Thursday, May 28, 2015

Lit Bits: May 28, 2015

From the recent medical literature...

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]

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.

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.

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).

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]

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.

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.

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.

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.

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].

Recently proposed cutoff criteria for cerebrospinal fluid (CSF) analyses might safely exclude a diagnosis of aneurysmal subarachnoid hemorrhage (aSAH).

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.

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.

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%).

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…

The remainder of the discussion (free):

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.

Editorial: Saving Lives with High-Flow Nasal Oxygen

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

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.

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.

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.

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.

17. Acute Appendicitis — Appendectomy or the “Antibiotics First” Strategy

Flum DR. N Engl J Med 2015; 372:1937-1943.

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? …

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

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):

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.

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.