1. Syncope Management
A. European Society of Cardiology
Issues New Guidelines On How To Stratify Syncope Patients In ED.
Written by whom? “The
most important aspect characterizing this document is the composition of the
Task Force, which is truly multidisciplinary. Cardiologists form a minority of the
panel; experts in emergency medicine, internal medicine and physiology,
neurology and autonomic diseases, geriatric medicine, and nursing cover all
aspects of management of the various forms of syncope and transient loss of
consciousness (TLOC).”
10 Key Points: http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2018/04/04/14/28/2018-esc-guidelines-for-syncope
Full-text (free): https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehy037/4939241
New Syncope
Guidelines Take Aim at ED Bottleneck
Patrice Wendling. Medscape, March 23, 2018
BARCELONA, Spain —
About half of all people will have an episode of syncope in their lifetime, and
up until now, an equal number in any part of the world will have been admitted
to the hospital, even if risk for recurrence is low.
New 2018 European Society of Cardiology (ESC) syncope
guidelines provide for the first time an algorithm to stratify these patients
in the emergency department (ED) and discharge those at low risk.
"I think this is a major advance of this guideline
because it goes beyond the individual management of the patient but has
organizational and financial implications because it provides a completely
different organizational structure of the hospital," task force chair,
Michele Brignole, MD, from Ospedali Del Tigullio, Lavagna, Italy, told
theheart.org | Medscape Cardiology.
He observed that, "Seventy-five percent of the cost
of syncope is hospitalization; so if you cut hospitalization, you cut 75% of
the cost."
Following an initial syncope examination in the ED,
including medical history, physical exam with resting and supine blood
pressure, and electrocardiography, for all patients, the guidelines recommend
that:
- Patients with low-risk features only, likely to have reflex, situational, or orthostatic syncope, be discharged directly from the ED;
- Patients with high-risk features should not be discharged but receive an intensive diagnostic evaluation in a syncope unit or ED observation unit, or hospitalized; and
- Patients with neither high- nor low-risk features should be observed in the ED or in a syncope unit instead of being hospitalized.
The essay
(registration required): https://www.medscape.com/viewarticle/894370
B. Syncope Prognosis Based on Emergency
Department Diagnosis: A Prospective Cohort Study.
Toarta C, et al. Acad Emerg Med. 2018 Apr;25(4):388-396.
doi: 10.1111/acem.13346. Epub 2018 Jan 11.
OBJECTIVE: Relatively little is known about outcomes after
disposition among syncope patients assigned various diagnostic categories
during emergency department (ED) evaluation. We sought to measure the outcomes
among these groups within 30 days of the initial ED visit.
METHODS: We prospectively enrolled adult syncope patients at
six EDs and excluded patients with presyncope, persistent mental status
changes, intoxication, seizure, and major trauma. Patient characteristics, ED
management, diagnostic impression (presumed vasovagal, orthostatic, cardiac, or
other/unknown) at the end of the ED visit, and physicians' confidence in
assigning the etiology were collected. Serious outcomes at 30 days included
death, arrhythmia, myocardial infarction, structural heart disease, pulmonary
embolism, and hemorrhage.
RESULTS: A total of 5,010 patients (mean ± SD age = 53.4 ±
23.0 years; 54.8% females) were enrolled; 3.5% suffered serious outcomes-deaths
(0.3%), arrhythmias (1.8%), nonarrhythmic cardiac (0.5%), and noncardiac (0.9%)
including pulmonary embolism (0.2%). The cause of syncope was presumed as
vasovagal among 53.3% and cardiac in 5.4% of patients. The proportion of
patients with ED investigations (p less than 0.001) and short-term serious
outcomes (p less than 0.01) increased in each diagnostic category in the
following order: presumed vasovagal, orthostatic hypotension, other/unknown
cause, and cardiac. No deaths occurred in patients with presumed vasovagal
syncope. A higher proportion of all serious outcomes occurred among patients
suspected of cardiac syncope in the ED (p less than 0.01). Confidence was highest
among physicians for a presumed vasovagal syncope diagnosis and lowest when the
cause was other/unknown.
CONCLUSION: Short-term serious outcomes strongly correlated
with the etiology assigned in the ED visit. The importance of the physician's
clinical judgment should be further studied to determine if it should become
incorporated in risk-stratification tools for prognostication and safe
management of ED syncope patients.
Full-text (free): https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13346
C. Development of a Patient Decision
Aid for Syncope in the Emergency Department: the SynDA Tool.
Probst MA, et al. Acad Emerg Med. 2018 Apr;25(4):425-433.
OBJECTIVES: The objective was to develop a patient decision
aid (DA) to promote shared decision making (SDM) for stable, alert patients who
present to the emergency department (ED) with syncope.
METHODS: Using input from patients, clinicians, and experts
in the field of syncope, health care design, and SDM, we created a prototype of
a paper-based DA to engage patients in the disposition decision (admission vs.
discharge) after an unremarkable ED evaluation for syncope. In phase 1, we
conducted one-on-one semistructured exploratory interviews with 10 emergency
physicians and 10 ED syncope patients. In phase 2, we conducted one-on-one
directed interviews with 15 emergency care clinicians, five cardiologists, and
12 ED syncope patients to get detailed feedback on DA content and design. We
iteratively modified the aid using feedback from each interviewee until clarity
and usability had been optimized.
RESULTS: The 11 × 17-inch, paper-based DA, titled SynDA,
includes four sections: 1) explanation of syncope, 2) explanation of future
risks, 3) personalized 30-day risk estimate, and 4) disposition options. The
personalized risk estimate is calculated using a recently published syncope
risk-stratification tool. This risk estimate is stated in natural frequency and
graphically displayed using a 100-person color-coded pictogram.
Patient-oriented questions are included to stimulate dialogue between patient
and clinician. At the end of the development process, patient and physician
participants expressed satisfaction with the clarity and usability of the DA.
CONCLUSIONS: We iteratively developed an evidence-based DA
to facilitate SDM for alert syncope patients after an unremarkable ED
evaluation. Further testing is required to determine its effects on patient
care. This DA has the potential to improve care for syncope patients and
promote patient-centered care in emergency medicine.
Full-text (free): https://onlinelibrary.wiley.com/doi/abs/10.1111/acem.13373
2. Prognosis After ED Intubation to Inform Shared
Decision‐Making
Ouchi K, et al. J Am
Geriatr Soc. 2018 Mar 15 [Epub ahead of print].
OBJECTIVES: To inform
the shared decision-making process between clinicians and older adults and
their surrogates regarding emergency intubation.
DESIGN: Retrospective
cohort study.
SETTING: Multicenter,
emergency department (ED)-based cohort.
PARTICIPANTS: Adults
aged 65 and older intubated in the ED from 2008 to 2015 from 262 hospitals
across the United States (greater than 95% of U.S. nonprofit academic medical
centers).
MEASUREMENTS: Our
primary outcome was age-specific in-hospital mortality. Secondary outcomes were
age-specific odds of death after adjusting for race, comorbid conditions,
admission diagnosis, hospital disposition, and geographic region.
RESULTS: We identified
41,463 ED intubation encounters and included 35,036 in the final analysis.
Sixty-four percent were in non-Hispanic whites and 54% in women. Overall
in-hospital mortality was 33% (95% confidence interval (CI)=34-35%).
Twenty-four percent (95% CI=24-25%) of subjects were discharged to home, and
41% (95% CI=40-42%) were discharged to a location other than home. Mortality
was 29% (95% CI=28-29%) for individuals aged 65 to 74, 34% (95% CI=33-35%) for
those aged 75 to 79, 40% (95% CI=39-41%) for those aged 80 to 84, 43% (95%
CI=41-44%) for those aged 85 to 89, and 50% (95% CI=48-51%) for those aged 90
and older.
CONCLUSION: After
emergency intubation, 33% percent of older adults die during the index
hospitalization. Only 24% of survivors are discharged to home. Simple, graphic
representations of this information, in combination with an experienced
clinician's overall clinical assessment, will support shared decision-making
regarding unplanned intubation.
3. The Effect of Door-to-Diuretic Time on Clinical Outcomes in
Patients with Acute Heart Failure
Park JJ, et al. JACC 2018;6(4):
Objectives This study sought to examine the impact of
door-to-diuretic (D2D) time on mortality in patients with acute heart failure
(AHF) who were presenting to an emergency department (ED).
Background Most patients with AHF present with congestion.
Early decongestion with diuretic agents could improve their clinical outcomes.
Methods The Korea Acute Heart Failure registry enrolled 5,625
consecutive patients hospitalized for AHF. For this analysis, the study
included patients who received intravenous diuretic agents within 24 h after ED
arrival. Early and delayed groups were defined as D2D time ≤60 min and D2D time
over 60 min, respectively. The primary outcomes were in-hospital death and
post-discharge death at 1 month and 1 year on the basis of D2D time.
Results A total of 2,761 patients met the inclusion criteria.
The median D2D time was 128 min (interquartile range: 63 to 243 min), and 663
(24%) patients belonged to the early group. The baseline characteristics were
similar between the groups. The rate of in-hospital death did not differ
between the groups (5.0% vs. 5.1%; p greater than 0.999), nor did the
post-discharge 1-month (4.0% vs. 3.0%; log-rank p = 0.246) and 1-year (20.6% vs.
19.3%; log-rank p = 0.458) mortality rates. Get With the Guidelines-Heart
Failure risk score was calculated for each patient. In multivariate analyses
with adjustment for Get With the Guidelines-Heart Failure risk score and other
significant clinical covariates and propensity-matched analyses, D2D time was
not associated with clinical outcomes.
Conclusions The D2D time was not associated with clinical
outcomes in a large prospective cohort of patients with AHF who were presenting
to an ED.
4. Diphenhydramine should be co-administered with IV prochlorperazine
to prevent akathisia.
Vinson DR, Friedman
BW. Emerg Med J. 2018 Feb 25.
We commend Dr D’Souza
et al for their systematic review of the effects of prophylactic
diphenhydramine in the reduction of akathisia induced by intravenous dopamine
D2 antagonist antiemetics.1 Akathisia is a dysphoric feeling of restlessness
that ranges from mild to severe, the more severe expressions of which can be
quite distressing to patients.2 Attention to its prevention is welcome. We took
particular interest in the systematic review because we led three of the four
studies included in the meta-analysis.2-4
The authors conclude
that adjunct diphenhydramine reduces akathisia when dopamine D2 antagonist
antiemetics are administered over 2 minutes, but diphenhydramine fails to
augment the reduction in akathisia achieved by simply slowing the antiemetic
infusion to 15 minutes. They report moderately high heterogeneity among the
four included studies (I2 =43%).5 This reveals an inconsistency in results
between studies that precludes a one-size-fits-all recommendation on the use of
prophylactic diphenhydramine. Such an elevated I2 requires explanation. The
authors attribute this heterogeneity to rates of infusion and determine that a
15-minute infusion is less likely to cause akathisia.
But another
explanation for the heterogeneity is at hand that the authors did not explore:
prochlorperazine and metoclopramide behave differently when it comes to
akathisia prevention. Their systematic review assumes a drug-class consistency
that is absent in the clinical trials. The meta-analysis includes three studies
of metoclopramide and one of prochlorperazine.1 This combination at first
appears reasonable: both medications are dopamine D2 antagonists and both are
effective in the treatment of migraine and vomiting. However, these two drugs
may not respond the same way to interventions aimed at akathisia prevention.
Slower infusion rates
of metoclopramide are associated with a reduction in akathisia, as multiple
studies have shown.2,6,7 The 15-minute infusion of metoclopramide is
sufficiently effective to render adjunct diphenhydramine redundant: “Routine
prophylaxis with diphenhydramine to prevent akathisia is unwarranted when intravenous
metoclopramide is administered over 15 minutes.”2
One might think that
slowing the infusion rate of prochlorperazine would have a similar
akathisia-reducing effect. The authors mention that “some studies have shown a
lower [extra-pyramidal symptom] incidence with [slower] infusion dosing,”1 then
reference two studies.6,7 Interestingly, both references are studies of
metoclopramide, not prochlorperazine. There are randomized trials of
prochlorperazine that compare slow infusion (15 minutes) with more rapid
administration (2 minutes), but these were not mentioned in the systematic
review.8,9 These studies found that slow infusion of prochlorperazine failed to
reduce akathisia. Such results undermine the conclusion of D’Souza et al that
slow infusion rates reduce akathisia for all dopamine D2 antagonists across the
board. Though a slower infusion rate seems an ineffective method to reduce
prochlorperazine-induced akathisia, prophylactic intravenous diphenhydramine is
effective.10
Until further studies
challenge these unexpected differences between prochlorperazine and
metoclopramide, we advocate the following: when administering intravenous
prochlorperazine, co-administer diphenhydramine to reduce akathisia; slow
infusion is not beneficial. When administering intravenous metoclopramide,
infuse it over 15 minutes; adjunct diphenhydramine is not necessary. This
approach is in sync with the evidence to date and avoids the drug-class
assumption that besets the otherwise helpful review by D’Souza et al.1
The original review: Effects
of prophylactic anticholinergic medications to decrease extrapyramidal side
effects in patients taking acute antiemetic drugs: a systematic review and
meta-analysis. http://emj.bmj.com/content/early/2018/02/03/emermed-2017-206944
5. Defer Urgent Noninvasive Testing in Low-Risk CP Patients
Sun BC. Ann Emerg Med.
2018;71(4):465-6.
To minimize missed
acute coronary syndrome, the American Heart Association endorses noninvasive
cardiac testing (eg, treadmill ECG, stress echocardiogram, stress myocardial
perfusion, coronary computed tomography [CT] angiogram) before discharge or
within 72 hours after discharge, after acute myocardial infarction has been
excluded by serial biomarker tests (Class 2A recommendation).1 The fundamental
assumption is that early identification of obstructive coronary artery disease
may lead to coronary revascularization, with a subsequent reduction in acute
myocardial infarction and cardiac death.
Despite decades of
clinical practice, millions of patients, and billions of health care dollars,
there is no evidence that this approach improves clinical outcomes. Previous
randomized comparisons of testing strategies did not include a “no-test” arm
and were powered on nonclinical outcomes such as health resource use. The
existing literature suggests that physicians collectively overtest patients,2,
3 resulting in false-positive results that in turn lead to higher-risk tests
(eg, invasive coronary angiography) and revascularization procedures, without
evidence of improved clinical outcomes.
Let us focus
specifically on the patient with “low” pretest risk of acute coronary syndrome,
in which the rationale for urgent noninvasive testing seems to be particularly
poor. For the purposes of this argument, I define “low risk” as less than 3%;
this is the pooled prevalence of 30-day death or major cardiac events in
several cohorts of emergency department (ED) chest pain patients, who were
ruled out for acute myocardial infarction with biomarkers and received
noninvasive cardiac testing. This population correlates with low-risk strata of
published risk scores (eg, HEART [history, electrocardiogram, age, risk factors
and troponin] 0 to 3; TIMI [thrombolysis in myocardial infarction] 0 to 1). In
such patients, Bayes’s theorem suggests minimal information gain with a
“normal” test result—that is, the posttest risk of disease—changes from
approximately 3% to somewhat less than 3%. Conversely, an “abnormal” result is
much more likely to represent a false-positive than a true-positive finding. In
a classic article published in 1979, Diamond and Forrester4 predicted that for
young women with a 3% pretest risk of obstructive coronary artery disease, an
abnormal treadmill test result would be falsely positive 24 times for each
true-positive result.
A large and consistent
observational experience from ED chest pain cohorts supports Bayesian
predictions. I summarize 4 studies that are representative of this
literature.5, 6, 7, 8 These pooled cohorts included 7,642 ED patients with
chest pain who received urgent noninvasive cardiac stress testing. There were
915 patients (12%) who had an abnormal stress test result, 233 (3%) who
received invasive coronary angiogram, and 72 (0.9%) who received a cardiac revascularization
procedure. These data highlight several important points. First, a significant
proportion of patients had abnormal noninvasive test results. Second, only one
quarter of abnormal results were followed up with coronary angiogram, which raises
the question, what was the purpose of performing the other three quarters of
noninvasive tests if there was no intent to perform confirmatory testing?
Third, only a tiny proportion of this population received cardiac
revascularization. Although the abnormal test result to revascularization ratio
is “only” 13:1, better than predicted, there is no information about the
appropriateness of revascularization or whether these procedures resulted in
reduced rates of acute myocardial infarction or death.
Several studies have
examined the link between noninvasive testing and clinical outcomes. In an
analysis (which I led) of 895 patients who received early stress testing
matched with 1,790 similar patients without testing, no association was found
between early testing and 30-day death or major cardiac events (odds ratio 1.0;
95% confidence interval 0.6 to 1.7).9 At 224 hospitals, higher rates of
noninvasive testing were correlated with increasing odds of admission, invasive
angiograms, and revascularization without reducing acute myocardial infarction
risk.2 In a retrospective cohort of 421,774 privately insured patients, stress
ECG, stress myocardial perfusion, and coronary CT angiogram were associated
with increased rates of invasive coronary angiograms and revascularization
without reduction in acute myocardial infarction risk, compared with no
testing.3 Of course, there will always be concerns about hidden confounding in
observational data, but the lack of any signal suggesting benefit is striking.
A single randomized
trial provides additional evidence that urgent noninvasive testing can be
deferred for low-risk patients.10 This study randomized 282 ED patients with
suspected acute coronary syndrome to usual care versus a structured decision
aid to identify low-risk patients (ie, low-risk HEART score and normal serial
troponin levels) who could defer subsequent stress testing or angiography.
Despite a 20% physician noncompliance rate in the intervention group (ie,
testing ordered despite protocol recommendation), the intervention reduced
objective testing by 12.1% (P=.048) and length of stay by 12 hours (P=.013). No
patients identified for early discharge experienced serious cardiac outcomes at
30 days.
Bottom line: rule out
acute myocardial infarction with biomarkers in low-risk patients and send them
home without further testing.
6. Helpful Only When Elevated: Initial Serum Lactate in Stable ED
Patients with Sepsis Is Specific, but Not Sensitive for Future Deterioration
Fernando SM, et al. J
Emerg Med. 2018 Mar 13 [Epub ahead of print].
Helpful Only When
Elevated: Initial Serum Lactate in Stable ED Patients with Sepsis Is Specific,
but Not Sensitive for Future Deterioration.
Background: Early
emergency department (ED) identification of septic patients at risk of
deterioration is critical. Lactate is associated with 28-day mortality in
admitted patients, but little evidence exists on its use in predicting
short-term deterioration.
Objective: Our aim was
to determine the role of initial serum lactate for prediction of short-term
deterioration in stable ED patients with suspected sepsis.
Methods: We conducted
a prospective cohort study of adult ED sepsis patients. Venous lactate was
obtained within 2 h of ED arrival. Main outcome was subsequent deterioration
(defined as any of the following: death, intensive care admission over 24 h,
intubation, vasoactive medications for over 1 h, or noninvasive positive
pressure ventilation for over 1 h) within 72 h. Patients meeting any endpoint
within 1 h of arrival were excluded.
Results: Nine hundred
and eighty-five patients were enrolled, of whom 84 (8.5%) met the primary
outcome of deterioration. Initial lactate ≥ 4.0 mmol/L had a specificity of 97%
(95% confidence interval [CI] 94-100%), but a sensitivity of 27% (95% CI
18-37%) for predicting deterioration, with positive and negative likelihood
ratios of 10.7 (95% CI 6.3-18.3) and 0.8 (95% CI 0.7-0.9), respectively. A
lower threshold of lactate (≥2.0 mmol/L) had a sensitivity of 67% (95% CI
55-76%) and specificity of 66% (95% CI 63-69%), with corresponding positive and
negative likelihood ratios of 2.0 (95% CI 1.7-2.3) and 0.5 (95% CI 0.4-0.7).
Conclusions: High ED
lactate is predictive of subsequent deterioration from sepsis within 72 h, and
may be useful in determining disposition, but low lactate is not effective in
screening stable patients at risk of deterioration.
7. Essays from ACEP Now
A. How the Surviving Sepsis Campaign Got Almost Everything
Wrong
Talan DA. ACEP Now.
March 13, 2018
Full-text (free): http://www.acepnow.com/article/opinion-surviving-sepsis-campaign-got-almost-everything-wrong/
B. ACEP Battles Anthem BlueCross BlueShield Policy That
Jeopardizes Prudent Layperson Standard
Wooster L. ACEP Now. March
14, 2018
Since early summer,
ACEP has been working hard on behalf of its members to protect the prudent…
Full-text (free): http://www.acepnow.com/article/acep-battles-anthem-bluecross-blueshield-policy-that-jeopardizes-prudent-layperson-standard/
8. Pneumonia with Negative Chest X-Ray but Positive CT Scan
Allan S. Brett, MD, Journal Watch, reviewing Upchurch
CP et al. Chest 2018 Mar.
These cases appear to be clinically similar to those in
which both x-ray and computed tomography show pneumonia.
Patients who present with suspected pneumonia sometimes
undergo both chest x-ray (CXR) and computed tomography (CT). Occasionally, CXR
is negative but CT suggests pneumonia. In this study, researchers compared
clinical characteristics of CXR-negative, CT-positive patients and patients in
whom pneumonia was visualized by both modalities. The data were obtained from a
previously published study of patients with community-acquired pneumonia who
were admitted to five U.S. hospitals; severely immunosuppressed patients were
excluded (NEJM JW Gen Med Sep 1 2015 and N Engl J Med 2015; 373:415).
All 2251 patients underwent CXR, and one third of them
also underwent CT. Among the 748 patients who underwent both CXR and CT, 87%
had pneumonia on both imaging studies, 9% had pneumonia only on CT, and 4% had
pneumonia only on CXR. Patients with CT-only pneumonia, compared with those
with pneumonia on both imaging studies, had a similar distribution of bacterial
and viral pathogens, similar rates of requiring intensive care, and similar
hospital lengths of stay. In contrast, in patients who were CXR positive but CT
negative for pneumonia, CT depicted nonpneumonia abnormalities in all cases.
COMMENT
This study suggests that patients with CXR-negative,
CT-positive community-acquired pneumonia and patients in whom both CXR and CT
are positive should be managed similarly, given that clinical characteristics
appear to be similar in the two groups. An editorialist advocates wider use of
lung ultrasound for CXR-negative patients in whom pneumonia still is suspected
clinically — but expertise in lung ultrasound is not available routinely in
many clinical settings.
Full-text (free): http://journal.chestnet.org/article/S0012-3692(17)31392-2/fulltext
9. Aortic Dissection Corner
A. Clinical Examination for Acute Aortic Dissection: A
Systematic Review and Meta-analysis.
Ohle R, et al. Acad Emerg Med. 2018
Apr;25(4):397-412.
OBJECTIVES: Acute aortic
dissection is a life-threatening condition due to a tear in the aortic wall. It
is difficult to diagnose and if missed carries a significant mortality.
METHODS: We conducted a
librarian-assisted systematic review of PubMed, MEDLINE, Embase, and the
Cochrane database from 1968 to July 2016. Titles and abstracts were reviewed
and data were extracted by two independent reviewers (agreement measured by
kappa). Studies were combined if low clinical and statistical heterogeneity (I2
less than 30%). Study quality
was assessed using the QUADAS-2 tool. Bivariate random effects meta analyses
using Revman 5 and SAS 9.3 were performed.
RESULTS: We identified 792
records: 60 were selected for full text review, nine studies with 2,400
participants were included (QUADAS-2 low risk of bias, κ = 0.89 [for full-text
review]). Prevalence of aortic dissection ranged from 21.9% to 76.1% (mean ± SD
= 39.1% ± 17.1%). The clinical findings increasing probability of aortic
dissection were 1) neurologic deficit (n = 3, specificity = 95%, positive
likelihood ratio [LR+] = 4.4, 95% confidence interval [CI] = 3.3-5.7, I2 = 0%) and 2) hypotension (n = 4, specificity
= 95%, LR+ = 2.9 95% CI = 1.8-4.6, I2 =
42%), and decreasing probability were the absence of a widened mediastinum (n =
4, sensitivity = 76%-95%, negative likelihood ratio [LR-] = 0.14-0.60, I2 = 93%) and an American Heart Association
aortic dissection detection (AHA ADD) risk score less
than 1 (n = 1, sensitivity = 91%, LR- = 0.22, 95% CI =
0.15-0.33).
CONCLUSIONS: Suspicion for acute
aortic dissection should be raised with hypotension, pulse, or neurologic
deficit. Conversely, a low AHA ADD score decreases suspicion. Clinical gestalt
informed by high- and low-risk features together with an absence of an
alternative diagnosis should drive investigation for acute aortic dissection.
Full-text (free): https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13360
B. High Risk Clinical Features for Acute Aortic Dissection: A
Case-Control Study.
Ohle R, et al. Acad Emerg Med. 2018
Apr;25(4):378-387.
BACKGROUND: Acute aortic
dissection (AAD) is a rare condition with a high mortality that is often
missed. The objective of our study was to assess the diagnostic accuracy of
clinical and laboratory findings for AAD, in confirmed cases of AAD and in a
low-risk control group.
METHODS: This was a
historical matched case-control study: participants were adults over 18 years old
presenting to two tertiary care emergency departments (EDs) or one regional
cardiac referral center. Cases were patients with new ED or in-hospital
diagnosis of nontraumatic AAD confirmed by computed tomography or
echocardiography. Controls were patients with a triage diagnosis of truncal
pain (less than 14 days) and an
absence of a clear diagnosis on basic investigation. Cases and controls were
matched in a 1:4 ratio by sex and age. A sample size of 165 cases and 660
controls was calculated based on 80% power and confidence interval of 95% to
detect an odds ratio of greater than 2.
RESULTS: Data were collected
from 2002 to 2014 yielding 194 cases of AAD and 776 controls (mean ± SD age =
65 ± 14.1 years; 66.7% male). Absence of abrupt-onset pain (sensitivity =
95.9%, negative likelihood ratio = 0.07 [0.03-0.14]) can help rule out AAD.
Presence of tearing/ripping pain (specificity = 99.7%, positive likelihood
ratio [LR+] = 42.1 [9.9-177.5]), aortic aneurysm (specificity = 97.8%, LR+ =
6.35 [3.54-11.42]), hypotension (specificity = 98.7%, LR+ = 17.2 [8.8-33.6]),
pulse deficit (specificity = 99.3, LR+ = 31.1 [11.2-86.6]), neurologic deficits
(specificity = 96.9%, LR+ = 5.26 [2.9-9.3]), and a new murmur (specificity =
97.8%, LR+ = 9.4 [5.5-16.2]) can help rule in the diagnosis of AAD.
CONCLUSIONS: Patients with one or
more high-risk feature should be considered high risk, whereas patients with no
high-risk and multiple low-risk features are at low risk for AAD.
Full-text (free): https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13356
C.
Editorial: Acute Aortic Dissection: Is There Something Better
than Physician Gestalt?
Smith LM, et al. Acad Emerg Med. 2018
Apr;25(4):464-466.
Acute aortic dissection (AAD) represents a high profile
example of a rare, deadly, and expensive to diagnose conditions. It is a
disease that every emergency physician (EP) considers on a daily basis, but
encounters only a handful during a career. Considerable attention has been
given to this disease after the American Heart Association, American College of
Cardiology, and 10 cosponsoring professional societies published the 2010
thoracic aortic disease guidelines to improve the missed or delayed treatment
of AAD.1 The American College of Emergency Physicians followed suit in 2015
with a clinical policy for the evaluation and management of suspected AAD,
although no clear guidance of when AAD should be suspected was provided.2
Driving our profession's conservative approach to the condition is a number of
high‐profile lawsuits and the fact that more than a quarter of patients
presenting with AAD will leave the ED misdiagnosed to suffer catastrophic consequences.1,
3 Still, a growing scrutiny on resource utilization from third‐party payers and
a legitimate concern for harm in overtesting has some in our profession
wondering what degree of diagnostic error is tolerable for AAD. In other words,
is it acceptable that one‐third of patients with a missed diagnosis of AAD will
suffer a bad outcome so long as those missed had atypical presentations? Will
we harm more patients not having the disease if we lower our threshold for
diagnostic workups to catch those exceedingly rare atypical presentations of
AAD. Better yet, will there ever be a validated decision rule to help us rule
out the diagnosis while simultaneously decreasing our resource utilization? To
answer these questions we must first come to a consensus on what constitutes
typical and atypical presentations of AAD and to what extent atypical
presentations are driving our miss rate. Only then will we be able to determine
if realistic, cost‐effective improvements in accuracy are possible.
We commend Ohle et al.4 on a well‐designed study that
provides and improved vantage point of AAD's clinical presentation to North
American EDs. Previous studies have likely misstated the importance of certain
high‐risk features due to a reliance on populations with a high prevalence of
AAD. It appears that this study has successfully narrowed our focus on the
actual patient population that we see on a daily basis. The authors have
reaffirmed much of what we already knew, identified some new high‐risk
features, and perhaps redirected our focus on more specific presentations. For
example, AAD is classically associated with features such as hypertension,
migrating pain, and neurologic deficits, but the authors found that patients
with abrupt onset of pain or hypotension had a higher odds of having the
disease. However, this becomes a bit problematic when our new definition of
typical features for AAD increases the overlap with lethal diagnostic mimics.
Would a reasonable EP be more worried about venous thromboembolism when confronted
with a hypotensive patient with abrupt chest pain instead of the far less
common AAD? When contemplating that question we were not comforted by the
authors' finding that 5% of patients with AAD presented with flank pain, and a
similar percentage of missed AADs were assigned an incorrect diagnosis of renal
colic. The author's findings illustrate a frequently unappreciated and
significant overlap of AAD presentations with more common, and often more
benign, diagnoses. Therefore, we stress the need for realistic expectations for
the performance of a decision aid derived from this study.
Complicating this problem is a lack of clinical features
that effectively rule out AAD. Features previously seen as atypical for AAD
such as palpable tenderness and resolving pain did not significantly lower the
odds of AAD. In fact, the condition most associated with reduced odds of AAD, a
history of ischemic heart disease, is likely a statistical effect from an
alternative diagnosis rather than a protective factor that will assist
clinicians in their decision making. The same can be said for a history of
diabetes, which also significantly lowered the odds of AAD but is unlikely to
reassure EPs facing a mixed clinical picture. In other words, the authors have
done an excellent job of describing the features that are high risk for AAD;
these data are less effective at identifying useful features that rule out the
disease.
The authors hint that the logical next step is the
development of a validated decision tool to assist in the risk stratification
of AAD. We agree to the extent that an effective tool must balance increased
diagnostic yield with increased overtesting. Aside from the difficulties in
recruiting patients with an exceedingly rare disease for a prospective trial,
this study suggests significant challenges in selecting a combination of
clinical features and screening tests that improve our ability to detect
atypical presentations. After all, a decision tool that only reaffirms
physician gestalt for high‐risk presentations is not helpful if it fails to
identify the 20% to 30% atypical presentations that are missed. The challenge
will be to catch the 20% to 30% with atypical presentations without causing
harm from increased costs and radiation exposure. A previous attempt at a
decision rule, the Aortic Dissection Detection Risk Score (AAD‐RS), was derived
from retrospective data on high‐risk patients and failed as a useful tool due
to poor specificity and because patients with low scores still had a 5% chance
of AAD.5, 6 The addition of a chest radiograph seeking mediastinal widening did
not improve the performance of the AAD‐RS. We are unsure how a decision tool
derived from the current study, using a lower‐risk population, would improve on
the AAD‐RS as there is considerable overlap in the high‐risk features such as
abrupt onset, tearing or ripping pain, and hypotension.
The authors have mentioned a combination of historical
features and selective use of D‐dimer testing to rule out low‐risk populations
despite lacking the power to accurately assess this test's performance in AAD.
Our concern with this approach is twofold…
Full-text here: https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13398
10. Images in Clinical Practice
Scleral Discoloration from Minocycline Treatment
ECG Pattern Associated with Left Anterior Descending
Coronary Artery Occlusion
Embolization of Struts from an Inferior Vena Cava Filter
Bouveret’s Syndrome (a variety of gallstone ileus)
Hand, Foot, and Mouth Disease in an Adult
Appendiceal Pinworms
Cutaneous Diphtheria
11. Pediatric Corner
A. Children with Isolated Vomiting
After Head Injury Are Unlikely to Have Intracranial Injuries
Only 0.2% of such children had intracranial injuries.
Borland ML, et al. Vomiting With Head Trauma and Risk of
Traumatic Brain Injury. Pediatrics. 2018 Apr;141(4).
OBJECTIVES: To determine the prevalence of traumatic brain
injuries in children who vomit after head injury and identify variables from
published clinical decision rules (CDRs) that predict increased risk.
METHODS: Secondary analysis of the Australasian Paediatric
Head Injury Rule Study. Vomiting characteristics were assessed and correlated
with CDR predictors and the presence of clinically important traumatic brain
injury (ciTBI) or traumatic brain injury on computed tomography (TBI-CT).
Isolated vomiting was defined as vomiting without other CDR predictors.
RESULTS: Of the 19 920 children enrolled, 3389 (17.0%) had
any vomiting, with 2446 (72.2%) over 2 years of age. In 172 patients with
ciTBI, 76 had vomiting (44.2%; 95% confidence interval [CI] 36.9%-51.7%), and
in 285 with TBI-CT, 123 had vomiting (43.2%; 95% CI 37.5%-49.0%). With isolated
vomiting, only 1 (0.3%; 95% CI 0.0%-0.9%) had ciTBI and 2 (0.6%; 95% CI
0.0%-1.4%) had TBI-CT. Predictors of increased risk of ciTBI with vomiting by
using multivariate regression were as follows: signs of skull fracture (odds
ratio [OR] 80.1; 95% CI 43.4-148.0), altered mental status (OR 2.4; 95% CI
1.0-5.5), headache (OR 2.3; 95% CI 1.3-4.1), and acting abnormally (OR 1.86;
95% CI 1.0-3.4). Additional features predicting TBI-CT were as follows: skull
fracture (OR 112.96; 95% CI 66.76-191.14), nonaccidental injury concern (OR
6.75; 95% CI 1.54-29.69), headache (OR 2.55; 95% CI 1.52-4.27), and acting
abnormally (OR 1.83; 95% CI 1.10-3.06).
CONCLUSIONS: TBI-CT and ciTBI are uncommon in children
presenting with head injury with isolated vomiting, and a management strategy
of observation without immediate computed tomography appears appropriate.
B. UTI Calculator Predicts Risk of
Infant Urinary Tract Infection
Calculator reduces testing and decreases the number of
urinary tract infections that were missed.
TUESDAY, April 17, 2018 (HealthDay News) -- The newly
developed UTICalc calculator can be used to guide testing and treatment in
children with suspected urinary tract infection (UTI), according to a study
published online April 16 in JAMA Pediatrics.
In an effort to develop a calculator that can first estimate
the probability of UTI based on clinical variables and then update that
probability based on laboratory results, Nader Shaikh, M.D., M.P.H., from the
Children's Hospital of Pittsburgh, analyzed electronic medical records from a
training database of 1,686 febrile children (aged 2 to 23 months) presenting to
the emergency department. The calculator was validated using a database of 384
patients.
The researchers found that, compared with the American Academy
of Pediatrics algorithm, the clinical model in UTICalc reduced testing by 8.1
percent and decreased the number of UTIs that were missed from three cases to
none. The dipstick model in UTICalc would have reduced the number of treatment
delays by 10.6 percent compared with empirically treating all children with a
leukocyte esterase test result of ≥1.
"Accurate diagnosis of UTI is important to reduce the
delay in diagnosis and to avoid unnecessary treatment with antimicrobial
drugs," the authors write. "The approach advocated here tailors
testing and treatment to the risk factors present in the child being assessed,
thus offering the potential to improve outcomes for children with UTI."
12. A Predictive Model Facilitates Early Recognition of Spinal
Epidural Abscess in Adults.
Artenstein AW, et al. West J Emerg Med. 2018 Mar;19(2):276-281.
INTRODUCTION: Spinal epidural abscess (SEA), a highly morbid
and potentially lethal deep tissue infection of the central nervous system has
more than tripled in incidence over the past decade. Early recognition at the
point of initial clinical presentation may prevent irreversible neurologic
injury or other serious, adverse outcomes. To facilitate early recognition of
SEA, we developed a predictive scoring model.
METHODS: Using data from a 10-year, retrospective,
case-control study of adults presenting for care at a tertiary-care, regional,
academic medical center, we used the Integrated Discrimination Improvement
Index (IDI) to identify candidate discriminators and created a multivariable
logistic regression model, refined based on p-value significance. We selected a
cutpoint that optimized sensitivity and specificity.
RESULTS: The final multivariable logistic regression model
based on five characteristics -patient age, fever and/or rigor, antimicrobial
use within 30 days, back/neck pain, and injection drug use - shows excellent discrimination
(AUC 0.88 [95% confidence interval {0.84, 0.92}]). We used the model's β
coefficients to develop a scoring system in which a cutpoint of six correctly
identifies cases 89% of the time. Bootstrapped validation measures suggest this
model will perform well across samples drawn from this population.
CONCLUSION: Our predictive scoring model appears to reliably
discriminate patients who require emergent spinal imaging upon clinical
presentation to rule out SEA and should be used in conjunction with clinical
judgment.
Full-text (free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851499/
13. High Prevalence of Sterile Pyuria in the Setting of STI in
Women Presenting to an ED
Shipman SB, et al. West J Emerg Med. 2018 Mar;19(2):282-286.
INTRODUCTION: The clinical presentations for sexually
transmitted infections (STI) and urinary tract infections (UTI) often overlap,
and symptoms of dysuria and urinary frequency/urgency occur with both STIs and
UTIs. Abnormal urinalysis (UA) findings and pyuria are common in both UTIs and
STIs, and confirmatory urine cultures are not available to emergency clinicians
to aid in decision-making regarding prescribing antibiotics for UTIs. The
objective of this study was to determine the frequency of sterile pyuria in
women with confirmed STIs, as well as whether the absolute number of leukocytes
on microscopy or nitrite on urine dipstick correlated with positive urine
cultures in patients with confirmed STIs. We also sought to determine how many
patients with STIs were inappropriately prescribed a UTI antibiotic.
METHODS: We performed a retrospective chart review of
patients aged 18-50 who had a urinalysis and pelvic examination in the
emergency department (including cervical cultures), and tested positive for
Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis. Descriptive
statistics were obtained for all variables, and associations between various
findings were sought using the Fisher's exact test for categorical variables.
We calculated comparison of proportions using the N-1 chi-squared analysis.
RESULTS: A total of 1,052 female patients tested positive
for Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis
and were entered into the database. The prevalence of pyuria in all cases was
394/1,052, 37% (95% confidence interval [CI] [0.34-0.40]). Of the cases with
pyuria, 293/394, 74% (95% CI [0.70-0.78]) had sterile pyuria with negative
urine cultures. The prevalence of positive urine cultures in our study
population was 101/1,052, 9.6% (95% CI [0.08-0.11]). Culture positive urines
had a mean of 34 leukocytes per high-power field, and culture negative urines
had a mean of 24 leukocytes per high-power field, with a difference of 10, (95%
CI [3.46-16.15]), which was statistically significant (p=0.003). Only 123 cases
tested positive for nitrite on the urinalysis dipstick; 50/123, 41% (95% CI
[0.32-0.49]) had positive urine cultures, and 73/123, 59% (95% CI [0.51-0.68])
had negative urine cultures. Nitrite-positive urines were actually 18% more
likely to be associated with negative urine cultures in the setting of positive
STI cases, (95% CI [4.95-30.42], p=0.0048). Antibiotics were prescribed for 295
patients with suspected UTI. Of these, 195/295, 66% (95% CI [0.61-0.71]) had
negative urine cultures, and 100/295, 34% (0.33, 95% CI [0.28-0.39]) had
positive urine cultures. Chi-square analysis yielded a difference of these
proportions of 32% (95% CI [23.92-39.62], p less than 0.0001).
CONCLUSION: This study demonstrated that in female patients
with STIs who have pyuria, there is a high prevalence of sterile pyuria. Our
results suggest that reliance on pyuria or positive nitrite for the decision to
add antimicrobial therapy empirically for a presumed urinary tract infection in
cases in which an STI is confirmed or highly suspected is likely to result in
substantial over-treatment.
Full-text (free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851500/
14. SCAD: The Heart Attack That Strikes Young Women
By Jennifer Clopton. WebMD. March 19, 2018
Christine Shockey suspected she was having a heart attack
when she awoke at 2 a.m. with excruciating pain shooting down her left arm. But
it took medical professionals 5 days to figure it out -- a delay that changed
her health forever.
Shockey went to the ER to have her pain checked out and told
the doctors that 8 days earlier, her 43-year-old sister had a type of heart
attack called spontaneous coronary artery dissection, or SCAD.
The mother of two living in Council Bluffs, IA, was 42 at
the time, a runner with no known health or heart problems. Doctors did an
electrocardiogram (EKG) on Shockey, and the results came back slightly
abnormal. A blood test also found some proteins called troponins in her blood
that are released when heart muscle is damaged during a heart attack.
Despite this, she says doctors diagnosed her with gastric
reflux and anxiety. While they kept her for 2 days, they refused repeated
requests by her family to do an angiogram to get a better look at her heart.
A SCAD heart attack starts with a tear in the wall of an
otherwise normal artery. She was still having arm pain when she was released,
so Shockey went to her primary care doctor. He diagnosed her with shingles --
even though she didn’t have a rash.
With the pain still not going away, Shockey was able to get
an appointment with a doctor the next day at the University of Nebraska Medical
Center at Omaha, just across the Missouri River from Council Bluffs. When he
did an EKG, he immediately announced she was having a heart attack and said
she’d been having it for the last 5 days -- since her symptoms started.
He handed her his personal cellphone before rushing her into
surgery. “He told me to call my husband and tell him goodbye because he wasn’t
sure he could save me,” Shockey says. Her heart was damaged so much, it
couldn't pump the way it should. The main artery to her heart was torn from the
top of her heart to the bottom. Although doctors restored blood flow to it by
using a stent, her heart never fully recovered.
That was in 2015. Two-and-a-half years later, she is back to
work and a fairly normal life, although she still has unexplained chest pain,
takes heart medication, and must avoid vigorous activities that could put too
much pressure on her heart.
“I have had to make some peace with the experience, but
certainly I am angry because I think in my mind, I was simply too young, too
fit, and too female for all of those doctors to recognize what was happening to
me,” Shockey says. “There is no way that if I was a man and I had come in with
those symptoms that I would have been turned away and told you just have
anxiety. I think if I was a man, I would have been taken seriously.”
What
Is SCAD?
Unlike a more typical heart attack caused by a rupture of
plaque in the arteries, a SCAD heart attack starts with a tear in the wall of
an otherwise normal artery. The tear tunnels within the wall of the artery, and
its effect blocks the artery and blood flow to the heart muscles, leading to a
heart attack.
Although SCAD causes a small percentage of heart attacks
overall, it’s responsible for 40% of heart attacks in women under the age of
50. And it mostly happens to women -- more than 90% of SCAD patients are
female.
“This is an important cause of heart attacks among younger
people, and it has really only been in the past 4 or 5 years that our thinking
on it has changed. For the past 100 years, we had been missing it,” says
Sharonne N. Hayes, MD, of the Mayo Clinic in Minnesota -- a renowned SCAD
researcher.
Many researchers have been rushing to learn more about SCAD
and are starting to better understand how it works and how to treat it. The
American Heart Association released the first scientific statement about the
condition in February. The 35-page document reviews relevant research and says,
among other things, that conservative treatment is generally best. There isn’t
yet enough high-quality evidence on the condition to write guidelines for
treatment…
The rest of the essay (free): https://www.webmd.com/heart-disease/news/20180319/scad-heart-attack-strikes-young-women
Hayes SN, et al; SCAD: Current State of the Science: A Scientific Statement From the AHA.
Circulation. 2018 Feb 22 [Epub
ahead of print]. http://circ.ahajournals.org/content/early/2018/02/21/CIR.0000000000000564.long
(select “Download pdf”
15. ED Management Issues
A. A Novel Approach to Addressing an
Unintended Consequence of Direct to Room: The Delay of Initial Vital Signs
Basile J, et al. West J Emerg Med. 2018 Mar;19(2):254-258.
INTRODUCTION: The concept of "direct to room"
(DTR) and "immediate bedding" has been described in the literature as
a mechanism to improve front-end, emergency department (ED) processing. The
process allows for an expedited clinician-patient encounter. An unintended
consequence of DTR was a time delay in obtaining the initial set of vital signs
upon patient arrival.
METHODS: This retrospective cohort study was conducted at a
single, academic, tertiary-care facility with an annual census of 94,000
patient visits. Inclusion criteria were all patients who entered the ED from
11/1/15 to 5/1/16 and between the hours of 7 am to 11 pm. During the
implementation period, a vital signs station was created and a personal care
assistant was assigned to the waiting area with the designated job of obtaining
vital signs on all patients upon arrival to the ED and prior to leaving the
waiting area. Time to first vital sign documented (TTVS) was defined as the
time from quick registration to first vital sign documented.
RESULTS: The pre-implementation period, mean TTVS was 15.3
minutes (N= 37,900). The post-implementation period, mean TTVS was 9.8 minutes
(N= 39,392). The implementation yielded a 35% decrease and an absolute
reduction in the average TTVS of 5.5 minutes (p less than 0.0001).
CONCLUSION: This study demonstrated that the coupling of
registration and a vital signs station was successful at overcoming delays in
obtaining the time to initial vital signs.
Full-text (free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851496/
B. Is ED hallway care dangerous? An
observational study
Rixe J, et al. Amer J Emerg Med. 2018 April 6 [Epub ahead of
print].
Objectives
In response to crowding the use of hallway beds has become
an increasingly prevalent practice in Emergency Departments (EDs). There is
limited research on whether caring for patients in hallways (HP) is associated
with adverse outcomes. The goal of this study was to examine the effects of HP
triage on 30 day outcomes for ED return, readmission, and mortality.
Methods
We performed a retrospective cohort study at an urban,
academic ED comparing HPs (defined as HP for ≥30 min) to matched controls
triaged to standard ED beds from 9/30/14 to 10/1/15. We analyzed data from the
hospital's clinical data warehouse. Matched controls were selected by gender,
age, ethnicity, and language. We used McNemar's test to assess the association
between triage location and 30 day study outcomes. We also examined adverse
outcomes by triage severity using McNemar's test.
Results
A total of 10,608 HPs were matched to control patients.
Compared to controls, HPs had 2.0 times the odds of returning to the ED in
30 days (95% CI: 1.8–2.1), 1.6 times the odds of inpatient readmission (95% CI:
1.4–1.9), and 1.7 times the odds of readmission to observation (95% CI: 1.4–2.0).
The odds ratio for mortality in HPs versus controls was 0.80, (95% CI:
0.50–1.3).
Conclusions
Patients initially triaged to the hallway have an increased
odds of 30 day return to the ED, observation and inpatient admission. After
adjusting for ESI, the increased odds for return remained similar. The small
sample size precluded testing effects of HP status on mortality.
16. Use an As-Needed Antivenom Dosing Strategy for Rattlesnake
Bites
It saves antivenom and leads to shorter hospital stays
Spyres MB et al. Crit Care Med 2018 Mar 7
Objectives: This study compares maintenance with clinical-
and laboratory-triggered (as-needed [PRN]) antivenom dosing strategies with
regard to patient-centered outcomes after rattlesnake envenomation.
Design: This is a retrospective cohort study of adult
rattlesnake envenomations treated at a regional toxicology center. Data on
demographics, envenomation details, antivenom administration, length of stay,
and laboratory and clinical outcomes were compared between the PRN and
maintenance groups. Primary outcomes were hospital length of stay and total
antivenom used, with a hypothesis of no difference between the two dosing
strategies.
Setting: A single regional toxicology center
Patients: Three-hundred ten adult patients envenomated by
rattlesnakes between 2007 and 2014 were included. Patients were excluded if no
antivenom was administered or for receiving an antivenom other than Crofab (BTG
International, West Conshohocken, PA).
Interventions: This is a retrospective study of rattlesnake
envenomations treated with and without maintenance antivenom dosing.
Main Results: One-hundred forty-eight in the maintenance
group and 162 in the PRN group were included. There was no difference in
demographics or baseline envenomation severity or hemotoxicity (32.7% vs 40.5%;
respectively; p = 0.158) between the two groups. Comparing the PRN with the
maintenance group, less antivenom was used (8 [interquartile range, 6–12] vs 16
[interquartile range, 12–18] vials, respectively; p less than 0.001), and
hospital length of stay was shorter (27 hr [interquartile range, 20–44 hr] vs
34 hr [interquartile range, 24–43 hr], respectively; p = 0.014). There were no
differences in follow-up outcomes of readmission, retreatment, or bleeding and
surgical complications.
Conclusions: Hospital length of stay was shorter, and less
antivenom was used in patients receiving a PRN antivenom dosing strategy after
rattlesnake envenomation.
17. Oral Nitroglycerin Solution May Be Effective for Esophageal
Food Impaction.
Willenbring BA, et al. J Emerg Med. 2018 Mar 5 [Epub ahead
of print].
BACKGROUND: Esophageal food impaction is a common illness
presenting to emergency departments (ED), and is frequently resistant to
pharmacologic therapy. Several medications have been promoted for this
indication, but so far have not proven effective. Endoscopic removal is
frequently required to resolve the impaction, resulting in risks from
anesthesia and the physical procedure, and in prolonged hospital stay for
recovery. Oral nitroglycerin solution was recently used in two such cases and
may represent a new therapeutic option.
CASE REPORTS: A 49-year-old man presented to an ED with
dysphagia 30 min after eating steak. He was given 0.4 mg nitroglycerin
dissolved in 10 mL tap water orally, and obtained complete relief of symptoms
within 2 min. A 43-year-old man with eosinophilic esophagitis and two prior
food impaction episodes presented to a community ED with dysphagia and
epigastric discomfort 110 min after eating steak. Five hours after symptom
onset and after failure of intravenous glucagon, he was given 0.4 mg
nitroglycerin sublingually, which resulted in headache but no relief in
dysphagia. Twenty-nine minutes later he received 0.4 mg nitroglycerin solution,
as above, with symptom resolution within 2 min.
WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The
cases presented above demonstrate close temporal relationships between
administration of oral nitroglycerin solution and symptom relief. Oral
nitroglycerin solution for esophageal food impaction seemed effective in these
cases, but further research on this therapeutic option is warranted.
18. Facing the Shortage of IV Fluids — A Hospital-Based Oral
Rehydration Strategy
Patiño AM, et al. N Engl J Med 2018 Apr
19;378(16):1475-1477.
Puerto Rico produces 44% of the intravenous (IV) fluid bags
used in the United States.1 On September 20, 2017, Hurricane Maria struck the
island, causing a humanitarian crisis and widespread devastation that escalated
a critical shortage of IV fluids throughout the United States. Initially,
small-volume bags — 50- and 100-ml bags used to dilute medications — became
scarce. Today, the larger 500- and 1000-ml IV-fluid bags are also in short
supply. U.S. hospitals are scrambling to develop strategies for rationing IV
fluids to ensure availability for the patients who need them most.
Hurricane Maria is only the latest challenge to the U.S.
IV-fluid supply. Since 2014, U.S. hospitals have faced varying degrees of
IV-fluid shortages, whose causes were multifactorial. IV-fluid production is
complex and highly regulated in order to ensure quality and safety, which makes
it expensive for hospitals and compounding pharmacies to produce their own.
Most of the IV fluid used in the United States is produced by only three
manufacturers, so availability is vulnerable to even small fluctuations in
supply. In addition, hospitals buy IV fluids through large group-purchasing
organizations representing hundreds of hospitals so that they can negotiate
with manufacturers for lower prices or better access to scarce resources. Some
observers argue that these organizations’ market power keeps prices so low that
they create a disincentive for manufacturers to increase production or for
small producers to enter the market.2
Given these supply-side constraints, the U.S. IV-fluid
supply will be vulnerable for the foreseeable future. It is therefore critical
for U.S. hospitals to develop both short- and long-term alternatives to
IV-fluid use.
Emergency departments (EDs) are substantial consumers of IV
fluids in the United States. The 59-bed ED at Brigham and Women’s Hospital
treats more than 62,000 adult patients each year and, in the 5 months from
September 2017 through January 2018, used 8519 liters of IV fluids — nearly 30%
of the hospital’s total consumption. As the current IV-fluid shortage worsened,
the team in the Division of International Emergency Medicine and Humanitarian
Programs of the Department of Emergency Medicine was asked to develop an oral
rehydration protocol for ED patients with mild dehydration. The protocol
outlined in the box has since been adopted hospital-wide.
BRIGHAM AND WOMEN’S HOSPITAL ORAL REHYDRATION PROTOCOL
Use for patients with mild dehydration — in general,
patients with the following conditions:
• Acute gastroenteritis
• Pregnancy-related hyperemesis
• Mild viral upper respiratory infection or pharyngitis
Exclusion Criteria:
• Moderate or severe dehydration
• Inability to receive oral intake for another reason
Protocol Steps:
Order oral rehydration fluids in the electronic health
record (EHR); add antiemetic, pain control, or both if needed. Consider
benzocaine or menthol lozenges in addition to acetaminophen or ibuprofen for
pharyngitis. If there is significant nausea or pain, wait 20 min after
medications to begin drinking (can start immediately otherwise).
The EHR order will direct the nurse to bring the patient two
500-ml pitchers of desired drink (flavored oral electrolyte solution or dilute
sports drink or juice).
• Provide patient with straw as well as 30-ml medicine cup.
• Instruct patient to drink two large sips or 30 ml every
3–5 min. Use timers on cell phones or ask family to assist.
• Explain target hydration goals (see below) and provide a
tracking sheet. Draw lines on pitcher for target volumes (e.g., “250 ml left”).
Patient or family member should complete the tracking sheet.
• Return to reencourage oral intake as needed.
Troubleshooting:
• If oral intake is insufficient, determine why and give
additional antiemetic, pain control, or both as needed.
• If taste is a problem and dehydration mild (or not due to
gastroenteritis), consider alternative liquid options, such as half-strength
sports drink, dilute juice, or ginger ale.
For pregnancy-related hyperemesis, oral intake can often
help. Encourage patients to try to eat a few crackers if possible.
Target Hydration Goals*:
Target times are given for the amount of liquid remaining at
2 sips or 30 ml every 3 min (or every 5 min)
• 1000 ml remaining: 0 min (0 min)
• 750 ml remaining: 25 min (40 min)
• 500 ml remaining: 50 min (1 hr 20 min)
• 250 ml remaining: 1 hr 15 min (2 hr)
• 0 ml remaining: 1 hr 40 min (2 hr 40 min)
* Patients with vomiting should be encouraged to maintain a
slower rate of intake until they tolerate the fluid well. Patients without
vomiting can drink faster, as tolerated. After an intake of 250 ml has been
successfully completed without vomiting, and if nausea is well controlled,
intake can increase to four sips or 60 ml every 3–5 min…
Conclusion
We share this protocol as a replicable model for other U.S.
hospitals looking for strategies during the IV-fluid shortage. Experience in
low-resource settings worldwide has proven the efficacy of oral rehydration
therapy, and vulnerabilities of the U.S. IV-fluid supply chain are expected to
continue. We believe that widespread use of oral rehydration protocols would
therefore be a rational practice change and a mainstream model for use in the
United States even after the current IV-fluid shortage crisis ends.
The rest of the study (free): http://www.nejm.org/doi/full/10.1056/NEJMp1801772
19. Clinical decision support increases diagnostic yield of CT
for suspected PE
Mills AM, et al. Am J Emerg Med. 2018;36(4):540-44.
OBJECTIVE: Determine effects of evidence-based clinical
decision support (CDS) on the use and yield of computed tomographic pulmonary
angiography for suspected pulmonary embolism (CTPE) in Emergency Department
(ED) patients.
METHODS: This multi-site prospective quality improvement
intervention conducted in three urban EDs used a pre/post design. For ED
patients aged 18+years with suspected PE, CTPE use and yield were compared
19months pre- and 32months post-implementation of CDS intervention based on the
Wells criteria, provided at the time of CTPE order, deployed in April 2012.
Primary outcome was the yield (percentage of studies positive for acute PE).
Secondary outcome was utilization (number of studies/100 ED visits) of CTPE.
Chi-square and statistical process control chart assessed pre- and
post-intervention differences. An interrupted time series analysis was also
performed.
RESULTS: Of 558,795 patients presenting October
2010-December 2014, 7987 (1.4%) underwent CTPE (mean age 52±17.5years, 66%
female, 60.1% black); 34.7% of patients presented pre- and 65.3% post-CDS
implementation. Overall CTPE diagnostic yield was 9.8% (779/7987 studies
positive for PE). Yield increased a relative 30.8% after CDS implementation
(8.1% vs. 10.6%; p=0.0003). There was no statistically significant change in
CTPE utilization (1.4% pre- vs. 1.4% post-implementation; p=0.25). A
statistical process control chart demonstrated immediate and sustained
improvement in CTPE yield post-implementation. Interrupted time series analysis
demonstrated the slope of PE findings versus time to be unchanged before and
after the intervention (p=0.9). However, there was a trend that the
intervention was associated with a 50% increased probability of PE finding
(p=0.08), suggesting an immediate rather than gradual change after the
intervention.
CONCLUSIONS: Implementing evidence-based CDS in the ED was
associated with an immediate, significant and sustained increase in CTPE yield
without a measurable decrease in CTPE utilization. Further studies will be
needed to assess whether stronger interventions could further improve
appropriate use of CTPE.
20. IV Continuous Infusion vs. Oral Immediate-release Diltiazem
for Acute Heart Rate Control in AF
Means KN, et al. West J Emerg Med. 2018 Mar;19(2):417-422.
INTRODUCTION: Atrial fibrillation (AF) is a common diagnosis
of patients presenting to the emergency department (ED). Intravenous (IV)
diltiazem bolus is often the initial drug of choice for acute management of AF
with rapid ventricular response (RVR). The route of diltiazem after the initial
IV loading dose may influence the disposition of the patient from the ED.
However, no studies exist comparing oral (PO) immediate release and IV
continuous infusion diltiazem in the emergency setting. The objective of this
study was to compare the incidence of treatment failure, defined as a heart
rate (HR) of above 110 beats/min at four hours or conversion to another agent,
between PO immediate release and IV continuous infusion diltiazem after an
initial IV diltiazem loading dose in patients in AF with RVR.
METHODS: This was a single-center, observational,
retrospective study conducted at a tertiary academic medical center. The study
population included patients ≥18 years old who presented to the ED in AF with a
HR above 110 beats/min and received an initial IV diltiazem loading dose. We
used multivariate logistic regression to assess the association between routes
of administration and treatment failure.
RESULTS: A total of 111 patients were included in this
study. Twenty-seven percent (11/41) of the patients in the PO immediate-release
group had treatment failure compared to 46% (32/70) in the IV
continuous-infusion group. The unadjusted odds ratio (OR) of treatment failure
with PO was less than IV at 0.4 (95% confidence interval [CI] [0.18, 0.99], p =
0.046). When we performed a multivariate analysis adjusted for race and initial
HR, PO was still less likely to be associated with treatment failure than IV
with an OR of 0.4 (95% CI [0.15, 0.94], p = 0.041). The median dose of PO
diltiazem and IV continuous infusion diltiazem at four hours was 30 mg and 10
mg/h, respectively.
CONCLUSION: After a loading dose of IV diltiazem, PO
immediate-release diltiazem was associated with a lower rate of treatment
failure at four hours than IV continuous infusion in patients with AF with RVR.
Full-text (free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851520/
21. Micro Bits
A.
Film Shines Light on Deadly Errors in Medicine
Death toll in U.S. as high as 440,000 per year
by Ian Ingram, Deputy Managing Editor, MedPage Today. April
06, 2018
Can a film help shift the conversation on reducing deadly
errors in medicine?
The documentary To Err
Is Human, which is currently in previews and opens to wide release in the
fall, attempts to answer that question, highlighting the obstacles,
consequences, and attempts to address the myriad factors on both the
institutional and individual level responsible for errors in medicine.
"It's a massive topic to address," said director
Mike Eisenberg, following a recent screening of his film…
Between interviews with experts in the field of patient
safety, To Err Is Human weaves in the
story of Susan Sheridan, whose family's intersection with the healthcare system
was met with two medical errors.
First, jaundice (a sign of too-high bilirubin) in her
newborn son, Cal, was ignored and led to brain damage and development of
cerebral palsy. Sheridan's experience led her to become a patient-safety
advocate. Today hospitals routinely tests for elevated bilirubin.
Years later her husband Patrick was diagnosed with and
treated for a benign brain tumor. Additional tests from pathology had revealed
a malignant tumor, yet this was never communicated to Patrick's physician. Left
untreated, the disease aggressively spread until it was too late. He died in
2002.
While the plan is for wide release in the fall, the trailer
is now available online and various upcoming screenings have been scheduled in
select cities -- including Cleveland on Monday, Tuesday and Wednesday next
week, and Philadelphia on April 20. The latter will include a panel discussion.
Trailer: https://vimeo.com/258832591
B.
Can Coffee Rev Up Your Workout? It May Depend on Your Genes
Author New York Times 2018 March 24
C.
Federal Efforts To Control Rare And Deadly Bacteria Working
The CDC is trying to stop E. coli and other bacteria that
have become resistant to antibiotics because they can cause a deadly infection.
D.
SIGECAPS, SSRIs, and Silence — Life as a Depressed Med Student
E.
Is chronic pain something more people should accept?
Amid the opioid crisis, the concept of “pain acceptance” is
gaining credibility.
Clare Foran. April 4, 2018. The Outline.
Research dating back more than a decade suggests that people with chronic pain may be able to
improve their quality of life if they stop trying to avoid or get rid of their
pain and instead learn to live as well as they can as the pain persists, a
concept referred to in clinical settings as pain acceptance. Some psychologists
and psychiatrists believe that pain acceptance might even help counteract
opioid abuse in the United States, a problem so severe that it has contributed
to a decline in American life expectancy. The idea that pain acceptance might
serve as an effective alternative to opioids is an emerging area of research
and not something that has been definitively established. As the idea attracts
attention in the world of pain management and in the media, it has also
generated controversy.
F.
Meal Delivery Linked To Fewer Emergency Room Visits, Lower Monthly Medical
Costs
Delivering meals, especially meals tailored to recipients’
medical needs, can reduce the use of costly health services among people
eligible for both Medicare and Medicaid. With medical issues and poverty making
them dually eligible for Medicare and Medicaid, this population is at high risk
of experiencing food insecurity and its associated costs, according to a new
study published in Health Affairs.
G.
Systematic review of presentation, management and prognosis idiopathic systemic
capillary leak syndrome
The idiopathic systemic capillary leak syndrome is
characterized by unexplained recurrent shock caused by capillary
hyperpermeability. This systematic review of the literature analyzed clinical
and laboratory data, treatment modalities, and mortality rate of patients. Two
hundred sixty-three published cases were reviewed. Patients had hypotension
(81.4%), edema (64.6%), and previous flu-like illness (34.2%). This disease was
misdiagnosed as hypovolemic shock, septic shock, polycythemia vera, or
angioedema. Twenty-three percent of cases were fatal. There were significant
differences in the survival rates between patients who were treated with
prophylactic beta-2 agonists, methylxanthines, and intravenous immunoglobulins
versus those who were not. The estimated one-, five-, and 10-year survival rate
of patients treated with intravenous immunoglobulins was 100%, 94%, and 94%,
respectively.
H.
Relationship between Clinic and Ambulatory Blood-Pressure Measurements and
Mortality.
Conclusions Ambulatory blood-pressure measurements were a
stronger predictor of all-cause and cardiovascular mortality than clinic
blood-pressure measurements. White-coat hypertension was not benign, and masked
hypertension was associated with a greater risk of death than sustained
hypertension.
I.
Some Caffeinated Beverages May Reduce Frequency Of Arrhythmias
HealthDay (4/16, Reinberg, 6K) reports that investigators
analyzed data from eight studies. The researchers “found that, among more than
228,000 patients, drinking coffee cut the frequency of episodes of atrial
fibrillation by 6 percent.” Meanwhile, “a further analysis of nearly 116,000
patients found a 13 percent risk reduction.” The investigators also “found that
caffeine had no effect on abnormal heartbeats in the lower chambers of the
heart, called ventricular arrhythmias.” The findings were published in JACC:
Clinical Electrophysiology.
J.
Physicians’ political preferences and the delivery of end of life care in the
United States
This study provided no evidence that physician political
affiliation is associated with the intensity of end of life care received by
patients in hospital. Other treatments for politically polarised healthcare
issues should be investigated.
K.
Lidocaine patch for back pain? Not helpful.
Palmer TR. Am Fam Physician. 2017 Nov 15;96(10):online.
I appreciated the excellent review of vertebral compression
fractures (VCFs) by Drs. McCarthy and Davis. The text of the article and Table
1 stated that lidocaine patches are an option for pain relief. However, the
best evidence does not show any benefit from lidocaine 5% patches compared with
placebo for somatic back pain.
There are no published randomized controlled trials (RCTs)
of lidocaine patches for pain from VCFs. However, two unpublished RCTs showed
no significant difference between placebo patches and lidocaine 5% patches for
low back pain.1,2 Another RCT showed no significant difference between placebo
and lidocaine patches for chronic low back pain.3 A final RCT showed no
improvement in pain control with lidocaine patches vs. placebo for traumatic
rib fractures.4
At a cost of $220 per month and with an over-the-counter
lidocaine 4% patch now available, the lidocaine 5% patch is an expensive
placebo for our patients.
L.
Prolonged Zika Virus Shedding in Semen of Symptomatic Infected Men
M.
Just 40% Of All Concussions In Children Result From Contact Sports, Researchers
Say.
Medscape (4/11, Brooks, Subscription Publication, 304K)
reports that “only 40% of all concussions in children” are “from contact
sports, including football, soccer, basketball, and hockey,” researchers found.
The findings, which were published online in the Journal of Pediatrics, suggest
that “strategies to prevent such injuries in children will have to extend
outside youth sports, the researchers say.”
Full-text (free): http://www.jpeds.com/article/S0022-3476(18)30167-7/fulltext
N.
Report: Ischemic heart disease top cause of death
A report in the Journal of the American Medical Association
said ischemic heart disease was the leading cause of death in the US from 1990
to 2016, while the overall mortality rate decreased. There were wide
disparities in disease burden, with increases in opioid use disorders and
decreases in breast cancer mortality, while high blood pressure, blood glucose
and body mass index, along with poor diet and alcohol and drug use, each
accounted for more than 5% of risk-attributable disability-adjusted life years
in 2016.
O.
Seven tips for mastering the art of medicine
Link: https://www.aafp.org/journals/fpm/blogs/inpractice/entry/art-of-medicine.html?cmpid=em_FPM_20180411
P.
TXA Superior to Packing for Epistaxis,
and Patients Like It Better.
Ballard DW, et al. Emerg Med
News. 2018;40(4):1,32.
Q.
Scientists Identify Interstitium As An Organ For First Time.
TIME (3/27, Park, 19.51M) reports scientists have proposed
there is an organ called the interstitium “that may play a critical role in how
many tissues and other organs do their jobs, as well as in some diseases.” The
article explains that the interstitium “is a series of connected, fluid-filled
spaces found under skin as well as throughout the gut, lungs, blood vessels and
muscles.” Newsweek (3/27, Gander, 1.67M) reports the study, which was published
in Scientific Reports, marks the “first time” that the interstitium “has been
identified as an organ.”
Scientific Reports: https://www.nature.com/articles/s41598-018-23062-6
