From the recent medical literature...
1. Induced Hypothermia After VF Cardiac Arrest Improves Outcomes
Hypothermia led to significantly better survival rates and neurological outcomes in patients with ventricular fibrillation but not in those with other initial rhythms.
Despite evidence that induced hypothermia therapy after cardiac arrest improves neurological outcomes and survival, cooling protocols have not been widely implemented. In a retrospective observational study, researchers compared outcomes in consecutive patients with out-of-hospital cardiac arrest who were resuscitated in the 2 years before (204 patients) and the 2 years after (287) implementation of a therapeutic hypothermia protocol at a teaching hospital in Seattle. Patients with severe infection, active bleeding, or nonintact skin from recent burns or who were in a persistent vegetative state prior to cardiac arrest were excluded.
Patients in the hypothermia group were cooled with ice packs, cooling blankets, or cooling pads and received intravenous vecuronium and diazepam. Temperature was measured with an esophageal probe; the goal of 32°C–34°C was achieved in 65% of patients. Passive rewarming commenced after 24 hours of cooling.
Rates of survival to hospital discharge were significantly higher in the hypothermia group than in the control group among patients with an initial rhythm of ventricular fibrillation (VF) (54% vs. 39%) but did not differ among patients with other rhythms. Similarly, the rate of favorable neurological outcomes was significantly higher in the hypothermia group than in the control group among patients with VF (35% vs. 15%).
Comment: Although a greater incidence of witnessed arrests in the hypothermia group (66%) than in the control group (57%) might have skewed the results, the findings suggest that cardiac arrest patients with an initial rhythm of VF might benefit from therapeutic cooling. Based on this and previous outcome studies and on other studies showing that induced hypothermia in the emergency department is feasible, it is time for EDs (and some emergency medical services systems) to implement hypothermia protocols for comatose survivors of cardiac arrest.
— Kristi L. Koenig, MD, FACEP. Published in Journal Watch EM November 6, 2009. Citation: Don CW et al. Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest: A retrospective before-and-after comparison in a single hospital. Crit Care Med 2009 Sep 16; [e-pub ahead of print]. (http://tinyurl.com/yht8qs7)
2. Capsule Endoscopy in ED Hastens Treatment of Upper GI Bleeding
By Anthony J. Brown, MD. NEW YORK (Reuters Health) Oct 26 - Use of real time capsule endoscopy in the emergency room can rapidly identify patients with upper gastrointestinal bleeding who require urgent treatment, according to study findings presented this week at the American College of Gastroenterology annual meeting in San Diego.
"A positive capsule endoscopy test, defined as visualization of a bleeding lesion, red blood or coffee grounds, (was) highly correlated with high-risk stigmata at endoscopy," senior researcher Dr. Moshe Rubin, from New York Hospital Queens, told Reuters Health. "We were surprised at the accuracy of capsule endoscopy in this small study."
Using capsule endoscopy, he added, "we may able to improve patient outcomes...by rapidly identifying those at high risk who need urgent endoscopic care."
The study featured 24 patients with a history of upper GI bleeding who were randomized to capsule endoscopy or standard clinical evaluation following admission to the emergency room.
Intravenous metoclopramide was given within 10 minutes after the capsule was swallowed. Images were evaluated in real-time at the bedside and then again later after download. Patients with positive findings received endoscopic treatment within 6 hours, whereas those without bleeding and control subjects underwent endoscopic assessment within 24 hours.
Seven of the 12 patients in the capsule endoscopy group had positive findings. In all, seven stigmata of bleeding were confirmed at endoscopy. In 6 of the 7, the actual lesion was identified either during bedside image viewing or upon download review, the researchers report.
Of the 5 patients with negative findings on capsule images, 4 had no bleeding stigmata at endoscopy and 1 had comorbidities that precluded endoscopy. Capsule endoscopy-positive patients had a significantly shorter time to endoscopy than did controls: 2.5 vs. 8.9 hours (p = 0.029).
No patient died, and blood transfusion requirements and length of stay were comparable in the two groups. A capsule was retained in one patient with a strictured esophagus, but it was retrieved with endoscopy.
"We need to validate these findings in a larger trial that we are planning," Dr. Rubin said. "In a follow up study, we will use capsule endoscopy to segregate high-risk patients who need urgent intervention from low-risk patients who can potentially be treated more conservatively, and then assess outcomes."
3. ED Waiting Times Increasing in US
Percentage of US Emergency Department Patients Seen Within the Recommended Triage Time: 1997 to 2006
Horwitz LI, et al. Arch Intern Med. 2009;169:1857-1865.
Background The wait time to see a physician in US emergency departments (EDs) is increasing and may differentially affect patients with varied insurance status and racial/ethnic backgrounds.
Methods Using a stratified random sampling of 151 999 visits, representing 539 million ED visits from 1997 to 2006, we examined trends in the percentage of patients seen within the triage target time by triage category (emergent, urgent, semiurgent, and nonurgent), payer type, and race/ethnicity.
Results The percentage of patients seen within the triage target time declined a mean of 0.8% per year, from 80.0% in 1997 to 75.9% in 2006 (P less than .001). The percentage of patients seen within the triage target time declined 2.3% per year for emergent patients (59.2% to 48.0%; P less than .001) compared with 0.7% per year for semiurgent patients (90.6% to 84.7%; P less than .001). In 2006, the adjusted odds of being seen within the triage target time were 30% lower than in 1997 (odds ratio, 0.70; 95% confidence interval, 0.55-0.89). The adjusted odds of being seen within the triage target time were 87% lower (odds ratio, 0.13; 95% confidence interval, 0.11-0.15) for emergent patients compared with semiurgent patients. Patients of each payment type experienced similar decreases in the percentage seen within the triage target over time (P for interaction = .24), as did patients of each racial/ethnic group (P = .05).
Conclusions The percentage of patients in the ED who are seen by a physician within the time recommended at triage has been steadily declining and is at its lowest point in at least 10 years. Of all patients in the ED, the most emergent are the least likely to be seen within the triage target time. Patients of all racial/ethnic backgrounds and payer types have been similarly affected.
4. Ultrasound Detects Central Line Placement and Postprocedure Pneumothorax
Chest x-ray missed 2 of 4 pneumothoraces and 1 of 25 misplaced catheter tips that were detected by bedside ultrasound.
Vezzani A et al. Crit Care Med 2009 Oct 12.
Objective: To determine the usefulness of ultrasound to evaluate central venous catheter misplacements and detection of pneumothorax, thus obviating postprocedural radiograph. After the insertion of a central venous catheter, chest radiograph is usually obtained to ensure correct positioning of the catheter tip and detect postprocedural complications.
Measurements and Main Results: A prospective study of 111 consecutive central venous catheter procedures, using a landmark technique, was conducted in an adult intensive care unit. At the end of the procedure, a B-mode ultrasonography was first performed to assess catheter position and detect pneumothorax. Then, contrast enhanced ultrasonography was used to facilitate visualization of catheter tip, avoiding unknown right atrium positioning or artifacts. A postprocedural chest radiograph was obtained for all patients and was considered as a reference technique. Right atrium positioning was detected in 19 patients by ultrasonography, and an additional six by contrast enhanced ultrasonography. Combining ultrasonography and contrast enhanced ultrasonography yielded a 96% sensitivity and 93% specificity in detecting catheter misplacement. Concordance was 95% and [kappa] value was 0.88 (p less than .001). Pneumothorax was detected in four patients by ultrasonography and in two by chest radiograph (concordance = 98%). The mean time required to perform ultrasonography plus contrast enhanced ultrasonography was 10 +/- 5 mins vs. 83 +/- 79 mins for chest radiograph (p less than .05).
Conclusions: The close concordance between ultrasonography plus contrast enhanced ultrasonography and chest radiograph justifies the use of sonography as a standard technique to ensure the correct positioning of the catheter tip and to detect pneumothorax after central venous catheter cannulation to optimize use of hospital resources and minimize time consumption and radiation. Chest radiograph will be necessary when sonographic examination is impossible to perform by technical limitations.
5. Updated Guidelines for the Care of Children in EDs
This joint policy statement provides a highly useful roadmap for standardizing emergency care of children in community EDs.
American Academy of Pediatrics et al. Pediatrics 2009;124:1233-1243.
Full-text (free): http://pediatrics.aappublications.org/cgi/content/full/124/4/1233
6. Cervical Collar, Physical Therapy, or "Wait and See" for Recent-Onset Cervical Radiculopathy?
Pain scores were significantly lower in the collar and physical therapy groups.
Kuijper B et al. BMJ 2009 Oct 7; 339:b3883.
Full-text: http://www.bmj.com/cgi/content/full/339/oct07_1/b3883
7. A Comparison of Parental and Nursing Assessments of Level of Illness or Injury in a Pediatric Emergency Department
Kestner V, et al., Pediatric Emergency Care. 2009;25:633-635.
Background: The 5-tier Emergency Severity Index (ESI) score is a well-accepted, validated triage tool with good interrater reliability. Parental perception of illness severity has not been compared to ESI score.
Objective: This study compares parental assessment of severity of illness to triage nurse acuity.
Design: Prospective and descriptive.
Setting: Large, urban pediatric emergency department (ED).
Participants: Parents/guardians of patients younger than 18 years.
Intervention: The triage nurse assigned an ESI score, and the parent/guardian assigned all patients a severity score on a scale of 1 to 5 (1, most sick and 5, least sick). Mean severity scores were compared between the groups.
Results: There were 142 participants with a mean patient age of 6.15 years. The mean participant and nurse severity scores were 3.01 and 3.35, respectively, with an intraclass correlation coefficient of 0.203 (P = 0.008). Most frequently, the parent/guardian and triage nurse assigned the same score (n = 44, 31%). Seventy-six percent of the parent/guardian scores were within 1 point of the triage nurse score.
Conclusions: Close agreement exists between parent/guardian and nurse ESI scores, illustrating objectivity in parent/guardian assessments. This study provides a springboard for future studies regarding ED use after educating families on ED triage.
8. Interobserver agreement in the interpretation of computed tomography in acute pulmonary embolism
Costantino G, Amer J Emerg Med. 2009;27:1109-1111.
Multidetector computed tomography (MDCT) is one of the best diagnostic tools for the diagnosis of pulmonary embolism (PE). However, differences in MDCT interpretation, depending on the operator personal expertise, is an important factor that could interfere with the right diagnosis and, consequently, with the more adequate and well-timed therapy.
The aim of the present study was to evaluate the interobserver agreement in the interpretation of MDCT for the diagnosis of acute PE.
On a blind basis, 4 radiologists with different expertise in CT interpretation evaluated 46 different MDCT executed for acute PE. They had to verify the presence or absence of PE and, in the positive case, localize (right-left) and quantify (massive, segmentarian or subsegmentarian) it. The interobserver concordance was expressed using the Cohen K statistic.
The mean concordance between the 4 operators was high (0.82; range, 0.68-0.95). Ruling out the massive PE cases, the mean concordance over the other cases was only moderate (0.47; range, 0.16-0.84).
We found a very good interobserver agreement in MDCT evaluation for the diagnosis of massive PE, whereas we observed a lower concordance in regard to segmentarian and subsegmentarian PE. In the case of negative or nonmassive PE diagnosis, a second evaluation of the CT performed by an expert CT radiologist would probably be effective to decrease the CT evaluation error.
9. Compress the Chest: Better CPR Improves Survival from Out-of-Hospital Cardiac Arrest
Implementation of the 2005 AHA CPR guidelines that focus on uninterrupted chest compressions nearly doubled the odds of survival among patients with out-of-hospital cardiac arrest.
In 2005, the American Heart Association (AHA) released updated evidence-based guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, but does adherence to the revised protocol improve outcomes? Investigators compared rates of survival from out-of-hospital cardiac arrest among 606 adult patients treated before and 1021 treated after implementation of the 2005 AHA guidelines in a single large emergency medical services system.
Review of a convenience sample of 69 electronic electrocardiogram recordings showed significant improvement in CPR quality after guideline implementation, including improvements in mean chest-compression rate, proportion of time that patients received chest compressions, and median preshock and postshock pause times for compressions. Unadjusted rates of survival to hospital discharge were significantly higher after implementation of the guidelines than before (9.4% vs. 6.1%). Among patients with witnessed arrest whose initial rhythm was ventricular fibrillation on EMS arrival, survival rates improved significantly from 24% (19 of 78) before implementation to 30% (34 of 112) after. Multivariate regression analysis that adjusted for initial rhythm, sex, arrest location, and witnessed arrest showed 1.8 greater odds of survival in the postintervention period.
Comment: The promising results of this large study suggest the AHA was on the right track with its renewed focus on basic CPR, including the importance of providing uninterrupted chest compressions.
— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine October 23, 2009. Citation: Sayre MR et al. Impact of the 2005 American Heart Association cardiopulmonary resuscitation and emergency cardiovascular care guidelines on out-of-hospital cardiac arrest survival. Prehosp Emerg Care 2009;13:469.
10. Methohexital Beats Pentobarbital for Head CT Sedation in Children
Chun TH et al. Pediatr Emerg Care 2009 Oct; 25:648.
Objectives: To determine if there are differences in the duration of sedation between pediatric emergency department (PED) patients receiving methohexital and PED patients receiving pentobarbital for the purpose of obtaining a head computed tomographic (CT) scan.
Methods: Retrospective cohort study of PED patients receiving either methohexital or pentobarbital for a sedated head CT. Data were collected on patient demographics and medical condition, indications for head CT, duration of sedation, medication dosage, and medication adverse events. Primary analyses investigated whether there were differences between the 2 groups. Secondary analysis determined whether the need for additional sedative doses contributed to observed differences between groups.
Results: The patients receiving methohexital completed their head CT more quickly and needed less total sedation monitoring than those receiving pentobarbital. The need for additional doses of medication does not appear to be responsible for the observed difference. Adverse medication events were minor and comparable between groups.
Conclusions: Methohexital may be superior to pentobarbital for the purpose of sedating PED patients for head CT.
11. Anticholinergic Drugs and Acute Urinary Retention
Risk is highest during the first several weeks of treatment.
Martín-Merino E et al. J Urol 2009 Oct; 182:1442.
Abstract: http://www.jurology.com/article/S0022-5347(09)01525-0/abstract
12. Doctors' Lack of Respect Weighs on the Obese
October 29, 2009 — Heavier patients get less respect from doctors, raising concerns about the impact on the quality of care, new research indicates.
Scientists reporting in the November issue of the Journal of General Internal Medicine say they found that the higher a patient’s body mass index (BMI), the less respect their doctors had for them.
Mary Margaret Huizinga, MD, MPH, of Johns Hopkins University School of Medicine and lead author of the study, says she came up with the idea for the research from her experiences working in a weight loss clinic.
She says that patients who'd visit would, by the time they left, “be in tears, saying 'no other physician talked with me like this before,'" and had failed to listen.
“Many patients felt like because they were overweight, they weren’t receiving the type of care other patients received,” she says in a news release.
She and colleagues looked at data on 238 patients and 40 physicians. The average BMI of the patients was 32.9.
A person with a BMI of 25 to 29.9 is considered overweight, and 30 or greater obese.
In the study, patients and physicians filled out questionnaires about a doctor’s visit. They were asked questions about their attitudes and perceptions of one another at the end of their encounter. Physicians were asked to rate the level of respect they had for each patient compared to “the average patient” on a 5-point scale.
The patients for whom doctors expressed low respect, on average, had a higher BMI than patients for whom the physicians had high respect, the researchers report. The researchers note that the findings don’t show a cause/effect relationship between BMI and physician respect. Their study also didn’t investigate patients’ health outcomes.
Huizinga writes that respect is critical because some patients may avoid the health care system altogether. In other research, physician respect has been linked to more information being provided by the physician during a patient visit. She says more research is needed “to really understand how physician attitudes toward obesity affect quality of care for those patients."
“If a doctor has a patient with obesity and has low respect for that person, is the doctor less likely to recommend certain types of weight loss programs or to send her for cancer screening?” Huizinger asks. “We need to understand these things better.”
SOURCES: News release, Johns Hopkins University School of Medicine.
Huizinga, M., Journal of General Internal Medicine, November 2009.
13. Divorce Risk Higher When Wife Gets Sick
By TARA PARKER-POPE. NY Times. Nov 12, 2009.
When Dr. Marc Chamberlain, a Seattle oncologist, was treating his brain cancer patients, he noticed an alarming pattern. His male patients were typically receiving much-needed support from their wives. But a number of his female patients were going it alone, ending up separated or divorced after receiving a brain tumor diagnosis.
Dr. Chamberlain, chief of the neuro-oncology division at the Fred Hutchinson Cancer Research Center, had heard similar stories from his colleagues. To find out if these observations were based in fact, he embarked on a study with Dr. Michael J. Glantz of the University of Utah Huntsman Cancer Institute and colleagues from three other institutions who began to collect data on 515 patients who received diagnoses of brain tumors or multiple sclerosis from 2001 through 2006.
The results were surprising. Women in the study who were told they had a serious illness were seven times as likely to become separated or divorced than men with similar health problems, according to the report published in the journal Cancer.
The remainder of the NY Times article: http://well.blogs.nytimes.com/2009/11/12/men-more-likely-to-leave-spouse-with-cancer/
The abstract of the study: http://www3.interscience.wiley.com/journal/122527377/abstract
14. Intranasal Naloxone Is Effective for Opioid Overdose
Time from patient contact to clinical response was the same with intranasal and intravenous naloxone.
Robertson TM, et al. Prehospital Emerg Care 2009;13:512-515.
Objective. To compare the prehospital time intervals from patient contact and medication administration to clinical response for intranasal (IN) versus intravenous (IV) naloxone in patients with suspected narcotic overdose.
Methods. This was a retrospective review of emergency medical services (EMS) and hospital records, before and after implementation of a protocol for administration of intranasal naloxone by the Central California EMS Agency. We included patients with suspected narcotic overdose treated in the prehospital setting over 17 months, between March 2003 and July 2004. Paramedics documented dose, route of administration, and positive response times using an electronic record. Clinical response was defined as an increase in respiratory rate (breaths/min) or Glasgow Coma Scale score of at least 6. Main outcome variables included time from medication to clinical response and time from patient contact to clinical response. Secondary variables included numbers of doses administered and rescue doses given by an alternate route. Between-group comparisons were accomplished using t-tests and chi-square tests as appropriate.
Results. One hundred fifty-four patients met the inclusion criteria, including 104 treated with IV and 50 treated with IN naloxone. Clinical response was noted in 33 (66%) and 58 (56%) of the IN and IV groups, respectively (p = 0.3). The mean time between naloxone administration and clinical response was longer for the IN group (12.9 vs. 8.1 min, p = 0.02). However, the mean times from patient contact to clinical response were not significantly different between the IN and IV groups (20.3 vs. 20.7 min, p = 0.9). More patients in the IN group received two doses of naloxone (34% vs. 18%, p = 0.05), and three patients in the IN group received a subsequent dose of IV or IM naloxone.
Conclusions. The time from dose administration to clinical response for naloxone was longer for the IN route, but the overall time from patient contact to response was the same for the IV and IN routes. Given the difficulty and potential hazards in obtaining IV access in many patients with narcotic overdose, IN naloxone appears to be a useful and potentially safer alternative.
15. Subarachnoid Hemorrhage Might Be a Common Cause of Out-of-Hospital Cardiac Arrest
In this Japanese study, 16% of survivors of out-of-hospital cardiac arrest had subarachnoid hemorrhage.
Inamasu J, et al. Resuscitation 2009;80:977-980.
Aim
Aneurysmal subarachnoid haemorrhage (SAH) is a relatively common cause of out-of-hospital cardiac arrest (OHCA). Early identification of SAH-induced OHCA with the use of brain computed tomography (CT) scan obtained immediately after resuscitation may help emergency physicians make therapeutic decision as quickly as they can.
Methods
During the 4-year observation period, brain CT scan was obtained prospectively in 142 witnessed non-traumatic OHCA survivors who remained haemodynamically stable after resuscitation. Demographics and clinical characteristics of SAH-induced OHCA survivors were compared with those with “negative” CT finding.
Results
Brain CT scan was feasible with an average door-to-CT time of 40.0min. SAH was found in 16.2% of the 142 OHCA survivors. Compared with 116 survivors who were negative for SAH, SAH-induced OHCA survivors were significantly more likely to be female, to have experienced a sudden headache, and trended to have achieved return of spontaneous circulation (ROSC) prior to arrival in the emergency department less frequently. Ventricular fibrillation (VF) was significantly less likely to be seen in SAH-induced than SAH-negative OHCA (OR, 0.06; 95% CI, 0.01–0.46). Similarly, Cardiac Trop-T assay was significantly less likely to be positive in SAH-induced OHCA (OR, 0.08; 95% CI, 0.01–0.61).
Conclusion
Aneurysmal SAH causes OHCA more frequently than had been believed. Immediate brain CT scan may particularly be useful in excluding SAH-induced OHCA from thrombolytic trial enrollment, for whom the use of thrombolytics is contraindicated. The low VF incidence suggests that VF by itself may not be a common cause of SAH-induced OHCA.
16. Combination of epinephrine and dexamethasone may reduce hospitalization in children with bronchiolitis
Frohna JG, et al. J Pediatrics 2009;155:761-762.
Commentary
Identifying effective treatments for children with bronchiolitis has proven elusive. In part, this is due to the heterogenous cause of wheezing, which can range from episodic wheezing (often caused by viral infections) to multifactorial wheezing that can be triggered by a variety of factors and often resulting in asthma. A meta-analysis showed limited short-term benefit from epinephrine, and it is well known that children with asthma respond to corticosteroids. Plint et al were surprised to find a synergistic effect between epinephrine and dexamethasone, which reduced the frequency of hospitalization for children in this study. In addition, there are likely many factors that influence the decision to hospitalize a child, such as the distance to the hospital, the ability of the parents to care for their ill child, and the availability of health care resources. While a number needed to treat of 11 to prevent 1 hospitalization might be appealing, there are several caveats to these results. First, the dose of corticosteroids used in this study is quite high, and there is still limited knowledge of potential risks associated with this treatment. Second, when the authors adjusted their results for the multiple comparisons that were made, the difference in hospitalization was no longer statistically significant. One area of future research would be to look at the subgroups of infants who respond better to corticosteroids and look for possible biomarkers that may even include virus identification techniques. Although we await follow-up studies to provide stronger evidence, it is prudent to provide supportive care and close monitoring for children with an initial episode of wheezing. Monitoring these infants in the general pediatrician's office does not require high-tech medicine—just some relatively straightforward clinical algorithims.
Full-text: http://www.jpeds.com/article/S0022-3476(09)00862-2/fulltext
17. The Oblique View: An Alternative Approach for Ultrasound-Guided Central Line Placement
Phelan M, et al. Amer J Emerg Med. 2009;37:403-408.
Background: Numerous studies have shown significant benefits of using real-time ultrasonography for central line intravenous access. Traditionally, the ultrasound probe is placed along the short axis of the vein to visualize and direct needle placement. This view has some limitations, particularly being able to visualize the needle tip. Some practitioners place the ultrasound probe in the long axis of the vessel to direct needle placement, allowing better visualization of the needle entering the vein, but this does not allow visualization of relevant anatomic structures.
Objectives: We describe an alternative means to obtain ultrasound-guided vascular access using an oblique axis rather than the traditional short-axis approach.
Discussion: This view allows better visualization of the needle shaft and tip but also offers the safety of being able to visualize all relevant anatomically significant structures at the same time and in the same plane. This orientation is halfway between the short and long axis of the vessel, allowing visualization of the needle as it enters the vessel. This capitalizes on the strengths of the long axis while optimizing short-axis visualization of important structures during intravenous line placement.
Conclusion: Ultrasound-guided vascular access can be obtained in a variety of ways. We describe a technique that is used by some experienced ultrasound users but that has never been fully described in the literature. This technique for obtaining ultrasound-guided vascular access offers another option for attempting ultrasound-guided vascular access that has the potential to improve success rates and minimize complications associated with intravenous access.
18. CT-STAT: CT Angiography Rules Out CAD Faster and Cheaper Than Standard Care
Michael O'Riordan. November 18, 2009 (Orlando, Florida) — The use of coronary computed tomography (CT) angiography in the emergency room can successfully triage at-risk chest-pain patients and can do so faster and less expensively than standard diagnostic testing, according to the results of a new study.
"I think the reassurance is that both strategies are very safe," said lead investigator Dr James Goldstein (William Beaumont Hospital, Royal Oak, MI). "We've chosen a chosen a low-risk population--we don't want anybody to go home with a heart attack. We already know that the standard of care is a very fine strategy, and we've gotten very good at evaluating chest pain, but it is cumbersome and expensive."
Although the use of CT to rule out coronary artery disease should not be used in all patients, especially those with manifest ischemia, electrocardiogram abnormalities, or elevations in enzymatic biomarkers, among low-risk patients, "wisely and prudently applied," CT angiography is a powerful addition to the armamentarium of clinicians, said Goldstein.
The results of the study, known as the Computed Tomographic Angiography for the Systematic Triage of Acute Chest Pain Patients to Treatment (CT-STAT) trial, were presented today at the American Heart Association 2009 Scientific Sessions.
The remainder of the essay: http://www.medscape.com/viewarticle/712673
19. Prophylactic Acetaminophen Blunts Immunogenicity of Childhood Vaccinations
Routine prophylactic use of acetaminophen at the time of childhood immunizations should be reconsidered.
Prymula R et al. Lancet 2009; 374:1339.
Abstract: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61208-3/abstract
20. Kubler-Ross’ Stages of Grief: Maybe Not so Cut-and-Dried
In 1969 the psychiatrist Elizabeth Kubler-Ross wrote one of the most influential books in the history of psychology, On Death and Dying. It exposed the heartless treatment of terminally-ill patients prevalent at the time. On the positive side, it altered the care and treatment of dying people. On the negative side, it postulated the now-infamous five stages of dying—Denial, Anger, Bargaining, Depression, and Acceptance (DABDA), so annealed in culture that most people can recite them by heart. The stages allegedly represent what a dying person might experience upon learning he or she had a terminal illness. “Might” is the operative word, because Kübler-Ross repeatedly stipulated that a dying person might not go through all five stages, nor would they necessarily go through them in sequence. It would be reasonable to ask: if these conditions are this arbitrary, can they truly be called stages?
Many people have contested the validity of the stages of dying, but here we are more concerned with the supposed stages of grief which derived from the stages of dying. As professional grief recovery specialists, we contend that the theory of the stages of grief has done more harm than good to grieving people. Having co-authored three books on the impact of death, divorce, and other losses, and having worked directly with over 100,000 grieving people during the past 30 years, our reasons for disputing the stages of grief theory are predicated on the horror stories we’ve heard from thousands of grieving people who’ve told us how they’d been harmed by them.
Friedman R, et al. The Myth of the Stages of Dying, Death and Grief. Skeptic. 2008;13:37-41.
Full-text: http://www.grief.net/Articles/Myth%20of%20Stages.pdf
Sunday, November 22, 2009
Wednesday, October 28, 2009
Lit Bits: Oct 28, 2009
From the recent medical literature...
1. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial
Jabre P, et al. Lancet. 2009;374(9686):293-300.
Introduction
Critically ill patients often require emergency orotracheal intubation for airway control. Rapid sequence intubation with administration of a sedative and a paralytic agent is common. Etomidate is the sedative-hypnotic drug that is most often used in rapid sequence intubation, but its use has been challenged because it can cause a reversible adrenal insufficiency by dose-dependent inhibition of 11β-hydroxylase.
Several studies have suggested an association between the use of etomidate and the occurrence of adrenal insufficiency and increased morbidity in critically ill or injured patients, particularly in those with sepsis. Because adrenal insufficiency when a patient is critically ill can increase the risk of death, several investigators have advised against the use of etomidate, even as a single bolus.9 However, no causal link has been established between its use and an increase in morbidity and mortality.
Etomidate's haemodynamic tolerance, even in patients with shock, and the excellent intubation conditions provided have to be weighed against potential adverse effects, including adrenal insufficiency. A possible alternative to etomidate is ketamine, which is not known to inhibit the adrenal axis. The aim of this randomised controlled study was to compare early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients.
Abstract
BACKGROUND: Critically ill patients often require emergency intubation. The use of etomidate as the sedative agent in this context has been challenged because it might cause a reversible adrenal insufficiency, potentially associated with increased in-hospital morbidity. We compared early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients.
METHODS: In this randomised, controlled, single-blind trial, 655 patients who needed sedation for emergency intubation were prospectively enrolled from 12 emergency medical services or emergency departments and 65 intensive care units in France. Patients were randomly assigned by a computerised random-number generator list to receive 0.3 mg/kg of etomidate (n=328) or 2 mg/kg of ketamine (n=327) for intubation. Only the emergency physician enrolling patients was aware of group assignment. The primary endpoint was the maximum score of the sequential organ failure assessment during the first 3 days in the intensive care unit. We excluded from the analysis patients who died before reaching the hospital or those discharged from the intensive care unit before 3 days (modified intention to treat). This trial is registered with ClinicalTrials.gov, number NCT00440102.
FINDINGS: 234 patients were analysed in the etomidate group and 235 in the ketamine group. The mean maximum SOFA score between the two groups did not differ significantly (10.3 [SD 3.7] for etomidate vs 9.6 [3.9] for ketamine; mean difference 0.7 [95% CI 0.0-1.4], p=0.056). Intubation conditions did not differ significantly between the two groups (median intubation difficulty score 1 [IQR 0-3] in both groups; p=0.70). The percentage of patients with adrenal insufficiency was significantly higher in the etomidate group than in the ketamine group (OR 6.7, 3.5-12.7). We recorded no serious adverse events with either study drug.
INTERPRETATION: Our results show that ketamine is a safe and valuable alternative to etomidate for endotracheal intubation in critically ill patients, and should be considered in those with sepsis.
FUNDING: French Ministry of Health.
Discussion
Our study shows that one etomidate bolus is not associated with a significant increase in morbidity or mortality compared with ketamine in patients admitted to the intensive care unit. The maximum SOFA score did not differ significantly between the two drugs in the subgroup of patients having sepsis or trauma. However, for the subgroup of septic patients (n=76), the small number of patients might account for the absence of significant difference. The mortality rate at day 28 in this subgroup did not differ between the treatment groups.
An association between the administration of etomidate and an increased mortality of patients with sepsis has been suggested previously. In a retrospective study of children with meningococcal sepsis or shock, mortality rate was 30% in patients who received etomidate versus 12% in those who did not, but the difference was not significant (OR 3•1 [95% CI 0•3–79•3]). In a post-hoc analysis of the Corticus study undertaken in patients with severe sepsis, the 28-day mortality rate was significantly higher in patients who received etomidate than in those who did not (p=0•03). The investigators, however, did not draw any cause and effect conclusion, presumably because of the lack of randomisation to sedative agents.
By contrast with the substantial increase in mortality reported by Ledingham and Watts, etomidate did not affect outcome in trauma patients in our study. This discrepancy between the two studies is probably related to the duration of etomidate administration: one bolus in our study versus prolonged sedation in Ledingham and Watts' study. Hildreth and co-workers reported increased use of blood products, ventilator days, and days in intensive care in trauma patients randomly assigned to etomidate (n=18) versus midazolam (n=12), but reported no difference in mortality. However, interpretation of this study is difficult because half of the eligible patients were excluded, with 11 of 31 patients having received etomidate.
Although adrenal axis dysfunction arises to some extent after etomidate use for rapid sequence intubation, the effect of such adrenal suppression on patients' outcome remains debated. Studies have reported increased mortality in non-responders to the adrenocorticotropin hormone stimulation test and in patients with adrenal insufficiency. One bolus of etomidate decreases cortisol secretion, which contributed to the increased morbidity and mortality reported in several studies. However, these findings have not been confirmed by other investigators. Clearly, the results of these studies could be biased owing to the presence of multiple confounding factors.
Our study confirms the finding of others that etomidate affects the adrenal axis: according to our criteria, more than four-fifths of etomidate recipients had adrenal insufficiency and were non-responders to the adrenocorticotropin hormone stimulation test. About half of patients given ketamine also had adrenal insufficiency, which emphasises that critical illness per se affects adrenal function. In one study, more than 30% of non-responders had not been exposed to etomidate, and in another, 51% of patients with septic shock who had not received etomidate were non-responders. Indeed, multiple mechanisms could account for adrenal insufficiency in critically ill patients. Adrenal insufficiency is probably associated with increased mortality in critically ill patients, including those with sepsis; however, whether the adrenal axis suppression and mortality are the result of some underlying process, or whether the adrenal axis suppression causes death, has never been established. Among established independent predictors of low cortisol response to adrenocorticotropin hormone stimulation are a low pH or bicarbonate and platelet count, disease severity, and organ failure. Fentanyl or sufentanil infusion can also modify cortisol concentrations. However, these factors should not affect the results of our study since both patient groups received the same type of continuous sedation (fentanyl or sufentanil combined with midazolam).
Etomidate is the sedative-hypnotic drug most often used by emergency physicians for rapid sequence intubation, and is the drug of choice for patients who are haemodynamically unstable. Use of ketamine instead of etomidate might have drawn attention to potential adverse effects of the use of ketamine during the intubation procedure. The most common side-effects of ketamine are psychodysleptic effects, but they could not be observed because, unlike in an operating theatre, patients are not awakened until several hours after intubation. We noted no difference between the sedative drugs tested in our study on the ease of intubation, probably because intubation conditions depend mostly on the muscle relaxant effects of succinylcholine. Accordingly, Sivilotti and Ducharme reported no significant difference in the overall successful intubation in a comparison of three hypnotic drugs.
With regard to the strengths and limitations of our study, we have confirmed the appropriateness of the choice of the maximum SOFA score as the primary endpoint. There is an established relation between the maximum SOFA score and Δ-SOFA score (from maximum to admission) and mortality in patients who are critically ill. Moreover, measurement of the SOFA score has good reliability and accuracy among intensivists. These scores have shown its usefulness in the assessment of in-hospital morbidity in seriously ill patients.
However, our study might not have had sufficient power to show a significant increase in morbidity related to the use of etomidate in patients with sepsis. Our failure to enroll and analyse a larger number of patients with sepsis could have led to a type-II error for this group. A future study should be based on patients with sepsis only, since the controversy regarding the use of etomidate focuses on these patients. We felt that patients admitted with trauma were important to study as well because of suggestions from recent reports that etomidate might be harmful to this group of patients. In conclusion, our results show that ketamine is a safe and valuable alternative to etomidate for intubation in critically ill patients, particularly in septic patients.
2. Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients
Chang AM, et al. Amer J Emerg Med. 2009;27:916-921.
Objective
Guidelines recommend treating patients with a new or presumed new left bundle-branch block (LBBB) similar to those with an acute ST-segment elevation myocardial infarction. It is often unclear which emergency department (ED) patients with potentially ischemic symptoms actually have an acute myocardial infarction (AMI), even in the setting of LBBB. Our null hypothesis was that in ED patients with potential AMI, the presence of a new or presumed new LBBB would not predict an increased likelihood of AMI.
Methods
This was an observational cohort study. Patients older than 30 years who presented with chest pain or other ischemic equivalent and had an electrocardiogram (ECG) to evaluate potential acute coronary syndrome (ACS) were enrolled. Data collected include demographics, history, ECG, and cardiac markers. Electrocardiograms were classified according to the standardized guidelines, including LBBB not known to be old (new or presumed new LBBB), LBBB known to be old, or no LBBB. The hospital course was followed, and 30-day follow-up was performed on all patients. Our main outcome was AMI.
Results
There were 7937 visits (mean age, 54.3 ± 15 years, 57% female, 68% black): 55 had new or presumed new LBBB, 136 had old LBBB, and 7746 had no LBBB. The rate of AMI was not significantly different between the 3 groups (7.3% vs 5.2% vs 6.1%; P = .75). Revascularization (7.8% vs old 5.2% vs 4.3%; P = .04) and coronary artery disease were more common in patients with new or presumed new LBBB (19.2% vs 11.9% vs 10.1%; P = .0004).
Conclusions
Despite guideline recommendations that patients with potential ACS and new or presumed new LBBB should be treated similar to STEMI, ED patients with a new or presumed new LBBB are not at increased risk of AMI. In fact, the presence of LBBB, whether new or old, did not predict AMI. Caution should be used in applying recommendations derived from patients with definite AMI to ED patients with potential ACS that may or may not be sustaining an AMI.
3. Recent-onset A Fibbers in the ED: Cardiovert?
Stead LG, et al. Rhythm Control With Electrocardioversion for Atrial Fibrillation and Flutter. Ann Emerg Med. 2009;54:745-747.
This review provides little evidence on which emergency physicians can base decisions about patients with acute atrial fibrillation. Because the majority of symptomatic patients encountered in the ED have atrial fibrillation of less than 48 hours’ duration and the risk of stroke and other complications in such patients is low, current practice remains cardioversion (electrical or medical) as soon as possible. In older patients with sustained atrial fibrillation, referral for cardioversion may be warranted for quality of life considerations; however, stroke prevention must be an integral
component of pre- and postcardioversion management to reduce the risk of embolic stroke.
Full-text (free): http://download.journals.elsevierhealth.com/pdfs/journals/0196-0644/PIIS0196064408020866.pdf
4. Arranging Follow-up Appointments for your Discharged Patients
Vinson DR, Patel PB. Facilitating follow-up after emergency care using an appointment assignment system. J Healthcare Quality. 2009; 31:18-24.
Many emergency department patients require urgent follow-up in primary care. The most effective way to help patients obtain their needed after-visit care is to secure the appointment on their behalf prior to their departure from the ED. This study describes the development, implementation, and outcomes of an appointment assignment system that facilitates patient follow-up at two community hospitals in an integrated healthcare system. This patient-centered system resulted in a high rate of compliance and a very low rate of unscheduled ED recidivism. Improving access in this manner will likely strengthen the continuum of care, improve quality, and increase patient satisfaction.
Full-text (free) available from the authors: drvinson@ucdavis.edu
5. Sleep-Deprived Attending Surgeons Have Higher Rates of Procedural Complications
Kathleen Louden. October 19, 2009 (Chicago, Illinois) — Attending surgeons who perform daytime surgical procedures within 6 hours of finishing an overnight shift have a nearly 3-fold higher rate of provider-related complications than when their opportunity for sleep between procedures exceeds 6 hours, a new study finds. The study was published in the October 14 issue of the Journal of the American Medical Association.
Until now, little was known about the effects of long work shifts and limited sleep opportunity on the performance of attending physicians, said lead author Jeffrey Rothschild, MD, MPH, a surgeon at Brigham and Women's Hospital and an assistant professor of medicine at Harvard Medical School in Boston, Massachusetts.
"Attendings who perform emergency overnight procedures . . . often perform elective procedures the next day," said Dr. Rothschild, who presented the results at a media briefing held to release new research on surgical care.
"Our data suggest that attending physicians, like residents and nurses, may be at increased risk of making errors when sleep-deprived or working extended shifts," he said.
The authors studied the outcomes of 919 "postnighttime" procedures performed by 86 attending surgeons over an 8-year period. The definition of a postnighttime procedure was one performed in the operating room the day after at least 1 operative case between midnight and 6 am. Dr. Rothschild's team compared outcomes of postnighttime procedures with those of 3552 control procedures, which were the same or similar procedures performed by the same 86 surgeons when they had not worked the previous night, within 12 months of the other procedures. Of the 86 surgeons, 32 were general surgeons. Their mean length of experience was 14 years.
Working Late Does Not Increase Next-Day Complications
Dr. Rothschild and colleagues found that the overall rate of complications — intraoperative adverse events likely attributable to the surgeon — did not significantly differ between postnighttime and control procedures. The complication rate was 7.5% in the postnighttime group and 7.8% in the control group. Likewise, the duration of the extended work shift did not have a statistically significant effect on the complication rate.
It was only when the investigators looked at the data by length of sleep opportunity — the time between the end of the last overnight case and the beginning of the first case later that day — that they observed a significant difference in the frequency of complications. When surgeons in the postnighttime group got 6 hours or less of sleep opportunity, there was a 2.7-fold increase in the rate of complications, compared with a longer time between shifts in the same group, Dr. Rothschild said. The difference between that 8.5% complication rate and the 3.1% rate for surgeons whose sleep opportunity was more than 6 hours was significant (P = .03), the authors write.
Actual sleep time was likely to be far shorter than sleep opportunity, owing to the need to change clothes and travel home, Dr. Rothschild noted.
Most of the complications that occurred were preventable, the authors report. The most frequent complications for both groups, according to Dr. Rothschild, were organ injury, bleeding, and infections.
Based on their findings, he said that "a limitless work week for attending physicians is not optimal for patient care."
Self-Regulation Needed
Unlike resident physicians, attending physicians in the United States have no restrictions on the number of hours they can work. Dr. Rothschild did not think that attendings' work hours would become federally regulated. Instead, he recommended strategies that surgeons can take to reduce complications due to fatigue.
"Surgeons can try to avoid scheduling elective surgeries the day after they take emergency call, or at least when risks are high for the elective procedure. And, if possible, they should use back-up personnel to assist when they are fatigued."
A limitation of the study, according to Dr. Rothschild, is that the investigators did not know the surgeons' sleep practices the night before control procedures. "Some physicians could have worked overnight at other hospitals," he explained. Also, the findings might not apply to nonteaching hospitals, he observed.
Although the study included data from only 1 center, it raised the profile of a common problem, said Phil Fontanarosa, MD, MBA, executive deputy editor of JAMA. "More awareness is needed about this problem among attending physicians, because all the focus [of fatigue contributing to medical errors] has been on residents," Dr. Fontanarosa told Medscape General Surgery.
JAMA. 2009;302:1565-1572.
6. Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment: U.S. Preventive Services Task Force Says “Don’t Bother”
Ann Intern Med. 2009;151:474-482.
The U.S. Preventive Services Task Force (USPSTF) has issued a recommendation statement on the use of 9 nontraditional risk factors (high-sensitivity C-reactive protein [CRP], ankle–brachial index, leukocyte count, fasting blood glucose level, periodontal disease, carotid intima–media thickness, coronary artery calcification on electron-beam computed tomography, homocysteine level, and lipoprotein[a] level) in assessing coronary heart disease (CHD) risk in asymptomatic persons. It concludes that the current evidence is insufficient to assess the balance of benefits and harms of using these nontraditional risk factors to screen asymptomatic men and women with no history of CHD to prevent CHD events (I statement).
Full-text (free): http://www.annals.org/cgi/content/full/151/7/474
7. Psychosocial Stress: Bad for your Heart
Milani RV, et al. Amer J Med. 2009;122:931-938.
Background
Exercise training reduces mortality in patients with coronary artery disease. Behavioral characteristics, including depression, hostility, and overall psychosocial stress, have been shown to be independent risk factors for recurrent myocardial infarction and death in these patients. Exercise training can reduce these high-risk behaviors, but it remains uncertain as to what extent the health benefits of exercise training can be attributed to improving these behaviors.
Methods
We evaluated the impact of exercise training during cardiac rehabilitation on mortality in 53 patients with coronary artery disease with high levels of psychosocial stress and in 469 patients with coronary artery disease with low levels of psychosocial stress and compared them with 27 control patients with high psychosocial stress who did not undergo formal cardiac rehabilitation and exercise training.
Results
Mortality was approximately 4-fold greater in patients with high psychosocial stress than in those with low psychosocial stress (22% vs 5%; P = .003). Exercise training decreased the prevalence of psychosocial stress from 10% to 4% (P less than .0001) and similarly improved peak oxygen uptake in patients with high and low psychosocial stress. Mortality in patients who improved exercise capacity by greater than 10% (high exercise change) was 60% lower than in patients who had less than 10% improvement in exercise capacity (low exercise change) (P=.009). Mortality was lower in patients with high psychosocial stress with high exercise change compared with patients with high psychosocial stress with low exercise change (0% vs 19%; P=.009). In contrast, there was no significant improvement in mortality in patients with high versus low exercise change with low psychosocial stress (4% vs 8%; P=.14).
Conclusion
Psychosocial stress is an independent risk factor for mortality in patients with coronary artery disease, and exercise training can effectively reduce its prevalence. Exercise training reduces mortality in patients with coronary artery disease, and this effect seems to be mediated in part because of the salutary effects of exercise on psychosocial stress.
Full-text: http://www.amjmed.com/article/PIIS0002934309004392/fulltext
8. Urinalysis (without culture) is not reliable to detect UTI in febrile ED infants
Reardon JM, et al. Amer J Emerg Med. 2009;27:930-932.
Objective
Urinary tract infections are a common source of serious bacterial infections in febrile infants younger than 2 years. Our objective was to compare urinalysis with urine culture in the emergency department evaluation of febrile infants.
Methods
A febrile infant registry was instituted at a tertiary care hospital treating an average of 55000 patients annually (27% children), from December 2002 to December 2003. Patients were eligible if they were younger than 3 months and had a temperature of at least 38°C or if they were between 3 and 24 months of age and had a temperature of at least 39°C. Data abstracted included age, sex, and temperature. Urinalysis (UA) and urine culture (UCx) results were obtained from electronic hospital archives.
Results
Nine hundred eighty-five patients were entered into the febrile infant registry. Male patients comprised 55%. The mean age of patients was 12.6 months; median was 12 months. Four hundred thirty-five (78% of eligible patients) had both a UA and UCx from the same specimen, and there were 45 (10.3%) positive UCx result. Females accounted for 33 (73%) of 45 positive results. The sensitivity of UA for predicting a positive UCx result was 64% (95% confidence interval [CI], 49%-78%), whereas the specificity was 91% (95% CI, 88%-94%). The positive predictive value was 46% (95% CI, 31%-53%), with a negative predictive value of 96% (95% CI, 93%-97%).
Conclusion
Urinalysis is not reliable for the detection of urinary tract infections in febrile infants when compared with urine cultures.
9. Crowding Delays Treatment and Lengthens Emergency Department Length of Stay, Even Among High-Acuity Patients
McCarthy ML, et al. Ann Emerg Med. 2009;54:492-503.e4.
Study objective
We determine the effect of crowding on emergency department (ED) waiting room, treatment, and boarding times across multiple sites and acuity groups.
Methods
This was a retrospective cohort study that included ED visit and inpatient medicine occupancy data for a 1-year period at 4 EDs. We measured crowding at 30-minute intervals throughout each patient's ED stay. We estimated the effect of crowding on waiting room time, treatment time, and boarding time separately, using discrete-time survival analysis with time-dependent crowding measures (ie, number waiting, number being treated, number boarding, and inpatient medicine occupancy rate), controlling for patient demographic and clinical characteristics.
Results
Crowding substantially delayed patients' waiting room and boarding times but not treatment time. During the day shift, when the number boarding increased from the 50th to the 90th percentile, the adjusted median waiting room time (range 26 to 70 minutes) increased by 6% to 78% (range 33 to 82 minutes), and the adjusted median boarding time (range 250 to 626 minutes) increased by 15% to 47% (range 288 to 921 minutes), depending on the site. Crowding delayed the care of high-acuity level 2 patients at all sites. During crowded periods (ie, 90%), the adjusted median waiting room times of high-acuity level 2 patients were 3% to 35% higher than during normal periods, depending on the site and crowding measure.
Conclusion
Using discrete-time survival analysis, we were able to dynamically measure crowding throughout each patient's ED visit and demonstrate its deleterious effect on the timeliness of emergency care, even for high-acuity patients.
Full-text (free): http://www.annemergmed.com/article/PIIS019606440900239X/fulltext
10. D-dimer Testing in Patients with Suspected Pulmonary Embolism and Impaired Renal Function: Still Useful
Karami-Djurabi R, et al. Amer J Med. 2009;122:1050-1053.
Background
Determination of pretest probability and D-dimer tests are the first diagnostic steps in patients with suspected pulmonary embolism, which can be ruled out when clinical probability is unlikely and D-dimer level is normal. We evaluated the utility of D-dimer testing in patients with impaired renal function.
Methods
D-dimer tests were performed in consecutive patients with suspected pulmonary embolism and an unlikely clinical probability. Creatinine levels were assessed as clinical routine. Glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula. Correlation between D-dimer level and renal function and proportions of patients with normal D-dimer in different categories of estimated glomerular filtration rate (eGFR) were assessed. Different categories of decreasing eGFR were defined as: normal renal function (eGFR over 89 mL/min), mild decrease in eGFR (eGFR 60-89 mL/min), and moderate decrease in eGFR (eGFR 30-59 mL/min).
Results
Creatinine levels were assessed in 351 of 385 patients (91%). D-dimer levels significantly increased in 3 categories of decreasing eGFR (P = .027 and P = .021 for moderate renal impairment compared with mild renal impairment and normal renal function, respectively). Normal D-dimer levels were found in 58% of patients with eGFR above 89 mL/min, in 54% with eGFR 60-89 mL/min, and in 28% with eGFR 30-59 mL/min.
Conclusions
The specificity of D-dimer testing in patients with suspected pulmonary embolism and decreased GFR is significantly decreased. Nonetheless, performing D-dimer tests is still useful because computed tomography scanning can be withheld in a significant proportion of these patients.
11. Pediatric myocarditis: presenting clinical characteristics
Durani Y, et al. Amer J Emerg Med. 2009;27:942-947.
Objective
The objective of the study was to characterize the clinical profiles of pediatric patients with acute myocarditis and dilated cardiomyopathy (DCM) before diagnosis.
Methods
A retrospective cross-sectional study was conducted to identify patients with myocarditis and DCM who presented over a 10-year span at 2 tertiary care pediatric hospitals. Patients were identified based on the International Classification of Diseases, Ninth Revision, diagnostic codes.
Results
A total of 693 charts were reviewed. Sixty-two patients were enrolled in the study. Twenty-four (39%) patients had a final diagnosis of myocarditis, and 38 (61%) had DCM. Of the 62 patients initially evaluated, 10 were diagnosed with myocarditis or DCM immediately, leaving 52 patients who required subsequent evaluation before a diagnosis was determined. Study patients had a mean age of 3.5 years, 47% were male, and 53% were female. Common primary complaints were shortness of breath, vomiting, poor feeding, upper respiratory infection (URI), and fever. Common examination findings were tachypnea, hepatomegaly, respiratory distress, fever, and abnormal lung examination result. Sixty-three percent had cardiomegaly on chest x-ray, and all had an abnormal electrocardiogram results.
Conclusions
These data suggest children with acute myocarditis and DCM most commonly present with difficulty breathing. Myocarditis and DCM may mimic other respiratory or viral illnesses, but hepatomegaly or the finding of cardiomegaly and an abnormal electrocardiogram result may help distinguish these diagnoses from other more common pediatric illnesses.
12. The Association between Transfer of ED Boarders to Inpatient Hallways and Mortality: A 4-Year Experience
Viccellio A, et al. Ann Emerg Med. 2009;54:487-491.
We posted this pre-publication abstract in our May Lit Bits, abstract #20. Since this article was published this month, the full-text is now available online for free: http://www.annemergmed.com/article/S0196-0644(09)00238-8/fulltext
13. New Analyses From ECASS 3 Support Use of tPA Up to 4.5 Hours After Stroke
Susan Jeffrey. October 20, 2009 (UPDATED October 21, 2009) — Secondary analyses of data from the third European Cooperative Acute Stroke Study (ECASS 3) trial appear to support the use of recombinant tissue plasminogen activator (rt-PA, alteplase) to treat stroke up to 4.5 hours after symptom onset in patients without exclusions for treatment, but who miss the approved time window of 0 to 3 hours.
"Almost all our additional outcome analyses strongly support the positive primary and secondary trial results of ECASS 3," the investigators, with lead author Werner Hacke, MD, PhD, professor and chairman of the Department of Neurology at Ruprecht-Karls-Universität, Germany, conclude.
Although not significant in every analysis, all additional efficacy endpoints showed "at least a clear pattern in favor of alteplase," the authors note, in particular confirming that treatment was effective in patients regardless of stroke severity.
However, Dr. Hacke told Medscape Neurology that in his view, the most critical point to make about ECASS 3, now supported by these subanalyses, is not that the time window for tPA can safely be extended to 4.5 hours.
"It is that the concept of thrombolytic therapy in acute ischemic stroke is supported now by a very straightforward, conservative, randomized clinical trial, a trial that is more than double the size of the National Institute of Neurological Disorders and Stroke trial that was positive for the 3-hour time window," he said.
Along with a collection of pooled and meta-analyses and data from a large European registry, he said, their results bolster the concept, still questioned by some, that thrombolysis as a valid therapy for stroke. "We have 2 independent randomized clinical trials that are positive with the primary outcome in favor of rtPA, so there is no reason any more to not accept this as a scientific fact," Dr. Hacke stressed.
This new report from ECASS 3 was published online October 21 and will appear in the December issue of Lancet Neurology. ECASS 3 was supported by Boehringer Ingelheim.
14. Images in EM
Traumatic Eye Swelling
http://www.annemergmed.com/article/S0196-0644(09)00365-5/fulltext
Psychotic Woman With Painful Abdominal Distension
http://www.annemergmed.com/article/S0196-0644(09)00373-4/fulltext
15. Facemasks and Hand Hygiene to Prevent Influenza Transmission in Households: A Cluster Randomized Trial
Cowling BJ, et al. Ann Intern Med. 2009;151:437-446
Few data are available on the effectiveness of nonpharmaceutical interventions for preventing influenza virus transmission. In this cluster randomized trial of 259 people with confirmed influenza virus infection and 794 household contacts, hand washing and facemasks seemed to prevent influenza virus transmission when healthy people started these measures within 36 hours of symptom onset in an infected family member. Although adherence to the interventions varied, these findings suggest that nonpharmaceutical interventions may help to mitigate pandemic and interpandemic influenza.
Abstract: http://www.annals.org/cgi/content/abstract/151/7/437
16. Validation of a Prediction Rule for the Identification of Children with Intra-abdominal Injuries After Blunt Torso Trauma
Holmes JF, et al. Ann Emerg Med. 2009;54:528-533.
Study objective
We validate the accuracy of a previously derived clinical prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma.
Methods
We conducted a prospective observational study of children with blunt torso trauma who were evaluated for intra-abdominal injury with abdominal computed tomography (CT), diagnostic laparoscopy, or laparotomy at a Level I trauma center during a 3-year period to validate a previously derived prediction rule. The emergency physician providing care documented history and physical examination findings on a standardized data collection form before knowledge of the results of diagnostic imaging. The clinical prediction rule being evaluated included 6 “high-risk” variables, the presence of any of which indicated that the child was not at low risk for intra-abdominal injury: low age-adjusted systolic blood pressure, abdominal tenderness, femur fracture, increased liver enzyme levels (serum aspartate aminotransferase concentration over 200 U/L or serum alanine aminotransferase concentration over 125 U/L), microscopic hematuria (urinalysis over 5 RBCs/high powered field), or an initial hematocrit level less than 30%.
Results
One thousand three hundred twenty-four children with blunt torso trauma were enrolled, and 1,119 (85%) patients had the variables in the decision rule documented by the emergency physician and therefore made up the study sample. The prediction rule had the following test characteristics: sensitivity=149 of 157, 94.9% (95% confidence interval [CI] 90.2% to 97.7%) and specificity=357 of 962, 37.1% (95% CI 34.0 to 40.3%). Three hundred sixty-five patients tested negative for the rule; thus, strict application would have resulted in a 33% reduction in abdominal CT scanning. Of the 8 patients with intra-abdominal injury not identified by the prediction rule, 1 underwent a laparotomy. This patient had a serosal tear and a mesenteric hematoma at laparotomy, neither of which required specific surgical intervention.
Conclusion
A clinical prediction rule consisting of 6 variables, easily available to clinicians in the ED, identifies most but not all children with intra-abdominal injury. Application of the prediction rule to this sample would have reduced the number of unnecessary abdominal CT scans performed but would have failed to identify 1 child undergoing (a nontherapeutic) laparotomy. Thus, further refinement of this prediction rule in a large, multicenter cohort is necessary before widespread implementation.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(09)00398-9/fulltext
17. Rapid Viral Testing Promising in Pediatric Emergencies
NEW YORK (Reuters Health) Oct 19 - In children with acute febrile respiratory illness, rapid viral testing techniques may save time and reduce demands on emergency department staff, according to a review published this month in the Cochrane Database of Systematic Reviews.
Nevertheless, lead investigator Dr. Quynh Doan said in a statement that "the existing evidence is not strong enough to prove that these tests help to reduce pressure on health systems, but it certainly does look promising."
Moreover, she told Reuters Health, "Rapid viral testing in a well defined context can provide physicians with very valuable information and potentially impact on management decision." However, "emphasis must be put on 'well defined context.'"
"We must remember," she added, "that only positive rapid viral testing adds any information, as these tests can only detect a specific virus -- commonly influenza -- and the absence of this virus in the sample is in no way indicative of what is causing the illness."
Dr. Doan of the British Columbia Children's Hospital in Vancouver, Canada, and colleagues studied data from 4 trials involving 759 children who underwent rapid testing and 829 who acted as controls.
Three of the studies employed influenza testing and the remaining study used a virus panel test encompassing influenza, parainfluenza, respiratory syncytial virus and adenovirus.
The team found that overall, viral testing reduced the use of chest X-rays (relative risk, 0.77) and that there was a trend toward less antibiotic usage (relative risk, 0.89) and fewer blood and urine investigations.
Dr. Doan also pointed out that "since the rate of positive rapid viral testing varied widely between 20 and 60% of tested subjects -- depending on which studies we look at -- perhaps we should be selective in the population to be tested in order to maximize its usefulness."
"In addition," she concluded, "it is important to note that all these studies were conducted before the H1N1 era. How rapid viral testing can contribute to managing the emergency department volume surges associated with the H1N1 pandemic can only be speculated."
Cochrane Database Syst Rev 2009.
18. The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics
Vaillancourt C, et al. Ann Emerg Med. 2009;54:663-671.e1
Study objective
We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting.
Methods
We conducted this prospective cohort study in 7 Canadian regions and involved alert (Glasgow Coma Scale score 15) and stable adult trauma patients at risk for neck injury. Advanced and basic care paramedics interpreted the Canadian C-Spine Rule status for all patients, who then underwent immobilization and assessment in the emergency department to determine the outcome, clinically important cervical spine injury.
Results
The 1,949 patients enrolled had these characteristics: median age 39.0 years (interquartile range 26 to 52 years), female patients 50.8%, motor vehicle crash 62.5%, fall 19.9%, admitted to the hospital 10.8%, clinically important cervical spine injury 0.6%, unimportant injury 0.3%, and internal fixation 0.3%. The paramedics classified patients for 12 important injuries with sensitivity 100% (95% confidence interval [CI] 74% to 100%) and specificity 37.7% (95% CI 36% to 40%). The κ value for paramedic interpretation of the Canadian C-Spine Rule (n=155) was 0.93 (95% CI 0.87 to 0.99). Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule.
Conclusion
This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.
Full-text (free): http://www.annemergmed.com/article/PIIS0196064409002418/fulltext
19. Serious Bacterial Infections Uncommon in Infants Who Have Experienced an Apparent Life-Threatening Event
Mittal MK, et al. Ann Emerg Med. 2009;54:523-527.
Study objective
We determine the incidence of serious bacterial infection in infants presenting to the emergency department (ED) with an apparent life-threatening event.
Methods
This was a prospective cohort study of infants younger than 12 months who were treated at an urban children's hospital ED during 1 year and who met standard criteria for an apparent life-threatening event. Sociodemographic data, presenting features, diagnostic testing, hospital course, and final diagnosis were collected. Follow-up information was obtained 4 weeks after the visit.
Results
Of the 198 infants enrolled, 44 (22.2%) had evaluation for serious bacterial infection: urine culture 36 (18%), blood culture 38 (19%) and cerebrospinal fluid culture 18 (9%). No infant (0/198; 95% confidence interval 0% to 1.8%) was found to have bacteremia, urinary tract infection, or bacterial meningitis, which was confirmed at the 4-week interview (99% ascertainment). Two infants were found to have enteroviral meningitis.
Conclusion
The incidence of serious bacterial infection in this cohort was extremely low. Infants presenting with an apparent life-threatening event need not be subjected to a full serious bacterial infection evaluation routinely.
20. Do Not Pardon the (CPR) Interruption
Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation
Wang HE, et al. Ann Emerg Med. 2009;54:645-652.e1
Emergency cardiac care guidelines emphasize treatment of cardiopulmonary arrest with continuous uninterrupted cardiopulmonary resuscitation (CPR) chest compressions. Paramedics in the United States perform endotracheal intubation on nearly all victims of out-of-hospital cardiopulmonary arrest. We quantified the frequency and duration of CPR chest compression interruptions associated with paramedic endotracheal intubation efforts during out-of-hospital cardiopulmonary arrest.
Methods
We studied adult out-of-hospital cardiopulmonary arrest treated by an urban and a rural emergency medical services agency from the Resuscitation Outcomes Consortium during November 2006 to June 2007. Cardiac monitors with compression sensors continuously recorded rescuer CPR chest compressions. A digital audio channel recorded all resuscitation events. We identified CPR interruptions related to endotracheal intubation efforts, including airway suctioning, laryngoscopy, endotracheal tube placement, confirmation and adjustment, securing the tube in place, bag-valve-mask ventilation between intubation attempts, and alternate airway insertion. We identified the number and duration of CPR interruptions associated with endotracheal intubation efforts.
Results
We included 100 of 182 out-of-hospital cardiopulmonary arrests in the analysis. The median number of endotracheal intubation–associated CPR interruption was 2 (interquartile range [IQR] 1 to 3; range 1 to 9). The median duration of the first endotracheal intubation–associated CPR interruption was 46.5 seconds (IQR 23.5 to 73 seconds; range 7 to 221 seconds); almost one third exceeded 1 minute. The median total duration of all endotracheal intubation–associated CPR interruptions was 109.5 seconds (IQR 54 to 198 seconds; range 13 to 446 seconds); one fourth exceeded 3 minutes. Endotracheal intubation–associated CPR pauses composed approximately 22.8% (IQR 12.6-36.5%; range 1.0% to 93.4%) of all CPR interruptions.
Conclusion
In this series, paramedic out-of-hospital endotracheal intubation efforts were associated with multiple and prolonged CPR interruptions.
Full-text (free): http://www.annemergmed.com/article/PIIS0196064409005344/fulltext
21. Abstracts from ACEP’s 2009 Scientific Assembly
A. ED Doctors Rarely Adjust Antibiotic Doses for Obese Patients
By Marilynn Larkin. NEW YORK (Reuters Health) Oct 07 - Emergency department physicians rarely adjust antimicrobial medication doses for obese patients, according to research reported Tuesday at the American College of Emergency Physicians annual meeting in Boston.
"We have a one-size-fits-all dose in our minds for most antibiotics, and we tend to give that dose regardless of size and other factors that should affect dosing, like age, renal function, and body mass index," study co-researcher Dr. Michael Mullins told Reuters Health.
Dr. Mullins and his colleagues, from Washington University School of Medicine, St. Louis, analyzed the rate at which their center's emergency physicians adhered to dose adjustment guidelines for selected antibiotics established by the university's antibiotic utilization review (AUR) committee.
They reviewed data for all emergency department patients treated over a 3-month period who weighed more than 100 kg, had a body mass index greater than 40 kg/m2, and were given cefazolin, cefepime, or ciprofloxacin.
Slightly more than a thousand patients met the study criteria. Overall, they were treated with 503 doses of cefepime, 293 doses of cefazolin, and 306 doses of ciprofloxacin. Thirty received more than one antibiotic.
Based on AUR guidelines, the initial dose for these patients should be 2 g IV for cefazolin or cefepime and 800 mg IV or 750 mg PO for ciprofloxacin.
These guidelines were followed for only 48 doses of cefepime (9.5%), 12 doses of cefazolin (4.1%), and 4 doses of ciprofloxacin (1.3%).
"Obesity is an epidemic in North America in particular, and unfortunately, we're seeing more people in the obese and severely obese range than we used to," Dr. Mullins observed. "I think this problem is under-recognized by emergency physicians and other specialists."
"If you give too low a dose," he cautioned, "you'll have treatment failure even if you pick the right antibiotic--and increase the likelihood that some of the bacteria you're trying to kill will form a mutation and become less sensitive to the drug."
B. Vast Increase in ED Visits for Head Injuries Seen After Natasha Richardson's Death
Fran Lowry. October 8, 2009 (Boston, Massachusetts) — Widespread media coverage of Natasha Richardson's death from a head injury on March 18, 2009 prompted a huge increase in emergency department (ED) visits, investigators reported here at the American College of Emergency Physicians 2009 Scientific Assembly.
The actress appeared well after she hit her head in a fall while skiing at Mont Tremblant, Quebec. She initially refused medical help, saying she felt fine, but died shortly afterward.
"We see this all the time in emergency rooms," Brian Walsh, MD, from Morristown Memorial Hospital in New Jersey, told Medscape Emergency Medicine. "Coverage about a certain disease, for instance meningitis deaths in young people, can cause a big bump in visits. We thought that the publicity surrounding her tragic death would do the same thing, and we wanted to quantify that."
Dr. Walsh and his colleagues compared the daily visits for head injury for the 10 days before and after March 18 in the EDs of 19 urban, suburban, and rural hospitals in New Jersey and New York. They classified patients as having head injury based on ICD9 codes.
They found that visits to the ED for head injury increased 73% (95% confidence interval, 53% - 94%; P less than .0001) for the 10 days after March 18 compared with the 10 days before. However, by March 31, the number of ED visits for head trauma was back to the pre–March 18 level.
According to Christina Campo-Ford, PA, from Morristown Memorial Hospital, who coauthored the study with Dr. Walsh, the media can cause quite a scare. "Good Morning America ran a spot a day after Natasha Richardson died about a little girl who was hit in the head with a softball and she was fine but then she went downhill. You can't show that on Good Morning America and not expect parents to bring their children in."
Pediatricians were telling concerned parents to bring their children who fell and hit their heads to the ED "just to be safe," she said. However, although the number of people who came to the ED for head trauma increased, the number of serious head injuries did not, nor did the percentage of computed tomography (CT) scans that were performed.
"We educated patients about the pros and cons of CTs and the radiation exposure risks and so on, and we did not do CTs unnecessarily," said Ms. Campo-Ford. "However, some patients insisted on having a CT, so we couldn't refuse them."
Ms. Campo-Ford believes that Ms. Richardson's death will continue to influence ED visits for head injury.
Media attention can definitely highlight issues, Debra Houry, MD, from Emory University in Atlanta, Georgia, told Medscape Emergency Medicine. "As emergency physicians, we need to make sure that we talk about injury prevention a well, such as helmet use, as this decreases the morbidity and mortality with a head injury."
Media reporting, which used headlines such as "Stand Up and Die" when reporting Ms. Richardson's death, fuels panic reactions on the part of the public, and encourages them to go to the ED even when such visits are not necessary. "The media called it "stand up and die," so why would you not come in if you hit your head," Ms. Campo-Ford noted.
Such reporting only compounds the already serious problem of ED overcrowding, said Dr. Walsh.
Physicians should educate their patients about head trauma and what symptoms to look for. But even when they do, some patients will insist on coming into the ED and having a CT scan anyway, Dr. Alexander M. Rosenau, DO, FACEP, from Lehigh Valley Hospital in Allentown, Pennsylvania, told Medscape Emergency Medicine. Dr. Rosenau is chair of the Emergency Medicine Foundation.
He pointed out how difficult it is to persuade patients that they don't need to come to the hospital after every head injury as a result of the publicity about Ms. Richardson. "A mother brought her daughter to the ED, insisting on a CT scan because the girl had fallen off her horse about 2 days prior and had hit her head. After taking a careful history and exam, we tried to reassure the mother that a CT was not necessary, but she was not convinced."
American College of Emergency Physicians 2009 Scientific Assembly. Abstract 156. Presented October 5, 2009.
C. Shorter Wait Times in the ED Mean More Patients Stay to See a Doctor
Marilynn Larkin. NEW YORK (Reuters Health) Oct 06 - Modest decreases in emergency department (ED) waiting times can have a big impact on whether a patient stays to see a doctor or leaves without being seen, investigators said Monday at the annual meeting of the American College of Emergency Physicians in Boston.
The research is based on an analysis of all visits to the George Washington Hospital ED from 2006-2008. Dr. Mehdi Sattarian and colleagues compared wait times for walk-in patients who left without being seen, either before or after nursing triage, to waiting times (from arrival to hospital bed) for people who arrived at the hospital at the same hour and stayed to see a doctor. They also recorded the total number of patients in the ED treatment area and lobby at the hour's end, and illness severity, Dr. Sattarian said at the Boston meeting.
During the study period, 187,663 patients came to the ED, 128,430 of whom were walk-ins. (The rest came by ambulance.) Of those, 5.2% left without being seen.
Further analysis revealed the proportion of walk-in patients who left without being seen fell from 5.5% in July-December 2006 to 3.5% in July-December 2008. During the same period, mean waiting times for walk-ins decreased from 61.4 to 52.6 minutes.
The drop in the number of patients who left without being seen occurred even while the total number of patients coming to the ED in a given hour increased (from 6.9 patients in 2006 to 7.5 patients in 2008), along with the number of patients left in the ED at the end of that hour (36.5 in 2006, 39.5 in 2008).
"We saw highly significant relationships between the number of people who left without being seen and both waiting times and the total number of patients in the emergency department," Dr. Sattarian told meeting attendees. In email to Reuters Health, he attributed improvements in "front-end processes" -- for example, streamlining registration and triage -- to the decreased waiting times and concomitant increase in the number of people who stayed to see a doctor.
Improving "back-end" processes -- what happens from the time a patient is seen by a doctor to the time they're either admitted or discharged -- could have "an even greater effect" on the number of people who stay to be seen by reducing the overall number of people in the ED, Dr. Sattarian observed.
Those strategies would include decreasing the amount of time it takes for seriously ill people to be moved to a hospital bed, and "improving laboratory and radiology turnaround times," he concluded.
D. Oxygen Therapy Relieves Headache Pain in the ED, Cuts Length of Stay, Drug Use
Marilyn Larkin. NEW YORK (Reuters Health) Oct 05 - Giving high-flow oxygen therapy for 15 minutes to emergency department patients with headaches provides rapid relief and reduces hospital stays, use of CT scans, and headache pharmacotherapy, according to a pilot study.
Dr. Boris Veysman of the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School reported the results on Monday at the annual meeting of the American College of Emergency Physicians in Boston.
"Very often, when a patient comes to the emergency department with one complaint being headache, they're uncomfortable and symptomatic and they have to wait for a workup before anyone can determine the cause. A diagnosis may not even be made in the emergency department," Dr. Veysman told Reuters Health. "So we approached it from a different perspective and asked, 'What if therapy were the first thing you did (for a headache) before attempting to find a cause?' And so we tried giving oxygen therapy, because it's so widespread and safe."
In the placebo-controlled study, 17 patients were randomized to 100% oxygen at 15 L/min for 15 minutes; 14 received high flow air for 15 minutes; and 17 received no intervention prior to standard treatment. Headache intensity was assessed using a 10-point visual analog scale.
Median times to relief were significantly shorter for patients treated with oxygen (40 minutes) compared with those treated with high flow air (110 minutes) or nothing (120 minutes). Median length of stay was also significantly shorter for patients treated with oxygen (57.5 minutes) than for those treated with air (210 minutes) or nothing (180 minutes).
In addition, CT scans were ordered less frequently: for four of 17 patients (24%) who received oxygen; 11 of 14 (79%) who received air; and eight of 17 (47%) who got nothing.
Medication was given to 29% of those who received oxygen, 86% of those who received air, and 82% of those who received no treatment.
Headache intensity was significantly reduced at both 15 minutes and 30 minutes after initiation of treatment, with patients treated with oxygen realizing the greatest reductions.
"It was a small study, and our results are preliminary," Dr. Veysman stressed. "But the medical community is starting to recognize that it's important to treat discomfort even when you don't know what's causing it, as long as you feel confident the treatment won't make the patient worse. In this case, we found more relief with oxygen than with placebo, although the fact that the headache goes away doesn't necessarily mean the patient can go home."
1. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial
Jabre P, et al. Lancet. 2009;374(9686):293-300.
Introduction
Critically ill patients often require emergency orotracheal intubation for airway control. Rapid sequence intubation with administration of a sedative and a paralytic agent is common. Etomidate is the sedative-hypnotic drug that is most often used in rapid sequence intubation, but its use has been challenged because it can cause a reversible adrenal insufficiency by dose-dependent inhibition of 11β-hydroxylase.
Several studies have suggested an association between the use of etomidate and the occurrence of adrenal insufficiency and increased morbidity in critically ill or injured patients, particularly in those with sepsis. Because adrenal insufficiency when a patient is critically ill can increase the risk of death, several investigators have advised against the use of etomidate, even as a single bolus.9 However, no causal link has been established between its use and an increase in morbidity and mortality.
Etomidate's haemodynamic tolerance, even in patients with shock, and the excellent intubation conditions provided have to be weighed against potential adverse effects, including adrenal insufficiency. A possible alternative to etomidate is ketamine, which is not known to inhibit the adrenal axis. The aim of this randomised controlled study was to compare early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients.
Abstract
BACKGROUND: Critically ill patients often require emergency intubation. The use of etomidate as the sedative agent in this context has been challenged because it might cause a reversible adrenal insufficiency, potentially associated with increased in-hospital morbidity. We compared early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients.
METHODS: In this randomised, controlled, single-blind trial, 655 patients who needed sedation for emergency intubation were prospectively enrolled from 12 emergency medical services or emergency departments and 65 intensive care units in France. Patients were randomly assigned by a computerised random-number generator list to receive 0.3 mg/kg of etomidate (n=328) or 2 mg/kg of ketamine (n=327) for intubation. Only the emergency physician enrolling patients was aware of group assignment. The primary endpoint was the maximum score of the sequential organ failure assessment during the first 3 days in the intensive care unit. We excluded from the analysis patients who died before reaching the hospital or those discharged from the intensive care unit before 3 days (modified intention to treat). This trial is registered with ClinicalTrials.gov, number NCT00440102.
FINDINGS: 234 patients were analysed in the etomidate group and 235 in the ketamine group. The mean maximum SOFA score between the two groups did not differ significantly (10.3 [SD 3.7] for etomidate vs 9.6 [3.9] for ketamine; mean difference 0.7 [95% CI 0.0-1.4], p=0.056). Intubation conditions did not differ significantly between the two groups (median intubation difficulty score 1 [IQR 0-3] in both groups; p=0.70). The percentage of patients with adrenal insufficiency was significantly higher in the etomidate group than in the ketamine group (OR 6.7, 3.5-12.7). We recorded no serious adverse events with either study drug.
INTERPRETATION: Our results show that ketamine is a safe and valuable alternative to etomidate for endotracheal intubation in critically ill patients, and should be considered in those with sepsis.
FUNDING: French Ministry of Health.
Discussion
Our study shows that one etomidate bolus is not associated with a significant increase in morbidity or mortality compared with ketamine in patients admitted to the intensive care unit. The maximum SOFA score did not differ significantly between the two drugs in the subgroup of patients having sepsis or trauma. However, for the subgroup of septic patients (n=76), the small number of patients might account for the absence of significant difference. The mortality rate at day 28 in this subgroup did not differ between the treatment groups.
An association between the administration of etomidate and an increased mortality of patients with sepsis has been suggested previously. In a retrospective study of children with meningococcal sepsis or shock, mortality rate was 30% in patients who received etomidate versus 12% in those who did not, but the difference was not significant (OR 3•1 [95% CI 0•3–79•3]). In a post-hoc analysis of the Corticus study undertaken in patients with severe sepsis, the 28-day mortality rate was significantly higher in patients who received etomidate than in those who did not (p=0•03). The investigators, however, did not draw any cause and effect conclusion, presumably because of the lack of randomisation to sedative agents.
By contrast with the substantial increase in mortality reported by Ledingham and Watts, etomidate did not affect outcome in trauma patients in our study. This discrepancy between the two studies is probably related to the duration of etomidate administration: one bolus in our study versus prolonged sedation in Ledingham and Watts' study. Hildreth and co-workers reported increased use of blood products, ventilator days, and days in intensive care in trauma patients randomly assigned to etomidate (n=18) versus midazolam (n=12), but reported no difference in mortality. However, interpretation of this study is difficult because half of the eligible patients were excluded, with 11 of 31 patients having received etomidate.
Although adrenal axis dysfunction arises to some extent after etomidate use for rapid sequence intubation, the effect of such adrenal suppression on patients' outcome remains debated. Studies have reported increased mortality in non-responders to the adrenocorticotropin hormone stimulation test and in patients with adrenal insufficiency. One bolus of etomidate decreases cortisol secretion, which contributed to the increased morbidity and mortality reported in several studies. However, these findings have not been confirmed by other investigators. Clearly, the results of these studies could be biased owing to the presence of multiple confounding factors.
Our study confirms the finding of others that etomidate affects the adrenal axis: according to our criteria, more than four-fifths of etomidate recipients had adrenal insufficiency and were non-responders to the adrenocorticotropin hormone stimulation test. About half of patients given ketamine also had adrenal insufficiency, which emphasises that critical illness per se affects adrenal function. In one study, more than 30% of non-responders had not been exposed to etomidate, and in another, 51% of patients with septic shock who had not received etomidate were non-responders. Indeed, multiple mechanisms could account for adrenal insufficiency in critically ill patients. Adrenal insufficiency is probably associated with increased mortality in critically ill patients, including those with sepsis; however, whether the adrenal axis suppression and mortality are the result of some underlying process, or whether the adrenal axis suppression causes death, has never been established. Among established independent predictors of low cortisol response to adrenocorticotropin hormone stimulation are a low pH or bicarbonate and platelet count, disease severity, and organ failure. Fentanyl or sufentanil infusion can also modify cortisol concentrations. However, these factors should not affect the results of our study since both patient groups received the same type of continuous sedation (fentanyl or sufentanil combined with midazolam).
Etomidate is the sedative-hypnotic drug most often used by emergency physicians for rapid sequence intubation, and is the drug of choice for patients who are haemodynamically unstable. Use of ketamine instead of etomidate might have drawn attention to potential adverse effects of the use of ketamine during the intubation procedure. The most common side-effects of ketamine are psychodysleptic effects, but they could not be observed because, unlike in an operating theatre, patients are not awakened until several hours after intubation. We noted no difference between the sedative drugs tested in our study on the ease of intubation, probably because intubation conditions depend mostly on the muscle relaxant effects of succinylcholine. Accordingly, Sivilotti and Ducharme reported no significant difference in the overall successful intubation in a comparison of three hypnotic drugs.
With regard to the strengths and limitations of our study, we have confirmed the appropriateness of the choice of the maximum SOFA score as the primary endpoint. There is an established relation between the maximum SOFA score and Δ-SOFA score (from maximum to admission) and mortality in patients who are critically ill. Moreover, measurement of the SOFA score has good reliability and accuracy among intensivists. These scores have shown its usefulness in the assessment of in-hospital morbidity in seriously ill patients.
However, our study might not have had sufficient power to show a significant increase in morbidity related to the use of etomidate in patients with sepsis. Our failure to enroll and analyse a larger number of patients with sepsis could have led to a type-II error for this group. A future study should be based on patients with sepsis only, since the controversy regarding the use of etomidate focuses on these patients. We felt that patients admitted with trauma were important to study as well because of suggestions from recent reports that etomidate might be harmful to this group of patients. In conclusion, our results show that ketamine is a safe and valuable alternative to etomidate for intubation in critically ill patients, particularly in septic patients.
2. Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients
Chang AM, et al. Amer J Emerg Med. 2009;27:916-921.
Objective
Guidelines recommend treating patients with a new or presumed new left bundle-branch block (LBBB) similar to those with an acute ST-segment elevation myocardial infarction. It is often unclear which emergency department (ED) patients with potentially ischemic symptoms actually have an acute myocardial infarction (AMI), even in the setting of LBBB. Our null hypothesis was that in ED patients with potential AMI, the presence of a new or presumed new LBBB would not predict an increased likelihood of AMI.
Methods
This was an observational cohort study. Patients older than 30 years who presented with chest pain or other ischemic equivalent and had an electrocardiogram (ECG) to evaluate potential acute coronary syndrome (ACS) were enrolled. Data collected include demographics, history, ECG, and cardiac markers. Electrocardiograms were classified according to the standardized guidelines, including LBBB not known to be old (new or presumed new LBBB), LBBB known to be old, or no LBBB. The hospital course was followed, and 30-day follow-up was performed on all patients. Our main outcome was AMI.
Results
There were 7937 visits (mean age, 54.3 ± 15 years, 57% female, 68% black): 55 had new or presumed new LBBB, 136 had old LBBB, and 7746 had no LBBB. The rate of AMI was not significantly different between the 3 groups (7.3% vs 5.2% vs 6.1%; P = .75). Revascularization (7.8% vs old 5.2% vs 4.3%; P = .04) and coronary artery disease were more common in patients with new or presumed new LBBB (19.2% vs 11.9% vs 10.1%; P = .0004).
Conclusions
Despite guideline recommendations that patients with potential ACS and new or presumed new LBBB should be treated similar to STEMI, ED patients with a new or presumed new LBBB are not at increased risk of AMI. In fact, the presence of LBBB, whether new or old, did not predict AMI. Caution should be used in applying recommendations derived from patients with definite AMI to ED patients with potential ACS that may or may not be sustaining an AMI.
3. Recent-onset A Fibbers in the ED: Cardiovert?
Stead LG, et al. Rhythm Control With Electrocardioversion for Atrial Fibrillation and Flutter. Ann Emerg Med. 2009;54:745-747.
This review provides little evidence on which emergency physicians can base decisions about patients with acute atrial fibrillation. Because the majority of symptomatic patients encountered in the ED have atrial fibrillation of less than 48 hours’ duration and the risk of stroke and other complications in such patients is low, current practice remains cardioversion (electrical or medical) as soon as possible. In older patients with sustained atrial fibrillation, referral for cardioversion may be warranted for quality of life considerations; however, stroke prevention must be an integral
component of pre- and postcardioversion management to reduce the risk of embolic stroke.
Full-text (free): http://download.journals.elsevierhealth.com/pdfs/journals/0196-0644/PIIS0196064408020866.pdf
4. Arranging Follow-up Appointments for your Discharged Patients
Vinson DR, Patel PB. Facilitating follow-up after emergency care using an appointment assignment system. J Healthcare Quality. 2009; 31:18-24.
Many emergency department patients require urgent follow-up in primary care. The most effective way to help patients obtain their needed after-visit care is to secure the appointment on their behalf prior to their departure from the ED. This study describes the development, implementation, and outcomes of an appointment assignment system that facilitates patient follow-up at two community hospitals in an integrated healthcare system. This patient-centered system resulted in a high rate of compliance and a very low rate of unscheduled ED recidivism. Improving access in this manner will likely strengthen the continuum of care, improve quality, and increase patient satisfaction.
Full-text (free) available from the authors: drvinson@ucdavis.edu
5. Sleep-Deprived Attending Surgeons Have Higher Rates of Procedural Complications
Kathleen Louden. October 19, 2009 (Chicago, Illinois) — Attending surgeons who perform daytime surgical procedures within 6 hours of finishing an overnight shift have a nearly 3-fold higher rate of provider-related complications than when their opportunity for sleep between procedures exceeds 6 hours, a new study finds. The study was published in the October 14 issue of the Journal of the American Medical Association.
Until now, little was known about the effects of long work shifts and limited sleep opportunity on the performance of attending physicians, said lead author Jeffrey Rothschild, MD, MPH, a surgeon at Brigham and Women's Hospital and an assistant professor of medicine at Harvard Medical School in Boston, Massachusetts.
"Attendings who perform emergency overnight procedures . . . often perform elective procedures the next day," said Dr. Rothschild, who presented the results at a media briefing held to release new research on surgical care.
"Our data suggest that attending physicians, like residents and nurses, may be at increased risk of making errors when sleep-deprived or working extended shifts," he said.
The authors studied the outcomes of 919 "postnighttime" procedures performed by 86 attending surgeons over an 8-year period. The definition of a postnighttime procedure was one performed in the operating room the day after at least 1 operative case between midnight and 6 am. Dr. Rothschild's team compared outcomes of postnighttime procedures with those of 3552 control procedures, which were the same or similar procedures performed by the same 86 surgeons when they had not worked the previous night, within 12 months of the other procedures. Of the 86 surgeons, 32 were general surgeons. Their mean length of experience was 14 years.
Working Late Does Not Increase Next-Day Complications
Dr. Rothschild and colleagues found that the overall rate of complications — intraoperative adverse events likely attributable to the surgeon — did not significantly differ between postnighttime and control procedures. The complication rate was 7.5% in the postnighttime group and 7.8% in the control group. Likewise, the duration of the extended work shift did not have a statistically significant effect on the complication rate.
It was only when the investigators looked at the data by length of sleep opportunity — the time between the end of the last overnight case and the beginning of the first case later that day — that they observed a significant difference in the frequency of complications. When surgeons in the postnighttime group got 6 hours or less of sleep opportunity, there was a 2.7-fold increase in the rate of complications, compared with a longer time between shifts in the same group, Dr. Rothschild said. The difference between that 8.5% complication rate and the 3.1% rate for surgeons whose sleep opportunity was more than 6 hours was significant (P = .03), the authors write.
Actual sleep time was likely to be far shorter than sleep opportunity, owing to the need to change clothes and travel home, Dr. Rothschild noted.
Most of the complications that occurred were preventable, the authors report. The most frequent complications for both groups, according to Dr. Rothschild, were organ injury, bleeding, and infections.
Based on their findings, he said that "a limitless work week for attending physicians is not optimal for patient care."
Self-Regulation Needed
Unlike resident physicians, attending physicians in the United States have no restrictions on the number of hours they can work. Dr. Rothschild did not think that attendings' work hours would become federally regulated. Instead, he recommended strategies that surgeons can take to reduce complications due to fatigue.
"Surgeons can try to avoid scheduling elective surgeries the day after they take emergency call, or at least when risks are high for the elective procedure. And, if possible, they should use back-up personnel to assist when they are fatigued."
A limitation of the study, according to Dr. Rothschild, is that the investigators did not know the surgeons' sleep practices the night before control procedures. "Some physicians could have worked overnight at other hospitals," he explained. Also, the findings might not apply to nonteaching hospitals, he observed.
Although the study included data from only 1 center, it raised the profile of a common problem, said Phil Fontanarosa, MD, MBA, executive deputy editor of JAMA. "More awareness is needed about this problem among attending physicians, because all the focus [of fatigue contributing to medical errors] has been on residents," Dr. Fontanarosa told Medscape General Surgery.
JAMA. 2009;302:1565-1572.
6. Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment: U.S. Preventive Services Task Force Says “Don’t Bother”
Ann Intern Med. 2009;151:474-482.
The U.S. Preventive Services Task Force (USPSTF) has issued a recommendation statement on the use of 9 nontraditional risk factors (high-sensitivity C-reactive protein [CRP], ankle–brachial index, leukocyte count, fasting blood glucose level, periodontal disease, carotid intima–media thickness, coronary artery calcification on electron-beam computed tomography, homocysteine level, and lipoprotein[a] level) in assessing coronary heart disease (CHD) risk in asymptomatic persons. It concludes that the current evidence is insufficient to assess the balance of benefits and harms of using these nontraditional risk factors to screen asymptomatic men and women with no history of CHD to prevent CHD events (I statement).
Full-text (free): http://www.annals.org/cgi/content/full/151/7/474
7. Psychosocial Stress: Bad for your Heart
Milani RV, et al. Amer J Med. 2009;122:931-938.
Background
Exercise training reduces mortality in patients with coronary artery disease. Behavioral characteristics, including depression, hostility, and overall psychosocial stress, have been shown to be independent risk factors for recurrent myocardial infarction and death in these patients. Exercise training can reduce these high-risk behaviors, but it remains uncertain as to what extent the health benefits of exercise training can be attributed to improving these behaviors.
Methods
We evaluated the impact of exercise training during cardiac rehabilitation on mortality in 53 patients with coronary artery disease with high levels of psychosocial stress and in 469 patients with coronary artery disease with low levels of psychosocial stress and compared them with 27 control patients with high psychosocial stress who did not undergo formal cardiac rehabilitation and exercise training.
Results
Mortality was approximately 4-fold greater in patients with high psychosocial stress than in those with low psychosocial stress (22% vs 5%; P = .003). Exercise training decreased the prevalence of psychosocial stress from 10% to 4% (P less than .0001) and similarly improved peak oxygen uptake in patients with high and low psychosocial stress. Mortality in patients who improved exercise capacity by greater than 10% (high exercise change) was 60% lower than in patients who had less than 10% improvement in exercise capacity (low exercise change) (P=.009). Mortality was lower in patients with high psychosocial stress with high exercise change compared with patients with high psychosocial stress with low exercise change (0% vs 19%; P=.009). In contrast, there was no significant improvement in mortality in patients with high versus low exercise change with low psychosocial stress (4% vs 8%; P=.14).
Conclusion
Psychosocial stress is an independent risk factor for mortality in patients with coronary artery disease, and exercise training can effectively reduce its prevalence. Exercise training reduces mortality in patients with coronary artery disease, and this effect seems to be mediated in part because of the salutary effects of exercise on psychosocial stress.
Full-text: http://www.amjmed.com/article/PIIS0002934309004392/fulltext
8. Urinalysis (without culture) is not reliable to detect UTI in febrile ED infants
Reardon JM, et al. Amer J Emerg Med. 2009;27:930-932.
Objective
Urinary tract infections are a common source of serious bacterial infections in febrile infants younger than 2 years. Our objective was to compare urinalysis with urine culture in the emergency department evaluation of febrile infants.
Methods
A febrile infant registry was instituted at a tertiary care hospital treating an average of 55000 patients annually (27% children), from December 2002 to December 2003. Patients were eligible if they were younger than 3 months and had a temperature of at least 38°C or if they were between 3 and 24 months of age and had a temperature of at least 39°C. Data abstracted included age, sex, and temperature. Urinalysis (UA) and urine culture (UCx) results were obtained from electronic hospital archives.
Results
Nine hundred eighty-five patients were entered into the febrile infant registry. Male patients comprised 55%. The mean age of patients was 12.6 months; median was 12 months. Four hundred thirty-five (78% of eligible patients) had both a UA and UCx from the same specimen, and there were 45 (10.3%) positive UCx result. Females accounted for 33 (73%) of 45 positive results. The sensitivity of UA for predicting a positive UCx result was 64% (95% confidence interval [CI], 49%-78%), whereas the specificity was 91% (95% CI, 88%-94%). The positive predictive value was 46% (95% CI, 31%-53%), with a negative predictive value of 96% (95% CI, 93%-97%).
Conclusion
Urinalysis is not reliable for the detection of urinary tract infections in febrile infants when compared with urine cultures.
9. Crowding Delays Treatment and Lengthens Emergency Department Length of Stay, Even Among High-Acuity Patients
McCarthy ML, et al. Ann Emerg Med. 2009;54:492-503.e4.
Study objective
We determine the effect of crowding on emergency department (ED) waiting room, treatment, and boarding times across multiple sites and acuity groups.
Methods
This was a retrospective cohort study that included ED visit and inpatient medicine occupancy data for a 1-year period at 4 EDs. We measured crowding at 30-minute intervals throughout each patient's ED stay. We estimated the effect of crowding on waiting room time, treatment time, and boarding time separately, using discrete-time survival analysis with time-dependent crowding measures (ie, number waiting, number being treated, number boarding, and inpatient medicine occupancy rate), controlling for patient demographic and clinical characteristics.
Results
Crowding substantially delayed patients' waiting room and boarding times but not treatment time. During the day shift, when the number boarding increased from the 50th to the 90th percentile, the adjusted median waiting room time (range 26 to 70 minutes) increased by 6% to 78% (range 33 to 82 minutes), and the adjusted median boarding time (range 250 to 626 minutes) increased by 15% to 47% (range 288 to 921 minutes), depending on the site. Crowding delayed the care of high-acuity level 2 patients at all sites. During crowded periods (ie, 90%), the adjusted median waiting room times of high-acuity level 2 patients were 3% to 35% higher than during normal periods, depending on the site and crowding measure.
Conclusion
Using discrete-time survival analysis, we were able to dynamically measure crowding throughout each patient's ED visit and demonstrate its deleterious effect on the timeliness of emergency care, even for high-acuity patients.
Full-text (free): http://www.annemergmed.com/article/PIIS019606440900239X/fulltext
10. D-dimer Testing in Patients with Suspected Pulmonary Embolism and Impaired Renal Function: Still Useful
Karami-Djurabi R, et al. Amer J Med. 2009;122:1050-1053.
Background
Determination of pretest probability and D-dimer tests are the first diagnostic steps in patients with suspected pulmonary embolism, which can be ruled out when clinical probability is unlikely and D-dimer level is normal. We evaluated the utility of D-dimer testing in patients with impaired renal function.
Methods
D-dimer tests were performed in consecutive patients with suspected pulmonary embolism and an unlikely clinical probability. Creatinine levels were assessed as clinical routine. Glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula. Correlation between D-dimer level and renal function and proportions of patients with normal D-dimer in different categories of estimated glomerular filtration rate (eGFR) were assessed. Different categories of decreasing eGFR were defined as: normal renal function (eGFR over 89 mL/min), mild decrease in eGFR (eGFR 60-89 mL/min), and moderate decrease in eGFR (eGFR 30-59 mL/min).
Results
Creatinine levels were assessed in 351 of 385 patients (91%). D-dimer levels significantly increased in 3 categories of decreasing eGFR (P = .027 and P = .021 for moderate renal impairment compared with mild renal impairment and normal renal function, respectively). Normal D-dimer levels were found in 58% of patients with eGFR above 89 mL/min, in 54% with eGFR 60-89 mL/min, and in 28% with eGFR 30-59 mL/min.
Conclusions
The specificity of D-dimer testing in patients with suspected pulmonary embolism and decreased GFR is significantly decreased. Nonetheless, performing D-dimer tests is still useful because computed tomography scanning can be withheld in a significant proportion of these patients.
11. Pediatric myocarditis: presenting clinical characteristics
Durani Y, et al. Amer J Emerg Med. 2009;27:942-947.
Objective
The objective of the study was to characterize the clinical profiles of pediatric patients with acute myocarditis and dilated cardiomyopathy (DCM) before diagnosis.
Methods
A retrospective cross-sectional study was conducted to identify patients with myocarditis and DCM who presented over a 10-year span at 2 tertiary care pediatric hospitals. Patients were identified based on the International Classification of Diseases, Ninth Revision, diagnostic codes.
Results
A total of 693 charts were reviewed. Sixty-two patients were enrolled in the study. Twenty-four (39%) patients had a final diagnosis of myocarditis, and 38 (61%) had DCM. Of the 62 patients initially evaluated, 10 were diagnosed with myocarditis or DCM immediately, leaving 52 patients who required subsequent evaluation before a diagnosis was determined. Study patients had a mean age of 3.5 years, 47% were male, and 53% were female. Common primary complaints were shortness of breath, vomiting, poor feeding, upper respiratory infection (URI), and fever. Common examination findings were tachypnea, hepatomegaly, respiratory distress, fever, and abnormal lung examination result. Sixty-three percent had cardiomegaly on chest x-ray, and all had an abnormal electrocardiogram results.
Conclusions
These data suggest children with acute myocarditis and DCM most commonly present with difficulty breathing. Myocarditis and DCM may mimic other respiratory or viral illnesses, but hepatomegaly or the finding of cardiomegaly and an abnormal electrocardiogram result may help distinguish these diagnoses from other more common pediatric illnesses.
12. The Association between Transfer of ED Boarders to Inpatient Hallways and Mortality: A 4-Year Experience
Viccellio A, et al. Ann Emerg Med. 2009;54:487-491.
We posted this pre-publication abstract in our May Lit Bits, abstract #20. Since this article was published this month, the full-text is now available online for free: http://www.annemergmed.com/article/S0196-0644(09)00238-8/fulltext
13. New Analyses From ECASS 3 Support Use of tPA Up to 4.5 Hours After Stroke
Susan Jeffrey. October 20, 2009 (UPDATED October 21, 2009) — Secondary analyses of data from the third European Cooperative Acute Stroke Study (ECASS 3) trial appear to support the use of recombinant tissue plasminogen activator (rt-PA, alteplase) to treat stroke up to 4.5 hours after symptom onset in patients without exclusions for treatment, but who miss the approved time window of 0 to 3 hours.
"Almost all our additional outcome analyses strongly support the positive primary and secondary trial results of ECASS 3," the investigators, with lead author Werner Hacke, MD, PhD, professor and chairman of the Department of Neurology at Ruprecht-Karls-Universität, Germany, conclude.
Although not significant in every analysis, all additional efficacy endpoints showed "at least a clear pattern in favor of alteplase," the authors note, in particular confirming that treatment was effective in patients regardless of stroke severity.
However, Dr. Hacke told Medscape Neurology that in his view, the most critical point to make about ECASS 3, now supported by these subanalyses, is not that the time window for tPA can safely be extended to 4.5 hours.
"It is that the concept of thrombolytic therapy in acute ischemic stroke is supported now by a very straightforward, conservative, randomized clinical trial, a trial that is more than double the size of the National Institute of Neurological Disorders and Stroke trial that was positive for the 3-hour time window," he said.
Along with a collection of pooled and meta-analyses and data from a large European registry, he said, their results bolster the concept, still questioned by some, that thrombolysis as a valid therapy for stroke. "We have 2 independent randomized clinical trials that are positive with the primary outcome in favor of rtPA, so there is no reason any more to not accept this as a scientific fact," Dr. Hacke stressed.
This new report from ECASS 3 was published online October 21 and will appear in the December issue of Lancet Neurology. ECASS 3 was supported by Boehringer Ingelheim.
14. Images in EM
Traumatic Eye Swelling
http://www.annemergmed.com/article/S0196-0644(09)00365-5/fulltext
Psychotic Woman With Painful Abdominal Distension
http://www.annemergmed.com/article/S0196-0644(09)00373-4/fulltext
15. Facemasks and Hand Hygiene to Prevent Influenza Transmission in Households: A Cluster Randomized Trial
Cowling BJ, et al. Ann Intern Med. 2009;151:437-446
Few data are available on the effectiveness of nonpharmaceutical interventions for preventing influenza virus transmission. In this cluster randomized trial of 259 people with confirmed influenza virus infection and 794 household contacts, hand washing and facemasks seemed to prevent influenza virus transmission when healthy people started these measures within 36 hours of symptom onset in an infected family member. Although adherence to the interventions varied, these findings suggest that nonpharmaceutical interventions may help to mitigate pandemic and interpandemic influenza.
Abstract: http://www.annals.org/cgi/content/abstract/151/7/437
16. Validation of a Prediction Rule for the Identification of Children with Intra-abdominal Injuries After Blunt Torso Trauma
Holmes JF, et al. Ann Emerg Med. 2009;54:528-533.
Study objective
We validate the accuracy of a previously derived clinical prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma.
Methods
We conducted a prospective observational study of children with blunt torso trauma who were evaluated for intra-abdominal injury with abdominal computed tomography (CT), diagnostic laparoscopy, or laparotomy at a Level I trauma center during a 3-year period to validate a previously derived prediction rule. The emergency physician providing care documented history and physical examination findings on a standardized data collection form before knowledge of the results of diagnostic imaging. The clinical prediction rule being evaluated included 6 “high-risk” variables, the presence of any of which indicated that the child was not at low risk for intra-abdominal injury: low age-adjusted systolic blood pressure, abdominal tenderness, femur fracture, increased liver enzyme levels (serum aspartate aminotransferase concentration over 200 U/L or serum alanine aminotransferase concentration over 125 U/L), microscopic hematuria (urinalysis over 5 RBCs/high powered field), or an initial hematocrit level less than 30%.
Results
One thousand three hundred twenty-four children with blunt torso trauma were enrolled, and 1,119 (85%) patients had the variables in the decision rule documented by the emergency physician and therefore made up the study sample. The prediction rule had the following test characteristics: sensitivity=149 of 157, 94.9% (95% confidence interval [CI] 90.2% to 97.7%) and specificity=357 of 962, 37.1% (95% CI 34.0 to 40.3%). Three hundred sixty-five patients tested negative for the rule; thus, strict application would have resulted in a 33% reduction in abdominal CT scanning. Of the 8 patients with intra-abdominal injury not identified by the prediction rule, 1 underwent a laparotomy. This patient had a serosal tear and a mesenteric hematoma at laparotomy, neither of which required specific surgical intervention.
Conclusion
A clinical prediction rule consisting of 6 variables, easily available to clinicians in the ED, identifies most but not all children with intra-abdominal injury. Application of the prediction rule to this sample would have reduced the number of unnecessary abdominal CT scans performed but would have failed to identify 1 child undergoing (a nontherapeutic) laparotomy. Thus, further refinement of this prediction rule in a large, multicenter cohort is necessary before widespread implementation.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(09)00398-9/fulltext
17. Rapid Viral Testing Promising in Pediatric Emergencies
NEW YORK (Reuters Health) Oct 19 - In children with acute febrile respiratory illness, rapid viral testing techniques may save time and reduce demands on emergency department staff, according to a review published this month in the Cochrane Database of Systematic Reviews.
Nevertheless, lead investigator Dr. Quynh Doan said in a statement that "the existing evidence is not strong enough to prove that these tests help to reduce pressure on health systems, but it certainly does look promising."
Moreover, she told Reuters Health, "Rapid viral testing in a well defined context can provide physicians with very valuable information and potentially impact on management decision." However, "emphasis must be put on 'well defined context.'"
"We must remember," she added, "that only positive rapid viral testing adds any information, as these tests can only detect a specific virus -- commonly influenza -- and the absence of this virus in the sample is in no way indicative of what is causing the illness."
Dr. Doan of the British Columbia Children's Hospital in Vancouver, Canada, and colleagues studied data from 4 trials involving 759 children who underwent rapid testing and 829 who acted as controls.
Three of the studies employed influenza testing and the remaining study used a virus panel test encompassing influenza, parainfluenza, respiratory syncytial virus and adenovirus.
The team found that overall, viral testing reduced the use of chest X-rays (relative risk, 0.77) and that there was a trend toward less antibiotic usage (relative risk, 0.89) and fewer blood and urine investigations.
Dr. Doan also pointed out that "since the rate of positive rapid viral testing varied widely between 20 and 60% of tested subjects -- depending on which studies we look at -- perhaps we should be selective in the population to be tested in order to maximize its usefulness."
"In addition," she concluded, "it is important to note that all these studies were conducted before the H1N1 era. How rapid viral testing can contribute to managing the emergency department volume surges associated with the H1N1 pandemic can only be speculated."
Cochrane Database Syst Rev 2009.
18. The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics
Vaillancourt C, et al. Ann Emerg Med. 2009;54:663-671.e1
Study objective
We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting.
Methods
We conducted this prospective cohort study in 7 Canadian regions and involved alert (Glasgow Coma Scale score 15) and stable adult trauma patients at risk for neck injury. Advanced and basic care paramedics interpreted the Canadian C-Spine Rule status for all patients, who then underwent immobilization and assessment in the emergency department to determine the outcome, clinically important cervical spine injury.
Results
The 1,949 patients enrolled had these characteristics: median age 39.0 years (interquartile range 26 to 52 years), female patients 50.8%, motor vehicle crash 62.5%, fall 19.9%, admitted to the hospital 10.8%, clinically important cervical spine injury 0.6%, unimportant injury 0.3%, and internal fixation 0.3%. The paramedics classified patients for 12 important injuries with sensitivity 100% (95% confidence interval [CI] 74% to 100%) and specificity 37.7% (95% CI 36% to 40%). The κ value for paramedic interpretation of the Canadian C-Spine Rule (n=155) was 0.93 (95% CI 0.87 to 0.99). Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule.
Conclusion
This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.
Full-text (free): http://www.annemergmed.com/article/PIIS0196064409002418/fulltext
19. Serious Bacterial Infections Uncommon in Infants Who Have Experienced an Apparent Life-Threatening Event
Mittal MK, et al. Ann Emerg Med. 2009;54:523-527.
Study objective
We determine the incidence of serious bacterial infection in infants presenting to the emergency department (ED) with an apparent life-threatening event.
Methods
This was a prospective cohort study of infants younger than 12 months who were treated at an urban children's hospital ED during 1 year and who met standard criteria for an apparent life-threatening event. Sociodemographic data, presenting features, diagnostic testing, hospital course, and final diagnosis were collected. Follow-up information was obtained 4 weeks after the visit.
Results
Of the 198 infants enrolled, 44 (22.2%) had evaluation for serious bacterial infection: urine culture 36 (18%), blood culture 38 (19%) and cerebrospinal fluid culture 18 (9%). No infant (0/198; 95% confidence interval 0% to 1.8%) was found to have bacteremia, urinary tract infection, or bacterial meningitis, which was confirmed at the 4-week interview (99% ascertainment). Two infants were found to have enteroviral meningitis.
Conclusion
The incidence of serious bacterial infection in this cohort was extremely low. Infants presenting with an apparent life-threatening event need not be subjected to a full serious bacterial infection evaluation routinely.
20. Do Not Pardon the (CPR) Interruption
Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation
Wang HE, et al. Ann Emerg Med. 2009;54:645-652.e1
Emergency cardiac care guidelines emphasize treatment of cardiopulmonary arrest with continuous uninterrupted cardiopulmonary resuscitation (CPR) chest compressions. Paramedics in the United States perform endotracheal intubation on nearly all victims of out-of-hospital cardiopulmonary arrest. We quantified the frequency and duration of CPR chest compression interruptions associated with paramedic endotracheal intubation efforts during out-of-hospital cardiopulmonary arrest.
Methods
We studied adult out-of-hospital cardiopulmonary arrest treated by an urban and a rural emergency medical services agency from the Resuscitation Outcomes Consortium during November 2006 to June 2007. Cardiac monitors with compression sensors continuously recorded rescuer CPR chest compressions. A digital audio channel recorded all resuscitation events. We identified CPR interruptions related to endotracheal intubation efforts, including airway suctioning, laryngoscopy, endotracheal tube placement, confirmation and adjustment, securing the tube in place, bag-valve-mask ventilation between intubation attempts, and alternate airway insertion. We identified the number and duration of CPR interruptions associated with endotracheal intubation efforts.
Results
We included 100 of 182 out-of-hospital cardiopulmonary arrests in the analysis. The median number of endotracheal intubation–associated CPR interruption was 2 (interquartile range [IQR] 1 to 3; range 1 to 9). The median duration of the first endotracheal intubation–associated CPR interruption was 46.5 seconds (IQR 23.5 to 73 seconds; range 7 to 221 seconds); almost one third exceeded 1 minute. The median total duration of all endotracheal intubation–associated CPR interruptions was 109.5 seconds (IQR 54 to 198 seconds; range 13 to 446 seconds); one fourth exceeded 3 minutes. Endotracheal intubation–associated CPR pauses composed approximately 22.8% (IQR 12.6-36.5%; range 1.0% to 93.4%) of all CPR interruptions.
Conclusion
In this series, paramedic out-of-hospital endotracheal intubation efforts were associated with multiple and prolonged CPR interruptions.
Full-text (free): http://www.annemergmed.com/article/PIIS0196064409005344/fulltext
21. Abstracts from ACEP’s 2009 Scientific Assembly
A. ED Doctors Rarely Adjust Antibiotic Doses for Obese Patients
By Marilynn Larkin. NEW YORK (Reuters Health) Oct 07 - Emergency department physicians rarely adjust antimicrobial medication doses for obese patients, according to research reported Tuesday at the American College of Emergency Physicians annual meeting in Boston.
"We have a one-size-fits-all dose in our minds for most antibiotics, and we tend to give that dose regardless of size and other factors that should affect dosing, like age, renal function, and body mass index," study co-researcher Dr. Michael Mullins told Reuters Health.
Dr. Mullins and his colleagues, from Washington University School of Medicine, St. Louis, analyzed the rate at which their center's emergency physicians adhered to dose adjustment guidelines for selected antibiotics established by the university's antibiotic utilization review (AUR) committee.
They reviewed data for all emergency department patients treated over a 3-month period who weighed more than 100 kg, had a body mass index greater than 40 kg/m2, and were given cefazolin, cefepime, or ciprofloxacin.
Slightly more than a thousand patients met the study criteria. Overall, they were treated with 503 doses of cefepime, 293 doses of cefazolin, and 306 doses of ciprofloxacin. Thirty received more than one antibiotic.
Based on AUR guidelines, the initial dose for these patients should be 2 g IV for cefazolin or cefepime and 800 mg IV or 750 mg PO for ciprofloxacin.
These guidelines were followed for only 48 doses of cefepime (9.5%), 12 doses of cefazolin (4.1%), and 4 doses of ciprofloxacin (1.3%).
"Obesity is an epidemic in North America in particular, and unfortunately, we're seeing more people in the obese and severely obese range than we used to," Dr. Mullins observed. "I think this problem is under-recognized by emergency physicians and other specialists."
"If you give too low a dose," he cautioned, "you'll have treatment failure even if you pick the right antibiotic--and increase the likelihood that some of the bacteria you're trying to kill will form a mutation and become less sensitive to the drug."
B. Vast Increase in ED Visits for Head Injuries Seen After Natasha Richardson's Death
Fran Lowry. October 8, 2009 (Boston, Massachusetts) — Widespread media coverage of Natasha Richardson's death from a head injury on March 18, 2009 prompted a huge increase in emergency department (ED) visits, investigators reported here at the American College of Emergency Physicians 2009 Scientific Assembly.
The actress appeared well after she hit her head in a fall while skiing at Mont Tremblant, Quebec. She initially refused medical help, saying she felt fine, but died shortly afterward.
"We see this all the time in emergency rooms," Brian Walsh, MD, from Morristown Memorial Hospital in New Jersey, told Medscape Emergency Medicine. "Coverage about a certain disease, for instance meningitis deaths in young people, can cause a big bump in visits. We thought that the publicity surrounding her tragic death would do the same thing, and we wanted to quantify that."
Dr. Walsh and his colleagues compared the daily visits for head injury for the 10 days before and after March 18 in the EDs of 19 urban, suburban, and rural hospitals in New Jersey and New York. They classified patients as having head injury based on ICD9 codes.
They found that visits to the ED for head injury increased 73% (95% confidence interval, 53% - 94%; P less than .0001) for the 10 days after March 18 compared with the 10 days before. However, by March 31, the number of ED visits for head trauma was back to the pre–March 18 level.
According to Christina Campo-Ford, PA, from Morristown Memorial Hospital, who coauthored the study with Dr. Walsh, the media can cause quite a scare. "Good Morning America ran a spot a day after Natasha Richardson died about a little girl who was hit in the head with a softball and she was fine but then she went downhill. You can't show that on Good Morning America and not expect parents to bring their children in."
Pediatricians were telling concerned parents to bring their children who fell and hit their heads to the ED "just to be safe," she said. However, although the number of people who came to the ED for head trauma increased, the number of serious head injuries did not, nor did the percentage of computed tomography (CT) scans that were performed.
"We educated patients about the pros and cons of CTs and the radiation exposure risks and so on, and we did not do CTs unnecessarily," said Ms. Campo-Ford. "However, some patients insisted on having a CT, so we couldn't refuse them."
Ms. Campo-Ford believes that Ms. Richardson's death will continue to influence ED visits for head injury.
Media attention can definitely highlight issues, Debra Houry, MD, from Emory University in Atlanta, Georgia, told Medscape Emergency Medicine. "As emergency physicians, we need to make sure that we talk about injury prevention a well, such as helmet use, as this decreases the morbidity and mortality with a head injury."
Media reporting, which used headlines such as "Stand Up and Die" when reporting Ms. Richardson's death, fuels panic reactions on the part of the public, and encourages them to go to the ED even when such visits are not necessary. "The media called it "stand up and die," so why would you not come in if you hit your head," Ms. Campo-Ford noted.
Such reporting only compounds the already serious problem of ED overcrowding, said Dr. Walsh.
Physicians should educate their patients about head trauma and what symptoms to look for. But even when they do, some patients will insist on coming into the ED and having a CT scan anyway, Dr. Alexander M. Rosenau, DO, FACEP, from Lehigh Valley Hospital in Allentown, Pennsylvania, told Medscape Emergency Medicine. Dr. Rosenau is chair of the Emergency Medicine Foundation.
He pointed out how difficult it is to persuade patients that they don't need to come to the hospital after every head injury as a result of the publicity about Ms. Richardson. "A mother brought her daughter to the ED, insisting on a CT scan because the girl had fallen off her horse about 2 days prior and had hit her head. After taking a careful history and exam, we tried to reassure the mother that a CT was not necessary, but she was not convinced."
American College of Emergency Physicians 2009 Scientific Assembly. Abstract 156. Presented October 5, 2009.
C. Shorter Wait Times in the ED Mean More Patients Stay to See a Doctor
Marilynn Larkin. NEW YORK (Reuters Health) Oct 06 - Modest decreases in emergency department (ED) waiting times can have a big impact on whether a patient stays to see a doctor or leaves without being seen, investigators said Monday at the annual meeting of the American College of Emergency Physicians in Boston.
The research is based on an analysis of all visits to the George Washington Hospital ED from 2006-2008. Dr. Mehdi Sattarian and colleagues compared wait times for walk-in patients who left without being seen, either before or after nursing triage, to waiting times (from arrival to hospital bed) for people who arrived at the hospital at the same hour and stayed to see a doctor. They also recorded the total number of patients in the ED treatment area and lobby at the hour's end, and illness severity, Dr. Sattarian said at the Boston meeting.
During the study period, 187,663 patients came to the ED, 128,430 of whom were walk-ins. (The rest came by ambulance.) Of those, 5.2% left without being seen.
Further analysis revealed the proportion of walk-in patients who left without being seen fell from 5.5% in July-December 2006 to 3.5% in July-December 2008. During the same period, mean waiting times for walk-ins decreased from 61.4 to 52.6 minutes.
The drop in the number of patients who left without being seen occurred even while the total number of patients coming to the ED in a given hour increased (from 6.9 patients in 2006 to 7.5 patients in 2008), along with the number of patients left in the ED at the end of that hour (36.5 in 2006, 39.5 in 2008).
"We saw highly significant relationships between the number of people who left without being seen and both waiting times and the total number of patients in the emergency department," Dr. Sattarian told meeting attendees. In email to Reuters Health, he attributed improvements in "front-end processes" -- for example, streamlining registration and triage -- to the decreased waiting times and concomitant increase in the number of people who stayed to see a doctor.
Improving "back-end" processes -- what happens from the time a patient is seen by a doctor to the time they're either admitted or discharged -- could have "an even greater effect" on the number of people who stay to be seen by reducing the overall number of people in the ED, Dr. Sattarian observed.
Those strategies would include decreasing the amount of time it takes for seriously ill people to be moved to a hospital bed, and "improving laboratory and radiology turnaround times," he concluded.
D. Oxygen Therapy Relieves Headache Pain in the ED, Cuts Length of Stay, Drug Use
Marilyn Larkin. NEW YORK (Reuters Health) Oct 05 - Giving high-flow oxygen therapy for 15 minutes to emergency department patients with headaches provides rapid relief and reduces hospital stays, use of CT scans, and headache pharmacotherapy, according to a pilot study.
Dr. Boris Veysman of the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School reported the results on Monday at the annual meeting of the American College of Emergency Physicians in Boston.
"Very often, when a patient comes to the emergency department with one complaint being headache, they're uncomfortable and symptomatic and they have to wait for a workup before anyone can determine the cause. A diagnosis may not even be made in the emergency department," Dr. Veysman told Reuters Health. "So we approached it from a different perspective and asked, 'What if therapy were the first thing you did (for a headache) before attempting to find a cause?' And so we tried giving oxygen therapy, because it's so widespread and safe."
In the placebo-controlled study, 17 patients were randomized to 100% oxygen at 15 L/min for 15 minutes; 14 received high flow air for 15 minutes; and 17 received no intervention prior to standard treatment. Headache intensity was assessed using a 10-point visual analog scale.
Median times to relief were significantly shorter for patients treated with oxygen (40 minutes) compared with those treated with high flow air (110 minutes) or nothing (120 minutes). Median length of stay was also significantly shorter for patients treated with oxygen (57.5 minutes) than for those treated with air (210 minutes) or nothing (180 minutes).
In addition, CT scans were ordered less frequently: for four of 17 patients (24%) who received oxygen; 11 of 14 (79%) who received air; and eight of 17 (47%) who got nothing.
Medication was given to 29% of those who received oxygen, 86% of those who received air, and 82% of those who received no treatment.
Headache intensity was significantly reduced at both 15 minutes and 30 minutes after initiation of treatment, with patients treated with oxygen realizing the greatest reductions.
"It was a small study, and our results are preliminary," Dr. Veysman stressed. "But the medical community is starting to recognize that it's important to treat discomfort even when you don't know what's causing it, as long as you feel confident the treatment won't make the patient worse. In this case, we found more relief with oxygen than with placebo, although the fact that the headache goes away doesn't necessarily mean the patient can go home."
Monday, September 21, 2009
Lit Bits: Sept 21, 2009
From the recent medical literature...
1. Validated Rules May Predict Children at Very Low Risk for Brain Injury After Head Trauma
Laurie Barclay, MD. September 18, 2009 — Validated prediction rules might help identify children at very low risk for brain injury after head trauma, according to the results of a study published online September 14 in The Lancet.
"CT imaging of head-injured children has risks of radiation-induced malignancy," write Nathan Kuppermann, from University of California, Davis Medical Center in Sacramento, and colleagues from the Pediatric Emergency Care Applied Research Network. "Our aim was to identify children at very low risk for clinically important traumatic brain injuries (ciTBI) for whom CT might be unnecessary."
The study sample consisted of 42,412 patients younger than 18 years of age with Glasgow Coma Scale scores of 14 or 15 who presented at 25 North American emergency departments within 24 hours of head trauma. The investigators derived and validated age-specific prediction rules for ciTBI, defined as death from traumatic brain injury, neurosurgery, intubation for longer than 24 hours, or hospital admission for 2 or more nights.
Among children younger than 2 years of age, 8502 were in the derivation population and 2216 in the validation population, and among children 2 years of age and older, there were 25,283 and 6411, respectively. CT scans were performed in 14,969 children (35.3%); 376 children (0.9%) were diagnosed with ciTBIs and 60 (0.1%) underwent neurosurgery.
For children younger than 2 years, the prediction rule was normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 seconds, nonsevere injury mechanism, no palpable skull fracture, and acting normally according to the parents. In the validation population, this rule had a negative predictive value for ciTBI of 1176/1176 (100.0%; 95% confidence interval [CI], 99.7 - 100.0) and a sensitivity of 25/25 (100%; 95% CI, 86.3 - 100·0). This low-risk group consisted of 167 (24.1%) of 694 CT-imaged patients younger than 2 years of age.
For children 2 years of age and older, the prediction rule was normal mental status, no loss of consciousness, no vomiting, nonsevere injury mechanism, no signs of basilar skull fracture, and no severe headache. This rule had a negative predictive value of 3798/3800 (99.95%; 95% CI, 99.81 - 99.99) and a sensitivity of 61/63 (96.8%; 95% CI, 89.·0 - 99.6). Of 2223 CT-imaged patients 2 years of age and older, 446 (20.1%) were in this low-risk group.
"Neither rule missed neurosurgery in validation populations," the study authors write. "These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated."
Using these prediction rules, CT scans and the attendant radiation exposure could be eliminated in 1 in 4 children younger than 2 years and in 1 in 5 children older than 2 years presenting with head trauma.
Limitations of this study include lack of CT scans on all patients and lack of assessment of long-term neurocognitive outcomes.
"Application of these rules could limit CT use, protecting children from unnecessary radiation risks," the study authors conclude. "Furthermore, these rules provide the necessary data to assist clinicians and families in CT decision making after head trauma."
In an accompanying Comment, Patricia C. Parkin, MD, and Jonathon L. Maguire, MD, from the Hospital for Sick Children, University of Toronto Faculty of Medicine in Ontario, note that decision aids offer structured presentations of options and outcomes.
"Many decisions, even in acute-care settings, are sensitive to patients' values and preferences," Drs. Parkin and Maguire write. "Perhaps as this field moves forward to assessment of the effect of the rules on physicians' behavior and clinical outcomes (impact analysis), clinicians and investigators might consider involving patients in the decision-making process. Then, when asking the question 'should my head-injured child have a CT scan?', parents can weigh the probability of a clinically important traumatic brain injury with the probability of harm from ionizing radiation from the CT scan."
The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services, funded this study. The study authors and editorialists have disclosed no relevant financial relationships.
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19758692
2. Multitasking Muddles the Mind?
By Constance Holden. ScienceNOW Daily News. 25 August 2009
Bad news for people who like to text their BFFs while surfing the Web for some new shoes and watching the latest episode of Project Runway. Scientists who've conducted what they say is the first-ever study of chronic multitaskers found that cognitive performance declines when people try to pay attention to many media channels at once.
Although media multitasking has become more and more prevalent, no one knows how chronic media immersion affects cognitive functioning. So a team headed by psychologist Eyal Ophir of Stanford University in Palo Alto, California, identified 19 "heavy media multitaskers" (HMMs) and 22 "light media multitaskers" (LMMs) among a group of students based on how often they reported simultaneously using media such as television, cell phones, computer games, and videos.
The researchers then gave subjects in the two groups tests to see how well they could sift relevant information from the environment, filter out irrelevant information in their memories, and quickly switch between cognitive tasks. One filtering test, for example, required viewers to note changes in red rectangles while ignoring changes in blue rectangles in the same pictures. In the task-switching experiment, participants were presented with images of paired numbers and letters and had to switch back and forth between classifying the numbers as even or odd and classifying the letters as vowels or consonants.
The HMMs did worse than the LMMs across the board. Surprisingly, says co-author and sociologist Clifford Nass, "They're bad at every cognitive control task necessary for multitasking." They were more easily distracted by irrelevant stimuli, and although their memories were no worse than those of the LMMs, they had more difficulty in selecting stored information that was relevant to the task at hand. In one filtering test, for example, the LMMs took 323 milliseconds to discern the correct answer, but the HMMs averaged 400 milliseconds.
Nass says the study has a disturbing implication in an age when more and more people are simultaneously working on a computer, listening to music, surfing the Web, texting, or talking on the phone: Access to more information tools is not necessarily making people more efficient in their intellectual chores. Also disconcerting, he notes, is that "people who chronically multitask believe they're good at it." The findings are reported this week in the Proceedings of the National Academy of Sciences.
Daphne Bavelier, a cognitive scientist at the University of Rochester in New York state, says the research presents a puzzle about the brain's ability to learn from experience. Bavelier has discovered that people who play action video games get better at the kind of task-switching those games require. In contrast, Bavelier says, the poor performance of multitaskers in the new study suggests that more experience doesn't always translate to improved performance.
It's still not clear, however, that multitasking really scrambles the brain. It's also possible that people with poor filtering and attentional abilities are more prone to multitasking to begin with. Anthony Wagner, a psychologist in the Stanford group, says he suspects that constant jumping among different media offers instant rewards that reinforce "exploratory" behavior at the expense of the ability to concentrate on a particular task.
Want more on how the brain works? See John Medina, Brain Rules: 12 Principles for Surviving and Thriving at Work, Home, and School (Seattle: Pear Press, 2008). Amazon See also the book’s webpage
3. Opioids May Be Unnecessary Adjuncts to Proposal
Randomized Clinical Trial of Propofol With and Without Alfentanil for Deep Procedural Sedation in the Emergency Department
Miner JR, et al. Acad Emerg Med. 2009;16:825–834.
Objectives: The objectives were to compare the efficacy, occurrence of adverse events, and recovery duration of propofol with and without alfentanil for use in procedural sedation in the emergency department (ED).
Methods: This was a randomized nonblinded prospective trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were given intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients received 1 mg/kg propofol either with or without a supplemental dose of 10 μg/kg alfentanil for deep procedural sedation. Doses, vital signs, nasal end-tidal CO2 (ETCO2), pulse oximetry, and bispectral electroencephalographic (EEG) analysis scores were recorded. Subclinical respiratory depression was defined as a change in ETCO2 of greater than 10 mmHg, an oxygen saturation of less than 92% at any time, or an absent ETCO2 waveform at any time. Clinical events related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure or had recall of the procedure.
Results: A total of 150 patients were enrolled; 146 underwent sedation and were included in the analysis. Seventy-four patients received propofol, and 71 received propofol with alfentanil. No clinically significant complications were noted. Subclinical respiratory depression was seen in 24/74 patients in the propofol group and 30/71 patients in the propofol/alfentanil group (effect size = 9.8%, 95% CI = –5.8% to 25.5%). Clinical signs of respiratory depression included an increase in supplemental oxygen use in 25 of the 74 propofol patients and 31 of the 71 propofol/alfentanil patients (effect size 9.9%, 95% CI = –5.9% to 25.7%), the use of bag-valve mask apparatus in seven patients in the propofol group and 12 in the propofol/alfentanil group (effect size = 5.6%, 95% CI = –3.5% to 18.4%), airway repositioning in 13 propofol patients and 20 propofol/alfentanil patients (effect size = 10.6%, 95% CI = –3.0% to 24.2%), and stimulation to induce breathing in 11 propofol patients and 20 propofol/alfentanil patients (effect size = 13.3%, 95% CI = 0.1% to 26.5%). The total time of the procedure was longer for the alfentanil/propofol group (median = 11 minutes, range = 5–22 minutes) than for the propofol group (median = 9 minutes, range = 1 to 43 minutes; effect size = 1.93 minutes, 95% CI = 0.73 to 2.58, p = 0.02). Pain during the procedure was reported by 10 of the 74 patients in the propofol group and 7 of the 71 patients in the propofol/alfentanil group (effect size = 4.5%, 95% CI = –6.8% to 14.1%). Recall of some part of the procedure was reported by 12 patients in the propofol group and 9 in the propofol/alfentanil group (effect size = 3.5%, 95% CI = –7.9% to 15.0%). All procedures were successfully completed.
Conclusions: The use of supplemental alfentanil with propofol for procedural sedation did not result in a difference in reported pain or recall immediately after the procedure. There was an increase in the proportion of patients who required stimulation to induce respiration during the procedure in patients who received propofol with supplemental alfentanil. The addition of supplemental opioid to procedural sedation with propofol does not appear beneficial.
4. Most Mistakes in the Emergency Department Caused by Human Error
Fran Lowry. September 17, 2009 — Most of the mistakes in the emergency department (ED) that have the potential to compromise patient safety are caused by human error, according to a study published online September 18 in BMC Emergency Medicine.
"[EDs] are challenging hospital settings with regard to patient safety. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety," Marleen Smits, MD, from the Netherlands Institute for Health Services Research, Utrecht, and colleagues write. "This can only be achieved if interventions tackle the dominant underlying causes."
The aim of this study was to examine the nature and causes of unintended events in EDs and the relationship between type of event and causal factor structure.
The study evaluated medical errors in the EDs of 10 hospitals in the Netherlands (1 university hospital, 3 tertiary teaching hospitals, and 6 general hospitals) for 8 to 10 weeks. ED staff members were asked to report all unintended events, no matter how trivial or commonplace, that could have harmed or did harm a patient.
A total of 522 events were reported, ranging from 46 to 71 per ED, for an average of 52 reports. Most of the reports (85%) were made by nurses; resident physicians or consultants reported 13% of the unintended events, and clerical staff reported 2%. The reporter was directly involved in 83% of the unintended events. Most occurred during daytime hours (44%); 34% occurred during evening and night, and for 22% of the unintended events, the time of occurrence was unknown or unspecified by the reporter.
Most errors occurred during medical examinations or lab tests (36%). More than half of the unintended events (56%) had consequences for the patient, and in 45% of these instances, the patient suffered some inconvenience, such as prolonged waiting time. One third of patients received suboptimal care, such as a delay in starting antibiotic treatment. The consequences of error were more severe in the 8% of patients who required an extra intervention, the 6% of patients who suffered pain, and the 3% of patients who suffered a physical injury, Dr. Smits and colleagues write.
Most root causes of error were human (60%), followed by organizational (25%) and technical (11%) causes. Nearly half of the root causes could be attributed to other departments either in or outside of the hospital.
In citing limitations to their study, the investigators note that, because the reporting was not anonymous, it is possible that certain mistakes were underreported. "This may have biased the results towards the reporting of less significant events, events without consequences for the patient, and errors originating in other departments, because these are 'safer' to report."
In addition, most errors were reported by nurses, and therefore the study results give information about events that are mainly related to nursing care and less to care by residents and specialists in the ED.
Although the majority of errors had no consequences for the patient or resulted in only minor inconveniences, their accumulated effect on patient well-being is likely to be large, the authors write. They conclude: "Event reporting gives insight into diverse unintended events. The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments."
Dr. Smits and colleagues have disclosed no relevant financial relationships.
BMC Emerg Med. 2009;9:16 http://www.biomedcentral.com/1471-227X/9/16/abstract
5. More Disturbing News About Prehospital Trauma Intubation
Prehospital intubation failed in 31% of trauma patients in a large urban trauma system.
Cobas MA, et al. Anesth Analg 2009 Aug; 109:489.
BACKGROUND: Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI.
METHODS: A prospective observational study was conducted evaluating trauma patients who had emergency prehospital airway management and were admitted during the period between August 2003 and June 2006. The PHI was considered a failure if the initial assessment determined improper placement of the endotracheal tube or if alternative airway management devices were used as a rescue measure after intubation was attempted.
RESULTS: One-thousand-three-hundred-twenty patients had emergency airway interventions performed by an anesthesiologist upon arrival at the trauma center. Of those, 203 had been initially intubated in the field by emergency medical services personnel, with 74 of 203 (36%) surviving to discharge. When evaluating the success of the intubation, 63 of 203 (31%) met the criteria for failed PHI, all of them requiring intubation, with only 18 of 63 (29%) surviving to discharge. These patients had rescue airway management provided either via Combitube® (n = 28), Laryngeal Mask Airway® (n = 6), or a cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not. Several other variables, including age, gender, weight, mechanism of injury, presence of facial injuries, and emergency medical services were not correlated with an increased incidence of failed intubations.
CONCLUSION: This prospective study showed a 31% incidence of failed PHI in a large metropolitan trauma center. We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.
6. Intervention for Non–ST-Segment-Elevation Acute Coronary Syndromes: What Difference Does a Day Make?
Interventions performed immediately or deferred to the next working day resulted in similar outcomes.
The advantages of invasive over conservative strategies for managing non–ST-segment-elevation acute coronary syndromes (NSTEACS) are established, but the optimal timing of intervention is undetermined. To find out whether immediate catheterization compared with delayed intervention reduces incident MI, investigators in France randomized 352 patients hospitalized for NSTEACS to undergo interventional treatment either immediately upon admission or on the next working day (8–60 hours after enrollment).
Median time from randomization to sheath insertion was 70 minutes in the immediate-intervention group and 21 hours in the delayed-intervention group. The primary endpoint, peak troponin level during hospitalization, did not differ significantly between the two strategies (median peak levels, 2.1 ng/mL and 1.7 ng/mL in the immediate- and delayed-intervention groups, respectively). The rate of the composite of death, MI, and urgent revascularization at 1 month also did not differ significantly between the two groups (13.7% and 10.2%, respectively). However, median hospital stay was significantly shorter with the immediate strategy than with the delayed strategy (55 hours vs. 77 hours).
Comment: These findings suggest that in patients with non–ST-segment-elevation acute coronary syndromes, immediate versus delayed intervention does not result in increased MI rates, as defined by peak troponin levels. Accordingly, rapid or urgent intervention appears to be appropriate in unstable patients, whereas logistical and cost concerns may factor into decisions about whether to defer intervention in stable patients.
— Beat J. Meyer, MD. Published in Journal Watch Cardiology September 16, 2009. Citation:
Montalescot G et al. Immediate vs delayed intervention for acute coronary syndromes: A randomized clinical trial. JAMA 2009 Sep 2; 302:947. http://www.ncbi.nlm.nih.gov/pubmed/19724041
7. Useful Clinical Aphorisms to Practice By
“Clinical aphorisms that have proved useful for me during more than 30 years of inpatient and outpatient attending at 4 US medical schools”
Alpert JS. Amer J Med. 2009;122:700-701;789-790.
Rule 1: Common things occur commonly. I make this point continuously to medical students and residents. Sometimes young clinicians will suggest an unusual diagnosis for a patient with the hope of being the only doctor to make the correct diagnosis. More experienced clinicians believe the correct diagnosis is usually something common. For example, consider a patient with an enlarged spleen. In North America, splenomegaly rarely results from entities such as primary lymphoma of the spleen or malaria. Rather, splenomegaly is often caused by portal hypertension or mononucleosis. One of my first, and best, residents during my internship told me “If it looks like a horse, whinnies like a horse, and smells like a horse, don't expect a zebra to appear” (Stone N, MD, personal communication, 1970).
Rule 2: Common sense occurs uncommonly. This aphorism is usually attributed to Voltaire. Over the years, I have seen many violations of this important rule in clinical medicine. Physicians should exercise common sense before ordering tests or performing therapeutic interventions. Examples abound in support of this rule. Recently, I saw a 60-year-old diabetic woman in my office. She had been admitted to our hospital several weeks earlier with a single bout of rest angina. Her cardiac catheterization revealed modest coronary arterial stenoses, and she was placed on medical therapy with brand name medications by another cardiologist: a statin, an angiotensin receptor blocker, and clopidogrel. Subsequently, I first saw her in my office. At that time, she and her family told me that they had paid more than $500 for 1 month's supply of the medicines that had been prescribed in the hospital. I quickly altered her regimen to include generic forms of a statin and an angiotensin-converting enzyme inhibitor, as well as 325 mg of aspirin. These new generic prescriptions would cost the patient less than $20 per month. Common sense should have been used earlier by the inpatient attending physician simply by informing the patient that generic brands cost less than brand name pharmaceuticals. As noted by Harvey Cushing (1869-1939), “Three-fifths of the practice of medicine depends on common sense, knowledge of people and of human reactions.” I would add knowledge of the patient's ability to pay for the medicines prescribed.
Rule 3: The less a procedure is indicated the more likely that its use will be accompanied by complications. This rule advises clinicians to ensure that every procedure or test ordered has a reasonable probability of altering patient management. An example of this aphorism in practice involved a healthy 55-year-old man without coronary heart disease risk factors. He became anxious when a neighbor had an acute myocardial infarction. His doctor suggested that he undergo a coronary calcium computed tomography scan. This test revealed modest coronary calcifications. The patient became more anxious when he heard the results of his computed tomography scan, and he convinced his physician that he needed a coronary angiogram. The angiogram was unremarkable, but the catheterization resulted in a large groin hematoma and pseudoaneurysm that required vascular surgical repair. If I had been involved in this patient's initial care, reassurance or, at most, a Bruce protocol electrocardiographically monitored exercise test, would have been my approach.
Rule 4: Listen between the lines.
Rule 5: Seven minutes is an inadequate amount of time to spend on a patient visit.
Rule 6: Practicing good medicine requires a triad of equal doses of hard work, kindness, and honesty.
Rule 7: No individual has a monopoly on truth.
Rule 8: Obtaining informed consent from a patient for a procedure can help or hurt the patient.
Rule 9: Physician, heal thyself.
Rule 10: Respect your fellow health care workers; they are your most important clinical asset.
Rule 11: Admission to an intensive care unit in a tertiary care hospital can be a harrowing experience for the patient.
Rule 12: True, true, and unrelated.
Rule 13: The enemy of good is perfect.
Rule 14: Physician error is often the result of overconfidence.
Rule 15: It is a privilege to practice medicine.
Full-texts (free): http://www.amjmed.com/article/S0002-9343(09)00223-X/fulltext
http://www.amjmed.com/article/S0002-9343(09)00222-8/fulltext
8. Switch to Part D Limits Access to Psychiatric Medications, Increases ED Use
Caroline Cassels. September 9, 2009 — The switch from Medicaid drug coverage to Medicare Part D has restricted access to psychiatric medications and contributed to a subsequent high rate of emergency room visits among patients with mental health disorders, new research suggests.
A study conducted at Harvard Medical School in Boston, Massachusetts, shows that since January 2006, when the switch occurred, 44% of psychiatric patients reported difficulties in accessing medications. In addition, the likelihood of visiting an emergency department was significantly higher for psychiatric patients who experienced a medication access problem than for those who did not (odds ratio, 1.75; mean P = .003).
"We were surprised by the high rate of reports of access problems — 44% of patients reported some type of access issue, and that's a pretty large number, even allowing for the fact that it is a relatively new initiative and you would expect a certain amount of miscommunication and confusion," lead author Haiden Huskamp, PhD, told Medscape Psychiatry.
The study is published in the September issue of Psychiatric Services.
Utilization Management
It is estimated that approximately one third of individuals dually eligible for Medicare and Medicaid benefits have a mental disorder. For these individuals, said Dr. Huskamp, pharmacotherapy is a key element of their treatment.
The authors point out that "dual eligibles" received coverage for prescription drugs through the Medicaid program in which patients paid little or none of the cost of their medications
However, under the Medicare Prescription Drug Improvement and Modernization Act of 2003, drug coverage for this population was shifted from Medicaid to the new Medicare Part D program, and all of these individuals were randomly assigned to a private Part D plan with associated premiums and other utilization management tools including prior authorization and stepped care.
"The creation of Part D represented an important switch for dually eligible patients. Now instead of getting their drugs from Medicaid, patients had to get their medications through private Part D plans, which had different coverage policies and restrictions," said Dr. Huskamp.
Dr. Huskamp added her group was particularly concerned about the potential effect of this policy change on the dually eligible psychiatric population.
"This is a particularly vulnerable population, and there was some concern that switching to a Part D plan that may have restrictions on the medications they were taking could have implications for the quality of care they received. So we wanted to look and see what was happening in this particular group," said Dr. Huskamp.
Drugs Not Covered or Approved
For the study, the researchers randomly sampled psychiatrists from the American Medical Association's Physicians Masterfile who reported on experiences of 1 dually eligible patient in the 9 to 12 months after Part D implementation.
Each psychiatrist was randomly assigned 1 of 21 start days and times to report on the next dually eligible patients treated during the psychiatrist's last typical work week. Information on patients' sociodemographics, treatment setting, diagnosis, clinical characteristics, and ability to access medication was gathered.
The researchers also obtained information on emergency department visits related to participants' psychiatric illness, as well as any psychiatric hospitalizations since January 1, 2006. A total of 908 patients were included in the final study sample. Of these 57% were women and 62% were between 41 and 64 years old. Almost two thirds had a diagnosis of either schizophrenia or bipolar disorder.
Overall, 400 individuals (44%) had some type of problem accessing their medications. Investigators found that 318 individuals (35%) were unable to access clinically indicated refills or new prescriptions because the drugs were not covered or approved.
In addition, 170 individuals (19%) were stable on a clinically desired or indicated medication but switched to a different drug because refills were not covered or approved, and 200 participants (22%) had problems accessing medications because of copayments.
Compared with a matched sample of dually eligible patients whose medication access was not disrupted, those with difficulty accessing their medication were more likely to incur a visit to the hospital emergency department related to their psychiatric illness.
It may be, said Dr. Huskamp, that switching from Medicaid to Part D had some unanticipated and unintended negative effects including the possibility of negative clinical outcomes, as indicated by a high rate of emergency room visits and increased health costs for non-drug-related health services.
"I think our study provides a red flag that some attention needs to be devoted to this issue. We need to examine the Part D data (which are currently not publicly available) so we can take a detailed look at utilization patterns and health outcomes for this population," said Dr. Huskamp.
"Certainly emergency department use is an indicator that things are not going well for patients, but having more concrete measures would be helpful to get a clearer understanding of how this policy change has affected patients' mental health status and functioning," she added.
Psychiatr Serv. 2009;60:1169–1174. http://www.ncbi.nlm.nih.gov/pubmed/19723730
9. Aspiration vs. Chest Tube for Spontaneous Pneumothorax: No Difference in Outcome
NEW YORK (Reuters Health) Sep 10 - For primary spontaneous pneumothorax in adults, percutaneous aspiration and standard chest tube drainage have similar outcomes, according to an abstract of a report from the Cochrane Database of Systematic Reviews.
The abstract appears in the September issue of the Annals of Emergency Medicine, in the journal's Evidence-Based Emergency Medicine section.
"The management of primary spontaneous pneumothorax is controversial, with bodies such as the American College of Chest Physicians recommending formal chest tube drainage for patients requiring intervention, (and) the British Thoracic Society recommending simple percutaneous aspiration as the primary management strategy," section editor Dr. John W. Hafner, of the University of Illinois College of Medicine at Peoria, told Reuters Health.
The abstract is based on a Cochrane Review titled "Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults," written in 2007 by Abel Wakai and colleagues. That report reviewed studies published through 2006.
Of 1735 reports of randomized trials initially identified by the researchers as potentially relevant, only one, involving 60 patients, met all the criteria for study design and quality.
In this one trial, there was no significant difference in the immediate success rate for simple percutaneous aspiration compared with intercostal chest tube drainage (relative risk (RR)=0.93).
Similarly, there were no significant differences between the two approaches in rates of early failure at 1 week (RR=1.12), 1-year success (RR=1.02), length of hospital stay (mean group difference, 1.09 days), or pleurodesis by thoracoscopic talc poudrage within a year (RR=0.95).
Simple percutaneous aspiration did reduce patients' number of hospitalizations (RR=0.52).
"Widespread use of simple percutaneous aspiration (for) primary spontaneous pneumothorax could limit more invasive chest tube placement that requires hospitalization and increased healthcare costs," Dr. Hafner said.
"Unfortunately," he added, "due to the small size of the single study in the review, the general application of these results remains in question and requires further study with a larger study sample."
Ann Emerg Med 2009;54:458-460.
10. FDA Adds Boxed Warning to Injectable Promethazine
September 16, 2009 — The US Food and Drug Administration (FDA) is requiring manufacturers of the injectable form of promethazine hydrochloride to add a boxed warning to the drug's labeling that highlights the risk of serious tissue injury if the drug is administered incorrectly.
"Intravenous administration of promethazine can cause severe tissue injury, including gangrene, requiring fasciotomy, skin graft, and/or amputation," according to information for healthcare professionals posted on the FDA Web site. In addition, "Severe tissue injury can occur from perivascular extravasation, unintentional intra-arterial injection, and intraneuronal or perineuronal infiltration."
The preferred route of administration is deep intramuscular injection. Subcutaneous and intra-arterial injection are contraindicated.
Based on these known risks, the FDA advises clinicians to “effectively communicate” the risk of severe tissue injury to the patient when promethazine is administered intravenously.
In an alert sent today from MedWatch, the FDA's safety information and adverse event reporting program, the FDA also advises healthcare professionals to monitor patients who have received promethazine via contraindicated routes of administration for signs and symptoms of potential tissue injury, including burning or pain at the site of injection, phlebitis, swelling, and blistering. And if a patient complains of pain during injection, administration should cease immediately.
The FDA is also requiring a revision in the Dosage and Administration section of the drug's labeling to highlight "specific recommendations for the maximum concentration (25 mg/mL) and rate of administration (25 mg/min) when intravenous administration of promethazine is required." The 50 mg/mL is for deep intramuscular injection only, and the intravenous line should be checked to ensure it is properly functioning with a rate of 25 mg per minute.
Promethazine hydrochloride injection, USP, first introduced to the market in 1956, is approved for a variety of uses including allergic reactions, sedation, motion sickness, nausea and vomiting associated with anesthesia and surgery, and as an adjunct to analgesics for control of postoperative pain.
Current prescribing information for promethazine does contain information on the risk of tissue injury, but it was not highlighted in a boxed warning.
More information can be found on the FDA Web site. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm182500.htm
11. Antivirals Slightly Shorten Duration of Seasonal Flu in Children
Treatment was well tolerated and slightly reduced transmission to household contacts.
Children may shed influenza virus longer than adults and are a main source of spread to household contacts. To examine the effect of antiviral treatment in children, researchers performed a meta-analysis of seven randomized controlled trials of neuraminidase inhibitors for outpatient treatment of seasonal influenza and postexposure prophylaxis in children aged 12 years or younger.
Two trials evaluated outpatient treatment with oseltamivir and two with zanamivir within 36 or 48 hours of onset of influenza-like symptoms. In a total of 1766 children (1243 with confirmed and 523 with suspected influenza), treatment reduced median time to symptom resolution, return to normal activities, or both by 0.5 to 1.5 days; reductions were statistically significant in one oseltamivir trial and one zanamivir trial. Recovery was significantly faster in children with confirmed influenza than in those with suspected influenza.
Three trials evaluated 10-day courses of oseltamivir (1 trial) or zanamivir (2 trials) for postexposure prophylaxis in 863 children. Treatment was associated with an 8% decrease in the incidence of symptomatic influenza (number needed to treat to prevent 1 additional case, 13). Compliance was high — 97% of children took more than 8 of the 10 doses of zanamivir and 90% took all 10 doses of oseltamivir. Both drugs were well tolerated; however, the incidence of vomiting was 5% higher with oseltamivir than with placebo. No deaths were reported.
Comment: This meta-analysis suggests that neuraminidase inhibitors are well tolerated in children and that they slightly reduce symptom duration and household transmission of seasonal influenza. Whether these data apply to the 2009 influenza A (H1N1) virus pandemic is not clear. Given that H1N1 disease has been mild so far in otherwise healthy children older than age 5 years, neuraminidase inhibitors cannot be recommended for routine outpatient treatment in low-risk children older than 5 years with uncomplicated suspected 2009 H1N1 influenza (JW Pediatr Adolesc Med Aug 21 2009).
— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine September 4, 2009. Citation: Shun-Shin M et al. Neuraminidase inhibitors for treatment and prophylaxis of influenza in children: Systematic review and meta-analysis of randomised controlled trials. BMJ 2009 Aug 10; 339:b3172. (http://dx.doi.org/10.1136/bmj.b3172)
12. Combined Corticosteroid and Antiviral Treatment for Bells Palsy: Two Big Reviews
A. A Systematic Review and Meta-analysis
de Almeida JR, et al. JAMA. 2009;302:985-993.
Context: New evidence has emerged regarding the use of corticosteroids and antiviral agents in Bell palsy.
Objective: To estimate the association of corticosteroids and antiviral agents with the risk of unsatisfactory facial recovery in patients with Bell palsy.
Data Sources: The search included MEDLINE, EMBASE, CENTRAL, PsychInfo, CINAHL, Web of Science, PAPERSFIRST, PROCEEDINGSFIRST, and PROQUEST to identify studies up to March 1, 2009.
Study Selection and Data Extraction: Eligible studies were randomized controlled trials comparing treatment with either corticosteroids or antiviral agents with a control and measuring at least 1 of the following outcomes: unsatisfactory facial recovery (4 months), unsatisfactory short-term recovery (6 weeks to 4 months), synkinesis and autonomic dysfunction, or adverse effects. Two reviewers extracted data on study characteristics, methods, and outcomes. Disagreement was resolved by consensus.
Results: Eighteen trials involving 2786 patients were eligible. Regression analysis identified a synergistic effect when corticosteroids and antiviral agents were administered in combination compared with alone (odds ratio for interaction term, 0.54 [95% confidence interval {CI}, 0.35-0.83]; P = .004). Meta-analysis using a random-effects model showed corticosteroids alone were associated with a reduced risk of unsatisfactory recovery (relative risk [RR], 0.69 [95% CI, 0.55-0.87]; P = .001) (number needed to treat to benefit 1 person, 11 [95% CI, 8-25]), a reduced risk of synkinesis and autonomic dysfunction (RR, 0.48 [95% CI, 0.36-0.65]; P less than .001) (number needed to treat to benefit 1 person, 7 [95% CI, 6-10]), and no increase in adverse effects. Antiviral agents alone were not associated with a reduced risk of unsatisfactory recovery (RR, 1.14 [95% CI, 0.80-1.62]; P = .48). When combined with antiviral agents, corticosteroids were associated with greater benefit (RR, 0.48 [95% CI, 0.29-0.79]; P = .004) than antiviral agents alone. When combined with corticosteroids, antiviral agents were associated with greater risk reduction of borderline significance compared with corticosteroids alone (RR, 0.75 [95% CI, 0.56-1.00]; P = .05).
Conclusions: In Bell palsy, corticosteroids are associated with a reduced risk of unsatisfactory recovery. Antiviral agents, when administered with corticosteroids, may be associated with additional benefit.
B. The benefits of steroids versus steroids plus antivirals for treatment of Bell’s palsy: a meta-analysis
Quant EC, et al. BMJ 2009;339:b3354
Objective: To determine whether steroids plus antivirals provide a better degree of facial muscle recovery in patients with Bell’s palsy than steroids alone.
Design Meta-analysis.
Data sources: PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for studies published in all languages from 1984 to January 2009. Additional studies were identified from cited references.
Selection criteria: Randomised controlled trials that compared steroids with the combination of steroids and antivirals for the treatment of Bell’s palsy were included in this study. At least one month of follow-up and a primary end point of at least partial facial muscle recovery, as defined by a House-Brackmann grade of at least 2 (complete palsy is designated a grade of 6) or an equivalent score on an alternative recognised scoring system, were required.
Review methods: Two authors independently reviewed studies for methodological quality, treatment regimens, duration of symptoms before treatment, length of follow-up, and outcomes. Odds ratios with 95% confidence intervals were calculated and pooled using a random effects model.
Results: Six trials were included, a total of 1145 patients; 574 patients received steroids alone and 571 patients received steroids and antivirals. The pooled odds ratio for facial muscle recovery showed no benefit of steroids plus antivirals compared with steroids alone (odds ratio 1.50, 95% confidence interval 0.83 to 2.69; P=0.18). A one study removed analysis showed that the highest quality studies had the greatest effect on the lack of difference between study arms shown by the odds ratio. Subgroup analyses assessing causes of heterogeneity defined a priori (time from symptom onset to treatment, length of follow-up, and type of antiviral studied) showed no benefit of antivirals in addition to that provided by steroids.
Conclusions: Antivirals did not provide an added benefit in achieving at least partial facial muscle recovery compared with steroids alone in patients with Bell’s palsy. This study does not, therefore, support the routine use of antivirals in Bell’s palsy. Future studies should use improved herpes virus diagnostics and newer antivirals to assess whether combination therapy benefits patients with more severe facial paralysis at study entry.
Full-text (free): http://www.bmj.com/cgi/content/full/339/sep07_1/b3354
13. Rapid Urine Chlamydia Test for Males Is Highly Sensitive
When tested on first-void urine samples, a new rapid chlamydia test had a sensitivity of 82%.
Nadala E-C et al. BMJ 2009 Jul 28; 339:b2655.
Conclusions: The performance of the new Chlamydia Rapid Test with first void male urine samples indicates that it would be an effective diagnostic tool for chlamydial infection in men. The availability of test results within an hour allows for immediate treatment and contact tracing, potentially reducing the risks of persistent infection and onward transmission. The test could also provide a simple and reliable alternative to nucleic acid amplification assays for testing of male urine in chlamydial screening programmes in high prevalence settings.
Full-text (free): http://www.bmj.com/cgi/content/full/339/jul28_2/b2655
14. Time to Abandon the "Shotgun Approach" to Syncope Evaluation
Many unnecessary and costly tests are obtained to evaluate elders with syncope.
Syncope is common, challenging, and expensive; it accounts for 1% to 3% of all U.S. emergency department visits and about 6% of inpatient admissions, with an estimated annual healthcare cost of US$2.5 billion. Most causes of syncope are benign, but the diagnostic challenge is to identify those that are life-threatening, particularly cardiovascular causes. Despite thorough and costly work-ups, syncope etiology remains undetermined in 40% of patients after their initial evaluations.
Researchers at Yale University performed a retrospective cohort study in 2106 consecutive older patients (age, 65) who were admitted with syncope. The investigators reviewed how often various diagnostic tests were ordered and how often such results helped to establish the etiology of syncope or affected diagnosis and management. They calculated the cost per test that affected diagnosis or management and whether use of the San Francisco Syncope Rule (SFSR; Ann Emerg Med 2004; 43:224) resulted in improved cost efficiency or diagnostic yield.
Postural blood pressure measurement (i.e., orthostatics), performed in only 38% of cases, affected diagnosis and management in about 25% of patients and identified syncope etiology in 15% to 21% of syncopal episodes; it returned the highest diagnostic yield and was the most cost-effective test ($17–$21). Cardiac enzymes, head computed tomography (CT) scans, carotid ultrasound (US), and electroencephalography (EEG) had little effect on diagnosis or management (less than 5%); rarely helped determine syncope etiology (less than 2%); and were among the least cost-effective tests: EEG ($33,000), head CT ($25,000), cardiac enzymes ($22,000), and carotid US ($20,000). Use of the SFSR led to higher diagnostic yield and better cost-effectiveness for most cardiac tests.
Comment: These findings underscore the importance of prioritizing diagnostic testing based on an initial standard evaluation, which should include a complete history and physical examination (including orthostatic blood pressure measurements and an electrocardiogram). Neurological tests (i.e., head magnetic resonance imaging or CT, EEG, and carotid US) shouldn't be performed, unless a neurological disease or event is suspected, based on the initial evaluation.
I am confident that the results of this study could be replicated in a variety of clinical settings. Although "shot gunning" multiple tests might reassure patients that they are getting the best care money can buy, we must take more financial stewardship of our resources, follow evidence-based guidelines, and be willing to live with some diagnostic uncertainty. Our healthcare system and economy can no longer support indiscriminate ordering of tests. More studies should be designed to evaluate cost-effectiveness, and those results should be incorporated into clinical guidelines.
— Aaron J. Calderon, MD, FACP. Published in Journal Watch Hospital Medicine August 31, 2009. Citation: Mendu ML et al. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med. 2009;169:1299. http://www.ncbi.nlm.nih.gov/pubmed/19636031
15. Unenhanced CT May Assist in Diagnosis of Children with Flank Pain
Laurie Barclay, MD. September 14, 2009 — Unenhanced computed tomography (UCT) plays an important role in diagnosing children with flank pain, according to the results of a retrospective study reported in the September issue of Pediatrics.
"Urolithiasis can cause acute abdominal or flank pain, and its incidence is increasing," write Andre C. Persaud, MD, from Akron Children's Hospital in Akron, Ohio, and colleagues. "With increases in the use of UCT for diagnosis, additional predictors that can aid clinicians in management are needed....The objective of this study was to identify factors that predict the presence of urolithiasis detected with...UCT in children."
Between January 2002 and December 2005, a total of 339 eligible patients younger than 21 years presented to the emergency department at Akron Children's Hospital and underwent UCT of the abdomen. Mean age of those with positive results on UCT for urolithiasis was 14.4 years; 72 patients (66%) were girls. A standardized form was used to abstract data regarding demographics, clinical presentation, diagnosis, treatment, and disposition. Factors associated with urolithiasis were identified with use of univariate and logistic regression analyses.
UCT detected 110 cases of urolithiasis in 95 individual patients. Initial urinalysis results were negative for blood in 17 cases of urolithiasis (15%). Of the 110 stones detected, 57 (51.8%) were ureteral, 26 (23.6%) were renal, and 4 (3.6%) were in the bladder. Among children in whom UCT did not reveal a stone, UCT did lead to potentially significant, alternative diagnoses in 23 children (10%).
Positive predictors of urolithiasis were a history of urolithiasis, a history of nausea and vomiting, flank pain on examination, and more than 2 red blood cells per high-power field seen on urine microscopic examination. Factors inversely associated with urolithiasis on UCT scans were a history of fever or dysuria and costovertebral angle tenderness on physical examination.
"UCT plays an important role in the diagnostic evaluation of children with flank pain," the study authors write. "Approximately 15% of children with urolithiasis do not have hematuria."
Limitations of this study include retrospective design, data limited to the information reported in the electronic charts, and UCT results interpreted by a single radiologist without set guidelines.
"A history of urolithiasis, nausea and vomiting, flank pain on examination, and hematuria are positively associated with urolithiasis in children," the study authors conclude. "Fever, dysuria, and costovertebral angle tenderness are inversely associated with urolithiasis....The relative cost and potential radiation risks of UCT must be balanced against its high sensitivity in depicting calculi, rapid results, and ability to reveal alternate pathologic conditions."
The study authors have disclosed no relevant financial relationships.
Pediatrics. 2009;124:888-894. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19661055
16. More Details on Corticosteroids for Bacterial Meningitis
This meta-analysis of published randomized, placebo-controlled trials suggests that the adjunctive administration of corticosteroids is beneficial in the treatment of adolescents and adults with acute bacterial meningitis in patient populations similar to those seen in high-income countries and in areas with a low prevalence of human immunodeficiency virus infection.
Assiri AM et al. Mayo Clin Proc 2009 May; 84:403.
Abstract: http://www.mayoclinicproceedings.com/content/84/5/403.abstract
17. "Spin" Not Uncommon in Negative RCTs, Study Shows
Shelley Wood. September 14, 2009 (Vancouver, British Columbia) — French researchers who set out to classify, then quantify the amount of "spin" in publications of negative randomized controlled trials say that the language used in and around the numbers themselves may frequently serve to sugar-coat negative results. Dr Isabelle Boutron (University Paris Descartes, France), who presented the results of the study during the 2009 International Congress on Peer Review and Biomedical Publication, said "spin" in reports of negative randomized controlled trials is by no means rare.
In randomized controlled trials, the "data should speak for themselves," she said during her presentation. The problem, however, is that scientists are rarely neutral about the results of their trial and consciously or unconsciously may try to portray their findings in a rosier light, often in the hopes of expediting publication, advancing their own careers, or even profiting financially. The aim of Boutron et al's study was to get a sense of just how often scientists may be "spinning" their findings, with spin defined as presenting or discussing the results in such a way as to convince the reader that an experimental treatment is beneficial, despite a nonstatistically significant difference for the primary end point.
Boutron and colleagues searched all two-arm randomized controlled trials indexed in PubMed in December 2006, ultimately identifying a total of 72 negative randomized controlled trials. They also developed a scoring system for identifying spin, based on linguistic choices and on instances when authors put particular emphasis on statistically significant results outside the primary end point (including within-group comparisons, subgroup analyses, and secondary outcomes), or interpreted results as demonstrating "comparable effectiveness" or "equivalence." Two independent reviewers then scored the papers, and reached a consensus for individual components of each of the papers.
Overall, evidence of spin was present in 18% of study titles, rising to 29% in the results, 43% in the discussions, and 50% in the conclusions. More than 40% of publications had spin in at least two of the three sections of the main text. Taking a closer look at the conclusions specifically, Boutron et al found that 33% of abstracts contained a "high level" of spin, defined as no acknowledgement of the negative primary outcome, no expression of uncertainty, and no recommendation to study the issue further in another trial. By contrast, a high level of spin was slightly less common in the conclusions of the full article.
Speaking with heartwire, Boutron emphasized that she hopes her work can ultimately be used to help authors write more objectively, and to also assist editors, reviewers, and readers.
"I think we should be reading articles differently," she said. "We should be really careful about the way people present and conclude their articles. And for academics, they should be very careful about the way they write articles. I often work with principle investigators in writing their articles, and I always need to calm them down, because they believe that their treatments work and they try to frame the results in a specific way."
An initial hurdle, she added, is for journal editors to think more critically about the discussion and conclusion sections of articles. "Sometimes the trials are very good and they have very straightforward ways of reporting their results and methods, but the interpretation of the results will be wrong. . . . This is an area where people aren't focusing too much; they're not looking at the discussion, they are looking at the results, and whether the statistical methods were well done, did they do the randomization correctly, etc. But for the discussion and interpretation, probably because it's subjective, people are afraid to look at it. . . . I think the journals need to take a tougher stand."
18. Comparison of GlideScope Video Laryngoscopy Versus Direct Laryngoscopy Intubation in the ED
Platts-Mills TF, et al. Acad Emerg Med. 2009;16:866–871.
Objectives: The first-attempt success rate of intubation was compared using GlideScope video laryngoscopy and direct laryngoscopy in an emergency department (ED).
Methods: A prospective observational study was conducted of adult patients undergoing intubation in the ED of a Level 1 trauma center with an emergency medicine residency program. Patients were consecutively enrolled between August 2006 and February 2008. Data collected included indication for intubation, patient characteristics, device used, initial oxygen saturation, and resident postgraduate year. The primary outcome measure was success with first attempt. Secondary outcome measures included time to successful intubation, intubation failure, and lowest oxygen saturation levels. An attempt was defined as the introduction of the laryngoscope into the mouth. Failure was defined as an esophageal intubation, changing to a different device or physician, or inability to place the endotracheal tube after three attempts.
Results: A total of 280 patients were enrolled, of whom video laryngoscopy was used for the initial intubation attempt in 63 (22%) and direct laryngoscopy was used in 217 (78%). Reasons for intubation included altered mental status (64%), respiratory distress (47%), facial trauma (9%), and immobilization for imaging (9%). Overall, 233 (83%) intubations were successful on the first attempt, 26 (9%) failures occurred, and one patient received a cricothyrotomy. The first-attempt success rate was 51 of 63 (81%, 95% confidence interval [CI] = 70% to 89%) for video laryngoscopy versus 182 of 217 (84%, 95% CI = 79% to 88%) for direct laryngoscopy (p = 0.59). Median time to successful intubation was 42 seconds (range, 13 to 350 seconds) for video laryngoscopy versus 30 seconds (range, 11 to 600 seconds) for direct laryngoscopy (p less than 0.01).
Conclusions: Rates of successful intubation on first attempt were not significantly different between video and direct laryngoscopy. However, intubation using video laryngoscopy required significantly more time to complete.
19. Images in EM
Adult Female With Weakness and Chills
http://www.annemergmed.com/article/S0196-0644(09)00054-7/fulltext
20. US Clinicians Underrecognize Abdominal Migraine in Children
Daniel M. Keller, PhD. September 14, 2009 (Philadelphia, Pennsylvania) — Abdominal migraine may represent up to 15% of pediatric gastrointestinal patients who experience idiopathic recurrent abdominal pain, if results presented here at the 14th International Headache Congress are representative.
Although the condition is well recognized in Europe, it is underdiagnosed in the United States, according to investigator Donald Lewis, MD, professor and chairman of the Department of Pediatrics at Eastern Virginia Medical School and senior vice president for academic affairs at Children's Hospital of the King's Daughters in Norfolk, Virginia.
Children with recurrent abdominal pain use significant amounts of healthcare resources, he said, and the condition can lead to dysfunction and disability that may interfere with school, family, and social activities.
Dr. Lewis told Medscape Neurology that abdominal migraine is classified as one of the period syndromes of childhood that are precursors to migraine. "If you track those kids [for] long through adolescence, most of them grow up to have migraine," he said.
Belly Pain a Cardinal Feature
Dr. Lewis, a pediatric neurologist, explained that abdominal migraine is characterized by episodes of moderate to severe midline, periumbilical, or poorly localized pain lasting for 1 to 72 hours with nausea, anorexia, pallor, and occasionally headache. "But headache is not one of the cardinal features. It's episodes of belly pain," he emphasized. The condition was included in the 2004 International Classification of Headache Disorders and recognized by the 2006 Rome III criteria for functional gastrointestinal disorders as a well-defined type of recurrent abdominal pain.
Through chart reviews, Dr. Lewis and colleagues assessed patients with recurrent abdominal pain in the hospital's pediatric gastroenterology clinic to define the proportion of patients who might fulfill the International Classification of Headache Disorders 2004 criteria for abdominal migraine. Eligible subjects were girls (41%) or boys (59%) who were 1 to 21 years old and who did not have a known diagnosis of causes of chronic abdominal pain. Of an initial cohort of 600 children, 458 met the inclusion criteria. Twenty children (4.4%) met the International Classification of Headache Disorders 2004 diagnostic criteria, with an additional 11% having probable abdominal migraine (documentation lacking for 1 or more diagnostic criterion).
"So we have this large subset of children who are languishing with a vague diagnosis in [gastrointestinal] clinics who most likely have abdominal migraine," Dr. Lewis said. Making the correct diagnosis of abdominal migraine means the spectrum of migraine medications will become available to these children, he added.
Migraine prophylactic medications and acute treatments for migraine attacks are available and efficacious for abdominal migraine. Because the study was solely demographic, it did not test medication efficacy, but Dr. Lewis said the European literature has documented the efficacy of these treatments.
He speculated that abdominal migraine is underrecognized in the United States because physicians have not been taught about it. The message about the existence of the condition is especially relevant to pediatric gastroenterologists and general pediatricians. Dr. Lewis suggested that pediatricians might better refer such patients to pediatric neurologists instead of to gastroenterologists. Informed families, too, may alert their physicians if their child has recurring symptoms consistent with a diagnosis of abdominal migraine, especially if a parent, particularly the mother, has a migraine condition, as migraine is often inherited.
Background of Episodic Abdominal Pain
Brian McGeeney, MD, MPH, assistant professor of neurology at Boston University, Massachusetts, who was not involved in the study, told Medscape Neurology that in his clinical experience with adults, abdominal migraine is a real entity. "They seem to have a background of episodic abdominal pain in childhood more than one would expect by chance," he said.
"Posters like this should really heighten the awareness of this unusual syndrome to adult neurologists as well as pediatricians." Knowing a patient's childhood history of abdominal symptoms may be one more clue in the diagnosis of adult migraine.
Although abdominal migraine may be a precursor to and temporally linked with later migraine, for Dr. McGeeney, a strong indication that abdominal migraine is really a form of migraine is that it often responds to a broad range of migraine prophylactic medications.
14th International Headache Congress: Abstract PO222. Presented Saturday, September 12, 2009.
1. Validated Rules May Predict Children at Very Low Risk for Brain Injury After Head Trauma
Laurie Barclay, MD. September 18, 2009 — Validated prediction rules might help identify children at very low risk for brain injury after head trauma, according to the results of a study published online September 14 in The Lancet.
"CT imaging of head-injured children has risks of radiation-induced malignancy," write Nathan Kuppermann, from University of California, Davis Medical Center in Sacramento, and colleagues from the Pediatric Emergency Care Applied Research Network. "Our aim was to identify children at very low risk for clinically important traumatic brain injuries (ciTBI) for whom CT might be unnecessary."
The study sample consisted of 42,412 patients younger than 18 years of age with Glasgow Coma Scale scores of 14 or 15 who presented at 25 North American emergency departments within 24 hours of head trauma. The investigators derived and validated age-specific prediction rules for ciTBI, defined as death from traumatic brain injury, neurosurgery, intubation for longer than 24 hours, or hospital admission for 2 or more nights.
Among children younger than 2 years of age, 8502 were in the derivation population and 2216 in the validation population, and among children 2 years of age and older, there were 25,283 and 6411, respectively. CT scans were performed in 14,969 children (35.3%); 376 children (0.9%) were diagnosed with ciTBIs and 60 (0.1%) underwent neurosurgery.
For children younger than 2 years, the prediction rule was normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 seconds, nonsevere injury mechanism, no palpable skull fracture, and acting normally according to the parents. In the validation population, this rule had a negative predictive value for ciTBI of 1176/1176 (100.0%; 95% confidence interval [CI], 99.7 - 100.0) and a sensitivity of 25/25 (100%; 95% CI, 86.3 - 100·0). This low-risk group consisted of 167 (24.1%) of 694 CT-imaged patients younger than 2 years of age.
For children 2 years of age and older, the prediction rule was normal mental status, no loss of consciousness, no vomiting, nonsevere injury mechanism, no signs of basilar skull fracture, and no severe headache. This rule had a negative predictive value of 3798/3800 (99.95%; 95% CI, 99.81 - 99.99) and a sensitivity of 61/63 (96.8%; 95% CI, 89.·0 - 99.6). Of 2223 CT-imaged patients 2 years of age and older, 446 (20.1%) were in this low-risk group.
"Neither rule missed neurosurgery in validation populations," the study authors write. "These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated."
Using these prediction rules, CT scans and the attendant radiation exposure could be eliminated in 1 in 4 children younger than 2 years and in 1 in 5 children older than 2 years presenting with head trauma.
Limitations of this study include lack of CT scans on all patients and lack of assessment of long-term neurocognitive outcomes.
"Application of these rules could limit CT use, protecting children from unnecessary radiation risks," the study authors conclude. "Furthermore, these rules provide the necessary data to assist clinicians and families in CT decision making after head trauma."
In an accompanying Comment, Patricia C. Parkin, MD, and Jonathon L. Maguire, MD, from the Hospital for Sick Children, University of Toronto Faculty of Medicine in Ontario, note that decision aids offer structured presentations of options and outcomes.
"Many decisions, even in acute-care settings, are sensitive to patients' values and preferences," Drs. Parkin and Maguire write. "Perhaps as this field moves forward to assessment of the effect of the rules on physicians' behavior and clinical outcomes (impact analysis), clinicians and investigators might consider involving patients in the decision-making process. Then, when asking the question 'should my head-injured child have a CT scan?', parents can weigh the probability of a clinically important traumatic brain injury with the probability of harm from ionizing radiation from the CT scan."
The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services, funded this study. The study authors and editorialists have disclosed no relevant financial relationships.
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19758692
2. Multitasking Muddles the Mind?
By Constance Holden. ScienceNOW Daily News. 25 August 2009
Bad news for people who like to text their BFFs while surfing the Web for some new shoes and watching the latest episode of Project Runway. Scientists who've conducted what they say is the first-ever study of chronic multitaskers found that cognitive performance declines when people try to pay attention to many media channels at once.
Although media multitasking has become more and more prevalent, no one knows how chronic media immersion affects cognitive functioning. So a team headed by psychologist Eyal Ophir of Stanford University in Palo Alto, California, identified 19 "heavy media multitaskers" (HMMs) and 22 "light media multitaskers" (LMMs) among a group of students based on how often they reported simultaneously using media such as television, cell phones, computer games, and videos.
The researchers then gave subjects in the two groups tests to see how well they could sift relevant information from the environment, filter out irrelevant information in their memories, and quickly switch between cognitive tasks. One filtering test, for example, required viewers to note changes in red rectangles while ignoring changes in blue rectangles in the same pictures. In the task-switching experiment, participants were presented with images of paired numbers and letters and had to switch back and forth between classifying the numbers as even or odd and classifying the letters as vowels or consonants.
The HMMs did worse than the LMMs across the board. Surprisingly, says co-author and sociologist Clifford Nass, "They're bad at every cognitive control task necessary for multitasking." They were more easily distracted by irrelevant stimuli, and although their memories were no worse than those of the LMMs, they had more difficulty in selecting stored information that was relevant to the task at hand. In one filtering test, for example, the LMMs took 323 milliseconds to discern the correct answer, but the HMMs averaged 400 milliseconds.
Nass says the study has a disturbing implication in an age when more and more people are simultaneously working on a computer, listening to music, surfing the Web, texting, or talking on the phone: Access to more information tools is not necessarily making people more efficient in their intellectual chores. Also disconcerting, he notes, is that "people who chronically multitask believe they're good at it." The findings are reported this week in the Proceedings of the National Academy of Sciences.
Daphne Bavelier, a cognitive scientist at the University of Rochester in New York state, says the research presents a puzzle about the brain's ability to learn from experience. Bavelier has discovered that people who play action video games get better at the kind of task-switching those games require. In contrast, Bavelier says, the poor performance of multitaskers in the new study suggests that more experience doesn't always translate to improved performance.
It's still not clear, however, that multitasking really scrambles the brain. It's also possible that people with poor filtering and attentional abilities are more prone to multitasking to begin with. Anthony Wagner, a psychologist in the Stanford group, says he suspects that constant jumping among different media offers instant rewards that reinforce "exploratory" behavior at the expense of the ability to concentrate on a particular task.
Want more on how the brain works? See John Medina, Brain Rules: 12 Principles for Surviving and Thriving at Work, Home, and School (Seattle: Pear Press, 2008). Amazon See also the book’s webpage
3. Opioids May Be Unnecessary Adjuncts to Proposal
Randomized Clinical Trial of Propofol With and Without Alfentanil for Deep Procedural Sedation in the Emergency Department
Miner JR, et al. Acad Emerg Med. 2009;16:825–834.
Objectives: The objectives were to compare the efficacy, occurrence of adverse events, and recovery duration of propofol with and without alfentanil for use in procedural sedation in the emergency department (ED).
Methods: This was a randomized nonblinded prospective trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were given intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients received 1 mg/kg propofol either with or without a supplemental dose of 10 μg/kg alfentanil for deep procedural sedation. Doses, vital signs, nasal end-tidal CO2 (ETCO2), pulse oximetry, and bispectral electroencephalographic (EEG) analysis scores were recorded. Subclinical respiratory depression was defined as a change in ETCO2 of greater than 10 mmHg, an oxygen saturation of less than 92% at any time, or an absent ETCO2 waveform at any time. Clinical events related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure or had recall of the procedure.
Results: A total of 150 patients were enrolled; 146 underwent sedation and were included in the analysis. Seventy-four patients received propofol, and 71 received propofol with alfentanil. No clinically significant complications were noted. Subclinical respiratory depression was seen in 24/74 patients in the propofol group and 30/71 patients in the propofol/alfentanil group (effect size = 9.8%, 95% CI = –5.8% to 25.5%). Clinical signs of respiratory depression included an increase in supplemental oxygen use in 25 of the 74 propofol patients and 31 of the 71 propofol/alfentanil patients (effect size 9.9%, 95% CI = –5.9% to 25.7%), the use of bag-valve mask apparatus in seven patients in the propofol group and 12 in the propofol/alfentanil group (effect size = 5.6%, 95% CI = –3.5% to 18.4%), airway repositioning in 13 propofol patients and 20 propofol/alfentanil patients (effect size = 10.6%, 95% CI = –3.0% to 24.2%), and stimulation to induce breathing in 11 propofol patients and 20 propofol/alfentanil patients (effect size = 13.3%, 95% CI = 0.1% to 26.5%). The total time of the procedure was longer for the alfentanil/propofol group (median = 11 minutes, range = 5–22 minutes) than for the propofol group (median = 9 minutes, range = 1 to 43 minutes; effect size = 1.93 minutes, 95% CI = 0.73 to 2.58, p = 0.02). Pain during the procedure was reported by 10 of the 74 patients in the propofol group and 7 of the 71 patients in the propofol/alfentanil group (effect size = 4.5%, 95% CI = –6.8% to 14.1%). Recall of some part of the procedure was reported by 12 patients in the propofol group and 9 in the propofol/alfentanil group (effect size = 3.5%, 95% CI = –7.9% to 15.0%). All procedures were successfully completed.
Conclusions: The use of supplemental alfentanil with propofol for procedural sedation did not result in a difference in reported pain or recall immediately after the procedure. There was an increase in the proportion of patients who required stimulation to induce respiration during the procedure in patients who received propofol with supplemental alfentanil. The addition of supplemental opioid to procedural sedation with propofol does not appear beneficial.
4. Most Mistakes in the Emergency Department Caused by Human Error
Fran Lowry. September 17, 2009 — Most of the mistakes in the emergency department (ED) that have the potential to compromise patient safety are caused by human error, according to a study published online September 18 in BMC Emergency Medicine.
"[EDs] are challenging hospital settings with regard to patient safety. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety," Marleen Smits, MD, from the Netherlands Institute for Health Services Research, Utrecht, and colleagues write. "This can only be achieved if interventions tackle the dominant underlying causes."
The aim of this study was to examine the nature and causes of unintended events in EDs and the relationship between type of event and causal factor structure.
The study evaluated medical errors in the EDs of 10 hospitals in the Netherlands (1 university hospital, 3 tertiary teaching hospitals, and 6 general hospitals) for 8 to 10 weeks. ED staff members were asked to report all unintended events, no matter how trivial or commonplace, that could have harmed or did harm a patient.
A total of 522 events were reported, ranging from 46 to 71 per ED, for an average of 52 reports. Most of the reports (85%) were made by nurses; resident physicians or consultants reported 13% of the unintended events, and clerical staff reported 2%. The reporter was directly involved in 83% of the unintended events. Most occurred during daytime hours (44%); 34% occurred during evening and night, and for 22% of the unintended events, the time of occurrence was unknown or unspecified by the reporter.
Most errors occurred during medical examinations or lab tests (36%). More than half of the unintended events (56%) had consequences for the patient, and in 45% of these instances, the patient suffered some inconvenience, such as prolonged waiting time. One third of patients received suboptimal care, such as a delay in starting antibiotic treatment. The consequences of error were more severe in the 8% of patients who required an extra intervention, the 6% of patients who suffered pain, and the 3% of patients who suffered a physical injury, Dr. Smits and colleagues write.
Most root causes of error were human (60%), followed by organizational (25%) and technical (11%) causes. Nearly half of the root causes could be attributed to other departments either in or outside of the hospital.
In citing limitations to their study, the investigators note that, because the reporting was not anonymous, it is possible that certain mistakes were underreported. "This may have biased the results towards the reporting of less significant events, events without consequences for the patient, and errors originating in other departments, because these are 'safer' to report."
In addition, most errors were reported by nurses, and therefore the study results give information about events that are mainly related to nursing care and less to care by residents and specialists in the ED.
Although the majority of errors had no consequences for the patient or resulted in only minor inconveniences, their accumulated effect on patient well-being is likely to be large, the authors write. They conclude: "Event reporting gives insight into diverse unintended events. The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments."
Dr. Smits and colleagues have disclosed no relevant financial relationships.
BMC Emerg Med. 2009;9:16 http://www.biomedcentral.com/1471-227X/9/16/abstract
5. More Disturbing News About Prehospital Trauma Intubation
Prehospital intubation failed in 31% of trauma patients in a large urban trauma system.
Cobas MA, et al. Anesth Analg 2009 Aug; 109:489.
BACKGROUND: Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI.
METHODS: A prospective observational study was conducted evaluating trauma patients who had emergency prehospital airway management and were admitted during the period between August 2003 and June 2006. The PHI was considered a failure if the initial assessment determined improper placement of the endotracheal tube or if alternative airway management devices were used as a rescue measure after intubation was attempted.
RESULTS: One-thousand-three-hundred-twenty patients had emergency airway interventions performed by an anesthesiologist upon arrival at the trauma center. Of those, 203 had been initially intubated in the field by emergency medical services personnel, with 74 of 203 (36%) surviving to discharge. When evaluating the success of the intubation, 63 of 203 (31%) met the criteria for failed PHI, all of them requiring intubation, with only 18 of 63 (29%) surviving to discharge. These patients had rescue airway management provided either via Combitube® (n = 28), Laryngeal Mask Airway® (n = 6), or a cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not. Several other variables, including age, gender, weight, mechanism of injury, presence of facial injuries, and emergency medical services were not correlated with an increased incidence of failed intubations.
CONCLUSION: This prospective study showed a 31% incidence of failed PHI in a large metropolitan trauma center. We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.
6. Intervention for Non–ST-Segment-Elevation Acute Coronary Syndromes: What Difference Does a Day Make?
Interventions performed immediately or deferred to the next working day resulted in similar outcomes.
The advantages of invasive over conservative strategies for managing non–ST-segment-elevation acute coronary syndromes (NSTEACS) are established, but the optimal timing of intervention is undetermined. To find out whether immediate catheterization compared with delayed intervention reduces incident MI, investigators in France randomized 352 patients hospitalized for NSTEACS to undergo interventional treatment either immediately upon admission or on the next working day (8–60 hours after enrollment).
Median time from randomization to sheath insertion was 70 minutes in the immediate-intervention group and 21 hours in the delayed-intervention group. The primary endpoint, peak troponin level during hospitalization, did not differ significantly between the two strategies (median peak levels, 2.1 ng/mL and 1.7 ng/mL in the immediate- and delayed-intervention groups, respectively). The rate of the composite of death, MI, and urgent revascularization at 1 month also did not differ significantly between the two groups (13.7% and 10.2%, respectively). However, median hospital stay was significantly shorter with the immediate strategy than with the delayed strategy (55 hours vs. 77 hours).
Comment: These findings suggest that in patients with non–ST-segment-elevation acute coronary syndromes, immediate versus delayed intervention does not result in increased MI rates, as defined by peak troponin levels. Accordingly, rapid or urgent intervention appears to be appropriate in unstable patients, whereas logistical and cost concerns may factor into decisions about whether to defer intervention in stable patients.
— Beat J. Meyer, MD. Published in Journal Watch Cardiology September 16, 2009. Citation:
Montalescot G et al. Immediate vs delayed intervention for acute coronary syndromes: A randomized clinical trial. JAMA 2009 Sep 2; 302:947. http://www.ncbi.nlm.nih.gov/pubmed/19724041
7. Useful Clinical Aphorisms to Practice By
“Clinical aphorisms that have proved useful for me during more than 30 years of inpatient and outpatient attending at 4 US medical schools”
Alpert JS. Amer J Med. 2009;122:700-701;789-790.
Rule 1: Common things occur commonly. I make this point continuously to medical students and residents. Sometimes young clinicians will suggest an unusual diagnosis for a patient with the hope of being the only doctor to make the correct diagnosis. More experienced clinicians believe the correct diagnosis is usually something common. For example, consider a patient with an enlarged spleen. In North America, splenomegaly rarely results from entities such as primary lymphoma of the spleen or malaria. Rather, splenomegaly is often caused by portal hypertension or mononucleosis. One of my first, and best, residents during my internship told me “If it looks like a horse, whinnies like a horse, and smells like a horse, don't expect a zebra to appear” (Stone N, MD, personal communication, 1970).
Rule 2: Common sense occurs uncommonly. This aphorism is usually attributed to Voltaire. Over the years, I have seen many violations of this important rule in clinical medicine. Physicians should exercise common sense before ordering tests or performing therapeutic interventions. Examples abound in support of this rule. Recently, I saw a 60-year-old diabetic woman in my office. She had been admitted to our hospital several weeks earlier with a single bout of rest angina. Her cardiac catheterization revealed modest coronary arterial stenoses, and she was placed on medical therapy with brand name medications by another cardiologist: a statin, an angiotensin receptor blocker, and clopidogrel. Subsequently, I first saw her in my office. At that time, she and her family told me that they had paid more than $500 for 1 month's supply of the medicines that had been prescribed in the hospital. I quickly altered her regimen to include generic forms of a statin and an angiotensin-converting enzyme inhibitor, as well as 325 mg of aspirin. These new generic prescriptions would cost the patient less than $20 per month. Common sense should have been used earlier by the inpatient attending physician simply by informing the patient that generic brands cost less than brand name pharmaceuticals. As noted by Harvey Cushing (1869-1939), “Three-fifths of the practice of medicine depends on common sense, knowledge of people and of human reactions.” I would add knowledge of the patient's ability to pay for the medicines prescribed.
Rule 3: The less a procedure is indicated the more likely that its use will be accompanied by complications. This rule advises clinicians to ensure that every procedure or test ordered has a reasonable probability of altering patient management. An example of this aphorism in practice involved a healthy 55-year-old man without coronary heart disease risk factors. He became anxious when a neighbor had an acute myocardial infarction. His doctor suggested that he undergo a coronary calcium computed tomography scan. This test revealed modest coronary calcifications. The patient became more anxious when he heard the results of his computed tomography scan, and he convinced his physician that he needed a coronary angiogram. The angiogram was unremarkable, but the catheterization resulted in a large groin hematoma and pseudoaneurysm that required vascular surgical repair. If I had been involved in this patient's initial care, reassurance or, at most, a Bruce protocol electrocardiographically monitored exercise test, would have been my approach.
Rule 4: Listen between the lines.
Rule 5: Seven minutes is an inadequate amount of time to spend on a patient visit.
Rule 6: Practicing good medicine requires a triad of equal doses of hard work, kindness, and honesty.
Rule 7: No individual has a monopoly on truth.
Rule 8: Obtaining informed consent from a patient for a procedure can help or hurt the patient.
Rule 9: Physician, heal thyself.
Rule 10: Respect your fellow health care workers; they are your most important clinical asset.
Rule 11: Admission to an intensive care unit in a tertiary care hospital can be a harrowing experience for the patient.
Rule 12: True, true, and unrelated.
Rule 13: The enemy of good is perfect.
Rule 14: Physician error is often the result of overconfidence.
Rule 15: It is a privilege to practice medicine.
Full-texts (free): http://www.amjmed.com/article/S0002-9343(09)00223-X/fulltext
http://www.amjmed.com/article/S0002-9343(09)00222-8/fulltext
8. Switch to Part D Limits Access to Psychiatric Medications, Increases ED Use
Caroline Cassels. September 9, 2009 — The switch from Medicaid drug coverage to Medicare Part D has restricted access to psychiatric medications and contributed to a subsequent high rate of emergency room visits among patients with mental health disorders, new research suggests.
A study conducted at Harvard Medical School in Boston, Massachusetts, shows that since January 2006, when the switch occurred, 44% of psychiatric patients reported difficulties in accessing medications. In addition, the likelihood of visiting an emergency department was significantly higher for psychiatric patients who experienced a medication access problem than for those who did not (odds ratio, 1.75; mean P = .003).
"We were surprised by the high rate of reports of access problems — 44% of patients reported some type of access issue, and that's a pretty large number, even allowing for the fact that it is a relatively new initiative and you would expect a certain amount of miscommunication and confusion," lead author Haiden Huskamp, PhD, told Medscape Psychiatry.
The study is published in the September issue of Psychiatric Services.
Utilization Management
It is estimated that approximately one third of individuals dually eligible for Medicare and Medicaid benefits have a mental disorder. For these individuals, said Dr. Huskamp, pharmacotherapy is a key element of their treatment.
The authors point out that "dual eligibles" received coverage for prescription drugs through the Medicaid program in which patients paid little or none of the cost of their medications
However, under the Medicare Prescription Drug Improvement and Modernization Act of 2003, drug coverage for this population was shifted from Medicaid to the new Medicare Part D program, and all of these individuals were randomly assigned to a private Part D plan with associated premiums and other utilization management tools including prior authorization and stepped care.
"The creation of Part D represented an important switch for dually eligible patients. Now instead of getting their drugs from Medicaid, patients had to get their medications through private Part D plans, which had different coverage policies and restrictions," said Dr. Huskamp.
Dr. Huskamp added her group was particularly concerned about the potential effect of this policy change on the dually eligible psychiatric population.
"This is a particularly vulnerable population, and there was some concern that switching to a Part D plan that may have restrictions on the medications they were taking could have implications for the quality of care they received. So we wanted to look and see what was happening in this particular group," said Dr. Huskamp.
Drugs Not Covered or Approved
For the study, the researchers randomly sampled psychiatrists from the American Medical Association's Physicians Masterfile who reported on experiences of 1 dually eligible patient in the 9 to 12 months after Part D implementation.
Each psychiatrist was randomly assigned 1 of 21 start days and times to report on the next dually eligible patients treated during the psychiatrist's last typical work week. Information on patients' sociodemographics, treatment setting, diagnosis, clinical characteristics, and ability to access medication was gathered.
The researchers also obtained information on emergency department visits related to participants' psychiatric illness, as well as any psychiatric hospitalizations since January 1, 2006. A total of 908 patients were included in the final study sample. Of these 57% were women and 62% were between 41 and 64 years old. Almost two thirds had a diagnosis of either schizophrenia or bipolar disorder.
Overall, 400 individuals (44%) had some type of problem accessing their medications. Investigators found that 318 individuals (35%) were unable to access clinically indicated refills or new prescriptions because the drugs were not covered or approved.
In addition, 170 individuals (19%) were stable on a clinically desired or indicated medication but switched to a different drug because refills were not covered or approved, and 200 participants (22%) had problems accessing medications because of copayments.
Compared with a matched sample of dually eligible patients whose medication access was not disrupted, those with difficulty accessing their medication were more likely to incur a visit to the hospital emergency department related to their psychiatric illness.
It may be, said Dr. Huskamp, that switching from Medicaid to Part D had some unanticipated and unintended negative effects including the possibility of negative clinical outcomes, as indicated by a high rate of emergency room visits and increased health costs for non-drug-related health services.
"I think our study provides a red flag that some attention needs to be devoted to this issue. We need to examine the Part D data (which are currently not publicly available) so we can take a detailed look at utilization patterns and health outcomes for this population," said Dr. Huskamp.
"Certainly emergency department use is an indicator that things are not going well for patients, but having more concrete measures would be helpful to get a clearer understanding of how this policy change has affected patients' mental health status and functioning," she added.
Psychiatr Serv. 2009;60:1169–1174. http://www.ncbi.nlm.nih.gov/pubmed/19723730
9. Aspiration vs. Chest Tube for Spontaneous Pneumothorax: No Difference in Outcome
NEW YORK (Reuters Health) Sep 10 - For primary spontaneous pneumothorax in adults, percutaneous aspiration and standard chest tube drainage have similar outcomes, according to an abstract of a report from the Cochrane Database of Systematic Reviews.
The abstract appears in the September issue of the Annals of Emergency Medicine, in the journal's Evidence-Based Emergency Medicine section.
"The management of primary spontaneous pneumothorax is controversial, with bodies such as the American College of Chest Physicians recommending formal chest tube drainage for patients requiring intervention, (and) the British Thoracic Society recommending simple percutaneous aspiration as the primary management strategy," section editor Dr. John W. Hafner, of the University of Illinois College of Medicine at Peoria, told Reuters Health.
The abstract is based on a Cochrane Review titled "Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults," written in 2007 by Abel Wakai and colleagues. That report reviewed studies published through 2006.
Of 1735 reports of randomized trials initially identified by the researchers as potentially relevant, only one, involving 60 patients, met all the criteria for study design and quality.
In this one trial, there was no significant difference in the immediate success rate for simple percutaneous aspiration compared with intercostal chest tube drainage (relative risk (RR)=0.93).
Similarly, there were no significant differences between the two approaches in rates of early failure at 1 week (RR=1.12), 1-year success (RR=1.02), length of hospital stay (mean group difference, 1.09 days), or pleurodesis by thoracoscopic talc poudrage within a year (RR=0.95).
Simple percutaneous aspiration did reduce patients' number of hospitalizations (RR=0.52).
"Widespread use of simple percutaneous aspiration (for) primary spontaneous pneumothorax could limit more invasive chest tube placement that requires hospitalization and increased healthcare costs," Dr. Hafner said.
"Unfortunately," he added, "due to the small size of the single study in the review, the general application of these results remains in question and requires further study with a larger study sample."
Ann Emerg Med 2009;54:458-460.
10. FDA Adds Boxed Warning to Injectable Promethazine
September 16, 2009 — The US Food and Drug Administration (FDA) is requiring manufacturers of the injectable form of promethazine hydrochloride to add a boxed warning to the drug's labeling that highlights the risk of serious tissue injury if the drug is administered incorrectly.
"Intravenous administration of promethazine can cause severe tissue injury, including gangrene, requiring fasciotomy, skin graft, and/or amputation," according to information for healthcare professionals posted on the FDA Web site. In addition, "Severe tissue injury can occur from perivascular extravasation, unintentional intra-arterial injection, and intraneuronal or perineuronal infiltration."
The preferred route of administration is deep intramuscular injection. Subcutaneous and intra-arterial injection are contraindicated.
Based on these known risks, the FDA advises clinicians to “effectively communicate” the risk of severe tissue injury to the patient when promethazine is administered intravenously.
In an alert sent today from MedWatch, the FDA's safety information and adverse event reporting program, the FDA also advises healthcare professionals to monitor patients who have received promethazine via contraindicated routes of administration for signs and symptoms of potential tissue injury, including burning or pain at the site of injection, phlebitis, swelling, and blistering. And if a patient complains of pain during injection, administration should cease immediately.
The FDA is also requiring a revision in the Dosage and Administration section of the drug's labeling to highlight "specific recommendations for the maximum concentration (25 mg/mL) and rate of administration (25 mg/min) when intravenous administration of promethazine is required." The 50 mg/mL is for deep intramuscular injection only, and the intravenous line should be checked to ensure it is properly functioning with a rate of 25 mg per minute.
Promethazine hydrochloride injection, USP, first introduced to the market in 1956, is approved for a variety of uses including allergic reactions, sedation, motion sickness, nausea and vomiting associated with anesthesia and surgery, and as an adjunct to analgesics for control of postoperative pain.
Current prescribing information for promethazine does contain information on the risk of tissue injury, but it was not highlighted in a boxed warning.
More information can be found on the FDA Web site. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm182500.htm
11. Antivirals Slightly Shorten Duration of Seasonal Flu in Children
Treatment was well tolerated and slightly reduced transmission to household contacts.
Children may shed influenza virus longer than adults and are a main source of spread to household contacts. To examine the effect of antiviral treatment in children, researchers performed a meta-analysis of seven randomized controlled trials of neuraminidase inhibitors for outpatient treatment of seasonal influenza and postexposure prophylaxis in children aged 12 years or younger.
Two trials evaluated outpatient treatment with oseltamivir and two with zanamivir within 36 or 48 hours of onset of influenza-like symptoms. In a total of 1766 children (1243 with confirmed and 523 with suspected influenza), treatment reduced median time to symptom resolution, return to normal activities, or both by 0.5 to 1.5 days; reductions were statistically significant in one oseltamivir trial and one zanamivir trial. Recovery was significantly faster in children with confirmed influenza than in those with suspected influenza.
Three trials evaluated 10-day courses of oseltamivir (1 trial) or zanamivir (2 trials) for postexposure prophylaxis in 863 children. Treatment was associated with an 8% decrease in the incidence of symptomatic influenza (number needed to treat to prevent 1 additional case, 13). Compliance was high — 97% of children took more than 8 of the 10 doses of zanamivir and 90% took all 10 doses of oseltamivir. Both drugs were well tolerated; however, the incidence of vomiting was 5% higher with oseltamivir than with placebo. No deaths were reported.
Comment: This meta-analysis suggests that neuraminidase inhibitors are well tolerated in children and that they slightly reduce symptom duration and household transmission of seasonal influenza. Whether these data apply to the 2009 influenza A (H1N1) virus pandemic is not clear. Given that H1N1 disease has been mild so far in otherwise healthy children older than age 5 years, neuraminidase inhibitors cannot be recommended for routine outpatient treatment in low-risk children older than 5 years with uncomplicated suspected 2009 H1N1 influenza (JW Pediatr Adolesc Med Aug 21 2009).
— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine September 4, 2009. Citation: Shun-Shin M et al. Neuraminidase inhibitors for treatment and prophylaxis of influenza in children: Systematic review and meta-analysis of randomised controlled trials. BMJ 2009 Aug 10; 339:b3172. (http://dx.doi.org/10.1136/bmj.b3172)
12. Combined Corticosteroid and Antiviral Treatment for Bells Palsy: Two Big Reviews
A. A Systematic Review and Meta-analysis
de Almeida JR, et al. JAMA. 2009;302:985-993.
Context: New evidence has emerged regarding the use of corticosteroids and antiviral agents in Bell palsy.
Objective: To estimate the association of corticosteroids and antiviral agents with the risk of unsatisfactory facial recovery in patients with Bell palsy.
Data Sources: The search included MEDLINE, EMBASE, CENTRAL, PsychInfo, CINAHL, Web of Science, PAPERSFIRST, PROCEEDINGSFIRST, and PROQUEST to identify studies up to March 1, 2009.
Study Selection and Data Extraction: Eligible studies were randomized controlled trials comparing treatment with either corticosteroids or antiviral agents with a control and measuring at least 1 of the following outcomes: unsatisfactory facial recovery (4 months), unsatisfactory short-term recovery (6 weeks to 4 months), synkinesis and autonomic dysfunction, or adverse effects. Two reviewers extracted data on study characteristics, methods, and outcomes. Disagreement was resolved by consensus.
Results: Eighteen trials involving 2786 patients were eligible. Regression analysis identified a synergistic effect when corticosteroids and antiviral agents were administered in combination compared with alone (odds ratio for interaction term, 0.54 [95% confidence interval {CI}, 0.35-0.83]; P = .004). Meta-analysis using a random-effects model showed corticosteroids alone were associated with a reduced risk of unsatisfactory recovery (relative risk [RR], 0.69 [95% CI, 0.55-0.87]; P = .001) (number needed to treat to benefit 1 person, 11 [95% CI, 8-25]), a reduced risk of synkinesis and autonomic dysfunction (RR, 0.48 [95% CI, 0.36-0.65]; P less than .001) (number needed to treat to benefit 1 person, 7 [95% CI, 6-10]), and no increase in adverse effects. Antiviral agents alone were not associated with a reduced risk of unsatisfactory recovery (RR, 1.14 [95% CI, 0.80-1.62]; P = .48). When combined with antiviral agents, corticosteroids were associated with greater benefit (RR, 0.48 [95% CI, 0.29-0.79]; P = .004) than antiviral agents alone. When combined with corticosteroids, antiviral agents were associated with greater risk reduction of borderline significance compared with corticosteroids alone (RR, 0.75 [95% CI, 0.56-1.00]; P = .05).
Conclusions: In Bell palsy, corticosteroids are associated with a reduced risk of unsatisfactory recovery. Antiviral agents, when administered with corticosteroids, may be associated with additional benefit.
B. The benefits of steroids versus steroids plus antivirals for treatment of Bell’s palsy: a meta-analysis
Quant EC, et al. BMJ 2009;339:b3354
Objective: To determine whether steroids plus antivirals provide a better degree of facial muscle recovery in patients with Bell’s palsy than steroids alone.
Design Meta-analysis.
Data sources: PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for studies published in all languages from 1984 to January 2009. Additional studies were identified from cited references.
Selection criteria: Randomised controlled trials that compared steroids with the combination of steroids and antivirals for the treatment of Bell’s palsy were included in this study. At least one month of follow-up and a primary end point of at least partial facial muscle recovery, as defined by a House-Brackmann grade of at least 2 (complete palsy is designated a grade of 6) or an equivalent score on an alternative recognised scoring system, were required.
Review methods: Two authors independently reviewed studies for methodological quality, treatment regimens, duration of symptoms before treatment, length of follow-up, and outcomes. Odds ratios with 95% confidence intervals were calculated and pooled using a random effects model.
Results: Six trials were included, a total of 1145 patients; 574 patients received steroids alone and 571 patients received steroids and antivirals. The pooled odds ratio for facial muscle recovery showed no benefit of steroids plus antivirals compared with steroids alone (odds ratio 1.50, 95% confidence interval 0.83 to 2.69; P=0.18). A one study removed analysis showed that the highest quality studies had the greatest effect on the lack of difference between study arms shown by the odds ratio. Subgroup analyses assessing causes of heterogeneity defined a priori (time from symptom onset to treatment, length of follow-up, and type of antiviral studied) showed no benefit of antivirals in addition to that provided by steroids.
Conclusions: Antivirals did not provide an added benefit in achieving at least partial facial muscle recovery compared with steroids alone in patients with Bell’s palsy. This study does not, therefore, support the routine use of antivirals in Bell’s palsy. Future studies should use improved herpes virus diagnostics and newer antivirals to assess whether combination therapy benefits patients with more severe facial paralysis at study entry.
Full-text (free): http://www.bmj.com/cgi/content/full/339/sep07_1/b3354
13. Rapid Urine Chlamydia Test for Males Is Highly Sensitive
When tested on first-void urine samples, a new rapid chlamydia test had a sensitivity of 82%.
Nadala E-C et al. BMJ 2009 Jul 28; 339:b2655.
Conclusions: The performance of the new Chlamydia Rapid Test with first void male urine samples indicates that it would be an effective diagnostic tool for chlamydial infection in men. The availability of test results within an hour allows for immediate treatment and contact tracing, potentially reducing the risks of persistent infection and onward transmission. The test could also provide a simple and reliable alternative to nucleic acid amplification assays for testing of male urine in chlamydial screening programmes in high prevalence settings.
Full-text (free): http://www.bmj.com/cgi/content/full/339/jul28_2/b2655
14. Time to Abandon the "Shotgun Approach" to Syncope Evaluation
Many unnecessary and costly tests are obtained to evaluate elders with syncope.
Syncope is common, challenging, and expensive; it accounts for 1% to 3% of all U.S. emergency department visits and about 6% of inpatient admissions, with an estimated annual healthcare cost of US$2.5 billion. Most causes of syncope are benign, but the diagnostic challenge is to identify those that are life-threatening, particularly cardiovascular causes. Despite thorough and costly work-ups, syncope etiology remains undetermined in 40% of patients after their initial evaluations.
Researchers at Yale University performed a retrospective cohort study in 2106 consecutive older patients (age, 65) who were admitted with syncope. The investigators reviewed how often various diagnostic tests were ordered and how often such results helped to establish the etiology of syncope or affected diagnosis and management. They calculated the cost per test that affected diagnosis or management and whether use of the San Francisco Syncope Rule (SFSR; Ann Emerg Med 2004; 43:224) resulted in improved cost efficiency or diagnostic yield.
Postural blood pressure measurement (i.e., orthostatics), performed in only 38% of cases, affected diagnosis and management in about 25% of patients and identified syncope etiology in 15% to 21% of syncopal episodes; it returned the highest diagnostic yield and was the most cost-effective test ($17–$21). Cardiac enzymes, head computed tomography (CT) scans, carotid ultrasound (US), and electroencephalography (EEG) had little effect on diagnosis or management (less than 5%); rarely helped determine syncope etiology (less than 2%); and were among the least cost-effective tests: EEG ($33,000), head CT ($25,000), cardiac enzymes ($22,000), and carotid US ($20,000). Use of the SFSR led to higher diagnostic yield and better cost-effectiveness for most cardiac tests.
Comment: These findings underscore the importance of prioritizing diagnostic testing based on an initial standard evaluation, which should include a complete history and physical examination (including orthostatic blood pressure measurements and an electrocardiogram). Neurological tests (i.e., head magnetic resonance imaging or CT, EEG, and carotid US) shouldn't be performed, unless a neurological disease or event is suspected, based on the initial evaluation.
I am confident that the results of this study could be replicated in a variety of clinical settings. Although "shot gunning" multiple tests might reassure patients that they are getting the best care money can buy, we must take more financial stewardship of our resources, follow evidence-based guidelines, and be willing to live with some diagnostic uncertainty. Our healthcare system and economy can no longer support indiscriminate ordering of tests. More studies should be designed to evaluate cost-effectiveness, and those results should be incorporated into clinical guidelines.
— Aaron J. Calderon, MD, FACP. Published in Journal Watch Hospital Medicine August 31, 2009. Citation: Mendu ML et al. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med. 2009;169:1299. http://www.ncbi.nlm.nih.gov/pubmed/19636031
15. Unenhanced CT May Assist in Diagnosis of Children with Flank Pain
Laurie Barclay, MD. September 14, 2009 — Unenhanced computed tomography (UCT) plays an important role in diagnosing children with flank pain, according to the results of a retrospective study reported in the September issue of Pediatrics.
"Urolithiasis can cause acute abdominal or flank pain, and its incidence is increasing," write Andre C. Persaud, MD, from Akron Children's Hospital in Akron, Ohio, and colleagues. "With increases in the use of UCT for diagnosis, additional predictors that can aid clinicians in management are needed....The objective of this study was to identify factors that predict the presence of urolithiasis detected with...UCT in children."
Between January 2002 and December 2005, a total of 339 eligible patients younger than 21 years presented to the emergency department at Akron Children's Hospital and underwent UCT of the abdomen. Mean age of those with positive results on UCT for urolithiasis was 14.4 years; 72 patients (66%) were girls. A standardized form was used to abstract data regarding demographics, clinical presentation, diagnosis, treatment, and disposition. Factors associated with urolithiasis were identified with use of univariate and logistic regression analyses.
UCT detected 110 cases of urolithiasis in 95 individual patients. Initial urinalysis results were negative for blood in 17 cases of urolithiasis (15%). Of the 110 stones detected, 57 (51.8%) were ureteral, 26 (23.6%) were renal, and 4 (3.6%) were in the bladder. Among children in whom UCT did not reveal a stone, UCT did lead to potentially significant, alternative diagnoses in 23 children (10%).
Positive predictors of urolithiasis were a history of urolithiasis, a history of nausea and vomiting, flank pain on examination, and more than 2 red blood cells per high-power field seen on urine microscopic examination. Factors inversely associated with urolithiasis on UCT scans were a history of fever or dysuria and costovertebral angle tenderness on physical examination.
"UCT plays an important role in the diagnostic evaluation of children with flank pain," the study authors write. "Approximately 15% of children with urolithiasis do not have hematuria."
Limitations of this study include retrospective design, data limited to the information reported in the electronic charts, and UCT results interpreted by a single radiologist without set guidelines.
"A history of urolithiasis, nausea and vomiting, flank pain on examination, and hematuria are positively associated with urolithiasis in children," the study authors conclude. "Fever, dysuria, and costovertebral angle tenderness are inversely associated with urolithiasis....The relative cost and potential radiation risks of UCT must be balanced against its high sensitivity in depicting calculi, rapid results, and ability to reveal alternate pathologic conditions."
The study authors have disclosed no relevant financial relationships.
Pediatrics. 2009;124:888-894. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19661055
16. More Details on Corticosteroids for Bacterial Meningitis
This meta-analysis of published randomized, placebo-controlled trials suggests that the adjunctive administration of corticosteroids is beneficial in the treatment of adolescents and adults with acute bacterial meningitis in patient populations similar to those seen in high-income countries and in areas with a low prevalence of human immunodeficiency virus infection.
Assiri AM et al. Mayo Clin Proc 2009 May; 84:403.
Abstract: http://www.mayoclinicproceedings.com/content/84/5/403.abstract
17. "Spin" Not Uncommon in Negative RCTs, Study Shows
Shelley Wood. September 14, 2009 (Vancouver, British Columbia) — French researchers who set out to classify, then quantify the amount of "spin" in publications of negative randomized controlled trials say that the language used in and around the numbers themselves may frequently serve to sugar-coat negative results. Dr Isabelle Boutron (University Paris Descartes, France), who presented the results of the study during the 2009 International Congress on Peer Review and Biomedical Publication, said "spin" in reports of negative randomized controlled trials is by no means rare.
In randomized controlled trials, the "data should speak for themselves," she said during her presentation. The problem, however, is that scientists are rarely neutral about the results of their trial and consciously or unconsciously may try to portray their findings in a rosier light, often in the hopes of expediting publication, advancing their own careers, or even profiting financially. The aim of Boutron et al's study was to get a sense of just how often scientists may be "spinning" their findings, with spin defined as presenting or discussing the results in such a way as to convince the reader that an experimental treatment is beneficial, despite a nonstatistically significant difference for the primary end point.
Boutron and colleagues searched all two-arm randomized controlled trials indexed in PubMed in December 2006, ultimately identifying a total of 72 negative randomized controlled trials. They also developed a scoring system for identifying spin, based on linguistic choices and on instances when authors put particular emphasis on statistically significant results outside the primary end point (including within-group comparisons, subgroup analyses, and secondary outcomes), or interpreted results as demonstrating "comparable effectiveness" or "equivalence." Two independent reviewers then scored the papers, and reached a consensus for individual components of each of the papers.
Overall, evidence of spin was present in 18% of study titles, rising to 29% in the results, 43% in the discussions, and 50% in the conclusions. More than 40% of publications had spin in at least two of the three sections of the main text. Taking a closer look at the conclusions specifically, Boutron et al found that 33% of abstracts contained a "high level" of spin, defined as no acknowledgement of the negative primary outcome, no expression of uncertainty, and no recommendation to study the issue further in another trial. By contrast, a high level of spin was slightly less common in the conclusions of the full article.
Speaking with heartwire, Boutron emphasized that she hopes her work can ultimately be used to help authors write more objectively, and to also assist editors, reviewers, and readers.
"I think we should be reading articles differently," she said. "We should be really careful about the way people present and conclude their articles. And for academics, they should be very careful about the way they write articles. I often work with principle investigators in writing their articles, and I always need to calm them down, because they believe that their treatments work and they try to frame the results in a specific way."
An initial hurdle, she added, is for journal editors to think more critically about the discussion and conclusion sections of articles. "Sometimes the trials are very good and they have very straightforward ways of reporting their results and methods, but the interpretation of the results will be wrong. . . . This is an area where people aren't focusing too much; they're not looking at the discussion, they are looking at the results, and whether the statistical methods were well done, did they do the randomization correctly, etc. But for the discussion and interpretation, probably because it's subjective, people are afraid to look at it. . . . I think the journals need to take a tougher stand."
18. Comparison of GlideScope Video Laryngoscopy Versus Direct Laryngoscopy Intubation in the ED
Platts-Mills TF, et al. Acad Emerg Med. 2009;16:866–871.
Objectives: The first-attempt success rate of intubation was compared using GlideScope video laryngoscopy and direct laryngoscopy in an emergency department (ED).
Methods: A prospective observational study was conducted of adult patients undergoing intubation in the ED of a Level 1 trauma center with an emergency medicine residency program. Patients were consecutively enrolled between August 2006 and February 2008. Data collected included indication for intubation, patient characteristics, device used, initial oxygen saturation, and resident postgraduate year. The primary outcome measure was success with first attempt. Secondary outcome measures included time to successful intubation, intubation failure, and lowest oxygen saturation levels. An attempt was defined as the introduction of the laryngoscope into the mouth. Failure was defined as an esophageal intubation, changing to a different device or physician, or inability to place the endotracheal tube after three attempts.
Results: A total of 280 patients were enrolled, of whom video laryngoscopy was used for the initial intubation attempt in 63 (22%) and direct laryngoscopy was used in 217 (78%). Reasons for intubation included altered mental status (64%), respiratory distress (47%), facial trauma (9%), and immobilization for imaging (9%). Overall, 233 (83%) intubations were successful on the first attempt, 26 (9%) failures occurred, and one patient received a cricothyrotomy. The first-attempt success rate was 51 of 63 (81%, 95% confidence interval [CI] = 70% to 89%) for video laryngoscopy versus 182 of 217 (84%, 95% CI = 79% to 88%) for direct laryngoscopy (p = 0.59). Median time to successful intubation was 42 seconds (range, 13 to 350 seconds) for video laryngoscopy versus 30 seconds (range, 11 to 600 seconds) for direct laryngoscopy (p less than 0.01).
Conclusions: Rates of successful intubation on first attempt were not significantly different between video and direct laryngoscopy. However, intubation using video laryngoscopy required significantly more time to complete.
19. Images in EM
Adult Female With Weakness and Chills
http://www.annemergmed.com/article/S0196-0644(09)00054-7/fulltext
20. US Clinicians Underrecognize Abdominal Migraine in Children
Daniel M. Keller, PhD. September 14, 2009 (Philadelphia, Pennsylvania) — Abdominal migraine may represent up to 15% of pediatric gastrointestinal patients who experience idiopathic recurrent abdominal pain, if results presented here at the 14th International Headache Congress are representative.
Although the condition is well recognized in Europe, it is underdiagnosed in the United States, according to investigator Donald Lewis, MD, professor and chairman of the Department of Pediatrics at Eastern Virginia Medical School and senior vice president for academic affairs at Children's Hospital of the King's Daughters in Norfolk, Virginia.
Children with recurrent abdominal pain use significant amounts of healthcare resources, he said, and the condition can lead to dysfunction and disability that may interfere with school, family, and social activities.
Dr. Lewis told Medscape Neurology that abdominal migraine is classified as one of the period syndromes of childhood that are precursors to migraine. "If you track those kids [for] long through adolescence, most of them grow up to have migraine," he said.
Belly Pain a Cardinal Feature
Dr. Lewis, a pediatric neurologist, explained that abdominal migraine is characterized by episodes of moderate to severe midline, periumbilical, or poorly localized pain lasting for 1 to 72 hours with nausea, anorexia, pallor, and occasionally headache. "But headache is not one of the cardinal features. It's episodes of belly pain," he emphasized. The condition was included in the 2004 International Classification of Headache Disorders and recognized by the 2006 Rome III criteria for functional gastrointestinal disorders as a well-defined type of recurrent abdominal pain.
Through chart reviews, Dr. Lewis and colleagues assessed patients with recurrent abdominal pain in the hospital's pediatric gastroenterology clinic to define the proportion of patients who might fulfill the International Classification of Headache Disorders 2004 criteria for abdominal migraine. Eligible subjects were girls (41%) or boys (59%) who were 1 to 21 years old and who did not have a known diagnosis of causes of chronic abdominal pain. Of an initial cohort of 600 children, 458 met the inclusion criteria. Twenty children (4.4%) met the International Classification of Headache Disorders 2004 diagnostic criteria, with an additional 11% having probable abdominal migraine (documentation lacking for 1 or more diagnostic criterion).
"So we have this large subset of children who are languishing with a vague diagnosis in [gastrointestinal] clinics who most likely have abdominal migraine," Dr. Lewis said. Making the correct diagnosis of abdominal migraine means the spectrum of migraine medications will become available to these children, he added.
Migraine prophylactic medications and acute treatments for migraine attacks are available and efficacious for abdominal migraine. Because the study was solely demographic, it did not test medication efficacy, but Dr. Lewis said the European literature has documented the efficacy of these treatments.
He speculated that abdominal migraine is underrecognized in the United States because physicians have not been taught about it. The message about the existence of the condition is especially relevant to pediatric gastroenterologists and general pediatricians. Dr. Lewis suggested that pediatricians might better refer such patients to pediatric neurologists instead of to gastroenterologists. Informed families, too, may alert their physicians if their child has recurring symptoms consistent with a diagnosis of abdominal migraine, especially if a parent, particularly the mother, has a migraine condition, as migraine is often inherited.
Background of Episodic Abdominal Pain
Brian McGeeney, MD, MPH, assistant professor of neurology at Boston University, Massachusetts, who was not involved in the study, told Medscape Neurology that in his clinical experience with adults, abdominal migraine is a real entity. "They seem to have a background of episodic abdominal pain in childhood more than one would expect by chance," he said.
"Posters like this should really heighten the awareness of this unusual syndrome to adult neurologists as well as pediatricians." Knowing a patient's childhood history of abdominal symptoms may be one more clue in the diagnosis of adult migraine.
Although abdominal migraine may be a precursor to and temporally linked with later migraine, for Dr. McGeeney, a strong indication that abdominal migraine is really a form of migraine is that it often responds to a broad range of migraine prophylactic medications.
14th International Headache Congress: Abstract PO222. Presented Saturday, September 12, 2009.
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