Monday, February 23, 2015

Lit Bits: Feb 23, 2015

From the recent medical literature...

1. Challenging the AAP 2014 Bronchiolitis Guidelines: Bonfire of the Evidence

Walsh P, et al. West J Emerg Med 2015;16:85-88.

The American Academy of Pediatrics (AAP) 2014 Bronchiolitis guidelines (the guidelines) were recently published in the official journal of the AAP, Pediatrics.1 The committee that wrote the guidelines anticipates that these will form the basis of bronchiolitis treatment throughout the house of medicine, not just in pediatricians’ offices. Emergency physicians may well encounter pressure to follow these guidelines from their pediatric colleagues who, not unreasonably, rely on guidelines from their professional organization.

However, two key recommendations in these guidelines could substantially change pediatric emergency medicine practice. These recommendations are (1) to not use even a trial of bronchodilators and (2) to regard oxygen saturations of 90% rather than 92%-94% as the degree of hypoxia at which oxygen should be administered.

Neither of these recommendations is sufficiently justified by the evidence and both are potentially harmful…

2. Diagnosing Acute HF in Patients with Undifferentiated Dyspnea: A Lung and Cardiac Ultrasound (LuCUS) Protocol.

Russell FM, et al. Acad Emerg Med. 2015 Feb;22(2):182-91.

OBJECTIVES: The primary goal of this study was to determine accuracy for diagnosing acutely decompensated heart failure (ADHF) in the undifferentiated dyspneic emergency department (ED) patient using a lung and cardiac ultrasound (LuCUS) protocol. Secondary objectives were to determine if US findings acutely change management and if findings are more accurate than clinical gestalt.

METHODS: This was a prospective, observational study of adult patients presenting to the ED with undifferentiated dyspnea. The intervention consisted of a 12-view LuCUS protocol performed by experienced emergency physician sonographers. The primary objective was measured by comparing US findings to the final diagnosis independently determined by two physicians blinded to the LuCUS result. Acute treatment changes based on US findings were tracked in real time through a standardized data collection form.

RESULTS: Data on 99 patients were analyzed; ADHF was the final diagnosis in 36%. The LuCUS protocol had sensitivity of 83% (95% confidence interval [CI] = 67% to 93%), specificity of 83% (95% CI = 70% to 91%), positive likelihood ratio of 4.8 (95% CI = 2.7 to 8.3), and negative likelihood ratio of 0.20 (95% CI = 0.09 to 0.42). Forty-seven percent of patients had changes in acute management, and 42% had changes in acute treatment. Observed agreement for the LuCUS protocol was 93% between coinvestigators. Overall, accuracy improved by 20% (83% vs. 63%, 95% CI = 8% to 31% for the difference) over clinical gestalt alone.

CONCLUSIONS: The LuCUS protocol may accurately identify ADHF and may improve acute clinical management in dyspneic ED patients. This protocol has improved diagnostic accuracy over clinical gestalt alone.

3. A randomized trial of icatibant in ACE-inhibitor-induced angioedema.

Baş M, et al. N Engl J Med. 2015 Jan 29;372(5):418-25.

Angioedema induced by treatment with angiotensin-converting–enzyme (ACE) inhibitors accounts for one third of angioedema cases in the emergency room; it is usually manifested in the upper airway and the head and neck region. There is no approved treatment for this potentially life-threatening condition.

In this multicenter, double-blind, double-dummy, randomized phase 2 study, we assigned patients who had ACE-inhibitor–induced angioedema of the upper aerodigestive tract to treatment with 30 mg of subcutaneous icatibant, a selective bradykinin B2 receptor antagonist, or to the current off-label standard therapy consisting of intravenous prednisolone (500 mg) plus clemastine (2 mg). The primary efficacy end point was the median time to complete resolution of edema.

All 27 patients in the per-protocol population had complete resolution of edema. The median time to complete resolution was 8.0 hours (interquartile range, 3.0 to 16.0) with icatibant as compared with 27.1 hours (interquartile range, 20.3 to 48.0) with standard therapy (P=0.002). Three patients receiving standard therapy required rescue intervention with icatibant and prednisolone; 1 patient required tracheotomy. Significantly more patients in the icatibant group than in the standard-therapy group had complete resolution of edema within 4 hours after treatment (5 of 13 vs. 0 of 14, P=0.02). The median time to the onset of symptom relief (according to a composite investigator-assessed symptom score) was significantly shorter with icatibant than with standard therapy (2.0 hours vs. 11.7 hours, P=0.03). The results were similar when patient-assessed symptom scores were used.

Among patients with ACE-inhibitor–induced angioedema, the time to complete resolution of edema was significantly shorter with icatibant than with combination therapy with a glucocorticoid and an antihistamine. (Funded by Shire and the Federal Ministry of Education and Research of Germany; number,NCT01154361.)

4. Transfuse Plasma, Platelets, and Red Blood Cells in a 1:1:1 Ratio in Trauma Patients

Daniel J. Pallin, MD, MPH reviewing Holcomb JB et al. JAMA 2015 Feb 3.

Compared with a 1:1:2 ratio, the 1:1:1 ratio improved hemostasis without causing more adverse effects, although mortality did not differ.

In recent years, the dogma regarding large-volume crystalloid resuscitation in trauma patients has changed, with increased emphasis on including plasma and platelets in addition to red blood cells in the immediate resuscitation protocol (NEJM JW Emerg Med May 8 2009 and NEJM JW Emerg Med Oct 8 2014). The long-awaited PROPPR trial compared the safety and efficacy of transfusion of plasma, platelets, and red blood cells in a 1:1:1 ratio versus a 1:1:2 ratio in 680 severely injured patients presenting to 12 North American trauma centers.

Mortality at 24 hours and 30 days (the primary outcomes) did not differ significantly between the 1:1:1 group and the 1:1:2 group (13% and 17% at 24 hours; 22% and 26% at 30 days). Significantly fewer patients in the 1:1:1 group exsanguinated (9.2% vs. 14.6%) and significantly more patients in the 1:1:1 group achieved hemostasis (86% vs. 78%). There were no significant differences between groups in incidence of acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, transfusion-related complications, or other adverse effects.

5. Differentiation between traumatic tap and aneurysmal SAH: prospective cohort study.

Perry JJ, et al. BMJ. 2015 Feb 18;350:h568.

OBJECTIVES: To describe the findings in cerebrospinal fluid from patients with acute headache that could distinguish subarachnoid hemorrhage from the effects of a traumatic lumbar puncture.

DESIGN: A substudy of a prospective multicenter cohort study.

SETTING: 12 Canadian academic emergency departments, from November 2000 to December 2009.

PARTICIPANTS: Alert patients aged over 15 with an acute non-traumatic headache who underwent lumbar puncture to rule out subarachnoid hemorrhage.

MAIN OUTCOME MEASURE: Aneurysmal subarachnoid hemorrhage requiring intervention or resulting in death.

RESULTS: Of the 1739 patients enrolled, 641 (36.9%) had abnormal results on cerebrospinal fluid analysis with more than 1×10(6)/L red blood cells in the final tube of cerebrospinal fluid and/or xanthochromia in one or more tubes. There were 15 (0.9%) patients with aneurysmal subarachnoid hemorrhage based on abnormal results of a lumbar puncture. The presence of fewer than 2000×10(6)/L red blood cells in addition to no xanthochromia excluded the diagnosis of aneurysmal subarachnoid hemorrhage, with a sensitivity of 100% (95% confidence interval 74.7% to 100%) and specificity of 91.2% (88.6% to 93.3%).

CONCLUSION: No xanthochromia and red blood cell count below 2000×10(6)/L reasonably excludes the diagnosis of aneurysmal subarachnoid hemorrhage. Most patients with acute headache who meet this cut off will need no further investigations and aneurysmal subarachnoid hemorrhage can be excluded as a cause of their headache.

6. Effect of an ED Fast Track on Press-Ganey Patient Satisfaction Scores

Hwang CE, et al. West J Emerg Med 12015;16:34-38.

Introduction: Mandated patient surveys have become an integral part of Medicare remuneration, putting hundreds of millions of dollars in funding at risk. The Centers for Medicare & Medicaid Services (CMS) recently announced a patient experience survey for the emergency department (ED). Development of an ED Fast Track, where lower acuity patients are rapidly seen, has been shown to improve many of the metrics that CMS examines. This is the first study examining if ED Fast Track implementation affects Press-Ganey scores of patient satisfaction.

Methods: We analyzed returned Press-Ganey questionnaires from all ESI 4 and 5 patients seen 11AM - 11PM, August-December 2011 (pre-fast track), and during the identical hours of fast track, August-December 2012. Raw ordinal scores were converted to continuous scores for paired student t-test analysis. We calculated an odds ratio with 100% satisfaction considered a positive response.

Results: An academic ED with 52,000 annual visits had 140 pre-fast track and 85 fast track respondents. Implementation of a fast track significantly increased patient satisfaction with the following: wait times (68% satisfaction to 88%, OR 4.13, 95% CI [2.32-7.33]), doctor courtesy (90% to 95%, OR 1.97, 95% CI [1.04-3.73]), nurse courtesy (87% to 95%, OR 2.75, 95% CI [1.46-5.15]), pain control (79% to 87%, OR 2.13, 95% CI [1.16-3.92]), likelihood to recommend (81% to 90%, OR 2.62, 95% CI [1.42-4.83]), staff caring (82% to 91%, OR 2.82, 95% CI [1.54-5.19]), and staying informed about delays (66% to 83%, OR 3.00, 95% CI [1.65-5.44]).

Conclusion: Implementation of an ED Fast Track more than doubled the odds of significant improvements in Press-Ganey patient satisfaction metrics and may play an important role in improving ED performance on CMS benchmarks.

7. Survival to Hospital Discharge after Out-Of-Hospital Cardiac Arrest Is Increasing

Unadjusted survival to hospital discharge among adults increased from 8.2% in 2006 to 10.4% in 2010.

Daya MR, et al. Out-of-hospital cardiac arrest survival improving over time: Results from the Resuscitation Outcomes Consortium (ROC). Resuscitation. 2015 Feb 9 [Epub ahead of print].

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death and a 2010 meta-analysis concluded that outcomes have not improved over several decades. However, guidelines have changed to emphasize CPR quality, minimization of interruptions, and standardized post-resuscitation care. We sought to evaluate whether OHCA outcomes have improved over time among agencies participating in the Resuscitation Outcomes Consortium (ROC) cardiac arrest registry (Epistry) and randomized clinical trials (RCTs).

METHODS: Observational cohort study of 47,148 EMS-treated OHCA cases in Epistry from 139 EMS agencies at 10 ROC sites that participated in at least one RCT between 1/1/2006 and 12/31/2010. We reviewed patient, scene, event characteristics, and outcomes of EMS-treated OHCA over time, including subgroups with initial rhythm of pulseless ventricular tachycardia or ventricular fibrillation (VT/VF).

RESULTS: Mean response interval, median age and male proportion remained similar over time. Unadjusted survival to discharge increased between 2006 and 2010 for treated OHCA (from 8.2% to 10.4%), as well as for subgroups of VT/VF (21.4% to 29.3%) and bystander witnessed VT/VF (23.5% to 30.3%). Compared with 2006, adjusted survival to discharge was significantly higher in 2010 for treated cases (OR=1.72; 95% CI 1.53, 1.94), VT/VF cases (OR=1.69; 95% CI 1.45, 1.98) and bystander witnessed VT/VF cases (OR=1.65; 95% CI 1.36, 2.00). Tests for trend in each subgroup were significant (p less than 0.001).

CONCLUSIONS: ROC-wide survival increased significantly between 2006 and 2010. Additional research efforts are warranted to identify specific factors associated with this improvement.

8. Underuse of pregnancy testing for women prescribed teratogenic medications in the ED

Goyal MK, et al. Acad Emerg Med. 2015 Feb;22(2):192-6.

OBJECTIVES: The objectives were to estimate the frequency of pregnancy testing in emergency department (ED) visits by reproductive-aged women administered or prescribed teratogenic medications (Food and Drug Administration categories D or X) and to determine factors associated with nonreceipt of a pregnancy test.

METHODS: This was a retrospective cross-sectional study using 2005 through 2009 National Hospital Ambulatory Medical Care Survey data of ED visits by females ages 14 to 40 years. The number of visits was estimated where teratogenic medications were administered or prescribed and pregnancy testing was not conducted. The association of demographic and clinical factors with nonreceipt of pregnancy testing was assessed using multivariable logistic regression.

RESULTS: Of 39,859 sampled visits, representing an estimated 141.0 million ED visits by reproductive-aged females nationwide, 10.1 million (95% confidence interval [CI] = 8.9 to 11.3 million) estimated visits were associated with administration or prescription of teratogenic medications. Of these, 22.0% (95% CI = 19.8% to 24.2%) underwent pregnancy testing. The most frequent teratogenic medications administered without pregnancy testing were benzodiazepines (52.2%; 95% CI = 31.1% to 72.7%), antibiotics (10.7%; 95% CI = 5.0% to 16.3%), and antiepileptics (7.7%; 95% CI = 0.12% to 15.5%). The most common diagnoses associated with teratogenic drug prescription without pregnancy testing were psychiatric (16.1%; 95% CI = 13.6% to 18.6%), musculoskeletal (12.7%; 95% CI = 10.8% to 14.5%), and cardiac (9.5%; 95% CI = 7.6% to 11.3%). In multivariable analyses, visits by older (adjusted odds ratio [AOR] = 0.57, 95% CI = 0.42 to 0.79), non-Hispanic white females (AOR = 0.71; 95% CI = 0.54 to 0.93); visits in the Northeast region (AOR = 0.60; 95% CI = 0.42 to 0.86); and visits during which teratogenic medications were administered in the ED only (AOR = 0.74; 95% CI = 0.57 to 0.97) compared to prescribed at discharge only were less likely to have pregnancy testing.

CONCLUSIONS: A minority of ED visits by reproductive-aged women included pregnancy testing when patients were prescribed category D or X medications. Interventions are needed to ensure that pregnancy testing occurs before women are prescribed potentially teratogenic medications, as a preventable cause of infant morbidity.

9. HA in Traumatic Brain Injuries from Blunt Head Trauma.

Dayan PS, et al. for the Pediatric Emergency Care Applied Research Network (PECARN). Pediatrics. 2015 Feb 2 [Epub ahead of print]

OBJECTIVE: To determine the risk of traumatic brain injuries (TBIs) in children with headaches after minor blunt head trauma, particularly when the headaches occur without other findings suggestive of TBIs (ie, isolated headaches).

METHODS: This was a secondary analysis of a prospective observational study of children 2 to 18 years with minor blunt head trauma (ie, Glasgow Coma Scale scores of 14-15). Clinicians assessed the history and characteristics of headaches at the time of initial evaluation, and documented findings onto case report forms. Our outcome measures were (1) clinically important TBI (ciTBI) and (2) TBI visible on computed tomography (CT).

RESULTS: Of 27 495 eligible patients, 12 675 (46.1%) had headaches. Of the 12 567 patients who had complete data, 2462 (19.6%) had isolated headaches. ciTBIs occurred in 0 of 2462 patients (0%; 95% confidence interval [CI]: 0%-0.1%) in the isolated headache group versus 162 of 10 105 patients (1.6%; 95% CI: 1.4%-1.9%) in the nonisolated headache group (risk difference, 1.6%; 95% CI: 1.3%-1.9%). TBIs on CT occurred in 3 of 456 patients (0.7%; 95% CI: 0.1%-1.9%) in the isolated headache group versus 271 of 6089 patients (4.5%; 95% CI: 3.9%-5.0%) in the nonisolated headache group (risk difference, 3.8%; 95% CI: 2.3%-4.5%). We found no significant independent associations between the risk of ciTBI or TBI on CT with either headache severity or location.

CONCLUSIONS: ciTBIs are rare and TBIs on CT are very uncommon in children with minor blunt head trauma when headaches are their only sign or symptom.

10. A simple tool to predict admission at the time of triage.

Cameron A, et al. Emerg Med J. 2015 Mar;32(3):174-9

AIM: To create and validate a simple clinical score to estimate the probability of admission at the time of triage.

METHODS: This was a multicentre, retrospective, cross-sectional study of triage records for all unscheduled adult attendances in North Glasgow over 2 years. Clinical variables that had significant associations with admission on logistic regression were entered into a mixed-effects multiple logistic model. This provided weightings for the score, which was then simplified and tested on a separate validation group by receiving operator characteristic (ROC) analysis and goodness-of-fit tests.

RESULTS: 215 231 presentations were used for model derivation and 107 615 for validation. Variables in the final model showing clinically and statistically significant associations with admission were: triage category, age, National Early Warning Score (NEWS), arrival by ambulance, referral source and admission within the last year. The resulting 6-variable score showed excellent admission/discharge discrimination (area under ROC curve 0.8774, 95% CI 0.8752 to 0.8796). Higher scores also predicted early returns for those who were discharged: the odds of subsequent admission within 28 days doubled for every 7-point increase (log odds=+0.0933 per point, p less than 0.0001).

CONCLUSIONS: This simple, 6-variable score accurately estimates the probability of admission purely from triage information. Most patients could accurately be assigned to 'admission likely', 'admission unlikely', 'admission very unlikely' etc., by setting appropriate cut-offs. This could have uses in patient streaming, bed management and decision support. It also has the potential to control for demographics when comparing performance over time or between departments.
A simple tool to predict admission at the time of triage
Table 4
Admission prediction score
1 point per decade
1 point per point on NEWS score
Triage category:
2 (or 3+)
Referred by GP
Arrived in ambulance
Admitted less than 1 year ago
NEWS, National Early Warning Score.

11. Images in Clinical Practice

Young Male with Rapidly Swelling Jaw

Young Man with Shortness of Breath and Why Does Your Dandruff Smell Like Urine?

Young Man with Pain in Finger


Contagious Ecthyma

Acute Lymphangitis

Lung Herniation with Coughing

Complications of New Medications

Tense Bullae and Urticaria in a Woman in Her Sixties

12. Ultrasound Corner

A. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization

On the basis of available data, we conclude that two-dimensional ultrasound offers small gains in safety and quality when compared with an anatomical landmark technique for subclavian (arterial puncture, haematoma formation) or femoral vein (success on the first attempt) cannulation for central vein catheterization. Data on insertion by inexperienced or experienced users, or on patients at high risk for complications, are lacking. The results for Doppler ultrasound techniques versus anatomical landmark techniques are uncertain.

B. The Utility of Transvaginal Ultrasound in the ED Evaluation of Complications of First Trimester Pregnancy

Panebianco NL, et al. Am J Emerg Med 2015 Feb 20 [Epub ahead of print]

For patients with early intrauterine pregnancy (IUP) the sonographic signs of the gestation may be below the resolution of transabdominal ultrasound (TAU), however may be identified by transvaginal ultrasound (TVU). We sought to determine how often TVU performed in the ED (ED TVU) reveals a viable IUP after a nondiagnostic ED TAU. and the impact of ED TVU on patient length of stay (LOS.

This was a retrospective cohort study of women presenting to our ED with complications of early pregnancy from 01/01/2007 to 02/28/2009 in a single urban adult ED. Abstractors recorded clinical and imaging data in a database. Patient imaging modality and results were recorded and compared with respect to ultrasound (US) findings and LOS.

Of 2,429 subjects identified, 795 required TVU as part of their care. ED TVU was performed in 528 patients, and 267 went to radiology (RAD). ED TVU identified a viable IUP in 261 patients (49.6%). Patients having initial ED US had shorter LOS that patients with initial RAD US (median 4.0 vs. 6.0 hours; p less than 0.001). ED LOS was shorter for women who had ED TVU performed compared to those sent for RAD TVU regardless of the findings of the US (median 4.9 vs. 6.7 hours p less than 0.001). There was no increased LOS for patients who needed further radiology US after an indeterminate ED TVU (7.0 vs. 7.1 hours; p=0.43). There was no difference in LOS for those who had a viable IUP confirmed on ED TAU vs ED (median 3.1 vs 3.2 hours respectively; p less than 0.32).

When an ED TVU was performed, a viable IUP was detected 49.6% of the time. ED LOS was significantly shorter for women who received ED TVU after indeterminate ED TAU compared to those sent to radiology for TVU, with more marked time savings among those with live IUP diagnosed on ED TVU. For patients who do not receive a definitive diagnosis of IUP on ED TVU, this approach does not result in increased LOS.

C. The utility of IVC diameter and the degree of inspiratory collapse in patients with systolic HF

Besli F, et al. Am J Emerg Med 2015 Feb 9 [Epub ahead of print]

Both inferior vena cava (IVC) diameter and the degree of inspiratory collapse are used in the estimation of right atrial pressure.

The purpose of this study is to evaluate the utility of IVC diameter, using echocardiography as a marker of volume overload and the relationship between these parameters and N-terminal pro-B natriuretic peptide (NT-proBNP) in patients with systolic heart failure (HF).

We included 136 consecutive patients with systolic HF (left ventricular ejection fraction, less than 50%), including 80 patients with acutely decompensated HF and 56 patients with compensated HF as well as 50 subjects without a diagnosis of HF. All patients underwent transthoracic echocardiography to assess both their IVC diameters and the degree of inspiratory collapse (≥50%, less than 50%, and no change [absence] groups); NT-proBNP levels were measured, and these data were compared between the 2 groups.

Inferior vena cava diameter and NT-proBNP were significantly higher among the patients with HF than among the control subjects (21.7 ± 2.6 vs 14.5 ± 1.6 mm, P less than .001 and 4789 [330-35000] vs 171 [21-476], P less than .001). The mean IVC diameter was higher among the patients with decompensated HF than among the patients with compensated HF (23.2 ± 2.1 vs 19.7 ± 1.9 mm, P less than .001). The values of NT-proBNP were associated with different collapsibility of IVC subgroups among HF patients. The NT-proBNP levels were 2760 (330-27336), 5400 (665-27210), and 16806 (1786-35000), regarding the collapsibility of the IVC subgroups: greater than or equal to 50%, less than 50%, and absence groups, P less than .001, respectively, among HF patients. There was a significant positive correlation between IVC diameter and NT-proBNP (r = 0.884, P less than .001). A cut off value of an IVC diameter greater than or equal to 20.5 mm predicted a diagnosis of compensated HF with a sensitivity of 90% and a specificity of 73%.

Inferior vena cava diameter correlated significantly with NT-proBNP in patients with HF. Inferior vena cava diameter may be a useful variable in determining a patient's volume status in the setting of HF and may also enable clinicians to distinguish patients with decompensated HF from those with compensated HF.

D. A Review of Lawsuits Related to Point-of-Care Emergency Ultrasound Applications

Stolz L, et al. West J Emerg Med 2015;16:1-4.

Introduction: New medical technology brings the potential of lawsuits related to the usage of that new technology. In recent years the use of point-of-care (POC) ultrasound has increased rapidly in the emergency department (ED). POC ultrasound creates potential legal risk to an emergency physician (EP) either using or not using this tool. The aim of this study was to quantify and characterize reported decisions in lawsuits related to EPs performing POC ultrasound.

Methods: We conducted a retrospective review of all United States reported state and federal cases in the Westlaw database. We assessed the full text of reported cases between January 2008 and December 2012. EPs with emergency ultrasound fellowship training reviewed the full text of each case. Cases were included if an EP was named, the patient encounter was in the emergency department, the interpretation or failure to perform an ultrasound was a central issue and the application was within the American College of Emergency Physician (ACEP) ultrasound core applications. In order to assess deferred risk, cases that involved ultrasound examinations that could have been performed by an EP but were deferred to radiology were included.

Results: We identified five cases. All reported decisions alleged a failure to perform an ultrasound study or a failure to perform it in a timely manner. All studies were within the scope of emergency medicine and were ACEP emergency ultrasound core applications. A majority of cases (n=4) resulted in a patient death. There were no reported cases of failure to interpret or misdiagnoses.

Conclusion: In a five-year period from January 2008 through December 2012, five malpractice cases involving EPs and ultrasound examinations that are ACEP core emergency ultrasound applications were documented in the Westlaw database. All cases were related to failure to perform an ultrasound study or failure to perform a study in a timely manner and none involved failure to interpret or misdiagnosis when using of POC ultrasound.

E. Half-dose Alteplase for Sub-massive PE Directed by ED Point-of-care Ultrasound

Amini R, et al. West J Emerg Med. 2015;16:181-183.

This report describes a patient with sub-massive pulmonary embolism (PE) who was successfully treated with half-dose thrombolytics guided by the use of point-of-care (POC) ultrasound. In this case, POC ultrasound was the only possible imaging since computed tomography was contraindicated. POC ultrasound demonstrated a deep vein thrombosis and evidence of cardiac strain. In situations or locations where definitive imaging is unobtainable, POC ultrasound can help diagnose submassive PE and direct the use of half-dose tissue plasminogen activator.

13. A comparison of acute treatment regimens for pediatric migraine in the ED

Bachur RG, et al. Pediatrics. 2015 Feb;135(2):232-8.

BACKGROUND AND OBJECTIVES: Migraine headache is a common pediatric complaint among emergency department (ED) patients. There are limited trials on abortive therapies in the ED. The objective of this study was to apply a comparative effectiveness approach to investigate acute medication regimens for the prevention of ED revisits.

METHODS: Retrospective study using administrative data (Pediatric Health Information System) from 35 pediatric EDs (2009-2012). Children aged 7 to 18 years with a principal diagnosis of migraine headache were studied. The primary outcome was a revisit to the ED within 3 days for discharged patients. The primary analysis compared the treatment regimens and individual medications on the risk for revisit.

RESULTS: The study identified 32 124 children with migraine; 27 317 (85%) were discharged, and 5.5% had a return ED visit within 3 days. At the index visit, the most common medications included nonopioid analgesics (66%), dopamine antagonists (50%), diphenhydramine (33%), and ondansetron (21%). Triptans and opiate medications were administered infrequently (3% each). Children receiving metoclopramide had a 31% increased odds for an ED revisit within 3 days compared with prochlorperazine. Diphenhydramine with dopamine antagonists was associated with 27% increased odds of an ED revisit compared with dopamine antagonists alone. Children receiving ondansetron had similar revisit rates to those receiving dopamine antagonists.

CONCLUSIONS: The majority of children with migraines are successfully discharged from the ED and only 1 in 18 required a revisit within 3 days. Prochlorperazine appears to be superior to metoclopramide in preventing a revisit, and diphenhydramine use is associated with increased rates of return.

14. Ann Emerg Med Evidence-based Reviews

A. Should Nerve Blocks Be Used for Pain Control in Children With Femur Fractures?

Take-home: Although nerve blocks show potential to be a superior method of pain control in children with femur fractures, the available evidence is limited. No definitive conclusion or recommendation can be made until higher-quality studies are performed.

B. Does Endovascular Therapy Benefit Patients With Acute Ischemic Stroke?

Take-home: In management of acute ischemic stroke, there is no evidence that endovascular therapy improves functional outcomes over that achieved with intravenous tissue plasminogen activator (tPA).

C. What Physical Examination Findings and Diagnostic Imaging Modalities Are Most Useful in the Diagnosis of Scaphoid Fractures?

Take-home: When a patient with acute wrist pain is evaluated, the absence of snuffbox tenderness substantially decreases the probability of a scaphoid fracture. Alternatively, to definitively diagnose a scaphoid fracture, advanced imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) may be necessary.

D. Are Antibiotics Beneficial for the Treatment of Symptomatic Dental Infections?

Take-home: There is insufficient evidence to draw a conclusion about the benefit or harm associated with prescribing antibiotics for symptomatic dental infections.

15. Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study.

Kieboom JK, BMJ. 2015 Feb 10;350:h418

OBJECTIVES: To evaluate the outcome of drowned children with cardiac arrest and hypothermia, and to determine distinct criteria for termination of cardiopulmonary resuscitation in drowned children with hypothermia and absence of spontaneous circulation.

DESIGN: Nationwide retrospective cohort study.

SETTING: Emergency departments and paediatric intensive care units of the eight university medical centres in the Netherlands.

PARTICIPANTS: Children aged up to 16 with cardiac arrest and hypothermia after drowning, who presented at emergency departments and/or were admitted to intensive care.

MAIN OUTCOME MEASURE: Survival and neurological outcome one year after the drowning incident. Poor outcome was defined as death or survival in a vegetative state or with severe neurological disability (paediatric cerebral performance category (PCPC) ≥4).

RESULTS: From 1993 to 2012, 160 children presented with cardiac arrest and hypothermia after drowning. In 98 (61%) of these children resuscitation was performed for more than 30 minutes (98/160, median duration 60 minutes), of whom 87 (89%) died (95% confidence interval 83% to 95%; 87/98). Eleven of the 98 children survived (11%, 5% to 17%), but all had a PCPC score ≥4. In the 62 (39%) children who did not require prolonged resuscitation, 17 (27%, 16% to 38%) survived with a PCPC score ≤3 after one year: 10 (6%) had a good neurological outcome (score 1), five (3%) had mild neurological disability (score 2), and two (1%) had moderate neurological disability (score 3). From the original 160 children, only 44 were alive at one year with any outcome.

CONCLUSIONS: Drowned children in whom return of spontaneous circulation is not achieved within 30 minutes of advanced life support have an extremely poor outcome. Good neurological outcome is more likely when spontaneous circulation returns within 30 minutes of advanced life support, especially when the drowning incident occurs in winter. These findings question the therapeutic value of resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia.

16. Pediatric Cervical Spine Injury Evaluation after Blunt Trauma: A Clinical Decision Analysis.

Hannon M, et al. Ann Emerg Med. 2015;65: 239–247.

STUDY OBJECTIVE: Although many adult algorithms for evaluating cervical spine injury use computed tomography (CT) as the initial screening modality, this may not be appropriate in low-risk children, considering radiation risks. We determine the optimal initial evaluation strategy for cervical spine injury in pediatric blunt trauma.

METHODS: We constructed a decision analysis tree for a hypothetical population of patients younger than 19 years with blunt trauma, using 3 strategies: clinical stratification, screening radiographs followed by focused CT if the radiograph result was positive, and CT. For the model inputs, we used the current literature to determine the probabilities of cervical spine injury and estimate the long-term risks of malignancy after CT, as well as test characteristics of radiographic imaging. We used published utilities and conducted 1- and 2-way sensitivity analyses to determine the optimal strategy for evaluation of pediatric cervical spine injury.

RESULTS: In our model of a population with blunt trauma, the expected value of a clinical stratification strategy was the highest of the 3 strategies, making it the overall preferred management. One-way sensitivity analysis of several contributing factors revealed that the only independent factor that altered the dominant strategy was the sensitivity of clinical clearance criteria, lowering the threshold at which screening-radiograph strategy is optimal. Within the patient population considered as having non-negligible risk by clinical stratification and thus requiring imaging, the preferred imaging modality was screening radiograph/focused CT. The probability of cervical spine injury above which CT became the preferred strategy was 24.9%.

CONCLUSION: The model highlights that clinical clearance and screening radiographs in a hypothetical trauma pediatric population are preferred strategies, whereas CT scanning is rarely the initial optimal evaluation.

17. ED Intubations Are Increasingly Successful

First-pass ED intubation success increased from 80% in 2002 to 86% in 2012, with concomitant increases in the use of video laryngoscopy and rocuronium.

Brown CA, et al. Techniques, Success, and Adverse Events of Emergency Department Adult Intubations. Ann Emerg Med. 2014 Dec 19 [Epub ahead of print].

STUDY OBJECTIVE: We describe the operators, techniques, success, and adverse event rates of adult emergency department (ED) intubation through multicenter prospective surveillance.

METHODS: Eighteen EDs in the United States, Canada, and Australia recorded intubation data onto a Web-based data collection tool, with a greater than or equal to 90% reporting compliance requirement. We report proportions with binomial 95% confidence intervals (CIs) and regression, with year as the dependent variable, to model change over time.

RESULTS: Of 18 participating centers, 5 were excluded for failing to meet compliance standards. From the remaining 13 centers, we report data on 17,583 emergency intubations of patients aged 15 years or older from 2002 to 2012. Indications were medical in 65% of patients and trauma in 31%. Rapid sequence intubation was the first method attempted in 85% of encounters. Emergency physicians managed 95% of intubations and most (79%) were physician trainees. Direct laryngoscopy was used in 84% of first attempts. Video laryngoscopy use increased from less than 1% in the first 3 years to 27% in the last 3 years (risk difference 27%; 95% CI 25% to 28%; mean odds ratio increase per year [ie, slope] 1.7; 95% CI 1.6 to 1.8). Etomidate was used in 91% and succinylcholine in 75% of rapid sequence intubations. Among rapid sequence intubations, rocuronium use increased from 8.2% in the first 3 years to 42% in the last 3 years (mean odds ratio increase per year 1.3; 95% CI 1.3 to 1.3). The first-attempt intubation success rate was 83% (95% CI 83% to 84%) and was higher in the last 3 years than in the first 3 (86% versus 80%; risk difference 6.2%; 95% CI 4.2% to 7.8%). The airway was successfully secured in 99.4% of encounters (95% CI 99.3% to 99.6%).

CONCLUSION: In the EDs we studied, emergency intubation has a high and increasing success rate. Both drug and device selection evolved significantly during the study period.

18. The effect of traumatic LP on hospitalization rate for febrile infants 28 to 60 days of age.

Pingree EW, et al. Acad Emerg Med. 2015 Feb;22(2):240-3.

OBJECTIVES: The authors measured the effect of a traumatic or unsuccessful lumbar puncture (LP) on the management of febrile infants.

METHODS: This was a 10-year retrospective cross-sectional study of low-risk infants by the "Boston" criteria 28 to 60 days of age presenting to the emergency department for evaluation of fever. "Normal LP" infants had cerebrospinal fluid (CSF) WBC less than 10 × 10(6) cells/L. "Traumatic" or "unsuccessful LP" infants had CSF red blood cell count ≥ 10 × 10(9) cells/L or no CSF cell counts obtained, respectively. A serious bacterial infection (SBI) was defined as growth of a bacterial pathogen from culture. The hospitalization and SBI rates were compared between infants with normal versus traumatic or unsuccessful LPs.

RESULTS: Of the 929 study infants, 756 (81.4%) had normal LPs, and 173 (18.6%) had traumatic or unsuccessful LPs. Infants with traumatic or unsuccessful LPs had a higher hospitalization rate (72.3% traumatic or unsuccessful LP vs. 18.1% normal LP; difference = 54.1%; 95% confidence interval [CI] = 46.4% to 60.8%), but a similar SBI rate (2.9% vs. 4.1%; difference = 1.2%; 95% CI = -2.7% to 3.6%). No infant had proven bacterial meningitis (0% risk, 95% CI = 0 to 0.3%).

CONCLUSIONS: Low-risk infants aged 28 to 60 days with traumatic or unsuccessful LPs are more frequently hospitalized, although SBI rates were similar to those of infants with normal LPs.

19. Dispelling an urban legend: frequent ED users have substantial burden of disease.

Billings J, Raven MC. Health Aff (Millwood). 2013;32(12):2099-108.

Urban legend has often characterized frequent emergency department (ED) patients as mentally ill substance users who are a costly drain on the health care system and who contribute to ED overcrowding because of unnecessary visits for conditions that could be treated more efficiently elsewhere.

This study of Medicaid ED users in New York City shows that behavioral health conditions are responsible for a small share of ED visits by frequent users, and that ED use accounts for a small portion of these patients' total Medicaid costs. Frequent ED users have a substantial burden of disease, and they have high rates of primary and specialty care use. They also have linkages to outpatient care that are comparable to those of other ED patients. It is possible to use predictive modeling to identify who will become a repeat ED user and thus to help target interventions. However, policy makers should view reducing frequent ED use as only one element of more-comprehensive intervention strategies for frequent health system users.

20. WebM&M: Morbidity and Mortality Cases on the Web by AHRQ

A. The Case of an IO Line Misadventure

A 72-year-old woman with a history of asthma, congestive heart failure, and medication noncompliance presented to the emergency department with 2 weeks of lower extremity edema, fatigue, and progressively worsening dyspnea. She reported shortness of breath at rest and with exertion, as well as a dry cough. On initial examination, she was wheezing and had notable right lower extremity erythema and bilateral lower extremity pitting edema greater on the right side with weeping from her skin. She was admitted for asthma exacerbation and lower extremity cellulitis. She improved with fluids, albuterol nebulizers, methylprednisolone, and ceftriaxone/doxycycline. During her next 2 hospital days, she had a lower extremity ultrasound that was negative for a deep vein thrombosis and a transthoracic echocardiogram that was normal except for biatrial enlargement.

At midnight of her second hospital day, the patient's son noted that his mother was feeling dizzy. Four hours later, the patient suddenly became bradycardic to a heart rate of 20 beats per minute. Walking to the bathroom, she was notably dyspneic, with an oxygen saturation of 87%. She then became unresponsive. Her initial rhythm was pulseless electrical activity. During the code, a senior resident placed an intraosseous (IO) line in the left tibia following several unsuccessful attempts to obtain peripheral venous access. After 10 minutes of chest compressions and advanced cardiovascular life support protocol, spontaneous circulation returned and the patient was transferred to the intensive care unit (ICU).

Three hours after the IO line was placed, a nurse notified the primary team that the left leg was a dusky purple, and on examination the leg was bluish and tensely edematous with sluggish distal pulses. Vascular surgery diagnosed compartment syndrome, removed the IO line, and performed a bedside fasciotomy later that morning. The fasciotomy wounds were slow to heal and required ongoing complex care. After 2 months in the ICU and multiple complications, the patient was discharged.

The Commentary
by Raymond L. Fowler, MD, and Melanie J. Lippmann, MD (July/August 2014)

Vascular access is a cornerstone of modern medical therapeutics. In a crisis situation, particularly one in which large volumes of fluids or vasoactive medications are required, physicians have been trained to access the vascular system through large veins in the neck or groin. Yet, particularly when the blood pressure or volume is low, or in children, intravenous (IV) access can be difficult, and many patients have died over the years because of inability to achieve access in a timely way.

Placing a vascular access device directly into the marrow cavity for medical treatment dates as far back as the 1920s.(1) These devices were used during World War II for the treatment of shock (2), but later fell out of favor in many countries until their reintroduction in the United States to pediatric resuscitations in the late 1980s. Their resurgence in adult medicine lagged and only regained popularity in the past decade.(3) The modern development of rapid and easy-to-use intraosseous (IO) placement devices has recently placed IO access within the grasp of the broad realm of advanced life support providers.(4)

The technique of IO line placement is now a well-accepted component of modern advanced life support algorithms.(3) Intraosseous access requires either drilling or punching through the bone cortex and placing a hollow needle in the marrow cavity, within which is a rich network of marrow vasculature that will rapidly transport fluids and medications into the vascular system at large (Figure). Generally, the penetrated bony cortex holds the IO device firmly, making the line more difficult to accidentally displace (though displacements may occur).

After establishing a favorable safety and efficacy profile, IO access is endorsed as a preferred first alternative to failed IV access by numerous professional bodies including the American Heart Association (AHA), American College of Emergency Physicians (ACEP), International Liaison Committee on Resuscitation (ILCOR), and National Association of EMS Physicians (NAEMSP). Intraosseous access placement by nonphysician providers is commonly employed and is proven to be time-saving in emergency resuscitation cases that frequently arise in both the prehospital and emergency department settings.(3,5)

Discussion continues here:

B. Pitfalls in Diagnosing Necrotizing Fasciitis

A 49-year-old previously healthy man presented to the emergency department (ED) after falling from his truck at work 3 days before. He had gone to a different ED the day prior with diffuse pain on his left side (the side of his impact) and was given nonsteroidal anti-inflammatory medications and sent home. He presented to this new ED with persistent and worsening left arm, chest, abdomen, and thigh pain.

On physical examination, he was afebrile but tachycardic. He had diffuse, tender ecchymoses involving his left shoulder, upper chest, lateral abdomen, and thigh. Although the ED physicians felt he had simple bruising from the fall, they noted that he was in severe pain requiring intravenous (IV) opiates and that he was unable to independently ambulate. Because of these symptoms, blood tests were obtained and results showed a white blood cell count of 2.8 × 109/L (normal range: 3.5–10.5 × 109/L) and acute renal insufficiency with a creatinine of 1.4 mg/dL (normal range: 0.6–1.2 mg/dL). A computed tomography scan of the abdomen and pelvis showed "induration in the left quadriceps muscle and fluid layering in the abdominal wall." He was seen by the trauma surgical service, who felt the findings were due to diffuse bruising. The patient was admitted to an internal medicine service.

Due to ED crowding, he remained in the ED overnight, receiving only IV fluids and opiates for his pain. Over the course of the night, his pain worsened and he had a persistent tachycardia. Early morning lab results showed a white blood cell count of 1.6 × 109/L, a creatinine of 1.6 mg/dL, a creatine kinase of 2650 U/L (normal range 55–170 U/L) (evidence of muscle breakdown), and a lactate of 6.2 mg/dL (normal range 0.5–2.2 mmol/L) (evidence of tissue hypoxia). He was seen by the internal medicine team mid-morning and diagnosed with rhabdomyolysis from trauma and acute renal failure. He continued to receive IV fluids. His pain had become so severe that he was switched to hydromorphone hydrochloride, administered through a patient-controlled analgesia pump.

Later that day, the patient had progressive respiratory distress and developed septic shock. He was re-evaluated by the surgical service and felt to have probable necrotizing fasciitis with pyomyositis. He was urgently taken to the operating room, where he required debridement of 7300 cm/sq (an area roughly 2 ft by 4 ft) of skin and soft tissue from his left arm and axilla, anterior chest wall, abdominal wall, thigh, and leg.

After surgery, he was progressively hypotensive despite multiple vasopressors. He developed multi-organ dysfunction and ultimately, after discussions with his family, care was withdrawn and he died peacefully. He underwent autopsy, which showed necrotizing fasciitis with pyomyositis secondary to methicillin-resistant Staphylococcus aureus.

Commentary by Terence Goh, MBBS, and Lee Gan Goh, MBBS

Infections of the skin and soft tissues are incredibly common in pediatric and adult medicine. The classic presentation of erythema, warmth, edema, tenderness, and fever may suggest such an infection. However, physicians must also be mindful of other non-infective diseases that can mimic skin and soft tissue infections (SSTIs), including drug eruptions, foreign body reactions, gout, deep vein thrombosis, contact dermatitis, and muscle contusion. SSTIs involve suppurative bacterial or fungal invasion of the epidermis, dermis, or subcutaneous tissues and can range in severity from benign to very serious (as in this case). An expert panel (1) has classified skin infections into four classes of severity to help guide treatment. The classes range from simple cellulitis (class 1) to life-threatening infections such as necrotizing fasciitis (class 4). This case provides an opportunity to focus on necrotizing fasciitis as this diagnosis is often missed or delayed with devastating consequences…

Discussion continues here:

21. New Study Brings NIH Attention to Bear on ED Crowding

Millard WB. Ann Emerg Med 2015;65:A11–A15.

Crowding, the bane of any emergency department (ED), has been recognized as a nationwide problem and a marker of an individual hospital's performance quality. Anecdotally, patients who face delays in receiving emergency care describe it as one of the worst aspects of the hospital experience; published accounts since the 1980s have translated those subjective impressions into quantitative terms. Crowding is more than a contributor to patients' dissatisfaction; it correlates with poorer clinical outcomes.

Yet as serious and prevalent as the problem is, it has been a relatively low priority at the National Institutes of Health (NIH) until recently.

Benjamin C. Sun, MD, MPP, associate professor of emergency medicine at Oregon Health & Science University in Portland, is now leading a large NIH-supported study of possible solutions to crowding in different types and sizes of hospitals.

The $3.8-million, 5-year, R01 grant is funded by the National Heart, Lung, and Blood Institute.

Using data from the Centers for Medicare & Medicaid Services’ Hospital Compare survey of more than 4,000 Medicare-certified hospitals, Dr. Sun and colleagues at Oregon Health & Science University's Center for Policy and Research in Emergency Medicine are pursuing a 2-phase investigation, first profiling hospitals' performance according to Hospital Compare's metrics for ED throughput and then analyzing practices used at 4 to 12 high-performing hospitals to determine what measures effectively control boarding times and length of stay under different conditions.

The first phase is approaching completion, Dr. Sun reported, and recruitment for the second is under way; once second-phase work begins, the Center for Policy and Research in Emergency Medicine team aims to complete interviews by December 2015, with publishable results appearing around mid-2016. This study should add several important elements to the knowledge base on crowding, including scale, methodologic and statistical sophistication, and attention to practical solutions, as well as causes. It also marks a milestone in the ability of the Office of Emergency Care Research, a relatively new entity within the National Institute of General Medical Sciences, to help emergency medicine investigators address clinically relevant aspects of hospital organization with the rigor that NIH branches have long brought to basic biomedical topics.

“There's a body of evidence that suggests that emergency department crowding is dangerous to patient safety,” noted Dr. Sun. Specialists outside and inside NIH agree that the new study is promising and timely, appearing in a context in which specific causes and remedies of crowding require increasingly detailed attention…

22. Micro Bits

A. PBS News: How the response to Ebola here and abroad has improved our infrastructure and tactics

B. ED Transfers and Transfer Relationships in United States Hospitals

Dana Kindermann Sax et al. Acad Emerg Med 2015

C. Depilatory agents dissolve hair under tension within minutes. However, they do not dissolve cotton, polyester, and rayon even after many hours of application.

D. Efficacy and Safety of Out-of-Hospital IV Metoprolol Administration in Anterior ST-Segment Elevation AMI: Insights from the METOCARD-CNIC Trial

E. Take your prophylactic aspirin at night

Morning platelet reactivity scores associated with preventive aspirin are lower when patients take the medication at night to reduce risks of a second stroke and heart disease, compared with a morning dose, according to a study from the Netherlands. Researchers did not find a difference in 24-hour ambulatory blood pressure rates between patients who took the aspirin in the morning or evening.

F. Nutrition committee urges Americans to cut back on sugar

The Dietary Guidelines Advisory Committee on Thursday eased some restrictions on cholesterol and fat intake, stating that Americans should focus more on eating patterns rather than individual nutrients. The panel also stressed that Americans are consuming too much added sugar and recommended a daily intake of roughly 12 teaspoons.

G. 2 antibiotics may lead to GI condition in newborns, study finds

Newborns given oral azithromycin and erythromycin may be at increased risk of the gastrointestinal condition pyloric stenosis, researchers from the Uniformed Services University of the Health Sciences reported in Pediatrics. The study found the biggest risk comes in the first two weeks of life, with reduced risk for babies ages 2 weeks to 6 weeks.

H. Divorce among U.S. Physicians

Divorce among physicians is less common than among non-healthcare workers and several health professions. Female physicians have a substantially higher prevalence of divorce than male physicians, which may be partly attributable to a differential effect of hours worked on divorce.

I. Anticoagulation Drug Therapy: A Review

Written for the emergency physician.

J. Bad is more powerful than good: The nocebo response

K. Daily Pill? No Thanks, I'll Take Early Death

One-third of survey respondents preferred shortened lifespan to daily cardiovascular meds.

L. Anticholinergics may increase dementia risk, study says

University of Washington research identified a dose-response relationship between anticholinergic drugs and the risk of dementia. The 3,434-person population study in JAMA Internal Medicine said even low doses taken over long periods of time were linked with increased rates of dementia compared with not taking the drugs at all.

M. Study: 4.6% of elderly hospitalized after ED discharge

A study from the University of California, Los Angeles, found 4.6% of Medicare beneficiaries discharged from a hospital emergency department were admitted to a hospital within seven days. The study in the Journal of the American Geriatrics Society linked an increased risk of admissions to diagnoses such as heart failure and end-stage renal disease, age, skilled nursing facility use and leaving the ED against medical advice.