Lit Bits: Feb 10, 2010

From the recent medical literature...

1. Nasogastric Aspiration and Lavage in Emergency Department Patients with Hematochezia or Melena Without Hematemesis

Palamidessi N, et al. Acad Emerg Med. 2010;17:126–132.

Objectives: The utility of nasogastric aspiration and lavage in the emergency management of patients with melena or hematochezia without hematemesis is controversial. This evidence-based emergency medicine review evaluates the following question: does nasogastric aspiration and lavage in patients with melena or hematochezia and no hematemesis differentiate an upper from lower source of gastrointestinal (GI) bleeding?

Methods: MEDLINE, EMBASE, the Cochrane Library, and other databases were searched. Studies were selected for inclusion in the review if the authors had performed nasogastric aspiration (with or without lavage) in all patients with hematochezia or melena and performed esophagogastroduodenal endoscopy (EGD) in all patients. Studies were excluded if they enrolled patients with history of esophageal varices or included patients with hematemesis or coffee ground emesis (unless the data for patients without hematemesis or coffee ground emesis could be separated out). The outcome was identifying upper GI hemorrhage (active bleeding or high-risk lesions potentially responsible for hemorrhage) and the rate of complications associated with the nasogastric tube insertion. Quality of the included studies was assessed using standard criteria for diagnostic accuracy studies.

Results: Three retrospective studies met our inclusion and exclusion criteria. The prevalence of an upper GI source for patients with melena or hematochezia without hematemesis was 32% to 74%. According to the included studies, the diagnostic performance of the nasogastric aspiration and lavage for predicting upper GI bleeding is poor. The sensitivity of this test ranged from 42% to 84%, the specificity from 54% to 91%, and negative likelihood ratios from 0.62 to 0.20. Only one study reported the rate complications associated with nasogastric aspiration and lavage (1.6%).

Conclusions: Nasogastric aspiration, with or without lavage, has a low sensitivity and poor negative likelihood ratio, which limits its utility in ruling out an upper GI source of bleeding in patients with melena or hematochezia without hematemesis.

2. Muscle Relaxant Adds No Benefit to Ibuprofen for Cervical Strain

Pain relief did not differ among patients who received ibuprofen, cyclobenzaprine, or both drugs.

Muscle relaxants often are prescribed for neck and back pain, despite the lack of evidence of benefit. Researchers evaluated the effect of cyclobenzaprine in a prospective, randomized, double-blind study in a convenience sample of 61 adult patients (mean age, 34; 58% women) who presented to a level I trauma center emergency department with acute cervical strain (87% caused by motor vehicle collisions). Patients received ibuprofen (800 mg), cyclobenzaprine (5 mg), or both drugs three times daily for up to 7 days, as needed for pain. All patients received an initial dose of 800 mg of ibuprofen in the ED.

Patients rated pain severity on a 100-mm visual analog scale 30 to 60 minutes after taking the morning dose of medication. Pain scores improved significantly over 7 days in all three groups and did not differ among groups. Adverse effects were minimal and included dizziness in four patients who received cyclobenzaprine alone or with ibuprofen and nausea in one patient who received ibuprofen alone.

Comment: A small dose of cyclobenzaprine was used in this study, perhaps to avoid the anticholinergic, antihistaminic, and sedative side effects of this drug, which is closely related chemically to tricyclic antidepressants. No convincing evidence supports the use of cyclobenzaprine in painful musculoskeletal conditions, and the drug's benefit-to-adverse effect profile therefore argues against prescribing it. Most patients with cervical strain will get better. Provide adequate analgesia as needed, and leave the cyclobenzaprine in the pharmacy.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine February 5, 2010. Citation: Khwaja SM et al. Comparison of ibuprofen, cyclobenzaprine or both in patients with acute cervical strain: A randomized controlled trial. CJEM 2010 Jan; 12:39.

3. Aspirin for the Primary Prevention of Stroke and Myocardial Infarction: Ineffective or Wrong Dose?

Dalen JE. Amer J Med. 2010;123:101-102.

The concluding paragraphs:

It is difficult to ignore the results of 7 consecutive randomized clinical trials. There are 2 possible conclusions. One conclusion is that the recommendations of aspirin for primary prevention by the organizations shown in Table 1 are incorrect because aspirin is ineffective. Millions of people throughout the world are taking aspirin for primary prevention. Should they be told to discontinue aspirin?

The other conclusion is that the recommended dose is insufficient; 7 clinical trials have documented that doses of 100 mg or less are ineffective. The US Physicians Health study reported a 44% reduction in myocardial infarction in physicians taking 325 mg every other day (162 mg/d). One might reasonably conclude that the recommended dosage should be increased to 162 mg per day. I will continue to recommend 162 mg per day to my patients.

Full-text (free): http://www.amjmed.com/article/S0002-9343(09)00976-0/fulltext

4. Spine Immobilization for Penetrating Trauma Can Be Harmful

Patients who underwent immobilization were twice as likely to die as those who did not.

Despite a lack of supportive evidence for the practice, prehospital providers often apply spine immobilization to patients who have penetrating trauma to the head, neck, or torso without neurological symptoms or deficit. These authors retrospectively assessed the effect of prehospital spine immobilization on mortality in patients with penetrating trauma using data from the American College of Surgeons National Trauma Data Bank between 2001 and 2004.

Of 45,284 patients (median age, 29), 4.3% received cervical collars, spinal backboards, or both. The overall mortality rate was 8.1%. Multiple logistic regression analysis that controlled for confounders, including Injury Severity Score and Revised Trauma Score, showed that immobilized patients had significantly increased mortality (odds ratio, 2.06); this finding held true in subgroups of patients with gunshot wounds (OR, 2.12), hypotension (OR, 2.42), and gunshot wounds and hypotension (OR, 3.19). Complete data on in-hospital procedures were available for about 31,000 patients. Only 30 patients (0.1%) underwent operative spine stabilizing procedures for incomplete spinal-cord injury. The number needed to treat with spine immobilization to potentially benefit 1 patient was 1032. The number needed to harm with spine immobilization to potentially contribute to 1 death was 66.

Comment: Increasing evidence indicates that limited intervention at the scene allows trauma patients to receive definitive care at a trauma center more rapidly. This study indicates that prehospital spine immobilization is associated with increased mortality in patients with penetrating trauma. Trying to assign cause and effect in a retrospective study is risky, but possibly increased scene time or interference with later care (e.g., intubation, radiography, examination of the patient's back) contribute to worse outcomes. Spine immobilization might be applied more wisely to patients with altered mental status, spine tenderness, or sensorimotor dysfunction.

— John A. Marx, MD, FAAEM. Published in Journal Watch Emergency Medicine January 29, 2010. Citation: Haut ER et al. Spine immobilization in penetrating trauma: More harm than good? J Trauma 2010 Jan; 68:115.

5. Placing Thoracic Central Lines in Coagulopathic Patients: A Sampling of the Lit

A. Low levels of prothrombin time (INR) and platelets do not increase the risk of significant bleeding when placing central venous catheters.

Weigand K, et al. Med Klin (Munich). 2009;104:331-5.

BACKGROUND AND PURPOSE: Central venous catheters are frequently placed in intensive care medicine for multiple indications. The risk of severe bleeding after cannulation is considered to be increased in patients with abnormal coagulation, common in critically ill patients. PATIENTS AND METHODS: This open prospective trial, performed at two medical intensive care units and one hematology intermediate care ward, investigated whether insertion of a central venous catheter in patients with coagulopathy (prothrombin time less than 50% [International Normalized Ratio, INR, 1.5 or greater] and/or platelets less than 50 x 10(9)/l) bears an increased risk of bleeding. RESULTS: In 196 patients with and without severe disorders of hemostasis, no significant difference in decrease of hemoglobin after catheter placement was observed. In addition, no correlation between a significant drop in hemoglobin and increased levels of creatinine or urea was seen. Mechanical complications were similar in frequency compared to previous publications. CONCLUSION: These findings demonstrate that coagulation disorders with altered prothrombin time (INR) or platelets do not increase the risk of significant bleeding when inserting a central venous catheter. Therefore, the prophylactic correction of coagulation by transfusion of blood products or coagulation factors is not necessary before central venous catheter insertion.

B. Central venous catheter placement in patients with disorders of hemostasis.

Mumtaz H, et al. Am J Surg. 2000;180:503-5; discussion 506.

BACKGROUND: Patients requiring central venous access frequently have disorders of hemostasis. The aim of this study was to identify factors predictive of bleeding complications after central venous catheterization in this group of patients. METHODS: A retrospective analysis of all central venous catheters placed over a 2-year period (1997 to 1999) at our institution were performed. The age, sex, clinical diagnosis, most recent platelet count, prothrombin international normalized ratio (INR), activated partial thromboplastin time (aPTT), catheter type, the number of passes to complete the procedure, and bleeding complications were retrieved from the medical records. RESULTS: In a 2-year period, 2,010 central venous catheters were placed in 1,825 patients. Three hundred and thirty placements were in patients with disorders of hemostasis. In 88 of the 330 patients, the underlying coagulopathy was not corrected before catheter placement. In these patients, there were 3 bleeding complications requiring placement of a purse string suture at the catheter entry site. In the remaining 242 patients, there was 1 bleeding complication. Of the variables analyzed, only a low platelet count (below 50 x 10(9)/L) was significantly associated with bleeding complications. CONCLUSION: Central venous access procedures can be safely performed in patients with underlying disorders of hemostasis. Even patients with low platelet counts have infrequent (3 of 88) bleeding complications, and these problems are easily managed.

C. Central venous catheter placement in patients with disorders of hemostasis.

Doerfler ME, et al. Chest. 1996;110:185-8.

OBJECTIVE: To define the incidence of bleeding complications from central venous access procedures performed by a critical care service in patients with disorders of hemostasis. DESIGN: Prospective, consecutive sample, collection of clinical data. SETTING: University teaching hospital. PATIENTS: Seventy-six consecutive patients with disorders of hemostasis who required central venous access for clinical management between October 1992 and October 1993. MEASUREMENTS: Age, sex, clinical diagnosis, most recent platelet count, prothrombin time (PT), and activated partial thromboplastin time (aPTT) were recorded from the medical record of patients with known coagulation or platelet abnormalities. The site of central venous catheter placement, the number of needle passes necessary to complete the procedure, and the occurrence of complications were reported by the critical care attending physician performing or supervising the procedure. RESULTS: One hundred four central venous access procedures were performed on 76 patients with disorders of hemostasis. Seventy-three percent of catheters were placed in patients with platelet counts less than 100,000/mL and 40% of catheters were placed in patients with abnormalities of PT, aPTT, or both. Thirteen percent of patients had abnormalities of both platelets and coagulation profile. There were no serious complications. Bleeding complicated 7 (6.5% of the procedures; 5 patients had bleeding from the skin (from the suture sites in four), and 2 patients developed small periosteal hematomas. All patients with bleeding complications had thrombocytopenia with mean platelet counts of 22,000/mL and a range of 6,000 to 37,000/mL. Most patients with platelet counts in this range did not have clinically evident bleeding. CONCLUSIONS: Central venous access procedures can be done safely in patients with disorders of hemostasis by skilled physicians who frequently perform these procedures. Patients most likely to experience bleeding from these procedures are patients with severe thrombocytopenia. In this series, only a single patient, with a platelet count of 6,000/mL, required therapeutic blood product administration.

D. Invasive line placement in critically ill patients: do hemostatic defects matter?

DeLoughery TG, et al. Transfusion. 1996;36:827-31.

BACKGROUND: Blood components are often given prophylactically before the placement of invasive lines in patients with coagulation defects. Little, however, is known about the epidemiology of defects in these patients. The purpose of this study is to ascertain what proportion of intensive care patients who receive invasive lines have hemostatic defects, what actions are taken by physicians to correct these abnormalities before invasive line insertion, and what the incidence is of bleeding complications after invasive line placement. STUDY DESIGN AND METHODS: Charts were retrospectively reviewed for 490 intensive care patients in whom 938 arterial, pulmonary artery, and central venous lines were placed. RESULTS: At least one defect in hemostasis was documented for 388 patients (41%) before line placement, with 253 (27%) of these patients evidencing severe abnormalities. Seventeen percent of patients had no preprocedure laboratory evaluation. Trauma patients showed the highest numbers of abnormalities in hemostatic testing, but medical patients had more-severe defects. The occurrence of isolated abnormal laboratory values did not predict bleeding, but a score derived from a consideration of multiple defects did. Correction of the abnormalities was attempted in 37 percent of patients with hemostatic defects. Sixteen patients had bleeding complications, but only two had complications that were life-threatening. None of the complications were fatal. CONCLUSION: Invasive lines are used frequently in patients with hemostatic defects, often without any attempt to correct the abnormalities. Nevertheless, rates of hemorrhage are low and appear to be closely related to the level of experience of the physician rather than to defects in hemostasis. These findings suggest that the use of blood components for preprocedure correction of hemostatic defects is not necessary, except in those patients who have the most severe hemostatic abnormalities.

6. Risk of Deep Vein Thrombosis Following a Single Negative Whole-Leg Compression Ultrasound: A Systematic Review and Meta-analysis

Johnson SA, et al. JAMA. 2010;303:438-445.

Context: In patients with suspected lower extremity deep vein thrombosis (DVT), compression ultrasound (CUS) is typically the initial test to confirm or exclude DVT. Patients with an initial negative CUS result often require repeat CUS after 5 to 7 days. Whole-leg CUS may exclude proximal and distal DVT in a single evaluation.

Objective To determine the risk of venous thromboembolism after withholding anticoagulation in patients with suspected lower extremity DVT following a single negative whole-leg CUS result.

Data Sources: MEDLINE, EMBASE, CINAHL, LILACS, Cochrane, and Health Technology Assessments databases were searched for articles published from January 1970 through November 2009. Supplemental searches were performed of Internet resources, reference lists, and by contacting content experts.

Study Selection: Included studies were randomized controlled trials and prospective cohort studies of patients with suspected DVT and a negative whole-leg CUS result who did not receive anticoagulant therapy, and were followed up at least 90 days for venous thromboembolism events.

Data Extraction: Two authors independently reviewed and extracted data regarding a single positive or negative whole-leg CUS result, occurrence of venous thromboembolism during follow-up, and study quality.

Results: Seven studies were included totaling 4731 patients with negative whole-leg CUS examinations who did not receive anticoagulation. Of these, up to 647 patients (13.7%) had active cancer and up to 725 patients (15.3%) recently underwent a major surgery. Most participants were identified from an ambulatory setting. Venous thromboembolism or suspected venous thromboembolism–related death occurred in 34 patients (0.7%), including 11 patients with distal DVT (32.4%); 7 patients with proximal DVT (20.6%); 7 patients with nonfatal pulmonary emboli (20.6%); and 9 patients (26.5%) who died, possibly related to venous thromboembolism. Using a random-effects model with inverse variance weighting, the combined venous thromboembolism event rate at 3 months was 0.57% (95% confidence interval, 0.25%-0.89%).

Conclusion: Withholding anticoagulation following a single negative whole-leg CUS result was associated with a low risk of venous thromboembolism during 3-month follow-up.

7. Red Flags May Help Identify Serious Infection in Children

Laurie Barclay, MD. February 5, 2010 — Rapid breathing, parental concern, and the clinician's instinct are among the red flags warning of serious infection in children in developed countries, according to the results of a systematic review reported online in the February 3 issue of The Lancet.

"Our aim was to identify which clinical features have value in confirming or excluding the possibility of serious infection in children presenting to ambulatory care settings in developed countries," write Ann Van den Bruel, MD, from Katholieke Universiteit in Leuven, Belgium, and colleagues from the European Research Network on Recognising Serious Infection investigators.

The reviewers searched electronic databases (Medline, Embase, DARE, CINAHL) and bibliographies of identified relevant studies. In addition, they asked experts to identify articles evaluating clinical characteristics of serious infection in children.

Inclusion criteria for studies were analysis of diagnostic accuracy or prediction rules, enrollment of otherwise healthy children aged 1 month to 18 years, ambulatory care setting, outcome measure of serious infection, features evaluable in the ambulatory care setting, and sufficient data reported.

Evaluation of study quality was based on Quality Assessment of Diagnostic Accuracy Studies criteria. For each clinical feature, the reviewers calculated likelihood ratios for the presence (positive likelihood ratio) or absence (negative likelihood ratio) of the outcome, as well as pretest and post-test probabilities.

Red flags, or warning signs for serious infection, were defined as clinical characteristics with a positive likelihood ratio of more than 5.0. Rule-out signs were defined as clinical characteristics with a negative likelihood ratio of less than 0.2.

Of 1939 potentially relevant studies identified, 30 studies met selection criteria and were included in the analysis. Red flags identified from several studies were cyanosis (positive likelihood ratio range, 2.66 - 52.20), rapid breathing (1.26 - 9.78), poor peripheral perfusion (2.39 - 38.80), and petechial rash (6.18 - 83.70). Factors identified as strong red flags in 1 primary care study were parental concern (positive likelihood ratio, 14.40; 95% confidence interval [CI], 9.30 - 22.10) and clinician instinct (positive likelihood ratio, 23.50; 95% CI, 16.80 - 32.70).

In settings with a low prevalence of serious infection, a temperature of 40°C or more had value as a red flag. Although no single clinical characteristic had rule-out value, some combinations were helpful in ruling out the possibility of serious infection. For example, if the child is not short of breath and there is no parental concern, pneumonia is very unlikely (negative likelihood ratio, 0.07; 95% CI, 0.01 - 0.46).

"The Yale Observation Scale had little value in confirming (positive likelihood ratio range 1.10–6.70) or excluding (negative likelihood ratio range 0.16–0.97) the possibility of serious infection," the study authors write. "The red flags for serious infection that we identified should be used routinely, but serious illness will still be missed without effective use of precautionary measures. We now need to identify the level of risk at which clinical action should be taken."

Limitations of this review are primarily those inherent in the included studies, such as reproducibility and poor interobserver agreement, and the paucity of studies from first-contact care settings.

"The main strength of this systematic review is that it highlights the nature and difficulty of the diagnostic task facing primary care and hospital clinicians responsible for identifying seriously ill children at initial presentation in countries where serious childhood illness is now rare," the study authors conclude. "Most of the red flags already recommended by WHO [World Health Organization] for use in developing countries can be used in the initial assessment of children presenting to ambulatory care settings in developed countries. There should be more emphasis on parental concern in the diagnostic process."

In an accompanying comment, Martin Dawes, MBBS, MD, from McGill University in Montreal, Canada, notes that how to effectively recognize or rule out severe disease in ill children is still unclear and that there is no cohesive national or global research strategy to address this problem.

"We need better-designed diagnostic and prognostic studies in primary care," Dr. Dawes writes. "Such studies require properly documented histories and examination as well as follow-up, but both are well within the scope of an organised practice and if centrally coordinated we could have ten times the evidence within a year or two. This research cannot be done without adequate funding and should be a priority for national and international research foundations."

Health Technology Assessment and National Institute for Health Research National School for Primary Care Research supported this study. The study authors and Dr. Dawes have disclosed no relevant financial relationships.

Lancet. Published online February 3, 2010.

8. Applying the Lean principles of the Toyota Production System to reduce wait times in the emergency department

Ng D, et al. CJEM 2010;12:50-57.

Objective: In recognition of patient wait times, and deteriorating patient and staff satisfaction, we set out to improve these measures in our emergency department (ED) without adding any new funding or beds.

Methods: In 2005 all staff in the ED at Hôtel Dieu Grace Hospital began a transformation, employing Toyota Lean manufacturing principles to improve ED wait times and quality of care. Lean techniques such as value stream mapping, just in time delivery techniques, workplace organization, reduction of systemic wastes, use of the worker as the source of quality improvement and ongoing refinement of our process steps formed the basis of our project.

Results: Our ED has achieved major improvements in depart mental flow without adding any additional ED or inpatient beds. The mean registration to physician time has decreased from 111 minutes to 78 minutes. The number of patients who left without being seen has decreased from 7.1% to 4.3%. The length of stay (LOS) for discharged patients has decreased from a mean of 3.6 to 2.8 hours, with the largest decrease seen in our patients triaged at levels 4 or 5 using the Canadian Emergency Department Triage and Acuity Scale. We noted an improvement in ED patient satisfaction scores following the implementation of Lean principles.

Conclusion: Lean manufacturing principles can improve the flow of patients through the ED, resulting in greater patient satisfaction along with reduced time spent by the patient in the ED.

9. Tachypnea Is a Poor Predictor of Pneumonia in Children

An elevated respiratory rate in children younger than 5 years is less than 50% sensitive for predicting pneumonia.

Shah S et al. Pediatr Infect Dis J 2009 Dec 21.

Background: The World Health Organization (WHO) recommends the use of tachypnea as a proxy to the diagnosis of pneumonia in resource poor settings.

Objective: To assess the relation between tachypnea and radiographic pneumonia among children evaluated in a pediatric emergency department (ED).

Methods: Prospective study of children less than 5 years of age undergoing chest radiography (CXR) for possible pneumonia was conducted in an academic pediatric ED. Tachypnea was defined using 3 different measurements: (1) mean triage respiratory rate (RR) by age group, (2) age-defined tachypnea based on WHO guidelines (less than 2 months [RR 60/min or greater], 2 to 12 months [RR 50 or greater], 1 to 5 years [RR 40 or greater]), and (3) physician-assessed tachypnea based on clinical impression assessed before CXR. The presence of pneumonia on CXR was determined by an attending radiologist.

Results: A total of 1622 patients were studied, of whom, 235 (14.5%) had radiographic pneumonia. Mean triage RR among children with pneumonia (RR = 39/min) did not differ from children without pneumonia (RR = 38/min). About 20% of children with tachypnea as defined by WHO age-specific cut-points had pneumonia, compared with 12% of children without tachypnea (P less than 0.001). About 17% of children who were assessed to be tachypneic by the treating physician had pneumonia, compared with 13% of children without tachypnea (P = 0.07).

Conclusion: Among an ED population of children who have a CXR performed to assess for pneumonia, RR alone, and subjective clinical impression of tachypnea did not discriminate children with and without radiographic pneumonia. However, children with tachypnea as defined by WHO RR thresholds were more likely to have pneumonia than children without tachypnea.

10. Standard Medical Care May Not Relieve Symptoms of Nonspecific Chest Pain

Laurie Barclay, MD. February 8, 2010 — Standard medical care may not relieve symptoms of nonspecific chest pain, according to the results of a prospective, general physician–based cohort study reported in the February 8 issue of the Archives of Internal Medicine.

"Nonspecific chest pain is common in primary care, yet knowledge is sparse about its course and outcome and how they relate to optimum health care usage," write Julia Anna Glombiewski, PhD, from Philipps-University of Marburg, Germany, and colleagues. "We investigated the following observations: (1) many patients who present with nonspecific chest pain in primary care show symptom persistence for 6 months, (2) many patients with nonspecific chest pain showed signs of overinvestigation, and (3) many patients with chronic chest pain were referred to mental health specialists."

From October 1, 2005, to July 31, 2006, approximately 190,000 consecutive patients visited their general physicians at 74 primary care offices in Hessen, Germany. An expert committee identified 807 of these patients as having nonspecific chest pain, with no underlying heart condition. Follow-ups were performed at 6 weeks and 6 months, with a dropout rate of 2.7%.

The primary study endpoints were persistent chest pain at 6-month follow-up and healthcare use at 6 months. Inappropriate healthcare use was defined as at least 2 visits to a cardiologist or at least 3 cardiac diagnostic investigations.

At 6-month follow-up, 55.5% of patients had persistent chest pain, 10.7% of patients had inappropriate healthcare use, and fewer than 2% were referred to mental health specialists. Most patients with persistent nonspecific chest pain were referred to a cardiologist.

"For most patients with nonspecific chest pain, standard medical care does not offer sufficient help for symptom relief," the study authors write. "One-tenth of patients with persistent chest pain underwent additional diagnostic testing of no known clinical benefit. Psychological referrals were rarely given...[which] is surprising because psychological factors are known to contribute to the development of chronic pain, and psychological consultations are covered by the health care system in Germany."

Limitations of this study include the low response rate of general practitioners approached to participate in the study, use of a proposed new cutoff for inappropriate healthcare use, limited generalizability, and use of an informal definition of nonspecific chest pain.

"Patients with psychologically caused non-specific chest pain showed more problematic health care–seeking behavior but were rarely referred to mental health professionals," the study authors conclude. "Patients, general practitioners or both seem to be hesitant to involve psychological interventions.... Future research should investigate the development of effective interventions for non-specific chest pain and their implementation within health care systems."

The German Federal Ministry of Education and Research supported this study. The study authors have disclosed no relevant financial relationships.

Arch Intern Med. 2010;170:251-255.

11. Images in Emergency Medicine

Adult Male with Altered Mental Status and New-Onset Seizures

http://www.annemergmed.com/article/S0196-0644(09)00644-1/fulltext

12. Accuracy of Very Low Pretest Probability Estimates for Pulmonary Embolism Using the Method of Attribute Matching Compared with the Wells Score

Kline JA, et al. Acad Emerg Med. 2010;17:133–141.

Objectives: Attribute matching matches an explicit clinical profile of a patient to a reference database to estimate the numeric value for the pretest probability of an acute disease. The authors tested the accuracy of this method for forecasting a very low probability of venous thromboembolism (VTE) in symptomatic emergency department (ED) patients.

Methods: The authors performed a secondary analysis of five data sets from 15 hospitals in three countries. All patients had data collected at the time of clinical evaluation for suspected pulmonary embolism (PE). The criterion standard to exclude VTE required no evidence of PE or deep venous thrombosis (DVT) within 45 days of enrollment. To estimate pretest probabilities, a computer program selected, from a large reference database of patients previously evaluated for PE, patients who matched 10 predictor variables recorded for each current test patient. The authors compared the outcome frequency of having VTE [VTE(+)] in patients with a pretest probability estimate of less than 2.5% by attribute matching, compared with a value of 0 from the Wells score.

Results: The five data sets included 10,734 patients, and 747 (7.0%, 95% confidence interval [CI] = 6.5% to 7.5%) were VTE(+) within 45 days. The pretest probability estimate for PE was less than 2.5% in 2,975 of 10,734 (27.7%) patients, and within this subset, the observed frequency of VTE(+) was 48 of 2,975 (1.6%, 95% CI = 1.2% to 2.1%). The lowest possible Wells score (0) was observed in 3,412 (31.7%) patients, and within this subset, the observed frequency of VTE(+) was 79 of 3,412 (2.3%, 95% CI = 1.8% to 2.9%) patients.

Conclusions: Attribute matching categorizes over one-quarter of patients tested for PE as having a pretest probability of less than 2.5%, and the observed rate of VTE within 45 days in this subset was less than 2.5%.

13. Kitchen Spoons Don't Work for Meds

The amount of medicine poured varies with the size of the spoon.

Many patients and parents use kitchen spoons to dose liquid medications, but the accuracy of spoon dosing is questionable. These authors conducted a simple study in 195 university students to examine the effect of spoon size on dosing of liquid medication.

Students were asked to pour a 5-mL (teaspoon) dose of cold medicine into a teaspoon, a medium-sized tablespoon, and a larger spoon. The amount of medicine poured varied with the size of the spoon: Participants underdosed by 8.4% (amount poured, 4.58 mL) with the medium-sized tablespoon and overdosed by 11.6% (amount poured, 5.58 mL) with the larger spoon. When asked to judge their dosing accuracy, participants had above average confidence that they had poured the correct dose into the medium and larger spoons.

Comment: Although the dosing errors demonstrated in this study might seem inconsequential for a cold medication, the cumulative effect of 20% variation in the delivery of medications could have considerable clinical impact for drugs with tighter risk-benefit profiles. Clearly, the size of the spoon is important when patients pour their medications. We should encourage parents to use accurate measures (e.g., measuring cap, dropper, or syringe) rather than convenient utensils for liquid-medication dosing.

— F. Bruder Stapleton, MD. Published in Journal Watch Pediatrics and Adolescent Medicine January 27, 2010. Citation: Wansink B and van Ittersum K. Spoons systematically bias dosing of liquid medicine. Ann Intern Med 2010 Jan 5; 152:66.

14. The Etiology and Prognostic Significance of Cardiac Troponin I Elevation in Unselected Emergency Department Patients

Ilva TJ, et al. J Emerg Med. 2010;38:1-5.

Background: Cardiac troponin elevations are associated not only with acute coronary syndromes (ACS) but also with multiple other cardiac and non-cardiac conditions. Study Objectives: To investigate the etiology and clinical significance of cardiac troponin I elevations in an unselected Emergency Department (ED) patient cohort.

Methods: The study population consisted of 991 consecutive troponin-positive patients admitted to the ED of a university hospital with ACS as the presumptive diagnosis. Cardiac troponin I was measured on admission and a follow-up sample was obtained at 6–12 h. Clinical diagnosis was ascertained retrospectively using all the available information including electrocardiogram, clinical data, laboratory tests, and available coronary angiograms.

Results: At admission, 805 (81.2%) patients were already troponin positive; of these, the troponin elevation was related to myocardial infarction (MI) in 654 (81.2%) patients. Finally, 83.0% of the troponin elevations were due to MI, 7.9% were related to other cardiac causes, and 9.1% to non-cardiac diseases. The leading non-cardiac causes were pulmonary embolism, renal failure, pneumonia, and sepsis. Non-cardiac patients with elevated troponin I at admission showed significantly higher in-hospital mortality (26.7% vs. 13.4%, p = 0.002) compared to cardiac patients.

Conclusion: Elevated troponin levels for reasons other than MI are common in the ED and are a marker of poor in-hospital prognosis.

15. Prehospital ECG Speeds STEMI Patients' Route to Cath Lab

January 27, 2010 (Southfield, Michigan) — Emergency medical services (EMS) evaluating suspected ST-elevation myocardial infarction (STEMI) patients in the field with a prehospital electrocardiogram (ECG) are able to get patients directly to a cath lab much faster than if they had to go through triage in the emergency room (ER), a study in Michigan shows.

A five-year study by Dr Anjani Rao (Providence Hospital, Southfield, MI) and colleagues found that the average door-to-balloon time of patients evaluated by EMS in the field with a 12-lead ECG was about one hour, compared with about 90 minutes for patients presenting to the emergency department without a prehospital ECG (p less than 0.0001). Furthermore, prehospital ECGs reduced the door-to-balloon time, regardless of what time of day the patient came to the hospital. Results of the study by Rao et al are published online January 21, 2010 in Catheterization and Cardiovascular Interventions.

"This study adds to the evidence that prehospital ECGs improve the door-to-balloon time," Dr Deepak Bhatt (Brigham and Women's Hospital, Boston, MA) told heartwire ."The data are now fairly consistent."

The study evaluated data from three hospitals in southeast Michigan from 2003 to 2008. At each center, EMS personnel obtained a 12-lead ECG during initial assessment in the field from patients with symptoms of STEMI and then transmitted that data to the emergency department by cellular link. If the emergency-department physicians determined that the ECG indicated STEMI, they would activate the cath lab immediately. A total of 108 STEMI patients were admitted with prehospital ECG in the study.

For the same period, similar data were collected for all patients who came to the emergency department by EMS or on their own without a prehospital ECG, a total of 241 patients.

The overall average door-to-balloon time for patients with in-hospital ECG only was 90.5 minutes, compared with 60.2 minutes in patients with prehospital ECG, and door-to-balloon time was also significantly lower for the prehospital ECG patients at each of the three hospitals. The median door-to-balloon time was also lower with prehospital ECG (62 vs 82 minutes), and more patients in the prehospital ECG group had door-to-balloon times under 90 minutes, the target set by ACC/AHA guidelines (97.4% vs 61.5%; p less than 0.001). There were no in-hospital deaths in the prehospital ECG group compared with seven (2%) in the control group.

Rao et al note that previous studies show that patients presenting to an emergency room with STEMI during normal working hours are almost twice as likely to have a door-to-balloon time under 90 minutes as patients presenting during off-hours. The southeast Michigan study had similar findings for the in-hospital ECG group, but 98% of the patients with prehospital ECG during off-hours had door-to-balloon times within 90 minutes.

The study did not show a mortality benefit, most likely because of the low total number of deaths, Rao et al observe, but they note that previous trials have shown that delays in reperfusion therapy, such as those encountered during off-hours, increase mortality in STEMI patients. "The use of the prehospital ECG is a way of overcoming the obstacle of delay in cath-lab activation during off-hours."

Bhatt agrees that further studies may show that prehospital ECG saves lives. "There is even some evidence to suggest an associated improvement in hard clinical outcomes, although more data in this regard would be useful."

Bhatt also points out that hospitals relying on prehospital ECG to bypass triage in the emergency department must be carefully managed to ensure there is no loss of diagnostic accuracy when shifting from an in-hospital to prehospital ECG protocol. "There still needs to be careful oversight of these programs to make sure that clinically ambiguous cases get triaged appropriately in the emergency department," he said.

16. Comparison of Antiarrhythmic Drug Therapy and Radiofrequency Catheter Ablation in Patients With Paroxysmal Atrial Fibrillation: A Randomized Controlled Trial

Wilber DJ, et al. JAMA. 2010;303:333-340.

Context: Antiarrhythmic drugs are commonly used for prevention of recurrent atrial fibrillation (AF) despite inconsistent efficacy and frequent adverse effects. Catheter ablation has been proposed as an alternative treatment for paroxysmal AF.

Objective: To determine the efficacy of catheter ablation compared with antiarrhythmic drug therapy (ADT) in treating symptomatic paroxysmal AF.

Design, Setting, and Participants: A prospective, multicenter, randomized (2:1), unblinded, Bayesian-designed study conducted at 19 hospitals of 167 patients who did not respond to at least 1 antiarrhythmic drug and who experienced at least 3 AF episodes within 6 months before randomization. Enrollment occurred between October 25, 2004, and October 11, 2007, with the last follow-up on January 19, 2009.

Intervention: Catheter ablation (n = 106) or ADT (n = 61), with assessment for effectiveness in a comparable 9-month follow-up period.

Main Outcome Measures: Time to protocol-defined treatment failure. The proportion of patients who experienced major treatment-related adverse events within 30 days of catheter ablation or ADT was also reported.

Results: At the end of the 9-month effectiveness evaluation period, 66% of patients in the catheter ablation group remained free from protocol-defined treatment failure compared with 16% of patients treated with ADT. The hazard ratio of catheter ablation to ADT was 0.30 (95% confidence interval, 0.19-0.47; P less than .001). Major 30-day treatment-related adverse events occurred in 5 of 57 patients (8.8%) treated with ADT and 5 of 103 patients (4.9%) treated with catheter ablation. Mean quality of life scores improved significantly in patients treated by catheter ablation compared with ADT at 3 months; improvement was maintained during the course of the study.

Conclusion: Among patients with paroxysmal AF who had not responded to at least 1 antiarrhythmic drug, the use of catheter ablation compared with ADT resulted in a longer time to treatment failure during the 9-month follow-up period.

17. New Guidance for In-Hospital Torsades De Pointes

Steve Stiles. February 9, 2010 (Dallas, Texas and Washington, DC) — Many common, useful drugs have the side effect of electrocardiographic QT-interval prolongation, which substantially increases the risk of sudden death from torsades de pointes, a polymorphic VT. A given QT-prolonging drug may more likely cause torsades in hospitalized patients than in the general population, as hospitalized patients "are often elderly people with underlying heart disease who may also have renal or hepatic dysfunction, electrolyte abnormalities, or bradycardia and to whom drugs may be administered rapidly via the intravenous route," observes a new scientific statement from the American Heart Association and American College of Cardiology. Those features, including advanced age, have confirmed or suspected associations with development of the malignant arrhythmia, the document states.

The document, also endorsed by the American Association of Critical-Care Nurses, describes the state of the art of how to identify the arrhythmia and its precursors on the ECG, drugs and patient features that promote it, strategies for prevention and monitoring, and acute management of both QT prolongation and the manifest arrhythmia. Dr Barbara J Drew (University of California, San Francisco) chaired its writing group.

The benefits of using QT-prolonging agents must be weighed against the risk in patients with increased susceptibility to torsades, it states. The susceptibility can include certain genetic mutations that, when such drugs are given, can promote the arrhythmia.

In such cases, continuous monitoring of the corrected QT (QTc) interval is recommended; "prompt action" is needed if the QTc exceeds 500 ms compared with an ECG obtained before drug administration; the QTc must be measured by the same method and/or device each time.

Responses can include drug withdrawal, correction of electrolyte abnormalities, temporary pacing, and "the ready availability of an external defibrillator."

Other ECG features can signal impending torsades, including distortions of the TU wave, visible T-wave alternans, new ventricular ectopic beats, and "couplets and nonsustained polymorphic ventricular tachycardia initiated in the beat after a pause."

Drugs that promote QTc prolongation and torsades, to different degrees, include the antiarrhythmics quinidine, disopyramide, procainamide, sotalol, dofetilide, and ibutilide as well as methadone, thioridazine, and haloperidol, according to the statement.

Still, it notes, "where benefit clearly outweighs risk, QT prolongation should not limit necessary therapy."

Drew BJ, et al. Prevention of torsade de pointes in hospital settings. A scientific statement from the American Heart Association and the American College of Cardiology Foundation. Circulation 2010; DOI: 10.1161/CIRCULATIONAHA.109.192704.

Full-text (free): http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.109.192704v1

18. Anticholinergics and Ketamine Sedation in Children: A Secondary Analysis of Atropine Versus Glycopyrrolate

Green SM, et al. Acad Emerg Med. 2010;17:157–162.
.
Objectives: Adjunctive anticholinergics are commonly administered during emergency department (ED) ketamine sedation in children under the presumption that drying oral secretions should decrease the likelihood of airway and respiratory adverse events. Pharmacologic considerations suggest that glycopyrrolate might exhibit a superior adverse effect profile to atropine. The authors contrasted the adverse events noted with use of each of these anticholinergics in a large multicenter observational database of ketamine sedations.

Methods: This was a secondary analysis of an observational database of 8,282 ED ketamine sedations assembled from 32 prior series. The authors compared the relative incidence of six adverse events (airway and respiratory adverse events, laryngospasm, apnea, emesis, recovery agitation, and clinically important recovery agitation) between children who received coadministered atropine, glycopyrrolate, or no anticholinergic. Multivariable analysis using the specific anticholinergic as a covariate was performed, while controlling for other known predictors.

Results: Atropine was associated with less vomiting (5.3%) than either glycopyrrolate (10.7%) or no anticholinergic (11.4%) in both unadjusted and multivariable analyses. Glycopyrrolate was associated with significantly more airway and respiratory adverse events (6.4%) than either atropine (3.3%) or no anticholinergic (3.0%) and similarly more clinically important recovery agitation (2.1% vs. 1.2 and 1.3%). There were, however, no differences noted in odds of laryngospasm and apnea.

Conclusions: This secondary analysis unexpectedly found that the coadministered anticholinergic atropine exhibited a superior adverse event profile to glycopyrrolate during ketamine sedation. Any such advantage requires confirmation in a separate trial; however, our data cast doubt on the traditional premise that glycopyrrolate might be superior. Further, neither anticholinergic showed efficacy in decreasing airway and respiratory adverse events.

19. A Prospective Case Series of Pediatric Procedural Sedation and Analgesia in the Emergency Department Using Single-syringe Ketamine–Propofol Combination (Ketofol)

Andolfatto G, et al. Acad Emerg Med. 2010;17:194–201.

Objectives: This study evaluated the effectiveness, recovery time, and adverse event profile of intravenous (IV) ketofol (mixed 1:1 ketamine–propofol) for emergency department (ED) procedural sedation and analgesia (PSA) in children.

Methods: Prospective data were collected on all PSA events in a trauma-receiving, community teaching hospital over a 3.5-year period, from which data on all patients under 21 years of age were studied. Patients receiving a single-syringe 1:1 mixture of 10 mg/mL ketamine and 10 mg/mL propofol (ketofol) were analyzed. Patients received ketofol in titrated aliquots at the discretion of the treating physician. Effectiveness, recovery time, caregiver and patient satisfaction, drug doses, physiologic data, and adverse events were recorded.

Results: Ketofol PSA was performed in 219 patients with a median age of 13 years (range = 1 to 20 years; interquartile range [IQR] = 8 to 16 years) for primarily orthopedic procedures. The median dose of medication administered was 0.8 mg/kg each of ketamine and propofol (range = 0.2 to 3.0 mg/kg; IQR = 0.7 to 1.0 mg/kg). Sedation was effective in all patients. Three patients (1.4%; 95% confidence interval [CI] = 0.0% to 3.0%) had airway events requiring intervention, of which one (0.4%; 95% CI = 0.0% to 1.2%) required positive pressure ventilation. Two patients (0.9%; 95% CI = 0.0% to 2.2%) had unpleasant emergence requiring treatment. All other adverse events were minor. Median recovery time was 14 minutes (range = 3 to 41 minutes; IQR = 11 to 18 minutes). Median staff satisfaction was 10 on a 1-to-10 scale.

Conclusions: Pediatric PSA using ketofol is highly effective. Recovery times were short; adverse events were few; and patients, caregivers, and staff were highly satisfied.

20. Adjunctive dexamethasone in bacterial meningitis: a meta-analysis of individual patient data

van de Beek D, et al. The Lancet Neurology. 2010; Early Online Publication, 4 February

Background
Dexamethasone improves outcome for some patients with bacterial meningitis, but not others. We aimed to identify which patients are most likely to benefit from dexamethasone treatment.

Methods
We did a meta-analysis of individual patient data from the randomised, double-blind, placebo-controlled trials of dexamethasone for bacterial meningitis in patients of all ages for which raw data were available. The pre-determined outcome measures were death at the time of first follow-up, death or severe neurological sequelae at 1 month follow-up, death or any neurological sequelae at first follow-up, and death or severe bilateral hearing loss at first follow-up. Combined odds ratios (ORs) and tests for heterogeneity were calculated using conventional Mantel-Haenszel statistics. We also did exploratory analysis of hearing loss among survivors and other exploratory subgroup analyses by use of logistic regression.

Findings
Data from 2029 patients from five trials were included in the analysis (833 [41•0%] aged less than 15 years). HIV infection was confirmed or likely in 580 (28•6%) patients and bacterial meningitis was confirmed in 1639 (80•8%). Dexamethasone was not associated with a significant reduction in death (270 of 1019 [26•5%] on dexamethasone vs 275 of 1010 [27•2%] on placebo; OR 0•97, 95% CI 0•79—1•19), death or severe neurological sequelae or bilateral severe deafness (42•3% vs 44•3%; 0•92, 0•76—1•11), death or any neurological sequelae or any hearing loss (54•2% vs 57•4%; 0•89, 0•74—1•07), or death or severe bilateral hearing loss (36•4% vs 38•9%; 0•89, 0•73—1•69). However, dexamethasone seemed to reduce hearing loss among survivors (24•1% vs 29•5%; 0•77, 0•60—0•99, p=0•04). Dexamethasone had no effect in any of the prespecified subgroups, including specific causative organisms, pre-dexamethasone antibiotic treatment, HIV status, or age. Pooling of the mortality data with those of all other published trials did not significantly change the results.

Interpretation
Adjunctive dexamethasone in the treatment of acute bacterial meningitis does not seem to significantly reduce death or neurological disability. There were no significant treatment effects in any of the prespecified subgroups. The benefit of adjunctive dexamethasone for all or any subgroup of patients with bacterial meningitis thus remains unproven.

21. Is there Anybody in There?

By Greg Miller. ScienceNOW Daily News. 3 February 2010

When a brain injury leaves a person unresponsive and unable to communicate, doctors and nurses must provide care without input from their patient, and families agonize over whether their loved one might still have--or someday recover--a flicker of consciousness. A new study provides hope that technology might open a line of communication with some such patients. Researchers report that a man with a severe brain injury can, by controlling his thoughts, influence scans of his brain activity and thereby answer simple questions.

The work builds on a 2006 Science paper by Adrian Owen, a neuroscientist at the Medical Research Council Cognition and Brain Sciences Unit in Cambridge, U.K., and colleagues. Using functional magnetic resonance imaging (fMRI), they tested a young woman diagnosed as being in a vegetative state following a car accident. Although she was unresponsive and apparently unaware of her surroundings, she exhibited distinct patterns of brain activity when asked to imagine herself playing tennis or walking through the rooms of her house. As in healthy volunteers, imagining tennis activated motor planning regions in the woman's brain, whereas picturing her house activated a brain region involved in recognizing familiar scenes.

In the new study, published today in the New England Journal of Medicine, Owen and several colleagues used similar methods to examine 53 additional people who were in a vegetative state or in the slightly less severe minimally conscious state, in which patients show occasional flashes of responsiveness. In four of these patients, the researchers found distinct patterns of brain activity during the tennis versus house imagination task, hinting at some level of awareness that could not be detected by observing their behavior, says co-author Steven Laureys, a neurologist at the University of Liège in Belgium.

In one patient, a 22-year-old man who'd been in a vegetative state for 5 years, the researchers took an additional step, asking him to answer six questions by imagining tennis to indicate "yes" or picturing his house to indicate "no." The questions all involved basic autobiographical details, such as the name of his father or whether he had any brothers or sisters. In a group of 16 healthy volunteers, this method worked 100% of the time, the researchers report. The vegetative state patient answered the first five questions correctly. The final question elicited virtually no activity in the brain regions of interest, and the researchers speculate that the man may have fallen asleep or simply decided not to answer.

"This is a major step forward," says Nicholas Schiff, a neurologist at Weill Cornell Medical College in New York City. The paper is important because it shows that the Science report was not an isolated case and that technology can be used to establish communication with some patients who show no outward signs of consciousness, Schiff says.

Laureys cautions, however, that the fMRI method is not ready for widespread use in hospitals. He and collaborators are now trying to adapt the imagination task to work with electroencephalography, a relatively low-tech alternative to fMRI that's less expensive and easier to operate. "Our mission now is to translate this to clinical reality," Laureys says.

If such methods do become more widely available, they are sure to raise a host of sticky clinical and ethical questions, says James Bernat, a neurologist at Dartmouth Medical School in Hanover, New Hampshire. For example, doctors would want to involve patients in decisions about their care. But, Bernat asks, would a system that allows only yes or no answers make a physician "confident that all the nuances have been dealt with ... that they're dealing with a rational wish of the person that has been thoughtfully considered?"

Lit Bits: Jan 29, 2010

From the recent medical literature...

1. Drive-Through Emergency Care May Be Feasible for Pandemics

Laurie Barclay, MD. January 26, 2010 — A drive-through model may be a feasible approach to emergency care during a pandemic, or even in other circumstances in which emergency care is needed, according to the results of a study published online January 13 in the Annals of Emergency Medicine.

"The most important message is that a drive-through medical clinic is not only a feasible model, but may be a preferred type of alternative care center," lead author Eric A. Weiss, MD, from the Stanford University School of Medicine in California, said in a news release. "It can expedite and facilitate seeing large numbers of patients while mitigating the spread of infectious diseases by providing a social distancing mechanism. And it not only can be used during a pandemic, but also would be an excellent strategy for bioterrorism, or for other emerging infectious disease events."
The investigators performed a full-scale exercise to determine the feasibility of a drive-through influenza clinic, as well as to measure throughput times of simulated patients, carbon monoxide levels of staff, and disposition decisions of participant physicians. Patient scenarios for the drive-through influenza clinic were created from medical records of 38 patients with influenza-like illness treated in the Stanford Hospital emergency department during the initial H1N1 outbreak in April 2009.

Mock patients were screened by a nurse in a parking garage near the hospital. Those who were relatively stable were directed into a lane for the drive-through clinic. Severely ill patients were triaged to the emergency department.

Nurses measured vital signs at 2 triage stations in the garage, and at a third station patients stepped outside their cars for a complete physical examination conducted in heated, draped-off areas. Mock medications and prescriptions were dispensed at a discharge station. Crash carts were available, and golf carts equipped with stretchers and resuscitation equipment circled the parking garage.

Total median length of stay was 26 minutes. Physicians taking part in the exercise were 100% accurate in identifying those patients who were admitted and discharged during the real ED visit (95% confidence interval, 91% - 100%), and they had no significant increases in carboxyhemoglobin.

"The drive-through model is a feasible alternative to a traditional walk-in [emergency department] or clinic and is associated with rapid throughput times," the study authors write. "It provides a social distancing strategy, using the patient's vehicle as an isolation compartment to mitigate person-to-person spread of infectious diseases."

Limitations of this study include use of a simulated environment involving dedicated staff and actors waiting in their cars, with historical data and pertinent examination findings listed on a data card. Another limitation was a possible Hawthorne effect. In addition, drive-through "patients" were all English speaking in this scenario, and starting the simulation and timing with the system empty may have produced artificially short lengths of stay.

Limitations of the drive-through model include lack of air conditioning and heating and a lack of bathrooms.

"You don't have the delays inherent in having to turn over a fixed number of rooms, waiting for patients to be discharged, having to change linens," Dr. Weiss concluded. "We developed a general drive-through plan for all the hospitals in the county. It's essentially a playbook that shows how to set up one of these centers at your own hospital."

Ann Emerg Med. Published online January 13, 2010.

2. Recent Caffeine Ingestion Reduces Adenosine Efficacy in the Treatment of Paroxysmal Supraventricular Tachycardia

Cabalag MS, et al. Acad Emerg Med. 2010;17:44-49.

Objectives: Caffeine, an adenosine receptor blocker, should theoretically reduce adenosine efficacy in the treatment of paroxysmal supraventricular tachycardia (SVT). We aimed to determine the effect of recent caffeine ingestion on the likelihood of reversion of SVT with adenosine.

Methods: This was a multicenter, case–control study of adult patients with SVT treated with adenosine between September 2007 and July 2008. The primary endpoint was reversion to sinus rhythm (SR) after a 6-mg adenosine bolus, as a function of recent (within 2, 4, 6, and 8 hours) caffeine ingestion. Caffeine ingestion data were collected using a self-administered questionnaire.

Results: Of 68 patients enrolled, 52 (76.5%, 95% confidence interval [CI] = 64.4% to 85.6%) reverted after a 6-mg adenosine bolus. There were no significant differences in age, sex, or daily caffeine ingestion between patients who did and did not revert (p greater than 0.05). However, as a group, patients who did not revert had recently ingested significantly more caffeine (p less than 0.05). If caffeine had been ingested less than 2 or 4 hours before the adenosine bolus, the odds of reversion to SR were significantly reduced (odds ratio [OR] = 0.18, 95% CI = 0.04 to 0.93; and OR = 0.14, 95% CI = 0.04 to 0.49, respectively). If caffeine had been ingested less than 6 or 8 hours before the adenosine, the odds of reversion were not reduced (OR = 0.31, 95% CI = 0.09 to 1.02; and OR = 0.31, 95% CI = 0.09 to 1.08, respectively).

Conclusions: Ingestion of caffeine less than 4 hours before a 6-mg adenosine bolus significantly reduces its effectiveness in the treatment of SVT. An increased initial adenosine dose may be indicated for these patients.

3. Outcomes for Patients with ST-Elevation Myocardial Infarction in Hospitals With and Without Onsite Coronary Artery Bypass Graft Surgery: The New York State Experience

Hannan EL, et al. Circulation 2009;2:519-527.

Background— The benefit of primary percutaneous coronary interventions (P-PCI) for patients with ST-elevation myocardial infarction (STEMI) has been well documented. However, controversy still exists as to whether PCI should be expanded to hospitals without coronary artery bypass graft surgery.

Methods and Results— Patients who were discharged after PCI for STEMI between January 1, 2003, and December 12, 2006, in P-PCI centers (hospitals with no coronary artery bypass graft surgery, and PCI only for patients with STEMI) were propensity matched with patients in full service centers, and mortality and subsequent revascularization rates were compared. For patients undergoing PCI, there were no differences for in-hospital/30-day mortality (2.3% for P-PCI centers versus 1.9% for full service centers [P=0.40]), emergency coronary artery bypass graft surgery immediately after PCI (0.06% versus 0.35%, P=0.06), 3-year mortality (7.1% versus 5.9%, P=0.07), or 3-year subsequent revascularization (23.8% versus 21.5%, P=0.52). P-PCI centers had a lower same/next day coronary artery bypass graft rate (0.23% versus 0.69%, P=0.046) and higher repeat target vessel PCI rates (12.1% versus 9.0%, P=0.003). For patients with STEMI who did not undergo PCI, P-PCI centers had higher in-hospital mortality (28.5% versus 22.3%; adjusted odds ratio, 1.38; 95% CI, 1.10 to 1.75).

Conclusions— No differences between P-PCI centers and full service centers were found in in-hospital/30-day mortality, the need for emergency surgery, 3-year mortality or subsequent revascularization, but P-PCI centers had higher repeat target vessel PCI rates and higher mortality rates for patients who did not undergo PCI. P-PCI centers should be monitored closely, including the monitoring of patients with STEMI who did not undergo PCI.

Full-text (free): http://circinterventions.ahajournals.org/cgi/content/full/2/6/519

4. Does the Early Administration of Beta-blockers Improve the In-hospital Mortality Rate of Patients Admitted with Acute Coronary Syndrome?

Brandler E, et al. Acad Emerg Med 2010:17:1-10.

Objectives: Beta-blockade is currently recommended in the early management of patients with acute coronary syndromes (ACS). This was a systematic review of the medical literature to determine if early beta-blockade improves the outcome of patients with ACS.

Methods: The authors searched the PubMed and EMBASE databases for randomized controlled trials from 1965 through May 2009 using a search strategy derived from the following PICO formulation of our clinical question: Patients included adults (18+ years) with an acute or suspected myocardial infarction (MI) within 24 hours of onset of chest pain. Intervention included intravenous or oral beta-blockers administered within 8 hours of presentation. The comparator included standard medical therapy with or without placebo versus early beta-blocker administration. The outcome was the risk of in-hospital death in the intervention groups versus the comparator groups. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. In-hospital mortality rates were compared using a forest plot of relative risk (RR; 95% confidence interval [CI]) between beta-blockers and controls. Statistical analysis was done with Review Manager V5.0.

Results: Eighteen articles (total N = 72,249) met the inclusion/exclusion criteria. For in-hospital mortality, RR = 0.95 (95% CI, 0.90–1.01). In the largest of these studies (n = 45,852), a significantly higher rate (p less than 0.0001) of cardiogenic shock was observed in the beta-blocker (5.0%) versus control group (3.9%).

Conclusions: This systematic review failed to demonstrate a convincing in-hospital mortality benefit for using beta-blockers early in the course of patients with an acute or suspected MI.

5. Introducing a Clinical Practice Guideline Using Early CT in the Diagnosis of Scaphoid and Other Fractures.

Pincus S, et al. West J Emerg Med. 2009;10:227-32.

OBJECTIVE: We developed and implemented clinical practice guideline (CPG) using computerized tomography (CT) as the initial imaging method in the emergency department management of scaphoid fractures. We hypothesized that this CPG would decrease unnecessary immobilization and lead to earlier return to work.

METHODS: This observational study evaluated implementation of our CPG, which incorporated early wrist CT in patients with "clinical scaphoid fracture": a mechanism of injury consistent with scaphoid fracture, anatomical snuff box tenderness, and normal initial plain x-rays. Outcome measures were the final diagnosis as determined by orthopaedic review of the clinical and imaging data. Patient outcomes included time to return to work and patient satisfaction as determined by telephone interview at ten days.

RESULTS: Eighty patients completed the study protocol in a regional emergency department. In this patient population CT detected 28 fractures in 25 patients, including six scaphoid fractures, five triquetral fractures, four radius fractures, and 13 other related fractures. Fifty-three patients had normal CT. Eight of these patients had significant ongoing pain at follow up and had an MRI, with only two bone bruises identified. The patients with normal CTs avoided prolonged immobilization (mean time in plaster 2.7 days) and had no or minimal time off work (mean 1.6 days). Patient satisfaction was an average 4.2/5.

CONCLUSION: This CPG resulted in rapid and accurate management of patients with suspected occult scaphoid injury, minimized unnecessary immobilization and was acceptable to patients.

Full-text (free): http://www.escholarship.org/uc/item/6098v3k6

6. ACEP's Ethics Committee: Gifts to Emergency Physicians From Industry

Ann Emerg Med. 2010;55:230.

The practice of the pharmaceutical and medical device industries to give gifts to physicians has come under increasing scrutiny in recent years. Prominent professional associations have issued reports recommending a ban on accepting gifts from industry. Many US academic medical centers have implemented policies prohibiting acceptance by physicians, other health care professionals, and trainees, of any gifts from industry representatives. The leading trade associations of the pharmaceutical and medical device industries have adopted revised guidelines for interaction with health care professionals that impose new voluntary restrictions on the practice of giving gifts.

Opponents of the practice of giving and accepting gifts cite neurobiological and psychosocial evidence that even small favors may create a subliminal sense of gratitude or loyalty that can influence physicians' medical treatment choices. The American College of Emergency Physicians believes that treatment choices should be based on an impartial assessment of the benefits, risks, and costs of the treatment for the patient, and not on a physician's relationship with industry representatives. For this reason, acceptance of gifts from the biomedical industry should be carefully limited, as detailed below.

The remainder of the statement can be found here: http://www.annemergmed.com/article/S0196-0644(09)01738-7/fulltext

7. Complications and Death at the Start of the New Academic Year: Is There a July Phenomenon?

Inaba K, et al. J Trauma 2010;68:19-22.

Background: The “July Phenomenon” refers to the propensity for increased errors to occur with new housestaff, as they assume new responsibilities at the beginning of the academic year. The purpose of this study was to examine the impact of the new residents presenting in July at a high volume Level I Academic Trauma Center.

Methods: The trauma registry at the Los Angeles County + University of Southern California Medical center was retrospectively reviewed to identify all injured patients admitted over a 5-year period ending in December 2006. All Morbidity and Mortality reports for the study period were reviewed to extract deaths and any complications classified as preventable or potentially preventable. Patients admitted in the first 2 months (July to August) of the academic year were compared with those treated at the end of the academic year (May to June). Baseline clinical and demographic characteristics were compared, and the rates of preventable and potentially preventable deaths and complications were determined for each of these groups.

Results: During the 5-year study period, 24,302 injured patients were admitted. Of those, 8,151 were admitted during the period from May to August with 4,030 (49.4%) at the beginning of the academic year (July to August) and 4,121 (50.6%) at the end of the academic year (May to June). Overall, the average age was 35.1 ± 17.7 years, 77% were men with an Injury Severity Score of 8.4 ± 9.7 and 24.2% penetrating injury rate. When examining mortality, after adjustment for differences between the two groups, there was no difference between patients admitted at the beginning or at the end of the academic year (adjusted odds ratio [95% confidence interval]: 1.1 [0.8, 1.5], p = 0.52). However, when compared with the patients treated for their injuries in May to June, those treated at the beginning of the academic year had a significantly higher rate of preventable and potentially preventable complications (adjusted odds ratio [95% confidence interval]: 1.9 [1.1, 3.2], p = 0.013).

Conclusions: At an academic Level I trauma center, admission at the beginning of the academic year was associated with an increased risk of errors resulting in preventable and potentially preventable complications; however, these errors did not impact mortality. Specific errors associated with this increased rate of preventable complications warrant further investigation.

8. Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax after Blunt Trauma

Wilkerson RG, et al. Acad Emerg Med. 2010;17:11-17.

Objectives: Supine anteroposterior (AP) chest radiographs in patients with blunt trauma have poor sensitivity for the identification of pneumothorax. Ultrasound (US) has been proposed as an alternative screening test for pneumothorax in this population. The authors conducted an evidence-based review of the medical literature to compare sensitivity of bedside US and AP chest radiographs in identifying pneumothorax after blunt trauma.

Methods: MEDLINE and EMBASE databases were searched for trials from 1965 through June 2009 using a search strategy derived from the following PICO formulation of our clinical question: patients included adult (18 + years) emergency department (ED) patients in whom pneumothorax was suspected after blunt trauma. The intervention was thoracic ultrasonography for the detection of pneumothorax. The comparator was the supine AP chest radiograph during the initial evaluation of the patient. The outcome was the diagnostic performance of US in identifying the presence of pneumothorax in the study population. The criterion standard for the presence or absence of pneumothorax was computed tomography (CT) of the chest or a rush of air during thoracostomy tube placement (in unstable patients). Prospective, observational trials of emergency physician (EP)-performed thoracic US were included. Trials in which the exams were performed by radiologists or surgeons, or trials that investigated patients suffering penetrating trauma or with spontaneous or iatrogenic pneumothoraces, were excluded. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. Data analysis consisted of test performance (sensitivity and specificity, with 95% confidence intervals [CIs]) of thoracic US and supine AP chest radiography.

Results: Four prospective observational studies were identified, with a total of 606 subjects who met the inclusion and exclusion criteria. The sensitivity and specificity of US for the detection of pneumothorax ranged from 86% to 98% and 97% to 100%, respectively. The sensitivity of supine AP chest radiographs for the detection of pneumothorax ranged from 28% to 75%. The specificity of supine AP chest radiographs was 100% in all included studies.

Conclusions: This evidence-based review suggests that bedside thoracic US is a more sensitive screening test than supine AP chest radiography for the detection of pneumothorax in adult patients with blunt chest trauma.

9. Exploring Emergency Physician–Hospitalist Handoff Interactions: Development of the Handoff Communication Assessment

Apker J, et al. Ann Emerg Med. 2010;55:161-170.

Study objective
We develop and evaluate the Handoff Communication Assessment, using actual handoffs of patient transfers from emergency department to inpatient care.

Methods
This was an observational qualitative study. We derived a Handoff Communication Assessment tool, using categories from discourse coding described in physician-patient communication, previous handoff research in medicine, health communication, and health systems engineering and pilot data from 3 physician-hospitalist handoffs. The resulting tool consists of 2 typologies, content and language form. We applied the tool to a convenience sample of 15 emergency physician-to-hospitalist handoffs occurring at a community teaching hospital. Using discourse analysis, we assigned utterances into categories and determined the frequency of utterances in each category and by physician role.

Results
The tool contains 11 content categories reflecting topics of patient presentation, assessment, and professional environment and 11 language form categories representing information-seeking, information-giving, and information-verifying behaviors. The Handoff Communication Assessment showed good interrater reliability for content (kappa=0.71) and language form (kappa=0.84). We analyzed 742 utterances, which provided the following preliminary findings: emergency physicians talked more during handoffs (67.7% of all utterances) compared with hospitalists (32.3% of all utterances). Content focused on patient presentation (43.6%), professional environment (36%), and assessment (20.3%). Form was mostly information-giving (90.7%) with periodic information-seeking utterances (8.8%) and rarely information-verifying utterances (0.4%). Questions accounted for less than 10% of all utterances.

Conclusion
We were able to develop and use the Handoff Communication Assessment to analyze content and structure of handoff communication between emergency physicians and hospitalists at a single center. In this preliminary application of the tool, we found that emergency physician–to-hospitalist handoffs primarily consist of information giving and are not geared toward question-and-answer events. This critical exchange may benefit from ongoing analysis and reformulation.

Full-text (free): http://www.annemergmed.com/article/PIIS0196064409015595/fulltext

10. A Randomized Clinical Trial to Reduce Patient Prehospital Delay to Treatment in Acute Coronary Syndrome

Dracup K, et al. Circulation. 2009;2:524-532.

Background— Delay from onset of acute coronary syndrome (ACS) symptoms to hospital admission continues to be prolonged. To date, community education campaigns on the topic have had disappointing results. Therefore, we conducted a clinical randomized trial to test whether an intervention tailored specifically for patients with ACS and delivered one-on-one would reduce prehospital delay time.

Methods and Results— Participants (n=3522) with documented coronary heart disease were randomized to experimental (n=1777) or control (n=1745) groups. Experimental patients received education and counseling about ACS symptoms and actions required. Patients had a mean age of 67±11 years, and 68% were male. Over the 2 years of follow-up, 565 patients (16.0%) were admitted to an emergency department with ACS symptoms a total of 842 times. Neither median prehospital delay time (experimental, 2.20 versus control, 2.25 hours) nor emergency medical system use (experimental, 63.6% versus control, 66.9%) was different between groups, although experimental patients were more likely than control to call the emergency medical system if the symptoms occurred within the first 6 months following the intervention (P=0.036). Experimental patients were significantly more likely to take aspirin after symptom onset than control patients (experimental, 22.3% versus control, 10.1%, P=0.02). The intervention did not result in an increase in emergency department use (experimental, 14.6% versus control, 17.5%).

Conclusions— The education and counseling intervention did not lead to reduced prehospital delay or increased ambulance use. Reducing the time from onset of ACS symptoms to arrival at the hospital continues to be a significant public health challenge.

11. Ultrasound detection of guidewire position during central venous catheterization

Stone MB, et al. Amer J Emerg Med. 2010;28:82-84.

Introduction
Ultrasound guidance decreases complications of central venous catheter (CVC) placement, but risks of arterial puncture and inadvertent arterial catheter placement exist. Ultrasound-assisted detection of guidewire position in the internal jugular vein could predict correct catheter position before dilation and catheter placement.

Methods
Ultrasound examinations were performed in an attempt to identify the guidewire before dilation and catheter insertion in 20 adult patients requiring CVC placement. Central venous pressures were measured after completion of the procedure.

Results
Guidewires were visible within the lumen of the internal jugular vein in all subjects. Central venous pressures confirmed venous placement of catheters. Ultrasound visualization of the guidewire predicted venous CVC placement with 100% sensitivity (95% confidence interval 80-100%) and 100% specificity (95% confidence interval 80%-100%).

Conclusions
Ultrasound reliably detects the guidewire during CVC placement and visualization of the wire before dilation and catheter insertion may provide an additional measure of safety during ultrasound-guided CVC placement.

12. The clinical differentiation of cerebellar infarction from common vertigo syndromes.

Nelson JA, Viirre E. West J Emerg Med. 2009;10:273-7.

This article summarizes the emergency department approach to diagnosing cerebellar infarction in the patient presenting with vertigo. Vertigo is defined and identification of a vertigo syndrome is discussed. The differentiation of common vertigo syndromes such as benign paroxysmal positional vertigo, Meniere's disease, migrainous vertigo, and vestibular neuritis is summarized. Confirmation of a peripheral vertigo syndrome substantially lowers the likelihood of cerebellar infarction, as do indicators of a peripheral disorder such as an abnormal head impulse test. Approximately 10% of patients with cerebellar infarction present with vertigo and no localizing neurologic deficits. The majority of these may have other signs of central vertigo, specifically direction-changing nystagmus and severe ataxia.

Full-text (free): http://www.escholarship.org/uc/item/6gt0d3x7

13. Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access

Dargin JM, et al. Amer J Emerg Med. 2010;28:1-7.

Objectives
We determined the survival and complications of ultrasonography-guided peripheral intravenous (IV) catheters in emergency department (ED) patients with difficult peripheral access.

Methods
This was a prospective, observational study conducted in an academic hospital from April to July of 2007. We included consecutive adult ED patients with difficult access who had ultrasonography-guided peripheral IVs placed. Operators completed data sheets and researchers examined admitted patients daily to assess outcomes. The primary outcome was IV survival more than 96 hours. As a secondary outcome, we recorded IV complications, including central line placement. We used descriptive statistics, univariate survival analysis with Kaplan Meier, and log-rank tests for data analysis.

Results
Seventy-five patients were enrolled. The average age was 52 years. Fifty-three percent were male, 21% obese, and 13% had a history of injection drug use. The overall IV survival rate was 56% (95% confidence interval, 44%-67%) with a median survival of 26 hours (interquartile range [IQR], 8-61). Forty-seven percent of IVs failed within 24 hours, most commonly due to infiltration. Although 47 (63%) operators reported that a central line would have been required if peripheral access was unobtainable, only 5 (7%; 95% confidence interval, 2%-15%) patients underwent central venous catheterization. Only 1 central line was placed as a result of ultrasonography-guided IV failure. We observed no infectious or thrombotic complications.

Conclusion
Despite a high premature failure rate, ultrasonography-guided peripheral IVs appear to be an effective alternative to central line placement in ED patients with difficult access.

14. Breath Alcohol Analyzer Mistakes Methanol Poisoning for Alcohol Intoxication

Caravati EM, et al. Ann Emerg Med. 2010;55:198-200.

Breath alcohol analyzers are used to detect ethanol in motorists and others suspected of public intoxication. One concern is their ability to detect interfering substances that may falsely increase the ethanol reading.

A 47-year-old-man was found in a public park, acting intoxicated. A breath analyzer test (Intoxilyzer 5000EN) measured 0.288 g/210 L breath ethanol, without an interferent noted. In the emergency department, the patient admitted to drinking HEET Gas-Line antifreeze, which contains 99% methanol. Two to three hours after ingestion, serum and urine toxicology screen results were negative for ethanol and multiple other substances. His serum methanol concentration was 589 mg/dL, serum osmolality 503 mOsm/kg, osmolar gap 193 mOsm/kg, and anion gap 17 mmol/L. The patient was treated with intravenous ethanol, fomepizole, and hemodialysis without complication.

This is a unique clinical case of a breath alcohol analyzer reporting methanol as ethanol. Intoxilyzer devices have been shown to indicate some substances (acetone) as interferents in humans but not methanol. Increased serum concentrations of methanol can be reported as ethanol by a commonly used breath alcohol analyzer, which can result in a delayed diagnosis or misdiagnosis and subsequent methanol toxicity if antidotal treatment is not administered in a timely manner.

15. Two Studies Validating the ABCD2 Score for Predicting Early Disabling Ischemic Stroke Risk after TIA in the ED

A. A Multicenter Evaluation of the ABCD2 Score's Accuracy for Predicting Early Ischemic Stroke in Admitted Patients With Transient Ischemic Attack

Asimos AW, et al. Ann Emerg Med. 2010;55:201-210.e5.

Study objective
We evaluate, in admitted patients with transient ischemic attack, the accuracy of the ABCD2 (age [A], blood pressure [B], clinical features [weakness/speech disturbance] [C], transient ischemic attack duration [D], and diabetes history [D]) score in predicting ischemic stroke within 7 days.

Methods
At 16 North Carolina hospitals, we enrolled a prospective, nonconsecutive sample of admitted patients with transient ischemic attack and with no stroke history, presenting within 24 hours of transient ischemic attack symptom onset. We conducted a medical record review to determine ischemic stroke outcomes within 7 days. According to a modified Rankin Scale Score, strokes were classified as disabling (greater than 2) or nondisabling (2 or less).

Results
During a 35-month period, we enrolled 1,667 patients, of whom 373 (23%) received a diagnosis of an ischemic stroke within 7 days. Eighteen percent (69/373) of all strokes were disabling. We were unable to calculate an ABCD2 score in 613 patients (37%); however, our imputed analysis indicated this did not significantly alter results. The discriminatory power of the ABCD2 score was modest for ischemic stroke in 7 days (c statistic 0.59), and fair for disabling ischemic stroke within 7 days (c statistic 0.71). Patients characterized as low risk according to ABCD2 score (3 or less) were at low risk for experiencing a disabling stroke within 7 days, with a negative likelihood ratio of 0.16 (95% confidence interval [CI] 0.04 to 0.64) with missing values excluded and 0.34 (95% CI 0.15 to 0.76) when missing values were imputed.

Conclusion
Our analysis suggests the best application of the ABCD2 score may be to identify patients at low risk for an early disabling ischemic stroke. Further study of the ability to determine an ABCD2 score in all patients is needed, along with validation in a large, consecutive population of patients with transient ischemic attack.

B. Validating the ABCD2 Score for predicting stroke risk after TIA in the ED

Ong ME, et al. Amer J Emerg Med. 2010;28:44-48.

Objectives
The aim of the study was to validate the use of the ABCD2 score for the prediction of stroke after transient ischemic attack (TIA) in patients presenting to the emergency department (ED). The ABCD2 scoring is based on 5 factors as follows: age of at least 60 years; blood pressure of at least 140/90 mm Hg; clinical features such as unilateral weakness and speech impairment alone; duration of at least 60 minutes or 10 to 59 minutes; and diabetes.

Methods
The authors conducted a retrospective observational study of all patients presented to the ED for TIA, as diagnosed by the attending emergency physicians, for a 2-year period. Sensitivity, specificity, and negative predictive value (NPV) were calculated for risk of stroke at 2, 7, 30, and 90 days after presentation.

Results
From January 1, 2005, to December 31, 2006, there were 470 patients diagnosed with TIA at the ED. Mean age was 61.0 years (SD, 13.2), with 63.3% males. Age of at least 60 years, unilateral weakness, and duration of at least 60 minutes were found to be significant predictors of stroke at 2 days. An admission rule based on an ABCD2 score of at least 4 showed sensitivity of 86.4% and NPV of 91.7% for stroke at 7 days. Admission based on a score of at least 3 showed sensitivity of 96.6% and NPV of 96.1%. Admission rate was 69.1% and. 83.6%, respectively.

Conclusion
The ABCD2 rule showed good sensitivity and NPV for stroke at 7 days. However, NPV was not 100%, and there would still be patients being discharged from the ED and returning with a stroke if this cutoff was implemented in our setting.

16. Molar pregnancy in the emergency department.

Masterson L, et al. West J Emerg Med. 2009;10:295-6.

A 15-year-old female presented to the emergency department with complaints of vaginal bleeding. She was pale, anxious, cool and clammy with tachycardic, thready peripheral pulses and hemoglobin of 2.4g/dL. Her abdomen was gravid appearing, approximately early to mid-second trimester in size. Pelvic examination revealed 2 cm open cervical os with spontaneous discharge of blood, clots and a copious amount of champagne-colored grapelike spongy material. After 2L boluses of normal saline and two units of crossmatched blood, patient was transported to the operating room. Surgical pathology confirmed a complete hydatidiform mole.

Full-text (free): http://www.escholarship.org/uc/item/569107db

17. Diagnostic Accuracy of Emergency Doppler Echocardiography for Identification of Acute Left Ventricular Heart Failure in Patients with Acute Dyspnea: Comparison with Boston Criteria and N-terminal Prohormone Brain Natriuretic Peptide

Nazerian P, et al. Acad Emerg Med. 2010;17:18-26.

Objectives: Echocardiography is a fundamental tool in the diagnosis of acute left ventricular heart failure (aLVHF). However, a consultative exam is not routinely available in every emergency department (ED). The authors investigated the diagnostic performance of emergency Doppler echocardiography (EDecho) performed by emergency physicians (EPs) for the diagnosis of aLVHF in patients with acute dyspnea.

Methods: A convenience sample of acute dyspneic patients was evaluated. For each patient, the Boston criteria score for heart failure was calculated, and N-terminal prohormone brain natriuretic peptide (NT-proBNP) and EDecho were contemporaneously performed. Four investigators, after a limited echocardiography course, performed EDechos and evaluated for a "restrictive" pattern on pulsed Doppler analysis of mitral inflow and reduced left ventricular (LV) ejection fraction. The final diagnosis, established after reviewing all patient clinical data except NT-proBNP and EDecho results, served as the criterion standard.

Results: Among 145 patients, 64 (44%) were diagnosed with aLVHF. The median time needed to perform EDecho was 4 minutes. Pulsed Doppler analysis was feasible in 125 patients (84%). The restrictive pattern was more sensitive (82%) and specific (90%) than reduced LV ejection fraction and more specific than the Boston criteria and NT-proBNP for the diagnosis of aLVHF. Considering noninterpretable values of the restrictive pattern and uncertain values ("gray areas") of Boston criteria (between 4 and 7) and of NT-proBNP (between 300 and 2,200 pg/mL) as false results, the accuracy of the restrictive pattern in the overall population was 75%, compared with accuracy of 49% for both NT-proBNP and Boston criteria.

Conclusions: EDecho, particularly pulsed Doppler analysis of mitral inflow, is a rapid and accurate diagnostic tool in the evaluation of patients with acute dyspnea.

18. Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures

Beaudoin FL, et al. Amer J Emerg Med. 2010;28:76-81.

Objectives
The primary objective of this study was to determine the feasibility of ultrasound-guided femoral nerve blocks in elderly patients with hip fractures in the emergency department (ED). The secondary objective was to examine the effectiveness of this technique as an adjunct for pain control in the ED.

Methods
This prospective observational study enrolled a convenience sample of 13 patients with hip fractures. Ultrasound-guided femoral nerve block was performed on all participants. To determine feasibility, time to perform the procedure, number of attempts, and complications were measured. To determine effectiveness of pain control, numerical rating scores were assessed at baseline and at 15 minutes, 30 minutes, and hourly after the procedure for 4 hours. Summary statistics were calculated for feasibility measures. Wilcoxon matched-pairs signed-rank tests and Friedman analysis of variance test were used to compare differences in pain scores.

Results
The median age of the participants was 82 years (range, 67-94 years); 9 were female. The median time to perform the procedure was 8 minutes (range, 7-11 minutes). All procedures required only one attempt; there were no complications. After the procedure, there were 44% and 67% relative decreases in pain scores at 15 minutes (P ≤ .002) and at 30 minutes (P ≤ .001), respectively. Pain scores were unchanged from 30 minutes to 4 hours after the procedure (P ≤ .77).

Conclusions
Ultrasound-guided femoral nerve blocks are feasible to perform in the ED. Significant and sustained decreases in pain scores were achieved with this technique.

19. “So, Doctor, What's So Bad About Being Fat?” Combating the Obesity Epidemic in the United States

Alpert JS. Amer J Med. 2010;123:1-2.

Each week, many of my middle-aged patients ask me the question cited above. Obesity has become so commonplace in the United States that thin, healthy individuals are becoming the exception rather than the rule. With the rising prevalence and incidence of obesity in our society, patients have begun seeing this state of body habitus as the norm rather than the exception. “What's the matter with being a little overweight, doc; everyone in my family is fat, so why not me?”

In response, I deliver my “fat” talk. In this sermonette on obesity, I stress the many increased health risks that overweight individuals incur: atherosclerosis, hypertension, gallstones, diabetes, colonic adenomas, degenerative joint disease, sleep apnea, deep venous thrombosis, and pulmonary embolism, among others. I try to communicate to my obese patients the importance of modest and gradual weight loss as compared with the cycle of rapid weight loss and equally rapid weight gain that is so common in our society. “Bouncing your weight up and down may even put you at greater risk for heart disease,” I continue, hoping that my message will take root in the patient's mind. “Regular exercise such as daily walking is a great help in losing weight. Try to cut back on portion size, simple carbohydrates such as sugar and products made with white flour, as well as saturated fat in your diet. Would you like to speak with one of our dieticians?”

My daily preaching often goes unheeded and leads me and my internal medicine colleagues to become cynical about the possibility of ever convincing our patients to lose weight. This is, unfortunately, the price to be paid in a society that gratifies itself with every type of food taken in excess combined with widespread physical inactivity.

The rest of the essay: http://www.amjmed.com/article/S0002-9343(09)00711-6/fulltext

20. Non-traumatic urologic emergencies in men: a clinical review.

Kessler CS, Bauml J. West J Emerg Med. 2009;10:281-7.

Although true urologic emergencies are extremely rare, they are a vital part of any emergency physician's (EP) knowledge base, as delays in treatment lead to permanent damage. The four urologic emergencies discussed are priapism, paraphimosis, testicular torsion, and Fournier's gangrene. An overview is given for each, including causes, pathophysiology, diagnosis, treatment, and new developments. The focus for priapism is on diagnosis and distinguishing high-flow from low-flow forms, as the latter requires emergent treatment. For paraphimosis, we describe various methods of relieving the stricture, from manual reduction to surgery in extreme cases. For testicular torsion, the most important factor in salvaging the testicle is decreasing time to treatment. This is accomplished through experience and understanding which signs and symptoms strongly suggest it, so that time-consuming tests are avoided. Lastly, Fournier's gangrene is potentially fatal. While aggressive medical and surgical therapy will improve chances of survival and outcome, it is vital for the emergency department (ED) physician to diagnose Fournier's. It often presents in the elderly, immunocompromised, or those with depressed mental status. The goal of this paper is to arm EPs with information to recognize urological emergencies and intervene quickly to preserve tissue, fertility, and life.

Full-text (free): http://www.escholarship.org/uc/item/2cj981j1

21. ED antibiotic use for acute respiratory illnesses since pneumonia performance measure inception

Fee C, et al. Amer J Emerg Med. 2010;28:23-31.

Objective
The study aimed to determine if emergency department (ED)–administered antibiotics for patients discharged home with nonpneumonia acute respiratory tract infections (ARIs) have increased since national pneumonia performance measure implementation, including antibiotic administration within 4 hours of arrival.

Methods
Design: Time series analysis. Setting: Six university and 7 Veterans Administration EDs participating in the Improving Antibiotic Use for Acute Care Treatment (IMPAACT) trial (randomized educational intervention to reduce antibiotics for bronchitis). Participants: Randomly selected adult (age older than 18 years) ED visits for acute cough, diagnosed with nonpneumonia ARIs, discharged home during winters (November-February) of 2003 to 2007. Main outcome: Time trend in ED-administered antibiotics, adjusted for patient demographics, comorbidities, vital signs, ED length of stay, IMPAACT intervention status, geographic region, Veterans Administration/university setting, and site and provider level clustering.

Results
Six thousand four hundred seventy-six met study criteria. Three hundred ninety-four (6.1%) received ED-administered antibiotics. Emergency department–administered antibiotics did not increase across the study period among all IMPAACT sites (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.76-1.01) after adjusting for age, congestive heart failure history, temperature higher than 100°F, heart rate more than 100, blood cultures obtained, diagnoses, and ED length of stay. The ED-administered antibiotic rate decreased at IMPAACT intervention (OR, 0.80; 95% CI, 0.69-0.93) but not nonintervention sites (OR, 1.04; 95% CI, 0.91-1.19). Adjusted proportions receiving ED-administered antibiotics were 6.1% (95% CI, 2.7%-13.2%) for 2003 to 2004; 4.8% (95% CI, 2.2%-10.0%) for 2004 to 2005; 4.6% (95% CI, 2.7%-7.8%) for 2005 to 2006; and 4.2% (95% CI, 2.2%-8.0%) for 2006 to 2007.

Conclusions
Emergency department–administered antibiotics did not increase for patients with acute cough discharged home with nonpneumonia ARIs since pneumonia antibiotic timing performance measure implementation in these academic EDs.