Saturday, December 06, 2014

Lit Bits: Dec 6, 2014

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%).

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  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.

Full-text of Figures and Tables here:

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.]

Associated editorial suggests caution:

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]

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).

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).

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.

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.

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.

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.

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.

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.

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.

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.

The traditional intraoral manual reduction of temporomandibular joint (TMJ) dislocations is time consuming, difficult, and at times ineffective, and commonly requires conscious sedation.

We describe a novel technique for the reduction of acute nontraumatic TMJ dislocations in the emergency department (ED).

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.

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.

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.

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.

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%).

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.

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

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

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

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

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.

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:

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]

Minor abrasions and skin tears are usually treated with gauze dressings and topical antibiotics requiring frequent and messy dressing changes.

We describe our experience with a low-cost, cyanoacrylate-based liquid dressing applied only once for minor abrasions and skin tears.

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.

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.

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.

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].

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.

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):

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.

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.

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.

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):

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…

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.


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

It works!