyer FX, et al. Ann Emerg Med. 2013;62:557-565.e2
Study objective: Emergency department (ED) patients with atrial fibrillation
or flutter are at risk of stroke, and guidelines recommend anticoagulation for
patients with increased cardiovascular risk. Emergency physicians have a unique
opportunity to provide appropriate anticoagulation for such patients, and we
wished to investigate whether this was accomplished.
Methods: This retrospective cohort study used a database from
2 urban EDs to identify consecutive patients with an ED discharge diagnosis of
atrial fibrillation or flutter from April 1, 2006, to March 31, 2010, who were
managed solely by the emergency physician. Comorbidities, rhythms, and
management were obtained by chart review, and complicated patients (those with
an acute underlying medical condition) were excluded by predefined criteria.
Patient medications on ED presentations were obtained through the provincial
Pharmanet database. Patients were stratified into CHADS 2 (congestive heart failure,
hypertension, age over 75, diabetes, stroke/transient ischemic attack) scores,
and the primary outcome was the proportion of
higher-risk (CHADS 2 score above 0) patients who were discharged home with the incorrect
anticoagulation by the emergency physician. The secondary outcome was the
number of lower-risk (CHADS 2=0) patients who began receiving warfarin by the
emergency physician orders. The regional ED database was interrogated to
ascertain the number of patients who had a stroke at 30 days.
Results: Consecutive patients (1,090) were enrolled and 732
were discharged home with no cardiology consultation (657 fibrillation and 75
flutter). Of 151 higher-risk (CHADS 2 score above 0) patients who should have been anticoagulated, 80
(53.0%; 95% confidence interval 44.7% to 61.0%) were discharged home from the
ED without appropriate anticoagulation. In this group, 1 patient had an
ischemic stroke at 24 days. Among 300 lower-risk patients (CHADS 2 score=0), 25
(8.3%; 95% confidence interval 5.6% to 12.2%) had warfarin initiated.
Conclusion: In this cohort of ED patients with uncomplicated
atrial fibrillation or flutter who were discharged without cardiology
involvement, many were not appropriately anticoagulated before ED arrival, and
more than half of such patients did not appear to have corrective measures
initiated by the emergency physician. This may represent a potential
opportunity to improve patient care and outcomes.
5. 4000 Clicks: a productivity analysis
of electronic medical records in a community hospital ED
Hill Jr. RG, et al.
Amer J Emerg Med. 2013;31:1591-94.
Objective: We evaluate physician productivity using electronic
medical records in a community hospital emergency department.
Methods: Physician time usage per hour was observed and
tabulated in the categories of direct patient contact, data and order entry,
interaction with colleagues, and review of test results and old records.
Results: The mean percentage of time spent on data entry was
43% (95% confidence interval, 39%-47%). The mean percentage of time spent in
direct contact with patients was 28%. The pooled weighted average time
allocations were 44% on data entry, 28% in direct patient care, 12% reviewing
test results and records, 13% in discussion with colleagues, and 3% on other
activities. Tabulation was made of the number of mouse clicks necessary for
several common emergency department charting functions and for selected patient
encounters. Total mouse clicks approach 4000 during a busy 10-hour shift.
Conclusion: Emergency department physicians spend significantly
more time entering data into electronic medical records than on any other
activity, including direct patient care. Improved efficiency in data entry
would allow emergency physicians to devote more time to patient care, thus
increasing hospital revenue.
6. Urine tests have limited ability to
detect UTI, study finds
A study published in
the New England Journal of Medicine showed urine tests may not always be
effective in detecting urinary tract infections. Researchers analyzed the urine
samples of 226 women and found no evidence of bacteria in the midstream urine
or in the bladder urine of almost 25% of women who showed signs of UTI.
"Our findings are further confirmation that collection of urine has
limited usefulness. You don't get the results back for two days, and just
practically speaking, it's an added cost because we know E. coli causes most
UTIs," lead author Thomas Hooton said.
7. Hold the Oxygen! Too Much O2 Can
Hasten Death in Ventilated Stroke Patients
In this multicenter
study, hyperoxia in ventilated stroke patients was associated with higher
OBJECTIVE: To test the hypothesis that hyperoxia was associated with
higher in-hospital mortality in ventilated stroke patients admitted to the ICU.
DESIGN: Retrospective multicenter cohort study.
SETTING: Primary admissions of ventilated stroke patients with
acute ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage
who had arterial blood gases within 24 hours of admission to the ICU at 84 U.S.
ICUs between 2003 and 2008. Patients were divided into three exposure groups:
hyperoxia was defined as PaO2 ≥300 mm Hg (39.99 kPa), hypoxia as any PaO2 less than 60 mm Hg (7.99 kPa) or PaO2/FiO2 ratio ≤300, and
normoxia, not defined as hyperoxia or hypoxia. The primary outcome was
PARTICIPANTS: Two thousand eight hundred ninety-four patients.
METHODS: Patients were divided into three exposure groups:
hyperoxia was defined as PaO2 more than or equal to 300 mm Hg (39.99 kPa),
hypoxia as any PaO2 less than 60 mm Hg (7.99 kPa) or PaO2/FIO2 ratio less than
or equal to 300, and normoxia, not defined as hyperoxia or hypoxia. The primary
outcome was in-hospital mortality.
INTERVENTIONS: Exposure to hyperoxia.
RESULTS: Over the 5-year period, we identified 554 ventilated
patients with acute ischemic stroke (19%), 936 ventilated patients with
subarachnoid hemorrhage (32%), and 1,404 ventilated patients with intracerebral
hemorrhage (49%) of whom 1,084 (38%) were normoxic, 1,316 (46%) were hypoxic,
and 450 (16%) were hyperoxic. Mortality was higher in the hyperoxia group as
compared with normoxia (crude odds ratio 1.7 [95% CI 1.3-2.1]; p less than 0.0001) and hypoxia groups (crude odds ratio, 1.3
[95% CI, 1.1-1.7]; p less than 0.01). In a multivariable analysis adjusted for
admission diagnosis, other potential confounders, the probability of being
exposed to hyperoxia, and hospital-specific effects, exposure to hyperoxia was
independently associated with in-hospital mortality (adjusted odds ratio, 1.2
[95% CI, 1.04-1.5]).
CONCLUSION: In ventilated stroke patients admitted to the ICU,
arterial hyperoxia was independently associated with in-hospital death as
compared with either normoxia or hypoxia. These data underscore the need for
studies of controlled reoxygenation in ventilated critically ill stroke
populations. In the absence of results from clinical trials, unnecessary oxygen
delivery should be avoided in ventilated stroke patients.
Rincon F, et al. Association Between Hyperoxia and Mortality After
Stroke: A Multicenter Cohort Study.Crit Care Med. 2013 Oct 25. [Epub ahead of print]
8. Hyperpronation Better for Nursemaid’s
Wu F, et al.
Emergency Physicians Monthly, November 16, 2013
Parents bring in their
daughter because they pulled on her arm, and now she is not using it. They are
thoroughly convinced that the child’s arm is either broken or dislocated. We
all recognize this as radial head subluxation or “nursemaid’s elbow” and
immediately attempt to reduce it. The provider takes the injured arm, supinates
at the wrist and flexes at the elbow. Does the child scream? What if nothing
happens? Is there an alternative technique to reducing a nursemaid’s elbow? …
of decision support tool fails to
reduce variation in imaging use for PE diagnosis
embolism computed tomography yield increased after clinical decision support
implementation despite significant heterogeneity among physicians. Increased
inter-physician variability in yield after clinical decision support was not
explained by patient characteristics alone and may be due to variable physician
acceptance of clinical decision support. Clinical decision support alone is
unlikely to eliminate unwarranted variability, and additional strategies and
interventions may be needed to help optimize acceptance of clinical decision
support to maximize returns on national investments in health information
of non-convulsive seizure and other EEG
abnormalities in ED patients with AMS
Zehtabchi S, et al. Amer J Emerg Med. 2013;31:1578-82.
Abstract: Four to ten percent of patients evaluated in
emergency departments (ED) present with altered mental status (AMS). The
prevalence of non-convulsive seizure (NCS) and other electroencephalographic
(EEG) abnormalities in this population is unknown.
Objectives: To identify the prevalence of NCS and other EEG
abnormalities in ED patients with AMS.
Methods: A prospective observational study at 2 urban ED.
Inclusion: patients ≥13 years old with AMS. Exclusion: An easily correctable
cause of AMS (e.g. hypoglycemia). A 30-minute standard 21-electrode EEG was
performed on each subject upon presentation. Outcome: prevalence of EEG
abnormalities interpreted by a board-certified epileptologist. EEGs were later
reviewed by 2 blinded epileptologists. Inter-rater agreement (IRA) of the
blinded EEG interpretations is summarized with κ. A multiple logistic
regression model was constructed to identify variables that could predict the
Results: Two hundred fifty-nine patients were enrolled (median
age: 60, 54% female). Overall, 202/259 of EEGs were interpreted as abnormal
(78%, 95% confidence interval [CI], 73-83%). The most common abnormality was
background slowing (58%, 95% CI, 52-68%) indicating underlying encephalopathy.
NCS (including non-convulsive status epilepticus [NCSE]) was detected in 5%
(95% CI, 3-8%) of patients. The regression analysis predicting EEG abnormality
showed a highly significant effect of age (P less than .001, adjusted odds ratio 1.66 [95% CI, 1.36-2.02]
per 10-year age increment). IRA for EEG interpretations was modest (κ: 0.45,
95% CI, 0.36-0.54).
Conclusions: The prevalence of EEG abnormalities in ED patients
with undifferentiated AMS is significant. ED physicians should consider EEG in
the evaluation of patients with AMS and a high suspicion of NCS/NCSE.
D. Does This Patient Have a Severe Upper Gastrointestinal
on nasogastric lavage, and a hemoglobin level less than 8 g/dL each increases
the likelihood of upper gastrointestinal tract bleeding, whereas a Blatchford
score of 0 effectively rules out the need for urgent intervention.
F. Rapid Reversal of Warfarin-Associated Hemorrhage in the
Emergency Department by Prothrombin Complex Concentrates
Frumkin K. Ann Emerg Med. 2013;62:616-626.e8
warfarin-associated hemorrhage is common, with a high mortality. In the United
States, the most commonly used therapies—fresh frozen plasma and vitamin K—are
slow and unpredictable and can result in volume overload. Outside of the United
States, prothrombin complex concentrates are often used instead; these pooled
plasma products reverse warfarin anticoagulation in minutes rather than hours.
This article reviews the literature relating to warfarin reversal with fresh frozen
plasma, prothrombin complex concentrates, and recombinant factor VIIa and
provides elements for a management protocol based on this literature.
accuracy of US
evaluation in foot and ankle trauma
Ekinci S, et al. Amer J Emerg Med. 2013;31:1151-1555.
Objectives: Foot and ankle injuries that result in sprains or
fractures are commonly encountered at the emergency department. The purpose of
the present study is to find out the accuracy of ultrasound (US) scanning in
injuries in the aforementioned areas.
Methods: Ottawa Ankle Rules–positive patients older than 16
years who presented to the emergency department with foot or ankle injuries
were eligible. For all patients, US evaluation of the whole foot and ankle was
performed by an emergency physician before radiographic imaging. All
radiographic images were evaluated by an orthopedic specialist and compared
with the interpretations of the US.
Results: One hundred thirty-one patients were included in the
study. Radiographic evaluation enabled the determination of fractures in 20
patients, and all of these were identified with US imaging. Moreover, US
evaluation radiographically detected a silent ankle fracture in 1 patient. The
sensitivity of US scanning in detecting fractures was 100% (95% confidence
interval [CI], 83.8-100), the specificity was 99.1% (95% CI, 95-99.8), the positive
predictive value was 95.2% (95% CI, 89.6-98), and the negative predictive value
was 100% (95% CI, 96.4-100), respectively. The most common fractures were
detected at the lateral malleolus and at the basis of the fifth metatarsal.
Conclusions: Ultrasound imaging permits the evaluation of foot and
ankle fractures. Because it is a highly sensitive technique, US can be
performed in the emergency department with confidence.
Abdominal Radiograph Use, Constipation, and Significant Misdiagnoses.
Freedman SB, et al. J Pediatr. 2013 Oct 12. [Epub ahead of print]
determine the proportion of children diagnosed with constipation assigned a
significant alternative diagnosis within 7 days (misdiagnosis), if there is an
association between abdominal radiograph (AXR) performance and misdiagnosis,
and features that might identify children with misdiagnoses.
STUDY DESIGN: We
conducted a retrospective cohort study of consecutive children less than 18 years who presented to a pediatric emergency
department in Toronto, between 2008 and 2010. Children assigned an
International Statistical Classification of Diseases and Related Health
Problems 10th Revision code consistent with constipation were eligible.
Misdiagnosis was defined as an alternative diagnosis during the subsequent 7
days that resulted in hospitalization or an outpatient procedure that included
a surgical or radiologic intervention. Constipation severity was classified
employing text word categorization and the Leech score.
eligible visits were identified. Mean age was 6.6 ± 4.4 years. AXR was
performed in 46% (1693/3685). Twenty misdiagnoses (0.5%; 95% CI 0.4, 0.8) were
identified (appendicitis [7%], intussusception [2%, bowel obstruction [2%],
other [9%]). AXR was performed more frequently in misdiagnosed children (75% vs
46%; P = .01). These children more often had abdominal pain (70% vs 49%; P =
.04) and tenderness (60% vs 32%; P =.01). Children in both groups had similar
amounts of stool on AXR (P = .38) and mean Leech scores (misdiagnosed = 7.9 ±
3.4; not misdiagnosed = 7.7 ± 2.9; P = .85).
in children with constipation are more frequent in those in whom an AXR was
performed and those with abdominal pain and tenderness. The performance of an
AXR may indicate diagnostic uncertainty; in such cases, the presence of stool
on AXR does not rule out an alternative diagnosis.
Diagnostic Accuracy, Confidence, and Resource Requests: A
Meyer AND, et al. JAMA Intern Med. 2013;173(21):1952-1958.
ImportanceLittle is known about the relationship
between physicians’ diagnostic accuracy and their confidence in that accuracy.
ObjectiveTo evaluate how physicians’ diagnostic
calibration, defined as the relationship between diagnostic accuracy and confidence
in that accuracy, changes with evolution of the diagnostic process and with
increasing diagnostic difficulty of clinical case vignettes.
Design, Setting, and
ParticipantsWe recruited general
internists from an online physician community and asked them to diagnose 4
previously validated case vignettes of variable difficulty (2 easier; 2 more
difficult). Cases were presented in a web-based format and divided into 4
sequential phases simulating diagnosis evolution: history, physical
examination, general diagnostic testing data, and definitive diagnostic
testing. After each phase, physicians recorded 1 to 3 differential diagnoses
and corresponding judgments of confidence. Before being presented with
definitive diagnostic data, physicians were asked to identify additional
resources they would require to diagnose each case (ie, additional tests,
second opinions, curbside consultations, referrals, and reference materials).
Main Outcomes and
MeasuresDiagnostic accuracy (scored as
0 or 1), confidence in diagnostic accuracy (on a scale of 0-10), diagnostic
calibration, and whether additional resources were requested (no or yes).
ResultsA total of 118 physicians with broad
geographical representation within the United States correctly diagnosed 55.3%
of easier and 5.8% of more difficult cases (P less than .001). Despite a large difference in diagnostic
accuracy between easier and more difficult cases, the difference in confidence
was relatively small (7.2 vs 6.4 out of 10, for easier and more difficult
cases, respectively) (P less than .001) and likely clinically insignificant. Overall,
diagnostic calibration was worse for more difficult cases (P less than .001) and characterized by overconfidence in
accuracy. Higher confidence was related to decreased requests for additional diagnostic
tests (P = .01); higher case difficulty was related to more requests for
additional reference materials (P = .01).
RelevanceOur study suggests that
physicians’ level of confidence may be relatively insensitive to both
diagnostic accuracy and case difficulty. This mismatch might prevent physicians
from reexamining difficult cases where their diagnosis may be incorrect.
16. Use of Butterfly Needles to Draw Blood Causes Less Hemolysis than IV Cath Use
Wollowitz A, et al. Acad
Emerg Med. 2013;20:1151-1155.
Objectives: Hemolysis of blood samples drawn in the emergency
department (ED) is a common problem that can interfere with timely diagnosis
and appropriate treatment. The objective of this study was to identify the
smallest number of remediable factors that independently increases the risk of
hemolysis to design an effective strategy to address this issue.
Methods: This was a prospective, observational,
cross-sectional study of blood specimens obtained by ED staff in an urban,
academic, adult ED in a tertiary care center. The staff member who drew the
specimen recorded data on a standardized data collection instrument about
device (intravenous [IV] catheter or butterfly needle), needle size, anatomic
site, fullness of collection tube, tourniquet time, and difficulty of
venipuncture. Specimens were sent to the laboratory by a vacuum-powered tube
system. A standard automated process that measures free hemoglobin was used to
identify hemolysis. A multivariable logistic regression and a tabular analysis
stratified by device were performed. Ninety-five percent confidence intervals
(CIs) were calculated around the odds ratios (ORs) and around the difference
between hemolysis rates.
Results: Data were collected on 5,118 blood specimens. There
were 4,513 specimens with complete data on all characteristics of the blood
draw included in the analyses. The overall hemolysis rate was 12.5% (95% CI =
11.6% to 13.5%), 14.6% in blood drawn from IV catheters and 2.7% from butterfly
needles (difference = 11.9%; 95% CI = 10.2% to 13.4%). Device was the strongest
independent predictor of hemolysis (OR = 7.7; 95% CI = 4.9 to 12.0). In specimens
drawn by IV catheter, hemolysis was significantly higher when blood was drawn
from locations other than the antecubital fossa, with small-gauge catheters,
collection tubes ≤ half full, tourniquet time ≥ 1 minute, and difficult
venipuncture. In contrast, none of these factors was associated with hemolysis
when blood was drawn by butterfly needle.
Conclusions: The device used to collect blood was the strongest
independent predictor of hemolysis in blood samples drawn in the ED in this
study. This finding suggests that the most effective strategy to reduce the
rate of hemolysis in the ED is to use butterfly needles for phlebotomy rather
than IV catheters.
17.Why Doctors Don’t Take Sick Days
By DANIELLE OFRI. New York
Times. November 15, 2013
THE bottle of Maalox
sat perched on the triage desk in the emergency room. It was mint flavor, or
maybe lemon — I don’t recall exactly — but it shimmered temptingly. I had just
finished with a new admission, and my stomach had been groaning ominously for hours.
It was after midnight, the whole night was still ahead of me, and I was getting
desperate. I scribbled the last of my medication orders and snagged the Maalox
bottle, popping the top and chugging two revolting capfuls on my way to the
As I rode upstairs,
I could feel the intestinal protestations growing. There was going to be an
apocalyptic resolution to this. The elevator opened and I burst into the
restroom, just in time to disgorge the Maalox and everything else into the
toilet, conscientiously keeping my white coat and stethoscope clear of the
I staggered into the
call room and flopped onto the couch. My fellow resident listened to my tale of
gastrointestinal woe and did what any residency buddy would do: he slid an
18-gauge IV into my antecubital vein and strung up a bag of IV saline. I spent
the pre-dawn hours prostrate on the couch doing phone work — renewing
medications, answering calls from nurses, ordering labs — while my colleagues
did the foot work on the wards and in the emergency room. Together we kept
rounds, I caught a few hours of sleep at home, showered, and then reported back
to the hospital at 10 p.m. for my next shift.
What I didn’t do was
call in sick.
It has long been
known that doctors make the worst patients. From day one in medical training,
the unspoken message is that calling in sick is for wimps. Much of this is
logistics. The staff has to scramble to reschedule patients — many of whom have
been waiting weeks or months for their appointments. Patients who need medical
attention that day are crammed into someone else’s schedule or sent to the
emergency room. Your already overworked colleagues are saddled with extra work,
and patients usually get the short end of the stick.
So most doctors
ignore their symptoms and resist taking the day off unless they are sick enough
to be hospitalized in the next bed over.
This, of course, is
ridiculous behavior on the part of medical professionals who would never
recommend such nonsense to their patients. Medical workers with respiratory
infections are contagious. Caregivers with gastrointestinal infections — as I
had — can easily infect their patients…
18. AAP issues "return to learn" checklist for students with concussion
Most students who
suffer from a concussion make a complete recovery within three weeks, but
specialists should be consulted when their recovery appears protracted,
according to a report released in the journal Pediatrics. Generally, students
with a concussion should be allowed to rest and slowly transition back to
school in order to allow the brain to heal. However, management of concussion
cases should be individualized because every concussion "is unique and may
encompass a different constellation and severity of symptoms," the
American Academy of Pediatrics said.
Diagnosis of Acute Mesenteric Ischemia: A Systematic Review and Meta-analysis
Cudnik MT, et al. Acad Emerg Med. 2013;20:1087–1100
Objectives: Acute mesenteric ischemia is an infrequent cause of
abdominal pain in emergency department (ED) patients; however, mortality for
this condition is high. Rapid diagnosis and surgery are key to survival, but
presenting signs are often vague or variable, and there is no pathognomonic
laboratory screening test. A systematic review and meta-analysis of the
available literature was performed to determine diagnostic test characteristics
of patient symptoms, objective signs, laboratory studies, and diagnostic modalities
to help rule in or out the diagnosis of acute mesenteric ischemia in the ED.
Methods: In concordance with published guidelines for
systematic reviews, the medical literature was searched for relevant articles.
The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for
systematic reviews was used to evaluate the overall quality of the trials
included. Summary estimates of diagnostic accuracy were computed by using a
random-effects model to combine studies. Those studies without data to fully
complete a two-by-two table were not included in the meta-analysis portion of
Results: The literature search identified 1,149 potentially
relevant studies, of which 23 were included in the final analysis. The quality
of the diagnostic studies was highly variable. A total of 1,970 patients were
included in the combined population of all included studies. The prevalence of
acute mesenteric ischemia ranged from 8% to 60%. There was a pooled sensitivity
for l-lactate of 86% (95% confidence interval [CI] = 73% to 94%) and a pooled
specificity of 44% (95% CI = 32% to 55%). There was a pooled sensitivity for
D-dimer of 96% (95% CI = 89% to 99%) and a pooled specificity of 40% (95% CI =
33% to 47%). For computed tomography (CT), we found a pooled sensitivity of 94%
(95% CI = 90% to 97%) and specificity of 95% (95% CI = 93% to 97%). The
positive likelihood ratio (+LR) for a positive CT was 17.5 (95% CI = 5.99 to
51.29), and the negative likelihood ratio (–LR) was 0.09 (95% CI = 0.05 to 0.17).
The pooled operative mortality rate for mesenteric ischemia was 47% (95% CI =
40% to 54%). Given these findings, the test threshold of 2.1% (below this
pretest probability, do not test further) and a treatment threshold of 74%
(above this pretest probability, proceed to surgical management) were
Conclusions: The quality of the overall literature base for
mesenteric ischemia is varied. Signs, symptoms, and laboratory testing are
insufficiently diagnostic for the condition. Only CT angiography had adequate
accuracy to establish the diagnosis of acute mesenteric ischemia in lieu of
Botulism: A Case Report and Review
Brown N, et al. J Emerg Med. 2013;45:842-5.
is the result of ingestion of Clostridium botulinum spores, and is the most
common form of infection with botulism in the United States. Ninety percent of
cases occur in infants less than 6 months old. The infants typically present with
vague symptoms such as hypotonia and poor feeding. This article reports an
infant with confirmed infantile botulism that presented to the Emergency
Department (ED) with complaints of decreased feeding and absence of
bowel movements for over 1 week.
Objectives: Review a case of infantile botulism, its diagnosis,
Case Report: A 4-month-old healthy Caucasian male presented to the
ED with a 6-day history of decreased feeding after referral from the
pediatrician. He had not had a bowel movement for 9 days, and his parents were
also concerned about increasing weakness, as he was no longer able to hold his
head up on his own. In the ED, he was minimally interactive. His vital signs
were within normal limits, and he had hypoactive bowel sounds and decreased
tone throughout. He was admitted to the Children's Hospital and eventually transferred
to the Pediatric Intensive Care Unit requiring intubation and mechanical
ventilation. The botulism immunoglobulin was administered, and a diagnosis was
confirmed with positive botulinum toxin in the stool samples. Full recovery was
made by the infant.
Conclusion: Awareness of the symptoms of botulism and a high
degree of clinical suspicion is needed to make a prompt diagnosis.
Speed of Sound: Comet Tails and Lung Sliding: Evaluating for Pneumothorax
Butts C. Emerg Med News2013;35:20.
A 30-year-old man is
brought to the ED after a motor vehicle crash. His GCS was 3 on scene, he was
intubated by paramedics, and was unresponsive on arrival. Vital signs are heart
rate of 120 bpm, blood pressure of 100/70 mm Hg, and SpO2 at 90%. Breath sounds
are decreased to the left chest, but supine chest x-ray appears normal.
Supine chest x-rays
have been shown to be significantly insensitive in diagnosing pneumothorax. CT
scan is the gold standard, but may not be immediately available in all centers
or prudent given a patient's hemodynamic status. Ultrasound has been
demonstrated to be markedly better at diagnosing pneumothorax than supine chest
x-ray in multiple head-to-head studies. A meta-analysis found that supine chest
x-ray had a pooled sensitivity of 52% and a specificity of 99%. (Chest
2011;140:859.) Ultrasound in comparison had a pooled sensitivity of 88% and
a specificity of 100%.
Ultrasound of the
pleura for pneumothorax primarily looks for two important findings: the
presence of lung “sliding” and of comet tail artifacts…
22. Tough Mudder: Unique
Obstacle Race Injuries at an Extreme Sports Event: A Case Series.
Greenberg MR, et al. Ann Emerg Med. 2013 Nov 7. [Epub ahead of print]
endurance events are becoming more common. Appropriate preparedness for the
volume and unique types of injury patterns, as well as the effect on public
health these events may cause, has yet to be reported in emergency literature.
We describe 5 patients who presented with diverse injuries to illustrate the
variety of injuries sustained in this competitive event. In particular, 4 of
the patients had a history of contact with electrical discharge, an obstacle
distinctive to the Tough Mudder experience.
23. Tid Bits
A. Flu Shots
Tied to Lower Risk of Cardiac Events
Influenza vaccination was associated with a reduced risk of
major adverse cardiovascular events among patients at high risk for heart
disease, a meta-analysis showed.
In pooled results from five published, randomized trials, the
event rate in the first year of follow-up was 2.9% in those who received flu
vaccine and 4.7% in those who didn't (risk ratio 0.64, 95% CI 0.48-0.86),
according to Jacob Udell, MD, MPH, of the University of Toronto, and
And the apparent benefit was even greater among those with a
history of acute coronary syndrome (ACS) in the year before randomization (RR
0.45, 95% CI 0.32-0.63), the researchers reported in the Oct. 23/30 issue of
the Journal of the American Medical Association.
drugs don't necessarily mean low prices
NewsHour Weekend's Megan Thompson reports on the surprising
disparity in pricing for generic drugs. Generics, generally thought to be
cheap, can actually vary widely in price from pharmacy to pharmacy, causing
some to skip medications altogether.
Thompson of Edina, Minnesota, was diagnosed with breast cancer in 2009.For part of the year, she paid more than $400
a month out-of-pocket for her brand-name drug because of her insurance plan’s
high deductible.A couple years later,
after the drug, called Letrozole, went generic, the price dropped
dramatically:to around $10 at her local
Costco.Always looking for an even
better deal, she decided to ask another big chain about its retail price.
gentleman looked it up and he came back to me with a price of around $400. And
I said to him, "Oh can't be.You
must be looking at the brand name drug.It can't be that expensive."
there was no mistake: one store quoted a price forty times more than the other.
How could that be?Especially when
generic drugs are commonly thought to be so inexpensive.
CAROL THOMPSON:I was
shocked.I was confused.I thought, "What am I missing?You know, this doesn't compute."
C. Most parents improperly administer inhaled asthma meds to
asked 169 parents or caregivers in New York City to demonstrate the
administration of asthma medications, and found that only one was able to show
all 10 critical steps for properly using a spacing device with an inhaler. Of
the five essentials steps for accurate medication delivery, asking the child to
take deep six breaths for a single actuation of the inhaler and waiting at
least 30 seconds following those breaths before administering the second dose
were the steps left out by most participants. The findings appear in the
Journal of Asthma.
D. Market withdrawal, labeling changes on cold, cough meds
curb pediatric ED visits
voluntary withdrawal of infant cold and cough medications from the U.S. market
in 2007, children younger than 2 years accounted for 2.4% of all emergency
department visits for suspected adverse reactions to the drugs, down from 4.1%
prior to the withdrawal, CDC researchers said. ED visits associated with the
medications also dropped among 2- to 3-year-olds from 9.5% to 6.5% after
manufacturers added labels warning that such medications should not be given to
children younger than 4, according to a report published in the journal
E. Analysis links exercise to a reduced risk of injuries from
Exercise can help
keep people over age 60 from falling and reduces the likelihood of injury when
they do fall, French researchers reported in BMJ. Their analysis included data
from 17 studies and found exercise was associated with a 37% reduction of injurious
falls, a 43% decrease in severe injurious falls and a 61% drop in falls
resulting in fracture.
Between October 2004
and September 2012, influenza-related complications claimed the lives of 830
children, and the majority of them did not get a flu shot, according to a CDC
study in the journal Pediatrics. Of the children who died, 43% were healthy,
without asthma, cancer, diabetes or other high-risk condition. "All too
often, people dismiss flu as a mild illness, but every year, children,
including healthy children, die from flu," CDC Director Tom Frieden said.
G. Fighting injuries result in reduced intelligence
injuries suffered in early adolescence may result in significant reductions in
intelligence in early adulthood. These reductions can have serious
ramifications across the rest of the life course.