Wednesday, February 26, 2014

Lit Bits: Feb 26, 2014

From the recent medical literature…

1. A Top-Five (or 17) List for EM: A Pilot Project to Improve the Value of Emergency Care

Schuur JD, et al. JAMA Intern Med 2014. February 17, 2014. [Epub ahead of print]

Importance  The mean cost of medical care in the United States is growing at an unsustainable rate; from 2003 through 2011, the cost for an emergency department (ED) visit rose 240%, from $560 to $1354. The diagnostic tests, treatments, and hospitalizations that emergency clinicians order result in significant costs.

Objective  To create a “top-five” list of tests, treatments, and disposition decisions that are of little value, are amenable to standardization, and are actionable by emergency medicine clinicians.

Design, Setting, and Participants  Modified Delphi consensus process and survey of 283 emergency medicine clinicians (physicians, physician assistants, and nurse practitioners) from 6 EDs.

Intervention  We assembled a technical expert panel (TEP) and conducted a modified Delphi process to identify a top-five list using a 4-step process. In phase 1, we generated a list of low-value clinical decisions from TEP brainstorming and e-mail solicitation of clinicians. In phase 2, the TEP ranked items on contribution to cost, benefit to patients, and actionability by clinicians. In phase 3, we surveyed all ordering clinicians from the 6 EDs regarding distinct aspects of each item. In phase 4, the TEP voted for a final top-five list based on survey results and discussion.
Main Outcomes and Measures  A top-five list for emergency medicine. The TEP ranked items on contribution to cost, benefit to patients, and actionability by clinicians. The survey asked clinicians to score items on the potential benefit or harm to patients and the provider actionability of each item. Voting and surveys used 5-point Likert scales. A Pearson interdomain correlation was used.

Results  Phase 1 identified 64 low-value items. Phase 2 narrowed this list to 7 laboratory tests, 3 medications, 4 imaging studies, and 3 disposition decisions included in the phase 3 survey (71.0% response rate). All 17 items showed a significant positive correlation between benefit and actionability (r, 0.19-0.37 [P ≤ .01]). One item received unanimous TEP support, 4 received majority support, and 12 received at least 1 vote.

Conclusions and Relevance  Our TEP identified clinical actions that are of low value and within the control of ED health care providers. This method can be used to identify additional actionable targets of overuse in emergency medicine.

1. Do not order CT of the cervical spine for patients after trauma who do not meet the NEXUS low-risk criteria or Canadian C-Spine Rule.

2. Do not order CT to diagnose PE without first risk stratifying for PE (pretest probability and D-dimer testing if low probability).

3. Do not order MRI of the lumbar spine for patients with lower back pain without high-risk features.

4. Do not order CT of the head for patients with mild traumatic head injury who do not meet New Orleans Criteria or Canadian CT Head Rule.

5. Do not order coagulation studies for patients without hemorrhage or suspected coagulopathy (eg, with anticoagulation therapy, clinical coagulopathy).

6. Do not order blood cultures for patients with a skin infection (eg, cellulitis, abscess) without sepsis.

7. Do not admit patients with low-risk chest pain (atypical chest pain with a negative troponin test result and nonischemic ECG) to the hospital for further evaluation.

8. Do not prescribe brand-name antibiotics for patients with community-acquired pneumonia, urinary tract infections, or cellulitis (use generic medications instead).

9. Do not give IV antibiotics to non–critically ill patients who can tolerate oral antibiotics.

10. Do not order blood cultures for patients with a urinary source of infection (eg, UTI, pyelonephritis) without sepsis.

11. Do not admit patients with low-risk syncope to the hospital.

12. Do not order screening laboratories (eg, CBC, chemistry studies) for patients with uncomplicated gastroenteritis or viral syndromes.

13. Do not give IV fluids to patients with mild dehydration without attempting oral rehydration first.

14. Do not order chest radiography for screening purposes for patients being admitted to the hospital.

15. Do not mandate follow-up wound checks in the ED for patients discharged with uncomplicated abscesses or cellulitis.

16. Do not order urine cultures for healthy patients with uncomplicated UTI.

17. Do not order repeated laboratory tests for patients transferred into the ED who have laboratory results within reference range available from the outside hospital.

2. Little Association of Traumatic Brain Injuries with Isolated Vomiting in Children with Minor Blunt Head Trauma

Dayan PS, et al for PECARN. Ann Emerg Med. 2014 Feb 19 [Epub ahead of print]

Study objective: We aimed to determine the prevalence of traumatic brain injuries in children who vomit after minor blunt head trauma, particularly when the vomiting occurs without other findings suggestive of traumatic brain injury (ie, isolated vomiting). We also aimed to determine the relationship between the timing and degree of vomiting and traumatic brain injury prevalence.

Methods: This was a secondary analysis of children younger than 18 years with minor blunt head trauma. Clinicians assessed for history and characteristics of vomiting at the initial evaluation. We assessed for the prevalence of clinically important traumatic brain injury and traumatic brain injury on computed tomography (CT).

Results: Of 42,112 children enrolled, 5,557 (13.2%) had a history of vomiting, of whom 815 of 5,392 (15.1%) with complete data had isolated vomiting. Clinically important traumatic brain injury occurred in 2 of 815 patients (0.2%; 95% confidence interval [CI] 0% to 0.9%) with isolated vomiting compared with 114 of 4,577 (2.5%; 95% CI 2.1% to 3.0%) with nonisolated vomiting (difference –2.3%, 95% CI –2.8% to –1.5%). Of patients with isolated vomiting for whom CT was performed, traumatic brain injury on CT occurred in 5 of 298 (1.7%; 95% CI 0.5% to 3.9%) compared with 211 of 3,284 (6.4%; 95% CI 5.6% to 7.3%) with nonisolated vomiting (difference –4.7%; 95% CI –6.0% to –2.4%). We found no significant independent associations between prevalence of clinically important traumatic brain injury and traumatic brain injury on CT with either the timing of onset or time since the last episode of vomiting.

Conclusion: Traumatic brain injury on CT is uncommon and clinically important traumatic brain injury is very uncommon in children with minor blunt head trauma when vomiting is their only sign or symptom. Observation in the emergency department before determining the need for CT appears appropriate for many of these children.

3. New ICD-10 Codes You Need to Know

It is about 200 days before the move to ICD-10 becomes a must-do. Lest the deadline slip your mind, MedPage Today is spotlighting some of those thousands of new codes that might just be getting a bit too granular.
  • V97.33XD: Sucked into jet engine, subsequent encounter [DRV: I see this every week
  • W61.92: Struck by other birds
  • Z63.1: Problems in relationship with in-laws [Is that a real diagnosis?]
  • V52.2XXA: Person on outside of pick-up truck or van injured in collision with two- or three-wheeled motor vehicle in nontraffic accident, initial encounter
  • X92.0: Assault by drowning and submersion while in bathtub

4. High dose droperidol and QT prolongation: analysis of continuous 12-lead recordings.

Calver L, Isbister GK. Br J Clin Pharmacol. 2013 Oct 30. [Epub ahead of print]

AIMS: To investigate the QT interval after high-dose droperidol using continuous 12-lead holter recordings.

METHODS: This was a prospective study of patients given droperidol with a continuous holter recording. Patients were recruited from the DORM II study which includes patients with aggression presenting to the emergency department. Patients initially received 10mg droperidol as part of a standardised sedation protocol. An additional 10mg dose was given after 15min if required and further doses at the clinical toxicologist's discretion. Continuous 12-lead holter recordings were obtained for 2-24hours utilising high resolution digital recordings with automated QT interval measurement. Electrocardiograms were extracted hourly from holter recordings. The QT interval was plotted against heart rate(HR) on the QT nomogram to determine if it was abnormal. QTcF(Fridericia's HR correction) was calculated and greater than 500msec was defined as abnormal.

RESULTS: Forty six patients had holter recordings after 10-40mg droperidol and 316 QT-HR pairs were included. There were 32 abnormal QT measurements in four patients, three given 10mg and one 20mg. In three of the four patients QTcF greater than 500msec but only in one taking methadone was the timing of QTcF greater than 500msec consistent with droperidol dosing. Of the three other patients, one took amphetamines, one still had QT prolongation 24hr after droperidol and one took a lamotrigine overdose. No patient given more than 30mg had a prolonged QT. There were no arrhythmias.

CONCLUSION: QT prolongation was observed with high-dose droperidol. However, there was little evidence supporting droperidol being the cause and QT prolongation was more likely due to pre-existing conditions or other drugs.

5. Dexamethasone Tames Acute Asthma in Kids, With Less Vomiting

Diedtra Henderson. Medscape News. February 10, 2014

Giving children with acute asthma flare-ups 1 or 2 doses of dexamethasone in the emergency department (ED) provides equivalent relief to a 5-day course of prednisone while reducing the chance of triggering vomiting, according to a meta-analysis by Grant E. Keeney, MD, from the Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and colleagues, who published the results of their analysis online February 10 in Pediatrics.

Some 6 million children in the United States suffer from asthma, a chronic inflammatory disease that accounts for 2% of all ambulatory care and ED visits by pediatric patients, the authors write. Oral prednisone, which tamps down inflammation and decreases mucus production, is the cornerstone of treatment for acute asthma exacerbations, but the remedy exacts a cost: vomiting.

The authors sought to determine whether dexamethasone might provide the same therapeutic benefit with fewer doses and less vomiting than is associated with a 5-day course of oral prednisone or prednisolone. Searching PubMed, the researchers identified 667 articles describing randomized clinical trials comparing the medicines of interest; they included 6 trials in the meta-analysis.

Each study was performed in the ED and enrolled from 15 to 272 patients, 63.5% of whom were boys. Dexamethasone was given as a single dose, either orally or intramuscularly, in 4 studies and was given as multiple doses in 2 studies. There was no statistically significant difference between the 2 therapies when it came to relapses to the clinic, ED, or hospitalization.
"Significantly fewer patients receiving dexamethasone vomited in the ED or at home after discharge. This finding has clinical significance for improving patient and parental satisfaction," according to the authors.

"This is a huge win for those of us in emergency medicine and, more importantly, for the families we take care of, when you consider that asthma is the most common chronic disease of children," Stephen J. Teach, MD, MPH, associate chief of the Division of Emergency Medicine at Children's National Medical Center in Washington, DC, told Medscape Medical News.

According to Dr. Teach, the facility handles 1% of ED visits made by children in the country for asthma. Practitioners recognized that if prednisone was given as early as possible during a significant asthma flare-up, it cut down on emergency admissions, and children missed less school.

"It was big breakthrough," he told Medscape Medical News. However, "prednisone is a terrible medication to take. It tastes awful. It's hard to mask it.... When it hits the stomach, it's an irritant. Kids throw it up all the time. It became this wonderful–terrible thing."
Dexamethasone's noxious taste, in contrast, can be masked with cherry syrup. Large-volume EDs already have begun to make the shift.

"There's really no difference, and it's more patient-centered," said Dr. Teach, who was not involved in the current study. "Kids take it better. They take fewer doses.... All of the available data suggest there is no difference in short-term outcomes."

The authors note that their results were based on studies based in the ED, making it unclear whether they apply to the ambulatory clinic setting.

"Based on our findings, emergency physicians should consider single or 2-dose dexamethasone regimens over 5-day prednisone/prednisolone regimens for the treatment of acute asthma exacerbations," the authors conclude.

Support for this study was provided by the National Center for Advancing Translational Sciences, National Institutes of Health. The authors and Dr. Teach have disclosed no relevant financial relationships. 

6. Impact of Increasing Ondansetron Use on Clinical Outcomes in Children with Gastroenteritis

Freedman SB, et al. JAMA Pediatr. 2014 February 24 [Epub ahead of print]

[From the editorial] Acute gastroenteritis (AGE) is one of the most common reasons for children seeking care in the emergency department (ED), accounting for nearly 2 million visits in the United States each year. For children with AGE and mild to moderate dehydration, oral rehydration therapy (ORT) is effective and recommended by the Centers for Disease Control and Prevention1 and American Academy of Pediatrics as first-line therapy. However, vomiting is common in children with AGE and may prevent the success of ORT. Ondansetron, which became available in generic formulation in 2006, is efficacious in reducing vomiting and the need for intravenous (IV) rehydration and hospital admission, but little is known about its effectiveness in real-world practice.

Importance  Ondansetron hydrochloride use in children with gastroenteritis is increasing rapidly; however, little is known about its impact on outcomes.

Objective  To determine whether increasing emergency department ondansetron use has resulted in a reduction in intravenous rehydration rates.

Design, Setting, and Participants  Retrospective observational analysis of eligible visits included in the Pediatric Health Information System administrative database. Eligible institutions included 18 emergency departments geographically distributed across the United States, and participants included 804 000 patients aged 0 to 18 years who were diagnosed as having gastroenteritis in an emergency department at an eligible participating institution between January 1, 2002, and December 31, 2011.

Interventions  The presence or absence of oral ondansetron administration was identified for each patient through database review. Visits were categorized based on institutional ondansetron use: low (less than 5% administered ondansetron), medium (5%-25%), or high (above 25%).

Main Outcomes and Measures  We conducted hospital-level analyses of the associations between ondansetron use and 3 outcomes: intravenous rehydration (primary), hospitalization, and emergency department revisits within 3 days. Time-series regression models were used, adjusting for demographic characteristics, laboratory testing, diagnostic imaging, and rotavirus infection.

Results  A total of 804 000 eligible patient visits were identified. Oral ondansetron use increased from a median institutional rate of 0.11% (interquartile range, 0.04%-0.44%) of patient visits in 2002 to 42.2% (interquartile range, 37.5%-49.1%) in 2011 (P  less than  .001). Intravenous rehydration was administered to 43 413 of 232 706 children (18.7%) during the low ondansetron period compared with 59 450 of 334 264 (17.8%) during the high ondansetron period (adjusted percentage change = −0.33%; 95% CI, −1.86% to 1.20%). During the transition from low to high ondansetron use, we observed no change in the hospitalization rate (adjusted percentage change = −0.33%; 95% CI, −0.95% to 0.29%), but emergency department revisits decreased (adjusted percentage change = −0.31%; 95% CI, −0.49% to −0.13%). The change in all 3 outcomes varied widely between low and high ondansetron use categories at an institutional level. Oral ondansetron was provided to 13.5% (95% CI, 13.3% to 13.7%) of children administered intravenous rehydration.

Conclusions and Relevance  Although ondansetron use increased during the study period, intravenous rehydration rates were unchanged. Most children administered intravenous fluids did not receive oral ondansetron. Our findings highlight the need to focus efforts to administer ondansetron to children at greatest risk for oral rehydration failure.

7. Watch for Clots During the “Fourth Trimester”

Eleanor Bimla Schwarz, MD, MS, Journal Watch Emerg Med, Feb 2014

Risk for thrombosis remains elevated for 12 weeks postpartum.

Women are hypercoagulable for the first 6 weeks postpartum, but the time course of thrombotic risk thereafter is unclear. To assess extended postpartum clot risk, researchers analyzed hospital discharge claims data from all California women who delivered between 2005 and 2010.

In models adjusted for factors such as age, race, smoking, and predisposition to clot, incidence of a first thrombotic event (ischemic stroke, acute myocardial infarction, or venous thrombosis) 7 to 12 weeks after delivery was twice that at 1 year postpartum, for an absolute risk difference of 3.0 thrombotic events per 100,000 deliveries. Thrombotic risk leveled off after 12 weeks postpartum.

Although we need further study of postpartum clot risk, I will now consider offering thrombotic prophylaxis to high-risk women throughout the first 12 weeks after delivery. In addition, although the CDC has stated that women without risk factors for thromboembolism can generally initiate estrogen-containing contraception 21 to 42 days after delivering (while women with cesarean deliveries or previous thrombosis should wait 42 days postpartum), I will encourage my postpartum patients to wait 12 weeks before using estrogen-containing contraception. For those who want immediate postpartum contraception, intrauterine devices and implants offer highly effective reversible contraception without increasing clot risk.

Source: Kamel H et al. N Engl J Med 2014 Feb 13.    

8. Outcomes and Radiation Exposure of ED Patients with Chest Pain and SOB and Ultralow Pretest Probability: A Multicenter Study

Kline JA, et al. Ann Emerg Med. 2014;63:281-288.

Study objective: Excessive radiation exposure remains a concern for patients with symptoms suggesting acute coronary syndrome and pulmonary embolism but must be judged in the perspective of pretest probability and outcomes. We quantify and qualify the pretest probability, outcomes, and radiation exposure of adults with both chest pain and dyspnea.

Methods: This was a prospective, 4-center, outcomes study. Patients were adults with dyspnea and chest pain, nondiagnostic ECGs, and no obvious diagnosis. Pretest probability for both acute coronary syndrome and pulmonary embolism was assessed with a validated method; ultralow risk was defined as pretest probability less than 2.5% for both acute coronary syndrome and pulmonary embolism. Patients were followed for diagnosis and total medical radiation exposure for 90 days.

Results: Eight hundred forty patients had complete data; 23 (3%) had acute coronary syndrome and 15 (2%) had pulmonary embolism. The cohort received an average of 4.9 mSv radiation to the chest, 48% from computed tomography pulmonary angiography. The pretest probability estimates for acute coronary syndrome and pulmonary embolism were less than 2.5% in 227 patients (27%), of whom 0 of 277 (0%; 95% confidence interval 0% to 1.7%) had acute coronary syndrome or pulmonary embolism and 7 of 227 (3%) had any significant cardiopulmonary diagnosis. The estimated chest radiation exposure per patient in this ultralow-risk group was 3.5 mSv, including 26 (3%) with greater than 5 mSv radiation to the chest and no significant cardiopulmonary diagnosis.

Conclusion: One quarter of patients with chest pain and dyspnea had ultralow risk and no acute coronary syndrome or pulmonary embolism but were exposed to an average of 3.5 mSv radiation to the chest. These data can be used in a clinical guideline to reduce radiation exposure.

[DRV: How did they determine pretest probability? Let me quote: “Pretest probability was assessed with the method of attribute matching separately for acute coronary syndrome and pulmonary embolism, as previously described. Briefly, attribute matching is a computer program that matches a profile of clinical predictors (8 for acute coronary syndrome and 10 for pulmonary embolism) that are input by the clinician. The program then sorts through 2 separate large databases containing patients who were previously evaluated for possible acute coronary syndrome and pulmonary embolism and extracts only the patients who have exact matches with the profile of the patient under consideration. This process results in a denominator of all matched patients and numerator of patients with acute coronary syndrome or pulmonary embolism, and the quotient reveals the pretest probability that can be expressed as a percentage value.”]

9. A Trial of Treatment for Acute Otorrhea in Children with Tympanostomy Tubes: Drops Beat Oral Antibiotics

van Dongen TMA, et al. N Engl J Med 2014; 370:723-733.

Background: Recent guidance for the management of acute otorrhea in children with tympanostomy tubes is based on limited evidence from trials comparing oral antibiotic agents with topical antibiotics.

Methods: In this open-label, pragmatic trial, we randomly assigned 230 children, 1 to 10 years of age, who had acute tympanostomy-tube otorrhea to receive hydrocortisone–bacitracin–colistin eardrops (76 children) or oral amoxicillin–clavulanate suspension (77) or to undergo initial observation (77). The primary outcome was the presence of otorrhea, as assessed otoscopically, 2 weeks after study-group assignment. Secondary outcomes were the duration of the initial otorrhea episode, the total number of days of otorrhea and the number of otorrhea recurrences during 6 months of follow-up, quality of life, complications, and treatment-related adverse events.

Results: Antibiotic–glucocorticoid eardrops were superior to oral antibiotics and initial observation for all outcomes. At 2 weeks, 5% of children treated with antibiotic–glucocorticoid eardrops had otorrhea, as compared with 44% of those treated with oral antibiotics (risk difference, −39 percentage points; 95% confidence interval [CI], −51 to −26) and 55% of those treated with initial observation (risk difference, −49 percentage points; 95% CI, −62 to −37). The median duration of the initial episode of otorrhea was 4 days for children treated with antibiotic–glucocorticoid eardrops versus 5 days for those treated with oral antibiotics (P less than 0.001) and 12 days for those who were assigned to initial observation (P less than 0.001). Treatment-related adverse events were mild, and no complications of otitis media, including local cellulitis, perichondritis, mastoiditis, and intracranial complications, were reported at 2 weeks.

Conclusions: Antibiotic–glucocorticoid eardrops were more effective than oral antibiotics and initial observation in children with tympanostomy tubes who had uncomplicated acute otorrhea.

10. Images in Clinical Practice

Infant With Projectile Vomiting

Elderly Woman With Right Thigh Pain

Bilateral Corneal Perforation 

An Unusual Auricular Foreign Body  (you’ll love the video)

Hypertensive Retinopathy Associated with Preeclampsia 

Valsalva Retinopathy

11. Ann Emerg Med Lit Reviews

A. Do Corticosteroids Prevent Postherpetic Neuralgia?

Voros J, et al. Ann Emerg Med. 2014;63:351-352.

Take-Home Message: Although corticosteroids do not prevent postherpetic neuralgia, they may decrease the duration of acute zoster pain when given as a 3-week course.

Commentary: Acute herpes zoster infection, or shingles, has an estimated lifetime incidence of 10% to 20%.5, 6 Of individuals affected, approximately 40% present with severe pain. Postherpetic neuralgia, defined as pain persisting at least 120 days after disease onset, is the most debilitating complication of shingles,4 affecting approximately 20% of patients postinfection.

Treatment of herpes zoster has 3 primary objectives: (1) treat the acute viral infection, (2) treat the acute pain associated with the infection, and (3) prevent postherpetic neuralgia. Antiviral agents, corticosteroids, and analgesics have all been used to accomplish these objectives. Though corticosteroids have commonly been prescribed, there has been a lack of consensus on their efficacy in preventing postherpetic neuralgia. Although this systematic review provides moderate-grade evidence that corticosteroids do not prevent postherpetic neuralgia, analysis of secondary outcomes suggests that a 3-week tapered dose of oral corticosteroids may reduce the duration of pain in the acute phase of shingles.

B. Is Ketamine Effective for the Management of Acute Asthma Exacerbations in Children?

Maddox RP, et al. Ann Emerg Med. 2014;63:309-310.

Take-Home Message: Limited data from a single randomized controlled trial do not support the routine use of ketamine for children with acute asthma exacerbations that are unresponsive to initial aerosolized β2-agonist or steroids.

Commentary: Asthma is the most common chronic disease of childhood, affecting millions of children in the United States, and is a major cause of morbidity and mortality. Children with severe acute asthma exacerbations have the potential to deteriorate into respiratory failure. In the most severe cases, standard aggressive treatment may fail and require intubation with mechanical ventilation.3, 4

The use of ketamine as a sedative for intubation and mechanical ventilation of children with severe asthma attacks has been well described.5 Ketamine maintains cardiac performance and airway reflexes while providing analgesia, amnesia, and decreased airway resistance.6 According to these physiologic benefits, one would expect ketamine to be useful in children with moderate to severe asthma who are at risk for failing conventional treatment. In fact, there have been case reports describing mitigation of intubation with the use of ketamine in combination with standard therapy.6, 7

Unfortunately, this systematic review identified only 1 small, high-quality, randomized, controlled trial evaluating nonintubated children who failed initial standard asthma therapy, with results that did not demonstrate improved outcomes with ketamine (0.2 mg/kg followed by a 2-hour infusion of 0.5 mg/kg) compared with standard therapy.2 The dosage used in this study may have been suboptimal, according to case reports using higher doses (2- to 3-mg/kg bolus followed by a 2- to 3-mg/kg per hour infusion).7 Although ketamine would seem to offer a physiologically plausible advantage, more high-quality randomized data are required to determine its efficacy in avoiding intubations in this patient population.

12. Phaeochromcytoma Crisis

Whitelaw BC, et al. Clin Endocrinol. 2014;80(1):13-22.

Phaeochromcytoma crisis is an endocrine emergency associated with significant mortality. There is little published guidance on the management of Phaeochromcytoma crisis. This clinical practice update summarizes the relevant published literature, including a detailed review of cases published in the past 5 years, and a proposed classification system. We review the recommended management of Phaeochromcytoma crisis including the use of alpha-blockade, which is strongly associated with survival of a crisis. Mechanical circulatory supportive therapy (including intra-aortic balloon pump or extra-corporeal membrane oxygenation) is strongly recommended for patients with sustained hypotension. Surgical intervention should be deferred until medical stabilization is achieved.

13. IV paracetamol (aka acetaminophen) versus dexketoprofen (NSAID) versus morphine in acute mechanical LBP in the ED: a randomised double-blind controlled trial

Eken C, et al. Emerg Med J  2014;31:177-181.  

Study objective The objective of this study was to determine the analgesic efficacy and safety of intravenous, single-dose paracetamol versus dexketoprofen versus morphine in patients presenting with mechanical low back pain (LBP) to the emergency department (ED).

Methods This randomised double-blind study compared the efficacy of intravenous 1 gm paracetamol, 50 mg dexketoprofen and 0.1 mg/kg morphine in patients with acute mechanical LBP. Visual analogue scale (VAS) was used for pain measurement at baseline, after 15 and after 30 min.

Results A total of 874 patients were eligible for the study, and 137 of them were included in the final analysis: 46 patients from the paracetamol group, 46 patients in the dexketoprofen group and 45 patients in the morphine group. The mean age of study subjects was 31.5±9.5 years, and 60.6% (n=83) of them were men. The median reduction in VAS score at the 30th minute for the paracetamol group was 65 mm (95% CI 58 to 72), 67 mm (95% CI 60 to 73) for the morphine group and 58 mm (95% CI 50 to 64) for the dexketoprophen group. Although morphine was not superior to paracetamol at 30 min (difference: 3.8±4.9 (95% CI −6 to 14), the difference between morphine and dexketoprofen in reducing pain was 11.2±4.7 (95% CI 2 to 21). At least one adverse effect occurred in 8.7% (n=4) of the cases in the paracetamol group, 15.5% (n=7) of the morphine group, and 8.7% (n=4) of the dexketoprophen group (p=0.482).

Conclusions Intravenous paracetamol, dexketoprofen and morphine are not superior to each other for the treatment of mechanical LBP in ED.

14. Association between ASA grade and complication rate in patients receiving procedural sedation for relocation of dislocated hip prostheses in a UK ED

Dawson N, et al. Emerg Med J  2014;31:207-209  

Objective To determine the association between the American Society of Anesthiologists (ASA) grade and the complication rate of patients receiving procedural sedation for relocation of hip prosthesis in an adult emergency department (ED) in the UK.

Design Retrospective study of registry data from a large UK teaching hospital ED. Consecutive adult patients (aged 16 years and over) in whom ASA grade could be calculated, with an isolated dislocation of a hip prosthesis between 8 September 2006 and 16 April 2010 were included for analyses (n=303). The primary outcome measure was association between ASA and complication rate (any of desaturation below 90%; apnoea; vomiting; aspiration; hypotension below 90 mm Hg; cardiac arrest). Secondary outcome measures were relationship between ASA grade and procedural success, choice of sedative agent and sedation depth, and complications and choice of sedative agent, arrival time and sedation depth.

Results There was no significant difference between ASA grade and the risk of complication (p=0.800). Moreover, there was no significant difference between ASA grade and procedural success (p=0.284), ASA and choice of sedative agent (p=0.243), or ASA and sedation depth (p=0.48). There was no association between complications and sedative agent (p=0.18), or complications and arrival time (p=0.12). There was a significant difference between sedative depth and complications (p less than 0.001).

Conclusions There is no clear association between a patient's physical status (ASA grade) and the risk of complications, chance of procedural success or choice of sedative agent in relocation of hip prostheses. There is a higher rate of complications with higher levels of sedation (p less than 0.001).

15. Adult Scaphoid Fracture

Carpenter CR, et al. Acad Emerg Med. 2014;21:101-121.

Objectives: Scaphoid fractures are the most common carpal fracture, representing 70% of carpal bone fractures. The diagnostic accuracy of physical examination findings and emergency medicine (EM) imaging studies for scaphoid fracture has not been previously described in the EM literature. Plain x-rays are insufficient to rule out scaphoid fractures in a patient with a suggestive mechanism and radial-sided tenderness on physical examination. This study was a meta-analysis of historical features, physical examination findings, and imaging studies for scaphoid fractures not visualized on plain x-ray in adult emergency department (ED) patients, specifically to address which types of imaging tests should be recommended in patients with persistent concern for acute fracture after ED discharge.

Methods: A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED and EMBASE. The original studies' bibliographies were reviewed for additional references and unpublished manuscripts were located via a hand search of EM research abstracts from national meetings. All abstracts were independently reviewed by the two physicians, and Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality. When two or more qualitatively similar studies were identified, meta-analysis was conducted using Meta-DiSc software. Primary outcomes were sensitivity, specificity, and likelihood ratios (LRs) for predictors of scaphoid fracture detected on follow-up in patients with normal ED x-rays.

Results: A total of 957 unique citations were identified, yielding 75 studies eligible for inclusion in this systematic review. Studies were significantly heterogeneous in design, study population, and criterion standard. The majority of studies were conducted in non-ED settings (e.g., orthopedic clinics). No studies used accepted diagnostic research publishing guidelines, and the overall QUADAS-2 methodologic quality was low, indicating an increased risk of bias in the estimates of diagnostic accuracy. The prevalence of scaphoid fractures ranged from 12% to 57% with the point estimate of 25% pretest probability for adult ED patients with concern for scaphoid injuries, nondiagnostic index x-rays, and scaphoid fractures on later imaging studies. Except for the absence of snuffbox tenderness (LR– = 0.15), physical examination findings lack accuracy to rule in or rule out scaphoid fractures, and no validated clinical decision rules exist. In patients with persistent concern for injury, magnetic resonance imaging (MRI) is superior to bone scan, computed tomography (CT), or ultrasound (US) to both rule in and rule out scaphoid fractures. Both MRI and CT share the added benefit of identifying alternative etiologies for posttraumatic wrist pain.

Conclusions: Except for the absence of snuffbox tenderness, which can significantly reduce the probability of scaphoid fracture, history and physical examination alone are inadequate to rule in or rule out scaphoid fracture. MRI is the most accurate imaging test to diagnose scaphoid fractures in ED patients with no evidence of fracture on initial x-rays. If MRI is unavailable, CT is adequate to rule in scaphoid fractures, but inadequate for ruling out scaphoid fractures.

16. The Effect of Point-of-care US on ED LOS and CT Utilization in Children with Suspected Appendicitis

Elikashvili I, et al. Acad Emerg Med. 2014;21:163-170.

Objectives: The role of clinician-performed ultrasonography (US) for suspected appendicitis is unclear. Published data conclude that US has high specificity to rule in the diagnosis of appendicitis, with variable sensitivity to rule it out. Newer data suggest that point-of-care (POC) US may have similar test characteristics. Our objective was to evaluate the effect of POC US in children with suspected appendicitis and its effect on emergency department (ED) length of stay (LOS) and computed tomography (CT) utilization.

Methods: This was a prospective observational convenience sample of children with suspected appendicitis requiring imaging evaluation that adhered to the Standards for the Reporting of Diagnostic accuracy studies (STARD) criteria. Outcomes were determined by operative or pathology report in those who had appendicitis, and 3-week phone follow-up in those patients who were nonoperative. Differences in ED LOS were analyzed by one-way analysis of variance (ANOVA) between patients who received dispositions after POC US, radiology US, or CT. Test performance characteristics were calculated for all imaging modalities.

Results: Among 150 enrolled patients, 50 had appendicitis (33.3%). There were no missed cases of appendicitis in discharged patients at 3-week phone follow-up, nor negative laparotomies in those who went to the operating room. Those who had dispositions after POC US (n = 25) had a significantly decreased mean ED LOS (154 minutes, 95% confidence interval [CI] = 115 to 193 minutes) compared with those requiring radiology US (288 minutes, 95% CI = 257 to 319 minutes) or CT scan (487 minutes; 95% CI = 434 to 540 minutes). Baseline CT rate was 44.2% (95% CI = 30.7% to 57.7%) prior to study start and decreased to 27.3% (95% CI = 20.17% to 34.43%) during the study. CTs were avoided in four patients with conclusive POC US results and inconclusive radiology US results. The sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR–) for POC US were 60% (95% CI = 46% to 72%), 94% (95% CI = 88% to 97%), 10 (95% CI = 4 to 23), and 0.4 (95% CI = 0.3 to 0.6). For radiology US they were 63% (95% CI = 48% to 75%), 99% (95% CI = 94% to 99%), 94 (95% CI = 6 to 1,500), and 0.4 (95% CI = 0.3 to 0.6); and for CT they were 83% (95% CI = 58% to 95%), 98% (95% CI = 85% to 99%), 45 (95% CI = 3 to 707), and 0.2 (95% CI = 0.05 to 0.5).

Conclusions: It may be feasible to reduce ED LOS and avoid CT scan when using POC US to evaluate children with suspected appendicitis. Test characteristics for POC US have high specificity to rule in appendicitis, similar to radiology US. Addition of POC US prior to sequential radiology imaging was safe, without missed cases of appendicitis or negative laparotomies.

17. The No-Interruption Zone

Jeremy Tucker, DO; Emergency Physicians Monthly, February 2014

In the hectic ED, interruptions and distractions can cause critical errors, even death. Here are five key areas where disruptions need to be eliminated, and practical ways to get there.

The following is an example of a typical cockpit to tower communication during landing. Pilot: “Cincinnati Tower, we’re six miles southeast and control VFR.” Tower: “Runway 18, wind 230 degrees, five knots, altimeter 30.” Pilot: “Roger, Runway 18.” Tower: “Have you in sight, cleared to land.” In safety critical industries such as commercial air travel, processes have been put into place to limit interruptions during certain tasks. The “sterile cockpit rule” limits non-essential communication and activities during taxi, takeoff, landing, and flying below 10,000 feet.

What would it be like to apply this same logic to a shift in the emergency department? If you could completely eliminate interruptions at critical moments, would you become more efficient and less error prone? Would you have more time to talk to your patients? While entirely eliminating interruptions in the ED isn’t realistic, how much interruption is OK? How do we minimize interruptions at critical moments in patient care to reduce the chance of error?

Out of the entire healthcare system, emergency physicians probably face the highest number of interruptions per hour.1,2 One study demonstrated an interruption rate of 6.6 times per hour based on direct observation. Doctors failed to return to task 18.5% of those times interrupted.2 Interruptions lead to lapses and slips due to memory recall problems and attention shifts. It has been shown by Westbrook, et al that interrupting nurses during medication administration increased the incidence of procedural failures and clinical errors.3 Clearly, interruptions present a significant patient safety risk.

The financial costs of unnecessary interruptions to the healthcare system have not been studied, however a report released in 2005 which looked at “knowledge workers” in the United States over an 18-month period sheds some light on the issue. After months of interviews and observation, the study concluded that interruptions consume 28% of an employee’s workday and cost U.S. companies an estimated $588 billion per year.4 The cost of interruptions to the healthcare industry are likely even higher. Not only are interruptions more prevalent in the healthcare industry, but salaries are also higher than the $21 per hour estimate used in the study.

The question then is how can we practically reduce interruptions in the emergency department. It starts by identifying the most critical moments of the patient encounter, coming up with solutions to minimize interruptions, and then learning how to get back on task when necessary interruptions do occur…

The remainder of the essay (with references):         

18. Treatment of Lower Extremity Superficial Thrombophlebitis

Di Nisio M, et al. Treatment of Lower Extremity Superficial Thrombophlebitis. JAMA 2014;311:729-730.

CLINICAL QUESTION: What treatments for lower extremity superficial thrombophlebitis are associated with lower rates of venous thromboembolic events (VTE), major bleeding, and superficial venous thrombosis extension?

BOTTOMLINE: Fondaparinux (2.5mg) subcutaneously once daily for 45 days is associated with fewer symptomatic VTEs and lower rates of superficial venous thrombosis extension and recurrence with no increases in major bleeding compared with placebo. Low-molecular-weight heparin and non-steroidal anti-inflammatory drugs are associated with lower rates of superficial thrombophlebitis extension or recurrence, but data regarding symptomatic VTEs are inconclusive.

19. Intubation Success with Ketamine vs. Etomidate

Rapid sequence intubations performed using ketamine for sedation were just as likely to achieve first-pass success as those using etomidate.

Patanwala AE, et al. Acad Emerg Med 2014;21:87-91.   

Objectives: The objective of this study was to compare first-pass intubation success between patients who received etomidate versus ketamine for rapid sequence intubation (RSI) in the emergency department (ED).

Methods: This was a retrospective analysis of prospectively collected data recorded in a quality improvement database between July 1, 2007, and December 31, 2012. The study was conducted in an academic ED in the United States. All patients who received etomidate or ketamine as part of RSI were included. The primary outcome measure was first-pass success. A multivariate analysis was conducted to determine if sedative type was associated with first-pass success, after adjusting for potential confounders and baseline differences.

Results: The final cohort consisted of 2,098 RSI procedures using either etomidate (n = 1,983) or ketamine (n = 115). First-pass success occurred in 77.0% of patients in the etomidate group and 79.1% of patients in the ketamine group (difference = –2.1%; 95% CI = –5.5% to 9.8%). In the multivariate analysis, after adjusting for potential confounders, sedative type was not associated with first-pass success (odds ratio = 0.89; 95% CI = 0.5 to 1.5; p = 0.632).

Conclusions: Etomidate and ketamine are associated with equivalent first-pass success when used in RSI. Ketamine may be an appropriate alternative to etomidate for RSI in the ED.

20. Intervention to Promote Physician Well-being, Job Satisfaction, and Professionalism: A RCT

West CP, et al. JAMA Intern Med. 2014 Feb 10. [Epub ahead of print]

IMPORTANCE Despite the documented prevalence and clinical ramifications of physician distress, few rigorous studies have tested interventions to address the problem. OBJECTIVE To test the hypothesis that an intervention involving a facilitated physician small-group curriculum would result in improvement in well-being.

DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 74 practicing physicians in the Department of Medicine at the Mayo Clinic in Rochester, Minnesota, conducted between September 2010 and June 2012. Additional data were collected on 350 nontrial participants responding to annual surveys timed to coincide with the trial surveys.

INTERVENTIONS The intervention involved 19 biweekly facilitated physician discussion groups incorporating elements of mindfulness, reflection, shared experience, and small-group learning for 9 months. Protected time (1 hour of paid time every other week) for participants was provided by the institution.

MAIN OUTCOMES AND MEASURES Meaning in work, empowerment and engagement in work, burnout, symptoms of depression, quality of life, and job satisfaction assessed using validated metrics. RESULTS Empowerment and engagement at work increased by 5.3 points in the intervention arm vs a 0.5-point decline in the control arm by 3 months after the study (P = .04), an improvement sustained at 12 months (+5.5 vs +1.3 points; P = .03). Rates of high depersonalization at 3 months had decreased by 15.5% in the intervention arm vs a 0.8% increase in the control arm (P = .004). This difference was also sustained at 12 months (9.6% vs 1.5% decrease; P = .02). No statistically significant differences in stress, symptoms of depression, overall quality of life, or job satisfaction were seen. In additional comparisons including the nontrial physician cohort, the proportion of participants strongly agreeing that their work was meaningful increased 6.3% in the study intervention arm but decreased 6.3% in the study control arm and 13.4% in the nonstudy cohort (P = .04). Rates of depersonalization, emotional exhaustion, and overall burnout decreased substantially in the trial intervention arm, decreased slightly in the trial control arm, and increased in the nontrial cohort (P = .03, .007, and .002 for each outcome, respectively).

CONCLUSIONS AND RELEVANCE An intervention for physicians based on a facilitated small-group curriculum improved meaning and engagement in work and reduced depersonalization, with sustained results at 12 months after the study

21. Sex-Specific CP Characteristics in the Early Diagnosis of AMI

Gimenez MR, et al. JAMA Intern Med. 2014;174(2):241-249.

Importance  Whether 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.

Objective  To improve the management of suspected AMI in women by exploring sex-specific CPCs.

Design, Setting, and Participants  From 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 independent cardiologists.

Interventions  Treatment of AMI in the emergency department.

Main Outcomes and Measures  Sex-specific diagnostic performance of 34 predefined and uniformly recorded CPCs in the early diagnosis of AMI.

Results  Acute 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).

Conclusions and Relevance  Differences 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.

22. Tid Bits

A. Women Get Their Own Stroke Guideline   

New guidance from the American Heart Association/American Stroke Association focuses on stroke prevention specifically in women, who have a risk profile that differs from that of men.

B. ISU prof finds laparoscopic surgeons improve speed, accuracy by playing video games

AMES, Iowa -- The first question laparoscopic surgery patients should ask prospective surgeons is "How many of these surgeries have you previously performed?" Maybe their second should be "Do you play video games?"

A study co-authored by an Iowa State University psychologist published in the February 2007 issue of the Archives of Surgery found that laparoscopic surgeons who previously played video games at least three hours a week made 37 percent fewer errors, were 27 percent faster, and scored 42 percent better overall than their non-playing colleagues when participating in a top laparoscopic training program. The surgeons among the top third in video gaming skills made 47 percent fewer errors and performed 39 percent faster than the other subjects in the study.

C. One quarter of Americans don't know the Earth revolves around the sun, study finds

Copernicus would be sad: In the survey of more than 2,200 people conducted in 2012, only 74% appeared to know the answer to a basic astronomy question.

In the survey of more than 2,200 people conducted in 2012, only 74% appeared to know basic astronomy. That means at least 550 people in the study got it wrong — and it's only been 500 years since legendary astronomer and mathematician Copernicus formulated a heliocentric model of the universe that placed the sun at the center.

D. USPSTF draft recommends against carotid screening for asymptomatic adults

The U.S. Preventive Services Task Force has recommended in a draft statement against screening for carotid artery stenosis in asymptomatic adults, stating that the procedure may do more harm than good, leading to false positives and unnecessary treatment. The recommendations do not apply to adults with a history of stroke, mini-stroke, or signs and symptoms of stroke.

E. Childhood bullying has lasting effects on mental, physical health

The risk of being bullied dropped as students got older, but having both past and present bullying experiences was linked to substantially lower mental and physical health scores in the 10th grade, according to a study in the journal Pediatrics. The findings emphasize the importance of early intervention to stop bullying and follow-up to address potential effects, researchers said.

F. Change in mental health after smoking cessation

According to this systematic review and meta-analysis, smoking cessation is associated with an improvement in mental health in comparison with continuing to smoke. Furthermore, the effect estimates are equal or larger to those of antidepressant treatment for mood disorders, say the authors.

G. Inadequate sleep linked to pain among seniors

In a U.K. study involving more than 4,300 people 65 and older, researchers found that the onset of widespread pain was more common among those who failed to get restorative sleep most nights compared with well-rested peers. Financial woes, limited social activity, not having normal body mass index, anxiety and poor quality of life related to physical health were linked to increased risk of the onset of widespread pain. The findings appear in the journal Arthritis & Rheumatism.

H. Vegetarian Diets Lower Blood Pressure

By about 5 mmHg in the systolic reading compared with omnivors like me.

I. Which Bullets Are Safe in an MRI?  

Don’t go ballistic -- only steel bullets will cause problems in MRI, says a study of 39 kinds of the projectiles.

“Ballistics made of lead with copper or alloy jackets appear to be safe with respect to MRI-related movement at 1.5-, 3-, and 7-T static magnetic fields, whereas ballistics containing steel may pose a danger if near critical body structures because of strong magnetic field interactions.”

J. Simulation: An Important Airway Training Strategy

A meta-analysis shows that simulation-based airway management training leads to superior education outcomes.

Kennedy CC et al. Crit Care Med 2014 Jan.