1. Marathon Day at Massachusetts General
Ann Intern Med. 2013 March 30 [Epub ahead of print]
Alasdair Conn, MD, Chief, Department of Emergency Medicine,
MGH
We thought it would be a normal Marathon Monday at
Massachusetts General Hospital (MGH). The Boston Marathon is always held on the
third Monday in April and is a public holiday—Patriots Day. All state offices
are closed, together with many businesses; but for hospitals, it is a regular
working day. The MGH normally expects to receive about 15 to 20 marathon
runners with hyponatremia and dehydration, many more are treated at the medical
tents along the route of the marathon. For many this is a day that Bostonians
look forward to each year as the unofficial start of spring.
It was not to be. At 2:50PM, an explosion rocked the area
near the finish line, closely followed 11 seconds later by a second blast. Two
minutes later, Boston EMS initiated a hospital ringdown; they contacted all of
the Boston hospitals requesting disaster capability. Our answer is always the
same; we have immediate capacity for 10 critical patients, 20 seriously
injured, and we can accept unlimited “walking wounded.” I was paged as soon as
the radio call came in; at this time we had no idea of the potential number of
injured patients or of their severity. I looked at the current ED census—we
were full and had one open stretcher bay in the entire department.
The first patient arrived without entry notification at
3:04PM by private vehicle; the patient was female and had sustained a traumatic
amputation of one of her legs together with multiple other injuries. Two
minutes later, a police van arrived with two additional patients—both also had
traumatic lower extremity amputations, again there had been no time for entry
notification. We activated our Hospital Incident Command System (HICS).
Simultaneously, several hundred MGH staff received a phone call to their home
and work, a message was also sent to their pagers, e-mail, and cell phone
alerting them of the need to respond to disaster stations. The response from
all staff was immediate and coordinated. Within minutes, the ED was vacated and
rooms stocked in preparation for the arrival of further victims. Disaster
packs, one for each expectant patient were opened, enabling us to identify
patient by prearranged medical record numbers, preprinted wrist bands with the
bar codes on them were attached to all disaster patients upon ED arrival. (We
use scanned bar codes for patient identification.) Eight critical patients
arrived to the hospital within 30 minutes of the explosion. Among the first was
the patient who arrived pulseless; she had already exsanguinated. IVs were
started; she was given four units of uncrossed blood and with her blood
pressure restored transferred immediately to the operating room. Over the next
few minutes five other patients—three with traumatic amputations—were also
resuscitated and sent to the operating room; at that time we had positive
identification on one of these six patients. More patients, albeit less
severely injured, followed them to the OR over the next two to three hours. The
MGH treated 31 patients that day; several more arrived over the subsequent 24
to 48 hours.
Unfortunately, three patients died at the scene of the
explosions; miraculously all of the patients who were transferred to hospitals
survived. There will be further debriefings over the next few weeks, several
factors undoubtedly contributed to this remarkable survival rate. At the scene,
there were many first responders who were immediately able to respond (despite
the personal risk of further potential bomb blasts) and to control the
hemorrhage from the multiple patients with lower extremity injuries. Stories
abound of clothes being torn to make improvised tourniquets—this proved to be
lifesaving. Staff in the medical tent close to the finish line changed their
role from treating dehydration to controlling external hemorrhage and
crystalloid resuscitation without missing a beat. Many ambulances were
stationed near the finish line and could transport the most critically injured
rapidly to the nearby hospitals. Boston EMS staff on scene performed an
exemplary function in triaging the severely injured to the trauma centers,
taking care not to overload the resources of any one hospital. Boston is
fortunate to have a plethora of hospital resources—five Level I Adult Trauma
Centers and three Level 1 Pediatric Trauma Centers are within three miles of
the finish line; all hospitals received critical patients in roughly equal
numbers.
The timing of the explosions was also opportune; the
incident occurred at the change of shift. The morning shift was completing the
7am to 3pm shift; the 3 pm to 11 pm shift was already in house. On every unit
in the hospital the medical, nursing, and support staff stayed to assist
however they could – it was as though there was immediate double coverage. It
was a Monday; the hospital was relatively open and had not yet filled with the
elective cases that tend to occur early in the week. Being a state holiday the
scheduled operating list was relatively light but because it was a normal
working day the operating rooms were fully staffed; the ORs were also
completing their operative schedules for the day. All of these factors
contributed, but above all, it was the training and the repeated disaster
drills that made the difference. Although we did not receive any patients from
Ground Zero on that fateful day in September 2001, we realized that our
hospital internal disaster plan was inadequate; we took the opportunity to
thoroughly revise our response. We requested a consultation with Israeli
emergency physicians—they let us know how they are able to respond to a bombing
on a bus—they told us they experience this scenario every six weeks and are
able to manage 70 to 80 patients arriving simultaneously. We worked with Boston
EMS to hone our coordination and skills and performed numerous drills, often on
a citywide basis. The simulated building collapse; the dirty bomb scenario at
Logan airport and the repetitive activation of the MGH disaster response
system—yes—on nights and weekends, all contributed to our learning and
familiarity. This training and the iterative improvement in response by all
involved made the difference on Marathon Monday. Our elected representatives
who help fund these efforts have to be informed that this is money well-spent;
this training made the difference and translated directly into lives saved.
Unfortunately, terrorism in today's world is a reality and
even in the United States we now realize we are not immune. As a medical
community we must be prepared to meet this challenge. In the ensuing months, I
am sure we will be analyzing the Boston marathon response in more detail and we
will surely find that there are more lessons to be learned. However, as a
medical professional working that day, I feel an enormous sense of pride in
being a member of a team of health care providers—both prehospital and
in-hospital—all of whom functioned in a rehearsed, choreographed, and
coordinated response. At the end of the day the system worked and lives were
saved. I remain convinced that it was mostly this coordination of effort that
contributed to the dramatic survival of the bombing victims. Or as one
physician stated to an ad hoc debriefing about 48 hours after the event, “We
all came together and worked as a team, and as a team we together saved lives”
It was truly a day to remember.
See also:
Under the Medical Tent at the Boston Marathon: http://www.nejm.org/doi/full/10.1056/NEJMp1305299
Marathon Bombings: An EM Physician's First-Hand Account: http://www.medscape.com/viewarticle/802900
Lessons from Boston:
2. Do All Patients with Major Blunt Trauma Need
C-Spine CT?
Clinical factors show promise for predicting fractures, but
until they're validated, all such patients should undergo C-spine computed tomography.
Both the National Emergency X-Radiography Utilization Study
(NEXUS) and Canadian cervical spine (C-spine) rules have demonstrated that
clinical exam is sufficient to clear the cervical spine for certain trauma
patients. However, the sensitivity and specificity of these rules for patients
with major trauma are not adequate, and many centers perform C-spine computed
tomography (CT) for all patients with major trauma. In this prospective
single-site study, investigators evaluated the correlation between findings on
C-spine CT and presence of any of 18 combined NEXUS and Canadian C-spine
criteria in 5812 trauma patients.
All patients met criteria for major trauma requiring trauma
team activation, which included Glasgow Coma Scale (GCS) score below 14, systolic
blood pressure less than 90 mm Hg, respiratory rate below 10 or above 20 per
minute, significant obvious anatomic injury (e.g., flail chest; two or more
long-bone fractures; crushed, degloved, or mangled extremity; amputation;
pelvic fractures; open or depressed skull fractures; paralysis), and
significant mechanism of injury (e.g., falls greater than 20 feet, high-risk
motor vehicle collision).
Fracture incidence was 6.3%. Clinical exam had 100%
sensitivity and 0.62% specificity for detecting fractures. Seven NEXUS/Canadian
C-spine criteria were independent predictors of fracture: midline tenderness,
GCS score less than15, paresthesias, rollover motor vehicle collision, ejection
from a motor vehicle, age ≥65, and not being able to sit up in the emergency
department. Use of these seven factors increased specificity nearly 20-fold, to
11.6%.
Comment: Prospective multicenter validation of these factors
is needed before practice changes. Until then, C-spine computed tomography
should continue be the study of choice to evaluate patients with major trauma
for possible cervical spine fracture.
— Richard D. Zane, MD, FAAEM. Published in Journal Watch
Emergency Medicine May 3, 2013
Citation: Duane TM et al. CT for all or selective approach?
Who really needs a cervical spine CT after blunt trauma. J Trauma Acute Care
Surg 2013 Apr; 74:1098.
3. Chest Pain: What Happens After the ED?
Patients who follow up with cardiologists do best.
Researchers examined patterns of follow-up care and outcomes
in high-risk patients with chest pain who presented to Ontario emergency
departments (EDs) from 2004 to 2010. High risk was defined as having a prior
diagnosis of cardiovascular disease, diabetes, or both. The primary outcome was
a composite of all-cause death and hospitalization for myocardial infarction
within 1 year after the index visit.
Of nearly 57,000 patients, 17% followed up with a cardiologist
(with or without a visit to primary care) within 30 days after ED discharge,
57% followed up with a primary care practitioner only, and 25% did not have a
visit to a physician recorded. After adjustment for clinical, demographic, and
hospital characteristics, the cardiologist group had a significantly lower
hazard ratio for the composite outcome (HR, 0.79; P less than 0.001) than the
no–follow-up group and the PCP-only group (HR, 0.85; P less than 0.001).
PCP-only follow-up was significantly beneficial compared to no follow-up (HR,
0.93; P less than 0.023). Patients seen by cardiologists underwent more testing
and received more evidence-based therapies within 100 days after discharge.
Comment: These robust results demonstrate that what happens
after the emergency department visit is as important as what happens during the
ED visit, and that postdischarge care for patients with high-risk chest pain
should include timely assessment by a cardiologist.
— J. Stephen Bohan, MD, MS, FACP, FACEP. Published in
Journal Watch Emergency Medicine April 19, 2013 .Citation: Czarnecki A et al.
Association between physician follow-up and outcomes of care after chest pain
assessment in high-risk patients. Circulation 2013 Apr 2; 127:1386-94.
4. Steroid-antiviral Treatment Improves the Recovery
Rate in Patients with Severe Bell's Palsy
Lee HY, et al. Amer J Med. 2013;126:336-41.
Background: The extent of facial nerve damage is expected to
be more severe in higher grades of facial palsy, and the outcome after applying
different treatment methods may reveal obvious differences between severe
Bell's palsy and mild to moderate palsy. This study aimed to systematically
evaluate the effects of different treatment methods and related prognostic
factors in severe to complete Bell's palsy.
Methods: This randomized, prospective study was performed in
patients with severe to complete Bell's palsy. Patients were assigned randomly
to treatment with a steroid or a combination of a steroid and an antiviral
agent. We collected data about recovery and other prognostic factors.
Results: The steroid treatment group (S group) comprised 107
patients, and the combination treatment group (S+A group) comprised 99
patients. There were no significant intergroup differences in age, sex,
accompanying disease, period from onset to treatment, or results of an
electrophysiology test (P above .05). There was a significant difference in
complete recovery between the 2 groups. The recovery (grades I and II) of the S
group was 66.4% and that of the S+A group was 82.8% (P=.010). The S+A group
showed a 2.6-times higher possibility of complete recovery than the S group,
and patients with favorable electromyography showed a 2.2-times higher
possibility of complete recovery.
Conclusions: Combined treatment with a steroid and an
antiviral agent is more effective in treating severe to complete Bell's palsy
than steroid treatment alone.
Full-text (free): http://www.amjmed.com/article/S0002-9343(12)00907-2/fulltext
5. A RCT of Cast vs.
Splint for Distal Radial Buckle Fracture: An Evaluation of Satisfaction,
Convenience, and Preference
Williams KG, et al. Pediatr Emerg Care. 2013;29:555-559.
Objectives: Buckle fractures are inherently stable and at
low risk for displacement. These advantages allow for treatment options that
may create confusion for the practitioner. Accepted immobilization methods
include circumferential cast, plaster or prefabricated splint, and soft
bandaging. Despite mounting evidence for splinting, the questions of pain,
preference, satisfaction, and convenience offer a challenge to changing
practice. The purposes of this study were (1) to compare cast versus splint for
distal radial buckle fractures in terms of parental and patient satisfaction,
convenience, and preference and (2) to compare pain reported for cast versus splint.
Methods: We conducted a prospective randomized trial of a
convenience sample of patients 2 through 17 years with a radiologically
confirmed distal radial buckle fracture. Subjects were randomly assigned to
short-arm cast or prefabricated wrist splint. We assessed satisfaction,
convenience, preference, and pain in the emergency department and at days 1, 3,
7, and 21 after immobilization.
Results: Ninety-four patients were enrolled. Compared with
the cast group, those in the splint group reported higher levels of
satisfaction, preference, and convenience on 10-point visual analog scale.
Although pain scores were higher for those in the splint group, the difference
was not statistically significant.
Conclusions: With the exception of pain reported in the
emergency department being higher for the splinted group, all other measures,
including convenience, satisfaction, and preference, showed a clear trend
favoring splints at almost every time period in the study. This study provides
additional evidence that splinting is preferable to casting for the treatment
of distal radial buckle fractures.
6. Yield of Chest Radiography after Removal of
Esophageal Foreign Bodies
Fisher J, et al. Pediatrics. 2013 Apr 22. [Epub ahead of
print]
OBJECTIVES: The aim of this study was to determine the
benefit of routine postoperative chest radiography after removal of esophageal
foreign bodies in children.
METHODS: Medical records were reviewed of all patients
evaluated with an esophageal foreign body at a single children’s hospital over
10 years. Operative records and imaging reports were reviewed for evidence of
esophageal injury.
RESULTS: Of 803 records identified, 690 were included. All
underwent rigid esophagoscopy and foreign body removal. The most common items
removed were coins (94%), food boluses (3%), and batteries (2%). The rate of
esophageal injury was 1.3% (9 patients). No injuries were identified on chest
radiographs done as routine or for concern of injury. Patients with operative
findings suggestive of an esophageal injury (n = 105) were significantly more
likely to have an injury (8.6% vs 0%, P = .0001). Of the 585 children who did
not have physical evidence of injury, 40% (n = 235) received a routine chest
radiograph. Regardless of the indication, no injuries were identified on chest
films.
CONCLUSIONS: We conclude that intraoperative findings during
rigid esophagoscopy suggestive of an injury are predictive of esophageal
perforation. Routine chest radiography is not warranted in children who do not
meet this criterion. In patients with a concern for injury, we suggest that
chest radiography should be deferred in favor of esophagram.
7. Bedside US Measurement of the IVC Does Not
Predict Hydration Status in Children
IVC collapsibility
index and IVC-to-aorta ratio did not correlate with central venous pressure ≤8
mm Hg.
In a prospective observational study at a pediatric critical
care unit, investigators evaluated the correlation between two bedside
ultrasound inferior vena cava (IVC) measurements and central venous pressure
(CVP) indicative of dehydration (≤8 mm Hg). The two IVC measurements were
percent decrease in IVC diameter between expiration and inspiration (IVC
collapsibility index) above 0.5 and IVC-to-aorta ratio ≤0.8.
In a convenience sample of 51 patients less than 21 years
(median age, 5 months) with central venous catheters, 67% were intubated, 65%
had a femoral central line site, 47% were admitted for cardiac diagnoses, and
10% were admitted for intra-abdominal diagnoses. Overall, 43% had CVP ≤8 mm Hg.
For predicting CVP ≤8 mm Hg, an IVC collapsibility index above 50% had a
sensitivity of 14%, specificity of 83%, positive predictive value of 38%, and
negative predictive value of 57%. Corresponding performance parameters of
IVC-to-aorta ratio ≤0.8 were 18%, 81%, 38%, and 60%, respectively.
Comment: IVC collapsibility index has been shown to
correlate well with CVP in adults (link below). The poor correlation between
IVC measurements and CVP in the children in the current study may be secondary
to the high incidences of intubation, with consequent alterations in
intrathoracic pressure, and femoral central line sites, where soft tissue
external pressure influences differ from those at other sites. However, until
supportive evidence emerges, bedside ultrasound IVC measurements should not be
relied on to estimate intravascular volume status in children.
— Katherine Bakes, MD. Published in Journal Watch Emergency
Medicine April 26, 2013
Citation: Ng L et al. Does bedside sonographic measurement
of the inferior vena cava diameter correlate with central venous pressure in
the assessment of intravascular volume in children? Pediatr Emerg Care 2013
Mar; 29:337.
Peds abstract: http://www.ncbi.nlm.nih.gov/pubmed/23426248
In adults: Nagdev AD et al. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. Ann Emerg Med 2010 Mar; 55:290. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/19556029
8. Focused Multiorgan Bedside Ultrasound in Patients
with Nontraumatic Hypotension: A "Medical" FAST Scan?
In patients with nontraumatic hypotension of unclear
etiology, immediate bedside ultrasound findings correlated well with final
diagnoses.
Volpicelli G et al. Intensive Care Med 2013 Apr 13. [Epub
ahead of print]
PURPOSE: We analyzed the efficacy of a point-of-care
ultrasonographic protocol, based on a focused multiorgan examination, for the
diagnostic process of symptomatic, non-traumatic hypotensive patients in the
emergency department.
METHODS: We prospectively enrolled 108 adult patients
complaining of non-traumatic symptomatic hypotension of uncertain etiology.
Patients received immediate point-of-care ultrasonography to determine cardiac
function and right/left ventricle diameter rate, inferior vena cava diameter
and collapsibility, pulmonary congestion, consolidations and sliding, abdominal
free fluid and aortic aneurysm, and leg vein thrombosis. The organ-oriented
diagnoses were combined to formulate an ultrasonographic hypothesis of the
cause of hemodynamic instability. The ultrasonographic diagnosis was then
compared with a final clinical diagnosis obtained by agreement of three
independent expert physicians who performed a retrospective hospital chart
review of each case.
RESULTS: Considering the whole population, concordance
between the point-of-care ultrasonography diagnosis and the final clinical
diagnosis was interpreted as good, with Cohen's k = 0.710 (95 % CI,
0.614-0.806), p less than 0.0001 and raw agreement (Ra) = 0.768. By eliminating
the 13 cases where the final clinical diagnosis was not agreed upon
(indefinite), the concordance increased to almost perfect, with k = 0.971 (95 %
CI, 0.932-1.000), p less than 0.0001 and Ra = 0.978.
CONCLUSIONS: Emergency diagnostic judgments guided by point-of-care
multiorgan ultrasonography in patients presenting with undifferentiated
hypotension significantly agreed with a final clinical diagnosis obtained by
retrospective chart review. The integration of an ultrasonographic multiorgan
protocol in the diagnostic process of undifferentiated hypotension has great
potential in guiding the first-line therapeutic approach.
9. Evidence Reviews in Annals
A. Pediatric UTI:
Does the Evidence Support Aggressively Pursuing the Diagnosis?
Newman DH, et al. Ann Emerg Med. 2013;61:559-565.
The epidemiology of pediatric fever has changed considerably
during the past 2 decades with the development of vaccines against the most
common bacterial pathogens causing bacteremia and meningitis. The decreasing
incidence of these 2 conditions among vaccinated children has led to an
emphasis on urinary tract infection as a remaining source of potentially hidden
infections in febrile children. Emerging literature, however, has led to
questions about both the degree and nature of the danger posed by urinary tract
infection in nonverbal children, whereas the aggressive pursuit of the
diagnosis consumes resources and leads to patient discomfort, medical risks,
and potential overdiagnosis. We review both early and emerging literature to
examine the utility and efficacy of early identification and treatment of
urinary tract infection in children younger than 24 months. We conclude that in
well children of this age, it may be reasonable to withhold or delay testing
for urinary tract infection if signs of other sources are apparent or if the
fever has been present for fewer than 4 to 5 days.
B. In Patients With
Severe Sepsis, Does a Single Dose of Etomidate to Facilitate Intubation
Increase Mortality?
Hunter BR, et al. Ann Emerg Med. 61:571-572.
Take-Home Message: Currently, single-dose etomidate has not
been shown to cause increased mortality in septic patients requiring
intubation; however, sufficiently powered randomized trials are required before
definitive conclusions can be drawn.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01913-0/fulltext
C. Does Combination
Treatment With Ibuprofen and Acetaminophen Improve Fever Control?
Malya RR, et al. Ann Emerg Med. 61:569-570.
Take-Home Message: Combination treatment with ibuprofen and
acetaminophen is beneficial over either agent alone for sustained fever
reduction in children older than 6 months.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)01698-8/fulltext
10. Advertising ED Wait Times
Weiner SG. West J Emerg Med 2013;14(2):77-78.
Advertising emergency department (ED) wait times has become
a common practice in the United States. Proponents of this practice state that
it is a powerful marketing strategy that can help steer patients to the ED.
Opponents worry about the risk to the public health that arises from a patient
with an emergent condition self-triaging to a further hospital, problems with
inaccuracy and lack of standard definition of the reported time, and directing
lower acuity patients to the higher cost ED setting instead to primary care.
Three sample cases demonstrating the pitfalls of advertising ED wait times are
discussed. Given the lack of rigorous evidence supporting the practice and
potential adverse effects to the public health, caution about its use is
advised.
Full-text (free): http://www.escholarship.org/uc/item/0bt69906#
11. Images in Clinical Medicine
Healthy 51-Year-Old Male With Peritonsillar Swelling
Man With a Rash
Woman With Worsening Exertional Dyspnea
Levamisole-adulterated Cocaine Induced Vasculitis with Skin
Ulcerations
Acute Vision Change in a 16-year-old Female
Perforation of Inferior Vena Cava by Inferior Vena Cava
Filter
Neonatal Umbilical Mass
12. Cardiovascular Risks with Azithromycin and Other
Antibacterial Drugs
Mosholder AD, et al. N Engl J Med 2013; 368:1665-1668.
In 2011, approximately 40.3 million people in the United
States (roughly one eighth of the population) received an outpatient
prescription for the macrolide azithromycin, according to IMS Health. During
that year, we at the Food and Drug Administration (FDA) reviewed the labels of
azithromycin and other approved macrolide antibacterials in view of
cardiovascular risks that had become evident from published studies and reports
emerging through postmarketing surveillance. On the basis of its review, the
FDA approved revisions to azithromycin product labels regarding risks of
QT-interval prolongation and the associated ventricular arrhythmia torsades de
pointes. The revised labels advise against using azithromycin in patients with
known risk factors such as QT-interval prolongation, hypokalemia,
hypomagnesemia, bradycardia, or use of certain antiarrhythmic agents, including
class IA (e.g., quinidine and procainamide) and class III (e.g., dofetilide,
amiodarone, and sotalol) — drugs that can prolong the QT interval. In March
2013, the FDA announced that azithromycin labels had been further revised to
reflect the results of a clinical study showing that azithromycin can prolong
the corrected QT interval.
In a 2012 observational study involving Tennessee Medicaid
patients, Ray et al.1 quantified the risk of death from cardiovascular causes
associated with azithromycin as compared with other antibacterial drugs or
nonuse. The study showed that the risks of death, both from any cause and from
cardiovascular causes, associated with azithromycin were greater than those
associated with amoxicillin. For every 21,000 outpatient prescriptions written
for azithromycin, one cardiovascular death occurred in excess of those observed
with the same number of amoxicillin prescriptions. The excess risk over amoxicillin
varied considerably according to cardiovascular risk factors; the researchers
estimated that there was one excess cardiovascular death per 4100 prescriptions
among patients at high cardiovascular risk but less than one per 100,000 among
patients with lower cardiovascular risk.
The study by Ray et al. has limitations that are intrinsic
to observational, nonrandomized clinical studies. In particular, nonrandomized
studies cannot exclude the possibility that patients receiving a drug under
evaluation differ from control patients in some important but undetected way,
causing bias in the results. Such confounding may bias comparisons not only
between patients receiving antibacterial drugs and those receiving no
antibacterials but also between patients receiving different antibacterials.
Although Ray et al. used appropriate analytic methods to address potential
confounding, we cannot know for certain whether these methods were fully
successful. Replication of the authors' results, through analysis of a distinct
data set, would provide more confidence in the finding of increased
cardiovascular mortality among patients receiving azithromycin.
Despite such caveats, the results presented by Ray et al.
warrant serious attention. A chief strength of the results is the time-limited
pattern of the risk: the azithromycin-associated increase in the rates of death
from any cause and from cardiovascular causes spanned days 1 through 5,
reflecting the typical 5-day duration of azithromycin administration (e.g.,
Zithromax Z-Pak). On days 6 through 10, an elevated risk of death from
cardiovascular causes was no longer detected. This pattern is consistent with
the timing of peak plasma azithromycin concentrations and the concomitant risk
of QT-interval prolongation. The elevated risk was statistically significant,
regardless of whether azithromycin treatment was compared with amoxicillin or
with nonuse of an antibacterial drug. Furthermore, the observed excess
mortality was attributable solely to cardiovascular deaths and, in particular,
to sudden cardiac death; although sudden cardiac death can result from causes
other than arrhythmias, an increase in deaths in this category would be the
pattern expected from an arrhythmogenic, QT-interval–prolonging drug. Also, the
azithromycin-associated risk was higher among patients with cardiovascular
disorders, which is consistent with a drug-related arrhythmia.
A new study by Svanström and colleagues (pages 1704–1712),
using Danish national health care data, found no difference between azithromycin
and penicillin V in the 5-day risk of cardiovascular death (relative risk,
0.93; 95% confidence interval [CI], 0.56 to 1.55). However, the upper bound of
the 95% confidence interval does not exclude an increased risk of as much as
55%. As Svanström et al. point out, the population they studied differed from
that studied by Ray et al. with respect to the baseline risk of death and
cardiovascular risk factors. Overall, the Danish patients had better
cardiovascular health than the Tennessee Medicaid patients. In a subgroup
analysis of patients with a history of cardiovascular disease, the risk ratio
for azithromycin versus penicillin V was greater than 1, though the difference
was not statistically significant (relative risk, 1.35; 95% CI, 0.69 to 2.64).
Svanström et al. conclude that their results do not conflict with those of Ray
et al. Rather, the effect on cardiovascular mortality may be limited to
patients with cardiovascular disease…
The remainder of the essay (free): http://www.nejm.org/doi/full/10.1056/NEJMp1302726
13. Brief ED
Interventions for Youth Who Use Alcohol and Other Drugs: A Systematic Review
Newton AS, et al. Pediatr Emerg Care. 2013;29:673-684.
Objective: Brief intervention (BI) is recommended for use
with youth who use alcohol and other drugs. Emergency departments (EDs) can
provide BIs at a time directly linked to harmful and hazardous use. The
objective of this systematic review was to determine the effectiveness of
ED-based BIs.
Methods: We searched 14 electronic databases, a clinical
trial registry, conference proceedings, and study references. We included
randomized controlled trials with youth 21 years or younger. Two reviewers
independently selected studies and assessed methodological quality. One
reviewer extracted and a second verified data. We summarized findings
qualitatively.
Results: Two trials with low risk of bias, 2 trials with
unclear risk of bias, and 5 trials with high risk of bias were included. Trials
evaluated targeted BIs for alcohol-positive (n = 3) and alcohol/other
drug–positive youth (n = 1) and universal BIs for youth reporting recent
alcohol (n = 4) or cannabis use (n = 1). Few differences were found in favor of
ED-based BIs, and variation in outcome measurement and poor study quality
precluded firm conclusions for many comparisons. Universal and targeted BIs did
not significantly reduce alcohol use more than other care. In one targeted BI
trial with high risk of bias, motivational interviewing (MI) that involved
parents reduced drinking quantity per occasion and high-volume alcohol use
compared with MI that was delivered to youth only. Another trial with high risk
of bias reported an increase in abstinence and reduction in physical
altercations when youth received peer-delivered universal MI for cannabis use.
In 2 trials with unclear risk of bias, MI reduced drinking and driving and
alcohol-related injuries after the ED visit. Computer-based MI delivered
universally in 1 trial with low risk of bias reduced alcohol-related
consequences 6 months after the ED visit.
Conclusions: Clear benefits of using ED-based BI to reduce
alcohol and other drug use and associated injuries or high-risk behaviours
remain inconclusive because of variation in assessing outcomes and poor study
quality.
14. Lactate and Poor Lactate Clearance Predict
Mortality in Trauma Patients
An elevated initial lactate may be an ominous sign, even in
patients with normal initial blood pressure.
Odom SR et al. J Trauma Acute Care Surg 2013 Apr;
74:999-1004.
BACKGROUND: Initial serum lactate has been associated with
mortality in trauma patients. It is not known if lactate clearance is
predictive of death in a broad cohort of trauma patients.
METHODS: We enrolled 4,742 trauma patients who had an
initial lactate measured during a 10-year period. Patients were identified via
the trauma registry. Lactate clearance was calculated at 6 hours. Multivariable
logistic regression was used to identify the independent contribution of both
initial lactate and lactate clearance with mortality, after adjustment for
severity of injury.
RESULTS: Initial lactate level was strongly correlated with
mortality: when lactate was less than 2.5 mg/dL, 5.4% (95% confidence interval
[CI], 4.5-6.2%) of patients died; with lactate 2.5 mg/dL to 4.0 mg/dL,
mortality was 6.4% (95% CI, 5.1-7.8%); with lactate 4.0 mg/dL or greater,
mortality was 18.8% (95% CI, 15.7-21.9%). After adjustment for age, Injury
Severity Score (ISS), Glasgow Coma Scale (GCS) score, heart rate, and blood
pressure, initial lactate remained independently associated with increased
mortality, with adjusted odds ratios of 1.0, 1.5 (95% CI, 1.1-2.0) and 3.8 (95%
CI, 2.8-5.3), for lactate less than 2.5 mg/dL, 2.5 mg/dL to 4.0 mg/dL, and 4.0
mg/dL or greater, respectively. Among patients with an initially elevated
lactate (≥4.0 mg/dL), lower lactate clearance at 6 hours strongly and
independently predicted an increased risk of death. For lactate clearances of
60% or greater, 30% to 59%, and less than 30%, the adjusted odds ratio for
death were 1.0, 3.5 (95% CI 1.2-10.4), and 4.3 (95% CI, 1.5-12.6),
respectively.
CONCLUSION: Both initial lactate and lactate clearance at 6
hours independently predict death in trauma patients.
15. A Clinician’s
Guide to the Diagnosis and Management of Gallbladder Volvulus
Pottorf BJ, et al. Perm J 2013 Spring; 17(2):80-83
Introduction: Gallbladder volvulus (GV), or torsion of the
gallbladder, is an uncommon surgical emergency. This article reviews the world
literature related to GV. We examine the history of gallbladder torsion and
highlight the critical constellation of presenting signs and symptoms, which
guide the acute care physician and surgeon to accurate and timely diagnosis of
GV before surgical intervention.
Methods: A comprehensive review of all published cases of GV
was performed using the National Library of Medicine (PubMed) database.
Results: Lists of typical symptoms and clinical
presentations are provided to allow clinicians to establish an accurate
preoperative diagnosis.
Conclusion: GV is frequently undiagnosed before surgical
intervention. However, clinical presentation and associated radiographic
findings can lead to an accurate diagnosis if the clinician is aware of this
uncommon condition. When the diagnosis has been established before operative
intervention, expeditious laparoscopic cholecystectomy can be performed safely.
Delays in diagnosis may mandate open cholecystectomy if laparoscopic extraction
is contraindicated because of undesirable sequelae of gallbladder necrosis,
specifically perforation, bilious peritonitis, and hemodynamic instability.
Full-text (free): http://www.thepermanentejournal.org/issues/2013/spring/5107-gallbladder-volvulus.html
16. Variability of ICU Use in Adult Patients with
Minor Traumatic Intracranial Hemorrhage
Nishijima DK, et al. Ann Emerg Med. 2013;61:509-517.e4.
Study objective: Patients with minor traumatic intracranial
hemorrhage are frequently admitted to the ICU, although many never require
critical care interventions. To describe ICU resource use in minor traumatic
intracranial hemorrhage, we assess (1) the variability of ICU use in a cohort
of patients with minor traumatic intracranial hemorrhage across multiple trauma
centers, and (2) the proportion of adult patients with traumatic intracranial
hemorrhage who are admitted to the ICU and never receive a critical care
intervention during hospitalization. In addition, we evaluate the association
between ICU admission and key independent variables.
Methods: A structured, historical cohort study of adult
patients (aged 18 years and older) with minor traumatic intracranial hemorrhage
was conducted within a consortium of 8 Level I trauma centers in the western
United States from January 2005 to June 2010. The study population included
patients with minor traumatic intracranial hemorrhage, defined as an emergency
department (ED) Glasgow Coma Scale (GCS) score of 15 (normal mental status) and
an Injury Severity Score less than 16 (no other major organ injury). The
primary outcome measure was initial ICU admission. The secondary outcome
measure was a critical care intervention during hospitalization. Critical care
interventions included mechanical ventilation, neurosurgical intervention,
transfusion of blood products, vasopressor or inotrope administration, and
invasive hemodynamic monitoring. ED disposition and the proportion of ICU patients
not receiving a critical care intervention were compared across sites with
descriptive statistics. The association between ICU admission and predetermined
independent variables was analyzed with multivariable regression.
Results: Among 11,240 adult patients with traumatic
intracranial hemorrhage, 1,412 (13%) had minor traumatic intracranial
hemorrhage and complete ED disposition data (mean age 48 years; SD 20 years).
ICU use within this cohort across sites ranged from 50% to 97%. Overall, 847 of
888 patients (95%) with minor traumatic intracranial hemorrhage who were
admitted to the ICU did not receive a critical care intervention during
hospitalization (range between sites 80% to 100%). Three of 524 (0.6%) patients
discharged home or admitted to the observation unit or ward received a critical
care intervention. After controlling for severity of injury (age, blood
pressure, and Injury Severity Score), study site was independently associated
with ICU admission (odds ratios ranged from 1.5 to 30; overall effect P less
than.001).
Conclusion: Across a consortium of trauma centers in the
western United States, there was wide variability in ICU use within a cohort of
patients with minor traumatic intracranial hemorrhage. Moreover, a large
proportion of patients admitted to the ICU never required a critical care
intervention, indicating the potential to improve use of critical care
resources in patients with minor traumatic intracranial hemorrhage.
17. Clinical
Impression and Ascites Appearance Do Not Rule Out Bacterial Peritonitis
Background: Previous research has demonstrated that
physician clinical suspicion, determined without assessing fluid appearance, is
not adequate to rule out spontaneous bacterial peritonitis (SBP) without fluid
testing.
Study Objective: To determine the sensitivity of physician
clinical suspicion, including a bedside assessment of fluid appearance, in the
detection of SBP in Emergency Department (ED) patients undergoing paracentesis.
Methods: We conducted a prospective, observational study of
ED patients with ascites undergoing paracentesis at three academic facilities.
The enrolling physician recorded the clinical suspicion of SBP (“none,” “low,”
“moderate,” or “high”), and ascites appearance (“clear,” “hazy,” “cloudy,” or
“bloody”). SBP was defined as an absolute neutrophil count ≥250 cells/mm3, or
culture pathogen growth. We defined “clear” ascites fluid as negative for SBP,
and “hazy,” “cloudy,” or “bloody” as positive. A physician clinical suspicion
of “none” or “low” was considered negative for SBP, and an assessment of
“moderate” or “high” was considered positive. The primary outcome measure was
sensitivity of physician clinical impression and ascites appearance for SBP.
Results: There were 348 cases enrolled, with SBP diagnosed
in 43 (12%). Physician clinical suspicion had a sensitivity of 42% (95%
confidence interval [CI] 29–55%) for the detection of SBP. Fluid appearance had
a sensitivity of 72% (95% CI 58–83%).
Conclusion: Physician clinical impression, which included an
assessment of fluid appearance, had poor sensitivity for the detection of SBP
and cannot be used to exclude the diagnosis. Routine laboratory fluid analysis
is indicated after ED paracentesis, even in patients considered to have a low
degree of suspicion for SBP.
18. Compartment
Pressure Measurements Have Poor Specificity for Compartment Syndrome in the
Traumatized Limb
Background: Osseofascial compartment syndrome is defined by
ischemic necrosis of muscle caused by elevated pressure within fascial
compartments. The diagnosis can be made either clinically or through
compartment pressure measurements. Compartment pressure above 30 mm Hg was
traditionally used as the threshold for diagnosis of compartment syndrome, but
was challenged due to a high number of false-positive results. Perfusion
pressure (diastolic blood pressure − compartment pressure) less than 30 mm Hg
came to be promoted as a confirmatory diagnostic test.
Objective: The objective of this article is to review the
specificity of perfusion pressure for compartment syndrome in the acutely
traumatized limb.
Discussion: Perfusion pressure has been shown to generate
false-positive results in 18–84% of patients with tibial fractures. Two studies
showed that not a single patient with measurements qualifying for fasciotomy
actually needed the procedure.
Conclusion: Both absolute compartment pressure and tissue
perfusion pressure generate a high rate of false-positive results in the
acutely traumatized limb. An alternative diagnostic test or process is needed
to prevent overtreatment. In the meantime, emergency medicine and orthopedic
surgery textbooks and guidelines should promote awareness of the limitations of
the test.
19. Cool EM Educational Resources
Podcast 94 – Has Video Laryngoscopy Killed the Direct
Laryngoscope?
Paul Mayo and Scott Weingart have established a tradition of
debating each other at the annual Greater NY Hospital Association Critical Care
Controversies Conference.
The topic here: Should All Intubations be Performed with
Video Laryngoscopy?
B. EM-RAP TV
143: STEMI vs. Pericarditis
Amal Mattu and his fantastic computer drawing machine return
with this talk on STEMI vs. Pericarditis.
142: 20 y.o. with Syncope
The maestro of the 12 lead is back again. This time with a
little latin flavor.
141: Hearts a Flutter
A case of a 63 Y.O. women with lightheadedness.
140: Irregularly irregular
Irregularly irregular? is that even a thing?
139: ST depressin in aVL
Link: http://emrap.tv/
20. On Second Pass, ACEP Opts to Join “Choosing
Wisely” Initiative
In the name of high quality, cost-conscious care, ACEP has
revised its stance on the Choosing Wisely campaign, voting to join the
initiative in the fight against low value care.
… The American College of Emergency Physicians (ACEP) has
started several initiatives to promote cost-effective care. Over the last eight
months, ACEP has chartered a taskforce to develop recommendations. The
taskforce began with an open survey of members soliciting ideas. In more than
150 responses, there were hundreds of specific actions that emergency physicians
could take to reduce costs without harming quality.
Examples of individual actions were “not ordering brain
natiuretic peptide (BNP) on patients with a clear clinical diagnosis of heart
failure or previously elevated levels.”
ED actions included interactions with other services, such as “not
ordering routine pre-operative chest X-rays,” or “engaging palliative care for
appropriate patients while in the ED.” Several suggestions would require formal
policy action by government, such as “not routinely bringing public intoxicants
to the ED for medical evaluation,” or “waiving the three-day Medicare rule for
skilled nursing facility coverage.”
A diverse panel was assembled to review all of the
recommendations and prioritize them based on their potential to reduce costs,
benefit or harm patients, and actionability by emergency providers. After
multiple rounds of review and revision, a large number of items remained that
the panel supported.
The ACEP Board of Directors reviewed the recommendations and
this ultimately led to their reconsidering the decision to not to join the
Choosing Wisely campaign. Ultimately, they reversed the decision and decided to
join the over 35 specialty societies involved in the campaign.
While the final Choosing Wisely “list” is still being
developed and won’t be public until later this spring, when you see it, you
probably won’t be too surprised. Many of the items are common sense,
evidence-based practices that could improve care, reduce costs and make ED care
safer. While some emergency providers are always practicing in a cost-conscious
way, there is good evidence to suggest that all of us can probably do a little
better.
What does this mean for you, the practicing emergency
physician? As it is becoming part of our professional responsibility to be good
stewards of health care dollars, we need to start working on how to make cost
containment part of our daily work.
Some general considerations:
1. The Link Between (Over)testing and Length of Stay
Pressure to reduce
length of stay can contribute to over testing, as ordering a wide panels of
tests after a brief triage evaluation is generally thought to be quicker than
ordering a small number of tests and adding on tests sequentially. But think
again: indiscriminately adding extra tests that take a long time can be
counterproductive. Ordering a marginal CT or lab test can add hours to a
patients’ length of stay. By spending a bit more time carefully considering
tests and using evidence-based clinical decision rules, we may actually help
unclog our EDs.
2. The Paradox of Patient Satisfaction
On one hand, we are
told to do less for patients; on the other hand we are told – even compelled –
to make patients happy. Yet sometimes patients want us to order ankle X-rays
when the Ottawa Ankle Rules say they have a sprain. Or they want a prescription
for antibiotics for viral upper respiratory infections. While some patients
will not be satisfied unless they get the test or treatment they want, what
most patients want are careful exams and clear explanations: it is possible to
talk most patients down off the cliff. Note to policymakers: it is equally
important to understand this daily trade off and to not penalize us for taking
the time to talk to patients and providing good, cost-conscious care.
3. Avoid Being the Vector for Low-Value Care
Some low value
services come at the request of a primary care provider or an admitting
physician. We need our EDs to work with the hospital and these services to
implement evidence-based protocols, so you don’t have to order that meaningless
pre-op chest x-ray, or coags in a healthy 22 year-old. But for the over 80% of
ED patients nationwide who are discharged after their visit, we are largely
responsible for the costs of their emergency care.
4. Don’t Wait for Liability Reform:
While this is a real
issue, comprehensive federal medical liability reform in the near future is
unlikely. Waiting for such reforms as a prerequisite for trying to reduce cost
could leave us in the dust if today’s focus on cost-containment is truly here
to stay. If we don’t define value in emergency medicine, the insurers, other
specialties and government will. We need to control our destiny, not wait for
it to happen to us…
Full-text (free): http://www.epmonthly.com/features/current-features/on-second-pass-acep-opts-to-join-choosing-wisely-initiative/
21. A Call to Action: Firearms, Public Health, and
Emergency Medicine
Ranney ML, et al. Ann Emerg Med. 2013
At the time of this writing, it has been 2 months since Newtown.
We have each mourned from a distance, imagining the heartbreak. We have asked
ourselves what we would have done were this our community, our school, our
child. We have formed opinions about what may or may not have stopped this tragedy.
And we have each quietly recalled other tragedies that we have witnessed.
Now it is time, as individuals and as a specialty, to take action
to decrease the likelihood of future deaths.
First, a review of the facts. Although mass shootings such
as the Sandy Hook Elementary School massacre generate the greatest public
attention, guns killed almost 32,000 American civilians in 2011 alone1 and
seriously injured another 74,000.2 The rate of firearm-related deaths for
children younger than 15 years is nearly 12 times higher in the United States
than in other industrialized nations.3 Our overall firearm-related death rate
is 7.5 times higher than in the world’s other 22 high-income countries.4,5 Case
control and cohort studies show that the presence of a gun in the home is
associated with a significantly increased risk of homicide, suicide, and
accidental death.6-9 Firearm injuries cost the United States more than $70
billion a year in medical expenditures and lost productivity.10 As emergency
physicians, we are often the first—and only—physicians to treat victims of gun
violence. We are therefore acutely aware that victims of shootings have a
higher mortality than those injured by other methods of assault or self-harm.
We know that patients with gun-related injuries are unlikely to present
anywhere other than the emergency department (except, perhaps, directly to the
morgue). And we know that to reduce firearm-related deaths and injuries, we
must prevent people from getting shot in the first place.11
We also know that emergency physicians can act collectively to
prevent injuries. Emergency medicine has long been at the forefront of public health.12,13
As a specialty, we have identified domestic violence, child abuse, and
vaccination, for instance, as just a few of the many public health issues that
warrant our involvement and our intervention. The American College of Emergency
Physicians (ACEP) has specific clinical care policies relating to these and other
public health issues, including firearm injury prevention.14 Through
well-designed research, advocacy campaigns, and public-private partnerships,
emergency physicians have effected inspiring change. We have helped reduce
drunk driving by supporting a shift in societal mores and implementation of
“.08” per se laws throughout the nation; we have advocated for child-resistant
caps on medications, leading to dramatic decreases in the rate of pediatric
poisonings; and we continue to research more effective means of reducing injury
from a variety of causes, ranging from suicide to opioid abuse to falls.
Emergency physicians are, of course, a diverse group that
includes proud, responsible gun owners and non–gun owners alike. We have a
history of advocating for public health and community well-being while
respecting individuals’ rights. Our work in highway and auto safety, for
instance, has helped to reduce US automobile fatalities by 31% without limiting
access to automobiles. Scientific concerns for public health are free of
agendas, and we are committed to finding solutions wherever they may lie.
The remainder of the essay (subscription only): http://www.annemergmed.com/article/S0196-0644(13)00137-6/fulltext
See also: ACEP
Policy: Firearm Injury Prevention
Ann Emerg Med. 2013;61:602-603.
22. Some Additional Tidbits
A. Transvaginal
Ultrasound Best to Find Ectopic Pregnancy
In women with abdominal pain or vaginal bleeding during
early pregnancy, transvaginal sonography appears to be the single best
diagnostic method for evaluating suspected ectopic pregnancy, a new
meta-analysis found.
B. Diagnosis issues
are most common medical errors
More than a quarter of U.S. medical malpractice claims
analyzed in a study were associated with missed or wrong diagnoses, making them
the most common, dangerous and expensive errors in the health care system.
Mistakes in diagnosis were also linked to "death or disability almost
twice as often as other error categories and accounted for the plurality of
these outcomes," researchers reported in BMJ Quality & Safety.
C. Many parents give
their children ineffective cold medicines
More than 40% of parents with children younger than age 4
reported giving their children multisymptom cough and cold medicines, according
to the University of Michigan C.S. Mott Children's Hospital National Poll on
Children's Health. Such medications are not effective for relieving cold
symptoms in young children and could be harmful. The FDA has cautioned against
their use in children under age 2.
Full-text (free): http://mottnpch.org/reports-surveys/parents-ignore-warning-labels-give-cough-cold-meds-young-kids
D. Meningitis in Kids
May Mean Troubled Future
Childhood bacterial meningitis was linked to lower
educational achievement and economic self-sufficiency later in life,
researchers found.
E. Obesity in
Physician and in Patients Impedes Care
1. Patients less inclined to trust overweight physicians
2. Doctors show less empathy for obese patients
F. Decline Facebook ‘Friend’
Appeals from Patients, Groups Say
Physicians should avoid making or accepting
"friend" requests through social networking websites with past or
current patients, a new policy statement advised.
G. New
Warfarin-reversal Agent Approved
The FDA has approved Kcentra for the urgent reversal of
vitamin K antagonist anticoagulation in adults with acute major bleeding,
according to the agency.
H. ESC Provides
Guidelines for Use of Novel Oral Anticoagulants for AF
I. 20% of U.S. adults
get recommended amount of exercise
A CDC study revealed that just 20% of more than 450,000
adults met federal guidelines for both muscle-strengthening activity and
aerobic exercise. Men and younger adults were more likely to meet the fitness
recommendations than women and older adults, researchers wrote in the Morbidity
and Mortality Weekly Report.
