1. AMI Corner
A. New Definition of Myocardial Infarction
Established
The new guidelines
are the 4-year work of a committee representing cardiologists and other
healthcare professionals from the European Society of Cardiology, the American
College of Cardiology, the American Heart Association, and the World Heart
Federation.
The term acute
MI should be used when there is acute myocardial injury with (1) detection of a
rise and/or fall of cardiac troponin values with at least 1 value above the
99th percentile upper reference limit and (2) clinical evidence of acute
myocardial ischaemia noted by at least 1 of the following:
- Symptoms of myocardial ischaemia
- New ischaemic electrocardiogram (ECG) changes
- Development of pathological Q waves
- Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischaemic etiology
- Identification of a coronary thrombus by angiography or autopsy
Summary here
at ACC: https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2018/08/24/00/09/fourth-universal-definition-of-mi-esc-2018
Thygesen K,
Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol
2018 Aug 25 [Epub ahead of print].
B. Recent ESC Guidelines Reviewed by EM-RAP
Ibanez B, et
al. 2017 ESC guidelines for the management of AMI in patients presenting with
ST-segment elevation: The task force for the management of AMI in patients
presenting with ST-segment elevation of the European Society of Cardiology
(ESC). Eur Heart J. 2018;39(2):119-177.
ED-specific
Highlights from EM-RAP, September 2018
By Anand Swaminathan MD and Amal Mattu MD
1. A reduction
in chest pain after nitroglycerin administration can be misleading and is not
recommended as a diagnostic maneuver.
2. The
criteria for diagnosis of ST elevation MI on ECG is more complex than just 1 mm
of elevation in two contiguous leads.
“In the proper clinical context, ST-segment elevation
(measured at the J-point) is considered suggestive of ongoing coronary artery acute
occlusion in the following cases: at least two contiguous leads with ST-segment
elevation ≥ 2.5 mm in men below 40 years, ≥2 mm in men ≥ 40 years, or ≥ 1.5 mm
in women in leads V2–V3 and/or ≥ 1 mm in the other leads [in the absence of
left ventricular (LV) hypertrophy or left bundle branch block LBBB)].”
3. Q waves on
the ECG should not change reperfusion strategy.
4. Should we
routinely look at additional leads to evaluate for right ventricular and
posterior MI?
Not routinely,
but selectively.
Example 1: “Isolated posterior MI. In AMI of the
inferior and basal portion of the heart, often corresponding to the left
circumflex territory, isolated ST-segment depression ≥ 0.5 mm in leads V1–V3 represents
the dominant finding. These should be managed as a STEMI. The use of additional
posterior chest wall leads [elevation V7–V9 ≥ 0.5 mm (≥1 mm in men, 40 years
old)] is recommended to detect ST-segment elevation consistent with inferior
and basal MI.”
Example 2: Right
Ventricular MI. Get right-sided leads in pts with inferior STEMIs. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5267627/
5. The ECG
diagnosis of acute myocardial infarction is difficult in the presence of a left
bundle branch block but often possible if marked ST-segment abnormalities are
present.
Use Scarbossa’s criteria, or Smith’s modified
criteria. https://www.annemergmed.com/article/S0196-0644(12)01368-6/pdf
6. Patients
with MI and right bundle branch block have a poor prognosis. It may be
difficult to detect transmural ischemia in patients with chest pain and RBBB. A
primary PCI strategy should be considered when persistent ischemic symptoms occur
with RBBB.
7. Some
patients with acute coronary occlusion may have an initial ECG without ST
elevation.
“Non-diagnostic ECG. Some patients with an acute
coronary occlusion may have an initial ECG without ST-segment elevation,
sometimes because they are seen very early after symptom onset (in which case,
one should look for hyper-acute T-waves, which may precede ST-segment elevation).
It is important to repeat the ECG or monitor for dynamic ST-segment changes. In
addition, there is a concern that some patients with acute occlusion of a
coronary artery and ongoing MI, such as those with an occluded circumflex
coronary artery,58,59 acute occlusion of a vein graft, or left main disease,
may present without ST-segment elevation and be denied reperfusion therapy,
resulting in a larger infarction and worse outcomes. Extending the standard
12-lead ECG with V7–V9 leads may identify some of these patients. In any case,
suspicion of ongoing myocardial ischaemia is an indication for a primary PCI
strategy even in patients without diagnostic ST-segment
elevation.8,38,46–49Table 3 lists the atypical ECG presentations that should
prompt a primary PCI strategy in patients with ongoing symptoms consistent with
myocardial ischaemia.”
8. ST
depression above 1 mm in eight or more surface leads, coupled with ST-segment
elevation in aVR and/or V1, suggests multi-vessel ischemia or left main
obstruction.
9. If the
patient has a STEMI post-arrest, they should go to PCI.
C. The OMI Manifesto (Occlusion MI)
A
collaboration by Dr. Smith’s ECG Blog and EMCrit
By Pendell
Meyers, MD, Scott Weingart, MD, FCCM, and Stephen Smith, MD
The current
guideline-recommended paradigm of acute MI management (“STEMI vs. NSTEMI”) is
irreversibly flawed, and has prevented meaningful progress in the science of
emergent reperfusion therapy over the past 25 years. Dr. Stephen Smith, my
mentor and co-editor of this post, has been saying this much more eloquently
for many years in his “STEMI/NSTEMI False Dichotomy” lecture series, but this
bears repeating and needs to be reiterated as widely as possible.
Deciding which
patients need emergent reperfusion therapy is complex, and our current criteria
for doing so are not adequate to the task. The patients who benefit from
emergent catheterization are those with acute coronary occlusion (ACO) or near
occlusion, with insufficient collateral circulation, whose myocardium is at
imminent risk of irreversible infarction without immediate reperfusion therapy.
This is the anatomic substrate of the entity we are supposed to refer to as
"STEMI." Unfortunately the term "STEMI" restricts our minds
into thinking that ACO is diagnosed reliably and/or only by "STEMI
criteria" and the ST segments. In reality, the STEMI criteria and
widespread current performance under the current paradigm have unacceptable
accuracy, routinely missing at least 25-30% of ACO in those classified as
“NSTEMI”1-9 and generating a similar false positive rate of emergent cath lab
activations.10-12…
D. Pre-activating the Cath Lab for STEMIs Improves
Outcomes
Association
Between Cardiac Catheterization Laboratory Pre-Activation and Reperfusion
Timing Metrics and Outcomes in Patients With ST-Segment Elevation Myocardial
Infarction Undergoing Primary Percutaneous Coronary Intervention: A Report From
the ACTION Registry
Shavadia JS,
et al. JACC
Cardiovasc Interv. 2018;11(18):1837-1847.
Activating the
cardiac catheterization laboratory at least 10 minutes before an ST-segment
elevation MI (STEMI) patient arrived at the hospital was associated with less
reperfusion delay – and possibly better in-hospital survival.
2. Effect of a Strategy of Initial Laryngeal Tube Insertion vs
Endotracheal Intubation on 72-Hour Survival in Adults with Out-of-Hospital
Cardiac Arrest: A RCT
Wang HE, et
al. JAMA 2018;320(8):769-778.
Key Points
Question What is the effect of an initial airway
management strategy using laryngeal tube insertion, compared with endotracheal
intubation, on survival among adults with out-of-hospital cardiac arrest?
Findings In this cluster-crossover randomized trial of
3004 adults with out-of-hospital cardiac arrest, 72-hour survival was 18.3% for
laryngeal tube insertion and 15.4% for endotracheal intubation, a significant
difference.
Meaning A strategy of initial laryngeal tube
insertion, compared with endotracheal intubation, was associated with greater
likelihood of 72-hour survival, but given limitations in study design and
findings, additional research is warranted.
Abstract
Importance Emergency medical services (EMS) commonly
perform endotracheal intubation (ETI) or insertion of supraglottic airways,
such as the laryngeal tube (LT), on patients with out-of-hospital cardiac
arrest (OHCA). The optimal method for OHCA advanced airway management is
unknown.
Objective To compare the effectiveness of a strategy of
initial LT insertion vs initial ETI in adults with OHCA.
Design,
Setting, and Participants Multicenter
pragmatic cluster-crossover clinical trial involving EMS agencies from the
Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and
anticipated need for advanced airway management who were enrolled from December
1, 2015, to November 4, 2017. The final date of follow-up was November 10,
2017.
Interventions Twenty-seven EMS agencies were randomized in
13 clusters to initial airway management strategy with LT (n = 1505 patients)
or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to
5-month intervals.
Main Outcomes
and Measures The primary outcome was
72-hour survival. Secondary outcomes included return of spontaneous circulation,
survival to hospital discharge, favorable neurological status at hospital
discharge (Modified Rankin Scale score ≤3), and key adverse events.
Results Among 3004 enrolled patients (median
[interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were
included in the primary analysis. Rates of initial airway success were 90.3%
with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group
vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04).
Secondary outcomes in the LT group vs ETI group were return of spontaneous
circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%];
P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI,
0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs
5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no
significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs
0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs
22.3%).
Conclusions
and Relevance Among adults with OHCA, a
strategy of initial LT insertion was associated with significantly greater
72-hour survival compared with a strategy of initial ETI. These findings
suggest that LT insertion may be considered as an initial airway management
strategy in patients with OHCA, but limitations of the pragmatic design,
practice setting, and ETI performance characteristics suggest that further
research is warranted.
3. How the Availability of Observation Status Affects Emergency
Physician Decision-making
Wright B, et
al. Ann Emerg Med 2018;72(4):401-409.
Study
objective
This study
seeks to understand how emergency physicians decide to use observation
services, and how placing a patient under observation influences physicians’
subsequent decisionmaking.
Methods
We conducted
detailed semistructured interviews with 24 emergency physicians, including 10
from a hospital in the US Midwest, and 14 from 2 hospitals in central and
northern England. Data were extracted from the interview transcripts with open
coding and analyzed with axial coding.
Results
We found that
physicians used a mix of intuitive and analytic thinking in initial decisions
to admit, observe, or discharge patients, depending on the physician’s
individual level of risk aversion. Placing patients under observation made some
physicians more systematic, whereas others cautioned against overreliance on
observation services in the face of uncertainty.
Conclusion
Emergency
physicians routinely make decisions in a highly resource-constrained
environment. Observation services can relax these constraints by providing
physicians with additional time, but absent clear protocols and metacognitive
reflection on physician practice patterns, this may hinder, rather than
facilitate, decisionmaking.
4. An Outbreak of Synthetic Cannabinoid–Associated Coagulopathy
in Illinois
Kelkar AH, et
al. N Engl J Med 2018;379:1216-1223.
BACKGROUND
In March and
April 2018, more than 150 patients presented to hospitals in Illinois with
coagulopathy and bleeding diathesis. Area physicians and public health
organizations identified an association between coagulopathy and synthetic
cannabinoid use. Preliminary tests of patient serum samples and drug samples
revealed that brodifacoum, an anticoagulant, was the likely adulterant.
METHODS
We reviewed
physician-reported data from patients admitted to Saint Francis Medical Center
in Peoria, Illinois, between March 28 and April 21, 2018, and included in a
case series adult patients who met the criteria used to diagnose synthetic
cannabinoid–associated coagulopathy. A confirmatory anticoagulant poisoning
panel was ordered at the discretion of the treating physician.
RESULTS
A total of 34
patients were identified as having synthetic cannabinoid–associated
coagulopathy during 45 hospitalizations. Confirmatory anticoagulant testing was
performed in 15 of the 34 patients, and superwarfarin poisoning was confirmed
in the 15 patients tested. Anticoagulant tests were positive for brodifacoum in
15 patients (100%), difenacoum in 5 (33%), bromadiolone in 2 (13%), and
warfarin in 1 (7%). Common symptoms at presentation included gross hematuria in
19 patients (56%) and abdominal pain in 16 (47%). Computed tomography was
performed to evaluate abdominal pain and revealed renal abnormalities in 12
patients. Vitamin K1 (phytonadione) was administered orally in all 34 patients
and was also administered intravenously in 23 (68%). Red-cell transfusion was
performed in 5 patients (15%), and fresh-frozen plasma infusion in 19 (56%).
Four-factor prothrombin complex concentrate was used in 1 patient. One patient
died from complications of spontaneous intracranial hemorrhage.
CONCLUSIONS
Our data
indicate that superwarfarin adulterants of synthetic cannabinoids can lead to
clinically significant coagulopathy. In our series, in most of the cases in
which the patient presented with bleeding diathesis, symptoms were controlled
with the use of vitamin K1 replacement therapy. The specific synthetic
cannabinoid compounds are not known.
5. Ann Emerg Med Quick Reviews
A. Are
Patients Receiving the Combination of Vancomycin and Piperacillin-Tazobactam at
Higher Risk for Acute Renal Injury?
Take-Home
Message
The
combination of vancomycin and piperacillin-tazobactam increases the risk of
acute kidney injury compared with vancomycin monotherapy,
piperacillin-tazobactam monotherapy, or vancomycin plus cefepime or a
carbapenem.
B. Are qSOFA
Criteria Better Than the Systemic Inflammatory Response Syndrome Criteria for
Diagnosing Sepsis and Predicting Inhospital Mortality?
Take-Home
Message
Systemic
inflammatory response syndrome (SIRS) criteria are more sensitive for
diagnosing sepsis, while quick Sequential [Sepsis-related] Organ Failure
Assessment (qSOFA) criteria are marginally more accurate for predicting
inhospital mortality among patients identified with sepsis.
6. Chemotherapy Corner
A. New Immunotherapy Revolutionizes Cancer Care, but
Guess Where Adverse Events End Up?
Ballard
D, et al. Emerg Med News. 2018;40(9):29.
A
69-year-old man with a history of cancer presented to our ED on day four of
taking Ceftin for pneumonia with a fever of 102.5°F and shortness of breath. He
had a history of non-small cell
lung
cancer after a wedge resection and hepatocellular carcinoma after a
hepatectomy. His chest film was read as “patchy airspace disease over mid- and
lower lung without improvement from prior,” and he was worked up, treated, and
admitted for severe sepsis. Sounds like a fairly bread-and-butter emergency
department case, right?
Of
course, there was a twist, which emerged after a CT of the chest and
bronchoscopy demonstrated diffuse ground glass opacity and tracheobronchitis,
findings that resolved with high-dose prednisone. The diagnosis was not pneumonia
but pneumonitis, a complication of the patient’s cancer treatment—pembrolizumab
(Keytruda), last administered several
months before presentation.
Pembrolizumab
is one of the new-generation cancer treatments that deploys the patient’s
immune system against cancer cells by removing the malignant cells’ ability to
disguise themselves rather than killing them directly. These checkpoint inhibitors
are revolutionizing
oncologic
treatment, but are not a risk-free panacea. We all know where these patients
are likely to be seen and evaluated when severe side effects emerge.
Be
on the Lookout
Immunotherapy
complications have been receiving some attention from scientific journals as
well as the lay press this year. Actual data on adverse effect risk, especially
for those
with
a delayed presentation like our patient, remain limited….
For
the rest of the essay, with references, and the poem below see here: https://journals.lww.com/em-news/Fulltext/2018/09000/Medically_Clear__New_Immunotherapy_Revolutionizes.15.aspx
Checkpoint Inhibitors in Rhyme
These meds can enhance
our immunity
By promoting a state of
disunity—
Releasing the brakes,
Raises the stakes,
With no guarantee of
impunity.
The system is on the
attack
Indifferent to who it
might sack:
Cancer? True;
But other cells, too,
Will find themselves on
the rack.
Events from these
agents immune
Need not occur anytime
soon;
Post-med delays
Can be hundreds of days—
Beware the long
honeymoon…
B. Are We Being Misled About Precision Medicine?
Doctors and
hospitals love to talk about the cancer patients they’ve saved, and reporters
love to write about them. But deaths still vastly outnumber the rare successes.
By Liz Szabo, a
health reporter for Kaiser Health News. New York Times, Sept 11, 2018
7. The Misunderstood Coagulopathy of Liver Disease: A Review for
the Acute Setting.
Harrison MF. West
J Emerg Med. 2018 Sep;19(5):863-871.
The
international normalized ratio (INR) represents a clinical tool to assess the
effectiveness of vitamin-K antagonist therapy. However, it is often used in the
acute setting to assess the degree of coagulopathy in patients with hepatic
cirrhosis or acute liver failure. This often influences therapeutic decisions
about invasive procedures or the need for potentially harmful and unnecessary
transfusions of blood product. This may not represent a best-practice or
evidence-based approach to patient care.
The author
performed a review of the literature related to the utility of INR in cirrhotic
patients using several scientific search engines. Despite the commonly accepted
dogma that an elevated INR in a cirrhotic patient corresponds with an increased
hemorrhagic risk during the performance of invasive procedures, the literature
does not support this belief. Furthermore, the need for blood-product
transfusion prior to an invasive intervention is not supported by the
literature, as this practice increases the risk of complications associated
with a patient's hospital course. Many publications ranging from case studies
to meta-analyses refute this evidence and provide examples of thrombotic events
despite elevated INR values. Alternative methods, such as thromboelastogram,
represent alternate means of assessing in vivo risk of hemorrhage in patients
with acute or chronic liver disease in real-time in the acute setting.
8. Does Point-of-Care US Improve Clinical Outcomes in ED
Patients with Undifferentiated Hypotension? An International RCT from the
SHoC-ED Investigators
Atkinson PR,
et al. Ann Emerg Med. 2018;72(4):478-489.
Study
objective
Point-of-care
ultrasonography protocols are commonly used in the initial management of
patients with undifferentiated hypotension in the emergency department (ED).
There is little published evidence for any mortality benefit. We compare the
effect of a point-of-care ultrasonography protocol versus standard care without
point-of-care ultrasonography for survival and clinical outcomes.
Methods
This
international, multicenter, randomized controlled trial recruited from 6
centers in North America and South Africa and included selected hypotensive
patients (systolic blood pressure less than 100 mm Hg or shock index over 1)
randomized to early point-of-care ultrasonography plus standard care versus
standard care without point-of-care ultrasonography. Diagnoses were recorded at
0 and 60 minutes. The primary outcome measure was survival to 30 days or
hospital discharge. Secondary outcome measures included initial treatment and
investigations, admissions, and length of stay.
Results
Follow-up was
completed for 270 of 273 patients. The most common diagnosis in more than half
the patients was occult sepsis. We found no important differences between
groups for the primary outcome of survival (point-of-care ultrasonography group
104 of 136 patients versus standard care 102 of 134 patients; difference 0.35%;
95% binomial confidence interval [CI] –10.2% to 11.0%), survival in North
America (point-of-care ultrasonography group 76 of 89 patients versus standard
care 72 of 88 patients; difference 3.6%; CI –8.1% to 15.3%), and survival in
South Africa (point-of-care ultrasonography group 28 of 47 patients versus
standard care 30 of 46 patients; difference 5.6%; CI –15.2% to 26.0%). There
were no important differences in rates of computed tomography (CT) scanning,
inotrope or intravenous fluid use, and ICU or total length of stay.
Conclusion
To our
knowledge, this is the first randomized controlled trial to compare
point-of-care ultrasonography to standard care without point-of-care
ultrasonography in undifferentiated hypotensive ED patients. We did not find
any benefits for survival, length of stay, rates of CT scanning, inotrope use,
or fluid administration. The addition of a point-of-care ultrasonography
protocol to standard care may not translate into a survival benefit in this
group.
Editorial: But
It Makes Sense Physiologically…
9. Discriminatory value of the ascending aorta diameter in
suspected acute type A aortic dissection.
Mark DG, et
al. Acad Emerg Med. 2018 Aug 9 [Epub ahead of print].
INTRO: Proximal
thoracic aortic dissections (Stanford classification Type A) occur with an
incidence of 4 per 100,000 person-years and an observed average mortality of
25%. While patients with specific structural and genetic diseases are at higher
risk for type A aortic dissection (TAAD), prospective registries have found
that the majority of cases occur in patients without these known
predispositions, but with similar resultant mortality rates.1
Unfortunately patients with acute TAAD have highly variable clinical
presentations2,3,
leaving clinicians to rely on gestalt and the liberal use of advanced imaging
modalities, in particular high-dose computed tomography (CT) angiography,
magnetic resonance imaging (MRI) and transesophageal echocardiography (TEE),
all of which have reported sensitivities for TAAD around 98%.4 Given
the highly morbid consequences of misdiagnosis, very low (i.e. less than 2%)
testing thresholds are commonly promoted with correspondingly low diagnostic
yields.5,6
However, despite liberal screening recommendations, rates of initial
misdiagnosis range from 14 to 31%.7,8 As
such, TAADs represent a high-risk diagnostic clinical challenge.
Fortunately,
there are anatomic factors that may reliably identify at-risk patients and
direct more appropriate use of advanced imaging. Analysis of one single-center
(177 patients)9 and
one multicenter registry (591 patients)1 of
patients with acute TAAD revealed that only 5 to 10% of patients in these
studies had maximal ascending aorta (AscAo) diameters less than 4.0 cm. Conversely,
nearly all healthy men and women have maximal AscAo diameters less than 4.0 cm
(upper 95th percentiles between 3.8-4.2 cm and 3.4-3.9 cm,
respectively).10 Along
these lines, predictive models using age, gender and body surface area (BSA)
have been developed to further refine population norms for AscAo diameters.10-13 Using
normalized measures based on these models might significantly improve the
discriminative ability of an AscAo diameter to detect TAAD, as opposed to using
a single raw threshold diameter.
We
hypothesized that, among emergency department (ED) patients undergoing CT
angiography to rule-out TAAD, the use of AscAo measurements (as measured on
non-contrast CT images) would allow for excellent discrimination between patients
with and without TAAD, allowing for determination of a threshold with 100%
sensitivity for TAAD as well as clinically useful specificity. We additionally
hypothesized that normalization of these AscAo measurements for patient age,
gender and BSA would further improve predictive performance. Identification of
such thresholds might allow for accurate TAAD risk stratification using AscAo
measurements obtained by transthoracic echocardiography (TTE) or non-contrast
CT, the latter being relevant for patients with contraindications to intravenous
contrast or non-diagnostic CT angiography.
ABSTRACT
OBJECTIVE: To
determine if ascending aorta (AscAo) diameters measured by non-contrast
computed tomography (CT) allow for meaningful discrimination between patients
with and without type A aortic dissection (TAAD), ideally with 100%
sensitivity.
METHODS: Retrospective
analysis of cases of TAAD, as well as controls undergoing evaluation for TAAD
with CT aortography, presenting to 21 emergency departments within an
integrated health system between 2007 and 2015. AscAo diameters were determined
using axial non-contrast CT images at the level of the right main pulmonary
artery by two readers. AscAo diameters were additionally normalized for age,
sex and body surface area (assessed by a Z-score, which is the number of
standard deviations between the observed and expected AscAo diameters). Overall
model discrimination was assessed using the area under the receiver operating
characteristic curve (AUC). Comparative discrimination was assessed using both
the change in area under the receiver operating characteristic curve (∆AUC) and
the continuous net reclassification index (NRI).
RESULTS: 230
cases of TAAD and 325 controls were included in the study. The median age for
cases and controls was 65 and 62 years, and the median AscAo diameters were 50
mm and 35 mm, respectively. The raw and normalized AscAo diameters demonstrated
similarly excellent discrimination (AUCs of 0.96 versus 0.97, respectively,
∆AUC = 0.01, p = 0.09) and an NRI of 0.30 (95% CI 0.13-0.47), both indicating
small incremental improvements in classification with the use of the normalized
AscAo measures. A raw AscAo diameter of 34 mm and a normalized Z-score of 1.84
both yielded 100% sensitivity for TAAD, with respective specificities of 35%
(95% CI 29.6% - 40.2%) and 67% (95% CI 61.7% - 72.2%).
CONCLUSIONS: Nearly
all patients with TAAD appear to have enlarged AscAo diameters as measured by
non-contrast CT, whereas most patients with suspected but absent TAAD have
relatively normal AscAo diameters. Both raw and normalized AscAo measures
provided relatively comparable discriminatory value. If validated, these data
may be useful in adjudicating risk among patients with suspected TAAD in whom a
gold-standard test is unavailable, non-diagnostic or contraindicated.
10. Images in Clinical Practice
Mycoplasma pneumoniae–Associated Mucositis
Congenital Cytomegalovirus Infection
Tuberculosis of the Finger
Tuberculous Peritonitis
Glandular Tularemia
Black Hairy Tongue
Adolescent With Chest Pain and Dyspnea
Child With Autism and a Limp
Man With Sudden Lower Leg Numbness
Young Boy With Lateral Foot Pain
11. Infectious Disease
A. Five-Year Follow-up of Antibiotic
Therapy for Uncomplicated Acute Appendicitis in the APPAC RCT.
Saliminen P, et al. JAMA. 2018 Sep 25;320(12):1259-1265.
IMPORTANCE:
Short-term results support antibiotics as an alternative to surgery
for treating uncomplicated acute appendicitis, but long-term outcomes are not
known.
OBJECTIVE:
To determine the late recurrence rate of appendicitis after
antibiotic therapy for the treatment of uncomplicated acute appendicitis.
DESIGN, SETTING, AND PARTICIPANTS:
Five-year observational follow-up of patients in the
Appendicitis Acuta (APPAC) multicenter randomized clinical trial comparing
appendectomy with antibiotic therapy, in which 530 patients aged 18 to 60 years
with computed tomography-confirmed uncomplicated acute appendicitis were
randomized to undergo an appendectomy (n = 273) or receive antibiotic therapy
(n = 257). The initial trial was conducted from November 2009 to June 2012 in
Finland; last follow-up was September 6, 2017. This current analysis focused on
assessing the 5-year outcomes for the group of patients treated with
antibiotics alone.
INTERVENTIONS:
Open appendectomy vs antibiotic therapy with intravenous
ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole.
MAIN OUTCOMES AND MEASURES:
In this analysis, prespecified secondary end points reported
at 5-year follow-up included late (after 1 year) appendicitis recurrence after
antibiotic treatment, complications, length of hospital stay, and sick leave.
RESULTS:
Of the 530 patients (201 women; 329 men) enrolled in the
trial, 273 patients (median age, 35 years [IQR, 27-46]) were randomized to
undergo appendectomy, and 257 (median age, 33 years, [IQR, 26-47]) were
randomized to receive antibiotic therapy. In addition to 70 patients who
initially received antibiotics but underwent appendectomy within the first year
(27.3% [95% CI, 22.0%-33.2%]; 70/256), 30 additional antibiotic-treated
patients (16.1% [95% CI, 11.2%-22.2%]; 30/186) underwent appendectomy between 1
and 5 years. The cumulative incidence of appendicitis recurrence was 34.0% (95%
CI, 28.2%-40.1%; 87/256) at 2 years, 35.2% (95% CI, 29.3%-41.4%; 90/256) at 3
years, 37.1% (95% CI, 31.2%-43.3%; 95/256) at 4 years, and 39.1% (95% CI,
33.1%-45.3%; 100/256) at 5 years. Of the 85 patients in the antibiotic group
who subsequently underwent appendectomy for recurrent appendicitis, 76 had
uncomplicated appendicitis, 2 had complicated appendicitis, and 7 did not have
appendicitis. At 5 years, the overall complication rate (surgical site
infections, incisional hernias, abdominal pain, and obstructive symptoms) was
24.4% (95% CI, 19.2%-30.3%) (n = 60/246) in the appendectomy group and 6.5%
(95% CI, 3.8%-10.4%) (n = 16/246) in antibiotic group (P less than .001), which calculates
to 17.9 percentage points (95% CI, 11.7-24.1) higher after surgery. There was
no difference between groups for length of hospital stay, but there was a
significant difference in sick leave (11 days more for the appendectomy group).
CONCLUSIONS AND RELEVANCE:
Among patients who were initially treated with antibiotics
for uncomplicated acute appendicitis, the likelihood of late recurrence within
5 years was 39.1%. This long-term follow-up supports the feasibility of
antibiotic treatment alone as an alternative to surgery for uncomplicated acute
appendicitis.
B. Risk of Bacterial Coinfections in
Febrile Infants 60 Days Old and Younger with Documented Viral Infections.
Mahajan P, et al. J Pediatr. 2018 Sep 6 [Epub ahead of
print]
OBJECTIVE:
To determine the risk of serious bacterial infections (SBIs)
in young febrile infants with and without viral infections.
STUDY DESIGN:
Planned secondary analyses of a prospective observational
study of febrile infants 60 days of age or younger evaluated at 1 of 26
emergency departments who did not have clinical sepsis or an identifiable site
of bacterial infection. We compared patient demographics, clinical, and
laboratory findings, and prevalence of SBIs between virus-positive and
virus-negative infants.
RESULTS:
Of the 4778 enrolled infants, 2945 (61.6%) had viral testing
performed, of whom 1200 (48.1%) were virus positive; 44 of the 1200 had SBIs
(3.7%; 95% CI, 2.7%-4.9%). Of the 1745 virus-negative infants, 222 had SBIs
(12.7%; 95% CI, 11.2%-14.4%). Rates of specific SBIs in the virus-positive
group vs the virus-negative group were: UTIs (33 of 1200 [2.8%; 95% CI,
1.9%-3.8%] vs 186 of 1745 [10.7%; 95% CI, 9.2%-12.2%]) and bacteremia (9 of
1199 [0.8%; 95% CI, 0.3%-1.4%] vs 50 of 1743 [2.9%; 95% CI, 2.1%-3.8%]). The
rate of bacterial meningitis tended to be lower in the virus-positive group
(0.4%) than in the viral-negative group (0.8%); the difference was not
statistically significant. Negative viral status (aOR, 3.2; 95% CI, 2.3-4.6),
was significantly associated with SBI in multivariable analysis.
CONCLUSIONS:
Febrile infants ≤60 days of age with viral infections are at
significantly lower, but non-negligible risk for SBIs, including bacteremia and
bacterial meningitis.
C. Pip/Tazo combo raises death risk in
patients with tough-to-treat infections
A study published in the Journal of the American Medical
Association indicated that the two-drug combo of piperacillin and tazobactam,
used to treat bloodstream infections induced by ceftriaxone-resistant
Escherichia coli or Klebsiella pneumoniae, could not be proved noninferior to
the broad-spectrum antibiotic meropenem. Study findings showed that all-cause
mortality rates at 30 days were 12.3% for those in the piperacillin/tazobactam
group versus 3.7% in the meropenem group, with researchers concluding that use
of the combo as a substitute for treating these infections should not be
considered.
12. Can Mobile Integrated Health Care Paramedics Safely Conduct
Medical Clearance of Behavioral Health Patients in a Pilot Project? A Report of
the First 1000 Consecutive Encounters.
Mackey KE, Qiu C. Prehosp Emerg Care. 2018 Aug 23 [Epub
ahead of print]
BACKGROUND:
Mental health patients wait lengthy periods in emergency
departments for disposition. This delay is secondary to the process of medical
clearance and then placement in an appropriate psychiatric specialty center.
ACEP clinical policy questions the necessity of laboratory investigation for
medical clearance and favors history and physical exam to determine safe
disposition to mental health facilities. This manuscript explores if specially
trained paramedics can effectively employ triage algorithms to determine proper
disposition of patients suffering an acute mental health crisis in a 9-1-1
system.
METHODS:
Six paramedics working for AMR in Stanislaus County,
California underwent 180 hours of specialized training to become Mobile
Integrated Healthcare Paramedics (MIHPs). Their training detailed the use of
two algorithms designed to identify patients that require evaluation in an
emergency department versus those that can be triaged directly to a licensed
mental health facility. Patients aged 18-59 with a suspected mental health
crisis who are encountered via the 9-1-1 system, law enforcement or who walk in
to the mental health facility for treatment were eligible. All patients in the
study were evaluated with the well person algorithm (WPA). Those that passed
the WPA were evaluated using the mental health clearance algorithm (MCHA).
MIHPs directed patients to either the ED or the mental health facility based
upon the evaluation results of the WPA and MHCA.
RESULTS:
1006 patients were evaluated between September 2015 and
December 2017. 404 patients failed one or more components of the WPA or MHCA.
326 patients passed both the WPA and the MHCA, but were ultimately transported
to a local emergency department, most often because of lack of available
psychiatric beds in the community. 276 patients were transported directly to a
psychiatric facility. Of these, 10 returned to the emergency department within
6 hours, but none of the 10 were admitted for a previously unidentified medical
or traumatic condition.
CONCLUSION:
Specially trained paramedics can effectively employ triage
algorithms to screen and select patients experiencing an acute mental health
crisis for transport directly to psychiatric treatment facilities.
13. A Multicenter Program to Implement the Canadian C-Spine Rule
by ED Triage Nurses
Stiell IG, et al. Ann Emerg Med 2018;72(4):333-341.
Study objective
The Canadian C-Spine Rule has been widely applied by
emergency physicians to safely reduce use of cervical spine imaging. Our
objective is to evaluate the clinical effect and safety of real-time Canadian
C-Spine Rule implementation by emergency department (ED) triage nurses to
remove cervical spine immobilization.
Methods
We conducted this multicenter, 2-phase, prospective cohort
program at 9 hospital EDs and included alert trauma patients presenting with
neck pain or with cervical spine immobilization. During phase 1, ED nurses were
trained and then had to demonstrate competence before being certified. During
phase 2, certified nurses were empowered by a medical directive to “clear” the
cervical spine of patients, allowing them to remove cervical spine
immobilization and to triage to a less acute area. The primary outcomes were
clinical effect (cervical spine clearance by nurses) and safety (missed
clinically important cervical spine injuries).
Results
In phase 1, 312 nurses evaluated 3,098 patients. In phase 2,
180 certified nurses enrolled 1,408 patients (mean age 43.1 years, women 52.3%,
collision 56.5%, and cervical spine injury 1.1%). In phase 2 and for the 806
immobilized ambulance patients, the primary outcome of immobilization removal
by nurses was 41.1% compared with 0% before the program. The primary safety outcome
of cervical spine injuries missed by nurses was 0. Time to discharge was
reduced by 26.0% (3.4 versus 4.6 hours) for patients who had immobilization
removed. In only 1.3% of cases did nurses indicate their discomfort with
applying the Canadian C-Spine Rule.
Conclusion
We clearly demonstrated that ED triage nurses can
successfully implement the Canadian C-Spine Rule, leading to more rapid and
comfortable management of patients without any threat to patient safety.
Widespread adoption of this approach should improve care and comfort for trauma
patients, and could decrease length of stay in our very crowded EDs.
14. Thrombophilia Testing and Venous Thrombosis
Connors JM. N Engl J Med 2017;377:1177-1187.
Summary: “Most patients with venous thromboembolism do not
require thrombophilia testing, since the results will not affect management.
Testing may be considered in younger patients with weak provoking factors, a
strong family history, or recurrence at a young age.”
Ordering thrombophilia tests is easy; determining whom to test
and how to use the results is not. Although inherited and acquired thrombophilias
are acknowledged to increase the risk of venous thromboembolism (VTE), the
majority of patients with VTE should not be tested for thrombophilia.
Data showing the clinical usefulness and benefits of testing
are limited or nonexistent, as are data supporting the benefit of primary or
secondary VTE prophylaxis based on thrombophilia status alone. Testing for
inherited thrombophilia is controversial, with some arguing that these tests
should never be performed.
No validated testing guidelines have been published. The
American College of Chest Physicians does not give guidance on thrombophilia
testing in its ninth edition of clinical practice guidelines for antithrombotic
therapy or its 2016 VTE update,1,2 whereas the American Society of Hematology’s
2013 Choosing Wisely campaign recommends not testing for thrombophilia in
adults with VTE who have major transient risk factors.3 According to the most
comprehensive guide, Clinical Guidelines for Testing for Heritable
Thrombophilia, published by the British Committee for Standards in Haematology,
“It is not possible to give a validated recommendation as to how such patients
(and families) should be selected” for testing.4 Although similar guidelines
advise limiting testing to a narrow range of specific clinical situations and
patients, the recommendations are not uniform.5-9 These recommendations have
been developed in response to indiscriminate testing practices and
misconceptions regarding the role of thrombophilia status in the management of
VTE.
Patients with inherited thrombophilia can often be
identified by coagulation experts on the basis of the patient’s personal and
family history of VTE, even without knowledge of test results…
Full-text (subscription required): https://www.nejm.org/doi/full/10.1056/NEJMra1700365
15. Low-dose Ketamine for Pain Reduction
A. Slow Infusion of Low-dose Ketamine
Reduces Bothersome Side Effects Compared to Intravenous Push: A Double-blind,
Double-dummy, Randomized Controlled Trial.
Clattenburg EJ, et al. Acad Emerg Med. 2018 Sep;25(9):1048-1052.
OBJECTIVE:
We compared the analgesic efficacy and incidence of side
effects when low-dose (0.3 mg/kg) ketamine (LDK) is administered as a slow
infusion (SI) over 15 minutes versus an intravenous push (IVP) over 1 minute.
METHODS:
This was a prospective, randomized, double-blind,
double-dummy, placebo-controlled trial of adult ED patients presenting with
moderate to severe pain (numerical rating scale [NRS] score ≥ 5). Patients
received 0.3 mg/kg ketamine administered either as a SI or a IVP. Our primary
outcome was the proportion of patients experiencing any psychoperceptual side
effect over 60 minutes. A secondary outcome was incidence of moderate or
greater psychoperceptual side effects. Additional outcomes included reduction
in pain NRS scores at 60 minutes and percent maximum summed pain intensity
difference (%SPID).
RESULTS:
Fifty-nine participants completed the study. A total of
86.2% of the IVP arm and 70.0% of the SI arm experienced any side effect
(difference = 16.2%, 95% confidence interval [CI] = -5.4 to 37.8). We found a
large reduction in moderate or greater psychoperceptual side effects with SI
administration-75.9% reported moderate or greater side effects versus 43.4% in
the SI arm (difference = 32.5%, 95% CI = 7.9 to 57.1). Additionally, the IVP
arm experienced more hallucinations (n = 8, 27.6%) than the SI arm (SI n = 2,
6.7%, difference = 20.9%, 95% CI = 1.8 to 43.4). We found no significant
differences in analgesic efficacy. At 60 minutes, the mean %SPID values in the
IVP and SI arms were 39.9 and 33.5%, respectively, with a difference of 6.5% (95%
CI = -5.8 to 18.7).
CONCLUSION:
Most patients who are administered LDK experience a
psychoperceptual side effect regardless of administration via SI or IVP.
However, patients receiving LDK as a SI reported significantly fewer moderate
or greater psychoperceptual side effects and hallucinations with equivalent
analgesia.
B. Continuous Intravenous
Sub-Dissociative Dose Ketamine Infusion for Managing Pain in the ED
Motov S, et al. West J Emerg Med. 2018;19(3):559-566.
INTRODUCTION:
Our objective was to describe dosing, duration, and pre- and
post-infusion analgesic administration of continuous intravenous
sub-dissociative dose ketamine (SDK) infusion for managing a variety of painful
conditions in the emergency department (ED).
METHODS:
We conducted a retrospective chart review of patients aged
18 and older presenting to the ED with acute and chronic painful conditions who
received continuous SDK infusion in the ED for a period over six years
(2010-2016). Primary data analyses included dosing and duration of infusion,
rates of pre- and post-infusion analgesic administration, and final diagnoses.
Secondary data included pre- and post-infusion pain scores and rates of side
effects.
RESULTS:
A total of 104 patients were enrolled in the study. Average
dosing of SDK infusion was 11.26 mg/hr, and the mean duration of infusion was
135.87 minutes. There was a 38% increase in patients not requiring
post-infusion analgesia. The average decrease in pain score was 5.04. There
were 12 reported adverse effects, with nausea being the most prevalent.
CONCLUSION:
Continuous intravenous SDK infusion has a role in
controlling pain of various etiologies in the ED with a potential to reduce the
need for co-analgesics or rescue analgesic administration. There is a need for
more robust, prospective, randomized trials that will further evaluate the
analgesic efficacy and safety of this modality across a wide range of pain
syndromes and different age groups in the ED.
16. The Search for Satisfaction Often Lies Beyond the ED
Combating
the grind of the daily shift can be overcome by branching out
By MICHAEL SILVERMAN, MD, Emergency Physicians Monthly. Aug 24,
2018
Dear Director,
I’m an experienced emergency physician but I’m looking for
more than just seeing patients. What
ideas do you have for me?
I think the first few years after residency are about
learning and mastering your craft as a physician, and enjoying the new free
time and financial freedom you have as an attending. At some point in a physician’s career, I
advise them to diversify a little and look for something outside of just
clinical shifts. We generally all went to residency with a passion for
emergency medicine, and throughout residency, we developed areas of interest
that we focused on.
However, over the years, the daily grind of shift world
combined with increasing family responsibilities can erode at this passion and
leave us just doing the shifts and wondering what else is out there. Being a
full-time clinician can be very fulfilling, but many people look to a little
diversity to help prevent burnout. As we look to diversify your career a touch,
ideally you can bring your expertise to an area of medicine you’re passionate
about.
In
the hospital
I got into administration because I wanted to help more than
one patient at a time. But the personal benefit to me as a medical director is
that I’ve really enjoyed getting to know the docs from different specialties
throughout the hospital. I’ve done this
by working side by side with them on committees, as we worked through clinical
issues, and by just spending time in the doctor’s lounge. Even as an attending physician, given your
training and skill set, there are numerous committees and projects throughout
the hospital that could benefit from your experience and expertise…
Out of the Hospital
There are numerous opportunities outside of your hospital where
you can apply your experience. These range from volunteering with your
professional organization to high hourly compensation for legal reviews.
I’ve been involved with my state chapter of ACEP on and off
for over 20 years. I’ve really enjoyed the people I’ve met and the
networking it’s allowed me. It’s also been a great opportunity to represent my
colleagues. State chapters usually work to improve patient care
throughout your state via advocacy and representing you to your state
government. Most state chapters also provide some educational benefits to
the members. Malpractice and balanced billing are popular topics for us,
but I’ve also seen colleagues become experts and then testify before lawmakers
on the impact of psychiatric boarders and issues involving pediatric emergency
medicine in the community hospital. Some of these opportunities will pique your
interest and remind you why you went into EM. There is a huge need for docs to
advocate for our specialty and our patients at the local, state and federal
levels….
17. Poor Accuracy of Height (of Fall) Estimation Among
Bystanders.
Carey S, et al. West J Emerg Med. 2018 Sep;19(5):813-819.
INTRODUCTION:
High-risk mechanisms in trauma usually dictate certain
treatment and evaluation in protocolized care. A 10-15 feet (ft) fall is
traditionally cited as an example of a high-risk mechanism, triggering trauma
team activations and costly work-ups. The height and other details of mechanism
are usually reported by lay bystanders or prehospital personnel. This small
observational study was designed to evaluate how accurate or inaccurate height
estimation may be among typical bystanders.
METHODS:
This was a blinded, prospective study conducted on the
grounds of a community hospital. Four panels with lines corresponding to
varying heights from 1-25 ft were hung within a building structure that did not
have stories or other possibly confounding factors by which to judge height.
The participants were asked to estimate the height of each line using a
multiple-choice survey-style ballot. Participants were adult volunteers
composed of various hospital and non-hospital affiliated persons, of varying
ages and genders. In total, there were 96 respondents.
RESULTS:
For heights equal to or greater than 15 ft, less than 50% of
participants of each job description were able to correctly identify the
height. When arranged into a scatter plot, as height increased, the likelihood
to underestimate the correct height was evident, having a strong correlation
coefficient (R=+0.926) with a statistically significant p value = less than 0.001.
CONCLUSION:
The use of vertical height as a predictor of injury severity
is part of current practice in trauma triage. This data is often an estimation
provided by prehospital personnel or bystanders. Our small study showed
bystanders may not estimate heights accurately in the field. The greater the
reported height, the less likely it is to be accurate. Additionally, there is a
higher likelihood that falls from greater than 15 ft may be underestimated.
18. How events in emergency medicine impact doctors'
psychological well-being.
Howard L, et al. Emerg Med J. 2018 Oct;35(10):595-599.
Background Emergency medicine is a high-pressured specialty
with exposure to disturbing events and risk. We conducted a qualitative study
to identify which clinical events resulted in emotional disruption and the
impact of these events on the well-being of physicians working in an ED.
Methods We used the principles of naturalistic inquiry to
conduct narrative interviews with physicians working in the ED at Central
Manchester University Hospitals NHS Foundation Trust, between September and
October 2016. Participants were asked, ‘Could you tell me about a time when an
event at work has continued to play on your mind after the shift in which it
occurred was over?’ Data were analysed using framework analysis. The study had
three a priori themes reported here. Other emergent themes were analysed
separately.
Results We interviewed 17 participants. Within the first a
priori theme (‘clinical events’) factors associated with emotional disruption
included young or traumatic deaths, patients or situations that physicians
could relate to, witnessing the impact of death on relatives, the burden of
responsibility (including medical error) and conflict in the workplace. Under
theme 2 (psychological and physical effects), participants reported substantial
upset leading to substance misuse, sleep disruption and neglecting their own
physical needs through preoccupation with caring. Within theme 3 (impact on
relationships), many interviewees described becoming withdrawn from personal
relationships following clinical events, while others described feeling
isolated because friends and family were non-medical.
Conclusions Clinical events encountered in the ED can affect
a physician’s psychological and physical well-being. For many participants
these effects were negative and long lasting.
19. IM Midazolam, Olanzapine, Ziprasidone, or Haloperidol for
Treating Acute Agitation in the ED
Klein L, et al. Ann Emerg Med 2018;72(4):374-85.
Study objective
Agitation in the emergency department (ED) can pose a threat
to patient and provider safety; therefore, treatment is indicated. The purpose
of this study is to compare haloperidol, olanzapine, midazolam, and ziprasidone
to treat agitation.
Methods
This was a prospective observational study of consecutive
patients receiving intramuscular medication to treat agitation in the ED.
Medications were administered according to an a priori protocol in which the
initial medication given was predetermined in the following 3-week blocks:
haloperidol 5 mg, ziprasidone 20 mg, olanzapine 10 mg, midazolam 5 mg, and
haloperidol 10 mg. The primary outcome was the proportion of patients
adequately sedated at 15 minutes, assessed with the Altered Mental Status
Scale.
Results
Seven hundred thirty-seven patients were enrolled (median
age 40 years; 72% men). At 15 minutes, midazolam resulted in a greater
proportion of patients adequately sedated (Altered Mental Status Scale less than 1) compared with
ziprasidone (difference 18%; 95% confidence interval [CI] 6% to 29%),
haloperidol 5 mg (difference 30%; 95% CI 19% to 41%), haloperidol 10 mg
(difference 28%; 95% CI 17% to 39%), and olanzapine (difference 9%; 95% CI –1%
to 20%). Olanzapine resulted in a greater proportion of patients adequately
sedated at 15 minutes compared with haloperidol 5 mg (difference 20%; 95% CI
10% to 31%), haloperidol 10 mg (difference 18%; 95% CI 7% to 29%), and
ziprasidone (difference 8%; 95% CI –3% to 19%). Adverse events were uncommon:
cardiac arrest (0), extrapyramidal adverse effects (2; 0.3%), hypotension (5;
0.5%), hypoxemia (10; 1%), and intubation (4; 0.5%), and occurred at similar
rates in each group.
Conclusion
Intramuscular midazolam achieved more effective sedation in
agitated ED patients at 15 minutes than haloperidol, ziprasidone, and perhaps
olanzapine. Olanzapine provided more effective sedation than haloperidol. No
differences in adverse events were identified.
20. Association Between Physical Therapy in the ED and ED
Revisits for Older Adult Fallers: A Nationally Representative Analysis
Lesser A, et al. J Am Geriatr Soc. 2018 Aug 21 [Epub ahead of print]
OBJECTIVES:
To determine whether providing physical therapy (PT)
services in the emergency department (ED) improves outcomes for older adults
who fall.
DESIGN:
We used Medicare claims data to examine differences in
recurrent fall-related ED revisit rates of older adults who presented to the ED
for a ground-level fall and whether they received PT services in the ED. Our
logistic regression model controlled for age, sex, Medicaid eligibility, acute
injury, and certain known chronic comorbidities associated with risk of
falling.
SETTING:
We analyzed national 2012-13 Medicare claims data for
individuals aged 65 and older.
PARTICIPANTS:
This was a claims-based analysis. We defined an index visit
as any ED claim that included an International Classification of Diseases,
Ninth Revision, Clinical Modification E-Code indicating a ground-level fall.
Visits resulting in admission were excluded, as were claims associated with an
individual who died during follow-up; 17,975 of the 560,277 claims for eligible
outpatient index visits included revenue center codes for PT services.
MEASUREMENTS:
We calculated the proportion of index visits associated with
a fall-related ED revisit within 30 and 60 days and assessed differences in
these proportions between individuals who did and did not receive PT services
in the ED.
RESULTS:
Receiving PT services in the ED during an index visit for a
ground-level fall was associated with a significantly lower likelihood of a
fall-related ED revisit within 30 days (odds ratio (OR)=0.655, p less than .001) and 60 days
(OR=0.684, p less than .001).
CONCLUSION:
Expanding PT services in the ED may reduce future fall-related
ED use of older adults. Additional analyses could assess characteristics of
individuals receiving PT in the ED and follow-up PT use after discharge.
21. LVADs in Emergency Medicine
A. Left Ventricular Assist Device
Management in the ED
Trinquero P, et al. West J Emerg Med. 2018
Sep;19(5):834-841.
The prevalence of patients living with a left ventricular
assist device (LVAD) is rapidly increasing due to improvements in pump
technology, limiting the adverse event profile, and to expanding device
indications. To date, over 22,000 patients have been implanted with LVADs
either as destination therapy or as a bridge to transplant. It is critical for
emergency physicians to be knowledgeable of current ventricular assist devices
(VAD), and to be able to troubleshoot associated complications and optimally
treat patients with emergent pathology. Special consideration must be taken
when managing patients with VADs including device inspection, alarm
interpretation, and blood pressure measurement. The emergency physician should
be prepared to evaluate these patients for cerebral vascular accidents, gastrointestinal
bleeds, pump failure or thrombosis, right ventricular failure, and VAD
driveline infections. Early communication with the VAD team and appropriate
consultants is essential for emergent care for patients with VADs.
B. Analysis of Patients with
Ventricular Assist Devices Presenting to an Urban ED
McKillip RP, et al. West J Emerg Med 2018 Sept 10 [Epub
ahead of print]
Introduction: Left ventricular assist device (LVAD)
insertion is an increasingly common intervention for patients with advanced
heart failure; however, published literature on the emergency department (ED)
presentation of this population is limited. The objective of this study was to
characterize ED presentations of patients with LVADs with a focus on
device-specific complications to inform provider education and preparation
initiatives.
Methods: This was a retrospective chart review of all
patients with LVADs followed at an urban academic medical center presenting to
the ED over a five-year period (July 1, 2009, to June 30, 2014). Two
abstractors reviewed 45 randomly selected charts to standardize the abstraction
process and establish a priori categories for reason for presentation to the
ED. Remaining charts were then divided evenly for review by one of the two
abstractors. Primary outcomes for this study were (1) frequency of and (2)
reason for presentation to the ED by patients with LVADs.
Results: Of 349 patients with LVADs identified, 143 (41.0%)
had ED encounters during the study period. There were 620 total ED encounters,
(range 1 to 32 encounters per patient, median=3, standard deviation=5.3). Among
the encounters, 431 (69.5%) resulted in admission. The most common reasons for
presentation were bleeding (e.g., gastrointestinal, epistaxis) (182, 29.4%);
infection (127, 20.5%); heart failure exacerbation (68, 11.0%); pain (56,
9.0%); other (45, 7.3%); and arrhythmias (40, 6.5%). Fifty-two encounters
(8.4%) were device-specific; these patients frequently presented with abnormal
device readings (37, 6.0%). Interventions for device-specific presentations
included anticoagulation regimen adjustment (16/52, 30.8%), pump exchange (9,
17.3%), and hardware repair (6, 11.5%). Pump thrombosis occurred in 23 cases
(3.7% of all encounters). No patients required cardiopulmonary resuscitation or
died in the ED.
Conclusion: This is the largest study known to the
investigators to report the rate of ED presentations of patients with LVADs and
provide analysis of device-specific presentations. In patients who do have
device-specific ED presentations, pump thrombosis is a common diagnosis and can
present without device alarms. Specialized LVAD education and preparation
initiatives for ED providers should emphasize the recognition and management of
the most common and critical conditions for this patient population, which have
been identified in this study as bleeding, infection, heart failure, and pump thrombosis.
22. Comparison of the Safety Planning Intervention with
Follow-up vs Usual Care of Suicidal Patients Treated in the ED.
Stanley B, et al. JAMA Psychiatry. 2018 Sep 1;75(9):894-900.
A
simple suicide intervention that worked
IMPORTANCE:
Suicidal behavior is a major public health problem in the
United States. The suicide rate has steadily increased over the past 2 decades;
middle-aged men and military veterans are at particularly high risk. There is a
dearth of empirically supported brief intervention strategies to address this
problem in health care settings generally and particularly in emergency
departments (EDs), where many suicidal patients present for care.
OBJECTIVE:
To determine whether the Safety Planning Intervention (SPI),
administered in EDs with follow-up contact for suicidal patients, was
associated with reduced suicidal behavior and improved outpatient treatment
engagement in the 6 months following discharge, an established high-risk
period.
DESIGN, SETTING, AND PARTICIPANTS:
Cohort comparison design with 6-month follow-up at 9 EDs (5
intervention sites and 4 control sites) in Veterans Health Administration
hospital EDs. Patients were eligible for the study if they were 18 years or
older, had an ED visit for a suicide-related concern, had inpatient
hospitalization not clinically indicated, and were able to read English. Data
were collected between 2010 and 2015; data were analyzed between 2016 and 2018.
INTERVENTIONS:
The intervention combines SPI and telephone follow-up. The
SPI was defined as a brief clinical intervention that combined evidence-based
strategies to reduce suicidal behavior through a prioritized list of coping
skills and strategies. In telephone follow-up, patients were contacted at least
2 times to monitor suicide risk, review and revise the SPI, and support
treatment engagement.
MAIN OUTCOMES AND MEASURES:
Suicidal behavior and behavioral health outpatient services
extracted from medical records for 6 months following ED discharge.
RESULTS:
Of the 1640 total patients, 1186 were in the intervention
group and 454 were in the comparison group. Patients in the intervention group
had a mean (SD) age of 47.15 (14.89) years and 88.5% were men (n = 1050);
patients in the comparison group had a mean (SD) age of 49.38 (14.47) years and
88.1% were men (n = 400). Patients in the SPI+ condition were less likely to
engage in suicidal behavior (n = 36 of 1186; 3.03%) than those receiving usual
care (n = 24 of 454; 5.29%) during the 6-month follow-up period. The SPI+ was
associated with 45% fewer suicidal behaviors, approximately halving the odds of
suicidal behavior over 6 months (odds ratio, 0.56; 95% CI, 0.33-0.95, P = .03).
Intervention patients had more than double the odds of attending at least 1
outpatient mental health visit (odds ratio, 2.06; 95% CI, 1.57-2.71; P less than .001).
CONCLUSIONS AND RELEVANCE:
This large-scale cohort comparison study found that SPI+ was
associated with a reduction in suicidal behavior and increased treatment
engagement among suicidal patients following ED discharge and may be a valuable
clinical tool in health care settings.
23. CT for Minor Head Injury in Kids and Adults
A. Effect of the Head CT Choice
Decision Aid in Parents of Children with Minor Head Trauma: A Cluster
Randomized Trial
Hess EP, et al. JAMA Network Open. 2018;1(5):e182430.
Key Points
Question What is the
effect of a decision aid in parents of children with minor head trauma?
Findings In this
cluster randomized trial of 172 clinicians caring for 971 children at
intermediate risk of traumatic brain injury, the Head Computed Tomography
Choice decision aid increased parental knowledge, decreased decisional
conflict, and increased engagement. The intervention did not reduce the
emergency department computed tomography rate but safely decreased 7-day health
care utilization.
Meaning Use of a
decision aid in parents of children with minor head trauma had no effect on the
emergency department computed tomography rate, but improved decisional quality
and safely decreased downstream health care utilization.
Abstract
Importance The
Pediatric Emergency Care Applied Research Network prediction rules for minor
head trauma identify children at very low, intermediate, and high risk of
clinically important traumatic brain injuries (ciTBIs) and recommend no
computed tomography (CT) for those at very low risk. However, the prediction
rules provide little guidance in the choice of home observation or CT in
children at intermediate risk for ciTBI.
Objective To compare
a decision aid with usual care in parents of children at intermediate risk for
ciTBI.
Design, Settings, and Participants This cluster randomized trial was conducted
in 7 geographically diverse US emergency departments (EDs) from April 1, 2014,
to September 30, 2016. Eligible participants were emergency clinicians,
children ages 2 to 18 years with minor head trauma at intermediate risk for
ciTBI, and their parents.
Interventions Clinicians were randomly assigned (1:1 ratio)
to shared decision-making facilitated by the Head CT Choice decision aid or to
usual care.
Main Outcomes and Measures
The primary outcome, selected by parent stakeholders, was knowledge of
their child’s risk for ciTBI and the available diagnostic options. Secondary
outcomes included decisional conflict, parental involvement in decision-making,
the ED CT rate, 7-day health care utilization, and missed ciTBI.
Results A total of
172 clinicians caring for 971 children (493 decision aid; 478 usual care) with
minor head trauma at intermediate risk for ciTBI were enrolled. The patient
mean (SD) age was 6.7 (7.1) years, 575 (59%) were male, and 253 (26%) were of
nonwhite race. Parents in the decision aid arm compared with the usual care arm
had greater knowledge (mean [SD] questions correct: 6.2 [2.0] vs 5.3 [2.0];
mean difference, 0.9; 95% CI, 0.6-1.3), had less decisional conflict (mean [SD]
decisional conflict score, 14.8 [15.5] vs 19.2 [16.6]; mean difference, −4.4;
95% CI, −7.3 to −2.4), and were more involved in CT decision-making (observing
patient involvement [OPTION] scores: mean [SD], 25.0 [8.5] vs 13.3 [6.5]; mean
difference, 11.7; 95% CI, 9.6-13.9). Although the ED CT rate did not
significantly differ (decision aid, 22% vs usual care, 24%; odds ratio, 0.81;
95% CI, 0.51-1.27), the mean number of imaging tests was lower in the decision
aid arm 7 days after injury. No child had a missed ciTBI.
Conclusions and Relevance
Use of a decision aid in parents of children at intermediate risk of
ciTBI increased parent knowledge, decreased decisional conflict, and increased
involvement in decision-making. The intervention did not significantly reduce
the ED CT rate but safely decreased health care utilization 7 days after
injury.
Full-text (free): https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2703135
B. External validation of CT decision
rules for minor head injury: prospective, multicentre cohort study in the
Netherlands
Foks KA, et al. BMJ 2018;362:k3527
OBJECTIVE:
To externally validate four commonly used rules in computed
tomography (CT) for minor head injury.
DESIGN:
Prospective, multicentre cohort study.
SETTING:
Three university and six non-university hospitals in the
Netherlands.
PARTICIPANTS:
Consecutive adult patients aged 16 years and over who
presented with minor head injury at the emergency department with a Glasgow
coma scale score of 13-15 between March 2015 and December 2016.
MAIN OUTCOME MEASURES:
The primary outcome was any intracranial traumatic finding
on CT; the secondary outcome was a potential neurosurgical lesion on CT, which
was defined as an intracranial traumatic finding on CT that could lead to a
neurosurgical intervention or death. The sensitivity, specificity, and clinical
usefulness (defined as net proportional benefit, a weighted sum of true
positive classifications) of the four CT decision rules. The rules included the
CT in head injury patients (CHIP) rule, New Orleans criteria (NOC), Canadian CT
head rule (CCHR), and National Institute for Health and Care Excellence (NICE)
guideline for head injury.
RESULTS:
For the primary analysis, only six centres that included
patients with and without CT were selected. Of 4557 eligible patients who
presented with minor head injury, 3742 (82%) received a CT scan; 384 (8%) had a
intracranial traumatic finding on CT, and 74 (2%) had a potential neurosurgical
lesion. The sensitivity for any intracranial traumatic finding on CT ranged
from 73% (NICE) to 99% (NOC); specificity ranged from 4% (NOC) to 61% (NICE).
Sensitivity for a potential neurosurgical lesion ranged between 85% (NICE) and
100% (NOC); specificity from 4% (NOC) to 59% (NICE). Clinical usefulness
depended on thresholds for performing CT scanning: the NOC rule was preferable
at a low threshold, the NICE rule was preferable at a higher threshold, whereas
the CHIP rule was preferable for an intermediate threshold.
CONCLUSIONS:
Application of the CHIP, NOC, CCHR, or NICE decision rules
can lead to a wide variation in CT scanning among patients with minor head
injury, resulting in many unnecessary CT scans and some missed intracranial
traumatic findings. Until an existing decision rule has been updated, any of
the four rules can be used for patients presenting minor head injuries at the
emergency department. Use of the CHIP rule is recommended because it leads to a
substantial reduction in CT scans while missing few potential neurosurgical
lesions.
Related: Around One
In Six American Adults Have Been Knocked Unconscious By Head Injury: NEJM: https://www.nejm.org/doi/full/10.1056/NEJMc1808550
Related: Concussion
Rate Plummets In Ivy League Football After Kickoff Change:
24. Micro Bits
A.
Psychological distress may increase odds of heart trouble
UK and Australian researchers found that women ages 45 and
older with high or very high levels of psychological distress were 44% more
likely to have a stroke and 18% more likely to have a heart attack, compared
with those with low levels of psychological distress. The findings in
Circulation: Cardiovascular Quality and Outcomes also showed a 30% increased
likelihood of heart attack among men ages 45 to 79 with high or very high
psychological distress, but the association was weaker among those ages 80 and
older.
B.
Study Shows Physicians, Nurses How They Talk to Each Other
Authors See Broad Utility in Model of Recording Medical
Setting Interactions
C.
Conflicting Beliefs Shouldn't Hinder Patient Care
Kim came to my office for a followup regarding hormone
replacement therapy, but when I asked how she was tolerating the medication,
Kim -- a transgender female -- said she had been unable to fill her
prescription. A pharmacist told her he could not do so, but did not explain why
and did not refer her elsewhere.
Kim's story sounded familiar because there have been other,
high-profile stories of patients being refused prescribed medications this
summer.
Essay in AAFP Leaders Blog: https://www.aafp.org/news/blogs/leadervoices/entry/20180828lv-pharmrefusal.html
D.
Interventions to improve patient flow in ED: an umbrella review
Conclusions Overall, the evidence supporting the
interventions to improve patient flow is weak. Only the fast track intervention
had moderate evidence to support its use but correlation/clustering was not
taken into consideration in the RCTs examining the intervention. Failure to
consider the correlation of the data in the primary studies could result in
erroneous conclusions of effectiveness.
E.
Survey Finds One in Three U.S. Teens Texts While Driving
Scary!
F.
My mother was in unbearable pain, but the ER staff didn’t seem to believe her
…Furthermore, pain experienced by women is often treated
differently than that of men. Studies have shown that in men and women
reporting similar levels of pain, women were less likely to receive any pain
medication and less likely to receive opiate medications. In addition, women
waited longer to receive such medications. Similarly, women are nearly twice as
likely as men to receive an “emotional or mental diagnosis” compared with one
for a physical ailment when showing the same symptoms.
Yet pain does not discriminate. Pain makes you vulnerable.
Pain is the great equalizer.
G.
Teens Who Get Too Little Sleep May Be More Likely To Engage In Risky Behaviors,
Study Indicates.
H.
Semi-Automatic Rifles Make Active Shooters More Deadly, Research Indicates.
Researchers have found that “active shooters with
semi-automatic rifles wound and kill twice as many people as those using
non-automatic weapons.”
I.
Aspirin Not so Hot for Primary Prevention of Cardiovascular Events
Allan S. Brett, MD. Journal Watch. September 6, 2018
Two new studies push the pendulum away from aspirin
prophylaxis.
…In sum, among nondiabetic patients with CV risk factors,
aspirin conferred no benefit and was associated with slight harm. Among
diabetic patients, the tradeoff between small probabilities of benefit and harm
was a close call. Notably, a large proportion of patients in both studies were
taking statins and antihypertensive drugs, and only a small proportion were
current smokers. Thus, one could reasonably conclude that these studies
examined the incremental benefit of aspirin, added to other standard preventive
interventions.
Full-text (free): https://www.jwatch.org/na47468/2018/09/06/aspirin-primary-prevention-cardiovascular-events
J.
USPSTF Recommends Intensive Behavioral Intervention for Obesity
K.
E-cigarette use increases MI risk
A study in the American Journal of Preventive Medicine found
daily e-cigarette use may nearly double the risk for myocardial infarction, and
using both e-cigarettes and conventional cigarettes daily increased the risk
fivefold. Senior author Stanton Glantz said patients should be reminded that
e-cigarettes do not actually help with smoking cessation, although they are
promoted as smoking cessation devices.
L.
Southern Diet Called Single Biggest Factor in HTN Racial Disparities: Higher
incidence among blacks also associated with other social, clinical factors
M.
Updated car seat guidance
The American Academy of Pediatrics' updated policy on
childhood passenger safety recommends basing car safety seat usage on height
and weight instead of largely on age. Family physicians should be aware of
these recommendations and discuss auto safety with parents and caregivers.
N.
WHO: One in 20 deaths globally related to alcohol use
The World Health Organization found more than 1 in 20 deaths
globally in 2016 was related to alcohol, with 28% due to traffic accidents,
self-harm, violence and other injuries. The report found more than 75% of the
deaths were among men.
O.
Irregular bedtimes increase health risks, study says
An analysis of sleeping patterns for almost 2,000 adults
found those who had irregular bedtimes had higher body mass index and blood
pressure, as well as higher levels of blood sugar and HbA1C, compared with
those who had more regular sleeping patterns, according to a study published in
Scientific Reports. People with irregular sleep patterns also had a higher risk
of heart attack, stroke, depression and stress.
P.
Patient-Identified Needs Related to Seeking a Diagnosis in the ED
Q.
Medical Expulsive Therapy No Longer Recommended for Ureterolithiasis
Radecki in ACEP Now. Aug 29, 2018
R.
ADHD May Affect One in Ten Children
U.S. prevalence jumped to 10%, up from 6% two decades ago
