From the recent
medical literature…
1. Low-dose ketamine vs morphine for acute pain in the ED: a
randomized controlled trial
Miller JP, et
al. Amer J Emerg Med 2015;33:402-8.
Objectives: To
compare the maximum change in numeric rating scale (NRS) pain scores, in
patients receiving low-dose ketamine (LDK) or morphine (MOR) for acute pain in
the emergency department.
Methods: We
performed an institutional review board–approved, randomized, prospective,
double-blinded trial at a tertiary, level 1 trauma center. A convenience sample
of patients aged 18 to 59 years with acute abdominal, flank, low back, or
extremity pain were enrolled. Subjects were consented and randomized to
intravenous LDK (0.3 mg/kg) or intravenous MOR (0.1 mg/kg). Our primary outcome
was the maximum change in NRS scores. A sample size of 20 subjects per group
was calculated based on an 80% power to detect a 2-point change in NRS scores
between treatment groups with estimated SDs of 2 and an α of .05, using a
repeated-measures linear model.
Results: Forty-five
subjects were enrolled (MOR 21, LDK 24). Demographic variables and baseline NRS
scores (7.1 vs 7.1) were similar. Ketamine was not superior to MOR in the
maximum change of NRS pain scores, MOR = 5 (confidence interval, 6.6-3.5) and
LDK = 4.9 (confidence interval, 5.8-4). The time to achieve maximum reduction
in NRS pain scores was at 5 minutes for LDK and 100 minutes for MOR. Vital
signs, adverse events, provider, and nurse satisfaction scores were similar
between groups.
Conclusion: Low-dose
ketamine did not produce a greater reduction in NRS pain scores compared with
MOR for acute pain in the ED. However, LDK induced a significant analgesic
effect within 5 minutes and provided a moderate reduction in pain for 2 hours.
2. Midstream clean-catch urine collection in newborns: a
randomized controlled study.
Altuntas N,
et al. Eur J Pediatr. 2014 Oct 17. [Epub ahead of print]
We aimed to
evaluate a recently defined technique based on bladder stimulation and
paravertebral lumbar massage maneuvers in collecting a midstream clean-catch
urine sample in newborns.
A total of
127 term newborns were randomly assigned either to the experimental group or
the control group. Twenty-five minutes after feeding, the genital and perineal
areas of the babies were cleaned. The babies were held under the armpits with
legs dangling. Bladder stimulation and lumbar paravertebral massage maneuvers
were only applied to the babies in the experimental group. Success was defined
as collection of a urine sample within 5 min of starting the stimulation
maneuvers in the experimental group and of holding under the armpits in the
control group.
The success
rate of urine collection was significantly higher in the experimental group (78
%) than in the control group (33 %; p less than 0.001). The median time
(interquartile range) for sample collection was 60 s (64.5 s) in the
experimental group and 300 s (95 s) in the control group (p less than 0.0001).
Contamination rates were similar in both groups (p = 0.770).
Conclusion:
We suggest that bladder stimulation and lumbar paravertebral massage is a safe,
quick, and effective way of collecting midstream clean-catch urine in newborns.
3. Annals of EM’s Literature Reviews
A. What Is the Most Effective
Treatment for Relieving the Pain of a Jellyfish Sting?
Hot-water
application may relieve the pain from a bluebottle jellyfish sting better than
ice packs; however, this is based on a single trial. There is insufficient
evidence to recommend for or against other pain treatment regimens for
jellyfish stings.
B. Are Colloids Better Than
Crystalloids for Fluid Resuscitation in Critically Ill Patients?
No. Colloid
solutions offer no advantage over crystalloids for the resuscitation of
critically ill patients.
C. Does Tranexamic Acid Improve Outcomes
in Patients Undergoing Urgent or Emergency Surgery?
The use of
tranexamic acid before surgery of hip or femur shaft fractures may reduce the
need for blood transfusion; however, inferences are limited due to the small
number of trials.
D. Is Rhythm Control Better Than Rate
Control for New-Onset A Fib in the ED?
In patients
with new-onset atrial fibrillation and symptom onset within 48 hours, rhythm
control is preferred over rate control if the patient is younger than 65 years.
For patients with congestive heart failure, valvular heart disease, hypertension,
or permanent atrial fibrillation, rate control remains the favored strategy.
E. Does the Choice of Antibiotic
Affect Outcome in Strep Throat?
There is
insufficient evidence to show clinically meaningful differences between
antibiotics for group A beta hemolytic streptococci tonsillopharyngitis.
Penicillin or amoxicillin is recommended as first choice, given the absence of
resistance and low cost.
4. Properties of serial US clinical diagnostic pathway in
suspected appendicitis and related CT use.
Schuh S, et
al. Acad Emerg Med. 2015 Apr;22(4):406-14.
OBJECTIVES:
The primary objective was to determine the diagnostic accuracy of a serial
ultrasound (US) clinical diagnostic pathway to detect appendicitis in children
presenting to the emergency department (ED). The secondary objective was to
examine the diagnostic performance of the initial and interval US and to
compare the accuracy of the pathway to that of the initial US.
METHODS: This
was a prospective cohort study of 294 previously healthy children 4 to 17 years
old with suspected appendicitis and baseline pediatric appendicitis scores of
≥2, who were managed with the serial US clinical diagnostic pathway. This
pathway consisted of an initial US followed by a clinical reassessment in each
patient and an interval US and surgical consultation in patients with equivocal
initial US and persistent concern about appendicitis. The USs were interpreted by
published criteria as positive, negative, or equivocal for appendicitis.
Children in whom this pathway did not rule in or rule out appendicitis
underwent computed tomography (CT). Cases with missed appendicitis, negative
operations, and CTs after the pathway were considered inaccurate. The primary
outcome was the diagnostic accuracy of the serial US clinical diagnostic
pathway. The secondary outcomes included the test performance of the initial
and interval US imaging studies.
RESULTS: Of
the 294 study children, 111 (38%) had appendicitis. Using the serial US
clinical diagnostic pathway, 274 of 294 children (93%, 95% confidence interval
[CI] = 90% to 96%) had diagnostically accurate results: 108 of the 111 (97%)
appendicitis cases were successfully identified by the pathway without CT scans
(two missed and one CT), and 166 of the 183 (91%) negative cases were ruled out
without CT scans (14 negative operations and three CTs). The sensitivity of
this pathway was 108 of 111 (97%, 95% CI = 94% to 100%), specificity 166 of 183
(91%, 95% CI = 87% to 95%), positive predictive value 108 of 125 (86%; 95% CI =
79% to 92%), and negative predictive value 166 of 169 (98%, 95% CI = 96% to
100%). The diagnostic accuracy of the pathway was higher than that of the
initial US alone (274 of 294 vs. 160 of 294; p less than 0.0001). Of 123
patients with equivocal initial US, concern about appendicitis subsided on
clinical reassessment in 73 (no surgery and no missed appendicitis). Of 50
children with persistent symptoms, 40 underwent interval US and 10 had surgical
consultation alone. The interval US confirmed or ruled out appendicitis in 22
of 40 children (55.0%) with equivocal initial US, with one false-positive
interval US.
CONCLUSIONS:
The serial US clinical diagnostic pathway in suspected appendicitis has an
acceptable diagnostic accuracy that is significantly higher than that of the
initial US and results in few CT scans. This approach appears most useful in
children with equivocal initial US, in whom the majority of negative cases were
identified at clinical reassessment and appendicitis was diagnosed by interval
US or surgical consultation in most study patients.
5. Prospective validation of a 1-hour algorithm to rule-out and
rule-in AMI using a high-sensitivity cardiac troponin T assay.
Reichlin T,
et al. CMAJ. 2015 Apr 13 [Epub ahead of print]
BACKGROUND:
We aimed to prospectively validate a novel 1-hour algorithm using
high-sensitivity cardiac troponin T measurement for early rule-out and rule-in
of acute myocardial infarction (MI).
METHODS: In a
multicentre study, we enrolled 1320 patients presenting to the emergency
department with suspected acute MI. The highsensitivity cardiac troponin T
1-hour algorithm, incorporating baseline values as well as absolute changes
within the first hour, was validated against the final diagnosis. The final
diagnosis was then adjudicated by 2 independent cardiologists using all
available information, including coronary angiography, echocardiography,
follow-up data and serial measurements of high-sensitivity cardiac troponin T
levels.
RESULTS:
Acute MI was the final diagnosis in 17.3% of patients. With application of the
high-sensitivity cardiac troponin T 1-hour algorithm, 786 (59.5%) patients were
classified as "rule-out," 216 (16.4%) were classified as
"rule-in" and 318 (24.1%) were classified to the "observational
zone." The sensitivity and the negative predictive value for acute MI in
the rule-out zone were 99.6% (95% confidence interval [CI] 97.6%-99.9%) and
99.9% (95% CI 99.3%-100%), respectively. The specificity and the positive
predictive value for acute MI in the rule-in zone were 95.7% (95% CI
94.3%-96.8%) and 78.2% (95% CI 72.1%-83.6%), respectively. The 1-hour algorithm
provided higher negative and positive predictive values than the standard
interpretation of high-sensitivity cardiac troponin T using a single cut-off
level (both p less than 0.05). Cumulative 30-day mortality was 0.0%, 1.6% and
1.9% in patients classified in the rule-out, observational and rule-in groups,
respectively (p = 0.001).
INTERPRETATION:
This rapid strategy incorporating high-sensitivity cardiac troponin T baseline
values and absolute changes within the first hour substantially accelerated the
management of suspected acute MI by allowing safe rule-out as well as accurate
rule-in of acute MI in 3 out of 4 patients.
6. Outcomes in Adults with Acute PE who are Discharged from EDs:
The Cardiovascular Research Network VTE Study
Fang MC, et
al. JAMA Intern Med. 2015 Apr 20 [Epub ahead of print].
Excerpts
Introduction
Patients with
acute pulmonary embolism (PE) have conventionally been hospitalized for their
initial management and initiation of anticoagulant treatment.1 A clinical
trial2 found that patients with PE who were considered at low risk by the PE
Severity Index could be safely treated as outpatients.3 However, it is unclear
how often outpatient PE treatment occurs in real-world settings or whether
outcomes are as favorable as in the clinical trial. Our study describes the
short-term rates of death and hospital admission for patients with acute PE who
were discharged from emergency department (ED) settings…
Discussion
Patients with
acute PE who were discharged from ED settings in4geographically diverse health
care delivery systems had mortality rates comparable with outcomes observed in
a clinical trial3 that examined outpatient management of PE. Although still
representing relatively few patients with PE, the proportion of discharges from
ED settings nearly doubled during the 7-year study. Shifting appropriate
patients to outpatient treatment may have benefits in terms of improved quality
of life, enhanced physical and social functioning, and reduced costs of medical
care.5 We note that at least 23.4% of the patients in our study would not have
been eligible for outpatient treatment in the clinical trial because they had a
higher PE Severity Index risk class.3
7. ED Patients With A Fib or Flutter and an Acute Underlying
Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm.
Scheuermeyer
FX, et al. Ann Emerg Med. 2015 May;65(5):511-522.e2.
STUDY
OBJECTIVE: Although the management and outcomes of emergency department (ED)
patients with atrial fibrillation or flutter have been explored, such studies
have typically excluded patients with acute underlying medical illnesses. We
seek to describe the ED treatment and outcomes of these complex patients with
atrial fibrillation or flutter.
METHODS: This
retrospective descriptive cohort study used an ECG database from 2 urban EDs to
identify consecutive ED patients with an ECG demonstrating atrial fibrillation
or flutter from January 1, 2009, to December 31, 2009. We categorized patients
with atrial fibrillation or flutter as "complex" according to
prespecified criteria and then grouped them as being managed with rate or
rhythm control attempts, or not. The primary outcome was safety of rate or
rhythm control, measured by whether patients had a predefined adverse event or
not. The secondary outcome was the success of rate or rhythm control, defined
as rate control decreasing the pulse rate by 20 beats/min and successful rhythm
control, both within 4 hours of treatment initiation. Descriptive statistics
were used to compare the 2 groups.
RESULTS: Four
hundred sixteen complex patients with atrial fibrillation or flutter were
identified. Patients managed with rate or rhythm control were similar in all
baseline characteristics and illness distribution to patients who were not
managed in this manner. The 135 patients with attempted rate control (105) or
rhythm control (30) had 55 adverse events (40.7%; 95% confidence interval [CI]
32.5% to 49.5%), whereas the 281 patients not managed with rate or rhythm
control had 20 adverse events (7.1%; 95% CI 4.5% to 10.9%), for a risk
difference of 33.6% (95% CI 24.3% to 42.5%) and a relative risk of 5.7 (95% CI
3.6 to 9.1). Twenty of 105 patients (19.1%; 95% CI 12.3% to 28.1%) were
successfully rate controlled, whereas 4 of 30 (13.3%; 95% CI 4.4% to 31.6%)
were successfully rhythm controlled.
CONCLUSION:
In ED patients with complex atrial fibrillation or flutter, attempts at rate
and rhythm control are associated with a nearly 6-fold higher adverse event
rate than that for patients who are not managed with rate or rhythm control.
Success rates of rate or rhythm control attempts appear low.
8. Isolated transient aphasia at emergency presentation is
associated with a high rate of cardioembolic embolism
Wassermanan
JK, et al. CJEM. 2015 March 18 [Epub ahead of print]
Objective A
cardiac source is often implicated in strokes where the deficit includes
aphasia. However, less is known about the etiology of isolated aphasia during
transient ischemic attack (TIA). Our objective was to determine whether
patients with isolated aphasia are likely to have a cardioembolic etiology for
their TIA.
Methods We
prospectively studied a cohort of TIA patients in eight tertiary-care emergency
departments. Patients with isolated aphasia were identified by the treating
physician at the time of emergency department presentation. Patients with
dysarthria (i.e., a phonation disturbance) were not included. Potential cardiac
sources for embolism were defined as atrial fibrillation on history,
electrocardiogram, Holter monitor, atrial fibrillation on echocardiography, or
thrombus on echocardiography.
Results Of
the 2,360 TIA patients identified, 1,155 had neurological deficits at the time
of the emergency physician assessment and were included in this analysis, and 41
had isolated aphasia as their only neurological deficit. Patients with isolated
aphasia were older (73.9±10.0 v. 67.2±14.5 years; p=0.003), more likely to have
a history of heart failure (9.8% v. 2.6%; p=0.027), and were twice as likely to
have any cardiac source of embolism (22.0% v. 10.6%; p=0.037).
Conclusions
Isolated aphasia is associated with a high rate of cardioembolic sources of
embolism after TIA. Emergency patients with isolated aphasia diagnosed with a
TIA warrant a rapid and thorough assessment for a cardioembolic source.
9. Predictive value of the usual clinical signs and laboratory
tests in the diagnosis of septic arthritis
Couderca M,
et al. CJEM 2015 March 30 [Epub ahead of print]
Objective To
determine the sensitivity and specificity of clinical and laboratory signs for
the diagnosis of septic arthritis (SA).
Patients and
methods This prospective study included all adult patients with suspected SA
seen in the emergency department or rheumatology department at the University
Hospital, Clermont-Ferrand, France, over a period of 18 months.
Results In
total, 105 patients with suspected SA were included, 38 (36%) presenting with
SA (29 [28%] with bacteriologically documented SA). In the univariate analysis,
chills (p=0.015), gradual onset (p=0.04), local redness (p=0.01), as well as an
entry site for infection (p=0.01) were most often identified in SA. A history
of crystal-induced arthritis (p=0.004) was more frequent in non-SA cases. An
erythrocyte sedimentation rate (ESR) above 50 mm (p=0.005), a C-reactive
protein (CRP) level above 100 mg/L (p=0.019), and radiological signs suggestive
of SA (p=0.001) were more frequent in the SA cases. Synovial fluid appearance:
purulent (p less than 0.001) and clear (p=0.007), synovial white blood cell
(WBC) count above 50,000/μL (p less than 0.001), differentiated between SA and
non-SA.
In
multivariate analysis, only chills (odds ration [OR]=4.7, 95% confidence
interval [CI] 1.3–17.1), a history of crystal-induced arthritis (OR=0.09, 95%
CI 0.01–0.9), purulent appearance of the joint fluid (OR=8.4, 95% CI 2.4–28.5),
synovial WBC count above 50,000/mm3 (OR=6.8, 95% CI 1.3–36), and radiological
findings (OR=7.1, 95% CI 13–37.9) remained significant.
Conclusion No
clinical sign or laboratory test (excluding bacteriological test), taken alone,
is conclusive for the differentiation between SA and non-SA, but the
association of several signs, notably chills, history of crystal-induced
arthritis, radiological findings, and the appearance and cellularity of joint
fluid may be suggestive.
10. Images in Clinical Practice
Rectus sheath
hematoma
Disseminated
Zoster
Hyphema
Epiglottitis
in an Adult
Incisional
Keloid
Arachnoid
Cyst
STEMI—in a
19-year-old! (from a coronary artery embolism)
Elderly Man with
Syncope
Elderly Woman
with Headache
Woman with
Severe Dyspnea
Neonate with
Pustular Rash
Male with
Throat Pain and Neck Swelling
11. Efficacy and safety of paracetamol (acetaminophen) for
spinal pain and osteoarthritis: systematic review and meta-analysis of
randomised placebo controlled trials.
(Pssst: It doesn’t work!) An analysis of data
from 13 clinical trials found acetaminophen may not be an effective treatment
for lower back pain and may offer limited help for osteoarthritis, researchers
reported in The BMJ. Researchers said guidelines recommending acetaminophen as
a first-line analgesic treatment for these conditions should be updated.
Machado GC,
et al. BMJ. 2015 Mar 31;350:h1225.
OBJECTIVE: To
investigate the efficacy and safety of paracetamol (acetaminophen) in the
management of spinal pain and osteoarthritis of the hip or knee.
DESIGN:
Systematic review and meta-analysis.
DATA SOURCES:
Medline, Embase, AMED, CINAHL, Web of Science, LILACS, International
Pharmaceutical Abstracts, and Cochrane Central Register of Controlled Trials
from inception to December 2014.
ELIGIBILITY
CRITERIA FOR SELECTING STUDIES: Randomised controlled trials comparing the
efficacy and safety of paracetamol with placebo for spinal pain (neck or low
back pain) and osteoarthritis of the hip or knee.
DATA
EXTRACTION: Two independent reviewers extracted data on pain, disability, and
quality of life. Secondary outcomes were adverse effects, patient adherence,
and use of rescue medication. Pain and disability scores were converted to a
scale of 0 (no pain or disability) to 100 (worst possible pain or disability).
We calculated weighted mean differences or risk ratios and 95% confidence
intervals using a random effects model. The Cochrane Collaboration's tool was
used for assessing risk of bias, and the GRADE approach was used to evaluate
the quality of evidence and summarise conclusions.
RESULTS: 12
reports (13 randomised trials) were included. There was "high
quality" evidence that paracetamol is ineffective for reducing pain
intensity (weighted mean difference -0.5, 95% confidence interval -2.9 to 1.9)
and disability (0.4, -1.7 to 2.5) or improving quality of life (0.4, -0.9 to
1.7) in the short term in people with low back pain. For hip or knee
osteoarthritis there was "high quality" evidence that paracetamol
provides a significant, although not clinically important, effect on pain
(-3.7, -5.5 to -1.9) and disability (-2.9, -4.9 to -0.9) in the short term. The
number of patients reporting any adverse event (risk ratio 1.0, 95% confidence
interval 0.9 to 1.1), any serious adverse event (1.2, 0.7 to 2.1), or withdrawn
from the study because of adverse events (1.2, 0.9 to 1.5) was similar in the
paracetamol and placebo groups. Patient adherence to treatment (1.0, 0.9 to
1.1) and use of rescue medication (0.7, 0.4 to 1.3) was also similar between
groups. "High quality" evidence showed that patients taking
paracetamol are nearly four times more likely to have abnormal results on liver
function tests (3.8, 1.9 to 7.4), but the clinical importance of this effect is
uncertain.
CONCLUSIONS:
Paracetamol is ineffective in the treatment of low back pain and provides
minimal short term benefit for people with osteoarthritis. These results
support the reconsideration of recommendations to use paracetamol for patients
with low back pain and osteoarthritis of the hip or knee in clinical practice
guidelines.
12. The bubble study: US confirmation of CVC placement
Duran-Gehring
PE, et al. Amer J Emerg Med 2015;33:315-9.
Study
objective
The objective
was to determine if ultrasound (US) can more rapidly confirm central venous
catheter (CVC) position in comparison to chest radiography (CXR) in the
emergency department.
Methods
The study
included a convenience sample of emergency department patients with
supradiaphragmatic CVCs and a CXR for confirmation. Ultrasound was used for CVC
confirmation by visualizing microbubble artifact in the right atrium after
injection of saline through the distal port. To evaluate for pneumothorax
(PTX), “sliding sign” of the pleura was noted on US of the anterior chest.
Blinded chart review was performed to assess CXR timing, catheter position and
CVC complications. Student's t test was used to compare US time to CXR
performance time and radiologist reading time.
Results
Fifty
patients were enrolled; 4 were excluded because of inadequate views. Forty-six
patients were included in the final analysis. Mean total US time was 5.0
minutes (95% confidence interval [CI], 4.2-5.9) compared to 28.2 minutes (95%
CI, 16.8-39.4) for CXR performance with a mean difference of 23.1 minutes (95%
CI, −34.5 to −11.8; P less than .0002). When comparing only US CVC confirmation
time to CXR time, US was an average of 24.0 minutes (95% CI, −35.4 to −12.7; P less
than .0001) faster. Comparing total US time to radiologist CXR reading time, US
was an average of 294 minutes faster (95% CI, −384.5 to -203.5; P less than
.0000). There were a total of 3 misplaced lines and 2 patients with PTX, all of
which were identified correctly on US.
Conclusion
Ultrasound
can confirm CVC placement and rule out PTX significantly faster than CXR,
expediting the use of CVCs in the critically ill.
13. Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest
in Children
This study of
targeted temperature interventions in 295 children who were comatose after
cardiac arrest showed no significant difference between the hypothermia group
(33.0°C) and the normothermia group (36.8°C) with respect to 1-year survival
with a good functional outcome.
Moler FW, et
al. N Engl J Med 2015 Apr 25 [Epub ahead of print]
Background
Therapeutic
hypothermia is recommended for comatose adults after witnessed out-of-hospital
cardiac arrest, but data about this intervention in children are limited.
Methods
We conducted
this trial of two targeted temperature interventions at 38 children's hospitals
involving children who remained unconscious after out-of-hospital cardiac
arrest. Within 6 hours after the return of circulation, comatose patients who
were older than 2 days and younger than 18 years of age were randomly assigned
to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic
normothermia (target temperature, 36.8°C). The primary efficacy outcome,
survival at 12 months after cardiac arrest with a Vineland Adaptive Behavior
Scales, second edition (VABS-II), score of 70 or higher (on a scale from 20 to
160, with higher scores indicating better function), was evaluated among
patients with a VABS-II score of at least 70 before cardiac arrest.
Results
A total of
295 patients underwent randomization. Among the 260 patients with data that
could be could be evaluated and who had a VABS-II score of at least 70 before
cardiac arrest, there was no significant difference in the primary outcome
between the hypothermia group and the normothermia group (20% vs. 12%; relative
likelihood, 1.54; 95% confidence interval [CI], 0.86 to 2.76; P=0.14). Among
all the patients with data that could be evaluated, the change in the VABS-II
score from baseline to 12 months was not significantly different (P=0.13) and
1-year survival was similar (38% in the hypothermia group vs. 29% in the
normothermia group; relative likelihood, 1.29; 95% CI, 0.93 to 1.79; P=0.13).
The groups had similar incidences of infection and serious arrhythmias, as well
as similar use of blood products and 28-day mortality.
Conclusions
In comatose
children who survived out-of-hospital cardiac arrest, therapeutic hypothermia,
as compared with therapeutic normothermia, did not confer a significant benefit
in survival with a good functional outcome at 1 year.
14. Systemic inflammatory response syndrome criteria in defining
severe sepsis (not the ultimate definition).
Kaukonen KM,
et al. N Engl J Med. 2015 Apr 23;372(17):1629-38.
BACKGROUND:
The consensus definition of severe sepsis requires suspected or proven
infection, organ failure, and signs that meet two or more criteria for the
systemic inflammatory response syndrome (SIRS). We aimed to test the
sensitivity, face validity, and construct validity of this approach.
METHODS: We
studied data from patients from 172 intensive care units in Australia and New
Zealand from 2000 through 2013. We identified patients with infection and organ
failure and categorized them according to whether they had signs meeting two or
more SIRS criteria (SIRS-positive severe sepsis) or less than two SIRS criteria
(SIRS-negative severe sepsis). We compared their characteristics and outcomes
and assessed them for the presence of a step increase in the risk of death at a
threshold of two SIRS criteria.
RESULTS: Of
1,171,797 patients, a total of 109,663 had infection and organ failure. Among
these, 96,385 patients (87.9%) had SIRS-positive severe sepsis and 13,278 (12.1%)
had SIRS-negative severe sepsis. Over a period of 14 years, these groups had
similar characteristics and changes in mortality (SIRS-positive group: from
36.1% [829 of 2296 patients] to 18.3% [2037 of 11,119], P less than 0.001;
SIRS-negative group: from 27.7% [100 of 361] to 9.3% [122 of 1315], P less than
0.001). Moreover, this pattern remained similar after adjustment for baseline
characteristics (odds ratio in the SIRS-positive group, 0.96; 95% confidence
interval [CI], 0.96 to 0.97; odds ratio in the SIRS-negative group, 0.96; 95%
CI, 0.94 to 0.98; P=0.12 for between-group difference). In the adjusted
analysis, mortality increased linearly with each additional SIRS criterion
(odds ratio for each additional criterion, 1.13; 95% CI, 1.11 to 1.15; P less than
0.001) without any transitional increase in risk at a threshold of two SIRS
criteria.
CONCLUSIONS:
The need for two or more SIRS criteria to define severe sepsis excluded one in
eight otherwise similar patients with infection, organ failure, and substantial
mortality and failed to define a transition point in the risk of death.
15. Incidence of "never events" among weekend
admissions versus weekday admissions to US hospitals: national analysis.
Attenello FJ,
et al. BMJ. 2015 Apr 15;350:h1460.
OBJECTIVE: To
evaluate the association between weekend admission to hospital and 11 hospital
acquired conditions recently considered by the Centers for Medicare and
Medicaid as "never events" for which resulting healthcare costs are
not reimbursed.
DESIGN:
National analysis.
SETTING: US
Nationwide Inpatient Sample discharge database.
PARTICIPANTS:
351 million patients discharged from US hospitals, 2002-10.
MAIN OUTCOME
MEASURES: Univariate rates and multivariable likelihood of hospital acquired
conditions among patients admitted on weekdays versus weekends, as well as the
impacts of these events on prolonged length of stay and total inpatient
charges.
RESULTS: From
2002 to 2010, 351 170 803 patients were admitted to hospital, with 19% admitted
on a weekend. Hospital acquired conditions occurred at an overall frequency of
4.1% (5.7% among weekend admissions versus 3.7% among weekday admissions).
Adjusting for patient and hospital cofactors the probability of having one or
more hospital acquired conditions was more than 20% higher in weekend
admissions compared with weekday admissions (odds ratio 1.25, 95% confidence
interval 1.24 to 1.26, P less than 0.01). Hospital acquired conditions have a
negative impact on both hospital charges and length of stay. At least one
hospital acquired condition was associated with an 83% (1.83, 1.77 to 1.90, P less
than 0.01) likelihood of increased charges and 38% likelihood of prolonged
length of stay (1.38, 1.36 to 1.41, P less than 0.01).
CONCLUSION:
Weekend admission to hospital is associated with an increased likelihood of
hospital acquired condition, cost, and length of stay. Future protocols and
staffing regulations must be tailored to the requirements of this high risk
subgroup.
16. Giant Cell Arteritis: Read the Fine Print!
Jhun P, et
al. Ann Emerg Med 2015;65:615-617.
Annals Case: A
75 year-old female presented to the emergency department (ED) complaining of 11
days of a stabbing headache in the right temporal region, without associated
jaw claudication or vision changes. She sought evaluation four times in the
week prior, but those evaluation results were negative, including head computed
tomography, magnetic resonance imaging, and laboratory testing. Physical
examination in the ED showed prominent, nontender temporal arteries.
Erythrocyte sedimentation rate (ESR) was 10 mm/hour.1
This time
around, instead of ending with the diagnosis, we start with the final
diagnosis: giant cell arteritis (GCA), also known as temporal arteritis. We
skip right to the answer in immature retribution for the patient’s not fully
conforming to our handy medical school mnemonic.
First, let’s
take a step back and recall what some of us have been taught about GCA. A
mnemonic sometimes used is the “rule of 50s”: consider GCA in headache patients
who are at least 50 years old and have a serum ESR greater than or equal to 50
mm/hour and then prescribe 50 mg of oral prednisone once a day. Patients should
undergo urgent temporal artery biopsy for definitive confirmation, as they say.
Not that we expect a mnemonic to carry the full weight of our jobs as
diagnosticians, but clearly this “rule” failed us. Let’s dig a little bit
deeper…
The remainder
of the article (free): http://www.annemergmed.com/article/S0196-0644(15)00125-0/fulltext
17. Critical reappraisal of IV metoclopramide in migraine
attack: a systematic review and meta-analysis
Eken C. Amer
J Emerg Med 2015;33:331–337.
Migraine is
one of the most common causes of headache presentations to emergency
departments (EDs). Patients with migraine attack need rapid pain relief rather
than diagnostic modalities. Metoclopramide, a dopamine antagonist with a
primary use of antiemetic, has been used commonly in ceasing migraine attack.
An earlier meta-analysis favors metoclopramide over placebo but includes
studies with significant methodological errors and heterogeneity. The present
article aimed to review the literature to reveal studies comparing
metoclopramide to either placebo or active comparators.
A literature
search including PubMed, Cochrane Database, and Google Scholar was performed by
using the evidence-based process for determining the study quality. Although
the studies comparing parenteral metoclopramide to placebo in ceasing migraine
headache favor metoclopramide to placebo and lower rates of rescue drug need,
however, they lack high methodological quality even to perform a meta-analysis.
Meanwhile, the effect of metoclopramide in ceasing migraine headache is also
comparable to active comparators.
It seems
reasonable to use metoclopramide in migraine attacks in EDs according to the
current literature. However, further studies with high methodological quality
are needed to reveal whether and how much metoclopramide is superior to
placebo.
18. Evaluation of the PE rule-out criteria (PERC) in a
retrospective cohort at an urban academic hospital
Bozarth AL,
et al. Amer J Emerg Med. 2105;33:483-7.
Background
The pulmonary
embolism rule-out criteria (PERC) is an 8-variable clinical decision rule that
identifies patients at low risk for pulmonary embolism (PE) to prevent
unnecessary diagnostic testing in the evaluation of suspected PE in the
emergency department (ED). The objective of this study was to determine PERC's
safety and diagnostic use in our institution's ED population.
Methods
We performed
a retrospective analysis on consecutive adult patients evaluated with computed
tomographic angiography (CTA) for suspicion of PE at our ED during the dates
January 1, 2011, to December 31, 2011. Patients negative for all 8 PERC
criteria (ie, “PERC [−]”) were considered to be at low risk for PE. All data
were analyzed using SPSS-20 (SPSS Inc, Chicago, IL) to calculate the variables
of interest and their respective 95% confidence intervals (95% CIs).
Results
During the
12-month study period, 729 subjects were evaluated with CTA for suspicion of
PE. Ten subjects were excluded because of nondiagnostic imaging studies. After exclusion,
719 subjects were available for analysis. Prevalence of PE was 4.5%. PERC (−)
had a sensitivity of 96.9% (95% CI, 84.3%-99.4%), a negative predictive value
of 98.8% (95% CI, 93.5%-99.8%), and a negative likelihood ratio of 0.26 (95%
CI, 0.04-1.82) when used as an independent diagnostic test to exclude PE.
Conclusions
Use of PERC
could have safely avoided 11.5% of CTAs, reducing potential patient harm,
health care costs, and unnecessary diagnostic testing. Consistent with prior
studies, PERC can be safely used to identify low-risk patients for whom further
testing can be deferred.
19. Randomized, Double-Blinded, Clinical Trial of Propofol, 1:1
Propofol/Ketamine, and 4:1 Propofol/Ketamine for Deep Procedural Sedation in
the ED.
Miner JR, et
al. Ann Emerg Med. 2015 May;65(5):479-488.e2
STUDY
OBJECTIVE: We compare the frequency of airway and respiratory adverse events
leading to an intervention between propofol with 1:1 and 4:1 mixtures of
propofol and ketamine (ketofol).
METHODS: We
performed a randomized, double-blinded trial in which emergency department
adults undergoing deep sedation received propofol, 1:1 propofol and ketamine,
or 4:1 propofol and ketamine. Our primary outcome was the frequency of airway
and respiratory adverse events leading to an intervention. Other outcomes
included sedation depth, efficacy, procedure and recovery time, patient
satisfaction, pain, and procedural recall.
RESULTS: Two
hundred seventy-one subjects completed the trial, 90 receiving propofol, 85
receiving 1:1 propofol and ketamine, and 96 receiving 4:1 propofol and
ketamine. Airway or respiratory adverse events leading to an intervention were
similar between groups: 29%, 19%, and 32%, respectively (P=.21). There were no
serious adverse events in any group. Secondary outcomes were generally similar
between groups, with greater recovery agitation observed in the 1:1 ketofol
group (8%, 21%, and 10%, respectively).
CONCLUSION:
We found a similar frequency of airway and respiratory adverse events leading
to intervention between propofol alone and either 1:1 or 4:1 ketofol.
20. Abx treatment strategies for community-acquired pneumonia in
adults.
Postma DF, et
al. N Engl J Med. 2015 Apr 2;372(14):1312-23.
BACKGROUND:
The choice of empirical antibiotic treatment for patients with clinically
suspected community-acquired pneumonia (CAP) who are admitted to non-intensive
care unit (ICU) hospital wards is complicated by the limited availability of
evidence. We compared strategies of empirical treatment (allowing deviations
for medical reasons) with beta-lactam monotherapy, beta-lactam-macrolide
combination therapy, or fluoroquinolone monotherapy.
METHODS: In a
cluster-randomized, crossover trial with strategies rotated in 4-month periods,
we tested the noninferiority of the beta-lactam strategy to the
beta-lactam-macrolide and fluoroquinolone strategies with respect to 90-day
mortality, in an intention-to-treat analysis, using a noninferiority margin of
3 percentage points and a two-sided 90% confidence interval.
RESULTS: A
total of 656 patients were included during the beta-lactam strategy periods,
739 during the beta-lactam-macrolide strategy periods, and 888 during the
fluoroquinolone strategy periods, with rates of adherence to the strategy of
93.0%, 88.0%, and 92.7%, respectively. The median age of the patients was 70
years. The crude 90-day mortality was 9.0% (59 patients), 11.1% (82 patients),
and 8.8% (78 patients), respectively, during these strategy periods. In the
intention-to-treat analysis, the risk of death was higher by 1.9 percentage
points (90% confidence interval [CI], -0.6 to 4.4) with the
beta-lactam-macrolide strategy than with the beta-lactam strategy and lower by
0.6 percentage points (90% CI, -2.8 to 1.9) with the fluoroquinolone strategy
than with the beta-lactam strategy. These results indicated noninferiority of
the beta-lactam strategy. The median length of hospital stay was 6 days for all
strategies, and the median time to starting oral treatment was 3 days
(interquartile range, 0 to 4) with the fluoroquinolone strategy and 4 days
(interquartile range, 3 to 5) with the other strategies.
CONCLUSIONS:
Among patients with clinically suspected CAP admitted to non-ICU wards, a
strategy of preferred empirical treatment with beta-lactam monotherapy was
noninferior to strategies with a beta-lactam-macrolide combination or
fluoroquinolone monotherapy with regard to 90-day mortality.
21. Poisoning in the United States: 2012 Emergency Medicine Report
of the National Poison Data System
Dart RC, et
al. Ann Emerg Med. 2015;65:416–422.
Deaths from
drug overdose have become the leading cause of injury death in the United
States, where the poison center system is available to provide real-time advice
and collect data about a variety of poisonings. In 2012, emergency medical
providers were confronted with new poisonings, such as bath salts (substituted
cathinones) and Spice (synthetic cannabinoid drugs), as well as continued
trends in established poisonings such as from prescription opioids. This
article addresses current trends in opioid poisonings; new substances
implicated in poisoning cases, including unit-dose laundry detergents, bath
salts, Spice, and energy drinks; and the role of poison centers in public
health emergencies such as the Fukushima radiation incident.
22. Career benefits associated with mentoring for mentors: a
meta-analysis
Ghosha R, et
al. J Vocational Behav 2013;83:106-116.
Mentoring has
been studied extensively as it is linked to protégé career development and
growth. Recent mentoring research is beginning to acknowledge however that
mentors also can accrue substantial benefits from mentoring.
A
meta-analysis was conducted where the provision of career, psychosocial and
role modeling mentoring support were associated with five types of subjective
career outcomes for mentors: job satisfaction, organizational commitment,
turnover intent, job performance, and career success.
The findings
indicated that mentors versus non-mentors were more satisfied with their jobs
and committed to the organization. Providing career mentoring was most
associated with career success, psychosocial mentoring with organizational
commitment, and role modeling mentoring with job performance. Turnover intent
was not linked significantly with any of the subjective career outcome
variables.
The findings
support mentoring theory in that mentoring is reciprocal and collaborative and
not simply beneficial for protégés. Longitudinal research is needed however to
determine the degree to which providing mentoring impacts a mentor’s career
over time. By alerting prospective mentors to the possible personal benefits of
providing career, psychosocial, and role modeling mentoring support for
protégés, HRD professionals can improve recruitment efforts for mentoring
programs.
23. Use of ondansetron during pregnancy and congenital
malformations in the infant.
Danielsson B,
et al. Repro Tox 2014;50:134-7
The study
investigates teratogenic risks with ondansetron (Zofran®). Data from the
Swedish Medical Birth Register combined with the Swedish Register of Prescribed
Drugs were used to identify 1349 infants born of women who had taken
ondansetron in early pregnancy, 1998-2012. Presence of congenital malformations
in the offspring was identified with three national health registers.
In a
Mantel-Haenszel analysis adjustment was made for year of delivery, maternal
age, parity, smoking in early pregnancy and pre-pregnancy body mass index.
Risks were expressed as odds or risk ratios with 95% confidence intervals.
No
statistically significantly increased risk for a major malformation was found.
The risks for a cardiovascular defect and notably a cardiac septum defect were
increased and statistically significant (OR=1.62, 95% CI 1.04-2.14, and RR
2.05, 95% CI 1.19-3.28, respective). The teratogenic risk with ondansetron is
low but an increased risk for a cardiac septum defect is likely.
24. Canadian Association of Emergency Physicians Position
Statement on Acute Ischemic Stroke
Harris D, et
al. CJEM; 2015;17:217 – 226.
Stroke
systems of care should be developed to optimize prehospital triage and
transport to designated stroke centers. We recommend intravenous thrombolysis
for eligible acute ischemic stroke patients who can be treated within three
hours of stroke symptom onset. We suggest against intravenous thrombolysis for
eligible patients who would receive treatment between 3 to 4.5 hours after
symptom onset until further research is available. The majority of stroke
patients should be managed in dedicated stroke units. Telestroke should be
supported as a means of providing acute stroke expertise where local support is
limited. Rural settings represent unique challenges to the safe and effective
administration of thrombolytic therapy within the three hour time window. In
some of these settings adherence to a 3 hour mark may not be possible.
Full-text
(free): http://caep.ca/sites/caep.ca/files/caep/PositionStatments/caep_ps_stroke_2015_eng.pdf
25. Micro Bits
A. New study refutes link between MMR
vaccine, autism
A large study
published in the Journal of the American Medical Association found that the
measles, mumps and rubella vaccine does not increase the risk of autism
spectrum disorder, even in children who are considered to be at an increased
risk because of an older sibling with the disorder. The findings revealed that
among the 95,727 children followed, the 2% with an older sibling with ASD had a
greater risk of developing the disorder themselves, but the risk was not
affected by whether or not they received the MMR vaccine.
B. Getting the Right Medical Students
— Nature versus Nurture
Schwartzstein
RM. N Engl J Med 2015; 372:1586-1587
The video
shows a fourth-year medical student interviewing a patient. The student is a
bit awkward and is using technical terms and inappropriate body language. A
leading medical educator asks, “How did we let this student into medical
school?” “Wherever I travel,” he continues, “I hear from public officials that
doctors demonstrate little empathy and don't communicate well with patients. We
have to fix the problem. We have to screen for more humanistic students in our
admissions processes.”
With many
patients complaining about doctors' poor interpersonal skills, it's hard to
deny that there's a problem. No admissions process is perfect, and some
students admitted to medical school may well demonstrate little empathy or lack
the requisite communication skills to be effective doctors — but is that the
primary cause of the problem?
C. Recognizing Measles: A Patient
Handout
D. Acute Stroke Intervention: A
Systematic Review
Prabhakaran
S, et al. JAMA. 2015;313(14):1451-1462.
Conclusions: Intravenous
rtPA remains the standard of care for patients with moderate to severe
neurological deficits who present within 4.5 hours of symptom onset. Outcomes
for some patients with acute ischemic stroke and moderate to severe
neurological deficits due to proximal artery occlusion are improved with
endovascular reperfusion therapy. Efforts to hasten reperfusion therapy,
regardless of the mode, should be undertaken within organized stroke systems of
care.
E. A Randomized Trial on Subject
Tolerance and the Adverse Effects Associated With Higher- versus Lower-Flow
Oxygen through a Standard Nasal Cannula
Participants were
able to tolerate higher-flow nasal cannula oxygen for 10 minutes without
difficulty. Higher-flow nasal cannula oxygen at 15 L/minute was associated with
some discomfort, but the discomfort quickly dissipated and caused no adverse
events.
F. Workplace Violence in the ED:
Giving Nursing Staff the Tools and Support to Report
Workplace
violence is increasing across the nation's Emergency Departments, and nurses
often perceive it as part of their job. Reporting processes were inconsistent,
and nurses often did not know what acts constitute violence and underreported
it. A staff nurse-led workgroup developed an initial survey and a reporting
tool, and education was provided. A posteducation survey documented the
reporting of violent acts has increased, and staff perceived the Emergency
Department to be a safer environment.
G. Noninvasive Sphenopalatine Ganglion
Block for Acute Headache in the ED: A Randomized Placebo-Controlled Trial
CONCLUSION:
For patients with acute anterior headache, sphenopalatine ganglion block with
the Tx360 device with bupivacaine did not result in a significant increase in
the proportion of patients achieving a greater than or equal to 50% reduction
in headache severity at 15 minutes compared with saline solution applied in the
same manner.
H. High blood pressure overtreatment
bad for the cognition of impaired patients
I. Patients with health coaches more
likely to hit goals, study says
Patients who
had health coaches were more likely than those receiving usual care to meet
clinical goals for hemoglobin A1C, blood pressure and cholesterol, according to
a study from the University of California at San Francisco. The study,
published in the Annals of Family Medicine, used medical assistants trained to
be health coaches in primary care clinics.
