From the
recent medical literature…
1. Protocolized Therapy for Severe Sepsis and Septic Shock?
Last issue
we opened with the ProCESS trial from the NEJM: http://www.nejm.org/doi/full/10.1056/NEJMoa1401602#t=article
One line
from the accompanying editorial provides an apt summary of the implications. Despite
the lack of benefit with either of the protocols, the trial results may point
out important elements of care for septic shock. "The...trial identifies
early recognition of sepsis, early administration of antibiotics, early
adequate volume resuscitation, and clinical assessment of the adequacy of
circulation as the elements we should focus on to save lives," writes
Craig M. Lilly, MD, from the Division of Pulmonary, Allergy and Critical Care
Medicine, University of Massachusetts Medical School in Worcester.
Here’s the
summary from EM Journal Watch: http://www.jwatch.org/na34016/2014/03/18/early-antibiotics-and-fluids-are-more-important-strict
a. Interviews with the study’s authors:
1.
Don Yealy, interviewed by Academic Life in EM
2.
Derek Angus, interviewed by Scott Weingart
b. Commentaries and Reviews
1.
Rob Orman and Scott Weingart discuss the study and the findings in EM-RAP.
2.
Medscape Essay by Laurie Barclay
3.
Medpage Today
4.
Yes, but how do we know how much fluid to give? By Rory Spiegel, the EM Nerd
Not Needed for Monitoring
So it may
be that the indications for central lines in sepsis management will be limited
to patients without peripheral access and those in need of aggressive pressure
support.
And doesn’t this make sense? Recent research has shown that emergency
physicians have been hesitant about placing central lines simply for monitoring
purposes in normotensive sepsis patients who were eligible for EGDT. The
investigators write: “It could be that the clinical gestalt of the physicians
tells them the central venous catheter may be unnecessary to the resuscitation
since vasopressors are unlikely to be indicated.” Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3935788/
Kaukonen K,
JAMA. 2014;311(13):1308-1316.
IMPORTANCE:
Severe sepsis and septic shock are major causes of mortality in intensive care
unit (ICU) patients. It is unknown whether progress has been made in decreasing
their mortality rate.
OBJECTIVE:
To describe changes in mortality for severe sepsis with and without shock in
ICU patients.
DESIGN,
SETTING, AND PARTICIPANTS: Retrospective, observational study from 2000 to 2012
including 101,064 patients with severe sepsis from 171 ICUs with various
patient case mix in Australia and New Zealand.
MAIN
OUTCOMES AND MEASURES: Hospital outcome (mortality and discharge to home, to
other hospital, or to rehabilitation).
RESULTS:
Absolute mortality in severe sepsis decreased from 35.0% (95% CI, 33.2%-36.8%;
949/2708) to 18.4% (95% CI, 17.8%-19.0%; 2300/12,512; P less than .001),
representing an overall decrease of 16.7% (95% CI, 14.8%-18.6%), an annual rate
of absolute decrease of 1.3%, and a relative risk reduction of 47.5% (95% CI,
44.1%-50.8%). After adjusted analysis, mortality decreased throughout the study
period with an odds ratio (OR) of 0.49 (95% CI, 0.46-0.52) in 2012, using the
year 2000 as the reference (P less than .001). The annual decline in
mortality did not differ significantly between patients with severe sepsis and
those with all other diagnoses (OR, 0.94 [95% CI, 0.94-0.95] vs 0.94 [95% CI,
0.94-0.94]; P = .37). The annual increase in rates of discharge to home was
significantly greater in patients with severe sepsis compared with all other
diagnoses (OR, 1.03 [95% CI, 1.02-1.03] vs 1.01 [95% CI, 1.01-1.01]; P less
than .001). Conversely, the annual increase in the rate of patients discharged
to rehabilitation facilities was significantly less in severe sepsis compared
with all other diagnoses (OR, 1.08 [95% CI, 1.07-1.09] vs 1.09 [95% CI,
1.09-1.10]; P less than .001). In the absence of comorbidities and older age,
mortality was less than 5%.
CONCLUSIONS
AND RELEVANCE: In critically ill patients in Australia and New Zealand with
severe sepsis with and without shock, there was a decrease in mortality from
2000 to 2012. These findings were accompanied by changes in the patterns of
discharge to home, rehabilitation, and other hospitals.
3. Two Studies on the Diagnosis of Venous Thromboembolism
A. Age-Adjusted D-Dimer Cutoff
Levels to Rule Out PE: The ADJUST-PE Study
Righini M,
et al. JAMA. 2014;311(11):1117-1124.
Importance D-dimer measurement is an important step in
the diagnostic strategy of clinically suspected acute pulmonary embolism (PE),
but its clinical usefulness is limited in elderly patients.
Objective To prospectively validate whether an
age-adjusted D-dimer cutoff, defined as age × 10 in patients 50 years or older,
is associated with an increased diagnostic yield of D-dimer in elderly patients
with suspected PE.
Design,
Settings, and Patients A multicenter,
multinational, prospective management outcome study in 19 centers in Belgium,
France, the Netherlands, and Switzerland between January 1, 2010, and February
28, 2013.
Interventions All consecutive outpatients who presented to
the emergency department with clinically suspected PE were assessed by a
sequential diagnostic strategy based on the clinical probability assessed using
either the simplified, revised Geneva score or the 2-level Wells score for PE;
highly sensitive D-dimer measurement; and computed tomography pulmonary
angiography (CTPA). Patients with a D-dimer value between the conventional
cutoff of 500 µg/L and their age-adjusted cutoff did not undergo CTPA and were
left untreated and formally followed-up for a 3-month period.
Main
Outcomes and Measures The primary
outcome was the failure rate of the diagnostic strategy, defined as adjudicated
thromboembolic events during the 3-month follow-up period among patients not
treated with anticoagulants on the basis of a negative age-adjusted D-dimer
cutoff result.
Results Of the 3346 patients with suspected PE
included, the prevalence of PE was 19%. Among the 2898 patients with a nonhigh
or an unlikely clinical probability, 817 patients (28.2%) had a D-dimer level
lower than 500 µg/L (95% CI, 26.6%-29.9%) and 337 patients (11.6%) had a
D-dimer between 500 µg/L and their age-adjusted cutoff (95% CI, 10.5%-12.9%).
The 3-month failure rate in patients with a D-dimer level higher than 500 µg/L
but below the age-adjusted cutoff was 1 of 331 patients (0.3% [95% CI,
0.1%-1.7%]). Among the 766 patients 75 years or older, of whom 673 had a
nonhigh clinical probability, using the age-adjusted cutoff instead of the 500
µg/L cutoff increased the proportion of patients in whom PE could be excluded
on the basis of D-dimer from 43 of 673 patients (6.4% [95% CI, 4.8%-8.5%) to
200 of 673 patients (29.7% [95% CI, 26.4%-33.3%), without any additional
false-negative findings.
Conclusions
and Relevance Compared with a fixed
D-dimer cutoff of 500 µg/L, the combination of pretest clinical probability
assessment with age-adjusted D-dimer cutoff was associated with a larger number
of patients in whom PE could be considered ruled out with a low likelihood of
subsequent clinical venous thromboembolism.
B. Modify Your Wells: It Does Not Safely Exclude DVT in Patients with
Cancer or Hx of DVT
A
meta-analysis suggests the combination of a Wells score ≤ 1 and a negative
d-dimer result should not be used to rule out DVT in patients with active
cancer or history of DVT.
Geersing GJ
et al. BMJ 2014 Mar 10.
OBJECTIVE: To
assess the accuracy of the Wells rule for excluding deep vein thrombosis and
whether this accuracy applies to different subgroups of patients.
DESIGN: Meta-analysis
of individual patient data.
DATA
SOURCES: Authors of 13 studies (n = 10,002) provided their datasets, and these
individual patient data were merged into one dataset.
ELIGIBILITY
CRITERIA: Studies were eligible if they enrolled consecutive outpatients with
suspected deep vein thrombosis, scored all variables of the Wells rule, and
performed an appropriate reference standard.
MAIN
OUTCOME MEASURES: Multilevel logistic regression models, including an
interaction term for each subgroup, were used to estimate differences in
predicted probabilities of deep vein thrombosis by the Wells rule. In addition,
D-dimer testing was added to assess differences in the ability to exclude deep
vein thrombosis using an unlikely score on the Wells rule combined with a
negative D-dimer test result.
RESULTS: Overall,
increasing scores on the Wells rule were associated with an increasing
probability of having deep vein thrombosis. Estimated probabilities were almost
twofold higher in patients with cancer, in patients with suspected recurrent
events, and (to a lesser extent) in males. An unlikely score on the Wells rule
(≤ 1) combined with a negative D-dimer test result was associated with an
extremely low probability of deep vein thrombosis (1.2%, 95% confidence
interval 0.7% to 1.8%). This combination occurred in 29% (95% confidence
interval 20% to 40%) of patients. These findings were consistent in subgroups
defined by type of D-dimer assay (quantitative or qualitative), sex, and care
setting (primary or hospital care). For patients with cancer, the combination
of an unlikely score on the Wells rule and a negative D-dimer test result
occurred in only 9% of patients and was associated with a 2.2% probability of
deep vein thrombosis being present. In patients with suspected recurrent
events, only the modified Wells rule (adding one point for the previous event)
is safe.
CONCLUSION:
Combined with a negative D-dimer test result (both quantitative and
qualitative), deep vein thrombosis can be excluded in patients with an unlikely
score on the Wells rule. This finding is true for both sexes, as well as for
patients presenting in primary and hospital care. In patients with cancer, the
combination is neither safe nor efficient. For patients with suspected
recurrent disease, one extra point should be added to the rule to enable a safe
exclusion.
Full-text
(free): http://www.bmj.com/content/348/bmj.g1340
4. A Clean ECG and One Normal hsTrop? Send ‘em Home
A single
measurement of high-sensitivity cardiac troponin T and a clean
electrocardiogram (ECG) might be enough to send a patient with chest pain home
from the emergency department (ED), a Swedish study suggested. (Although the
assay used in this study has not been approved for use in the U.S., similar
troponin T tests are already used frequently at many centers in the U.S.)
Bandstein
N, et al. Undetectable High Sensitivity Cardiac Troponin T Level in the ED and
Risk of MI. J Am Coll Cardiol. 2014 March [Epub ahead of print]
Objectives To evaluate if an undetectable (less than 5
ng/l) high-sensitivity cardiac troponin T (hs-cTnT) level, and an
electrocardiogram (ECG) without signs of ischemia can rule out myocardial infarction
(MI) in the emergency department (ED).
Background Chest pain is a common symptom often
associated with benign conditions, but may be a sign of MI. Since there is no
rapid way to rule out MI many patients are admitted to hospital.
Methods All patients who sought medical attention for
chest pain, and had at least one hs-cTnT analyzed, during two years at the
Karolinska university hospital, Stockholm, Sweden were included. We calculated
the negative predictive values of an undetectable hs-cTnT, and ECG without
ischemia, for MI and death within 30 days.
Results We included 14,636 patients of whom 8,907
(61%) had an intial hs-cTnT of less than 5 ng/l, 21% had 5 to 14 ng/l, and 18%
had greater than 14 ng/l. During 30 days of follow-up 39 (0.44%) patients with
undetectable hs-cTnT had a MI, of whom 15 (0.17%) had no ischemic ECG changes.
The negative predictive value for MI within 30 days in patients with
undetectable hs-cTnT, and no ischemic ECG changes was 99.8% (95% confidence
interval (CI) 99.7-99.9). The negative predictive value for death was 100% (95%
CI 99.9-100).
Conclusions All patients with chest pain who have an
initial hs-cTnT level of less than 5 ng/l and no signs of ischemia on ECG have
a minimal risk of MI or death within 30 days and can be safely discharged directly
from the ED.
5. ACEP Clinical Policy: Critical Issues in the Evaluation and
Management of Adults Presenting to the ED with Seizures
Huff JS, et
al. Ann Emerg Med. 2014;63:437-447.e15
This
clinical policy from the American College of Emergency Physicians is the
revision of a 2004 policy on critical issues in the evaluation and management
of adult patients with seizures in the emergency department.1 A writing
subcommittee reviewed the literature to derive evidence-based recommendations
to help clinicians answer the following critical questions:
(1) In
patients with a first generalized convulsive seizure who have returned to their
baseline clinical status, should antiepileptic therapy be initiated in the
emergency department to prevent additional seizures?
·
Level
C recommendations: Emergency physicians need not initiate antiepileptic
medication in the ED for patients who have had a first provoked seizure.
Precipitating medical conditions should be identified and treated.
·
Level
C recommendations: Emergency physicians need not initiate antiepileptic
medication in the ED for patients who have had a first unprovoked seizure
without evidence of brain disease or injury.
·
Level
C recommendations: Emergency physicians may initiate antiepileptic medication
in the ED, or defer in coordination with other providers, for patients who
experienced a first unprovoked seizure with a remote history of brain disease
or injury.
(2) In
patients with a first unprovoked seizure who have returned to their baseline
clinical status in the emergency department, should the patient be admitted to
the hospital to prevent adverse events?
·
Level
C recommendations: Emergency physicians need not admit patients with a first
unprovoked seizure who have returned to their clinical baseline in the ED.
(3) In
patients with a known seizure disorder in which resuming their antiepileptic
medication in the emergency department is deemed appropriate, does the route of
administration impact recurrence of seizures?
·
Level
C recommendations: When resuming antiepileptic medication in the ED is deemed
appropriate, the emergency physician may administer IV or oral medication at
their discretion.
(4) In
emergency department patients with generalized convulsive status epilepticus
who continue to have seizures despite receiving optimal dosing of a
benzodiazepine, which agent or agents should be administered next to terminate
seizures?
·
Level
A recommendations: Emergency physicians should administer an additional
antiepileptic medication in ED patients with refractory status epilepticus who
have failed treatment with benzodiazepines.
·
Level
B recommendations: Emergency physicians may administer intravenous phenytoin,
fosphenytoin, or valproate in ED patients with refractory status epilepticus
who have failed treatment with benzodiazepines.
·
Level
C recommendations: Emergency physicians may administer intravenous
levetiracetam, propofol, or barbiturates in ED patients with refractory status
epilepticus who have failed treatment with benzodiazepines.
A
literature search was performed, the evidence was graded, and recommendations
were given based on the strength of the available data in the medical
literature.
6. Derivation of a Clinical Decision Instrument to Identify
Adults with Mild Traumatic ICH at Low Risk for Requiring ICU Admission
Nishijima
DK, et al. Ann Emerg Med. 2014;63:448-456.e2
Study
objective: The objective of this study is to derive a clinical decision
instrument with a sensitivity of at least 95% (with upper and lower bounds of
the 95% confidence intervals [CIs] within a 5% range) to identify adult
emergency department patients with mild traumatic intracranial hemorrhage who
are at low risk for requiring critical care resources during hospitalization
and thus may not need admission to the ICU.
Methods: This
was a prospective, observational study of adult patients with mild traumatic
intracranial hemorrhage (initial Glasgow Coma Scale [GCS] score 13 to 15, with
traumatic intracranial hemorrhage) presenting to a Level I trauma center from
July 2009 to February 2013. The need for ICU admission was defined as the
presence of an acute critical care intervention (intubation, neurosurgical
intervention, blood product transfusion, vasopressor or inotrope
administration, invasive monitoring for hemodynamic instability, urgent
treatment for arrhythmia or cardiopulmonary resuscitation, and therapeutic
angiography). We derived the clinical decision instrument with binary recursive
partitioning (with a misclassification cost of 20 to 1). The accuracy of the
decision instrument was compared with the treating physician's (emergency
medicine faculty) clinical impression.
Results: A
total of 600 patients with mild traumatic intracranial hemorrhage were
enrolled; 116 patients (19%) had a critical care intervention. The derived
instrument consisted of 4 predictor variables: admission GCS score less than
15, nonisolated head injury, aged 65 years or older, and evidence of swelling
or shift on initial cranial computed tomography scan. The decision instrument
identified 114 of 116 patients requiring an acute critical care intervention
(sensitivity 98.3%; 95% CI 93.9% to 99.5%) if at least 1 variable was present
and 192 of 484 patients who did not have an acute critical care intervention
(specificity 39.7%; 95% CI 35.4% to 44.1%) if no variables were present.
Physician clinical impression was slightly less sensitive (90.1%; 95% CI 83.1%
to 94.4%) but overall similar to the clinical decision instrument.
Conclusion:
We derived a clinical decision instrument that identifies a subset of patients
with mild traumatic intracranial hemorrhage who are at low risk for acute
critical care intervention and thus may not require ICU admission. Physician
clinical impression had test characteristics similar to those of the decision
instrument. Because the results are based on single-center data without a
validation cohort, external validation is required.
7. Ten Ways to Safely Push Ketamine in the ED
By Elbert
Chu, Medpage Today. Mar 20, 2014
A doctor
recently took me on a ketamine trip, and I enjoyed it immensely.
Reuben
Strayer, MD, led a "We should do ____ more often" session at the
recent American Academy of Emergency Medicine (AAEM) meeting. The blank was, as
you've probably guessed, "push ketamine," the N-methyl-D-aspartate
receptor antagonist originally used in horses, but notorious as a street drug
often called "Special K."
Clinically,
ketamine has an established presence among anesthesiologists, psychiatrists,
pediatric EDs, and has even spread to rural Uganda. Now, it seems physicians in
the general ED have started to push ketamine more often. Richard Levitan, MD,
recently called it a "comeback kid."
The number
of articles about ketamine in PubMed has jumped to 730 in 2013, from 384 in 2000.
But even as researchers study ketamine as a new antidepressant, some have
warned of urinary tract dysfunction in long-term use and pointed out a growing
problem of abuse in Southeast and East Asia.
So why is
ketamine earning a spot in the general ED now? Here are 10 ways to ketamine can
be used safely, lightly remixed from Strayer's presentation and with
information from Howard Mell, MD, MPH, and Graham Walker, MD.
1. Push
Ketamine for Analgesia
Analgesia
is a sweet spot for ketamine, and underutilized, according to Strayer, an
assistant clinical professor of emergency medicine at Mount Sinai. He said
ketamine is a safe and powerful analgesic at 0.15 mg/kg and can be an option
when opiates fail to reduce pain. And it's Strayer's second-line choice after
opiates for recovering addicts, patients on methadone, or those with marginal
blood pressure or breathing.
2. Consider
Ketamine for Procedural Sedation
Strayer's
ketamine pros are complete analgesia, sedation, and amnesia. Ketamine maintains
airway reflexes and augments cardiorespiratory tone. "It's really a wonder
drug for procedural sedation," Strayer said: It provides rapid onset, predictable
duration, can be used intramuscularly, and has an unmatched margin of safety.
3. Reach
For Ketamine in Rapid Sequence Induction (RSI)
Because
ketamine has bronchodilation properties, Strayer recommended ketamine for
patients being intubated for asthma or COPD. He also prefers ketamine as the
RSI induction agent in all hypotensive patients, including trauma versus
etomidate. It's Strayers "agent of choice" because it can be used in
all patients where increase in heart rate and blood pressure is acceptable.
"Dose big," said Strayer. He advised docs to take advantage of the
long flat part at the end of the dose response curve.
Levithan
referenced a 2011 clinical guideline for dissociative sedation as the
definitive paper for RSI at a recent talk. The exception here is obtunded
patients and those who are very hypotensive.
4. Dilate
in Asthma
In cases
where adult and pediatric patients who have near death asthma attacks, and
intubation is imminent, Strayer recommended ketamine for its bronchodilation
profile at induction dose, given over 30-60 seconds.
5. Sedate
Post-Intubation
An
under-sedated intubated patient is a dangerous situation. In this case, push
ketamine, not vecuronium, says Strayer. Choose ketamine when RSI isn't the
right SI, and when you don't want paralysis.
6. Keep It
Handy as a Tranquilizer
Speed,
safety, reliability, and intramuscular dosing are Strayer's top reasons to
reach for ketamine to tranquilize patients, as discussed in the ACEP Excited
Delirium Task Force.
"Ketamine
is unrivaled for this indication," Strayer said. "No matter how big
strong, or intoxicated, ketamine turns him into a complete bunny rabbit while
ABCs are maintained 100% of the time."
He added
that doctors need to weigh ketamine's risk of increased heart rate and blood
pressure (see #8) against dangers to staff and nearby patients if using it to
sedate someone having an uncontrolled thrashing rage. This is equivalent to
procedural sedation – so treat patients as such. They should have one-to-one
nursing or a physician at bedside. Strayer recommended ketamine 500 mg IM x 1.
7. Manage
Ketamine's Psychiatric Distress
The
psychiatric distress caused by ketamine is not dangerous, says Strayer. Prevent
it by pre-induction comfort and pre-induction coaching. Tell them the drug will
give them very vivid dreams, but they can control it. He recommended
suggestions such as, "Imagine that you are on a beach." Anticipate
any distress and be careful with small doses. Eventually, patients just need to
metabolize the drug. Strayer added that docs can use propofol to manage
hypertension, which is better than ketofol.
8. Remember
the Cardiac Factor
The main
downer on the ketamine party is that it can cause hypertension and tachycardia.
A recent paper described two patients on ketamine who had cardiac arrest
following RSI, although over at Resus.me, Cliff G. Reid, MD, notes three
possible confounders the authors didn't take into account. Still, doctors
should be aware of this risk, particularly in critically ill patients.
9. Lock it
Down: Prevent Abuse
Afraid of
ketamine dependency? Ketamine is not euphoric like opiates, Strayer said. It
makes patients feel kind of weird, so people less likely to turn into addicts.
Mell mentioned that he has staff double the number of inventory checks for
ketamine, to prevent diversion, and also includes supervisors in the protocols.
10. Limit
Risks of Laryngospasm, Hypertonicity, Hypersalivation
Laryngospasm
is less common in adults than children but can happen. Anyone receiving
dissociative-dose ketamine should be monitored as a procedural sedation
patient. Strayer said physicians should respond with positive pressure
ventilation, paralyze the patient, and intubate. Other possible side effects
include hypertonicity, and hypersalivation. Also, there’s no reversal agent…
For Strayer's
guide to what happens at different doses of ketamine, see the rest of the essay:
http://www.medpagetoday.com/EmergencyMedicine/EmergencyMedicine/44833
8. ECGs in Clinical Practice
Spodick’s Sign: A Helpful ECG Clue
to the Diagnosis of Acute Pericarditis
ECG Diagnosis: The Effect of Ionized
Serum Calcium Levels
High and
low levels of ionized serum calcium concentration can produce characteristic
changes on the electrocardiogram. These changes are almost entirely limited to
the duration of the ST segment with no change in the QRS complexes or T waves.
High ionized serum calcium shortens the ST segment, and low ionized serum
calcium prolongs the ST segment. Two common clinical scenarios are presented.
9. Predicting Ureteral Stones: The new “STONE” Score
Derivation
and validation of a clinical prediction rule for uncomplicated ureteral stone—the
STONE score: retrospective and prospective observational cohort studies
Moore CL, et
al. BMJ 2014;348:g2191
INTRO: Kidney
stones are estimated to occur at some point in nearly 1 in 11 people in the
United States, with flank or kidney pain resulting in over two million annual
visits to the emergency department. Computed tomography (CT) has been described
as the “best imaging study to confirm the diagnosis of a urinary stone” and is
now the first line imaging study for suspected kidney stone in the United
States. Though accurate, CT is costly, involves the use of ionizing radiation,
and does not seem to have impacted patient centered outcomes, such as rates of
diagnosis or hospital admission, in those with suspected kidney stones.
Many
patients with flank pain will not benefit from a CT scan, as most kidney stones
will pass spontaneously. Moreover, it is unlikely that a CT scan in the setting
of flank pain will detect acutely important alternative findings in patients
without signs of infection. Hence an objective clinical prediction rule for
renal colic that could reliably identify patients highly likely to have a
ureteral stone (and thus unlikely to have an important alternative diagnosis)
may allow patients to be safely managed without imaging, or imaged with other
approaches such as ultrasonography or reduced dose CT.
ABSTRACT: OBJECTIVE:
To derive and validate an objective clinical prediction rule for the presence
of uncomplicated ureteral stones in patients eligible for computed tomography
(CT). We hypothesized that patients with a high probability of ureteral stones
would have a low probability of acutely important alternative findings.
DESIGN:
Retrospective observational derivation cohort; prospective observational
validation cohort.
SETTING:
Urban tertiary care emergency department and suburban freestanding community
emergency department.
PARTICIPANTS:
Adults undergoing non-contrast CT for suspected uncomplicated kidney stone. The
derivation cohort comprised a random selection of patients undergoing CT
between April 2005 and November 2010 (1040 patients); the validation cohort
included consecutive prospectively enrolled patients from May 2011 to January
2013 (491 patients).
MAIN OUTCOME
MEASURES: In the derivation phase a priori factors potentially related to
symptomatic ureteral stone were derived from the medical record blinded to the
dictated CT report, which was separately categorized by diagnosis. Multivariate
logistic regression was used to determine the top five factors associated with
ureteral stone and these were assigned integer points to create a scoring
system that was stratified into low, moderate, and high probability of ureteral
stone. In the prospective phase this score was observationally derived blinded
to CT results and compared with the prevalence of ureteral stone and important
alternative causes of symptoms.
RESULTS: The
derivation sample included 1040 records, with five factors found to be most
predictive of ureteral stone: male sex, short duration of pain, non-black race,
presence of nausea or vomiting, and microscopic hematuria, yielding a score of
0-13 (the STONE score). Prospective validation was performed on 491
participants. In the derivation and validation cohorts ureteral stone was
present in, respectively, 8.3% and 9.2% of the low probability (score 0-5)
group, 51.6% and 51.3% of the moderate probability (score 6-9) group, and 89.6%
and 88.6% of the high probability (score 10-13) group. In the high score group,
acutely important alternative findings were present in 0.3% of the derivation
cohort and 1.6% of the validation cohort.
CONCLUSIONS:
The STONE score reliably predicts the presence of uncomplicated ureteral stone
and lower likelihood of acutely important alternative findings. Incorporation
in future investigations may help to limit exposure to radiation and
over-utilization of imaging.
Table 3: STONE score, factors, and categories
STONE
score by factors and categories
|
Odds
ratio (95% CI)
|
Points
|
Sex
|
||
Sex:
|
||
Female
|
1
|
0
|
Male
|
4.31
(3.13 to 5.98)
|
2
|
Timing
|
||
Duration
of pain to presentation:
|
||
Above 24
hours
|
1
|
0
|
6-24
hours
|
1.85
(1.27 to 2.70)
|
1
|
Less
than 6 hours
|
6.34
(4.26 to 9.33)
|
3
|
Origin
|
||
Race:
|
||
Black
|
1
|
0
|
Non-black
|
6.77
(3.79 to 12.64)
|
3
|
Nausea
|
||
Nausea
and vomiting:
|
||
None
|
1
|
0
|
Nausea
alone
|
1.98
(1.38 to 2.86)
|
1
|
Vomiting
alone
|
5.26
(3.53 to 7.93)
|
2
|
Erythrocytes
|
||
Hematuria
(on urine dipstick):
|
||
Absent
|
1
|
0
|
Present
|
5.61
(3.96 to 8.04)
|
3
|
Total
|
0-13
|
|
Full-text
(free): http://www.bmj.com/content/348/bmj.g2191
10. Images in Clinical Practice
Image Diagnosis: Sudden Paraplegia
in Abdominal Aortic Thrombosis
A
79-year-old woman with a medical history of hypertension and cardiac surgery
for mitral valve repair was seen in the Emergency Department after falling to
the floor in her bedroom. Acute abdominal aortic occlusion is an uncommon
condition frequently resulting from saddle embolism or thrombus of an
atherosclerotic plaque. Sudden neurologic symptoms can occur.
A
60-Year-Old Man With Scleral Nodules
Anterior
Dislocation of the Lens
Bilateral
Digital Ischemia
Reexpansion
Pulmonary Edema after Thoracentesis
Man with
Altered Mentation after Trauma
Man with
Abdominal Distention
Fever and
Macular Lesions on Toes
11. High-Flow Nasal Cannula Support: A New Option for Pediatric
Interfacility Transport
High-flow
nasal cannula therapy reduced the need for intubation compared with low-flow
oxygen supplementation and noninvasive ventilation in this single-center,
retrospective study.
Schlapbach
LJ, et al. High-flow nasal cannula (HFNC) support in interhospital transport of
critically ill children. Intensive Care Med 2014 Apr;40(4):592-9.
PURPOSE: Optimal
respiratory support for interhospital transport of critically ill children is
challenging and has been scarcely investigated. High-flow nasal cannula (HFNC)
therapy has emerged as a promising support mode in the paediatric intensive
care unit (PICU), but no data are available on HFNC used during interhospital
transport. We aimed to assess the safety of HFNC during retrievals of
critically ill children and its impact on the need for invasive ventilation
(IV).
METHODS: This
was a retrospective, single-centre study of children under 2 years old
transported by a specialized paediatric retrieval team to PICU. We compared IV
rates before (2005-2008) and after introduction of HFNC therapy (2009-2012).
RESULTS: A
total of 793 infants were transported. The mean transport duration was 1.4 h
(range 0.25-8), with a mean distance of 205 km (2-2,856). Before introduction
of HFNC, 7 % (n = 23) were retrieved on non-invasive ventilation (NIV) and 49 %
(n = 163) on IV. After introduction of HFNC, 33 % (n = 150) were retrieved on
HFNC, 2 % (n = 10) on NIV, whereas IV decreased to 35 % (n = 162, p less than
0.001). No patients retrieved on HFNC required intubation during retrieval, or
developed pneumothorax or cardiac arrest. Using HFNC was associated with a
significant reduction in IV initiated by the retrieval team (multivariate OR
0.51; 95 % CI 0.27-0.95; p = 0.032).
CONCLUSIONS:
We report on a major change of practice in transport of critically ill children
in our retrieval system. HFNC therapy was increasingly used and was not
inferior to low-flow oxygen or NIV. Randomized trials are needed to assess
whether HFNC can reduce the need for IV in interhospital transport of
critically ill children.
What’s high-flow nasal cannula? Here’s a thorough review that
summarizes the physical features, advantages, limitations, and current
literature on clinical application of HFNC.
Ward JJ. Respiratory
Care. 2013;58:98-122.
Full-text
(free): http://rc.rcjournal.com/content/58/1/98.full
12. Canalith Repositioning Maneuvers No Better than Standard
Therapy in the Treatment of BPPV
Sacco RR,
et al. Management of Benign Paroxysmal Positional Vertigo: A Randomized
Controlled Trial. J Emerg Med. 2014;46:575-81.
Background:
Benign paroxysmal positional vertigo (BPPV) is a common presenting problem.
Objective: Our
aim was to compare the efficacy of vestibular rehabilitation (maneuver) vs.
conventional therapy (medications) in patients presenting to the emergency
department (ED) with BPPV.
Methods: This
was a prospective, single-blinded physician, randomized pilot study comparing
two groups of patients who presented to the ED with a diagnosis of BPPV at a
Level 1 trauma center with an annual census of approximately 75,000. The first
group received standard medications and the second group received a canalith repositioning
maneuver. The Dizziness Handicap Inventory was used to measure symptom
resolution.
Results: Twenty-six
patients were randomized; 11 to the standard treatment arm and 15 to the
interventional arm. Mean age ± standard deviation of subjects randomized to
receive maneuver and medication were 59 ± 12.6 years and 64 ± 11.2 years,
respectively. There was no significant difference in mean ages between the two
treatment arms (p = 0.310). Two hours after treatment, the symptoms between the
groups showed no difference in measures of nausea (p = 0.548) or dizziness (p =
0.659). Both groups reported a high level of satisfaction, measured on a 0−10
scale. Satisfaction in subjects randomized to receive maneuver and medication
was 9 ± 1.5 and 9 ± 1.0, respectively; there was no significant difference in
satisfaction between the two arms (p = 0.889). Length of stay during the ED
visit did not differ between the treatment groups (p = 0.873). None of the
patients returned to an ED for similar symptoms.
Conclusions:
This pilot study shows promise, and would suggest that there is no difference
in symptomatic resolution, ED length of stay, or patient satisfaction between
standard medical care and canalith repositioning maneuver. Physicians should [re]consider
the canalith repositioning maneuver as a treatment option.
13. The Downsides of Crowded Hallway Medicine
Derlet RW,
et al. Emergency Department Crowding and Loss of Medical Licensure: A New Risk
of Patient Care in Hallways. West J Emerg Med. 2014 Mar;15(2):137-41
We report
the case of a 32-year-old male recently diagnosed with type 2 diabetes treated
at an urban university emergency department (ED) crowded to 250% over capacity.
His initial symptoms of shortness of breath and feeling ill for several days
were evaluated with chest radiograph, electrocardiogram (EKG), and laboratory
studies, which suggested mild diabetic ketoacidosis. His medical care in the ED
was conducted in a crowded hallway. After correction of his metabolic
abnormalities he felt improved and was discharged with arrangements made for
outpatient follow-up.
Two days
later he returned in cardiac arrest, and resuscitation efforts failed. The
autopsy was significant for multiple acute and chronic pulmonary emboli but no
coronary artery disease. The hospital settled the case for $1 million and
allocated major responsibility to the treating emergency physician (EP). As a
result the state medical board named the EP in a disciplinary action, claiming
negligence because the EKG had not been personally interpreted by that
physician. A formal hearing was conducted with the EP’s medical license placed in
jeopardy.
This case
illustrates the risk to EPs who treat patients in crowded hallways, where it is
difficult to provide the highest level of care. This case also demonstrates the
failure of hospital administration to accept responsibility and provide resources
to the ED to ensure patient safety.
Full-text
(free): http://www.escholarship.org/uc/item/3203m6fj
14. The Impact of Patient Telephone Call after Discharge on
Likelihood to Recommend in an Academic ED
Guss DA, et
al. J Emerg Med. 2014;46:560-6.
Background:
Patient satisfaction is a common parameter tracked by health care systems, and
likely influences patient provider choice and may impact insurer payment.
Achieving high satisfaction in an academic emergency department (ED) can be a
daunting task due to variable volumes, acuity, and overcrowding.
Objective: The
objective of this study was to assess the impact of a postdischarge telephone
call by a staff member after discharge from the ED on patient satisfaction.
Methods: This
was a prospective cohort study conducted in the two University of California
San Diego Health System EDs. Press Ganey patient satisfaction surveys are
mailed to a random sample of 50% of all discharged patients. In August 2010 a
program of MD and RN telephone call back 1 to 5 days after the ED visit was
initiated. In conjunction with this program, a custom question was added to the
standard survey, “Called back after discharge, Yes/No?” All surveys returned
between September 22, 2010 and December 7, 2010 were reviewed, and those that
chose to self-identify were selected to allow for ED chart review. The key
outcome variable “likelihood to recommend score” was dichotomized into the
highest category, 5 (very good) and remaining levels, 1–4 (very poor, poor,
fair, good). ED records were abstracted for data on waiting time (WT), length
of stay (LOS), and triage class (TC). These variables were selected because
they have been shown to impact patient satisfaction in prior studies.
Likelihood to recommend ratings for those reporting “Yes” to call back were
compared to those reporting “No” to call back. Summary statistics were
generated for patient characteristics in the “Yes” and “No” groups. Ninety-five
percent confidence intervals (CIs) for all counts and proportions were
calculated with the “exact” method. A logistic regression model was constructed
assessing odds ratio (OR) for likelihood-to-recommend score 5 while controlling
for the variables of WT, LOS, and TC.
Results: In
the study period, about 5000 surveys were mailed, 507 were returned, and 368
self-identified. Of those that self-identified, 136 patients answered “Yes” to
the callback question and 232 answered “No.” The mean age for those indicating
“Yes” was 55.8 years (CI 52.9–58.7), and for those indicating “No,” 50.7 years
(CI 47.9–53.5). Gender and triage code were similar between the two groups.
Among those answering “Yes,” 89.0% (CI 82.5–93.7) provided a “5” rating for
“likelihood to recommend,” compared to 55.6% (CI 49.0–62.1) who replied “No”
for call back. The logistic regression model generated an OR of 6.35 (CI 3.4–11.7)
for providing a level 5 rating for “likelihood to recommend” for patients
reporting “Yes” for call back after controlling for WT, LOS, and TC.
Conclusion:
In the study institution, patients that are called back are much more likely to
have a favorable impression of the visit as assessed by likelihood to recommend
regardless of WT, LOS, or TC. These data support “call back” as an effective
strategy to improve ED patient satisfaction.
15. Lit Reviews from Ann Emerg Med
A.
In Patients With Acute Ischemic Stroke, Do Different Thrombolytic Doses,
Agents, or Routes of Administration Lead to Different Outcomes?
Take-Home
Message
Study data
are inadequate. No one thrombolytic agent, dose, or route of administration has
been shown to be superior. Limited data show that higher doses may lead to more
intracranial hemorrhage.
B. Does Immediate Total-Body
Computed Tomography Reduce Mortality and Time in the Emergency Department for
Trauma Patients?
Take-Home
Message
Based only
on retrospective observational cohort studies, immediate total-body computed
tomography (CT) reduces time in the emergency department (ED) and to the
operating room but does not reduce mortality compared with selective imaging.
C. How Useful Are Clinical Findings
in Patients With Blunt Abdominal Trauma?
Take-Home
Message
No single
clinical finding reliably excludes significant injury in blunt abdominal
trauma, but a positive bedside ultrasonographic result confirms injury when
clinical suspicion is high.
D. Does the Use of Tranexamic Acid Improve
Trauma Mortality?
Bottom Line
According
to the available evidence, tranexamic acid has been shown to significantly
decrease mortality in bleeding trauma patients, with no significant increase in
serious prothrombotic complications if administered within 3 hours of injury.
There is, however, no evidence of benefit in patients with traumatic brain
injury. As such, we recommend early treatment with tranexamic acid in trauma
patients without isolated brain injuries who have or are at risk for significant
hemorrhage and in patients who receive resuscitation with blood products,
particularly if they require massive transfusion or have a high risk of death
at baseline.
16. Optic Neuritis Diagnosed by Bedside Emergency
Physician−Performed US: A Case Report
Wayman D. J
Emerg Med 2014; Epub ahead of print
Background:
Optic neuritis is an inflammatory demyelinating condition of the optic nerve
that causes subacute visual loss. It is often the result of an underlying
systemic condition, such as multiple sclerosis. Due to the possible long-term
morbidity associated with this condition, it is essential that the emergency
physician recognizes the diagnosis and expedites treatment.
Objective: This
case report describes optic neuritis diagnosed at the bedside by emergency
physician−performed ultrasound.
Case Report:
This is a case report of a young man presenting with unilateral painful vision
loss. Optic neuritis must be considered in the differential diagnosis of any
young patient who presents with visual complaints without any other neurologic
findings. This report is unique because there are very few cases describing the
findings of optic neuritis on emergency physician−performed bedside ultrasound
in the literature.
Conclusions:
This article presents the case, describes diagnostic modalities, especially the
use of ultrasound in its diagnosis, and the course of treatment for this
particular condition.
17. (Lots of) Imaging of Frequent ED Users with Alcohol Use
Disorders (and Lots of Pathology)
Hamilton
BH, et al. J Emerg Med. 2014;46:582-7.
Background:
Patients with altered level of consciousness secondary to alcohol use disorders
(AUDs) often undergo imaging in the emergency department (ED), although the
frequency and yield of this practice over time are unknown.
Study
Objectives: We describe the use of imaging, the associated ionizing radiation
exposure, cumulative costs, and identified acute and chronic injuries and
abnormalities among frequent users of the ED with AUDs.
Methods: This
is a retrospective case series of individuals identified through an
administrative database having 10 or more annual ED visits in 2 consecutive
years who were prospectively followed for a third year. International
Classification of Diseases, 9th Revision, Clinical Modification and Current
Procedural Terminology codes were used to select individuals with
alcohol-related diagnoses, track imaging procedures, and calculate cost.
Diagnoses, imaging results, and radiation exposure per computed tomography (CT)
study were abstracted from the medical record.
Results: Fifty-one
individuals met inclusion criteria and had a total of 1648 imaging studies over
the 3-year period. Subjects had a median of 5 (interquartile range [IQR] 2–10)
CT scans, 20 (IQR 10–33) radiographs, 28.3 mSv (IQR 8.97–61.71) ionizing radiation,
0.2% (IQR 0.07–0.4) attributable risk of cancer, and $2979 (IQR 1560–5440) in
charges using a national rate. The incidence of acute fracture or intracranial
head injury was 55%, and 39% of the cohort had a history of moderate or severe
traumatic brain injury.
Conclusion:
The remarkable use of imaging and occurrence of injury among these highly
vulnerable and frequently encountered individuals compels further study to
refine clinical practices through the development of evidence-based, effective
interventions.
18. How Best to Pursue a Diagnosis for UE DVT
Safety and
Feasibility of a Diagnostic Algorithm Combining Clinical Probability, d-Dimer
Testing, and Ultrasonography for Suspected Upper Extremity Deep Venous
Thrombosis: A Prospective Management Study.
Kleinjan A,
Ann Intern Med. 2014 Apr 1;160(7):451-7.
BACKGROUND:
Although well-established for suspected lower limb deep venous thrombosis, an
algorithm combining a clinical decision score, d-dimer testing, and
ultrasonography has not been evaluated for suspected upper extremity deep
venous thrombosis (UEDVT).
OBJECTIVE:
To assess the safety and feasibility of a new diagnostic algorithm in patients
with clinically suspected UEDVT.
DESIGN:
Diagnostic management study. (ClinicalTrials.gov: NCT01324037) SETTING: 16
hospitals in Europe and the United States.
PATIENTS:
406 inpatients and outpatients with suspected UEDVT.
MEASUREMENTS:
The algorithm consisted of the sequential application of a clinical decision
score, d-dimer testing, and ultrasonography. Patients were first categorized as
likely or unlikely to have UEDVT; in those with an unlikely score and normal
d-dimer levels, UEDVT was excluded. All other patients had (repeated)
compression ultrasonography. The primary outcome was the 3-month incidence of
symptomatic UEDVT and pulmonary embolism in patients with a normal diagnostic
work-up.
RESULTS:
The algorithm was feasible and completed in 390 of the 406 patients (96%). In
87 patients (21%), an unlikely score combined with normal d-dimer levels
excluded UEDVT. Superficial venous thrombosis and UEDVT were diagnosed in 54
(13%) and 103 (25%) patients, respectively. All 249 patients with a normal
diagnostic work-up, including those with protocol violations (n = 16), were
followed for 3 months. One patient developed UEDVT during follow-up, for an
overall failure rate of 0.4% (95% CI, 0.0% to 2.2%).
LIMITATIONS:
This study was not powered to show the safety of the substrategies. d-Dimer
testing was done locally.
CONCLUSION:
The combination of a clinical decision score, d-dimer testing, and
ultrasonography can safely and effectively exclude UEDVT. If confirmed by other
studies, this algorithm has potential as a standard approach to suspected
UEDVT.
19. Take a HINTS: A Helpful Test for Vertigo?
Brian Cohn,
MD. EP Monthly,
A
65-year-old gentleman with hypertension and hyperlipidemia presents to your
emergency department one evening complaining of continuous vertigo that began
suddenly two hours prior to arrival. He notes significant head motion
intolerance, is nauseated, and has vomited several times. On exam, he has
horizontal nystagmus in lateral gaze, is very unsteady on his feet, but
otherwise has a normal neurologic exam. He denies hearing changes, recent URI
symptoms and lightheadedness. His head CT, ECG, and labs are normal, and after
receiving 25 mg of oral meclizine, he notes moderate improvement in his
symptoms. He is now able to ambulate without assistance, with minimal ataxia,
and is asking if he can go home. You ask yourself how confident you are that
this gentleman’s vertigo is peripheral in nature, and you entertain the
possibility that he has suffered a cerebellar stroke. You then consider the
options: 1) discharge the patient home with oral meclizine to take as needed;
2) admit the patient to the hospital for a brain MRI and a neurology consult;
or 3) call the neurologist at home to ask for assistance. What you really want
is a cheap, quick bedside test to help differentiate central from peripheral
vertigo.
Dizziness
remains one of the more challenging chief complaints encountered in the
emergency department. This complaint encompasses a wide variety of symptoms,
including vertigo, lightheadedness, weakness, and just plain not feeling good.
Even when the symptom truly is vertigo, the diagnostic conundrum is no less
daunting, as the symptom type is not a good predictor of cause. The challenge
becomes differentiating benign peripheral vertigo from potentially
life-threatening central vertigo, often the result of a cerebellar stroke.
While a normal neurologic exam may feel reassuring to most clinicians, focal
neurologic deficits are unfortunately frequently absent in cases of posterior
circulation stroke. CT scan is often the initial imaging modality when stroke
is being considered, but is notoriously insensitive, particularly when it comes
to the posterior fossa, missing 60-90% of acute ischemic strokes in the
brainstem or cerebellum. MRI with diffusion-weighted imaging, considered by
many to be the “gold standard” for the diagnosis of stroke, is more reliable
than CT, but is still far from perfect. Around 15-20% of patients with
posterior circulation stroke will have a normal MRI in the early period. In addition,
MRI is expensive, costly, and not available in most emergency departments. When
posterior circulation stroke is considered in patients with vertigo, hospital
admission or transfer is often required to complete the necessary work-up.
A rapid,
bedside test to help differentiate central from peripheral vertigo would
therefore have great value. The HINTS exam has been proposed as just such a
test. HINTS stands for Head Impulse, Nystagmus, and Test of Skew, and is a
three-part oculomotor test. If any portion of the test indicates a central
etiology, the test is considered positive and further evaluation for stroke (or
other central pathology) is warranted. The three components of the exam are as
follows…
The
remainder of the essay: http://www.epmonthly.com/www.epmonthly.com/features/current-features/take-a-hints/
20. Pigtail Insertion for PTX: A How To
Azan B, et
al. EP Monthly. March 25, 2014.
A detailed
guide for small-bore catheter insertion for the treatment of pneumothorax in
the emergency department.
It’s a
typical busy Saturday night in your ED. The next chart you pick up is a
15-year-old male with cough shortness of breath and chest pain for one day. He
is tall, with normal vitals and in no distress, and you note decreased breath
sounds on his right side. Chest X-ray confirms it: pneumothorax. As you begin
thinking about how best to manage him, the trauma team is paged overhead. EMS
brings in a 40-year-old female pedestrian who was struck by a car. She has normal
vitals and is complaining of left rib pain and shortness of breath. On your extended fast exam you detect no lung
sliding on the left, and your suspicion of traumatic pneumothorax is confirmed
by chest X-ray. Though you are expert at conventional tube thoracostomy you
wonder if there are other, perhaps less painful or traumatic methods for
relieving the pneumothoraces of these two stable patients…
21. Droperidol Gets Dropped
by Daniel Miller, MD & Brett Faine, PharmD.
EP Monthly, March 12, 2014
In 40 years
this versatile drug has gone from panacea to blackbox to shortage
Droperidol
has been used successfully in the emergency department (ED) and operating room
(OR) for over 40 years. It has been employed with success for the treatment of
headache, nausea, agitation, pain in opiate-tolerance and even the dreaded
multidrug-resistant abdominal pain (MDRAP).(1,2) Unfortunately, in 2001 the FDA
issued a black box warning indicating there was a significant risk of cardiac
arrhythmias with droperidol. At the time of the black box warning, droperidol
held more than 30% of the market share for antiemetics.(3) After the black box
warning was issued, many institutions put restrictions on the use of droperidol
or completely removed it from their hospital formularies.(4) The timing of the
black box warning became a hot topic for conspiracy theorists. Why did it take
over 30 years of clinical use to uncover serious adverse events? Why were there
so many case reports submitted simultaneously? The proximity in time of these
developments to the release of a new class of patent-protected antiemetics
(5HT3 receptor antagonists) trying to take a portion of droperidol’s market
share raised skepticism.
When the
data behind the black-box warning were reviewed, they were found wanting. Prior
to 2000, twenty five million doses of droperidol had been sold, but only 10
adverse cardiac events had been reported to the FDA at doses of 1.25mg or less
– and all of these cases involved confounding factors.(5) Additionally, the
European studies that the FDA cited in their warning had employed droperidol at
doses of 50-100 times the usual doses used in the US. In 2013 AAEM issued a
clinical practice statement supporting the use of doses under 2.5mg without ECG
monitoring.(6) While extrapyramidal effects (akathisia, dystonia) occur in up
to 15% of patients who receive droperidol, this is similar to other dopamine
antagonists used in the ED to treat nausea, vomiting and headache and these
adverse effects can usually be reversed quickly with the administration of an
anticholinergic agent (eg, diphenhydramine or benztropine).(7,8)
After the
FDA’s report came under scrutiny, droperidol started to resurface in EDs across
the country and some institutions allowed droperidol to be administered to
selected populations without extensive monitoring.(9) Once again, droperidol
became an important medication in the ED.
Unfortunately
it fell on hard times once again in late 2012 when it appeared on shortage
lists and supplies quickly ran out.10 According to the American Society of
Health-System Pharmacists (ASHP) web-site there are multiple reasons for the
continuing droperidol shortage.(10) The two manufacturers who produce the drug
(Hospira and American Regent) suspended distribution of their droperidol due to
manufacturing delays and shortage of raw material…
Read more: http://www.epmonthly.com/www.epmonthly.com/features/current-features/droperidol-gets-dropped/
22. Today’s Best Science: Accessible and Entertaining
A. Our Place in a Dynamic Universe
Neil
DeGrasse Tyson has revamped Carl Sagan’s Cosmos for a new generation. This
13-part series is currently running. http://www.space.com/22058-cosmos-a-spacetimes-odyssey-with-neil-degrasse-tyson-revealed-video.html
B. Tracing Human Origins
This 3-part
PBS special unpacks Neil Shubin’s book Our
Inner Fish. It begins this week: http://www.tangledbankstudios.org/
23. Tid Bits
A. Familiar with FOAMed?
FOAM stands
for Free Open Access Meducation – Medical education for anyone, anywhere,
anytime. Read more: http://lifeinthefastlane.com/foam/
B. Reasons for and Outcomes Related
to Intrauterine Device Removals in the Emergency Department: A Case Series
C. ACEP Policy: Withholding or
Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic
Cardiopulmonary Arrest
D. Use of macrolides in mother and
child increases risk of infantile hypertrophic pyloric stenosis: nationwide
cohort study
Full-text
(free): http://www.bmj.com/content/348/bmj.g1908
E. Study ties shingles episodes to
increased stroke risk
A study
published in Clinical Infectious Diseases showed patients with shingles had a
63% higher risk of stroke in the first month following the onset of the skin
rash, but the risk declined during the next five months. Researchers also found
that the risk of stroke was three times greater among patients who had the rash
around one or both eyes. Patients treated with antiviral drugs, however, were
less likely to suffer a stroke compared with those who didn't receive the
drugs, researchers noted.
F. FDA OKs Naloxone Pen for
Overdose
The FDA has
okayed an auto-injector formulation of naloxone (Evzio), intended to expand the
use of an agent that can rapidly reverse an opioid overdose.
G. Can Botox Take Away Frown and
Depression?
Botox
injections to disable the facial muscles responsible for frowning were
effective in relieving clinical depression in a randomized, placebo-controlled
trial, researchers said.
H. Study: 31.3% of prescriptions go
unfilled
A study in
the Annals of Internal Medicine found 31.3% of 37,506 new prescriptions were
unfilled after nine months, with prescriptions for autonomic drugs, gastrointestinal
drugs and skin agents less likely to be filled than anti-infectives. The study,
conducted in a primary care network, showed increasing patient age, co-payments
and proportion of office visits with prescribing physician were factors in nonadherence.
I. Greater hospitalist workloads
tied to longer stays, higher costs
Although
greater utilization of hospitalists is generally seen as a way to improve care
and hold down costs, heavy workloads coincide with reduced efficiency and
longer stays for patients, according to a study reported in JAMA Internal
Medicine. Researchers also reported a correlation between increased workload
and higher costs, even after adjusting for increased length of stay.
J. Being Buff Pays? Heart disease,
diabetes risks lower in strong children
The lead
author says, "It's a widely held belief that BMI [body mass index],
sedentary behaviors and low cardiovascular fitness levels are linked to
diabetes, heart disease and stroke, but our findings suggest muscle strength
possibly may play an equally important role in cardiometabolic health in children."
K. Springing Ahead Can Be Dangerous
In
Michigan, the "spring forward" onto daylight saving time -- thus
losing an hour's sleep -- appears to be associated with a temporary spike in
heart attacks.
L. Plantar
Fasciitis: A Concise Review
One of the
challenges in the treatment of plantar fasciitis is that there are very few
high-quality studies comparing different treatment modalities to guide
evidence-based management. Current literature suggests a change to the way that
plantar fasciitis is managed. This article reviews the most current literature
on plantar fasciitis and showcases recommended treatment guidelines.
M. Many patients receive
inappropriate treatment for sepsis
Researchers
reported in the journal PLOS One that 38% of 1,500 community hospital patients
with bloodstream infections were given inappropriate antibiotic treatment.
Those who had been hospitalized within the previous year, those with impaired
function and those with multidrug-resistant pathogens were more likely to
receive inappropriate antibiotic therapy
N. The utility of ED clinical
pharmacists: what does the EM staff think?
Full-text
(free): http://www.escholarship.org/uc/item/7xz6p29m#
