1. New Stroke Literature
A. Tenecteplase better than Alteplase before Thrombectomy for
Ischemic Stroke
Campbell BCV, et al. N
Engl J Med. 2018 Apr 26;378(17):1573-1582.
BACKGROUND: Intravenous
infusion of alteplase is used for thrombolysis before endovascular thrombectomy
for ischemic stroke. Tenecteplase, which is more fibrin-specific and has longer
activity than alteplase, is given as a bolus and may increase the incidence of
vascular reperfusion.
METHODS: We randomly
assigned patients with ischemic stroke who had occlusion of the internal
carotid, basilar, or middle cerebral artery and who were eligible to undergo
thrombectomy to receive tenecteplase (at a dose of 0.25 mg per kilogram of body
weight; maximum dose, 25 mg) or alteplase (at a dose of 0.9 mg per kilogram;
maximum dose, 90 mg) within 4.5 hours after symptom onset. The primary outcome
was reperfusion of greater than 50% of the involved ischemic territory or an
absence of retrievable thrombus at the time of the initial angiographic
assessment. Noninferiority of tenecteplase was tested, followed by superiority.
Secondary outcomes included the modified Rankin scale score (on a scale from 0
[no neurologic deficit] to 6 [death]) at 90 days. Safety outcomes were death
and symptomatic intracerebral hemorrhage.
RESULTS: Of 202
patients enrolled, 101 were assigned to receive tenecteplase and 101 to receive
alteplase. The primary outcome occurred in 22% of the patients treated with
tenecteplase versus 10% of those treated with alteplase (incidence difference,
12 percentage points; 95% confidence interval [CI], 2 to 21; incidence ratio,
2.2; 95% CI, 1.1 to 4.4; P=0.002 for noninferiority; P=0.03 for superiority).
Tenecteplase resulted in a better 90-day functional outcome than alteplase
(median modified Rankin scale score, 2 vs. 3; common odds ratio, 1.7; 95% CI,
1.0 to 2.8; P=0.04). Symptomatic intracerebral hemorrhage occurred in 1% of the
patients in each group.
CONCLUSIONS: Tenecteplase
before thrombectomy was associated with a higher incidence of reperfusion and
better functional outcome than alteplase among patients with ischemic stroke
treated within 4.5 hours after symptom onset.
B. MRI-Guided Thrombolysis for Stroke with Unknown Time of
Onset
Thomalla G, et al. N
Engl J Med 2018 May 16 [Epub ahead of print]
INTRO
Intravenous
thrombolysis with alteplase, a recombinant tissue plasminogen activator, is the
standard medical treatment for acute ischemic stroke within 4.5 hours after the
onset of symptoms. In 14 to 27% of strokes, the time of symptom onset is not
known, frequently because stroke symptoms are recognized when the patient
awakes from sleeping. Such patients are generally excluded from treatment with
intravenous alteplase, and only some of them are candidates for mechanical
thrombectomy.
A substantial
proportion of strokes that are evident after sleep probably occur in the last
few hours before awakening, which would be within the approved time window for
the use of intravenous thrombolysis. Magnetic resonance imaging (MRI) in
patients with stroke with a known time of symptom onset has identified the
presence of a visible ischemic lesion on diffusion-weighted imaging, combined
with the absence of a clearly visible hyperintense signal in the same region on
fluid-attenuated inversion recovery (FLAIR), as predictive of symptom onset
within 4.5 hours before imaging. We conducted the Efficacy and Safety of
MRI-Based Thrombolysis in Wake-Up Stroke (WAKE-UP) trial to determine whether
treatment with alteplase would improve functional outcomes in patients with an
unknown time of stroke onset and a mismatch between diffusion-weighted imaging
and FLAIR findings on MRI.
BACKGROUND
Under current guidelines,
intravenous thrombolysis is used to treat acute stroke only if it can be
ascertained that the time since the onset of symptoms was less than 4.5 hours.
We sought to determine whether patients with stroke with an unknown time of
onset and features suggesting recent cerebral infarction on magnetic resonance
imaging (MRI) would benefit from thrombolysis with the use of intravenous
alteplase.
METHODS
In a multicenter
trial, we randomly assigned patients who had an unknown time of onset of stroke
to receive either intravenous alteplase or placebo. All the patients had an
ischemic lesion that was visible on MRI diffusion-weighted imaging but no
parenchymal hyperintensity on fluid-attenuated inversion recovery (FLAIR),
which indicated that the stroke had occurred approximately within the previous
4.5 hours. We excluded patients for whom thrombectomy was planned. The primary
end point was favorable outcome, as defined by a score of 0 or 1 on the
modified Rankin scale of neurologic disability (which ranges from 0 [no
symptoms] to 6 [death]) at 90 days. A secondary outcome was the likelihood that
alteplase would lead to lower ordinal scores on the modified Rankin scale than
would placebo (shift analysis).
RESULTS
The trial was stopped
early owing to cessation of funding after the enrollment of 503 of an
anticipated 800 patients. Of these patients, 254 were randomly assigned to
receive alteplase and 249 to receive placebo. A favorable outcome at 90 days
was reported in 131 of 246 patients (53.3%) in the alteplase group and in 102
of 244 patients (41.8%) in the placebo group (adjusted odds ratio, 1.61; 95%
confidence interval [CI], 1.09 to 2.36; P=0.02). The median score on the
modified Rankin scale at 90 days was 1 in the alteplase group and 2 in the
placebo group (adjusted common odds ratio, 1.62; 95% CI, 1.17 to 2.23;
P=0.003). There were 10 deaths (4.1%) in the alteplase group and 3 (1.2%) in
the placebo group (odds ratio, 3.38; 95% CI, 0.92 to 12.52; P=0.07). The rate
of symptomatic intracranial hemorrhage was 2.0% in the alteplase group and 0.4%
in the placebo group (odds ratio, 4.95; 95% CI, 0.57 to 42.87; P=0.15).
CONCLUSIONS
In patients with acute
stroke with an unknown time of onset, intravenous alteplase guided by a
mismatch between diffusion-weighted imaging and FLAIR in the region of ischemia
resulted in a significantly better functional outcome and numerically more
intracranial hemorrhages than placebo at 90 days.
C. AHA Rescinds Large Sections of New Stroke Guidelines
Sue Hughes. Medscape. April
27, 2018
In a somewhat bizarre
turn of events, the American Heart Association (AHA)/American Stroke
Association (ASA) has rescinded its recently released stroke guidelines,
publishing a "correction" in which large parts of the document have
been deleted.
A new paper, published
online in Stroke on April 18, states: "Based on recent feedback received
from the clinical stroke community…the American Heart Association/American
Stroke Association has reviewed the guideline and is preparing clarifications,
modifications, and/or updates to several sections in it. Currently, those
sections, listed here, have been deleted from the guideline while this
clarifying work is in process."
The AHA/ASA adds:
"After review, a revised guideline, with consideration given to the
clarifications, modifications, and/or updates of the sections noted above, will
be posted over the coming weeks."
The sections that have
been deleted are the following:
Section 1.3: EMS
Systems Recommendation 4
Section 1.4: Hospital
Stroke Capabilities Recommendation 1
Section 1.6:
Telemedicine Recommendation 3
Section 2.2: Brain
Imaging Recommendation 11
Section 3.2: Blood
Pressure Recommendation 3
Section 4.3: Blood
Pressure Recommendation 2
Section 4.6: Dysphagia
Recommendation 1
Section 6.0: All
subsections
The rescinding of the
guidelines was done without the agreement of the Guideline Writing Committee.
Chair of the Guideline
Writing Committee, William J Powers, MD, H Houston Merritt Distinguished
Professor and Chair, Department of Neurology, University of North Carolina at
Chapel Hill, told Medscape Medical News: "This action by the AHA was carried
out against the strongly voiced opposition and without the agreement of the
majority of the 2018 Acute Ischemic Stroke Writing Group."
He added that he was
"surprised and disappointed" by the way the AHA/ASA had handled the
situation.
Commenting for
Medscape Medical News, Mark Alberts, MD, chief of neurology, Hartford Hospital,
Connecticut, said, "I don't think this has ever happened before. This is a
challenging and unfortunate situation.
It's not good for anyone — the AHA, the guidelines writing committee, or
the patients." …
Full-text of AHA corrections
(free): http://stroke.ahajournals.org/content/early/2018/04/17/STR.0000000000000172
The corrected AHA/ASA
guidelines are here:
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;49:e46-e99
2. Children Who Receive Sedation Despite Not Meeting Fasting
Guidelines Do Not Experience Increased Adverse Events
Key Points
Question Does the duration of preprocedural fasting
alter the risk pulmonary aspiration and associated adverse outcomes in children
undergoing emergency department procedural sedation?
Findings In this study of 6183 healthy patients
undergoing sedation in 1 of 6 geographically separate and nationally
representative Canadian emergency departments, 2974 (48.1%) did not meet
fasting guidelines prior to sedation. Data analysis failed to identify an
association between preprocedural fasting of any duration and any type of adverse
event, and there were no cases of clinically apparent pulmonary aspiration.
Meaning Delaying sedation to meet established fasting
guidelines appears not to improve sedation outcomes for children in the
emergency department.
Abstract
Importance It is not clear whether adherence to
preprocedural fasting guidelines prevent pulmonary aspiration and associated
adverse outcomes during emergency department (ED) sedation of children.
Objective To examine the association between
preprocedural fasting duration and the incidence of sedation-related adverse
outcomes in a large sample of children.
Design, Setting, and
Participants We conducted a planned
secondary analysis of a multicenter prospective cohort study of children aged 0
to 18 years who received procedural sedation for a painful procedure in 6
Canadian pediatric EDs from July 2010 to February 2015. The primary risk factor
was preprocedural fasting duration. Secondary risk factors were age, sex,
American Society of Anesthesiologists classification, preprocedural and
sedation medications, and procedure type.
Main Outcomes and
Measures Four outcomes were examined:
(1) pulmonary aspiration, (2) the occurrence of any adverse event, (3) serious
adverse events, and (4) vomiting.
Results A total of 6183 children with a median age of
8.0 years (interquartile range, 4.0-12.0 years), of whom 6166 (99.7%) had
healthy or mild systemic disease (American Society of Anesthesiologists levels
I or II), were included in the analysis. Of these, 2974 (48.1%) and 310 (5.0%)
children did not meet American Society of Anesthesiologists fasting guidelines
for solids and liquids, respectively. There were no cases of pulmonary
aspiration. There were 717 adverse events (11.6%; 95% CI, 10.8%-12.4%), of
which 68 (1.1%; 95% CI, 0.9%-1.3%) were serious adverse events and 315 (5.1%;
95% CI, 4.6%-5.7%) were vomiting. The odds ratio (OR) of occurrence of any
adverse event, serious adverse events, and vomiting did not change
significantly with each additional hour of fasting duration for both solids
(any adverse event: OR, 1.00; 95% CI, 0.98 to 1.02; serious adverse events, OR,
1.01; 95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.97-1.03) and liquids
(any adverse event: OR, 1.00; 95% CI, 0.98-1.02; serious adverse events: 1.01,
95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.96-1.03).
Conclusions and
Relevance In this study, there was no
association between fasting duration and any type of adverse event. These
findings do not support delaying sedation to meet established fasting
guidelines.
3. The Two-Bag Method for Treatment of Diabetic Ketoacidosis in
Adults
A. Comparison of a 'two-bag system' versus conventional
treatment protocol ('one-bag system') in the management of DKA
Munir I, et al. BMJ
Open Diabetes Res Care. 2017 Aug 11;5(1):e000395.
Context:
The ‘two-bag system’
was first described in the early 1990s in pediatric patients. As opposed to the
conventional protocol (one-bag system), the two-bag system uses two bags of
fluids with identical electrolyte content but different dextrose
concentrations, 0% and 10%.20 21 The two bags are connected in a ‘Y’ fashion
and by adjusting the infusion rates from each bag, the concentration of
dextrose can be customized to prevent unpredictable excursions in blood
glucose. The two-bag system has been more commonly used and exclusively studied
in the pediatric population and has been found to be cost effective.21 22 It
has also been shown to result in more rapid improvement in bicarbonate and
ketone correction and a trend toward faster improvement of hyperglycemia in
DKA.22 In one study, the two-bag system was well received by nursing and house
staff because it was less labor intensive than the traditional one-bag
system.23
Abstract
OBJECTIVE:
We compared the
conventional 'one-bag protocol' of management of diabetic ketoacidosis (DKA)
with the 'two-bag protocol' which utilizes two bags of fluids, one containing
saline and supplemental electrolytes and the other containing the same solution
with the addition of 10% dextrose.
RESEARCH DESIGN AND
METHODS:
A retrospective chart
review and analysis was done on adult patients admitted for DKA to the
Riverside University Health System Medical Center from 2008 to 2015. There were
249 cases of DKA managed by the one-bag system and 134 cases managed by the
two-bag system.
RESULTS:
The baseline patient
characteristics were similar in both groups. The anion gap closed in
13.56 hours in the one-bag group versus 10.94 hours in the two-bag group (p
value less than 0.0002). None of the individual factors significantly
influenced the anion gap closure time; only the two-bag system favored earlier
closure of the anion gap. Plasma glucose levels improved to less than 250 mg/dL
earlier with two-bag protocol (9.14 vs 7.82 hours, p=0.0241). The incidence of
hypoglycemic events was significantly less frequent with the two-bag protocol
compared with the standard one-bag system (1.49% vs 8.43%, p=0.0064). Neither
the time to improve serum HCO3 level over 18 mg/dL nor the hospital length of
stay differed between the two groups.
CONCLUSIONS:
Our study indicates
that the two-bag protocol closes the anion gap earlier than the one-bag
protocol in adult patients with DKA. Blood glucose levels improved faster with
the two-bag protocol compared with the one-bag protocol with fewer associated
episodes of hypoglycemia. Prospective studies are needed to evaluate the
clinical significance of these findings.
B. The Two-Bag Method for Treatment of DKA in Adults.
Haas NL, et al. J
Emerg Med. 2018;54(5):593–599.
BACKGROUND:
The "two-bag
method" of management of diabetic ketoacidosis (DKA) allows for titration
of dextrose delivery by adjusting the infusions of two i.v. fluid bags of
varying dextrose concentrations while keeping fluid, electrolyte, and insulin
infusion rates constant.
OBJECTIVE:
We aimed to evaluate
the feasibility and potential benefits of this strategy in adult emergency
department (ED) patients with DKA.
METHODS:
This is a
before-and-after comparison of a protocol using the two-bag method
operationalized in our adult ED in 2015. A retrospective electronic medical
record search identified adult ED patients presenting with DKA from January 1,
2013 to June 30, 2016. Clinical and laboratory data, timing of medical
therapies, and safety outcomes were collected and analyzed.
RESULTS:
Sixty-eight patients
managed with the two-bag method (2B) and 107 patients managed with the one-bag
method (1B) were identified. The 2B and 1B groups were similar in demographics
and baseline metabolic derangements, though significantly more patients in the
2B group received care in a hybrid ED and intensive care unit setting (94.1%
vs. 51.4%; p less than 0.01). 2B patients experienced a shorter interval to
first serum bicarbonate ≥ 18 mEq/L (13.4 vs. 20.0 h; p less than 0.05), shorter
duration of insulin infusion (14.1 vs. 21.8 h; p less than 0.05), and fewer
fluid bags were charged to the patient (5.2 vs. 29.7; p less than 0.01).
Frequency of any measured hypoglycemia or hypokalemia trended in favor of the
2B group (2.9% vs. 10.3%; p = 0.07; 16.2% vs. 27.1%; p = 0.09; respectively),
though did not reach significance.
CONCLUSIONS:
The 2B method appears
feasible for management of adult ED patients with DKA, and use was associated
with earlier correction of acidosis, earlier discontinuation of insulin
infusion, and fewer i.v. fluid bags charged than traditional 1B methods, while
no safety concerns were observed.
4. Mortality Risk Seen from Liberal Oxygen Delivery in MI,
Stroke, Other Acute Illnesses
Steve Stiles. Medscape
Medical News. May 04, 2018
Short- and long-term
mortality goes up after liberal use of supplemental oxygen, compared with a
more conservative oxygen delivery approach, in patients with any of a range of
acute illnesses, a meta-analysis of randomized trials shows.
The analysis, based on
patient-level data from 25 trials, also saw the mortality risk from liberal
oxygen as dose-dependent, in that in-hospital and long-term mortality rates
climbed with oxygen saturations rising above the threshold of 94% to 96%.
No apparent gains were
associated with the liberal approach; the two groups didn't differ in
prevalence of hospital-acquired pneumonia, hospital length of stay, or
subsequent patient disability.
The findings are
"distinct" from "the current notion that at worst, liberal
oxygen is not beneficial for acute illnesses," note the authors, led by
Derek K. Chu, MD, and Lisa H.-Y. Kim, MD, both from McMaster University,
Hamilton, Ontario, Canada.
The current analysis,
she said, shows about a 20% increase in hospital mortality when oxygen is given
to nonhypoxic critically ill patients, "which is quite significant
considering how many patients get exposed to supplemental oxygen in the
hospital setting."
Across the studies,
she said, there was one death for about every 71 patients given liberal oxygen,
a number needed to harm that rose to about 100 in the studies limited to
patients with acute coronary syndromes.
"Oxygen shouldn't
be treated as a harmless intervention," Kim said. "Now that we have
high-quality data that too much oxygen is harmful, we should be really cautious
in administering supplemental oxygen. We should really be, frankly, treating it
as any prescribed drug, recognizing that it has both benefits and adverse
effects."
Mortality and morbidity in acutely ill adults treated with
liberal versus conservative oxygen therapy (IOTA): a systematic review and
meta-analysis
Chu DK. Et al. Lancet
2018 Apr 28 [Epub ahead of print]
Background
Supplemental oxygen is
often administered liberally to acutely ill adults, but the credibility of the
evidence for this practice is unclear. We systematically reviewed the efficacy
and safety of liberal versus conservative oxygen therapy in acutely ill adults.
Methods
In the Improving
Oxygen Therapy in Acute-illness (IOTA) systematic review and meta-analysis, we
searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase,
HealthSTAR, LILACS, PapersFirst, and the WHO International Clinical Trials
Registry from inception to Oct 25, 2017, for randomised controlled trials
comparing liberal and conservative oxygen therapy in acutely ill adults (aged
≥18 years). Studies limited to patients with chronic respiratory diseases or
psychiatric disease, patients on extracorporeal life support, or patients
treated with hyperbaric oxygen therapy or elective surgery were excluded. We
screened studies and extracted summary estimates independently and in
duplicate. We also extracted individual patient-level data from survival
curves. The main outcomes were mortality (in-hospital, at 30 days, and at
longest follow-up) and morbidity (disability at longest follow-up, risk of
hospital-acquired pneumonia, any hospital-acquired infection, and length of
hospital stay) assessed by random-effects meta-analyses. We assessed quality of
evidence using the grading of recommendations assessment, development, and
evaluation approach. This study is registered with PROSPERO, number
CRD42017065697.
Findings
25 randomised
controlled trials enrolled 16 037 patients with sepsis, critical illness,
stroke, trauma, myocardial infarction, or cardiac arrest, and patients who had
emergency surgery. Compared with a conservative oxygen strategy, a liberal
oxygen strategy (median baseline saturation of peripheral oxygen [SpO2] across
trials, 96% [range 94–99%, IQR 96–98]) increased mortality in-hospital
(relative risk [RR] 1·21, 95% CI 1·03–1·43, I2=0%, high quality), at 30 days
(RR 1·14, 95% CI 1·01–1·29, I2=0%, high quality), and at longest follow-up (RR
1·10, 95% CI 1·00–1·20, I2=0%, high quality). Morbidity outcomes were similar
between groups. Findings were robust to trial sequential, subgroup, and
sensitivity analyses.
Interpretation
In acutely ill adults,
high-quality evidence shows that liberal oxygen therapy increases mortality
without improving other patient-important outcomes. Supplemental oxygen might
become unfavourable above an SpO2 range of 94–96%. These results support the conservative
administration of oxygen therapy.
5. The Surviving Sepsis Campaign Bundle: 2018 update.
Levy MM, et al. Intensive Care Med. 2018 Apr 19 [Epub ahead
of print].
The “sepsis bundle” has been central to the implementation
of the Surviving Sepsis Campaign (SSC) from the first publication of its
evidence-based guidelines in 2004 through subsequent editions [1, 2, 3, 4, 5,
6]. Developed separately from the guidelines publication by the SSC, the
bundles have been the cornerstone of sepsis quality improvement since 2005 [7,
8, 9, 10, 11]. As noted when they were introduced, the bundle elements were
designed to be updated as indicated by new evidence and have evolved accordingly.
In response to the publication of “Surviving Sepsis Campaign: International
Guidelines for Management of Sepsis and Septic Shock: 2016” [12, 13], a revised
“hour-1 bundle” has been developed and is presented below (Fig. 1).
Fig. 1. Hour-1 Surviving Sepsis Campaign Bundle of Care
The compelling nature of the evidence in the literature,
which has demonstrated an association between compliance with bundles and
improved survival in patients with sepsis and septic shock, led to the adoption
of the SSC measures by the National Quality Forum (NQF) and subsequently both
by the New York State (NYS) Department of Health [14] and the Centers for
Medicare and Medicaid Services (CMS) [15] in the USA for mandated public
reporting. The important relationship between the bundles and survival was
confirmed in a publication from this NYS initiative [16].
Paramount in the management of patients with sepsis is the
concept that sepsis is a medical emergency. As with polytrauma, acute
myocardial infarction, and stroke, early identification and appropriate
immediate management in the initial hours after development of sepsis improves
outcomes…
See the link above for the full-text (free).
6. A Systematic Review and Meta-Analysis of the Management and
Outcomes of Isolated Skull Fractures in Children
Bressen S, et al.
PECARN. Ann Emerg Med. 2018;71(6):714–724.e2.
STUDY OBJECTIVE: Most
studies of children with isolated skull fractures have been relatively small,
and rare adverse outcomes may have been missed. Our aim is to quantify the
frequency of short-term adverse outcomes of children with isolated skull
fractures.
METHODS: PubMed,
EMBASE, the Cochrane Library, Scopus, Web of Science, and gray literature were
systematically searched to identify studies reporting on short-term adverse
outcomes of children aged 18 years or younger with linear, nondisplaced,
isolated skull fractures (ie, without traumatic intracranial injury on
neuroimaging). Two investigators independently reviewed identified articles for
inclusion, assessed quality, and extracted relevant data. Our primary outcome
was emergency neurosurgery or death. Secondary outcomes were hospitalization
and new intracranial hemorrhage on repeated neuroimaging. Meta-analyses of
pooled estimate of each outcome were conducted with random-effects models, and
heterogeneity across studies was assessed.
RESULTS: Of the 587
studies screened, the 21 that met our inclusion criteria included 6,646
children with isolated skull fractures. One child needed emergency neurosurgery
and no children died (pooled estimate 0.0%; 95% confidence interval [CI] 0.0%
to 0.0%; I2=0%). Of the 6,280 children with known emergency department
disposition, 4,914 (83%; 95% CI 71% to 92%; I2=99%) were hospitalized. Of the
569 children who underwent repeated neuroimaging, 6 had new evidence of
intracranial hemorrhage (0.0%; 95% CI 0.0% to 9.0%; I2=77%); none required
operative intervention.
CONCLUSION: Children
with isolated skull fractures were at extremely low risk for emergency
neurosurgery or death, but were frequently hospitalized. Clinically stable
children with an isolated skull fracture may be considered for outpatient
management in the absence of other clinical concerns.
7. Clinical Aspects of Anticoagulation
A. Safety of Lumbar Puncture Performed
on Dual Antiplatelet Therapy.
Carabenciov ID, et al. Mayo Clin Proc. 2018.
Practice guidelines generally recommend delaying lumbar
puncture (LP) in patients on dual antiplatelet therapy, with these
recommendations often citing an increased risk of hemorrhagic complications,
specifically the development of epidural hematomas. However, no data exist
about the risks of performing an LP in the setting of dual antiplatelet therapy
and conclusions are often based on data from spinal anesthesia literature. We
reviewed the medical records of 100 patients who underwent LP while taking dual
antiplatelet therapy. We recorded the number of traumatic and bloody
cerebrospinal fluid results as well as the presence of any complications
occurring within 3 months of the procedure. Complications requiring imaging or
hospitalization were considered serious.
The most common complication was back pain, which was
reported by 2 patients, only 1 of which was ultimately found to be attributable
to the procedure. No serious complications occurred. Cerebrospinal fluid
analysis was consistent with a traumatic LP, defined as having at least 100 red
blood cells per microliter, in 8% of cases. Bloody LP, defined as having 1000
red blood cells per microliter, occurred in 4% of cases. The percentage of
traumatic or bloody LPs was within the range reported previously for LPs
performed in any setting. Although this is a small study and additional review
is necessary, performing LPs in the setting of dual antiplatelet therapy may
not pose an increased risk of serious complications.
B. Management of Bleeding in Patients
Taking Oral Anticoagulants: ACC Guidelines
Anderson I, et al. JAMA.
2018;319(19):2032-2033.
Summary of the
Clinical Problem
More than 6 million
people in the United States take OACs.1 The most common indications for OACs
are atrial fibrillation and treatment or prevention of venothromboembolism.1
Hemorrhage and its related morbidity and mortality are the primary risks
associated with these agents.2 A meta-analysis of 13 randomized clinical trials
involving 102 707 adults showed major bleeding case-fatality rates of 7.57%
with DOACs and 11.05% with warfarin.2 With the approval of 4 DOACs since 2010,
management of OAC-associated bleeding has become more complex.
Guideline title:
American College of Cardiology Expert Consensus Decision Pathway on Management
of Bleeding in Patients on Oral Anticoagulants
Developer: ACC
Foundation
Release date: December
1, 2017
Target population:
Patients treated with direct oral anticoagulants (DOACs) or warfarin for any
indication who have acute bleeding
Major recommendations:
For patients treated with an oral anticoagulant (OAC) who experience either
life-threatening bleeding or major bleeding at a critical site, management
should include at least temporarily discontinuing the OAC, local therapy,
supportive measures, and, when appropriate, administering a reversal agent.
•For warfarin, 5 to 10
mg of intravenous vitamin K and intravenous 4-factor prothrombin complex
concentrate (4F-PCC)
•For dabigatran,
intravenous idarucizumab or intravenous 4F-PCC/activated prothrombin complex
concentrate (aPCC)
•For apixaban,
edoxaban, and rivaroxaban, intravenous 4F-PCC or intravenous aPCC
Laboratory testing may
be useful to determine reversal strategy for life-threatening bleeding or
bleeding at a critical site or prior to urgent unplanned procedures.
For dabigatran
•Normal levels of any
of the following probably indicate that drug levels are insignificant: dilute
thrombin time (TT); ecarin clotting time (ECT); ecarin chromogenic assay (ECA).
•Normal activated
partial thromboplastin time (aPTT) usually indicates that drug levels are
insignificant. Prolonged aPTT suggests that a patient has a significant drug
level (either therapeutic or supratherapeutic).
For apixaban,
edoxaban, and rivaroxaban
•Negative anti–factor
Xa assay activity usually indicates that drug levels are insignificant.
•Normal prothrombin
time/aPTT does not exclude a significant drug level. Prolonged prothrombin time
suggests that a patient has a clinically significant drug level (either
therapeutic or supratherapeutic).
C. FDA Approves First Factor Xa
Inhibitor Antidote, Andexxa
Patrice Wendling. Medscape. May 04, 2018
The US Food and Drug Administration (FDA) has approved
Andexxa (coagulation factor Xa [recombinant] inactivated-zhzo) to reverse the
anticoagulation effects of factor Xa inhibitors when needed due to
life-threatening or uncontrolled bleeding, Portola Pharmaceuticals has
announced.
An estimated 4 million people are taking factor Xa
inhibitors, such as rivaroxaban (Xarelto, Bayer/Janssen Pharmaceuticals) and
apixaban (Eliquis, Bristol-Myers Squibb), but until now, there has been no
approved reversal agent.
Last month, the FDA gave full approval to idarucizumab
(Praxbind, Boehringer Ingelheim) to reverse the anticoagulant effect of
dabigatran (Pradaxa, Boehringer Ingelheim), a direct thrombin inhibitor, in the
event of urgent surgery or life-threatening or uncontrolled bleeding.
In the United States alone, there were approximately 117,000
hospital admissions attributable to factor Xa inhibitor-related bleeding and
nearly 2000 bleeding related deaths per month, according to the company's news
release, posted May 3.
"The expansion of available reversal agents for people
prescribed newer oral anticoagulant therapies is crucial," Randy
Fenninger, chief executive officer of the National Blood Clot Alliance, said in
the release. "The availability now of a reversal agent specific to
rivaroxaban and apixaban expands choice and enables patients and providers to
consider these treatment options with greater confidence."
Andexxa was approved under the FDA's accelerated approval
pathway based on effects in healthy volunteers, and continued approval may be
contingent on postmarketing studies to demonstrate an improvement in hemostasis
in patients. A clinical trial comparing this agent or usual care is scheduled
to start in 2019 and to be reported in 2023.
Andexxa was approved with a boxed warning for thromboembolic
risks, ischemic risks, cardiac arrest, and sudden death. Treatment with the
agent has been associated with serious and life-threatening adverse events,
including arterial and venous thromboembolic events, cardiac arrest, sudden
deaths, and ischemic events, such as myocardial infarction and ischemic stroke.
The most common adverse reactions in at least 5% of patients
receiving Andexxa were urinary tract infections and pneumonia.
8. ED Intubation Success with Succinylcholine Versus Rocuronium:
A National Emergency Airway Registry Study
April MD, et al. Ann
Emerg Med 2018 May 7 [Epub ahead of print]
Study objective
Although both
succinylcholine and rocuronium are used to facilitate emergency department (ED)
rapid sequence intubation, the difference in intubation success rate between
them is unknown. We compare first-pass intubation success between ED rapid sequence
intubation facilitated by succinylcholine versus rocuronium.
Methods
We analyzed
prospectively collected data from the National Emergency Airway Registry, a
multicenter registry collecting data on all intubations performed in 22 EDs. We
included intubations of patients older than 14 years who received
succinylcholine or rocuronium during 2016. We compared the first-pass
intubation success between patients receiving succinylcholine and those
receiving rocuronium. We also compared the incidence of adverse events (cardiac
arrest, dental trauma, direct airway injury, dysrhythmias, epistaxis,
esophageal intubation, hypotension, hypoxia, iatrogenic bleeding, laryngoscope
failure, laryngospasm, lip laceration, main-stem bronchus intubation, malignant
hyperthermia, medication error, pharyngeal laceration, pneumothorax,
endotracheal tube cuff failure, and vomiting). We conducted subgroup analyses
stratified by paralytic weight-based dose.
Results
There were 2,275 rapid
sequence intubations facilitated by succinylcholine and 1,800 by rocuronium.
Patients receiving succinylcholine were younger and more likely to undergo
intubation with video laryngoscopy and by more experienced providers.
First-pass intubation success rate was 87.0% with succinylcholine versus 87.5%
with rocuronium (adjusted odds ratio 0.9; 95% confidence interval 0.6 to 1.3).
The incidence of any adverse event was also comparable between these agents:
14.7% for succinylcholine versus 14.8% for rocuronium (adjusted odds ratio 1.1;
95% confidence interval 0.9 to 1.3). We observed similar results when they were
stratified by paralytic weight-based dose.
Conclusion
In this large
observational series, we did not detect an association between paralytic choice
and first-pass rapid sequence intubation success or peri-intubation adverse
events.
9. Ultrasound Corner
A. Introducing the CASA Exam: A New Protocol to Guide
Point-Of-Care Ultrasound in Cardiac Arrest
Gardner K, et al. ACEP
Now, May 1, 2018
Excerpt:
The CASA exam is a
three-step protocol that evaluates for:
Pericardial effusion
Right heart strain
indicative of a pulmonary embolus
Cardiac activity
All three steps can be
rapidly performed with a cardiac (phased array) transducer.
Tamponade and
pulmonary embolism (PE) are potentially reversible causes if identified
quickly, and the presence or absence of cardiac activity provides information
regarding prognosis.5 This step-wise approach allows for the integration of
POCUS in the resuscitation of the critically ill patient while maintaining the
evidence-based principles of continuous, high-quality CPR. If and when return
of spontaneous circulation (ROSC) is achieved, a more comprehensive ultrasound
assessment should be performed.
Full-text (free): http://www.acepnow.com/article/introducing-the-casa-exam-a-new-protocol-to-guide-point-of-care-ultrasound-in-cardiac-arrest/
B. Lung ultrasound better than CXR for diagnosis of pediatric
pneumonia: A meta‐analysis
Balk DS, et al. Pediatr
Pulmonol 2018 April 26
OBJECTIVE: Although a
clinical diagnosis, the standard initial imaging modality for patients with
concern for pediatric community acquired pneumonia (pCAP) is a chest x-ray
(CXR), which has a relatively high false negative rate, exposes patients to
ionizing radiation, and may not be available in resource limited settings. The
primary objective of this meta-analysis is to evaluate the accuracy of lung
ultrasound (LUS) compared to CXR for the diagnosis of pCAP.
METHODS: Data were
collected via a systematic review of PubMed, EMBASE, and Web of Science with
dates up to August 2017. Keywords and search terms were generated for
pneumonia, lung ultrasound, and pediatric population. Two independent
investigators screened abstracts for inclusion. PRISMA was used for selecting
appropriate studies. QUADAS was applied to these studies to assess quality for
inclusion into the meta-analysis. We collected data from included studies and
calculated sensitivity, specificity, positive predictive value, and negative
predictive values of CXR and LUS for the diagnosis of pCAP.
RESULTS: Twelve
studies including 1510 patients were selected for data extraction. LUS had a
sensitivity of 95.5% (93.6-97.1) and specificity of 95.3% (91.1-98.3). CXR had
a sensitivity of 86.8% (83.3-90.0) and specificity of 98.2% (95.7-99.6).
Variations between the studies included ultrasound findings diagnostic of
pneumonia, study setting (inpatient vs emergency department) and inclusion of
CXR in the reference standard for pneumonia.
CONCLUSIONS: In our
meta-analysis, lung ultrasound had significantly better sensitivity with
similar specificity when compared to chest x-ray for the diagnosis of pediatric
community acquired pneumonia.
C. Bedside ultrasound to detect CVC
misplacement and associated iatrogenic complications: a systematic review and
meta-analysis.
Smit JM, et al. Crit Care. 2018 Mar 13;22(1):65.
BACKGROUND: Insertion of a central venous catheter (CVC) is
common practice in critical care medicine. Complications arising from CVC
placement are mostly due to a pneumothorax or malposition. Correct position is
currently confirmed by chest x-ray, while ultrasonography might be a more
suitable option. We performed a meta-analysis of the available studies with the
primary aim of synthesizing information regarding detection of CVC-related
complications and misplacement using ultrasound (US).
METHODS: This is a systematic review and meta-analysis
registered at PROSPERO (CRD42016050698). PubMed, EMBASE, the Cochrane Database
of Systematic Reviews, and the Cochrane Central Register of Controlled Trials
were searched. Articles which reported the diagnostic accuracy of US in
detecting the position of CVCs and the mechanical complications associated with
insertion were included. Primary outcomes were specificity and sensitivity of
US. Secondary outcomes included prevalence of malposition and pneumothorax,
feasibility of US examination, and time to perform and interpret both US and
chest x-ray. A qualitative assessment was performed using the QUADAS-2 tool.
RESULTS: We included 25 studies with a total of 2548
patients and 2602 CVC placements. Analysis yielded a pooled specificity of 98.9
(95% confidence interval (CI): 97.8-99.5) and sensitivity of 68.2 (95% CI: 54.4-79.4).
US examination was feasible in 96.8% of the cases. The prevalence of CVC
malposition and pneumothorax was 6.8% and 1.1%, respectively. The mean time for
US performance was 2.83 min (95% CI: 2.77-2.89 min) min, while chest x-ray
performance took 34.7 min (95% CI: 32.6-36.7 min). US was feasible in 97%.
Further analyses were performed by defining subgroups based on the different
utilized US protocols and on intra-atrial and extra-atrial misplacement.
Vascular US combined with transthoracic echocardiography was most accurate.
CONCLUSIONS: US is an accurate and feasible diagnostic
modality to detect CVC malposition and iatrogenic pneumothorax. Advantages of
US over chest x-ray are that it can be performed faster and does not subject
patients to radiation. Vascular US combined with transthoracic echocardiography
is advised. However, the results need to be interpreted with caution since
included studies were often underpowered and had methodological limitations. A
large multicenter study investigating optimal US protocol, among other things,
is needed.
D. Prehospital Ultrasound: Ready for Prime Time?
Michael T. Hilton, MD,
MPH. Medscape. May 03, 2018
Commonly used by
physicians in emergency departments and intensive care units as a physical
examination adjunct for rapid bedside diagnostic testing and for procedural
guidance,[1] portable ultrasound has been making its way into the hands of
emergency medical technicians (EMTs) and paramedics on ambulances and
helicopters in the United States and abroad.[2]
In North America, 4%
of emergency medical services (EMS) systems use ultrasound and 20% are
considering implementing ultrasound within their systems.[3] The most common
uses for prehospital ultrasound are the Focused Assessment with Sonography for
Trauma (FAST) and assessment of pulseless electrical activity arrest.[3] With
education and training, paramedics and EMTs can obtain images of sufficient
quality.[4,5] However, whether this improves outcomes for patients is unclear.
There is no
standardized training for paramedics or EMTs in the use of ultrasound, leading
to great variability in curricula published in the literature. For specific
ultrasound skills, such as image acquisition for abdominal trauma (FAST), a
1-day training course may be sufficient.[6] A 6-hour FAST training program has
been published.[7] Alternatively, a comprehensive multimodal 2-month training
course has also been proposed to train paramedics to perform the Extended
Focused Assessment with Sonography for Trauma (eFAST).[8] For identification of
pericardial effusion, pneuomothorax, and cardiac standstill, a 1-hour lecture
has been trialed among EMT and paramedic students, and a 2-hour program has
also been used to train paramedics for these indications.[9,10] A systematic
review of training courses for paramedic prehospital ultrasound has shown that
FAST ultrasound examination can be taught in 6-8 hours and that pleural
ultrasound can be taught in 25 minutes.[11] For the other uses of ultrasound in
the field, training programs have not been published in the literature.
10. Images in Clinical Practice
A Woman With Stridor and Respiratory Failure
A Woman With a Click in Her Throat
Young Woman With a Sore Throat and Neck Mass
Young Man With Wrist Pain
Adult Male With Scrotal Swelling and Pain
Woman With Hand Pain and Swelling
Adolescent Female With Right Ear Redness
Infant With Episodes of Bilious Vomiting
Young Woman With Postpartum Chest and Abdominal Pain
Colon Cutoff Sign
Orbital Apex Syndrome
Aspiration of a Chicken Bone
Relapsing Polychondritis
Trypanosoma cruzi Reactivation in the Brain
Xanthoma Striatum Palmare
Raindrop Skull
Tuberculous Pericarditis
11. Helpful Reviews from Ann Emerg Med
A.
Does Bed Rest or Fluid Supplementation Prevent Post–Dural Puncture Headache?
Take-Home Message
Neither bed rest nor fluid supplementation decreases the
incidence of headache after dural puncture.
B.
Managing Peripheral Facial Palsy
Patients with acute-onset peripheral facial palsy commonly
present to the ED for evaluation and treatment. ED clinicians should promptly
initiate appropriate therapy to improve long-term recovery. For patients with
high risk for Lyme disease facial palsy, we recommend empiric antibiotics while
awaiting Lyme disease test results. All other patients should be treated with
corticosteroids, and those with severe facial palsy should also be treated with
antivirals.
C.
Diagnosing Patients With Acute-Onset Persistent Dizziness
Introduction
Three percent of emergency department (ED) patients present
with dizziness, vertigo, lightheadedness, or imbalance.1 These words are not
diagnostically meaningful.2 Rather, it is the timing and the factors that
trigger the dizziness that best inform the differential diagnosis.3 Asking a
patient, “What do you mean by ‘dizzy’?” is less important than defining the
rapidity of onset, the context, presence of associated symptoms, the
intermittent or persistent nature of the dizziness, and triggers of intermittent
symptoms.2, 4, 5, 6
Approximately 50% of dizzy patients have general medical
conditions.1 Associated symptoms (eg, gastrointestinal bleeding) or context
(eg, new antihypertensive medications) usually suggest these diagnoses. Some
patients endorse brief episodes of dizziness triggered by head or body
movement, suggesting benign paroxysmal positional vertigo or orthostatic
hypotension. Other patients have short spontaneous episodes of dizziness that
are not triggered by anything consistent with posterior circulation transient
ischemic attacks or vestibular migraine.
This article focuses on a different group of patients: those
with the acute onset of severe persistent and continuous dizziness or vertigo
often associated with nausea or vomiting and postural instability that remains
present in the ED without an obvious medical cause. Classically, nystagmus is
included as a component of the acute vestibular syndrome.7 However, not all
patients with acute-onset severe persistent dizziness have nystagmus.
To be clear about this distinction, I use the terms “acute
vestibular syndrome with nystagmus” and “acute vestibular syndrome without
nystagmus.” The distinction is important because the diagnostic approach
differs somewhat between these 2 groups. The word vestibular refers to the
symptoms, not to any anatomic localization. The major differential diagnosis is
vestibular neuritis versus posterior circulation stroke. This article focuses
on distinguishing these 2 entities in the ED and uses the term dizziness in the
general sense…
E. How Reliable Are Signs and Symptoms
for Diagnosing Pneumonia in Pediatric Patients?
Take-Home Message
In children younger than 5 years, no single historical
features or findings can reliably differentiate pneumonia from other pediatric
respiratory illnesses.
Full-text (free): https://www.annemergmed.com/article/S0196-0644(17)31697-9/fulltext
12. Impact of Emergency Physician–Provided Patient Education
About Alternative Care Venues
Patel PB, et al. Am J Manag Care. 2018;24(5):225-231.
Objectives: Interventions that focus on educating patients
appear to be the most effective in directing healthcare utilization to more
appropriate venues. We sought to evaluate the effects of mailed information and
a brief scripted educational phone call from an emergency physician (EP) on
subsequent emergency department (ED) utilization by low-risk adults with a
recent treat-and-release ED visit.
Study Design: Patients were randomized into 3 groups for
post-ED follow-up: EP phone call with mailed information, mailed information
only, and no educational intervention. Each intervention group was compared
with a set of matched controls.
Methods: We undertook this study in 6 EDs within an
integrated healthcare delivery system. Overall, 9093 patients were identified;
the final groups were the phone group (n = 609), mail group (n = 771), and
matched control groups for each (n = 1827 and n = 1542, respectively). Analysis
was stratified by age (less than 65 and 65 years or older). Patients were
educated about available venues of care delivery for their future medical
needs. The primary outcome was the rate of 6-month ED utilization after the
intervention compared with the 6-month utilization rate preceding the
intervention.
Results: Compared with matched controls, subsequent ED utilization
decreased by 22% for patients 65 years or older in the phone group (P = .04)
and by 27% for patients younger than 65 years in the mail group (P = .03).
Conclusions: ED utilization subsequent to a low-acuity ED
visit decreased after a brief post-ED education intervention by an EP
explaining alternative venues of care for future medical needs. Response to the
method of communication (phone vs mail) varied significantly by patient age.
Full-text (free): http://www.ajmc.com/journals/issue/2018/2018-vol24-n5/impact-of-emergency-physician-provided-patient-education-about-alternative-care-venues
Editorial: Delivery of acute
unscheduled healthcare: who should judge whether a visit is appropriate (or
not)? http://www.ajmc.com/journals/issue/2018/2018-vol24-n5/delivery-of-acute-unscheduled-healthcare-who-should-judge-whether-a-visit-is-appropriate-or-not
Press release: Can Patients Be
Taught to Avoid Unnecessary Trips to the ER? A Study in AJMC® Suggests Some Can https://www.businesswire.com/news/home/20180515006231/en/Patients-Taught-Avoid-Unnecessary-Trips-ER-Study
13. Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy
Among Adult ED Patients: A RCT
April MD, et al. Ann Emerg Med 2018 Feb 17 [Epub ahead of
print]
Study Objective
We compare aromatherapy with inhaled isopropyl alcohol
versus oral ondansetron for treating nausea among emergency department (ED)
patients not requiring immediate intravenous access.
Methods
In a randomized, blinded, placebo-controlled trial, we
enrolled a convenience sample of adults presenting to an urban tertiary care ED
with chief complaints including nausea or vomiting. We randomized subjects to 1
of 3 arms: inhaled isopropyl alcohol and 4 mg oral ondansetron, inhaled
isopropyl alcohol and oral placebo, and inhaled saline solution placebo and 4
mg oral ondansetron. The primary outcome was mean nausea reduction measured by
a 0- to 100-mm visual analog scale from enrollment to 30 minutes
postintervention. Secondary outcomes included receipt of rescue antiemetic
medications and adverse events.
Results
We enrolled 122 subjects, of whom 120 (98.3%) completed the
study. Of randomized subjects, 40 received inhaled isopropyl alcohol and oral
ondansetron, 41 received inhaled isopropyl alcohol and oral placebo, and 41
received inhaled saline solution placebo and oral ondansetron. The mean decrease
in nausea visual analog scale score in each arm was 30 mm (95% confidence
interval [CI] 22 to 37 mm), 32 mm (95% CI 25 to 39 mm), and 9 mm (95% CI 5 to
14 mm), respectively. The proportions of subjects who received rescue
antiemetic therapy in each arm were 27.5% (95% CI 14.6% to 43.9%), 25.0% (95%
CI 12.7% to 41.2%), and 45.0% (95% CI 29.3% to 61.5%), respectively. There were
no adverse events.
Conclusion
Among ED patients with acute nausea and not requiring
immediate intravenous access, aromatherapy with or without oral ondansetron
provides greater nausea relief than oral ondansetron alone.
14. Towards a Better Understanding of Our Patients
A. ‘How Were You Hoping I Could Help
You Today?’
Walker G. Emerg Med News. 2018;40(5):19
It is obvious why many of our patients come to the ED:
Something happened to them (they were hit by a car) or they developed some
acute symptom (six hours of right lower abdominal pain), and they're seeking
answers—diagnosis, treatment, or both. Because we emergency physicians know our
resources and our scope, it's easy for us to understand their motivations, and
we work them up and treat them as needed.
But it is not readily obvious to us why
some of our patients presented: “Six months of abdominal pain,” “URI symptoms;
has two siblings with the same,” “rash times seven years.” These patients
always confuse and bewilder me. More often than not, they seem just as
dissatisfied after the ED visit as they did before. I've tried
all kinds of questions to sort them out:
In residency, I would sometimes smarmily ask patients, “What
is your emergency today?” It felt vindicating, especially when
the patient's chief complaint was “sore throat for 20 minutes,” and she's in
the exam room eating a toasted Quizno's sub.
I've also tried asking people, “Oh, what has your primary
care physician said about this?” (when I know they have a primary care
physician). They usually look back at me perplexed, confused by the suggestion
that their primary care physician could handle most of these issues.
And adults, I find, don't like the questions that typically
work in pediatrics: “What's your biggest concern today?” or
“What are you worried about?” I imagine that these patients don't
respond well to “concern” or “worry” because they're not really worried about
the rash on their side; they just want it gone.
As I matured, I tried asking people, “What made you come
in today if it's been going on for three years? Did it get
worse? Did something change? Did you have a new symptom? Or were you just tired
of it?” The vast majority of patients typically shrug and choose the last
answer, almost to the point of suggesting that it was pure fate, and they had
no free will or choice in deciding to register in the ED.
None of these questions really ever seemed to get the
answers I was seeking: What did the patient expect from me,what did
the patient want from me (they're not always the same thing),
and what would it take to satisfy him? Then I came across the
phrase that seemed to sum up all of this: How were you hoping I could
help you today?
A Dose of Reassurance
This is best used with patients who have chronic complaints,
but it works quite well with the patients who have already correctly
self-diagnosed: “I think I have a cold;” “I think I sprained my ankle;” “I
scraped my knee;” “I want an abortion.” The magic of this phrase is that it
also engages the patient, revealing any hidden anxieties he may have and
letting you reassure him.
It also lets you instantly know how realistic or delusional
they are about what will or won't or can or can't happen in the emergency
department. You immediately know, “OK, this is going to be an easy one,” or
“Oof, this is going to take some teamwork to set expectations and come up with
a plan, and even after that, it may not go smoothly.”
Take any one of the many patients I saw last week with the
three to four days of the flu, many of which stated outright, “I think I have
the flu.” Ask the magic question, and you'll get a variety of responses, most
of which require a variety of solutions. “How were you hoping I could help you
today?”
“I've been sick all week, and I have midterms on Monday.”
Ta-da, here's your school/work note.
“I'm worried it's not the flu. I take Tylenol, but then my
fever comes back.” Ta-da, education about fever and a recommendation to add
ibuprofen.
“I've seen my doctor for this twice already this week, and
I'm still not feeling better. I only have one kidney, so I'm worried I'm
dehydrated.” Shared decision-making about other testing like a chest x-ray and
labs (which, of course, turned out totally normal; diagnosis: flu).
“I have a newborn at home, so I'm worried I might give this
to him.” Education about hand washing, masks, and lots of new parenting advice,
as well as gathering information about the infant's age, taking an infant's
temperature, etc. Discussion about risks/benefits of oseltamivir.
You'll notice that only one of these four scenarios required
much in the way of medical workup or even medical care; it's much more about
targeted education and reassurance (because you've already taken a history,
examined the patient, and deemed his condition not to require any testing).
It's far better to spend an extra five minutes with the
patient doing a thorough physical exam and answering all of his questions and
then being able to discharge him than to order unnecessary testing, come back
an hour later, announce, “Good news. The x-ray is normal!” and then have him
leave annoyed. Even worse is then having him ask you or the nurse five minutes of
additional questions. And the ultimate fail is having the patient re-triage an
hour later for the same complaint, already worked up and annoyed for your
colleague to see. (That being said, sometimes you don't have five minutes to
spare for patients with minor complaints, or tests have already been ordered in
triage.)
Give the phrase a try. I promise you at least a patient a
day will be easier for you to handle, understand, empathize with, and
disposition.
B. Uncertainty Commonly Leads To Repeat
ED Visits
New tool may clarify the reasons, point to solutions
Jennifer Thew RN, HealthLeaders Media. April 29, 2018
Until now, the reasons why patients return to the emergency
department after an initial visit have been anyone's guess.
"We don't do a good job of predicting which patients
will come back to the emergency department, which means we don't have a good
understanding of why patients are coming back and how we could be assisting
them in having a safer transition home from the first emergency department
visit," Kristin Rising, MD, director of acute care transitions and
associate professor of emergency medicine at Thomas Jefferson University in
Philadelphia, said in a news release.
However, through interview-based studies, Rising identified
a common theme among these patients -- uncertainty.
To better understand, document, and create effective
solutions to address uncertainty -- whether it be about managing symptoms or a
disease process -- Rising and a team of Jefferson researchers developed the
Uncertainty Scale.
"As a field, we've had difficulty finding an approach
that consistently works to identify and address individual patient needs. The
Uncertainty Scale we developed gives us a tool to help do that," Rising
said.
Reasons for Uncertainty
The researchers took a patient-centered approach and
developed the U-Scale based on direct patient input and listening sessions. The
team spent two 6-hour days with two groups, each of about 20 patients, who had
recently been patients in the ED. The patients brainstormed the types of
uncertainty people have when they experience symptoms that may trigger an ED
visit. They then worked with the research team to map the ideas into
categories.
Some of the categories were:
- Concern over treatment quality, which may lead a patient to return in hopes of a second opinion
- Concern about lack of a diagnosis, thus leaving a patient with no satisfying explanation for their symptoms
- Lack of clarity regarding self-management, such that patients are unsure how to deal with symptoms at home
- Lack of self-efficacy, manifesting as patients not knowing where to go for help for certain symptoms
- Lack of clarity about the decision to seek care, meaning that patients do not know which symptoms are serious enough to warrant seeing a health professional
- Psychosocial factors, including worries that getting medical care might interfere with home and work commitments
- General worries and concerns
Improve Provider-Patient Conversations
Rising advocates for training healthcare professionals about
patient struggles related to uncertainty. She is working to develop a
curriculum to teach physician residents to have more effective discharge
conversations with patients when testing has not identified a definitive cause
of their symptoms.
“As emergency physicians, we focus primarily on acute care,
fixing the most immediate life-threatening problems. Facilitating a safe and
effective transition home for patients who do not appear to have a
life-threatening problem is also a really critical part of our job that is
often overlooked,” Rising says.
The research has changed how Rising delivers news to her
patients. She realized what she considers good news – that tests are normal and
a patient’s symptoms do not appear to be life threatening – could actually be
experienced as bad news from the patient perspective. She now takes time to
acknowledge and validate potential patient struggles related to ongoing
uncertainty.
“If a patient comes in with a problem and I tell him that
testing is normal and I haven’t found a cause of his symptoms, it might give
momentary relief, but that patient still is no closer to understanding what is
causing his distress. It’s not all good news, and we have to acknowledge that
we have not improved patients’ sense of uncertainty about their disease with
this news,” she says.
The team of researchers plans to continue to refine and
validate the U-Scale, and use it to test interventions to alleviate different
categories of uncertainty.
15. ALiEM Highlights
A. Ketamine for Severe Ethanol
Withdrawal: A New Hope?
By Bryan D Hayes. ALiEM. May 16, 2018
Ethanol withdrawal is a complex disease state. Two of the
main players are GABA (an inhibitory neurotransmitter) and glutamate (an
excitatory transmitter that can act on NMDA receptors). Chronic ethanol use
leads to a down-regulation of GABA receptors and an up-regulation in
glutaminergic receptors, such as NMDA. When ethanol is abruptly discontinued,
we are left with a largely excitatory state with less ability for GABA-mediated
inhibition and more capacity for NMDA/glutamate-mediated excitation. While much
of the treatment of severe ethanol withdrawal is focused on GABA, there are
agents, such as phenobarbital and propofol, that can suppress the glutaminergic
response. Ketamine seems like it would confer benefit as well due to its NMDA
antagonist properties. Until now there was only one clinical study using
ketamine for severe ethanol withdrawal.1 Now there are two.2
In this post, we will review the body of evidence for
ketamine in severe ethanol withdrawal and explain its potential application to
clinical practice…
B. A Can’t Miss ED Diagnosis:
Euglycemic DKA
Theresa Kim, MD. March 19th, 2018
A middle-aged man with a history of diabetes and
hypertension presents with nausea, vomiting, and shortness of breath. His
laboratory testing is remarkable for a leukocytosis, ketonemia, and an anion
gap acidosis (pH of 7.13). The EM resident caring for this patient is surprised
to find that the blood glucose is 121 mg/dL.
Which home medication is likely responsible for this
presentation?
- Metformin
- Glipizide
- Liraglutide
- Canagliflozin
16. Only 5.5 Percent of Emergency Visits Are Nonurgent and Wait
Times Continue to Improve, CDC Says
WASHINGTON, April 23, 2018 /PRNewswire-USNewswire/ -- New
data from the Centers for Disease Control and Prevention (CDC) show that 136.9
million people visited the emergency department in 2015 and only 5.5 percent of
these visits were considered "nonurgent," according to the latest CDC
National Hospital Ambulatory Medical Care (NHAMC) survey.
"Emergency care is a unique success story," said
Paul Kivela, MD, MBA, FACEP, president of ACEP. "No other medical
specialty is the safety net for millions of patients with such a broad range of
symptoms and conditions. The nation's emergency physicians care for any
patient, any time, regardless of ability to pay — and we play an increasingly
integral role in our health system."
Wait times continued to improve, according to the report.
Typically, about 35 percent of patients waited less than 15 minutes to see a
provider and 68 percent were seen in less than one hour. The median wait time
to see a physician or advanced practice provider is 18 minutes, and the median
time spent in the emergency department was around 180 minutes, which includes
time with the physician and other members of the care team and other clinical
services.
Injuries, stomach pain and chest pain top the list of
conditions bringing patients to the emergency department. Various injuries
accounted for about 28 percent of visits. Illness accounted for about 65
percent of visits, and mental health related conditions or other reasons made
up the remaining 7 percent or so…
The rest of the essay (free): https://www.prnewswire.com/news-releases/acep-only-5-5-percent-of-emergency-visits-are-nonurgent-and-wait-times-continue-to-improve-cdc-says-300634514.html
17. Opioid Corner
A. ED Makes Only Small Contribution to
the Prescription Opioid Epidemic.
Axeen S, Seabury SA, Menchine M. Ann Emerg Med. 2018;71(6):659–667.e3.
Study objective
We characterize the relative contribution of emergency
departments (EDs) to national opioid prescribing, estimate trends in opioid
prescribing by site of care (ED, office-based, and inpatient), and examine
whether higher-risk opioid users receive a disproportionate quantity of their
opioids from ED settings.
Methods
This was a retrospective analysis of the nationally
representative Medical Expenditure Panel Survey from 1996 to 2012. Individuals
younger than 18 years and with malignancy diagnoses were excluded. All
prescriptions were standardized through conversion to milligrams of morphine
equivalents. Reported estimates are adjusted with multivariable regression
analysis.
Results
From 1996 to 2012, 47,081 patient-years (survey-weighted
population of 483,654,902 patient-years) surveyed by the Medical Expenditure
Panel Survey received at least 1 opioid prescription. During the same period,
we observed a 471% increase in the total quantity of opioids (measured by total
milligrams of morphine equivalents) prescribed in the United States. The
proportion of opioids from office-based prescriptions was high and increased
throughout the study period (71% of the total in 1996 to 83% in 2012). The
amount of opioids originating from the ED was modest and declined throughout
the study period (7.4% in 1996 versus 4.4% in 2012). For people in the top 5%
of opioid consumption, ED prescriptions accounted for only 2.4% of their total
milligrams of morphine equivalents compared with 87.8% from office visits.
Conclusion
Between 1996 and 2012, opioid prescribing for noncancer
patients in the United States significantly increased. The majority of this
growth was attributable to office visits and refills of previously prescribed
opioids. The relative contribution of EDs to the prescription opioid problem
was modest and declining. Thus, further efforts to reduce the quantity of
opioids prescribed may have limited effect in the ED and should focus on
office-based settings. EDs could instead focus on developing and disseminating
tools to help providers identify high-risk individuals and refer them to
treatment.
B. The Supply of Prescription Opioids:
Contributions of Episodic-Care Prescribers and High-Quantity Prescribers
Schneberk T, Raffetto B, Kim D, Schriger DL. Ann Emerg Med
2018;71(6):668–673.e3.
STUDY OBJECTIVE:
We determine episodic and high-quantity prescribers' contribution
to opioid prescriptions and total morphine milligram equivalents in California,
especially among individuals prescribed large amounts of opioids.
METHODS:
This was a cross-sectional descriptive analysis of opioid
prescribing patterns during an 8-year period using the de-identified Controlled
Substance Utilization Review and Evaluation System (CURES) database, the
California subsection of the prescription drug monitoring program. We took a
10% random sample of all patients and stratified them by the amount of
prescription opioids obtained during their maximal 90-day period. We identified
"episodic prescribers" as those whose prescribing pattern included
short-acting opioids on greater than 95% of all prescriptions, fewer than or
equal to 31 pills on 95% of all prescriptions, only 1 prescription in the
database for greater than 90% of all patients to whom they gave opioids, fewer
than 6 prescriptions in the database to greater than 99% of patients given
opioids, and fewer than 540 prescriptions per year. We identified top 5%
prescribers by their morphine milligram equivalents per day in the database. We
examined the relationship between patient opioid prescriptions and provider
type, with the primary analysis performed on the patient cohort who received
only short-acting opioids in an attempt to avoid guideline-concordant
palliative, oncologic, and addiction care, and a secondary analysis performed
on all patients.
RESULTS:
Among patients with short-acting opioid only, episodic
prescribers (14.6% of 173,000 prescribers) wrote at least one prescription to
25% of 2.7 million individuals but were responsible for less than 9% of the
10.5 million opioid prescriptions and less than 3% of the 3.9 billion morphine
milligram equivalents in our sample. Among individuals with high morphine
milligram equivalents use, episodic prescribers were responsible for 2.8% of
prescriptions and 0.6% of total morphine milligram equivalents. Conversely, the
top 5% of prescribers prescribed at least 29.8% of prescriptions and 48.8% of
total morphine milligram equivalents, with a greater contribution in patients
with high morphine milligram equivalents.
CONCLUSION:
Episodic prescribers contribute minimally to total opioid
prescriptions, especially among individuals categorized as using high morphine
milligram equivalents. Interventions focused on reducing opioid prescriptions
in the episodic care setting are unlikely to yield important reductions in the
prescription opioid supply; conversely, targeting high-quantity prescribers has
the potential to create substantial reductions.
C. Looking Ahead: The Role of Emergency
Physicians in the Opioid Epidemic
Lynch MJ, Yealy DM. Ann Emerg Med. 2018:71(6):676-678.
Excerpts from the editorial accompanying the two studies
above:
…Despite the common narrative implicating EDs as a
high-frequency site instigating or sustaining a cascade of events leading to
nonmedical opioid use, addiction, and death, the data by Axeen et al8 and
Schneberk et al9 indicate that EDs play a small role in the overall supply of
prescription opioids, particularly to individuals at highest risk. These
findings are consistent with previously published work. Barnett et al10 found
that the rate of 1-year opioid use after opioid-naive patients obtained an
initial prescription obtained from an ED was no greater than 1.5%. The authors
were not able to distinguish whether successive opioid prescriptions were
related to nonmedical use, ongoing pain, or recurrent acutely painful
conditions. Their finding of a maximum incidence of 1-year post-ED opioid use
of 1.5% contrasts with the 6% of patients prescribed at least 1 day of opioid
therapy from any site, as reported by Shah et al.11 Jeffery et al12 found that
opioid prescriptions originating from EDs were more likely to be compliant with
Centers for Disease Control and Prevention guidelines and significantly less
likely to result in long-term use than prescriptions provided to opioid-naive
patients in other health care settings.
… Despite the small ED role, we believe it
is incumbent on all physicians—including ED providers—to critically review
analgesic options, both pharmacologic and behavioral, to adequately treat pain
and mitigate the very small but present risk of developing an opioid use
disorder. The observation that 80% of injection drug users “started” with
nonmedical use of prescription opioids14 may mischaracterize addiction as a de
novo development resulting from a single, short-term prescription. Such a
causal conclusion ignores preexisting risk factors and indicators, including
nonopioid substance use and psychological trauma unrecognized by the provider
and patient.
Finally, the ED remains ground zero for interfacing with the
tragedy of opioid addiction; in our roles as emergency physicians or other care
providers, we see the effect of addiction and the death or near-death
experience, often in otherwise young and healthy patients. Our ability to
recognize and address the addiction, withhold opioids in this select group, and
prepare for any re-exposure by teaching and easing delivery of reversal therapy
for home use (naloxone) is key and likely more influential than any regulation
limiting ED prescribing to “X tablets or days” for all. Starting acute
detoxification, advocating and working to create accessible addiction treatment
after an ED visit, and other steps are needed and sorely missing in most
settings; we should lead these efforts to create and fund solutions if we seek
to stem the opioid overdose tide. Advocating for these steps—harder and more
expensive steps—is more likely to alter the opioid epidemic than ED prescribing
regulations, and recognizing patients who achieve these interventions is more
worthy than “going opioid free.”
Across the United States, EDs care for many patients with
acutely painful conditions, making these sites attractive targets for policy
interventions. We think multimodal analgesic education, coupled with easy
prescription monitoring access, is a better ED option, followed by accessible
addiction and long-term pain management options. Although we think seeking to
match ED opioid prescribing optimally for need is important and an ongoing
opportunity, we also think ceilings or other restrictive approaches through
regulation will be more influential in office-based settings and longer-term
care, curbing individual risk and the opioid pool more effectively. We see the
harms and know the real ED role; let’s join others to educate governmental and
health care leaders and advocate smart actions.
D. Prescription Opioid Shopping Does
Not Increase Overdose Rates in Medicaid Beneficiaries
Sun BC, et al. Ann Emerg Med. 2018;71(6):679–687.e3
Study objective
The link between prescription opioid shopping and overdose
events is poorly understood. We test the hypothesis that a history of
prescription opioid shopping is associated with increased risk of overdose
events.
Methods
This is a secondary analysis of a linked claims and
controlled substance dispense database. We studied adult Medicaid beneficiaries
in 2014 with prescription opioid use in the 6 months before an ambulatory care
or emergency department visit with a pain-related diagnosis. The primary
outcome was a nonfatal overdose event within 6 months of the cohort entry date.
The exposure of interest (opioid shopping) was defined as having opioid
prescriptions by different prescribers with greater than or equal to 1-day
overlap and filled at 3 or more pharmacies in the 6 months before cohort entry.
We used a propensity score to match shoppers with nonshoppers in a 1:1 ratio.
We calculated the absolute difference in outcome rates between shoppers and
nonshoppers.
Results
We studied 66,328 patients, including 2,571 opioid shoppers
(3.9%). There were 290 patients (0.4%) in the overall cohort who experienced a
nonfatal overdose. In unadjusted analyses, shoppers had higher event rates than
nonshoppers (rate difference of 4.4 events per 1,000; 95% confidence interval
0.8 to 7.9). After propensity score matching, there were no outcome differences
between shoppers and nonshoppers (rate difference of 0.4 events per 1,000; 95%
confidence interval –4.7 to 5.5). These findings were robust to various
definitions of opioid shoppers and look-back periods.
Conclusion
Prescription opioid shopping is not independently associated
with increased risk of overdose events.
E. Association
of an Opioid Standard of Practice Intervention with IV Opioid Exposure in
Hospitalized Patients
Ackerman AL, et al. JAMA Intern Med. 2018 May 14 [Epub ahead
of print]
Key Points
Question Can adopting
a new standard of inpatient opioid prescribing that prefers oral and
subcutaneous over intravenous administration result in reduced intravenous
opioid exposure?
Findings In this
pilot study of 127 patients and 2459 patient-days on an adult medical unit,
intravenous opioid dosing was reduced by 84% after adopting an opioid standard
of practice, with mean pain scores similar to those before implementation of
the new standard.
Meaning This
intervention may be associated with significant reduction in inpatient
intravenous opioid exposure in adult medical patients; further investigation is
warranted.
Abstract
Importance Opioids
are commonly used to treat pain in hospitalized patients; however, intravenous
administration carries an increased risk of adverse effects compared with oral
administration. The subcutaneous route is an effective method of opioid
delivery with favorable pharmacokinetics.
Objective To assess
an intervention to reduce intravenous opioid use, total parenteral opioid
exposure, and the rate of patients administered parenteral opioids.
Design, Setting, and Participants A pilot study was conducted in an adult
general medical unit in an urban academic medical center. Attending physicians,
nurse practitioners, and physician assistants who prescribed drugs were the
participants. Use of opioids was compared between a 6-month control period and
3 months following education for the prescribers on opioid routes of
administration.
Interventions
Adoption of a local opioid standard of practice, preferring the oral and
subcutaneous routes over intravenous administration, and education for
prescribers and nursing staff on awareness of the subcutaneous route was
implemented.
Main Outcomes and Measures
The primary outcome was a reduction in intravenous doses administered
per patient-day. Secondary measures included total parenteral and overall
opioid doses per patient-day, parenteral and overall opioid exposure per
patient-day, and daily rate of patients receiving parenteral opioids. Pain
scores were measured on a standard 0- to 10-point Likert scale over the first 5
days of hospitalization.
Results The control
period included 4500 patient-days, and the intervention period included 2459
patient-days. Of 127 patients in the intervention group, 59 (46.5%) were men;
mean (SD) age was 57.6 (18.5) years. Intravenous opioid doses were reduced by
84% (0.06 vs 0.39 doses per patient-day, P less than .001), and doses of all parenteral
opioids were reduced by 55% (0.18 vs 0.39 doses per patient-day, P less than .001). In addition, mean (SD) daily
parenteral opioid exposure decreased by 49% (2.88 [0.72] vs 5.67 [1.14]
morphine-milligram equivalents [MMEs] per patient-day). The daily rate of
patients administered any parenteral opioid decreased by 57% (6% vs 14%; P less than .001). Doses of opioids given by oral
or parenteral route were reduced by 23% (0.73 vs 0.95 doses per patient-day,
P = .02), and mean daily overall opioid exposure decreased by 31% (6.30 [4.12]
vs 9.11 [7.34] MMEs per patient-day). For hospital days 1 through 3, there were
no significant postintervention vs preintervention differences in mean reported
pain score for patients receiving opioid therapy: day 1, –0.19 (95% CI, −0.94
to 0.56); day 2, −0.49 (95% CI, −1.01 to 0.03); and day 3, −0.54 (95% CI, −1.18
to 0.09). However, significant improvement was seen in the intervention group
on days 4 (−1.07; 95% CI, −1.80 to −0.34) and 5 (−1.06; 95% CI, −1.84 to
−0.27).
Conclusions and Relevance
An intervention targeting the use of intravenous opioids may be
associated with reduced opioid exposure while providing effective pain control
to hospitalized adults.
F. Opportunities for Prevention and Intervention
of Opioid Overdose in the ED
Houry DE, et al. Ann Emerg Med. 2018;71(6):688-690.
Consider “Jane,” a 30-year-old female patient brought in by
emergency medical services (EMS) to the emergency department (ED), reflecting
just one of more than 100,000 opioid overdose patients treated in EDs each
year. Naloxone, an opioid antagonist and overdose reversal drug, was
administered in the field by EMS; however, additional rounds of naloxone were
required in the ED because of high opioid potency. Once she was stabilized, a
quick review of her chart revealed several recent visits for opioid-related
overdoses. A review of her history revealed that she was prescribed opioids
initially in the ED 5 years earlier after sustaining minor injuries in a motor
vehicle crash. She began misusing prescription opioids during the following
year, receiving prescriptions from multiple providers in primary care clinics
and EDs. Yet, because a check of the state’s prescription drug monitoring
program was not completed before any prescription, her use of multiple
providers and high dosages was not identified, and opioids continued to be
prescribed in different clinical settings for pain management. Soon thereafter,
Jane initiated heroin use and presented to the ED several times with cellulitis
from injection drug use, as well as after an overdose of prescription and
illicit opioids. Each time, she was discharged without a referral to substance
use treatment or without a naloxone kit.
Jane’s hypothetical story, although based on actual cases
treated in the ED, reflects just one of many cases that continue to be on the
increase. Emergency physicians, as front-line providers, without question save
lives by reversing opioid overdoses, but they also have a unique opportunity to
engage in prevention of a future overdose, particularly for patients who may
not have other contact with the health care system. A Centers for Disease
Control and Prevention (CDC) Vital Signs report has revealed that from July
2016 to September 2017, across 52 jurisdictions in 45 states, there were more
than 140,000 suspected opioid-involved overdose ED visits, with a nearly 30%
increase during the period.1 Increases were observed across both sexes (30% in
men and 24% in women) and all age groups, with those aged 35 to 54 years
representing the largest increase (36%). All regions across the United States
experienced increases, but the largest increases were observed in the Midwest
(70%), West (40%), and the Northeast (21%). Across 16 states with more
geographically specific data available, there was a 35% increase, with
continued worsening of overdose morbidity through 2017. All urbanization levels
experienced increases over the time period, with significant increases in the
largest cities (54%). The report relied on syndromic surveillance; that is, an
approach in which near real-time data from EDs were shared and analyzed.
Syndromic surveillance offers rapid data that can be used to facilitate public
health action more quickly. The CDC Vital Signs report highlighted the need to
better detect and respond to spikes in overdoses and to coordinate a
systems-level response in communities, such as health alerts and advisories to
address the ongoing opioid overdose epidemic…
G. Distribution of take-home opioid
antagonist kits during a synthetic opioid epidemic in British Columbia, Canada
Irvine MA, et al. Lancet Public Health. 2018
May;3(5):e218-e225
BACKGROUND: Illicit use of high-potency synthetic opioids
has become a global issue over the past decade. This misuse is particularly
pronounced in British Columbia, Canada, where a rapid increase in availability
of fentanyl and other synthetic opioids in the local illicit drug supply during
2016 led to a substantial increase in overdoses and deaths. In response,
distribution of take-home naloxone (THN) overdose prevention kits was scaled up
(6·4-fold increase) throughout the province. The aim of this study was to
estimate the impact of the THN programme in terms of the number of deaths
averted over the study period.
METHODS: We estimated the impact of THN kits on the ongoing
epidemic among people who use illicit opioids in British Columbia and explored
counterfactual scenarios for the provincial response. A Markov chain model was
constructed explicitly including opioid-related deaths, fentanyl-related
deaths, ambulance-attended overdoses, and uses of THN kits. The model was
calibrated in a Bayesian framework incorporating population data between Jan 1,
2012, and Oct 31, 2016.
FINDINGS: 22 499 ambulance-attended overdoses and 2121
illicit drug-related deaths (677 [32%] deaths related to fentanyl) were
recorded in the study period, mostly since January, 2016. In the same period,
19 074 THN kits were distributed. We estimate that 298 deaths (95% credible
interval [CrI] 91-474) were averted by the THN programme. Of these deaths, 226
(95% CrI 125-340) were averted in 2016, following a rapid scale-up in
distribution of kits. We infer a rapid increase in fentanyl adulterant at the
beginning of 2016, with an estimated 2·3 times (95% CrI 2·0-2·9) increase from
2015 to 2016. Counterfactual modelling indicated that an earlier scale-up of
the programme would have averted an additional 118 deaths (95% CrI 64-207). Our
model also indicated that the increase in deaths could parsimoniously be
explained through a change in the fentanyl-related overdose rate alone.
INTERPRETATION: The THN programme substantially reduced the
number of overdose deaths during a period of rapid increase in the number of
illicit drug overdoses due to fentanyl in British Columbia. However, earlier
adoption and distribution of the THN intervention might have had an even
greater impact on overdose deaths. Our findings show the value of a fast and
effective response at the start of a synthetic opioid epidemic. We also believe
that multiple interventions are needed to achieve an optimal impact.
Full-text (free): https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30044-6/fulltext
H. Association of Medical and Adult-Use
Marijuana Laws with Opioid Prescribing for Medicaid Enrollees
Wen H, et al. JAMA Intern Med. 2018;178(5):673-679.
Key Points
Question Are medical
and adult-use marijuana laws passed after 2010 associated with lower rates of
opioid prescribing for Medicaid enrollees?
Findings In this
population-based, cross-sectional study using the all-capture Medicaid
prescription data for 2011 to 2016, medical marijuana laws and adult-use
marijuana laws were associated with lower opioid prescribing rates (5.88% and
6.38% lower, respectively).
Meaning Medical and
adult-use marijuana laws have the potential to lower opioid prescribing for
Medicaid enrollees, a high-risk population for chronic pain, opioid use
disorder, and opioid overdose, and marijuana liberalization may serve as a
component of a comprehensive package to tackle the opioid epidemic.
Abstract
Importance
Overprescribing of opioids is considered a major driving force behind
the opioid epidemic in the United States. Marijuana is one of the potential
nonopioid alternatives that can relieve pain at a relatively lower risk of
addiction and virtually no risk of overdose. Marijuana liberalization,
including medical and adult-use marijuana laws, has made marijuana available to
more Americans.
Objective To examine
the association of state implementation of medical and adult-use marijuana laws
with opioid prescribing rates and spending among Medicaid enrollees.
Design, Setting, and Participants This cross-sectional study used a
quasi-experimental difference-in-differences design comparing opioid
prescribing trends between states that started to implement medical and
adult-use marijuana laws between 2011 and 2016 and the remaining states. This
population-based study across the United States included all Medicaid
fee-for-service and managed care enrollees, a high-risk population for chronic
pain, opioid use disorder, and opioid overdose.
Exposures State
implementation of medical and adult-use marijuana laws from 2011 to 2016.
Main Outcomes and Measures
Opioid prescribing rate, measured as the number of opioid prescriptions
covered by Medicaid on a quarterly, per-1000-Medicaid-enrollee basis.
Results State
implementation of medical marijuana laws was associated with a 5.88% lower rate
of opioid prescribing (95% CI, −11.55% to approximately −0.21%). Moreover, the
implementation of adult-use marijuana laws, which all occurred in states with
existing medical marijuana laws, was associated with a 6.38% lower rate of
opioid prescribing (95% CI, −12.20% to approximately −0.56%).
Conclusions and Relevance
The potential of marijuana liberalization to reduce the use and
consequences of prescription opioids among Medicaid enrollees deserves
consideration during the policy discussions about marijuana reform and the opioid
epidemic.
I. FDA Approves First Treatment For
Opioid Withdrawal Symptoms
LA Times: http://www.latimes.com/science/sciencenow/la-sci-sn-lucemyra-opioid-withdrawal-20180516-story.html
18. ACEP Clinical Policy:
Critical Issues in the Evaluation and Management of Adult Patients Presenting
to the ED with Suspected Acute VTE Disease
Wolf SJ, et al. Ann Emerg Med. 2018;71(5):e59–e109
The 2011 American College of Emergency Physicians (ACEP)
clinical policy on this topic focused on 6 critical questions: pretest
probability and clinical assessment, utility of the PERC, the diagnostic role
of highly sensitive D-dimer assays, computed tomography (CT) pulmonary
angiogram, CT venogram, and the therapeutic role of thrombolysis in
hemodynamically stable and unstable patients with PE.9
This revision will focus on 5 areas of interest or controversy
that have developed or still exist since the 2011 policy was formulated. The
first 2 critical questions address the role of unique clinical prediction rules
and age-adjusted D-dimer testing in the diagnosis of PE, whereas the remaining
3 questions focus on optimal treatment and disposition for individuals
receiving a diagnosis of venous thromboembolic disease.
The 5 Questions and Recommendations
1.
In adult patients with suspected acute PE, can a clinical prediction rule be
used to identify a group of patients at very low risk for the diagnosis of PE
for whom no additional diagnostic workup is required?
Level B recommendation: For patients who are at low risk for
acute PE, use the PERC to exclude the diagnosis without further diagnostic
testing
2.
In adult patients with low to intermediate pretest probability for acute PE,
does a negative age-adjusted D-dimer result identify a group of patients at
very low risk for the diagnosis of PE for whom no additional diagnostic workup
is required?
Level B recommendation: In patients older than 50 years
deemed to be low or intermediate risk for acute PE, clinicians may use a
negative age-adjusted D-dimer∗ result to exclude the diagnosis of PE.
3.
In adult patients with subsegmental PE, is it safe to withhold anticoagulation?
Level C recommendations: Given the lack of evidence,
anticoagulation treatment decisions for patients with subsegmental PE without
associated DVT should be guided by individual patient risk profiles and
preferences. [Consensus recommendation]
4.
In adult patients diagnosed with acute PE, is initiation of anticoagulation and
discharge from the ED safe?
Level C recommendations: Selected patients with acute PE who
are at low risk for adverse outcomes as determined by PESI, simplified PESI (sPESI),
or the Hestia criteria may be safely discharged from the ED on anticoagulation,
with close outpatient follow-up.
5.
In adult patients diagnosed with acute lower-extremity DVT who are discharged
from the ED, is treatment with a NOAC safe and effective compared with
treatment with LMWH and VKA?
Level B recommendations: In selected patients diagnosed with
acute DVT, a NOAC may be used as a safe and effective treatment alternative to
LMWH/VKA.
19. Effect of Systematic Physician Cross-checking on Reducing
Adverse Events in the ED: The CHARMED Cluster Randomized Trial
Freund Y, et al. JAMA Intern Med. 2018 Apr 23 [Epub ahead of
print]
IMPORTANCE:
Emergency departments (ED) are environments that are at high
risk for medical errors. Previous studies suggested that the proportion of
medical errors may decrease when more than 1 physician is involved.
OBJECTIVE:
To reduce the proportion of medical errors by implementing
systematic cross-checking between emergency physicians.
DESIGN, SETTING, AND PARTICIPANTS:
This cluster randomized crossover trial includes a random
sample of 14 adult patients (age ≥18 years) per day during two 10-day period in
6 EDs (n = 1680 patients) in France.
INTERVENTIONS:
Systematic cross-checking between emergency physicians, 3
times a day, which included a brief presentation of one physician's case to
another, followed by the second physician's feedback to the first.
MAIN OUTCOMES AND MEASURES:
Medical error in the ED, defined as an adverse event (either
a near miss or a serious adverse event). The primary end point was identified
using a 2-level error detection surveillance system, blinded to the strategy
allocation.
RESULTS:
Among the 1680 included patients (mean [SD] age, 57.5 [21.7]
years), 144 (8.6%) had an adverse event. There were 54 adverse events among 840
patients (6.4%) in the cross-check group compared with 90 adverse events among
840 patients (10.7%) in the standard care group (relative risk reduction [RRR],
40% [95% CI, 12% to 59%]; absolute risk reduction [ARR], 4.3%; number needed to
treat [NNT], 24). There was also a significant reduction rate of near misses
(RRR, 47% [95% CI, 15% to 67%]; ARR, 2.7%; NNT, 37) but not of the rate of
preventable serious adverse events (RRR, 29% [95% CI, -18% to 57%]; ARR, 1.2%;
NNT, 83).
CONCLUSIONS AND RELEVANCE:
The implementation of systematic cross-checking between
emergency physicians was associated with a significant reduction in adverse
events, mainly driven by a reduction in near misses.
20. Comparative Trends in Heart Disease, Stroke, and All-Cause
Mortality in the United States and a Large Integrated Healthcare Delivery
System
Sidney S, et al. Am J Med. 2018 Apr 2 [Epub ahead of print].
Objectives
Heart disease and stroke remain among the leading causes of
death nationally. We examined whether differences in recent trends in heart
disease, stroke, and total mortality exist in the United States and Kaiser
Permanente Northern California (KPNC), a large integrated healthcare delivery
system.
Methods
The main outcome measures were comparisons of US and KPNC
total, age-specific, and sex-specific changes from 2000 to 2015 in mortality
rates from heart disease, coronary heart disease, stroke, and all causes. The
Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic
Research data system was used to determine US mortality rates. Mortality rates
for KPNC were determined from health system, Social Security vital status, and
state death certificate databases.
Results
Declines in age-adjusted mortality rates were noted in KPNC
and the United States for heart disease (36.3% in KPNC vs 34.6% in the United
States), coronary heart disease (51.0% vs 47.9%), stroke (45.5% vs 38.2%), and
all-cause mortality (16.8% vs 15.6%). However, steeper declines were noted in
KPNC than the United States among those aged 45 to 65 years for heart disease
(48.3% KPNC vs 23.6% United States), coronary heart disease (55.6% vs 35.9%),
stroke (55.8% vs 26.0%), and all-cause mortality (31.5% vs 9.1%). Sex-specific
changes were generally similar.
Conclusions
Despite significant declines in heart disease and stroke
mortality, there remains an improvement gap nationally among those aged less
than 65 years when compared with a large integrated healthcare delivery system.
Interventions to improve cardiovascular mortality in the vulnerable middle-aged
population may play a key role in closing this gap.
21. IV Fluids
A. The Association of Prehospital IV
Fluids and Mortality in Patients with Penetrating Trauma
Bores SA, et al. Am J Emerg Med 2018;54(4):487–499.e6.
BACKGROUND: The optimal approach to prehospital care of
trauma patients is controversial, and thought to require balancing advanced
field interventions with rapid transport to definitive care.
OBJECTIVE: We sought principally to examine any association
between the amount of prehospital IV fluid (IVF) administered and mortality.
METHODS: We conducted a retrospective cohort analysis of
trauma registry data patients who sustained penetrating trauma between January
2008 and February 2011, as identified in the Pennsylvania Trauma Systems
Foundation registry with corresponding prehospital records from the
Philadelphia Fire Department. Analyses were conducted with logistic regression
models and instrumental variable analysis, adjusted for injury severity using
scene vital signs before the intervention was delivered.
RESULTS: There were 1966 patients identified. Overall
mortality was 22.60%. Approximately two-thirds received fluids and one-third
did not. Both cohorts had similar Trauma and Injury Severity Score-predicted
mortality. Mortality was similar in those who received IVF (23.43%) and those
who did not (21.30%) (p = 0.212). Patients who received IVF had longer mean
scene times (10.82 min) than those who did not (9.18 min) (p less than 0.0001), although call times were
similar in those who received IVF (24.14 min) and those who did not (23.83 min)
(p = 0.637). Adjusted analysis of 1722 patients demonstrated no benefit or harm
associated with prehospital fluid (odds ratio [OR] 0.905, 95% confidence
interval [CI] 0.47-1.75). Instrumental variable analysis utilizing variations
in use of IVF across different Emergency Medical Services (EMS) units also
found no association between the unit's percentage of patients that were
provided fluids and mortality (OR 1.02, 95% CI 0.96-1.08).
CONCLUSIONS: We found no significant difference in mortality
or EMS call time between patients who did or did not receive prehospital IVF
after penetrating trauma.
B. Are three ports better than one? An
evaluation of flow rates using all ports of a triple lumen central venous
catheter in volume resuscitation.
Traylor S, et al. Am J Emerg Med. 2018 May;36(5):739-740.
BACKGROUND:
Poiseuille's law states flow rates are directly proportional
to the radius to the 4th power and indirectly proportional to the length of a
tube. Because of this property, large bore catheters are commonly used in the
resuscitation of the critically ill patient. However, there are no studies
comparing simultaneous use of all three lumens of a triple lumen (TL) central
venous catheter (CVC) with other catheter types. Our objective was to compare
the flow rates of normal saline (NS) through various resuscitation catheters
against a TL CVC using all 3 ports.
METHODS:
We performed a blinded prospective observational study of
flow rates utilizing multiple resuscitation catheters. Each catheter type was
attached to a 1l bag of NS using standard saline tubing and mean time to infuse
1l of normal saline was determined. Three trials each were completed with and
without pressure bags.
RESULTS:
Simultaneous infusion of NS through all ports of a TL CVC
demonstrated no statistically significant difference compared to the following
catheters: 16ga peripheral venous catheter (PVC) and 6 Fr CVC with pressure
bag. The 14 g PVC and 8.5Fr CVC had statistically significant faster flow rates
than the TL CVC both with and without a pressure bag. The 6Fr CVC showed
significantly faster flow rates than the TL CVC without a pressure bag.
CONCLUSIONS:
Simultaneous use of all 3 ports of a TL CVC generates flow
rates comparable to many other commonly used resuscitation catheters.
22. Suffering in Silence: Medical Error and its Impact on Health
Care Providers.
Robertson JJ, Long B. J Emerg Med. 2018 Apr;54(4):402-409.
BACKGROUND: All humans are fallible. Because physicians are
human, unintentional errors unfortunately occur. While unintentional medical
errors have an impact on patients and their families, they may also contribute
to adverse mental and emotional effects on the involved provider(s). These may
include burnout, lack of concentration, poor work performance, posttraumatic
stress disorder, depression, and even suicidality.
OBJECTIVES: The objectives of this article are to 1) discuss
the impact medical error has on involved provider(s), 2) provide potential
reasons why medical error can have a negative impact on provider mental health,
and 3) suggest solutions for providers and health care organizations to
recognize and mitigate the adverse effects medical error has on providers.
DISCUSSION: Physicians and other providers may feel a
variety of adverse emotions after medical error, including guilt, shame,
anxiety, fear, and depression. It is thought that the pervasive culture of
perfectionism and individual blame in medicine plays a considerable role toward
these negative effects. In addition, studies have found that despite
physicians' desire for support after medical error, many physicians feel a lack
of personal and administrative support. This may further contribute to poor
emotional well-being. Potential solutions in the literature are proposed,
including provider counseling, learning from mistakes without fear of punishment,
discussing mistakes with others, focusing on the system versus the individual,
and emphasizing provider wellness. Much of the reviewed literature is limited
in terms of an emergency medicine focus or even regarding physicians in
general. In addition, most studies are survey- or interview-based, which limits
objectivity. While additional, more objective research is needed in terms of
mitigating the effects of error on physicians, this review may help provide
insight and support for those who feel alone in their attempt to heal after
being involved in an adverse medical event.
CONCLUSIONS: Unintentional medical error will likely always
be a part of the medical system. However, by focusing on provider as well as
patient health, we may be able to foster resilience in providers and improve
care for patients in healthy, safe, and constructive environments.
23. Reduction in Lactate Levels After Hemodialysis in Patients with End-Stage Renal Disease.
Hourmozdi JJ, et al. Ann Emerg Med. 2018;71(6):737-742.
STUDY OBJECTIVE:
Patients with end-stage renal disease commonly visit the emergency department (ED). The purpose of this investigation is to examine the prevalence of baseline abnormal lactate levels and to evaluate the effects of hemodialysis on serum lactate levels.
METHODS:
This was a prospective observational cohort study performed at an outpatient dialysis facility at an urban tertiary care hospital. The study consisted of 226 patients with end-stage renal disease who were receiving long-term hemodialysis and were enrolled during a 2-day period at the beginning of December 2015. Blood drawn for lactate levels was immediately analyzed before and after hemodialysis sessions. All patients completed their hemodialysis sessions.
RESULTS:
The prevalence of an abnormal lactate level (greater than 1.8 mmol/L) before hemodialysis was 17.7% (n=40). Overall, lactate levels decreased by 27% (SD 35%) after hemodialysis, with a decrease of 37% (SD 31%) for subgroups with a lactate level of 1.9 to 2.4 mmol/L, and 62% (SD 14%) with a lactate of 2.5 to 3.9 mmol/L.
CONCLUSION:
The data presented help providers understand the prevalence of abnormal lactate values in an outpatient end-stage renal disease population. After hemodialysis, lactate levels decreased significantly. This information may help medical providers interpret lactate values when patients with end-stage renal disease present to the ED.
24. Micro Bits
A.
Vertebroplasty no better than sham procedure for painful acute osteoporotic
vertebral compression fractures (VERTOS IV): randomised sham controlled
clinical trial
B.
Satirical post: Ortho Consults Medicine to See if It’s Spelled Orthopedics or
Orthopaedics
C.
MRI Glove Gives Doctors a Deeper Look at the Hand
A new kind of MRI component in the shape of a glove delivers
the first clear images of bones, tendons and ligaments moving together, a new
study finds.
Led by NYU School of Medicine and just published in Nature
Biomedical Engineering, the study shows how a new MRI element design woven into
garment-like detectors can capture high-quality images of moving joints for the
first time.
D.
Some oral antibiotics tied to kidney stone risk
Children and adults who took sulfas, cephalosporins,
fluoroquinolones, nitrofurantoin/methenamine or broad-spectrum penicillins --
all oral antibiotics -- three to 12 months prior to an index date were more
likely to develop nephrolithiasis, according to a study in the Journal of the
American Society of Nephrology. Researchers found the strongest risk
relationship between antibiotics and risk of kidney stones among those younger
than 18 and those exposed three to six months before the index date.
NY Times: https://www.nytimes.com/2018/05/10/well/antibiotics-may-raise-the-risk-for-kidney-stones.html
E.
First-Ever Suicide Prevention Recommendations Released
F.
Myocardial Infarction with Nonobstructive Coronary Arteries: The Importance of
Achieving Secondary Prevention Targets
G.
Nationwide Trends in Mortality Following Penetrating Trauma: Are We Up for the
Challenge?
Study abstract: https://journals.lww.com/jtrauma/Abstract/publishahead/Nationwide_Trends_in_Mortality_Following.98709.aspx
H.
Alcohol consumption may impair sleep quality
A study reported in JMIR Mental Health found alcohol intake,
even at low or moderate levels, was associated with less restorative sleep. The
findings, based on data from 4,098 men and women ages 18 to 65, showed the
effect of alcohol intake was more apparent among younger individuals than older
ones.
I.
Bacterial treatment may benefit youths, adults with eczema
Four in 5 children and 6 in 10 adults with eczema who
sprayed their skin with sugar water containing increasing doses of live
Roseomonas mucosa bacteria taken from individuals without eczema had their
symptoms improve by more than 50%, according to a study in JCI Insight. The
findings also showed no complications from the bacterial treatment.
J.
Single-Dose Packaging May Reduce Kids’ Unintentional Exposure To Narcotic
Medicines, Research Suggests.
K.
Palliative care reduces hospital costs, stays, study finds
Adding a palliative care consultation within three days of
hospital admission reduced per-patient costs by an average of $3,237, compared
with not providing the consult, according to a study in JAMA Internal Medicine.
Palliative care's effect on the length and cost of a hospital stay was greater
for patients with four or more comorbidities than it was for those with two or
fewer comorbidities.
NBC News: https://www.nbcnews.com/health/health-news/palliative-care-saves-money-study-finds-n870226
L.
No Radiographic Safe Margin Found in the “Easy IJ” Internal Jugular Vein
Procedure
M.
Who Should Perform REBOA Technique? Guideline Limiting Emergency Physician Use
Draws Fire
N.
New Rabies Test May Transform Animal-Bite Treatment: Molecular assay quickly and
accurately determines if animals are infected
O.
Will Posting Nutritional Information on Menus Prod Diners to Make Healthier
Choices?
