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)…
Full-text (free): http://www.bmj.com/content/349/bmj.g7094
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…
Full-text (free): http://www.bmj.com/content/349/bmj.g7179
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.
Full-text (free): http://www.bmj.com/content/349/bmj.g7346.long
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.
Full-text (free): http://www.bmj.com/content/349/bmj.g7184.long
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.
Full-text (free): http://www.bmj.com/content/349/bmj.g7073
F. Use of Google Translate in medical communication: evaluation of accuracy
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.
Full-text (free): http://www.bmj.com/content/349/bmj.g7392
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
Full-text (free): http://www.annemergmed.com/article/S0196-0644(14)01396-1/fulltext
B. Ebola Update from the NEJM: An Interactive Perspective
C. Health Care Worker Quarantine for Ebola: To Eradicate the Virus or Alleviate Fear?
Full-text (free): http://www.annemergmed.com/article/S0196-0644(14)01571-6/fulltext
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 .).
Full-text (free): http://www.nejm.org/doi/full/10.1056/NEJMoa1411587#t=article
Interventional Thrombectomy for Major Stroke — A Step in the Right Direction
Full-text (free): http://www.nejm.org/doi/full/10.1056/NEJMe1413346
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.
There is controversy about the efficacy of currently used treatment modalities to alleviate migraine headaches.
We aimed to evaluate and compare the effects of magnesium sulfate and combined use of dexamethasone/metoclopramide on relieving acute migraine headache.
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.
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).
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.
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.
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.
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.
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.
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).
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.
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.
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.
Full-text (free): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3913120/
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.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(14)01478-4/fulltext
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]
We compare the analgesic effectiveness of intranasal fentanyl and ketamine in children.
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.
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.
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.
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.
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%.
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).
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.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(13)00688-4/fulltext
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
We synthesize the available evidence on the effect of ketamine on intracranial and cerebral perfusion pressures, neurologic outcomes, ICU length of stay, and mortality.
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.
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.
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.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(14)00428-4/fulltext
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]
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]
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.
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.
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.
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.
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.
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
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.
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).
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.
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.
Research article (full-text free): http://www.ncbi.nlm.nih.gov/pubmed/25526794
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.
Full-text (free): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4174370/
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
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.
Wall Street Journal article: http://www.wsj.com/articles/the-20-who-spread-most-disease-1418686476