1. New Guidelines: CVA and Pancreatitis
A. AHA/ASA Extend Thrombectomy Window to 24 Hours and Expand Lytic
Criteria
by Crystal Phend,
Senior Associate Editor, MedPage Today, January 24, 2018
LOS ANGELES -- In a
radical move for the typically glacial pace of comprehensive guideline
overhaul, the American Heart Association/American Stroke Association expanded
the treatment window for endovascular thrombectomy within hours of release of
supporting trial data.
The guideline,
released here at the International Stroke Conference (ISC) and online in
Stroke, moved from a 6-hour time frame for stent retriever use to up to 24
hours after patients with acute ischemic stroke were last known to be well. The
recommendation was class Ia for the period from 6 to 16 hours as both the DAWN
trial and the DEFUSE 3 trial, released the same day here at ISC, confirmed
better outcomes than medical therapy alone; it was a IIa recommendation out to
24 hours, reflecting that only a single trial for this window (DAWN) was
available.
"This will be
perhaps a once in a lifetime situation where a study gets published [and]
within 2 hours is incorporated into new guidelines," DEFUSE 3 presenter
Gregory Albers, MD, of Stanford University in Stanford, California, said at a
press conference. He noted that this was made possible by provision of an
embargoed copy of the trial to the guideline-writing group.
The guidelines
recommend physicians use either DAWN or DEFUSE 3 criteria for determining which
large vessel occlusions are candidates for clot removal. DEFUSE 3 used broader
inclusion characteristics (mainly in allowing a larger ischemic core and less
severe strokes), with about 40% of participants not fitting DAWN criteria.
Basically, that comes
down to being as generous as possible in inclusion to reach "anybody who
is eligible based on either one" before the 16-hour window, but follow
DAWN criteria from past 16 hours to 24 hours, guideline writing committee chair
William Powers, MD, of the University of Chapel Hill in North Carolina, told
MedPage Today at the press conference.
While Mark Alberts,
MD, of Hartford HealthCare in Hartford, Connecticut, noted that his center had
already adopted the 24-hour strategy based on DAWN, they will consider the two
in resetting criteria. "Our stroke staff will meet and we'll discuss them.
I think that's what's going to go on in most systems; they'll come up with a
happy medium."
That also necessitated
a shift to the guidelines recommending more sophisticated imaging, specifically
diffusion weighted MRI or MRI perfusion to aid in patient selection for
mechanical thrombectomy. In practical terms, these changes are likely to
increase the thrombectomy-eligible population by 20% nationwide, commented
Jeffrey Saver, MD, of the University of California Los Angeles.
"Now ... it
doesn't matter where you are, there's nowhere in the country that you can't get
to a [thrombectomy] center in 24 hours," Albers noted. However,
"there's a lot of work to be done," toward the class Ia
recommendation for development of regional systems of care that remained
unchanged from the 2015 update, Powers noted. Each individual region has many
issues to work out with "no easy recipe" that all can follow, he
said. Now adding the complexities of thrombectomy scans and transfers,
"it's a new world," agreed Albers.
Thrombolytics, too,
saw some changes in the guidelines. Overall, the recommendations for IV
thrombolysis were broadened, with an increase in indications and reduction in
absolute contraindications, such as recent dural puncture or non-major head
trauma. Use in otherwise eligible patients with mild stroke even in 3 to 4.5
hour windows was also deemed reasonable.
Other changes
included:
- Prevention of deep vein thrombosis for immobile patients during the hospital stay should focus on intermittent pneumatic compression (upgraded to class I) instead of heparin, which was downgraded from a Ia to IIb recommendation
- Candidates for carotid endarterectomy should be evaluated for that within 24 hours and surgery should occur within 7 days
- Acute blood pressure management recommendations got downgraded to reflect increasingly equivocal evidence of benefit
The guidelines were
also endorsed by the American Association of Neurological Surgeons, Congress of
Neurological Surgeons, and the Society for Academic Emergency Medicine.
New AHA Guidelines: Powers
WJ, et al. 2018 Guidelines for the Early Management of Patients With Acute
Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan 24 [Epub ahead
of print]. http://stroke.ahajournals.org/content/early/2018/01/23/STR.0000000000000158.long
Marcolini: Tissue over
Time The DAWN of a New Era: https://journals.lww.com/em-news/Fulltext/2018/02000/Brain_Trust__Tissue_over_Time_The_DAWN_of_a_New.4.aspx
B. New Amer Gastro Assn
guideline steers early treatment for acute pancreatitis
A new clinical
guideline from the American Gastroenterological Association provides up-to-date
recommendations for early treatment decisions in acute pancreatitis.
Aiming to promote consistent
practices and quality care, the new guideline focuses on clinical decisions
made within the first 48 to 72 hours of hospital admission for acute
pancreatitis, which can “alter the course of disease and duration of
hospitalization.” It includes recommendations on goal-directed fluid
resuscitation, early oral feeding, enteral vs. parenteral nutrition, routine
prophylactic antibiotic use and routine endoscopic retrograde
cholangiopancreatography (ERCP).
According to the
guideline committee, acute pancreatitis is a leading gastrointestinal cause of
inpatient care. More than 275,000 patients are hospitalized per year costing
more than $2.6 billion in the U.S., and evidence suggests incidence is on the
rise.
The guideline issued
four “strong” recommendations based on moderate quality evidence, including:
- Oral feeding should be given within 24 hours as tolerated rather than following the “nothing by mouth” or nil per os (NPO) practice;
- Enteral rather than parenteral nutrition should be used in patients who are unable to feed orally;
- Cholecystectomy should be performed at initial admission in patients with acute biliary pancreatitis, rather than after they are discharged; and
- A brief alcohol intervention should be performed during admission in patients with acute alcohol-induced pancreatitis.
Guidelines: Crockett
SD, et al. Gastroenterol. 2018 Feb 3 [Epub ahead of print]
Full-text (requires
subscription): http://www.gastrojournal.org/article/S0016-5085(18)30076-3/fulltext
2. ED Patients with Chest Pain
A. Performance of coronary risk scores in patients with CP in
the ED.
Mark DG, et al, with
the KP CREST Network. J Am Coll Cardiol. 2018;71(6):606-616.
BACKGROUND: Both the
modified History, Electrocardiogram, Age, Risk factors and Troponin (HEART)
score and the Emergency Department Assessment of Chest pain Score (EDACS) can
identify patients with possible acute coronary syndrome (ACS) at low risk (less
than 1%) for major adverse cardiac events (MACE).
OBJECTIVES: The
authors sought to assess the comparative accuracy of the EDACS (original and
simplified) and modified HEART risk scores when using cardiac troponin I (cTnI)
cutoffs below the 99th percentile, and obtain precise MACE risk estimates.
METHODS: The authors
conducted a retrospective study of adult emergency department (ED) patients
evaluated for possible ACS in an integrated health care system between 2013 and
2015. Negative predictive values for MACE (composite of myocardial infarction,
cardiogenic shock, cardiac arrest, and all-cause mortality) were determined at
60 days. Reclassification analyses were used to assess the comparative accuracy
of risk scores and lower cTnI cutoffs.
RESULTS: A total of
118,822 patients with possible ACS were included. The 3 risk scores' accuracies
were optimized using the lower limit of cTnI quantitation (less than 0.02
ng/ml) to define low risk for 60-day MACE, with reclassification yields ranging
between 3.4% and 3.9%, while maintaining similar negative predictive values
(range 99.49% to 99.55%; p = 0.27). The original EDACS identified the largest
proportion of patients as low risk (60.6%; p less than 0.0001).
CONCLUSIONS: Among ED
patients with possible ACS, the modified HEART score, original EDACS, and
simplified EDACS all predicted a low risk of 60-day MACE with improved accuracy
using a cTnI cutoff below the 99th percentile. The original EDACS identified
the most low-risk patients, and thus may be the preferred risk score.
In the press:
https://www.tctmd.com/news/risk-scores-combined-lower-troponin-cut-points-may-help-refine-rule-out-tests-chest-pain
B. Myths in EM: Even if Stress Tests Found
Patients at High Risk for MI (They Don't), To What End?
Spiegel R. Emerg Med News. 2018;40(1):10-11
Whether you are aware of it or not, you make three major
assumptions every time you employ any diagnostic strategy in the emergency
department—that the diagnostic test will identify patients at risk of a poor
outcome because of an undiagnosed process, that an effective intervention will
avert that outcome, and that discovering this process early will make the
intervention more effective than if we had waited for the disease to manifest
clinically obvious characteristics.
These assumptions are frequently based purely on
physiological reasoning and good intentions, but these are poor surrogates for
patient-oriented outcomes and often fail to survive the test of scientific
inquiry. Such is the case for noninvasive cardiac testing. Multiple studies
suggest its ineffectiveness, but the stress test has maintained its lofty
position for managing patients presenting to the ED with chest pain.
A recent study by Sandhu, et al., utilized a large insurance
claims database to identify patients who presented to the ED with chest pain
and compared outcomes in patients who did or did not undergo noninvasive
testing. (JAMA Intern Med 2017;177[8]:1175.) The authors used a fairly
novel and elegant approach to control for the many imbalances one would expect
from such a large, heterogeneous, nonrandomized cohort.
Using what is called an instrumental-variables approach, the
authors exploited the fact that care is not delivered consistently across all
seven days of the week. Their premise, according to previous data, was that
patients seen in the ED on the weekend (Friday-Sunday) were less likely to
undergo stress testing than those who presented Monday-Thursday, based not on
differences in patient-level characteristics, but rather the universal distaste
of working on the weekend.
The researchers excluded patients with diagnoses suggestive
of acute ischemia and those whose chest pain could be explained with an
alternate diagnosis, and they identified 926,633 unique adult ED visits from
2011 to 2012. Unsurprisingly, patients who received testing were older, with
more risk factors than patients who did not undergo testing. Conversely,
patients who presented on the weekend appeared to be fairly similar at baseline
when compared with those who presented during the week.
Downstream Testing
As the authors predicted, patients evaluated on the weekend
underwent less stress testing when compared with those who presented during the
week (18.18% vs 12.30%). They also observed more early angiography (2.10% vs
1.30%) and downstream testing, defined as any invasive or noninvasive testing
done over the next 30 days (26.10% vs 21.35%). Even after adjusting for
possible bias, not controlled for with their instrumental approach, the authors
noted an increase in the rates of invasive angiography in patients who
presented on the weekday when compared with those who presented on the weekend.
They also noted that this increase in invasive or noninvasive testing did not
lead to an observed decrease in the rate of myocardial infarction.
Despite the elegance with which these authors manipulated
this large unwieldy dataset, its innate structure creates the potential for
multiple sources of bias that cannot be controlled by any statistical
manipulations. That said, their results are fairly consistent with the majority
of the previous literature examining noninvasive stress testing. More
importantly, the stress test has failed to meet the three initial assumptions
required when examining any diagnostic testing strategy.
The concept that noninvasive stress tests identify a
population at higher risk for a myocardial infarction is based on poor data.
Amsterdam, et al., using a prospective dataset, claimed that patients with
positive stress tests were at significantly higher risk of adverse events than
those with negative tests (17% vs 0.16%). (J Am Coll Cardiol 2002;40[2]:251.)…
The
rest of the myth-busting review (full-text free):
3. Sex Differences in AMI and CVA
A. Sex Differences in the Presentation and Perception of
Symptoms Among Young Patients With MI: Evidence from the
VIRGO Study
Lichtman JH, et al. Circulation.
2018;137:781-790.
What Is New?
Sex differences in symptom presentation for acute
myocardial infarction have been shown in older populations, but less is known
about potential sex differences in self-reported symptoms, perception of
symptoms, and self-reported care-seeking behavior in young patients with acute
myocardial infarction.
Based on direct patient interviews, almost 90% of young
women and men presented with chest pain, pressure, tightness, or discomfort;
women were more likely to present with ≥3 additional non–chest pain symptoms in
comparison with men.
Among patients who sought care for symptoms before their
hospitalization, women were less likely to be told their symptoms were
heart-related.
What Are the Clinical Implications?
Chest pain, pressure, tightness, or discomfort is the
hallmark symptom for young patients presenting with acute myocardial
infarction.
Presentation with multiple non–chest pain symptoms may
influence the decision to initiate a workup for ischemic heart disease,
particularly if chest pain or the various ways chest pressure is described is
not the primary or most emphasized symptom.
Most of the young patients in the VIRGO study (Variation
in Recovery: Role of Gender on Outcomes of Young AMI Patients) had ≥1
traditional cardiac risk factor; physicians should listen carefully and
consider the diagnosis of heart disease in young patients, particularly those
with multiple cardiac risk factors who mention chest pain, pressure, tightness,
or discomfort in a history.
Full-text (free): http://circ.ahajournals.org/content/137/8/781
B. Neurology Concepts: Young Women and Ischemic
Stroke-Evaluation and Management in the ED.
Chang BP, et al. Acad Emerg Med 2018; 25(1):54-64
OBJECTIVE: Ischemic stroke is a
leading cause of morbidity and mortality worldwide. While the incidence of
ischemic stroke is highest in older populations, incidence of ischemic stroke
in adults has been rising particularly rapidly among young (e.g.,
premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in
young women presents a challenging situation in the emergency department, due
to a range of sex-specific risk factors and to broad differentials. The goals
of this concepts paper are to summarize existing knowledge regarding the
evaluation and management of young women with ischemic stroke in the acute
setting.
METHODS: A panel of six
board-certified emergency physicians, one with fellowship training in stroke
and one with training in sex- and sex-based medicine, along with one vascular
neurologist were coauthors involved in the paper. Each author used various
search strategies (e.g., PubMed, PsycINFO, and Google Scholar) for primary
research and reviewed articles related to their section. The references were
reviewed and evaluated for relevancy and included based on review by the lead
authors.
RESULTS: Estimates on the
incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per
100,000 in the United States. Several risk factors for ischemic stroke exist
for young women including oral contraceptive (OCP) use and migraine with aura.
Pregnancy and the postpartum period (up to 12 weeks) is also an important
transient state during which risks for both ischemic stroke and cerebral
hemorrhage are elevated, accounting for 18% of strokes in women under 35.
Current evidence regarding the management of acute ischemic stroke in young
women is also summarized including use of thrombolytic agents (e.g., tissue
plasminogen activator) in both pregnant and nonpregnant individuals.
CONCLUSION: Unique challenges
exist in the evaluation and diagnosis of ischemic stroke in young women. There
are still many opportunities for future research aimed at improving detection
and treatment of this population.
Full-text (free): http://onlinelibrary.wiley.com/doi/10.1111/acem.13243/full
4. Pediatric Corner
A. Oral Analgesics Utilization for Children with
Musculoskeletal Injury (OUCH Trial): An RCT.
Le May S, et al. Pediatrics.
2017 Nov;140(5).
BACKGROUND: Musculoskeletal
injuries (MSK-Is) are a common and painful condition among children that
remains poorly treated in the emergency department (ED). We aimed to test the
efficacy of a combination of an anti-inflammatory drug with an opioid for pain
management of MSK-I in children presenting to the ED.
METHODS: In this
randomized, double-blinded, placebo-controlled trial, we enrolled children
between 6 and 17 years presenting to the ED with an MSK-I and a pain score above
29 mm on the visual analog scale (VAS). Participants were randomly assigned to
oral morphine (0.2 mg/kg) + ibuprofen (10 mg/kg) (morphine + ibuprofen) or
morphine (0.2 mg/kg) + placebo of ibuprofen or ibuprofen (10 mg/kg) + placebo
of morphine. Primary outcome was children with VAS pain score below 30 mm at 60
minutes postmedication administration.
RESULTS: A total of
501 participants were enrolled and 456 were included in primary analyses
(morphine + ibuprofen = 177; morphine = 188; ibuprofen = 91). Only 29.9%
(morphine + ibuprofen), 29.3% (morphine), and 33.0% (ibuprofen) of participants
achieved the primary outcome (P = .81). Mean VAS pain reduction at 60 minutes
were -18.7 (95% confidence interval [CI]: -21.9 to -16.6) (morphine +
ibuprofen), -17.0 (95% CI: -20.0 to -13.9) (morphine), -18.6 (95% CI: -22.9 to
-14.2) (ibuprofen) (P = .69). Children in the morphine + ibuprofen group (P less
than .001) and in the morphine group (P less than .001) experienced more side
effects than those in the ibuprofen group. No serious adverse event was
reported.
CONCLUSIONS: Combination
of morphine with ibuprofen did not provide adequate pain relief for children
with MSK-I in the ED. None of the study medication provided an optimal pain
management because most of children did not reach a mild pain score
B. Association of Time to Treatment with Short-term Outcomes
for Pediatric Patients with
Refractory Convulsive Status Epilepticus.
GaÃnza-Lein M, et al. JAMA Neurol. 2018 Jan 22 [Epub ahead of print]
IMPORTANCE: Treatment
delay for seizures can lead to longer seizure duration. Whether treatment delay
is associated with major adverse outcomes, such as death, remains unknown.
OBJECTIVE: To evaluate
whether untimely first-line benzodiazepine treatment is associated with
unfavorable short-term outcomes.
DESIGN, SETTING, AND
PARTICIPANTS: This multicenter, observational, prospective cohort study
included 218 pediatric patients admitted between June 1, 2011, and July 7,
2016, into the 11 tertiary hospitals in the United States within the Pediatric
Status Epilepticus Research Group. Patients, ranging in age from 1 month to 21
years, with refractory convulsive status epilepticus (RCSE) that did not stop
after the administration of at least 2 antiseizure medications were included.
Patients were divided into 2 cohorts: those who received the first-line
benzodiazepine treatment in less than 10 minutes and those who received it 10
or more minutes after seizure onset (untimely). Data were collected and
analyzed from June 1, 2011, to July 7, 2016.
MAIN OUTCOMES AND
MEASURES: The primary outcome was death during the related hospital admission.
The secondary outcome was the need for continuous infusion for seizure
termination. Multivariate analysis of mortality controlled for structural
cause, febrile RCSE, age, and previous neurological history (including previous
RCSE events). Use of continuous infusions was additionally adjusted for generalized
RCSE, continuous RCSE, and 5 or more administrations of antiseizure medication.
RESULTS: A total of
218 patients were included, among whom 116 (53.2%) were male and the median
(interquartile range) age was 4.0 (1.2-9.6) years. The RCSE started in the
prehospital setting for 139 patients (63.8%). Seventy-four patients (33.9%)
received their first-line benzodiazepine treatment in less than 10 minutes, and
144 (66.1%) received untimely first-line benzodiazepine treatment. Multivariate
analysis showed that patients who received untimely first-line benzodiazepine
treatment had higher odds of death (adjusted odds ratio [AOR], 11.0; 95% CI,
1.43 to ∞; P = .02), had greater odds of receiving continuous infusion (AOR,
1.8; 95% CI, 1.01-3.36; P = .047), had longer convulsive seizure duration (AOR,
2.6; 95% CI, 1.38-4.88; P = .003), and had more frequent hypotension (AOR 2.3;
95% CI, 1.16-4.63; P = .02). In addition, the timing of the first-line
benzodiazepine treatment was correlated with the timing of the second-line (95%
CI, 0.64-0.95; P less than .001) and third-line antiseizure medications (95%
CI, 0.25-0.78; P less than .001).
CONCLUSIONS AND
RELEVANCE: Among pediatric patients with RCSE, an untimely first-line
benzodiazepine treatment is independently associated with a higher frequency of
death, use of continuous infusions, longer convulsion duration, and more
frequent hypotension. Results of this study raise the question as to whether
poor outcomes could, in part, be prevented by earlier administration of
treatment.
C. Oral prednisolone in preschool children with
virus-associated wheeze: a prospective, randomised, double-blind,
placebo-controlled trial.
Foster SJ, et al. Lancet
Respir Med. 2018 Feb;6(2):97-106.
BACKGROUND: Children
of preschool age often have episodes of virus-associated wheeze, and research
assessing efficacy of corticosteroids for paediatric wheeze exacerbations is
inconclusive.
METHODS: This
non-inferiority, randomised, double-blind, placebo-controlled trial was to
compare the efficacy of placebo versus oral prednisolone in children aged 24-72
months presenting with virus-associated wheeze at the paediatric emergency
department of Princess Margaret Hospital in Perth, WA, Australia. Eligible
participants were randomly assigned (1:1) using a computer-generated random
number program to receive placebo or prednisolone (1 mg/kg per day) for 3 days.
The primary outcome was total length of stay in hospital until ready for
discharge. Following an analysis to test the hypothesis that placebo is
non-inferior to prednisolone, a post-hoc superiority analysis was done to test
the hypothesis that prednisolone was superior to placebo. A non-inferiority
margin of 10% was used to establish non-inferiority. Efficacy analyses were on
a modified intention-to-treat basis, whereby patients were excluded from the
final efficacy analysis if consent was withdrawn, two doses of study drug were
vomited, or paperwork was lost. All participants were included in safety
analyses. This study is registered with the Australian and New Zealand Clinical
Trials Registry, number ACTRN12612000394842.
FINDINGS: Between June
11, 2012, and June 10, 2015, we screened 3727 patients for eligibility. 624
eligible patients were randomly assigned to treatment, and 605 patients were
included in the modified intention-to-treat analysis (300 patients from the
placebo group, 305 patients from the prednisolone group). The median length of
stay until ready for discharge was longer in the placebo group (540 min [IQR
124-971]) than in the prednisolone group (370 min [121-709]); placebo was
inferior to prednisolone. In the post-hoc superiority analysis of 605 patients,
the unadjusted ratio of geometric mean for length of stay was 0·79 (95% CI
0·64-0·97; p=0·0227) for the prednisolone group relative to the placebo group.
No serious adverse events were reported during the study or follow-up period.
One child in the placebo group had a non-specific maculopapular rash, which
resolved spontaneously. Two children (one from each group) were reported to be
hyperactive during follow-up assessments.
INTERPRETATION: Oral
prednisolone had a clear benefit over placebo at reducing the length of stay in
children presenting to a paediatric emergency department with virus-associated
wheeze and was well tolerated.
D. Cerebrospinal Fluid Reference Values for Young Infants
Undergoing LP
Thomson J, et al. Pediatrics.
2018 Feb 2 [Epub ahead of print]
OBJECTIVES: To
determine age-specific reference values and quantify age-related changes for
cerebrospinal fluid (CSF) white blood cell (WBC) counts and protein and glucose
concentrations in infants ≤60 days of age.
METHODS: This
multicenter, cross-sectional study included infants ≤60 days old with CSF
cultures and complete CSF profiles obtained within 24 hours of presentation.
Those with conditions suspected or known to cause abnormal CSF parameters (eg,
meningitis) and those with a hospital length of stay of greater than 72 hours
were excluded. Reference standards were determined for infants ≤28 days of age
and 29 to 60 days of age by using the third quartile +1.5 interquartile range
for WBC and protein and the first quartile -1.5 interquartile range for
glucose. CSF parameter centile curves based on age were calculated by using the
LMST method.
RESULTS: A total of
7766 patients were included. CSF WBC counts were higher in infants ≤28 days of
age (upper bound: 15 cells/mm3) than in infants 29 to 60 days of age (upper
bound: 9 cells/mm3; P less than .001). CSF protein concentrations were higher
in infants ≤28 days of age (upper bound: 127 mg/dL) than in infants 29 to 60
days of age (upper bound: 99 mg/dL; P less than .001). CSF glucose
concentrations were lower in infants ≤28 days of age (lower bound: 25 mg/dL)
than in infants 29 to 60 days of age (lower bound: 27 mg/dL; P less than .001).
CONCLUSIONS: The
age-specific CSF WBC count, protein concentration, and glucose concentration
reference values identified in this large, multicenter cohort of infants can be
used to interpret the results of lumbar puncture in infants ≤60 days of age.
E. Epidemiology of Bacteremia in Febrile Infants Aged 60 Days
and Younger.
Powell EC, and PECARN.
Ann Emerg Med. 2018 Feb;71(2):211-216.
…CONCLUSION: The
prevalence of bacteremia and meningitis among febrile infants 28 days of age
and younger is high and exceeds that observed in infants aged 29 to 60 days. E
coli and group B streptococcus are the most common bacterial pathogens.
F. Adenosine Administration with a Stopcock Technique Delivers Lower-Than-Intended Drug Doses.
Weberding NT, et al. Ann
Emerg Med. 2018 Feb;71(2):220-224.
STUDY OBJECTIVE: Adenosine
administration with a stopcock is the recommended treatment for pediatric
patients with acute supraventricular tachycardia. Recent reports suggest that
many infants do not respond to the first dose of adenosine administered. Our
aim is to determine whether administration of adenosine with a stopcock
delivers lower-than-expected drug doses in patients weighing less than 10 kg,
corresponding to weights of infants.
CONCLUSION: Administration
of adenosine through a stopcock delivers doses lower than intended in patients
weighing less than 10 kg, which may account for the decreased response of
infants to the first dose of adenosine.
G. What Measures Improve Reduction of Intussusception in
Pediatric Patients?
Long B, et al. Ann
Emerg Med. 2018 Feb;71(2):236-238.
Take-Home Message
Air enema may be
superior to liquid enema for successful reduction of intussusception, and
dexamethasone intramuscularly as an adjuvant therapy may reduce intussusception
recurrence after air or liquid enema. Glucagon with liquid enema versus liquid
enema alone did not result in improved intussusception reduction.
5. Blunt Head Trauma in Pts on Blood Thinners
A. Incidence of Delayed Intracranial Hemorrhage in Older
Patients After Blunt Head Trauma.
Chenoweth JA, et al,
for Sacramento County Prehospital Research Consortium. JAMA Surg. 2018 Feb 14
[Epub ahead of print].
Importance Current
guidelines conflict on the management of older adults who have blunt head
trauma taking anticoagulant and antiplatelet medications. This is partially due
to the limited data comparing patients who are taking these medications with
those who are not.
Objective To
investigate the incidence of delayed traumatic intracranial hemorrhage in older
adults with head trauma, including those taking anticoagulant and antiplatelet
medications.
Design, Setting, and
Participants This prospective observational cohort study included patients 55
years and older who had blunt head trauma and were transported via emergency
medical services between August 1, 2015, and September 30, 2016. The setting
was a multicenter study conducted at 11 hospitals in northern California.
Patients were excluded if they had traumatic intracranial hemorrhage on the
initial cranial computed tomographic scan, did not have a cranial computed
tomographic scan performed at the initial emergency department visit, refused
consent for a follow-up telephone call, or did not have reliable means of
follow-up.
Main Outcome and
Measure The primary outcome of this study was the incidence of delayed
traumatic intracranial hemorrhage within 14 days of injury. Results Among 859
patients enrolled in the study, the median age was 75 years (interquartile
range, 64-85 years), and 389 (45.3%) were male. A total of 343 patients (39.9%)
were taking an anticoagulant or antiplatelet medication. Three patients (0.3%;
95% CI, 0.1%-1.0%) had a delayed traumatic intracranial hemorrhage. Of the 3
patients, 1 of 75 patients (1.3%; 95% CI, 0.0%-7.2%) who were taking warfarin
sodium alone and 2 of 516 patients (0.4%; 95% CI, 0.1%-1.4%) who were not
taking any anticoagulant or antiplatelet medication had a delayed traumatic
intracranial hemorrhage. Thirty-nine patients (4.5%; 95% CI, 3.2%-6.2%) were
lost to follow-up. Conclusions and
Relevance Overall, the
incidence of delayed intracranial hemorrhage in older adults who have blunt
head trauma is low, including patients taking an anticoagulant or antiplatelet
medication. These findings suggest that routine observation and serial cranial
computed tomography may not be necessary in these patients.
B. Association of ICH Among Patients Taking Non-Vitamin K
Antagonist vs Vitamin K Antagonist OACs with In-Hospital Mortality.
Inohara T, et al. JAMA. 2018 Jan 25 [Epub ahead of print]
IMPORTANCE: Although non-vitamin K antagonist oral
anticoagulants (NOACs) are increasingly used to prevent thromboembolic disease,
there are limited data on NOAC-related intracerebral hemorrhage (ICH).
OBJECTIVE: To assess the association between preceding oral
anticoagulant use (warfarin, NOACs, and no oral anticoagulants [OACs]) and
in-hospital mortality among patients with ICH.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort
study of 141 311 patients with ICH admitted from October 2013 to December 2016
to 1662 Get With The Guidelines-Stroke hospitals.
EXPOSURES: Anticoagulation therapy before ICH, defined as
any use of OACs within 7 days prior to hospital arrival.
MAIN OUTCOMES AND MEASURES: In-hospital mortality.
RESULTS: Among 141 311 patients with ICH (mean [SD] age,
68.3 [15.3] years; 48.1% women), 15 036 (10.6%) were taking warfarin and 4918
(3.5%) were taking NOACs preceding ICH, and 39 585 (28.0%) and 5783 (4.1%) were
taking concomitant single and dual antiplatelet agents, respectively. Patients
with prior use of warfarin or NOACs were older and had higher prevalence of
atrial fibrillation and prior stroke. Acute ICH stroke severity (measured by
the National Institutes of Health Stroke Scale) was not significantly different
across the 3 groups (median, 9 [interquartile range, 2-21] for warfarin, 8
[2-20] for NOACs, and 8 [2-19] for no OACs). The unadjusted in-hospital mortality
rates were 32.6% for warfarin, 26.5% for NOACs, and 22.5% for no OACs. Compared
with patients without prior use of OACs, the risk of in-hospital mortality was
higher among patients with prior use of warfarin (adjusted risk difference
[ARD], 9.0% [97.5% CI, 7.9% to 10.1%]; adjusted odds ratio [AOR], 1.62 [97.5%
CI, 1.53 to 1.71]) and higher among patients with prior use of NOACs (ARD, 3.3%
[97.5% CI, 1.7% to 4.8%]; AOR, 1.21 [97.5% CI, 1.11-1.32]). Compared with
patients with prior use of warfarin, patients with prior use of NOACs had a
lower risk of in-hospital mortality (ARD, -5.7% [97.5% CI, -7.3% to -4.2%];
AOR, 0.75 [97.5% CI, 0.69 to 0.81]). The difference in mortality between
NOAC-treated patients and warfarin-treated patients was numerically greater
among patients with prior use of dual antiplatelet agents (32.7% vs 47.1%; ARD,
-15.0% [95.5% CI, -26.3% to -3.8%]; AOR, 0.50 [97.5% CI, 0.29 to 0.86]) than
among those taking these agents without prior antiplatelet therapy (26.4% vs
31.7%; ARD, -5.0% [97.5% CI, -6.8% to -3.2%]; AOR, 0.77 [97.5% CI, 0.70 to
0.85]), although the interaction P value (.07) was not statistically
significant.
CONCLUSIONS AND RELEVANCE: Among patients with ICH, prior
use of NOACs or warfarin was associated with higher in-hospital mortality
compared with no OACs. Prior use of NOACs, compared with prior use of warfarin,
was associated with lower risk of in-hospital mortality.
6. NEJM Essays on Physician Burnout
A. To Care Is Human — Collectively Confronting the
Clinician-Burnout Crisis
Dzau VJ, et al. N Engl J Med 2018; 378:312-314.
he ethical principles
that guide clinical care — a commitment to benefiting the patient, avoiding
harm, respecting patient autonomy, and striving for justice in health care —
affirm the moral foundation and deep meaning underlying many clinicians’ view of
their profession as a worthy and gratifying calling. It is clear, however, that
owing to the growing demands, burdensome tasks, and increasing stress
experienced by many clinicians, alarmingly high rates of burnout, depression,
and suicide threaten their well-being. More than half of U.S. physicians report
significant symptoms of burnout — a rate more than twice that among
professionals in other fields. Moreover, we know that the problem starts early.
Medical students and residents have higher rates of burnout and depression than
their peers who are pursuing nonmedical careers. Nor is the trend limited to
physicians: nurses also experience alarming rates of burnout.1 Clinicians are
human, and it takes a personal toll on them when circumstances make it difficult
to fulfill their ethical commitments and deliver the best possible care.
Burnout — a syndrome
characterized by emotional exhaustion and depersonalization (which includes
negativity, cynicism, and the inability to express empathy or grief), a feeling
of reduced personal accomplishment, loss of work fulfillment, and reduced
effectiveness — has serious consequences in terms of both human cost and system
inefficiency.1 Nothing puts these consequences into starker relief than the
devastating rates of suicide among physicians. As many as 400 U.S. physicians
die by suicide every year.2 Nearly every clinician has been touched at some
point by such a tragedy.
Not only are
clinicians’ lives at risk, so is patient safety. Some studies have revealed
links between clinician burnout and increased rates of medical errors,
malpractice suits, and health care–associated infections. In addition,
clinician burnout places a substantial strain on the health care system,
leading to losses in productivity and increased costs. Burnout is independently
associated with job dissatisfaction and high turnover rates. In one
longitudinal study, the investigators calculated that annual productivity loss
in the United States that is attributable to burnout may be equivalent to
eliminating the graduating classes of seven medical schools.1 These
consequences are unacceptable by any standard. Therefore, we have an urgent,
shared professional responsibility to respond and to develop solutions.
Indeed, there is broad
recognition in the health care community that the problem of clinician burnout,
depression and other mental disorders, and suicide has reached a crisis level.
There are many existing efforts by individual organizations, hospitals,
training programs, professional societies, and specialties to confront the
crisis. But no single organization can address all the issues that will need to
be explored and resolved. There is no mechanism for systematically and
collectively gathering data on, analyzing, and mitigating the causes of burnout.
The problem is not lack of concern, disagreement about the severity or urgency
of the crisis, or absence of will to act. Rather, there is a need to coordinate
and synthesize the many ongoing efforts within the health care community and to
generate momentum and collective action to accelerate progress. Furthermore,
any solution will need to involve key influencers beyond the health care
community, such as information technology (IT) vendors, payers, regulators,
accreditation agencies, policymakers, and patients….
B. Beyond Burnout — Redesigning Care to Restore Meaning and
Sanity for Physicians
Wright AA, et al. N
Engl J Med 2018; 378:309-311.
Excerpts
…Burnout rates are now
twice as high in medicine as in other fields, even after adjustment for factors
such as age, sex, level of education, and hours worked in the past week. In
2014, a national survey found that 54% of U.S. physicians reported at least one
symptom of burnout: emotional exhaustion, depersonalization, or a diminished
sense of personal accomplishment due to work-related stressors. Those in
“front-line” specialties, including general internal medicine, family medicine,
emergency medicine, and neurology, are at the highest risk.2
“There was this
assumption that doctors could take on extra work seamlessly, but now it is
crowding out our true work as healers,” notes Sinsky. “Physicians are at the
sharp end of the stick for accountability, regulatory issues, and now even data
acquisition and entry — it’s too much.”
Shanafelt and others
argue that the situation needs to change and that there’s a business case for
addressing physician burnout. At the most basic level, physicians with symptoms
of burnout are twice as likely to leave an organization as those without such
symptoms, and the cost of replacing a physician is estimated to be $500,000 to
$1 million, according to a recent report from Atrius Health. This estimate
reflects the expenses for physician recruitment, “onboarding” and training, and
lost revenue…
… Female physicians may be at highest risk, particularly those
with heavy clinical loads. A survey of Stanford School of Medicine faculty
found that few female faculty members reported “feeling supported” in their
career development. The survey prompted the administration to consider novel
ways to improve work–life integration and prevent burnout. Stanford piloted a
“time bank” to ensure that faculty were rewarded for activities that are rarely
recognized by medical centers, such as serving on committees. This program allowed
faculty to trade time spent on these activities for in-home support, such as
meal delivery and cleaning services, or support at work, including assistance
with grant writing and submission. Though this initiative was meant for all
physicians and basic scientists, women used these services more frequently than
men, and the number of female faculty members who reported “feeling supported”
had nearly doubled by the end of the pilot program.
…Whereas past efforts
to address burnout have focused on bolstering individuals’ resilience skills,
there’s a growing recognition that organizations also need to redesign the way
that clinical care is delivered. In 2015, the Department of Family Medicine at
the University of Colorado health system instituted a team-based model called
ambulatory process excellence, or APEX. Under this system, medical assistants
gather data, reconcile medications, set the agenda for patient visits, and
identify opportunities to increase preventive care. After they complete this
structured process, they share this information with a physician or nurse
practitioner and remain in the room to document the visit. When the clinician
leaves, the medical assistant provides patient education and health coaching.
This arrangement allows physicians and midlevel clinicians to focus on
synthesizing data, performing the physical exam, and making medical decisions
without distractions.
“The chaos in exam
rooms before APEX was akin to texting while driving,” explains Corey Lyon,
associate professor at the University of Colorado School of Medicine and
medical director of the A.F. Williams Family Medicine Center. “The greatest
advantage now is that the computer no longer stands between me and my patients.
This allows for deeper thinking and connection.”…
7. Cardiac Standstill: What Do We know?
A. Does Spontaneous Cardiac Motion, Identified With Point-of-Care Echocardiography During Cardiac Arrest, Predict Survival?
A. Does Spontaneous Cardiac Motion, Identified With Point-of-Care Echocardiography During Cardiac Arrest, Predict Survival?
April MD, et al. Ann
Emerg Med. 2018 Feb;71(2):208-210.
Take-Home Message
Point-of-care
echocardiography demonstrating no spontaneous cardiac motion is associated with
lower likelihood of return of spontaneous circulation and survival to hospital
admission. This may be used to assist with decisionmaking about resuscitation
termination.
B. Variability in Interpretation of Cardiac Standstill Among
Physician Sonographers.
Hu K, et al. Ann Emerg
Med. 2018 Feb;71(2):193-198.
STUDY OBJECTIVE: Cardiac
standstill on point-of-care ultrasonography has been widely studied as a marker
of prognosis in cardiac arrest. Return of spontaneous circulation has been
reported in as few as 0% and as many as 45% of patients with cardiac
standstill. When explicitly documented, the definition of cardiac activity in
these studies varied from any slight change in echogenicity of the myocardium
to any kinetic cardiac activity. We hypothesize that the variability in
research definitions of cardiac activity may affect interpretation of video
clips of patients in cardiac arrest. The goal of this study is to assess the
variability in interpretation of standstill among physician sonographers.
METHODS: We surveyed
physician sonographers at 6 conferences held at 3 academic medical centers in
the Greater New York area. Survey respondents were allotted 20 seconds per
slide to determine whether each of 15 video clips of patients in cardiac arrest
were standstill or not. Data were collected anonymously with radio frequency
remotes.
RESULTS: There were
127 total participants, including faculty, fellows, and resident physicians
specializing in emergency medicine, critical care, and cardiology. There was only
moderate interrater agreement among all participants (α=0.47). This lack of
agreement persisted across specialties, self-reported training levels, and
self-reported ultrasonographic expertise.
CONCLUSION: According
to the results of our study, there appears to be considerable variability in
interpretation of cardiac standstill among physician sonographers. Consensus
definitions of cardiac activity and standstill would improve the quality of
cardiac arrest ultrasonographic research and standardize the use of this
technology at the bedside.
Editorial
(subscription required): http://www.annemergmed.com/article/S0196-0644(17)31746-8/fulltext
C. Transesophageal Echocardiography: Guidelines for
Point-of-Care Applications in Cardiac Arrest Resuscitation.
Fair J, et al. Ann
Emerg Med. 2018 Feb;71(2):201-207.
Cardiac arrest is one
of the most challenging patient presentations managed by emergency care
providers, and echocardiography can be instrumental in the diagnosis,
prognosis, and treatment guidance in these critically ill patients.
Transesophageal echocardiography has many advantages over transthoracic
echocardiography in a cardiac arrest resuscitation. As transesophageal
echocardiography is implemented more widely at the point of care during cardiac
arrest resuscitations, guidelines are needed to assist emergency providers in
acquiring the equipment and skills necessary to successfully incorporate it
into the management of cardiac arrest victims.
Full-text
(subscription required): http://www.annemergmed.com/article/S0196-0644(17)31651-7/fulltext
8. On Pulmonary Embolism
A. Very Low Prevalence of PE in ED Patients With Syncope.
Costantino G, et al. JAMA
Intern Med. 2018 Jan 29 [Epub ahead of print]
IMPORTANCE: Sparse
data and conflicting evidence exist on the prevalence of pulmonary embolism
(PE) in patients with syncope.
OBJECTIVE: To estimate
the prevalence of PE among patients presenting to the emergency department (ED)
for evaluation of syncope.
DESIGN, SETTING, AND
PARTICIPANTS: This retrospective, observational study analyzed longitudinal
administrative data from 5 databases in 4 different countries (Canada, Denmark,
Italy, and the United States). Data from all adult patients (aged ≥18 years)
who presented to the ED were screened to identify those with syncope codes at
discharge. Data were collected from January 1, 2000, through September 30, 2016.
MAIN OUTCOMES AND
MEASURES: The prevalence of PE at ED and hospital discharge, identified using
codes from the International Classification of Diseases, was considered the
primary outcome. Two sensitivity analyses considering prevalence of PE at 90 days
of follow-up and prevalence of venous thromboembolism were performed.
RESULTS: A total of
1 671 944 unselected adults who presented to the ED for syncope were included.
The prevalence of PE, according to administrative data, ranged from 0.06% (95%
CI, 0.05%-0.06%) to 0.55% (95% CI, 0.50%-0.61%) for all patients and from 0.15%
(95% CI, 0.14%-0.16%) to 2.10% (95% CI, 1.84%-2.39%) for hospitalized patients.
The prevalence of PE at 90 days of follow-up ranged from 0.14% (95% CI,
0.13%-0.14%) to 0.83% (95% CI, 0.80%-0.86%) for all patients and from 0.35%
(95% CI, 0.34%-0.37%) to 2.63% (95% CI, 2.34%-2.95%) for hospitalized patients.
Finally, the prevalence of venous thromboembolism at 90 days ranged from 0.30%
(95% CI, 0.29%-0.31%) to 1.37% (95% CI, 1.33%-1.41%) for all patients and from
0.75% (95% CI, 0.73%-0.78%) to 3.86% (95% CI, 3.51%-4.24%) for hospitalized
patients.
CONCLUSIONS AND
RELEVANCE: Pulmonary embolism was rarely identified in patients with syncope.
Although PE should be considered in every patient, not all patients should
undergo evaluation for PE.
Related study: Frizell A, et al. Prevalence of PE in patients
presenting to the ED with syncope. Am J Emerg Med 2018;36:253-6. Abstract: https://www.ncbi.nlm.nih.gov/pubmed/28811209
B. Effect of the PE Rule-Out Criteria on Subsequent
Thromboembolic Events Among Low-Risk ED Patients: The PROPER Randomized
Clinical Trial
Freund Y, et al. JAMA.
2018 Feb 13;319(6):559-566..
IMPORTANCE: The safety
of the pulmonary embolism rule-out criteria (PERC), an 8-item block of clinical
criteria aimed at ruling out pulmonary embolism (PE), has not been assessed in
a randomized clinical trial.
OBJECTIVE: To
prospectively validate the safety of a PERC-based strategy to rule out PE.
DESIGN, SETTING, AND
PATIENTS: A crossover cluster-randomized clinical noninferiority trial in 14
emergency departments in France. Patients with a low gestalt clinical
probability of PE were included from August 2015 to September 2016, and
followed up until December 2016.
INTERVENTIONS: Each
center was randomized for the sequence of intervention periods. In the PERC
period, the diagnosis of PE was excluded with no further testing if all 8 items
of the PERC rule were negative.
MAIN OUTCOMES AND
MEASURES: The primary end point was the occurrence of a thromboembolic event
during the 3-month follow-up period that was not initially diagnosed. The
noninferiority margin was set at 1.5%. Secondary end points included the rate
of computed tomographic pulmonary angiography (CTPA), median length of stay in
the emergency department, and rate of hospital admission.
RESULTS: Among 1916
patients who were cluster-randomized (mean age 44 years, 980 [51%] women), 962
were assigned to the PERC group and 954 were assigned to the control group. A
total of 1749 patients completed the trial. A PE was diagnosed at initial
presentation in 26 patients in the control group (2.7%) vs 14 (1.5%) in the
PERC group (difference, 1.3% [95% CI, -0.1% to 2.7%]; P = .052). One PE (0.1%)
was diagnosed during follow-up in the PERC group vs none in the control group
(difference, 0.1% [95% CI, -∞ to 0.8%]). The proportion of patients undergoing
CTPA in the PERC group vs control group was 13% vs 23% (difference, -10% [95%
CI, -13% to -6%]; P less than.001). In the PERC group, rates were
significantly reduced for the median length of emergency department stay (mean
reduction, 36 minutes [95% CI, 4 to 68]) and hospital admission (difference,
3.3% [95% CI, 0.1% to 6.6%]).
CONCLUSIONS AND
RELEVANCE: Among very low-risk patients with suspected PE, randomization to a
PERC strategy vs conventional strategy did not result in an inferior rate of
thromboembolic events over 3 months. These findings support the safety of PERC
for very low-risk patients presenting to the emergency department.
9. Geriatric Emergency Medicine
A. An ED Observation Unit Is
a Feasible Setting for Multidisciplinary Geriatric Assessments in Compliance with the Geriatric ED Guidelines
Southerland LT, et al. Acad Emerg Med. 2018
Jan;25(1):76-82.
BACKGROUND: The Geriatric
Emergency Department (ED) Guidelines recommend providing multidisciplinary
geriatric assessment in the ED, but these assessments can be difficult to
coordinate and may prolong length of stay. Patients who need longer than a
typical ED stay can be placed in an ED observation unit (Obs Unit). We
investigated the effects of offering multidisciplinary assessments for ED
patients in an Obs Unit.
METHODS: Evaluation by a geriatric
hospital consultation team, physical therapist, case manager, and/or pharmacist
was made available to all Obs Unit patients. Use of any or all of these
ancillary consult services could be requested by the Obs Unit physician. A
retrospective chart review of random older adult Obs Unit patients was done to
assess rates of consult use and interventions by these consulting teams. All
patients ≥ 65 years old in our institutional review board-approved, monthly Obs
Unit quality database from October 2015 through March 2017 were included.
RESULTS: Our quality database
included 221 older patients over 18 months. The mean (±SD) age was 73.3 (±6.8)
years (range = 65-96 years) and 55.2% were women. The mean (±SD) observation
length of stay was 14.7 (±6.5) hours. The majority (74.3%) were discharged from
the Obs Unit and 72-hour ED recidivism was 3.6%. Overall, at least one of the
multidisciplinary consultant services were requested in 40.3% of patients (n =
89). Additional interventions or services were recommended in 80.0% of patients
evaluated by physical therapy (32 of 40 patients), 100% of those evaluated by a
pharmacist (five of five patients), 38% of those evaluated by case management
(27 of 71 patients), and 100% of those evaluated by a geriatrician (eight of
eight patients). Only 5.4% (n = 12) of patients were placed in observation
specifically for multidisciplinary assessment; these patients had a mean (±SD)
length of stay of 12.2 (±5) hours and an admission rate of 41.7%.
CONCLUSIONS: Incorporating elements
of multidisciplinary geriatric assessment for older patients is feasible within
an observation time frame and resulted in targeted interventions. An Obs Unit
is a reasonable setting to offer services in compliance with the Geriatric ED
Guidelines.
Full-text (free): http://onlinelibrary.wiley.com/doi/10.1111/acem.13328/full
B. ED
Innovations: Transitional Care Nurses Reduce Hospital Admissions for Elderly Pts
Hwang U, et al. J Am
Geriatr Soc. 2018 Jan 10 [Epub ahead of print].
OBJECTIVES: To examine
the effect of an emergency department (ED)-based transitional care nurse (TCN)
on hospital use.
DESIGN: Prospective
observational cohort.
SETTING: Three U.S.
(NY, IL, NJ) EDs from January 1, 2013, to June 30, 2015.
PARTICIPANTS: Individuals
aged 65 and older in the ED (N = 57,287).
INTERVENTION: The
intervention was first TCN contact. Controls never saw a TCN during the study
period.
MEASUREMENTS: We
examined sociodemographic and clinical characteristics associated with TCN use
and outcomes. The primary outcome was inpatient admission during the index ED
visit (admission on Day 0). Secondary outcomes included cumulative 30-day
admission (any admission on Days 0-30) and 72-hour ED revisits.
RESULTS: A TCN saw
5,930 (10%) individuals, 42% of whom were admitted. After accounting for
observed selection bias using entropy balance, results showed that when
compared to controls, TCN contact was associated with lower risk of admission
(site 1: -9.9% risk of inpatient admission, 95% confidence interval (CI) =
-12.3% to -7.5%; site 2: -16.5%, 95% CI = -18.7% to -14.2%; site 3: -4.7%, 95%
CI = -7.5% to -2.0%). Participants with TCN contact had greater risk of a
72-hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7-2.3%; site 2: 1.4%,
95% CI = 0.7-2.1%). Risk of any admission within 30 days of the index ED visit
also remained lower for TCN patients at both these sites (site 1: -7.8%, 95% CI
= -10.3% to -5.3%; site 2: -13.8%, 95% CI = -16.1% to -11.6%).
CONCLUSION: Targeted
evaluation by geriatric ED transitions of care staff may be an effective
delivery innovation to reduce risk of inpatient admission.
10. Improving ED Atrial Fibrillation Management
A. Improving Stroke Prevention
Vinson DR, et al, with
the KP CREST Network. Thromboprophylaxis for High-risk AF/FL Discharged from
the ED. West J Emerg Med. 2018 Feb 12 [Epub ahead of print].
Background: Many
patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk
for ischemic stroke are not receiving evidence-based thromboprophylaxis. We
examined anticoagulant prescribing within 30 days of receiving dysrhythmia care
for nonvalvular AF/FL in the emergency department (ED).
Methods: This
prospective study included non-anticoagulated adults at high-risk for ischemic
stroke (ATRIA score ≥7) who received emergency AF/FL care and were discharged
home from seven community EDs between May 2011 and August 2012. We
characterized oral anticoagulant prescribing patterns and identified predictors
of receiving anticoagulants within 30 days of the index ED visit. We also
describe documented reasons for withholding anticoagulation.
Results: Of 312
eligible patients, 128 (41.0%) were prescribed anticoagulation at ED discharge
or within 30 days. Independent predictors of anticoagulation included younger
age (adjusted odds ratio [aOR] 0.89 per year, 95% CI 0.82-0.96), ED cardiology
consultation (aOR 1.89, 95% CI 1.10-3.23), and failure of sinus restoration by
time of ED discharge (aOR 2.65, 95% CI 1.35-5.21). Reasons for withholding
anticoagulation at ED discharge were documented in 139 of 227 cases (61.2%),
the most common of which were deferring the shared decision-making process to
the patient’s outpatient provider, perceived bleeding risk, patient refusal,
and restoration of sinus rhythm.
Conclusions:
Approximately 40% of non-anticoagulated AF/FL patients at high risk for stroke
who presented for emergency dysrhythmia care were prescribed anticoagulation
within 30 days. Physicians were less likely to anticoagulate older patients and
those with ED sinus restoration. Opportunities exist to improve rates of
thromboprophylaxis in this high-risk population.
Physician misunderstandings
were prevalent. Two common ones:
- Older pts were less commonly treated because physicians were more worried about bleeds than strokes—a sizable miscalculation. Strokes are far more dangerous than bleeds in the older anticoagulated AF population.
- High-risk pts who converted in the ED were less likely to receive stroke prevention medication, as though paroxysmal AF that flipped back into NSR significantly reduced stroke risk. It doesn’t. Intermittent AF warrants thromboprophylaxis as much as persistent AF.
For the discussion,
see the full-text (free): https://escholarship.org/uc/item/7hn511dt
B. Improving ED Rate Reduction
de Leon E, et al. Impact
of standardizing management of atrial fibrillation with rapid heart rate in the
emergency department. Perm J.
2018;22:17-049.
Context: There is
substantial variation in the emergency treatment of atrial fibrillation with
tachycardia. A standardized treatment approach at an academic center decreased
admissions without adverse outcomes, but this approach has not been evaluated
in a community Emergency Department (ED).
Objective: To evaluate
the implementation of a standardized treatment guideline for patients with
atrial fibrillation and a rapid heart rate in a community ED.
Design: An
observational pre-/postimplementation (August 2013 to July 2014 and August 2014
to July 2015, respectively) study at a community ED. The standardized treatment
guideline encouraged early oral treatment with rate control medication,
outpatient echocardiogram, and early follow-up. A multiple logistic regression
model adjusting for patient characteristics was generated to investigate the
association between the intervention and ED discharge rate.
Main Outcome Measures:
The primary measure was ED discharge. Secondary measures included stroke or
death, ED return visit, hospital readmission, length of stay, and use of oral
rate control medications.
Results: A total of
199 (104 pre/95 post) ED encounters were evaluated. The ED discharge rate
increased 14% after intervention (57.7% to 71.6%, p = 0.04), and use of rate
control medications increased by 19.4% (p less than 0.01). Adjusted
multivariate results showed a nearly 2-fold likelihood of ED discharge after
guideline implementation (odds ratio = 1.97, 95% confidence interval =
1.07-3.63). Length of stay, return visits, and hospital readmissions were
similar.
Conclusion: A
standardized approach to ED patients with atrial fibrillation and tachycardia
is associated with a decrease in hospital admissions without adversely
affecting patient safety.
Full-text (free): http://www.thepermanentejournal.org/issues/2018/winter/6605-atrial-fibrillation-emergency-department.html
11. Images in Clinical Practice
Calcified Spleen and Gallstones
Creutzfeldt–Jakob Disease
ECG Changes in Hypothermia
A 76-year-old woman with a history of dementia and coronary
heart disease was brought to the emergency department after she had been found
lying outdoors for an undetermined period; her core body temperature was 26°C
(78.8°F) at presentation. An electrocardiogram showed prominent Osborn waves,
also known as J waves (Panel A, arrows), along with prolonged QRS duration and
corrected QT interval.
Herpetic Whitlow
Phlegmasia Cerulea Dolens with Compartment Syndrome
An 81-year-old man with hypertension presented to the
emergency department with pain and swelling of the left thigh and lower leg
that had developed during the previous several hours. He had no history of
recent surgery or trauma and no known personal or family history of clotting
disorders. The left lower leg was tender, cold, and swollen (Panel A), and the
left dorsalis pedis pulse was not palpable.
Man With Bumps on His Shin
Man With Chest Pain and Lump in Neck
Male With Sore Throat
Infant With a Diffuse Rash and a Fever
Hyperactive Child With Chest Pain
Elderly Woman With Decreased Right-Sided Vision
Adolescent With a Non-Healing Thigh Injury
Man With Rash
Child With Diffuse Bullous Rash
Adult Male With Chest Pain After a Fall
Man With Abdominal Pain
Elderly Woman With Abdominal Pain
Young Boy With Roughening in the Inner Eyelids
12. Computer-Interpreted ECGs: Benefits and Limitations.
Schläpfer J, Wellens HJ. J Am Coll Cardiol. 2017 Aug
29;70(9):1183-1192.
Computerized interpretation of the electrocardiogram (CIE)
was introduced to improve the correct interpretation of the electrocardiogram
(ECG), facilitating health care decision making and reducing costs. Worldwide,
millions of ECGs are recorded annually, with the majority automatically
analyzed, followed by an immediate interpretation. Limitations in the
diagnostic accuracy of CIE were soon recognized and still persist, despite ongoing
improvement in ECG algorithms. Unfortunately, inexperienced physicians ordering
the ECG may fail to recognize interpretation mistakes and accept the automated
diagnosis without criticism. Clinical mismanagement may result, with the risk
of exposing patients to useless investigations or potentially dangerous
treatment. Consequently, CIE over-reading and confirmation by an experienced
ECG reader are essential and are repeatedly recommended in published reports.
Implementation of new ECG knowledge is also important. The current status of
automated ECG interpretation is reviewed, with suggestions for improvement.
Full-text (requires subscription): https://www.sciencedirect.com/science/article/pii/S0735109717387946
Commentary:
How Computer-Interpreted ECGs May Lead to Errors
By Amal Mattu, MD. Medscape, Nov 28, 2017
Background
ECG was invented more than 100 years ago.[1] Despite many
technical advances in the field of emergency cardiology, the basic 12-lead ECG
still remains a cornerstone test in the acute diagnosis of many types of
cardiac conditions, both acute and chronic.
Automated ECG analysis was initiated in the 1950s in an
attempt to assist providers who had less training in ECG interpretation.[1]
Unfortunately, despite improvements in the automated interpretations over the
past 60 years, computer ECG interpretations remain far from perfect. Despite
the common teaching that we should not trust the computer interpretations, many
healthcare providers still rely heavily on these interpretations in their
clinical practice.
The following review provides some excellent information
regarding the benefits and limitations of the computer interpretation programs.
Study Summary
- The authors reviewed technical specifications about the various computer programs and also numerous articles regarding accuracy data on the various algorithms. The following is a list of key points they made.
- There is no international accepted standard for computer interpretations. As a result, significant variability exists among interpretations from different manufacturers' algorithms.
- Direct comparative evaluations of the various commercially available computer-interpreted ECG (CIE) programs has never been performed.
- A 1991 study of nine CIE programs versus eight cardiologists demonstrated consistently lower accuracy among the CIEs compared with the cardiologists, and also (surprisingly) significant variation in accuracy among the various programs.[2]
- CIE programs have a frequent tendency to overcall atrial fibrillation, especially in elderly persons, potentially leading to inappropriate administration of harmful medications.
- CIE programs have a tendency to double-count the rate due to large T-waves (eg, in the setting of hyperkalemia).
- CIE programs are particularly inaccurate in diagnosing pacemaker rhythms.
- CIE programs demonstrate wide variations in the false-positive (0%-42%) and false-negative (22%-42%) rates of diagnosis of ST-segment myocardial infarction; therefore, it is not recommended that CIEs be used as a sole means of activation of the cardiac catheterization lab.
- CIE programs frequently tend to underestimate the QT interval, especially in the presence of artifact or improperly placed leads.
- The authors cite a 2008 study indicating that "It has been roughly estimated that [CIE] misdiagnoses may account for up to 10,000 adverse effects or avoidable deaths worldwide annually."[3]
- The authors summarize, "Computer-based analysis of the ECG may lead to erroneous diagnosis with useless, inappropriate, or even dangerous care of the patient."
Viewpoint
This article sheds some much-needed light on the true
accuracy of CIE programs. Although these programs may help providers who are
inexperienced in ECG interpretation, they appear to decrease the accuracy of
experienced providers by frequently providing a false sense of security with
benign interpretations and also by encouraging less scrutiny of the ECG. I
truly believe that if the computer interpretations were removed, providers
would pay closer attention to the ECG, resulting in more accurate
interpretations and fewer errors. I also believe that our trainees would feel
compelled to work harder at their ECG interpretation skills if the computer
interpretations were removed.
During the past 15 years, I've seen at least a half-dozen
malpractice cases in which the computer interpretation simply indicated
"nonspecific" findings on ECGs that demonstrated fairly obvious
ischemia. In each of these cases, the treating physician was misled by the
computer, and only in retrospect, too late, did the physician recognize the
ischemic findings. These cases are typically nearly impossible to defend.
ECG interpretation is a life-saving skill. Proficiency is a
must for us all. We must exercise extreme caution regarding the utility of
these CIE programs and gain enough skill and confidence to avoid using them
entirely.
13. “Sometimes You Feel Like the Freak Show”: A Qualitative
Assessment of Emergency Care Experiences Among Trans and Gender Non-Conforming
Patients
Samuels EA, et al. Ann Emerg Med. 2018;71(2):170–182.e1
STUDY OBJECTIVE: Transgender, gender-variant, and intersex
(trans) people have decreased access to care and poorer health outcomes
compared with the general population. Little has been studied and documented
about such patients' emergency department (ED) experiences and barriers to
care. Using survey and qualitative research methods, this study aims to
identify specific areas for improvement and generate testable hypotheses about
the barriers and challenges for trans individuals needing acute care.
METHODS: A survey and 4 focus groups were conducted with
trans individuals older than 18 years who had been to an ED in the last 5
years. Participants were recruited by trans e-mail listservs; outreach to local
trans organizations; and lesbian, gay, bisexual, and transgender periodical
advertisements. The interview guide was reviewed by qualitative research and
trans health content experts. Deidentified participant demographic information
was collected with a standardized instrument. All discussions were captured on
digital audio recorders and professionally transcribed. Interview coding and
thematic analysis were conducted with a grounded theory approach.
RESULTS: Among 32 participants, 71.9% were male identified
and 78.1% were white. Nearly half (43.8%) reported avoiding the ED when they
needed acute care. The factors that had the greatest influence on ED avoidance
were fear of discrimination, length of wait, and negative previous experiences.
There were 4 overarching discussion themes: system structure, care competency,
discrimination and trauma, and avoidance of emergency care. Improvement
recommendations focused on staff and provider training about gender and trans
health, assurance of private gender identity disclosure, and accurate capture
of sex, gender, and sexual orientation information in the electronic medical
record.
CONCLUSION: Efforts to improve trans ED experiences should
focus on provider competency and communication training, electronic medical
record modifications, and assurance of private means for gender disclosure.
Future research directions include quantifying the frequency of care avoidance,
the effect of avoidance on trans patient morbidity and mortality, and comparing
ED patient outcomes by gender identity. Further research with increased
inclusion of transwomen and people of color is needed to identify themes that
may not have been raised in this preliminary investigation.
14. Differences Between Snakebites with Concomitant Use of
Alcohol or Drugs and Single Snakebites.
Schulte J, et al. South Med J. 2018 Feb;111(2):113-117.
OBJECTIVES: Published reports have suggested that the
concurrent use of alcohol or drugs occurs among some snakebite victims, but no
national assessment of such data exists.
METHODS: We used data from US poison control centers
collected during telephone calls in calendar years 2000-2013 to compare snake
envenomations with concomitant use of drugs, alcohol, or both to snakebites
lacking such use.
RESULTS: A total of 608 snakebites with 659 instances of
concomitant alcohol/drug use were reported, which represent approximately 1% of
92,751 snakebites reported to US poison control centers. An annual mean of 48
snakebites with concomitant use of alcohol/drugs was reported, compared with a
mean of 6625 snakebites per year with no concomitant use of alcohol/drugs. Most
cases involved men, peaked during the summer months, and involved copperheads
or rattlesnakes, which mirrored overall trends. Snakebite victims who also used
alcohol/drugs were more likely than victims with only a snakebite reported to
be bitten by rattlesnakes, to be admitted to the hospital, and die. Alcohol was
the most common reported concomitant substance, but other substances were
reported.
CONCLUSIONS: Snakebites with concomitant use of
alcohol/drugs are uncommon, accounting for approximately 1% of the snakebite
envenomations reported annually to US poison control centers; however,
snakebite victims also reporting alcohol/drug use are more likely to be bitten
by rattlesnakes, be admitted to a healthcare facility, and die.
15. Sepsis Research
A. No Evidence Underpinning the U.S.
Government–Mandated Hemodynamic Interventions for Sepsis: A Systematic Review
Pepper DJ, et al. Ann Intern Med. 2018 Feb 20 [Epub ahead of
print]
Background: The Severe Sepsis and Septic Shock Early
Management Bundle (SEP-1), the sepsis performance measure introduced by the
Centers for Medicare & Medicaid Services (CMS), requires up to 5
hemodynamic interventions, as many as 141 tasks, and 3 hours to document for a
single patient.
Purpose: To evaluate whether moderate- or high-level
evidence shows that use of SEP-1 or its hemodynamic interventions improves
survival in adults with sepsis.
Data Sources: PubMed, Embase, Scopus, Web of Science, and
ClinicalTrials.gov from inception to 28 November 2017 with no language
restrictions.
Study Selection: Randomized and observational studies of
death among adults with sepsis who received versus those who did not receive
either the entire SEP-1 bundle or 1 or more SEP-1 hemodynamic interventions,
including serial lactate measurements; a fluid infusion of 30 mL/kg of body
weight; and assessment of volume status and tissue perfusion with a focused
examination, bedside cardiovascular ultrasonography, or fluid responsiveness
testing.
Data Extraction: Two investigators independently extracted
study data and assessed each study's risk of bias; 4 authors rated level of
evidence by consensus using CMS criteria. High- or moderate-level evidence
required studies to have no confounders and low risk of bias.
Data Synthesis: Of 56 563 references, 20 studies (18
reports) met inclusion criteria. One single-center observational study reported
lower in-hospital mortality after implementation of the SEP-1 bundle. Sixteen
studies (2 randomized and 14 observational) reported increased survival with
serial lactate measurements or 30-mL/kg fluid infusions. None of the 17 studies
were free of confounders or at low risk of bias. In 3 randomized trials, fluid
responsiveness testing did not alter survival.
Limitation: Few trials, poor-quality and confounded studies,
and no studies (with survival outcomes) of the focused examination or bedside
cardiovascular ultrasonography.
Conclusion: No high- or moderate-level evidence shows that
SEP-1 or its hemodynamic interventions improve survival in adults with sepsis.
B. Prognostic Accuracy of the Quick
Sequential Organ Failure Assessment for Mortality in Patients with Suspected
Infection: A Systematic Review and Meta-analysis.
Fernando SM, et al. Ann Intern Med. 2018 Feb
20;168(4):266-275.
BACKGROUND: The quick Sequential Organ Failure Assessment
(qSOFA) has been proposed for prediction of mortality in patients with
suspected infection.
PURPOSE: To summarize and compare the prognostic accuracy of
qSOFA and the systemic inflammatory response syndrome (SIRS) criteria for
prediction of mortality in adult patients with suspected infection.
DATA SOURCES: Four databases from inception through November
2017.
STUDY SELECTION: English-language studies using qSOFA for
prediction of mortality (in-hospital, 28-day, or 30-day) in adult patients with
suspected infection in the intensive care unit (ICU), emergency department
(ED), or hospital wards.
DATA EXTRACTION: Two investigators independently extracted
data and assessed study quality using standard criteria.
DATA SYNTHESIS: Thirty-eight studies were included (n = 385
333). qSOFA was associated with a pooled sensitivity of 60.8% (95% CI, 51.4% to
69.4%) and a pooled specificity of 72.0% (CI, 63.4% to 79.2%) for mortality.
The SIRS criteria were associated with a pooled sensitivity of 88.1% (CI, 82.3%
to 92.1%) and a pooled specificity of 25.8% (CI, 17.1% to 36.9%). The pooled
sensitivity of qSOFA was higher in the ICU population (87.2% [CI, 75.8% to
93.7%]) than the non-ICU population (51.2% [CI, 43.6% to 58.7%]). The pooled
specificity of qSOFA was higher in the non-ICU population (79.6% [CI, 73.3% to
84.7%]) than the ICU population (33.3% [CI, 23.8% to 44.4%]).
LIMITATION: Potential risk of bias in included studies due
to qSOFA interpretation and patient selection.
CONCLUSION: qSOFA had poor sensitivity and moderate
specificity for short-term mortality. The SIRS criteria had sensitivity
superior to that of qSOFA, supporting their use for screening of patients and
as a prompt for treatment initiation.
16. Beware the Danger Lurking Under the Shroud of Alcohol
Sheehy M, et al. Ann Emerg Med 2018;71(3):289-91.
Annals Case
An alcohol-dependent patient well known to your emergency
department (ED) presents with…drumroll please…alcohol intoxication. A Good
Samaritan called 911 after finding the patient asleep on a park bench. His
chart is overflowing with ED visits for alcohol intoxication and usually
conclude with an early-morning discharge. His vital signs are pulse rate 98
beats/min, respiratory rate 18 breaths/min, blood pressure 156/76 mm Hg, and
oxygen saturation 97% on room air. On examination, he appears
intoxicated—alcohol on his breath, opens his eyes and speaks confused words to
painful stimuli—and is protecting his airway. There are no signs of acute head
trauma or other injury.
So what’s the plan? Does this patient need laboratory tests,
head computed tomography (CT), or withdrawal prevention?
Introduction
You have probably treated a patient like this recently. The
statistics sure say you have. Rates of alcohol intoxication ED visits are
increasing out of proportion to overall ED visits.1 Average blood alcohol
concentrations (BACs) are increasing too!2 So patients are getting more
intoxicated more frequently. Although many simply require observation until
clinically sober, with an eventual turkey sandwich, badness may lurk beneath
the shroud of alcohol…and it may be hard to identify on initial evaluation.
Klein et al3 looked for badness retrospectively in 31,364
cases of low-risk acute alcohol intoxication. One percent of their study
cohort, or 325 patients, required critical care resources while in the ED.
Included patients were deemed to be at low risk according to triage nurse and
emergency physician assessment after a mandatory alcohol level and fingerstick
glucose-level test.3 The rate of badness, therefore, among all comers with
presumed alcohol abuse is undoubtedly higher; hence, the common refrain,
“Alcoholics were put on this earth to humble emergency physicians.”
What can we learn from this study? Indicators for potential
badness were abnormal vital signs, hypoglycemia, or need for chemical sedation.
Although these red flags may seem obvious in hindsight, they can be easily
dismissed with seemingly benign explanations. Tachycardia and hypotension may
be attributed to dehydration, a coingestion, or anxiety, especially when
anchored on a diagnosis of alcohol intoxication. This article reminds us to
always consider other causes for the patient’s altered mental status. And make
sure there is a full set of vital signs recorded. What was our example
patient’s temperature? Oh, it wasn’t taken?!
17. Association of Clinician Denial of Patient Requests with Patient
Satisfaction.
Jerant A, et al. JAMA Intern Med. 2018 Jan 1;178(1):85-91.
IMPORTANCE: Prior studies suggesting clinician fulfillment
or denial of requests affects patient satisfaction included limited adjustment
for patient confounders. The studies also did not examine distinct request
types, yet patient expectations and clinician fulfillment or denial might vary
among request types.
OBJECTIVE: To examine how patient satisfaction with the
clinician is associated with clinician denial of distinct types of patient
requests, adjusting for patient characteristics.
DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional
observational study of 1319 outpatient visits to family physicians (n = 56) by
1141 adults at one Northern California academic health center.
MAIN OUTCOMES AND MEASURES: We used 6 Consumer Assessment of
Healthcare Providers and Systems Clinician and Group Adult Visit Survey items
to measure patient satisfaction with the visit physician. Standardized items
were averaged to form the satisfaction score (Cronbach α = 0.80), which was
then percentile-transformed. Seven separate linear mixed-effects models
examined the adjusted mean differences in patient satisfaction percentile
associated with denial of each of the following requests (if present)-referral,
pain medication, antibiotic, other new medication, laboratory test, radiology
test, or other test-compared with fulfillment of the respective requests. The
models adjusted for patient sociodemographics, weight, health status,
personality, worry over health, prior visit with clinician, and the other 6
request categories and their dispositions.
RESULTS: The mean (SD) age of the 1141 patients was 45.6
(16.1) years, and 902 (68.4%) were female. Among 1319 visits, 897 (68.0%)
included at least 1 request; 1441 (85.2%) were fulfilled. Requests by category
were referral, 294 (21.1%); pain medication, 271 (20.5%); antibiotic, 107
(8.1%); other new medication, 271 (20.5%); laboratory test, 448 (34.0%);
radiology test, 153 (11.6%); and other tests, 147 (11.1%). Compared with
fulfillment of the respective request type, clinician denials of requests for
referral, pain medication, other new medication, and laboratory test were
associated with worse satisfaction (adjusted mean percentile differences, -19.75
[95% CI, -30.75 to -8.74], -10.72 [95% CI, -19.66 to -1.78], -20.36 [95% CI,
-29.54 to -11.18], and -9.19 [95% CI, -17.50 to -0.87]), respectively.
CONCLUSIONS AND RELEVANCE: Clinician denial of some types of
requests was associated with worse patient satisfaction with the clinician, but
not for others, when compared with fulfillment of the requests. In an era of
patient satisfaction-driven compensation, the findings suggest the need to
train clinicians to deal effectively with requests, potentially enhancing
patient and clinician experiences.
18. Pain Reduction in Trauma Patients
A. Acetaminophen equal to NSAIDs in
Acute Musculoskeletal Trauma: A Multicenter, Double-Blind, RCT
Ridderikhof ML, et al. Ann Emerg Med. 2018
Mar;71(3):357-368.e8.
STUDY OBJECTIVE: We determine whether pain treatment with
acetaminophen was not inferior to nonsteroidal anti-inflammatory drugs or the
combination of both in minor musculoskeletal trauma.
METHODS: The Paracetamol or NSAIDs in Acute Musculoskeletal
Trauma Study was a double-blind, randomized, clinical trial conducted in 2
general practices and 2 emergency departments in the Netherlands. A total of
547 adults, aged 18 years and older, with acute blunt minor musculoskeletal
extremity trauma were randomly assigned in a 1:1:1 ratio to acetaminophen 4,000
mg/day, diclofenac 150 mg/day, or acetaminophen 4,000 mg/day+diclofenac 150
mg/day during 3 consecutive days. Patients, health care staff, and outcome
assessors were blinded for treatment allocation. Follow-up for each patient was
30 days. Primary outcome measures were between-group differences in mean
numeric rating scale (NRS) pain scores in rest and with movement at 90 minutes
after initial drug administration compared with baseline pain scores with a
predefined noninferiority margin of 0.75 NRS points. Secondary outcomes
included NRS pain scores during 3 consecutive days and need for additional
analgesia.
RESULTS: One hundred eighty-two patients were treated with
acetaminophen, 183 with diclofenac, and 182 with combination treatment.
Intention-to-treat analysis revealed mean NRS reduction in rest -1.23 (95%
confidence interval [CI] -1.50 to -0.95) and -1.72 (95% CI -2.01 to -1.44) with
movement, both for acetaminophen at 90 minutes compared with baseline. Pairwise
comparison in rest with diclofenac showed a difference of -0.027 (97.5% CI
-0.45 to 0.39) and -0.052 (97.5% CI -0.46 to 0.36) for combination treatment.
With movement, these numbers were -0.20 (97.5% CI -0.64 to 0.23) and -0.39
(97.5% CI -0.80 to 0.018), respectively. All differences were well below the
predefined noninferiority margin.
CONCLUSION: Pain treatment with acetaminophen was not
inferior to that with diclofenac or the combination of acetaminophen and
diclofenac in acute minor musculoskeletal extremity trauma, both in rest and
with movement.
B. How Effective Is a Regional Nerve
Block for Treating Pain Associated with Hip Fractures?
Gottlieb M, et al. Ann Emerg Med. 2018 Mar;71(3):378-380.
Take-Home Message
Regional nerve blockade reduces pain on movement, risk of
pneumonia, and time to first mobilization among patients with hip fractures
with no major complications.
19. Quick Lit Reviews
From BMJ’s Rapid Recommendations
A. Antibiotics after incision and drainage for uncomplicated
skin abscesses: a clinical practice guideline
What you need to know
For uncomplicated skin
abscesses, we suggest using trimethoprim-sulfamethoxazole (TMP-SMX) or
clindamycin in addition to incision and drainage rather than incision and
drainage alone, and emphasise the need for shared decision making
TMP-SMX or clindamycin
modestly reduces pain and treatment failure and probably reduces abscess
recurrence, but increases the risk of adverse effects including nausea and
diarrhoea
We suggest TMP-SMX
rather than clindamycin because TMP-SMX has a lower risk of diarrhoea
Cephalosporins in
addition to incision and drainage are probably not more effective than incision
and drainage alone in most settings
From a societal
perspective, the modest benefits from adjuvant antibiotics may not outweigh the
harms from increased antimicrobial resistance in the community, although this
is speculative
Related article: Frazee B. Antibiotics for
simple skin abscesses: the new evidence in
perspective. Emerg Med
J. 2018 Jan 24 [Epub ahead of print]. Link (subscription required): http://emj.bmj.com/content/early/2018/01/24/emermed-2017-207323.long
B. Corticosteroids for sore throat: a clinical practice guideline
What you need to know:
Sore throat is one of
the most common reasons for primary care appointments, and international
guidance varies about whether to use corticosteroids to treat it, but a trial
published in April 2017 suggested that costicosteroids might be effective
We make a weak
recommendation to use a single dose of oral corticosteroids, in those
presenting with acute sore throat, after performing a systematic review of the
new evidence in this rapid recommendation publication package
The recommendation is
weak and shared decision making is needed because corticosteroids did not help
all patient reported outcomes and patients’ preferences varied substantially
Steroids somewhat
reduced the severity and duration of pain by one day, but time off school or
work was unchanged. Harm seems unlikely with one steroid dose.
The treatment is
inexpensive and likely to be offered in the context of a consultation that
would have taken place anyway.
From Ann Emerg Med
A. Does Prestroke Antiplatelet Therapy
Increase the Risk of Symptomatic Intracranial Hemorrhage in Patients Receiving tPA
for Acute Ischemic Stroke?
Take home: In patients receiving prestroke aspirin and
clopidogrel combination therapy, thrombolysis in acute ischemic stroke is
associated with an increased risk of symptomatic intracranial hemorrhage, yet
there is no evidence for increased mortality or worse functional outcomes.
B. Do IV Benzodiazepines or
Benzodiazepines by an Alternative Route (Nonintravenous) Abort Seizures Faster
[in pts without initial IV access]?
Take home: Benzodiazepines by an alternative route abort
seizures faster and possess superior efficacy compared with intravenous
benzodiazepines in patients without intravenous access.
20. On Being Sued for Malpractice
A. Provider and Practice Factors Associated with Emergency
Physicians Being Named in a Malpractice Claim
Carlson JN, et al. Ann Emerg Med 2018;71(2):157–164.e4
Study objective
We examine the
association between emergency physician characteristics and practice factors
with the risk of being named in a malpractice claim.
Methods
We used malpractice
claims along with provider, operational, and jurisdictional data from a
national emergency medicine group (87 emergency departments [EDs] in 15 states
from January 1, 2010, to June 30, 2014) to assess the relationship between
individual physician and practice variables and being named in a malpractice
claim. Individual and practice factors included years in practice, emergency
medicine board certification, visit admission rate, relative value units
generated per hour, total patients treated as attending physician of record,
working at multiple facilities, working primarily overnight shifts, patient
experience data percentile, and state malpractice environment. We assessed the
relationship between emergency physician and practice variables and malpractice
claims, using logistic regression.
Results
Of 9,477,150 ED visits
involving 1,029 emergency physicians, there were 98 malpractice claims against
90 physicians (9%). Increasing total number of years in practice (adjusted odds
ratio 1.04; 95% confidence interval 1.02 to 1.06) and higher visit volume
(adjusted odds ratio 1.09 per 1,000 visits; 95% confidence interval 1.05 to
1.12) were associated with being named in a malpractice claim. No other factors
were associated with malpractice claims.
Conclusion
In this sample of
emergency physicians, 1 in 11 were named in a malpractice claim during 4.5
years. Total number of years in practice and visit volume were the only
identified factors associated with being named, suggesting that exposure to
higher patient volumes and longer practice experience are the primary contributors
to malpractice risk.
B. Editorial: Malpractice Claims: It’s a Crapshoot. Time to
Stop the Self-Blame and Ask Different Questions
Sachs CJ. Ann Emerg
Med 2018;71(2):165-7.
Physicians are experts
at self-blame for poor outcomes, experiencing deep and disturbing consequences
even when the care appears to be reasonable or even exceptional. Malpractice
litigation makes this situation that much worse. Events preceding, during, and
after a claim of medical malpractice affect the health and well-being of both
patients and physicians. Surgeons with an active lawsuit in the previous 2
years are 1.64 times more likely to consider suicide in the subsequent year.1
In addition, those who consider suicide are 3.4 times more likely to report a
self-perceived medical error in the previous 3 months.2 Emergency physicians,
like surgeons, “exist in a culture that, like it or not, honors self-denial,
prizes impervious resilience, and tends to interpret imperfection as failure.”3
In “Provider and
Practice Factors Associated With Emergency Physicians Being Named in a
Malpractice Claim” in this issue of Annals, Venkat et al4 searched for ways to
mitigate the negative effect by attenuating malpractice claim risk. The authors
sought to identify modifiable physician and practice characteristics associated
with malpractice claims in a multistate emergency physician group, using 4.5
years of closed claims data. They give us 2 primary findings: first, as emergency
physicians, we are likely to be sued, and second, we can’t predict or prevent
it.
This editorial reviews
some of the medical malpractice literature, places the work by Venkat et al in
context, and suggests alternative actions to predict malpractice claims and
reduce resultant provider stress. Ultimately, the work by Venkat et al suggests
that future investigators should radically alter their approach to exploring,
analyzing, and responding to medical malpractice.
Venkat et al remind us
of the sobering fact that under the current US malpractice system, at least 75%
of emergency physicians will be named in a malpractice lawsuit during their
careers—and 95% if they practice until aged 65 years. The US malpractice system
as a whole fails to serve the best interests of our patients, who most often do
not receive satisfactory explanations or any compensation when injured, and
still sabotages the patient-physician relationship.5 Malpractice allegations
induce self-doubt, anger, and often depression. We may suffer for years from a
form of posttraumatic stress disorder termed malpractice stress syndrome.6, 7
Lawsuits may taint our future interactions with patients and threaten our
well-being at work for years and potentially for the duration of our careers.
With this as a
backdrop, many authors have researched methods to avoid malpractice claims. The
majority of previous research in the emergency medicine literature examines
series of claims cases and in doing so cannot accurately determine the risk
associated with the studied variables. One way to think about this is to
consider that these previous studies were limited to variables in the numerator
(cases with lawsuits) and did not incorporate the denominator (all patients
treated during the time and location from which the cases arose). As a result,
the variables found to be associated with malpractice risk may be just as
common in cases without lawsuits as in cases with them; the case series
methodology can’t determine whether a difference exists.8, 9, 10 Studies
comparing physicians with multiple lawsuits (as cases) with those with only one
lawsuit (as controls) lack utility in uncovering potentially predictive
variables because the majority of physicians will have only one lawsuit in a 4-
to 10-year database. What is found may not be generalizable because it focuses
on the rare event of a physician with multiple lawsuits, who likely is not
representative of most physicians facing lawsuits.11 Indeed, in the current
Annals analysis, 92% of emergency physicians accrued a single lawsuit. By using
both numerator data and denominator data, the research by Venkat et al improves
greatly on that of previous studies exploring risk factor associations. Their
approach does have the ability to differentiate provider and practice factors
associated with increased risk from the larger group of all emergency
department (ED) visits.
In the present study,
Venkat et al explored several independent variables that the previous research
suggested might be associated with malpractice risk. The variables included
years in practice, board certification, admission rate (a proxy for physician
risk adversity), relative value units generated hourly, total patients treated,
multiple facility work, night shift work, patient experience rank (per Press
Ganey), and American College of Emergency Physicians (ACEP) state malpractice
grade. The authors found only 2 elements
statistically associated with risk of lawsuit: increased patient volume and
years in clinical practice…
The rest of the essay
(subscription required): http://www.annemergmed.com/article/S0196-0644(17)31662-1/fulltext
21. Effect of ED and ICU Occupancy on Admission
Decisions and Outcomes for Critically Ill Patients
Mathews KS, et al. Crit Care Med. 2018
Jan 30 [Epub ahead of
print]
OBJECTIVES: ICU admission delays
can negatively affect patient outcomes, but emergency department volume and
boarding times may also affect these decisions and associated patient outcomes.
We sought to investigate the effect of emergency department and ICU capacity
strain on ICU admission decisions and to examine the effect of emergency
department boarding time of critically ill patients on in-hospital mortality.
DESIGN: A retrospective
cohort study.
SETTING: Single academic
tertiary care hospital.
PATIENTS: Adult critically ill
emergency department patients for whom a consult for medical ICU admission was
requested, over a 21-month period.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: Patient data,
including severity of illness (Mortality Probability Model III on Admission),
outcomes of mortality and persistent organ dysfunction, and hourly census
reports for the emergency department, for all ICUs and all adult wards were
compiled. A total of 854 emergency department requests for ICU admission were
logged, with 455 (53.3%) as "accept" and 399 (46.7%) as
"deny" cases, with median emergency department boarding times 4.2
hours (interquartile range, 2.8-6.3 hr) and 11.7 hours (3.2-20.3 hr) and similar
rates of persistent organ dysfunction and/or death 41.5% and 44.6%,
respectively. Those accepted were younger (mean ± SD, 61 ± 17 vs 65 ± 18 yr)
and more severely ill (median Mortality Probability Model III on Admission
score, 15.3% [7.0-29.5%] vs 13.4% [6.3-25.2%]) than those denied admission. In
the multivariable model, a full medical ICU was the only hospital-level factor
significantly associated with a lower probability of ICU acceptance (odds
ratio, 0.55 [95% CI, 0.37-0.81]). Using propensity score analysis to account
for imbalances in baseline characteristics between those accepted or denied for
ICU admission, longer emergency department boarding time after consult was
associated with higher odds of mortality and persistent organ dysfunction (odds
ratio, 1.77 [1.07-2.95]/log10 hour increase).
CONCLUSIONS: ICU admission
decisions for critically ill emergency department patients are affected by
medical ICU bed availability, though higher emergency department volume and
other ICU occupancy did not play a role. Prolonged emergency department
boarding times were associated with worse patient outcomes, suggesting a need
for improved throughput and targeted care for patients awaiting ICU admission.
22. The Newest Threat to ED Procedural Sedation.
Green SM, et al. Ann Emerg Med. 2018
Feb 2 [Epub ahead of
print]
Guidelines for procedural sedation first appeared in 1985—a
National Institutes of Health guideline for dentists1 and an American Academy
of Pediatrics guideline for children.2 Because procedural sedation is a
multidisciplinary field, a wide array of specialty societies, including the
American College of Emergency Physicians (ACEP), subsequently crafted and
periodically update their own sedation guidelines. These documents are not
mandated by regulatory bodies such as The Joint Commission or the Centers for
Medicare & Medicaid Services (CMS), but are instead initiated by the
specialty societies on behalf of their members. These guidelines begin with
accepted core sedation principles3, 4 and include customized elements to
address specialty-specific needs, challenges, and patient populations.
The American Society of Anesthesiologists (ASA) is one of
the many specialty societies to issue sedation guidelines. However, ASA
guidelines have been fundamentally different because they have not been crafted
for their own members, but instead were unilaterally written to apply to all
other sedation providers. It is inexplicable why sedation practice by
anesthesiologists would be excluded from guidelines designed to ensure patient
safety. Their first practice guidelines for sedation and analgesia by nonanesthesiologists
were released in 1996 and updated in 2002.5, 6 The term “nonanesthesiologists”
is imprecise and antiquated, given that the diversity of other specialties
practicing sedation is far from homogenous and demonstrates a broad continuum
of sedation skills.7, 8, 9 Rather than endorsing the ASA guidelines, major
specialty societies, including ACEP and the American Academy of Pediatrics,
have chosen to continue updating and applying their own established guidelines.
Despite minor differences, these specialty-specific guidelines have been widely
implemented with a high level of safety, and are specifically endorsed by the
CMS: “A hospital could use multiple guidelines, for example, ACEP for sedation
in the ED [emergency department] and ASA for anesthesia/sedation in surgical
services, etc.”10
Now the ASA has released updated sedation guidelines that
again assert a scope beyond the practice of anesthesiologists, stating that
their guidelines “are intended for use by all providers…in any inpatient or
outpatient setting.”11 These new guidelines contain vague, confusing, and
misleading statements that run contrary to the existing scientific evidence and
threaten the well-established sedation practices of emergency physicians and
other specialists. Procedural sedation has long been a core competency in
emergency medicine and critical care medicine, and our patients depend on us to
provide effective sedation and analgesia for procedures that are often
extremely painful (eg, cardioversion, abscess incision and drainage, fracture
and dislocation reduction) or unduly frightening (eg, facial laceration repair,
neuroimaging in a child). These revised ASA guidelines restrict the use of
propofol and ketamine—our 2 most commonly administered sedative agents12, 13,
14, 15, 16, 17—and any adoption or enforcement of these directives would
restrict emergency physician access to these drugs, resulting in widespread use
of alternative agents that are less safe and provide much less effective
sedation and analgesia.
Despite these concerns, there are some positive aspects to
this update. First, this is the first ASA guideline to drop the patronizing and
divisive7, 8, 9 “nonanesthesiologists” nomenclature.5, 6, 18, 19, 20 Second,
they now concur with the ACEP recommendations in regard to fasting,13, 14, 15
stating: “In urgent or emergent situations where complete gastric emptying is
not possible, do not delay moderate procedural sedation based on fasting time
alone.”11 Additionally, this is the first ASA guideline to invite selected
outside specialty organizations to comment during its drafting. Five of these
societies have chosen to endorse these guidelines: the American Association of
Oral and Maxillofacial Surgeons, the American College of Radiology, the
American Dental Association, the American Society of Dentist Anesthesiologists,
and the Society of Interventional Radiology. ACEP chose not to endorse the
guideline when their key suggestions were not incorporated. The American
College of Cardiology and the American Society for Gastrointestinal Endoscopy
also declined to endorse the document. (Of note, these latter 3 societies have
been omitted from the final document with their dissent unacknowledged.)
Despite the disproportionate need for sedation in children, the ASA did not invite
the American Academy of Pediatrics or the Society for Pediatric Sedation to
provide guideline input. Similarly, no critical care specialists were included
despite their common provision of sedation and their frequent management of
hospital sedation services.21, 22
Most evident in this ASA guideline is a detailed
itemization of now-routine sedation precautions that have been reiterated in
many such guidelines from multiple specialty organizations during the past 33
years. Of concern, however, are other guideline elements that are imprecise,
overly broad, or omitting important context or detail. We describe the most
concerning of these as follows:
- What Happened to Deep Sedation?...
- An Anesthesiologist Guideline to Govern All Specialties?...
- Propofol and Ketamine: “Medications Intended for General Anesthesia”…
…Conclusion
In summary, the ASA guideline update contains numerous
confusing statements on critical issues relating to ED sedation practice and
misleading characterizations in regard to deep sedation, ketamine, and propofol
that are contrary to the existing scientific evidence. Key issues such as deep
sedation, guideline relationships, skill sets, and specific drugs lack
sufficient clarity for meaningful understanding or consistent interpretation.
Given the critical need for emergency physicians to advocate on behalf of their
patients, and given that each of the vague or omitted areas favors previously
asserted adverse ASA positions, we believe that emergency physicians must
assume the document to be politically motivated until proven otherwise.
Emergency physicians are fully qualified by their training
to administer all levels of sedation, and emergency medicine has long been at
the forefront of sedation research and safe sedation practice.
Non–evidence-based efforts by another specialty to dictate our scope of
practice must be vigorously opposed.
Full-text (requires subscription):
http://www.annemergmed.com/article/S0196-0644(17)31970-4/fulltext
22. Hemorrhagic Shock Review
Cannon JW. N Engl J Med 2018;378(4):370-379.
Understanding the pathophysiology of the body’s response to
hemorrhage has led to improvements in prehospital care, more rapid hemostasis,
avoidance of massive crystalloid resuscitation, and improved survival.
23. Micro Bits
A.
Study ties influenza to elevated heart attack risk
A study in The New England Journal of Medicine found
individuals with influenza had a six times increased likelihood of having a
heart attack during the first seven days of flu diagnosis. The findings, based
on 364 heart attacks from mid-2008 to mid-2015 among 332 patients aged 35 or
older, showed a slightly, but not statistically significant, higher heart
attack risk among those older than 65 and those with influenza type B.
B.
Regular dental care can reduce risk of stroke
Regular dental care was linked to a 50% reduction in the
risk of stroke, compared with not seeing a dentist regularly, a study in the
journal Stroke found. The risk of stroke increased with the severity of
periodontal disease.
C.
Increased screen time tied to lower psychological well-being in teens
Adolescents who spent more time watching TV, playing
computer games, texting, and using social media and the internet had lower
self-esteem, less happiness and reduced life satisfaction, compared with those
who spent more time on nonscreen activities, researchers reported in the
journal Emotion. The findings, based on 1991 to 2016 Monitoring the Future
study data involving 1.1 million eighth-, 10th- and 12-grade students, also
showed the greatest happiness among those who had less than an hour of daily
screen time.
LA Times: http://www.latimes.com/science/sciencenow/la-sci-sn-teens-phones-happiness-20180123-story.html
D.
Walking is associated with lower mortality, even if recommended levels are not
met
This cohort study examined the relationship between walking,
the most common physical activity for older adults, and total mortality.
Compared with inactivity, walking below minimum recommended levels is
associated with lower all-cause mortality. Walking at or above physical
activity recommendations is associated with further decreased risk of
mortality. Walking was most strongly associated with lower risk of respiratory
disease mortality followed by cardiovascular disease mortality and cancer
mortality.
E.
Does a Healthy Diet Protect Against Depression in Adolescence?
Oddy WH et al. Brain Behav Immun 2018 Jan 12
More-frequent consumption of healthy nutrients at age 14 was
associated with fewer depressive symptoms at age 17.
Journal
Watch. Daniel D. Dressler, MD, MSc, SFHM, FACP reviewing Mortensen MB and
Nordestgaard BG. Ann Intern Med 2018 Jan 16.
They
vary substantially in the proportions of patients who are deemed to be eligible
for statin therapy.
G.
People with anxiety are more likely to be bitten by dogs
Cuddling with your pet is usually a good way to unwind after
a particularly challenging day. However, a new study indicates that you might
want to think twice before getting too close to your dog when you’re feeling
anxious as it could make them more likely to bite.
H.
What Google Can do with Big Data to Predict Clinical Outcomes
Rajkomar AR, et al. Scalable and accurate deep learning for
electronic health records.
Predictive modeling with electronic health record (EHR) data
is anticipated to drive personalized medicine and improve healthcare quality.
Constructing predictive statistical models typically requires extraction of
curated predictor variables from normalized EHR data, a labor-intensive process
that discards the vast majority of information in each patient's record.
We propose a representation of patients' entire, raw EHR
records based on the Fast Healthcare Interoperability Resources (FHIR) format.
We demonstrate that deep learning methods using this representation are capable
of accurately predicting multiple medical events from multiple centers without
site-specific data harmonization. We validated our approach using de-identified
EHR data from two U.S. academic medical centers with 216,221 adult patients
hospitalized for at least 24 hours. In the sequential format we propose, this
volume of EHR data unrolled into a total of 46,864,534,945 data points,
including clinical notes. Deep learning models achieved high accuracy for tasks
such as predicting in-hospital mortality (AUROC across sites 0.93-0.94), 30-day
unplanned readmission (AUROC 0.75-0.76), prolonged length of stay (AUROC
0.85-0.86), and all of a patient's final discharge diagnoses (frequency-weighted
AUROC 0.90). These models outperformed state-of-the-art traditional predictive
models in all cases. We also present a case-study of a neural-network
attribution system, which illustrates how clinicians can gain some transparency
into the predictions.
We believe that this approach can be used to create accurate
and scalable predictions for a variety of clinical scenarios, complete with
explanations that directly highlight evidence in the patient's chart.
I. Lifestyle Medicine: A Brief Review of Its
Dramatic Impact on Health and Survival
Bodai BI, et al. Perm J 2018
Full-text (free): http://www.thepermanentejournal.org/issues/2018/winter/6536-lifestyle-medicine.html
J.
Concussions Can Be Detected With New Blood Test Approved by F.D.A.
K.
Opioid Analgesic Use Increases Risk for Invasive Pneumococcal Diseases: A
Nested Case–Control Study
L.
Study finds many ibuprofen users exceed daily dosing limit of NSAIDs
A study in Pharmacoepidemiology & Drug Safety found around
15% of adults using nonsteroidal anti-inflammatory drugs were taking the drugs
at a higher daily dose than the maximum recommended dose, raising their risk
for heart attacks, internal bleeding and other serious side effects. The
findings, based on 1,326 ibuprofen users who completed an online daily
medication diary for a week, showed 16% used ibuprofen daily, 55% took the drug
at least three days a week and 37% used at least one other nonsteroidal
anti-inflammatory drug during the week.
M.
Differences of energy expenditure while sitting versus standing: A systematic
review and meta-analysis
Results: By substituting sitting with standing for 6
hours/day, a 65 kg person will expend an additional 54 kcal/day. Assuming no
increase in energy intake, this difference in energy expenditure would be
translated into the energy content of about 2.5 kg of body fat mass in 1 year.
N.
Aspirin use not tied to better outcomes in HF without AFib
A study in JACC: Heart Failure found patients with heart
failure but without atrial fibrillation who used low-dose aspirin did not have
a significantly lower risk of all-cause mortality or hospital admission for
stroke or myocardial infarction. However, low-dose aspirin treatment was tied
to a slightly higher risk of readmission for heart failure and to an elevated
risk of myocardial infarction, according to the findings, based on nearly
12,300 individuals with new-onset heart failure enrolled in a Danish registry.
O.
Simulation Leaders Will Appreciate This
Proceedings of the 2017 AEM Consensus Conference: Catalyzing
System Change Through Healthcare Simulation
Many papers—free.
