1. Extracorporeal Treatment for Salicylate Poisoning: Systematic
Review and Recommendations from the EXTRIP Workgroup.
Juurlink DN,
et al, for the EXTRIP Workgroup. Ann Emerg Med. 2015 May 8 [Epub ahead of
print]
STUDY
OBJECTIVE
Salicylate
poisoning is a challenging clinical entity associated with substantial
morbidity and mortality. The indications for extracorporeal treatments such as
hemodialysis are poorly defined. We present a systematic review of the
literature along with evidence- and consensus-based recommendations on the use
of extracorporeal treatment in salicylate poisoning.
METHODS
The
Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup is a
multidisciplinary group with international representation whose aim is to
provide evidence-based recommendations on the use of extracorporeal treatments
in poisoning. We conducted a systematic literature review followed by data
extraction and summarized findings, following a predetermined format. The
entire work group voted by a 2-round modified Delphi method to reach consensus
on voting statements, using a RAND/UCLA Appropriateness Method to quantify
disagreement. Anonymous votes were compiled, returned, and discussed in person.
A second vote determined the final recommendations.
RESULTS
Eighty-four
articles met inclusion criteria, including 1 controlled clinical trial, 3
animal studies, and 80 case reports or case series, yielding an overall very
low quality of evidence for all recommendations. Clinical data on 143 patients
(130 sets of which could be analyzed for patient-level entry data), including
14 fatalities, were reviewed. Toxicokinetic data on 87 patients were also
included. After the second round of voting, the workgroup concluded that
salicylates are dialyzable by hemodialysis and hemoperfusion (level of
evidence=B) and recommended extracorporeal treatment in patients with severe
salicylate poisoning (1D), including any patient with altered mental status
(1D), with acute respiratory distress syndrome requiring supplemental oxygen
(1D), and for those in whom standard therapy is deemed to be failing (1D)
regardless of the salicylate concentration. High salicylate concentrations
warrant extracorporeal treatment regardless of signs and symptoms (above 7.2
mmol/L [100 mg/dL] [1D]; and above 6.5 mmol/L [90 mg/dL] [2D]), with lower
thresholds applied for patients with impaired kidney function (above 6.5 mmol/L
[90 mg/dL] [1D]; above 5.8 mmol/L [80 mg/dL] [2D]). Extracorporeal treatment is
also suggested for patients with severe acidemia (pH ≤7.20 in the absence of
other indications) (2D). Intermittent hemodialysis is the preferred modality
(1D), although hemoperfusion (1D) and continuous renal replacement therapies
(3D) are acceptable alternatives if hemodialysis is unavailable, as is exchange
transfusion in neonates (1D).
CONCLUSION
Salicylates
are readily removed by extracorporeal treatment, with intermittent hemodialysis
being the preferred modality. The signs and symptoms of salicylate toxicity
listed warrant extracorporeal treatment, as do high concentrations regardless
of clinical status.
2. ED Corticosteroid Use for Allergy or Anaphylaxis Is Not
Associated With Decreased Relapses
Grunau BE et
al. Ann Emerg Med. 2015 Mar 25. [Epub ahead of print]
STUDY
OBJECTIVE
Corticosteroids
(steroids) are often used to mitigate symptoms and prevent subsequent reactions
in emergency department (ED) patients with allergic reactions, despite a lack
of evidence to support their use. We sought to determine the association of
steroid administration with improved clinical outcomes.
METHODS
Adult
allergy-related encounters to 2 urban EDs during a 5-year period were
identified and classified as "anaphylaxis" or "allergic
reaction." Regional and provincial databases identified subsequent ED
visits or deaths within a 7-day period. The primary outcome was allergy-related
ED revisits in the steroid- and nonsteroid-exposed groups, adjusting for
potential confounders with a propensity score analysis; secondary outcomes
included the number of clinically important biphasic reactions and deaths.
RESULTS
Two thousand
seven hundred one encounters (473 anaphylactic) were included; 48% were treated
with steroids. Allergy-related ED revisits occurred in 5.8% and 6.7% of
patients treated with and without steroids, respectively (adjusted odds ratio
[OR] 0.91; 95% confidence interval [CI] 0.64 to 1.28), with a number needed to
treat (NNT) to benefit of 176 (95% CI NNT to benefit 39 to ∞ to NNT to harm
65). The adjusted OR in the anaphylaxis subgroup was 1.12 (95% CI 0.41 to
3.27). In the allergic reaction group, the adjusted OR was 0.91 (95% CI 0.63 to
1.31), with an NNT to benefit of 173 (95% CI NNT to benefit 38 to ∞ to NNT to
harm 58). In the steroid and nonsteroid groups, there were 4 and 1 clinically
important biphasic reactions, respectively. There were no deaths.
CONCLUSION
Among ED
patients with allergic reactions or anaphylaxis, corticosteroid use was not
associated with decreased relapses to additional care within 7 days.
3. Risk for Clinically Relevant Adverse Cardiac Events in
Patients with CP at Hospital Admission.
Weinstock MB,
et al. JAMA Intern Med. 2015 May 18 [Epub ahead of print].
Importance: Patients
with potentially ischemic chest pain are commonly admitted to the hospital or
observed after a negative evaluation in the emergency department (ED) owing to
concern about adverse events. Previous studies have looked at 30-day mortality,
but no current large studies have examined the most important information
regarding ED disposition: the short-term risk for a clinically relevant adverse
cardiac event (including inpatient ST-segment elevation myocardial infarction,
life-threatening arrhythmia, cardiac or respiratory arrest, or death).
Objective: To
determine the incidence of clinically relevant adverse cardiac events in
patients hospitalized for chest pain with 2 troponin-negative findings,
nonconcerning initial ED vital signs, and nonischemic, interpretable
electrocardiographic findings.
Design,
Setting, and Participants: We conducted a blinded data review of 45 416
encounters obtained from a prospectively collected database enrolling adult
patients admitted or observed with the following inclusion criteria: (1)
primary presenting symptom of chest pain, chest tightness, chest burning, or
chest pressure and (2) negative findings for serial biomarkers. Data were
collected and analyzed from July 1, 2008, through June 30, 2013, from the EDs
of 3 community teaching institutions with an aggregate census of more than 1
million visits. We analyzed data extracted by hypothesis-blinded abstractors.
Main Outcomes
and Measures: The primary outcome was a composite of life-threatening
arrhythmia, inpatient ST-segment elevation myocardial infarction, cardiac or
respiratory arrest, or death during hospitalization.
Results: Of
the 45 416 encounters, 11 230 met criteria for inclusion. Mean patient age was
58.0 years. Of the 11 230 encounters, 44.83% of patients arrived by ambulance
and 55.00% of patients were women. Relevant history included hypertension in
46.00%, diabetes mellitus in 19.72%, and myocardial infarction in 13.16%. The
primary end point occurred in 20 of the 11 230 patients (0.18% [95% CI,
0.11%-0.27%]). After excluding patients with abnormal vital signs,
electrocardiographic ischemia, left bundle branch block, or a pacemaker rhythm,
we identified a primary end point event in 4 of 7266 patients (0.06% [95% CI,
0.02%-0.14%]). Of these events, 2 were noncardiac and 2 were possibly
iatrogenic.
Conclusions
and Relevance: In adult patients with chest pain admitted with 2 negative
findings for serial biomarkers, nonconcerning vital signs, and nonischemic
electrocardiographic findings, short-term clinically relevant adverse cardiac
events were rare and commonly iatrogenic, suggesting that routine inpatient
admission may not be a beneficial strategy for this group.
4. Should We Anticoagulate Patients with CHA2DS2-VASc Scores of
1?
Journal Watch
Emergency Medicine 2015 May 7
Kirsten E.
Fleischmann, MD, MPH reviewing Friberg L et al. J Am Coll Cardiol 2015 Jan 27.
Singer DE and Ezekowitz MD. J Am Coll Cardiol 2015 Jan 27. Chao T-F et al. J Am
Coll Cardiol 2015 Feb 24. Lip GY et al. J Am Coll Cardiol 2015 Apr 14.
Reported
stroke rates vary widely. Kirsten E. Fleischmann, MD, MPHThe CHA2DS2-VASc score
is used to stratify stroke risk in patients with atrial fibrillation (AF) based
on seven features (Congestive heart failure, Hypertension, Age ≥75, Diabetes,
prior Stroke or transient ischemic attack, Vascular disease, Age 65–74, and
Sex). For patients with nonvalvular AF and scores of ≥2, U.S. guidelines
recommend lowering stroke risk with anticoagulation (warfarin or novel
anticoagulants; NEJM JW Cardiol Jun 2014 and Circulation 2014 Mar 28; [e-pub]),
whereas patients with scores of 1 can be treated with aspirin, anticoagulants,
or no agent at all. But are patients with scores of 1 likely to benefit from
full anticoagulation? Several recent studies address aspects of this question.
In an
analysis of over 140,000 Swedish patients with AF but without anticoagulant
exposure, researchers used both lenient and more stringent definitions of
“stroke events” to determine risk for stroke in men and women with CHA2DS2-VASc
scores of 1. Annual stroke rates were 0.1% to 0.2% in women and 0.5% to 1.3% in
men, depending on the definition used. The authors concluded that patients in
this risk group are unlikely to benefit substantially from anticoagulation.
Conversely,
in a retrospective database analysis from Taiwan, annual risks for stroke in
patients with a single risk factor other than sex (i.e., men with CHA2DS2-VASc
scores of 1 and women with scores of 2) were 2.75% and 2.55%, respectively.
Stroke risk was highest in people between ages 65 and 74, with annual stroke
risks of 3.5% in men and 3.3% in women in this group.
Finally, in a
Danish cohort, stroke rates at 1 year for untreated patients without additional
risk factors (i.e., CHA2DS2-VASc scores of 0 for men and 1 for women) were very
low (0.49 per 100 person-years), but this risk tripled (1.55 per 100
person-years) in those with one additional risk factor.
Comment
In the first
study, stroke rates for patients with CHA2DS2-VASc scores of 1 who did not
receive anticoagulation were lower than in the other two reports; therefore,
the benefit of initiating anticoagulation was marginal. Editorialists point out
the relatively wide variation in stroke rates seen in the literature, as
demonstrated by the higher rates observed in the Danish and Taiwanese studies.
Both the Swedish and Taiwanese studies show that not all factors worth 1 point
in the CHA2DS2-VASc score convey equal risk. For example, age between 65 and 74
was associated with higher risk than other factors. Until we have randomized
data in lower-risk patients, individualized decision making about
antithrombotic therapy seems reasonable in patients with a single risk factor,
with recognition of the strong effect of age on stroke risk.
5. Validation of CSF findings in aneurysmal SAH: a case series
study.
Mark DG, et
al. Amer J Emerg Med. 2015 May 15 [Epub ahead of print].
Background
Recently
proposed cutoff criteria for cerebrospinal fluid (CSF) analyses might safely
exclude a diagnosis of aneurysmal subarachnoid hemorrhage (aSAH).
Objective
The objective
of this study was to examine the sensitivity of a CSF red blood cell (RBC)
count greater than 2000 × 106/L (ie, 2000 RBCs per microliter) or the presence
of visible CSF xanthochromia in identifying patients with aSAH.
Methods
We identified
a retrospective case series of patients diagnosed with aSAH after lumbar
puncture (LP) in an integrated health delivery system between January 2000 and
June 2013 by chart review. All identified patients had at least 1 cerebral
aneurysm that was treated with a neurosurgical or endovascular intervention
during the index hospitalization. The lowest CSF RBC count was used for
validation analysis. Cerebrospinal fluid color was determined by visual
inspection. Xanthochromia was defined as pink, orange, or yellow pigmentation
of CSF supernatant.
Results
Sixty-four
patients met study inclusion criteria. Of these, 17 (33%) of 52 underwent LP
within 12 hours of headache onset, and 49 (84%) of 58 exhibited CSF
xanthochromia. The median CSF RBC count was 63250 × 106/L. The sensitivity of a
CSF RBC count of greater than 2000 × 106/L in identifying aSAH was 96.9% (95%
confidence interval, 89.3%-99.1%). Additional consideration of CSF
xanthochromia resulted in a sensitivity of 100% (95% confidence interval,
94.3%-100%).
Conclusions
All patients
in this case series of patients with aSAH had either a CSF RBC count greater
than 2000 × 106/L or visible CSF xanthochromia, increasing the likelihood that
this proposed cutoff strategy may safely identify patients who warrant further
investigation for an aneurysmal cause of subarachnoid hemorrhage.
6. Departure from central line ritual.
Ballard DW, et
al. AHRQ WebM&M [serial online]. May 2015.
The Case: A
55-year-old man with a history of poorly controlled diabetes mellitus,
pancreatic insufficiency, and alcohol and cocaine abuse was found unconscious
by his neighbors. The patient had last been seen 2 days prior and complained of
dizziness, thirst, and nausea. Emergency medical services found him
unresponsive, with a Glasgow Coma Scale score of 3. He was intubated in the
field. Upon arrival in the emergency department (ED), his pH was less than 6.8,
carbon dioxide 37 mm Hg, oxygen 80 mm Hg, potassium 7.8 mEq/L, glucose 1400
mg/dL, lactate 11.2 mg/dL, and anion gap 42 mEq/L.
A right
internal jugular line was placed for access. The resident who placed the line
was relatively experienced in line placement but was unable to confirm
placement with ultrasound. Instead he used manometry, which was not a part of
the normal ED routine for line placement. He ultimately chose to pull the line.
Just then, another trauma patient arrived, and the supervising attending
physician left the room. The resident opened a second line insertion kit and
restarted the process. Ultrasound was used to confirm correct placement. Upon
flushing the line, it was noted that one of the ports was not working. The
patient soon went into atrial tachycardia, which broke with adenosine. A chest
radiograph was not obtained until later, after the patient went into
ventricular fibrillation in the intensive care unit.
When the
chest radiograph was finally completed, a retained wire was noted in the
pulmonary artery. The interventional radiology team was consulted for wire
removal. The retained wire likely caused a cardiac arrest, which required
shocks, chest compressions, and cooling. After guidewire removal, the patient
had no further episodes of arrhythmias, but experienced several other serious
complications during a prolonged and stormy hospitalization.
The
Commentary: This case represents a preventable medical error. In fact, this
particular error—retained guidewire after central venous catheterization
(CVC)—is so preventable that it has been characterized in the literature as
"completely avoidable" and a "never event."(1,2)
Nevertheless, this error continues to occur in numerous hospitals annually with
a relatively constant event rate of 0.04 to 0.08 reported events per 1000
staffed hospital beds.(3) In order to successfully address this issue, we must
systematically examine the root causes and focus proposed solutions on both
error prevention and risk mitigation though early error recognition…
7. Rapid sequence induction of anaesthesia via the intraosseous
route: a prospective observational study.
Barnard EB,
et al. Emerg Med J. 2015 Jun;32(6):449-52.
BACKGROUND: Intraosseous
(IO) drug infusion has been reported to have similar pharmacokinetics to
intravenous (IV) infusion. In military and civilian trauma, the IO route is
often used to obtain rapid and reliable parenteral access for drug
administration. Only a few case reports have described the use of IO infusion
to administer drugs for rapid sequence induction of anaesthesia (RSI).
OBJECTIVE: We
aimed to assess the feasibility of the administration of RSI drugs via an IO
catheter in a prospective observational study.
METHODS: A
prospective observational study was undertaken at a combat hospital in
Afghanistan. A validated data form was used to record the use of IO drugs for
RSI by the prehospital, physician-led Medical Emergency Response Team (MERT),
and by inhospital physicians. Data were captured between January and May 2012
by interview with MERT physicians and inhospital physicians directly after RSI.
The primary outcome measure was the success rate of first-pass intubation with
direct laryngoscopy.
RESULTS: 34
trauma patients (29 MERT and 5 inhospital) underwent RSI with IO drug
administration. The median age was 24 years and median injury severity score
25; all were male. The predominant mechanism of injury was blast (n=24),
followed by penetrating (n=6), blunt (n=3) and burn (n=1). First-pass
intubation success rate was 97% (95% CI 91% to 100%). A Cormack-Lehane grade 1
view, by direct laryngoscopy, was obtained at first look in 91% (95% CI 81% to
100%) of patients.
CONCLUSIONS: In
this prospective, observational study, IO drug administration was successfully
used for trauma RSI, with a comparable first pass intubation success than
published studies describing the IV route.
8. High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic
Respiratory Failure.
Frat JP, et
al. N Engl J Med. 2015 May 17. [Epub ahead of print]
Background:
Whether noninvasive ventilation should be administered in patients with acute
hypoxemic respiratory failure is debated. Therapy with high-flow oxygen through
a nasal cannula may offer an alternative in patients with hypoxemia.
Methods: We
performed a multicenter, open-label trial in which we randomly assigned
patients without hypercapnia who had acute hypoxemic respiratory failure and a
ratio of the partial pressure of arterial oxygen to the fraction of inspired
oxygen of 300 mm Hg or less to high-flow oxygen therapy, standard oxygen
therapy delivered through a face mask, or noninvasive positive-pressure
ventilation. The primary outcome was the proportion of patients intubated at
day 28; secondary outcomes included all-cause mortality in the intensive care
unit and at 90 days and the number of ventilator-free days at day 28.
Results: A
total of 310 patients were included in the analyses. The intubation rate
(primary outcome) was 38% (40 of 106 patients) in the high-flow-oxygen group,
47% (44 of 94) in the standard group, and 50% (55 of 110) in the
noninvasive-ventilation group (P=0.18 for all comparisons). The number of
ventilator-free days at day 28 was significantly higher in the high-flow-oxygen
group (24±8 days, vs. 22±10 in the standard-oxygen group and 19±12 in the
noninvasive-ventilation group; P=0.02 for all comparisons). The hazard ratio
for death at 90 days was 2.01 (95% confidence interval [CI], 1.01 to 3.99) with
standard oxygen versus high-flow oxygen (P=0.046) and 2.50 (95% CI, 1.31 to 4.78)
with noninvasive ventilation versus high-flow oxygen (P=0.006).
Conclusions:
In patients with nonhypercapnic acute hypoxemic respiratory failure, treatment
with high-flow oxygen, standard oxygen, or noninvasive ventilation did not
result in significantly different intubation rates. There was a significant
difference in favor of high-flow oxygen in 90-day mortality.
Full-text
(free): http://www.nejm.org/doi/full/10.1056/NEJMoa1503326?query=OF#t=article
Editorial: Saving Lives with High-Flow
Nasal Oxygen
Full-text
(free): http://www.nejm.org/doi/full/10.1056/NEJMe1504852
9. Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis:
an etiology worth considering in the differential diagnosis of delirium.
Punja M, et
al. Clin Toxicol (Phila). 2013 Sep-Oct:51(8):794-7.
Medical
toxicologists are frequently consulted when young patients present with
delirium attributed to suspected poisoning. Medical toxicologists should be
aware of non-toxicological mimics of delirium. We describe two patients
ultimately diagnosed with anti-N-methyl-D-aspartate receptor (NMDAR)
encephalitis for which a toxicological consultation was requested to evaluate
for neuroleptic malignant syndrome (NMS).
A 21 year old
male was sent from a psychiatric facility for new, worsening psychotic
symptoms. He had autonomic instability, confusion, and hyper-reflexia. He was
treated for NMS without improvement, and after an extensive workup was
unrevealing, he was discharged home with significant cognitive dysfunction.
Stored CSF later tested positive for anti-NMDAR antibodies.
CASE 2: A 27
year old female was sent from a psychiatric facility for a seizure and new
psychiatric symptoms. She was agitated and had violent, alternating extremity
flexion and extension along with autonomic instability. She was treated for
NMS, rhabdomyolysis, and rabies before analysis of CSF demonstrated anti-NMDAR
antibodies. Treatment included surgical resection of a suspicious ovarian cyst,
steroids and IVIG, with moderate improvement.
Autoimmune
syndromes of the central nervous system result from receptor dysfunction after
an antibody response to extracellular or intracellular antigens, such as
subunits of the NMDA receptor. The NMDA subunits NR2b and NR2a, in addition to
the N-terminal region of the glycine binding NR1 subunit, have been implicated.
Typical features such as memory loss, movement disorders, and hallucinations
reflect the density and distribution of neuronal NDMA receptors. As young
people, particularly young women, are predominantly affected, initial symptoms
may be attributed to encephalopathy from drug abuse or schizophrenia.
Toxicologists may be consulted as many features mimic NMS. Serum and
cerebrospinal fluid can be checked for anti-NMDAR antibodies as part of a
paraneoplastic or meningioencephalitis panel. Effective treatments have been
described and include surgical resection and immunosuppressive medications.
10. Images in Clinical Practice
Young Man with
Pain in Right Eye
Discussion of
eye FB case: http://www.annemergmed.com/article/S0196-0644(15)00229-2/fulltext
Elderly Woman
with Shortness of Breath
Man with Pain
in Left Eye
Trapped Lung
Conjunctival
Melanoma
Intraoral
Malignant Melanoma
Lindsay’s
Nails in Chronic Kidney Disease
Disseminated
Lyme Disease
Verrucous
Tongue Lesion
Hemichoreoathetosis
in Neurosarcoidosis
11. Safety and efficacy of antihypertensive prescription at ED
discharge.
Brody A, et
al. Acad Emerg Med. 2015 May;22(5):632-5.
BACKGROUND:
Poor blood pressure (BP) control is a primary risk factor for target organ
damage in the heart, brain, and kidney. Uncontrolled hypertension is common
among emergency department (ED) patients, particularly in underresourced
settings, but it is unclear what role ED providers should play in the management
of chronic antihypertensive therapy.
OBJECTIVES:
The objective was to evaluate the safety and efficacy of prescribing
antihypertensive therapy from the ED.
METHODS: This
was a retrospective study of data pooled from two prospective, longitudinal, randomized
controlled trials, both of which enrolled ED patients with asymptomatic
hypertension. Antihypertensives were prescribed at emergency physician
discretion, and this was not related to randomization arm. Demographic data, BP
at screening and randomization visit, and data on adverse effects potentially
related to antihypertensive therapy were compiled. Means were compared using
Student's t-tests, and proportions were compared using chi-square tests. The
effect of antihypertensive therapy on BP control was further analyzed using
multivariable regression modeling controlling for age, race, sex, hypertension
history, study cohort, and ED BP.
RESULTS: Data
were abstracted for 217 subjects. The median interval from ED visit to
randomization was 12 days. Seventy-six subjects (35%) received one or more
prescriptions for antihypertensive therapy. Age, sex, race, hypertension
history, and mean duration of hypertension were equivalent between groups.
Although mean ED BP was higher among those who received prescriptions, the mean
systolic BP (sBP) reduction from ED to randomization was significantly greater
(difference = 19 mm Hg, 95% confidence interval = 12 to 26 mm Hg). No patient
in either group had an sBP less than 100 mm Hg at randomization. On multiple regression
modeling, randomization sBP reduction was independently associated with
antihypertensive prescription (p = 0.001). The incidence of adverse effects was
equivalent and low in both groups. No new neurological deficits, ischemic
events, or life-threatening anaphylactic reactions were reported in either
group.
CONCLUSIONS:
Prescription of antihypertensive medication from the ED is associated with
significantly lower sBP at short-term outpatient follow-up. Antihypertensive
therapy was not associated with an increased incidence of adverse events, and
BP reduction did not exceed potentially harmful levels. Initiation of chronic
antihypertensive therapy in the ED is safe and effective and may be a
reasonable consideration for at-risk populations.
12. Procedures in Children
A. A Randomized Clinical Trial of
Jet-Injected Lidocaine to Reduce Venipuncture Pain for Young Children
Lunoe MM, et
al. Ann Emerg Med 2015 April 24 [Epub ahead of print]
STUDY
OBJECTIVE: The J-Tip (National Medical Products Inc, Irvine, CA) uses air
instead of a needle to push lidocaine into the skin. To our knowledge, no
studies have investigated its use for venipuncture in young children. We
determine whether the J-Tip decreased venipuncture pain in young children
compared with vapocoolant spray.
METHODS:
Children aged 1 to 6 years were randomized into 3 groups: intervention (J-Tip),
control (vapocoolant spray), and sham (vapocoolant spray and pop of an empty
J-Tip). The procedure was videotaped and scored with the Face, Legs, Activity,
Cry and Consolability (FLACC) tool at 3 points; baseline, before approach;
device, at J-Tip deployment; and at venipuncture. The FLACC tool was scored 0
(none) to 10 (severe). Comparisons of pain scores over time were made with the
generalized estimating equation. Venipuncture success and adverse effects were
assessed and compared with χ2.
RESULTS: Two
hundred five children enrolled: intervention 96, control 53, and sham 56. There
were no between-group differences in baseline characteristics. There was no
mean change in pain scores from device to venipuncture in the intervention
group (0.26; 95% confidence interval [CI] -0.31 to 0.82), but there was an
increase in pain in the control (2.82; 95% CI 1.91 to 3.74) and sham (1.68; 95%
CI 0.83 to 2.52) groups. This change was greater for the control and sham
compared to the intervention group. There was no difference in venipuncture
success between groups. No severe adverse events occurred. Minor adverse events
were the same between groups.
CONCLUSION: Use
of the J-Tip for children aged 1 to 6 years reduced venipuncture pain compared
with vapocoolant spray or sham treatment.
B. US or near-infrared vascular
imaging to guide peripheral IV catheterization in children: a pragmatic RCT.
Curtis SJ, et
al. CMAJ. 2015 May 19;187(8):563-70.
BACKGROUND: Peripheral
intravenous catheterization in children is challenging, and success rates vary
greatly. We conducted a pragmatic randomized controlled trial to determine
whether the use of ultrasound or near-infrared vascular imaging to guide
catheterization would be more effective than the standard approach in achieving
successful catheter placement on the first attempt.
METHODS: We
enrolled a convenience sample of 418 children in a pediatric emergency
department who required peripheral intravenous catheterization between June
2010 to August 2012. We stratified them by age (≤ 3 yr and over 3 yr) and
randomly assigned them to undergo the procedure with the standard approach, or
with the help of either ultrasound or near-infrared vascular imaging. The
primary outcome was the proportion of patients who had successful placement of
a catheter on the first attempt.
RESULTS: The
rate of successful first attempts did not differ significantly between either
of the 2 intervention groups and the standard approach group (differences in
proportions -3.9%, 95% confidence interval [CI] -14.2% to 6.5%, for ultrasound
imaging; -8.7%, 95% CI -19.4% to 1.9%, for near-infrared imaging). Among
children 3 years and younger, the difference in success rates relative to
standard care was also not significant for ultrasound imaging (-9.6%, 95% CI
-29.8% to 10.6%), but it was significantly worse for near-infrared imaging
(-20.1%, 95% CI -40.1% to -0.2%). Among children older than 3 years, the
differences in success rates relative to standard care were smaller but not
significant (-2.3%, 95% CI -13.6% to 9.0%, for ultrasound imaging; -4.1%, 95%
CI -15.7% to 7.5%, for near-infrared imaging). None of the pairwise comparisons
were statistically significant in any of the outcomes.
INTERPRETATION:
Neither technology improved first-attempt success rates of peripheral
intravenous catheterization in children, even in the younger group. These
findings do not support investment in these technologies for routine peripheral
intravenous catheterization in children.
13. Impact of relative contraindications to home management in ED
patients with low-risk PE.
Vinson DR, et
al. Ann Amer Thoracic Soc. 2015;12(5):666-673
Rationale:
Studies of adults presenting to the emergency department (ED) with acute
pulmonary embolism (PE) suggest that those who are low risk on the PE Severity
Index (classes I and II) can be managed safely without hospitalization.
However, the impact of relative contraindications to home management on
outcomes has not been described.
Objectives:
To compare 5-day and 30-day adverse event rates among low-risk ED patients with
acute PE without and with outpatient ineligibility criteria.
Methods: We
conducted a retrospective multicenter cohort study of adults presenting to the
ED with acute low-risk PE between 2010 and 2012. We evaluated the association
between outpatient treatment eligibility criteria based on a comprehensive list
of relative contraindications and 5-day adverse events and 30-day outcomes,
including major hemorrhage, recurrent venous thromboembolism, and all-cause
mortality.
Measurements
and Main Results: Of 423 adults with acute low-risk PE, 271 (64.1%) had no
relative contraindications to outpatient treatment (outpatient eligible),
whereas 152 (35.9%) had at least one contraindication (outpatient ineligible).
Relative contraindications were categorized as PE-related factors (n = 112;
26.5%), comorbid illness (n = 42; 9.9%), and psychosocial barriers (n = 19;
4.5%). There were no 5-day events in the outpatient-eligible group (95% upper
confidence limit, 1.7%) and two events (1.3%; 95% confidence interval [CI],
0.1–5.0%) in the outpatient-ineligible group (P = 0.13). At 30 days, there were
five events (two recurrent venous thromboemboli and three major bleeding
events) in the outpatient-eligible group (1.8%; 95% CI, 0.7–4.4%) compared with
nine in the ineligible group (5.9%; 95% CI, 2.7–10.9%; P less than 0.05). This
difference remained significant when controlling for PE severity class.
Conclusions:
Nearly two-thirds of adults presenting to the ED with low-risk PE were
potentially eligible for outpatient therapy. Relative contraindications to
outpatient management were associated with an increased frequency of adverse
events at 30 days among adults with low-risk PE.
14. Annals of EM: Brief Lit Reviews
A. What Is the Accuracy of Emergency
Physician–Performed Ultrasonography for Deep Venous Thrombosis?
Take-home: Using
bedside ultrasonography in carefully selected patients, emergency physicians
can accurately diagnose lower extremity deep venous thrombosis.
Full-text (free):
http://www.annemergmed.com/article/S0196-0644(14)00594-0/fulltext
B. Does Intravenous Magnesium Reduce
the Need for Hospital Admission Among Adult Patients With Acute Asthma
Exacerbations?
Take-home: Administration
of intravenous magnesium sulfate may result in a modest reduction in hospital
admissions among adult ED patients with acute asthma who have not responded to
standard therapies.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(14)00626-X/fulltext
15. Ethanol Alters the Cutoff for Abnormal Lactate and Base
Deficit in Trauma Patients
A large
retrospective study shows that moderately elevated lactate and base deficit
values do not predict mortality in intoxicated patients.
Daniel J.
Pallin, MD, MPH, Journal Watch Emerg Med 2015 May 15
Reviewing Gustafson
ML et al. Am J Emerg Med 2015 May
In trauma
patients, lactic acid or base deficit levels greater than 2 mmol/L predict
higher mortality risk. To evaluate the influence of ethanol intoxication on
these associations, researchers retrospectively reviewed data for 2482 patients
admitted to a single trauma center between 2005 and 2014. Of these patients,
784 tested positive for ethanol.
In the
ethanol-negative group, mortality was 2.6 times more likely in those with
elevated lactate than in those without elevated lactate, and it was 1.9 times
more likely in those with elevated base deficit than in their counterparts.
However, in the intoxicated group, there was no significant relationship
between either lactate or base deficit and mortality. Secondary analyses
suggested that a lactate level over 4.45 mmol/L or a base deficit over 6.97
mmol/L predicted mortality in the ethanol-positive group.
Article
abstract: http://www.ncbi.nlm.nih.gov/pubmed/25770595
16. The evaluation of suspected child physical abuse: New AAP
Guidelines
Christian CW;
AAP COMMITTEE ON CHILD ABUSE AND NEGLECT. Pediatrics. 2015 May;135(5):e1337-54.
Child
physical abuse is an important cause of pediatric morbidity and mortality and
is associated with major physical and mental health problems that can extend
into adulthood. Pediatricians are in a unique position to identify and prevent
child abuse, and this clinical report provides guidance to the practitioner
regarding indicators and evaluation of suspected physical abuse of children.
The role of the physician may include identifying abused children with
suspicious injuries who present for care, reporting suspected abuse to the
child protection agency for investigation, supporting families who are affected
by child abuse, coordinating with other professionals and community agencies to
provide immediate and long-term treatment to victimized children, providing
court testimony when necessary, providing preventive care and anticipatory
guidance in the office, and advocating for policies and programs that support
families and protect vulnerable children.
Full-text
(free): http://pediatrics.aappublications.org/content/135/5/e1337.long
17. Acute Appendicitis — Appendectomy or the “Antibiotics First”
Strategy
Flum DR. N
Engl J Med 2015; 372:1937-1943.
CASE
A 56-year-old
man presents with a 2-day history of abdominal pain. The pain began centrally
but has moved to the right lower quadrant of his abdomen in the past 6 hours.
He has a body-mass index (the weight in kilograms divided by the square of the
height in meters) of 33, a body temperature of 100°F (37.8°C), and a white-cell
count of 11,500 per cubic millimeter. The right side of his lower abdomen is
tender to palpation. A computed tomographic (CT) scan was ordered by his
primary care physician after he was examined in the clinic, and the results are
consistent with appendicitis. He has had three prior surgical procedures: an open
Nissen fundoplication complicated by a pulmonary embolism and two incisional
hernia repairs with mesh. After receiving the results of his CT scan, he found
information online about doctors in Europe who are using antibiotics alone to
treat appendicitis, and he asks specifically about that option. How would you
manage this case? …
EXCERPTS
BELOW
…CONCLUSIONS
AND RECOMMENDATIONS
The patient
described in the vignette has clinical symptoms and signs consistent with acute
appendicitis, and the diagnosis was confirmed by diagnostic imaging. In the
United States, the usual treatment recommendation for people with uncomplicated
appendicitis is a prompt appendectomy. The laparoscopic approach is preferred
to the open approach by most surgeons (owing to a lower incidence of surgical-site
infection and a faster return for the patient to usual activities) in the
absence of contraindications to laparoscopy. However, experience in Europe
suggests that an antibiotics-first strategy is an alternative that warrants
consideration, particularly in a patient who has had prior surgical
complications and has a strong preference for avoiding appendectomy. Patients
should understand that European randomized trials comparing this approach with
appendectomy have shown that it is not associated with an increased risk of
perforation or a higher rate of complications; however, these trials have also
shown that as many as half the patients so treated will have early treatment
failures, and all have a risk of recurrent appendicitis that may ultimately require
appendectomy.
It remains to
be determined whether the benefits of potentially avoiding an operation with
the antibiotics-first approach are outweighed by the burden to the patient
related to future appendicitis episodes, more days of antibiotic therapy,
lingering symptoms, and uncertainty that may affect quality of life. This is
especially true given that appendectomy, as performed in the United States, has
a very favorable safety profile and typically involves a short hospitalization.
Although appendectomy remains the recommended treatment for appendicitis,
clinicians should inform appropriate patients about the evidence related to an
antibiotics-first strategy, as well as the uncertainties. I recommend that,
pending more information regarding the effectiveness of an antibiotics-first
approach and the longer-term outcomes of this strategy, patients interested in
considering an antibiotics-first approach should be encouraged to participate
in clinical trials. When an antibiotics-first strategy is used outside a
clinical trial, I would encourage treating physicians to include their
experience in a patient registry
KEY CLINICAL
POINTS
Appendicitis
is the most common reason for emergency abdominal surgery, with a lifetime
incidence of 7 to 14%.
As compared
with open appendectomy, laparoscopic appendectomy is associated with a reduced
risk of surgical-site infection, a faster return to function, and a reduced
risk of subsequent bowel obstruction.
Several
small, randomized trials comparing an antibiotics-first strategy (with
appendectomy performed if patients do not have a response) with prompt
appendectomy in patients with uncomplicated appendicitis showed no significant
increase in complications with an antibiotics-first approach but also showed a
substantial rate of crossover to surgery in the first 48 hours or appendectomy
in the ensuing year.
Appendectomy
is still recommended for most people with uncomplicated appendicitis, but
patients should be informed about options, and an antibiotics-first strategy
may be considered in those who have strong preferences for avoiding an
operation or who have contraindications to surgery.
Link
(subscription required): http://www.ncbi.nlm.nih.gov/pubmed/25970051
18. Intravenous Subdissociative-Dose Ketamine Versus Morphine
for Analgesia in the Emergency Department: A Randomized Controlled Trial
Motov S, et
al. Ann Emerg Med. 2015 Mar 26. [Epub ahead of print]’
STUDY
OBJECTIVE: We assess and compare the analgesic efficacy and safety of
subdissociative intravenous-dose ketamine with morphine in emergency department
(ED) patients.
METHODS: This
was a prospective, randomized, double-blind trial evaluating ED patients aged
18 to 55 years and experiencing moderate to severe acute abdominal, flank, or
musculoskeletal pain, defined as a numeric rating scale score greater than or
equal to 5. Patients were randomized to receive ketamine at 0.3 mg/kg or
morphine at 0.1 mg/kg by intravenous push during 3 to 5 minutes. Evaluations
occurred at 15, 30, 60, 90, and 120 minutes. Primary outcome was reduction in
pain at 30 minutes. Secondary outcome was the incidence of rescue analgesia at
30 and 60 minutes.
RESULTS:
Forty-five patients per group were enrolled in the study. The primary change in
mean pain scores was not significantly different in the ketamine and morphine
groups: 8.6 versus 8.5 at baseline (mean difference 0.1; 95% confidence
interval -0.46 to 0.77) and 4.1 versus 3.9 at 30 minutes (mean difference 0.2;
95% confidence interval -1.19 to 1.46; P=.97). There was no difference in the
incidence of rescue fentanyl analgesia at 30 or 60 minutes. No statistically
significant or clinically concerning changes in vital signs were observed. No
serious adverse events occurred in either group. Patients in the ketamine group
reported increased minor adverse effects at 15 minutes post-drug
administration.
CONCLUSION:
Subdissociative intravenous ketamine administered at 0.3 mg/kg provides
analgesic effectiveness and apparent safety comparable to that of intravenous
morphine for short-term treatment of acute pain in the ED.
19. Ultrasound-guided hematoma block in distal radial fracture
reduction: a randomised clinical trial.
Fathi M, et
al. Emerg Med J. 2015 Jun;32(6):474-7.
OBJECTIVE: We
compared the efficacy and safety of ultrasound-guided haematoma block with that
of procedural sedation and analgesia in patients with acute distal radial
fracture reduction pain control.
METHODS: This
was a randomised clinical trial on adult patients conducted in two teaching
hospitals. Patients received intravenous midazolam plus fentanyl in the
procedural sedation and analgesia group, and fracture site injection of
lidocaine 10% in the ultrasound guided haematoma block group. We measured pain
scores before reduction, during reduction and 5, 10 and 15 min after reduction
by a numeric rating scale, and patient and physician satisfaction by a
four-level Likert scale. Time to discharge, early adverse effects and late
complications were also compared.
RESULTS: We
enrolled 160 patients with distal radial fracture and randomised 143 patients
into two groups (after excluding 17 patients). Pain was effectively controlled
in both groups. Pain scores had no statistically significant difference before
and during reduction and 5 and 15 min after reduction in the procedural
sedation and analgesia and ultrasound guided haematoma block groups. Patient
and physician overall satisfaction were similar in the two groups. Time to
discharge was significantly lower in the ultrasound guided haematoma block
group. Four patients (5.5%) in the procedural sedation and analgesia group
showed early adverse effects. No patient in either group showed any late
complications.
CONCLUSIONS: Ultrasound
guided haematoma block may be a safe and effective alternative to procedural
sedation and analgesia.
20. Diagnostic Performance of Focused Cardiac Ultrasound
Performed by Emergency Physicians for the Assessment of Ascending Aorta
Dilation and Aneurysm
Nazerian P,
et al. Acad Emerg Med. 2015 May;22(5):536-41.
OBJECTIVES:
The diagnostic performance of transthoracic focused cardiac ultrasound (FoCUS)
performed by emergency physicians (EP) to estimate ascending aorta dimensions
in the acute setting has not been prospectively studied. The diagnostic
accuracy and the interobserver variability of EP-performed FoCUS were
investigated to estimate thoracic aortic dilation and aneurysm compared with
the results of computed tomography angiography (CTA).
METHODS: This
was a prospective single-center cohort study of a convenience sample of
patients who underwent CTA in the emergency department for suspected aortic
pathology. FoCUS was performed before CTA, and the maximum ascending aorta
diameter evaluated in parasternal long-axis view. Aorta diameter less than 40
mm by visual estimation or by diameter measurement was considered normal.
Measurements were recorded in all patients with aorta diameter ≥ 40 mm.
Diagnostic accuracy of FoCUS for detection of aortic dilation (diameter ≥ 40
mm) and aneurysm (diameter ≥ 45 mm) were calculated considering the CTA result
as reference standard. In a subgroup of patients, a second EP-sonographer
performed FoCUS to evaluate interobserver agreement for the diagnosis of
ascending aorta dilation.
RESULTS: A
total of 140 patients were enrolled in the study. Ascending aorta dilation and
aneurysm were detected with FoCUS in 50 (35.7%) and in 27 (17.8%) patients,
respectively. Sensitivity and specificity of FoCUS were 78.6% (95% confidence
interval [CI] = 65.6% to 88.4%) and 92.9% (95% CI = 85.1% to 97.3%),
respectively, for ascending aorta dilation and 64.7% (95% CI = 46.5% to 80.2%)
and 95.3% (95% CI = 89.3% to 98.4%), respectively, for ascending aorta
aneurysm. Interobserver agreement of FoCUS was k = 0.82.
CONCLUSIONS:
FoCUS performed by EP is specific for ascending aorta dilation and aneurysm
when compared to CTA and appears a reproducible technique.
21. Say "ow" to help cope with pain
Exclamations
such as "ouch," "ow," and "owie" seem to be
common, spontaneous responses to sudden experiences of pain. But what motivates
them? Why do they occur irrespective of whether sufferers are alone or in
company?
The authors
investigated whether vocalization helps alleviate pain and sought to discern
potential underlying mechanisms. Participants immersed their hand into
painfully cold water longer when saying "ow" than when doing nothing.
Whereas button-pressing had a similar effect, hearing one's own or another
person's "ow" did not. Thus, vocalizing in pain is not only
communicative. Like other behaviors, it helps cope with pain, the authors
conclude.
22. Case Series of Patients with Ruptured Abdominal Aortic
Aneurysm
Taylor S, et
al. West J Emerg Med. 2015 May;16(3):367-71.
INTRODUCTION:
Traditionally, patients with suspected ruptured abdominal aortic aneurysm
(rAAA) are taken immediately for operative repair. Computed tomography (CT) has
been considered contraindicated. However, with the emergence of endovascular
repair, this approach to suspected rAAA could be changing.
METHODS: We
present retrospective data in a case series of 110 patients with rAAA. Patients
were managed at a single tertiary medical center over a five-year period. At
this site, there was an established multidisciplinary protocol in which
patients with suspected rAAA undergo CT with consideration for endovascular
aortic repair (EVAR).
RESULTS: Our
results demonstrated a mortality of 30% with our institutional protocol for CT
in suspected rAAA. Comparing patients who ultimately had EVAR with open repair,
those able to have endovascular aneurysm repair (EVAR) had lower mortality,
shorter hospital stays for survivors, and a greater likelihood of being
discharged to home than those with open repair. While survivors were more
likely to have had EVAR, surviving patients were younger, had a significantly
lower creatinine at presentation, and required fewer blood transfusions than
those who died.
CONCLUSION: Based
on this case series, an institutional approach endorsing CT for presumed rAAA
appears to be reasonable. Our results suggest that EVAR may be beneficial in
appropriately-selected patients and that CT may potentially facilitate superior
management options for patient care.
Full-text
(free): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4427205/
23. Micro Bits
A. Fecal transplants effective in 85%
of patients with recurrent C. diff infection
A review
study funded by the Department of Veterans Affairs found fecal transplantation
successfully treated recurrent Clostridium difficile infection in 85% of cases
and helped 55% of patients who did not respond to drugs. Researchers said,
however, the available data is "low strength" and is inadequate to
draft guidelines for determining ideal donors, identifying fecal preparation
methods or recommending the best way to deliver the stool to patients.
The findings
were published in Annals of Internal Medicine
B. Supplemental Temporary IVC Filters
No Help in Anticoagulated PE Patients
No reduction
in recurrence or mortality in randomized study.
C. Eleanor Roosevelt's last days: A
bioethical case study
When Eleanor
Roosevelt died in 1962, she was widely regarded as "the greatest woman in
the world." Despite her celebrity, or more likely because of it, she had
to endure a prolonged period of intense suffering and humiliation before dying,
which was due in large part to her medical care. Her case reveals a great deal
about the evolution of the bioethics of dying and concepts of end-of-life care
in America.
D. Metabolic syndrome affects 35% of
U.S. adults, study finds
Metabolic
syndrome, a combination of health conditions including hypertension, waist
measurements, high blood sugar and irregular cholesterol, is a key sign of
heart disease and diabetes risk, according to a study in the Journal of the
American Medical Association. Researchers found that in 2011 to 2012, 35% of
adult Americans had metabolic syndrome. Among people 60 years old and older,
47% of people had metabolic syndrome, while 18% between ages 20 to 39 had the
condition.
E. Report estimates 10% of children
are diagnosed with ADHD
A report from
the CDC says that 1 in 10 children and teenagers has been diagnosed with
attention-deficit/hyperactivity disorder. Boys are diagnosed at about double
the rate of girls. Hispanic children and teens are the least likely to be
diagnosed with ADHD, and children from more affluent families are less likely
to have an ADHD diagnosis than children from lower-income families.
F. Conditioned analgesia from known
placebo
Belief in
effective placebo treatment is widely thought to be critical for placebo
analgesia. Many placebo responses appear to be mediated by expectations that
are strengthened as treatment cues are reinforced with positive outcomes. Yet
placebo effects may occur even when participants know they are receiving
placebo. Can conditioned placebo analgesia persist in the absence of
expectations? This report studied long (four days) vs. short (one day)
conditioning to placebo treatment. After an initial placebo test, a
"reveal" manipulation convincingly showed participants they had never
received an active drug. Placebo analgesia persisted after the reveal in the
long conditioning group only.
G. Concussion may affect children's
academic performance
Researchers
followed 349 students, ages 5 to 18, who had a concussion and found that 77% of
those still recovering had difficulty taking notes and took longer to complete
homework, while 88% experienced fatigue, headaches, had problems concentrating
or found it difficult to understand lessons. The findings, published in
Pediatrics, also showed students with severe head injuries were more likely to
have the most academic problems.
