Sunday, September 07, 2014

Lit Bits: Sep 7, 2014

From the recent medical literature...

1. Ambulatory management of large spontaneous PTX with pigtail catheters.

Voisin F, et al. Ann Emerg Med. 2014;64(3):222-8.

STUDY OBJECTIVE: There is no consensus about the management of large spontaneous pneumothoraces. Guidelines recommend either needle aspiration or chest tube drainage and most patients are hospitalized. We assess the efficiency of ambulatory management of large spontaneous pneumothoraces with pigtail catheters.

METHODS: From February 2007 to January 2011, all primary and secondary large spontaneous pneumothoraces from Lorient's hospital (France) were managed with pigtail catheters with a 1-way valve. The patients were discharged immediately and then evaluated every 2 days according to a specific algorithm.

RESULTS: Of the 132 consecutive patients (110 primary, 22 secondary), 103 were exclusively managed as outpatients, with full resolution of the pneumothorax by day 2 or 4, which represents an ambulatory success rate of 78%. Mean time (SD) of drainage was 3.4 days (1.8). Seven patients were initially hospitalized but quickly discharged and had full resolution by day 2 or 4, leading to a total success rate of 83%. The use of analgesics was low. The 1-year recurrence rate was 26%. If successful, this outpatient management is potentially cost saving, with a mean cost of $926, assuming up to 2 outpatient visits and 1 chest radiograph, compared with $4,276 if a chest tube was placed and the patient was admitted to the hospital for 4 days.

CONCLUSION: Ambulatory management with pigtail catheters with 1-way valves could be a reasonable first-line of treatment for large spontaneous pneumothoraces. Compared with that of other studies, our protocol does not require hospitalization and is cost saving.

2. Timely antibiotics in septic pts is associated with better outcomes

A. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program

Ferrer R, et al. Crit Care Med. 2014 Aug;42(8):1749-55.

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.

B. How Soon Do We Need to Give Antibiotics to Septic Children?

A retrospective registry study suggests that delaying antibiotics for more than 3 hours is detrimental.

Weiss SL et al. Delayed Antimicrobial Therapy Increases Mortality and Organ Dysfunction Duration in Pediatric Sepsis. Crit Care Med 2014 Aug 21 [Epub ahead of print]

OBJECTIVES: Delayed antimicrobials are associated with poor outcomes in adult sepsis, but data relating antimicrobial timing to mortality and organ dysfunction in pediatric sepsis are limited. We sought to determine the impact of antimicrobial timing on mortality and organ dysfunction in pediatric patients with severe sepsis or septic shock.

DESIGN: Retrospective observational study.

SETTING: PICU at an academic medical center.

PATIENTS: One hundred thirty patients treated for severe sepsis or septic shock.

MEASUREMENTS AND MAIN RESULTS: We determined if hourly delays from sepsis recognition to initial and first appropriate antimicrobial administration were associated with PICU mortality (primary outcome); ventilator-free, vasoactive-free, and organ failure-free days; and length of stay. Median time from sepsis recognition to initial antimicrobial administration was 140 minutes (interquartile range, 74-277 min) and to first appropriate antimicrobial was 177 minutes (90-550 min). An escalating risk of mortality was observed with each hour delay from sepsis recognition to antimicrobial administration, although this did not achieve significance until 3 hours. For patients with more than 3-hour delay to initial and first appropriate antimicrobials, the odds ratio for PICU mortality was 3.92 (95% CI, 1.27-12.06) and 3.59 (95% CI, 1.09-11.76), respectively. These associations persisted after adjustment for individual confounders and a propensity score analysis. After controlling for severity of illness, the odds ratio for PICU mortality increased to 4.84 (95% CI, 1.45-16.2) and 4.92 (95% CI, 1.30-18.58) for more than 3-hour delay to initial and first appropriate antimicrobials, respectively. Initial antimicrobial administration more than 3 hours was also associated with fewer organ failure-free days (16 [interquartile range, 1-23] vs 20 [interquartile range, 6-26]; p = 0.04).

CONCLUSIONS: Delayed antimicrobial therapy was an independent risk factor for mortality and prolonged organ dysfunction in pediatric sepsis.

3. Clinical practice. Care of the asplenic patient.

Rubin LG, Schaffner W. N Engl J Med. 2014 Jul 24;371(4):349-56.

·         Asplenic patients are at risk for episodes of rapidly progressive septicemia that are fatal in up to 50% of cases.
·         Asplenic patients should be informed that any illness with fever or severe symptoms without fever could indicate the onset of a life-threatening infection.
·         Asplenic patients in whom fever develops should receive empirical antimicrobial therapy immediately.
·         Vaccinations against pneumococci, Haemophilus influenzae type b, meningococci, and influenza virus are recommended for asplenic patients.
·         Prophylactic antimicrobial therapy is generally recommended for asplenic children younger than 5 years of age and may be considered for older children and adults during the initial 1 to 2 years after splenectomy, with lifelong prophylaxis for persons who have had an episode of postsplenectomy sepsis.

Management of Febrile Episodes
If fever develops in an asplenic patient, immediate administration of an antimicrobial agent is indicated, because fever can be the initial manifestation of a fulminant infection and prompt administration of an antimicrobial agent may prevent the development of clinical sepsis. Ceftriaxone administered intravenously or intramuscularly with or without vancomycin is a reasonable empirical choice. Ceftriaxone is active against most S. pneumoniae strains as well as H. influenzae, N. meningitidis, and many community-acquired gram-negative bacilli, including capnocytophaga.

Full-text (subscription required):

4. Reliance on Oximetry Readings Increases Hospital Admissions for Mild-to-Moderate Bronchiolitis

F. Bruder Stapleton, MD, Journal Watch Emerg Med 2014 Aug 26

Artificially elevated oximetry readings resulted in fewer hospitalizations.

Pulse oximetry measurement of 90% to 95% is one criterion used to determine the need for hospitalization in infants with bronchiolitis. To examine the effect of pulse oximetry reading on hospitalization, researchers in Canada randomized 213 children (age range, 4–12 months) in the emergency department (ED) with mild-to-moderate bronchiolitis (oxygen saturation ≥88%) and no other comorbidities to undergo pulse oximetry with true oxygen saturation readings or readings that were artificially elevated by 3%.

Significantly more infants in the true-oximetry group than in the elevated-oximetry group were hospitalized within 72 hours (41% vs. 25%). Among infants with triage oxygen saturations below 94%, 6 of 11 and 11 of 17 infants, respectively, were discharged home at the index ED visit, and none were hospitalized within 72 hours. No child required intensive care. In sensitivity analysis, adjustment for reported oxygenation values showed no association between hospitalization and study group. Length of ED stay, use of supplemental oxygen, and rates of subsequent unscheduled visits were similar in the two groups.

Comment: These data remind us that oxygen saturation is only one of several criteria that should determine the need for hospitalization in infants with mild-to-moderate bronchiolitis. The results suggest that overemphasis on oximetry results in unnecessary hospitalizations. An accompanying editorial raises legitimate ethical questions about the study design but concedes that great care was given to assure patient safety.

Schuh S et al. Effect of oximetry on hospitalization in bronchiolitis: A randomized clinical trial. JAMA 2014 Aug 20; 312:712.

Vinci R and Bauchner H.Bronchiolitis, deception in research, and clinical decision making. JAMA 2014 Aug 20; 312:699.

5. Stroke Prophylaxis in AF: Searching for Management Improvement Opportunities in the ED: The HERMES-AF Study

Coll-Vinent B, et al. Ann Emerg Med. 2014 Aug 30 [Epub ahead of print]

Study objective: We determine the prevalence of stroke prophylaxis prescription in emergency department (ED) patients with atrial fibrillation and the factors associated with a lack of prescription of anticoagulation in high-risk patients without contraindications.

Methods: This was a multicenter, observational, cross-sectional study with prospective standardized data collection carried out in 124 Spanish EDs. Clinical variables, risk factors for stroke, type of prophylaxis prescribed, and reasons for not prescribing anticoagulation in high-risk patients (congestive heart failure/left ventricular dysfunction, hypertension, age over 75 years, diabetes and previous stroke/transient ischemic attack/systemic embolism [CHADS2] score ≥2 and the congestive heart failure/left ventricular dysfunction, hypertension, age over 75 years, diabetes, previous stroke/transient ischemic attack/systemic embolism, vascular disease age 65 to 74 years and sex category [CHA2DS2-VASc] score ≥2) without contraindications were collected.

Results: Of 3,276 patients enrolled, 71.5% were at high risk according to CHADS2; 89.7% according to CHA2DS2-VASc. At discharge from the ED, 2,255 patients (68.8%) were receiving anticoagulants, 1,691 of whom (75%) were high-risk patients. Of the 1,931 patients discharged home, anticoagulation was prescribed for 384 patients (19.9%) de novo and for 932 patients (48.3%) previously receiving anticoagulation. The main reasons for not prescribing anticoagulation to eligible patients were considering antiplatelet therapy as adequate prophylaxis (33.1%), advanced age (15%), and considering stroke risk as low (8.3%). Advanced age (odds ratio 0.46; 95% confidence interval 0.30 to 0.69) and female sex (odds ratio 0.50; 95% confidence interval 0.36 to 0.71) were significantly associated with the lack of prescription of anticoagulation to eligible patients.

Conclusion: In Spain, most patients with atrial fibrillation treated in EDs who do not receive anticoagulation are at high risk of stroke, with relevant differences with regard to the risk stratification scheme used. Anticoagulation is underused, mainly because the risk of stroke is underestimated by the treating physicians and the benefits of antiplatelets are overrated, principally in female patients and the elderly. Efforts to increase the prescription of anticoagulation in these patients appear warranted.

6. Evaluating the hematoma block as an adjunct to procedural sedation for closed reduction of distal forearm fractures.

Constantine E, et al. Pediatr Emerg Care. 2014 Jul;30(7):474-8.

OBJECTIVES: Although procedural sedation using intravenous agents is highly effective for forearm fracture reduction, the process is both resource and time intensive. Our objective was to determine whether the use of a hematoma block as an adjunct to procedural sedation with ketamine and midazolam reduces (1) pain during the procedure (scored using the Observational Score for Behavioral Distress-Revised score) or (2) the excess sedation time, defined by the time between procedure completion and discharge from sedation. Our secondary outcome measure was total ketamine dose administered during the procedure.

METHODS: A randomized, double-blind, placebo-controlled clinical trial was conducted. Before fracture reduction, children 3 to 17 years of age randomly received 2% lidocaine (L) or normal saline (NS) into the hematoma of their fracture site during sedation with intravenous ketamine and midazolam.

RESULTS: Ninety patients were randomized: 50 to L and 40 to NS. The groups were similar with regard to age, sex, type of fracture, and prior administration of pain medication. Median Observational Score for Behavioral Distress-Revised scores were 1.11 and 1.69 for the L and NS groups, respectively (P = 0.23). Excess sedation time was not significantly different between the groups (P = 0.36), with a median excess sedation time of 33.0 and 36.0 minutes for the L and NS groups, respectively. Mean ketamine dose administered was not different between the groups (P = 0.42). The mean total dose administered was 1.00 mg/kg and 1.07 mg/kg in the L and NS groups, respectively. Mean midazolam dose was 0.05 mg/kg for both groups.

CONCLUSIONS: The use of a hematoma block as an adjunct to procedural sedation with ketamine and midazolam for forearm fracture reduction conferred no additional benefit and did not decrease observed pain scores, excess sedation time, or total ketamine dose administered.

7. Point-of-care US for the Diagnosis of Acute Cardiogenic Pulmonary Edema in Patients Presenting with Acute Dyspnea: A Systematic Review and Meta-analysis.

Al Deeb M, et al. Acad Emerg Med. 2014;21(8):843-852.

OBJECTIVES: Acute dyspnea is a common presenting complaint to the emergency department (ED), and point-of-care (POC) lung ultrasound (US) has shown promise as a diagnostic tool in this setting. The primary objective of this systematic review was to determine the sensitivity and specificity of US using B-lines in diagnosing acute cardiogenic pulmonary edema (ACPE) in patients presenting to the ED with acute dyspnea.

METHODS: A systematic review protocol adhering to Cochrane Handbook guidelines was created to guide the search and analysis, and we searched the following databases: PubMed, EMBASE, Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, and the Cochrane Database of Systematic Reviews. References of reviewed articles were hand-searched, and electronic searches of conference abstracts from major emergency medicine, cardiology, and critical care conferences were conducted. The authors included prospective cohort and prospective case-control studies that recruited patients presenting to hospital with symptomatic, acute dyspnea, or where there was a clinical suspicion of congestive heart failure, and reported the sensitivity and specificity of B-lines in diagnosing ACPE. Studies of asymptomatic individuals or in patients where there was no suspicion of ACPE were excluded. The outcome of interest was a diagnosis of ACPE using US B-lines. A final diagnosis from clinical follow-up was accepted as the reference standard. Two reviewers independently reviewed all citations to assess for inclusion, abstracted data, and assessed included studies for methodologic quality using the QUADAS-2 tool. Contingency tables were used to calculate sensitivity and specificity. Three subgroup analyses were planned a priori to examine the effects of the type of study, patient population, and lung US protocol employed.

RESULTS: Seven articles (n = 1,075) were identified that met inclusion criteria (two studies completed in the ED, two in the intensive care unit [ICU], two on inpatient wards, and one in the prehospital setting). The seven studies were rated as average to excellent methodologic quality. The sensitivity of US using B-lines to diagnosis ACPE is 94.1% (95% confidence interval [CI] = 81.3% to 98.3%) and the specificity is 92.4% (95% CI = 84.2% to 96.4%). Preplanned subgroup analyses did not reveal statistically significant changes in the overall summary estimates, nor did exclusion of three potential outlier studies.

CONCLUSIONS: This study suggests that in patients with a moderate to high pretest probability for ACPE, an US study showing B-lines can be used to strengthen an emergency physician's working diagnosis of ACPE. In patients with a low pretest probability for ACPE, a negative US study can almost exclude the possibility of ACPE. Further studies including large numbers of ED patients presenting with undifferentiated dyspnea are required to gain more valid and reliable estimates of test accuracy in ED patients.

8. Compression stockings in ankle sprain: a multicenter randomized study

Bendahou M, et al. Amer J Emerg Med. 2014;32:1005-1010.

Objectives: Ankle sprain is a frequently encountered traumatic injury in emergency departments and is associated with important health expenses. However, the appropriate care of this traumatic injury remains a matter of debate. We tested the hypothesis that compression stockings speed up recovery from ankle sprain.

Methods: Recent (within 48 hours) cases of ankle sprain without other traumatic injury in patients aged between 18 and 55 years were included. Patients were randomly allocated to placebo Jersey or class II compression stockings (Venoflex; Thuasne, Levallois-Perret, France). The primary end point was the time to recovery of normal painless walking without requirement for analgesic drug. Secondary end points were time to return to sport activity, pain, analgesic consumption, and ankle edema (bimalleolar and midfoot circumferences).

Results: We randomized 126 patients and analyzed 117 patients (60 in the placebo group and 57 in the compression group). The median time to normal painless walking was not significantly decreased (P = .16). No significant differences were observed in pain, analgesic consumption, and bimalleloar and midfoot circumferences. No safety issue was reported. In the subgroup of patients with regular sport activity, the time to return to sport activity was shorter in patients treated with compression stockings (P = .02).

Conclusions: Compression stockings failed to significantly modify the time to return to normal painless walking in ankle sprain. A beneficial effect was observed only in a subgroup of patients, as compression stockings significantly decreased the time to return to sport activity.

9. Brief Reviews

A. Clinical Utility of an Age-Adjusted D-dimer in the Diagnosis of Venous Thromboembolism

Take-Home Message: Applying an age-adjusted D-dimer cutoff value to rule out suspected venous thromboembolism in non–high-risk older patients increases the specificity of the D-dimer test without significantly decreasing the sensitivity.

B. Do patients with an asymptomatic sub-segmental PE need anticoagulation therapy?

Emerg Med J  2014;31:769-

A short cut review was carried out to establish whether therapeutic anticoagulation is required for patients who have an incidental diagnosis of subsegmental pulmonary embolism (PE), which is asymptomatic. 4 studies were relevant to the three-part question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated.

The evidence suggests that patients with clinically unsuspected PE may have better prognostic outcomes than those with symptomatic presentations, especially if the PE is at the sub-segmental level. The only direct comparison of anti-coagulation versus no anti-coagulation in patients with an asymptomatic, unsuspected PE suggests a survival benefit from anti-coagulation. However, this study included patients with cancer and was not restricted to patients with subsegmental PE. Consequently, the clinical bottom line is that level 1 evidence is required to answer this question. In the meantime decisions must continue to be informed by clinical judgment.

10. A simple algorithm reduces CT use in the diagnosis of appendicitis in children

Polites SF, et al. Surgery 2014;156:448-454

Use of ultrasound and early surgical consultation decreased CT imaging from 39% to 18%.

A diagnostic algorithm for appendicitis in children was created to reduce computed tomography (CT) use owing to the risk of cancer from radiation exposure and cost of CT. This study evaluates the impact of the algorithm on CT use and diagnostic accuracy of appendicitis.

Patients ≤18 years who underwent appendectomy for suspected appendicitis after presenting to the emergency department for 2 years before and 3 years after algorithm implementation were identified. Clinical characteristics and outcomes, including use of CT and negative appendectomy rate, were compared between the pre- and post-implementation periods. Multivariable analysis was used to determine the impact of CT on negative appendectomy.

We identified 331 patients—41% in the pre- and 59% in the post-implementation period. CT utilization decreased from 39% to 18% (P less than .001) after implementation. The negative appendectomy rate increased from 9% to 11% (P = .59). Use of CT did not impact the risk of negative appendectomy (P = .64).

Utilization of CT was significantly reduced after implementation of a diagnostic algorithm for appendicitis without impacting diagnostic accuracy. Given the concern for increased risk of cancer after CT, these results support use of an algorithm in children with suspected appendicitis.

11. Images in Clinical Practice

Discharge Dental Sinus Tract

Mechanical Small-Bowel Obstruction

Young Woman With Cardiac Arrest

Young Woman With Epigastric Pain and Vomiting

Isolated Uvulitis

Complex Thoracic Aortic Dissection

12. Does a single dose of IV dex reduce symptoms in ED patients with LBP and radiculopathy (SEBRA)? A double-blind RCT

IV dex for LBP? Of some transient benefit  

Balakrishnamoorthy R, et al. Emerg Med J. 2014 Aug 13  [Epub ahead of print]

OBJECTIVE: To assess the effect of a single dose of intravenous dexamethasone in addition to routine treatment on visual analogue scale (VAS) pain scores at 24 h in emergency department (ED) patients with low back pain with radiculopathy (LBPR).

METHODS: Double-blind randomised controlled trial of 58 adult ED patients with LBPR, conducted in one tertiary and one urban ED. The intervention was 8 mg of intravenous dexamethasone (or placebo) in addition to current routine care. The primary outcome was the change in VAS pain scores between presentation and 24 h. Secondary outcomes included VAS pain scores at 6 weeks, ED length of stay (EDLOS), straight leg raise (SLR) angles and Oswestry functional scores.

RESULTS: Patients treated with dexamethasone had a 1.86 point (95% CI 0.31 to 3.42, p=0.019) greater reduction in VAS pain scores at 24 h than placebo (dexamethasone: -2.63 (95% CI -3.63 to -1.63) versus placebo: -0.77 (95% CI -2.04 to 0.51)). At 6 weeks, both groups had similar significant and sustained decrease in VAS scores compared with baseline. Patients receiving dexamethasone had a significantly shorter EDLOS (median: 3.5 h vs 18.8 h, p=0.049) and improved SLR angle at discharge (14.7°, p=0.040). There was no difference in functional scores.

CONCLUSIONS: In patients with LBPR, a single dose of intravenous dexamethasone in addition to routine management improved VAS pain scores at 24 h, but this effect was not statistically significant at 6 weeks. Dexamethasone may reduce EDLOS and can be considered as a safe adjunct to standard treatment.

Related: What about oral prednisone for LBP? No good.

13. Spectrophotometry or Visual Inspection to Most Reliably Detect Xanthochromia in SAH: Systematic Review.

Chu K, et al. Ann Emerg Med. 2014 Sep;64(3):256-264.e5.

STUDY OBJECTIVE: We assess the sensitivity and specificity of xanthochromia as adjudicated by visual inspection and spectrophotometry at predicting the presence of cerebral aneurysm in patients with suspected subarachnoid hemorrhage who have a normal computed tomography (CT) head scan result.

METHODS: A systematic review was performed. MEDLINE and EMBASE databases were searched. Relevant studies with clinical data on the diagnostic accuracy of visual inspection or spectrophotometry were considered. Patients who had a normal CT head scan result followed by a lumbar puncture were included in this review. Sensitivities, specificities, and heterogeneity (I2) were calculated. Subgroup analyses were performed to explore reasons for the heterogeneity.

RESULTS: There were major methodological limitations in the studies found. Twenty-two relevant articles were heterogeneous in regard to time to lumbar puncture, spectrophotometry methods, and follow-up of patients not undergoing cerebral angiography. Twelve of the 22 studies selected patients on the basis of a cerebral aneurysm or subarachnoid hemorrhage on imaging, or a positive lumbar puncture result. These studies were excluded from our initial analysis, which included only patients with clinically suspected subarachnoid hemorrhage. In this initial analysis, pooled estimates of sensitivity and specificity for spectrophotometry were 87% (95% confidence interval [CI] 71% to 96%; I2=26%) and 86% (95% CI 84% to 88%; I2=96%), respectively. For visual inspection, pooled sensitivity and specificity were 83% (95% CI 59% to 96%; I2=52%) and 96% (95% CI 93% to 97%; I2=76%), respectively. Sensitivity estimates are difficult to interpret without knowing time to lumbar puncture.

CONCLUSION: The heterogeneity in the underlying studies, combined with significant overlap in pooled confidence limits, makes it impossible to provide a definite conclusion about the diagnostic accuracy of spectrophotometry versus visual inspection.

14. What do our patients think?

A. Return Visits to the ED: The Patient Perspective

Rising KL, et al. Ann Emerg Med. 2014 Sept 02 [Epub ahead of print]

Study objective
Reasons for recurrent emergency department (ED) visits have been examined primarily through administrative data review. Inclusion of patients’ perspectives of reasons for ED return may help inform future initiatives aimed at reducing recurrent utilization. The objective of this study is to describe the personal experiences and challenges faced by patients transitioning home after an ED discharge.

We performed semistructured qualitative interviews of adult patients with an unscheduled return to the ED within 9 days of an index ED discharge. Questions focused on problems with the initial discharge process, medications, outpatient care access, social support, and health care decisionmaking. Themes were identified with a modified grounded theory approach.

Sixty interviews were performed. Most patients were satisfied with the discharge process at the index discharge, but many had complaints about the clinical care delivered, including insufficient evaluation and treatment. The primary reason for returning to the ED was fear or uncertainty about their condition. Most patients had a primary care physician, but they rarely visited a physician before returning to the ED. Patients cited convenience and more expedited evaluations as primary reasons for seeking care in the ED versus the clinic.

Postdischarge factors, including perceived inability to access timely follow-up care and uncertainty and fear about disease progression, are primary motivators for return to the ED. Many patients prefer hospital-based care because of increased convenience and timely results. Further work is needed to develop alternative pathways for patients to ask questions and seek guidance when and where they want.

B. Exploring Real-time Patient Decision-making for Acute Care: A Pilot Study

Sharp AL, et al. West J Emerg Med. 2014;15:675-681.

Introduction: Research has described emergency department (ED) use patterns in detail. However, evidence is lacking on how, at the time a decision is made, patients decide if healthcare is required or where to seek care.

Methods: Using community-based participatory research methods, we conducted a mixed-methods descriptive pilot study. Due to the exploratory, hypothesis-generating nature of this research, we did not perform power calculations, and financial constraints only allowed for 20 participants. Hypothetical vignettes for the 10 most common low acuity primary care complaints (cough, sore throat, back pain, etc.) were texted to patients twice daily over six weeks, none designed to influence the patient’s decision to seek care. We conducted focus groups to gain contextual information about participant decision-making. Descriptive statistics summarized responses to texts for each scenario. Qualitative analysis of open-ended text message responses and focus group discussions identified themes associated with decision-making for acute care needs.

Results: We received text survey responses from 18/20 recruited participants who responded to 72% (1092/1512) of the texted vignettes. In 48% of the vignettes, participants reported they would do nothing, for 34% of the vignettes participants reported they would seek care with a primary care provider, and 18% of responses reported they would seek ED care. Participants were not more likely to visit an ED during “off-hours.” Our qualitative findings showed: 1) patients don’t understand when care is needed; 2) patients don’t understand where they should seek care.

Conclusion: Participants were unclear when or where to seek care for common acute health problems, suggesting a need for patient education. Similar research is necessary in different populations and regarding the role of urgent care in acute care delivery.

15. Clinical effects and safety of different strategies for administering IV diuretics in acutely decompensated HF: a RCT

Bottom line: boluses are best

Llorens P, et al. Emerg Med J. 2014 Sep;31(9):706-13

BACKGROUND: The mainstay of treatment for acutely decompensated heart failure (ADHF) is intravenous diuretic therapy either as a bolus or via continuous infusion.

OBJECTIVES: We evaluated the clinical effects and safety of three strategies of intravenous furosemide administration used in emergency departments (EDs) for ADHF.

METHODS: We performed a multicentre, randomised, parallel-group study. Patients with ADHF were randomised within 2 h of ED arrival to receive furosemide by continuous infusion (10 mg/h, group 1) or boluses (20 mg/6 h, group 2; or 20 mg/8 h, group 3). The primary end point was total diuresis, and secondary end points were dyspnoea, orthopnoea, extension of rales and peripheral oedema, blood pressure, respiratory and heart rates, and pulse oximetry, which were measured at arrival and 3, 6, 12 and 24 h after treatment onset. We also measured serum creatinine, sodium and potassium levels at arrival and after 24 h.

RESULTS: Group 1 patients (n=36) showed greater 24 h diuresis (3705 mL) than those in groups 2 (n=37) and 3 (n=36) (3093 and 2670 mL, respectively; p less than 0.01), and this greater diuretic effect was observed earlier. However, no differences were observed among groups in the nine secondary clinical end points evaluated. Creatinine deterioration developed in 15.6% of patients, hyponatraemia in 9.2%, and hypokalaemia in 19.3%, with the only difference among groups observed in hypokalaemia (group 1, 36.3%; group 2, 13.5%; group 3, 8.3%; p less than 0.01).

CONCLUSIONS: In patients with ADHF attending the ED, boluses of furosemide have a smaller diuretic effect but provide similar clinical relief, similar preservation of renal function, and a lower incidence of hypokalaemia than continuous infusion.

16. PRAM Score as Predictor of Pediatric Asthma Hospitalization.

Alnaji F, et al. Acad Emerg Med. 2014 Aug;21(8):872-878.

OBJECTIVES: The objective was to determine the association between asthma severity as measured by the Pediatric Respiratory Assessment Measure (PRAM) score and the likelihood of admission for pediatric patients who present to the emergency department (ED) with moderate-to-severe asthma exacerbations and who receive intensive asthma therapy.

METHODS: This was a secondary analysis of a prospective study of triage nurse-initiated steroid therapy in pediatric asthma. Children aged 2 to 17 years inclusive, presenting with moderate-to-severe acute asthma exacerbations (defined as PRAM ≥ 4), were included. To be eligible for inclusion in the study, children must have received "intensive asthma therapy," defined as nurse-initiated initial bronchodilator and oral steroid therapy at arrival to triage. PRAM scores were measured hourly as per ED protocol. The primary outcome was inpatient hospitalization; secondary outcome was ED stay greater than 8 hours. Logistic regression models were used to predict admission based on PRAM score at triage and then hourly thereafter. The area under the receiver operating characteristic curve (AUC) was calculated for each hour.

RESULTS: A total of 297 patients were included in the analysis, with an admission rate of 11.4% for patients receiving intensive therapy. The 3-hour PRAM (AUC = 0.85) significantly improved prediction of admission compared to PRAM at triage (p = 0.04).

CONCLUSIONS: The 3-hour PRAM scores best predicts the need for hospitalization. These results may be applied in clinical settings to facilitate the decision to admit or initiate more aggressive adjunctive therapy to decrease the need for hospitalization.

17. Occult bloodstream infections in adults: a “benign” entity

González-Del Vecchio M, et al. Amer J Emerg Med. 2014;32:966-71.

Background: Patients with septic episodes whose blood cultures turn positive after being sent home from emergency departments (EDs) are recognized as having occult bloodstream infections (BSI). The incidence, etiology, clinical circumstances, and outcome of occult BSI in children are well known, but, to our knowledge, data in adult patients are scarce. We analyzed the episodes of occult BSI in adult patients at our institution.

Methods: This is a retrospective cohort study (September 2010 to September 2012), in adult patients discharged from the ED in whom blood cultures turned positive. Patients were evaluated according to a preestablished protocol.

Results: We recorded 4025 cases of significant BSI in the ED and 113 patients with adult occult BSI. In other words, the incidence of occult BSI in the ED was 2.8 per 100 episodes. The predominant microorganisms were gram-negative bacteria (57%); Escherichia coli was the most common (41%), followed by gram-positive bacteria (29%), anaerobes (6.9%), polymicrobial (6.1%), and yeasts (0.8%). The most frequent suspected origin was urinary tract infection (53%), and most infections were community acquired (63.7%). Of the 105 patients that we were able to trace, 54 (42.5%) were asymptomatic and were receiving adequate antibiotic treatment at the time of the call, and 65 (51.2%) had persistent fever or were not receiving adequate antibiotic treatment.

Conclusions: Occult BSI is relatively common in patients in the adult ED. Despite the need for readmission of a fairly high proportion of patients, occult BSI behaves as a relatively benign entity.

18. The Effect of CYP2D6 Drug-Drug Interactions on Hydrocodone Effectiveness.

Monte AA, et al. Acad Emerg Med. 2014 Aug;21(8):879-885.

OBJECTIVES: The hepatic cytochrome 2D6 (CYP2D6) is a saturable enzyme responsible for metabolism of approximately 25% of known pharmaceuticals. CYP interactions can alter the efficacy of prescribed medications. Hydrocodone is largely dependent on CYP2D6 metabolism for analgesia, ondansetron is inactivated by CYP2D6, and oxycodone analgesia is largely independent of CYP2D6. The objective was to determine if CYP2D6 medication coingestion decreases the effectiveness of hydrocodone.

METHODS: This was a prospective observational study conducted in an academic U.S. emergency department (ED). Subjects were included if they had self-reported pain or nausea and were excluded if they were unable to speak English, were less than 18 years of age, had liver or renal failure, or carried diagnoses of chronic pain or cyclic vomiting. Detailed drug ingestion histories for the preceding 48 hours prior to the ED visit were obtained. The patient's pain and nausea were quantified using a 100-mm visual analog scale (VAS) at baseline prior to drug administration and following doses of hydrocodone, oxycodone, or ondansetron. We used a mixed model with random subject effect to determine the interaction between CYP2D6 drug ingestion and study drug effectiveness. Odds ratios (ORs) were calculated to compare clinically significant VAS changes between CYP2D6 users and nonusers.

RESULTS: A total of 250 (49.8%) of the 502 subjects enrolled had taken at least one CYP2D6 substrate, inhibitor, or inducing pharmaceutical, supplement, or illicit drug in the 48 hours prior to ED presentation. CYP2D6 drug users were one-third as likely to respond to hydrocodone (OR = 0.33, 95% confidence interval [CI] = 0.1 to 0.8) and more than three times as likely as nonusers to respond to ondansetron (OR = 3.4, 95% CI = 1.3 to 9.1). There was no significant difference in oxycodone effectiveness between CYP2D6 users and nonusers (OR = 0.53, 95% CI = 0.3 to 1.1).

CONCLUSIONS: CYP2D6 drug-drug interactions appear to change effectiveness of commonly prescribed drugs in the ED. Drug-drug interaction should be considered prior to prescribing CYP2D6 drugs.

19. Nebulized fentanyl vs intravenous morphine for ED patients with acute limb pain: a randomized clinical trial

Farahmand S, et al. Amer J Emerg Med. 2014;32:1011-1015.

Objective: Intravenous morphine has been used as a common method of pain control in emergency care. Nebulized fentanyl is also an effective temporary substitute. This study was designed to compare the effectiveness of nebulized fentanyl with intravenous (IV) morphine on management of acute limb pain.

Methods: This was a placebo-controlled, double-blind randomized clinical trial. Ninety emergency department patients with moderate to severe pain aged 15 to 50 years were blocked randomized and enrolled in this study. Forty-seven patients in the experimental group received nebulized fentanyl (4 μg/kg) and IV normal saline as placebo, and the remaining 43 patients in the control group received IV morphine (0.1 mg/kg) and nebulized normal saline as placebo. All participants' pain scores were assessed by Numerical Rating Scale before and after intervention at 5-, 10-, 15-, 30-, 45-, and 60-minute intervals. Patients' vital sign and possible adverse effects were recorded respectively. Finally, all participants were assessed for their satisfaction.

Results: The mean initial pain score in the experimental group was 8.7 and 8.4 in the control group (P = .1). Pain relief in both groups after 5 and 10 minutes were similar (P = .72). Although the pain relief was significantly greater with fentanyl at 15 minutes, this difference is not clinically significant. Pain management in both groups was successful and was more than 3 scores reduction in Numerical Rating Scale. Patient satisfaction in both groups was similar. No adverse effects were reported in the experimental group.

Conclusion: This study suggests that nebulized fentanyl is a rapid, safe, and effective method for temporary control of acute limb pain in emergency department patients.

20. Risk of TBIs in children younger than 24 months with isolated scalp hematomas.

Dayan PS, et al. (PECARN). Ann Emerg Med. 2014 Aug;64(2):153-62.

STUDY OBJECTIVE: We aimed to determine the association between scalp hematoma characteristics and traumatic brain injuries in young children with blunt head trauma who have no other symptoms or signs suggestive of traumatic brain injuries (defined as "isolated scalp hematomas").

METHODS: This was a secondary analysis of children younger than 24 months with minor blunt head trauma from a prospective cohort study in 25 Pediatric Emergency Care Applied Research Network emergency departments. Treating clinicians completed a structured data form. For children with isolated scalp hematomas, we determined the prevalence of and association between scalp hematoma characteristics and (1) clinically important traumatic brain injury (death, neurosurgery for traumatic brain injury, intubation beyond 24 hours for traumatic brain injury, or positive computed tomography (CT) scan in association with hospitalization ≥2 nights for traumatic brain injury); and (2) traumatic brain injury on CT.

RESULTS: Of 10,659 patients younger than 24 months were enrolled, 2,998 of 10,463 (28.7%) with complete data had isolated scalp hematomas. Clinically important traumatic brain injuries occurred in 12 patients (0.4%; 95% confidence interval [CI] 0.2% to 0.7%); none underwent neurosurgery (95% CI 0% to 0.1%). Of 570 patients (19.0%) for whom CTs were obtained, 50 (8.8%; 95% CI 6.6% to 11.4%) had traumatic brain injuries on CT. Younger age, non-frontal scalp hematoma location, increased scalp hematoma size, and severe injury mechanism were independently associated with traumatic brain injury on CT.

CONCLUSION: In patients younger than 24 months with isolated scalp hematomas, a minority received CTs. Despite the occasional presence of traumatic brain injuries on CT, the prevalence of clinically important traumatic brain injuries was very low, with no patient requiring neurosurgery. Clinicians should use patient age, scalp hematoma location and size, and injury mechanism to help determine which otherwise asymptomatic children should undergo neuroimaging after minor head trauma.

21. Effectiveness of granisetron in controlling pediatric gastroenteritis–related vomiting after discharge from the ED

Qazi K, et al. Amer J Emerg Med. 2014;32:1046-1050

Objective: The objective of the study is to determine the efficacy of oral granisetron (a long-acting 5-HT3 receptor antagonist) in stopping vomiting subsequent to discharge from emergency department (ED), in 6-month-old to 8-year-old patients with gastroenteritis-related vomiting and dehydration, who had failed an initial trial of oral rehydration (ORT).

Methods: Eligible patients were offered ORT on a slowly advancing schedule. Patients who tolerated the initial ORT were discharged home. Patients who vomited were randomized to receive either 40 μg/kg of granisetron or placebo, and ORT was resumed. Patients who tolerated the postrandomization ORT were discharged home with another dose of the study drug. Parents were contacted by telephone every 24 hours until complete resolution of symptoms. The primary outcome was the proportion of patients with vomiting at 24 hours.

Results: Of the 900 eligible patients, 537 (60%) tolerated the initial ORT and were discharged home. Of the patients who vomited during the initial ORT, 165 were included in the final study sample (placebo, n = 82; granisetron, n = 83). There was no statistically significant difference in the proportion of patients with vomiting at 24 hours (granisetron, n = 38; placebo, n = 45; odds ratio, 0.64; 95% confidence interval, 0.34-1.19; P = .16). A similar trend in the proportion of patients with vomiting was noted for the entire follow-up period (granisetron, n = 43; placebo, n = 47; odds ratio, 0.73; P = .33; 95% confidence interval, 0.39-1.36).

Conclusion: Granisetron was not effective in controlling gastroenteritis-related vomiting subsequent to discharge from ED. It did not change the expected course of the illness.

22. Compassion Fatigue is Similar in EM Residents Compared to other Medical and Surgical Specialties

Bellolio MF, et al. West J Emerg Med. 2014;15:629-635.

Introduction: Compassion fatigue (CF) is the emotional and physical burden felt by those helping others in distress, leading to a reduced capacity and interest in being empathetic towards future suffering. Emergency care providers are at an increased risk of CF secondary to their first responder roles and exposure to traumatic events. We aimed to investigate the current state of compassion fatigue among emergency medicine (EM) resident physicians, including an assessment of contributing factors.

Methods: We distributed a validated electronic questionnaire consisting of the Professional Quality of Life Scale with subscales for the three components of CF (compassion satisfaction, burnout and secondary traumatic stress), with each category scored independently. We collected data pertaining to day- versus night-shift distribution, hourly workload and child dependents. We included residents in EM, neurology, orthopedics, family medicine, pediatrics, obstetrics, and general surgery.

Results: We surveyed 255 residents, with a response rate of 75%. Of the 188 resident respondents, 18% worked a majority of their clinical shifts overnight, and 32% had child dependents. Burnout scores for residents who worked greater than 80 hours per week, or primarily worked overnight shifts, were higher than residents who worked less than 80 hours (mean score 25.0 vs 21.5; p=0.013), or did not work overnight (mean score 23.5 vs 21.3; p=0.022).  EM residents had similar scores in all three components of CF when compared to other specialties. Secondary traumatic stress scores for residents who worked greater than 80 hours were higher than residents who worked less than 80 hours (mean score 22.2 vs 19.5; p=0.048), and those with child dependents had higher secondary traumatic stress than those without children (mean score 21.0 vs 19.1; p=0.012).

Conclusion: CF scores in EM residents are similar to residents in other surgical and medical specialties. Residents working primarily night shifts and those working more than 80 hours per week appear to be at high risk of developing compassion fatigue. Residents with children are more likely to experience secondary traumatic stress.