1. Highlights from BMJ’s Annual Comic Christmas Edition
A. The Darwin Awards: sex differences
in idiotic behaviour
This paper
reviews the data on winners of the Darwin Award over a 20 year period. Winners
of the Darwin Award must eliminate themselves from the gene pool in such an
idiotic manner that their action ensures one less idiot will survive. This
paper reports that males are much more likely to receive such an award, a
finding that is entirely consistent with male idiot theory (MIT)…
B. Healer, dealer, heart stealer:
portrayals of the doctor in popular music
Typing
“doctor + lyrics” into a well known search engine retrieved 8.4 million
results—far more than the 1.3 million hits generated by a similar search
involving “lawyer,” for example. Doctors are intimately involved in our lives
from birth until death, so it is perhaps not surprising that musicians are
interested in them.
The portrayal
of doctors in popular music is revealing and varied…
C. Televised medical talk shows—what
they recommend and the evidence to support their recommendations: a prospective
observational study
OBJECTIVE: To
determine the quality of health recommendations and claims made on popular
medical talk shows.
DESIGN:
Prospective observational study.
SETTING:
Mainstream television media.
SOURCES:
Internationally syndicated medical television talk shows that air daily (The Dr
Oz Show and The Doctors).
INTERVENTIONS:
Investigators randomly selected 40 episodes of each of The Dr Oz Show and The
Doctors from early 2013 and identified and evaluated all recommendations made
on each program. A group of experienced evidence reviewers independently
searched for, and evaluated as a team, evidence to support 80 randomly selected
recommendations from each show.
MAIN OUTCOMES
MEASURES: Percentage of recommendations that are supported by evidence as
determined by a team of experienced evidence reviewers. Secondary outcomes
included topics discussed, the number of recommendations made on the shows, and
the types and details of recommendations that were made.
RESULTS: We
could find at least a case study or better evidence to support 54% (95%
confidence interval 47% to 62%) of the 160 recommendations (80 from each show).
For recommendations in The Dr Oz Show, evidence supported 46%, contradicted
15%, and was not found for 39%. For recommendations in The Doctors, evidence
supported 63%, contradicted 14%, and was not found for 24%. Believable or
somewhat believable evidence supported 33% of the recommendations on The Dr Oz
Show and 53% on The Doctors. On average, The Dr Oz Show had 12 recommendations
per episode and The Doctors 11. The most common recommendation category on The
Dr Oz Show was dietary advice (39%) and on The Doctors was to consult a
healthcare provider (18%). A specific benefit was described for 43% and 41% of
the recommendations made on the shows respectively. The magnitude of benefit
was described for 17% of the recommendations on The Dr Oz Show and 11% on The
Doctors. Disclosure of potential conflicts of interest accompanied 0.4% of
recommendations.
CONCLUSIONS:
Recommendations made on medical talk shows often lack adequate information on
specific benefits or the magnitude of the effects of these benefits.
Approximately half of the recommendations have either no evidence or are
contradicted by the best available evidence. Potential conflicts of interest
are rarely addressed. The public should be skeptical about recommendations made
on medical talk shows.
D. CARTOONS KILL: casualties in
animated recreational theater in an objective observational new study of kids'
introduction to loss of life.
OBJECTIVES:
To assess the risk of on-screen death of important characters in children's
animated films versus dramatic films for adults.
DESIGN:
Kaplan-Meier survival analysis with Cox regression comparing time to first
on-screen death.
SETTING:
Authors' television screens, with and without popcorn.
PARTICIPANTS:
Important characters in 45 top grossing children's animated films and a
comparison group of 90 top grossing dramatic films for adults.
MAIN OUTCOME
MEASURES: Time to first on-screen death.
RESULTS:
Important characters in children's animated films were at an increased risk of
death compared with characters in dramatic films for adults (hazard ratio 2.52,
95% confidence interval 1.30 to 4.90). Risk of on-screen murder of important
characters was higher in children's animated films than in comparison films
(2.78, 1.02 to 7.58).
CONCLUSIONS:
Rather than being the innocuous form of entertainment they are assumed to be,
children's animated films are rife with on-screen death and murder.
E. Are “armchair socialists” still
sitting? Cross sectional study of political affiliation and physical activity
Conclusions
There is little evidence to support the notion of armchair socialists, as they
are more active than the mainstream in the political centre. Encouraging
centrists to adopt stronger political views may be an innovative approach to
increasing their physical activity, potentially benefiting population health.
F. Use of Google Translate in medical
communication: evaluation of accuracy
Excerpt
Methods: Ten
commonly used medical statements were chosen by author consensus. These were
translated via Google Translate to 26 languages. Translations only were sent to
native speakers of each of these languages and translated back to English by
them. The returned English phrases were compared with the originals and
assessed for meaning. If translations did not make sense or were factually
incorrect they were considered as wrong. Minor grammatical errors were allowed.
Results: Ten
medical phrases were evaluated in 26 languages (8 Western European, 5 Eastern
European, 11 Asian, and 2 African), giving 260 translated phrases. Of the total
translations, 150 (57.7%) were correct while 110 (42.3%) were wrong. African
languages scored lowest (45% correct), followed by Asian languages (46%),
Eastern European next with 62%, and Western European languages were most
accurate at 74%. The medical phrase that was best translated across all
languages was “Your husband has the opportunity to donate his organs” (88.5%),
while “Your child has been fitting” was translated accurately in only 7.7%
(table⇓).
Swahili scored lowest with only 10% correct, while Portuguese scored highest at
90%.
There were
some serious errors. For instance, “Your child is fitting” translated in
Swahili to “Your child is dead.” In Polish “Your husband has the opportunity to
donate his organs” translated to “Your husband can donate his tools.” In
Marathi “Your husband had a cardiac arrest” translated to “Your husband had an
imprisonment of heart.” “Your wife needs to be ventilated” in Bengali
translated to “Your wife wind movement needed.”
Discussion: Google
Translate is an easily available free online machine translation tool for 80
languages worldwide.5 However, we have found limited usefulness for medical
phrases used in communications between patients and doctor.3 6 7
We found many
translations that were completely wrong. Google Translate uses statistical
matching to translate rather than a dictionary/grammar rules approach, which
leaves it open to nonsensical results.4 8
In today’s
world “just Google it” is considered to be the answer to everything, but for
health related questions this should be treated with caution.9 Google Translate
should not be used for taking consent for surgery, procedures, or research from
patients or relatives unless all avenues to find a human translator have been
exhausted, and the procedure is clinically urgent. We have, however, not
assessed the accuracy of human translators, who cannot be assumed to be perfect
and may be subject to confidentiality breaches.
We looked at
translations from and to English only. Western European languages were the most
accurately translated, implying a bias in translating algorithms towards those
languages more commonly used in computing. Previous research has used one
phrase, using the same algorithm to translate and retranslate, which is likely
to increase the stated accuracy.10 11
Conclusion: Google
Translate has only 57.7% accuracy when used for medical phrase translations and
should not be trusted for important medical communications. However, it still
remains the most easily available and free initial mode of communication
between a doctor and patient when language is a barrier. Although caution is
needed when life saving or legal communications are necessary, it can be a
useful adjunct to human translation services when these are not available.
2. Identification of the optimum vagal manoeuvre technique for
maximising vagal tone
Smith G, et
al. Emerg Med J 2015;32:51-54.
Objectives
This study sought to determine the most effective technique for Valsalva
Manoeuvre (VM) and Human Dive Reflex Manoeuvre (HDR) generation of vagal tone.
Methods We
conducted a repeated-measures trial of healthy adult volunteers from a
university campus, aged 18–56 years, in sinus rhythm. Participants were
randomised to VM (in supine or Trendelenberg postures) and HDR (supine or
sitting postures) sequentially. Participants performed three trials of each
technique, in random order, with a continuous ECG recording. Single-blinded
analysis of ECG data was conducted. Mean differences between premanoeuvre and
postmanoeuvre R-R intervals and heart rates were calculated for each posture
within and between vagal manoeuvres.
Results
Seventy-two participants were enrolled. The difference between VM (supine) and
VM (Trendelenberg) was not significant at 0.008 s (−0.023 to 0.038). The
difference in mean R-R intervals for HDR (supine) was greater than HDR
(sitting) 0.062 (0.031 to 0.093), although this significance was not reflected
in a heart-rate change of −0.87 (−3.00 to 1.26). VM supine generated greatest
overall mean R-R interval difference, while HDR (sitting) provided the smallest
change in R-R interval. The VM (supine) provided a significant maximum
effectiveness over the HDR (supine) of 0.102 s (0.071 to 0.132).
Conclusions
This study demonstrates that VM (supine) generates the greatest vagal tone
producing the largest transient heart rate decrease in healthy volunteers. No
advantage was identified in Trendelenberg posturing for the VM in this study.
These results may assist in the standardisation of vagal manoeuvre technique
for the range of therapeutic and diagnostic applications.
3. Ebola Updates and Debates
A. Ebola Virus Outbreak 2014: Clinical
Review for Emergency Physicians from Annals
B. Ebola Update from the NEJM: An
Interactive Perspective
C. Health Care Worker Quarantine for
Ebola: To Eradicate the Virus or Alleviate Fear?
4. A Randomized Trial of Intraarterial Treatment for Acute
Ischemic Stroke (Mr CLEAN)
Berkhemer OA,
et al. N Engl J Med. 2014 Dec 17. [Epub ahead of print]
Background In
patients with acute ischemic stroke caused by a proximal intracranial arterial
occlusion, intraarterial treatment is highly effective for emergency
revascularization. However, proof of a beneficial effect on functional outcome
is lacking.
Methods We
randomly assigned eligible patients to either intraarterial treatment plus
usual care or usual care alone. Eligible patients had a proximal arterial
occlusion in the anterior cerebral circulation that was confirmed on vessel
imaging and that could be treated intraarterially within 6 hours after symptom
onset. The primary outcome was the modified Rankin scale score at 90 days; this
categorical scale measures functional outcome, with scores ranging from 0 (no
symptoms) to 6 (death). The treatment effect was estimated with ordinal
logistic regression as a common odds ratio, adjusted for prespecified
prognostic factors. The adjusted common odds ratio measured the likelihood that
intraarterial treatment would lead to lower modified Rankin scores, as compared
with usual care alone (shift analysis).
Results We
enrolled 500 patients at 16 medical centers in the Netherlands (233 assigned to
intraarterial treatment and 267 to usual care alone). The mean age was 65 years
(range, 23 to 96), and 445 patients (89.0%) were treated with intravenous
alteplase before randomization. Retrievable stents were used in 190 of the 233
patients (81.5%) assigned to intraarterial treatment. The adjusted common odds
ratio was 1.67 (95% confidence interval [CI], 1.21 to 2.30). There was an
absolute difference of 13.5 percentage points (95% CI, 5.9 to 21.2) in the rate
of functional independence (modified Rankin score, 0 to 2) in favor of the
intervention (32.6% vs. 19.1%). There were no significant differences in
mortality or the occurrence of symptomatic intracerebral hemorrhage.
Conclusions
In patients with acute ischemic stroke caused by a proximal intracranial
occlusion of the anterior circulation, intraarterial treatment administered
within 6 hours after stroke onset was effective and safe. (Funded by the Dutch
Heart Foundation and others; MR CLEAN Netherlands Trial Registry number,
NTR1804 , and Current Controlled Trials number, ISRCTN10888758 .).
Editorial:
Interventional
Thrombectomy for Major Stroke — A Step in the Right Direction
5. Headache Management: Droperidol, Mag, and Occipital Nerve
Blocks
A. Droperidol for the Treatment of
Acute Migraine Headaches.
Thomas MC, et
al. Ann Pharmacother. 2014 Nov 21. [Epub ahead of print]
OBJECTIVE: To
evaluate the safety and efficacy of droperidol for the relief of acute migraine
headaches.
DATA SOURCES:
A MEDLINE search (1946 to August 2014) was performed using the following
keywords and associated medical subject headings: droperidol, inapsine,
headache, migraine, and migraine disorder.
STUDY
SELECTION AND DATA EXTRACTION: The search was conducted to identify randomized
controlled trials comparing droperidol with placebo or an active control in
adult patients with acute migraine headaches that were published in English.
Primary end points included acute headache improvement after the intervention.
Safety end points included the frequency of extrapyramidal symptoms,
somnolence, and cardiac adverse effects.
DATA
SYNTHESIS: In all, 5 manuscripts are included in this review. Patients
presenting to the emergency department with acute headache desire rapid pain
relief, which was the primary objective in each of the evaluated studies.
Droperidol was better than placebo and at least as effective as comparator
drugs such as prochlorperazine, meperidine, or olanzapine using droperidol
doses of 2.5 to 5 mg, given either intramuscularly (IM) or intravenously (IV).
The most commonly reported adverse effects were extrapyramidal symptoms and
sedation. Cardiac adverse effects were not reported in any of the studies;
however, only 2 articles described using cardiac monitoring.
CONCLUSIONS:
Parenteral droperidol is an effective option for the treatment of acute
migraine. The minimum effective dose is 2.5 mg given IM or IV. Clinicians must
be aware of the risk for adverse events, select appropriate patients, perform
EKG monitoring for patients at risk of QTc prolongation, and institute
treatment if necessary.
B. Magnesium Sulfate Beats
Dexamethasone/Metoclopramide on Alleviating Acute Migraine Headache
Shahrami A,
et al. J Emerg Med 2015;48:69-76.
Background
There is
controversy about the efficacy of currently used treatment modalities to
alleviate migraine headaches.
Objective
We aimed to
evaluate and compare the effects of magnesium sulfate and combined use of
dexamethasone/metoclopramide on relieving acute migraine headache.
Methods
We randomly
divided 70 patients who had been referred to an emergency department, into two
equal treatment groups with the two treatment plans, and analyzed pain severity
at baseline using a numeric rating scale (NRS). We gave
dexamethasone/metoclopramide to one group and magnesium sulfate to the other
group, and evaluated pain severity at 20 min and at 1- and 2-h intervals after
infusion. Finally, we used repeated-measure and two-way analysis of variance
for intra- and inter-group evaluations of pain severity and complications, respectively.
Results
We found no
significant differences in demographic data and pain severity at baseline (8.2
vs. 8.0) between the two groups (p less than 0.05). In the
dexamethasone/metoclopramide group, pain severity (mean ± standard deviation)
was 7.4 ± 1.4 (p = 0.36), 6.0 ± 2.4, and 2.5 ± 2.9 (p less than 0.0001) at
20-min, 1-h, and 2-h intervals after treatment, respectively, with
statistically significant differences between the baseline values and 1-h and
2-h interval values. Administration of magnesium sulfate was associated with
decreased pain severity at the three intervals (5.2 ± 1.7, 2.3 ± 1.9, and 1.3 ±
0.66, respectively), exhibiting significant differences compared to baseline
values and the corresponding time intervals in the dexamethasone/metoclopramide
group (p less than 0.0001).
Conclusions
According to
the results, magnesium sulfate was a more effective and fast-acting medication
compared to a combination of dexamethasone/metoclopramide for the treatment of
acute migraine headaches.
C. Occipital Nerve Blocks in the
Treatment of Headaches: Safety and Efficacy
Voigt CL, et
al. J Emerg Med 2015;48:115-129.
Background
Considering
current limitations in known treatment options and the significant disability
associated with headache disorders, investigation of additional options is
needed. Although occipital nerve blocks (ONBs) are currently being utilized
frequently in specialty settings, the potential role of ONBs as an alternative
to opioids for the management of acute headache episodes in primary and
emergency care settings is not yet understood.
Objective
Our aim was
to conduct a systematic literature review of the available evidence regarding
the use of ONBs for the management of acute headaches, and then determine its
potential for use in the emergency care setting. Techniques, medication
selection, adverse reactions, frequency of use, candidates, and measures that
can help improve safety were reviewed in order to better evaluate the
usefulness of this tool in emergency care.
Discussion
Occipital
nerve blocks are technically simple procedures that are highly successful in
providing dramatic pain relief results. They are also a relatively safe and
beneficial alternative to other headache treatment options. Case reports and
research have demonstrated that ONBs can be performed safely in outpatient
settings. However, due to the paucity of literature on the use of ONBs in
emergency care settings, it can only be speculated that the same outcomes can
be achieved.
Conclusions
Interest in
the use of ONBs in acute care settings is increasing. Current evidence supports
that ONBs can be delivered safely in an outpatient setting by providers who
have been trained in and have practiced this procedure. Although additional
research is needed, current evidence supports that ONBs can be useful in
treating acute headaches in an emergency care setting.
6. Patient care transitions from the ED to the medicine ward:
evaluation of a standardized electronic signout tool.
Gonzalo JD,
et al. Int J Qual Health Care. 2014 Aug;26(4):337-47.
OBJECTIVE: To
evaluate the impact of a new electronic handoff tool for emergency department
to medicine ward patient transfers over a 1-year period.
DESIGN:
Prospective mixed-methods analysis of data submitted by medicine residents
following admitting shifts before and after eSignout implementation.
SETTING:
University-based, tertiary-care hospital.
PARTICIPANTS:
Internal medicine resident physicians admitting patients from the emergency
department.
INTERVENTION:
An electronic handoff tool (eSignout) utilizing automated paging communication
and responsibility acceptance without mandatory verbal communication between
emergency department and medicine ward providers.
MAIN OUTCOME
MEASURES: (i) Incidence of reported near misses/adverse events, (ii)
communication of key clinical information and quality of verbal communication
and (iii) characterization of near misses/adverse events.
RESULTS:
Seventy-eight of 80 surveys (98%) and 1058 of 1388 surveys (76%) were completed
before and after eSignout implementation. Compared with pre-intervention,
residents in the post-intervention period reported similar number of shifts
with a near miss/adverse event (10.3 vs. 7.8%; P = 0.27), similar communication
of key clinical information, and improved verbal signout quality, when it
occurred. Compared with the former process requiring mandatory verbal
communication, 93% believed the eSignout was more efficient and 61% preferred
the eSignout. Patient safety issues related to perceived sufficiency/accuracy
of diagnosis, treatment or disposition, and information quality.
CONCLUSIONS:
The eSignout was perceived as more efficient and preferred over the mandatory
verbal signout process. Rates of reported adverse events were similar before
and after the intervention. Our experience suggests electronic platforms with
optional verbal communication can be used to standardize and improve the
perceived efficiency of patient handoffs.
7. Evaluation of the effectiveness of bedside point-of-care US
in the diagnosis and management of distal radius fractures
Kozaci N, et
al. Amer J Emerg Med. 2015;33:67-71.
Objective
The aim of
the study was to compare the effectiveness of point-of-care ultrasound (POCUS)
with direct radiography in diagnosis and management of the patients with distal
radius fractures (DRFs).
Methods
In this
study, patients between ages 5 and 55 years admitted to the emergency
department with low energy upper extremity trauma with suspected DRF were
evaluated with POCUS and direct radiography by emergency physicians (EPs)
trained in either musculoskeletal (MSK) imaging or x-ray interpretation of DRF.
The EP performing the POCUS examination was blinded to the x-ray results.
Results
A total of 83
patients with DRF were included in the study. There were 18 (22%) females, and
65 (78%) males enrolled in the study. Mean age was 13 ± 14 years for males, and
15 ± 13 years for females. Compared with direct radiography, POCUS yielded 98%
sensitivity, 96% specificity, 98% positive predictive value, 96% negative
predictive value, and 98% accuracy of the test in detecting fractures. POCUS
yielded 96% sensitivity, 93% specificity value in detecting linear fractures;
78% sensitivity, 98% specificity in detecting torus-type fractures, and 100%
specificity and sensitivity for detecting fissure fractures. Specificity of
POCUS in the decision for reduction was 100% and sensitivity was 98%;
specificity was 100% for splint application.
Conclusion
In our study,
it was shown that POCUS could be applied easily by EPs trained in MSK POCUS
imaging with success in diagnosing DRF and determining the correct fracture
type and required treatment methods.
8. Management dilemmas in acute PE
Condliffe R,
et al. Thorax. 2014;69(2):174-80.
BACKGROUND:
Physicians treating acute pulmonary embolism (PE) are faced with difficult
management decisions while specific guidance from recent guidelines may be
absent.
METHODS:
Fourteen clinical dilemmas were identified by physicians and haematologists
with specific interests in acute and chronic PE. Current evidence was reviewed
and a practical approach suggested.
RESULTS:
Management dilemmas discussed include: sub-massive PE, PE following recent
stroke or surgery, thrombolysis dosing and use in cardiac arrest, surgical or
catheter-based therapy, failure to respond to initial thrombolysis, PE in
pregnancy, right atrial thrombus, role of caval filter insertion, incidental
and sub-segmental PE, differentiating acute from chronic PE, early discharge
and novel oral anticoagulants.
CONCLUSION:
The suggested approaches are based on a review of the available evidence and
guidelines and on our clinical experience. Management in an individual patient
requires clinical assessment of risks and benefits and also depends on local
availability of therapeutic interventions.
9. Clinical Policy: Critical Issues in the Evaluation and
Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic
Dissection
Diercks DB,
et al. Ann Emerg Med. 2015;65:32–42.e12
This clinical
policy from the American College of Emergency Physicians addresses key issues
in the evaluation and management of patients with suspected acute nontraumatic
thoracic aortic dissection. A writing subcommittee conducted a systematic
review of the literature to derive evidence-based recommendations to answer the
following clinical questions:
(1) In adult
patients with suspected acute nontraumatic thoracic aortic dissection, are
there clinical decision rules that identify a group of patients at very low
risk for the diagnosis of thoracic aortic dissection?
(2) In adult
patients with suspected acute nontraumatic thoracic aortic dissection, is a
negative serum D-dimer sufficient to identify a group of patients at very low
risk for the diagnosis of thoracic aortic dissection?
(3) In adult
patients with suspected acute nontraumatic thoracic aortic dissection, is the
diagnostic accuracy of a computed tomography angiogram at least equivalent to
transesophageal echocardiogram or magnetic resonance angiogram to exclude the
diagnosis of thoracic aortic dissection?
(4) In adult
patients with suspected acute nontraumatic thoracic aortic dissection, does an
abnormal bedside transthoracic echocardiogram establish the diagnosis of
thoracic aortic dissection?
(5) In adult
patients with acute nontraumatic thoracic aortic dissection, does targeted
heart rate and blood pressure lowering reduce morbidity or mortality? Evidence
was graded and recommendations were made based on the strength of the available
data.
10. The PICHFORK (Pain in Children Fentanyl or Ketamine) Trial:
A Randomized Controlled Trial Comparing Intranasal Ketamine and Fentanyl for
the Relief of Moderate to Severe Pain in Children with Limb Injuries
Graudins A,
et al. Ann Emerg Med. 2014 Nov 17 [Epub ahead of print]
Study
objective
We compare
the analgesic effectiveness of intranasal fentanyl and ketamine in children.
Methods
This was a
double-blind, randomized, controlled trial comparing fentanyl at 1.5 μg/kg with
ketamine at 1 mg/kg in children aged 3 to 13 years and weighing less than 50
kg, with isolated limb injury and pain of more than 6 of 10 at triage. The
sample size was 40 in each arm. Subjects were coadministered oral ibuprofen at
10 mg/kg. The primary outcome was median pain rating reduction at 30 minutes.
Secondary outcomes were pain rating reduction at 15 and 60 minutes, subjective
improvement and satisfaction, University of Michigan Sedation Score, adverse
events, and rescue analgesia.
Results
Eighty
children enrolled, and 73 were available for analysis: 37 fentanyl and 36
ketamine. Median age was 8 years; 63% were male children; median baseline pain
rating was 80 mm. At 30 minutes, median reductions for ketamine and fentanyl
were 45 and 40 mm, respectively (difference 5 mm; 95% confidence interval [CI]
−10 to 20 mm). Reductions exceeded 20 mm for ketamine and fentanyl in 82% and
79% of patients, respectively (difference 3%; 95% CI −22% to 16%). Pain rating
reduction was maintained to 60 minutes in both groups. Satisfaction was
reported for ketamine and fentanyl by 83% and 72% of patients, respectively
(difference 11%; 95% CI −9% to 30%). Adverse events, mainly mild, were reported
for ketamine and fentanyl by 78% and 40% of patients, respectively (difference
38%; 95% CI −58% to 16%). Three ketamine patients had a moderate degree of
sedation by University of Michigan Sedation Score.
Conclusion
Intranasal
fentanyl and ketamine were associated with similar pain reduction in children
with moderate to severe pain from limb injury. Ketamine was associated with
more minor adverse events.
11. Images in Clinical Practice
Palpitations after Dinner
A 76-year-old
woman with rheumatoid arthritis, diabetes, and hypertension presented with
palpitations that occurred only after she had eaten dinner. The sensation was
felt at the center of the chest and lasted for 10 to 15 minutes after the meal.
Woman With Cough and Dyspnea
Teenage Male With Sudden Left
Hemiparesis
12. Tranexamic acid for traumatic brain injury: a systematic
review and meta-analysis.
Zehtabchi S,
et al. Am J Emerg Med. 2014 Dec;32(12):1503-9.
OBJECTIVE:
The antifibrinolytic agent tranexamic acid (TXA) has demonstrated clinical
benefit in trauma patients with severe bleeding, but its effectiveness in
patients with traumatic brain injury (TBI) is unclear. We conducted a
systematic review to evaluate the following research question: In ED patients
with or at risk of intracranial hemorrhage (ICH) secondary to TBI, does TXA
compared to placebo improve patients' outcomes?
METHODS:
MEDLINE, EMBASE, CINAHL, and other databases were searched for randomized
controlled trial (RCT) or quasi-RCT studies that compared the effect of TXA to
placebo on outcomes of TBI patients. The main outcomes of interest included
mortality, neurologic function, hematoma expansion, and adverse effects. We
used "Grading quality of evidence and strength of recommendations" to
assess the quality of trials. Two authors independently abstracted data using a
data collection form. Results from studies were pooled when appropriate.
RESULTS: Of
1030 references identified through the search, 2 high-quality RCTs met
inclusion criteria. The effect of TXA on mortality had a pooled relative risk
of 0.64 (95% confidence interval [CI], 0.41-1.02); on unfavorable functional
status, a relative risk of 0.77 (95% CI, 0.59-1.02); and on ICH progression, a
relative risk of 0.76 (95% CI, 0.58-0.98). No serious adverse effects (such as
thromboembolic events) associated with TXA group were reported in the included
trials.
CONCLUSION:
Pooled results from the 2 RCTs demonstrated statistically significant reduction
in ICH progression with TXA and a nonstatistically significant improvement of
clinical outcomes in ED patients with TBI. Further evidence is required to
support its routine use in patients with TBI.
13. A randomized controlled trial of capnography during sedation
in a pediatric emergency setting
Langhan ML,
et al. Amer J Emerg Med. 2015;33:25-30.
Objective
Data suggest
that capnography is a more sensitive measure of ventilation than standard
modalities and detects respiratory depression before hypoxemia occurs. We
sought to determine if adding capnography to standard monitoring during
sedation of children increased the frequency of interventions for
hypoventilation, and whether these interventions would decrease the frequency
of oxygen desaturations.
Methods
We enrolled
154 children receiving procedural sedation in a pediatric emergency department.
All subjects received standard monitoring and capnography, but were randomized
to whether staff could view the capnography monitor (intervention) or were
blinded to it (controls). Primary outcome were the rate of interventions
provided by staff for hypoventilation and the rate of oxygen desaturation less
than 95%.
Results
Seventy-seven
children were randomized to each group. Forty-five percent had at least 1
episode of hypoventilation. The rate of hypoventilation per minute was
significantly higher among controls (7.1% vs 1.0%, P = .008). There were
significantly fewer interventions in the intervention group than in the control
group (odds ratio, 0.25; 95% confidence interval [CI], 0.13-0.50).
Interventions were more likely to occur contemporaneously with hypoventilation
in the intervention group (2.26; 95% CI, 1.34-3.81). Interventions not in time
with hypoventilation were associated with higher odds of oxygen desaturation
less than 95% (odds ratio, 5.31; 95% CI, 2.76-10.22).
Conclusion
Hypoventilation
is common during sedation of pediatric emergency department patients. This can
be difficult to detect by current monitoring methods other than capnography.
Providers with access to capnography provided fewer but more timely
interventions for hypoventilation. This led to fewer episodes of
hypoventilation and of oxygen desaturation.
14. Ann Emerg Med Lit Reviews
A. Valsalva Maneuver for Termination
of Supraventricular Tachycardia
Take-Home
Message: The Valsalva maneuver appears to be a modestly effective intervention,
with a low risk of adverse events, but is supported by only a small number of
low-quality trials.
B. The Effect of Ketamine on
Intracranial and Cerebral Perfusion Pressure and Health Outcomes: A Systematic
Review
Cohen L, et
al. Ann Emerg Med 2015;65: 43–51.e2
Study
objective
We synthesize
the available evidence on the effect of ketamine on intracranial and cerebral
perfusion pressures, neurologic outcomes, ICU length of stay, and mortality.
Methods
We developed
a systematic search strategy and applied it to 6 electronic reference
databases. We completed a gray literature search and searched medical journals
as well as the bibliographies of relevant articles. We included randomized and
nonrandomized prospective studies that compared the effect of ketamine with
another intravenous sedative in intubated patients and reported at least 1
outcome of interest. Two authors independently performed title, abstract, and
full-text reviews, and abstracted data from all studies, using standardized
forms. Data from randomized controlled trials and prospective studies were
synthesized in a qualitative manner because the study designs, patient
populations, reported outcomes, and follow-up periods were heterogeneous. We
used the Jadad score and Cochrane Risk of Bias tool to assess study quality.
Results
We retrieved
4,896 titles, of which 10 studies met our inclusion criteria, reporting data on
953 patients. One study was deemed at low risk of bias in all quality
assessment domains. All others were at high risk in at least 1 domain. Two of 8
studies reported small reductions in intracranial pressure within 10 minutes of
ketamine administration, and 2 studies reported an increase. None of the
studies reported significant differences in cerebral perfusion pressure,
neurologic outcomes, ICU length of stay, or mortality.
Conclusion
According to
the available literature, the use of ketamine in critically ill patients does
not appear to adversely affect patient outcomes.
Related
editorial (the title says it all): Ketamine and Intracranial Pressure: No
Contraindication Except Hydrocephalus
C. Is Dexamethasone as Effective as
Prednisone or Prednisolone in the Management of Pediatric Asthma Exacerbations?
Take-home: The
use of 1 to 2 doses of dexamethasone for acute pediatric asthma exacerbation
does not appear to increase the frequency of unscheduled return visits compared
with a 5-day course of prednisone or prednisolone.
D. Should Children With Acute Asthma
Exacerbation Receive Inhaled Anticholinergics?
Take-home: The
use of inhaled anticholinergics (ipratropium bromide) along with inhaled
short-acting β-agonists (albuterol) can reduce hospital admission rates in
children with moderate to severe asthma exacerbations.
15. ED visits greater following health plan enrollment
Research
published in the American Journal of Emergency Medicine revealed recently
insured patients exhibited greater emergency department use for nonemergency
care compared with when they were uninsured. Researchers also found 27.7% of
patients without a usual health care source said lack of access drove them to
use the ED.
Janke AT, et
al. Access to care issues and the role of EDs in the wake of the Affordable
Care Act. Am J Emerg Med. 2014 Nov 13 [Epub ahead of print]
Abstract
CONTEXT:
Americans who received public insurance under the Affordable Care Act use the
emergency department (ED) more frequently than before they were insured. If
newly enrolled patients cannot access primary care and instead rely on the ED,
they may not enjoy the full benefits of health care services.
OBJECTIVE:
The objective of the study is to characterize reasons for ED utilization among
American adults by insurance status and usual source of care.
DESIGN,
SETTING, AND PARTICIPANTS: Cross-sectional analysis of adult sample respondents
to the 2013 National Health Interview Survey reporting 1 or more ED visits in
the preceding 12 months.
MAIN OUTCOMES
AND MEASURES: Among American ED users that reported no usual source of care and
who reported relying on the ED, 27.7% (95% confidence interval [CI],
23.6%-32.2%) and 35.1% (95% CI, 28.0%-43.0%) noted at least 1 issue of access
and none of acuity as a reason for their last ED visit, as compared to 17.7%
(95% CI, 16.3%-19.2%) among those with a stable usual source of care.
CONCLUSIONS
AND RELEVANCE: Although past research has shown that those who lack a stable
usual source of care use the ED more often, this is the first population-level
study to demonstrate their propensity for lack of access-based utilization. In
the wake of the Affordable Care Act, EDs will need to evolve into outlets that
service a wider range of health care needs rather than function in their
current capacity, which is largely to address acute issues in isolation.
16. IV Lipid Emulsion in the ED: A Systematic Review of Recent
Literature
Cao D, et al.
J Emerg Med 2014 December 19 [Epub ahead of print]
Background
Intravenous
lipid emulsion (ILE) has been broadly attempted in the resuscitation of
neurologic and cardiac toxic drug overdoses, however, the role of ILE in the
emergency department is poorly defined.
Objective
This review
aims to identify recent literature on the use of ILE in humans as an antidote
and to familiarize emergency providers with the indications, availability,
dosing recommendations, and adverse reactions associated with ILE use.
Methods
A systemic
literature search of MEDLINE, EMBASE, and major toxicology conference abstracts
was performed for human cases using ILE as an antidote with documented clinical
outcomes through January 2014.
Results
Ninety-four
published articles and 40 conference abstracts were identified, 85% of which
had positive outcomes. The most common indication for ILE was for local
anesthetic systemic toxicity (LAST). The most common nonlocal anesthetic
xenobiotics were tricyclic-antidepressants and verapamil.
Discussion
No standard
of care is defined for the use of ILE, although the American Heart Association
recommends use in LAST, and the American College of Medical Toxicology
recommends consideration for circumstances of hemodynamic instability resultant
from lipid-soluble xenobiotics. ILE should be administered per American Society
of Regional Anesthesia and Pain Medicine dosing recommendations. Laboratory
interference, pancreatitis, respiratory distress syndrome, and interference
with vasopressors should be considered as risks but are uncommon.
Conclusions
In the
setting of severe hemodynamic compromise by lipid-soluble xenobiotics, ILE may
be considered for resuscitation by emergency physicians. As such, ILE may be
stocked in emergency departments in close proximity to resuscitation rooms and
areas where local nerve blocks are performed.
17. (In)Sensitivity of Plain Pelvis Radiography in Children With
Blunt Torso Trauma
Kwok MY, et
al. Ann Emerg Med. 2015;65: 63–71.e1
Study
objective
Plain
anteroposterior pelvic radiographs are commonly used to screen children for
pelvic fractures or dislocations after blunt torso trauma. The test sensitivity
and utility, however, are unclear. We assessed the sensitivity of
anteroposterior pelvic radiographs for identifying children with pelvic
fractures or dislocations after blunt torso trauma. We hypothesized that
anteroposterior pelvic radiographs fail to identify all children with pelvic
fractures or dislocations, including patients undergoing operative intervention
and those with hypotension.
Methods
We conducted
a prospective multicenter observational study of children (less than 18 years)
with blunt torso trauma in the Pediatric Emergency Care Applied Research
Network. We compared plain anteroposterior pelvic radiographs to the final
diagnosis of pelvic fractures or dislocations as documented by the orthopedic
faculty physician before emergency department (ED)/hospital discharge. We
described the data with descriptive statistics, including 95% confidence
intervals (CIs).
Results
Of 12,044
patients enrolled in the parent study, 451 (3.7%; 95% CI 3.4% to 4.1%) had
pelvic fractures or dislocations. Of these patients, 65 (14%; 95% CI 11% to
18%) underwent operative intervention and 21 (4.7%; 95% CI 2.9% to 7.0%) had
age-adjusted hypotension on initial presentation. In the ED, 382 of the 451
patients underwent plain anteroposterior pelvic radiographs, with a sensitivity
of 297 of 382 (78%; 95% CI 73% to 82%) for patients with pelvic fractures or
dislocations, 55 of 60 (92%; 95% CI 82% to 97%) for patients undergoing
operative intervention, and 14 of 17 (82%; 95% CI 57% to 96%) for patients with
hypotension.
Conclusion
Plain
anteroposterior pelvic radiographs have a limited sensitivity for identifying
children with pelvic fractures or dislocations after blunt trauma, including
patients undergoing operative intervention and those with hypotension.
18. Personal breathalysers may give false reassurance to
drivers, research shows
Gornall J. BMJ
2014;349:g7745
Researchers
who tested three types of personal breathalysers on drinkers in bars in Oxford
city centre found widely different levels of accuracy that they say “could have
catastrophic safety implications for drivers” who rely on the devices to decide
whether they are fit to drive after drinking.
The
researchers, from the Nuffield Department of Primary Care Health Sciences at
the University of Oxford, tested the diagnostic accuracy of two single use
disposable breathalysers and one multi-use digital device against results
obtained from a Home Office approved breathalyser used by police for roadside
testing.
In a paper
published today on BMJ Open the researchers reported that the relative accuracy
of the three breathalysers varied from 26% to 95%, which in the case of the
worst performing device meant that as many as “three people in four . . . are
falsely reassured when over the limit.” 1
Earlier this
month Dorset Police advised motorists not to rely on personal breathalysers,
after county trading standards officers tested 14 devices and found that nine
falsely assured users that they were safe to drive. Ivan Hancock, trading
standards service manager for Dorset County Council, said, “Drivers would be
extremely foolish to rely on the readings they get from one of these cheap
devices.”2
The Oxford
findings are particularly relevant at this time of year, at the height of the
police’s seasonal drink driving campaigns—and even more so in Scotland, where
on 5 December the drink driving limit was reduced from 80 mg to 50 mg of
alcohol in every 100 mL of blood, bringing the country into line with the rest
of Europe.
19. Jehovah's Witness patients presenting with ruptured ectopic
pregnancies: two case reports.
Murphy NC, et
al. J Med Case Rep. 2014 Sep 19;8:312
INTRODUCTION:
The management of emergencies in Jehovah's Witnesses presents several
challenges to obstetricians and gynaecologists. We present two cases of ectopic
pregnancies in Jehovah's Witnesses recently managed in our institution. This is
the first case review series of its kind that we could identify. We feel it is
of clinical importance for all physicians caring for Jehovah's Witnesses.
CASE
PRESENTATION: The first patient was a 28-year-old Caucasian Irish woman who
presented in a state of collapse and a ruptured ectopic pregnancy was
suspected. She refused treatment and took her own discharge against the advice of
senior hospital staff. She re-presented to our Emergency Room 6 hours later in
hypovolaemic shock. She ultimately consented to blood products including plasma
and platelets and underwent laparoscopic left-sided salpingectomy. This consent
was queried postoperatively by her next-of-kin but the validity of her consent
was clarified by the hospital legal team.The second patient was a 35-year-old
Nigerian woman who presented to our Emergency Room with a 2-week history of
intermittent vaginal bleeding and abdominal pain with a haemoglobin of 5.4
g/dL. An ectopic pregnancy was diagnosed following assessment. She refused all
blood products and underwent right-sided salpingectomy. Intravenous tranexamic
acid was administered and cell salvage employed intraoperatively.
CONCLUSIONS:
We feel that this case review series emphasises the importance of appropriate
management of Jehovah's Witnesses in our units. In both of the above cases,
these women were in potentially life-threatening situations. Advances in
haematology and pharmaceutical therapy contributed to their survival. We
welcome these advances in the treatment of this patient population.
20. Two Femoral Nerve Block Techniques Compared for Patients
with Femur Fractures
The fascia
iliaca and 3-in-1 femoral nerve blocks were equally effective for reducing pain
from femoral neck fractures.
Reavley P et
al. Emerg Med J 2014 Nov 27 [Epub ahead of print]
INTRODUCTION:
Femoral neck fractures are a common and painful injury. Femoral nerve blocks,
and a variant of this technique termed the '3-in-1' block, are often used in
this patient group, but their effect is variable. The fascia iliaca compartment
block (FIB) has been proposed as an alternative, but the relative effectiveness
of the two techniques in the early stages of care is unknown. We therefore
compared the FIB versus the 3-in-1 block in a randomised trial conducted in two
UK emergency departments.
METHODS:
Parallel, two-group randomised equivalence trial. Consenting patients over 18 years
with a femoral neck fracture were randomly allocated to receive either a FIB or
a 3-in-1 block. The primary outcome was pain measured on a 100 mm visual
analogue scale at 60 min. The between-group difference was adjusted for centre,
age, sex, fracture type, pre-block analgesia and pre-block pain score.
RESULTS: 178
patients were randomised and 162 included in the primary analysis. The mean
100 mm visual analogue pain scale score at 60 min was 38 mm in the FIB arm and
35 mm in the 3-in-1 arm. The adjusted difference between the arms was 3 mm,
with a 95% CI (-4.7 to 10.8) that excluded a clinically important difference
between the two interventions.
CONCLUSIONS:
FIB is equivalent to the 3-in-1 block for immediate pain relief in adult neck
of femur fractures.
21. CMS releases video outlining ICD-10 basics
Akanksha
Jayanthi Becker’s Hospital Review. December 09, 2014
Still have
questions about ICD-10?
CMS attempts
to answer some of those questions in a new video, "Coding for ICD-10-CM:
More of the Basics," that reviews basic information over the new coding
system set to be integrated October 2015.
In the video,
Sue Bowman, senior director of coding policy and compliance of AHIMA, and Nelly
Leon-Chisen, director of coding and classification of the American Hospital
Association, discuss key topics such as the differences between ICD-9 and
ICD-10, how to assign a diagnosis code using ICD-10, code structures, coding
process and examples and resources for coders.
The video runs
for approximately 37 minutes: https://www.youtube.com/watch?v=s86pXhhOG7c&list=UUhHTRPxz8awulGaTMh3SAkA
22. Micro Lit Bits
A. The association
between exaggeration in health related science news and academic press
releases: retrospective observational study
B. Study: Aspirin's
bleeding risk outweighs benefits in women under 65
The
risk of major gastrointestinal bleeding outweighed the benefits of low-dose
aspirin in reducing the risk of heart disease, stroke and colon cancer among
women younger than 65, according to a study in the journal Heart. For women
ages 65 and older, the benefits of aspirin use against heart disease and colon
cancer surpassed the risk of bleeding. Researchers stressed that the decision
on whether to use aspirin should ultimately depend on a woman's personal risk
factors.
C. How and When Do
Expert Emergency Physicians Generate and Evaluate Diagnostic Hypotheses? A
Qualitative Study Using Head-Mounted Video Cued-Recall Interviews
Results:
The emergency physicians generated an average of 5 diagnostic hypotheses. Most
of these hypotheses were generated before meeting the patient or within the
first 5 minutes of the meeting. The hypotheses were then rank ordered within
the context of a verification procedure based on identifying key information.
These tasks were usually accomplished without conscious effort. No hypothesis
was completely confirmed or refuted until the results of investigations were
available.
D. Group recommends high
fluid intake to prevent kidney stones
The
American College of Physicians released new guidelines urging people with
kidney stones to drink the amount of fluid needed to produce two liters of
urine per day in order to prevent the formation of more kidney stones. If high
fluid intake isn't effective, taking a thiazide diuretic or citrate could help,
the group said. The recommendations were published in the Annals of Internal
Medicine.
E. High-dose flu vaccine
may work better for frail seniors
A
high-dose flu shot appeared to be more effective than the standard vaccine in
protecting frail seniors in nursing homes against influenza, according to a
study in the Journal of Infectious Diseases. Researchers said the high-dose
vaccine elicited a greater immune response against nearly all flu strains.
F. Superspreaders tied
to 80% of certain infectious disease transmissions
So-called
superspreaders represent 20% of the population yet spread 80% of certain viral
and bacterial infections, but the reasons some people spread more disease than
others are not well understood. Research published in the Proceedings of the
National Academy of Science suggests that superspreaders may have a higher
level of tolerance to antibiotics and viral or bacterial disturbances. It's
also possible coinfections or lowered immunity are to blame.
G. Medicare Reforms
Reduce Hospital-Acquired Conditions
The
2008 Centers for Medicare & Medicaid Services (CMS) payment reform includes
a refusal to pay for treatment of certain preventable hospital-acquired
conditions. This refusal has translated into a lower incidence of
hospital-acquired pulmonary embolism (PE) or deep vein thrombosis (DVT) after
knee and hip replacement surgery.
H. Decreased facial
expression variability in patients with serious cardiopulmonary disease in the
emergency care setting
I. Editorial:
Progesterone for Traumatic Brain Injury — Resisting the Sirens' Song
Schwamm
LH, et al. N Engl J Med 2014; 371:2522-2523
The
results of two randomized, controlled trials of the neurosteroid progesterone
in patients with traumatic brain injury (TBI), now published in the Journal,
1,2 showed no benefit with respect to favorable functional outcome at 6 months,
as assessed by means of the Extended Glasgow Outcome Scale (GOS-E), or several
prespecified secondary outcomes. Both trials selected and stratified patients
on the basis of a Glasgow Coma Scale (GCS) score.
Abstracts:
http://www.nejm.org/doi/full/10.1056/NEJMoa1404304 http://www.nejm.org/doi/full/10.1056/NEJMoa1411090
