Lit Bits: Nov 26, 2011

From the recent medical literature...

1. Number of Coronary Heart Disease Risk Factors and Mortality in Patients with First MI

Risk of fatal heart attack higher without warning signs

One in seven patients who did not display risk factors suggestive of heart disease died after experiencing a heart attack compared with 1 in 28 with five risk factors, according to a study in the Journal of the American Medical Association. The survival of patients with more risk factors might be due to medications they took, researchers said. The findings were based on data from a national registry of nearly 550,000 first-time heart attack cases from 1994 to 2006

Canto JG, et al. JAMA 2011; 306(19):2120-2127.

Context: Few studies have examined the association between the number of coronary heart disease risk factors and outcomes of acute myocardial infarction in community practice.

Objective: To determine the association between the number of coronary heart disease risk factors in patients with first myocardial infarction and hospital mortality.

Design: Observational study from the National Registry of Myocardial Infarction, 1994-2006.

Patients: We examined the presence and absence of 5 major traditional coronary heart disease risk factors (hypertension, smoking, dyslipidemia, diabetes, and family history of coronary heart disease) and hospital mortality among 542 008 patients with first myocardial infarction and without prior cardiovascular disease.

Main Outcome Measure: All-cause in-hospital mortality.

Results: A majority (85.6%) of patients who presented with initial myocardial infarction had at least 1 of the 5 coronary heart disease risk factors, and 14.4% had none of the 5 risk factors. Age varied inversely with the number of coronary heart disease risk factors, from a mean age of 71.5 years with 0 risk factors to 56.7 years with 5 risk factors (P for trend less than .001). The total number of in-hospital deaths for all causes was 50 788. Unadjusted in-hospital mortality rates were 14.9%, 10.9%, 7.9%, 5.3%, 4.2%, and 3.6% for patients with 0, 1, 2, 3, 4, and 5 risk factors, respectively. After adjusting for age and other clinical factors, there was an inverse association between the number of coronary heart disease risk factors and hospital mortality adjusted odds ratio (1.54; 95% CI, 1.23-1.94) among individuals with 0 vs 5 risk factors. This association was consistent among several age strata and important patient subgroups.

Conclusion: Among patients with incident acute myocardial infarction without prior cardiovascular disease, in-hospital mortality was inversely related to the number of coronary heart disease risk factors.

2. Children with Normal CT after Blunt Head Injury Are at Low Risk for Neurological Complications

No neurosurgical interventions were required in children with blunt head injury who had GCS scores of 14 or 15 and normal head CT scans in the emergency department.

In a planned secondary analysis of a prospective observational cohort study from PECARN (the Pediatric Emergency Care Applied Research Network), investigators evaluated the frequency of neurological complications in children (age, below 18 years) with blunt head trauma (isolated or multisystem trauma), initial Glasgow Coma Scale (GCS) scores of 14 or 15, and normal emergency department head computed tomography (CT) scans. CT scans were performed at the discretion of the treating provider. Patients discharged to home were followed up at 1 week by telephone survey (capture rate, 79%); morgue and medical records were reviewed for patients with incomplete surveys.

Of 13,543 patients (mean age, 8.9 years; 20% below 2 years) who met inclusion criteria during the 2-year study period, 2485 (18%) were hospitalized. Among hospitalized patients, 137 (6%) underwent subsequent neuroimaging, and 16 (0.6%) had abnormal findings. Among discharged patients, 197 (2%) underwent subsequent neuroimaging, and 5 (0.05%) had abnormal findings. No patient in either group required neurosurgical intervention.

Comment: Children with blunt head injury who have normal GCS scores and head CT scans can be safely discharged home with postconcussive follow-up care instructions regarding signs of deterioration and outpatient follow-up before resuming physical activities, such as sports.

— Katherine Bakes, MD. Published in Journal Watch Emergency Medicine November 4, 2011

Citation: Holmes JF et al. Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation? Ann Emerg Med 2011 Oct; 58:315.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21683474

3. Cardioversion of acute AF in the short observation unit in Italy: comparison of a protocol focused on electrical cardioversion with simple antiarrhythmic treatment

Cristoni L, et al. Emerg Med J 2011;28:932-937

Background: Direct current cardioversion (DCC) has been shown to be effective for the management of atrial fibrillation (AF) in the emergency department (ED). Pharmacological cardioversion was compared with a strategy including DCC on patients with uncomplicated, recent-onset (within 48 h) AF managed in a short observation unit (SOU).

Methods: A prospective observational study was undertaken over a period of 13 months in two institutions. A DCC-centred protocol was applied to 171 AF cases in a hospital (DCC-cohort) and pharmacological cardioversion to 151 AF cases in another hospital (P-cohort). Patients remaining in AF after 24 h were admitted. The outcomes were rate of discharge in sinus rhythm, length of stay in the ED-SOU, rate of hospitalisation and complications of treatment. Data collected were analysed according to Student t test and χ2 statistics.

Results: Discharge in sinus rhythm was achieved in 159/171 cases in the DCC-cohort and 77/151 cases in the P-cohort (93% vs 51%; number needed to treat (NNT) 2.4; 95% CI 2.0 to 3.1, p less than 0.001), whereas mean length of stay was 7+7 h in the DCC-cohort and 9+6 h in the P-cohort (p=0.43). Eleven cases from the DCC-cohort and 67 from the P-cohort were admitted (admission rate 6% vs 44%; NNT 2.6; 95% CI 2.2 to 3.5, p less than 0.001). Three short-term complications occurred in the DCC-cohort and five in the P-cohort (2% vs 3%, p=0.59). Two strokes were registered in the DCC-cohort during 6-month follow-up (p undefined).

Conclusions: Electrical cardioversion of recent-onset AF in the SOU is safe, effective and reduces hospitalisations. Further studies are needed to identify the most cost-effective strategy for the management of AF patients in emergency settings.

Cf a U.S. ED study with similar results without employing an obs unit: Managing ED Patients with Recent-onset AF. J Emerg Med. 2010 Jul 15. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/20634022

4. Broken Toe? Forget the Follow-up

by Kevin Klauer, DO, Emergency Physicians Monthly, November 10, 2011

Want to save the healthcare system time and money? Forget the follow-up and make the emergency department the last stop for a range of simple injuries. First up: broken toes.

Definitive management? Aren’t we capable of finishing anything we start? In a different place, in a different time, in a world where common sense outweighs defensive medicine, we should be the last stop for certain conditions.

Toe fractures are an excellent place to start. Let’s assume that complications are expected with toe fractures. How bad could they be? Even if there is a non-union, you have nine others! Clearly, many patients cannot receive definitive management in the ED, either due to the need for specialized care (i.e., complex fracture management), assessment for response to treatment (i.e., community acquired pneumonia or cellulitis) or the need for further diagnostic evaluation (i.e., low risk chest or undifferentiated abdominal pain). In contrast to a toe, chest pain patients only have one heart, and that organ trumps a toe any day.

I have no idea how many toe fractures are seen annually in U.S. EDs. However, I would venture to guess it’s more than a baker’s dozen. Thus, the impact for providing more efficient and cost-effective care by providing definitive management for toe fractures is likely to be substantial. About a year and a half ago, I dropped a trailer hitch on my right 5th toe. I knew upon impact it was broken. I’m not a swearing man. However, I consulted the socially unacceptable thesaurus on that one. It hurt. It swelled, and it wasn’t back to normal for about 5 weeks, but I didn’t seek medical attention for it. In my “N” of one, the outcome has been good and the cost of care was $0.00. Not withstanding the lack of value of radiographic evaluation, buddy taping and buying a post-op shoe, follow-up care wouldn’t have changed the outcome.

Not only is definitive management of toe fractures a reasonable consideration, with respect to incorporating cost-saving strategies for healthcare reform, using less diagnostics makes sense also. So, what are we worried about? Sure. It’s broken. So, the reflex is to order an x-ray. However, when you already know it’s broken and you won’t do anything different with the test you’re considering ordering, just say no. In my opinion, too many radiographs are ordered due to culture and not used to improve care. Most patients want an answer, not a test. So, if you can give them a definitive answer without order a radiograph, you both might be happier.

Although there is much data on this topic, let’s just discuss one contemporary article by Van Vliet-Koppert…

The remainder of the essay is here: http://www.epmonthly.com/subspecialties/management/broken-toe-forget-the-follow-up/

5. Relationship between Pain Severity and Outcomes in Patients Presenting with Potential ACS

Edwards M, et al. Ann Emerg Med. 2011;58:501-507.

Study objective: Although lay people often assume that severe pain is more commonly associated with worse outcomes, the relationship between pain severity and outcome for patients presenting with potential acute coronary syndrome has not been well described. We hypothesize that pain severity will not be associated with acute myocardial infarction or 30-day cardiovascular complications.

Methods: We conducted a secondary analysis of a prospective cohort study of patients presenting to the emergency department (ED) with potential acute coronary syndrome. Trained research assistants collected data, including demographics, medical history, symptoms, hospital course, and 30-day outcomes (record review and telephone). Pain score on arrival (0 to 10) was abstracted from nurses' triage documentation in the electronic record. Severe pain was defined as 9 or 10. The main outcomes were the prevalence of acute myocardial infarction during index visit and composite of death, acute myocardial infarction, revascularization including percutaneous coronary intervention, or coronary bypass artery grafting at 30 days. Multivariable modeling was prespecified to adjust for age, race, sex, pain duration, thrombolysis in myocardial infarction (TIMI) score, and mode of arrival. Data are presented as relative risk (RR) with 95% confidence intervals (CI).

Results: Patients (3,306) had pain documented (mean age 51.0 years; SD 12.6 years; 57% women; 66% black). Follow-up was 93%. By 30 days, 34 patients had died, 105 patients underwent revascularization (94 percutaneous coronary intervention, 14 coronary bypass artery grafting), and 111 patients experienced acute myocardial infarction. There was not a relationship between severe pain and acute myocardial infarction (RR 1.28; 95% CI 0.93 to 1.76) or 30-day composite outcome (1.19; 95% CI 0.91 to 1.56). After adjusting for potential confounding variables, we found that the prevalence of inhospital acute myocardial infarction was related to TIMI score (adjusted relative risk [aRR] 2.00; 95% CI 1.05 to 3.80), male sex (aRR 1.48; 95% CI 1.00 to 2.18), and arrival by emergency medical services (EMS) (aRR 1.73; 95% CI 1.13 to 2.63) but not age (aRR 1.42; 95% CI 0.68 to 2.95), white race (aRR 1.25; 95% CI 0.85 to 1.86), pain duration greater than 1 hour (aRR 1.36; 95% CI 0.89 to 2.07), or severe pain (aRR 1.43; 95% CI 0.91 to 2.22). Thirty-day composite outcome was related to male sex (aRR 1.53; 95% CI 1.16 to 2.01), white race (aRR 1.43; 95% CI 1.09 to 1.87), and higher TIMI score (aRR 2.24; 95% CI 1.39 to 3.60) but was not related to age (aRR 1.26; 95% CI 0.75 to 2.11), pain duration greater than 1 hour (aRR 0.8; 95% CI 0.60 to 1.06), EMS arrival (aRR 1.23; 95% CI 0.96 to 1.60), or severe pain (aRR 1.39; 95% CI 0.95 to 1.97).

Conclusion: For patients who present to the ED with potential acute coronary syndrome, severe pain is not related to likelihood of acute myocardial infarction at presentation or death, acute myocardial infarction or revascularization within 30 days.

6. Lytics for Acute CVA

A. Stroke Mimics and Intravenous Thrombolysis

Artto V, et al. Ann Emerg Med. 2011; in press.

Study objective: The necessity for rapid administration of intravenous thrombolysis in patients with acute ischemic stroke may lead to treatment of patients with conditions mimicking stroke. We analyze stroke patients treated with intravenous thrombolysis in our center to characterize cases classified as stroke mimics.

Methods: We identified and reviewed all cases with a diagnosis other than ischemic stroke in our large-scale single-center stroke thrombolysis registry. We compared these stroke mimics with patients with neuroimaging-negative and neuroimaging-positive ischemic stroke results.

Results: Among 985 consecutive intravenous thrombolysis–treated patients, we found 14 stroke mimics (1.4%; 95% confidence interval 0.8% to 2.4%), 694 (70.5%) patients with neuroimaging-positive ischemic stroke results, and 275 (27.9%) patients with neuroimaging-negative ischemic stroke results. Stroke mimics were younger than patients with neuroimaging-negative or -positive ischemic stroke results. Compared with patients with neuroimaging-positive ischemic stroke results, stroke mimics had less severe symptoms at baseline and better 3-month outcome. No differences appeared in medical history or clinical features between stroke mimics and patients with neuroimaging-negative ischemic stroke results. None of the stroke mimics developed symptomatic intracerebral hemorrhage compared with 63 (9.1%) among patients with neuroimaging-positive ischemic stroke results and 6 (2.2%) among patients with neuroimaging-negative ischemic stroke results.

Conclusion: Stroke mimics were infrequent among intravenous thrombolysis–treated stroke patients in this cohort, and their treatment did not lead to harmful complications.

B. Patients with Diabetes and Prior Stroke Benefit from Thrombolytic Therapy for Treatment of Acute Stroke

This finding will expand eligibility for thrombolysis in the U.S.

Concomitant diabetes mellitus and prior stroke is thought to potentially mitigate the benefits of thrombolytic therapy for acute stroke. In Europe, concomitant diabetes and prior stroke is considered a contraindication to thrombolytic therapy, whereas in the U.S., it is considered a contraindication only for patients who present in the expanded treatment window (3–4.5 hours).

Researchers used registry data to assess the effect of diabetes and prior stroke on outcomes (adjusted 90-day modified Rankin Scale score) in patients who received tissue plasminogen activator (TPA) for acute stroke (data from the Safe Implementation of Thrombolysis in Stroke–International Stroke Thrombolysis Register) and control patients who did not (data from the Virtual International Stroke Trials Archive). Analyses were controlled for the following confounding patient variables: National Institutes of Health Stroke Scale score, age, and comorbidities.

Of 29,500 patients, 19% had diabetes, 17% had prior stroke, and 6% had both. Among patients with diabetes, prior stroke, or both, those who received TPA had significantly better outcomes than those who did not receive TPA. Among patients who received TPA, those with diabetes, prior stroke, or both had similar outcomes to those with neither diabetes nor prior stroke.

Comment: This large study does not support excluding patients with diabetes mellitus, prior stroke, or both from consideration for thrombolytic therapy for treatment of acute stroke. This finding will expand eligibility for thrombolytic therapy.

— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine November 18, 2011. Citation: Mishra NK et al. Thrombolysis outcomes in acute ischemic stroke patients with prior stroke and diabetes mellitus. Neurology 2011 Nov 22; 77:1866.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22094479

7. Patterns and Predictors of Short-Term Death after ED Discharge

Gelareh Z. Gabayan GZ, et al. Ann Emerg Med. 2011;58:551-558.e2.

Study objective: The emergency department (ED) is an inherently high-risk setting. Early death after an ED evaluation is a rare and devastating outcome; understanding it can potentially help improve patient care and outcomes. Using administrative data from an integrated health system, we describe characteristics and predictors of patients who experienced 7-day death after ED discharge.

Methods: Administrative data from 12 hospitals were used to identify death after discharge in adults aged 18 year or older within 7 days of ED presentation from January 1, 2007, to December 31, 2008. Patients who were nonmembers of the health system, in hospice care, or treated at out-of-network EDs were excluded. Predictors of 7-day postdischarge death were identified with multivariable logistic regression.

Results; The study cohort contained a total of 475,829 members, with 728,312 discharges from Kaiser Permanente Southern California EDs in 2007 and 2008. Death within 7 days of discharge occurred in 357 cases (0.05%). Increasing age, male sex, and number of preexisting comorbidities were associated with increased risk of death. The top 3 primary discharge diagnoses predictive of 7-day death after discharge included noninfectious lung disease (odds ratio [OR] 7.1; 95% confidence interval [CI] 2.9 to 17.4), renal disease (OR 5.6; 95% CI 2.2 to 14.2), and ischemic heart disease (OR 3.8; 95% CI 1.0 to 13.6).

Conclusion; Our study suggests that 50 in 100,000 patients in the United States die within 7 days of discharge from an ED. To our knowledge, our study is the first to identify potentially “high-risk” discharge diagnoses in patients who experience a short-term death after discharge.

8. What Do We Do With a Positive Troponin Test?

Amal Mattu, MD. Medscape Emerg Med. Posted: 10/28/2011

Introduction

A physician recently emailed me with a question (paraphrasing): "Our lab recently switched over to using the new high-sensitivity troponin test and we're confused. What do we do with a positive troponin (TN) test?"

A handful of years ago, I suppose my gut response to someone asking what to do with a positive TN test would have been to tell that person to do more continuing medical education before seeing any more patients. My belief now, however, has become one of complete empathy with this physician and his colleagues. It seems that we all are having a tough time figuring this out, including our own cardiologists. The most recent high-profile article pertaining to the high-sensitivity (HS)-TN test has prompted another flurry of emails, questions, and uncertainty. Here's a quick summary and then some further thoughts about the article, TN testing, and evaluating patients with possible acute coronary syndromes.

Rapid Exclusion of Acute Myocardial Infarction in Patients With Undetectable Troponin Using a High-Sensitivity Assay

Body R, Carley S, McDowell G, et al. J Am Coll Cardiol. 2011;58:1332-1339

Study Summary

The study authors evaluated 703 patients presenting with chest pain to a large hospital's emergency department (ED) in the United Kingdom. A total of 130 (18.5%) patients were diagnosed with acute myocardial infarction (AMI) using standard, accepted criteria for diagnosis with TN testing, which incorporates a serial rise (or fall) of TN. Serial testing in this case meant that the researchers obtained a TN level (a HS-TN-T assay was used in this study) at the time of presentation and a second level at 12 hours after the onset of symptoms. Nearly half (46%) of the patients presented within 3 hours of symptom onset, so the study did incorporate many early presenters.

The study authors found that of 130 patients diagnosed with AMI, 100% had an elevated HS-TN level at the time of presentation (95% confidence interval was 95.1%-100%). In other words, no patients who presented initially with a negative HS-TN level had a positive HS-TN on serial testing. The study authors suggested that this HS-TN level would obviate the need for serial testing and therefore allow early discharge of these patients from the ED. Sounds great! No more serial TN testing is needed, and we can now make dispositions after only 1 blood test and, at least slightly, decrease ED crowding. Right?

Viewpoint

Before we even begin to address the limitations associated with the study and its conclusions, let's first try to agree on a few things:

• Nothing in medicine is 100%: Nothing is 100% positive, 100% negative, or 100% accurate. Well, death is 100% certain, but not much else. Just like every other study in history that claimed 100% accuracy, subsequent attempts to validate this study will demonstrate numbers less than 100%.

• What we do in emergency medicine is not to rule in or rule out diseases, but we risk stratify everything. For example, if you see a patient with chest pain who has an ECG with ST-segment elevation in the anterior leads and ST-depression in the inferior leads, it risk stratifies that patient to a higher likelihood of AMI, but it doesn't definitely rule in AMI. In fact, the accuracy of such an ECG for AMI is only ~90%. Similarly, if a patient with chest pain has a normal ECG, it risk stratifies that patient to a lower likelihood of AMI but doesn't rule it out.

• This same concept of risk stratification applies to TN testing. A negative TN risk stratifies a patient to a lower likelihood of AMI but not to 0%. Also, a positive TN risk stratifies a patient to a higher likelihood of AMI, but not to 100%. This last point is critically important to remember: Positive TNs are markers of myocardial injury, but AMI is only one cause of myocardial injury. There are numerous other causes of positive TN: cardiac trauma, congestive heart failure, aortic valve disease, dysrhythmias (tachy- or brady-), rhabdomyolysis, pulmonary embolism, acute neurologic disease (including stroke and subarachnoid hemorrhage), inflammatory diseases of the heart (pericarditis, myocarditis), infiltrative diseases of the heart, sepsis, toxins, and so on.[1] In fact, many cardiologists already think that the current TN tests are too sensitive!

• The fact that there are so many causes of positive TNs is the exact reason why the international universal definition of AMI[1] incorporates serial TN testing rather than relying on an isolated positive TN. True atherosclerosis-related AMI produces a rise and fall of TNs, whereas the majority of other causes of positive TN do not produce this typical sequence of levels.

•It's important to remember that our mandate in the ED -- at least in the United States -- is not to simply evaluate patients for AMI. We also need to evaluate patients for acute coronary syndrome. Elevated levels of TN are helpful for diagnosing myocardial injury, but they are nearly worthless for diagnosing ischemia (ie, unstable angina). Therefore, what we currently have in TN is a test that, when positive, doesn't rule in acute coronary syndrome and when negative doesn't rule out acute coronary syndrome.

Putting history and ECG aside, let's focus on just the TN. How exactly are we supposed to use TN testing? First, it's important that we all change our mind-set such that we don't think of TNs as a test to rule in or rule out disease. They are only useful at risk stratifying the disease and making decisions that are based on that risk. If the TN is positive, you and your consulting cardiologists might consider cardiac catheterization or instead consider performing serial testing to distinguish between the typical rise of true AMI vs the "smoldering" elevation that is often seen in the other conditions. On the other hand, if the TN is negative, it simply risk stratifies patients to a lower likelihood of acute coronary syndrome (but not zero). Essentially, negative TNs indicate that a patient is now stable for a provocative test; they do not exclude acute coronary syndrome. The current national American College of Cardiology/American Heart Association (ACC/AHA)[2,3] and American College of Emergency Physicians (ACEP)[4] guidelines allow us to discontinue the ACS workup only after a negative provocative test; they do not allow us to discontinue the workup after negative TNs.

The remainder of the article can be found here: http://www.medscape.com/viewarticle/752166

9. Low yield of ED MRI for suspected epidural abscess

El Sayed M, et al. Amer J Emerg Med. 2011;978-982.

Purpose: The aim of this study was to estimate the yield of emergency department (ED) magnetic resonance imaging (MRI) in detecting spinal epidural abscess (SEA) and to identify clinical factors predicting positive MRI results.

Basic Procedure: We examined a cohort of patients who underwent MRI to rule out SEA, followed by a nested case-control comparison of those with positive results and a sample with negative results. A positive result was defined as osteomyelitis, discitis, or SEA. Predictor variables included temperature, presenting complaint, drug abuse status, history of SEA or back surgery, midline back tenderness, neurologic deficit, MRI level, mean white blood cell count, erythrocyte sedimentation rate, and C-reactive protein level.

Main Findings: Fourteen of the 120 available MRIs were excluded; 7 (6.6%) of the remaining 106 were positive. Temperature was 1.1°C higher in cases than controls (95% CI, 0.6-1.7).

Conclusion: Emergency department MRI for suspected SEA has a low yield. Clinical guidelines are needed to improve efficiency.

10. Rapid (60 mL/kg) versus standard (20 mL/kg) intravenous rehydration in paediatric gastroenteritis: pragmatic blinded randomised clinical trial

Freedman SB, et al. BMJ 2011;343:bmj.d6976

Introduction

Gastroenteritis remains a disease of major importance in public health. Although oral rehydration is appropriate for most children, many receive prolonged intravenous rehydration, which contributes to overcrowding in the emergency department. Given the safety of replacing fluid deficits over 24 hours in haemodynamically stable children, traditional teaching and the National Patient Safety Agency have advocated such an approach. Experts have noted, however, that there is a disparity between the slow restoration regimens recommended and the rapid rehydration regimens used by clinicians treating dehydration. The latter has the potential to reduce a child’s level of agitation and clinical signs of dehydration, in addition to enhancing alertness and appetite. These potential benefits might enable clinicians to achieve earlier rehydration with subsequent reductions in length of stay and costs. A review of rapid intravenous rehydration studies concluded that evidence of efficacy is lacking. Thus gastroenteritis treatment guidelines aimed at developed countries, where severe dehydration is uncommon, rarely provide a detailed rapid rehydration strategy.

Because of its potential benefits, and despite a paucity of evidence, rapid intravenous rehydration has gradually become incorporated into clinical practice9 and is recommended in a leading textbook of emergency medicine. This procedure, however, is not without risks. A recent study of fluid bolus resuscitation in febrile African children had to be stopped early because of increased mortality in the bolus group. Moreover, advocates for rapid intravenous rehydration4 suggest that serum should be routinely tested to enable the detection of severe hyponatraemia or hypernatraemia, which necessitates specific therapeutic approaches to reduce the risk of central pontine myelinolysis and cerebral oedema, respectively. As only 30% of academic paediatric emergency medicine physicians routinely check electrolytes in the United States, the widespread use of rapid intravenous rehydration might place children at unnecessary risk. Given the established safety of standard rehydration in haemodynamically stable children, the lack of evidence of benefit, and the potential complications that might arise with the widespread use of rapid intravenous rehydration, a rigorous evaluation of this more aggressive approach is needed.

We carried out a pragmatic randomised, blinded, comparative effectiveness trial among haemodynamically stable children in whom oral rehydration had failed and who were deemed to require intravenous rehydration. Our primary objective was to determine whether treatment with rapid intravenous rehydration resulted in a clinically important increase in the number of children achieving rehydration compared with standard treatment.

Abstract

Objective: To determine if rapid rather than standard intravenous rehydration results in improved hydration and clinical outcomes when administered to children with gastroenteritis.

Design: Single centre, two arm, parallel randomised pragmatic controlled trial. Blocked randomisation stratified by site. Participants, caregivers, outcome assessors, investigators, and statisticians were blinded to the treatment assignment.

Setting: Paediatric emergency department in a tertiary care centre in Toronto, Canada.

Participants: 226 children aged 3 months to 11 years; complete follow-up was obtained on 223 (99%). Eligible children were aged over 90 days, had a diagnosis of dehydration secondary to gastroenteritis, had not responded to oral rehydration, and had been prescribed intravenous rehydration. Children were excluded if they weighed less than 5 kg or more than 33 kg, required fluid restriction, had a suspected surgical condition, or had an insurmountable language barrier. Children were also excluded if they had a history of a chronic systemic disease, abdominal surgery, bilious or bloody vomit, hypotension, or hypoglycaemia or hyperglycaemia.

Interventions: Rapid (60 mL/kg) or standard (20 mL/kg) rehydration with 0.9% saline over an hour; subsequent fluids administered according to protocol.

Main outcome measures: Primary outcome: clinical rehydration, assessed with a validated scale, two hours after the start of treatment. Secondary outcomes: prolonged treatment, mean clinical dehydration scores over the four hour study period, time to discharge, repeat visits to emergency department, adequate oral intake, and physician’s comfort with discharge. Data from all randomised patients were included in an intention to treat analysis.

Results: 114 patients were randomised to rapid rehydration and 112 to standard. One child was withdrawn because of severe hyponatraemia at baseline. There was no evidence of a difference between the rapid and standard rehydration groups in the proportions of participants who were rehydrated at two hours (41/114 (36%) v 33/112 (30%); difference 6.5% (95% confidence interval −5.7% to 18.7%; P=0.32). The results did not change after adjustment for weight, baseline dehydration score, and baseline pH (odds ratio 1.8, 0.90 to 3.5; P=0.10). The rates of prolonged treatment were similar (52% rapid v 43% standard; difference 8.9%, 21% to −5%; P=0.19). Although dehydration scores were similar throughout the study period (P=0.96), the median time to discharge was longer in the rapid group (6.3 v 5.0 hours; P=0.03).

Conclusions: There are no relevant clinical benefits from the administration of rapid rather than standard intravenous rehydration to haemodynamically stable children deemed to require intravenous rehydration.

Full-text: http://www.bmj.com/content/343/bmj.d6976

11. Febrile Infants Aged 30 to 90 Days with Positive Urinalyses Require LP

Despite the authors' conclusion that lumbar puncture is not needed, this study failed to show lower risk for meningitis in febrile infants with urinary tract infections.

Paquette K et al. Pediatr Emerg Care. 2011 Nov;27(11):1057-61.

Is a lumbar puncture necessary when evaluating febrile infants (30 to 90 days of age) with an abnormal urinalysis?

OBJECTIVES: Guidelines for the management of febrile infants aged 30 to 90 days presenting to the emergency department (ED) suggest that a lumbar puncture (LP) should be performed routinely if a positive urinalysis is found during initial investigations. The aim of our study was to assess the necessity of routine LPs in infants aged 30 to 90 days presenting to the ED for a fever without source but are found to have a positive urine analysis.

METHODS: We retrospectively reviewed the records of all infants aged 30 to 90 days, presenting to the Montreal Children's Hospital ED from October 2001 to August 2005 who underwent an LP for bacterial culture, in addition to urinalysis and blood and urine cultures. Descriptive statistics and their corresponding confidence intervals were used.

RESULTS: Overall, 392 infants were identified using the microbiology laboratory database. Fifty-seven patients had an abnormal urinalysis. Of these, 1 infant (71 days old) had an Escherichia coli urinary tract infection, bacteremia, and meningitis. This patient, however, was not well on history, and the peripheral white blood cell count was low at 2.9 × 10/L. Thus, the negative predictive value of an abnormal urinalysis for meningitis was 98.2%.

CONCLUSIONS: Routine LPs are not required in infants (30-90 days) presenting to the ED with a fever and a positive urinalysis if they are considered at low risk for serious bacterial infection based on clinical and laboratory criteria. However, we recommend that judicious clinical judgment be used; in doubt, an LP should be performed before empiric antibiotic therapy is begun..

12. Standard Therapy Is Sufficient for Most Patients with Saddle PE

In this small retrospective study, most patients responded to unfractionated heparin.

Saddle pulmonary embolism: Is it as bad as it looks? A community hospital experience.

Sardi A et al. Crit Care Med. 2011 Nov;39(11):2413-8.

BACKGROUND: Saddle pulmonary embolism represents a large clot and a risk for sudden hemodynamic collapse. However, the clinical presentation and outcomes vary widely. On the basis of the findings of right heart dysfunction on echocardiograms, computed tomography angiography, or cardiac enzyme elevation, some argue for the use of thrombolytics or catheter thrombectomy even for hemodynamically stable patients.

OBJECTIVE: To investigate the outcomes and management of patients with saddle pulmonary embolism, including radiographic appearance (estimate of clot burden) and echocardiographic features.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: This study is a retrospective evaluation of all patients with computed tomography angiography positive for pulmonary embolism from June 1, 2004, to February 28, 2009. Two radiologists selected those with saddle pulmonary embolism and evaluated the clot burden score. The clinical information, echocardiography, treatments, and outcomes of these patients were extracted via chart review. Saddle pulmonary embolism was found in 37 of 680 patients (5.4%, 95% confidence interval 4% to 7%) with documented pulmonary embolism on computed tomography angiography. For patients with saddle pulmonary embolism, the median age was 60 yrs and 41% were males. Major comorbidities were neurologic (24%), recent surgery (24%), and malignancy (22%). Transient hypotension occurred in 14% and persistent shock in 8%. One patient required mechanical ventilation. Echocardiography was performed in 27 patients (73%). Right ventricle enlargement and dysfunction were found in 78% and elevated pulmonary artery systolic pressure in 67%. Computed tomography angiography demonstrated a high median pulmonary artery clot burden score of 31 points. The median right ventricle to left ventricle diameter ratio was 1.39. Inferior vena cava filters were placed in 46%. Unfractionated heparin was administered in 33 (87%) and thrombolytics in four (11%). The median hospital length of stay was 9 days. Two of 37 saddle pulmonary embolism patients (5.4%) died in the hospital (95% confidence interval 0.7% to 18%).

CONCLUSIONS: Most patients with saddle pulmonary embolism found on computed tomography angiography responded to the standard management for pulmonary embolism with unfractionated heparin. Although ominous in appearance, most patients with saddle pulmonary embolism are hemodynamically stable and do not require thrombolytic therapy or other interventions.

13. Oxygen therapy for AMI: a systematic review and meta-analysis

Burls A, et al. Emerg Med J2011;28:917-923

Oxygen (O2) is widely recommended in international guidelines for treatment of acute myocardial infarction (AMI), but there is uncertainty about its safety and benefits. A systematic review and meta-analysis were performed to determine whether inhaled O2 in AMI improves pain or the risk of death.

Cochrane CENTRAL Register of Controlled Trials, MEDLINE, MEDLINE In-Process, EMBASE, CINAHL, LILACS and PASCAL were searched from start date to February 2010. Other sources included British Library ZETOC, Web of Science, ISI Proceedings, relevant conferences, expert contacts. Randomised controlled trials of inhaled O2 versus air in patients with suspected or proven AMI of less than 24 h onset were included. Two authors independently reviewed studies to confirm inclusion criteria met, and undertook data abstraction. Quality of studies and risk of bias was assessed according to Cochrane Collaboration guidance. Main outcomes were death, pain, and complications. Measure of effect used was the RR.

Three trials (n=387 patients) were included. Pooled RR of death on O2 compared to air was 2.88 (95%CI 0.88 to 9.39) on ITT analysis and 3.03 (95%CI 0.93 to 9.83) in confirmed AMI. While suggestive of harm, this could be a chance occurrence. Pain was measured by analgesic use. Pooled RR for the use of analgesics was 0.97 (95%CI 0.78 to 1.20).

Evidence for O2 in AMI is sparse, of poor quality and pre-dates advances in reperfusion and trial methods. Evidence is suggestive of harm but lacks power and excess deaths in the O2 group could be due to chance. More research is required.

Systematic review registration number Original protocol registered with the Cochrane Collaboration. RevMan ID 848507032313175590, doi:10.1002/14651858.CD007160.

14. Images in (Emergency) Medicine

Lingual Zoster
http://www.nejm.org/doi/full/10.1056/NEJMicm1107466

Man with Rash and Nausea
http://www.annemergmed.com/article/S0196-0644(11)00352-0/fulltext

Man with Shoulder Pain after a Fall
http://www.annemergmed.com/article/S0196-0644(11)00360-X/fulltext

Unilateral Facial Swelling With Fever
http://www.annemergmed.com/article/S0196-0644(11)00716-5/fulltext

15. Chest compressions linked to physical fitness

Russo SG, et al. BMC Emerg Med 2011;11:20

Assessment of BMI and physical fitness, particularly focusing on the upper body, can predict quality of external chest compressions, with rescuers with higher BMI and greater physical fitness performing better quality external chest compressions and experiencing less fatigue.

Full-text (free): http://www.biomedcentral.com/1471-227X/11/20/abstract

16. Do Alert, Neurologically Intact Trauma Patients with Persistent Midline Tenderness and Negative CT Results Require C-Spine MRI? Maybe

Ackland HM, et al. Ann Emerg Med. 2011;58:521-530.

Study objective: We aim to determine the prevalence and factors associated with cervical discoligamentous injuries detected on magnetic resonance imaging (MRI) in acute, alert, neurologically intact trauma patients with computed tomography (CT) imaging negative for acute injury and persistent midline cervical spine tenderness. We present the cross-sectional analysis of baseline information collected as a component of a prospective observational study.

Methods: Alert, neurologically intact trauma patients presenting to a Level I trauma center with CT negative for acute injury, who underwent MRI for investigation of persistent midline cervical tenderness, were prospectively recruited. Deidentified images were assessed, and injuries were identified and graded. Outcome measures included the presence and extent of MRI-detected injury of the cervical ligaments, intervertebral discs, spinal cord and associated soft tissues.

Results: There were 178 patients recruited during a 2-year period to January 2009. Of these, 78 patients (44%) had acute cervical injury detected on MRI. There were 48 single-column injuries, 15 two-column injuries, and 5 three-column injuries. Of the remaining 10 patients, 6 had isolated posterior muscle edema, 2 had alar ligamentous edema, 1 had epidural hematoma, and 1 had atlanto-occipital edema. The injuries to 38 patients (21%) were managed clinically; 33 patients were treated in cervical collars for 2 to 12 weeks, and 5 patients (2.8%) underwent operative management, 1 of whom had delayed instability. Ordinal logistic regression revealed that factors associated with a higher number of spinal columns injured included advanced CT-detected cervical spondylosis (odds ratio [OR] 11.6; 95% confidence interval [CI] 3.9 to 34.3), minor isolated thoracolumbar fractures (OR 5.4; 95% CI 1.5 to 19.7), and multidirectional cervical spine forces (OR 2.5; 95% CI 1.2 to 5.2).

Conclusion: In patients with cervical midline tenderness and negative acute CT findings, we found that a subset of patients had MRI-detected cervical discoligamentous injuries and that advanced cervical spine degeneration evident on CT, minor thoracolumbar fracture, and multidirectional cervical spine forces were associated with increased injury extent. However, a larger study is required to validate which variables may reliably predict clinically important injury in such patients, thereby indicating the need for further radiographic assessment.

17. Using appendicitis scores in the pediatric ED

Mandeville K, et al. Amer J Emerg Med 2011:29:972-977.

Study Objective: The aims of the study were to prospectively evaluate the Alvarado and Samuel (pediatric appendicitis score [PAS]) appendicitis scoring systems in children and determine performance based on sex.

Methods: Children with abdominal pain concerning for appendicitis were recruited. Nine parameters evaluated by the scores were documented before imaging/surgery consultation. Test characteristics were calculated on all patients and by sex.

Results: Two hundred eighty-seven patients enrolled; median age was 9.8 years; and 155 (54%) were diagnosed with pathologic examination-confirmed appendicitis. Patients with appendicitis had mean PAS of 7.6, and those without had mean of 5.6 (P less than .001). Patients with appendicitis had a mean Alvarado of 7.2, and those without had a mean of 5.2 (P < .001). In appendicitis patients, PAS cutoff of 6 or greater would give 137 correct diagnoses; sensitivity, 88%; specificity, 50%; and positive predictive value (PPV), 67%. An Alvarado cutoff of 7 or greater would give 118 correct diagnoses; sensitivity, 76%; specificity, 72%; and PPV, 76%. Both performed better in males than females.

Conclusion: Regardless of sex, neither PAS nor Alvarado has adequate predictive values for sole use to diagnose appendicitis.

18. Yoga Works for Chronic Low Back Pain: A Randomized Trial

Tilbrook HE, et al. Ann Intern Med. 2011; 155;569-578.

Background: Previous studies indicate that yoga may be an effective treatment for chronic or recurrent low back pain.

Objective: To compare the effectiveness of yoga and usual care for chronic or recurrent low back pain.

Design: Parallel-group, randomized, controlled trial using computer-generated randomization conducted from April 2007 to March 2010. Outcomes were assessed by postal questionnaire. (International Standard Randomised Controlled Trial Number Register: ISRCTN 81079604)

Setting: 13 non–National Health Service premises in the United Kingdom.

Patients: 313 adults with chronic or recurrent low back pain.

Intervention: Yoga (n = 156) or usual care (n = 157). All participants received a back pain education booklet. The intervention group was offered a 12-class, gradually progressing yoga program delivered by 12 teachers over 3 months.

Measurements: Scores on the Roland–Morris Disability Questionnaire (RMDQ) at 3 (primary outcome), 6, and 12 (secondary outcomes) months; pain, pain self-efficacy, and general health measures at 3, 6, and 12 months (secondary outcomes).

Results: 93 (60%) patients offered yoga attended at least 3 of the first 6 sessions and at least 3 other sessions. The yoga group had better back function at 3, 6, and 12 months than the usual care group. The adjusted mean RMDQ score was 2.17 points (95% CI, 1.03 to 3.31 points) lower in the yoga group at 3 months, 1.48 points (CI, 0.33 to 2.62 points) lower at 6 months, and 1.57 points (CI, 0.42 to 2.71 points) lower at 12 months. The yoga and usual care groups had similar back pain and general health scores at 3, 6, and 12 months, and the yoga group had higher pain self-efficacy scores at 3 and 6 months but not at 12 months. Two of the 157 usual care participants and 12 of the 156 yoga participants reported adverse events, mostly increased pain.

Limitation: There were missing data for the primary outcome (yoga group, n = 21; usual care group, n = 18) and differential missing data (more in the yoga group) for secondary outcomes.

Conclusion: Offering a 12-week yoga program to adults with chronic or recurrent low back pain led to greater improvements in back function than did usual care.

Full-text (free): http://www.annals.org/content/155/9/569.full.pdf+html

19. CNS Events in Children with Sickle Cell Disease Presenting Acutely with HA

Hines PC, et al. J Pediatr. 2011;159:472-478

Background. The incidence of headache as a chief complaint in children with sickle cell disease (SCD) is relatively common and not too different from the incidence in healthy children. However, the higher baseline risk for intracranial pathology in patients with SCD makes evaluation of headache in this population more concerning for clinicians. The goal of this study was to use existing data to determine whether an approach could be devised that would help guide clinicians on how aggressive to be in evaluating patients with SCD and headache.

Methods. The participants were children and young adults, ages 5-21 years, with homozygous SCD who were treated in the pediatric emergency department of a single children's hospital from 2001 to 2005. All patients had a chief complaint of headache. By reviewing various inpatient, emergency department, and outpatient records, the investigators obtained clinical data about the presentation of headache including vital signs, physical exam findings, and neurologic exam findings. They also collected data on medical history such as whether a child participated in transfusion protocols, participated in hydroxyurea protocols, and had a history of seizures or central nervous system (CNS) pathology such as stroke and obtained results of any previous CNS imaging.

Findings. The investigators identified 73 patients who presented with 102 episodes of headache during the study period, with 83% of those visits being conducted in the emergency department and the remainder in an acute access hematology clinic. Headache was the exclusive complaint in 60 of the 102 visits, whereas headache was an accompanying complaint in the other 42 visits. Across all visits, 6.9% of the headache episodes were associated with new or changes in known intracranial pathology. However, only 42% of the headache visits in children with SCD prompted imaging. Therefore, the frequency of new pathology in patients with SCD with headache who received imaging was 16.3%. Children with an acute CNS event were much more likely to have a history of a stroke, a transient ischemic attack, or a seizure (40%-60%) than children who did not have CNS events (4.6%-8.5%). With respect to neurologic complaints at presentation, 40%-50% of the children with an acute CNS event had vision changes, weakness, any focal weakness, or numbness compared with only 0%-8.2% of children with no CNS events. At least 1 focal neurologic complaint was found upon presentation in 85% of the children with an acute CNS event compared with 9.5% of the children with no CNS pathology. Similarly, 85% of the children with an acute CNS event had at least 1 neurologic exam abnormality compared with only 5.3% of the children without CNS events.

The investigators concluded that a history of stroke, transient ischemic attack, or the presence of neurologic symptoms or focal neurologic findings suggest a higher risk for CNS pathology in patients with SCD and acute headache. They emphasized that 6.9% of the visits for acute headache in children with SCD were associated with evidence of acute CNS pathology compared with frequencies of 0.5% in healthy children noted in other studies.

Comment: William T. Basco, Jr., MD. Medscape Emerg Med. Posted: 11/04/2011 Full-text: http://www.medscape.com/viewarticle/752295

20. Treating primary headaches in the ED: can droperidol regain its role?

Faine B, et al. Amer J Emerg Med. 2011; in press

Objective: The aim of this study was to describe the use and efficacy of low-dose (≤2 mg) droperidol for the treatment of primary headaches (ie, migraine, cluster, tension-type headache and trigeminal autonomic cephalalgias, and other primary headaches) in the emergency department (ED).

Methods: A report was generated from a pharmacy database to identify all adult patients who received low-dose droperidol in the ED over a 7-month period; a subsequent retrospective chart review was conducted. Low-dose droperidol was defined as a cumulative dose of ≤2 mg. Patients who received droperidol for any other reason than the treatment of a headache were excluded. Data were analyzed descriptively.

Results: Seventy-three cases in which droperidol was administered for the treatment of a headache were identified over the 7-month period. Most doses (92%) administered were 1.25 mg or less. Fifty-three patients (73%) had complete resolution or significant improvement of headache symptoms as subjectively or objectively (eg, numerical pain scale) documented by the treating physician. Eight patients (11%) had minimal improvement in their headaches symptoms; 12 patients (16%) received no relief after the administration of droperidol. The average time to discharge from the ED was 94.8 ± 67.2 minutes. No cardiac arrhythmias were noted. Other adverse events included 2 cases of extrapyramidal side effects; one patient reported restlessness/anxiousness and the other patient had dystonia.

Conclusion: The administration of low-dose (≤2 mg) droperidol may be safe and effective for the treatment of primary headaches in the ED.

21. Intraosseous Bests IV Access During Out-of-Hospital Cardiac Arrest: A Randomized Controlled Trial

Reades R, et al. Ann Emerg Med. 2011;58:509-516.

Study objective; Intraosseous needle insertion during out-of-hospital cardiac arrest is rapidly replacing peripheral intravenous routes in the out-of-hospital setting. However, there are few data directly comparing the effectiveness of intraosseous needle insertions with peripheral intravenous insertions during out-of-hospital cardiac arrest. The objective of this study is to determine whether there is a difference in the frequency of first-attempt success between humeral intraosseous, tibial intraosseous, and peripheral intravenous insertions during out-of-hospital cardiac arrest.

Methods: This was a randomized trial of adult patients experiencing a nontraumatic out-of-hospital cardiac arrest in which resuscitation efforts were initiated. Patients were randomized to one of 3 routes of vascular access: tibial intraosseous, humeral intraosseous, or peripheral intravenous. Paramedics received intensive training and exposure to all 3 methods before study initiation. The primary outcome was first-attempt success, defined as secure needle position in the marrow cavity or a peripheral vein, with normal fluid flow. Needle dislodgement during resuscitation was coded as a failure to maintain vascular access.

Results: There were 182 patients enrolled, with 64 (35%) assigned to tibial intraosseous, 51 (28%) humeral intraosseous, and 67 (37%) peripheral intravenous access. Demographic characteristics were similar among patients in the 3 study arms. There were 130 (71%) patients who experienced initial vascular access success, with 17 (9%) needles becoming dislodged, for an overall frequency of first-attempt success of 113 (62%). Individuals randomized to tibial intraosseous access were more likely to experience a successful first attempt at vascular access (91%; 95% confidence interval [CI] 83% to 98%) compared with either humeral intraosseous access (51%; 95% CI 37% to 65%) or peripheral intravenous access (43%; 95% CI 31% to 55%) groups. Time to initial success was significantly shorter for individuals assigned to the tibial intraosseous access group (4.6 minutes; interquartile range 3.6 to 6.2 minutes) compared with those assigned to the humeral intraosseous access group (7.0 minutes; interquartile range 3.9 to 10.0 minutes), and neither time was significantly different from that of the peripheral intravenous access group (5.8 minutes; interquartile range 4.1 to 8.0 minutes).

Conclusion: Tibial intraosseous access was found to have the highest first-attempt success for vascular access and the most rapid time to vascular access during out-of-hospital cardiac arrest compared with peripheral intravenous and humeral intraosseous access.

22. The Captain Morgan Technique for the Reduction of the Dislocated Hip

We highlighted this article in an earlier Lit Bits. It’s now in print and available for free. See below.

Article full-text: http://www.annemergmed.com/article/S0196-0644(11)01307-2/fulltext

Video: http://www.annemergmed.com/article/S0196-0644(11)01307-2/attachment?filename=mmc1.mpg

Lit Bits: Oct 31, 2011

From the recent medical literature...

1. ROSC or Death: Some EMS Systems Stop Transporting Cardiac Arrest Patients, Perform CPR at Scene, Roadside, Ambulance Bay

Joanne Kenen, Ann Emerg Med. 2011;58:A17-A19.

The patient was alert and talking as the ambulance reached the Texas hospital. In the parking lot, he went into cardiac arrest. The paramedics started an aggressive attempt to restart his heart right there. He was then brought into the emergency department (ED), where efforts to resuscitate him continued, unsuccessfully. He died.

The initial effort to save him in the parking lot took place within view of the hospital ED itself, a foolproof recipe for miscommunication, misperception, misunderstanding. Yet ultimately the experience led to greater understanding of the boundaries and barriers—and bridges—between hospital and “out-of-hospital” care, of what the ever-evolving body of evidence now suggests may often be the best option for the patient, even if it runs counter to ingrained practices.

“If you looked out the window, you didn't understand the circumstances,” said Paul Hinchey, MD, MBA, who is the medical director of emergency services for Travis County, which includes Austin, and is also an attending emergency physician at South Austin Medical Center, where the parking lot incident occurred. “They didn't understand what was going on. All they saw was the [emergency medical services] EMS crew working a cardiac arrest in the parking lot. They didn't understand the patient had literally arrested right there.”

Eventually the tensions subsided after lots of discussions not just in that hospital but also in other hospitals in the larger community. And it led to an expanding appreciation that with out-of-hospital cardiac arrest seconds—not minutes, but seconds—count. It's not about on whose turf the patient's heart stopped but about how to improve the dismal odds of restarting it. If and when a similar situation arises in Austin, Dr. Hinchey said, the paramedics would again start aggressive care on the spot, even if the spot were a parking lot near the hospital. The difference is that next time emergency physicians may well come out and join them. Dr. Hinchey added that people inside the hospital often think it takes only seconds to move a patient from ambulance into the ED, but the EMS team knows the transition usually takes minutes.

The Bay Debate

“We discussed it extensively,” Dr. Hinchey said of his colleagues in the area hospitals. They came to understand and then re-examine the invisible but not unbreachable barrier between themselves and the patient outside their doors. “The whole point of EMS advanced care is to extend out to the field. But it's OK—not only OK but essential—for doctors to be part of the process,” added Dr. Hinchey, whose city is part of the “Take Heart America” demonstration project designed to show how cardiac arrest survival rates can be improved through state-of-the-art science partnered with interdisciplinary community approaches.

“It is the cooperative care that makes the difference. The focus should always be on the patient, and their outcome based on what we know in the science,” Dr. Hinchey later said in a follow-up e-mail. “EMS can never replace emergency department care, only supplement it. If done well, everyone benefits, most importantly our patients.”

Clifton W. Callaway, MD, PhD, Associate Professor, vice chair of the Department of Emergency Medicine, University of Pittsburgh, served on the advanced cardiac life support subcommittee when the American Heart Association updated its resuscitation guidelines. Dr. Callaway, who describes himself as “aggressive” when trying to resuscitate, appreciates why it might be better for ambulance crews that find themselves in a parking lot arrest situation to get to work right then and there.

But he likes the idea of having more ED staff, including physicians when practical and appropriate, to get out there and join them. If you can't get the patient to the ED, get the ED to the patient. Enough personnel on hand may also allow the patient to be transported inside while receiving good-quality compressions en route.

Two paramedics can't try resuscitation and move the patient. But 2 paramedics plus a couple of nurses, ED techs, and a physician may be able to. “That patient wants the maximum resources brought to bear if they are going to have a chance of survival,” Dr. Callaway said. “Leaving the paramedics to manage themselves when more experienced physicians or other resources are only a few meters away is not best for the patient.”

Improvement is sorely needed. According to the American Heart Association, EMS treat about 300,000 people with out-of-hospital cardiac arrest each year. Less than 8% survive.

In recent years, protocols have changed in communities across the country; not everyone is automatically rushed to the nearest hospital. For cardiac arrest, if the patient can't be resuscitated at the scene, there's usually no sense in rushing him or her to the hospital. (Several physicians interviewed observed that the exceptions would include cardiac arrest in a trauma victim, exsanguination, metabolic abnormalities, or a situation in which emergency vehicles were ill equipped and lacking defibrillators.)

Manually performed cardiopulmonary resuscitation (CPR) while a patient is in motion just doesn't work all that well, according to some studies. And CPR in the back of a speeding ambulance is dangerous to the patient, to the emergency medical technicians (EMTs) bouncing around unbelted while precariously perched over the patient's chest, and to the pedestrians and vehicles in the ambulance's path.

“The patient is at risk, and so is everyone else,” noted Brent Myers, MD, MPH, the medical director for the Wake County EMS System, whose community has also dealt with parking lot incidents near hospitals and who is also a strong advocate of treating the patient on site.

“I’ve done a lot of CPR in the back of moving vehicles for a long time. It's virtually impossible to do it well,” said Joseph P. Ornato, MD, chairman of emergency medicine at Virginia Commonwealth University Medical Center, as well as operational medical director of Richmond Ambulance Authority. With 37 years of experience working in hospitals, ambulances, helicopters, and fixed-wing aircraft, Dr. Ornato should know. He is also cardiac cochair for the National Institutes of Health–sponsored Resuscitation Outcomes Consortium, which performs large, randomized clinical trials on out-of-hospital cardiac arrest.

The rest of the article (free): http://www.annemergmed.com/article/S0196-0644(11)01551-4/fulltext

2. Scientific Support for Adrenaline’s (Temporary) Benefit in Cardiac Arrest

Adrenaline improves chance of return of spontaneous circulation but not survival to discharge.

Adrenaline has been used to treat patients with cardiac arrest for more than half a century but has not been evaluated in a placebo-controlled clinical trial in humans. Indeed, there is concern that it might have untoward effects on myocardial function and cerebral microcirculation in postcardiac arrest patients. In the first randomized, double-blind, placebo-controlled trial of adrenaline in cardiac-arrest patients, researchers in Australia randomized 534 adults (mean age, 65; 73% men) with out-of-hospital cardiac arrest from any cause to receive 1 mL of either adrenaline 1:1000 (i.e., 1 mg) or normal saline every 3 minutes to a maximum of 10 mL. No other resuscitation drugs were given. Paramedics were allowed to use other standard methods of cardiopulmonary resuscitation, including defibrillation.

Rates of survival to hospital discharge — the primary outcome — did not differ significantly between the adrenaline and control groups (4.0% and 1.9%; odds ratio, 2.2; 95% confidence interval 0.7-6.3). Patients receiving adrenaline had significantly higher likelihood of prehospital return of spontaneous circulation (ROSC) than placebo recipients (23.5% vs. 8.4%; OR, 3.4) and of admission to the hospital from the emergency department (25.4% vs. 13.0%; OR, 2.3).

Comment: This trial should diminish persistent speculation about the advantages of adrenaline in cardiac arrest. The finding that the more-than-doubled rate of survival to hospital discharge in adrenaline recipients failed to reach statistical significance might be explained by the fact that the trial was underpowered. The effect of the significantly higher rate of prehospital ROSC in the adrenaline group might be enhanced by use of post-ROSC hypothermic therapy, which has been shown to lower mortality and improve neurological outcomes at hospital discharge and thereafter.

— John A. Marx, MD, FAAEM. Published in Journal Watch Emergency Medicine October 14, 2011. Citation: Jacobs IG et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation 2011 Sep; 82:1138.

Medline abstract (free): http://www.ncbi.nlm.nih.gov/pubmed/21745533

3. Anterior Versus Lateral Needle Decompression of Tension Pneumothorax: Comparison by CT Chest Wall Measurement

Sanchez LD, et al. Acad Emerg Med. 2011;18:1022-1026.

Objectives:  Recent research describes failed needle decompression in the anterior position. It has been hypothesized that a lateral approach may be more successful. The aim of this study was to identify the optimal site for needle decompression.

Methods:  A retrospective study was conducted of emergency department (ED) patients who underwent computed tomography (CT) of the chest as part of their evaluation for blunt trauma. A convenience sample of 159 patients was formed by reviewing consecutive scans of eligible patients. Six measurements from the skin surface to the pleural surface were made for each patient: anterior second intercostal space, lateral fourth intercostal space, and lateral fifth intercostal space on the left and right sides.

Results:  The distance from skin to pleura at the anterior second intercostal space averaged 46.3 mm on the right and 45.2 mm on the left. The distance at the midaxillary line in the fourth intercostal space was 63.7 mm on the right and 62.1 mm on the left. In the fifth intercostal space the distance was 53.8 mm on the right and 52.9 mm on the left. The distance of the anterior approach was statistically less when compared to both intercostal spaces (p less than 0.01).

Conclusions:  With commonly available angiocatheters, the lateral approach is less likely to be successful than the anterior approach. The anterior approach may fail in many patients as well. Longer angiocatheters may increase the chances of decompression, but would also carry a higher risk of damage to surrounding vital structures.

4. Screened and Examined: Placebo on the Brain

Ballard, Dustin MD. Emerg Med News. 2011;33.

I had placebo on the brain the other day. This occurred shortly after I took my morning glucosamine supplement (to ward off arthritis, of course) and right before I ordered two mg of morphine for a drug-seeking patient with chronic pain.

The principle of placebo is at work all the time in our daily and professional lives, and its power is undeniable. The medical literature has demonstrated it in dozens of studies, and the media have followed that lead. Last year, for instance, a Newsweek cover story examined the remarkable performance of the placebo arms in clinical trials evaluating new anti-depressants. (http://bit.ly/p5vsP6) Their performance was so robust that it's making it difficult for drug makers to demonstrate the superiority of their new medications over placebo.

Similarly, a recent Harvard study of asthmatics found 45 percent improvement in symptoms with a fake inhaler and 46 percent improvement with impostor acupuncture compared with 50 percent with an actual treatment (albuterol). Beyond just tricking the brain to feel better, placebo treatments seem capable of causing actual neurological and physiological changes. But the trickery has been somewhat of a sticking point for placebo. Many physicians consider using an impure placebo (a treatment with dubious physiological effect) for its psychological benefits, but would not go as far as prescribing fake pills. In fact, a survey-based study found that approximately 50 percent of U.S. doctors report using such impure treatments. I count myself among them. It was with great interest, then, that I read a recent study of patients with irritable bowel syndrome (IBS) that utilized an “open-label” placebo, a placebo treatment without deception.

In this investigation, which was led by Ted J. Kaptchuk and colleagues and published in December 2010 in PLos ONE, 80 IBS patients were given either no additional therapy or open-label placebo. This placebo treatment was described to patients as “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes.”

Both arms of the study received a counseling session from a physician and nurse that emphasized the importance of maintaining a positive mindset toward the therapy (suspending disbelief). Self-reported symptom scores were assessed at 0, 11, and 21 days. The results demonstrated significant improvements in symptom severity and relief in the placebo group at 11 and 21 days. These included an improvement in the global improvement scores of the placebo group of 5 points (vs. 3.9 for the control group, p=.002).

This study was a small one, with possible confounders such as unreliability in patient symptom reporting, but it certainly is provocative and promising. For years, physicians have struggled with placebo treatments because we've assumed that trickery was necessary for them to work. Trickery puts us in an uncomfortable position, having to choose between two ethical principles: beneficence and autonomy. But if the results of the IBS study are borne out in subsequent studies, the ramifications are tremendous. The placebo effect may not require deception at all. Perhaps it's been mischaracterized for decades. To prescribe placebo freely without the troublesome concealment component opens up a pathway for placebo treatments for many conditions: depression, asthma, chronic pain, IBS, addiction, hypertension, and more. And in the ED? Well, I see some obvious possibilities:

The Patient: Bonked Brenda who bumped her head on a kitchen cabinet last week, and today was reminded of the Natasha Richardson tragedy by a friend.

The Treatment: Trick O'Tomography. This happy-thought scanner is radiation- and risk-free! Who cares that it doesn't generate any pictures? They weren't needed to begin with.

The Patient: Snotty Scott with a touch of congestion, convinced that he has the sinusitis.

The Treatment: Placebiotics. Sweet-tasting and side effect-free, these pills help provide exactly what's needed: some harmless reassurance.

The Patient: Worried Wilma who is not happy with the past 48 hours of her life, and wants to let someone know it.

The Treatment: DeceptoTherapy. This is where your registration clerk can come in super-therapeutic. Rather than call in the psychiatrist in the middle of the night, send in someone qualified to provide the necessary treatment: a set of ears.

The Patient: Anxious Alejandro. A high-stress meeting at work has him breathing like a bunny and complaining of tingling in the hands and feet. He tells you he just can't catch his breath.

The Treatment: A dose of Ativan plus two puffs from the Placebo Pump. With this benzo/placebo cocktail, Alejandro will be ready to bolt back to the office before you can even begin to consider an alternative diagnosis.

These are, of course, tongue-in-cheek examples but perhaps not that farfetched. Could we use placebo to help with the expectant management of conditions like rule-out strep, bronchitis, and, yes, sinusitis? And could we use a simple strategy to improve mood and alleviate discomfort in certain segments of our patient population? Of course. We already do this in myriad ways.

Clearly, the physiologic possibilities for placebo have limits. We can't expect mind-over-matter to work with a bleeding limb, widely metastatic cancer, or a hardcore tweaker. In fact, a 2010 Cochrane review suggests that placebo may be ineffective beyond conditions with subjective symptoms (like pain and nausea). But in the ED, the sickest patients are not always the trickiest ones. Instead they are often the ones with subjective complaints and requests for treatment they don't need. For them, open-label placebo holds tremendous promise.

For more on Dr. Ballard, http://journals.lww.com/em-news/Fulltext/2011/10201/Screened_and_Examined__Placebo_on_the_Brain.2.aspx

5. The Public Lacks Knowledge about Automated External Defibrillators and Willingness to Use Them

In a survey of international travelers in the Netherlands, less than half could identify an AED and less than half were willing to use one.

To investigate attitudes and understanding about automated external defibrillators (AEDs) among the public, investigators conducted a cross-sectional survey of adults traveling through the Central Railway Station in Amsterdam, the Netherlands. Participants were asked a series of structured open-ended questions (e.g., did they recognize an AED, were they aware of public access AED programs, would they be willing to use an AED).

A total of 1018 individuals from 38 countries participated. When asked what they would do when first encountering a person with cardiac arrest, only 6% of respondents mentioned defibrillation or AEDs, 64% knew what a defibrillator is used for, and 43% were aware that defibrillators are often available for public access. When the interviewer pointed to an AED, only 47% of participants correctly identified it, 53% knew what an AED is used for, and 47% said they would be willing to use one.

Comment: Widespread placement of public-access AEDs is incomplete without the requisite public education or a method of ensuring ready availability of trained personnel (e.g., employees) in all locations. Both requirements are tall orders.

— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine October 7, 2011. Citation: Schober P et al. Public access defibrillation: Time to access the public. Ann Emerg Med 2011 Sep; 58:240.

6. Docs admit malpractice fears lead to overly aggressive care

Doctors admit to being part of the healthcare problem, fessing up that they provide too much medical care in a nationwide survey published in the Archives of Internal Medicine. They said malpractice concerns, current reimbursement structure, and quality measurement systems drove them to practice more aggressive healthcare.

Almost half (42 percent) of the 627 surveyed physicians said their patients "were receiving too much medical care" and another 28 percent said they had ordered more tests and made more referrals to specialists than they would like, reports the Los Angeles Times.

The doctors said fear of malpractice lawsuits (76 percent) and clinical performance measures (52 percent) were the most common drivers of their more aggressive practices. Another 40 percent don't spend enough time with their patients to figure out what's wrong, so they ordered tests and consultations to provide answers.

Eighty-three percent of the physicians said they could be sued if they didn't order a test that was indicated, whereas only 21 percent said they could be sued for ordering a test that wasn't indicated, according to the Wall Street Journal. The incentives, therefore, point toward "when in doubt, do more," says Brenda Sirovich, an author of the study and a staff physician and research associate in the Outcomes Group at the VA Medical Center in White River Junction, Vt.

The study also found that 40 percent of doctors thought other primary care physicians were driven by extra income that results from ordering more tests, although only 3 percent said financial considerations influenced their own practice style, Reuters reports.

"I'm not saying that physicians do tests in order to make money--there is a potential to be a real cynic here--but I think that the reimbursement model for most healthcare encourages utilization in a variety of ways," Sirovich said. "It's a time for us to reflect about what incentives we have built into our healthcare system, and what directions they are taking us in," she added.

Abstract: http://archinte.ama-assn.org/cgi/content/short/171/17/1582

7. Diagnostic accuracy of venous blood gas electrolytes for identifying diabetic ketoacidosis in the ED

Menchine M, Acad Emerg Med. 2011 Oct;18(10):1105-8.

Objectives: Diagnosing diabetic ketoacidosis (DKA) has traditionally required a venous blood gas (VBG) to obtain serum pH and a serum chemistry panel to obtain electrolyte values. Because newer blood gas analyzers have the ability to report electrolyte values and glucose in addition to pH, this diagnostic process could theoretically be condensed. However, neither the diagnostic accuracy of the VBG for DKA nor the agreement between the VBG electrolytes and the serum chemistry electrolytes, including sodium, chloride, and bicarbonate, has been evaluated in the context of acute hyperglycemia. The purpose of this study was to assess the accuracy of VBG electrolytes for diagnosing DKA using serum chemistry electrolytes measures as the criterion standard and to describe the correlation between VBG and serum chemistry electrolytes in a sample of hyperglycemic patients seen in the emergency department (ED).

Methods: The authors prospectively identified a convenience sample of ED patients with serum blood glucose ≥ 250 mg/dL and examined their paired VBG and serum chemistry electrolytes. The diagnosis of DKA was made by using American Diabetes Association (ADA) criteria including serum glucose ≥ 250 mg/dL, serum anion gap above 10 mEq/L, bicarbonate ≤ 18 mEq/L, serum pH ≤ 7.30, and presence of ketosis. Serum chemistry electrolyte values were considered to be the criterion standard. Diagnostic test characteristics of VBG electrolytes including sensitivity and specificity were compared against this standard. In addition, correlation coefficients for individual electrolytes and anion gap between VBG and chemistry electrolytes were calculated.

Results: Paired VBG and serum chemistry panels were available for 342 patients, of whom 46 (13.5%) had DKA. The sensitivity and specificity of the VBG electrolytes for diagnosing DKA was 97.8% (95% confidence interval [CI] = 88.5% to 99.9%) and 100% (95% CI = 98.8% to 100%), respectively. One case of DKA was missed by the VBG. Correlation coefficients between VBG and serum chemistry were 0.90, 0.73, 0.94, and 0.81 for sodium, chloride, bicarbonate, and anion gap, respectively.

Conclusions: The VBG electrolytes were 97.8% sensitive and 100% specific for the diagnosis of DKA in hyperglycemic patients. These preliminary findings support the use of VBG electrolytes in lieu of VBG along with serum chemistry analysis to rule in or rule out DKA.

8. A Decision Rule for Chest Imaging in Blunt Trauma

A combination of seven clinical criteria was 99% sensitive for detection of significant thoracic injury.

Rodriguez RM et al. J Trauma 2011 Sep; 71:549
.
BACKGROUND: To derive a decision instrument (DI) that identifies patients who have virtually no risk of significant intrathoracic injury (SITI) visible on chest radiography and, therefore, no need for chest imaging.

METHODS: This is a prospective observational study. At three Level 1 trauma centers, physicians caring for blunt trauma patients above 14 years were asked to record the presence or absence of 12 clinical criteria before viewing chest imaging results. SITI was defined as pneumothorax, hemothorax, aortic/great vessel injury, two or more rib fractures, ruptured diaphragm, sternal fracture, and pulmonary contusion on official radiograph readings. The κ (interrater reliability) and screening performance of individual criteria were determined. By using recursive partitioning, the most highly sensitive combination of criteria for SITI was derived.

RESULTS: Of the 2,628 subjects enrolled, 271 (10.3%) were diagnosed with a total of 462 SITIs, with rib fractures (73%), pneumothorax (38%), and pulmonary contusion (29%) as the most common injuries. Chest pain and chest wall tenderness had the highest sensitivity for SITI (65%). The DI of chest pain, distracting injury, chest wall tenderness, intoxication, age over 60 years, rapid deceleration, and altered alertness/mental status had the following screening performance: sensitivity 99.3% (95% confidence interval [CI], 97.4-99.8), specificity 14.0% (95% CI, 12.6-15.4), negative predictive value 99.4% (95% CI, 97.8-99.8), and positive predictive value 11.7% (95% CI, 10.5-13.1). All seven criteria in the DI met the predetermined cut off for acceptable κ (range, 0.51-0.81).

CONCLUSIONS: We derived a DI consisting of seven clinical criteria that can identify SITI in blunt trauma patients with extremely high sensitivity. If validated, this instrument will allow for safe, selective chest imaging with potential resource savings.

9. Diagnostic Blood Loss from Phlebotomy and Hospital-Acquired Anemia during AMI

Salisbury AC, et al. Arch Intern Med. 2011;171(18):1646-1653.

Background: Hospital-acquired anemia (HAA) during acute myocardial infarction (AMI) is associated with higher mortality and worse health status and often develops in the absence of recognized bleeding. The extent to which diagnostic phlebotomy, a modifiable process of care, contributes to HAA is unknown.

Methods: We studied 17 676 patients with AMI from 57 US hospitals included in a contemporary AMI database from January 1, 2000, through December 31, 2008, who were not anemic at admission but developed moderate to severe HAA (in which the hemoglobin level declined from normal to below 11 g/dL), a degree of HAA that has been shown to be prognostically important. Patients' total diagnostic blood loss was calculated by multiplying the number and types of blood tubes drawn by the standard volume for each tube type. Hierarchical modified Poisson regression was used to test the association between phlebotomy and moderate to severe HAA, after adjusting for site and potential confounders.

Results: Moderate to severe HAA developed in 3551 patients (20%). The mean (SD) phlebotomy volume was higher in patients with HAA (173.8 [139.3] mL) vs those without HAA (83.5 [52.0 mL]; P less than .001). There was significant variation in the mean diagnostic blood loss across hospitals (moderate to severe HAA: range, 119.1-246.0 mL; mild HAA or no HAA: 53.0-110.1 mL). For every 50 mL of blood drawn, the risk of moderate to severe HAA increased by 18% (relative risk [RR], 1.18; 95% confidence interval [CI], 1.13-1.22), which was only modestly attenuated after multivariable adjustment (RR, 1.15; 95% CI, 1.12-1.18).

Conclusions: Blood loss from greater use of phlebotomy is independently associated with the development of HAA. These findings suggest that HAA may be preventable by implementing strategies to limit blood loss from laboratory testing.

10. Droperidol Analgesia for Opioid-Tolerant Patients

Richards JR, et al. J Emerg Med. 2011;41:389-396.

Background: Patients with acute and chronic pain syndromes such as migraine headache, fibromyalgia, and sickle cell disease represent a significant portion of emergency department (ED) visits. Certain patients may have tolerance to opioid analgesics and often require large doses and prolonged time in the ED to achieve satisfactory pain mitigation. Droperidol is a unique drug that has been successfully used not only as an analgesic adjuvant for the past 30 years, but also for treatment of nausea/vomiting, psychosis, agitation, sedation, and vertigo.

Objectives: In this review, we examine the evidence supporting the use of droperidol for analgesia, adverse side effects, and controversial United States (US) Food and Drug Administration (FDA) black box warning.

Discussion: Droperidol has myriad pharmacologic properties that may explain its efficacy as an analgesic, including: dopamine D2 antagonist, dose-dependent GABA agonist/antagonist, α2 adrenoreceptor agonist, serotonin antagonist, histamine antagonist, muscarinic and nicotinic cholinergic antagonist, anticholinesterase activity, sodium channel blockade similar to lidocaine, and μ opiate receptor potentiation.

Conclusion: Droperidol is an important adjuvant for patients who are tolerant to opioid analgesics. The FDA black box warning does not apply to doses below 2.5mg.

11. An Algorithm for Minimizing Pelvic X-Rays in Blunt Trauma

Implementation of the algorithm reduced pelvic x-ray charges at the study institution by $207,000 over 6 months.

The current Advanced Trauma Life Support protocol recommends anteroposterior plain pelvic radiographs for blunt trauma patients. However, if patients are undergoing abdominal pelvic computed tomography (AP-CT), pelvic radiographs are less accurate and redundant. These authors developed an algorithm for obtaining pelvic radiographs and conducted a prospective observational study of its effects during a 6-month period at a single level I trauma center in California. The algorithm dictated that blunt trauma patients undergoing AP-CT would forgo pelvic radiographs unless systolic blood pressure was below 90 mm Hg, hemoglobin was below 8 mg/dL, hemoglobin fell more than 3 mg/dL in the emergency department (ED), and significant pelvic examination findings were present. The algorithm could be overridden by the attending physician.

Of 978 consecutive blunt trauma patients scheduled for AP-CT, 57 (6%) underwent pelvic radiography. Reasons for ordering radiographs were severe pelvic pain (61%), proximal fractures (25%), unexplained hypotension (9%), and hip dislocation (5%). Patients who underwent pelvic radiography were older (mean, 46 vs. 37), had higher mean Injury Severity Scores (12 vs. 7), and required more transfusions (10.5% vs. 1.6%). Pelvic radiographs changed management in two patients: One received an immediate blood transfusion despite normotension, and one had a pelvic binder placed before undergoing AP-CT. There were no complications, including hypotension in the ED, delayed administration of blood products or pelvic binder, or delay in contacting interventional radiology.

Comment: Healthcare imaging costs have risen from US$7 billion to $14 billion in 6 years in the U.S. Compared with abdominal pelvic CT scans, pelvic radiographs have a sensitivity of 55% for identifying pelvic fractures. This simple algorithm eliminated 94% of pelvic radiographs, with a projected annual reduction in charges of nearly $400,000 at a single hospital. Implementing the algorithm makes sense and saves cents.

— John A. Marx, MD, FAAEM. Published in Journal Watch Emergency Medicine October 21, 2011. Citation: Barleben A et al. Implementation of a cost-saving algorithm for pelvic radiographs in blunt trauma patients. J Trauma 2011 Sep; 71:582.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21908996

12. Blood cultures in the ED evaluation of childhood pneumonia.

Shah SS, et al. Pediatr Infect Dis J. 2011 Jun;30(6):475-9.

BACKGROUND: Blood cultures are frequently obtained in the emergency department (ED) evaluation of children with community-acquired pneumonia (CAP).

OBJECTIVES: To determine the prevalence of bacteremia in children presenting to the ED with CAP, identify subgroups at increased risk for bacteremia, and quantify the effect of positive blood cultures on management.

METHODS: This case-control study was nested within a cohort of children followed up at 35 pediatric practices. Patients from this cohort who were ≤18 years of age, evaluated in the ED in 2006-2007, and diagnosed with CAP were eligible. Cases were those with bacteremia. Controls included those with negative blood cultures and those without blood cultures performed.

RESULTS: A total of 877 (9.6%) of 9099 children with CAP were evaluated in the ED. The mean age was 3.6 years; 53% were male. Blood cultures were obtained from 291 children (33.2%). Overall, the prevalence of bacteremia was 2.1% (95% confidence interval [CI]: 0.8%-4.4%). Bacteremia occurred in 2.6% (95% CI: 1.0%-5.6%) with an infiltrate on chest radiograph and in 13.0% (95% CI: 2.8%-33.6%) with complicated pneumonia. Streptococcus pneumoniae accounted for 4 of the 6 cases of bacteremia. Blood culture results altered management in 5 of the 6 bacteremic patients; 1 had an appropriate broadening and 4 had an appropriate narrowing of coverage. The contamination rate was 1.0% (95% CI: 0.2%-3.0%).

CONCLUSION: Children presenting to the ED for evaluation of CAP are at low-risk for bacteremia. Although positive blood cultures frequently altered clinical management, the overall impact was small because of the low prevalence of bacteremia.

13. Early stroke risk and ABCD2 score performance in tissue- vs time-defined TIA: A multicenter study.

Giles MF, et al. Neurology. 2011 Sep 27;77(13):1222-8.

OBJECTIVES: Stroke risk immediately after TIA defined by time-based criteria is high, and prognostic scores (ABCD2 and ABCD3-I) have been developed to assist management. The American Stroke Association has proposed changing the criteria for the distinction between TIA and stroke from time-based to tissue-based. Research using these definitions is lacking. In a multicenter observational cohort study, we have investigated prognosis and performance of the ABCD2 score in TIA, subcategorized as tissue-positive or tissue-negative on diffusion-weighted imaging (DWI) or CT imaging according to the newly proposed criteria.

METHODS: Twelve centers provided data on ABCD2 scores, DWI or CT brain imaging, and follow-up in cohorts of patients with TIA diagnosed by time-based criteria. Stroke rates at 7 and 90 days were studied in relation to tissue-positive or tissue-negative subcategorization, according to the presence or absence of brain infarction. The predictive power of the ABCD2 score was determined using area under receiver operator characteristic curve (AUC) analyses.

RESULTS: A total of 4,574 patients were included. Among DWI patients (n = 3,206), recurrent stroke rates at 7 days were 7.1%(95% confidence interval 5.5-9.1) after tissue-positive and 0.4% (0.2-0.7) after tissue-negative events (p diff less than 0.0001). Corresponding rates in CT-imaged patients were 12.8% (9.3-17.4) and 3.0% (2.0-4.2), respectively (p diff less than 0.0001). The ABCD2 score had predictive value in tissue-positive and tissue-negative events (AUC = 0.68 [95% confidence interval 0.63-0.73] and 0.73 [0.67-0.80], respectively; p sig less than 0.0001 for both results, p diff = 0.17). Tissue-positive events with low ABCD2 scores and tissue-negative events with high ABCD2 scores had similar stroke risks, especially after a 90-day follow-up.

CONCLUSIONS: Our findings support the concept of a tissue-based definition of TIA and stroke, at least on prognostic grounds.
__________

Context: The American Stroke Association has recently proposed revising the definitions from time-based to tissue-based criteria, advocating that stroke and TIA be distinguished by the presence or absence of brain infarction identified on diffusion-weighted MRI (DWI).

Cf: Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease Stroke 2009;40:2276–2293. Full-text (free): http://stroke.ahajournals.org/content/40/6/2276.long

Albers GW, Caplan LR, Easton JD, et al. Transient ischemic attack: proposal for a new definition. N Engl J Med 2002;347:1713–1716.

14. Morbidity related to emergency endotracheal intubation--a substudy of the KETAmine SEDation trial.

Jabre P, et al. Resuscitation. 2011;82(5):517-22.

OBJECTIVES: To evaluate the association between emergency tracheal intubation difficulty and the occurrence of immediate complications and mortality, when standardised airway management is performed by emergency physicians.

METHODS: The present study was a substudy of the KETAmine SEDation (KETASED) trial, which compared morbidity and mortality after randomisation to one of two techniques for rapid sequence intubation in an emergency setting. Intubation difficulty was measured using the intubation difficulty scale (IDS) score. Complications recognised within 5 min of endotracheal intubation were recorded. We used multivariate logistic regression analysis to determine the factors associated with the occurrence of complications. Finally, a Cox proportional hazards regression model was used to examine the association of difficult intubation with survival until 28 days.

RESULTS: A total of 650 patients were included, with mean age of 55 ± 19 years. Difficult intubation (IDS above 5) was recorded in 73 (11%) patients and a total of 248 complications occurred in 192 patients (30%). Patients with at least one complication had a significantly higher median IDS score than those without any complications. The occurrence of a complication was independently associated with intubation difficulty (odds ratio 5.9; 95% confidence interval (CI) [3.5;10.1], p less than 0.0001) after adjustment on other significant factors. There was a positive linear relationship between IDS score and complication rate (R(2) = 0.83; p less than 0.001). The Cox model for 28-day mortality indicated that difficult intubation (hazard ratio 1.59; 95%CI [1.04;2.42], p = 0.03) was a significant independent predictor of death.

CONCLUSION: Difficult intubation, measured by the IDS score, is associated with increased morbidity and mortality in patients managed under emergent conditions.

15. Emergency Airway Management: A Multi-Center Report of 8937 Emergency Department Intubations

Walls RM, et al. J Emerg Med. 2011;41:347-354.

Objective: Emergency department (ED) intubation personnel and practices have changed dramatically in recent decades, but have been described only in single-center studies. We sought to better describe ED intubations by using a multi-center registry.

Methods: We established a multi-center registry and initiated surveillance of a longitudinal, prospective convenience sample of intubations at 31 EDs. Clinicians filled out a data form after each intubation. Our main outcome measures were descriptive. We characterized indications, methods, medications, success rates, intubator characteristics, and associated event rates. We report proportions with 95% confidence intervals and chi-squared testing; p-values below 0.05 were considered significant.

Results: There were 8937 encounters recorded from September 1997 to June 2002. The intubation was performed for medical emergencies in 5951 encounters (67%) and for trauma in 2337 (26%); 649 (7%) did not have a recorded mechanism or indication. Rapid sequence intubation was the initial method chosen in 6138 of 8937 intubations (69%) and in 84% of encounters that involved any intubation medication. The first method chosen was successful in 95%, and intubation was ultimately successful in 99%. Emergency physicians performed 87% of intubations and anesthesiologists 3%. Several other specialties comprised the remaining 10%. One or more associated events were reported in 779 (9%) encounters, with an average of 12 per 100 encounters. No medication errors were reported in 6138 rapid sequence intubations. Surgical airways were performed in 0.84% of all cases and 1.7% of trauma cases.

Conclusion: Emergency physicians perform the vast majority of ED intubations. ED intubation is performed more commonly for medical than traumatic indications. Rapid sequence intubation is the most common method of ED intubation.

16. The “Million Hearts” Initiative — Preventing Heart Attacks and Strokes

Frieden TR, et al. N Engl J Med 2011; 365:e27

Each year, more than 2 million Americans have a heart attack or stroke, and more than 800,000 of them die; cardiovascular disease is the leading cause of death in the United States and the largest cause of lower life expectancy among blacks. Related medical costs and productivity losses approach $450 billion annually, and inflation-adjusted direct medical costs are projected to triple over the next two decades if present trends continue.1

To reduce this burden, the Department of Health and Human Services (DHHS), other federal, state, and local government agencies, and a broad range of private-sector partners are today launching a “Million Hearts” initiative to prevent 1 million heart attacks and strokes over the next 5 years by implementing proven, effective, inexpensive interventions (see tableThe Million Hearts Initiative: Principles and Examples of Interventions.).

Cardiovascular prevention works in two realms: the clinic and the community. Clinical and community interventions each contributed about equally to the 50% reduction in U.S. mortality due to heart attacks between 1980 and 2000.2 If used consistently, proven interventions could prevent more than half of heart attacks and strokes. It's time to take the next big step.

In the clinical realm, Million Hearts will improve management of the “ABCS” — aspirin for high-risk patients, blood-pressure control, cholesterol management, and smoking cessation. As for community-based prevention, the initiative will encourage efforts to reduce smoking, improve nutrition, and reduce blood pressure. It will implement the cardiovascular-disease–prevention priorities of the National Quality and National Prevention Strategies and help in meeting targets set by Healthy People 2020.

Improving management of the ABCS can prevent more deaths than other clinical preventive services.3 Patients reduce their risk of heart attack or stroke by taking aspirin as appropriate. Treating high blood pressure and high cholesterol substantially and quickly reduces mortality among high-risk patients. Even brief smoking-cessation advice from clinicians doubles the likelihood of a successful quit attempt, and the use of medications increases quit rates further.

Currently, less than half of people with ischemic heart disease take daily aspirin or another antiplatelet agent; less than half with hypertension have it adequately controlled; only a third with hyperlipidemia have adequate treatment; and less than a quarter of smokers who try to quit get counseling or medications. As a result, more than 100 million people — half of American adults — smoke or have uncontrolled high blood pressure or cholesterol; many have more than one of these cardiovascular risk factors. Increasing utilization of these simple interventions could save more than 100,000 lives a year.3 Measuring and monitoring can encourage providers to improve preventive care.4

The remainder of the essay (free): http://www.nejm.org/doi/full/10.1056/NEJMp1110421

17. Images in (Emergency) Medicine

A Woman with Unilateral Sudden Painless Vision Loss
http://www.annemergmed.com/article/S0196-0644(11)00351-9/fulltext

Man with Back Pain
http://www.annemergmed.com/article/S0196-0644(11)00350-7/fulltext

A Refractory Wart?
http://www.annemergmed.com/article/S0196-0644(11)00484-7/fulltext

Human Papillomavirus Lesions of the Oral Cavity
http://www.nejm.org/doi/full/10.1056/NEJMicm1104783

Multiple Intracranial Tuberculomas
http://www.nejm.org/doi/full/10.1056/NEJMicm1103165

18. Most Long-Term Survivors of Out-of-Hospital Cardiac Arrest Have Positive Neurological Outcomes

Although some suffer long-term memory deficits

Long-term survival after out-of-hospital cardiac arrest (OHCA) has improved dramatically during the last several decades, due in large part to the "chain of survival" concept, which emphasizes cardiopulmonary resuscitation (CPR) and early defibrillation. In this prospective study, researchers assessed cognitive function in long-term (beyond 6 months) survivors of OHCA due to ventricular fibrillation (VF).

Of 332 patients with OHCA due to VF in one Minnesota county from 1990 to 2008, 140 patients survived to hospital discharge and 79 were alive in 2009. Of these, 47 patients (mean age, 61) agreed to participate in the study. The median time between OHCA and neurological and neuropsychological testing was 7.8 years. The median call to shock time was 5.6 minutes. Mean test results for the study population were compared to age-standardized normal population values in the same county. Overall, the study population had generally positive neurological outcomes (ability to live independently; mean Mini-Mental State Examination scores similar to standard values) and preserved cognitive ability. Patients suffered minor long-term memory deficits, but these did not affect their ability to live independently. Delayed time to defibrillation and older age at time of arrest were not independent predictors of neurological impairment.

Comment: These results reaffirm the importance of public education and the chain of survival, and they provide emergency physicians with valuable information for counseling patients and their family members.

— Richard D. Zane, MD, FAAEM. Published in Journal Watch Emergency Medicine October 28, 2011. Citation: Mateen FJ et al. Long-term cognitive outcomes following out-of-hospital cardiac arrest: A population-based study. Neurology 2011 Oct 11; 77:1438.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/21917772

19. Selective Use of CT Compared With Routine Whole Body Imaging in Patients with Blunt Trauma

Gupta M, et al. Ann Emerg Med. 2011;58:407-416.e15.

Study objective: Routine pan–computed tomography (CT, including of the head, neck, chest, abdomen/pelvis) has been advocated for evaluation of patients with blunt trauma based on the belief that early detection of clinically occult injuries will improve outcomes. We sought to determine whether selective imaging could decrease scan use without missing clinically important injuries.

Methods: This was a prospective observational study of 701 patients with blunt trauma at an academic trauma center. Before scanning, the most senior emergency physician and trauma surgeon independently indicated which components of pan-CT were necessary. We calculated the proportion of scans deemed unnecessary that: (a) were abnormal and resulted in a pre-defined critical action or (b) were abnormal.

Results: Pan-CT was performed in 600 of the patients; the remaining 101 underwent limited scanning. One or both physicians indicated a willingness to omit 35% of the individual scans. An abnormality was present in 18% of scans, including 22% of desired scans and 10% of undesired scans. Among the 95 patients who had one of the 102 undesired scans with abnormal results, 3 underwent a predefined critical action. There is disagreement among the authors about the clinical significance of the abnormalities found on the 99 undesired scans that did not lead to a critical action.

Conclusion: Selective scanning could reduce the number of scans, missing some injuries but few critical ones. The clinical importance of injuries missed on undesired scans was subject to individual interpretation, which varied substantially among authors. This difference of opinion serves as a microcosm of the larger debate on appropriate use of expensive medical technologies.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(11)00611-1/fulltext

20. CMS Approves 10% Medi-Cal Provider Rate Cut

State Continues to Balance the Budget on the Backs of Patients & Physicians

Today, the Centers for Medicare & Medicaid Services (CMS) approved the State of California's 10% cut to provider reimbursement through the Medi-Cal program, which was approved as part of this year's budget deal to close another multi-billion dollar deficit.

The move will most certainly result in further access-to-care problems for Medi-Cal recipients, whose primary care providers may continue their exodus from the program. Provider rate cuts over the past five years have resulted in increased ED visits by Medi-Cal recipients - double digits in some counties - according to data compiled by California ACEP from the Office of Statewide Health Planning & Development.

California ACEP will explore all possible avenues to reverse this short-sighted move which is likely to further erode physician participation and faith in Medi-Cal, while exacerbating ED over-crowding in California.

21. CDC’s (!) Preparedness 101: Zombie Apocalypse

There are all kinds of emergencies out there that we can prepare for. Take a zombie apocalypse for example. That’s right, I said z-o-m-b-i-e a-p-o-c-a-l-y-p-s-e. You may laugh now, but when it happens you’ll be happy you read this, and hey, maybe you’ll even learn a thing or two about how to prepare for a real emergency.

A Brief History of Zombies
We’ve all seen at least one movie about flesh-eating zombies taking over (my personal favorite is Resident Evil), but where do zombies come from and why do they love eating brains so much? The word zombie comes from Haitian and New Orleans voodoo origins. Although its meaning has changed slightly over the years, it refers to a human corpse mysteriously reanimated to serve the undead. Through ancient voodoo and folk-lore traditions, shows like the Walking Dead were born.

In movies, shows, and literature, zombies are often depicted as being created by an infectious virus, which is passed on via bites and contact with bodily fluids. Harvard psychiatrist Steven Scholzman wrote a (fictional) medical paper on the zombies presented in Night of the Living Dead and refers to the condition as Ataxic Neurodegenerative Satiety Deficiency Syndrome caused by an infectious agent. The Zombie Survival Guide identifies the cause of zombies as a virus called solanum. Other zombie origins shown in films include radiation from a destroyed NASA Venus probe (as in Night of the Living Dead), as well as mutations of existing conditions such as prions, mad-cow disease, measles and rabies.

The rise of zombies in pop culture has given credence to the idea that a zombie apocalypse could happen. In such a scenario zombies would take over entire countries, roaming city streets eating anything living that got in their way. The proliferation of this idea has led many people to wonder “How do I prepare for a zombie apocalypse?”

Well, we’re here to answer that question for you, and hopefully share a few tips about preparing for real emergencies too!

Full-text (free) at the CDC: http://emergency.cdc.gov/socialmedia/zombies_blog.asp