1. Just Out: New 2015 AHA ACS Guidelines
The 2015
Guidelines Update marks a change in the scope of the AHA guidelines for the
evaluation and management of ACS. Starting with this update, recommendations
will be limited to the prehospital and ED phases of care. In-hospital care is
addressed by guidelines for the management of myocardial infarction published
jointly by the AHA and the American College of Cardiology Foundation.
Publication
of the 2015 American Heart Association (AHA) Guidelines Update for
Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
marks 49 years since the first CPR guidelines were published in 1966 by an Ad
Hoc Committee on Cardiopulmonary Resuscitation established by the National
Academy of Sciences of the National Research Council.1 Since that time,
periodic revisions to the Guidelines have been published by the AHA in 1974,2
1980,3 1986,4 1992,5 2000,6 2005,7 2010,8 and now 2015. The 2010 AHA Guidelines
for CPR and ECC provided a comprehensive review of evidence-based
recommendations for resuscitation, ECC, and first aid. The 2015 AHA Guidelines
Update for CPR and ECC focuses on topics with significant new science or
ongoing controversy, and so serves as an update to the 2010 AHA Guidelines for
CPR and ECC rather than a complete revision of the Guidelines.
The formal
guidelines (in 15 parts), published in Circulation 2015 October
supplement: http://circ.ahajournals.org/content/132/18_suppl_2.toc
Selected excerpts
A. Troponin to Identify Patients Who
Can Be Safely Discharged from the ED
High-sensitivity
cardiac troponin is now widely available. The 2015 CoSTR review examined
whether a negative troponin test could reliably exclude a diagnosis of ACS in
patients who did not have signs of STEMI on ECG. For emergency department
patients with a presenting complaint consistent with ACS, high-sensitivity
cardiac troponin T (hs-cTnT) and cardiac troponin I (cTnI) measured at 0 and 2
hours should not be interpreted in isolation (without performing clinical risk
stratification) to exclude the diagnosis of ACS. In contrast, high-sensitivity
cardiac troponin I (hs-cTnI), cTnI, or cardiac troponin T (cTnT) may be used in
conjunction with a number of clinical scoring systems to identify patients at
low risk for 30-day major adverse cardiac events (MACE) who may be safely
discharged from the emergency department.
We recommend
that hs-cTnI measurements that are less than the 99th percentile, measured at 0
and 2 hours, may be used together with low risk stratification (Thrombolysis in
Myocardial Infarction [TIMI] score of 0 or 1) to predict a less-than-1% chance
of 30-day MACE (Class IIa, LOE B-NR).
We recommend
that negative cTnI or cTnT measurements at 0 and between 3 and 6 hours may be
used together with very low risk stratification (Vancouver score of 0 or North
American Chest Pain score of 0 and age less than 50 years) to predict a
less-than-1% chance of 30-day MACE (Class IIa, LOE B-NR).
B. Withhold Oxygen in Normoxic
Patients
Supplementary
oxygen has been routinely administered to patients with suspected ACS for
years. Despite this tradition, the usefulness of supplementary oxygen therapy
has not been established in normoxemic patients.
The
usefulness of supplementary oxygen therapy has not been established in normoxic
patients. In the prehospital, emergency department, and hospital settings, the
withholding of supplementary oxygen therapy in normoxemic patients with
suspected or confirmed ACS may be considered (Class IIb, LOE C-LD).
C. Reperfusion Strategies
Timely restoration
of blood flow to ischemic myocardium in acute STEMI remains the highest
treatment priority. While the Class of Recommendation regarding reperfusion
strategies remains unchanged from 2010, the choice between fibrinolysis and PCI
has been reexamined to focus on clinical circumstances, system capabilities,
and timing, and the recommendations have been updated accordingly. The
anticipated time to PCI has been newly examined in 2015, and new time-dependent
recommendations regarding the most effective reperfusion strategy are made. In
STEMI patients, when long delays to primary PCI are anticipated (more than 120
minutes), a strategy of immediate fibrinolysis followed by routine early
angiography (within 3 to 24 hours) and PCI, if indicated, is reasonable. It is
acknowledged that fibrinolysis becomes significantly less effective at more
than 6 hours after symptom onset, and thus a longer delay to primary PCI is
acceptable in patients at more than 6 hours after symptom onset. To facilitate
ideal treatment, systems of care must factor information about hospital
capabilities into EMS destination decisions and interfaculty transfers.
In adult
patients presenting with STEMI in the emergency department (ED) of a
non–PCI-capable hospital, we recommend immediate transfer without fibrinolysis
from the initial facility to a PCI center instead of immediate fibrinolysis at
the initial hospital with transfer only for ischemia-driven PCI (Class I, LOE
B-R).
When STEMI
patients cannot be transferred to a PCI-capable hospital in a timely manner,
fibrinolytic therapy with routine transfer for angiography may be an acceptable
alternative to immediate transfer to primary PCI (Class IIb, LOE C-LD).
When
fibrinolytic therapy is administered to STEMI patients in a non–PCI-capable
hospital, it may be reasonable to transport all postfibrinolysis patients for
early routine angiography in the first 3 to 6 hours and up to 24 hours rather
than transport postfibrinolysis patients only when they require ischemia-guided
angiography (Class IIb, LOE B-R).
Full-text of
the handy colorful summary (pdf): https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-AHA-Guidelines-Highlights-English.pdf
2. Does This Patient with CP Have ACS? The Rational Clinical
Examination Systematic Review
Fanaroff AC,
et al. JAMA. 2015;314(18):1955-1965.
Importance About 10% of patients with acute chest pain
are ultimately diagnosed with acute coronary syndrome (ACS). Early, accurate
estimation of the probability of ACS in these patients using the clinical
examination could prevent many hospital admissions among low-risk patients and
ensure that high-risk patients are promptly treated.
Objective To review systematically the accuracy of the
initial history, physical examination, electrocardiogram, and risk scores
incorporating these elements with the first cardiac-specific troponin.
Study
Selection MEDLINE and EMBASE were
searched (January 1, 1995-July 31, 2015), along with reference lists from
retrieved articles, to identify prospective studies of diagnostic test accuracy
among patients admitted to the emergency department with symptoms suggesting
ACS.
Data
Extraction and Synthesis We identified
2992 unique articles; 58 met inclusion criteria.
Main Outcomes
and Measures Sensitivity, specificity,
and likelihood ratio (LR) of findings for the diagnosis of ACS. The reference
standard for ACS was either a final hospital diagnosis of ACS or occurrence of
a cardiovascular event within 6 weeks.
Results The clinical findings and risk factors most
suggestive of ACS were prior abnormal stress test (specificity, 96%; LR, 3.1
[95% CI, 2.0-4.7]), peripheral arterial disease (specificity, 97%; LR, 2.7 [95%
CI, 1.5-4.8]), and pain radiation to both arms (specificity, 96%; LR, 2.6 [95%
CI, 1.8-3.7]). The most useful electrocardiogram findings were ST-segment
depression (specificity, 95%; LR, 5.3 [95% CI, 2.1-8.6]) and any evidence of
ischemia (specificity, 91%; LR, 3.6 [95% CI,1.6-5.7]). Both the History, Electrocardiogram,
Age, Risk Factors, Troponin (HEART) and Thrombolysis in Myocardial Infarction
(TIMI) risk scores performed well in diagnosing ACS: LR, 13 (95% CI, 7.0-24)
for the high-risk range of the HEART score (7-10) and LR, 6.8 (95% CI, 5.2-8.9)
for the high-risk range of the TIMI score (5-7). The most useful for
identifying patients less likely to have ACS were the low-risk range HEART
score (0-3) (LR, 0.20 [95% CI, 0.13-0.30]), low-risk range TIMI score (0-1)
(LR, 0.31 [95% CI, 0.23-0.43]), or low to intermediate risk designation by the
Heart Foundation of Australia and Cardiac Society of Australia and New Zealand
risk algorithm (LR, 0.24 [95% CI, 0.19-0.31]).
Conclusions
and Relevance Among patients with
suspected ACS presenting to emergency departments, the initial history,
physical examination, and electrocardiogram alone did not confirm or exclude
the diagnosis of ACS. Instead, the HEART or TIMI risk scores, which incorporate
the first cardiac troponin, provided more diagnostic information.
3. More on Troponins
A. The meaning of elevated troponin I
levels: Not always ACS
Harvell B, et
al. Amer J Emerg Med 2015 Oct 2 [Epub ahead of print]
Background
Troponin
elevation can be caused by etiologies other than acute coronary syndromes
(ACS). Our hypothesis was that elevated troponins occur more frequently in
non-ACS cases but that ACS cases (Type 1 STEMI and type 1 NSTEMI) have
significantly higher troponin elevations.
Methods
This was a
cross sectional cohort analysis of a random subset of all patients with
elevated troponins (defined as ≥ 0.06 ng/mL) over a 1 year period from July
2013-June 2014. The first positive troponin I and the peak were used in this
study. All included patients had chart reviews looking for whether our
Cardiologists or Hospitalists attributed the elevated troponin to an ACS
(NSTEMI or STEMI) or non-ACS cause. Non-ACS causes were categorized as
infection, cancer, renal diseases, cardiovascular disease, pulmonary disease,
trauma, cardiac arrest, neurological disease, hypertension or other. Data were
extracted by two investigators on the cause of the elevated troponin. Three sessions
to educate data extractors were arranged and methods of data extraction
discussed, then a 5% sample was re-evaluated by the other extractor to
determine inter-rater agreement measures. Parametric data were evaluated with
t-test and ANOVA. Dichotomous variables were compared using chi-square.
Troponin data were evaluated using non-parametric Kruskal Wallis or Mann
Whitney U. A logistic regression model was created with variables selected a
priori to evaluate the predictive ability of these variables in differentiating
ACS vs. non-ACS causes of elevated troponin.
Results
We evaluated
458 randomly-selected patients from 1317 unique cases of all patients with
initial elevated troponins ≥ 0.06 mg/mL during the study period. There was 84%
inter-rater agreement in the 5% sampling. Seventy-nine percent had a non-ACS
cause of elevated troponin and the average initial positive troponin I level
was significantly lower in the non-ACS cases (0.14, 95%CI=0.08, 0.37) than
those with documented STEMI (10.2, 95%CI=0.75, 20.1) or NSTEMIs (0.4, 95%CI=
0.13, 1.7). In the non-ACS group the median initial troponin was 0.14 ng/mL
(0.08,0.37). Peak troponin levels were highest in STEMI, next NSTEMI, lowest in
non ACS causes. The most frequent subgroups in the non-ACS group were non-ACS
cardiovascular, infectious, renal or hypertensive causes. In a linear
regression model adjusting for age and gender, higher troponin levels had
higher odds of being related to ACS causes (aOR=1.4,95%CI=1.2, 1.6) than
non-ACS causes.
Conclusion
The etiology
for the majority of initial elevated troponin I levels in a randomly selected
population are the result of non-ACS causes. As initial+ troponin levels
increased, they were more likely associated with ACS causes than with non-ACS
causes. Average initial + and peak troponin values were highest in STEMIs, next
highest in NSTEMIs and lowest overall in non-ACS causes.
B. Does undetectable troponin I at
presentation using a contemporary sensitive assay rule out MI? A cohort study
Kelly AM, et
al. Emerg Med J 2015;32:760-763
Aim Recent
evidence suggests that an undetectable troponin level at emergency department
(ED) presentation can rule out the presence of myocardial infarction (MI) in
low-risk patients. The aim of this study was to investigate whether an
undetectable troponin I (TnI) level at presentation using a contemporary
troponin assay can accurately rule out MI at various front-door thrombolysis in
myocardial infarction (fTIMI) score cut-offs.
Methods
Planned substudy of a prospective observational cohort study of patients
presenting to ED with chest pain without ECG evidence of ischaemia who
underwent a ‘rule out’ acute coronary syndrome process. Clinical,
investigational and outcome data were collected. A contemporary TnI assay (Siemens
TnI Ultra) was used. Primary outcome of interest was diagnostic accuracy for MI
of undetectable initial TnI at presentation at various fTIMI scores
(sensitivity, specificity, positive predictive value and negative predictive
value (NPV)).
Results 1076
patients were studied, of whom 156 had a final diagnosis of MI (14.5%). For
patients with undetectable TnI and fTIMI scores 0, 0–1, 0–2 and 0–6,
sensitivities were 98.7%, 98.1%, 97.4% and 97.4%, respectively, specificities
were 22.6%, 41.7%, 53.8% and 69.9%, respectively, and NPV were 99%, 99.2%,
99.2% and 99.4%, respectively. If early presenters (less than 2 h of symptoms)
were excluded, undetectable initial troponin had 100% sensitivity (95% CI 95.2%
to 100%) and NPV (95% CI 98.8% to 100%).
Conclusions
Using a contemporary TnI assay, undetectable initial TnI has high but not
perfect sensitivity and NPV, unless early presenters are excluded.
4. Emergency physician attitudes, preferences, and risk
tolerance for stroke as a potential cause of dizziness symptoms
Kene MV, et al. Emergency physician attitudes, preferences, and risk
tolerance for stroke as a potential cause of dizziness symptoms. West J
Emerg Med. 2015;16(5):768-776.
INTRO
Dizziness is
a common presenting symptom in the emergency department (ED) that is usually
benign, but rarely the harbinger of stroke, particularly in the posterior
circulation. Nationally, dizziness and vertigo symptoms accounted for 4% of ED
visits overall in 2011.1 The total cost for these visits was estimated at $4
billion, which reflects the often substantial resources involved in evaluating
these patients in the ED with neuroimaging, specialty consultation, and
hospital admission.1,2 Although dizziness-related ED visits and use of imaging
studies during these visits increased from 1995-2004, there was no
corresponding increase in the diagnosis of cerebrovascular disease among these
patients.3 The prevalence of stroke was low in patients with dizziness as well:
3.2% of all ED patients with undifferentiated dizziness and only 0.7% of
patients with isolated dizziness (dizziness, vertigo or imbalance without
motor, sensory or language findings) were diagnosed with stroke or transient
ischemic attack (TIA).4
Within this
context, a clinical prediction rule to risk-stratify patients with dizziness
could be useful in decision making and resource utilization. Clinical
prediction rules rely on readily obtainable historical, physical examination
and clinical data to provide a standardized risk assessment for bedside
decision making. For example, the PECARN (Pediatric Emergency Care Applied
Research Network) head injury clinical decision rule helps clinicians identify
children at risk of clinically important brain injury after head trauma, in
order to target the use of CT imaging.5
As part of
the process for developing a useful clinical prediction rule for dizziness in
the ED, a better understanding of emergency physicians’ (EPs) perceptions of
their current practice and attitudes towards currently available diagnostic
aids is crucial. Recently, a three-step bedside evaluation developed and tested
by expert neuro-otologists (head-thrust test, gaze-evoked nystagmus, and skew deviation
[HINTS]) has been proposed to clinically differentiate central from peripheral
etiologies of vertigo, but its actual use in current emergency practice is
unknown.6 Similarly, the required performance of a clinical prediction rule for
dizziness evaluation to be clinically useful for EPs is also unknown.
Therefore, we conducted a survey of EPs to assess their current practice, their
attitudes and preferences for decision support, and to determine the specific
risk thresholds that would make a clinical prediction rule useful in evaluating
dizziness in the ED.
ABSTRACT
Introduction:
We evaluated emergency physicians’ (EP) current perceptions, practice, and
attitudes towards evaluating stroke as a cause of dizziness among emergency
department patients.
Methods: We
administered a survey to all EPs in a large integrated healthcare delivery
system. The survey included clinical vignettes, perceived utility of historical
and exam elements, attitudes about the value of and requisite post-test
probability of a clinical prediction rule for dizziness. We calculated
descriptive statistics and post-test probabilities for such a clinical
prediction rule.
Results: The
response rate was 68% (366/535). Respondents’ median practice tenure was eight
years (37% female, 92% emergency medicine board certified). Symptom quality and
typical vascular risk factors increased suspicion for stroke as a cause of
dizziness. Most respondents reported obtaining head computed tomography (CT)
(74%). Nearly all respondents used and felt confident using cranial nerve and
limb strength testing. A substantial minority of EPs used the Epley maneuver
(49%) and HINTS (head-thrust test, gaze-evoked nystagmus, and skew deviation)
testing (30%); however, few EPs reported confidence in these tests’ bedside
application (35% and 16%, respectively). Respondents favorably viewed applying
a properly validated clinical prediction rule for assessment of immediate and
30-day stroke risk, but indicated it would have to reduce stroke risk to less
than 0.5% to be clinically useful.
Conclusion:
EPs report relying on symptom quality, vascular risk factors, simple physical
exam elements, and head CT to diagnose stroke as the cause of dizziness, but
would find a validated clinical prediction rule for dizziness helpful. A clinical
prediction rule would have to achieve a 0.5% post-test stroke probability for
acceptability.
5. A Randomized Trial of Single-Dose Oral Dex Vs Multidose
Prednisolone for Acute Exacerbations of Asthma in Children who Attend the ED
Cronin JJ, et
al. Ann Emerg Med 2015 Oct 10 [Epub ahead of print]
Study
objective
In acute
exacerbations of asthma in children, corticosteroids reduce relapses,
subsequent hospital admission, and the need for ß2-agonist bronchodilators.
Prednisolone is the most commonly used corticosteroid, but prolonged treatment
course, vomiting, and a bitter taste may reduce patient compliance.
Dexamethasone has a longer half-life and has been used safely in other acute
pediatric conditions. We examine whether a single dose of oral dexamethasone is
noninferior to prednisolone in the emergency department (ED) treatment of
asthma exacerbations in children, as measured by the Pediatric Respiratory
Assessment Measure (PRAM) at day 4.
Methods
We conducted
a randomized, open-label, noninferiority trial comparing oral dexamethasone
(single dose of 0.3 mg/kg) with prednisolone (1 mg/kg per day for 3 days) in
patients aged 2 to 16 years and with a known diagnosis of asthma or at least 1
previous episode of ß2-agonist–responsive wheeze who presented to a tertiary
pediatric ED. The primary outcome measure was the mean PRAM score (range of 0
to 12 points) performed on day 4. Secondary outcome measures included
requirement for further steroids, vomiting of study medication, hospital
admission, and unscheduled return visits to a health care practitioner within
14 days.
Results
There were
245 enrollments involving 226 patients. There was no difference in mean PRAM
scores at day 4 between the dexamethasone and prednisolone groups (0.91 versus
0.91; absolute difference 0.005; 95% CI –0.35 to 0.34). Fourteen patients
vomited at least 1 dose of prednisolone compared with no patients in the dexamethasone
group. Sixteen children (13.1%) in the dexamethasone group received further
systemic steroids within 14 days after trial enrollment compared with 5 (4.2%)
in the prednisolone group (absolute difference 8.9%; 95% CI 1.9% to 16.0%).
There was no significant difference between the groups in hospital admission
rates or the number of unscheduled return visits to a health care practitioner.
Conclusion
In children
with acute exacerbations of asthma, a single dose of oral dexamethasone (0.3
mg/kg) is noninferior to a 3-day course of oral prednisolone (1 mg/kg per day)
as measured by the mean PRAM score on day 4.
6. Predictors of infection from dog bite wounds: which patients
may benefit from prophylactic antibiotics?
Tabaka ME, et
al. Emerg Med J. 2015 Nov;32(11):860-3.
OBJECTIVES:
To determine a current infection rate of dog bite wounds and predictors of
wounds at risk for infection that may benefit from prophylactic antibiotics.
METHODS: A
prospective multicentre observational study was conducted over 4.5 years. At
the time of treatment Emergency Physicians completed a structured data form
evaluating patient, wound and treatment characteristics of patients with dog
bite wounds. Patients were followed up at 30 days to assess for infection.
Predictor variables were analysed with univariate analysis, using either χ(2),
parametric or nonparametric methods where appropriate. Significant variables
and those with important interactions on univariate analysis were considered in
a logistic regression (LR) analysis.
RESULTS: 495
patients with dog bites were enrolled and 345 had complete follow-up. Eighteen
patients (5.2%, 95% CI 3.1% to 8.1%) had bites that became infected. On
univariate analysis, only puncture wounds were found to be significantly
associated with infection RR 2.8 (95% CI 1.2 to 6.9). However, location and
wound closure met criteria for entry into the model having important
interactions; facial wounds had a higher risk of infection than anticipated but
were also more likely to be closed (p less than 0.0001). A LR model considering
puncture wounds, wound closure and wound location found that puncture wounds
(OR 4.1 [95% CI 1.4 to 11.7]) and wound closure (OR 3.1 [95% CI 1.03 to 9.0])
were independent predictors of infection. The incidence of infection in wounds
that were not punctured or closed during treatment was only 2.6% (95% CI 0.7%
to 6.5%).
CONCLUSIONS:
Puncture wounds or wounds closed during treatment are dog bite wounds at a high
risk of infection and should be considered for treatment with prophylactic
antibiotics.
7. PECARN undertaking large study of RNA transcriptional
biosignature analysis for identifying febrile infants with SBI
Introduction from the recent publication
of their methods
There is a
large degree of variability in the evaluation and management of febrile infants
younger than 60 days of age in the setting of the emergency department (ED).1
Approximately 6% to 10% of these infants have serious bacterial infections
(SBIs) that require prompt antimicrobial therapy,1,2 and many other infants
without bacterial infections are hospitalized unnecessarily until culture
results are available. Microbiologic culture for identification of bacteria in
the relevant body fluids (e.g., blood, urine, cerebrospinal fluid [CSF])
remains the reference standard for diagnosis of SBIs, as it has been for
decades.3–6 However, using cultures, and more specifically blood culture, as
the gold standard for diagnosis of SBI has important limitations, including a
noninconsequential number of false-positive and false-negative results, and
lengthy duration (up to 48 to 72 hours) to determine or exclude a positive
result.6–8 In great part because of these limitations, many febrile infants are
subjected to excessive evaluation procedures, receive empiric antibiotic
therapy, and are hospitalized, exposing them to iatrogenic risks.9 Therefore,
there is a clear need for developing less invasive, highly accurate, and more
timely diagnostic strategies for the evaluation of young febrile infants.
Advances in
genomic techniques now allow us to distinguish the types of infections by
assessing the host response to infection caused by different microbes. Previous
research has shown that host responses can reliably be measured with distinct
transcriptional biosignatures in the RNA of host blood leukocytes.6,10,11
Studies in hospitalized children have demonstrated that RNA biosignatures can
distinguish patients with bacterial and viral infections with 95% accuracy.10
This transition from bench to clinical research suggests the potential
application of transcriptional biosignatures for the evaluation of febrile
infants in the ED.
The Pediatric
Emergency Care Applied Research Network (PECARN) annually evaluates more than
4000 febrile infants 60 days of age or younger. PECARN, thus, offers an ideal
setting to evaluate the application of RNA expression analysis for diagnosis
and management of febrile infants in a prospective manner.12 Because there is
limited experience in conducting large multi-center studies with this new
technology, especially with a young infant population in the setting of the ED,
it was necessary to develop an infrastructure to identify and recruit eligible
patients in a consistent and reliable fashion. We also sought obtain
high-quality blood RNA samples for expression analysis from these patients
across multiple sites. Finally, it was important to demonstrate that the RNA
samples collected from multiple sites do not substantially degrade during
transport, storage, and processing.
We are
currently conducting a prospective cross-sectional study of a convenience
sample of more than 4000 febrile infants younger than 60 days of age in the
PECARN. The objective of the present article is to describe the development of
the necessary infrastructure and methods for conducting genomic studies in this
population. We also aim to demonstrate the ability to obtain samples in 21
PECARN EDs that yield adequate quantities of high-quality RNA for transcriptional
profiles which would be required for identifying the diagnostic bacterial (SBI)
and nonbacterial (non-SBI) biosignatures in febrile infants…
Mahajan P, et
al. RNA Transcriptional Biosignature Analysis for Identifying Febrile Infants
With Serious Bacterial Infections in the ED: A Feasibility Study. Pediatr Emerg
Care. 2015; 31(1): 1–5.
The results
of this fascinating study are under peer-review and should be published in early
2016.
8. Two New Studies on SAH Diagnostics
A. An Observational Study of 2,248
Patients Presenting With Headache, Suggestive of Subarachnoid Hemorrhage, who Received
LPs Following Normal CT of the Head
Sayer D, et
al. Acad Emerg Med. 2015 Oct 19 [Epub ahead of print]
OBJECTIVES:
The objective was to determine the incidence of subarachnoid hemorrhage (SAH)
diagnosed by lumbar puncture (LP) when the head computed tomography (CT) was
reported as demonstrating no subarachnoid blood.
METHODS: Data
were obtained on patients who received LP to diagnose or exclude SAH attending
six hospitals over 5 years. Subsequent investigations and outcomes were
reviewed in all patients with LPs that did not exclude SAH.
RESULTS: A
total of 2,248 patients were included. A total of 1,898 LPs were suitable for
biochemical analysis, of which 92 (4.8%) were positive for blood, suggesting
SAH; 1,507 (79.4%) were negative; and 299 (15.6%) were inconclusive. Of the 92
patients with positive cerebrospinal fluid analysis, eight patients (0.4%) had
aneurysms on further imaging, and one had a carotid cavernous fistula.
CONCLUSIONS:
In patients presenting to the emergency department with acute severe headache,
LP to diagnose or exclude SAH after negative head CT has a very low diagnostic
yield, due to low prevalence of the disease and uninterpretable or inconclusive
samples. A clinical decision rule may improve diagnostic yield by selecting patients
requiring further evaluation with LP following nondiagnostic or normal
noncontrast CT brain imaging.
Comments by Ryan Radecki: How Many LPs
Does It Take to Find SAH?
In this
observational series: 204.
This study
describes the findings of 2,248 patients with “headache, suggestive of
subarachnoid hemorrhage” who underwent computed tomography, followed by lumbar
puncture. CT is quite sensitive for
aneurysmal hemorrhage in the few hours following onset, but fades with
time. Spectrophotometric analysis of CSF
is the gold standard for diagnosis in the United Kingdom, and was used by these
facilities to describe positive, negative, and indeterminate results on LP.
Of these
2,248 patients, LP were negative in 1,507, uninterpretable in 350,
indeterminate in 299, and positive in 92.
All patients with positive LP had follow-up CTA or MRA, and there were 9
vascular abnormalities. Then, a subset
of the uninterpretable and indeterminate patients underwent CTA or MRA, as
well, resulting in an additional two vascular abnormalities.
Thus, 204.
There are a
few surprising bits regarding these data.
The ~4% rate of “SAH” detected in this study is lower than most other
observation series. Some of these were
neurosurgical referral centers, with much higher rates. Then, of course, the incidence will further
depend on various definitions of positivity and the rate at which patients with
lower pre-test likelihood are evaluated for SAH. Additionally, the rate of vascular abnormality
in those with “SAH” was also quite low.
In such a small sample, the confidence intervals are quite wide, so it’s
hard to estimate the generalizability of these findings.
Regardless of
the precise numbers, their overall conclusion is reasonable: CT + LP is
extremely low yield for true pathology.
There is a definite need for decision instruments with improved
specificity to prevent such extensive resource utilization.
B. Sensitivity of a SAH decision rule
and early CT in patients with aneurysmal SAH: a retrospective cohort study.
Mark DG, et
al. West J Emerg Med. 2015;16(5):671-676.
Background
Approximately
80% of non-traumatic cases of subarachnoid hemorrhage are attributable to
ruptured cerebral aneurysms, for which delays in definitive aneurysm treatment
can increase the risk of disability or death.1,2 While the vast majority of
aneurysmal SAH (aSAH) cases are identified by cranial CT, the sensitivity of CT
diminishes with time such that lumbar puncture is recommended as the definitive
test to exclude a diagnosis of “CT-negative” SAH. While two large studies have
reported that early cranial CT (i.e. performed within six hours of headache
onset) may be up to 100% sensitive for SAH among patients presenting with a
normal mental status,3-6 a prior study by our research group demonstrated
imperfect sensitivity of this definition of early cranial CT in the
non-academic emergency department (ED) setting.7 Accordingly we proposed that
sequential application of a validated SAH clinical decision rule (age over 40,
presence of neck pain or stiffness, headache onset with exertion, loss of
consciousness at headache onset) in such a clinical scenario might further
reduce the posterior probability of CT-negative SAH to an acceptable level of
risk. 8,9
Abstract
Introduction:
Application of a clinical decision rule for subarachnoid hemorrhage, in
combination with cranial computed tomography (CT) performed within six hours of
ictus (early cranial CT), may be able to reasonably exclude a diagnosis of
aneurysmal subarachnoid hemorrhage (aSAH). This study’s objective was to
examine the sensitivity of both early cranial CT and a previously validated
clinical decision rule among emergency department (ED) patients with aSAH and a
normal mental status.
Methods:
Patients were evaluated in the 21 EDs of an integrated health delivery system
between January 2007 and June 2013. We identified by chart review a
retrospective cohort of patients diagnosed with aSAH in the setting of a normal
mental status and performance of early cranial CT. Variables comprising the SAH
clinical decision rule (age over 40, presence of neck pain or stiffness,
headache onset with exertion, loss of consciousness at headache onset) were
abstracted from the chart and assessed for inter-rater reliability.
Results: One
hundred fifty-five patients with aSAH met study inclusion criteria. The
sensitivity of early cranial CT was 95.5% (95% CI [90.9-98.2]). The sensitivity
of the SAH clinical decision rule was also 95.5% (95% CI [90.9-98.2]). Since
all false negative cases for each diagnostic modality were mutually
independent, the combined use of both early cranial CT and the clinical
decision rule improved sensitivity to 100% (95% CI [97.6-100.0]).
Conclusion:
Neither early cranial CT nor the SAH clinical decision rule demonstrated ideal
sensitivity for aSAH in this retrospective cohort. However, the combination of
both strategies might optimize sensitivity for this life-threatening disease.
9. Lit Reviews
A. Which form of aspirin is the
fastest to inhibit platelet aggregation in ED patients with non-STEMI?
Morris N, et
al. Emerg Med J 2015;32:823-826
A short cut
review was carried out to establish whether, in patients with suspected acute
coronary syndromes presenting to the emergency department, what form of aspirin
has the most rapid onset of action. Papers comparing the speed of onset of
chewable aspirin, or soluble aspirin or solid aspirin were included. This
summarises all three parts of a combined best evidence topic report (BET). The
clinical bottom line is that chewable aspirin may be faster than soluble
aspirin at decreasing the amount of time to achieve platelet inhibition in a
patient. Soluble aspirin is faster than whole solid aspirin, which is faster
than enteric-coated aspirin.
B. Safety of Epinephrine in Digital
Nerve Blocks: A Literature Review
Ilicki J, et
al. J Emerg Med 2015;49:799-809.
Background
Digital nerve
blocks are commonly performed in emergency departments. Health care
practitioners are often taught to avoid performing blocks with epinephrine due
to a risk of digital necrosis.
Objective
To review the
literature on the safety of epinephrine 1:100,000–200,000 (5–10 μg/mL) with
local anesthetics in digital nerve blocks in healthy patients and in patients
with risk for poor peripheral circulation.
Methods
PubMed, Web
of Science, and the Cochrane Library were searched in June 2014 using the query
“digital block AND epinephrine OR digital block AND adrenaline”. The searches
were performed without any limits.
Results
Sixty-three
articles were identified, and 39 of these were found to be relevant. These
include nine reviews, 12 randomized control trials, and 18 other articles. Most
studies excluded patients with risk for poor peripheral circulation. Two
studies described using epinephrine on patients with vascular comorbidities. No
study reported digital necrosis or gangrene attributable to epinephrine, either
in healthy patients or in patients with risk for poor peripheral circulation.
In total, at least 2797 digital nerve blocks with epinephrine have been
performed without any complications.
Conclusions
Epinephrine
1:100,000–200,000 (5–10 μg/mL) is safe to use in digital nerve blocks in
healthy patients. Physiological studies show epinephrine-induced
vasoconstriction to be transient. There are no reported cases of
epinephrine-induced harm to patients with risk for poor peripheral circulation
despite a theoretical risk of harmful epinephrine-induced vasoconstriction. A
lack of reported complications suggests that the risk of epinephrine-induced
vasoconstriction to digits may be overstated.
C. The Safety of Topical Anesthetics
in the Treatment of Corneal Abrasions: A Review
Swaminathan
A, et al. J Emerg Med. 2015;49:810-815.
Background
Despite the
fact that topical anesthetics provide superb analgesia to the painful eye, they
are not prescribed routinely to patients when they are discharged from the
emergency department because of concerns for delayed healing and corneal
erosion.
Objective
To summarize
the evidence for the safety of topical proparacaine and tetracaine for pain
relief in patients with corneal abrasions.
Methods
This is a
systematic review looking at the use of topical anesthetic agents in the
treatment of corneal abrasions in the emergency department.
Results
Our
literature search produced two emergency department−based, randomized, double
blind, placebo-controlled studies on human patients with corneal abrasions.
Additionally, we found four studies that investigated the application of
topical anesthetics in patients who underwent photorefractive keratectomy. All
six studies demonstrated that a short course of dilute topical anesthetic
provided efficacious analgesia without adverse effects or delayed epithelial
healing.
Conclusion
Limited
available data suggests that the use of dilute topical ophthalmologic
proparacaine or tetracaine for a short duration of time is effective, though
their safety for outpatient use is inconclusive.
10. Comparative Analgesic Efficacy of Oxycodone/APAP Vs
Hydrocodone/APAP for Short-term Pain Management in Adults Following ED
Discharge
Chang AK, et
al. Acad Emerg Med 2015 Oct 19 [Epub ahead of print]
Objectives
The objective
was to test the hypothesis that oxycodone/acetaminophen provides superior
analgesia to hydrocodone/acetaminophen for the treatment of acute extremity
pain following emergency department (ED) discharge.
Methods
This was a
prospective, randomized, double-blind clinical trial of nonelderly adult ED
patients with acute musculoskeletal extremity pain, randomly allocated at
discharge to receive oxycodone/acetaminophen (5 mg/325 mg) or
hydrocodone/acetaminophen (5 mg/325 mg). The primary outcome was the
between-group difference in improvement in numerical rating scale (NRS) pain
scores over a 2-hour period following the most recent ingestion of study drug,
obtained during telephone contact 24 hours after ED discharge. Secondary
outcomes included proportionate decrease in pain, comparative side-effect
profiles, and patient satisfaction.
Results
A total of
240 patients were enrolled. The final sample consisted of 220 patients, 107
randomly allocated to oxycodone/acetaminophen and 113 to
hydrocodone/acetaminophen. At 24 hours after ED discharge, the mean NRS pain
scores prior to the most recent dose of outpatient pain medication were 7.8 and
7.9 in the oxycodone/acetaminophen and hydrocodone/acetaminophen groups,
respectively. The mean decreases in pain scores over 2 hours were 4.4 NRS units
in the oxycodone/acetaminophen group versus 4.0 NRS units in the
hydrocodone/acetaminophen group, for a difference of 0.4 NRS units (95%
confidence interval = −0.2 to 1.1 NRS units). Satisfaction with the analgesics
was similar.
Conclusions
This study
design could not detect a clinically or statistically significant difference in
analgesic efficacy between oxycodone/acetaminophen (5 mg/325 mg) and
hydrocodone/acetaminophen (5 mg/325 mg) for treatment of acute musculoskeletal
extremity pain in adults following ED discharge. Both opioids reduced pain
scores by approximately 50%.
11. Images in Clinical Practice
Bullous
Pemphigoid
Megaduodenum
in Systemic Sclerosis
Septic
Cerebral Venous Thrombosis
Bursitis and
Tenosynovitis Due to Mycobacterium avium Complex
Young Woman with
Chest Pain After Fall
Discussion:
Chest Pain Bounce-Back: Posterior Sternoclavicular Dislocation
Young Adult with
Abdominal Pain
Isolated Posterior
Wall Myocardial Infarction.
Erucism Due
to Lepidoptera Caterpillar Envenomation
12. Assessing the association between occupancy and outcome in
critically Ill hospitalized patients with sepsis
Yergens DW,
et al. BMC Emergency Medicine 2015, 15:31
Background
Sepsis has a
high prevalence, mortality-rate and cost. Sepsis patients usually enter the
hospital through the Emergency Department (ED). Process or structural issues
related to care may affect outcome.
Methods
Multi-centered
retrospective observational cohort study using administrative databases to
identify adult patients (18 years or greater) with sepsis and severe sepsis
admitted to Alberta Health Services Calgary zone adult multisystem intensive
care units (ICU) through the ED between January 1, 2006 and September 30, 2009.
We examined the association between ICU occupancy and hospital outcome. We
explored other associations of hospital outcome including the effect of ED wait
time, admission from ED during weekdays versus weekends and ED admission during
the day versus at night.
Results
One thousand
and seven hundred seventy patients were admitted to hospital via ED, 1036 (58.5%)
with sepsis and 734 (41.5 %) with severe sepsis. In patients with sepsis, ICU
occupancy over 90% was associated with an increase in hospital mortality even
after adjusting for age, sex, triage level, Charlson index, time of first ED
physician assessment and ICU admission. No differences in hospital mortality
were found for patients who waited more than 7 h, were admitted during the day
versus night or weekdays versus weekends.
Conclusions
In patients
with sepsis admitted via the ED, increased ICU occupancy was associated with
higher in-hospital mortality.
13. Acute Medical Diagnoses Are Common in "Found Down"
Adult Patients Presenting to the ED as Trauma.
Jacobs BG, et
al. J Emerg Med. 2015 Jun 2 [Epub ahead of print]
BACKGROUND:
Patients often present to the emergency department (ED) as "found
down," with limited history to suggest a primary traumatic or medical
etiology.
OBJECTIVE:
The study objective was to describe the characteristics of "found
down" adult patients presenting to the ED as trauma, specifically the
incidence of acute medical diagnoses and major trauma.
METHODS:
Using an institutional trauma registry, we reviewed trauma activations with the
cause of injury "found down" between January 2008 and December 2012.
We excluded patients with cardiac arrest, transfers from other hospitals, and
patients with a more than likely (above 50%) traumatic or medical etiology on
initial ED presentation. Inclusion and exclusion criteria were reviewed by two
independent abstractors. We abstracted demographic, clinical, injury severity,
and outcomes variables. Major trauma was defined as Injury Severity Score ≥ 16.
RESULTS:
There were 659 patients identified with the cause of injury "found
down." A total of 207 (31%) patients met inclusion criteria; median age
was 67 years (interquartile range 50-82 years), and 110 (53%) were male. Among
the included patients, 137 (66%, 95% confidence interval [Cl] 59-73%) had a
discharge diagnosis of an acute medical condition, 14 (7%, 95% Cl 4-11%) with
major trauma alone, 21 (10%, 95% Cl 6-15) with both an acute medical condition
and major trauma, and 35 (17%, 95% Cl 12-23%) with minor trauma. The most
common acute medical diagnoses were toxicological (56 patients, 35%; 95% Cl
28-43%) and infectious (32 patients, 20%; 95% Cl 14-27%).
CONCLUSION:
Acute medical diagnoses were common in undifferentiated ED patients "found
down" in an institutional trauma registry. Clinicians should maintain a
broad differential diagnosis in the workup of the undifferentiated "found
down" patient.
14. Endovascular Thrombectomy for Acute Ischemic Stroke: A
Meta-analysis.
Badhiwala JH,
et al. JAMA. 2015 Nov 3;314(17):1832-43.
IMPORTANCE:
Endovascular intervention for acute ischemic stroke improves revascularization.
But trials examining endovascular therapy yielded variable functional outcomes,
and the effect of endovascular intervention among subgroups needs better
definition.
OBJECTIVE: To
examine the association between endovascular mechanical thrombectomy and
clinical outcomes among patients with acute ischemic stroke.
DATA SOURCES:
We systematically searched MEDLINE, EMBASE, CINAHL, Google Scholar, and the
Cochrane Library without language restriction through August 2015.
STUDY
SELECTION: Eligible studies were randomized clinical trials of endovascular
therapy with mechanical thrombectomy vs standard medical care, which includes
the use of intravenous tissue plasminogen activator (tPA).
DATA
EXTRACTION AND SYNTHESIS: Independent reviewers evaluated the quality of
studies and abstracted the data. We calculated odds ratios (ORs) and 95% CIs
for all outcomes using random-effects meta-analyses and performed subgroup and
sensitivity analyses to examine whether certain imaging, patient, treatment, or
study characteristics were associated with improved functional outcome. The
strength of the evidence was examined for all outcomes using the GRADE method.
MAIN OUTCOMES
AND MEASURES: Ordinal improvement across modified Rankin scale (mRS) scores at
90 days, functional independence (mRS score, 0-2), angiographic
revascularization at 24 hours, symptomatic intracranial hemorrhage within 90
days, and all-cause mortality at 90 days.
RESULTS: Data
were included from 8 trials involving 2423 patients (mean [SD] age, 67.4 [14.4]
years; 1131 [46.7%] women), including 1313 who underwent endovascular
thrombectomy and 1110 who received standard medical care with tPA. In a
meta-analysis of these trials, endovascular therapy was associated with a
significant proportional treatment benefit across mRS scores (OR, 1.56; 95% CI,
1.14-2.13; P = .005). Functional independence at 90 days (mRS score, 0-2)
occurred among 557 of 1293 patients (44.6%; 95% CI, 36.6%-52.8%) in the
endovascular therapy group vs 351 of 1094 patients (31.8%; 95% CI, 24.6%-40.0%)
in the standard medical care group (risk difference, 12%; 95% CI, 3.8%-20.3%;
OR, 1.71; 95% CI, 1.18-2.49; P = .005). Compared with standard medical care,
endovascular thrombectomy was associated with significantly higher rates of
angiographic revascularization at 24 hours (75.8% vs 34.1%; OR, 6.49; 95% CI,
4.79-8.79; P less than .001) but no significant difference in rates of
symptomatic intracranial hemorrhage within 90 days (70 events [5.7%] vs 53
events [5.1%]; OR, 1.12; 95% CI, 0.77-1.63; P = .56) or all-cause mortality at
90 days (218 deaths [15.8%] vs 201 deaths [17.8%]; OR, 0.87; 95% CI, 0.68-1.12;
P = .27).
CONCLUSIONS
AND RELEVANCE: Among patients with acute ischemic stroke, endovascular therapy
with mechanical thrombectomy vs standard medical care with tPA was associated
with improved functional outcomes and higher rates of angiographic
revascularization, but no significant difference in symptomatic intracranial
hemorrhage or all-cause mortality at 90 days.
15. Outcomes of Basic vs Advanced Life Support for
Out-of-Hospital Medical Emergencies
Sanghavi P,
et al. Ann Intern Med. 2015 Oct 13 [Epub
ahead of print]
Ann Intern
Med. 2015 Oct 13. doi: 10.7326/M15-0557. [Epub ahead of print]
Background:
Most Medicare patients seeking emergency medical transport are treated by
ambulance providers trained in advanced life support (ALS). Evidence supporting
the superiority of ALS over basic life support (BLS) is limited, but some
studies suggest ALS may harm patients.
Objective: To
compare outcomes after ALS and BLS in out-of-hospital medical emergencies.
Design:
Observational study with adjustment for propensity score weights and
instrumental variable analyses based on county-level variations in ALS use.
Setting:
Traditional Medicare.
Patients: 20%
random sample of Medicare beneficiaries from nonrural counties between 2006 and
2011 with major trauma, stroke, acute myocardial infarction (AMI), or
respiratory failure.
Measurements:
Neurologic functioning and survival to 30 days, 90 days, 1 year, and 2 years.
Results:
Except in cases of AMI, patients showed superior unadjusted outcomes with BLS
despite being older and having more comorbidities. In propensity score
analyses, survival to 90 days among patients with trauma, stroke, and
respiratory failure was higher with BLS than ALS (6.1 percentage points [95%
CI, 5.4 to 6.8 percentage points] for trauma; 7.0 percentage points [CI, 6.2 to
7.7 percentage points] for stroke; and 3.7 percentage points [CI, 2.5 to 4.8
percentage points] for respiratory failure). Patients with AMI did not exhibit
differences in survival at 30 days but had better survival at 90 days with ALS
(1.0 percentage point [CI, 0.1 to 1.9 percentage points]). Neurologic
functioning favored BLS for all diagnoses. Results from instrumental variable
analyses were broadly consistent with propensity score analyses for trauma and
stroke, showed no survival differences between BLS and ALS for respiratory
failure, and showed better survival at all time points with BLS than ALS for
patients with AMI.
Limitation:
Only Medicare beneficiaries from nonrural counties were studied.
Conclusion:
Advanced life support is associated with substantially higher mortality for
several acute medical emergencies than BLS.
16. Synthetic Cannabinoid Abuse in Adolescents: A Case Series
Besli GE, et
al. J Emerg Med 2015;49:644-50.
Background
Synthetic
cannabinoids, referred to as “Bonzai” in Turkey, are relatively new
recreational drugs of abuse. Although the use of synthetic cannabinoids has
been dramatically increasing in young populations in many countries, their
adverse effects are not well known.
Objectives
To report on
the clinical features and social history of pediatric patients with a diagnosis
of synthetic cannabinoid intoxication and to highlight the dangers of these
drugs to public health.
Methods
We
retrospectively reviewed 16 cases presenting to our Emergency Department (ED)
with synthetic cannabinoid intoxication in the last 10 months. Usage
characteristics and the psychoactive, physical, and metabolic effects of
synthetic cannabinoids were analyzed.
Results
The mean age
of the 16 patients with a diagnosis of synthetic cannabinoid intoxication was
15.4 ± 1.7 years (15 males, 1 female). The most common physical symptoms were
eye redness, nausea/vomiting, sweating, and altered mental status; the main
psychoactive findings were agitation, anxiety, hallucinations, and perceptual
changes. We observed hypotension and bradycardia in 8 (50%) and 5 (31.3%) of
the patients, respectively. Although most patients were discharged from the ED,
25% were transferred to an intensive care unit. They all had reduced school
attendance and performance. The rates of cigarette smoking and alcohol drinking
were also significantly higher.
Conclusion
Synthetic
cannabinoids are unsafe and potentially harmful drugs of abuse; they may even
cause life-threatening effects. It is important for pediatricians to be
familiar with the signs and symptoms of consumption of synthetic cannabinoid
products. Education of parents, teachers, and adolescents about the potential health
risks of using these products is essential.
17. ED Rotational Patient Assignment Improves Operational
Metrics
Traub SJ, et al. Ann Emerg Med. 2015 Oct 6 [Epub ahead of print].
STUDY
OBJECTIVE: We compare emergency department (ED) operational metrics obtained in
the first year of a rotational patient assignment system (in which patients are
assigned to physicians automatically according to an algorithm) with those
obtained in the last year of a traditional physician self-assignment system (in
which physicians assigned themselves to patients at physician discretion).
METHODS: This
was a pre-post retrospective study of patients at a single ED with no financial
incentives for physician productivity. Metrics of interest were length of stay;
arrival-to-provider time; rates of left before being seen, left subsequent to
being seen, early returns (within 72 hours), and early returns with admission;
and complaint ratio.
RESULTS: We
analyzed 23,514 visits in the last year of physician self-assignment and 24,112
visits in the first year of rotational patient assignment. Rotational patient
assignment was associated with the following improvements (percentage change):
median length of stay 232 to 207 minutes (11%), median arrival to provider time
39 to 22 minutes (44%), left before being seen 0.73% to 0.36% (51%), and
complaint ratio 9.0/1,000 to 5.4/1,000 (40%). There were no changes in left
subsequent to being seen, early returns, or early returns with admission.
CONCLUSION:
In a single facility, the transition from physician self-assignment to
rotational patient assignment was associated with improvement in a broad array
of ED operational metrics. Rotational patient assignment may be a useful
strategy in ED front-end process redesign.
DRV: These
results validates those from Kaiser Permanente.
Patel PB, et al. Team assignment system: expediting emergency department
care. Ann Emerg Med. 2005;46(6):499-506. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/16308063
Song H, Tucker AL, Murrell KL. The diseconomies of queue pooling:
an empirical investigation of Emergency Department length of stay. Man Sci. 2015 May 28 [Epub ahead of
print].
18. Accuracy of ‘My Gut Feeling:’ Comparing System 1 to System 2
Decision-Making for Acuity Prediction, Disposition and Diagnosis in an Academic
ED
Cabrera D, et
al. West J Emerg Med 2015;16(5):653-657.
Introduction:
Current cognitive sciences describe decision-making using the dual-process
theory, where a System 1 is intuitive and a System 2 decision is
hypothetico-deductive. We aim to compare the performance of these systems in
determining patient acuity, disposition and diagnosis.
Methods:
Prospective observational study of emergency physicians assessing patients in
the emergency department of an academic center. Physicians were provided the
patient’s chief complaint and vital signs and allowed to observe the patient
briefly. They were then asked to predict acuity, final disposition (home,
intensive care unit (ICU), non-ICU bed) and diagnosis. A patient was classified
as sick by the investigators using previously published objective criteria.
Results: We
obtained 662 observations from 289 patients. For acuity, the observers had a
sensitivity of 73.9% (95% CI [67.7-79.5%]), specificity 83.3% (95% CI
[79.5-86.7%]), positive predictive value 70.3% (95% CI [64.1-75.9%]) and
negative predictive value 85.7% (95% CI [82.0-88.9%]). For final disposition,
the observers made a correct prediction in 80.8% (95% CI [76.1-85.0%]) of the
cases. For ICU admission, emergency physicians had a sensitivity of 33.9% (95%
CI [22.1-47.4%]) and a specificity of 96.9% (95% CI [94.0-98.7%]). The correct
diagnosis was made 54% of the time with the limited data available.
Conclusion:
System 1 decision-making based on limited information had a sensitivity close
to 80% for acuity and disposition prediction, but the performance was lower for
predicting ICU admission and diagnosis. System 1 decision-making appears
insufficient for final decisions in these domains but likely provides a
cognitive framework for System 2 decision-making.
19. Association of a Guardian's Report of a Child Acting
Abnormally With TBI after Minor Blunt Head Trauma.
Nishijima DK,
et al. JAMA Pediatr. 2015 Oct 19 [Epub ahead of print]
Importance:
Increased use of computed tomography (CT) in children is concerning owing to
the cancer risk from ionizing radiation, particularly in children younger than
2 years. A guardian report that a child is acting abnormally is a risk factor
for clinically important traumatic brain injury (ciTBI) and may be a driving
factor for CT use in the emergency department.
Objective: To
determine the prevalence of ciTBIs and TBIs in children younger than 2 years
with minor blunt head trauma and a guardian report of acting abnormally with
(1) no other findings or (2) other concerning findings for TBI.
Design,
Setting, and Participants: Secondary analysis of a large, prospective,
multicenter cohort study that included 43 399 children younger than 18 years
with minor blunt head trauma evaluated in 25 emergency departments. The study
was conducted on data obtained between June 2004 and September 2006. Data
analysis was performed between August 21, 2014, and March 9, 2015.
Exposures: A
guardian report that the child was acting abnormally after minor blunt head
trauma.
Main Outcomes
and Measures: The prevalence of ciTBI (defined as death, neurosurgery,
intubation for more than 24 hours, or hospitalization for ≥2 nights in
association with TBI on CT imaging) and TBI on CT imaging in children with a
guardian report of acting abnormally with (1) no other findings and (2) other
concerning findings for TBI.
Results: Of
43 399 children in the cohort study, a total of 1297 children had reports of
acting abnormally, of whom 411 (31.7%) had this report as their only finding.
Reported as percentage (95% CI), 1 of 411 (0.2% [0-1.3%]) had a ciTBI, and 4
TBIs were noted on the CT scans in 185 children who underwent imaging (2.2% [0.6%-5.4%]).
In children with reports of acting abnormally and other concerning findings for
TBI, 29 of 886 (3.3% [2.2%-4.7%]) had ciTBIs and 66 of 674 (9.8% [7.7%-12.3%])
had TBIs on CT.
Conclusions
and Relevance: Clinically important TBIs are very uncommon, and TBIs noted on
CT are uncommon in children younger than 2 years with minor blunt head trauma
and guardian reports of the child acting abnormally with no other clinical
findings suspicious for TBI. Computed tomographic scans are generally not
indicated in these children although observation in the emergency department
may be warranted.
20. Three Studies on the Acute Management of Low Back Pain
A. Naproxen with Cyclobenzaprine,
Oxycodone/Acetaminophen, or Placebo for Treating Acute LBP: A RCT
Neither
cyclobenzaprine nor opioids are helpful as adjuncts to naproxen therapy for
LBP.
Friedman BW,
et al. JAMA. 2015 Oct 20;314(15):1572-80.
IMPORTANCE:
Low back pain (LBP) is responsible for more than 2.5 million visits to US
emergency departments (EDs) annually. These patients are usually treated with
nonsteroidal anti-inflammatory drugs, acetaminophen, opioids, or skeletal
muscle relaxants, often in combination.
OBJECTIVE: To
compare functional outcomes and pain at 1 week and 3 months after an ED visit
for acute LBP among patients randomized to a 10-day course of (1)
naproxen + placebo; (2) naproxen + cyclobenzaprine; or (3)
naproxen + oxycodone/acetaminophen.
DESIGN,
SETTING, AND PARTICIPANTS: This randomized, double-blind, 3-group study was
conducted at one urban ED in the Bronx, New York City. Patients who presented
with nontraumatic, nonradicular LBP of 2 weeks' duration or less were eligible
for enrollment upon ED discharge if they had a score greater than 5 on the
Roland-Morris Disability Questionnaire (RMDQ). The RMDQ is a 24-item
questionnaire commonly used to measure LBP and related functional impairment on
which 0 indicates no functional impairment and 24 indicates maximum impairment.
Beginning in April 2012, a total of 2588 patients were approached for
enrollment. Of the 323 deemed eligible for participation, 107 were randomized
to receive placebo and 108 each to cyclobenzaprine and to oxycodone/acetaminophen.
Follow-up was completed in December 2014.
INTERVENTIONS:
All participants were given 20 tablets of naproxen, 500 mg, to be taken twice a
day. They were randomized to receive either 60 tablets of placebo;
cyclobenzaprine, 5 mg; or oxycodone, 5 mg/acetaminophen, 325 mg. Participants
were instructed to take 1 or 2 of these tablets every 8 hours, as needed for
LBP. They also received a standardized 10-minute LBP educational session prior
to discharge.
MAIN OUTCOMES
AND MEASURES: The primary outcome was improvement in RMDQ between ED discharge
and 1 week later.
RESULTS:
Demographic characteristics were comparable among the 3 groups. At baseline,
median RMDQ score in the placebo group was 20 (interquartile range
[IQR],17-21), in the cyclobenzaprine group 19 (IQR,17-21), and in the
oxycodone/acetaminophen group 20 (IQR,17-22). At 1-week follow-up, the mean
RMDQ improvement was 9.8 in the placebo group, 10.1 in the cyclobenzaprine
group, and 11.1 in the oxycodone/acetaminophen group. Between-group difference
in mean RMDQ improvement for cyclobenzaprine vs placebo was 0.3 (98.3% CI, -2.6
to 3.2; P = .77), for oxycodone/acetaminophen vs placebo, 1.3 (98.3% CI, -1.5
to 4.1; P = .28), and for oxycodone/acetaminophen vs cyclobenzaprine, 0.9
(98.3% CI, -2.1 to 3.9; P = .45).
CONCLUSIONS
AND RELEVANCE: Among patients with acute, nontraumatic, nonradicular LBP
presenting to the ED, adding cyclobenzaprine or oxycodone/acetaminophen to
naproxen alone did not improve functional outcomes or pain at 1-week follow-up.
These findings do not support use of these additional medications in this
setting.
Reviewed by
Daniel J. Pallin, MD, MPH, Journal Watch Emerg Med 2015 Oct 20.
Comment: Back
pain is vexing for providers and patients alike. Opioids and so-called muscle
relaxants appear to add little to nonsteroidal anti-inflammatory medications.
Cyclobenzaprine has sedative and anticholinergic side effects, and prescribing
opioids for a condition that evidence-based consensus guidelines warn against
can lead to abuse and addiction.
B. Does a Single Dose of IV Dex Reduce
Symptoms in ED Patients With LBP and RAdiculopathy (SEBRA)? A Double-Blind RCT
Balakrishnamoorthy
R, et al. Emerg Med J. 2015;32(7):525-530.
OBJECTIVE: To
assess the effect of a single dose of intravenous dexamethasone in addition to
routine treatment on visual analogue scale (VAS) pain scores at 24 h in
emergency department (ED) patients with low back pain with radiculopathy
(LBPR).
METHODS:
Double-blind randomised controlled trial of 58 adult ED patients with LBPR,
conducted in one tertiary and one urban ED. The intervention was 8 mg of
intravenous dexamethasone (or placebo) in addition to current routine care. The
primary outcome was the change in VAS pain scores between presentation and
24 h. Secondary outcomes included VAS pain scores at 6 weeks, ED length of stay
(EDLOS), straight leg raise (SLR) angles and Oswestry functional scores.
RESULTS:
Patients treated with dexamethasone had a 1.86 point (95% CI 0.31 to 3.42,
p=0.019) greater reduction in VAS pain scores at 24 h than placebo
(dexamethasone: -2.63 (95% CI -3.63 to -1.63) versus placebo: -0.77 (95% CI
-2.04 to 0.51)). At 6 weeks, both groups had similar significant and sustained
decrease in VAS scores compared with baseline. Patients receiving dexamethasone
had a significantly shorter EDLOS (median: 3.5 h vs 18.8 h, p=0.049) and
improved SLR angle at discharge (14.7°, p=0.040). There was no difference in
functional scores.
CONCLUSIONS:
In patients with LBPR, a single dose of intravenous dexamethasone in addition
to routine management improved VAS pain scores at 24 h, but this effect was not
statistically significant at 6 weeks. Dexamethasone may reduce EDLOS and can be
considered as a safe adjunct to standard treatment.
C. Early Physical Therapy vs Usual
Care in Patients with Recent-Onset LBP: A RCT
Fritz JM, et
al. JAMA. 2015;314(14):1459-1467.
Importance Low back pain (LBP) is common in primary
care. Guidelines recommend delaying referrals for physical therapy.
Objective To evaluate whether early physical therapy
(manipulation and exercise) is more effective than usual care in improving
disability for patients with LBP fitting a decision rule.
Design,
Setting, and Participants Randomized
clinical trial with 220 participants recruited between March 2011 and November
2013. Participants with no LBP treatment in the past 6 months, aged 18 through
60 years (mean age, 37.4 years [SD, 10.3]), an Oswestry Disability Index (ODI)
score of 20 or higher, symptom duration less than 16 days, and no symptoms
distal to the knee in the past 72 hours were enrolled following a primary care
visit.
Interventions All participants received education. Early
physical therapy (n = 108) consisted of 4 physical therapy sessions. Usual care
(n = 112) involved no additional interventions during the first 4 weeks.
Main Outcomes
and Measures Primary outcome was change
in the ODI score (range: 0-100; higher scores indicate greater disability;
minimum clinically important difference, 6 points) at 3 months. Secondary
outcomes included changes in the ODI score at 4-week and 1-year follow-up, and
change in pain intensity, Pain Catastrophizing Scale (PCS) score,
fear-avoidance beliefs, quality of life, patient-reported success, and health
care utilization at 4-week, 3-month, and 1-year follow-up.
Results One-year follow-up was completed by 207
participants (94.1%). Using analysis of covariance, early physical therapy
showed improvement relative to usual care in disability after 3 months (mean
ODI score: early physical therapy group, 41.3 [95% CI, 38.7 to 44.0] at
baseline to 6.6 [95% CI, 4.7 to 8.5] at 3 months; usual care group, 40.9 [95%
CI, 38.6 to 43.1] at baseline to 9.8 [95% CI, 7.9 to 11.7] at 3 months;
between-group difference, −3.2 [95% CI, −5.9 to −0.47], P = .02). A significant
difference was found between groups for the ODI score after 4 weeks (between-group
difference, −3.5 [95% CI, −6.8 to −0.08], P = .045]), but not at 1-year
follow-up (between-group difference, −2.0 [95% CI, −5.0 to 1.0], P = .19).
There was no improvement in pain intensity at 4-week, 3-month, or 1-year
follow-up (between-group difference, −0.42 [95% CI, −0.90 to 0.02] at 4-week
follow-up; −0.38 [95% CI, −0.84 to 0.09] at 3-month follow-up; and −0.17 [95%
CI, −0.62 to 0.27] at 1-year follow-up). The PCS scores improved at 4 weeks and
3 months but not at 1-year follow-up (between-group difference, −2.7 [95% CI,
−4.6 to −0.85] at 4-week follow-up; −2.2 [95% CI, −3.9 to −0.49] at 3-month
follow-up; and −0.92 [95% CI, −2.7 to 0.61] at 1-year follow-up). There were no
differences in health care utilization at any point.
Conclusions
and Relevance Among adults with
recent-onset LBP, early physical therapy resulted in statistically significant
improvement in disability, but the improvement was modest and did not achieve
the minimum clinically important difference compared with usual care.
21. Relief: Scientists Harness the Power of Perception to Fade
Out Chronic Pain
By Rachel
Adelson, The Observer, Nov 2015
Whether it’s
from an unrelenting backache, a persistently stiff neck, or arthritis in the
knee, chronic pain — pain that lasts more than 12 weeks — is considered a
disease by the US government’s National Institutes of Health.
Chronic pain
from any source affects mood along with physical and mental functioning, making
it the most common cause of long-term disability in the United States. As baby
boomers everywhere get older, “chronic pain is arguably the biggest health
burden our species faces at the moment in terms of years lived with disability
and economic load,” says Lorimer Moseley, a clinical neuroscientist at the
University of South Australia.
Because pain
is unique to every person, it’s difficult to quantify and treat, making it a
major ongoing focus of study for psychological science. Clinicians already
deliver a range of mind-based treatments, from guided relaxation, stress
management, and self-hypnosis to cognitive-behavioral therapy (CBT), which
helps patients challenge catastrophic thoughts about their pain. Increasingly,
scientists are using new insights into the brain to devise new forms of pain
relief. In pilot studies that involve interventions ranging from placebos to
virtual-reality technology, they’re building a solid body of evidence on the
power of perception to muffle pain…
The remainder
of the essay: http://www.psychologicalscience.org/index.php/publications/observer/2015/november-15/relief.html
22. Talking to a car or smartphone impairs driving for longer
than you think
Drivers
remain distracted for up to 27 seconds after giving voice commands to
cellphones or infotainment systems, The Washington Post reports. Past research
has shown that hands-free systems, including ones built into cars, are not safe
to use while a car is moving. Now, an American Automobile Association-funded
study has found that people need between 15 and 27 seconds to refocus
afterward, suggesting that that drivers should refrain from using hands-free
technology even while stopped at a stoplight.
23. Book Recommendation: The
Marshmallow Test: Lessons for personal development, parenting, education, and
public policy
Walter Mischel, The Marshmallow Test: Mastering
Self-Control (New
York: Little, Brown and Co, 2014).
Renowned
psychologist Walter Mischel, designer of the famous Marshmallow Test, explains
what self-control is and how to master it.
A child is
presented with a marshmallow and given a choice: Eat this one now, or wait and
enjoy two later. What will she do? And what are the implications for her
behavior later in life?
The world's
leading expert on self-control, Walter Mischel has proven that the ability to
delay gratification is critical for a successful life, predicting higher SAT
scores, better social and cognitive functioning, a healthier lifestyle and a
greater sense of self-worth. But is willpower prewired, or can it be taught?
In The
Marshmallow Test, Mischel explains how self-control can be mastered and applied
to challenges in everyday life--from weight control to quitting smoking,
overcoming heartbreak, making major decisions, and planning for retirement.
With profound implications for the choices we make in parenting, education,
public policy and self-care, The Marshmallow Test will change the way you think
about who we are and what we can be.
24. Micro Bits
A. ED Visits for Adverse Events
Related to Dietary Supplements
Conclusions
An estimated
23,000 emergency department visits in the United States every year are
attributed to adverse events related to dietary supplements. Such visits
commonly involve cardiovascular manifestations from weight-loss or energy
products among young adults and swallowing problems, often associated with
micronutrients, among older adults.
B. Nonmedical Prescription Opioid Use
and Use Disorders Among Adults Aged 18 Through 64 Years in the United States,
2003-2013
Conclusions
During the
2003-2013 years, among adults aged 18 through 64 years, the percentage of
nonmedical use of prescription opioids decreased. In contrast, the prevalence
of prescription opioid use disorders, frequency of use, and related mortality
increased.
C. Allergic sensitization tied to
secondhand smoke exposure
Secondhand
smoke exposure in infancy, but not while inside the womb, was associated with
an increased risk of food sensitization in children who were tested at ages 4,
8 and 16, Swedish researchers reported in the journal Allergy. The findings,
based on 3,316 children who were followed from birth up to age 16, also showed
an association between secondhand smoke exposure in infancy and an overall
increased risk of eczema in combination with sensitization.
D. American Cancer Society, in a
Shift, Recommends Fewer Mammograms
One of the
most respected and influential groups in the continuing breast-cancer screening
debate said on Tuesday that women should begin mammograms later and have them
less frequently than it had long advocated.
The American
Cancer Society, which has for years taken the most aggressive approach to
screening, issued new guidelines on Tuesday, recommending that women with an
average risk of breast cancer start having mammograms at 45 and continue once a
year until 54, then every other year for as long as they are healthy and likely
to live another 10 years.
The rest of
the story: http://www.nytimes.com/2015/10/21/health/breast-cancer-screening-guidelines.html
E. Dalai Lama’s American doctor wants
more compassion in medicine
PBS Newshour,
October 27, 2015
Before he was
a personal physician to the Dalai Lama, Dr. Barry Kerzin never imagined that a
professional trip to Tibet would lead him down a decades-long path studying
Buddhism and meditation. Special correspondent Fred de Sam Lazaro talks to
Kerzin in India about his feeling that compassion and empathy are essential to
medical training.
Video (6
min): http://www.pbs.org/newshour/bb/dalai-lamas-american-doctor-wants-compassion-medicine/
F. Breast Cancer Screening for Women
at Average Risk: 2015 Guideline Update From the American Cancer Society
G. Temporal Trends in Mortality in the
United States, 1969-2013
H. How Can a Mother's Childhood
Experiences Be Transmitted to Her Children?
Maternal
trauma in childhood may affect placental function.
I. Got allergies? Blame parasites
Why are
millions of people allergic to peanuts or pollen, but hardly anyone seems to
have a reaction to rice or raisins? Because some of these foods have proteins
that mimic those of nasty parasites that send our immune systems into
hyperdrive. The new findings could help researchers predict what other foods
might cause allergies and give doctors a more accurate way to dose allergy
shots.
J. Scarlet Fever is Making a Comeback
with Antibiotic Resistance
After nearly
100 years, scarlet fever may be making a comeback. Scientists have used genome
sequencing techniques to investigate a rise in the incidence of this childhood
disease and its increasing resistance to antibiotics.
K. All-cause mortality down 43% over
more than 4 decades
Death rates
related to five of six major diseases or conditions -- heart disease, stroke,
cancer, diabetes and injuries -- dropped from 1969 to 2013, according to a
report in the Journal of the American Medical Association. The all-cause
mortality rate has dropped 43% overall, but mortality for chronic obstructive
pulmonary disease has surged 101%. Mortality for heart disease and stroke
declined 68% and 77%, respectively, while death rates dropped 40% for injuries,
18% for cancer and 17% for diabetes.
L. Hospitals strain to accommodate
climbing ER visits
Emergency
department visits to Washington hospitals have risen more than 16 percent in
two years, according to data from the state Department of Health.
That’s in
line with a national trend since implementation of the Affordable Care Act in
late 2013, which brought insurance coverage to millions of people who may have
little experience using the health care system in general.
