0. Three Free Resources
A. Entertaining: ZDoggMD sings Les Mis
The Confrontation: the
spats between emergency physicians and hospitalists can be ... well, misérable.
But ZDoggMD turns
these sometimes stressful situations into a musical parody of "The
Confrontation" from the hit Broadway musical and movie "Les
Misérables." Take a listen!
B. Enlightening: Connections and Curiosity
Winner J. In Practice.
A Blog from FPM Journal. Jun 28, 2018
Two ways to find meaning
in medicine
Rushing through your
workday can leave you feeling frustrated, distracted, and depleted. But mindful
interactions can help you feel more effective and fulfilled. To practice
mindfulness during patient visits, focus on cultivating connection and
curiosity.
1. To build
connection, find areas of commonality:
Do you both have
children?
Have you both
struggled with a parent's illness?
Do you have any
similar experiences of suffering, challenges, or joys?
2. To practice
curiosity, consider the other person's circumstances:
What is it like to be
a migrant farmer?
How does this patient
deal with chronic pain or anxiety?
What kind of support
does this patient have at home?
C. Educational: SAEM Presentations: Free for the Learning
Up to 225 Hours of
Free SAEM18 Content Available on SOAR
All SAEM18 educational
content is now open access and available online at SOAR (SAEM Online Academic
Resources). Experience convenient online and mobile viewing of Advanced EM
Workshops, didactics, forums, abstracts—225 hours of original educational
content from SAEM18. Downloadable PDFs and MP3 provide convenient, on–the-go
viewing, and presenters' slides can be viewed while listening to fully
synchronized audio. Enjoy!
1. Recent Acute Stroke Studies
A. Clopidogrel and Aspirin in Acute Ischemic Stroke and
High-Risk TIA (the POINT trial).
Johnston SC, et al. N
Engl J Med. 2018 Jul 19;379(3):215-225.
BACKGROUND: Combination
antiplatelet therapy with clopidogrel and aspirin may reduce the rate of
recurrent stroke during the first 3 months after a minor ischemic stroke or
transient ischemic attack (TIA). A trial of combination antiplatelet therapy in
a Chinese population has shown a reduction in the risk of recurrent stroke. We
tested this combination in an international population.
METHODS: In a
randomized trial, we assigned patients with minor ischemic stroke or high-risk
TIA to receive either clopidogrel at a loading dose of 600 mg on day 1,
followed by 75 mg per day, plus aspirin (at a dose of 50 to 325 mg per day) or
the same range of doses of aspirin alone. The dose of aspirin in each group was
selected by the site investigator. The primary efficacy outcome in a
time-to-event analysis was the risk of a composite of major ischemic events,
which was defined as ischemic stroke, myocardial infarction, or death from an
ischemic vascular event, at 90 days.
RESULTS: A total of
4881 patients were enrolled at 269 international sites. The trial was halted
after 84% of the anticipated number of patients had been enrolled because the
data and safety monitoring board had determined that the combination of
clopidogrel and aspirin was associated with both a lower risk of major ischemic
events and a higher risk of major hemorrhage than aspirin alone at 90 days.
Major ischemic events occurred in 121 of 2432 patients (5.0%) receiving
clopidogrel plus aspirin and in 160 of 2449 patients (6.5%) receiving aspirin
plus placebo (hazard ratio, 0.75; 95% confidence interval [CI], 0.59 to 0.95;
P=0.02), with most events occurring during the first week after the initial
event. Major hemorrhage occurred in 23 patients (0.9%) receiving clopidogrel
plus aspirin and in 10 patients (0.4%) receiving aspirin plus placebo (hazard
ratio, 2.32; 95% CI, 1.10 to 4.87; P=0.02).
CONCLUSIONS: In
patients with minor ischemic stroke or high-risk TIA, those who received a
combination of clopidogrel and aspirin had a lower risk of major ischemic
events but a higher risk of major hemorrhage at 90 days than those who received
aspirin alone.
Editorial excerpt
What is the take-home message for the clinician? The
evidence from the SAMMPRIS, CHANCE, and POINT trials is that the combination of
aspirin plus clopidogrel reduces the chance of recurrent ischemic stroke during
the high-risk period in the first few weeks after a TIA or noncardioembolic
ischemic stroke. However, to conform to the results of the POINT trial, if dual
therapy is used, it should be confined to the first 3 weeks after a TIA or
minor stroke and then transitioned to monotherapy. If patient follow-up and
adherence to therapy are not reliable, then dual therapy perhaps should not be
considered. Dual therapy may also not be advisable in patients with an
uncertain diagnosis of TIA, who either would have been excluded from the trial
or did not benefit. Finally, patients who are at increased risk for bleeding,
such as those with cerebral microbleeding or a history of brain or systemic
bleeding, were excluded from this trial and may not be appropriate candidates
for such dual therapy. The POINT trial has provided useful data to help us
further personalize our efforts in preventing recurrent stroke.
B. Lytics No Better Than Aspirin in Mild Ischemic Stroke
Trial
Effect of Alteplase vs
Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor
Nondisabling Neurologic Deficits: The PRISMS RCT
Khatri P, et al. JAMA.
2018;320(2):156-166.
IMPORTANCE:
More than half of
patients with acute ischemic stroke have minor neurologic deficits (National
Institutes of Health Stroke Scale [NIHSS] score of 0-5) at presentation.
Although prior major trials of alteplase included patients with low NIHSS
scores, few without clearly disabling deficits were enrolled.
OBJECTIVE:
To evaluate the efficacy
and safety of alteplase in patients with NIHSS scores of 0 to 5 whose deficits
are not clearly disabling.
DESIGN, SETTING, AND
PARTICIPANTS:
The PRISMS trial was
designed as a 948-patient, phase 3b, double-blind, double-placebo, multicenter
randomized clinical trial of alteplase compared with aspirin for emergent
stroke at 75 stroke hospital networks in the United States. Patients with acute
ischemic stroke whose deficits were scored as 0 to 5 on the NIHSS and judged
not clearly disabling and in whom study treatment could be initiated within 3
hours of onset were eligible and enrolled from May 30, 2014, to December 20,
2016, with final follow-up on March 22, 2017.
INTERVENTIONS:
Participants were
randomized to receive intravenous alteplase at the standard dose (0.9 mg/kg)
with oral placebo (n = 156) or oral aspirin, 325 mg, with intravenous placebo
(n = 157).
MAIN OUTCOMES AND
MEASURES:
The primary outcome
was the difference in favorable functional outcome, defined as a modified
Rankin Scale score of 0 or 1 at 90 days via Cochran-Mantel-Haenszel test
stratified by pretreatment NIHSS score, age, and time from onset to treatment.
Because of early termination of the trial, prior to unblinding or interim
analyses, the plan was revised to examine the risk difference of the primary
outcome by a linear model adjusted for the same factors. The primary safety end
point was symptomatic intracranial hemorrhage (sICH) within 36 hours of
intravenous study treatment.
RESULTS:
Among 313 patients
enrolled at 53 stroke networks (mean age, 62 [SD, 13] years; 144 [46%] women;
median NIHSS score, 2 [interquartile range {IQR}, 1-3]; median time to
treatment, 2.7 hours [IQR, 2.1-2.9]), 281 (89.8%) completed the trial. At 90
days, 122 patients (78.2%) in the alteplase group vs 128 (81.5%) in the aspirin
group achieved a favorable outcome (adjusted risk difference, -1.1%; 95% CI,
-9.4% to 7.3%). Five alteplase-treated patients (3.2%) vs 0 aspirin-treated
patients had sICH (risk difference, 3.3%; 95% CI, 0.8%-7.4%).
CONCLUSIONS AND
RELEVANCE:
Among patients with
minor nondisabling acute ischemic stroke, treatment with alteplase vs aspirin
did not increase the likelihood of favorable functional outcome at 90 days.
However, the very early study termination precludes any definitive conclusions,
and additional research may be warranted.
Commentary by Ryan Radecki: Stopping the Alteplase Indication
Creep
Ever since the narrow
approval and strict inclusion criteria of the first trials for alteplase in
stroke, our benevolent corporate overlords have been doing their utmost to
expand its indications – all while continuing to unilaterally boost its price.
This includes sponsoring “expert” convocations to whittle down
contraindications, as well as sponsoring, and then cancelling, trials destined
to futility.
This is another
example of the latter.
This is the remnants
of PRISMS, a trial testing the alteplase versus aspirin in a randomized,
placebo-controlled trial of mild stroke. In this trial, “mild stroke” included
a NIHSS of ≤5 and the absence of any disabling deficits. That is to say,
rather, every patient entered in this trial met, in theory, the primary outcome
of an mRS of 0-1 at entry. The trial expected to find an advantage to treatment
of 9% and incidence of sICH of 2%, a NNT of 11, NNH of 50, and a requirement of
948 patients for the statistical power to validate such findings.
The trial, however,
was stopped after 313 patients due to “slow enrollment”. Of these, 32 were lost
to follow-up, leaving 281 available for 90-day assessment without imputation.
The bulk of patients ranged in NIHSS 1 to 3, with sensory symptoms, facial
palsy, and dysarthria the most frequently represented stroke symptoms. Of those
with 90-day follow-up, 83.1% of the aspirin arm achieved mRS 0-1, compared with
77.5% of those randomized to alteplase. Conversely, 3.4% of these mild strokes
were ultimately mRS 4-6 – a typical definition of “poor outcome” – in the
aspirin arm, compared with 10% of those randomized to alteplase. The 5 patients
with sICH following alteplase administration contributed to these poor
outcomes, compared with none following administration of aspirin.
So, very clearly,
there is no evidence here to support a presumption of benefit from alteplase
administration, but quite clearly evidence of harm. The authors – with hardly
any conflict-of-interest to speak of – go to great lengths to assure us…
C. FAST Fails to Improve TIA, Minor Stroke Response in
Britain
Success in boosting
major stroke recognition doesn't trickle down to minor symptoms
Medpage. July 2, 2018.
The Face, Arm, Speech,
Time (FAST) public education campaign has not improved transient ischemic
attack (TIA) and minor stroke response in England, a prospective
population-based study found.
In 5 years after the
campaign launch, the percentage of people seeking medical attention within 3
hours of a TIA or minor stroke did not change, reported Peter Rothwell, MD, PhD,
of John Radcliffe Hospital at University of Oxford, and co-authors.
The percentage of
major strokes that were preceded by an unheeded TIA also remained unchanged…
2. Is Inpatient Volume Or ED Crowding A Greater Driver Of
Ambulance Diversion?
Hsia RY, et al. Health
Affairs 2018 Jul;37(7):1115-1122.
Inpatient volume has
long been believed to be a contributing factor to ambulance diversion, which
can lead to delayed treatment and poorer outcomes. We examined the extent to
which both daily inpatient and emergency department (ED) volumes at specified
hospitals, and diversion levels (that is, the number of hours ambulances were
diverted on a given day) at their nearest neighboring hospitals, were
associated with diversion levels in the period 2005–12. We found that a 10
percent increase in patient volume was associated with a sevenfold greater
increase in diversion hours when the volume increase occurred among inpatients
(5 percent) versus ED visitors (0.7 percent). When the next-closest ED
experienced mild, moderate, or severe diversion, the study hospital’s diversion
hours increased by 8 percent, 23 percent, and 44 percent, respectively. These
findings suggest that efforts focused on managing inpatient volume and flow
might reduce diversion more effectively than interventions focused only on ED
dynamics.
3. Cardiogenic Shock and Cardiac Arrest
A. Epinephrine Not Best
Choice for Cardiogenic Shock in MI
Associated with higher
rates of refractory shock than with norepinephrine
Levy B, et al. Epinephrine
Versus Norepinephrine for Cardiogenic Shock After Acute Myocardial Infarction.
J Am Coll Cardiol. 2018 Jul 10;72(2):173-182.
BACKGROUND: Vasopressor
agents could have certain specific effects in patients with cardiogenic shock
(CS) after myocardial infarction, which may influence outcome. Although
norepinephrine and epinephrine are currently the most commonly used agents, no
randomized trial has compared their effects, and intervention data are lacking.
OBJECTIVES: The goal
of this paper was to compare in a prospective, double-blind, multicenter,
randomized study, the efficacy and safety of epinephrine and norepinephrine in
patients with CS after acute myocardial infarction.
METHODS: The primary
efficacy outcome was cardiac index evolution, and the primary safety outcome
was the occurrence of refractory CS. Refractory CS was defined as CS with
sustained hypotension, end-organ hypoperfusion and hyperlactatemia, and high
inotrope and vasopressor doses.
RESULTS: Fifty-seven
patients were randomized into 2 study arms, epinephrine and norepinephrine. For
the primary efficacy endpoint, cardiac index evolution was similar between the
2 groups (p = 0.43) from baseline (H0) to H72. For the main safety endpoint,
the observed higher incidence of refractory shock in the epinephrine group (10
of 27 [37%] vs. norepinephrine 2 of 30 [7%]; p = 0.008) led to early
termination of the study. Heart rate increased significantly with epinephrine
from H2 to H24 while remaining unchanged with norepinephrine (p less than
0.0001). Several metabolic changes were unfavorable to epinephrine compared
with norepinephrine, including an increase in cardiac double product (p =
0.0002) and lactic acidosis from H2 to H24 (p less than 0.0001).
CONCLUSIONS: In
patients with CS secondary to acute myocardial infarction, the use of
epinephrine compared with norepinephrine was associated with similar effects on
arterial pressure and cardiac index and a higher incidence of refractory shock.
B. Epinephrine
[Ultimately Not Helpful] in Cardiac
Arrest
Adrenaline after
cardiac arrest doubles risk of serious brain damage, finds trial.
Perkins GD, et al. A
Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J
Med. 2018 Jul 18 [Epub ahead of print]
Background Concern
about the use of epinephrine as a treatment for out-of-hospital cardiac arrest
led the International Liaison Committee on Resuscitation to call for a
placebo-controlled trial to determine whether the use of epinephrine is safe
and effective in such patients.
Methods In a
randomized, double-blind trial involving 8014 patients with out-of-hospital
cardiac arrest in the United Kingdom, paramedics at five National Health
Service ambulance services administered either parenteral epinephrine (4015
patients) or saline placebo (3999 patients), along with standard care. The
primary outcome was the rate of survival at 30 days. Secondary outcomes
included the rate of survival until hospital discharge with a favorable
neurologic outcome, as indicated by a score of 3 or less on the modified Rankin
scale (which ranges from 0 [no symptoms] to 6 [death]).
Results At 30 days,
130 patients (3.2%) in the epinephrine group and 94 (2.4%) in the placebo group
were alive (unadjusted odds ratio for survival, 1.39; 95% confidence interval
[CI], 1.06 to 1.82; P=0.02). There was no evidence of a significant difference
in the proportion of patients who survived until hospital discharge with a
favorable neurologic outcome (87 of 4007 patients [2.2%] vs. 74 of 3994 patients
[1.9%]; unadjusted odds ratio, 1.18; 95% CI, 0.86 to 1.61). At the time of
hospital discharge, severe neurologic impairment (a score of 4 or 5 on the
modified Rankin scale) had occurred in more of the survivors in the epinephrine
group than in the placebo group (39 of 126 patients [31.0%] vs. 16 of 90
patients [17.8%]).
Conclusions In adults
with out-of-hospital cardiac arrest, the use of epinephrine resulted in a
significantly higher rate of 30-day survival than the use of placebo, but there
was no significant between-group difference in the rate of a favorable
neurologic outcome because more survivors had severe neurologic impairment in
the epinephrine group.
C. AHA commits to improving in-hospital cardiac arrest survival
through innovative competency improvement solution
Maintenance of
resuscitation skills a key element in increasing survival rates
AHA. DALLAS, February 24,
2018 — The overall odds of surviving a cardiac arrest in the U.S. could vary by
as much as 42 percent between randomly selected hospitals.1 Research has found that poor quality CPR
should be considered a preventable harm, and timely delivery of high-quality
CPR is the greatest determinant of survival from cardiac arrest.2
Unfortunately, even with trained professionals, poor quality CPR is common.3 In
response, the American Heart Association, the world’s leading voluntary health
organization devoted to fighting cardiovascular disease and stroke, is
addressing the need for alternative training models to support and develop
highly skilled healthcare professionals. On February 24, the Association made a
commitment to saving an additional 50,000 lives each year at the 6th Annual
World Patient Safety, Science & Technology Summit in London, U.K.
The Association is seeking a paradigm shift in hospital
resuscitation practice. Advances in technology and evidence now show that
low-dose, high-frequency hands on training is significantly more effective than
traditional annual or biennial CPR training at increasing and maintaining CPR
skills competency. Resuscitation quality improvement initiatives are both
necessary and effective at saving and extending lives of in-hospital cardiac
arrest patients.4 This shift from a traditional compliance mindset to a
resuscitation skills competency approach centered on patient-safety will create
a new standard of care, resulting in a transformational, organization-wide
resuscitation quality improvement program.
Developed through the Association’s strategic alliance
with Laerdal Medical, and launched in February 2015, the Resuscitation Quality Improvement (RQI®) program develops
high-quality resuscitation skills through low-dose, high-frequency CPR skills
practice, delivering a new standard in resuscitation performance. Validated by
actual patient care and survival evidence, lives are being saved.5. Since
introduction, approximately 300 hospitals in the U.S. have adopted the
Resuscitation Quality Improvement program and the competency of more than
300,000 healthcare providers has been improved.
“Increasing the number of healthcare providers using the
Resuscitation Quality Improvement program will save more lives,” says John
Meiners, Chief of Mission-aligned Businesses for the American Heart
Association. “Approximately 10 minutes
of CPR skills practice each quarter helps to eliminate ‘skills decay’ and offer
‘skills mastery,’ resulting in high-quality CPR performance.”
In addition to delivering high-quality CPR, the Resuscitation
Quality Improvement program is continuously evolving to integrate additional
evidence-based features that can dramatically improve survival as part of a
bundle of care. The Resuscitation Quality Improvement Analytics program
(currently deployed), combined with structured team debriefings and rapid
response teams will help drive excellence in clinical performance.
3-minute video: https://vimeo.com/120532597
More on RQI: https://cpr.heart.org/AHAECC/CPRAndECC/Training/RQI/UCM_476470_Resuscitation-Quality-Improvement-Program-RQI.jsp
More on AHA’s Overall
Strategy:
Neumar RW, et al. AHA Response to the
2015 Institute of Medicine Report on Strategies to Improve Cardiac Arrest
Survival. Circulation.
2018;132:1049-1070.
Highlights: https://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_501781.pdf
D. Dual
defibrillation in patients with refractory VF: Lit Review
In the setting of
cardiac arrest, refractory ventricular fibrillation (VF) is difficult to
manage, and mortality rates are high. Double sequential defibrillation (DSD)
has been described in the literature as a successful means to terminate this
malignant rhythm, after failure of traditional Advanced Cardiac Life Support
(ACLS) measures. The authors herein present a case of refractory VF in a
patient with cardiac arrest, on whom DSD was successful in reversion to sinus
rhythm, and provide a thorough review of similar cases in the literature.
E. Autopsy Recharacterizes Many Cardiac Arrest-Related Deaths
by Ashley Lyles, MedPage Today. June 20, 2018
Many reported sudden cardiac deaths (SCDs) can be
attributed to non-sudden causes, with drug overdose and even other organ
failures in the top five, according to a study probing the discrepancies
between autopsy and SCD surveillance records reported to the medical examiner.
About 40% of such deaths reported from San Francisco
County between February 1, 2011 and March 1, 2014 were not unforeseen and were
noncardiac, and half were not even arrhythmic, according to a prospective
autopsy analysis published in the June 19 issue of Circulation.
Only 55.8% turned out to be autopsy-defined sudden
arrhythmic deaths, Zian Tseng, MD, MAS, a cardiac electrophysiologist at the
University of California San Francisco, and colleagues reported.
"[T]hese data reflect the decreasing prevalence of
coronary disease and increasing prevalence of nonischemic causes; therefore,
further inroads into reducing the overall burden of sudden death requires
investigation and earlier recognition of nonischemic and nonarrhythmic
causes," they wrote.
"We can't assume that all sudden deaths are
cardiac," Tseng said in an interview. "I think it's a wake up call
for cardiologists overall to say that we can say that death is sudden, but we
can't say that it's SCD."
The study's main findings applied to urban and suburban
communities alike. On subgroup analysis, the leading causes of death were found
to be coronary disease (32%), occult overdose (13.5%), cardiomyopathy (10%),
cardiac hypertrophy (8%), and neurological causes (5.5%).
"One of our major findings is that overdose deaths
was the second largest cause of death. So these are overdoses that weren't
apparent at the scene. These were overdoses that the paramedics called cardiac
arrest," Tseng emphasized to MedPage Today. "There was no evidence of
drug use at the scene and only after toxicology did we find that these were
actually do to overdose, and in more than half of those cases it was due to
opioids and so that's very reflective of the ongoing opioid crisis."
The remainder of the
essay: https://www.medpagetoday.com/cardiology/arrhythmias/73605
Full-text (free): https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.033427
4. The Rise of Fake Medical News
More and more websites are peddling “alternative facts” to
deceive the public and sell bogus cures. Fixes won’t be simple.
Proto. Mass Gen
Hospital. June 18, 2018.
LAST WINTER, THE WEBSITE YourNewsWire published a story
with this headline: “CDC Doctor: ‘Disastrous’ Flu Shot Is Causing Deadly Flu
Outbreak.” Appearing during one of the worst flu seasons in years, the article
quoted an anonymous physician at the Centers for Disease Control and Prevention
who warned that nearly all the people dying of the flu had one thing in common:
They had gotten flu shots. “This scares the crap out of me,” says the physician
in the article. The story also cast Big Pharma as a co- conspirator for failing
to disclose to the public the toxic chemicals contained in the vaccine.
None of this was true; the entire story, including the
quotes, was fabricated. Yet that didn’t stop the piece from going viral on the
internet, popping up on a variety of alternative-health and conspiracy-theory
websites. The story was widely shared on Facebook, generating about 500,000
engagements in January alone—more than any story that week from the Wall Street
Journal, NPR, ABC, CBS, CNN or Fox News. It also generated thousands of online
comments, some fanning broader fears about vaccinations, with “anti-vax”
campaigners writing to support the story’s claims and even purported incidents
in which the flu shot itself caused paralysis or even death. Although several
fact-checking websites poked holes in the story’s narrative, that did nothing
to slow its momentum.
Welcome to the world of fake medical news. During and
after the 2016 U.S. presidential campaign, the phrase “fake news” marked a new
phase of distrust in media, serving on the one hand as a way for politicians to
denounce any news coverage they didn’t like, and describing on the other a
proliferation of stories that were baldly untrue. The medical realm is not
immune and has become home to some of the most egregious examples. “There’s no
empirical way to measure it, but my sense is that of all the categories of fake
news, medical news is the worst, and there’s more of it out there,” says Kelly
McBride, vice president of the Poynter Institute, a nonprofit journalism school
in St. Petersburg, Fla.
Watchdog groups have identified hundreds of websites
purveying fake medical news, and countless more fly under the radar. This
misinformation runs the gamut from truly ridiculous to more subtle misreporting
and overhyping of stories from mainstream news sources…
5. Pediatric Corner
A. Should patients with complex febrile seizure be admitted
for further management?
Olson H, et al. Am J
Emerg Med. 2018;36(8):1386–1390
BACKGROUND AND AIMS: Children
with first complex febrile seizure (CFS) are often admitted for observation.
The goals of this study were 1) to assess the risk of seizure recurrence during
admission, 2) to determine whether early EEG affects acute management.
DESIGN/METHODS: We retrospectively
reviewed a cohort of children 6-60months of age admitted from a Pediatric
Emergency Department for first CFS over a 15year period. We excluded children
admitted for supportive care of their febrile illness. Data extraction included
age, gender, seizure features, laboratory and imaging studies, EEG, further
seizures during admission, and antiepileptic drugs (AEDs) given.
RESULTS: One hundred
eighty three children met inclusion criteria. Seven patients had seizures
during the admission (7/183 or 3.8%) Since 38 children were loaded with
anti-epileptic medication during their visit, the adjusted rate is 7/145 or
4.8. Increased risk of seizure recurrence during admission was observed in
children presenting with multiple seizures (P=0.005). EEG was performed in
104/183 children (57%) and led to change in management in one patient (1%, 95%
C.I. 0.05-6%). Six of the 7 children with seizure had an EEG. The study was
normal in 3 and findings in the other 2 did not suggest/predict further
seizures during the admission.
CONCLUSIONS: Children
with first CFSs are at low risk for seizure recurrence during admission.
Multiple seizures at presentation are associated with risk of early recurrence
and may warrant an admission. EEG had limited effect on acute management and
should not be an indication for admission.
B. A Randomized Trial Comparing Metered Dose Inhalers and
Breath Actuated Nebulizers.
Snider MA, et al. J
Emerg Med. 2018 Jul;55(1):7-14.
BACKGROUND: Despite
little evidence for its effectiveness, the breath-actuated nebulizer (BAN) is
the default albuterol delivery method in our pediatric emergency department.
OBJECTIVE: We compared
the clinical efficacy of BAN and the metered-dose inhaler (MDI) in treating
subjects patients 2 to 17 years of age who presented with mild to moderate
asthma exacerbations.
METHODS: This is a
randomized, nonblinded, noninferiority study conducted at a single pediatric
tertiary care emergency department. Subjects presenting with a Pediatric Asthma
Score ranging from 5 to 11 received albuterol by BAN or MDI via standard
weight-based and symptom severity dosing protocols. Aerosolized ipratropium
(via BAN) and intravenous magnesium sulfate were given when clinically
indicated. The primary outcome was patient disposition. The noninferiority
margin for the primary outcome was an admission rate difference ≤10%. Analyses
were adjusted for confounders that were significant at p ≤ 0.10.
RESULTS: We enrolled
890 subjects between October 2014 and April 2015. BAN and MDI groups were
comparable for age, gender, and race but not for pretreatment symptom severity;
51% in the MDI group had a Pediatric Asthma Score of moderate severity (8-11)
vs. 63% in the BAN group (p less than 0.003). Unadjusted admission rates were
11.9% for MDI and 12.8% for BAN, for an unadjusted risk difference of -0.9%
(95% confidence interval -5% to 3%). After adjusting for baseline confounder
severity, the risk difference was 2% (95% confidence interval -4% to 7%), which
met the criteria for noninferiority.
CONCLUSIONS: Albuterol
therapy by MDI is noninferior to BAN for the treatment of mild to moderate
asthma exacerbations in children 2 to 17 years of age.
C. Systematic Review: Rectal Administration of Medications
for Pediatric Procedural Sedation
Lam SHF, et al. J Emerg
Med. 2018 Jul;55(1):51-63.
BACKGROUND: Per rectum
(PR) medication delivery is an alternative to traditional oral (PO),
intravenous (IV), or intramuscular (IM) administration of medication for
procedural sedation of pediatric emergency department patients. However, many
emergency physicians are unfamiliar with its use, and there are no widely
adopted guidelines or reviews dedicated to this topic.
OBJECTIVE: Our aim was
to provide emergency physicians with an overview of PR procedural sedation
medications in pediatric patients.
METHODS: We performed
a PubMed literature search of relevant keywords limited to studies of human
subjects published in English between January 1, 1990 and December 31, 2017. We
excluded case reports, general review articles, editorial/opinion pieces,
correspondence, and abstracts. Two of the authors then conducted a structured
review of the selected studies.
RESULTS: A total of
315 PubMed citations meeting the search criteria were found. Twenty-eight
articles were included for final detailed review. Only 4 of the 28 included
studies were conducted in the emergency department setting. A total of 9
different medications have been studied for PR procedural sedation. Sedation
effectiveness ranged from 40% to 98%. No life-threatening complications were
reported in any of the included clinical trials. Hypoxia was found to occur in
up to 10% of those receiving PR sedation.
CONCLUSIONS: Pediatric
procedural sedation with PR medications appears to be feasible, moderately
effective, and safe based on our review of the current literature. However,
further studies on its applicability in the emergency department setting are
needed.
D. Atypical Presentation of Incomplete Kawasaki Disease: A
Peripheral Facial Nerve Palsy.
Rodriguez-Gonzalez M, et al. J Emerg Med. 2018 Jul;55(1):118-120.
Background
Kawasaki disease (KD)
is a multisystem vasculitic disease. Coronary artery aneurysms (CAAs) are the
most important and life-threatening complication of KD. Various neurologic
complications have been described to occur in 1–30% of patients with KD, but
peripheral facial nerve palsy (FNP) is rare (0.9%).
Case Report
We describe a
5-month-old male infant who presented to us with unilateral left infranuclear
FNP in the convalescent phase (day 18 of illness) of incomplete KD. The initial
diagnosis was not made during the first 10 days of illness (therapeutic window
for immunoglobulin treatment) as he was suspected to have hand-mouth-foot
disease. We believe that both the delay in diagnosis and treatment of an
atypical presentation of KD, combined with the more severe vasculitis and
inflammatory burden reported in these cases, contributed to the development of
CAA in our patient.
Why Should An
Emergency Physician Be Aware of This?
This case highlights
the importance of considering KD diagnosis in children with prolonged
unexplained fever, even with incomplete diagnostic features, as well as the
need to be aware of unusual manifestations, such as FNP. Atypical cases like
this may be at increased risk of CAA because of delayed diagnosis and a higher
inflammatory burden; therefore, a more aggressive treatment approach may be
necessary.
E. Screen time may increase risk of ADHD symptoms
More frequent screen
time may boost teens' risk of attention-deficit/hyperactivity disorder
symptoms, according to a study of 2,587 10th-graders in Los Angeles in the
Journal of the American Medical Association. Findings show that students who
were high frequency users of seven or 14 digital media platforms studied were
more than twice as likely to develop ADHD symptoms as students who didn't have
a high frequency use rate of any of the online social activities.
F. All Young Cannabis Users Face Psychosis Risk
Cannabis use directly
increases the risk for psychosis in teens, new research suggests.
Pauline Anderson. Medscape.
June 15, 2018
A large prospective
study of teens shows that "in adolescents, cannabis use is harmful"
with respect to psychosis risk, study author Patricia J. Conrod, PhD, professor
of psychiatry, University of Montreal, Canada, told Medscape Medical News.
The effect was
observed for the entire cohort. This finding, said Conrod, means that all young
cannabis users face psychosis risk, not just those with a family history of
schizophrenia or a biological factor that increases their susceptibility to the
effects of cannabis.
"The whole
population is prone to have this risk," she said.
The study was
published online June 6 in JAMA Psychiatry.
Rigorous Causality
Test
Increasingly,
jurisdictions across North America are moving toward cannabis legalization. In
Canada, a marijuana law is set to be implemented later this year.
With such changes,
there's a need to understand whether cannabis use has a causal role in the
development of psychiatric diseases, such as psychosis.
To date, the evidence
with respect to causality has been limited, as studies typically assess
psychosis symptoms at only a single follow-up and rely on analytic models that
might confound intraindividual processes with initial between-person
differences.
Determining causality
is especially important during adolescence, a period when both psychosis and
cannabis use typically start.
For the study,
researchers used random intercept cross-lagged panel models (RI-CLPMs), which
Conrod described as "a very novel analytic strategy."
RI-CLPMs use a
multilevel approach to test for within-person differences that inform on the
extent to which an individual's increase in cannabis use precedes an increase
in that individual's psychosis symptoms, and vice versa.
The approach provides
the most rigorous test of causal predominance between two outcomes, said
Conrod.
"One of the
problems in trying to assess a causal relationship between cannabis and mental
health outcomes is the chicken or egg issue. Is it that people who are prone to
mental health problems are more attracted to cannabis, or is it something about
the onset of cannabis use that influences the acceleration of psychosis
symptoms?" she said.
The study included
3720 adolescents from the Co-Venture cohort, which represents 76% of all grade
7 students attending 31 secondary schools in the greater Montreal area.
For 4 years, students
completed an annual Web-based survey in which they provided self-reports of
past-year cannabis use and psychosis symptoms.
Such symptoms were
assessed with the Adolescent Psychotic-Like Symptoms Screener; frequency of
cannabis use was assessed with a six-point scale (0 indicated never, and 5
indicated every day)…
6. Brief Summaries from Ann Emerg Med
A. Should Buprenorphine Be Administered to Patients With
Opioid Withdrawal in the Emergency Department?
Take-Home Message
Compared with α2-adrenergic
agonists (eg, clonidine), buprenorphine improves withdrawal scores and has
higher rates of adherence to withdrawal regimen completion.
B. Is Procalcitonin Useful in the Diagnosis and Treatment of
Acute Respiratory Infections in the ED?
Take-Home Message
A procalcitonin-guided
approach to the initiation and discontinuation of antibiotics in acute
respiratory infections has the potential to reduce antibiotic-related adverse
effects and duration of therapy, but further study of emergency department (ED)
patients is needed.
Additional discussion
in the letters: https://www.annemergmed.com/article/S0196-0644(18)30263-4/fulltext
See also this RCT in a
recent issue of NEJM: Procalcitonin-Guided Use of Antibiotics for Lower
Respiratory Tract Infection. Abstract: https://www.nejm.org/doi/full/10.1056/NEJMoa1802670
C. What Is the Utility of Noninvasive Ventilation in the
Management of Acute Hypercapnic Respiratory Failure Associated With COPD?
Take-Home Message
In patients with acute
respiratory failure from chronic obstructive pulmonary disease exacerbation,
noninvasive ventilation reduces death and intubation compared with standard
treatments.
D. Update: Is Needle Aspiration Better Than Chest Tube
Placement for the Management of Primary Spontaneous Pneumothorax?
Take-Home Message
Chest tube placement
is successful more often than needle aspiration in the treatment of primary
spontaneous pneumothorax, yet is associated with longer hospital length of stay
and potentially more adverse events. Therefore, both needle aspiration and chest
tube placement are reasonable first-line options, depending on individual
patient preferences and circumstances.
E. What Interventions Are Most Effective for Emergency
Contraception?
Take-Home Message
For emergency
contraception, mifepristone (RU-486) is more effective than levonorgestrel
(Plan B), which is more efficacious than an estradiol-levonorgestrel
combination (Yuzpe) in preventing pregnancy.
F. Is Low-Dose Ketamine an Effective Alternative to Opioids
for the Treatment of Acute Pain in the ED?
Take-Home Message
According to limited
evidence, low-dose ketamine and morphine appear to provide similar levels of
pain relief at 30 minutes; however, low-dose ketamine is associated with a
higher rate of self-limited neuropsychological adverse events.
G. Are Nonsteroidal Anti-inflammatory Drugs Safe and
Effective for Treatment of Acute Renal Colic?
Take-Home Message
For patients
presenting with acute renal colic, treatment with nonsteroidal anti-inflammatory
drugs offers effective pain relief with fewer adverse effects than opioids or
paracetamol.
H. Are Corticosteroids Superior to NSAIDs in the Treatment of Acute Gout?
Take-Home Message
Corticosteroids
provide pain relief similar to that of nonsteroidal anti-inflammatory drugs for
acute gout, with fewer adverse effects.
I. Nerve Blocks: Feeling Blocked? Another Pain Management
Tool in the ED
7. First-Ever Ketamine Guidelines for Acute Pain Management
Released
Megan Brooks. Medscape.
June 15, 2018
Evidence supports the
use of intravenous (IV) ketamine for acute pain in a variety of contexts,
including as a stand-alone treatment, as an adjunct to opioids, and, to a
lesser extent, as an intranasal formulation, according to the first guidelines
on the use of ketamine for acute pain management.
Ketamine has captured
headlines recently for its potential role in treating severe depression and
posttraumatic stress syndrome. Ketamine is also increasingly being used in
inpatient and outpatient settings to manage acute pain.
One driving force
behind this is the growing effort to reduce the risk for long-term opioid use
after acute exposure and its subsequent complications, including addiction.
Yet, to date, few recommendations have been available to guide this emerging
acute pain therapy.
"The goal of this
document is to provide a framework for doctors, for institutions and for payers
on use of ketamine for acute pain, who should get it and who should not get
it," guideline author Steven Cohen, MD, from Johns Hopkins School of
Medicine in Baltimore, Maryland, told Medscape Medical News.
The guidelines were
published online June 7 in Regional Anesthesia and Pain Medicine.
Guidelines (full-text
free): https://journals.lww.com/rapm/Fulltext/2018/07000/Consensus_Guidelines_on_the_Use_of_Intravenous.2.aspx
8. Manual Uterine Aspiration: Adding to the Emergency Physician
Stabilization Toolkit.
Quinley KE, et al. Ann
Emerg Med. 2018 Jul;72(1):86-92. doi:
Emergency physicians
are often the first physician contact for women with bleeding from
first-trimester miscarriage, which is the most common gynecologic emergency; 1
in 4 women experiences miscarriage in her lifetime.1, 2 Up to 31% of
pregnancies end in miscarriage, contributing to the 1.6% (500,000) of emergency
department (ED) visits in the United States annually that are prompted by
vaginal bleeding in pregnancy.3, 4, 5, 6, 7 Despite the emergency physician’s
role as a specialist in hemodynamic stabilization, scant emergency medicine
literature addresses the management of patients with hemodynamically significant
uterine bleeding in the ED. Manual uterine aspiration, a proven effective,
expeditious, and simple technique for uterine evacuation, is a procedure that
is routinely taught to obstetric and gynecology residents and midlevel
providers, is commonly performed in nonoperative settings, and has classically
been excluded from emergency medicine education. The integration of this
procedure into the training curriculum of the emergency medicine resident and
into the armamentarium of the practicing emergency physician could grant the
emergency clinician a stabilizing and potentially lifesaving tool for patients
presenting with hemodynamically compromising uterine bleeding from miscarriage.
The idea that
emergency medicine residents and physicians should be trained in uterine
aspiration for miscarriage is not a novel concept; it was first described in
Annals of Emergency Medicine in 1982 and recently discussed in a June 2017
issue of the EM:RAP emergency medicine podcast series.8, 9 We present a brief
review of the emergency medicine literature on miscarriage, as well as an
overview of the manual uterine aspiration procedure and its indications. We
also suggest that emergency medicine residency training programs and attending
physicians consider training in manual uterine aspiration, and we explore
potential implications for the ED and health care system should ED providers
adopt this procedure….
9. Medical Therapy Shows Promise over Surgical Drainage for
Peritonsillar Abscess
Ballard DW, et al.
Emerg Med News. 2018;40(7):6.
Suction. Check. Head lamp. Check. Cetacaine. Check. Gauze.
Check. Vaginal ultrasound probe. Check. Needle and syringe. Check.
Does that sound familiar? This has always been one of the
most awkward procedures in the ED: Invasive drainage of a quinsy requires a
patient patient, a patient nurse, and, if all goes well, a functional Yankauer.
What could go wrong? An overactive gag reflex, a primal scream, or an unexpected
intersection with Big Red.
Does it have to be this way, or might there be an
opportunity to relegate peritonsillar abscess incision and drainage to the
annals of the anachronistic, like plain films for nasal fractures, rectal exams
in blunt trauma, and bloodletting for evil humors?
Some limited retrospective literature on the topic
suggests that nonoperative management of peritonsillar abscess may already be
fairly common and cost-effective and have complications and bounceback rates
similar to those of invasive ED management.
The Evidence: Battaglia, et al.,
studied 12 centers in Southern California over six years (2008-2013) that
adopted medical therapy for peritonsillar abscess while seven continued with
the surgical drainage and needle aspiration. (Otolaryngol Head Neck Surg
2018;158[2]:280.) Diagnosis was primarily based on clinical exam, with low
rates of CT and ultrasound. Medical management consisted of D5NS 1 L bolus;
ceftriaxone 1 g and clindamycin 600 mg, both IV; dexamethasone 10 mg IV; and ED
observation for one to two hours with PO trial prior to discharge and
transition to incision and drainage or needle aspiration if medical management
failed. (http://bit.ly/2ItYTnl.) Home management
consisted of clindamycin 300 mg QID x 10 days and next-day follow-up with ENT
for repeat IV meds and invasive management if the patient had no improvement or
worsened.
The authors retrospectively identified 1,787 patients with
uncomplicated peritonsillar abscess, and randomly selected 307 (211 receiving
medical treatment only) in which to compare outcomes, which included
complications, return visit and failure rates, and quality of life outcomes
such as volume of opioid prescriptions and number of days feeling sore and days
off work. They also performed a sensitivity analysis among those patients reporting
trismus to address the potential for selection bias.
The authors reported no difference in complication or
failure rates nor any difference in the time until patients could tolerate
liquids or solids across cohorts with similar baseline demographic and clinical
characteristics. They found, however, that medical management was associated
with an eight percent rate of PO challenge failure in the ED, lower volumes of
liquid opioid prescribed in the entire study group and trismus-present
subgroup, and a lower average of days feeling sore and days off work across all
patients. Recognizing that such outcomes could certainly be the result of
unaddressed confounding, particularly treatment selection bias, the authors
nonetheless concluded that aggressive intervention is not necessary to achieve
resolution of pain, resume oral intake, or return to work. We agree with the
premise here of less aggressive ED treatment with similar or perhaps even
superior results, so let's see how it works in practice….
The remainder of the
essay (free): https://journals.lww.com/em-news/Fulltext/2018/07000/Medically_Clear__Medical_Therapy_Shows_Promise.5.aspx
10. Images in Clinical Practice
The Poor Man's Tox Screen: ECG Findings in the Acute
Overdose
Cryptococcus neoformans Meningoencephalitis
Severe Mitral Stenosis
Echinococcal Cysts in the Liver
Vertebral Hydatidosis
Tongue Necrosis in Giant-Cell Arteritis
Macular Hole from a Laser Pointer
Nine-Year-Old Girl With Right Hip Pain
Woman With Periorbital Rash
Infant With Poor Feeding
Man With Finger Swelling
Young Woman With Abdominal Pain
Young Adult With Upper Abdominal Pain
Man With Scrotal Mass
Eleven-Year-Old Male With Weakness
A Woman With Severe Rash
Construction Worker With Chest Pain
Young Man With Unilateral Neck Swelling
Young Man With Flank Pain
Girl With Chest Pain
Acute atraumatic pinna (auricular) perichondritis
11. Is hallway care dangerous? An observational study
Rixe JA, et al. Am J Emerg Med. 2018;36(8):1451–1454
OBJECTIVES: In response to crowding the use of hallway beds
has become an increasingly prevalent practice in Emergency Departments (EDs).
There is limited research on whether caring for patients in hallways (HP) is
associated with adverse outcomes. The goal of this study was to examine the
effects of HP triage on 30 day outcomes for ED return, readmission, and
mortality.
METHODS: We performed a retrospective cohort study at an
urban, academic ED comparing HPs (defined as HP for ≥30 min) to matched
controls triaged to standard ED beds from 9/30/14 to 10/1/15. We analyzed data
from the hospital's clinical data warehouse. Matched controls were selected by gender,
age, ethnicity, and language. We used McNemar's test to assess the association
between triage location and 30 day study outcomes. We also examined adverse
outcomes by triage severity using McNemar's test.
RESULTS: A total of 10,608 HPs were matched to control
patients. Compared to controls, HPs had 2.0 times the odds of returning to the
ED in 30 days (95% CI: 1.8-2.1), 1.6 times the odds of inpatient readmission
(95% CI: 1.4-1.9), and 1.7 times the odds of readmission to observation (95%
CI: 1.4-2.0). The odds ratio for mortality in HPs versus controls was 0.80,
(95% CI: 0.50-1.3).
CONCLUSIONS: Patients initially triaged to the hallway have
an increased odds of 30 day return to the ED, observation and inpatient
admission. After adjusting for ESI, the increased odds for return remained
similar. The small sample size precluded testing effects of HP status on
mortality.
12. AF Management
A. Reduce AF Hospitalizations by Prioritizing
ORAL rate reduction meds over IV and Promoting Cardioversion when Applicable
DeMeester S, et al. Implementation of a Novel Algorithm to
Decrease Unnecessary Hospitalizations in Patients Presenting to a Community ED
With AF. Acad Emerg Med. 2018 Jun;25(6):641-649.
OBJECTIVES: Atrial fibrillation (AFib) is the most common
dysrhythmia in the United States. Patients seen in the emergency department
(ED) in rapid AFib are often started on intravenous rate-controlling agents and
admitted for several days. Although underlying and triggering illnesses must be
addressed, AFib, intrinsically, is rarely life-threatening and can often be
safely managed in an outpatient setting. At our academic community hospital, we
implemented an algorithm to decrease hospital admissions for individuals
presenting with a primary diagnosis of AFib. We focused on lenient oral rate
control and discharge home. Our study evaluates outcomes after implementation
of this algorithm.
METHODS: Study design is a retrospective cohort analysis
pre- and postimplementation of the algorithm. The primary outcome was hospital
admissions. Secondary outcomes were 3- and 30-day ED visits and any associated
hospital admissions. These outcomes were compared before (March 2013-February
2014) and after (March 2015-February 2016) implementation. Chi-square tests and
logistic regressions were run to test for significant changes in the three
outcome variables.
RESULTS: A total of 1,108 individuals met inclusion criteria
with 586 patients in the preimplementation group and 522 in the
postimplementation group. Cohorts were broadly comparable in terms of
demographics and health histories. Admissions for persons presenting with AFib
after implementation decreased significantly (80.4% pre vs. 67.4% post,
adjusted odds ratio [OR] = 3.4, p less than 0.001). Despite this difference there
was no change in ED return rates within 3 or 30 days (adjusted ORs = 0.93 and
0.89, p = 0.91 and 0.73, respectively).
CONCLUSIONS: Implementation of a novel algorithm to identify
and treat low-risk patients with AFib can significantly decrease the rate of
hospital admissions without increased ED returns. This simple algorithm could
be adopted by other community hospitals and help lower costs.
B. Stroke Prophylaxis After a New ED
Diagnosis of AF
Kea B, et al. J Am Coll Cardiol. 2018 Jul 24;72(4):471-472.
Excerpts
Up to 25% of all new atrial fibrillation (AF) diagnoses are
made in the emergency department (ED); however, this patient population is
often understudied and overlooked. Prior efforts to characterize oral anticoagulation
(OAC) prescribing patterns after an ED visit for incident AF is scant, although
this information is critical to improve care. Using a national cohort of older
U.S. patients, we describe patterns and identify predictors of OAC prescription
for patients with a new ED diagnosis of AF.
Medicare fee-for-service OAC-naïve beneficiaries age 65
years and older from 2011 to 2012 who had an incident, new, ED diagnosis of AF
(and discharged home) were analyzed… The primary outcome was an OAC
prescription by an ED provider, filled after an ED diagnosis of AF, defined as a Part D claim within 10 days of diagnosis. Prescription
filling was a proxy for prescribing… A secondary outcome was follow-up care
within 30 days of the ED visit, identified from provider and facility
outpatient claims. Predictors examined included demographics, comorbidities,
prior major bleeding, bleeding risk, and stroke risk scores, and ED and
hospital characteristics. An indication for OAC was defined as AF patients with
high stroke risk (by CHA2DS2-VASc score of 2 or greater, and low/intermediate bleeding
risk (by HAS-BLED score 0-2).
Of the 110,636 beneficiaries with AF, 9,147 met inclusion/exclusion
criteria. The mean age was 77.3 (SD 7.9 years); 5,744 (62.8%) were female and
8,488 (92.8%) were Caucasian. Overall, 17.2% patients (1,573 of 9,147) were
prescribed an OAC. In the OAC-indicated group, an OAC was prescribed to 18.1% (Table
1). Among OACs prescribed, 62.7% was warfarin followed by direct oral
anticoagulant at 26.6%, and combination of warfarin and enoxaparin in 8.3%.
In multivariate analyses, an indication for OAC prescription
(high stroke and low/intermediate bleeding risk) was not associated with OAC prescription (aOR:
1.02; 95% CI: 1.00 to 1.04). Presence of heart failure or hypertension (aOR:
1.04; 95% CI: 1.01 to 1.06), diabetes (aOR: 1.03; 95% CI: 1.02 to 1.05), and treatment
at teaching hospitals (aOR: 1.05; 95% CI: 1.01 to 1.08) were associated with a
higher odds of OAC prescription… More patients who filled an OAC had a
cardiology visit within 30 days than those who did not (64.1% vs. 53.7%, p less than 0.001). The proportions of primary
care follow-up were similar (45.7% vs. 44.0%, p ¼ 0.220).
In this cohort of Medicare beneficiaries, OAC prescription was
infrequent and inconsistent with published professional guidelines… A
recent study indicated multiple barriers to U.S. ED provider prescribing (4). A multipronged approach is essential
to bridge this gap, including educating EM providers about indications, risks,
and benefits of anticoagulation; active multidisciplinary engagement in
guideline development and dissemination with emphasis on shared responsibility of stroke prophylaxis;
intra-institutional collaboration in development of clinical pathways with short-term follow up
that empower ED providers to prescribe OAC for AF.
C. Enlisting EM clinicians to help
reduce strokes in high-risk patients with AF and AFL
Vinson DR, et al. Clin
Pharmacol Ther. 2018 July 14 [Epub ahead of print].
Excerpt
The continued under-prescribing of oral anticoagulants
(OACs) described by Hsu and Freeman indicate that improvements in stroke
prevention will require concerted efforts from all providers who contribute to
AF care. AF patients frequent the ED for rhythm-related complaints, where they
often receive rate reduction and cardioversion interventions. Providing this
level of care for AF patients creates a natural opportunity for the emergency
medicine clinician to discuss stroke prevention with those who are at high risk
and are not already on OACs. The ED experience itself might serve as a sentinel
event for the AF patient, facilitating needed changes in healthcare behaviors.
There are many ways emergency medicine clinicians can
contribute to stroke reduction, ranging from simply introducing the topic with
eligible patients to prescribing OACs on discharge (Table). Approximately 20%
to 50% of actionable high-risk AF patients receive a prescription of OACs on ED
discharge, with higher prescribing for patients who were in the ED primarily
for AF-related complaints (4) (see supplemental material). Initiating
anticoagulation at the time of discharge for stroke-prone AF patients does not
increase bleeding rates and contributes to decreased mortality (2). The most
appropriate course of action in each situation, however, will vary by
clinician, patient, shift, practice setting, and resource availability.
12. Physician Cognitive and Interpersonal Performance
A. Influence of Shift Duration on
Cognitive Performance of Emergency Physicians: A Prospective Cross-Sectional
Study.
Persico N, et al. Ann Emerg Med. 2018;72(2):171–180
STUDY OBJECTIVE:
The relationship between tiredness and medical errors is now
commonly accepted. The main objective of this study is to evaluate the
cognitive performance of emergency physicians after a night shift of 14 hours
(H14) and after a work shift of 24 hours (H24) and to compare it with tests
performed after a rest night at home (H0).
METHODS:
Forty emergency physicians (19 staff physicians and 21
residents) were randomly evaluated at H0, H14, and H24. Four cognitive
abilities (processing speed, working memory capacity, perceptual reasoning, and
cognitive flexibility) were tested according to the Wechsler Adult Intelligence
Scale and the Wisconsin Card Sorting Test.
RESULTS:
No cognitive ability was significantly altered after H14
compared with H0. Three of 4 cognitive abilities were impaired at H24 compared
with H0: processing speed (11.2 [SD 2.7] versus 12.4 [SD 3.2]; mean
difference=-1.2 [95% confidence interval -1.9 to -0.5]), working memory
capacity (10.1 [SD 2.9] versus 11.6 [SD 3.0]; mean difference=-1.5 [95% confidence
interval -2.2 to -0.8]), and perceptual reasoning (8.4 [SD 2.7] versus 10.6 [SD
2.8]; mean difference=-2.2 [95% confidence interval -3.4 to -1.0]). Cognitive
abilities were not different between residents and staff physicians (except for
perceptual reasoning) and were not affected by the amount of sleep during the
night shift.
CONCLUSION:
The cognitive abilities of emergency physicians were
significantly altered after a 24-hour shift, whereas they were not
significantly different from the rested condition after a 14-hour night shift.
Limiting 24-hour shift work for emergency physicians should be considered and
further evaluated.
Editorial (subscription required): https://www.annemergmed.com/article/S0196-0644(18)30218-X/fulltext
B. Depression, burnout may contribute
to medical mistakes, study finds
Researchers found that physicians who showed signs of
burnout or reported having suicidal thoughts in the past year were more than
twice as likely to report making medical errors, while those with signs of
fatigue were 38% more likely to report making medical errors. The study,
reported in Mayo Clinic Proceedings, also showed that pediatricians,
anesthesiologists and psychiatrists reported the fewest errors, while
radiologists, emergency department physicians and neurosurgeons reported the
most.
ABC News essay: https://abcnews.go.com/Health/physician-burnout-depression-lead-major-medical-errors-study/story?id=56427381
C. InFocus: How to be a Good Emergency
Physician
Roberts JR. Emerg Med News 2018;40(6):8-9.
Excerpt
…Above all, always, always, always be nice. Patients and
family rarely remember what you said, but they always remember how you made
them feel. There is only one time to make that first impression, a great
opportunity to brand yourself as a hero and an angel of mercy. Be nice to the
cleaning lady, security guard, cafeteria worker, and x-ray tech. Learn their
names; they know yours.
Talk effusively to your patients, talk to them again, and
always, always, always talk to the family. Look them in the eye, not into the
computer record. Sit down whenever possible; it says you are truly giving them
the personal time and attention you would want. That 280-pound demented nursing
home patient with bedsores and a feeding tube is somebody's mother, and maybe
she was the best third grade teacher Philadelphia ever had.
Full-text (free): https://journals.lww.com/em-news/Fulltext/2018/06000/InFocus__How_to_be_a_Good_EP.7.aspx
13. Recent Systematic Reviews from the Emerg Med Literature
A. Safety and Efficacy of
IV Lidocaine for Pain Management in the ED: A Systematic Review
Oliveira J E Silva L, et
al. Ann Emerg Med. 2018;72(2):135–144.e3.
Study objective
We evaluate the safety
and efficacy of intravenous lidocaine in adult patients with acute and chronic
pain who are undergoing pain management in the emergency department (ED).
Methods
We searched Ovid
CENTRAL, Ovid EMBASE, and Ovid MEDLINE databases for randomized controlled
trials and observational studies from inception to January 2017. Efficacy
outcomes included reduction in pain scores from baseline to postintervention
and need for rescue analgesia. Safety outcomes included incidence of serious
(eg, cardiac arrest) and nonserious (eg, dizziness) adverse events. We used the
Cochrane Collaboration tool and a modified Newcastle-Ottawa Scale to evaluate
the risk of bias across studies. The Grading of Recommendations Assessment,
Development and Evaluation approach was used to evaluate the confidence in the
evidence available.
Results
From a total of 1,947
titles screened, 61 articles were selected for full-text review. Eight studies
met the inclusion criteria and underwent qualitative analysis, including 536
patients. The significant clinical heterogeneity and low quality of studies
precluded a meta-analysis. Among the 6 randomized controlled trials included,
intravenous lidocaine had efficacy equivalent to that of active controls in 2
studies, and was better than active controls in 2 other studies. In particular,
intravenous lidocaine had pain score reduction comparable to or higher than
that of intravenous morphine for pain associated with renal colic and critical
limb ischemia. Lidocaine did not appear to be effective for migraine headache
in 2 studies. There were 20 adverse events reported by 6 studies among 225
patients who received intravenous lidocaine in the ED, 19 nonserious and 1
serious (rate 8.9%, 95% confidence interval 5.5% to 13.4% for any adverse
event; and 0.4%, 95% confidence interval 0% to 2.5% for serious adverse
events). The confidence in the evidence available for the outcomes evaluated
was deemed to be very low because of methodological limitations, including risk
of bias, inconsistency, and imprecision.
Conclusion
There is limited
current evidence to define the role of intravenous lidocaine as an analgesic
for patients with acute renal colic and critical limb ischemia pain in the ED.
Its efficacy for other indications has not been adequately tested. The safety
of lidocaine for ED pain management has not been adequately examined.
B. PE Among Patients with Acute Exacerbation Of COPD: Implications For EM.
Pourmand A, et al. J Emerg Med. 2018
Jun 23 [Epub ahead of
print]
BACKGROUND:
Chronic obstructive pulmonary disease (COPD) is a leading
cause of morbidity and mortality worldwide. Common in COPD are acute
exacerbations (AE-COPD) that cause acute dyspnea, cough, and bronchospasm.
Symptoms of AE-COPD mimic pulmonary embolism (PE).
METHODS:
We conducted a systematic review of the literature to
assess the prevalence of PE in patients admitted to the hospital with a
clinical diagnosis of AE-COPD. Following the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis guidelines, we queried PubMed and MEDLINE
databases from 1990 to 2017. The search term "prevalence pulmonary
embolism, COPD" was used, and Boolean operators were used to combine
search terms. Data were extracted from each article, specifically the sample
size, study setting, design, and the prevalence of PE.
RESULTS:
A total of 5 articles were included that demonstrated a
prevalence of PE among patients with a clinical diagnosis of AE-COPD that
ranged from 3.3-29.1%. Sample sizes varied from 49-197 patients. Studies
occurred in both emergency department and inpatient settings, including
intensive care units. Among the studies that reported patient characteristics
associated with PE in AE-COPD, both obesity and immobility were important.
CONCLUSION:
Studies reporting the prevalence of PE during AE-COPD vary
considerably in their methods and results. Because of the relatively high
prevalence of PE during AE-COPD, it is important for providers to be aware of
this linkage between the 2 conditions and to screen patients using clinical
gestalt and validated screening tools until more emergency department data are
available.
C. Effectiveness of Implementing Evidence-based Interventions
to Reduce C-spine Image Ordering in the ED: A Systematic Review.
Desai S, et al. Acad
Emerg Med. 2018 Jun;25(6):672-683.
OBJECTIVES:
Appropriate use of
imaging for adult patients with cervical spine (C-spine) injuries in the
emergency department (ED) is a longstanding issue. Guidance for C-spine
ordering exists; however, the effectiveness of the decision support
implementation in the ED is not well studied. This systematic review examines
the implementation and effectiveness of evidence-based interventions aimed at
reducing C-spine imaging in adults presenting to the ED with neck trauma.
METHODS:
Six electronic
databases and the gray literature were searched. Comparative intervention
studies were eligible for inclusion. Two independent reviewers screened for
study eligibility, study quality, and extracted data. The change in imaging was
reported using individual odds ratios (ORs) with 95% confidence intervals (CIs)
using random effects.
RESULTS:
A total of 990 unique
citations were screened for relevance of which six before-after studies and one
randomized controlled trial were included. None of the studies were assessed as
high quality. Interventions consisted primarily of locally developed guidelines
or established clinical decision rules such as the NEXUS or the Canadian
C-spine rule. Overall, implementation of interventions aimed at reducing
C-spine image ordering resulted in a statistically significant reduction in
imaging (OR = 0.69, 95% CI = 0.51-0.93); however, heterogeneity was high
(I2 = 82%). Subgroup analysis revealed
no differences between studies that specified enrolling alert and stable
patients compared to unspecified trauma (p = 0.81) or between studies employing
multifaceted versus nonmultifaceted interventions (p = 0.66). While studies
generally provided details on implementation strategies (e.g., teaching
sessions, pocket cards, posters, computerized decision support) the
effectiveness of these implementation strategies were frequently not reported.
CONCLUSION:
There is moderate
evidence regarding the effectiveness of interventions to reduce C-spine image
ordering in adult patients seen in the ED with neck trauma. Given the national
and international focus on improving appropriateness and reducing unnecessary
C-spine imaging through campaigns such as Choosing Wisely, additional
interventional research in this field is warranted.
D. The Accuracy and Prognostic Value of Point-of-care US for
Nephrolithiasis in the ED: A Systematic Review and Meta-analysis.
Wong C, et al. Acad
Emerg Med. 2018 Jun;25(6):684-698.
INTRODUCTION:
Point-of-care
ultrasound (POCUS) has been suggested as an initial investigation in the
management of renal colic. Our objectives were: 1) to determine the accuracy of
POCUS for the diagnosis of nephrolithiasis and 2) to assess its prognostic
value in the management of renal colic.
METHODS:
The review protocol
was registered to the PROSPERO database (CRD42016035331). An electronic
database search of MEDLINE, Embase, and PubMed was conducted utilizing subject
headings, keywords, and synonyms that address our research question.
Bibliographies of included studies and narrative reviews were manually
examined. Studies of adult emergency department patients with renal colic
symptoms were included. Any degree of hydronephrosis was considered a positive
POCUS finding. Accepted criterion standards were computed tomography evidence
of renal stone or hydronephrosis, direct stone visualization, or surgical
findings. Screening of abstracts, quality assessment with the QUADAS-2
instrument, and data extraction were performed by two reviewers, with
discrepancies resolved by consensus with a third reviewer. Test performance was
assessed by pooled sensitivity and specificity, calculated likelihood ratios,
and a summary receiver operator curve (SROC). The secondary objective of
prognostic value was reported as a narrative summary.
RESULTS:
The electronic search
yielded 627 unique titles. After relevance screening, 26 papers underwent
full-text review, and nine articles met all inclusion criteria. Of these, five
high-quality studies (N = 1,773) were included in the meta-analysis for
diagnostic accuracy and the remaining yielded data on prognostic value. The
pooled results for sensitivity and specificity were 70.2% (95% confidence
interval [CI] = 67.1%-73.2%) and 75.4% (95% CI = 72.5%-78.2%), respectively.
The calculated positive and negative likelihood ratios were 2.85 and 0.39. The
SROC generated did not show evidence of a threshold effect. Two of the studies
in the meta-analysis found that the finding of moderate or greater
hydronephrosis yielded a specificity of 94.4% (95% CI = 92.7%-95.8%). Four
studies examining prognostic value noted a higher likelihood of a large stone
when positive POCUS findings were present. The largest randomized trial showed
lower cumulative radiation exposure and no increase in adverse events in those
who received POCUS investigation as the initial renal colic investigation.
CONCLUSION:
Point-of-care
ultrasound has modest diagnostic accuracy for diagnosing nephrolithiasis. The
finding of moderate or severe hydronephrosis is highly specific for the
presence of any stone, and the presence of any hydronephrosis is suggestive of
a larger (greater than 5 mm) stone in those presenting with renal colic.
E. Effectiveness of Interventions to Decrease Image Ordering
for Low Back Pain Presentations in the ED: A Systematic Review
Liu C, et al. Acad
Emerg Med. 2018 Jun;25(6):614-626.
BACKGROUND:
Low back pain (LBP) is
an extremely frequent reason for patients to present to an emergency department
(ED). Despite evidence against the utility of imaging, simple and advanced
imaging (i.e., computed tomography [CT], magnetic resonance imaging) for
patients with LBP has become increasingly frequent in the ED. The objective of
this review was to identify and examine the effectiveness of interventions
aimed at reducing image ordering in the ED for LBP patients.
METHODS:
A protocol was
developed a priori, following the PRISMA guidelines, and registered with
PROSPERO. Six bibliographic databases (including MEDLINE, EMBASE, EBM Reviews,
SCOPUS, CINAHL, and Dissertation Abstracts) and the gray literature were
searched. Comparative studies assessing interventions that targeted image
ordering in the ED for adult patients with LBP were eligible for inclusion. Two
reviewers independently screened study eligibility and completed data extraction.
Study quality was completed independently by two reviewers using the
before-after quality assessment checklist, with a third-party mediator
resolving any differences. Due to a limited number of studies and significant
heterogeneity, only a descriptive analysis was performed.
RESULTS:
The search yielded 603
unique citations of which a total of five before-after studies were included.
Quality assessment identified potential biases relating to comparability
between the pre- and postintervention groups, reliable assessment of outcomes,
and an overall lack of information on the intervention (i.e., time point,
description, intervention data collection). The type of interventions utilized
included clinical decision support tools, clinical practice guidelines, a
knowledge translation initiative, and multidisciplinary protocols. Overall,
four studies reported a decrease in the relative percentage change in imaging
in a specific image modality (22.7%-47.4%) following implementation of the
interventions; however, one study reported a 35% increase in patient referrals
to radiography, while another study reported a subsequent 15.4% increase in
referrals to CT and myelography after implementing an intervention which
reduced referrals for simple radiography.
DISCUSSION:
While imaging of LBP
has been identified as a key area of imaging overuse (e.g., Choosing Wisely
recommendation), evidence on interventions to reduce image ordering for ED
patients with LBP is sparse. There is some evidence to suggest that interventions
can reduce the use of simple imaging in LBP in the ED; however, a shift in
imaging modality has also been demonstrated. Additional studies employing
higher-quality methods and measuring intervention fidelity are strongly
recommended to further explore the potential of ED-based interventions to
reduce image ordering for this patient population.
F. Biphasic anaphylaxis: A review of
the literature and implications for emergency management.
Pourmand A, et al. Am J Emerg Med. 2018;36(8):1480-5.
BACKGROUND:
The biphasic reaction is a feared complication of
anaphylaxis management in the emergency department (ED). The traditional
recommended ED observation time is 4-6 h after complete resolution of symptoms
for every anaphylaxis patient. However, there has been great controversy
regarding whether this standard of care is evidence-based.
METHODS:
Articles were selected using a PubMed, MEDLINE search for
the keywords "biphasic anaphylaxis", yielding 155 articles. Articles
were filtered by English language, and the keyword biphasic in the title. Case
reports and case series were excluded, narrowing to 33 articles. Then, articles
were filtered by relevance to the ED setting, and studies conducted in
outpatient clinic settings were excluded, narrowing the search to 16 articles.
All remaining articles were reviewed and findings were discussed.
RESULTS:
The reported mean time to onset between the resolution of
initial anaphylaxis and biphasic reaction ranges widely by study from 1 to 72 h
with the majority of studies reporting the mean time to onset over 8 h. A delay
between anaphylaxis symptom onset and administration of epinephrine of
60-190 min was reported to correlate with biphasic anaphylaxis in three
studies. Anaphylaxis requiring more than 1 dose of epinephrine to achieve
symptom resolution was also reported to correlate with biphasic reactions in
two studies. No definitive conclusions about the role of corticosteroids in
preventing biphasic reactions can be made at this time however; a couple small
studies have shown that they may decrease the incidence of biphasic reactions.
Additional risk factors correlated with biphasic reaction vary widely between
studies and the generalizability of these risk factors is questionable.
CONCLUSIONS:
There is a need for further research to identify true risk
factors associated with biphasic anaphylaxis and to clearly define the role of
corticosteroids in biphasic reactions. However, given the low incidence and
rare mortality of biphasic reactions, patients who receive epinephrine within
one hour of symptom onset and who respond to epinephrine with rapid and
complete symptom resolution can probably be discharged from the ED with careful
return precautions and education without the need for prolonged observation.
Related study: Anaphylaxis-related
Malpractice Lawsuits
Lindor RA, et al. West J Emerg Med. 2018 Jul;19(4):693-700.
INTRODUCTION:
Anaphylaxis continues to cause significant morbidity and
mortality. Healthcare providers struggle to promptly recognize and
appropriately treat anaphylaxis patients. The goal of this study was to
characterize anaphylaxis-related malpractice lawsuits.
METHODS:
We collected jury verdicts, settlements, and court opinions
regarding alleged medical malpractice involving anaphylaxis from May 2011 through
May 2016 from an online legal database (Thomson Reuters Westlaw). Data were
abstracted onto a standardized data form.
RESULTS:
We identified 30 anaphylaxis-related malpractice lawsuits.
In 80% of cases, the trigger was iatrogenic (40% intravenous [IV] contrast, 33%
medications, 7% latex). Sixteen (53%) cases resulted in death, 7 (23%) in
permanent cardiac and/or neurologic damage, and 7 (23%) in less severe
outcomes. Fourteen (47%) of the lawsuits were related to exposure to a known
trigger. Delayed recognition or treatment was cited in 12 (40%) cases and
inappropriate IV epinephrine dosing was reported in 5 (17%) cases. Defendants
were most commonly physicians (n=15, 50%) and nurses (n=5, 17%). The most
common physician specialties named were radiology and primary care (n=3, 10%
each), followed by emergency medicine, anesthesiology, and cardiology (n=2, 7%
each). Among the 30 cases, 14 (47%) favored the defendant, 8 (37%) resulted in
findings of negligence, 3 (10%) cases settled, and 5 (17%) had an unknown legal
outcome.
CONCLUSION:
Additional anaphylaxis education, provision of epinephrine
autoinjectors or other alternatives to reduce dosing errors, and stronger
safeguards to prevent administration of known allergens would all likely reduce
anaphylaxis-related patient morbidity and mortality and providers' legal
vulnerability to anaphylaxis-related lawsuits.
G. Incidence of intracranial bleeding
in anticoagulated patients with minor head injury: a systematic review and
meta-analysis of prospective studies.
Minhas H, et al. Br J Haematol. 2018 Jul 20 [Epub ahead of
print]
Guidelines advise performing a computed tomography head scan
for all anticoagulated head injured patients, but the risk of intracranial
haemorrhage (ICH) after a minor head injury is unclear.
We conducted a systematic review and meta-analysis to
determine the incidence of ICH in anticoagulated patients presenting with a
minor head injury and a Glasgow Coma Score (GCS) of 15. We followed
Meta-Analyses and Systematic Reviews of Observational Studies guidelines. We
included all prospective studies recruiting consecutive anticoagulated
emergency patients presenting with a head injury. Anticoagulation included
vitamin-K antagonists (warfarin, fluindione), direct oral anticoagulants
(apixaban, rivaroxaban, dabigatran and edoxaban) and low molecular weight heparin.
A total of five studies (including 4080 anticoagulated
patients with a GCS of 15) were included in the analysis. The majority of
patients took vitamin K antagonists (98·3%). There was significant
heterogeneity between studies with regards to mechanism of injury and methods.
The random effects pooled incidence of ICH was 8·9% (95% confidence interval
5·0-13·8%).
In conclusion, around 9% of patients on vitamin K
antagonists with a minor head injury develop ICH. There is little data on the
risk of traumatic intracranial bleeding in patients who have a GSC 15 post-head
injury and are prescribed a direct oral anticoagulant.
14. Prospective Validation and Refinement of a Decision Rule to
Obtain Chest X-ray in Patients with Nontraumatic Chest Pain in the ED.
Newsom C, et al. Acad Emerg Med. 2018 Jun;25(6):650-656.
OBJECTIVES:
The objective was to prospectively validate and refine
previously published criteria to determine the potential utility of chest x-ray
(CXR) in the evaluation and management of patients presenting to the emergency
department (ED) with nontraumatic chest pain (CP).
What
were the criteria for CXR?
We sought to validate Rothrock's high‐yield criteria (age ≥
60, hemoptysis, prior/current alcohol abuse, prior tuberculosis, prior thromboembolic
disease, oxygen saturation less than 90%, respiratory rate over 24,
temperature ≥ 100.4°F (38°C), rales, diminished breath sounds) with the
addition of the two significant historical variables provided by Hess
et al. and Newsom et al. (history of CHF and history of smoking)
in a prospective multicenter study.
METHODS:
A prospective observational study was performed of patients
presenting to three EDs in the United States with a chief complaint of
nontraumatic CP. Previously defined high-risk history and examination elements
were combined into a refined decision rule and these elements were recorded for
each patient by the ED physician. CXR results were reviewed and analyzed to
determine the presence of clinically significant findings including pneumonia, pleural
effusion, pneumothorax, congestive heart failure, or the presence of a new
mass. Odds ratios for each history and examination element were analyzed as
well as sensitivity, specificity, and negative predictive value (NPV) of the
rule overall.
RESULTS:
A total of 1,111 patients were enrolled and 1,089 CXRs were
analyzed. There were 70 (6.4%) patients with clinically relevant findings on
CXR. The refined decision rule had a sensitivity of 92.9% (confidence interval
[CI] = 83.4%-97.3%) and specificity of 30.4% (CI = 27.6%-33.4%) to predict
clinically relevant findings on CXR, with a NPV of 98.4% (CI = 96.1%-99.4%).
Five CXRs with clinically significant findings would have been missed by
application of the refined rule (three pneumonias and two pleural effusions).
Applying these criteria as a CXR decision rule to this population would have
reduced CXR utilization by 28.9%.
CONCLUSIONS:
This study validates previous research suggesting a low
clinical yield for CXR in the setting of nontraumatic CP in the ED. This
refined clinical decision rule has a favorable sensitivity and NPV in a patient
population with low incidence of disease. Further validation is needed prior to
use in practice.
15. Patient Preference for Pain Medication in the ED Is
Associated with Non-fatal Overdose History.
Whiteside LK, et al. West J Emerg Med. 2018
Jul;19(4):722-730.
INTRODUCTION:
Opioid overdose is a major public health problem. Emergency
physicians need information to better assess a patient's risk for overdose or
opioid-related harms. The purpose of this study was to determine if
patient-reported preference for specific pain medications was associated with a
history of lifetime overdose among patients seeking care in the emergency
department (ED).
METHODS:
ED patients (18-60 years) completed a screening survey that
included questions on overdose history, ED utilization, opioid misuse behaviors
as measured by the Current Opioid Misuse Measure (COMM), and analgesic
medication preferences for previous ED visits for pain with specific responses
for preference for hydromorphone (Dilaudid®), morphine, ketorolac (Toradol®),
"no preference" or "never visited the ED for pain." We
compared individuals who reported a lifetime history of overdose descriptively
to those without a lifetime history of overdose. Logistic regression was used
to determine factors associated with a history of overdose.
RESULTS:
We included 2,233 adults in the analysis (71.5% response
rate of patients approached) with 532 reporting at least one lifetime overdose.
In the univariate analysis, medication preference was significantly associated
with overdose history (p less than .001); more patients in the overdose
group reported preferring morphine and hydromorphone and those without a
history of overdose were more likely to have no preference or say they had never
visited the ED for pain. In the logistic regression analysis, patients with
higher odds of overdose included those of Caucasian race, participants with a
higher COMM score, preference for ketorolac, morphine or hydromorphone. Those
who were younger, female and reported never having visited the ED for pain had
lower odds of reporting a lifetime overdose. Having "any preference"
corresponded to 48% higher odds of lifetime overdose.
CONCLUSION:
Patients with a pain medication preference have higher odds
of having a lifetime overdose compared to patients without a specific pain
medication preference, even after accounting for level of opioid misuse. This
patient-reported preference could cue emergency physicians to identifying
high-risk patients for overdose and other substance-related harms.
16. No Radiographic Safe Margin Found in the “Easy IJ” Internal
Jugular Vein Procedure
McCarter RN, et al. J Emerg Med. 2018 Jul;55(1):29-33.
BACKGROUND:
The Easy IJ procedure involves placement of a 4.8-cm
intravenous catheter into the internal jugular (IJ) vein using ultrasound
guidance. It is not known whether this needle length has the potential to cause
a pneumothorax.
OBJECTIVE:
The objective of this study was to determine if a
radiographic "safe margin" exists. We hypothesized that an average
margin of ≥2 cm would exist between the catheter tip and the pleura.
METHODS:
Operators used a central approach to the IJ vein. We
reviewed radiographic images taken immediately after the Easy IJ procedure.
Using digital software, we measured the distance from the catheter tip to the
closest point of the pleura and from the catheter tip to the level of the lung
apex. We defined distances exceeding the margin of safety-either passing the
pleura or ending inferior to the apex-as negative for the purpose of
calculating an average. We used the t distribution to calculate 95% confidence
intervals (CIs) for average values.
RESULTS:
Radiographs showing the catheter tip were available from 62
patients. The mean needle-to-pleura distance was -0.1 cm (95% CI -0.7 to 0.5
cm). The mean vertical distance to the apex was -0.2 cm (95% CI -0.8 to 0.3
cm), with a standard deviation of 2.25 cm.
CONCLUSION:
Radiographic analysis failed to show a margin of safety for
the Easy IJ procedure. Postprocedure imaging may still be necessary to exclude
pneumothorax.
17. The Newest Threat to ED Procedural Sedation.
Green SM, et al. Ann Emerg Med. 2018
Article Outline
What Happened to Deep Sedation?
An Anesthesiologist Guideline to Govern All Specialties?
Propofol and Ketamine: “Medications Intended for General
Anesthesia”
Excerpt
Now the ASA has released updated sedation guidelines that
again assert a scope beyond the practice of anesthesiologists, stating that
their guidelines “are intended for use by all providers…in any inpatient or
outpatient setting.”11 These new guidelines contain vague, confusing, and
misleading statements that run contrary to the existing scientific evidence and
threaten the well-established sedation practices of emergency physicians and
other specialists. Procedural sedation has long been a core competency in
emergency medicine and critical care medicine, and our patients depend on us to
provide effective sedation and analgesia for procedures that are often
extremely painful (eg, cardioversion, abscess incision and drainage, fracture
and dislocation reduction) or unduly frightening (eg, facial laceration repair,
neuroimaging in a child). These revised ASA guidelines restrict the use of
propofol and ketamine—our 2 most commonly administered sedative agents12, 13,
14, 15, 16, 17—and any adoption or enforcement of these directives would
restrict emergency physician access to these drugs, resulting in widespread use
of alternative agents that are less safe and provide much less effective
sedation and analgesia.
Despite these concerns, there are some positive aspects to
this update…
Related
ACEP
Hosts Meeting to Create Unscheduled-Sedation Guidelines
18. High-Velocity Nasal Insufflation in the Treatment of
Respiratory Failure: A Randomized Clinical Trial.
Doshi P, et al. Ann Emerg Med. 2018 Jul;72(1):73-83.e5. doi:
STUDY OBJECTIVE: We compare high-velocity nasal
insufflation, a form of high-flow nasal cannula, with noninvasive
positive-pressure ventilation in the treatment of undifferentiated respiratory
failure with respect to therapy failure, as indicated by requirement for
endotracheal intubation or cross over to the alternative therapy.
METHODS: This was a multicenter, randomized trial of adults
presenting to the emergency department (ED) with respiratory failure requiring
noninvasive positive-pressure ventilation. Patients were randomly assigned to
high-velocity nasal insufflation (initial flow 35 L/min; temperature 35°C
(95°F) to 37°C (98.6°F); FiO2 1.0) or noninvasive positive-pressure ventilation
using an oronasal mask (inspiratory positive airway pressure 10 cm H2O;
expiratory positive airway pressure 5 cm H2O). The primary outcome was therapy
failure at 72 hours after enrollment. A subjective outcome of crossover was
allowed as a risk mitigation to support deferment of informed consent.
Noninferiority margins were set at 15 and 20 percentage points, respectively.
RESULTS: A total of 204 patients were enrolled and included
in the analysis, randomized to high-velocity nasal insufflation (104) and
noninvasive positive-pressure ventilation (100). The intubation rate
(high-velocity nasal insufflation=7%; noninvasive positive-pressure
ventilation=13%; risk difference=-6%; 95% confidence interval -14% to 2%) and
any failure of the assigned arm (high-velocity nasal insufflation=26%;
noninvasive positive-pressure ventilation=17%; risk difference 9%; confidence
interval -2% to 20%) at 72 hours met noninferiority. The effect on PCO2 over
time was similar in the entire study population and in patients with baseline
hypercapnia. Vital signs and blood gas analyses improved similarly over time.
The primary limitation was the technical inability to blind the clinical team.
CONCLUSION: High-velocity nasal insufflation is noninferior
to noninvasive positive-pressure ventilation for the treatment of
undifferentiated respiratory failure in adult patients presenting to the ED.
19. Necrotizing Fasciitis Diagnoses and Therapy Tips
By Anton Helman, MD, CCFP(EM), FCFP
How to quickly recognize and begin treating this rapidly
progressing infection of the fascia with secondary necrosis of the subcutaneous
tissues.
Necrotizing fasciitis is a rapidly progressive inflammatory
infection of the fascia, with secondary necrosis of the subcutaneous tissues.
The spectrum of presentation is wide, ranging from a benign-appearing rash in a
well person to obvious skin necrosis with hemodynamic instability, multi-organ
failure, and death. Patients who present early in this spectrum of disease are
difficult to diagnose, with an initial misdiagnosis rate of 71.4 percent.1
However, initiation of treatment in these early stages gives patients the
greatest chance of survival in this otherwise deadly disease. In this early
phase, necrotizing fasciitis can be mistaken for simple cellulitis, and while
the skin may appear benign, it is often the tip of the iceberg to what lies
beneath.
The diagnostic difficulty also lies in the fact that there are
no lab test results or even imaging that can definitively rule out necrotizing
fasciitis. In fact, the diagnosis is a clinical one that can only be confirmed
with surgical exploration. Therefore, it is imperative that if you have
anything more than the slightest suspicion based on your clinical exam, you
consider early consultation with a surgeon for definitive diagnosis and
surgical debridement as well as start empiric antibiotics. Lab findings that
are suggestive but not diagnostic of necrotizing fasciitis include
coagulopathy, hypoalbuminemia, thrombocytopenia, lactic acidosis, creatine
phosphokinase elevation, and C-reactive protein (CRP) elevation, which all tend
to occur in later stages of disease.1
While clinical decision tools, such as the Laboratory Risk
Indicator for Necrotizing Fasciitis (LRINEC) score that includes CRP, white
blood cell count, hemoglobin, sodium, creatinine, and glucose, might help raise
your suspicion for necrotizing fasciitis, validation studies showed that a
LRINEC cutoff of six points only had a negative predictive value of 92.5
percent.2,3 While these lab findings and imaging findings of subcutaneous air
and fascial thickening on X-ray, CT, and MRI can help support the diagnosis,
they should not delay definitive treatment in the operating room in clinically
obvious cases and should never override clinical judgment.
Findings on point-of-care ultrasound, which has the
advantage of speed over other imaging modalities, may help support the
diagnosis but again cannot rule it out.4……
20. A Simple ED
Intervention Can Help Cut Suicide Risk
Chatterjee. NPR. July
11, 2018
Many people who
attempt suicide end up in an emergency room for immediate treatment. But few of
those suicide survivors get the follow-up care they need at a time when they
are especially likely to attempt suicide again.
Now, a study shows
that a simple intervention conducted by staff in emergency departments can
reduce the risk of future attempts. The intervention involves creating a safety
plan for each patient and following up with phone calls after discharge.
"It reduced the
odds of suicidal behavior by half," says Barbara Stanley, a psychologist
at Columbia University and the lead author of the study. "That's a
phenomenal difference."
The study, which was
published Wednesday in JAMA Psychiatry, included 1,200 patients at five
Veterans Affairs hospitals around the country. The findings offer a way for
hospitals and clinics to help reduce the rising numbers of death by suicide
across the country.
“When someone goes to
the emergency room for a suicide attempt, they are at risk of another suicide
attempt for the next three months," says Stanley. "It's like a
ticking time bomb."
This is the first large-scale
study of the Safety Planning Intervention, which Stanley and her group
developed in 2008 and which has been adopted at hospitals and clinics around
the country. It can be provided by a physician, a nurse or a social worker and
requires very little training….
21. Only 30% of patients given follow-up medications after
opioid overdose
A study in the Annals of Internal Medicine found that only
three in 10 patients who survived an opioid overdose were prescribed some type
of medication-assisted treatment that could prevent a subsequent life-threatening
event. The findings, based on data from 17,568 people in Massachusetts who
overdosed on opioids, showed 3,022 received buprenorphine and 2,040 received
methadone, and the groups had a 40% and 60% lower death rate after one year,
respectively, compared with patients who were not prescribed any medications.
22. Prevalence and outcomes of incidentalomas on imaging:
umbrella review
O’Sullivan JW, et al. Cite this as: BMJ 2018;361:k2387
Introduction
Incidentalomas, incidental imaging findings serendipitously
diagnosed in an asymptomatic patient or symptomatic patient undergoing imaging
for an unrelated reason,123 are fast becoming a modern medical crisis.4 The
rapid rise in demand for imaging,56 coupled with rapidly advancing image
resolution is driving a surge in incidentalomas.789
Incidentalomas are problematic because they can lead to
patient anxiety.10 Given the clinical uncertainty surrounding their ideal
management, they can encourage further investigations and potentially
overtreatment. In response to the risks of incidentalomas, a US Presidential
Commission encouraged clinicians to discuss with patients incidentalomas as a
risk of imaging before they order a scan.4 Despite this, informed consent
before imaging remains poor.11 It is difficult for clinicians to appropriately
inform patients of the chance of incidental findings because the data
quantifying prevalence is inconsistent and unclear.
Clinicians have also expressed uncertainty about the ideal
management of incidentalomas, particularly primary care physicians.312 Although
some guidelines exist,11314151617 they are often directed at radiologists151617
and for many organs (eg, colon, spine, breast, brain, prostate, and parotid)
there are no guidelines to address the management of incidentalomas…
The rest of the study (full-text free): https://www.bmj.com/content/361/bmj.k2387
23. The New Alternatives to the ConCert Examination: Will the
Shorter Tests Make Emergency Physicians Less Miserable?
Kelly M. Ann Emerg Med. 2018;72:A15–A17.
Excerpt
Beyond the cost in terms of money, anxiety, and time,
however, some emergency physicians have a more significant complaint: They
grouse that the recertification process has done nothing to add to their
hands-on skills or help their patients. “None of us can think of anything more
irrelevant to the practice of emergency medicine than taking an outdated
multiple-choice test every 10 years,” said Paul Tripathi, MD, the lead
physician at Inova Fair Oaks Hospital pediatric emergency department. He
remarked that the test in no way improved him as a physician during the 9 years
when he wasn’t studying for it—and also didn’t help once he passed because of
the “irrelevant and non–real-world material.”
24. Micro Bits
A.
Complementary medicine tied to lower cancer survival rates
The use of complementary medicine by cancer patients was
associated with poorer overall five-year survival and an increased mortality
risk, compared with not using CM, researchers reported in JAMA Oncology. The
increase in mortality was attributed to patients delaying or refusing
potentially curative conventional treatments.
B.
Common symptoms before multiple sclerosis diagnosis identified
A Canadian study in the Multiple Sclerosis Journal found
common symptoms of multiple sclerosis five years before diagnosis include
mental health disorders, pain and sleep problems. The findings, based on health
records for 14,000 patients with multiple sclerosis and 67,000 controls without
the disease, also showed that those who were later diagnosed with the disease
more commonly have fibromyalgia, irritable bowel syndrome and migraines,
compared with controls.
C.
Study links childhood socioeconomic disadvantages to health risks in adulthood
Researchers followed 3,467 individuals in Finland for an
average of 30 years and found that growing up in a socioeconomically
disadvantaged neighborhood was associated with increased risk of type 2
diabetes, obesity, hypertension and fatty liver in adulthood. The findings in
The Lancet Public Health "support policies that increase resources and opportunities
for those living in socioeconomically disadvantaged areas," researchers
said.
D.
Risk For Heart Attack During Pregnancy Increasing In US Women, Research
Indicates.
Research indicates “the number of women who have a heart
attack during pregnancy, labor or in the weeks following birth appears to be
rising.” The findings were published in Mayo Clinical Proceedings.
E.
FDA Updates Safety Warnings for Fluoroquinolones
July 17, 2018 04:18 pm News Staff – Following an extensive
review of adverse event reports and case reports published in the medical
literature, the FDA on July 10 announced changes(www.fda.gov) to the safety
labeling of fluoroquinolones. The changes include strengthened warnings about
the risks of mental health side effects and disturbances in blood sugar, and
more consistent labeling for all fluoroquinolones administered orally or by
injection.
F.
Taking NSAIDs with anticoagulants may raise risk for bleeding, stroke
Patients with atrial fibrillation who use oral
anticoagulants and nonsteroidal anti-inflammatory drugs are at an increased
risk for major bleeding and stroke, based on findings from the Randomized
Evaluation of Long-Term Anticoagulant Therapy trial reported in the Journal of
the American College of Cardiology. "This study shows that both with
warfarin and the newer anticoagulant dabigatran, you get more bleeding, but you
can also get more thrombotic complications when you add an NSAID,"
according to Sam Schulman, MD, who co-wrote an accompanying editorial on the
study.
G.
Pills are not the answer to unhealthy lifestyles
More than half of adults aged over 45 will be labelled as
hypertensive if new US guidelines are adopted, concludes a study in The
BMJ this week (doi:10.1136/bmj.k2357).
This equates to 70 million people in the US and 267 million people in China
being eligible for antihypertensive drugs, a marked increase on already high
rates of drug treatment for high blood pressure.
H.
Most patients get 11 seconds to explain symptoms before interruption
Researchers who analyzed recorded consultations between 112
patients and their doctors found that in 7 out of every 10 cases, physicians
interrupted patients as they explained their symptoms within a median 11
seconds. The study, in the Journal of General Internal Medicine, found primary
care physicians allowed patients more time to describe their ailments without
interruption than specialists.
I.
Review: No evidence of heart health benefits with vitamin-mineral supplements
A review of 18 studies with more than 2 million participants
showed that the use of multivitamins and mineral supplements was not associated
with the risk of death from coronary heart or cardiovascular disease, or of
stroke incidence or deaths. The review was published in Circulation:
Cardiovascular Quality and Outcomes.
J.
Early solid food introduction may improve infant sleep
Breastfed babies who ate solid foods at age 3 months had
almost two hours of additional sleep and nearly two fewer sleep disturbances
per week, with sleep improvements persisting even after the first year of
infancy, compared with those who were exclusively breastfed until age 6 months,
UK researchers reported in JAMA Pediatrics. The findings also showed that very
serious sleep problems were less likely to be reported by parents of those in
the early solid food introduction group.
K.
Will You Forgive Me for Saving You?
Excerpt
I hope you forgive me. You were so close to gone, and I was
so afraid you wouldn’t make it. Even then, I knew that “making it” would be
relative, and the life I was saving you for would be troubled at best. I hope
some part of you finds joy and that it overshadows the pain. I hope you
remember a little, because I will never forget you.
I wonder: Did I save you for a good life? Are you glad I did
it? Will your mom and grandma still thank me when the endless days of caring
for you heap into years of sacrifice? Will you forgive me for saving you?
L.
Weight loss tied to atrial fibrillation reversal, study finds
Australian researchers used a cohort of 355 patients with
atrial fibrillation and obesity and found more of those who lost at least 10%
of their weight experienced a reverse progression of AF after four years,
compared with those who lost less than 3% of their weight. The findings in the
journal Europace also revealed that 88% of those who lost at least 10% of their
weight did not have AFib in the past year or had gone from persistent AFib to
paroxysmal AFib episodes.
M.
Atul Gawande Named CEO of Health Venture by Amazon, Berkshire Hathaway and
JPMorgan
N.
How 3 big Southern California hospitals are dealing with their growing number
of ER visitors
Kaiser, USC, and Antelope Valley
O.
A little satirical reprieve
Five-Second
Rule Validated in the Operating Room: 'Total game changer'
Skelepuns. June 21, 2018. CHICAGO – In a paradigm shift for
the operating room, a new study has found that reusing instruments dropped on
the operating room floor does not increase the incidence of postoperative
infections, so long as the instruments are picked up within 5 seconds of being
dropped.
In this multi-center, prospective, randomized, double-blind
placebo-controlled study, surgical instruments were dropped on the operating
room floor and picked up immediately and at 5, 10, and 15 seconds and then used
in surgery. It was found that using instruments dropped for 5 seconds or less
did not result in an increased incidence of infections. However, using
instruments dropped for more than 5 seconds resulted in overwhelming sepsis in
100% of study patients.
"This is a total game changer for the OR. No more
opening peel packs when the medical student drops the suture scissors and then
drops the replacement suture scissors. We just have to make sure that
anesthesia actually gets the antibiotics in before incision," said lead
study author Sharon Weeksie. "Sure, you drop them and they get dirty. But
it's a distinction without a difference."
Blowing on the instruments after pickup was not found to
affect infection rates in any meaningful way.
