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.
KEY CLINICAL POINTS
·
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.
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.
Citations:
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%.
Background
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.
Methods
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.
Results
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).
Conclusion
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.
Methods
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.
Results
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.
Conclusion
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.
Full-text
(free): http://www.escholarship.org/uc/item/5zr8g21f
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.
Remind me, what’s the PRAM score?
http://www.cmaj.ca/content/suppl/2009/11/23/cmaj.071638.DC1/ach-mcivor-1-at.pdf
http://www.cmaj.ca/content/suppl/2009/11/23/cmaj.071638.DC1/ach-mcivor-1-at.pdf
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.
Full-text
(free): http://www.escholarship.org/uc/item/4pn5d48k