0. How to Crush Your Habits in the New Year with the Help of
Science
Make 2019 the
year you actually do all the things you want to do. We asked the experts and
checked the journals for the most useful tips you can take to heart.
1. Leading Studies in 2018
Journal Watch
- Emergency Medicine: https://www.jwatch.org/na47978/2018/12/28/nejm-journal-watch-emergency-medicine-top-stories-2018
- Hospital Medicine: https://www.jwatch.org/na48183/2018/12/21/nejm-journal-watch-hospital-medicine-top-stories-2018
Ryan Radecki
in ACEP News: https://www.acepnow.com/article/10-of-the-best-medical-journal-articles-from-2018/
2. Treat Near Syncope in Older Patients like “True” Syncope
2. Treat Near Syncope in Older Patients like “True” Syncope
Bastani A et
al. Ann Emerg Med 2018 Dec 7
In this study,
serious outcomes were relatively common for patients with both syncope and near
syncope.
STUDY
OBJECTIVE:
Controversy
remains in regard to the risk of adverse events for patients presenting with
syncope compared with near-syncope. The purpose of our study is to describe the
difference in outcomes between these groups in a large multicenter cohort of
older emergency department (ED) patients.
METHODS:
From April 28,
2013, to September 21, 2016, we conducted a prospective, observational study
across 11 EDs in adults (≥60 years) with syncope or near-syncope. A
standardized data extraction tool was used to collect information during their
index visit and at 30-day follow-up. Our primary outcome was the incidence of
30-day death or serious clinical events. Data were analyzed with descriptive
statistics and multivariate logistic regression analysis adjusting for relevant
demographic or historical variables.
RESULTS:
A total of
3,581 patients (mean age 72.8 years; 51.6% men) were enrolled in the study.
There were 1,380 patients (39%) presenting with near-syncope and 2,201 (61%)
presenting with syncope. Baseline characteristics revealed a greater incidence
of congestive heart failure, coronary artery disease, previous arrhythmia,
nonwhite race, and presenting dyspnea in the near-syncope compared with syncope
cohort. There were no differences in the primary outcome between the groups
(near-syncope 18.7% versus syncope 18.2%). A multivariate logistic regression
analysis identified no difference in 30-day serious outcomes for patients with
near-syncope (odds ratio 0.94; 95% confidence interval 0.78 to 1.14) compared
with syncope.
CONCLUSION:
Near-syncope
confers risk to patients similar to that of syncope for the composite outcome
of 30-day death or serious clinical event.
3. Association of the Hospital Readmissions Reduction Program with
(Increased!) Mortality among Medicare Beneficiaries Hospitalized for HF, AMI,
and Pneumonia.
Wadhera RK, et
al. JAMA. 2018 Dec 25;320(24):2542-2552.
Key Points
Question Was the announcement and implementation of
the Hospital Readmissions Reduction Program (HRRP) associated with an increase
in patient-level mortality?
Findings In this retrospective cohort study that
included approximately 8 million Medicare beneficiary fee-for-service
hospitalizations from 2005 to 2015, implementation of the HRRP was associated
with a significant increase in trends in 30-day postdischarge mortality among
beneficiaries hospitalized for heart failure and pneumonia, but not for acute
myocardial infarction.
Meaning There was a statistically significant
association with implementation of the HRRP and increased post-discharge
mortality for patients hospitalized for heart failure and pneumonia, but
whether this finding is a result of the policy requires further research.
Abstract
IMPORTANCE:
The Hospital
Readmissions Reduction Program (HRRP) has been associated with a reduction in
readmission rates for heart failure (HF), acute myocardial infarction (AMI),
and pneumonia. It is unclear whether the HRRP has been associated with change
in patient mortality.
OBJECTIVE:
To determine
whether the HRRP was associated with a change in patient mortality.
DESIGN,
SETTING, AND PARTICIPANTS:
Retrospective
cohort study of hospitalizations for HF, AMI, and pneumonia among Medicare
fee-for-service beneficiaries aged at least 65 years across 4 periods from
April 1, 2005, to March 31, 2015. Period 1 and period 2 occurred before the
HRRP to establish baseline trends (April 2005-September 2007 and October
2007-March 2010). Period 3 and period 4 were after HRRP announcement (April
2010 to September 2012) and HRRP implementation (October 2012 to March 2015).
EXPOSURES:
Announcement
and implementation of the HRRP.
MAIN OUTCOMES
AND MEASURES:
Inverse
probability-weighted mortality within 30 days of discharge following
hospitalization for HF, AMI, and pneumonia, and stratified by whether there was
an associated readmission. An additional end point was mortality within 45 days
of initial hospital admission for target conditions.
RESULTS:
The study
cohort included 8.3 million hospitalizations for HF, AMI, and pneumonia, among
which 7.9 million (mean age, 79.6 [8.7] years; 53.4% women) were alive at
discharge. There were 3.2 million hospitalizations for HF, 1.8 million for AMI,
and 3.0 million for pneumonia. There were 270 517 deaths within 30 days of
discharge for HF, 128 088 for AMI, and 246 154 for pneumonia. Among patients
with HF, 30-day postdischarge mortality increased before the announcement of
the HRRP (0.27% increase from period 1 to period 2). Compared with this
baseline trend, HRRP announcement (0.49% increase from period 2 to period 3;
difference in change, 0.22%, P = .01) and implementation (0.52% increase from
period 3 to period 4; difference in change, 0.25%, P = .001) were significantly
associated with an increase in postdischarge mortality. Among patients with
AMI, HRRP announcement was associated with a decline in postdischarge mortality
(0.18% pre-HRRP increase vs 0.08% post-HRRP announcement decrease; difference
in change, -0.26%; P = .01) and did not significantly change after HRRP
implementation. Among patients with pneumonia, postdischarge mortality was
stable before HRRP (0.04% increase from period 1 to period 2), but
significantly increased after HRRP announcement (0.26% post-HRRP announcement
increase; difference in change, 0.22%, P = .01) and implementation (0.44%
post-HPPR implementation increase; difference in change, 0.40%, P less than .001).
The overall increase in mortality among patients with HF and pneumonia was
mainly related to outcomes among patients who were not readmitted but died
within 30 days of discharge. For all 3 conditions, HRRP implementation was not
significantly associated with an increase in mortality within 45 days of
admission, relative to pre-HRRP trends.
CONCLUSIONS
AND RELEVANCE:
Among Medicare
beneficiaries, the HRRP was significantly associated with an increase in 30-day
postdischarge mortality after hospitalization for HF and pneumonia, but not for
AMI. Given the study design and the lack of significant association of the HRRP
with mortality within 45 days of admission, further research is needed to
understand whether the increase in 30-day postdischarge mortality is a result
of the policy.
4. Neurology Corner
A.
Ruling Out SAH? What’s Next If the CT is Negative?
Factors
influencing variation in investigations after a negative CT brain scan in
suspected subarachnoid haemorrhage: a qualitative study.
Chu K, et al. Emerg
Med J. 2018 Dec 20 [Epub ahead of print]
INTRODUCTION:
Variation in
the approach to the patient with a possible subarachnoid haemorrhage (SAH) has
been previously documented. The purpose of this study was to identify factors
that influence emergency physicians' decisions about diagnostic testing after a
normal CT brain scan for ED patients with a headache suspicious of a SAH.
METHODS:
We conducted
an interview-based qualitative study informed by social constructionist theory.
Fifteen emergency physicians from six EDs across Queensland, Australia,
underwent individual face-to-face or telephone interviews. Content analysis was
performed whereby transcripts were examined and coded independently by two
co-investigators, who then jointly agreed on the influencing factors.
RESULTS:
Six categories
of influencing factors were identified. Patient interaction was at the
forefront of the identified factors. This shared decision-making process
incorporated 'what the patient wants' but may be biased by how the clinician
communicates the benefits and harms of the diagnostic options to the patient.
Patient risk profile, practice evidence and guidelines were also important.
Other influencing factors included experiential factors of the clinician,
consultation with colleagues and external influences where practice location
and work processes impose constraints on test ordering external to the
preferences of the clinician or patient. The six categories were organised
within a conceptual framework comprising four components: the context, the
evidence, the experience and the decision.
CONCLUSIONS:
When
clinicians are faced with a diagnostic challenge, such as the workup of a
patient with suspected SAH, there are a number of influencing factors that can
result in a variation in approach. These need to be considered in approaches to
improve the appropriateness and consistency of medical care.
B. Subarachnoid Mirage: A Case of
Pseudosubarachnoid Hemorrhage
Camacho MA, et al. Ann Emerg Med. 2019;73(2):130-132.
A 22-year-old man with a history of intravenous
methamphetamine use presented with severe headache for 5 days, was afebrile,
and had nuchal rigidity. Computed tomography and magnetic resonance imaging
results were interpreted as revealing acute subarachnoid hemorrhage.
Twenty-four hours later, he developed acute neurologic deterioration. A lumbar
puncture was performed, revealing the presence of Staphylococcus aureus. The
false-positive image mimicking blood was potentially a result of an extremely
high protein concentration present in the cerebrospinal fluid, provoked by an
intense inflammatory reaction leading to disruption of the blood-brain barrier.
Pyogenic meningitis is one of the causes of pseudosubarachnoid hemorrhage, or a
false diagnosis of subarachnoid hemorrhage, when one does not actually exist.
C. Fast Protocol for Treating Acute
Ischemic Stroke by Emergency Physicians.
Heikkilä I, et al. Ann Emerg Med. 2019;73(2):105–112.
STUDY OBJECTIVE:
Thrombolysis with tissue plasminogen activator should occur
promptly after ischemic stroke onset. Various strategies have attempted to
improve door-to-needle time. Our objective is to evaluate a strategy that uses
an emergency physician-based protocol when no stroke neurologist is available.
METHODS:
This was a retrospective before-after intervention analysis
in an urban hospital. Reorganization of the acute ischemic stroke treatment
process was carried out in 2013. We evaluated time delay, symptomatic
intracerebral hemorrhage, and clinical recovery of patients before and after
the reorganization. We used multivariable linear regression to estimate the
change in door-to-needle time before and after the reorganization.
RESULTS:
A total of 107 patients with comparable data were treated
with tissue plasminogen activator in 2009 to 2012 (group 1) and 46 patients
were treated during 12 months in 2013 to 2014 (group 2). Median door-to-needle
time was 54 minutes before the reorganization and 20 minutes after it
(statistical estimate of difference 32 minutes; 95% confidence interval 26 to
38 minutes). After adjusting for several potential cofounders in multivariable
regression analysis, the only factor contributing to a significant reduction in
delay was group (after reorganization versus before). Median onset-to-treatment
times were 135 and 119 minutes, respectively (statistical estimate of
difference 23 minutes; 95% confidence interval 6 to 39 minutes). The rates of
symptomatic intracerebral hemorrhage were 4.7% (5/107) and 2.2% (1/46),
respectively (difference 2.5%; 95% confidence interval -8.7% to 9.2%).
Approximately 70% of treated patients were functionally independent (modified
Rankin Scale score 0 to 2) when treated after the reorganization.
CONCLUSION:
Implementation of a stroke protocol with emergency
physician-directed acute care decreased both door-to-needle time and
onset-to-treatment time without increasing the rate of symptomatic
intracerebral hemorrhage.
Full-text (free): https://www.annemergmed.com/article/S0196-0644(18)30651-6/fulltext
D. A Randomized Trial of a Long-Acting
Depot Corticosteroid vs Dexamethasone to Prevent HA Recurrence Among Pts with
Acute Migraine Discharged from an ED
Latev A, et al. Ann Emerg Med. 2019;73(2):141-149.
Study objective
Migraine patients continue to report headache during the
days and weeks after emergency department (ED) discharge. Dexamethasone is an
evidence-based treatment of acute migraine that decreases the frequency of
moderate or severe headache within 72 hours of ED discharge. We hypothesize
that intramuscular methylprednisolone acetate, a long-acting steroid that
remains biologically active for 14 days, will decrease the number of days with
headache during the week after ED discharge by at least 1 day compared with
intramuscular dexamethasone.
Methods
We conducted a randomized, blinded clinical trial comparing
intravenous metoclopramide at 10 mg+intramuscular dexamethasone at 10 mg with
intravenous metoclopramide at 10 mg+intramuscular methylprednisolone acetate at
a dose of 160 mg for patients presenting to 2 different EDs with moderate or
severe migraine. Outcomes were assessed by telephone with a standardized
instrument. The primary outcome was number of days with headache during the
week after ED discharge. Secondary outcomes were complete freedom from
headache, without the necessity of additional headache medication for the
entire week after ED discharge, and medication preference, as determined by
asking the patient whether he or she would want to receive the same medication
again.
Results
One hundred nine patients received dexamethasone and 111
received methylprednisolone acetate. We obtained primary outcome data from 101
dexamethasone patients and 106 methylprednisolone acetate patients.
Dexamethasone patients reported 3.0 headache days and methylprednisolone
acetate 3.3 headache days (95% confidence interval for rounded mean difference
of 0.4 days: –0.4 to 1.1). Of 107 dexamethasone patients with analyzable data,
10 (9%) reported complete freedom from headache at 1 week versus 6 of 110 (5%)
methylprednisolone acetate patients (95% confidence interval for difference of
4%: –3% to 11%). In the dexamethasone group, 76 of 101 (75%) patients would
want the same medication again versus 75 of 106 (71%) of methylprednisolone
acetate patients (95% confidence interval for difference of 4%: –8% to 17%).
Other than injection site reactions, which were more common in the
methylprednisolone acetate group, there were no substantial differences in
frequency of adverse events.
Conclusion
Methylprednisolone acetate does not decrease the frequency
of post-ED discharge headache days compared with dexamethasone. Most migraine
patients are likely to continue to experience headache during the week after ED
discharge.
E. Low-dose Ketamine Does Not Improve
Migraine in the ED: A Randomized Placebo-controlled Trial.
Etchison AR, et al. West J Emerg Med. 2018
Nov;19(6):952-960.
INTRODUCTION:
Patients frequently present to the emergency department (ED)
with migraine headaches. Although low-dose ketamine demonstrates analgesic
efficacy for acute pain complaints in the ED, headaches have historically been
excluded from these trials. This study evaluates the efficacy and safety of
low-dose ketamine for treatment of acute migraine in the ED.
METHODS:
This randomized, double-blinded, placebo-controlled trial
evaluated adults 18 to 65 years of age with acute migraine at a single academic
ED. Subjects were randomized to receive 0.2 milligrams per kilogram of
intravenous (IV) ketamine or an equivalent volume of normal saline. Numeric
Rating Scale (NRS-11) pain scores, categorical pain scores, functional
disability scores, side effects, and adverse events were assessed at baseline
(T0) and 30 minutes post-treatment (T30). The primary outcome was between-group
difference in NRS score reduction at 30 minutes.
RESULTS:
We enrolled 34 subjects (ketamine=16, placebo=18).
Demographics were similar between treatment groups. There was no statistically
significant difference in NRS score reductions between ketamine and
placebo-treated groups after 30 minutes. Median NRS score reductions at 30
minutes were 1.0 (interquartile range [IQR] 0 to 2.25) for the ketamine group
and 2.0 (IQR 0 to 3.75) for the placebo group. Between-group median difference
at 30 minutes was -1.0 (IQR -2 to 1, p=0.5035). No significant differences
between treatment groups occurred in categorical pain scores, functional
disability scores, rescue medication request rate, and treatment satisfaction.
Side Effect Rating Scale for Dissociative Anesthetics scores in the ketamine
group were significantly greater for generalized discomfort at 30 minutes
(p=0.008) and fatigue at 60 minutes (p=0.0216). No serious adverse events
occurred in this study.
CONCLUSION:
We found that 0.2mg/kg IV ketamine did not produce a greater
reduction in NRS score compared to placebo for treatment of acute migraine in
the ED. Generalized discomfort at 30 minutes was significantly greater in the
ketamine group. Overall, ketamine was well tolerated by migraine-suffering
subjects. To optimize low-dose ketamine as an acute migraine treatment, future
studies should investigate more effective dosing and routes of administration.
F. Deep learning algorithms for
detection of critical findings in head CT scans: a retrospective study.
Chilamkurthy S, et al. Lancet. 2018 Dec
1;392(10162):2388-2396.
BACKGROUND:
Non-contrast head CT scan is the current standard for
initial imaging of patients with head trauma or stroke symptoms. We aimed to
develop and validate a set of deep learning algorithms for automated detection
of the following key findings from these scans: intracranial haemorrhage and
its types (ie, intraparenchymal, intraventricular, subdural, extradural, and
subarachnoid); calvarial fractures; midline shift; and mass effect.
METHODS:
We retrospectively collected a dataset containing 313 318
head CT scans together with their clinical reports from around 20 centres in
India between Jan 1, 2011, and June 1, 2017. A randomly selected part of this
dataset (Qure25k dataset) was used for validation and the rest was used to
develop algorithms. An additional validation dataset (CQ500 dataset) was
collected in two batches from centres that were different from those used for
the development and Qure25k datasets. We excluded postoperative scans and scans
of patients younger than 7 years. The original clinical radiology report and
consensus of three independent radiologists were considered as gold standard
for the Qure25k and CQ500 datasets, respectively. Areas under the receiver
operating characteristic curves (AUCs) were primarily used to assess the
algorithms.
FINDINGS:
The Qure25k dataset contained 21 095 scans (mean age 43
years; 9030 [43%] female patients), and the CQ500 dataset consisted of 214
scans in the first batch (mean age 43 years; 94 [44%] female patients) and 277
scans in the second batch (mean age 52 years; 84 [30%] female patients). On the
Qure25k dataset, the algorithms achieved an AUC of 0·92 (95% CI 0·91-0·93) for
detecting intracranial haemorrhage (0·90 [0·89-0·91] for intraparenchymal, 0·96
[0·94-0·97] for intraventricular, 0·92 [0·90-0·93] for subdural, 0·93
[0·91-0·95] for extradural, and 0·90 [0·89-0·92] for subarachnoid). On the
CQ500 dataset, AUC was 0·94 (0·92-0·97) for intracranial haemorrhage (0·95
[0·93-0·98], 0·93 [0·87-1·00], 0·95 [0·91-0·99], 0·97 [0·91-1·00], and 0·96
[0·92-0·99], respectively). AUCs on the Qure25k dataset were 0·92 (0·91-0·94)
for calvarial fractures, 0·93 (0·91-0·94) for midline shift, and 0·86
(0·85-0·87) for mass effect, while AUCs on the CQ500 dataset were 0·96
(0·92-1·00), 0·97 (0·94-1·00), and 0·92 (0·89-0·95), respectively.
INTERPRETATION:
Our results show that deep learning algorithms can
accurately identify head CT scan abnormalities requiring urgent attention,
opening up the possibility to use these algorithms to automate the triage
process.
FUNDING: Qure.ai.
5. ED Shared Decision-Making Mitigates Malpractice Risk
Schoenfeld EM,
et al. The Effect of Shared Decisionmaking on Patients’ Likelihood of Filing a
Complaint or Lawsuit: A Simulation Study. Ann Emerg Med. 2019 Jan 03 [Epub
ahead of print].
STUDY
OBJECTIVE:
Shared decisionmaking
has been promoted as a method to increase the patient-centeredness of medical
decisionmaking and decrease low-yield testing, but little is known about its
medicolegal ramifications in the setting of an adverse outcome. We seek to
determine whether the use of shared decisionmaking changes perceptions of fault
and liability in the case of an adverse outcome.
METHODS:
This was a
randomized controlled simulation experiment conducted by survey, using clinical
vignettes featuring no shared decisionmaking, brief shared decisionmaking, or
thorough shared decisionmaking. Participants were adult US citizens recruited
through an online crowd-sourcing platform. Participants were randomized to
vignettes portraying 1 of 3 levels of shared decisionmaking. All other
information given was identical, including the final clinical decision and the
adverse outcome. The primary outcome was reported likelihood of pursuing legal
action. Secondary outcomes included perceptions of fault, quality of care, and
trust in physician.
RESULTS:
We recruited
804 participants. Participants exposed to shared decisionmaking (brief and
thorough) were 80% less likely to report a plan to contact a lawyer than those
not exposed to shared decisionmaking (12% and 11% versus 41%; odds ratio 0.2;
95% confidence interval 0.12 to 0.31). Participants exposed to either level of
shared decisionmaking reported higher trust, rated their physicians more
highly, and were less likely to fault their physicians for the adverse outcome
compared with those exposed to the no shared decisionmaking vignette.
CONCLUSION:
In the setting
of an adverse outcome from a missed diagnosis, use of shared decisionmaking may
affect patients' perceptions of fault and liability.
6. Quick Reviews from Ann Emerg Med
A.
Is the Liberal Use of Oxygen Associated with Worse Outcomes Among Critically Ill Patients?
Take-Home Message
Compared with conservative oxygen therapy, liberal
oxygen therapy is associated with increased mortality without improving other
patient-relevant outcomes.
Full-text
(free): https://www.annemergmed.com/article/S0196-0644(18)30650-4/fulltext
B.
Are Topical Nonsteroidal Anti-Inflammatory Drugs
Useful for Analgesia in Patients with
Traumatic Corneal Abrasions?
Take-Home Message
There is no strong evidence to suggest that topical
nonsteroidal anti-inflammatory drugs provide adequate analgesia for patients
with traumatic corneal abrasions, yet there is low-quality evidence to suggest
that the drugs decreased the need for oral analgesia 24 hours later.
Full-text
(free): https://www.annemergmed.com/article/S0196-0644(18)31156-9/fulltext
7. Cardiology Corner
A. Long-Term Outcomes of
Out-of-Hospital Cardiac Arrest Care Better at Regionalized Centers.
Elmer J, et al. Ann Emerg Med. 2019 Jan;73(1):29-39.
STUDY OBJECTIVE:
It is unknown whether regionalization of postarrest care by
interfacility transfer to cardiac arrest receiving centers reduces mortality.
We seek to evaluate whether treatment at a cardiac arrest receiving center,
whether by direct transport or early interfacility transfer, is independently
associated with long-term outcome.
METHODS:
We performed a retrospective cohort study including adults
resuscitated from out-of-hospital cardiac arrest in southwestern Pennsylvania
and neighboring Ohio, West Virginia, and Maryland, which includes approximately
5.7 million residents in urban, suburban, and rural counties. Patients were
treated by 1 of 78 ground emergency medical services agencies or 2 air medical
transport agencies between January 1, 2010, and November 30, 2014. Our primary
exposures of interest were interfacility transfer to a cardiac arrest receiving
center within 24 hours of arrest or any treatment at a cardiac arrest receiving
center regardless of transfer status. Our primary outcome was vital status,
assessed through December 31, 2014, with National Death Index records. We used
unadjusted and adjusted survival analyses to test the independent association
of cardiac arrest receiving center care, whether through direct or
interfacility transport, on mortality.
RESULTS:
Overall, 5,217 cases were observed for 3,629 person-years,
with 3,865 total deaths. Most patients (82%) were treated at 42 non-cardiac
arrest receiving centers with median annual volume of 17 cases (interquartile
range 1 to 53 cases per center annually), whereas 18% were cared for at cardiac
arrest receiving centers receiving at least 1 interfacility transfer per month.
In adjusted models, treatment at a cardiac arrest receiving center was
independently associated with reduced hazard of death compared with treatment
at a non-cardiac arrest receiving center (adjusted hazard ratio 0.84; 95%
confidence interval 0.74 to 0.94). These effects were unchanged when analysis
was restricted to patients brought from the scene to the treating hospital. No
other hospital characteristic, including total out-of-hospital cardiac arrest
patient volume and cardiac catheterization capabilities, independently
predicted outcome.
CONCLUSION:
Both early interfacility transfer to a cardiac arrest
receiving center and direct transport to a cardiac arrest receiving center from
the scene are independently associated with reduced mortality.
B.
Ibutilide-induced Torsade de Pointes
Le DD, et al. Perm J
2019;23:18-187.
INTRODUCTION
Ibutilide is recommended by professional society
guidelines for the cardioversion of atrial fibrillation and flutter.1,2 Its
rapid effect and minimal impact on hemodynamics make it well suited for use in
the Emergency Department (ED).3 Ibutilide, however, prolongs the corrected QT
(QTc) interval and increases risk for ventricular tachycardia (VT).4-6 The risk
of VT can be greatly mitigated by careful selection of low-risk patients, the
optimal dose of prophylactic magnesium sulfate, and at least 4 hours of
postibutilide electrocardiographic monitoring.3 This case illustrates the
dangers of overlooking ibutilide contraindications and provides practical
lessons in ibutilide use and management of ibutilide-induced VT.
CASE
PRESENTATION
Here (free): https://doi.org/10.7812/TPP/18-187
DISCUSSION
The ED management of the stable patient with primary
nonvalvular paroxysmal atrial fibrillation or flutter and recent-onset symptoms
may include attempts at pharmacologic or electrical cardioversion.1,8 The
choice to pursue the restoration of sinus rhythm in the ED is influenced by
many variables and is well suited for shared decision making.9,10 An ED
rhythm-control strategy was a viable option for our patient, although the
selection of ibutilide was not ideal because he had 2 notable
contraindications: A prolonged QTc interval and hypokalemia. Both of these are
known to increase the risk for polymorphic VT, which is a dangerous rhythm that
can degenerate into ventricular fibrillation and cause cardiac arrest.3,11,12
Barring contraindications, ibutilide is a good
selection for the pharmacologic cardioversion of recent-onset (less than 48 hours)
atrial fibrillation. In a multicenter retrospective cohort study in a
real-world, community-based ED setting, ibutilide was found to be comparable to
procainamide in the cardioversion of recent-onset atrial fibrillation at 90
minutes (40% vs 46% effective, respectively) and superior to intravenous
amiodarone (40% vs 18% effective, respectively). 3,13,14
Among pharmacologic agents for the cardioversion of recent-onset atrial
flutter, however, ibutilide is unrivaled (eg, ibutilide had a 64% cardioversion
rate at 90 minutes vs 22% for procainamide).3,13,14
Polymorphic VT is the most serious side effect of
ibutilide. The multiple ventricular foci of polymorphic VT are evident in QRS
complexes of varying amplitude, axis, and duration. When associated with
acquired or congenital QTc interval prolongation, polymorphic VT is called
torsade de pointes (TdP). This French term has 2 complementary meanings: 1)
“twisting of points,” referring to the ribbon-like twisting of the rhythm
around the ECG isoelectric line; and 2) “fringe of pointed tips,” another apt
description of the ECG image (Figure 3). TdP is uncommonly captured on a
12-lead ECG because of the brevity and paroxysmal nature of the dysrhythmia and
the gravity of the clinical situation.
Risk factors for drug-induced TdP include
hypokalemia, female sex, drug-drug interactions, advancing age, genetic
predisposition, hypomagnesemia, heart failure, bradycardia, and QTc interval
prolongation.15-17 Numerous medications are known to prolong the QTc interval,
including levofloxacin, erythromycin (and other macrolides), haloperidol, and
methadone, as well as Class III antiarrhythmics such as ibutilide.15 These
medications induce TdP by inhibiting positive ion channels, making individuals
with preexisting hypokalemia particularly susceptible to TdP.3,11,12 Because
the QTc interval is generally more prolonged as the heart rate slows,
polymorphic VT develops more commonly in bradycardic hearts, after ibutilide
has resolved atrial fibrillation or flutter (as in our patient).
The most common and effective treatments for TdP
include defibrillation and intravenous magnesium sulfate for unstable patients
and magnesium sulfate alone for stable patients, regardless of baseline serum
magnesium levels.18,19 Intravenous lidocaine (a Class Ib antiarrhythmic agent),
which shortens the QTc interval, can also be useful. If TdP persists or recurs
despite initial interventions, temporary overdrive pacing or intravenous
isoproterenol can be used because these increase the heart rate and thereby
shorten the QTc interval. Class Ia (eg, procainamide) and class III
antiarrhythmics (eg, amiodarone, ibutilide, sotalol) should be avoided because
they prolong the QTc interval and can aggravate TdP. Although amiodarone has
been occasionally successful in the treatment of TdP, its use is discouraged
given the unfavorable risk-benefit profile in this population and the
availability of safer, more reliable TdP treatments.20-22 In addition to
treatments aimed at terminating TdP, causative medications should be
discontinued and electrolyte deficiencies corrected.
CONCLUSION
This case teaches us several important clinical
lessons. First, ibutilide should be avoided in patients with hypokalemia or
prolonged QTc interval.15 Defibrillation would have been a safer choice than
pharmacologic options for restoring sinus rhythm in this patient. Second, the
1-g dose of prophylactic magnesium that was administered as an adjunct to
ibutilide was insufficient to either facilitate cardioversion or reduce the
incidence of ibutilide-induced TdP. The dose of magnesium needed to enhance
ibutilide effectiveness, even in patients with normal serum magnesium levels,
is 2-4 g. The dose of magnesium required to minimize TdP is 5 g during the 1
hour preceding ibutilide administration and then 5 g during the 2 hours following
the ibutilide infusion.3,23 (Ibutilide is contraindicated in patients with low
magnesium levels.) Third, amiodarone is not ideal for TdP treatment, as noted
above.19,20,24,25 When used properly, ibutilide can be an effective—and
relatively safe—medication for the cardioversion of recent-onset atrial
fibrillation and flutter.3
Images and
references (free): https://doi.org/10.7812/TPP/18-187
C. “Troponinemia”? Cardiac Troponin
Elevation in Patients without a Specific Diagnosis.
Eggers KM, et al. J Am Coll Cardiol. 2019 Jan 8;73(1):1-9.
BACKGROUND:
Cardiac troponin (cTn) elevation is a common finding in
acutely admitted patients, even in the absence of acute coronary syndrome. In
some of these patients, no etiology of cTn elevation can be identified. The
term troponinemia is sometimes used to describe this scenario.
OBJECTIVES:
This study aimed to investigate the associations of cTn
levels with clinical findings and long-term outcome in acutely admitted
patients with suspected acute coronary syndrome who had been discharged without
a specified diagnosis.
METHODS:
Retrospective registry-based cohort study investigating
48,872 patients (SWEDEHEART [Swedish Web-system for Enhancement and Development
of Evidence-based care in Heart disease Evaluated According to Recommended
Therapies] registry). Patients were stratified into cohorts with cTn levels
less than or equal to the assay-specific 99th percentile and separated by
assay-specific cTn tertiles in case of higher levels.
RESULTS:
A cTn level over the 99th percentile was noted in 9,800
(20.1%) patients. The prevalence of cardiovascular risk factors as well as
cardiovascular and noncardiovascular comorbidities increased across higher cTn
strata. In total, 7,529 (15.4%) patients had a major adverse event (MAE),
defined as the composite of all-cause mortality, myocardial infarction,
readmission for heart failure, or stroke (median follow-up 4.9 years). MAE risk
was associated with higher cTn strata (hazard ratio for highest assay-specific
cTn tertile: 2.59; 95% confidence interval: 2.39 to 2.80; hazard ratio in
patients without cardiovascular comorbidities, renal dysfunction, left
ventricular dysfunction, or significant coronary stenosis: 3.57; 95% confidence
interval: 2.30 to 5.54).
CONCLUSIONS:
cTn elevation is associated with cardiovascular and
noncardiovascular comorbidities and predicts major adverse events in acutely
admitted patients, in whom no definite diagnosis could have been established.
The term troponinemia is trivializing and should be avoided. Instead, careful
work-up is required in these patients.
D. Effect of early physician follow-up
on mortality and subsequent hospital admissions after emergency care for HF: a
retrospective cohort study
Atzema CL, et
al. CMAJ. 2018 Dec 17;190(50):E1468-E1477.
BACKGROUND:
The 1-year mortality rate in patients with heart failure who are discharged
from an emergency department is 20%. We sought to determine whether early
follow-up after discharge from the emergency department was associated with
decreased mortality or subsequent admission to hospital.
METHODS: This
retrospective cohort study conducted in Ontario, Canada, included adult
patients who were discharged from 1 of 163 emergency departments between April
2007 and March 2014 with a primary diagnosis of heart failure. Using a
propensity score–matched landmark analysis, we assessed follow-up in relation
to mortality and admissions to hospital for cardiovascular conditions.
RESULTS: Of 34
519 patients, 16 274 (47.1%) obtained follow-up care within 7 days and 28 846
(83.6%) within 30 days. Compared with follow-up between day 8 and 30, patients
with follow-up care within 7 days had a lower rate of mortality over 1 year
(hazard ratio [HR] 0.92; 95% confidence interval [CI] 0.87–0.97), and a reduced
rate of admission to hospital over 90 days (HR 0.87, 95% CI 0.80–0.94) and 1
year (HR 0.92; 95% CI 0.87–0.97); the mortality rate over 90 days in this group
trended to a lower rate (HR 0.90, 95% CI 0.10–1.00). Follow-up care within 30
days, compared with patients without 30-day follow-up, was associated with a
reduction in 1-year mortality (HR 0.89, 95% CI 0.82–0.97) but not admission to
hospital (HR 1.02, 95% CI 0.94–1.10). In this group, there was a trend toward
an increase in 90-day admission to hospital (HR 1.14, 95% CI 1.00–1.29).
INTERPRETATION:
Follow-up care within 7 days of discharge from the emergency department was
associated with lower rates of long-term mortality, as well as subsequent
hospital admissions, and a trend to lower short-term mortality rates. Timely
access to longitudinal care for patients with heart failure who are discharged
from the emergency setting should be prioritized.
8. Myths in Emergency Medicine: Cricoid
Pressure Nothing More than Nostalgia
Spiegel R. Emerg Med News. 2019;41(1):1,32
The use of cricoid pressure is a polarizing issue. It
is not uncommon for experts in emergency airway management to come close to
blows when discussing the efficacy of Sellick's famous maneuver. Until
recently, there has been a paucity of data to support or discredit its use, but
the publication of the IRIS trial represents the first large, high-quality empiric
examination of this historic piece of airway dogma.
The IRIS (Sellick Interest in Rapid Sequence
Induction) trial examined using cricoid pressure in surgical patients
undergoing rapid sequence induction (RSI) at 10 centers across France. (JAMA Surg 2019; link below). The authors
enrolled 3,472 adult patients requiring RSI for any type of surgical procedure
under general anesthesia who were considered to have a full stomach (less than
six hours of fasting) or at least one risk factor for pulmonary aspiration.
Patients were randomized to receive a sham procedure or true cricoid pressure,
defined as an expected pressure equivalent to 30 newtons applied using the
first three fingers on the cricoid cartilage. Operators were trained to apply
the procedure correctly before being permitted to participate in the study.
This study was technically negative, but the authors
reported the sham cricoid procedure failed to demonstrate noninferiority when
compared with the true Sellick technique. This is most likely an error in the
authors' statistical analysis rather than any clinical benefit of cricoid
pressure. The rate of primary endpoint, pulmonary aspiration (detected at the
glottis level during laryngoscopy or by tracheal aspiration just after tracheal
intubation), was essentially identical in both groups. It occurred in 10
patients (0.6%) in the Sellick group and in nine (0.5%) in the sham group. The
rates were similar for suspected pneumonia within 24 hours of intubation (0.9%
vs 0.6%), aspiration pneumonia (0.2% vs 0.2%), and severe pneumonia (0.1% vs
0.1%).
The only element that was noticeably different
between the groups was the difficulty of intubation. Patients randomized to the
cricoid pressure group had a higher incidence of grade 3 and 4 Cormack and
Lehane views. Interruption of the maneuver also occurred more frequently in the
cricoid pressure group. Abandoning these attempts more often improved the view
after its release. The cricoid pressure group required longer times to
intubation and more frequently experienced intubations exceeding 30 seconds.
The incidence of difficult tracheal intubation did not reach statistical
significance, but it was numerically higher in the cricoid pressure group (72
v. 51).
The remainder
of the essay (free): https://journals.lww.com/em-news/Fulltext/2019/01000/Myths_in_Emergency_Medicine__Cricoid_Pressure.2.aspx
The trial: Birenbaum A, et al. Effect of
Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction
of Anesthesia:
the IRIS RCT. JAMA Surg. 2019;154(1):9-17.
9. ALiEM on Leg Fractures
SplintER
Series: Tibial Plateau Fractures | Leg Day #1
The SplintER series is back with a new sub-series - Leg Day!
We will review lower extremity orthopedic injuries, introduce advanced
concepts, and highlight ways to implement these into your practice.
SplintER
Series: Hip Dislocation | Leg Day #2
Welcome to Leg Day #2 of the SplintER Series. Following up
with the Leg Day #1's primer on tibial plateau fractures, another key
orthopedic injury of the leg is hip dislocation.
10. Images in Clinical Practice
Necrosis in the Fingers and Toes
Jaw Clonus and Limb Fasciculations
Man With Abdominal Pain
Man With Accidentally Swallowed Dental C+ File
Woman With Hip Pain
Man With Persistent Rash
Young Girl With Torticollis
Young Woman With Unilateral Vision Loss
Image Diagnosis: Esophageal Intramural Hematoma in
Sudden-Onset Chest Pain and Dysphagia
Image Diagnosis: Thoracic Epidural Hematoma from a Fall
Requiring Emergent Decompressive Laminectomy and Hematoma Evacuation
Image Diagnosis: Aortic Thrombus in Severe Hypercortisolemia
11. OR Shutdown Enters Third Week Over Drape Wall Impasse:
Anesthesiologists want to build the drape wall. Surgeons more flexible on issue
by Gomer Blog Team. January 17, 2019
Disclaimer: This post is from a satirical site about
healthcare.
FORT CUSTER, Neb. – The operating room at Armstrong Memorial
Hospital has entered a third week of shutdown as anesthesia and surgery
continued to spar over their demands for the surgical drape wall. Both sides
remain unwilling to compromise on any of their demands for the wall.
Anesthesiologists insist on a fortified construction with multiple
reinforcing drape layers and drones to patrol the wall from above. They assert
that such a powerful and tall structure is needed to contain the flow of
undocumented body fluids, foul surgical language, and illegal surgical elements
emanating from the surgery side of the wall.
Surgery insists on a light and flexible structure, citing
diversion of scarce drapes and clamps from unpredictable and rapidly changing
conditions on the southern side of the wall. Location of the wall also remains
a major issue as surgeons assert that the wall should abut the chin, allowing
for a greater surgical field while anesthesiology insists on having access all
the way to the cricoid cartilage.
Hospitalists' attempts to mediate the conflict was
unsuccessful; they had no idea where the operating room was and wandered on the
loading dock. While both parties remain dug in, patients here are feeling the
pain. Edward Dwindles, whose ruptured aortic aneurysm has gone untreated, told
GomerBlog that a solution is needed ASAP because having a systolic blood
pressure of 60 for the last two weeks is really starting to suck.
12. Pediatric Corner
A. Implementation of a Clinical
Decision Support System for Children with Minor Blunt Head Trauma Who Are at
Nonnegligible Risk for Traumatic Brain Injuries.
Ballard DW, et al. with PECARN and CREST. Ann Emerg Med.
2018 Dec 22 [Epub ahead of print]
STUDY OBJECTIVE:
To determine the effect of providing risk estimates of
clinically important traumatic brain injuries and management recommendations on
emergency department (ED) outcomes for children with isolated intermediate
Pediatric Emergency Care Applied Research Network clinically important
traumatic brain injury risk factors.
METHODS:
This was a secondary analysis of a nonrandomized clinical
trial with concurrent controls, conducted at 5 pediatric and 8 general EDs
between November 2011 and June 2014, enrolling patients younger than 18 years
who had minor blunt head trauma. After a baseline period, intervention sites
received electronic clinical decision support providing patient-level
clinically important traumatic brain injury risk estimates and management
recommendations. The following primary outcomes in patients with one
intermediate Pediatric Emergency Care Applied Research Network risk factor were
compared before and after clinical decision support: proportion of ED computed
tomography (CT) scans, adjusted for age, time trend, and site; and prevalence
of clinically important traumatic brain injuries.
RESULTS:
The risk of clinically important traumatic brain injuries
was known for 3,859 children with isolated findings (1,711 at intervention
sites before clinical decision support, 1,702 at intervention sites after
clinical decision support, and 446 at control sites). In this group, pooled CT
proportion decreased from 24.2% to 21.6% after clinical decision support (odds
ratio 0.86; 95% confidence interval 0.73 to 1.01). Decreases in CT use were
noted across intervention EDs, but not in controls. The pooled adjusted odds
ratio for CT use after clinical decision support was 0.73 (95% confidence
interval 0.60 to 0.88). Among the entire cohort, clinically important traumatic
brain injury was diagnosed at the index ED visit for 37 of 37 (100%) patients
before clinical decision support and 32 of 33 patients (97.0%) after clinical
decision support.
CONCLUSION:
Providing specific risks of clinically important traumatic
brain injury through electronic clinical decision support was associated with a
modest and safe decrease in ED CT use for children at nonnegligible risk of
clinically important traumatic brain injuries.
B. Study evaluates EMLA cream for
infant venipuncture pain relief
Researchers found that the eutectic mixture of lidocaine
cream was slightly better than placebo but not better than breastfeeding and/or
sucrose in providing pain relief in babies younger than 3 months who underwent
venipuncture. The findings in Pediatrics -- based on a review of 10 randomized
control trials involving 907 infants -- also linked EMLA cream use with
increased methemoglobin levels and skin blanching, but researchers said the
results may not be applicable to infants ages 3 months and older.
13. Behavioral Health Problems in the ED—More Prevalent than
Documented, but There for the Asking
Kene M, et al. Feasibility of expanded ED screening for
behavioral health problems. Am J Manag Care. 2018 Dec;24(12):585-591.
OBJECTIVES:
Behavioral health conditions and social problems are common
yet underrecognized among emergency department (ED) patients. Traditionally,
ED-based behavioral health screening is limited. We evaluated the feasibility
of expanded behavioral health screening by a trained nonclinician.
STUDY DESIGN:
Prospective observational study of a convenience sample of
ED patients.
METHODS:
A research assistant (RA) approached a convenience sample of
adult ED patients within an integrated healthcare delivery system. Patients
completed a paper screening instrument (domains: mood, anxiety, alcohol use,
drug use, sleep, intimate partner violence, and chronic pain) and reviewed
responses with the RA, who shared positive screening results with the treating
ED physician. We abstracted behavioral health and medical diagnoses from the
electronic health record (EHR), comparing the screened cohort with the eligible
population. We used χ2 tests to assess differences in demographics and
comorbidities between screened patients and the eligible group and differences
between self-reported symptoms and EHR diagnoses among screened patients.
RESULTS:
Among 598 screened patients, the prevalence of self-reported
symptoms was higher than that of associated EHR diagnoses in the year prior to
the ED visit (anxiety, 45% vs 19% [P <.001]; depression, 40% vs 22% [P less than .001]; drug use,
7% vs 4% [P = .011]; risky alcohol use, 12% vs 5% [P less than .001]; chronic
pain, 47% vs 30% [P less
than .001]; and sleep problems, 47% vs 4% [P less than .001]).
CONCLUSIONS:
A dedicated RA was able to integrate screening into patient
idle times in the ED visit. The prevalence of behavioral health problems was
higher than indicated in the EHR.
Full-text (free): https://www.ajmc.com/journals/issue/2018/2018-vol24-n12/feasibility-of-expanded-emergency-department-screening-for-behavioral-health-problems
14. Opioid Corner
A. RCT of IV Acetaminophen Vs IV
Hydromorphone for the Treatment of Acute Pain in the ED
Barnaby DP, et al. Ann Emerg Med. 2019;73(2):133-140.
STUDY OBJECTIVE:
As clinicians look to nonnarcotic analgesics in the
emergency department (ED), it is essential to understand the effectiveness and
adverse effects of nonopioid medications in comparison with existing opioid
treatments. Studies of intravenous acetaminophen for acute pain in the ED
demonstrate mixed results and suffer from small sample sizes and methodological
limitations. This study compares intravenous hydromorphone with intravenous
acetaminophen in adult ED patients presenting with acute pain.
METHODS:
This was a prospective, randomized, clinical trial comparing
1 g intravenous acetaminophen with 1 mg intravenous hydromorphone for treatment
of adults with severe, acute pain in the ED. The primary outcome was
between-group difference in change in numeric rating scale from baseline to 60
minutes postadministration of study medication. Secondary outcomes included the
difference in proportion of patients in each group who declined additional
analgesia at 60 minutes, received additional medication before 60 minutes, and
developed nausea, vomiting, or pruritus.
RESULTS:
Of 220 subjects randomized, 103 patients in each arm had
sufficient data for analysis. At 60 minutes, the mean decrease in numeric rating
scale pain score was 5.3 in the hydromorphone arm and 3.3 in the acetaminophen
arm, a difference of 2.0 (95% confidence interval [CI] 1.2 to 2.7) favoring
hydromorphone. A greater proportion of patients in the hydromorphone arm also
declined additional analgesia at 60 minutes (65% versus 44%; difference 21%;
(95% CI 8% to 35%). There was no difference in the proportion of patients
receiving rescue analgesia before 60 minutes. Significantly more subjects in
the hydromorphone group developed nausea (19% versus 3%; difference 16%; 95% CI
4% to 28%) and vomiting (14% versus 3%; difference 11%; 95% CI 0% to 23%).
CONCLUSION:
Although both 1 mg intravenous hydromorphone and 1 g
intravenous acetaminophen provided clinically meaningful reductions in pain
scores, treatment with hydromorphone provided both clinically and statistically
greater analgesia than acetaminophen, at the cost of a higher incidence of
nausea and vomiting.
Full-text (free): https://www.annemergmed.com/article/S0196-0644(18)30550-X/fulltext
B. EDs — A 24/7/365 Option for
Combating the Opioid Crisis
D’Onofrio G, et al. N Engl J Med 2018 Dec
27;379(26):2487-2490.
Emergency departments (EDs) administer lifesaving
interventions all day every day and all night every night. In addition to
rapidly resuscitating and stabilizing patients with acute illness and injury,
emergency physicians are charged with identifying the appropriate level and
type of care within the health care system — from intensive care to treatment
in an outpatient clinic — for patients who are seen in the ED. The ED is less
well known for its role in the identification of chronic diseases, including
hypertension and diabetes, and subsequent treatment initiation and referral.
Many emergency physicians no longer blink at starting patients on treatment for
such conditions and then making a handoff to a primary care provider or
federally qualified health center.
When it comes to opioid use disorder (OUD), however, there
has been reluctance among emergency physicians to initiate treatment with
buprenorphine, despite the preponderance of evidence from well-designed
clinical trials supporting opioid-agonist treatment. Most recently, a
randomized trial conducted by Yale School of Medicine investigators, including
one of us (G.D.), demonstrated the feasibility and efficacy of ED-initiated
buprenorphine treatment in 329 patients who were enrolled with OUD and who
presented to the ED seeking treatment (34%) or were identified by screening
(66%), including 9% after an overdose. Patients who were assigned to a brief
psychosocial intervention, started on buprenorphine treatment in the ED, and
linked to the hospital’s primary care center for 10 weeks of continued
treatment were twice as likely to be engaged in formal addiction treatment at
30 days as those who were given a referral to treatment alone or a brief
psychosocial intervention and a facilitated referral to community-based
treatment services.1 ED-initiated buprenorphine was also found to be
cost-effective.2
The lack of uptake of buprenorphine treatment despite
compelling evidence may be attributed in part to factors such as misconceptions
or stigma associated with addiction and concerns about diversion of
medications, increased ED length of stay, and the potential precipitation of an
influx of people seeking treatment…
C. Hospital Observation Upon Reversal
(HOUR) With Naloxone: A Prospective Clinical Prediction Rule Validation Study
Clemency BM, et al.
Acad Emerg Med 2018 December 28 [Epub ahead of print]
Objective
St. Paul's Early Discharge Rule was derived to determine
which patients could be safely discharged from the emergency department after a
1‐hour observation period following naloxone administration for opiate
overdose. The rule suggested that patients could be safely discharged if they
could mobilize as usual and had a normal oxygen saturation, respiratory rate,
temperature, heart rate, and Glasgow Coma Scale score. Validation of the St.
Paul's Early Discharge Rule is necessary to ensure that these criteria are
appropriate to apply to patients presenting after an unintentional presumed
opioid overdose in the context of emerging synthetic opioids and expanded
naloxone access.
Methods
In this prospective, observational validation study,
emergency medicine providers assessed patients 1 hour after administration of
prehospital naloxone. Unlike in the derivation study the threshold for normal
oxygen saturation was set at 95% and patients were not immediately discharged
after a normal 1‐hour evaluation. Patients were judged to have a normal 1‐hour
evaluation if all six criteria of the rule were met. Patients were judged to
have an adverse event (AE) if they had one or more of the preestablished AEs.
Results
A total of 538 patients received at least one administration
of prehospital naloxone, were transported to the study hospital, and had a
1‐hour evaluation performed by a provider. AEs occurred in 82 (15.4%) patients.
The rule exhibited a sensitivity of 84.1% (95% confidence interval [CI] =
76.2%–92.1%), a specificity of 62.1% (95% CI = 57.6%–66.5%), and a negative predictive
value of 95.6% (95% CI = 93.3%–97.9%). Only one patient with a normal 1‐hour
evaluation subsequently received additional naloxone following a presumed
heroin overdose.
Conclusion
This rule may be used to risk stratify patients for early
discharge following naloxone administration for suspected opioid overdose.
Full-text (free): https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13567
15. A New Mindset (Selective Home Discharge) is a Win-Win for PE
Patients
Ballard D, et al. Emerg Med News. 2018;40(12):12.
Changing practice can be difficult. Not only do we have to learn
a new way of doing things, we also have to unlearn old ways and unprogram
heuristics that may be well established. Translation of new evidence into
practice can take years. Take, for example, managing acute hemodynamically
stable pulmonary embolism (PE). Disposing this patient has always been simple: anticoagulate
and admit. From the EP’s mindset, this formula seems like a win-win: clean
disposition and a clean conscience that the patient would be safe in the
hospital. But what is a win for one might not be for the other. The other
in this case is the hospitalist who has one more patient to round on, the
hospital supervisor who has one fewer inpatient bed available, the hospital
administrator who may have to write off unreimbursed admission costs.
And data suggest that lower-risk PE patients who have a
longer length of stay also have a much higher rate of hospital-acquired complications, most notably
pneumonia. (PLoS One 2017;12[10]:e0185022; http://bit.ly/2PqtZQh.)
Is our longstanding clinical practice of admitting acute PE patients really the winner that it has seemed?
Sending Patients Home
Outpatient management of ED patients with PE is nothing new.
Several hospitals in Canada launched an outpatient pathway in the late 1990s,
publishing their reassuring results in 2000, and a number of prospective
studies followed. (Ann Emerg Med 2012;60[5]:651; http://bit.ly/2yawtM8.
The most rigorous was a multinational
trial of low-risk ED patients who lacked contraindications to home care and who
were stratified using the PE Severity Index (PESI). Patients were randomized to
outpatient v. inpatient care and followed for 90 days. (Lancet 2011;378[9785]:41.)…
The rest of the essay (free), along with others by Dr
Ballard: https://journals.lww.com/em-news/Pages/collectiondetails.aspx?TopicalCollectionId=24
16. Unexpected Medical Emergencies
A. In-Flight Medical Emergencies: A
Review
Martin-Gill C,
et al. JAMA. 2018;320(24):2580-2590.
Importance In-flight medical emergencies (IMEs) are
common and occur in a complex environment with limited medical resources.
Health care personnel are often asked to assist affected passengers and the
flight team, and many have limited experience in this environment.
Observations In-flight medical emergencies are estimated
to occur in approximately 1 per 604 flights, or 24 to 130 IMEs per 1 million
passengers. These events happen in a unique environment, with airplane cabin
pressurization equivalent to an altitude of 5000 to 8000 ft during flight,
exposing patients to a low partial pressure of oxygen and low humidity. Minimum
requirements for emergency medical kit equipment in the United States include
an automated external defibrillator; equipment to obtain a basic assessment,
hemorrhage control, and initiation of an intravenous line; and medications to
treat basic conditions. Other countries have different minimum medical kit
standards, and individual airlines have expanded the contents of their medical
kit.
The most
common IMEs involve syncope or near-syncope (32.7%) and gastrointestinal
(14.8%), respiratory (10.1%), and cardiovascular (7.0%) symptoms. Diversion of
the aircraft from landing at the scheduled destination to a different airport
because of a medical emergency occurs in an estimated 4.4% (95% CI, 4.3%-4.6%)
of IMEs. Protections for medical volunteers who respond to IMEs in the United
States include a Good Samaritan provision of the Aviation Medical Assistance
Act and components of the Montreal Convention, although the duty to respond and
legal protections vary across countries. Medical volunteers should identify
their background and skills, perform an assessment, and report findings to
ground-based medical support personnel through the flight crew. Ground-based
recommendations ultimately guide interventions on board.
Conclusions
and Relevance In-flight medical
emergencies most commonly involve near-syncope and gastrointestinal,
respiratory, and cardiovascular symptoms. Health care professionals can assist
during these emergencies as part of a collaborative team involving the flight
crew and ground-based physicians.
B.
The 2017 Fire in Santa Rosa, California
UC Davis, EM
Pulse Podcast (episode 13): Last Stand
in Santa Rosa (46
min)
Imagine you’re working a shift in the Emergency
Department when a fast moving wildfire hits. What would you do if you found out
your home was burning? Or your family was in danger? And how do you react when
the Fire Department tells you they are making a last stand a block away from
your hospital? This situation is all too real for many physicians and providers
affected by devastating wildfires in California. In this episode, we follow the
story of the 2017 Santa Rosa fires from the perspective of three Emergency
Physicians, Dr. Josh Weil, Dr. Suzy Fitzgerald, and Dr. Dane Stevenson. Their
powerful story, and the lessons learned from their experience, are guaranteed
to improve your personal and professional disaster preparedness.
17. Prospective study of the (poor) sensitivity of the Wood's
lamp for common eye abnormalities.
Hooker EA, et al. Emerg Med J. 2019 Jan 10. [Epub ahead of
print]
OBJECTIVE:
The Wood's lamp, a handheld instrument that uses long-wave
ultraviolet (UV) light with magnification of 2-3 times, is commonly used by
non-ophthalmologists for examining patients with eye complaints. The goal of
current research was to determine the sensitivity and specificity of the Wood's
lamp for common eye abnormalities.
STUDY DESIGN:
We examined a convenience sample of patients, 18 years of
age and older, who presented for eye complaints to an urgent clinic of a large
ophthalmology practice. This prospective observational trial was performed from
December 2016 until July 2017. An ophthalmologist examined the patient's eyes
with a Wood's lamp, followed by examination of the eyes using a slit lamp. The
Wood's lamp was compared with the slit lamp, which served as the gold standard.
RESULTS:
There were 73 patients recruited. The mean age of study
subjects (29 female and 44 male) was 49 years. The overall sensitivity of the
Wood's lamp was 52% (38/73; 95% CI 40% to 64%). Based on the principal final
diagnosis made with the slit lamp, the Wood's lamp only detected 9 of 16
corneal abrasions, 5 of 10 corneal ulcers, 5 of 9 corneal foreign bodies, 0 of
4 cases of non-herpetic keratitis, 1 of 2 cases of herpes keratitis, 1 of 5
rust rings and 18 of 28 other diagnoses.
CONCLUSIONS AND RELEVANCE:
Examination using the Wood's lamp fails to detect many
common eye abnormalities. Our findings support the need for a slit lamp
examination of patients with eye complaints whenever possible.
18. Emergency Care—Say Thanks to the Whole Team!
Emergentology: The Less Sung, Less Thanked, Less Recognized
Walker G. Emerg Med News. 2018;40(12):25.
After signing out to me, a colleague recently texted me on
his way home. “I hope Molly and Ron were able to get room 19 out like I said.
He needed a lot of TLC during the shift.”
Nurses Molly and Ron certainly did: I didn't hear a peep
from room 19, and the patient apparently left the ED without any issues.
Later that same night shift, I looked up to see a card taped
to the wall with my name on it. “Dr. Walker, thank you for your care,” the note
read. I'd run into the patient's daughter the night prior and said hello. The
patient had been a fairly hairy ethical and medical dilemma about a year ago
and was back after a fall.
I was showing the nice card to the night nurses and quickly
realized that none of them received a card. Nor did the techs, nor the
housekeepers, nor the patient care coordinator, nor the social worker. Not the
nurse manager, or the ED director, or the unit assistant. No card for the
phlebotomist. Or the materials and supplies worker. Or the pharmacist. Or the
paramedic who was already gone. Certainly not the engineer we call when the
tube system goes down or the heating or cooling goes haywire.
Sure, the doctor is often the captain of the ship in the
patient's eyes, and the health care team certainly is structured that way, but
often the entire fleet is barely staying afloat, and it's the entire team that
is to thank for keeping our patients safe. I don't have much more to say in
this month's column besides this: Thank you. Thank you. Thank you. My editor
said I couldn't just repeat “Thank you” for another 600 words, so I'd like to
highlight some examples of how much of a difference people make to my ability
to see patients, discharge patients, and maintain my sanity.
- The nurse who is able to answer all of the questions that I've already answered three times, so the patient doesn't ask to see me a fourth time at the bedside and so I can spend time at the bedside of a critical patient. Thank you.
- The nurse who explains the plan and discusses the status of the patient to the first family member and the second and the third, so I can actually create the complicated plan. Thank you.
- The patient care coordinator who knows everyone in the hospital and clinic and is able to get a neonate with a fever directly admitted to the NICU for his entire workup and admission, bypassing the ED. Thank you.
- The tech who anticipates my needs and proactively predicts my plan: “Hey, I overheard you telling bed 3 it's a distal radius fracture. Is it OK if I get the fingertraps and some splinting stuff ready?” Thank you.
- The housekeeper who sees that a patient has been discharged and immediately starts cleaning the room because she knows the waiting room is full. Thank you.
- The social worker who pulls an amazing community resource out of his back pocket (that you never knew existed) to safely get a disposition nightmare to a better locale than the ED hallway for three days. Thank you.
- The charge nurse who lets you take up a code bed for three minutes to suture a laceration so you can see the next patient. Thank you.
- The nursing manager who pushes the house supervisor to get beds ready because a STEMI, a stroke, and three appys that will need the OR just showed up. Thank you.
- The tech who does the road test and PO challenge for the patient and is experienced enough to know that the drunk patient needs a little more time to make sure it's a safe discharge. Thank you.
- The paramedic who just had a suspicion about a patient and ended up putting in two big lines before the patient decided to code for no good reason. Thank you.
19. Infectious Disease
A. Toward a More Nuanced Approach to
the Early Administration of IV Fluids in Patients with Sepsis
Rhee C, et al. JAMA Netw Open. 2018;1(8):e185844.
After decades of research and dozens of failed trials, the
mainstay of the treatment of sepsis remains early administration of antibiotics
and intravenous fluid resuscitation. The importance of early antibiotics in
severe bacterial infection is biologically plausible and supported by numerous
studies demonstrating a strong association with sepsis mortality. On the other
hand, the evidence supporting the association of early intravenous fluid
resuscitation with mortality in patients with sepsis is much more equivocal.
Elucidating the precise role of intravenous fluids is critical in light of the
high burden of sepsis as well as recent policy initiatives, such as the Centers
for Medicare & Medicaid Services’ Early Management Bundle, Severe
Sepsis/Septic Shock (SEP-1) measure, that mandate early aggressive intravenous
fluid resuscitation.
The concept of intravenous fluid therapy for sepsis is based
in part on the pathophysiological characteristics of sepsis that induce changes
in vascular permeability and decrease fluid retention in the vascular
compartment.1 Much of the clinical evidence supporting the use of intravenous
fluid therapy in sepsis stems from the original early goal-directed therapy
trial, in which early liberal intravenous fluid therapy and optimization of
specific hemodynamic targets led to reduced mortality in patients with septic
shock.2 This study, and the Surviving Sepsis Campaign that followed, catalyzed
the implementation of sepsis treatment bundles in hospitals around the world
that led to administration of larger volumes of intravenous fluids during the
ensuing decade.3 Concurrently, sepsis-related mortality declined, but it is
difficult to attribute this decline to greater intravenous fluid resuscitation,
because numerous diagnostic, treatment, and organ support factors have also
been changed in the last decade.
The contribution of intravenous fluid resuscitation is
difficult to disentangle from the other interventions contained within sepsis
treatment bundles, particularly early initiation of antibiotics. A recent
Bayesian analysis of 37 studies that included approximately 20 000 patients
suggested that the mortality benefit in the early goal-directed therapy trials
was explained solely by earlier administration of appropriate antibiotics,
rather than intravenous fluids or any of the protocol’s hemodynamic targets.4
Another recent analysis of nearly 50 000 patients with sepsis who were treated
with mandated care in New York state hospitals found a strong association in
mortality with delays in antibiotic therapy but not completion of the initial
30-mL/kg fluid bolus.5 A multicenter analysis of the effect of compliance with
SEP-1 suggested that failing on the 3-hour antibiotic measure was associated
with higher mortality, while failing the treatment bundle on any other
component (including the 30-mL/kg fluid requirement) was not.6
Furthermore, the liberal intravenous fluid paradigm has
recently been challenged by observational studies and randomized clinical
trials suggesting poorer outcomes associated with a positive fluid balance in
patients with sepsis.7,8 In addition to endothelial leak, vasoplegia is a
central feature of the pathophysiological characteristics of sepsis and may
predominate in patients who are not responsive to intravenous fluids.1
Furthermore, preexisting or sepsis-induced cardiac and lung dysfunction is
common, and tissue edema from volume overload can impair blood flow and
drainage and contribute to organ dysfunction.
In light of these uncertainties around the role of early
intravenous fluid resuscitation in sepsis, the study by Lane and colleagues9 is
a welcome contribution….
B. Evaluation and Management of Septic
Arthritis and its Mimics in the ED
Long B, et al. West J Emerg Med. 2018 Dec 06 [Epub ahead of
print].
Septic arthritis is a dangerous medical condition associated
with significant morbidity and mortality. However, the differential diagnosis
can be broad with conditions that mimic this disease and require different
evaluation and treatment.
This narrative review presents the emergency medicine evaluation
and management, as well as important medical conditions that may mimic this
disease. Septic arthritis commonly presents with monoarticular joint pain with
erythema, warmth, swelling, and pain on palpation and movement. Fever is
present in many patients, though most are low grade. Blood testing and imaging
may assist with the diagnosis, but the gold standard is joint aspiration.
Management includes intravenous antibiotics and orthopedic surgery consult for
operative management vs. serial aspirations.
Clinicians should consider mimics, such as abscess,
avascular necrosis, cellulitis, crystal-induced arthropathies, Lyme disease,
malignancy, osteomyelitis, reactive arthritis, rheumatoid arthritis, and
transient synovitis. While monoarticular arthritis can be due to septic
arthritis, other medical and surgical conditions present similarly and require
different management. It is essential for the emergency clinician to be aware
how to diagnose and treat these mimics.
C. Emergency medical services oxygen
equipment: a fomite for transmission of MRSA?
Gibson CV. Emerg Med J. 2018 Dec 1 [Epub ahead of print]
Objectives The primary purpose of this study was to
determine if methicillin-resistant Staphylococcus aureus (MRSA) was present on
the surface of oxygen cylinders and regulators used in the prehospital setting
and secondarily to assess other surfaces for MRSA within the ambulance
compartment, as a comparison.
Methods On 17 March 2018, the surface of oxygen cylinders
and regulators located in ambulances at an emergency medical services (EMS)
station in North Alabama (n=9) and at an offsite oxygen cylinder storage area
(n=70) were swabbed using sterile cotton-tipped applicators saturated in an
0.9% NaCl solution. These cotton-tipped applicators were then streaked across
the surface of HardyCHROM MRSA plates, followed by incubation at 36°C for
24 hours. The growth of pink or magenta colonies was considered a positive
indication for the presence of MRSA. The motivation for assessing oxygen
cylinders at the offsite storage area was to outline the persistence of MRSA on
stored oxygen cylinders.
Results Of nine oxygen cylinders tested in the ambulances,
nine had MRSA colonisation (100%). MRSA was also present on 67 of 70 oxygen
cylinders (96%) tested at the offsite oxygen cylinder storage area.
Conclusion Oxygen cylinders appear to act as a fomite for
MRSA. The development of universal disinfection protocols for oxygen equipment
could help reduce the risk of patient infection due to cross-contamination.
D. Identification of risk factors for
failure in patients with skin and soft tissue infections.
Cieri B, et al. Am J Emerg Med. 2019 Jan;37(1):48-52.
PURPOSE:
The purpose was to determine significant predictors of
treatment failure of skin and soft tissue infections (SSTI) in the inpatient
and outpatient setting.
METHODS:
A retrospective chart review of patients treated between
January 1, 2005 to July 1, 2016 with ICD-9 or ICD-10 code of cellulitis or
abscess. The primary outcome was failure defined as an additional prescription
or subsequent hospital admission within 30 days of treatment. Risk factors for
failure were identified through multivariate logistic regression.
RESULTS:
A total of 541 patients were included. Seventeen percent
failed treatment. In the outpatient group, 24% failed treatment compared to 9%
for inpatients. Overweight/obesity (body mass index (BMI) over 25 kg/m2) was
identified in 80%, with 15% having a BMI over 40 kg/m2. BMI, heart failure, and
outpatient treatment were determined to be significant predictors of failure.
The unit odds ratio for failure with BMI was 1.04 (95% [Cl] = 1.01 to 1.1,
p = 0.0042). Heart failure increased odds by 2.48 (95% [Cl] = 1.3 to 4.7,
p = 0.0056). Outpatients were more likely to fail with an odds ratio of 3.36.
CONCLUSION:
Patients with an elevated BMI and heart failure were found
to have increased odds of failure with treatment for SSTIs. However, inpatients
had considerably less risk of failure than outpatients. These risk factors are
important to note when making the decision whether to admit a patient who
presents with SSTI in the emergency department. Thoughtful strategies are
needed with this at-risk population to prevent subsequent admission.
20. Physicians Are Steering the Conversation About Gun Violence
Rubin R. JAMA.
2019;321(2):133-135.
This Medical News story is an interview with Megan
Ranney, MD, MPH, one of the leading voices in the “This Is Our Lane” movement,
which discusses the role of physicians and other health-care professionals in
addressing firearm violence as a public health issue.
Full-text
(free): https://jamanetwork.com/journals/jama/fullarticle/2719213
21. Micro Bits
A.
1 in 4 globally will have a stroke at age 25 or older, according to new study
B.
Opioids only slightly better than placebo to treat chronic pain
Results from a recent study examining the effect of opioids
versus placebo on chronic pain in patients with osteoarthritis, fibromyalgia
and sciatica indicated that opioids offer only marginally better outcomes
compared with placebo and should be used only as a last option. Opioids cause a
range of adverse effects, including nausea, vomiting and constipation, in
addition to working no better than nonsteroidal anti-inflammatory drugs like
ibuprofen.
C.
Study looks at efficacy of mindfulness-based eating in obesity
A study in The Journal of Clinical Endocrinology &
Metabolism showed that adults with obesity who participated in four 90-minute
group sessions teaching mindfulness-based eating strategies saw a mean weight
loss of 3.1 kilograms compared with 0.21 kilograms in the control group and had
a 4% improvement in overall self-reported eating style. Researchers evaluated
33 individuals and noted that "such intervention can be applied not only
to improve the effectiveness of specialist weight management programs, but also
more widely to tackle the problem of unhealthy lifestyle," said study
author Petra Hanson.
D.
Wearing Contacts 24/7 Can Bring Infection, Blindness, Doctors Warn
Dangerous infections, blinding ulcers in the eyes: These are
just some of the troubles that can come from wearing your contacts for too
long. Contact lenses are generally considered safe, but wearing them while
asleep significantly raises the risk of developing serious complications that
can cause permanent visual loss, the U.S. Centers for Disease Control and
Prevention warns.
U.S. News & World Report: https://www.usnews.com/news/health-news/articles/2018-12-19/wearing-contacts-24-7-can-bring-infection-blindness-doctors-warn
Ann Emerg Med article (full-text free): https://www.annemergmed.com/article/S0196-0644(18)31475-6/fulltext
E.
Social Determinants of Health in the Digital Age: Determining the Source Code
for Nurture
The scope and types of data available in social networks
represent growing potential resources for deciphering and addressing the social
determinants of health. Between 2005 and 2018, the use of social media among
individuals in the United States increased from 5% to 69%.1 In 2016, the Pew
Research Center found that Facebook was the most popular platform, used by 68%
of the US population (76% of whom visited the site daily, engaging for nearly
an hour a day), followed by Instagram, Pinterest, LinkedIn, and Twitter.1
Social media user profiles represent archives of people’s activities and
connections, curated in real time. Furthermore, the relationships between and among
users are dynamic social network structures that intertwine people, places, and
their interests.2 This information has the potential to improve understanding
of the social determinants of health in a deeper way than prior data sources
have ever allowed, and, in turn, identify novel targets that could meaningfully
influence health outcomes.….
F.
Gut microbiome may seed sepsis
Using a new bioinformatics tool that can rapidly identify
pathogens in a patient's gut microbiome, researchers have found evidence that a
patient's own microbiome may be the source of hospital-acquired bloodstream
infections (BSIs).
G.
Despite an
opioid crisis, most ERs don’t offer addiction treatment. California is changing
that.
This is what
it looks like when we stop treating addiction as a moral failure.
By German
Lopez. Vox, Jan 8, 2019
SACRAMENTO,
California — When Michael Curci still used opioid painkillers and heroin, he
didn’t see himself living beyond his mid-20s.
“I didn’t even
think I was going to make it,” Curci told me, while at the El Dorado County
clinic where he receives treatment for opioid addiction. “I didn’t think I was
going to have any type of future.”
Curci is now
28. The moment that helped him survive came in October 2017, when he went to an
emergency room not due to an overdose or an injection-related infection but to
seek treatment for addiction. Unlike most hospitals in the US, Marshall Medical
Center, an hour’s drive east of Sacramento, provided him with real treatment —
particularly, buprenorphine, a highly effective medication that treats opioid
addiction by mitigating withdrawal and cravings for the drugs…
H.
Poor Sleep? Arteries May Suffer
Short, disrupted sleep associated with atherosclerosis
I.
Does Loneliness Add to Physician Burnout? Yes, and you can fix it
J.
Medical Errors Increase with Physician Burnout
K.
Operative treatment versus nonoperative treatment of Achilles tendon ruptures:
systematic review and meta-analysis
L.
Many children, adults receive antibiotics they don't need
M.
Effect of maternal caffeine intake on birth outcomes examined
Researchers who studied about 1,000 Irish women found about
double the risk of delivering babies with short gestational age or abnormally
low birth weight among those who had the highest consumption of caffeine during
pregnancy. The study in The
American Journal of Clinical Nutrition found the link
was consistent regardless of whether caffeine was consumed in coffee or tea,
and the authors urged expectant women to at least limit caffeine intake.
N.
Most People Don't Need Vitamins or Nutritional Supplements
JAMA Patient Handout: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2720139
