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.
See comments in JWEM: http://www.jwatch.org/na33743/2014/02/17/five-ways-reduce-emergency-care-costs
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
Wanna look them up? http://www.icd10data.com/ICD10CM/Codes
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.
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): http://www.epmonthly.com/www.epmonthly.com/features/current-features/the-no-interruption-zone
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.
Full-text
(and more): http://my.americanheart.org/professional/ScienceNews/Guidelines-for-the-Prevention-of-Stroke-in-Women_UCM_459842_Article.jsp
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.
