Monday, June 19, 2017

Lit Bits: June 19, 2017

From the recent medical literature...

1. Effect of Cephalexin plus TMP-SMX vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A RCT

Moran GJ, et al. JAMA. 2017 May 23;317(20):2088-2096.

Key Points
Question  Does cephalexin plus trimethoprim-sulfamethoxazole yield higher clinical cure rates than cephalexin alone for treatment of patients with uncomplicated cellulitis?

Findings  In this randomized clinical trial of 500 patients with cellulitis, the clinical cure rate was not significantly different between those treated with cephalexin plus trimethoprim-sulfamethoxazole vs cephalexin plus placebo (83.5% vs 85.5% in the per-protocol analysis and 76.2% vs 69.0% in the modified intention-to-treat analysis). However, the 95% confidence interval for the difference in the intention-to-treat analysis was −1.0% to +15.5%, which included the minimal clinically important difference of 10%.

Meaning  Addition of trimethoprim-sulfamethoxazole to cephalexin did not result in a statistically significant improvement in clinical cure for uncomplicated cellulitis. However, because the imprecision around the findings in the modified intention-to-treat analysis included a clinically important difference favoring the combination, further research may be needed.

IMPORTANCE: Emergency department visits for skin infections in the United States have increased with the emergence of methicillin-resistant Staphylococcus aureus (MRSA). For cellulitis without purulent drainage, β-hemolytic streptococci are presumed to be the predominant pathogens. It is unknown if antimicrobial regimens possessing in vitro MRSA activity provide improved outcomes compared with treatments lacking MRSA activity.

OBJECTIVE: To determine whether cephalexin plus trimethoprim-sulfamethoxazole yields a higher clinical cure rate of uncomplicated cellulitis than cephalexin alone.

DESIGN, SETTING, AND PARTICIPANTS: Multicenter, double-blind, randomized superiority trial in 5 US emergency departments among outpatients older than 12 years with cellulitis and no wound, purulent drainage, or abscess enrolled from April 2009 through June 2012. All participants had soft tissue ultrasound performed at the time of enrollment to exclude abscess. Final follow-up was August 2012.

INTERVENTIONS: Cephalexin, 500 mg 4 times daily, plus trimethoprim-sulfamethoxazole, 320 mg/1600 mg twice daily, for 7 days (n = 248 participants) or cephalexin plus placebo for 7 days (n = 248 participants).

MAIN OUTCOMES AND MEASURES: The primary outcome determined a priori in the per-protocol group was clinical cure, defined as absence of these clinical failure criteria at follow-up visits: fever; increase in erythema (above 25%), swelling, or tenderness (days 3-4); no decrease in erythema, swelling, or tenderness (days 8-10); and more than minimal erythema, swelling, or tenderness (days 14-21). A clinically significant difference was defined as greater than 10%.

RESULTS: Among 500 randomized participants, 496 (99%) were included in the modified intention-to-treat analysis and 411 (82.2%) in the per-protocol analysis (median age, 40 years [range, 15-78 years]; 58.4% male; 10.9% had diabetes). Median length and width of erythema were 13.0 cm and 10.0 cm. In the per-protocol population, clinical cure occurred in 182 (83.5%) of 218 participants in the cephalexin plus trimethoprim-sulfamethoxazole group vs 165 (85.5%) of 193 in the cephalexin group (difference, -2.0%; 95% CI, -9.7% to 5.7%; P = .50). In the modified intention-to-treat population, clinical cure occurred in 189 (76.2%) of 248 participants in the cephalexin plus trimethoprim-sulfamethoxazole group vs 171 (69.0%) of 248 in the cephalexin group (difference, 7.3%; 95% CI, -1.0% to 15.5%; P = .07). Between-group adverse event rates and secondary outcomes through 7 to 9 weeks, including overnight hospitalization, recurrent skin infections, and similar infection in household contacts, did not differ significantly.

CONCLUSIONS AND RELEVANCE: Among patients with uncomplicated cellulitis, the use of cephalexin plus trimethoprim-sulfamethoxazole compared to cephalexin alone did not result in higher rates of clinical resolution of cellulitis in the per-protocol analysis. However, because imprecision around the findings in the modified intention-to-treat analysis included a clinically important difference favoring cephalexin plus trimethoprim-sulfamethoxazole, further research may be needed.

2. H1-antihistamines Reduce Progression to Anaphylaxis among ED Patients with Allergic Reactions.

Kawano T, et al. Acad Emerg Med. 2017 Jun;24(6):733-741.

OBJECTIVES: H1-antihistamines (H1a) can be used to treat emergency department (ED) patients with allergic reactions; however, this is inconsistently done, likely because there is no evidence that this therapy has an impact on serious outcomes. Among ED patients initially presenting with allergic reactions, we investigated whether H1a were associated with lower rates of progression to anaphylaxis.

METHODS: This was a retrospective cohort study conducted at two urban Canadian EDs from April 1, 2007, to March 31, 2012. We included consecutive adult patients with allergic reactions while excluding those presenting with anaphylaxis, according to prespecified criteria. The primary outcome was the proportion of patients who subsequently developed anaphylaxis during medical care, either by emergency medical services (EMS) or in the ED. A prespecified subgroup analysis excluded patients who received H1a prior to EMS or ED contact. We compared those who received H1a and those who did not and used multivariable regression and propensity score adjustment techniques to compare outcomes.

RESULTS: Of 2,376 overall patients included, 1,880 (79.1%) were managed with H1a. Of the latter group, 36 of 1,880 (1.9%) developed anaphylaxis, compared to 17 of 496 (3.4%) in the non-H1a-treated group (adjusted odds ratio [AOR] = 0.34, 95% confidence interval [CI] = 0.17-0.70; number needed to treat [NNT] to benefit = 44.74, 95% CI = 35.36-99.67). In the subgroup analysis of 1,717 patients who did not receive H1a prior to EMS or ED contact, a similar association was observed (AOR = 0.26, 95% CI = 0.10-0.50; NNT to benefit 38.20, 95% CI = 32.58-55.24).

CONCLUSIONS: Among ED patient with allergic reactions, H1a administration was associated with a lower likelihood of progression to anaphylaxis. These data indicate that early H1a treatment in the ED or prehospital setting may decrease progression to anaphylaxis.

3. Toxicology Corner

A. CDC reports on poisonings from "death cap" mushrooms in California

CDC researchers, including Steve Offerman from Kaiser Permamente Northern CA, reported 14 cases of poisoning from ingestion of wild "death cap" mushrooms in California last December. The findings in the agency's Morbidity and Mortality Weekly Report showed that all patients eventually recovered but three had to undergo liver transplants, including an 18-month-old infant who developed irreversible liver failure and permanent neurologic damage after eating one-half of a mushroom cap.

Vo KT, et al. Amanita phalloides Mushroom Poisonings - Northern California, December 2016. MMWR Morb Mortal Wkly Rep. 2017 Jun 2;66(21):549-553. 

Amanita phalloides, colloquially known as the “death cap,” belongs to the Phalloideae section of the Amanita family of mushrooms and is responsible for most deaths following ingestion of foraged mushrooms worldwide (1). On November 28, 2016, members of the Bay Area Mycological Society notified personnel at the California Poison Control System (CPCS) of an unusually large A. phalloides bloom in the greater San Francisco Bay Area, coincident with the abundant rainfall and recent warm weather. Five days later, CPCS received notification of the first human A. phalloides poisoning of the season. Over the following 2 weeks, CPCS was notified of an additional 13 cases of hepatotoxicity resulting from A. phalloides ingestion. In the past few years before this outbreak, CPCS received reports of only a few mushroom poisoning cases per year. A summary of 14 reported cases is presented here. Data extracted from patient medical charts revealed a pattern of delayed gastrointestinal manifestations of intoxication leading to dehydration and hepatotoxicity. Three patients received liver transplants and all but one recovered completely. The morbidity and potential lethality associated with A. phalloides ingestion are serious public health concerns and warrant medical provider education and dissemination of information cautioning against consuming foraged wild mushrooms.

Initial case. A man aged 37 years (patient A) picked two wild mushrooms in Santa Rosa, California (Table). He cooked and ate one mushroom, and approximately 10 hours later developed nausea, vomiting, and diarrhea. He was evaluated in a local emergency department (ED) for abdominal discomfort 20.5 hours after ingestion. A mycologist identified the uncooked mushroom sample provided by the patient as A. phalloides. Initial laboratory findings were notable for an elevated white blood cell count with lactate elevation and elevated creatinine suggesting dehydration (Table). Liver function tests (LFTs) 6 hours later showed elevated aspartate aminotransferase (AST) (92 IU/L; normal = 15–41) and alanine aminotransferase (ALT) (95 IU/L; normal = 17–63) levels. He was treated with aggressive intravenous (IV) fluid hydration, IV octreotide,* and IV silibinin.† Two days after ingestion, the patient’s LFTs peaked at AST = 6,159 IU/L, ALT = 3,084 IU/L, total bilirubin = 2.9 mg/dL (normal = 0.2–1.2), and international normalized ratio (INR) (standardized prothrombin time) 3.2 units (normal = 0.8–1.2). Gastrointestinal symptoms and laboratory values gradually improved, and the patient was discharged home on day 6…

B. Sodium Nitrite and Sodium Thiosulfate Are Effective Against Acute Cyanide Poisoning When Administered by IM Injection

Bebarta VS, et al. Ann Emerg Med. 2017 Jun;69(6):718-725.e4.

STUDY OBJECTIVE: The 2 antidotes for acute cyanide poisoning in the United States must be administered by intravenous injection. In the out-of-hospital setting, intravenous injection is not practical, particularly for mass casualties, and intramuscular injection would be preferred. The purpose of this study is to determine whether sodium nitrite and sodium thiosulfate are effective cyanide antidotes when administered by intramuscular injection.

METHODS: We used a randomized, nonblinded, parallel-group study design in 3 mammalian models: cyanide gas inhalation in mice, with treatment postexposure; intravenous sodium cyanide infusion in rabbits, with severe hypotension as the trigger for treatment; and intravenous potassium cyanide infusion in pigs, with apnea as the trigger for treatment. The drugs were administered by intramuscular injection, and all 3 models were lethal in the absence of therapy.

RESULTS: We found that sodium nitrite and sodium thiosulfate individually rescued 100% of the mice, and that the combination of the 2 drugs rescued 73% of the rabbits and 80% of the pigs. In all 3 species, survival in treated animals was significantly better than in control animals (log rank test, P less than 0.05). In the pigs, the drugs attenuated an increase in the plasma lactate concentration within 5 minutes postantidote injection (difference: plasma lactate, saline solution-treated versus nitrite- or thiosulfate-treated 1.76 [95% confidence interval 1.25 to 2.27]).

CONCLUSION: We conclude that sodium nitrite and sodium thiosulfate administered by intramuscular injection are effective against severe cyanide poisoning in 3 clinically relevant animal models of out-of-hospital emergency care.

4. Can Comfort Care At The ER Help Older People Live Longer And Suffer Less?

Melissa Bailey, NPR. May 26, 2017

A man sobbed in a New York emergency room. His elderly wife, who suffered from advanced dementia, had just had a breathing tube stuck down her throat. He knew she never would have wanted that. Now he had to decide whether to reverse the life-sustaining treatment that medics had begun.

When Dr. Kei Ouchi faced this family as a young resident at Long Island Jewish Medical Center, he had no idea what to say. The husband, who had cared for his wife for the past 10 years, knew her condition had declined so much that she wouldn't want to be rescued. But when Ouchi offered to take out the tube, the man cried more: "She's breathing. How can we stop that?"

Ouchi had pursued emergency medicine to rescue victims of gunshot wounds and car crashes. He was unprepared, he says, for what he encountered: a stream of older patients with serious illnesses like dementia, cancer and heart disease — patients for whom the life-saving techniques he was trained to perform often only prolonged the suffering.

As baby boomers age, more of them are visiting the emergency room, which can be an overcrowded, disorienting and even traumatic place. Adults 65 and older made 20.8 million emergency room visits in 2013, up from 16.2 million in 2000, according to the most recent hospital survey by the Centers for Disease Control and Prevention. The survey found 1 in 6 visits to the ER were made by an older patient, a proportion that's expected to rise.

Half of adults in this age group visit the ER in their last month of life, according to a study in the journal Health Affairs. Of those, half die in the hospital, even though most people say they'd prefer to die at home.

Some states on board

The influx is prompting more clinicians to rethink what happens in the fast-paced emergency room, where the default is to do everything possible to extend life. Hospitals across the country — including in Ohio, Texas, Virginia and New Jersey — are bringing palliative care, which focuses on improving quality of life for patients with advanced illness, into the emergency department.

Interest is growing among doctors: 149 emergency physicians have become certified in palliative care since that option became available just over a decade ago, and others are working closely with palliative care teams. But efforts to transform the ER face significant challenges, including a lack of time, staffing and expertise, not to mention a culture clash.

Researchers who interviewed emergency room staff at two Boston hospitals, for instance, found resistance to palliative care. ER doctors questioned how they could handle delicate end-of-life conversations for patients they barely knew. Others argued that the ER, with its "cold, simple rooms" and drunken patients screaming, is not an appropriate place to provide palliative care, which tends to physical, psychological and spiritual needs.

Ouchi saw some of these challenges during his residency in New York, when he visited the homes of older patients who frequently visited the emergency room. He saw how obstacles like transportation, frailty and poor vision made it difficult for them to leave the house to see a doctor.

"So what do they do?" Ouchi asks. "They call 911."

When these patients arrive at the emergency room, doctors treat their acute symptoms, but not their underlying needs, Ouchi says. In more severe cases, when the patient can't talk and doesn't have an advanced directive or a medical decision-maker available, doctors pursue the most aggressive care possible to keep them alive: CPR, intravenous fluids, breathing tubes.

"Our default in the ER is pedal to the metal," says Dr. Corita Grudzen, an emergency physician at NYU Langone Medical Center who studies palliative care in the ER. But when doctors learn after the fact that the patient would not have wanted that, the emergency rescue forces families to choose whether to remove life support…

Now Ouchi and others are trying to come up with systematic ways to identify which patients could benefit from palliative care.

One such screening tool, dubbed P-CaRES, developed at Brown University in Providence, R.I., gives ER doctors a list of questions. Does the patient have life-limiting conditions such as advanced dementia or sepsis? How often does the patient visit the ER? Would the doctor be surprised if the patient died within 12 months?

Doctors are using the tool to refer patients at the University of California-San Francisco Medical Center at Parnassus to palliative care doctors, says Dr. Kalie Dove-Maguire, a clinical instructor there. The questions pop up automatically on the electronic medical record for every ER patient who is about to be admitted to the hospital.

Dove-Maguire says UCSF hasn't published results, but the tool has helped individual patients, including a middle-aged man with widespread cancer who showed up at the ER with low blood pressure. The man "would have been admitted to the ICU with lines and tubes and invasive procedures," she says, but staff talked to his family, learned his wishes and sent him to home hospice.

"Having that conversation in the ER, which is the entry point to the hospital, is vital," Dove-Maguire says….

Half Of Older Americans Seen In ED In Last Month Of Life; Most Admitted To Hospital, And Many Die There:

Demonstrations of clinical initiatives to improve palliative care in the ED: a report from the IPAL-EM Initiative:

Am I doing the right thing? Provider perspectives on improving palliative care in the ED:

Acceptability and Reliability of a Novel Palliative Care Screening Tool Among ED Providers:

PV Card: Palliative Care Screening in the ED:

5. Peds Corner

A. Ultrasound not helpful for children with abdominal trauma

The focused assessment with sonography in trauma (FAST) exam did not reduce use of abdominal CT, ED length of stay, or hospital charges in this single center study.

Holmes JF, et al. Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial. JAMA.  2017;317(22):2290-2296.

Key Points 
Question  Does the focused assessment with sonography for trauma (FAST) examination safely improve care when used in the emergency department (ED) evaluation of hemodynamically stable children with blunt torso trauma?

Findings  In this trial of 925 hemodynamically stable children with blunt torso trauma, randomization to the FAST vs standard trauma examination did not result in significant improvement in the rate of abdominal computed tomographic scans, time in the ED, hospital charges, or missed intra-abdominal injuries vs children randomized to standard trauma evaluation.

Meaning  The study findings do not support the routine use of FAST in the ED for hemodynamically stable children with blunt torso trauma.

Importance  The utility of the focused assessment with sonography for trauma (FAST) examination in children is unknown.

Objective  To determine if the FAST examination during initial evaluation of injured children improves clinical care.

Design, Setting, and Participants  A randomized clinical trial (April 2012-May 2015) that involved 975 hemodynamically stable children and adolescents younger than 18 years treated for blunt torso trauma at the University of California, Davis Medical Center, a level I trauma center.

Interventions  Patients were randomly assigned to a standard trauma evaluation with the FAST examination by the treating ED physician or a standard trauma evaluation alone.

Main Outcomes and Measures  Coprimary outcomes were rate of abdominal computed tomographic (CT) scans in the ED, missed intra-abdominal injuries, ED length of stay, and hospital charges.

Results  Among the 925 patients who were randomized (mean [SD] age, 9.7 [5.3] years; 575 males [62%]), all completed the study. A total of 50 patients (5.4%, 95% CI, 4.0% to 7.1%) were diagnosed with intra-abdominal injuries, including 40 (80%; 95% CI, 66% to 90%) who had intraperitoneal fluid found on an abdominal CT scan, and 9 patients (0.97%; 95% CI, 0.44% to 1.8%) underwent laparotomy. The proportion of patients with abdominal CT scans was 241 of 460 (52.4%) in the FAST group and 254 of 465 (54.6%) in the standard care–only group (difference, −2.2%; 95% CI, −8.7% to 4.2%). One case of missed intra-abdominal injury occurred in a patient in the FAST group and none in the control group (difference, 0.2%; 95% CI, −0.6% to 1.2%). The mean ED length of stay was 6.03 hours in the FAST group and 6.07 hours in the standard care–only group (difference, −0.04 hours; 95% CI, −0.47 to 0.40 hours). Median hospital charges were $46 415 in the FAST group and $47 759 in the standard care–only group (difference, −$1180; 95% CI, −$6651 to $4291).

Conclusions and Relevance  Among hemodynamically stable children treated in an ED following blunt torso trauma, the use of FAST compared with standard care only did not improve clinical care, including use of resources; ED length of stay; missed intra-abdominal injuries; or hospital charges. These findings do not support the routine use of FAST in this setting.

B. Concomitant Bacterial Meningitis in 1% of Infants less than 28 days with UTI

Grether-Jones KL, et al. Pediatr Infect Dis J. 2017 May 2 [Epub ahead of print]

To determine age-stratified prevalence of concomitant bacterial meningitis in infants ≤ 60 days with a urinary tract infection (UTI), we performed a 23-center retrospective study of 1,737 infants with UTI. Concomitant bacterial meningitis was rare, but more common in infants 0-28 days (0.9%, 95% CI: 0.4-1.9%) compared with infants 29-60 days (0.2%, 95% CI: 0-0.8%).

C. A Vibrating Cold Device to Reduce Pain in the Pediatric ED: A RCT

Potts DA, et al. Pediatr Emerg Care. 2017 Jan 24 [Epub ahead of print]

OBJECTIVE: Pain of intravenous (IV) catheter insertion can be mitigated with appropriate analgesia, thereby avoiding unnecessary distress. Our objective was to compare the self-reported pain of IV catheter insertion in children when using a vibrating cold device (VCD) versus standard of care 4% topical lidocaine cream (TL).

METHODS: This was a 2-arm randomized controlled noninferiority trial with a convenience sample of 4- to 18-year-olds requiring nonemergent IV catheter insertion. Self-reported pain was measured with the Faces Pain Scale-Revised, anxiety with the Child's Rating of Anxiety scale, and observed pain with the Face, Legs, Activity, Crying, Consolability scale. Caregivers and nurses completed satisfaction surveys.

RESULTS: Two hundred twenty-four children were included in the analysis: 114 (90%) of 127 in the VCD group and 110 (89%) of 124 in the TL group. Faces Pain Scale-Revised scores for both groups were equivalent (median, 2.0 cm; interquartile range, 0-5 cm; linear regression difference, 0 [95% confidence interval, -0.82 to 0.82]), as were median Face, Legs, Activity, Crying, Consolability scale scores (difference, 0.33 [95% confidence interval, -0.01 to 0.68]). The time of completion for the IV procedure was significantly shorter for the VCD group compared with the TL group (median, 3.0 vs 40.5 minutes; P less than 0.0001). There were no significant differences between groups for self-reported state or trait anxiety, success of IV catheter insertion on first attempt, or satisfaction of caregivers or staff.

CONCLUSIONS: A VCD and TL showed equal effectiveness in reducing pain and distress for children undergoing IV catheter insertion. The VCD has the added benefit of quick onset time and an acceptable alternative for caregivers and nurses.

D. Increase in Medical Management of Nonperforated Pediatric Appendicitis

The rate of nonoperative management of pediatric appendicitis increased 20% from 2010 to 2016, although failure rates were high.

Bachur RG et al. Pediatrics 2017 Jun 1;171(6):505-506.

Appendicitis is the most common acute surgical condition, with a lifetime risk of 8%. Over the last 2 decades, there have been significant improvements in the diagnosis and surgical management, which has led to fewer negative appendectomies, shorter hospitalizations, and faster recoveries.1 The prospect of nonoperative management has been proposed as the next major advance in appendicitis care, which shows promise but also brings challenges.

6. An Observational Study to Determine Whether Routinely Sending Patients Home With a 24-Hour Supply of Topical Tetracaine From the ED for Simple Corneal Abrasion Pain Is Potentially Safe.

Waldman N, et al. Ann Emerg Med. 2017 May 2 [Epub ahead of print]

STUDY OBJECTIVE: To determine if the number of emergency department (ED) rechecks, persistent fluorescein uptake, ophthalmology referrals, or complications would be affected by the prescription of topical tetracaine for pain relief from simple corneal abrasions (SCAs).

METHODS: This retrospective cohort study was conducted in an ED where policy change allowed physicians to use topical tetracaine hydrochloride 1% eye drops for 24 hours for pain treatment for patients with corneal abrasions. Outcomes were compared between patients who did or did not received tetracaine (adjusting for the propensity for treatment).

RESULTS: Of 1,576 initial ED presentations, 532 were SCAs, with 1,044 deemed nonsimple corneal abrasions (NSCAs). Tetracaine was dispensed at the initial visit for 303 SCA presentations (57%) and inappropriately for 141 NSCA presentations (14%). There were no serious complications or uncommon adverse events attributed to tetracaine for all SCAs and NSCAs combined (0/459; upper 95% confidence interval [CI] 0.80%). The relative risks (RRs) of ED recheck and fluorescein staining were increased overall among patients who received tetracaine (RR 1.67, 95% CI 1.25 to 2.23; and RR 1.65, 95% CI 1.07 to 2.53 for recheck and staining, respectively). However, the relative risks for only SCAs receiving tetracaine was 1.16 (95% CI 0.69 to 1.93) and 0.77 (95% CI 0.37 to 1.62), respectively. Referrals to ophthalmology were significantly decreased for all patients (SCAs and NSCAs) dispensed tetracaine (relative risk 0.33; 95% CI 0.19 to 0.59). The number of complications was too small to permit modeling.

CONCLUSION: There was no evidence that up to 24-hour topical tetracaine for the treatment of pain caused by SCA was unsafe; however, CIs were wide and some increased risks were observed for NSCAs.

7. American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients

Part I: Introduction, Review and Evidence-Based Guidelines

Anderson EL, et al. West J Emerg Med 2017;18(2):235-242.

INTRODUCTION: In the United States, the number of patients presenting to the emergency department (ED) for a mental health concern is significant and expected to grow. The breadth of the medical evaluation of these patients is controversial. Attempts have been made to establish a standard evaluation for these patients, but to date no nationally accepted standards exist. A task force of the American Association of Emergency Psychiatry, consisting of physicians from emergency medicine and psychiatry, and a psychologist was convened to form consensus recommendations on the medical evaluation of psychiatric patients presenting to EDs.

METHODS: The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED (Part I) and then combined this with expert consensus (Part II).

RESULTS: In Part I, we discuss terminological issues and existing evidence on medical exams and laboratory studies of psychiatric patients in the ED.

CONCLUSION: Emergency physicians should work cooperatively with psychiatric receiving facilities to decrease unnecessary testing while increasing the quality of medical screening exams for psychiatric patients who present to EDs.

Part II: Controversies over Medical Assessment, and Consensus Recommendations

Wilson MP, et al. West J Emerg Med. 2017;18(4):640-646.

Introduction: The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed “medical clearance,” often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs.

Methods: The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors.Results: Eight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term “medical clearance,” and the need for better science in this area.
Conclusion: The evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial.

8. Ketamine as an Adjunct to Opioids for Acute Pain in the ED: A RCT

Bowers KJ, et al. Acad Emerg Med. 2017 Jun;24(6):676-685.

OBJECTIVES: This study had five objectives: 1) to measure and compare total opioid use and number of opioid doses in patients treated with opioids versus ketamine in conjunction with opioids; 2) to measure pain scores up to 2 hours after presentation in the ED patient with pain, comparing standard opioid pain control to ketamine in conjunction with opioids; 3) to compare patient satisfaction with pain control using opioids alone versus ketamine in conjunction with opioids; 4) to monitor and compare side effects in patients treated with opioids versus ketamine in conjunction with opioids; and 5) to identify effect variation between different subgroups of patients, with the purpose of focusing future research. We hypothesized that low-dose ketamine, compared to placebo, as an adjunctive treatment to opioids would result in better pain control over 2 hours and greater patient satisfaction with pain control; further, this protocol will result in a lower opioid dosage over 2 hours.

METHODS: This was a randomized, double-blinded, placebo-controlled trial at a single academic emergency department evaluating the use of ketamine versus placebo in conjunction with opioids for moderate to severe pain. Subjects with a continued high level of pain after an initial dose of opioid analgesia were randomized to receive either 0.1 mg/kg ketamine or placebo prior to protocol-based dosing of additional opioid analgesia, if required. Over 120 minutes, subjects were assessed for pain level (0-10), satisfaction with pain control (0-4), side effects, sedation level, and need for additional pain medication. Total opioid dose, including the initial dose, was compared between groups.

RESULTS: Sixty-three subjects were randomized to the placebo group and 53 to the ketamine group. No significant differences were found in demographics between the groups. Patients receiving ketamine reported lower pain scores over 120 minutes than patients receiving placebo (p = 0.015). Total opioid dose was lower in the ketamine group (mean ± SD = 9.95 ± 4.83 mg) compared to placebo (mean ± SD = 12.81 ± 6.81 mg; p = 0.02). Satisfaction did not differ between groups. Fewer patients in the ketamine group required additional opioid doses. More patients reported light-headedness and dizziness in the ketamine group.

CONCLUSIONS: Ketamine, as an adjunct to opioid therapy, was more effective at reducing pain over 120 minutes and resulted in a lower total opioid dose as well as fewer repeat doses of analgesia. More side effects were reported in the ketamine group (51% vs. 19%), but the side effect profile appears tolerable.

9. Management of Septic Shock

Berger RE, River E, Levy MM. N Engl J Med 2017; 376:2282-2285.

CASE VIGNETTE: A Woman with Septic Shock

Ms. Jones is a 65-year-old woman with a history of hypertension who presents to the emergency department with a 3-day history of chills and dysuria. The only medication she is taking is amlodipine, at a dose of 10 mg daily; she had had normal electrolyte levels and renal function at a routine visit 6 weeks earlier. On arrival at the emergency department, she reports feeling dizzy.

She is 165 cm (65 in.) tall and weighs 70 kg (154 lb). Her temperature is 38.6°C (101.5°F), heart rate 125 beats per minute, blood pressure 85/55 mm Hg (mean arterial pressure, 65 mm Hg), respiratory rate 28 breaths per minute, and oxygen saturation as measured by pulse oximetry 94% while she is breathing ambient air. A physical examination reveals dry mucous membranes; undetectable jugular venous pulsation; tachycardia without gallops, rubs, or murmurs; clear lungs; and warm extremities. She has tenderness on palpation of her suprapubic region. You begin intravenous administration of a bolus of crystalloid solution.

Laboratory testing shows a creatinine level of 1.8 mg per deciliter (159 μmol per liter) (normal range, 0.5 to 1.1 mg per deciliter [44 to 97 μmol per liter]), blood urea nitrogen 76 mg per deciliter (27 mmol per liter) (normal range, 7 to 20 mg per deciliter [2 to 7 mmol per liter]), lactate 5.0 mmol per liter (normal value, less than 2.0), anion gap 25 mmol per liter (normal range, 8 to 15), white-cell count 20,000 per cubic millimeter (normal range, 4500 to 11,000), and hemoglobin 9.0 g per deciliter (normal range, 12.0 to 15.5). Urinalysis shows 3+ leukocyte esterase, more than 100 white cells per high-power field, and abundant bacteria.

You make a presumptive diagnosis of sepsis from a urinary source and begin treatment with intravenous antibiotics to target likely urinary pathogens. Ultrasonography of the kidneys and bladder reveals no hydronephrosis or evidence of obstruction.

After administration of 2100 ml of crystalloid fluid (30 ml per kilogram of body weight), the patient’s jugular venous pressure is 8 cm of water, but her systemic arterial pressure has decreased to 80/50 mm Hg (mean arterial pressure, 60 mm Hg). During the 3 hours that she has been in the emergency department, she has produced 20 ml of urine, as measured through a Foley catheter that was placed on her arrival.

You place a central venous catheter and initiate a norepinephrine infusion, which you adjust with a goal of raising her mean arterial pressure to 65 to 70 mm Hg. She is transferred to the intensive care unit (ICU); on arrival in the ICU, her mean arterial pressure is 65 mm Hg while she is receiving 40 μg of norepinephrine per minute, and her heart rate is 100 beats per minute. A chest radiograph shows early evidence of acute lung injury and good central catheter placement. Her arterial oxygen saturation is 100% while she is receiving 4 liters of oxygen through a nasal cannula.

You are aware that there are two main approaches to the management of septic shock in a patient such as Ms. Jones. One approach involves serial measurement of central venous pressure, central venous oxygen saturation (Scvo2), and hemoglobin, and following the early, goal-directed therapy (EGDT) protocol, in which specified targets are used for the initiation of inotropic agents or transfusion of red cells.1 For example, if the central venous pressure is less than 8 mm Hg, additional fluid resuscitation is administered; if the Scvo2 is less than 70%, the patient receives a transfusion of red cells until a hematocrit goal of at least 30% is reached, and if the Scvo2 remains less than 70%, inotropic support is initiated.

The second approach involves continuing intravenous administration of antibiotics and vasopressors, guided by clinical signs including blood pressure and urine output, without serial central venous pressure monitoring, serial Scvo2 monitoring, transfusion of red cells, or administration of inotropic agents. You are undecided about which of these approaches would maximize the chance of survival for your patient with septic shock.

Which of the following treatment strategies should you pursue for this patient?....

For the remainder of the discussion, full-text (free):

10. Images in Clinical Practice

Rapidly enlarging scrotal hematoma: A complication of femoral access?

Seesaw Nystagmus

Large Arachnoid Cyst

Evolution of Purpura Fulminans

Galloping Heart

Adolescent With Chest Pain

Young Boy With Unilateral Facial Flushing

Middle-Aged Woman With Right Upper Quadrant Pain

Elderly Woman With Diffuse Abdominal Pain

Young Male With Shoulder Mass

Adolescent Male With Syncope

11. Ureteral Stone Research

A. Ultrasound vs. CT for Severity of Hydronephrosis and Its Importance in Renal Colic

Leo MM, et al. West J Emerg Med. 2017;18(4):559-568.

Introduction: Supporting an “ultrasound-first” approach to evaluating renal colic in the emergency department (ED) remains important for improving patient care and decreasing healthcare costs. Our primary objective was to compare emergency physician (EP) ultrasound to computed tomography (CT) detection of hydronephrosis severity in patients with suspected renal colic. We calculated test characteristics of hydronephrosis on EP-performed ultrasound for detecting ureteral stones or ureteral stone size over 5mm. We then analyzed the association of hydronephrosis on EP-performed ultrasound, stone size  over 5mm, and proximal stone location with 30-day events.

Methods: This was a prospective observational study of ED patients with suspected renal colic undergoing CT. Subjects had an EP-performed ultrasound evaluating for the severity of hydronephrosis. A chart review and follow-up phone call was performed.

Results: We enrolled 302 subjects who had an EP-performed ultrasound. CT and EP ultrasound results were comparable in detecting severity of hydronephrosis (x2=51.7, p less than 0.001). Hydronephrosis on EP- performed ultrasound was predictive of a ureteral stone on CT (PPV 88%; LR+ 2.91), but lack of hydronephrosis did not rule it out (NPV 65%). Lack of hydronephrosis on EP-performed ultrasound makes larger stone size over 5mm less likely (NPV 89%; LR-0.39). Larger stone size over 5mm was associated with 30-day events (OR 2.30, p=0.03).

Conclusion: Using an ultrasound-first approach to detect hydronephrosis may help physicians identify patients with renal colic. The lack of hydronephrosis on ultrasound makes the presence of a larger ureteral stone less likely. Stone size over 5mm may be a useful predictor of 30-day events.

B. A Comparison of Urolithiasis in the Presence and Absence of Microscopic Hematuria in the ED

Mefford JM, et al. West J Emerg Med 2017;18(4):775-779.

Introduction: Urolithiasis is a common medical condition that accounts for a large number of emergency department (ED) visits each year and contributes significantly to annual healthcare costs. Urinalysis is an important screening test for patients presenting with symptoms suspicious for urolithiasis. At present there is a paucity of medical literature examining the characteristics of ureteral stones in patients who have microscopic hematuria on urinalysis versus those who do not. The purpose of this study was to examine mean ureteral stone size and its relationship to the incidence of clinically significant hydronephrosis in patients with and without microscopic hematuria.

Methods: This is a retrospective chart review of patient visits to a single, tertiary academic medical center ED between July 1, 2008, and August 1, 2013, of patients who underwent non-contrast computed tomography of the abdomen and pelvis and urinalysis. For patient visits meeting inclusion criteria, we compared mean stone size and the rate of moderate-to-severe hydronephrosis found on imaging in patients with and without microscopic hematuria on urinalysis.

Results: Out of a total of 2,370 patient visits 393 (16.6%) met inclusion criteria. Of those, 321 (82%) had microscopic hematuria present on urinalysis. Patient visits without microscopic hematuria had a higher rate of moderate-to-severe hydronephrosis (42%), when compared to patients with microscopic hematuria present (25%, p=.005). Mean ureteral stone size among patient visits without microscopic hematuria was 5.7 mm; it was 4.7 mm for those patients with microscopic hematuria (p=.09). For ureteral stones 5 mm or larger, the incidence of moderate-to-severe hydronephrosis was 49%, whereas for ureteral calculi less than 5 mm in size, the incidence of moderate-to-severe hydronephrosis was 14% (p less than 0.0001).

Conclusion: Patients visiting the ED with single-stone ureterolithiasis without microscopic hematuria on urinalysis could be at increased risk of having moderate-to-severe hydronephrosis compared to similar patients presenting with microscopic hematuria on urinalysis. Although the presence of hematuria on urinalysis is a moderately sensitive screening test for urolithiasis, these results suggest patients without hematuria tend to have more clinically significant ureteral calculi, making their detection more important. Clinicians should maintain a high index of suspicion for urolithiasis, even in the absence of hematuria, since ureteral stones in these patients were found to be associated with a higher incidence of obstructive uropathy.

C. Are α-Blockers Beneficial for Outpatient Management of Uncomplicated Ureteric Stones?

Take-Home Message
α-Blockers may accelerate passage and prevent complications such as hospital admission or surgery when ureteric stones are 5 to 10 mm, but there is no evidence to support their use in stones less than 5 mm. Benefits appear to be similar regardless of location in the ureter.

12. Chest Pain Evaluation Research

A. CP associated with cocaine use

Although hospital admissions for chest pain are not uncommon among cocaine users, the outcomes and associated burden on the health care system are not well known. Identifying and recategorizing patients presenting to the emergency department with cocaine-related chest pain into low, intermediate, and high risk can help avoid unnecessary hospital admissions and lessen the need for cardiac procedures. For the low-risk cohort, where acute coronary syndrome has been ruled out, hospitalization may not be beneficial.

Singh V, et al. Hospital Admissions for Chest Pain Associated with Cocaine Use in the United States. Am J Med. 2017 Jun;130(6):688-698.

BACKGROUND: The outcomes related to chest pain associated with cocaine use and its burden on the healthcare system are not well studied.

METHODS: Data were collected from the Nationwide Inpatient Sample (2001-2012). Subjects were identified by using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Primary outcome was a composite of mortality, myocardial infarction, stroke, and cardiac arrest.

RESULTS: We identified 363,143 admissions for cocaine-induced chest pain. Mean age was 44.9 (±21.1) years with male predominance. Left heart catheterizations were performed in 6.7%, whereas the frequency of acute myocardial infarction and percutaneous coronary interventions were 0.69% and 0.22%, respectively. The in-hospital mortality was 0.09%, and the primary outcome occurred in 1.19% of patients. Statistically significant predictors of primary outcome included female sex (odds ratio [OR], 1.16; confidence interval [CI], 1.00-1.35; P = .046), age over 50 years (OR, 1.24, CI, 1.07-1.43; P = .004), history of heart failure (OR, 1.63, CI, 1.37-1.93; P less than .001), supraventricular tachycardia (OR, 2.94, CI, 1.34-6.42; P = .007), endocarditis (OR, 3.5, CI, 1.50-8.18, P = .004), tobacco use (OR, 1.3, CI, 1.13-1.49; P less than .001), dyslipidemia (OR, 1.5, CI, 1.29-1.77; P less than .001), coronary artery disease (OR, 2.37, CI, 2.03-2.76; P less than .001), and renal failure (OR, 1.27, CI, 1.08-1.50; P = .005). The total annual projected economic burden ranged from $155 to $226 million with a cumulative accruement of more than $2 billion over a decade.

CONCLUSION: Hospital admissions due to chest pain and concomitant cocaine use are associated with low rates of adverse outcomes. For the low-risk cohort in whom acute coronary syndrome has been ruled out, hospitalization may not be beneficial and may result in unnecessary cardiac procedures.

B. Utility of the History and Physical Examination in the Detection of ACS in ED Patients

Dezman ZDW, Mattu A, et al. West J Emerg Med 2017;18(4):752-760.

Chest pain accounts for approximately 6% of all emergency department (ED) visits and is the most common reason for emergency hospital admission. One of the most serious diagnoses emergency physicians must consider is acute coronary syndrome (ACS). This is both common and serious, as ischemic heart disease remains the single biggest cause of death in the western world. The history and physical examination are cornerstones of our diagnostic approach in this patient group. Their importance is emphasized in guidelines, but there is little evidence to support their supposed association. The purpose of this article was to summarize the findings of recent investigations regarding the ability of various components of the history and physical examination to identify which patients presenting to the ED with chest pain require further investigation for possible ACS.

Previous studies have consistently identified a number of factors that increase the probabilityof ACS. These include radiation of the pain, aggravation of the pain by exertion, vomiting, and diaphoresis. Traditional cardiac risk factors identified by the Framingham Heart Study are of limited diagnostic utility in the ED. Clinician gestalt has very low predictive ability, even in patients with anon-diagnostic electrocardiogram (ECG), and gestalt does not seem to be enhanced appreciably by clinical experience. The history and physical alone are unable to reduce a patient’s risk of ACS to a generally acceptable level (less than 1%).

Ultimately, our review of the evidence clearly demonstrates that “atypical” symptoms cannot rule out ACS, while “typical” symptoms cannot rule it in. Therefore, if a patient has symptoms that are compatible with ACS and an alternative cause cannot be identified, clinicians must strongly consider the need for further investigation with ECG and troponin measurement.

C. Pitfalls in ECG Diagnosis of ACS in Low-Risk Chest Pain

Tewelde S, Mattu A, et al. West J Emerg Med. 2017;18(4):601-606.

Less than half of patients with a chest pain history indicative of acute coronary syndrome have a diagnostic electrocardiogram (ECG) on initial presentation to the emergency department. The physician must dissect the ECG for elusive, but perilous, characteristics that are often missed by machine analysis.

ST depression is interpreted and often suggestive of ischemia; however, when exclusive to leads V1‒V3 with concomitant tall R waves and upright T waves, a posterior infarction should first and foremost be suspected. Likewise, diffuse ST depression with elevation in aVR should raise concern for left main- or triple-vessel disease and, as with the aforementioned, these ECG findings are grounds for acute reperfusion therapy. Even in isolation, certain electrocardiographic findings can suggest danger. Such is true of the lone T-wave inversion in aVL, known to precede an inferior myocardial infarction.

Similarly, something as ordinary as an upright and tall T wave or a biphasic T wave can be the only marker of ischemia. ECG abnormalities, however subtle, should give pause and merit careful inspection since misinterpretation occurs in 20-40% of misdiagnosed myocardial infarctions.

D. Less-Aggressive Approach to Non-ST Segment Elevation ACS Advised

By Scott Baltic. Reuters Health Information. May 01, 2017

NEW YORK (Reuters Health) - Holding off on coronary angiography for patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and elevated cardiac troponin T is not associated with higher long-term risks of death or myocardial infarction (MI), a new report by Dutch researchers indicates.

The ICTUS trial compared a routine early invasive treatment strategy with an ischemia-driven strategy, both of which included anti-anginal and anti-thrombotic medical treatment.
In the early invasive group, coronary angiography was done within 24 to 72 hours, followed by appropriate angiography-guided treatment, either revascularization or continued pharmacological therapy. In the ischemia-driven group, angiography was done only for refractory angina or when ischemia was inducible by noninvasive stress testing.

The study recruited 1,200 patients, about three-quarters male, with a median age of 62, of whom 14% had diabetes. More procedure-related MI occurred in the early invasive group, but after 10 years of follow-up there was no significant difference between the groups in risk of death or spontaneous MI.

“The current result confirms and extends the results of previous studies, with one-third of patients enduring death or spontaneous MI within 10 years despite treatment,” the authors wrote.

“We conclude that a strategy of selective invasive management is an option for selected patients. Not everyone with a positive troponin needs to be rushed to the cath lab,” coauthor Dr. R.J. de Winter, of the Academic Medical Center in Amsterdam told Reuters Health by email.

The authors point out that their findings contrast with the long-term results of two other studies (FRISC-II and RITA-3), “where a benefit of an early invasive strategy was shown.” To explain this disparity, they note that the trials “enrolled patients in different time periods, and there were differences in clinical practice.”

13. A Modified Lung and Cardiac US Protocol Saves Time and Rules in the Diagnosis of Acute HF.

Russell FM, et al. J Emerg Med. 2017 Jun;52(6):839-845.

BACKGROUND: Multiorgan ultrasound (US), which includes evaluation of the lungs and heart, is an accurate method that outperforms clinical gestalt for diagnosing acutely decompensated heart failure (ADHF). A known barrier to ultrasound use is the time needed to perform these examinations.

OBJECTIVE: The primary goal of this study was to determine the test characteristics of a modified lung and cardiac US (LuCUS) protocol for the accurate diagnosis of ADHF.

METHODS: This was a secondary analysis of a prospective observational study that enrolled adult patients presenting to the emergency department with undifferentiated dyspnea. Intervention consisted of a modified LuCUS protocol performed by experienced emergency physician sonographers. A positive modified LuCUS protocol was defined as the presence of B+ lines in both the left and right anterosuperior lung zones, plus a left ventricular ejection fraction less than 45%. If all three of these findings were not present, the modified LuCUS result was interpreted as negative for ADHF. The primary objective was measured by comparing US findings to final diagnosis independently determined by two physicians, both blinded to US findings and each other's final diagnosis.

RESULTS: We analyzed data on 99 patients; 36% had a final diagnosis of ADHF. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of the modified LuCUS protocol are 25% (95% confidence interval [CI] 14-41%), 100% (95% CI 94-100%), undefined, and 0.75 (95% CI 0.62-0.91%), respectively. This modified protocol takes on average 1 min and 32 sec to complete.

CONCLUSION: The point estimate for the specificity of the modified LuCUS protocol in this pilot study, accomplished by a reanalysis of data collected for a previously reported investigation of the full LuCUS protocol, was 100% for the diagnosis of ADHF.

14. Dual sequential external defibrillation: not much literature to go on

A. Make it two: A case report of dual sequential external defibrillation

Bell CR, et al. CJEM 2017 Jun 7 [Epub ahead of print]

Dual sequential external defibrillation (DSED) is the process of near simultaneous discharge of two defibrillators with differing pad placement to terminate refractory arrhythmias. Previously used in the electrophysiology suite, this technique has recently been used in the emergency department and prehospital setting for out-of-hospital cardiac arrest (OHCA). We present a case of successful DSED in the emergency department with neurologically intact survival to hospital discharge after refractory ventricular fibrillation (RVF) and review the putative mechanisms of action of this technique.

B. Use of double sequential external defibrillation for refractory VF during out-of-hospital cardiac arrest.

Cortez E, et al. Resuscitation. 2016 Nov;108:82-86.

INTRODUCTION: Survival from out of hospital cardiac arrest (OHCA) is highest in victims with shockable rhythms when early CPR and rapid defibrillation are provided. However, a subset of individuals present with ventricular fibrillation (VF) that does not respond to defibrillation (refractory VF). One intervention that may be a possible option in refractory VF is double sequential external defibrillation (DSD). The objective of this case series was to describe the outcome of prehospital victims with refractory VF treated with DSD in the out-of-hospital setting.

METHODS: This evaluation is a retrospective chart review of VF patients treated with DSD in the prehospital setting from August 1st, 2010 through June 30th, 2014. Patients were excluded if less than 17 years of age. The outcomes we evaluated were the number of patients with return of spontaneous circulation, conversion from VF, survival-to-hospital discharge, and Cerebral Performance Category score.

RESULTS: Total of 2428 OHCA events were reviewed with twelve patients treated with DSD. Median DSD and prehospital resuscitation times were 27min (IQR 22-33) and 32 (IQR 24-38), respectively. Of the 12 patients treated, return of spontaneous circulation was achieved in three patients, nine patients were converted out of ventricular fibrillation, three patients survived to hospital discharge, and two patients (2/12, 17%) were discharged with Cerebral Performance Category scores of 1 (good cerebral performance).

CONCLUSIONS: Double sequential defibrillation may be another tool to improve neurologically intact survival from OHCA. Further studies are needed to demonstrate direct benefits to patient outcomes.

C. Double Sequential External Defibrillation and Survival from Out-of-Hospital Cardiac Arrest: A Case Report.

Johnston M, et al. Prehosp Emerg Care. 2016 Sep-Oct;20(5):662-6.

BACKGROUND: Patients who present in ventricular fibrillation are typically treated with cardiopulmonary resuscitation (CPR), epinephrine, antiarrhythmic medications, and defibrillation. Although these therapies have shown to be effective, some patients remain in a shockable rhythm. Double sequential external defibrillation has been described as a viable option for patients in refractory ventricular fibrillation.

OBJECTIVE: To describe the innovative use of two defibrillators used to deliver double sequential external defibrillation by paramedics in a case of refractory ventricular fibrillation resulting in prehospital return of spontaneous circulation and survival to hospital discharge with good neurologic function.

CASE: A 28-year-old female sustained a witnessed out-of-hospital cardiac arrest (OHCA). Bystander CPR was performed by her husband followed by paramedics providing high-quality CPR, antiarrhythmic medication, and 6 biphasic defibrillations using standard energy levels. Double sequential external defibrillation was applied and a return of spontaneous circulation was attained on scene and maintained through to arrival to the emergency department. Following admission to hospital the patient was diagnosed with long QT syndrome. An implantable cardioverter defibrillator was placed and the patient was discharged with a Cerebral Performance Category of 2 as well as a modified Rankin Scale of 2 after an 18-day hospital stay. The patient's functional status continued to improve post discharge.

CONCLUSION: The addition of double sequential external defibrillation as part of a well-organized resuscitation effort may be a valid treatment option for OHCA patients who present in refractory ventricular fibrillation.

15. Chest X-Ray Misses Most Rib Fractures

In a large multicenter cohort of blunt trauma patients, 24% had rib fractures and two thirds of these were missed by plain films.

Murphy CE IV, et al. Ann Emerg Med 2017 May 27 [Epub ahead of print]

STUDY OBJECTIVE: With increased use of chest computed tomography (CT) in trauma evaluation, traditional teachings in regard to rib fracture morbidity and mortality may no longer be accurate. We seek to determine rates of rib fracture observed on chest CT only; admission and mortality of patients with isolated rib fractures, rib fractures observed on CT only, and first or second rib fractures; and first or second rib fracture-associated great vessel injury.

METHODS: We conducted a planned secondary analysis of 2 prospectively enrolled cohorts of the National Emergency X-Radiography Utilization Study chest studies, which evaluated patients with blunt trauma who were older than 14 years and received chest imaging in the emergency department. We defined rib fractures and other thoracic injuries according to CT reports and followed patients through their hospital course to determine outcomes.

RESULTS: Of 8,661 patients who had both chest radiograph and chest CT, 2,071 (23.9%) had rib fractures, and rib fractures were observed on chest CT only in 1,368 cases (66.1%). Rib fracture patients had higher admission rates (88.7% versus 45.8%; mean difference 42.9%; 95% confidence interval [CI] 41.4% to 44.4%) and mortality (5.6% versus 2.7%; mean difference 2.9%; 95% CI 1.8% to 4.0%) than patients without rib fracture. The mortality of patients with rib fracture observed on chest CT only was not statistically significantly different from that of patients with fractures also observed on chest radiograph (4.8% versus 5.7%; mean difference -0.9%; 95% CI -3.1% to 1.1%). Patients with first or second rib fractures had significantly higher mortality (7.4% versus 4.1%; mean difference 3.3%; 95% CI 0.2% to 7.1%) and prevalence of concomitant great vessel injury (2.8% versus 0.6%; mean difference 2.2%; 95% CI 0.6% to 4.9%) than patients with fractures of ribs 3 to 12, and the odds ratio of great vessel injury with first or second rib fracture was 4.4 (95% CI 1.8 to 10.4).

CONCLUSION: Under trauma imaging protocols that commonly incorporate chest CT, two thirds of rib fractures were observed on chest CT only. Patients with rib fractures had higher admission rates and mortality than those without rib fractures. First or second rib fractures were associated with significantly higher mortality and great vessel injury.

16. ED Pain Management Following Implementation of a Geriatric Hip Fracture Program

Casey SD, et al. West J Emerg Med. 2017;18(4):585-591.

Introduction: Over 300,000 patients in the United States sustain low-trauma fragility hip fractures annually. Multidisciplinary geriatric fracture programs (GFP) including early, multimodal pain management reduce morbidity and mortality. Our overall goal was to determine the effects of a GFP on the emergency department (ED) pain management of geriatric fragility hip fractures.

Methods: We performed a retrospective study including patients age ≥65 years with fragility hip fractures two years before and two years after the implementation of the GFP. Outcomes were time to (any) first analgesic, use of acetaminophen and fascia iliaca compartment block (FICB) in the ED, and amount of opioid medication administered in the first 24 hours. We used permutation tests to evaluate differences in ED pain management following GFP implementation.

Results: We studied 131 patients in the pre-GFP period and 177 patients in the post-GFP period. In the post-GFP period, more patients received FICB (6% vs. 60%; difference 54%, 95% confidence interval [CI] 45-63%; p less than 0.001) and acetaminophen (10% vs. 51%; difference 41%, 95% CI 32-51%;p less than 0.001) in the ED. Patients in the post-GFP period also had a shorter time to first analgesic (103 vs. 93 minutes; p=0.04) and received fewer morphine equivalents in the first 24 hours (15mg vs.10mg, p less than 0.001) than patients in the pre-GFP period.

Conclusion: Implementation of a GFP was associated with improved ED pain management for geriatric patients with fragility hip fractures. Future studies should evaluate the effects of these changes in pain management on longer-term outcomes.

See also Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review.

Ritcey B, et al. CJEM. 2016 Jan;18(1):37-47.

17. Anticoagulation Reversal for Supratherapeutic INR: A Teachable Moment

Tummalapalli SL, et al. JAMA Intern Med. 2017;177(6):869-870.

An 81-year-old woman with metastatic breast cancer, atrial fibrillation on warfarin, and congestive heart failure presented with shortness of breath. She was found to have a recurrent malignant pleural effusion and was admitted to the medicine service. On laboratory evaluation, her international normalized ratio (INR) was supratherapeutic to 7.4. She had no tachypnea, hypoxia, or signs or symptoms of bleeding.

She was given oral vitamin K, and 4 units of fresh frozen plasma (FFP) were ordered to reverse her anticoagulation for a therapeutic thoracentesis. After the third FFP unit, the patient developed diffuse and intensely pruritic urticaria on her neck, chest, and legs, with no stridor or angioedema.

She subsequently developed hypoxia with an oxygen saturation of 86%, tachypnea, and increased work of breathing using accessory muscles. Systolic blood pressure was in the 170s, and electrocardiogram demonstrated atrial fibrillation with rapid ventricular rate. Chest radiography showed new bilateral opacities consistent with acute pulmonary edema. The patient was placed on nonrebreather oxygen, given intravenous furosemide, and her oxygen saturations subsequently improved. Intravenous diphenhydramine was administered which led to lethargy and mild confusion. Her urticaria persisted for several hours, and she was transitioned to high-flow nasal cannula with improvement in her respiratory status.

18. Can Neutropenic Fever Ever Be Low Risk?

Paddock M, et al. Ann Emerg Med. 2017 Jun;69(6):765-767.

Annals Case
While on a typical, busy shift in the emergency department (ED), you are notified by a nurse about a febrile patient. She is currently receiving chemotherapy and has an absolute neutrophil count less than 500 × 103/µL. Finally, a case with an unequivocal plan! We are obviously confident of the traditional management: broad-spectrum antibiotics, source identification, and admission.1, 2

But what if we told you there was some subtlety in the evaluation of neutropenic fever, some gray area, some evidence that there might be another way? It turns out that these well-appearing patients without signs of end-organ dysfunction may be at low risk for serious complications.2, 3, 4 In fact, in the ambulatory hematology-oncology setting, these low-risk patients, identified by risk-stratification indices such as the Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores, are sent home with oral antibiotics.3, 4 These risk-stratification tools, however, have yet to be applied to the ED…until now.

In this article by Coyne et al,2 the authors retrospectively apply these risk-stratification scores to a cohort of febrile, neutropenic ED patients and review adverse outcome rates across the various risk groups.

But how does this apply to the patient sitting in front of you?

The Case
A 54-year-old woman with breast cancer who is currently undergoing chemotherapy with docetaxel presents to the ED, reporting subjective fever and generalized malaise for 6 hours. Review of systems reveals nausea with decreased oral intake since her last chemotherapy 1 week ago. In the ED, she is febrile to 38.3°C (101°F) and has pulse rate 108, blood pressure 110/65 mm Hg, respiratory rate 18 breaths/min, and oxygen saturation 99% on room air. Her physical examination result demonstrates dry oral mucosa, painful mouth ulcerations, and mild tachycardia, without any other significant findings. Chest radiography and urinalysis results are negative for pneumonia or urinary tract infection. After ibuprofen, antiemetics, intravenous fluids, and a delicious tray of hospital food (including at least one mystery meat), she is no longer febrile or tachycardic and is asking to be discharged.

Is she at low risk for adverse outcomes? Can we discharge her?...

The rest of the article (full-text free):

19. Randomized Trial Shows Icatibant Useless for Angiotensin-Converting Enzyme Inhibitor-Induced Upper Airway Angioedema.

Sinert R, et al. J Allergy Clin Immunol Pract. 2017 May 25 [Epub ahead of print].

BACKGROUND: Upper airway angioedema is a rare, unpredictable, and at times life-threatening adverse effect of angiotensin-converting enzyme inhibitors (ACE-Is) with no existing effective pharmacologic treatment. Icatibant is a bradykinin B2 receptor antagonist that may be beneficial in patients with ACE-I-induced angioedema.

OBJECTIVE: We aimed to evaluate the efficacy of icatibant in subjects with ACE-I-induced angioedema.

METHODS: At 31 centers in 4 countries, adults on ACE-Is who presented within 12 hours of the onset of at least moderately severe angioedema were randomized 1:1 to icatibant 30 mg or placebo administered subcutaneously. The primary efficacy end point was time to meeting discharge criteria after study drug administration, based on the severity of airway symptoms assessed hourly by a blinded physician using clinical ratings across 4 domains.

RESULTS: A total of 121 subjects were randomized (icatibant, n = 61; placebo, n = 60); 118 received treatment a median of 7.8 hours from symptom onset. We observed no difference in time to meeting discharge criteria between groups (median, 4.0 hours in each group; P = .63). There also was no difference in time to onset of symptom relief (median, icatibant, 2.0 hours; placebo, 1.6 hours; P = .57) or any other secondary end point. Similar findings were noted in prespecified and post hoc subgroup analyses stratified by symptom severity, time interval to treatment, age, and other clinical covariates. No new safety signals were detected.

CONCLUSIONS: Icatibant was no more efficacious than placebo in at least moderately severe ACE-I-induced angioedema of the upper airway.

Radecki’s comments:

20. Low- Versus Standard-Dose Alteplase in Patients on Prior Antiplatelet Therapy: The ENCHANTED Trial (Enhanced Control of Hypertension and Thrombolysis Stroke Study).

Robinson TG, et al. Stroke. 2017 Jun 15 [Epub ahead of print]

BACKGROUND AND PURPOSE: Many patients receiving thrombolysis for acute ischemic stroke are on prior antiplatelet therapy (APT), which may increase symptomatic intracerebral hemorrhage risk. In a prespecified subgroup analysis, we report comparative effects of different doses of intravenous alteplase according to prior APT use among participants of the international multicenter ENCHANTED study (Enhanced Control of Hypertension and Thrombolysis Stroke Study).

METHODS: Among 3285 alteplase-treated patients (mean age, 66.6 years; 38% women) randomly assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) intravenous alteplase within 4.5 hours of symptom onset, 752 (22.9%) reported prior APT use. Primary outcome at 90 days was the combined end point of death or disability (modified Rankin Scale [mRS] scores, 2-6). Other outcomes included mRS scores 3 to 6, ordinal mRS shift, and symptomatic intracerebral hemorrhage by various standard criteria.

RESULTS: There were no significant differences in outcome between patients with and without prior APT after adjustment for baseline characteristics and management factors during the first week; defined by mRS scores 2 to 6 (adjusted odds ratio [OR], 1.01; 95% confidence interval [CI], 0.81-1.26; P=0.953), 3 to 6 (OR, 0.95; 95% CI, 0.75-1.20; P=0.662), or ordinal mRS shift (OR, 1.03; 95% CI, 0.87-1.21; P=0.770). Alteplase-treated patients on prior APT had higher symptomatic intracerebral hemorrhage (OR, 1.82; 95% CI, 1.00-3.30; P=0.051) according to the safe implementation of thrombolysis in stroke-monitoring study definition. Although not significant (P-trend, 0.053), low-dose alteplase tended to have better outcomes than standard-dose alteplase in those on prior APT compared with those not using APT (mRS scores of 2-6; OR, 0.84; 95% CI, 0.62-1.12 versus OR, 1.16; 95% CI, 0.99-1.36).

CONCLUSIONS: Low-dose alteplase may improve outcomes in thrombolysis-treated acute ischemic stroke patients on prior APT, but this requires further evaluation in a randomized controlled trial.

21. Syncope: Outcomes and Conditions Associated with Hospitalization.

Joy PS, et al. Am J Med. 2017 Jun;130(6):699-706.e6.

PURPOSE: Syncope is a perplexing problem for which hospital admission and readmission are contemplated but outcomes remain uncertain. Our purpose was to determine the incidence of admissions and readmissions for syncope and compare associated conditions, in-hospital outcomes, and resource utilization.

METHODS: The 2005-2011 California Statewide Inpatient Database was utilized. Patients of age ≥18 years admitted under International Classification of Diseases, Ninth Revision, Clinical Modification code 780.2 ("syncope or collapse") were selected. Records with a primary discharge diagnosis of syncope were classified as primary syncope. Primary outcome was mortality and secondary outcome measures were cardiopulmonary resuscitation, mechanical ventilation, discharge disposition, length of stay, frequency of readmission and hospital charges.

RESULTS: An estimated 1.52 ± 0.02% admissions every year are related to syncope. Among admissions for syncope, in 42.1%, the cause remained unknown; 23% of syncope admissions were for recurrent episodes. The top 5 associated new diagnoses were hypokalemia (0.24%), ventricular tachycardia (0.17%), atrial fibrillation (0.16%), dehydration (0.12%), and hyponatremia (0.12%). Mortality rates are lower for primary vs secondary syncope (0.2% vs 1.4%; P less than .0001). Greatest risk factors for mortality in primary syncope were pulmonary hypertension (odds ratio 12.3; 95% confidence interval, 3.34-45.04) and metastatic cancer (odds ratio 7.22; 95% confidence interval, 4.50-11.58). Major adverse events showed a decreasing trend for patients with multiple syncope admissions. Older patients and defibrillators or pacemaker recipients are admitted more often but experience negligible adverse events. Over a decade, median hospital charge for a single syncope admission has increased by 1.5 times.

CONCLUSIONS: Despite a good prognosis, syncope is a frequent cause for hospitalization, particularly in the elderly. Present evaluation strategies are expensive and lack diagnostic value.

22. Micro Bits

AA. New Online Clinical Resource

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A. Study finds inappropriate NOAC dosing patterns in patients with AFib

Researchers reviewed data for nearly 15,000 patients with atrial fibrillation who were taking a non-vitamin K antagonist oral anticoagulant and found that the standard dose was given to more than 40% of those with a renal indication for dose reduction, and more than 10% of those with no indication for dose reduction were underdosed. The findings, published in the Journal of the American College of Cardiology, also found an association between inappropriate dosing and increased risk of stroke.

B. Moderate alcohol consumption as risk factor for adverse brain outcomes and cognitive decline: longitudinal cohort study

Conclusions: Alcohol consumption, even at moderate levels, is associated with adverse brain outcomes including hippocampal atrophy. These results support the recent reduction in alcohol guidance in the UK and question the current limits recommended in the US.

C. AAFP, HHS collaborate to promote myhealthfinder tool

The AAFP and the HHS' Office of Disease Prevention and Health Promotion have joined to promote the myhealthfinder tool, found on the Academy's website, which helps patients learn which preventive services the US Preventive Services Task Force, the CDC Advisory Committee on Immunization Practices, and the Health Resources and Services Administration recommends they receive. Myhealthfinder offers information in either English or Spanish based on a patient's age, sex and pregnancy status.

D. Combined low-dose BP meds may effectively control hypertension

A study in the journal Hypertension found a combination of quarter doses of four blood pressure-lowering drugs had almost twice the effectiveness of a full dose of one drug, while a combination of quarter doses of two drugs demonstrated similar effectiveness to a full dose of one drug. The findings, based on data from 42 studies that involved 20,284 participants with hypertension, also found fewer side effects with quarter-dose therapies.

E. U.S. places 36th among best countries for youths

The US ranked 36th out of 172 countries in providing a good childhood -- based on factors such as health care, education, violence and quality of life -- with Norway and Slovenia topping the list, according to a Save the Children report. An accompanying report showed the top US states where childhood is the least threatened, including New Hampshire, Massachusetts, New Jersey, Vermont and Iowa, while Louisiana, Mississippi, New Mexico, Oklahoma and Georgia were at the bottom of the list.

F. More Aggressive BP Targets?

Key Points
Question  What is the optimal target for reduction of systolic blood pressure among patients with hypertension?

Findings  In this systematic review and network meta-analysis of 42 trials, including 144 220 patients, linear associations were seen between mean achieved systolic blood pressure and risk of cardiovascular disease and mortality, with the lowest risk at a systolic blood pressure of 120 to 124 mm Hg.

Meaning  Reducing systolic blood pressure below currently recommended targets with commonly used antihypertensive medications may significantly reduce the risk of cardiovascular disease and all-cause mortality.

G. EHR study shows inpatient progress notes often copied or imported

An analysis of 23,630 inpatient progress notes in an Epic EHR system written by direct care hospitalists, residents and medical students found that 18% of the text was entered manually, 36% was imported and 46% was copied. Researchers noted in a JAMA Internal Medicine research letter that importing or copying text can cause clinical errors because of the possibility of including inaccurate or outdated information.

H. Chocolate and Afib

Chocolate has been associated with heart health in as many varieties as, well, a box of chocolates. Now researchers have added atrial fibrillation (Afib) to that list.

Reporting in Heart, the population-based prospective Danish Diet, Cancer, and Health Study showed a roughly 20% lower risk of clinically apparent Afib or flutter with weekly chocolate intake and 10% reduced risk with a few servings a month compared with less than once-a-month indulgence.

However, an accompanying editorial cautioned about possible confounding, as chocolate eaters in the study were healthier and more highly educated and the study did not account for Afib risk factors like kidney disease and sleep apnea.

"Regardless of the limitations of the Danish chocolate study, the findings are interesting and warrant further consideration, especially given the importance of identifying effective prevention strategies," the editorialists concluded. "Perhaps what is bad for the pancreas is good for the atria."

I. Polyneuropathy patients at risk with long-term opioids

A population-based study in JAMA Neurology linked long-term opioid use among polyneuropathy patients to an increased risk of adverse events without improved function. Patients taking opioids for at least 90 days were more likely to rely on gait aids, have trouble climbing stairs, have depression, and experience opioid dependence and overdose, compared with patients in a control group.

J. Socially Assistive Robots Help Patients Make Behavioral Changes

Jennifer Abbasi. JAMA. Published online June 7, 2017.

Speaking to a group of journalists last October at the annual meeting of the American Association for the Advancement of Science, Maja Matarić, PhD, stated the problem bluntly: “There aren’t enough people for people.”

Matarić is a professor of computer science, neuroscience, and pediatrics at the University of Southern California, where she oversees the development of socially assistive robots. These intelligent machines are being designed to help patients with convalescence, rehabilitation, and training through social interactions rather than physical ones.

Socially assistive robotics—a term Matarić and a graduate researcher coined 15 years ago—is being studied at her pioneering Interaction Lab for use in stroke rehabilitation, autism behavior therapy, dementia, and traumatic brain injury, among other health applications. The robots monitor and chat with patients, coaching and motivating their human companions to do tasks they might be disinclined to do, like exercise a stroke-affected limb.

Matarić and her collaborators in the growing field are harnessing the power of social influence to change behavior. She says that interacting with socially intelligent machines can give patients the “psychological oomph” they need to do the work their physicians have prescribed.

Matarić hopes to release the first commercially available socially assistive robots through her Pasadena-based start-up Embodied in 2019. She recently spoke with JAMA about her work and the future of socially assistive robots. The following is an edited version of the interview.

JAMA: How long have you been working on socially assistive robots?...

K. Evaluating the Laboratory Risk Indicator to Differentiate Cellulitis from Necrotizing Fasciitis in the ED

Conclusion: The LRINEC score may not be an accurate tool for NF risk stratification and differentiation between cellulitis and NF in the ED setting. This decision instrument demonstrated a high false positive rate when determining NF risk stratification in confirmed cases of celulitis and a high false negative rate in cases of confirmed NF.

L. Drones Deliver AEDs Faster Than Ambulances in a Swedish Experiment

Claesson A et al. JAMA 2017 Jun 13.   

In 18 simulated cardiac arrests, aerial drones delivered automated external defibrillators almost 17 minutes faster than ambulances had done in real life.

M. Detectable lead found in 20% of baby food samples

The Environmental Defense Fund looked at 2003 to 2013 FDA study data involving more than 12,200 food samples and found that 20% of baby food samples had detectable lead levels, compared with 14% of general food samples. The report also determined that lead was most prevalent in fruit juices, root vegetables, arrowroot cookies and teething biscuits and was more often detected in baby food variants of apple and grape juices, compared with regular versions.

N. Older patients should take PPIs to cut risk of bleed from aspirin, study says

Elderly people who take long term daily aspirin have a higher than expected risk of disabling or fatal upper gastrointestinal bleeding, a major UK study has found. The researchers recommend prescribing proton pump inhibitors (PPIs) to prevent bleeds.

From the Lancet
In patients receiving aspirin-based antiplatelet treatment without routine PPI use, the long-term risk of major bleeding is higher and more sustained in older patients in practice than in the younger patients in previous trials, with a substantial risk of disabling or fatal upper gastrointestinal bleeding. Given that half of the major bleeds in patients aged 75 years or older were upper gastrointestinal, the estimated NNT for routine PPI use to prevent such bleeds is low, and co-prescription should be encouraged.

O. Excess weight, obesity affects more than 2 billion people worldwide

A study in the New England Journal of Medicine found that 2.2 billion people, or 30% of the world's population, were overweight or obese in 2015, including nearly 108 million obese youths. The findings, based on 1980 to 2015 data from 195 countries, also showed that the US had the highest obesity rate among children and young adults of the 20 most populated countries, while China and India had the most number of obese youths.