Monday, April 07, 2014

Lit Bits: April 7, 2014

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:

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.

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:

2. Mortality Related to Severe Sepsis and Septic Shock among Critically Ill Patients in Australia and New Zealand, 2000-2012

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.

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, 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:

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)
4.31 (3.13 to 5.98)
Duration of pain to presentation:
 Above 24 hours
 6-24 hours
1.85 (1.27 to 2.70)
 Less than 6 hours
6.34 (4.26 to 9.33)
6.77 (3.79 to 12.64)
Nausea and vomiting:
 Nausea alone
1.98 (1.38 to 2.86)
 Vomiting alone
5.26 (3.53 to 7.93)
Hematuria (on urine dipstick):
5.61 (3.96 to 8.04)

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.

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.

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. ( 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…

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:

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.

B. Tracing Human Origins
This 3-part PBS special unpacks Neil Shubin’s book Our Inner Fish. It begins this week:

23. Tid Bits

 A. Familiar with FOAMed?

FOAM stands for Free Open Access Meducation – Medical education for anyone, anywhere, anytime. Read more:

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

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?