1. ED Atrial Fibrillation Research
A. Early or Delayed Cardioversion in
Recent-Onset AF
Pluymaekers NAHA, et al. RACE 7 ACWAS Investigators. N Engl
J Med. 2019 Mar 18 [Epub ahead of print].
BACKGROUND:
Patients with recent-onset atrial fibrillation commonly
undergo immediate restoration of sinus rhythm by pharmacologic or electrical
cardioversion. However, whether immediate restoration of sinus rhythm is
necessary is not known, since atrial fibrillation often terminates
spontaneously.
METHODS:
In a multicenter, randomized, open-label, noninferiority
trial, we randomly assigned patients with hemodynamically stable, recent-onset
(less than 36 hours), symptomatic atrial fibrillation in the emergency
department to be treated with a wait-and-see approach (delayed-cardioversion
group) or early cardioversion. The wait-and-see approach involved initial
treatment with rate-control medication only and delayed cardioversion if the
atrial fibrillation did not resolve within 48 hours. The primary end point was
the presence of sinus rhythm at 4 weeks. Noninferiority would be shown if the
lower limit of the 95% confidence interval for the between-group difference in
the primary end point in percentage points was more than -10.
RESULTS:
The presence of sinus rhythm at 4 weeks occurred in 193 of
212 patients (91%) in the delayed-cardioversion group and in 202 of 215 (94%)
in the early-cardioversion group (between-group difference, -2.9 percentage
points; 95% confidence interval [CI], -8.2 to 2.2; P = 0.005 for
noninferiority). In the delayed-cardioversion group, conversion to sinus rhythm
within 48 hours occurred spontaneously in 150 of 218 patients (69%) and after
delayed cardioversion in 61 patients (28%). In the early-cardioversion group,
conversion to sinus rhythm occurred spontaneously before the initiation of
cardioversion in 36 of 219 patients (16%) and after cardioversion in 171
patients (78%). Among the patients who completed remote monitoring during 4
weeks of follow-up, a recurrence of atrial fibrillation occurred in 49 of 164
patients (30%) in the delayed-cardioversion group and in 50 of 171 (29%) in the
early-cardioversion group. Within 4 weeks after randomization, cardiovascular
complications occurred in 10 patients and 8 patients, respectively.
CONCLUSIONS:
In patients presenting to the emergency department with
recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was
noninferior to early cardioversion in achieving a return to sinus rhythm at 4
weeks.
Full-text (free): https://www.nejm.org/doi/full/10.1056/NEJMoa1900353
Use
of the “wait and see” approach in the community ED setting in Kaiser Permanente
From a three-center prospective observational study: “Management
of patients with recent-onset atrial fibrillation and flutter was not
standardized, but was left to the discretion of the treating physician. Our
taxonomy of management approaches is based on whether cardioversion was
spontaneous, attempted, hoped for, or contraindicated.
The four groups were as follows:
1) Patients who spontaneously cardioverted to sinus rhythm
in the ED after their initial diagnostic ECG.
2) Patients who underwent attempted pharmacological or
electrical cardioversion.
3) Patients who were not cardioverted, but were discharged
in atrial fibrillation with short-term home observation in hopes of spontaneous
cardioversion. They were scheduled to return within 48 hours of symptom-onset,
at which time a repeat ECG would guide further management.
4) Patients who did not spontaneously convert and were
deemed ineligible for attempted ED cardioversion.”
16 of 206 study patients (7.8%) were treated with the “wait
and see” approach, 11 of whom were found to have spontaneously cardioverted on
follow-up.
Vinson DR, et al. Managing ED patients with recent-onset AF.
J Emerg Med. 2012;42(2):139-148. https://www.ncbi.nlm.nih.gov/pubmed/20634022
B. The Canadian Community Utilization
of Stroke Prevention Study in AF in the ED (C-CUSP ED).
Parkash R, et al. Ann Emerg Med. 2019;73(4):382-92.
INTRODUCTION:
Atrial fibrillation is the most common sustained cardiac
dysrhythmia and has been targeted as becoming a worldwide epidemic in the
upcoming decades.1 It is associated with significant morbidity, mortality, and
cost, including a 2-fold increase in mortality and a 6-fold increase in the
risk of stroke.2, 3 The attributable stroke risk caused by atrial fibrillation
is 15%, two thirds of which may be prevented with adequate oral
anticoagulation.4 Administrative data in Alberta demonstrated that the use of
oral anticoagulation was associated with a significantly reduced risk of stroke
and all-cause mortality in patients with incident atrial fibrillation.5 The
emergency department (ED) is often the location of the first diagnosis of
atrial fibrillation.6 The Randomized Evaluation of Long-Term Anticoagulation Therapy
Atrial Fibrillation Registry is an ED-based registry of 15,400 patients with
ECG-documented atrial fibrillation in 46 countries; the reported use of oral
anticoagulation at discharge from an ED for patients with a CHADS2 score of
greater than or equal to 2 was found to be 65.7%.7 Recognizing that this is a
significant gap in care of patients with atrial fibrillation8, 9 and that
addressing this gap could lead to reductions in stroke and death, we sought to
determine whether a multidisciplinary ED-based intervention, with prompt
follow-up by a community-based clinic dedicated to the care of atrial
fibrillation, would improve prescription of oral anticoagulation for patients
presenting to the ED with atrial fibrillation.
STUDY OBJECTIVE:
Lack of oral anticoagulation prescription in the emergency
department (ED) has been identified as a care gap in atrial fibrillation
patients. This study seeks to determine whether the use of a tool kit for
emergency physicians with a follow-up community-based atrial fibrillation
clinic resulted in greater oral anticoagulation prescription at ED discharge
than usual care.
METHODS:
This was a before-after study in 5 Canadian EDs in 3 cities.
Patients who presented to the ED with atrial fibrillation were eligible for
inclusion. The before phase (1) was retrospective; 2 after phases (2 and 3)
were prospective: phase 2 used an oral anticoagulation prescription tool for
emergency physicians and patient education materials, whereas phase 3 used the
same prescription tool, patient materials, atrial fibrillation educational
session, and follow-up in an atrial fibrillation clinic. Each phase was 1 year
long. The primary outcome was the rate of new oral anticoagulation prescription
at ED discharge for patients who were oral anticoagulation eligible and not
receiving oral anticoagulation at presentation.
RESULTS:
A total of 631 patients were included. Mean age was 69 years
(SD 14 years), 47.4% were women, and 69.6% of patients had a CHADS2 score
greater than or equal to 1. The rate of new oral anticoagulation prescription
in phase 1 was 15.8% compared with 54.1% and 47.2%, in phases 2 and 3, respectively.
After multivariable adjustment, the odds ratio for new oral anticoagulation
prescription was 8.03 (95% confidence interval 3.52 to 18.29) for phase 3
versus 1. The 6-month rate of oral anticoagulation use was numerically but not
significantly higher in phase 3 compared with phase 2 (71.6% versus 79.4%;
adjusted odds ratio 2.30; 95% confidence interval 0.89 to 5.96). The rate of
major bleeding at 6 months was 0%, 0.8%, and 1% in phases 1, 2, and 3,
respectively.
CONCLUSION:
An oral anticoagulation prescription tool was associated
with an increase in new oral anticoagulation prescription in the ED,
irrespective of whether an atrial fibrillation clinic follow-up was scheduled.
The use of an atrial fibrillation clinic was associated with a trend to a
higher rate of oral anticoagulation at 6-month follow-up.
Full-text (free): https://www.annemergmed.com/article/S0196-0644(18)31259-9/fulltext
2. Diagnosing ACS
A. True 99th centile of high sensitivity cardiac troponin for
hospital patients: prospective, observational cohort study.
Mariathas M, et al.
BMJ. 2019;364:l729.
OBJECTIVE:
To determine the
distribution, and specifically the true 99th centile, of high sensitivity
cardiac troponin I (hs-cTnI) for a whole hospital population by applying the
hs-cTnI assay currently used routinely at a large teaching hospital.
DESIGN:
Prospective,
observational cohort study.
SETTING:
University Hospital
Southampton NHS Foundation Trust, Southampton, United Kingdom, between 29 June
2017 and 24 August 2017.
PARTICIPANTS:
20 000 consecutive
inpatients and outpatients undergoing blood tests for any clinical reason.
Hs-cTnI concentrations were measured in all study participants and nested for
analysis except when the supervising doctor had requested hs-cTnI for clinical
reasons.
MAIN OUTCOME MEASURES:
Distribution of
hs-cTnI concentrations of all study participants and specifically the 99th
centile.
RESULTS:
The 99th centile of
hs-cTnI for the whole population was 296 ng/L compared with the manufacturer's
quoted level of 40 ng/L (currently used clinically as the upper limit of
normal; ULN). Hs-cTnI concentrations were greater than 40 ng/L in one in 20
(5.4%, n=1080) of the total population. After excluding participants diagnosed
as having acute myocardial infarction (n=122) and those in whom hs-cTnI was
requested for clinical reasons (n=1707), the 99th centile was 189 ng/L for the
remainder (n=18 171). The 99th centile was 563 ng/L for inpatients (n=4759) and
65 ng/L for outpatients (n=9280). Patients from the emergency department
(n=3706) had a 99th centile of 215 ng/L, with 6.07% (n=225) greater than the
recommended ULN. 39.02% (n=48) of all patients from the critical care units
(n=123) and 14.16% (n=67) of all medical inpatients had an hs-cTnI
concentration greater than the recommended ULN.
CONCLUSIONS:
Of 20 000 consecutive
patients undergoing a blood test for any clinical reason at our hospital, one
in 20 had an hs-cTnI greater than the recommended ULN. These data highlight the
need for clinical staff to interpret hs-cTnI concentrations carefully,
particularly when applying the recommended ULN to diagnose acute myocardial
infarction, in order to avoid misdiagnosis in the absence of an appropriate
clinical presentation.
B. Effect of a HEART Care Pathway on CP Management Within an
Integrated Health System.
Sharp AL, et al. Ann
Emerg Med. 2019 Feb 20 [Epub ahead of
print]
STUDY OBJECTIVE:
We describe the
association of implementing a History, ECG, Age, Risk Factors, and Troponin
(HEART) care pathway on use of hospital care and noninvasive stress testing, as
well as 30-day patient outcomes in community emergency departments (EDs).
METHODS:
We performed a
prospective interrupted-time-series study of adult encounters for patients
evaluated for suspected acute coronary syndrome. The primary outcome was
hospitalization or observation, noninvasive stress testing, or both within 30
days. The secondary outcome was 30-day all-cause mortality or acute myocardial
infarction. A generalized estimating equation segmented logistic regression
model was used to compare the odds of the primary outcome before and after
HEART implementation. All models were adjusted for patient and facility
characteristics and fit with physicians as a clustering variable.
RESULTS:
A total of 65,393 ED
encounters (before, 30,522; after, 34,871) were included in the study. Overall,
33.5% (before, 35.5%; after, 31.8%) of ED chest pain encounters resulted in
hospitalization or observation, noninvasive stress testing, or both. Primary
adjusted results found a significant decrease in the primary outcome
postimplementation (odds ratio 0.984; 95% confidence interval [CI] 0.974 to
0.995). This resulted in an absolute adjusted month-to-month decrease of 4.39%
(95% CI 3.72% to 5.07%) after 12 months' follow-up, with a continued trend
downward. There was no difference in 30-day mortality or myocardial infarction
(0.6% [before] versus 0.6% [after]; odds ratio 1.02; 95% CI 0.97 to 1.08).
CONCLUSION:
Implementation of a
HEART pathway in the ED evaluation of patients with chest pain resulted in less
inpatient care and noninvasive cardiac testing and was safe. Using HEART to
risk stratify chest pain patients can improve the efficiency and quality of
care.
C. Marijuana Lollipop-Induced Myocardial Infarction
Saunders A, et al.
Canadian J Cardiol 2019;35:229.e1–229.e3.
A 70-year-old man with
known coronary artery disease presented with crushing chest pain, diaphoresis,
and pallor after consuming a marijuana lollipop; the pain began within 30
minutes of consumption. His troponin T increased from 94 ng/L to 216 ng/L, with
slight ST changes but no gross ST elevations. Discharge diagnosis was
non–ST-elevation myocardial infarction, and subsequent nuclear medicine wall
motion studies showed worsening ejection fraction (40% to 31%). He also
described worsening functional status and exercise capacity after the event.
The outcome of this case is important with new marijuana legalization—hopefully
with marijuana use no longer criminalized, more research into the cardiovascular
side effects will emerge.
3. Diagnosing PE in Pregnancy
Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected PE
Van der Pol L, et al. N
Engl J Med 2019; 380:1139-1149
BACKGROUND
Pulmonary embolism is
one of the leading causes of maternal death in the Western world. Because of
the low specificity and sensitivity of the d-dimer test, all pregnant women
with suspected pulmonary embolism undergo computed tomographic (CT) pulmonary
angiography or ventilation–perfusion scanning, both of which involve radiation
exposure to the mother and fetus. Whether a pregnancy-adapted algorithm could
be used to safely avoid diagnostic imaging in pregnant women with suspected
pulmonary embolism is unknown.
METHODS
In a prospective study
involving pregnant women with suspected pulmonary embolism, we assessed three
criteria from the YEARS algorithm (clinical signs of deep-vein thrombosis,
hemoptysis, and pulmonary embolism as the most likely diagnosis) and measured
the d-dimer level. Pulmonary embolism was ruled out if none of the three
criteria were met and the d-dimer level was less than 1000 ng per milliliter or
if one or more of the three criteria were met and the d-dimer level was less
than 500 ng per milliliter. Adaptation of the YEARS algorithm for pregnant
women involved compression ultrasonography for women with symptoms of deep-vein
thrombosis; if the results were positive (i.e., a clot was present), CT
pulmonary angiography was not performed. All patients in whom pulmonary
embolism had not been ruled out underwent CT pulmonary angiography. The primary
outcome was the incidence of venous thromboembolism at 3 months. The secondary
outcome was the proportion of patients in whom CT pulmonary angiography was not
indicated to safely rule out pulmonary embolism.
RESULTS
A total of 510 women
were screened, of whom 12 (2.4%) were excluded. Pulmonary embolism was
diagnosed in 20 patients (4.0%) at baseline. During follow-up, popliteal
deep-vein thrombosis was diagnosed in 1 patient (0.21%; 95% confidence interval
[CI], 0.04 to 1.2); no patient had pulmonary embolism. CT pulmonary angiography
was not indicated, and thus was avoided, in 195 patients (39%; 95% CI, 35 to
44). The efficiency of the algorithm was highest during the first trimester of
pregnancy and lowest during the third trimester; CT pulmonary angiography was
avoided in 65% of patients who began the study in the first trimester and in
32% who began the study in the third trimester.
CONCLUSIONS
Pulmonary embolism was
safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all
trimesters of pregnancy. CT pulmonary angiography was avoided in 32 to 65% of
patients.
4. IV Lidocaine for Pain: Not the Best, Unfortunately
Chinn E, et al. Randomized
Trial of Intravenous Lidocaine Versus Hydromorphone for Acute Abdominal Pain in
the ED. Ann Emerg Med. 2019 Feb 26
[Epub ahead of print].
Study objective
We compare the
efficacy and safety of intravenous lidocaine with that of hydromorphone for the
treatment of acute abdominal pain in the emergency department (ED).
Methods
This was a randomized,
double-blind, clinical trial conducted in 2 EDs in the Bronx, NY. Adults
weighing 60 to 120 kg were randomized to receive 120 mg of intravenous
lidocaine or 1 mg of intravenous hydromorphone. Thirty minutes after
administration of the first dose of the study drug, participants were asked
whether they needed a second dose of the investigational medication to which
they were randomized. Patients were also stratified according to clinical
suspicion of nephrolithiasis. The primary outcome was improvement in pain
scores of 0 to 10 between baseline and 90 minutes. An important secondary
outcome was need for “off-protocol” parenteral analgesics, including opioids
and nonsteroidal anti-inflammatory drugs.
Results
We enrolled 154
patients, of whom 77 received lidocaine and 77 received hydromorphone. By 90
minutes, patients randomized to lidocaine improved by a mean of 3.8 points on
the 0-to-10 scale, whereas those randomized to hydromorphone improved by a mean
of 5.0 points (mean difference 1.2; 95% confidence interval 0.3 to 2.2). Need
for off-protocol “rescue” analgesics occurred for 39 of 77 lidocaine patients
(51%) and 20 of 77 hydromorphone patients (26%) (difference 25%; 95% confidence
interval 10% to 40%). Adverse events were comparable between groups. Among the
subset of 22 patients with nephrolithiasis, lidocaine patients reported a mean
improvement of 3.4 points on the pain scale, whereas hydromorphone patients
reported a mean improvement of 6.4 points (mean difference 3.0; 95% confidence
interval 0.5 to 5.5).
Conclusion
Intravenous
hydromorphone was superior to intravenous lidocaine both for general abdominal
pain and a subset of patients with nephrolithiasis. A majority of patients
randomly allocated to lidocaine required additional analgesics.
For a review of
lidocaine in the ED, see Silva here: https://www.ncbi.nlm.nih.gov/pubmed/29395284
5. Does this patient have a severe snake envenomation?: The
Rational Clinical Examination Systematic Review.
Gerardo
CJ, et al. JAMA Surg. 2019 Feb 13 [Epub ahead of print].
Key Points
Question What clinical features risk-stratify patients
with snakebite as having severe envenomations?
Findings In this systematic review, the pooled
prevalence of severe systemic envenomation, severe tissue injury, and severe
hematologic venom effects was 14%, 14%, and 18%, respectively. Time from bite
to care longer than 6 hours, patient age younger than 12 years, large snake
size, and ptosis increased the likelihood of severe systemic envenomation,
while envenomation by cottonmouth and copperhead (Agkistrodon) snakes (compared
with rattlesnakes) decreases the likelihood of severe systemic envenomation and
initial hypofibrinogenemia and thrombocytopenia increases the likelihood of
severe hematologic venom effects.
Meaning Physicians should evaluate patients with snakebites
for these features to determine which are at increased likelihood of severe
envenomation and should also be wary of progression from nonsevere to a severe
envenomation.
Abstract
Importance Venomous snakebite severity ranges from an
asymptomatic dry bite to severe envenomation and death. The clinical evaluation
aids in prognosis and is essential to determine the risks and potential
benefits of antivenom treatment.
Objectives To identify historical features, clinical
examination findings, basic laboratory testing, and clinical grading scales
that will risk-stratify patients with pit viper snake envenomation for severe
systemic envenomation, severe tissue injury, and/or severe hematologic venom
effects.
Data Sources We conducted a structured search of PubMed
(1966-October 3, 2017) and Embase database (1980-October 3, 2017) to identify
English-language studies that evaluated clinical features predictive of severe
envenomation.
Study Selection We included studies that evaluated the test
performance of at least 1 clinical finding with an acceptable reference
standard of severe envenomation for venomous snakes of the Western Hemisphere.
Only studies involving the most common subfamily, Crotalinae (pit vipers), were
evaluated. Seventeen studies with data were available for abstraction.
Data Extraction and
Synthesis The clinical features assessed
and severity outcome measures were extracted from each original study. We
assessed severity in 3 categories: systemic toxicity, tissue injury, and
hematologic effects. Differences were resolved by author consensus.
Results The pooled prevalence of severe systemic
envenomation was 14% (95% CI, 9%-21%). The pooled prevalence of severe tissue
injury and severe hematologic venom effects were 14% (95% CI, 12%-16%) and 18%
(95% CI, 8%-27%), respectively. Factors increasing the likelihood of severe
systemic envenomation included the time from bite to care of 6 or more hours
(likelihood ratio [LR], 3.4 [95% CI, 1.1-6.4]), a patient younger than 12 years
(LRs, 3.2 [95% CI, 1.5-7.1] and 2.9 [95% CI, 1.3-6.2]), large snake size (LR,
3.1 [95% CI, 1.5-5.7]), and ptosis (LRs, 1.4 [95% CI, 1.0-2.1] and 3.8 [95% CI,
1.8-8.3]). Envenomation by the genus Agkistrodon (copperhead and cottonmouth),
as opposed to rattlesnakes, decreased the likelihood of severe systemic
envenomation (LR, 0.28 [95% CI, 0.10-0.78]). Initial hypofibrinogenemia (LR,
5.1 [95% CI, 1.7-15.0]) and thrombocytopenia (LR, 3.7 [95% CI, 1.9-7.3])
increased the likelihood of severe hematologic venom effects. Other clinical
features from history, physical examination, or normal laboratory values were
not discriminative.
Conclusions Clinical features can identify patients at
increased risk of severe systemic envenomation and severe hematologic venom
effects, but there are few features that are associated with severe tissue
injury or can confidently exclude severe envenomation. Physicians should
monitor patients closely and be wary of progression from nonsevere to a severe
envenomation and have a low threshold to escalate therapy as needed.
6. ‘A’ is for AIRWAY
A. Bag-Mask Ventilation during Tracheal Intubation of
Critically Ill Adults
Casey JD, et al. N
Engl J Med. 2019 Feb 28;380(9):811-821
BACKGROUND:
Hypoxemia is the most
common complication during tracheal intubation of critically ill adults and may
increase the risk of cardiac arrest and death. Whether positive-pressure
ventilation with a bag-mask device (bag-mask ventilation) during tracheal
intubation of critically ill adults prevents hypoxemia without increasing the
risk of aspiration remains controversial.
METHODS:
In a multicenter,
randomized trial conducted in seven intensive care units in the United States,
we randomly assigned adults undergoing tracheal intubation to receive either
ventilation with a bag-mask device or no ventilation between induction and
laryngoscopy. The primary outcome was the lowest oxygen saturation observed
during the interval between induction and 2 minutes after tracheal intubation.
The secondary outcome was the incidence of severe hypoxemia, defined as an
oxygen saturation of less than 80%.
RESULTS:
Among the 401 patients
enrolled, the median lowest oxygen saturation was 96% (interquartile range, 87
to 99) in the bag-mask ventilation group and 93% (interquartile range, 81 to
99) in the no-ventilation group (P = 0.01). A total of 21 patients (10.9%) in
the bag-mask ventilation group had severe hypoxemia, as compared with 45
patients (22.8%) in the no-ventilation group (relative risk, 0.48; 95%
confidence interval [CI], 0.30 to 0.77). Operator-reported aspiration occurred
during 2.5% of intubations in the bag-mask ventilation group and during 4.0% in
the no-ventilation group (P = 0.41). The incidence of new opacity on chest
radiography in the 48 hours after tracheal intubation was 16.4% and 14.8%,
respectively (P = 0.73).
CONCLUSIONS:
Among critically ill
adults undergoing tracheal intubation, patients receiving bag-mask ventilation
had higher oxygen saturations and a lower incidence of severe hypoxemia than
those receiving no ventilation.
B. Pre-hospital advanced airway management for adults with
out-of-hospital cardiac arrest: nationwide cohort study.
Izawa J, t al. BMJ.
2019 Feb 28;364:l430
OBJECTIVE:
To determine survival
associated with advanced airway management (AAM) compared with no AAM for
adults with out-of-hospital cardiac arrest.
DESIGN:
Cohort study between
January 2014 and December 2016.
SETTING:
Nationwide, population
based registry in Japan (All-Japan Utstein Registry).
PARTICIPANTS:
Consecutive adult
patients with out-of-hospital cardiac arrest, separated into two sub-cohorts by
their first documented electrocardiographic rhythm: shockable (ventricular
fibrillation or pulseless ventricular tachycardia) and non-shockable (pulseless
electrical activity or asystole). Patients who received AAM during
cardiopulmonary resuscitation were sequentially matched with patients at risk
of AAM within the same minute on the basis of time dependent propensity scores.
MAIN OUTCOME MEASURES:
Survival at one month
or at hospital discharge within one month.
RESULTS:
Of the 310 620
patients eligible, 8459 (41.2%) of 20 516 in the shockable cohort and 121 890
(42.0%) of 290 104 in the non-shockable cohort received AAM during
cardiopulmonary resuscitation. After time dependent propensity score sequential
matching, 16 114 patients in the shockable cohort and 236 042 in the
non-shockable cohort were matched at the same minute. In the shockable cohort,
survival did not differ between patients with AAM and those with no AAM:
1546/8057 (19.2%) versus 1500/8057 (18.6%) (adjusted risk ratio 1.00, 95%
confidence interval 0.93 to 1.07). In the non-shockable cohort, patients with
AAM had better survival than those with no AAM: 2696/118 021 (2.3%) versus
2127/118 021 (1.8%) (adjusted risk ratio 1.27, 1.20 to 1.35).
CONCLUSIONS:
In the time dependent
propensity score sequential matching for out-of-hospital cardiac arrest in
adults, AAM was not associated with survival among patients with shockable
rhythm, whereas AAM was associated with better survival among patients with
non-shockable rhythm.
7. ED Use in California: Demographics,
Trends, and the Impact of the ACA
McConville S, et al. 2019 Public Policy
Institute of California
Hospital emergency departments (EDs) have a vital role in
our health care system. As the only
guaranteed access point to medical care for all Californians, they
are often characterized as the safety net of the safety net. But they are also a
relatively expensive setting to provide health services. A substantial uptick
in ED use over the past several years has raised questions about the impact of
the Affordable Care Act (ACA). In particular, the large expansion of the
Medi-Cal program under the ACA has raised concerns that the dramatic declines in
uninsured residents in such a short timeframe may be spurring increases
in ED use.
In this report, we look at trends in ED use from 2005 to
2016, with a particular focus on rates of ED
use since ACA insurance expansions were fully implemented in 2014. We find no
evidence that the ACA was responsible for increased ED use—indeed, our
analysis suggests that ED visit rates for non-elderly adults would have been
higher in the absence of the coverage expansions.
Our key findings include…
Full report (free): https://www.ppic.org/wp-content/uploads/emergency-department-use-in-california-demographics-trends-and-the-impact-of-the-aca-february-2019.pdf
8. Coronary Angiography after Cardiac Arrest without ST-Segment
Elevation
Lemkes JS1, N Engl J Med. 2019 Mar 18 [Epub ahead of
print]
BACKGROUND:
Ischemic heart disease is a major cause of out-of-hospital
cardiac arrest. The role of immediate coronary angiography and percutaneous
coronary intervention (PCI) in the treatment of patients who have been
successfully resuscitated after cardiac arrest in the absence of ST-segment
elevation myocardial infarction (STEMI) remains uncertain.
METHODS:
In this multicenter trial, we randomly assigned 552 patients
who had cardiac arrest without signs of STEMI to undergo immediate coronary
angiography or coronary angiography that was delayed until after neurologic
recovery. All patients underwent PCI if indicated. The primary end point was
survival at 90 days. Secondary end points included survival at 90 days with
good cerebral performance or mild or moderate disability, myocardial injury,
duration of catecholamine support, markers of shock, recurrence of ventricular
tachycardia, duration of mechanical ventilation, major bleeding, occurrence of
acute kidney injury, need for renal-replacement therapy, time to target
temperature, and neurologic status at discharge from the intensive care unit.
RESULTS:
At 90 days, 176 of 273 patients (64.5%) in the immediate
angiography group and 178 of 265 patients (67.2%) in the delayed angiography
group were alive (odds ratio, 0.89; 95% confidence interval [CI], 0.62 to 1.27;
P = 0.51). The median time to target temperature was 5.4 hours in the immediate
angiography group and 4.7 hours in the delayed angiography group (ratio of
geometric means, 1.19; 95% CI, 1.04 to 1.36). No significant differences
between the groups were found in the remaining secondary end points.
CONCLUSIONS:
Among patients who had been successfully resuscitated
after out-of-hospital cardiac arrest and had no signs of STEMI, a strategy of
immediate angiography was not found to be better than a strategy of delayed
angiography with respect to overall survival at 90 days.
Full-text (free): https://www.nejm.org/doi/full/10.1056/NEJMoa1816897
Except from Associated Editorial
“The COACT trial
represents an important step forward in the care of patients after a cardiac
arrest, and the results suggest that for the majority of comatose patients who
have had a cardiac arrest without evidence of STEMI, coronary angiography need
not be performed immediately. Further work will be required to better define
personalized treatment strategies for selected patients after cardiac arrest.
Two multicenter investigations are currently under way; the ACCESS trial (ClinicalTrials.gov
number, NCT03119571) and the Direct or Subacute Coronary Angiography in
Out-of-hospital Cardiac Arrest trial (DISCO; NCT02309151) are investigating the
timing of coronary angiography after cardiac arrest. It will be useful to
compare the results of these trials with those of the COACT trial.9,10”
Full-text (free): https://www.nejm.org/doi/full/10.1056/NEJMe1901651
9. Clinical Practice Guideline for ED Procedural Sedation with
Propofol: 2018 Update
Miller KA, et al. Ann
Emerg Med 2019 Feb 4 [Epub ahead of print]
We update an
evidence-based clinical practice guideline for the administration of propofol
for emergency department procedural sedation. Both the unique considerations of
using this drug in the pediatric population and the substantial new research
warrant revision of the 2007 advisory. We discuss the indications,
contraindications, personnel requirements, monitoring, dosing, coadministered
medications, and adverse events for propofol sedation.
Full-text
(subscription required): https://www.annemergmed.com/article/S0196-0644(18)31576-2/fulltext
10. Images in Clinical Practice
Image Diagnosis: Scapholunate Dissociation
Heroin body-packing and naloxone
Diffuse Melanosis and Melanuria
Lemierre’s Syndrome
An Umbilical Nodule (Sister Mary Joseph)
African Tick-Bite Fever
“Doughnut” Lesions in Strep Throat
Man With Erythematous Rash and Muscle Weakness
Young Male With Epigastric Pain
Woman With Abdominal Pain
Neonate With Abdominal Distention
Young Male With Low Back Pain
Child With Unilateral Temporal Swelling
11. Sepsis Research
A. ED Door-to-Antibiotic Time and
Long-term Mortality in Sepsis
Peltan ID, et al. CHEST 2019 Feb 16 [Epub ahead of print]
BACKGROUND:
The impact of antibiotic timing on sepsis outcomes remains
controversial due to conflicting results from previous studies.
OBJECTIVES:
This study investigated the association of
door-to-antibiotic time with long-term mortality in ED patients with sepsis.
METHODS:
This retrospective cohort study included nontrauma adult ED
patients with clinical sepsis admitted to four hospitals from 2013 to 2017.
Only patients' first eligible encounter was included. Multivariable logistic
regression was used to measure the adjusted association between
door-to-antibiotic time and 1-year mortality. Secondary analyses used
alternative antibiotic timing measures (antibiotic initiation within 1 or 3 h
and separate comparison of antibiotic exposure at each hour up to hour 6),
alternative outcomes (hospital, 30-day, and 90-day mortality), and alternative
statistical methods to mitigate indication bias.
RESULTS:
Among 10,811 eligible patients, median door-to-antibiotic
time was 166 min (interquartile range, 115-230 min), and 1-year mortality was
19%. After adjustment, each additional hour from ED arrival to antibiotic
initiation was associated with a 10% (95% CI, 5-14; P less than .001) increased
odds of 1-year mortality. The association remained linear when each 1-h
interval of door-to-antibiotic time was independently compared with
door-to-antibiotic time ≤ 1 h and was similar for hospital, 30-day, and 90-day
mortality. Mortality at 1 year was higher when door-to-antibiotic times were over
3 h vs ≤ 3 h (adjusted OR, 1.27; 95% CI, 1.13-1.43) but not over 1 h vs ≤ 1 h
(adjusted OR, 1.26; 95% CI, 0.98-1.62).
CONCLUSIONS:
Delays in ED antibiotic initiation time are associated with
clinically important increases in long-term, risk-adjusted sepsis mortality.
B. ED Crowding Is Associated with
Delayed Antibiotics for Sepsis.
Peltan ID, et al. Ann Emerg Med. 2019;73(4):345-355.
STUDY OBJECTIVE:
Barriers to early antibiotic administration for sepsis
remain poorly understood. We investigated the association between emergency
department (ED) crowding and door-to-antibiotic time in ED sepsis.
METHODS:
We conducted a retrospective cohort study of ED sepsis
patients presenting to 2 community hospitals, a regional referral hospital, and
a tertiary teaching hospital. The primary exposure was ED occupancy rate,
defined as the ratio of registered ED patients to licensed ED beds. We defined
ED overcrowding as an ED occupancy rate greater than or equal to 1. We used
multivariable regression to measure the adjusted association between ED
crowding and door-to-antibiotic time (elapsed time from ED arrival to first
antibiotic initiation). Using Markov multistate models, we also investigated
the association between ED crowding and pre-antibiotic care processes.
RESULTS:
Among 3,572 eligible sepsis patients, 70% arrived when the
ED occupancy rate was greater than or equal to 0.5 and 14% arrived to an
overcrowded ED. Median door-to-antibiotic time was 158 minutes (interquartile
range 109 to 216 minutes). When the ED was overcrowded, 46% of patients
received antibiotics within 3 hours of ED arrival compared with 63% when it was
not (difference 14.4%; 95% confidence interval 9.7% to 19.2%). After
adjustment, each 10% increase in ED occupancy rate was associated with a
4.0-minute increase (95% confidence interval 2.8 to 5.2 minutes) in
door-to-antibiotic time and a decrease in the odds of antibiotic initiation
within 3 hours (odds ratio 0.90; 95% confidence interval 0.88 to 0.93).
Increasing ED crowding was associated with slower initial patient assessment
but not further delays after the initial assessment.
CONCLUSION:
ED crowding was associated with increased sepsis antibiotic
delay. Hospitals must devise strategies to optimize sepsis antibiotic
administration during periods of ED crowding.
C. Prehospital Care and ED
Door-to-Antibiotic Time in Sepsis.
Peltan ID, et al. Ann Am Thorac Soc. 2018
Dec;15(12):1443-1450.
RATIONALE:
Early antibiotics improve outcomes for patients with sepsis.
Factors influencing antibiotic timing in emergency department (ED) sepsis
remain unclear.
OBJECTIVES:
Determine the relationship between prehospital level of care
of patients with sepsis and ED door-to-antibiotic time.
METHODS:
This retrospective cohort study comprised patients admitted
from the community to an academic ED June 2009 to February 2015 with
fluid-refractory sepsis or septic shock. Transfer patients and those whose
antibiotics began before ED arrival or after ED discharge were excluded. We
used multivariable regression to evaluate the association between the time from
ED arrival to antibiotic initiation and prehospital level of care, defined as
the highest level of emergency medical services received: none, basic life
support (BLS) ambulance, or advanced life support (ALS) ambulance. We measured
variation in this association when hypotension was or was not present by ED
arrival.
RESULTS:
Among 361 community-dwelling patients with sepsis, the level
of prehospital care correlated with illness severity. ALS-treated patients
received antibiotics faster than patients who did not receive prehospital care
(median, 103 [interquartile range, 75 to 135] vs. 144 [98 to 251] minutes,
respectively) or BLS-only patients (168 [100-250] minutes; P less than 0.001
for each pairwise comparison with ALS). This pattern persisted after
multivariable adjustment, where ALS care (-43 min; 95% confidence interval
[CI], -84 to -2; P = 0.033) but not BLS-only care (-4 min; 95% CI, -41 to +34;
P = 0.97) was associated with less antibiotic delay compared with no
prehospital care. ALS-treated patients more frequently received antibiotics
within 3 hours of ED arrival (91%) compared with walk-in patients (62%;
adjusted odds ratio, 3.11; 95% CI, 1.20 to 8.03; P = 0.015) or BLS-treated
patients (56%; adjusted odds ratio, 4.51; 95% CI, 1.89 to 11.35; P less than 0.001).
ALS-treated patients started antibiotics faster than walk-in patients in the
absence of hypotension by ED arrival (-41 min; 95% CI, -110 to -13; P = 0.009)
but not when hypotension was present (+25 min; 95% CI, -43 to +92; P = 0.66).
CONCLUSIONS:
Prehospital ALS but not BLS-only care was associated with
faster antibiotic initiation for patients with sepsis without hypotension.
Process redesign for non-ALS patients may improve antibiotic timeliness for ED
sepsis.
D. The 2018 Surviving Sepsis Campaign’s
Treatment Bundle: When Guidelines Outpace the Evidence Supporting Their Use
Spiegel R, et al. Ann Emerg Med. 2019;73(4):356–358.
Inadvertent catastrophes often arise from good intentions.
One recent medical care example of this phenomenon was the 2002 Centers for
Medicare & Medicaid Services (CMS) National Hospital Quality Measure for
the initial management of community-acquired pneumonia.1 This measure called
for obtaining blood cultures and administering antibiotics within 4 hours of
emergency department (ED) triage in patients being admitted with pneumonia,
even if pneumonia was not clearly present on arrival. These metrics had little
evidentiary basis but led to an institutional-fostered culture of overdiagnosis
and overtreatment.2 Eventually, many recognized the downstream harms of
antibiotic overuse and misuse,2 prompting the loss of the National Quality
Forum measure endorsement and the measure’s subsequent removal as a CMS quality
metric. Have we learned from this folly or does a new sepsis guideline promote
similar time-based treatment strategies with little direct supporting evidence?
The most recent iteration of the Surviving Sepsis Campaign
treatment bundle now exists, published simultaneously in Critical Care Medicine
and Intensive Care Medicine by Levy et al.3 The newest guidelines from this
group propose a novel 1-hour care bundle, in contrast to the National Quality
Forum 0-500 and the Sepsis CMS Core measures that defined 3- and 6-hour target
care bundles. The Surviving Sepsis Campaign group argues that the temporal
nature of sepsis means benefit from even more rapid identification and
intervention. They identify the start of the bundle as patient arrival at
triage, when sepsis may or may not be present. Items to be successfully
initiated within this brief window include the following:
•Measure lactate level and remeasure if the initial lactate
level is greater than 2 mmol/L.
•Obtain blood cultures before administration of antibiotics.
•Administer broad-spectrum antibiotics.
•Begin rapid administration of crystalloid at 30 mL/kg for
hypotension or lactate level greater than or equal to 4 mmol/L.
•Start vasopressors if the patient is hypotensive during or
after fluid resuscitation to maintain mean arterial pressure level greater than
or equal to 65 mm Hg.
Although no one would argue against an appropriate and timely
recognition plus resuscitation for patients presenting with septic shock, this
is not the mandate that such a guideline will promote. First, although triage
is a reliable, extractable time stamp, it is likely a poor surrogate for many
patients for the onset of sepsis. Think of the parable of the drunk who
searches for lost keys beneath a lamp because “that is where I can see”;
starting where things one thinks are easiest to measure may not really aid the
task at hand (getting the right care started when needed). Next, by condensing
the 3- and 6-hour bundles into a single 1-hour treatment directive, the authors
create an operational challenge with the potential of leading to downstream
patient harms. To achieve compliance with these new recommendations, most EDs,
already challenged by the current 3-hour bundle,4 will likely use strategies
such as those in the 2002 CMS pneumonia measure efforts, applying this 1-hour
bundle broadly to the majority of patients presenting with a suspected
infection in the event a sepsis or septic shock diagnosis is later
entertained.5
Like the pneumonia quality measure, this resource-heavy care
flows from an overreaching interpretation of evidence…
E. Development and Evaluation of a
Machine Learning Model for the Early Identification of Patients at Risk for
Sepsis
Delahanty RJ, et al. Ann Emerg Med 2019;73(4):334–344.
STUDY OBJECTIVE:
The Third International Consensus Definitions (Sepsis-3)
Task Force recommended the use of the quick Sequential [Sepsis-related] Organ
Failure Assessment (qSOFA) score to
screen patients for sepsis outside of the ICU. However,
subsequent studies raise concerns about the sensitivity of qSOFA as a screening
tool. We aim to use machine learning to develop a
new sepsis screening tool,
the Risk of Sepsis (RoS) score, and compare it with a slate
of benchmark sepsis-screening tools, including the Systemic Inflammatory
Response Syndrome, Sequential Organ Failure Assessment (SOFA), qSOFA,
Modified Early Warning Score, and National Early Warning
Score.
METHODS:
We used retrospective electronic health record data from
adult patients who presented to 49 urban community hospital emergency
departments during a 22-month period (N=2,759,529). We used the Rhee clinical
surveillance criteria as our standard definition of sepsis and as the
primary target for developing our model. The data were randomly split into
training and test cohorts to derive and then evaluate the model. A feature
selection process was carried out in 3 stages: first, we reviewed existing
models for sepsis screening; second, we consulted with local subject
matter experts; and third, we used a
supervised machine learning called gradient boosting. Key
metrics of performance included alert rate, area under the receiver operating
characteristic curve, sensitivity, specificity, and precision. Performance was
assessed at 1, 3, 6, 12, and 24 hours after an index time.
RESULTS:
The RoS score was the most discriminant screening tool at
all time thresholds (area under the receiver operating characteristic curve
0.93 to 0.97). Compared with the next most discriminant benchmark (Sequential
Organ Failure Assessment), RoS was significantly more sensitive (67.7% versus
49.2% at 1 hour and 84.6% versus 80.4% at 24 hours) and precise (27.6%
versus 12.2% at 1 hour and 28.8% versus 11.4% at 24 hours). The sensitivity of
qSOFA was relatively low (3.7% at 1 hour and 23.5% at 24 hours).
CONCLUSION:
In this retrospective study, RoS was more timely and
discriminant than benchmark screening tools, including those recommend by
the Sepsis-3 Task Force. Further study is needed to validate the RoS score
at independent sites.
12. Ann Emerg Med Brief Lit Reviews (from April 2019)
A. Does the Severe Sepsis and Septic
Shock Early Management Bundle (SEP-1) Improve Survival in Septic Adults?
Take-Home Message
No high- or moderate-level evidence shows that the Severe
Sepsis and Septic Shock Early Management Bundle (SEP-1) hemodynamic
interventions improve survival in sepsis.
B. What Signs Increase the Likelihood
of Acute Aortic Dissection?
Take-Home Message
Hypotension, a pulse deficit, and a focal neurologic deficit
increase the likelihood of acute aortic dissection, whereas a low Aortic
Dissection Detection score decreases the likelihood of acute aortic dissection.
C. In Patients with AMI and No
Hypoxemia, Does Oxygen Therapy Improve Outcomes Compared With No Supplemental
Oxygen?
Take-Home Message
Oxygen therapy does not reduce the risk of all-cause
mortality, recurrent ischemia or myocardial infarction, heart failure, or
arrhythmias compared with no supplemental oxygen therapy for patients with
acute myocardial infarction and normal oxygen saturation.
13. Pediatric Corner
A. Delayed Presentations to ED of
Children with Head Injury: A PREDICT Study
Borland ML, et al. on behalf of the Paediatric Research in
Emergency Department International Collaborative (PREDICT) Group
STUDY OBJECTIVE:
Existing clinical decision rules guide management for
head-injured children presenting 24 hours or sooner after injury, even though
some may present greater than 24 hours afterward. We seek to determine the
prevalence of traumatic brain injuries for patients presenting to emergency
departments greater than 24 hours after injury and identify symptoms and signs
to guide management.
METHODS:
This was a planned secondary analysis of the Australasian
Paediatric Head Injury Rule Study, concentrating on first presentations greater
than 24 hours after injury, with Glasgow Coma Scale scores 14 and 15. We sought
associations with predictors of traumatic brain injury on computed tomography
(CT) and clinically important traumatic brain injury.
RESULTS:
Of 19,765 eligible children, 981 (5.0%) presented greater
than 24 hours after injury, and 465 injuries (48.5%) resulted from falls less
than 1 m and 37 (3.8%) involved traffic incidents. Features associated
significantly with presenting greater than 24 hours after injury in comparison
with presenting within 24 hours were nonfrontal scalp hematoma (20.8% versus
18.1%), headache (31.6% versus 19.9%), vomiting (30.0% versus 16.3%), and
assault with nonaccidental injury concerns (1.4% versus 0.4%). Traumatic brain
injury on CT occurred in 37 patients (3.8%), including suspicion of depressed
skull fracture (8 [0.8%]) and intracranial hemorrhage (31 [3.8%]). Clinically
important traumatic brain injury occurred in 8 patients (0.8%), with 2 (0.2%)
requiring neurosurgery, with no deaths. Suspicion of depressed skull fracture
was associated with traumatic brain injury on CT consistently, with the only
other significant factor being nonfrontal scalp hematoma (odds ratio 19.0; 95%
confidence interval 8.2 to 43.9). Clinically important traumatic brain injury
was also associated with nonfrontal scalp hematoma (odds ratio 11.7; 95%
confidence interval 2.4 to 58.6) and suspicion of depressed fracture (odds
ratio 19.7; 95% confidence interval 2.1 to 182.1).
CONCLUSION:
Delayed presentation after head injury, although infrequent,
is significantly associated with traumatic brain injury. Evaluation of delayed
presentations must consider identified factors associated with this increased
risk.
B1. Many children with mental disorders
do not receive long-term care
A research letter published in JAMA Pediatrics found up to 1
in 6 children in the US ages 6 to 17 had anxiety, depression or another treatable
mental health disorder, but almost half were not given counseling or treatment
from a mental health practitioner.
B2. More U.S. youth seeking help during
psychiatric emergencies
B3. Best Practices for Evaluation and
Treatment of Agitated Children and Adolescents (BETA) in the ED: Consensus
Statement of the American Association for Emergency Psychiatry
Gerson R, et al. West J Emerg Med. 2019;20(2):409-18.
Introduction: Agitation in children and adolescents in the
emergency department (ED) can be dangerous and distressing for patients, family
and staff. We present consensus guidelines for management of agitation among
pediatric patients in the ED, including non-pharmacologic methods and the use
of immediate and as-needed medications.
Methods: Using the Delphi method of consensus, a workgroup
comprised of 17 experts in emergency child and adolescent psychiatry and
psychopharmacology from the the American Association for Emergency Psychiatry
and the American Academy of Child and Adolescent Psychiatry Emergency Child
Psychiatry Committee sought to create consensus guidelines for the management
of acute agitation in children and adolescents in the ED.
Results: Consensus found that there should be a multimodal
approach to managing agitation in the ED, and that etiology of agitation should
drive choice of treatment. We describe general and specific recommendations for
medication use.
Conclusion: These guidelines describing child and adolescent
psychiatry expert consensus for the management of agitation in the ED may be of
use to pediatricians and emergency physicians who are without immediate access
to psychiatry consultation.
13. Bedside Tool for Suicidal Patients
Suicide is a leading cause of death in the U.S. Each year,
nearly 650,000 ED visits are related to suicidal behavior. We've created a
bedside tool, iCAR2E, to help you improve your management of suicidal patients
in your ED.
14. Assessment of Physician Well-being
Lall MD, et al. West J
Emerg Med. 2019; Two parts, below.
Part One: Burnout and Other Negative
States
Physician well-being is a complex and multifactorial issue.
A large number of tools have been developed in an attempt to measure the
nature, severity, and impact of both burnout and well-being in a range of
clinical populations. This two-article series provides a review of relevant
tools and offers guidance to clinical mentors and researchers in choosing the
appropriate instrument to suit their needs, whether assessing mentees or
testing interventions in the research setting. Part One begins with a
discussion of burnout and focuses on assessment tools to measure burnout and
other negative states. Part Two of the series examines the assessment of
well-being, coping skills, and other positive states.
Part Two: Beyond Burnout
Part One of this two-article series reviews assessment tools
to measure burnout and other negative states. Physician well-being goes beyond
merely the absence of burnout. Transient episodes of burnout are to be
expected. Measuring burnout alone is shortsighted. Well-being includes being
challenged, thriving, and achieving success in various aspects of personal and
professional life. In this second part of the series, we identify and describe
assessment tools related to wellness, quality of life, resilience, coping
skills, and other positive states.
15. Can pulse check by the photoplethysmography sensor on a
smart watch replace carotid artery palpation during cardiopulmonary
resuscitation in cardiac arrest patients? a prospective observational
diagnostic accuracy study
Lee Y, et al. BMJ Open 2019;9:e023627.
Objective The purpose of this study was to assess whether a
photoplethysmography (PPG) sensor in a smart watch can accurately recognise the
return of spontaneous circulation (ROSC) in cardiac arrest patients compared
with carotid artery palpation.
Methods This prospective observational study was conducted
on 50 out-of-hospital cardiac arrest patients who visited the emergency department
(ED) of one tertiary hospital. As soon as the patient arrived at the ED,
advanced cardiac life support was carried out immediately. At this time, three
smart watches were attached to the carotid artery, forehead and wrist and were
checked for pulse measurements every 2 min. In the case of ROSC, blood
pressure, heart rate and heart rate regularity were confirmed, and pulse was
simultaneously measured at three sites with smart watches. In the case of no
ROSC, only the pulse was measured at three sites with the smart watches.
Results There were 33 males (66%) and the mean age was
68±11.57 years. In 14 patients (28%), spontaneous circulation was recovered
through cardiopulmonary resuscitation, and all survived. The sensitivity and
specificity of manual palpation were 78.6% and 90.4%, respectively.
False-positive and false-negative rates were 9.6% and 21.4%, respectively.
Smart watches at all three sites had the same or higher sensitivity than manual
palpation. The sensitivity of the smart watch was the highest, at 100%, in the
carotid region and the lowest, at 78.6%, in the wrist region. The specificity
of the smart watch was the highest, at 100%, in the wrist region and the
lowest, at 78.7%, in the carotid region.
Conclusion Compared with manual pulse check, the PPG sensor
embedded in the smart watch showed the same sensitivity and a higher
specificity for recognising ROSC when measured at the wrist.
Full-text (free): https://bmjopen.bmj.com/content/9/2/e023627.long
16. Myths in Emergency Medicine: Tidal Volume, False
Dichotomies, and Straw Man Comparators
Spiegel R. Emerg Med News. 2019;41(3):4-5.
DRV Note: The Society of Critical Care Medicine reproduced
this essay in their “Critical Care Update”
Lung-protective ventilation is a simple truth when managing
critical care patients on mechanical ventilation. The knowledge of exactly how
and when to perform such ventilatory strategies, however, is incomplete. The
recent PReVENT trial adds more uncertainty to the true efficacy of low tidal
volume ventilation in patients without acute respiratory distress syndrome.
(JAMA 2018;320[18]:1872; http://bit.ly/2DsabZ3.)
The authors conducted a randomized controlled trial in six
ICUs in the Netherlands, enrolling patients admitted to the ICU on mechanical
ventilation who were not expected to be extubated within 24 hours and who did not
have acute respiratory distress syndrome (ARDS), per the Berlin definition.
Patients were randomized to a low (6 mL/kg) or an intermediate tidal volume
strategy (10 mL/kg). The authors were permitted to utilize a volume assist
control or pressure support mode of ventilation to achieve their respiratory
goals.
Approximately 25 percent of 961 patients enrolled over three
years were admitted post-cardiac arrest, 16 percent for pneumonia. Tidal
volumes and airway pressures during the initial three days of ventilation
differed significantly between the groups. No difference was seen in primary
endpoint, the mean number of ventilator-free days (15.2 v. 15.5 days), nor in
ICU or hospital length of stay, ICU mortality, need for a tracheostomy, or
development of ARDS, pneumonia, pneumothorax, or atelectasis. The number of
patients who experienced delirium in the low tidal volume group increased 6.8
percent, though this was not statistically significant (p=0.06) and should be
viewed with skepticism.
Many have questioned these results, citing significant
heterogeneity between the groups, lack of blinding, and inadequate separation
in achieved tidal volumes between groups as potential sources of bias that
limit this study's validity. These confounders may explain why these results
diverge from our common beliefs regarding low tidal volume ventilation. On the
other hand, PReVENT may represent the true effects of low tidal volume
ventilation in patients without ARDS, and it is our interpretation of the
literature that is limited….
The rest of the essay: https://journals.lww.com/em-news/Fulltext/2019/03000/Myths_in_Emergency_Medicine__Tidal_Volume,_False.4.aspx
17. Don’t delay antibiotics in elderly with UTI
Antibiotic management of UTI in elderly patients in primary
care and its association with bloodstream infections and all-cause mortality:
population based cohort study
Gharbi M, et al, BMJ 2019;364:l525
OBJECTIVE:
To evaluate the association between antibiotic treatment for
urinary tract infection (UTI) and severe adverse outcomes in elderly patients
in primary care.
DESIGN:
Retrospective population based cohort study.
SETTING:
Clinical Practice Research Datalink (2007-15) primary care
records linked to hospital episode statistics and death records in England.
PARTICIPANTS:
157 264 adults aged 65 years or older presenting to a
general practitioner with at least one diagnosis of suspected or confirmed
lower UTI from November 2007 to May 2015.
MAIN OUTCOME MEASURES:
Bloodstream infection, hospital admission, and all cause
mortality within 60 days after the index UTI diagnosis.
RESULTS:
Among 312 896 UTI episodes (157 264 unique patients), 7.2%
(n=22 534) did not have a record of antibiotics being prescribed and 6.2%
(n=19 292) showed a delay in antibiotic prescribing. 1539 episodes of
bloodstream infection (0.5%) were recorded within 60 days after the initial
UTI. The rate of bloodstream infection was significantly higher among those
patients not prescribed an antibiotic (2.9%; n=647) and those recorded as
revisiting the general practitioner within seven days of the initial
consultation for an antibiotic prescription compared with those given a
prescription for an antibiotic at the initial consultation (2.2% v 0.2%;
P=0.001). After adjustment for covariates, patients were significantly more
likely to experience a bloodstream infection in the deferred antibiotics group
(adjusted odds ratio 7.12, 95% confidence interval 6.22 to 8.14) and no
antibiotics group (8.08, 7.12 to 9.16) compared with the immediate antibiotics
group. The number needed to harm (NNH) for occurrence of bloodstream infection
was lower (greater risk) for the no antibiotics group (NNH=37) than for the
deferred antibiotics group (NNH=51) compared with the immediate antibiotics
group. The rate of hospital admissions was about double among cases with no
antibiotics (27.0%) and deferred antibiotics (26.8%) compared with those
prescribed immediate antibiotics (14.8%; P=0.001). The risk of all cause
mortality was significantly higher with deferred antibiotics and no antibiotics
than with immediate antibiotics at any time during the 60 days follow-up
(adjusted hazard ratio 1.16, 95% confidence interval 1.06 to 1.27 and 2.18,
2.04 to 2.33, respectively). Men older than 85 years were particularly at risk
for both bloodstream infection and 60 day all cause mortality.
CONCLUSIONS:
In elderly patients with a diagnosis of UTI in primary care,
no antibiotics and deferred antibiotics were associated with a significant
increase in bloodstream infection and all cause mortality compared with
immediate antibiotics. In the context of an increase of Escherichia coli
bloodstream infections in England, early initiation of recommended first line
antibiotics for UTI in the older population is advocated.
Full-text (free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391656/
18. Increase in Acute Flaccid Myelitis—United States, 2018
Rouhani AA, et al. Ann Emerg Med. 2019;73(4):379–380.
In August 2018, the Centers for Disease Control and
Prevention (CDC) noted that, compared with August 2017, there was an increased
number of reports of patients having symptoms clinically compatible with acute
flaccid myelitis, a rare condition characterized by rapid onset of flaccid
weakness in one or more limbs and spinal cord gray matter lesions. Since 2014,
CDC has conducted surveillance for acute flaccid myelitis by using a
standardized case definition.1, 2 An Epi-X notice was issued on August 23,
2018, to increase clinician awareness and provide guidance for case reporting.
Patients who meet the clinical case criteria for acute
flaccid myelitis, defined as acute flaccid limb weakness, are classified with
the Council of State and Territorial Epidemiologists case definitions of
“confirmed” (magnetic resonance imaging [MRI] with spinal cord lesion largely
restricted to gray matter and spanning ≥1 spinal segment), “probable”
(cerebrospinal fluid pleocytosis [greater than 5 WBCs/mm3]), or “not a case.”…
19. Relegate Ondansetron to Auxiliary Role in Pregnancy
Pescatore R. Emerg Med News. 2019;41:11.
…The American College of Obstetrics and Gynecology has
published guidelines for years on pharmacologically managing nausea and
vomiting in pregnancy, recommending a stepwise approach, starting with
pyridoxine (vitamin B6) and doxylamine and then—depending on the presence or
absence of dehydration—adding intravenous fluids and agents such as
promethazine, prochlorperazine, or metoclopramide before proceeding to
therapies like ondansetron and methylprednisolone. (Obstet Gynecol 2018
Jan;131[1]:e15.) This measured and incremental approach represents an
evidence-based and effective strategy that allows for all possible useful
therapies while keeping maternal and fetal safety paramount.
Ondansetron has proven itself to be generally but not
completely safe in these patients, but has yet to show its superiority over
traditional agents. As emergency physicians and pregnant women engage in
collaborative efforts to provide effective symptom management, ondansetron
should remain relegated to its important but auxiliary role.
Full-text (free): https://journals.lww.com/em-news/Fulltext/2019/03000/What_to_D_O___Relegate_Ondansetron_to_Auxiliary.9.aspx
ACOG Practice Bulletin No. 189: Nausea And Vomiting Of
Pregnancy: https://journals.lww.com/greenjournal/Abstract/2018/01000/ACOG_Practice_Bulletin_No__189___Nausea_And.39.aspx
20. Two Docs are Better than One
Barnett ML, et al. Comparative
Accuracy of Diagnosis by Collective Intelligence of Multiple Physicians vs
Individual Physicians. JAMA Netw Open. 2019;2(3):e190096.
Key Points
Question Is a collective intelligence approach of
pooling multiple clinician and medical student diagnoses associated with
improvement in diagnostic accuracy in online, structured clinical cases?
Findings This cross-sectional study analyzing data
from the Human Diagnosis Project found that, across a broad range of medical
cases and common presenting symptoms, independent differential diagnoses of
multiple physicians combined into a weighted list significantly outperformed
diagnoses of individual physicians with groups as small as 2, and accuracy
increased with larger groups up to 9 physicians. Groups of nonspecialists also
significantly outperformed individual specialists solving cases matched to the
individual specialist’s specialty.
Meaning Pooling the diagnoses of multiple physicians
into a ranked list could be an effective approach to improving diagnostic
accuracy, but further study in a clinical setting is needed.
DRV Comment: Only 20%
of the “pooled” docs were attending-level physicians. Still, the concept has
face validity, especially among those in emergency medicine who have the luxury
of working alongside peers, whose “collective intelligence” can be invaluable.
Abstract
Importance The traditional approach of diagnosis by
individual physicians has a high rate of misdiagnosis. Pooling multiple
physicians’ diagnoses (collective intelligence) is a promising approach to
reducing misdiagnoses, but its accuracy in clinical cases is unknown to date.
Objective To assess how the diagnostic accuracy of
groups of physicians and trainees compares with the diagnostic accuracy of
individual physicians.
Design, Setting, and
Participants Cross-sectional study using
data from the Human Diagnosis Project (Human Dx), a multicountry data set of
ranked differential diagnoses by individual physicians, graduate trainees, and
medical students (users) solving user-submitted, structured clinical cases.
From May 7, 2014, to October 5, 2016, groups of 2 to 9 randomly selected
physicians solved individual cases. Data analysis was performed from March 16,
2017, to July 30, 2018.
Main Outcomes and
Measures The primary outcome was
diagnostic accuracy, assessed as a correct diagnosis in the top 3 ranked
diagnoses for an individual; for groups, the top 3 diagnoses were a collective
differential generated using a weighted combination of user diagnoses with a
variety of approaches. A version of the McNemar test was used to account for
clustering across repeated solvers to compare diagnostic accuracy.
Results Of the 2069 users solving 1572 cases from the
Human Dx data set, 1228 (59.4%) were residents or fellows, 431 (20.8%) were
attending physicians, and 410 (19.8%) were medical students. Collective
intelligence was associated with increasing diagnostic accuracy, from 62.5%
(95% CI, 60.1%-64.9%) for individual physicians up to 85.6% (95% CI,
83.9%-87.4%) for groups of 9 (23.0% difference; 95% CI, 14.9%-31.2%; P
less than .001). The range of
improvement varied by the specifications used for combining groups’ diagnoses,
but groups consistently outperformed individuals regardless of approach.
Absolute improvement in accuracy from individuals to groups of 9 varied by
presenting symptom from an increase of 17.3% (95% CI, 6.4%-28.2%; P = .002) for
abdominal pain to 29.8% (95% CI, 3.7%-55.8%; P = .02) for fever. Groups from 2
users (77.7% accuracy; 95% CI, 70.1%-84.6%) to 9 users (85.5% accuracy; 95% CI,
75.1%-95.9%) outperformed individual specialists in their subspecialty (66.3%
accuracy; 95% CI, 59.1%-73.5%; P less than .001 vs groups of 2 and 9).
Conclusions and
Relevance A collective intelligence
approach was associated with higher diagnostic accuracy compared with
individuals, including individual specialists whose expertise matched the case
diagnosis, across a range of medical cases. Given the few proven strategies to
address misdiagnosis, this technique merits further study in clinical settings.
21. B-Type Natriuretic Peptides and Cardiac
Troponins for Diagnosis and Risk-Stratification of Syncope
de Lavallaz J, et al. Circulation 2019 Feb 25 [Epub ahead of print]
BACKGROUND:
The utility of B-type Natriuretic Peptide (BNP),
N-terminal proBNP (NT-proBNP), and high-sensitivity cardiac troponin (hs-cTn)
concentrations for diagnosis and risk-stratification of syncope is incompletely
understood.
METHODS:
We evaluated the diagnostic and prognostic accuracy of
BNP, NT-proBNP, hs-cTnT, and hs-cTnI concentrations, alone and against the ones
of clinical assessments, in patients greater than 45years presenting
with syncope to the emergency department (ED) in a prospective diagnostic
multicenter study. BNP, NT-proBNP, hs-cTnT and hs-cTnI concentrations were
measured in a blinded fashion. Cardiac syncope, as adjudicated by two
physicians based on all information available including cardiac work-up and
1-year follow-up, was the diagnostic endpoint. The EGSYS, a syncope-specific
diagnostic score, served as the diagnostic comparator. Death and MACE at 30 and
720 days were the prognostic endpoints. MACE were defined as death,
cardiopulmonary resuscitation, life-threatening arrhythmia, implantation of
pacemaker/implantable cardioverter defibrillator, acute myocardial infarction,
pulmonary embolism, stroke/transient ischemic attack, intracranial bleeding or
valvular surgery. The ROSE, OESIL, San Fransisco Syncope Rule (SFSR) and Canadian
Syncope Risk Score (CSRS) served as the prognostic comparators.
RESULTS:
Among 1538 patients eligible for diagnostic assessment,
cardiac syncope was the adjudicated diagnosis in 234 patients (15.2%). BNP,
NT-proBNP, hs-cTnT, and hs-cTnI were significantly higher in cardiac syncope
vs. other causes (p less than 0.01). The
diagnostic accuracy for cardiac syncope, as quantified by the area under the
curve (AUC), was 0.77-0.78 (95% confidence interval (CI) 0.74-0.81) for all
four biomarkers, and superior to the one of EGSYS (AUC 0.68 [95%-CI 0.65-0.71],
p less than 0.001). Combining
BNP/NT-proBNP with hs-cTnT/hs-cTnI further improved diagnostic accuracy to an
AUC of 0.81 (p less than 0.01). BNP,
NT-proBNP, hs-cTnT, and hs-cTnI cut-offs, achieving pre-defined thresholds for
sensitivity and specificity (95%), allowed for rule-in or rule-out of ~30% of
all patients. A total of 450 MACE occurred during follow-up. The prognostic
accuracy of BNP, NT-proBNP, hs-cTnI, and hs-cTnT for MACE was moderate-to-good
(AUC 0.75-0.79), superior to ROSE, OESIL and SFSR, and inferior to the CSRS.
CONCLUSIONS:
BNP, NT-proBNP, hs-cTnT, and hs-cTnI concentrations
provide useful diagnostic and prognostic information in ED patients with
syncope.
22. Micro Bits
A.
Study Finds Google Translate Largely Accurate When Translating Discharge
Instructions.
B.
Chatting improves patient satisfaction
How can you reconcile the pressure to see more patients more
quickly with the need to maintain patient satisfaction? Researchers examined
this question by observing 2,315 visits and asking patients the degree to which
they were satisfied with the amount of time their family physician spent with
them.
Researchers found that satisfaction with time spent was
correlated with several factors beyond the physician’s control, including
longer visits and, when length was controlled for, factors such as greater
patient age and better perceived health status.
But satisfaction with time spent was also correlated with
two factors within the physician's power to influence:
1. Even a brief amount of “chatting,” defined as nonmedical
talk about the patient's job, hobbies, children, etc., was associated with
greater patient satisfaction with the time spent with the physician. In the
study, the average amount of time family physicians spent chatting was less
than 45 seconds…
C.
Making Patients with Obesity the Enemy Is Never Acceptable
Kyle TK, et al. Medscape. 2019 Feb 21.
To the Editor:
In a recent Medscape commentary, Dr George Lundberg
describes people with obesity as gluttonous and slothful —"pigging
out." He dwells on foods like "whipped cream, root beer floats,
banana splits," and other "anti-nutritious garbage." He depicts
"really fat people shoveling down large quantities" of such food.
This kind of attack on a population of patients living with
a chronic disease such as obesity cannot be tolerated. It is a vivid example of
the weight bias that is prevalent even among healthcare professionals. Up to
40% of Americans live with obesity and should expect that health providers will
help them with this common and consequential problem. The misperception that
patients with obesity have excess body weight due to a presumed lack of
willpower is unacceptable for healthcare providers. We must lead by example to
bring an end to weight bias. Thus, a well-established medical education website
such as Medscape should set the record straight and have zero tolerance for
promoting weight bias…
D.
GPs should consider offering statins to all patients aged over 75, researchers
say
Statins should be considered for everyone over 75 according
to the authors of a large meta-analysis, published in the Lancet ,1 which found
the drugs reduced major vascular events, such as heart attacks and strokes, in
patients of all ages. Only a third of the 5.5 million over 75s in the UK take
statins and up to 8000 deaths per year could be prevented if all took them,
said Colin Baigent ...
But
not aspirin…
Cardiology groups issue new guidance on aspirin use for
heart disease
The American Heart Association and the American College of
Cardiology have released a revised recommendation that says most people never
previously diagnosed with heart disease should not take aspirin to prevent
heart attacks and other heart disease, releasing a set of "primary
prevention" guidelines during a recent ACC conference. The recommendation
was based on findings from studies that showed an increased risk of bleeding in
aspirin users, particularly gastrointestinal bleeding, although the drug is
still recommended for prevention of heart attacks in those previously diagnosed
with cardiovascular illnesses.
2019 ACC/AHA Guideline on the Primary Prevention of
Cardiovascular Disease
E.
Research links tramadol to higher mortality risk for OA patients
A study in the Journal of the American Medical Association
said the use of tramadol in older patients with osteoarthritis was associated
with higher all-cause mortality risk, compared with other nonsteroidal
anti-inflammatory drugs. Researchers said tramadol's mortality risk was similar
to the risk associated with codeine.
F.
First-time opioid prescriptions down 54% in 5 years, study finds
An analysis of insurance claims data from over 86 million
people showed the number of first-time opioid prescriptions fell 54% from 2012
to 2017 as fewer physicians prescribed the painkillers. The findings, published
in The New England Journal of Medicine, showed the number of prescriptions for
three days' and seven days' worth of opioids dropped by 57% and 68%,
respectively.
G.
Survey shows declines in physician burnout
A physician survey published in Mayo Clinic Proceedings
showed burnout rates significantly decreased from 2014 to 2017, and
satisfaction with work-life balance increased. The Academy's efforts to help
fight physician burnout are wide-ranging and include resources on its Physician
Health First portal.
H.
Witness Observations Can Be Key To Determining Cause Of Transient Loss Of Consciousness,
Study Indicates.
Neurology Advisor (3/12, Jacobs) reports researchers
concluded that “a comprehensive profile of witness-observable manifestations of
transient loss of consciousness (TLOC) can play an important role in
differentiating between the 3 most common causes of TLOC: epilepsy, syncope,
and psychogenic nonepileptic seizures (PNES).” The findings were published in
Neurology.
I.
ICU: What it's really like to work in an intensive care unit
Aoife Abbey. IMAGE. 03 MARCH 2019
J.
Do Mention the D Word
Siobhan Harris. Medscape UK. March 04, 2019
Doctors sometimes find it hard to talk to their patients
about death. There are many reasons why it may be a struggle, not least because
it can be a difficult and sensitive conversation to have.
A recent report by the Royal College of Physicians (RCP),
'Talking About Dying', suggested that doctors need to improve their
conversations with patients with terminal illnesses or chronic conditions, to
handle them in a more timely way and with more compassion and confidence.
So why is it such a difficult conversation?
K.
An Unvaccinated Boy Got Tetanus. His Oregon Hospital Stay: 57 Days and
$800,000.
L.
How Emergency Physicians Can Advocate for Vaccination
By David A. Talan. ACEP Now. March 4, 2019
M.
This Is the Truth About Vaccines: Deadly diseases that should be seen only in
history books are showing up in our emergency rooms.
N.
Daily Marijuana Use and Highly Potent Weed Linked To Psychosis
