1. Topical Tetracaine Used for 24 Hours Is Safe and Rated Highly
Effective by Patients for the Treatment of Pain Caused by Corneal Abrasions: A
Double-blind RCT
Waldman N,
et al. Acad Emerg Med. 2014;21:374-82.
Objectives:
The objective of this study was to test the hypothesis that topical tetracaine
would be safe to use for 24 hours and would not affect corneal healing, that
patients would experience more pain relief, and that patients would perceive
tetracaine to be more effective than saline eye drops for the treatment of pain
caused by corneal abrasions.
Methods: The
study was a 12-month, prospective, double-blind, randomized trial of tetracaine
versus saline set in the emergency department (ED) of a regional tertiary care
teaching hospital. A total of 116 patients presenting with uncomplicated
corneal abrasions were included in this study. The intervention was either
undiluted, preservative-free, topical tetracaine hydrochloride 1% or saline,
applied up to every 30 minutes while awake for 24 hours. Main safety outcome
measures were repeat ED examinations at 48 hours with fluorescein staining and
slit-lamp examination, 1-week and 1-month telephone interviews with additional
examinations as needed, and monitoring of charts for complications. Secondary
outcome measures were 100-mm visual analogue scale (VAS) pain scores recorded
every 2 hours while awake for 48 hours and patient-perceived overall
effectiveness using a numeric rating scale (NRS) of 0 to 10 obtained during
telephone interviews.
Results: At
least one follow-up encounter was completed on each of the 116 patients. No
complications specifically attributed to topical anesthetic use occurred in the
59 patients in the tetracaine group, and the binomial probability confidence
interval (CI) of this occurring is 0 to 6.1. There was no significant
difference in corneal healing as measured by the percentage of patients with
persistent fluorescein uptake at 48 hours between the two groups (23.9% vs.
21.3%, difference = 2.6%, 95% CI = –14% to 20%, p = 0.761) or persistent
symptoms at 48 hours (21.7% vs. 21.3%, difference = 0.4%, 95% CI = –16% to 17%,
p = 0.957). There was no clinical difference in VAS pain scores between the
groups. Patients in the tetracaine group rated the study drugs' overall
effectiveness significantly higher on the NRS (7.7 vs. 3.9) compared to
patients in the saline group (difference = 3.9, 95% CI = 2.4 to 5.3, p less
than 0.0005).
Conclusions:
Topical tetracaine used for 24 hours is safe, and while there was no
significant difference in patient VAS pain ratings over time, patient surveys
on overall effectiveness showed that patients perceived tetracaine to be
significantly more effective than saline.
2. Predicting hematoma expansion after primary ICH
Brouwers HB,
et al. JAMA Neurol. 2014 Feb;71(2):158-64.
IMPORTANCE:
Many clinical trials focus on restricting hematoma expansion following acute
intracerebral hemorrhage (ICH), but selecting those patients at highest risk of
hematoma expansion is challenging.
OBJECTIVE: To
develop a prediction score for hematoma expansion in patients with primary ICH.
DESIGN,
SETTING, AND PARTICIPANTS: Prospective cohort study at 2 urban academic medical
centers among patients having primary ICH with available baseline and follow-up
computed tomography for volumetric analysis (817 patients in the development
cohort and 195 patients in the independent validation cohort).
MAIN
OUTCOMES AND MEASURES: Hematoma expansion was assessed using semiautomated
software and was defined as more than 6 mL or 33% growth. Covariates were
tested for association with hematoma expansion using univariate and
multivariable logistic regression. A 9-point prediction score was derived based
on the regression estimates and was subsequently tested in the independent
validation cohort.
RESULTS: Hematoma
expansion occurred in 156 patients (19.1%). In multivariable analysis,
predictors of expansion were as follows: warfarin sodium use, the computed
tomography angiography spot sign, and shorter time to computed tomography (≤ 6
vs beyond 6 hours) (P less than .001 for all), as well as baseline ICH volume
(below 30 [reference], 30-60 [P = .03], and over 60 [P = .005] mL). The
incidence of hematoma expansion steadily increased with higher scores. In the
independent validation cohort (n = 195), our prediction score performed well
and showed strong association with hematoma expansion (odds ratio, 4.59; P less
than .001 for a high vs low score). The C statistics for the score were 0.72
for the development cohort and 0.77 for the independent validation cohort.
CONCLUSIONS
AND RELEVANCE: A 9-point prediction score for hematoma expansion was developed
and independently validated. The results open a path for individualized
treatment and trial design in ICH aimed at patients at highest risk of hematoma
expansion with maximum potential for therapeutic benefit.
3. Effect of Out-of-Hospital Noninvasive Positive-Pressure
Support Ventilation in Adult Patients with Severe Respiratory Distress: A
Systematic Review and Meta-analysis
Mal S, et
al. Ann Emerg Med. 2014;63: 600–607.e1
Study
objective: Noninvasive positive-pressure ventilation (NIPPV) is increasingly
being used by emergency medical services (EMS) for treatment of patients in
respiratory distress. The primary objective of this systematic review is to
determine whether out-of-hospital NIPPV for treatment of adults with severe
respiratory distress reduces inhospital mortality compared with “standard”
therapy. Secondary objectives are to examine the need for invasive ventilation,
hospital and ICU length of stay, and complications.
Methods: Electronic
searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials,
and Cumulative Index to Nursing and Allied Health Literature were conducted and
reference lists of relevant articles hand searched. Randomized controlled
trials comparing out-of-hospital NIPPV with standard therapy in adults (aged
≥16 years) with severe respiratory distress published in English were included.
Two reviewers independently screened abstracts, assessed quality of the
studies, and extracted data. Data were pooled with random-effects models and
reported as risk ratios (RRs) with 95% confidence intervals (CIs) and number
needed to treat (NNT).
Results: Seven
randomized controlled trials were included, with a combined total of 632
patients; 313 in the standard therapy group and 319 in the NIPPV group. In
patients treated with NIPPV, the pooled estimate showed a reduction in both
inhospital mortality (RR 0.58; 95% CI 0.35 to 0.95; NNT=18) and need for
invasive ventilation (RR 0.37; 95% CI 0.24 to 0.58; NNT=8). There was no difference
in ICU or hospital length of stay.
Conclusion:
Out-of-hospital administration of NIPPV appears to be an effective therapy for
adult patients with severe respiratory distress.
4. Intermediate-Risk Patients with PE Should Receive
Thrombolytics Only If They Decompensate
Raja AS,
Journal Watch Emergency Medicine. April 9, 2014
Primary
thrombolysis did not improve mortality but did increase major hemorrhage and
stroke in patients with intermediate-risk pulmonary embolism.
Administration
of thrombolytic therapy for acute pulmonary embolism (PE) requires weighing the
substantial risk of hemorrhage against the potential benefits, mainly improved
hemodynamics and reduced mortality. For patients in shock with clear evidence
of PE (high risk), the benefits seem to outweigh the risks, but for hemodynamically
stable patients with evidence of right ventricular dysfunction and elevated
troponin levels (intermediate risk), the evidence has been less clear. To
determine the safety and efficacy of thrombolytic therapy in intermediate-risk
patients, researchers in France performed a multicenter, randomized,
double-blind trial comparing tenecteplase plus heparin with placebo plus
heparin in 1005 hemodynamically stable patients with PE, right ventricular
dysfunction on ultrasound or computed tomography, and troponin elevation.
Mortality
was similar in the tenecteplase and placebo groups at 7 days (1.2% and 1.8%)
and 30 days (2.4% and 3.2%). The tenecteplase group had higher rates of both
intracranial bleeding (2.0% vs. 0.2%) and extracranial bleeding (6.3% vs.
1.2%). However, significantly more patients in the placebo group had
hemodynamic decompensation and needed rescue thrombolysis during their
admission (5.0% vs. 1.6%).
Comment: Given
the risk for hemorrhage, primary thrombolysis should not be given to hemodynamically
stable patients with intermediate-risk pulmonary embolism. However,
intermediate-risk patients can decompensate and should be closely monitored in
case they need rescue thrombolysis or mechanical embolectomy during
hospitalization. These results are similar to those of earlier smaller trials
and reinforce current practice.
Source: Meyer
G et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N
Engl J Med 2014;370:1402.
5. Occult Pneumothoraces in Children with Blunt Torso Trauma:
Observation Works
Lee LK, et
al. Acad Emerg Med. 2014;21:440–448
Objectives:
Plain chest x-ray (CXR) is often the initial screening test to identify
pneumothoraces in trauma patients. Computed tomography (CT) scans can identify
pneumothoraces not seen on CXR (“occult pneumothoraces”), but the clinical
importance of these radiographically occult pneumothoraces in children is not
well understood. The objectives of this study were to determine the proportion
of occult pneumothoraces in injured children and the rate of treatment with
tube thoracostomy among these children.
Methods: This
was a planned substudy from a large prospective multicenter observational
cohort study of children younger than 18 years old evaluated in emergency
departments (EDs) in the Pediatric Emergency Care Applied Research Network
(PECARN) for blunt torso trauma from May 2007 to January 2010. Children with CXRs
as part of their trauma evaluations were included for analysis. The faculty
radiologist interpretations of the CXRs and any subsequent imaging studies,
including CT scans, were reviewed for the absence or presence of
pneumothoraces. An “occult pneumothorax” was defined as a pneumothorax that was
not identified on CXR, but was subsequently demonstrated on cervical, chest, or
abdominal CT scan. Rates of pneumothoraces and placement of tube thoracostomies
and rate differences with 95% confidence intervals (CIs) were calculated.
Results: Of
12,044 enrolled in the parent study, 8,020 (67%) children (median age = 11.3
years, interquartile range [IQR] = 5.3 to 15.2 years) underwent CXRs in the ED,
and these children make up the study population. Among these children, 4,276
had abdominal CT scans performed within 24 hours. A total of 372 of 8,020
children (4.6%; 95% CI = 4.2% to 5.1%) had pneumothoraces identified by CXR
and/or CT. The CXRs visualized pneumothoraces in 148 patients (1.8%; 95% CI =
1.6% to 2.2%), including one false-positive pneumothorax, which was identified
on CXR, but was not demonstrated on CT. Occult pneumothoraces were present in
224 of 372 (60.2%; 95% CI = 55.0% to 65.2%) children with pneumothoraces. Tube
thoracostomies were performed in 85 of 148 (57.4%; 95% CI = 49.0% to 65.5%)
children with pneumothoraces on CXR and in 35 of 224 (15.6%; 95% CI = 11.1% to
21.1%) children with occult pneumothoraces (rate difference = –41.8%; 95% CI =
–50.8 to –32.3%).
Conclusions:
In pediatric patients with blunt torso trauma, pneumothoraces are uncommon, and
most are not identified on the ED CXR. Nearly half of pneumothoraces, and most
occult pneumothoraces, are managed without tube thoracostomy. Observation,
including in children requiring endotracheal intubation, should be strongly
considered during the initial management of children with occult
pneumothoraces.
6. Does a Prehospital ECG Improve MI Care?
Daniel J.
Pallin, MD, MPH, Journal Watch Emergency Medicine. Apr 5 2013
An
observational study in England and Wales correlates obtaining a prehospital ECG
with better care and outcomes.
Most
emergency medical services (EMS) systems can perform prehospital
electrocardiograms (ECGs), and some can even bypass the emergency department to
transport patients straight to the catheterization lab. However, debate
continues about whether specific prehospital interventions actually improve
patient care or outcomes. Investigators reviewed a national myocardial
infarction (MI) registry in England and Wales to determine whether obtaining a
prehospital ECG was associated with better processes of care and patient
outcomes.
Of 288,990
MI patients transported to the hospital by EMS between 2005 and 2009, 50%
received prehospital ECGs, and 32% did not (ECG status was unknown for 18%).
Among patients with ST segment elevation myocardial infarction, those with a
prehospital ECG were more likely than those without to undergo reperfusion (84%
vs. 74%), have a call-to-balloon time below 90 minutes (28% vs. 21%), and have
an arrival-to-fibrinolysis time below 30 minutes (91% vs. 84%). Overall, 30-day
mortality was lower in patients with a prehospital ECG (7.4% vs. 8.2%).
Comment: There
may be reasons why some patients received prehospital electrocardiograms and
others did not: The ones who did not may have been sicker or may have had more
obscure presentations. Although this study is flawed by its design, its
findings are consistent with those of other studies showing that obtaining a
prehospital ECG shortens time to treatment and improves care -
Source: Quinn
T et al. Effects of prehospital 12-lead ECG on processes of care and mortality
in acute coronary syndrome: A linked cohort study from the Myocardial Ischaemia
National Audit Project. Heart 2014 Apr 14 [Epub ahead of print]
7. An ED scribe program is able to improve throughput time and
patient satisfaction
Bastani A,
et al. Amer J Emerg Med. 2014;32:399-402.
Introduction:
At our institution, we previously described the detrimental effect of
computerized physician order entry (CPOE) on throughput time and patient
satisfaction (Ann of Emer Med, Vol 56, P S83-S84). To address these quality
metrics, we conducted a pilot program using scribes in the emergency department
(ED).
Methods: We
conducted a before-and-after study of ED throughput at our 320-bed suburban
community hospital with a census of 70000 annual visits. Our primary outcome
measure was the effect of scribes on ED throughput as measured by the effect on
(1) door-to-room time; (2) room-to-doc time; (3) door-to-doc time; (4)
doc-to-dispo time; and (5) length of stay for discharged/admitted patients,
between pre-CPOE and post-CPOE cohorts. Our secondary outcome measure was
patient satisfaction as provided by Press Ganey surveys. Data were analyzed
using descriptive statistics, and means were compared using a standard t test.
Results: Patient
data from a total of 11729 patients in the before cohort were compared with
data from 12609 patients in the after cohort. Despite a 7.5 % increase in
volume between the post-CPOE and post-scribe cohorts, all throughput metrics
improved in the post-scribe cohort. This process improved the overall
door-to-doc time to 61 minutes in the after cohort from 74 minutes in the
before cohort. Furthermore, patient and physician satisfaction was improved
from the 58th and 62nd percentile to 75th and 92nd percentile, respectively.
8. Post-Intubation Sedation: The Tube Is In, Now What?
by Neil
Singh, MD, Emerg Physicians Monthly, May 5, 2014
How to
reduce anxiety and improve comfort while not oversedating.
A
70-year-old male comes to the emergency department via EMS febrile, with
worsening respiratory distress and altered mental status. You quickly diagnose
him as having severe sepsis stemming from pneumonia, and initiate treatment.
After setting up and preoxygenating him, you have first-pass success on your
intubation, pat yourself on the back, and admit him to the ICU. But your
nursing manager then informs you that the hospital is full, including the ICU.
So now your severely septic patient will be boarding in the ED. He quickly
starts to get hypotensive on your sedation and you can only sweat and wonder,
“How am I supposed to manage him now?”
Once
mechanical ventilation has been initiated, the physician’s initial goals are to
relieve patient anxiety and keep them comfortable. In “The ICU Book,” Marino
states “the common denominator in these conditions (anxiety and delirium) is
the absence of a sense of well-being.”
Reducing
anxiety on a ventilated patient is challenging. Double breathing the
ventilator, pulling at lines and persistent tachycardia are all obvious signs of
anxiety. In the “good old days,” trying to achieve those two goals under these
conditions was often met with a slight dose of paralysis – vecuronium at times
– while maintaining ventilator synchrony, mixed with a few pushes of
benzodiazepines to relieve anxiety and hopefully introduce some amnesia.
Fortunately,
as emergency medicine knowledge progressed, so did pharmacology, and now the
idea of paralyzing an awake patient brings chills to us all. Unfortunately,
while the use of opiates and benzodiazepines post-intubation may be a step
forward, they come with their own unique set of complications. The normotensive
patient that becomes hypotensive on sedation is markedly common, and
unfortunately many respond by simply adding some wrist restraints and cutting
back on drips. The other side of the coin occurs just as often — patients
overmedicated with enough sedation to knock out a small elephant. These
dilemmas occur often in the ED and even in many ICUs, but with new ICU
guidelines on sedation, the ED can take evidence-based decisive measures to
improve patient care for the most critically ill patients.1
The
remainder of the essay: http://www.epmonthly.com/www.epmonthly.com/features/current-features/post-intubation-sedation-the-tube-is-in-now-what
Reference
1: Barr J, et al. Clinical practice guidelines for the management of pain,
agitation, and delirium in adult patients in the intensive care unit. Crit Care
Med. 2013;41(1):263-306
9. Airflow efficacy of ballpoint pen tubes: a consideration for
use in bystander cricothyrotomy
Owens D, et al. Emerg Med J 2010;27:317-320.
OBJECTIVE
To examine the suitability of commonly available ballpoint pens as a substitute
emergency tracheostomy tube.
METHODS
commonly available ballpoint pens were examined and compared against two
standard cricothyroidotomy sets. The pens were evaluated for dimensions, speed
of construction of a temporary tracheostomy tube and airway resistance with
differing flow rates.
RESULTS
Internal diameters of the pens varied considerably. Time taken to construct a
temporary tube ranged from 3 to 170 s, and in the majority of pens the airway
resistance increased dramatically as the airflow rate increased.
CONCLUSION
Contrary to popular belief, the majority of ballpoint pens appear unsuitable
for use as a substitute tracheostomy tube. In this study only two pens
fulfilled the criteria for use: the Baron retractable ballpoint and the BIC
soft feel Jumbo.
10. Give Antibiotics Quickly for Severe Sepsis and Septic Shock
Probability
of death steadily increased with each hour's delay to antibiotics.
Ferrer R, et
al. Empiric Antibiotic Treatment Reduces Mortality in Severe Sepsis and Septic
Shock From the First Hour: Results From a Guideline-Based Performance
Improvement Program. Crit Care Med. 2014 Apr 8. [Epub ahead of print]
OBJECTIVES:
Compelling evidence has shown that aggressive resuscitation bundles, adequate
source control, appropriate antibiotic therapy, and organ support are
cornerstone for the success in the treatment of patients with sepsis. Delay in
the initiation of appropriate antibiotic therapy has been recognized as a risk
factor for mortality. To perform a retrospective analysis on the Surviving
Sepsis Campaign database to evaluate the relationship between timing of
antibiotic administration and mortality.
DESIGN: Retrospective
analysis of a large dataset collected prospectively for the Surviving Sepsis
Campaign.
SETTING: One
hundred sixty-five ICUs in Europe, the United States, and South America.
PATIENTS: A
total of 28,150 patients with severe sepsis and septic shock, from January 2005
through February 2010, were evaluated.
INTERVENTIONS:
Antibiotic administration and hospital mortality.
MEASUREMENTS
AND MAIN RESULTS: A total of 17,990 patients received antibiotics after sepsis
identification and were included in the analysis. In-hospital mortality was
29.7% for the cohort as a whole. There was a statically significant increase in
the probability of death associated with the number of hours of delay for first
antibiotic administration. Hospital mortality adjusted for severity (sepsis
severity score), ICU admission source (emergency department, ward, vs ICU), and
geographic region increased steadily after 1 hour of time to antibiotic
administration. Results were similar in patients with severe sepsis and septic
shock, regardless of the number of organ failure.
CONCLUSIONS:
The results of the analysis of this large population of patients with severe
sepsis and septic shock demonstrate that delay in first antibiotic
administration was associated with increased in-hospital mortality. In
addition, there was a linear increase in the risk of mortality for each hour
delay in antibiotic administration. These results underscore the importance of
early identification and treatment of septic patients in the hospital setting.
11. What decides the suspicion of ACS in acute CP patients?
Kamali A,
et al. BMC Emergency Medicine 2014, 14:9
BACKGROUND:
Physicians assessing chest pain patients in the emergency department (ED) base
the likelihood of acute coronary syndrome (ACS) mainly on ECG, symptom history
and blood markers of myocardial injury. Among these, the ECG has been stated to
be the most important diagnostic tool. We aimed to analyze the relative
contributions of these three diagnostic modalities to the ED physicians'
evaluation of ACS likelihood in clinical practice.
METHODS:
1151 consecutive ED chest pain patients were prospectively included. The ED
physician's subjective assessment of the patient's likelihood of ACS (obvious
ACS, strong, vague or no suspicion of ACS), the symptoms and the ECG were
recorded on a special form. The ED TnT value was retrieved from the medical
records. Frequency tables and logistic regression models were used to evaluate
the contributions of the diagnostic tests to the level of ACS suspicion.
RESULTS:
Symptoms determined whether the physician had any suspicion of ACS (odds ratio,
OR 526 for symptoms typical compared to not suspicious of ACS) since neither
ECG nor TnT contributed significantly (ORs not significantly different from 1)
to this assessment. ACS was suspected in only one in ten patients with symptoms
not suspicious of ACS. Symptoms were also more important (OR 620 for typical
symptoms) than ECG (OR 31 for ischemic ECG) and TnT (OR 3.4 for a positive TnT)
for the assessment of obvious ACS/strong suspicion versus vague/no suspicion.
Of the patients with ST-elevation on ECG, 71% were considered to have an
obvious ACS, as opposed to only 6% of those with symptoms typical of ACS and
10% of those with a positive TnT.
CONCLUSION:
The ED physicians used symptoms as the most important assessment tool and
applied primarily the symptoms to determine the level of ACS suspicion and to
rule out ACS. The ECG was primarily used to rule in ACS. The TnT level played a
minor role for the assessment of ACS likelihood. Further studies regarding ACS
prediction based on symptoms may help improve decision-making in ED patients
with possible ACS.
Full-text
(free): http://www.biomedcentral.com/1471-227X/14/9
12. Images in Clinical Practice
Measles is
back: But what does it look like?
Man with
severe shoulder pain
Female With
Lower Abdominal Pain and Bleeding
Fever and
macular lesions on toes
Reversible
posterior leukoencephalopathy syndrome
13. Geriatrics
A. An intro to the Geriatric ED
Christina
Shenvi, Geriatric Emergency Departments: Coming to a Hospital Near You? Acad
Life in Emerg Med. April 29th, 2014
We are all
familiar with the concept of pediatric EDs. We see them as medical students, we
train in them as residents, and we work alongside pediatric EM fellows. It is
generally clear what pediatric EDs have to offer: smaller sized beds and
equipment, nurses trained in pediatric triage and assessment who know how to
put IVs in babies and calm crying kids, and physicians with training in
pediatric Emergency Medicine. But what about the other end of the age spectrum?
Over the last 10 years geriatric EDs, also called Senior EDs, have been popping
up around the country. You may have been wondering why that is, and what they
have to offer. Here are a few thoughts.
The
remainder of the essay: http://academiclifeinem.com/geriatric-emergency-departments-coming-hospital-near/
B. New Geri-ED Guidelines
This
document is the product of two years of consensus-based work that included
representatives from the American College of Emergency Physicians, The American
Geriatrics Society, Emergency Nurses Association, and the Society for Academic
Emergency Medicine.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(14)00118-8/fulltext
C. Impact of a New Senior Emergency
Department on Emergency Department Recidivism, Rate of Hospital Admission, and
Hospital Length of Stay
D. Toward Patient-Centered Care: A
Systematic Review of Older Adults’ Views of Quality Emergency Care
E. Screening for Delirium in the
Emergency Department: A Systematic Review
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(13)01584-9/fulltext
14. Door-to-Needle Times for tPA Administration and Clinical
Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement
Initiative
Fonarow GC,
et al. JAMA. 2014;311(16):1632-1640
Importance The benefits of intravenous tissue
plasminogen activator (tPA) in patients with acute ischemic stroke (AIS) are
time dependent and guidelines recommend a door-to-needle (DTN) time of 60
minutes or less. However, studies have found that less than 30% of US patients
are treated within this time window. Target: Stroke was designed as a national
quality improvement initiative to improve DTN times for tPA administration in
patients with AIS.
Objectives To evaluate DTN times for tPA administration
and the proportion of patients with times of 60 minutes or less before and
after initiation of a quality improvement initiative and to determine whether
potential improvements in DTN times were associated with improvements in
clinical outcomes.
Design,
Setting, and Patients The Target: Stroke
initiative disseminated 10 care strategies to achieve faster DTN times for tPA
administration, provided clinical decision support tools, facilitated hospital
participation, and encouraged sharing of best practices. This study included
71 169 patients with AIS treated with tPA (27 319 during the preintervention
period from April 2003-December 2009 and 43 850 during the postintervention
period from January 2010-September 2013) from 1030 Get With The
Guidelines—Stroke participating hospitals (52.8% of total).
Main
Outcomes and Measures The DTN times for
tPA administration of 60 minutes or less and in-hospital risk-adjusted
mortality, symptomatic intracranial hemorrhage, ambulatory status at discharge,
and discharge destination.
Results Median DTN time for tPA administration
declined from 77 minutes (interquartile range [IQR], 60-98 minutes) during the
preintervention period to 67 minutes (IQR, 51-87 minutes) during the
postintervention period (P less than .001). The DTN times for tPA
administration of 60 minutes or less increased from 26.5% (95% CI, 26.0%-27.1%)
of patients during the preintervention period to 41.3% (95% CI, 40.8%-41.7%)
during the postintervention period (P less than .001). The DTN times of 60
minutes or less increased from 29.6% (95% CI, 27.8%-31.5%) of patients in the
quarter immediately before the intervention (fourth quarter of 2009) to 53.3%
(95% CI, 51.5%-55.2%) in the final postintervention quarter (third quarter of
2013) (P less than .001). The annual rate of improvement in DTN times of 60
minutes or less increased from 1.36% (95% CI, 1.04%-1.67%) per year
preintervention to 6.20% (95% CI, 5.58%-6.78%) per year postintervention (P less
than .001). In-hospital all-cause mortality improved significantly from the
preintervention to the postintervention period (9.93% vs 8.25%, respectively;
adjusted odds ratio [OR], 0.89 [95% CI, 0.83-0.94], P less than .001),
symptomatic intracranial hemorrhage within 36 hours was less likely to occur
(5.68% vs 4.68%; adjusted OR, 0.83 [95% CI, 0.76-0.91], P less than .001), and
discharge to home was more frequent (37.6% vs 42.7%; adjusted OR, 1.14 [95% CI,
1.09-1.19], P less than .001).
Conclusions
and Relevance Implementation of a
national quality improvement initiative was associated with improved timeliness
of tPA administration following AIS on a national scale, and this improvement
was associated with lower in-hospital mortality and intracranial hemorrhage,
along with an increase in the percentage of patients discharged home.
15. Adverse childhood experiences predict health-harming
behaviors
Bellis MA,
et al. BMC Medicine 2014, 12:72
Background:
Epidemiological and biomedical evidence link adverse childhood experiences
(ACEs) with health-harming behaviors and the development of non-communicable
disease in adults. Investment in interventions to improve early life
experiences requires empirical evidence on levels of childhood adversity and
the proportion of HHBs potentially avoided should such adversity be addressed.
Methods: A
nationally representative survey of English residents aged 18 to 69 (n = 3,885)
was undertaken during the period April to July 2013. Individuals were
categorized according to the number of ACEs experienced. Modeling identified
the proportions of HHBs (early sexual initiation, unintended teenage pregnancy,
smoking, binge drinking, drug use, violence victimization, violence
perpetration, incarceration, poor diet, low levels of physical exercise)
independently associated with ACEs at national population levels.
Results: Almost
half (47%) of individuals experienced at least one of the nine ACEs. Prevalence
of childhood sexual, physical, and verbal abuse was 6.3%, 14.8%, and 18.2%
respectively (population-adjusted). After correcting for sociodemographics, ACE
counts predicted all HHBs, e.g. (0 versus 4+ ACEs, adjusted odds ratios (95%
confidence intervals)): smoking 3.29 (2.54 to 4.27); violence perpetration 7.71
(4.90 to 12.14); unintended teenage pregnancy 5.86 (3.93 to 8.74). Modeling
suggested that 11.9% of binge drinking, 13.6% of poor diet, 22.7% of smoking,
52.0% of violence perpetration, 58.7% of heroin/crack cocaine use, and 37.6% of
unintended teenage pregnancy prevalence nationally could be attributed to ACEs.
Conclusions:
Stable and protective childhoods are critical factors in the development of
resilience to health-harming behaviors in England. Interventions to reduce ACEs
are available and sustainable, with nurturing childhoods supporting the
adoption of health-benefiting behaviors and ultimately the provision of
positive childhood environments for future generations.
Full-text
(free): http://www.biomedcentral.com/1741-7015/12/72
16. The Association between Pretest Probability of CAD and
Stress Test Utilization and Outcomes in a CP Observation Unit
Napoli AM,
et al. Acad Emerg Med. 2014;21:401–407
Objectives:
Cardiology consensus guidelines recommend use of the Diamond and Forrester
(D&F) score to augment the decision to pursue stress testing. However,
recent work has reported no association between pretest probability of coronary
artery disease (CAD) as measured by D&F and physician discretion in stress
test utilization for inpatients. The author hypothesized that D&F pretest
probability would predict the likelihood of acute coronary syndrome (ACS) and a
positive stress test and that there would be limited yield to diagnostic
testing of patients categorized as low pretest probability by D&F score who
are admitted to a chest pain observation unit (CPU).
Methods: This
was a prospective observational cohort study of consecutively admitted CPU
patients in a large-volume academic urban emergency department (ED).
Cardiologists rounded on all patients and stress test utilization was driven by
their recommendations. Inclusion criteria were as follows: age over 18 years,
American Heart Association (AHA) low/intermediate risk, nondynamic
electrocardiograms (ECGs), and normal initial troponin I. Exclusion criteria
were as follows: age older than 75 years with a history of CAD. A D&F score
for likelihood of CAD was calculated on each patient independent of patient
care. Based on the D&F score, patients were assigned a priori to low-,
intermediate-, and high-risk groups (less than 10, 10 to 90, and above 90%,
respectively). ACS was defined by ischemia on stress test, coronary artery
occlusion of ≥70% in at least one vessel, or elevations in troponin I
consistent with consensus guidelines. A true-positive stress test was defined
by evidence of reversible ischemia and subsequent angiographic evidence of
critical stenosis or a discharge diagnosis of ACS. An estimated 3,500 patients
would be necessary to have 1% precision around a potential 0.3% event rate in
low-pretest-probability patients. Categorical comparisons were made using
Pearson chi-square testing.
Results: A
total of 3,552 patients with index visits were enrolled over a 29-month period.
The mean (± standard deviation [SD]) age was 51.3 (±9.3) years. Forty-nine
percent of patients received stress testing. Pretest probability based on
D&F score was associated with stress test utilization (p less than 0.01),
risk of ACS (p less than 0.01), and true-positive stress tests (p = 0.03). No
patients with low pretest probability were subsequently diagnosed with ACS (95%
CI = 0 to 0.66%) or had a true-positive stress test (95% CI = 0 to 1.6%).
Conclusions:
Physician discretionary decision-making regarding stress test use is associated
with pretest probability of CAD. However, based on the D&F score,
low-pretest-probability patients who meet CPU admission criteria are very
unlikely to have a true-positive stress test or eventually receive a diagnosis
of ACS, such that observation and stress test utilization may be obviated.
Remind me: what’s the D&F score?
17. Epinephrine May Be of No Survival Benefit in Cardiac Arrest
A
meta-analysis shows similar survival to discharge and neurological outcomes in
adult cardiac arrest patients irrespective of epinephrine use or dose.
Lin S, et
al. Adrenaline for out-of-hospital cardiac arrest resuscitation: A systematic
review and meta-analysis of randomized controlled trials. Resuscitation 2014
March 15 [Epub ahead of print]
Introduction:
The evidence for adrenaline in out-of-hospital cardiac arrest (OHCA)
resuscitation is inconclusive. We systematically reviewed the efficacy of
adrenaline for adult OHCA.
Methods: We
searched in MEDLINE, EMBASE, and Cochrane Library from inception to July 2013
for randomized controlled trials (RCTs) evaluating standard dose adrenaline
(SDA) to placebo, high dose adrenaline (HDA), or vasopressin (alone or
combination) in adult OHCA patients. Meta-analyses were performed using random
effects modeling. Subgroup analyses were performed stratified by cardiac rhythm
and by number of drug doses. The primary outcome was survival to discharge and
the secondary outcomes were return of spontaneous circulation (ROSC), survival
to admission, and neurological outcome.
Results: Fourteen
RCTs (n = 12,246) met inclusion criteria: one compared SDA to placebo
(n = 534), six compared SDA to HDA (n = 6174), six compared SDA to an
adrenaline/vasopressin combination (n = 5202), and one compared SDA to
vasopressin alone (n = 336). There was no survival to discharge or neurological
outcome differences in any comparison group, including subgroup analyses. SDA
showed improved ROSC (RR 2.80, 95%CI 1.78–4.41, p less than 0.001) and
survival to admission (RR 1.95, 95%CI 1.34–2.84, p less than 0.001) compared
to placebo. SDA showed decreased ROSC (RR 0.85, 95%CI 0.75–0.97, p = 0.02;
I2 = 48%) and survival to admission (RR 0.87, 95%CI 0.76–1.00, p = 0.049;
I2 = 34%) compared to HDA. There were no differences in outcomes between SDA
and vasopressin alone or in combination with adrenaline.
Conclusions:
There was no benefit of adrenaline in survival to discharge or neurological
outcomes. There were improved rates of survival to admission and ROSC with SDA
over placebo and HDA over SDA.
18. Oseltamivir for influenza in adults and children: pros and
cons
Jefferson
T, et al. BMJ 2014;348:g2545
Objective
To describe the potential benefits and harms of oseltamivir by reviewing all
clinical study reports (or similar document when no clinical study report
exists) of randomised placebo controlled trials and regulatory comments
(“regulatory information”).
Design
Systematic review of regulatory information.
Data
sources Clinical study reports, trial registries, electronic databases,
regulatory archives, and correspondence with manufacturers.
Eligibility
criteria for selecting studies Randomised placebo controlled trials on adults
and children who had confirmed or suspected exposure to natural influenza.
Main
outcome measures Time to first alleviation of symptoms, influenza outcomes,
complications, admissions to hospital, and adverse events in the intention to
treat population.
Results
From the European Medicines Agency and Roche, we obtained clinical study
reports for 83 trials. We included 23 trials in stage 1 (reliability and
completeness screen) and 20 in stage 2 (formal analysis). In treatment trials
on adults, oseltamivir reduced the time to first alleviation of symptoms by
16.8 hours (95% confidence interval 8.4 to 25.1 hours, P less than 0.001).
There was no effect in children with asthma, but there was an effect in
otherwise healthy children (mean difference 29 hours, 95% confidence interval
12 to 47 hours, P=0.001). In treatment trials there was no difference in
admissions to hospital in adults (risk difference 0.15%, 95% confidence
interval −0.91% to 0.78%, P=0.84) and sparse data in children and for
prophylaxis. In adult treatment trials, oseltamivir reduced investigator
mediated unverified pneumonia (risk difference 1.00%, 0.22% to 1.49%; number
needed to treat to benefit (NNTB) 100, 95% confidence interval 67 to 451). The
effect was not statistically significant in the five trials that used a more
detailed diagnostic form for “pneumonia,” and no clinical study reports
reported laboratory or diagnostic confirmation of “pneumonia.” The effect on
unverified pneumonia in children and for prophylaxis was not significant. There
was no significant reduction in risk of unverified bronchitis, otitis media,
sinusitis, or any complication classified as serious or that led to study withdrawal.
14 of 20
trials prompted participants to self report all secondary illnesses to an
investigator. Oseltamivir in the treatment of adults increased the risk of
nausea (risk difference 3.66%, 0.90% to 7.39%; number needed to treat to harm
(NNTH) 28, 95% confidence interval 14 to 112) and vomiting (4.56%, 2.39% to
7.58%; 22, 14 to 42). In treatment of children, oseltamivir induced vomiting
(5.34%, 1.75% to 10.29%; 19, 10 to 57).
In
prophylaxis trials, oseltamivir reduced symptomatic influenza in participants
by 55% (3.05%, 1.83% to 3.88%; NNTB 33, 26 to 55) and households (13.6%, 9.52%
to 15.47%; NNTB 7, 6 to 11) based on one study, but there was no significant
effect on asymptomatic influenza and no evidence of a reduction in
transmission. In prophylaxis studies, oseltamivir increased the risk of
psychiatric adverse events during the combined “on-treatment” and
“off-treatment” periods (risk difference 1.06%, 0.07% to 2.76%; NNTH 94, 36 to
1538) and there was a dose-response effect on psychiatric events in two
“pivotal” treatment trials of oseltamivir, at 75 mg (standard dose) and 150 mg
(high dose) twice daily (P=0.038). In prophylaxis studies, oseltamivir
increased the risk of headaches on-treatment (risk difference 3.15%, 0.88% to
5.78%; NNTH 32, 18 to 115), renal events with treatment (0.67%, −0.01% to
2.93%), and nausea while receiving treatment (4.15%, 0.86% to 9.51%; NNTH 25,
11 to 116).
Conclusions
In prophylactic studies oseltamivir reduces the proportion of symptomatic
influenza. In treatment studies it also modestly reduces the time to first
alleviation of symptoms, but it causes nausea and vomiting and increases the
risk of headaches and renal and psychiatric syndromes. The evidence of
clinically significant effects on complications and viral transmission is
limited because of rarity of such events and problems with study design. The
trade-off between benefits and harms should be borne in mind when making
decisions to use oseltamivir for treatment, prophylaxis, or stockpiling.
19. Lorazepam vs Diazepam for Pediatric Status Epilepticus: A
RCT
Chamberlain
JM, et al. JAMA. 2014;311(16):1652-1660.
Importance Benzodiazepines are considered first-line
therapy for pediatric status epilepticus. Some studies suggest that lorazepam
may be more effective or safer than diazepam, but lorazepam is not Food and
Drug Administration approved for this indication.
Objective To test the hypothesis that lorazepam has
better efficacy and safety than diazepam for treating pediatric status
epilepticus.
Design,
Setting, and Participants This
double-blind, randomized clinical trial was conducted from March 1, 2008, to
March 14, 2012. Patients aged 3 months to younger than 18 years with convulsive
status epilepticus presenting to 1 of 11 US academic pediatric emergency
departments were eligible. There were 273 patients; 140 randomized to diazepam
and 133 to lorazepam.
Interventions Patients received either 0.2 mg/kg of diazepam
or 0.1 mg/kg of lorazepam intravenously, with half this dose repeated at 5
minutes if necessary. If status epilepticus continued at 12 minutes,
fosphenytoin was administered.
Main
Outcomes and Measures The primary
efficacy outcome was cessation of status epilepticus by 10 minutes without
recurrence within 30 minutes. The primary safety outcome was the performance of
assisted ventilation. Secondary outcomes included rates of seizure recurrence
and sedation and times to cessation of status epilepticus and return to
baseline mental status. Outcomes were measured 4 hours after study medication
administration.
Results Cessation of status epilepticus for 10
minutes without recurrence within 30 minutes occurred in 101 of 140 (72.1%) in
the diazepam group and 97 of 133 (72.9%) in the lorazepam group, with an
absolute efficacy difference of 0.8% (95% CI, −11.4% to 9.8%). Twenty-six
patients in each group required assisted ventilation (16.0% given diazepam and
17.6% given lorazepam; absolute risk difference, 1.6%; 95% CI, −9.9% to 6.8%).
There were no statistically significant differences in secondary outcomes
except that lorazepam patients were more likely to be sedated (66.9% vs 50%,
respectively; absolute risk difference, 16.9%; 95% CI, 6.1% to 27.7%).
Conclusions
and Relevance Among pediatric patients
with convulsive status epilepticus, treatment with lorazepam did not result in
improved efficacy or safety compared with diazepam. These findings do not
support the preferential use of lorazepam for this condition.
20. Admit or Transfer? The Role of Insurance in High-Transfer-Rate
Medical Conditions in the ED
Kindermann
DR, et al. Ann Emerg Med. 2014;63:561–571.e8
Study
objective: We study the association of payer status with odds of transfer
compared with admission from the emergency department (ED) for multiple diagnoses
with a high percentage of transfers.
Methods: This
was a retrospective study of adult ED encounters using the Healthcare Cost and
Utilization Project 2010 Nationwide Emergency Department Sample. We used the
Clinical Classification Software to identify disease categories with 5% or more
encounters resulting in transfer (27 categories; 3.7 million encounters based
on survey weights). We sorted encounters by condition into 12 groups according
to expected medical or surgical specialist needs. We used logistic regression
to assess the role of payer status on odds of transfer compared with admission
and report adjusted odds ratios (ORs).
Results: Among
high-transfer conditions in 2010, uninsured patients had double the odds of
transfer compared with privately insured patients (OR 2.12; 95% confidence
interval [CI] 1.72 to 2.62). Medicaid patients were also more likely to be
transferred (OR 1.2; 95% CI 1.04 to 1.38). Uninsured patients had higher odds
of transfer in all specialist categories (significant in 9 of 12). The
categories with the highest odds of transfer for the uninsured included
nephrology (OR 2.44; 95% CI 1.07 to 5.55), psychiatry (OR 2.26; 95% CI 1.65 to
3.25), and hematology-oncology (OR 2.21; 95% CI 1.50 to 3.25); the highest for
Medicaid were general surgery (OR 1.61; 95% CI 1.09 to 1.83),
hematology-oncology (OR 1.55; 95% CI 1.05 to 2.30), and vascular surgery (OR
1.55; 95% CI 1.02 to 2.28).
Conclusion:
Insurance status appears to play a role in ED disposition (transfer versus
admission) for many high-transfer conditions.
21. An Apple a Day? Exploring Medical Myths
George
Johnson. New York Times. April 21,
2014. SAN DIEGO — A trip to almost any bookstore or a cruise around the
Internet might leave the impression that avoiding cancer is mostly a matter of
watching what you eat. One source after another promotes the protective powers
of “superfoods,” rich in antioxidants and other phytochemicals, or advises
readers to emulate the diets of Chinese peasants or Paleolithic cave dwellers.
But there
is a yawning divide between this nutritional folklore and science. During the
last two decades the connection between the foods we eat and the cellular
anarchy called cancer has been unraveling string by string.
This month
at the annual meeting of the American Association for Cancer Research, a
mammoth event that drew more than 18,500 researchers and other professionals
here, the latest results about diet and cancer were relegated to a single
poster session and a few scattered presentations. There were new hints that
coffee may lower the risk of some cancers and more about the possible benefits
of vitamin D. Beyond that there wasn’t much to say.
In the
opening plenary session, Dr. Walter C. Willett, a Harvard epidemiologist who
has spent many years studying cancer and nutrition, sounded almost rueful as he
gave a status report. Whatever is true for other diseases, when it comes to
cancer there was little evidence that fruits and vegetables are protective or
that fatty foods are bad.
About all
that can be said with any assurance is that controlling obesity is important,
as it also is for heart disease, Type 2 diabetes, hypertension, stroke and
other threats to life. Avoiding an excess of alcohol has clear benefits. But
unless a person is seriously malnourished, the influence of specific foods is
so weak that the signal is easily swamped by noise.
The
situation seemed very different in 1997, when the World Cancer Research Fund
and the American Institute for Cancer Research published a report, thick as a
phone book, concluding that diets loaded with fruits and vegetables might
reduce the overall incidence of cancer by more than 20 percent.
After
reviewing more than 4,000 studies, the authors were persuaded that green
vegetables helped ward off lung and stomach cancer. Colon and thyroid cancer
might be avoided with broccoli, cabbage and brussels sprouts. Onions, tomatoes,
garlic, carrots and citrus fruits all seemed to play important roles.
In 2007, a
major follow-up all but reversed the findings. While some kinds of produce
might have subtle benefits, the authors concluded, “in no case now is the
evidence of protection judged to be convincing.”
The reason
for the change was more thorough epidemiology. The earlier studies tended to be
“retrospective,” relying on people to remember dietary details from the distant
past. These results were often upended by “prospective” protocols, in which the
health of large populations was followed in real time.
The
remainder of the essay: http://www.nytimes.com/2014/04/22/science/an-apple-a-day-and-other-myths.html
22. Impact of Increasing Ondansetron Use on Clinical Outcomes in
Children with Gastroenteritis
Freedman SB,
et al. JAMA Pediatr. 2014 Apr 1;168(4):321-9.
IMPORTANCE
Ondansetron hydrochloride use in children with gastroenteritis is increasing
rapidly; however, little is known about its impact on outcomes. OBJECTIVE To
determine whether increasing emergency department ondansetron use has resulted
in a reduction in intravenous rehydration rates.
DESIGN,
SETTING, AND PARTICIPANTS Retrospective observational analysis of eligible
visits included in the Pediatric Health Information System administrative
database. Eligible institutions included 18 emergency departments
geographically distributed across the United States, and participants included
804 000 patients aged 0 to 18 years who were diagnosed as having
gastroenteritis in an emergency department at an eligible participating
institution between January 1, 2002, and December 31, 2011.
INTERVENTIONS
The presence or absence of oral ondansetron administration was identified for
each patient through database review. Visits were categorized based on
institutional ondansetron use: low (<5% administered ondansetron),
medium (5%-25%), or high (>25%).
MAIN
OUTCOMES AND MEASURES We conducted hospital-level analyses of the associations
between ondansetron use and 3 outcomes: intravenous rehydration (primary),
hospitalization, and emergency department revisits within 3 days. Time-series
regression models were used, adjusting for demographic characteristics,
laboratory testing, diagnostic imaging, and rotavirus infection.
RESULTS A
total of 804 000 eligible patient visits were identified. Oral ondansetron use
increased from a median institutional rate of 0.11% (interquartile range,
0.04%-0.44%) of patient visits in 2002 to 42.2% (interquartile range,
37.5%-49.1%) in 2011 (P < .001). Intravenous rehydration was
administered to 43 413 of 232 706 children (18.7%) during the low ondansetron
period compared with 59 450 of 334 264 (17.8%) during the high ondansetron period
(adjusted percentage change = -0.33%; 95% CI, -1.86% to 1.20%). During the
transition from low to high ondansetron use, we observed no change in the
hospitalization rate (adjusted percentage change = -0.33%; 95% CI, -0.95% to
0.29%), but emergency department revisits decreased (adjusted percentage
change = -0.31%; 95% CI, -0.49% to -0.13%). The change in all 3 outcomes varied
widely between low and high ondansetron use categories at an institutional
level. Oral ondansetron was provided to 13.5% (95% CI, 13.3% to 13.7%) of
children administered intravenous rehydration.
CONCLUSIONS
AND RELEVANCE Although ondansetron use increased during the study period,
intravenous rehydration rates were unchanged. Most children administered
intravenous fluids did not receive oral ondansetron. Our findings highlight the
need to focus efforts to administer ondansetron to children at greatest risk
for oral rehydration failure.
23. Informed consent for LP in the ED
Patel PB, et
al. West J Emerg Med. 2014;15(3):318-324.
Introduction:
Informed consent is a required process for procedures performed in the
emergency department (ED), though it is not clear how often or adequately it is
obtained by emergency physicians.Incomplete performance and documentation of
informed consent can lead to patient complaints,medico-legal risk, and
inadequate education for the patient/guardian about the procedure. Weundertook
this study to quantify the incidence of informed consent documentation in the
ED setting forlumbar puncture (LP) and to compare rates between pediatric (,18
years) and adult patients.
Methods: In
this retrospective cohort study, we reviewed the ED electronic health records
(EHR) for allpatients who underwent successful LPs in 3 EDs between April 2010
and June 2012. Specific elementsof informed consent documentation were
reviewed. These elements included the presence of generalED and LP-specific
consent forms, signatures of patient/guardian, witness, and
physician,documentation of purpose, risks, benefits, alternatives, and
explanation of the LP. We also reviewedthe use of educational material about
the LP and LP-specific discharge information.
Results:
Our cohort included 937 patients; 179 (19.1%) were pediatric. A signed general
ED consent form was present in the EHR for 809 (86%) patients. A consent form
for the LP was present for 524 (56%) patients, with signatures from 519 (99%)
patients/guardians, 327 (62%) witnesses, and 349 (67%) physicians.
Documentation rates in the EHR were as follows: purpose (698; 74%), risks (742;
79%), benefits (605; 65%), alternatives (635; 68%), and explanation for the LP
(57; 6%). Educational material about the LP was not documented as having been
given to any of the patients and LP-specific discharge information was documented
as given to 21 (2%) patients. No significant differences were observed in the
documentation of informed consent elements between pediatric and adult
patients.
Conclusion:
General ED consent was obtained in the vast majority of patients, but use of a specific
LP consent form and documentation of the elements of informed consent for LP in
the ED were suboptimal, though comparable between pediatric and adult patients.
There is significant opportunity for improvement in many aspects of documenting
informed consent for LP in the ED.
24. Tid Bits
A. Antibiotics alone may be
effective for treating pediatric appendicitis
Among 30 7-
to 17-year-olds who received intravenous antibiotics for treatment of
appendicitis, 93% recovered successfully without undergoing appendectomy,
according to a study in the Journal of the American College of Surgeons. The
antibiotic group took an average of three days to recover compared with 17 days
among the surgical patients.
B. Many U.S. parents still believe
vaccines are linked to autism
A National
Consumers League survey of 1,756 adults showed that 33% of those with children
under age 18 believed that vaccines can cause autism. Half of the parents
surveyed knew about the study linking vaccines to autism, but just 50% of those
were aware that the research has been retracted.
C. Potential Use of Pulse Oximetry
for the Diagnosis of Testicular Torsion
Link
(subscription required for full-text): http://archpedi.jamanetwork.com/article.aspx?articleID=1863906
D. A Consensus Parameter for the
Evaluation and Management of Angioedema in the ED
Moellman
JJ, et al. Acad Emerg Med. 2014;21:469–484.
Endorsed by
the American College of Allergy, Asthma & Immunology (ACAAI) and the
Society for Academic Emergency Medicine (SAEM).
E. Standard GlideScope Outperforms
the Cobalt GlideScope in the ED
The
standard GlideScope had greater intubation success and fewer image problems
than its single-use cousin.
F. Diabetes on the rise among kids
and teens
Full-text
in JAMA (free): http://jama.jamanetwork.com/article.aspx?articleid=1866098
G. Trauma Centers: Past Performance
Predicts Future Care
Patients
admitted to trauma centers that were the lowest performers two years earlier
had two-fold higher mortality than patients admitted to the highest-performing
centers.
H. Tubular Gauze Finger Dressing:
Not too tight!
I. Intra-articular Lidocaine for
Reduction of Shoulder Dislocation: Review
Aronson, PL,
et al. Pediatr Emerg Care 2014 May;30(5):363-5.
Intra-articular
injection of lidocaine has demonstrated efficacy in reduction of pain and
facilitation of shoulder reduction compared with analgesia and sedation.
Intra-articular lidocaine may also reduce time to successful reduction of
shoulder dislocations
Link (need
subscription): http://www.ncbi.nlm.nih.gov/pubmed/24786995
J. Epidemiology of Nursemaid’s
Elbow: Over 1200 cases
Vitello S,
et al. West J Emerg Med. 2014 [Epub ahead of print]
Objective:
To provide an epidemiological description of radial head subluxation, also
known as nursemaid’s elbow, from a database of emergency department visits.
Methods: We
conducted a retrospective medical record review of patients six years of age
and younger, who presented to the emergency department between January 1, 2005
and December 31, 2012 and were diagnosed with nursemaid’s elbow. Inclusion
criteria consisted of chart information including date, unique account number,
medical record number, weight, age, sex, and arm affected. Exclusion criteria
included any charts with missing or incomplete data.
Results:
There were 1,228 charts that met inclusion criteria. The majority of patients
were female (60%) The mean age was 28.6 months (±12.6). The left arm was
affected 60% of the time. Most of the included patients were over the 75th
percentile for weight and more than one quarter were over the 95th percentile
in each gender.
Conclusion:
The average age of children presenting with nursemaid’s elbow was 28.6 months.
Females were affected more than males, and the left arm was predominately
affected. Most patients were above the 75th percentile for weight and more than
one quarter were over the 95th percentile for weight.
Full-text
(free): http://www.escholarship.org/uc/item/7x25w9wm#
K. FDA advises against aspirin use
in patients with no history of heart disease
Aspirin
should not be used for stroke or heart attack prevention in people with no
history of heart disease, the FDA said on Monday. Although evidence indicates
that aspirin's benefits outweigh its bleeding risks for patients with a history
of a cardiovascular event, the data do not support the use of the drug for the
prevention of first heart attack, the agency said. The FDA released the
statement in response to Bayer's request to change its aspirin product
labeling.
L. CDC: 39% of premature deaths
across U.S. could be prevented
Up to 39%
of premature deaths each year from heart disease, cancer, chronic lower
respiratory disease, stroke and unintentional injury could be averted, the CDC
said Thursday. Southeastern states had the highest number of potentially
preventable deaths from all of the five leading causes. "With preventive
care, we can drive down heart disease and stroke, in particular, as well as
[improve] cancer screening," CDC Director Tom Frieden said.
M. A Review of and Recommendations
for the Management of Patients With Life-Threatening Dabigatran-Associated
Hemorrhage: A Single-Center University Hospital Experience.
N. End Tidal CO2 not helpful in ED
COPD Management
O. Many U.S. children in the ED are
still given codeine despite safety risks
Codeine
prescriptions written for 3- to 17-year-olds dropped from 644,394 in 2001 to
577,270 in 2010, according to a study published in the journal Pediatrics.
Nearly 3% of emergency department visits led to a prescription of the narcotic
in 2010, down from 3.7% of visits in 2001. Despite these declines, too many
children are getting the medication when safer options are available,
researchers said.
P. IV Ketamine Rapidly Effective in
PTSD
Patients
with moderate to severe post-traumatic stress symptoms showed rapid and
substantial relief with a single intravenous dose of ketamine in a pilot
randomized trial, researchers said.
Q. Yield of Skeletal Survey by Age
in Children Referred to Abuse Specialists
R. Oral Zinc for the Common Cold
Clinical
Question Is oral zinc associated with a
shorter duration, decreased severity, and reduced incidence of the common cold
compared with placebo ?
Bottom
Line When initiated within 24 hours of
symptom onset, oral zinc is associated with a shorter duration of the common
cold in healthy people. However, there is no association between oral zinc and
symptom severity, and the prevalence of adverse effects with zinc lozenges is
high. Given the high heterogeneity of data, these results should be interpreted
with caution. Used prophylactically, oral zinc is associated with a reduced
cold incidence in children. Prophylactic use has not been studied in adults.
