From the
recent medical literature…
1. BLS Outperforms ALS for Out-of-Hospital Cardiac Arrest
Ali S.
Raja, MD, MBA, MPH, FACEP reviewing Sanghavi P et al. JAMA Intern Med 2014 Nov
24 [Epub ahead of print]
Survival to
hospital discharge and neurological outcomes were better with basic than
advanced life support.
Patients
with out-of-hospital cardiac arrest are typically treated with advanced life
support (ALS) rather than basic life support (BLS). However, there is little
evidence of benefit for ALS, and the 2004 Ontario Prehospital Advanced Life
Support (OPALS) study found no improvements in survival or neurological outcome
after implementation of ALS protocols in 17 cities in Ontario (NEJM JW Emerg
Med Sep 29 2004). Given the significant resources allocated to ALS training and
response, these authors analyzed Medicare data to compare outcomes between
patients with out-of-hospital cardiac arrest treated with ALS and those treated
with BLS.
The
analysis included 32,935 patients, of whom 5% were treated with BLS. Patients
treated with ALS had lower rates of both survival to hospital discharge (9% vs.
13%) and survival to 90 days (5% vs. 8%). Among patients admitted to the
hospital, a higher proportion of those treated with ALS had poor neurological
outcomes (45% vs. 22%).
Comment:
Although
this study relied on administrative data, the authors use of propensity scores
and sensitivity analyses make their conclusions robust. It is time to refocus
our attention on improving access to proven BLS interventions, such as
high-quality early bystander cardiopulmonary resuscitation and early
defibrillation, instead of spending resources on ALS treatments with no
benefit.
2. A new and rapid method for epistaxis treatment using
injectable form of tranexamic acid topically: a RCT
Zahed R, Am
J Emerg Med. 2013 Sep;31(9):1389-92.
OBJECTIVE:
Epistaxis is a common problem in the emergency department (ED). Sixty percent
of people experience it at least once in their life. There are different kinds
of treatment for epistaxis. This study intended to evaluate the topical use of
injectable form of tranexamic acid vs anterior nasal packing with pledgets
coated with tetracycline ointment.
METHODS:
Topical application of injectable form of tranexamic acid (500 mg in 5 mL) was
compared with anterior nasal packing in 216 patients with anterior epistaxis
presented to an ED in a randomized clinical trial. The time needed to arrest
initial bleeding, hours needed to stay in hospital, and any rebleeding during
24 hours and 1 week later were recorded, and finally, the patient satisfaction
was rated by a 0-10 scale.
RESULTS:
Within 10 minutes of treatment, bleedings were arrested in 71% of the patients
in the tranexamic acid group, compared with 31.2% in the anterior nasal packing
group (odds ratio, 2.28; 95% confidence interval, 1.68-3.09; P less than .001).
In addition, 95.3% in the tranexamic acid group were discharged in 2 hours or
less vs 6.4% in the anterior nasal packing group (P less than .001). Rebleeding
was reported in 4.7% and 11% of patients during first 24 hours in the
tranexamic acid and the anterior nasal packing groups, respectively (P = .128).
Satisfaction rate was higher in the tranexamic acid compared with the anterior
nasal packing group (8.5 ± 1.7 vs 4.4 ± 1.8, P less than .001).
CONCLUSIONS:
Topical application of injectable form of tranexamic acid was better than
anterior nasal packing in the initial treatment of idiopathic anterior
epistaxis.
3. Epidemiology of Blunt Head Trauma in Children in U.S. EDs
Quayle KS,
et al. N Engl J Med 2014; 371:1945-1947
Traumatic
brain injury is the leading cause of death and disabilities in children older
than 1 year of age.1 Detailed data about head trauma in children are needed to
better understand the rates and unique age-related risks of injury. We examined
the characteristics of children with blunt head trauma from a large,
prospective, observational study conducted in the United States through the
Pediatric Emergency Care Applied Research Network (PECARN).
We
previously derived and validated prediction rules for clinically important
traumatic brain injuries in children with minor blunt head trauma in 25 PECARN
emergency departments from 2004 through 2006.2 In this planned secondary
analysis, we provide clinical details for the entire cohort of children with
head injuries of all severities, ranging from 3 (deep coma) to 15 (normal
neurologic status) on the Glasgow Coma Scale (GCS). We categorized children
into three age groups (less than 2 years, 2 to 12 years, and 13 to 17 years)
and three categories of head-injury severity on the basis of the initial GCS
score (mild [GCS score, 14 or 15], moderate [GCS score, 9 to 13], and severe
[GCS score, ≤8]).
Of the
57,030 eligible patients, 43,904 (77%) were enrolled. After exclusions, the
final study population was 43,399, and of these patients 98% had mild head
trauma. (The patients' demographic characteristics and mechanisms of injury are
described in Table 1 and in Table S1 and Figure S1 in the Supplementary
Appendix, available with the full text of this letter at NEJM.org.) Falls were the most frequent mechanism of
injury for children under the age of 12 years. Injuries among adolescents were
more frequently caused by assaults, sports activities, and motor vehicle
crashes. The top three mechanisms of injury according to age group are provided
in Table S2 in the Supplementary Appendix.
Cranial
computed tomography (CT) was performed in 15,908 of the 43,399 children (37%),
including 32% of those under the age of 2 years, 32% of those between the ages
of 2 and 12 years, and 53% of those between the ages of 13 and 17 years.
Traumatic brain injuries were identified in 1157 (7%) children who underwent
CT, and an additional 500 (3%) had skull fractures without intracranial
findings. Of all the children who were evaluated, 78 (0.2%) died.
The rate of
traumatic brain injury as seen on CT was 5% for children with mild injuries, 27%
for those with moderate injuries, and 65% for those with severe injuries.
Overall, subdural hematoma was the most common injury, followed by subarachnoid
hemorrhage and cerebral contusion, with great variability according to age and
GCS score (Tables S3 and S4 and Figure S2, S3, and S4 in the Supplementary
Appendix). Nearly half of children with traumatic brain injuries on CT had more
than one type of brain injury.
Neurosurgical
procedures were performed in 200 children (0.5%), representing 17% of those
with traumatic brain injuries identified on CT; 43% of these children underwent
more than one procedure. Types of neurosurgical procedures, stratified
according to age and GCS score, varied greatly (Tables S5 and S6 in the
Supplementary Appendix).
This prospective,
multicenter study provides more detailed and representative clinical and
radiographic information about the spectrum of traumatic brain injuries in
children than is available in previous studies of administrative databases or
from single institutions.3-5 Our findings may be useful in the development of
future injury-prevention measures and age-stratified targeted interventions,
such as campaigns to promote the use of bicycle helmets and automobile
restraints.
4. Expanding Uses of Ketamine
A. Prehospital
Use of IM Ketamine for Sedation of Violent and Agitated Patients
Scheppke KA, et al. West J Emerg Med 2014;15(7):
Introduction: Violent and agitated patients pose a serious challenge for
emergency medical services (EMS) personnel. Rapid control of these patients is
paramount to successful prehospital evaluation and also for the safety of both
the patient and crew. Sedation is often required for these patients, but the
ideal choice of medication is not clear. The objective is to demonstrate that
ketamine, given as a single intramuscular injection for violent and agitated
patients, including those with suspected excited delirium syndrome (ExDS), is
both safe and effective during the prehospital phase of care, and allows for
the rapid sedation and control of this difficult patient population.
Methods: We reviewed paramedic run sheets from five different catchment
areas in suburban Florida communities. We identified 52 patients as having been
given intramuscular ketamine 4mg/kg IM, following a specific protocol devised
by the EMS medical director of these jurisdictions, to treat agitated and violent
patients, including a subset of which would be expected to suffer from ExDS.
Twenty-six of 52 patients were also given parenteral midazolam after medical
control was obtained to prevent emergence reactions associated with ketamine.
Results: Review of records demonstrated that almost all patients (50/52)
were rapidly sedated and in all but three patients no negative side effects
were noted during the prehospital care. All patients were subsequently
transported to the hospital before ketamine effects wore off.
Conclusion: Ketamine may be safely and effectively used by trained
paramedics following a specific protocol. The drug provides excellent efficacy
and few clinically significant side effects in the prehospital phase of care,
making it an attractive choice in those situations requiring rapid and safe
sedation especially without intravenous access. [West J Emerg Med.
2014;15(7):–0.]
Full-text (free): http://www.escholarship.org/uc/item/64p9m3xt#
Associated editorial suggests caution: http://www.escholarship.org/uc/item/6kx2b3q7
B. The First
500: initial experience with widespread use of low-dose ketamine for acute pain
management in the ED
Ahern TL,
et al. Amer J Emerg Med. 2014 Nov 14 [Epub ahead of print]
Objectives
To describe
the clinical use and safety profile of low-dose ketamine (LDK; (0.1-0.3mg/kg))
for pain management in the emergency department (ED).
Methods
This was a
retrospective case series of consecutive patients given LDK for pain at a
single urban ED between 2012–2013. Using a standardized data abstraction form,
two physicians reviewed patient records to determine demographics, indication,
dose, route, disposition and occurrence of adverse events. Adverse events were
categorized as minor (emesis, psychomimetic or dysphoric reaction, transient
hypoxia) and serious (apnea, laryngospasm, hypertensive emergency, cardiac
arrest). Additional parameters measured were heart rate (HR) and systolic blood
pressure (SBP).
Results
530
patients received LDK in the ED over a two-year period. Indications for LDK
were diverse. Median patient age was 41 years, 55% were women and 63% were
discharged. Route of administration was intravenous (IV) in 93% and
intramuscular (IM) in 7%. Most patients (92%) received a dose of 10-15mg.
Co-morbid diseases included hypertension (26%), psychiatric disorder (12%),
obstructive airway disease (11%) and coronary artery disease (4%). There was no
significant change in HR or SBP. 30 patients (6%) met our criteria for adverse
events. Eighteen patients (3.5%) experienced psychomimetic or dysphoric
reactions. Seven patients (1.5%) developed transient hypoxia. Five patients
(1%) had emesis. There were no cases of serious adverse events. Agreement
between abstractors was almost perfect.
Conclusion
Use of LDK
as an analgesic in a diverse ED patient population appears to be safe and
feasible for the treatment of many types of pain.
5. Ultrasound-Guided Central Venous Access Using Google Glass
Wu TS, et
al. J Emerg Med. 2014;47:668-675.
Background
The use of
ultrasound during invasive bedside procedures is quickly becoming the standard
of care. Ultrasound machine placement during procedures often requires the
practitioner to turn their head during the procedure to view the screen. Such
turning has been implicated in unintentional hand movements in novices. Google
Glass is a head-mounted computer with a specialized screen capable of
projecting images and video into the view of the wearer. Such technology may
help decrease unintentional hand movements.
Objective
Our aim was
to evaluate whether or not medical practitioners at various levels of training
could use Google Glass to perform an ultrasound-guided procedure, and to
explore potential advantages of this technology.
Methods
Forty
participants of varying training levels were randomized into two groups. One
group used Google Glass to perform an ultrasound-guided central line. The other
group used traditional ultrasound during the procedure. Video recordings of eye
and hand movements were analyzed.
Results
All
participants from both groups were able to complete the procedure without
difficulty. Google Glass wearers took longer to perform the procedure at all
training levels.
Conclusions
In this
study, it was possible to perform ultrasound-guided procedures with Google
Glass. Google Glass wearers, on average, took longer to gain access, and had
more needle redirections, but less head movements were noted.
6. Bronchiolitis, Simplified
Ryan
Radecki, MD. EM Lit of Note. November 26, 2014
There are
new guidelines from the American Academy of Pediatrics, just in time for the
2014-15 bronchiolitis season looming on the horizon – as if we don't have
enough to worry about with influenza and various West African hemorrhagic
fevers.
But, the
good news – these guidelines substantially reduce the things you have to
remember to do for bronchiolitis.
Specifically, the only evidence-supported intervention you have is: supportive care.
Ineffective,
or of inadequate risk/benefit, treatments:
- A trial of bronchodilators, such as albuterol or salbutamol.
- Nebulized epinephrine.
- Nebulized hypertonic saline, except possibly those requiring hospitalization.
- Systemic or inhaled corticosteroids.
- Chest physiotherapy.
… which
basically covers everything.
And, not
inconsistent with a recent trial regarding the misleading clinical weight of
pulse oximetry, the guidelines state it is reasonable not to perform continuous
oximetry on infants and children with bronchiolitis, and set 90% as an
acceptable oxygen saturation. Finally,
the authors also state routine chest radiography should be avoided, as
abnormalities are common in bronchiolitis – thus leading to ineffective, and
harmful, antibiotic administration.
Simply put
– do no harm!
Reference: Ralston
SL, et al. AAP clinical practice guideline: the diagnosis, management, and
prevention of bronchiolitis. Pediatrics. 2014 Nov;134(5):e1474-502.
Full-text
(free): http://pediatrics.aappublications.org/content/134/5/e1474.full
7. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange
(THRIVE): a physiological method of increasing apnoea time in patients with
difficult airways
Patel A, et
al. Anaesthesia 2014 Nov 10 [Epub ahead of print]
Emergency
and difficult tracheal intubations are hazardous undertakings where successive
laryngoscopy–hypoxaemia–re-oxygenation cycles can escalate to airway loss and
the ‘can't intubate, can't ventilate’ scenario.
Between
2013 and 2014, we extended the apnoea times of 25 patients with difficult
airways who were undergoing general anaesthesia for hypopharyngeal or
laryngotracheal surgery. This was achieved through continuous delivery of
transnasal high-flow humidified oxygen, initially to provide pre-oxygenation,
and continuing as post-oxygenation during intravenous induction of anaesthesia
and neuromuscular blockade until a definitive airway was secured. Apnoea time
commenced at administration of neuromuscular blockade and ended with
commencement of jet ventilation, positive-pressure ventilation or
recommencement of spontaneous ventilation. During this time, upper airway
patency was maintained with jaw-thrust.
Transnasal
Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) was used in 15
males and 10 females. Mean (SD [range]) age at treatment was 49 (15 [25–81])
years. The median (IQR [range]) Mallampati grade was 3 (2–3 [2–4]) and direct
laryngoscopy grade was 3 (3–3 [2–4]). There were 12 obese patients and nine
patients were stridulous. The median (IQR [range]) apnoea time was 14 (9–19
[5–65]) min. No patient experienced arterial desaturation less than 90%. Mean
(SD [range]) post-apnoea end-tidal (and in four patients, arterial) carbon
dioxide level was 7.8 (2.4 [4.9–15.3]) kPa. The rate of increase in end-tidal
carbon dioxide was 0.15 kPa.min−1.
We conclude
that THRIVE combines the benefits of ‘classical’ apnoeic oxygenation with
continuous positive airway pressure and gaseous exchange through flow-dependent
deadspace flushing. It has the potential to transform the practice of
anaesthesia by changing the nature of securing a definitive airway in emergency
and difficult intubations from a pressured stop–start process to a smooth and
unhurried undertaking.
8. The “Syringe” Technique: A Hands-Free Approach for the
Reduction of Acute Nontraumatic TMJ Dislocations in the ED
Gorchynski
J, et al. J Emerg Med 2014;47:676-681.
Background
The
traditional intraoral manual reduction of temporomandibular joint (TMJ)
dislocations is time consuming, difficult, and at times ineffective, and
commonly requires conscious sedation.
Objectives
We describe
a novel technique for the reduction of acute nontraumatic TMJ dislocations in the
emergency department (ED).
Methods
This study
was a prospective convenience sample population during a 3-year period at two
university teaching-hospital EDs where acute nontraumatic TMJ dislocations were
reduced utilizing our syringe technique. Demographics, mechanism, duration of
dislocation, and reduction time were collected. Briefly, the “syringe”
technique is a hands-free technique that requires a syringe to be placed
between the posterior molars as they slide over the syringe to glide the anteriorly
displaced condyle back into its normal anatomical position. Procedural sedation
or intravenous analgesia is not required.
Results
Of the 31
patients, the mean age was 38 years. Thirty patients had a successful reduction
(97%). The majority of dislocations were reduced in less than 1 min (77%). The
two most common mechanisms for acute TMJ dislocations were due to chewing (n =
19; 61%) and yawning (n = 8; 29%). There were no recurrent dislocations at
3-day follow-up.
Conclusion
We describe
a novel technique for the reduction of the acutely nontraumatic TMJ dislocation
in the ED. It is simple, fast, safe, and effective.
What does
this look like? Ryan Radecki can show us:
9. To Be Blunt: Are We Wasting Our Time? ED Thoracotomy
Following Blunt Trauma: A Systematic Review and Meta-Analysis
Slessor D,
et al. Ann Emerg Med 2014 Oct 22 [Epub ahead of print]
Study
objective
The role of
emergency department (ED) thoracotomy after blunt trauma is controversial. The
objective of this review is to determine whether patients treated with an ED
thoracotomy after blunt trauma survive and whether survivors have a good
neurologic outcome.
Methods
A
structured search was performed with MEDLINE, EMBASE, CINAHL, and PubMed.
Inclusion criteria were ED thoracotomy or out-of-hospital thoracotomy, cardiac
arrest or periarrest, and blunt trauma. Outcomes assessed were mortality and
neurologic result. The articles were appraised with the system designed by the
Institute of Health Economics of Canada. A fixed-effects model was used to
meta-analyze the data. Heterogeneity was assessed with the I2 statistic.
Results
Twenty-seven
articles were included in the review. All were case series. Of 1,369 patients
who underwent an ED thoracotomy, 21 (1.5%) survived with a good neurologic
outcome. All 21 patients had vital signs present on scene or in the ED and a
maximum duration of cardiopulmonary resuscitation of 11 to 15 minutes. Thirteen
studies were included in the meta-analysis. If there were either vital signs or
signs of life present in the ED, the probability of a poor outcome was 99.2%
(95% confidence interval 96.4% to 99.7%).
Conclusion
There may
be a role for ED thoracotomy after blunt trauma, but only in a limited group of
patients. Good outcomes have been achieved for patients who had vital signs on
admission and for patients who received an ED thoracotomy within 15 minutes of
cardiac arrest. The proposed guideline should be used to determine which
patients should be considered for an ED thoracotomy, according to level 4
evidence.
10. Why a Return Visit to the ED? The Patient Perspective
Rising KL,
et al. Ann Emerg Med 2014 Sept 02 [Epub ahead of print]
Study
objective
Reasons for
recurrent emergency department (ED) visits have been examined primarily through
administrative data review. Inclusion of patients’ perspectives of reasons for
ED return may help inform future initiatives aimed at reducing recurrent
utilization. The objective of this study is to describe the personal
experiences and challenges faced by patients transitioning home after an ED
discharge.
Methods
We
performed semistructured qualitative interviews of adult patients with an
unscheduled return to the ED within 9 days of an index ED discharge. Questions
focused on problems with the initial discharge process, medications, outpatient
care access, social support, and health care decisionmaking. Themes were
identified with a modified grounded theory approach.
Results
Sixty
interviews were performed. Most patients were satisfied with the discharge
process at the index discharge, but many had complaints about the clinical care
delivered, including insufficient evaluation and treatment. The primary reason
for returning to the ED was fear or uncertainty about their condition. Most
patients had a primary care physician, but they rarely visited a physician
before returning to the ED. Patients cited convenience and more expedited
evaluations as primary reasons for seeking care in the ED versus the clinic.
Conclusion
Postdischarge
factors, including perceived inability to access timely follow-up care and
uncertainty and fear about disease progression, are primary motivators for
return to the ED. Many patients prefer hospital-based care because of increased
convenience and timely results. Further work is needed to develop alternative
pathways for patients to ask questions and seek guidance when and where they want.
11. Images in Clinical Practice
Female With Asymmetrically Dilated
Right Pupil
Gas Gangrene of a Prosthetic
Hip
An
82-year-old man with diabetes mellitus who had undergone a total hip
replacement 10 years earlier presented to the emergency department with the
acute onset of pain in the left hip and groin and a fever (temperature,
39.2°C). On presentation, the blood pressure was 96/57 mm Hg, and the
white-cell count was 12,400 per cubic milliliter. A radiograph and subsequent
computed tomographic scan of the hip (Panels A and B, respectively) showed free
air extending lateral to the greater trochanter and superior to the acetabular
component…
Corkscrew Esophagus
Emphysematous Pyelonephritis
A
67-year-old woman with diabetes and poor glycemic control who had recently been
treated for pyelonephritis presented to the emergency department in septic
shock. She had a 2-day history of fever, flank pain, lethargy, and confusion.
Blood tests showed leukocytosis and hyperglycemia. Urinary microscopy revealed
pyuria…
Enteroenteric Intussusception
12. Is Outpt Diverticulitis Management Safe?
Bottom
line: Yes! Serious adverse events in uncomplicated diverticulitis are rare, and
outpatient management could be selected as an option. Evidence that all
patients could be treated as outpatients is too scanty, and the decision should
still be individualized in each case.
Paolillo C,
et al. Is it safe to send home an uncomplicated diverticulitis? The DIVER trial.
Intern
Emerg Med. 2014 4 Dec
Background
Hospitalization,
bowel rest, intravenous fluids and antibiotic therapy are universally accepted
as the first choice treatment for mild diverticulitis [1]. Even if hospital
admission is presently considered essential, the majority of patients do not
develop a complicated disease and are treated medically, with fewer than 15 %
of patients requiring surgical intervention during the same admission [2]. For
this reason, there is increasing interest in the ambulatory management of
low-risk diverticulitis patients.
Summary
The Diver
trial was a multicenter, 2-arm, parallel, 1:1, randomized non-inferiority trial
[3]. The aim of the study was to determine the non-inferiority of home
treatment vs hospitalization in the management of patients with uncomplicated
left colonic diverticulitis.
Patients
with acute uncomplicated diverticulitis were randomly allocated to
hospitalization and usual treatment (group 1) or to outpatient management
(group 2). In this case, they were discharged from the emergency department
(ED), and called daily for 5 consecutive days by the study investigators.
All
patients admitted to the ED with a clinical suspicion of diverticulitis
underwent abdominal computed tomography (CT) with intravenous contrast
administration. The severity of diverticulitis was graded according to the
modified Hinchey classification (“Appendix”).
Patients
were eligible if they were older than 18 years, with uncomplicated
diverticulitis able to tolerate oral intake, and with good response to first
treatment measures in the ED: improvement of pain and fever, and willing to
continue treatment at home under supervision.
Exclusion
criteria were complicated colonic diverticulitis, absence of symptom relief,
pregnancy or breastfeeding, antibiotic treatment for colonic diverticulitis in
the previous month, colorectal cancer suspicion on the CT scan, concomitant
unstable comorbid conditions, immunosuppression, cognitive, social, or
psychiatric impairment, intolerance to oral intake and persisting vomiting, or
patients’ rejection of written consent.
The primary
end point of the trial was the treatment failure rate, defined as the
persistence, increase, or recurrence of abdominal pain or fever, inflammatory
bowel obstruction, need for radiological abscess drainage or immediate surgery
due to complicated diverticulitis, need for hospital admission, and mortality
during the first 60 days after discharge.
Secondary
end points included a quality-of-life assessment at days 14 and 60 after
discharge, and the evaluation of costs for both management strategies.
To evaluate
the primary end point, a 10 % non-inferiority boundary was used. Data were
analyzed by intention-to-treat.
All
patients in the study protocol were randomized to hospitalization (group 1) or
to outpatient management (group 2). The first dose of antibiotic treatment was
given intravenously to all patients of both groups in the ED. Antibiotic
treatment in both arms was discontinued after 10 days.
Seven
patients were readmitted because of treatment failure: 4 patients (6.1 %) in
group 1 and 3 patients (4.5 %) in group 2. No differences were observed between
the two groups (P = 0.619). No patients needed emergency surgery as a
consequence of readmission, and no death was observed.
The quality
of life was similar in both groups at 14 and 60 days. The overall healthcare
cost per episode was 3 times lower in group 2 as compared to group 1.
The rest of
the study, including strengths, weaknesses, and remaining questions, is free
online: http://link.springer.com/article/10.1007/s11739-014-1162-8/fulltext.html
13. Evaluation of a Liquid Dressing for Minor Nonbleeding
Abrasions and Class I and II Skin Tears in the ED
Singer AJ,
et al. J Emerg Med. 2014 Nov 20 [Epub ahead of press]
Background
Minor
abrasions and skin tears are usually treated with gauze dressings and topical
antibiotics requiring frequent and messy dressing changes.
Objective
We describe
our experience with a low-cost, cyanoacrylate-based liquid dressing applied
only once for minor abrasions and skin tears.
Methods
We
conducted a single-center, prospective, noncomparative study in adult emergency
department (ED) patients with minor nonbleeding skin abrasions and class I and
II skin tears. After cleaning the wound and achieving hemostasis, the wounds
were covered with a single layer of a cyanoacrylate liquid dressing. Patients
were followed every 1−2 days until healing.
Results
We enrolled
40 patients with 50 wounds including 39 abrasions and 11 skin tears. Mean
(standard deviation) age was 54.5 (21.9) years and 57.5% were male. Wounds were
located on the face (n = 16), hands (n = 14), legs (n = 11), and arms (n = 9).
Pain scores (0 to 10 from none to worst) after application of the liquid
dressing were 0 in 62% and 1−3 in the remaining patients. Follow-up was
available on 36 patients and 46 wounds. No wounds re-bled and there were no
wound infections. Only one wound required an additional dressing. Median
(interquartile range [IQR]) time to complete sloughing of the adhesive was 7
(5.5–8) days. Median (IQR) time to complete healing and sloughing of the
overlying scab was 10 (7.4–14) days.
Conclusions
Our study
suggests that a single application of a low-cost cyanoacrylate-based liquid
adhesive is a safe and effective treatment for superficial nonbleeding
abrasions and class I and II skin tears that eliminates the need for topical
antibiotics and dressings.
14. Is epinephrine during cardiac arrest associated with worse
outcomes in resuscitated patients? [Yes!]
Dumas F, et
al. J Am Coll Cardiol. 2014 Dec 9;64(22):2360-7.
BACKGROUND:
Although epinephrine is essential for successful return of spontaneous
circulation (ROSC), the influence of this drug on recovery during the
post-cardiac arrest phase is debatable.
OBJECTIVES:
This study sought to investigate the relationship between pre-hospital use of
epinephrine and functional survival among patients with out-of-hospital cardiac
arrest (OHCA) who achieved successful ROSC.
METHODS: We
included all patients with OHCA who achieved successful ROSC admitted to a
cardiac arrest center from January 2000 to August 2012. Use of epinephrine was
coded as yes/no and by dose (none, 1 mg, 2 to 5 mg, more than 5 mg). A
favorable discharge outcome was coded using a Cerebral Performance Category 1
or 2. Analyses incorporated multivariable logistic regression, propensity
scoring, and matching methods.
RESULTS: Of
the 1,556 eligible patients, 1,134 (73%) received epinephrine; 194 (17%) of
these patients had a good outcome versus 255 of 422 patients (63%) in the
nontreated group (p less than 0.001). This adverse association of epinephrine
was observed regardless of length of resuscitation or in-hospital interventions
performed. Compared with patients who did not receive epinephrine, the adjusted
odds ratio of intact survival was 0.48 (95% confidence interval [CI]: 0.27 to
0.84) for 1 mg of epinephrine, 0.30 (95% CI: 0.20 to 0.47) for 2 to 5 mg of
epinephrine, and 0.23 (95% CI: 0.14 to 0.37) for more than 5 mg of epinephrine.
Delayed administration of epinephrine was associated with worse outcome.
CONCLUSIONS:
In this large cohort of patients who achieved ROSC, pre-hospital use of
epinephrine was consistently associated with a lower chance of survival, an
association that showed a dose effect and persisted despite post-resuscitation
interventions. These findings suggest that additional studies to determine if and
how epinephrine may provide long-term functional survival benefit are needed.
Associated
essay in MedPage Today: http://www.medpagetoday.com/Cardiology/Arrhythmias/48884
15. Pneumothorax is a rare complication of thoracic central
venous catheterization in community EDs
Vinson DR, et
al, for the CREST Network Investigators. Amer J Emerg Med. 2014 Oct 17 [Epub
ahead of print].
Introduction
Central
venous catheterization can be a mainstay for the delivery of fluids and
medications to patients without peripheral access and those who are critically
ill or injured. The success and safety of the procedure has improved
significantly in this era of ultrasound use (1,2). Yet there remain valid
concerns about mechanical, infectious and thromboembolic complications. Among
the most threatening mechanical complications that immediately attend thoracic
central line placement is pneumothorax. Iatrogenic pneumothorax directly
effects patient morbidity, as it often requires an evacuation procedure.
Moreover, this complication is known to increase healthcare resource use and
mortality. The US Agency for Healthcare Research and Quality found in 2012 that
iatrogenic pneumothorax was associated with 4.4 days of extra hospitalization,
over $17,000 in additional hospital charges, and 7.0% excess mortality (3).
The rates
of central venous catheterization in emergency medicine have been on the
rise.4, 5 Nearly all emergency medicine research on central venous
catheterization, however, has been performed in an academic setting (6-12).
Moreover, the bulk of the literature on the incidence of iatrogenic
pneumothorax has examined the procedure in the hands of intensivists,
anesthesiologists, and surgeons. Less is known about the safety of the
procedure in the community emergency department (ED) setting, where the
majority of emergency care in the United States is provided (13). A more
accurate estimation of these contemporary complication rates are needed to help
inform the risk/benefit calculus of this common procedure. This is particularly
important since emergency physicians report that the risk of iatrogenic
complications is an impediment to central venous catheterization (14). In
addition, informed consent undertaken by emergency physicians has resulted in
as many as one-fourth of patients refusing central venous catheterization after
hearing of the perceived procedural risks (15).
We
undertook this secondary analysis of two retrospective cohort studies with two
aims in mind: (1) to estimate the incidence of immediate iatrogenic
pneumothorax following thoracic central venous catheterization in community
EDs; (2) to determine the association between vein site (internal jugular vs
subclavian), initial catheterization site failure, and positive pressure
ventilation on pneumothorax rates.
Abstract
Study
objectives: The rate of iatrogenic pneumothorax associated with thoracic
central venous catheterization in community emergency departments (EDs) is
poorly described, although such information is vital to inform the procedure’s
risk/benefit analysis. We undertook this multicenter study to estimate the
incidence of immediate catheter-related pneumothorax in community EDs and to
determine associations with site of access, failed access, and positive
pressure ventilation.
Methods:
This was a secondary analysis of 2 retrospective cohort studies of adultswho
underwent attempted thoracic central venous catheterization in 1 of 21 EDs.
Pneumothorax was identified by post-procedural anteroposterior chest radiograph
or emergent evacuation for presumed tension pneumothorax. Frequencies were
compared using Fisher's exact test.
Results:
Among 1249 patient encounters, the initial vein of catheterization was internal
jugular in 1054 cases (84.4%) and subclavian in 195 cases (15.6%). Success at
the initial internal jugular vein was more common than at the initial
subclavian vein (95.4% vs 83.6%, P b .001). Peri-procedural positive pressure
ventilation was administered in 316 patients (25.3%). We identified 6
pneumothoraces (0.5%; 95% confidence interval, 0.2%-1.1%). The incidence of
pneumothorax was higher with the subclavian vein than the internal jugular vein
(2.3% vs 0.1%,
P less than.001),
with failed access at the initial vein (2.5% vs 0.3%, P=.05), and among
patients receiving positive pressure ventilation (1.6% vs 0.1%, P less than .01).
Conclusion:
The incidence of pneumothorax from thoracic central venous catheterization in
community EDs is low. The risk of pneumothorax is higher with a subclavian vein
approach, failed access at the initial vein, and positive pressure ventilation.
16. Ann Emerg Med Evidence-based Reviews
A. What Is the Best First-Line Agent
for Benzodiazepine-Resistant Convulsive Status Epilepticus?
Who Knows.
Or in the words of the authors, “There is a lack of high-quality evidence to
support one medication over another in the treatment of
benzodiazepine-resistant convulsive status epilepticus.”
Full-text (free): http://www.annemergmed.com/article/S0196-0644(14)00330-8/fulltext
Full-text (free): http://www.annemergmed.com/article/S0196-0644(14)00330-8/fulltext
B. Are Antifibrinolytic Agents
Effective in the Treatment of Aneurysmal Subarachnoid Hemorrhage?
Antifibrinolytic
agents for the treatment of patients with aneurysmal subarachnoid hemorrhage
may decrease rebleeding but appear to increase cerebral ischemia and do not
reduce mortality or severe disability.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(14)00497-1/fulltext
C. Can Heimlich Valves Along With
Intercostal Catheters Be Used to Safely Manage Pneumothoraces for Outpatients?
Heimlich
valves attached to intercostal catheters may allow ambulatory management of
spontaneous pneumothorax; however, further randomized trials comparing the
safety and efficacy to standard chest tube or needle aspiration are needed.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(14)00414-4/fulltext
D. Are Inhaled Steroids Beneficial
on Discharge From the Emergency Department for Acute Asthma?
Inhaled
corticosteroids, either in conjunction with or in place of oral steroids, do
not reduce acute asthma relapse rates compared with standard oral steroid
therapy after emergency department (ED) discharge for acute asthma.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(14)00591-5/fulltext
E. Is It Time to Raise the Bar?
Age-Adjusted D-dimer Cutoff Levels for Excluding Pulmonary Embolism
The Journal
Club discussion.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(14)01112-3/fulltext
Full-text (free): http://www.annemergmed.com/article/S0196-0644(14)01112-3/fulltext
17. Relation of NSAIDs to Serious Bleeding and Thromboembolism
Risk in Patients with AF Receiving Antithrombotic Therapy: A Nationwide Cohort
Study
Lamberts L,
et al. Ann Intern Med.
2014;161(10):690-698.
Background:
Nonsteroidal anti-inflammatory drugs (NSAIDs) are assumed to increase bleeding
risk, but their actual relation to serious bleeding in patients with atrial
fibrillation (AF) who are receiving antithrombotic medication is unknown.
Objective:
To investigate the risk for serious bleeding and thromboembolism associated
with ongoing NSAID and antithrombotic therapy.
Design:
Observational cohort study.
Setting:
Nationwide registries.
Patients:
Danish patients with AF hospitalized between 1997 and 2011.
Measurements:
Absolute risk for serious bleeding and thromboembolism with ongoing NSAID and
antithrombotic therapy, assessed by using Cox models.
Results: Of
150 900 patients with AF (median age, 75 years [interquartile range, 65 to 83
years]; 47% female), 53 732 (35.6%) were prescribed an NSAID during a median
follow-up of 6.2 years (interquartile range, 2.1 to 14.0 years). There were 17
187 (11.4%) and 19 561 (13.0%) occurrences of serious bleeding and
thromboembolism, respectively. At 3 months, the absolute risk for serious
bleeding within 14 days of NSAID exposure was 3.5 events per 1000 patients
compared with 1.5 events per 1000 patients without NSAID exposure. The risk
difference was 1.9 events per 1000 patients. In patients selected for oral
anticoagulant therapy, the absolute risk difference was 2.5 events per 1000
patients. Use of NSAIDs was associated with increased absolute risks for
serious bleeding and thromboembolism across all antithrombotic regimens and
NSAID types. An NSAID dosage above the recommended minimum was associated with
a substantially increased hazard ratio for bleeding.
Limitation:
Observational design and unmeasured confounders.
Conclusion:
Use of NSAIDs was associated with an independent risk for serious bleeding and
thromboembolism in patients with AF. Short-term NSAID exposure was associated
with increased bleeding risk. Physicians should exercise caution with NSAIDs in
patients with AF.
18. Violence against women and girls
The Lancet.
November 21, 2014
Executive
summary
Every day,
millions of women and girls worldwide experience violence. This abuse takes
many forms, including intimate physical and sexual partner violence, female
genital mutilation, child and forced marriage, sex trafficking, and rape. The
Lancet Series on Violence against women and girls shows that such abuse is
preventable. Five papers cover the evidence base for interventions, discuss the
vital role of the health sector in care and prevention, show the need for men
and women to be involved in effective programmes, provide practical lessons
from experience in countries, and present a call for action with five key
recommendations and indicators to track progress.
19. Platelet Transfusion: A Clinical Practice Guideline From the
AABB
Ann Intern
Med. 11 November 2014 [Epub ahead of print]
Background:
Platelet transfusions are administered to prevent or treat bleeding in patients
with quantitative or qualitative platelet disorders. The AABB (formerly, the
American Association of Blood Banks) developed this guideline on appropriate
use of platelet transfusion in adult patients.
Methods:
These guidelines are based on a systematic review of randomized, clinical
trials and observational studies that reported clinical outcomes on patients
receiving prophylactic or therapeutic platelet transfusions. A literature
search from 1900 to September 2014 with no language restrictions was done.
Examined outcomes included all-cause mortality, bleeding-related mortality,
bleeding, and number of platelet units transfused. An expert panel reviewed the
data and developed recommendations using the Grading of Recommendations
Assessment, Development and Evaluation (GRADE) framework.
Recommendation
1: The AABB recommends that platelets should be transfused prophylactically to
reduce the risk for spontaneous bleeding in hospitalized adult patients with
therapy-induced hypoproliferative thrombocytopenia. The AABB recommends transfusing hospitalized adult patients with a
platelet count of 10 × 109 cells/L or less to reduce the risk for
spontaneous bleeding. The AABB recommends transfusing up to a single
apheresis unit or equivalent. Greater doses are not more effective, and lower
doses equal to one half of a standard apheresis unit are equally effective
(Grade: strong recommendation; moderate-quality evidence).
Recommendation
2: The AABB suggests prophylactic platelet transfusion for patients having elective central venous catheter placement
with a platelet count less than 20 × 109 cells/L (Grade: weak
recommendation; low-quality evidence).
Recommendation
3: The AABB suggests prophylactic platelet transfusion for patients having elective diagnostic lumbar puncture with a
platelet count less than 50 × 109 cells/L (Grade: weak
recommendation; very low-quality evidence).
Recommendation
6: The AABB cannot recommend for or
against platelet transfusion for patients receiving antiplatelet therapy who
have intracranial hemorrhage (traumatic or spontaneous) (Grade: uncertain
recommendation; very low-quality evidence).
20. Ditch the Spine Board
Kroll M, et
al. Emergency Physicians Monthly. November 6, 2014
Reflexively
placing a patient in spinal immobilization can adversely affect breathing and
airway management, but do those possibilities outweigh the dangers of not
immobilizing?
It’s the
middle of the night when the paramedics roll into the ED with a pedestrian that
was struck by a car. The patient reports that the car came around the corner
and hit his leg. He remembers everything about the accident and complains only
of his leg hurting. He appears to have an open, compound fracture to his leg,
which was splinted in the field. In addition, the paramedics inform you that,
on his initial exam, he did not have any midline neck tenderness or any pain
with full range of motion. However, secondary to his distracting injury, a
C-collar and backboard were placed on the patient. After the paramedics leave,
you’re left wondering what the evidence is on C-collar immobilization, and if
it was really necessary to place a collar and backboard this patient without
any neck or back pain.
What’s the
literature say? Ah, read on…
21. Micro Lit Bits
A. An Empty Toolbox: Hydrocodone to
Schedule II
A recent
federal Drug Enforcement Administration (DEA) decision has some emergency
physicians scrambling to comply so they can continue to prescribe common pain
medications. Effective October 6, 2014, the DEA has rescheduled hydrocodone
combination products (HCPs) such as Norco from schedule III to schedule II.1
The change
comes as prescription drug abuse, including HCPs, has overtaken automobile
accidents as a leading cause of death in the United States, killing
approximately 100 people a day, according to Centers for Disease Control and
Prevention statistics. Emergency physicians acknowledged the addiction problem
but worried that the DEA move might be ineffective in battling the problem, or,
worse, might have unintended consequences that exacerbate it.
Under
federal law, schedule II controlled substances merely require a physician’s
signature for a prescription.2 However, many states such as Texas and
California have passed detailed laws and regulations governing the prescription
of schedule II controlled substances. Originally, this meant the physician had
to use triplicate prescription pads. Currently, Texas, California, and several
other states require the use of restricted tamper-resistant prescription forms
for schedule II controlled substances…
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(14)01407-3/fulltext
B. Nonobstructive CAD Not Benign
Conclusion:
In this cohort of patients undergoing elective coronary angiography,
nonobstructive CAD, compared with no apparent CAD, was associated with a
significantly greater 1-year risk of MI and all-cause mortality. These findings
suggest clinical importance of nonobstructive CAD and warrant further
investigation of interventions to improve outcomes among these patients.
Abstract: http://jama.jamanetwork.com/article.aspx?articleid=1920971
Abstract: http://jama.jamanetwork.com/article.aspx?articleid=1920971
C. Association of Inpatient vs
Outpatient Onset of ST-Elevation Myocardial Infarction With Treatment and
Clinical Outcomes
D. Many people
wrongly believe they are allergic to penicillin, studies show
Most people
who think they are allergic to penicillin actually are not and tested negative
for penicillin allergy, according to two studies presented at a meeting of the
American College of Allergy, Asthma and Immunology. The findings suggest the
importance of testing patients for penicillin and other antibiotic allergy to
avoid the use of alternate drugs that are more expensive or potentially toxic,
experts said.
E. Pacemakers Get Hacked on TV, but
Could It Happen in Real Life?
F. FDA: Children under 2 should not
receive OTC meds for cough, colds
The FDA has
cautioned that over-the-counter drugs for cough and colds should not be used in
children younger than 2 years, as such medications may trigger adverse side
effects. "A cold is self-limited, and patients will get better on their
own in a week or two without any need for medications. For older children, some
OTC medicines can help relieve the symptoms -- but won't change the natural
course of the cold or make it go away faster," said FDA official Amy
Taylor.
G. Hyperkalemia Pipeline Promising
New drugs
under study.
H. Overuse of anti-clotting drugs
may increase dementia risk
A study
presented at the American Heart Association meeting found that patients with
atrial fibrillation who showed signs of overtreatment with anti-clotting drugs
had a twofold greater risk of developing dementia. The results suggest that
microbleeds may cause chronic brain injury and could be a contributing factor
to the link between atrial fibrillation and dementia, said an expert.
I: Study links readmission risks for
elderly to poor neighborhoods
Data on
almost 256,00 Medicare patients showed those living in the poorest
neighborhoods had a higher rate of hospital readmission for heart disease or
pneumonia than those in other areas, University of Wisconsin researchers
reported in the Annals of Internal Medicine. Researcher Amy Kind said seniors
in poorer areas may have trouble getting their prescriptions filled or
following a healthy diet and tend to rely on support networks for help.
J. Long-Term Safety and Efficacy of
Factor IX Gene Therapy in Hemophilia B
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