April 2016 EM Articles

NNR This Month = 32

NNR = Number Needed to Read

You'd have to read 959 articles to find these 30 gems.

Academic Emergency Medicine

  1. Sensitivity of CT for SAH may be higher than previously thought, since "negative" scans were retrospectively overread as positive.
  2. The PECARN head injury rule for pediatric TBI had greater sensitivity but lower specificity than physician clinical judgment.
  3. Alcohol-related Tweets correlated with increased alcohol-related ED visits.
  4. Sucrose in infants did not reduce pain score with IV start but reduced crying time.
  5. A RCT comparing direct laryngoscopy and video laryngoscopy showed no statistically significant difference in first pass success.
  6. Four factor prothrombin complex concentrate reversed warfarin as safely as plasma with fewer problems with volume overload.

1.

Acad Emerg Med. 2016 May;23(5):591-8. doi: 10.1111/acem.12941. Epub 2016 Apr 17.

False-negative Interpretations of Cranial Computed Tomography in Aneurysmal Subarachnoid Hemorrhage.

Mark DG1, Sonne DC2, Jun P3, Schwartz DT4, Kene MV5, Vinson DR6, Ballard DW7.

Author information:

1Departments of Emergency Medicine and Critical Care, Kaiser Permanente, Oakland, CA.

2Department of Radiology, Kaiser Permanente, Oakland, CA.

3Department of Radiology, Kaiser Permanente, Santa Clara, CA.

4Department of Emergency Medicine, New York University School of Medicine, New York, NY.

5Department of Emergency Medicine, Kaiser Permanente, San Leandro, CA.

6Department of Emergency Medicine, Kaiser Permanente, Roseville, CA.

7Department of Emergency Medicine, Kaiser Permanente, San Rafael, CA.

 

Abstract

OBJECTIVES:

Prior studies examining the sensitivity of cranial computed tomography (CT) for the detection of subarachnoid hemorrhage (SAH) have used the final radiology report as the reference standard. However, optimal sensitivity may have been underestimated due to misinterpretation of reportedly normal cranial CTs. This study aims to estimate the incidence of missed CT evidence of SAH among a cohort of patients with aneurysmal SAH (aSAH).

METHODS:

We performed a retrospective chart review of emergency department (ED) encounters within an integrated health delivery system between January 2007 and June 2013 to identify patients diagnosed with aSAH. All initial noncontrast CTs from aSAH cases diagnosed by lumbar puncture (LP) and angiography following a reportedly normal noncontrast cranial CT (CT-negative aSAH) were then reviewed in a blinded, independent fashion by two board-certified neuroradiologists to assess for missed evidence of SAH. Reviewers rated the CT studies as having definite evidence of SAH, probable evidence of SAH, or no evidence of SAH. Control patients who underwent a negative evaluation for aSAH based on cranial CT and LP results were also included at random in the imaging review cohort.

RESULTS:

A total of 452 cases of aSAH were identified; 18 (4%) were cases of CT-negative aSAH. Of these, seven (39%) underwent cranial CT within 6 hours of headache onset, and two (11%) had their initial CTs formally interpreted by board-certified neuroradiologists. Blinded independent CT review revealed concordant agreement for either definite or probable evidence of SAH in nine of 18 (50%) cases overall and in five of the seven (71%) CTs performed within 6 hours of headache onset. Inter-rater agreement was 83% for definite SAH and 72% for either probable or definite SAH.

CONCLUSIONS:

CT evidence of SAH was frequently present but unrecognized according to the final radiology report in cases of presumed CT-negative aSAH. This finding may help explain some of the discordance between prior studies examining the sensitivity of cranial CT for SAH.

© 2016 by the Society for Academic Emergency Medicine.

PMID: 26918885 [PubMed - in process]

 

2.

Acad Emerg Med. 2016 May;23(5):566-75. doi: 10.1111/acem.12923. Epub 2016 Apr 20.

Comparison of Prediction Rules and Clinician Suspicion for Identifying Children With Clinically Important Brain Injuries After Blunt Head Trauma.

Atabaki SM1, Hoyle JD Jr2,3, Schunk JE4, Monroe DJ5, Alpern ER6,7, Quayle KS8, Glass TF9,10, Badawy MK11,12, Miskin M4, Schalick WO13, Dayan PS14, Holmes JF15, Kuppermann N15,16.

Author information:

1Department of Pediatrics and Emergency Medicine, George Washington University School of Medicine, Washington, DC.

2Department of Emergency Medicine, Michigan State University School of Medicine, Grand Rapids, MI.

3Departments of Emergency Medicine and Pediatrics, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, MI.

4Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT.

5Department of Emergency Medicine, Howard County General Hospital, Columbia, MD.

6Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA.

7Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL.

8Department of Pediatrics, Washington University School of Medicine, St. Louis, MO.

9Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.

10Department of Pediatrics, Nemours Children's Hospital, Orlando, FL.

11Departments of Emergency Medicine and Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY.

12Department of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX.

13Departments of Orthopedics Rehabilitation, University of Wisconsin School of Medicine, Madison, WI.

14Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY.

15Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA.

16Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA.

 

Abstract

OBJECTIVE:

Children with minor head trauma frequently present to emergency departments (EDs). Identifying those with traumatic brain injuries (TBIs) can be difficult, and it is unknown whether clinical prediction rules outperform clinician suspicion. Our primary objective was to compare the test characteristics of the Pediatric Emergency Care Applied Research Network (PECARN) TBI prediction rules to clinician suspicion for identifying children with clinically important TBIs (ciTBIs) after minor blunt head trauma. Our secondary objective was to determine the reasons for obtaining computed tomography (CT) scans when clinical suspicion of ciTBI was low.

METHODS:

This was a planned secondary analysis of a previously conducted observational cohort study conducted in PECARN to derive and validate clinical prediction rules for ciTBI among children with minor blunt head trauma in 25 PECARN EDs. Clinicians recorded their suspicion of ciTBI before CT as <1, 1-5, 6-10, 11-50, or >50%. We defined ciTBI as 1) death from TBI, 2) neurosurgery, 3) intubation for more than 24 hours for TBI, or 4) hospital admission of 2 nights or more associated with TBI on CT. To avoid overfitting of the prediction rules, we performed comparisons of the prediction rules and clinician suspicion on the validation group only. On the validation group, we compared the test accuracies of clinician suspicion > 1% versus having at least one predictor in the PECARN TBI age-specific prediction rules for identifying children with ciTBIs (one rule for children <2 years [preverbal], the other rule for children >2 years [verbal]).

RESULTS:

In the parent study, we enrolled 8,627 children to validate the prediction rules, after enrolling 33,785 children to derive the prediction rules. In the validation group, clinician suspicion of ciTBI was recorded in 8,496/8,627 (98.5%) patients, and 87 (1.0%) had ciTBIs. CT scans were obtained in 2,857 (33.6%) patients in the validation group for whom clinician suspicion of ciTBI was recorded, including 2,099/7,688 (27.3%) of those with clinician suspicion of ciTBI of <1% and 758/808 (93.8%) of those with clinician suspicion >1%. The PECARN prediction rules were significantly more sensitive than clinician suspicion >1% of ciTBI for preverbal (100% [95% confidence interval {CI} = 86.3% to 100%] vs. 60.0% [95% CI = 38.7% to 78.9%]) and verbal children (96.8% [95% CI = 88.8% to 99.6%] vs. 64.5% [95% CI = 51.3% to 76.3%]). Prediction rule specificity, however, was lower than clinician suspicion >1% for preverbal children (53.6% [95% CI = 51.5% to 55.7%] vs. 92.4% [95% CI = 91.2% to 93.5%]) and verbal children (58.2% [95% CI = 56.9% to 59.4%] vs. 90.6% [95% CI = 89.8% to 91.3%]). Of the 7,688 patients in the validation group with clinician suspicion recorded as <1%, CTs were nevertheless obtained in 2,099 (27.3%). Three of 16 (18.8%) patients undergoing neurosurgery had clinician suspicion of ciTBI <1%.

CONCLUSIONS:

The PECARN TBI prediction rules had substantially greater sensitivity, but lower specificity, than clinician suspicion of ciTBI for children with minor blunt head trauma. Because CT ordering did not follow clinician suspicion of <1%, these prediction rules can augment clinician judgment and help obviate CT ordering for children at very low risk of ciTBI.

© 2016 by the Society for Academic Emergency Medicine.

PMID: 26825755 [PubMed - in process]

 

3.

Acad Emerg Med. 2016 Apr 7. doi: 10.1111/acem.12983. [Epub ahead of print]

Tweet Now, See You In the ED Later?: Examining the Association Between Alcohol-Related Tweets and Emergency Care Visits.

Ranney ML1, Chang B2, Freeman JR3, Norris B4, Silverberg M5, Choo EK1.

Author information:

1Emergency Digital Health Innovation program, Department of Emergency Medicine, Rhode Island Hospital/Alpert Medical School, Brown University, Providence, RI.

2Department of Emergency Medicine, University of California at San Francisco, San Francisco, CA.

3Department of Biostatistics and Epidemiology, School of Public Health and Health Sciencies, University of Massachusetts-Amherst.

4Perscio, Fishers, IN.

5Socrata, Washington, DC.

 

Abstract

BACKGROUND:

Alcohol use is a major and unpredictable driver of ED visits. Regional Twitter activity correlates ecologically with behavioral outcomes. No such correlation has been established in real time.

OBJECTIVES:

To examine the correlation between real-time, alcohol-related tweets and alcohol-related ED visits.

METHODS:

We developed and piloted a set of 11 keywords that identified tweets related to alcohol use. In-state tweets were identified using self-declared profile information or geographic coordinates. Using Datasift, a 3rd -party vendor, a random sample of 1% of eligible Tweets containing the keywords and originating in-state were downloaded (including tweet date/time) over 3 discrete weeks in 3 different months. In the same timeframe, we examined visits to an urban, high-volume, level I trauma center that receives >25% of the emergency care volume in the state. Alcohol-related ED visits were defined as visits with a chief complaint of alcohol use, positive blood alcohol, or alcohol-related ICD-9 code. Spearman's correlation coefficient was used to examine the hourly correlation between alcohol-related tweets, alcohol-related ED visits, and all ED visits.

RESULTS:

A total of 7,820 tweets (representing 782,000 in-state alcohol-related tweets during the 3 weeks) were identified. Concurrently, 404 ED visits met criteria for being alcohol-related versus 2939 non-alcohol-related ED visits. There was a statistically significant relationship between hourly alcohol-related tweet volume and number of alcohol-related ED visits (rs =0.31, p<0.00001), but not between hourly alcohol-related tweet volume and number of non-alcohol-related ED visits (rs = -0.07, p=0.11).

CONCLUSION:

In a single state, a statistically significant relationship was observed between the hourly number of alcohol-related tweets and the hourly number of alcohol-related ED visits. Real-time Twitter monitoring may help predict alcohol-related surges in ED visits. Future studies should include larger numbers of EDs and natural language processing. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 27062454 [PubMed - as supplied by publisher]

 

4.

Acad Emerg Med. 2016 Apr 21. doi: 10.1111/acem.12991. [Epub ahead of print]

A randomized controlled trial evaluating the efficacy of oral sucrose in infants 1 to 3 months old needing intravenous cannulation.

Desjardins MP1, Gaucher N1, Curtis S2, LeMay S3, Lebel D4, Gouin S1.

Author information:

1Division of Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal.

2Division of Emergency Medicine & Women and Children's Health Research Institute Department of Pediatrics, University of Alberta.

3Research Institute, Centre Hospitalier Universitaire Sainte-Justine.

4Department of Pharmacy, Centre Hospitalier Universitaire Sainte-Justine.

 

Abstract

OBJECTIVES:

To compare the efficacy of an oral sucrose versus placebo in reducing pain in infants 1 to 3 months of age during intravenous (IV) cannulation in the Emergency Department (ED).

METHODS:

A randomized, double-blind, placebo clinical trial was conducted. Participants were randomly allocated to receive 2 ml of an oral 88% sucrose solution or 2 ml of a placebo solution orally. The outcome measure were mean difference in pain score at one minute post IV cannulation assessed by the Face, Legs, Activity, Cry and Consolability Pain Scale (FLACC) and the Neonatal Infant Pain Scale (NIPS), crying time and variations in heart rate.

RESULTS:

87 participants completed the study, 45 in the sucrose group and 42 in the placebo group. There was no statistical difference in variations in both the FLACC score (p=0.49) and NIPS score (p=0.36) between the two groups as per the Mann Whitney U test. Using the same test, median crying times following IV cannulation were statistically significantly different between both groups (17 seconds in the sucrose group vs 41 seconds in the placebo group, p=0.04). Mean changes in heart rate one minute after IV cannulation were similar in both groups (16 ± 4 for sucrose vs 18 ± 4 beats per minute for placebo, p=0.74). Side effects were similar for both groups and no adverse events were reported.

CONCLUSIONS:

Administration of an oral sucrose solution in infants 1 to 3 months of age during IV cannulation did not lead to statistically significant changes in pain scores. However the cry time was significantly reduced. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 27098499 [PubMed - as supplied by publisher]

 

5.

Acad Emerg Med. 2016 Apr;23(4):433-9. doi: 10.1111/acem.12933. Epub 2016 Mar 24.

Direct Versus Video Laryngoscopy Using the C-MAC for Tracheal Intubation in the Emergency Department, a Randomized Controlled Trial.

Driver BE1, Prekker ME1,2, Moore JC1, Schick AL1, Reardon RF1, Miner JR1.

Author information:

1Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.

2Division of Pulmonary/Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN.

 

Abstract

BACKGROUND:

Direct laryngoscopy (DL) has long been the most common approach for emergency endotracheal intubation, although the use of video laryngoscopy (VL) is becoming more widespread. Current observational data suggest that VL has higher first-pass success, although randomized trials are lacking.

OBJECTIVES:

The objective was to compare first-pass success in patients undergoing emergency intubation with DL or VL using a C-MAC device.

METHODS:

This was an open-label, prospective, randomized, controlled trial in an academic emergency department of patients undergoing emergency intubation with a plan of DL for the first attempt. Patients were randomly assigned in a 1:1 ratio to either DL or VL using a C-MAC device for the first intubation attempt. The primary outcome was first-pass success. Secondary outcomes included time to intubation, development of aspiration pneumonia, and hospital length of stay (LOS). The study was registered at Clinicaltrials.gov, number NCT01710891.

RESULTS:

A total of 198 patients were enrolled and intubated with either DL (n = 95) or VL (n = 103). First-attempt success was 86 and 92% for the DL and VL groups, respectively (difference = -5.9%, 95% confidence interval = -14.5% to 2.7%, p = 0.18). Time to intubation, rates of aspiration pneumonia, and hospital LOS were not different between the two groups.

CONCLUSIONS:

In patients undergoing emergency intubation in whom DL was planned for the first attempt, we did not detect a difference between VL or DL using the C-MAC device in first-pass success, duration of intubation attempt, aspiration pneumonia, or hospital LOS.

© 2016 by the Society for Academic Emergency Medicine.

PMID: 26850232 [PubMed - in process]

 

6.

Acad Emerg Med. 2016 Apr;23(4):466-75. doi: 10.1111/acem.12911. Epub 2016 Mar 21.

Safety of a Four-factor Prothrombin Complex Concentrate Versus Plasma for Vitamin K Antagonist Reversal: An Integrated Analysis of Two Phase IIIb Clinical Trials.

Milling TJ Jr1, Refaai MA2, Sarode R3, Lewis B4, Mangione A5, Durn BL5, Harman A5, Lee ML6, Goldstein JN7.

Author information:

1Seton Clinical Research Institute, Dell University of Texas Medical School, Dell Children's Medical Center, University Medical Center at Brackenridge, Austin, TX.

2University of Rochester Medicine, Rochester, NY.

3UT Southwestern Medical Center, Dallas, TX.

4St. Joseph Regional Health Center, Bryan, Texas A&M Health Science Center, College Station, TX.

5CSL Behring, King of Prussia, PA.

6UCLA School of Public Health, Los Angeles, CA.

7Massachusetts General Hospital, Boston, MA.

 

Abstract

OBJECTIVES:

Clinicians often need to rapidly reverse vitamin K antagonists (VKAs) in the setting of major hemorrhage or urgent need for surgery. Little is known about the safety profile of the traditional reversal agent, plasma, or the newly approved agent, four-factor prothrombin complex concentrate (4F-PCC), in a randomized setting. This is an integrated analysis of safety data from two clinical trials that evaluated 4F-PCC versus plasma for the treatment of patients requiring rapid VKA reversal for acute major bleeding or prior to an urgent surgical/invasive procedure.

METHODS:

This descriptive analysis comprised adverse event (AE) data from two phase IIIb, randomized, controlled trials. The bleeding and surgical studies were performed across 36 and 33 sites, respectively, in nine countries, with the integrated analysis comprising 388 patients (4F-PCC, n = 191; plasma, n = 197) aged ≥ 18 years, who required VKA reversal due to major bleeding or prior to an urgent surgical/invasive procedure. Patients received either 4F-PCC, containing nonactivated factors II, VII, IX, and X and proteins C and S (Beriplex/Kcentra, CSL Behring) or plasma, both dosed according to baseline international normalized ratio and body weight. Patients were also to receive vitamin K1. AEs and serious AEs (SAEs) were assessed up to days 10 and 45, respectively.

RESULTS:

The proportion of patients with AEs (4F-PCC, 115/191 [60.2%]; plasma, 124/197 [62.9%]) and SAEs (4F-PCC, 54/191 [28.3%]; plasma, 49/197 [24.9%]) was similar between groups. The proportion of patients with thromboembolic events was also similar between groups (4F-PCC, 14/191 [7.3%]; plasma, 14/197 [7.1%]). There were 13 (6.8%) deaths in the 4F-PCC group and 13 (6.6%) in the plasma group. Fluid overload events occurred in more patients in the plasma group than the 4F-PCC group (25 [12.7%] and 9 [4.7%], respectively).

CONCLUSIONS:

These safety data represent the largest controlled assessment of a 4F-PCC to date. For patients requiring urgent VKA reversal, 4F-PCC had a safety profile similar to that of plasma (AEs, SAEs, thromboembolic events, and deaths), but was associated with fewer fluid overload events.

© 2016 by the Society for Academic Emergency Medicine.

PMID: 26822172 [PubMed - in process]


 

American Journal of Emergency Medicine

A new shoulder reduction technique was highly successful, allowed patients to sit up, and required no sedation.  It is called the Sool's method. See the video on You Tube.

Am J Emerg Med. 2016 Apr 9. pii: S0735-6757(16)30036-5. doi: 10.1016/j.ajem.2016.04.012. [Epub ahead of print]

The effectiveness of a newly developed reduction method of anterior shoulder dislocations; Sool's method.

Park MS1, Lee JH2, Kwon H3, Kim YJ4, Jung JY4.

Author information:

1Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea.

2Department of Emergency Medicine, Seoul National Hospital, Seoul, Republic of Korea.

3Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea. Electronic address: jinuking3g@naver.com.

4Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea.

 

Abstract

OBJECTIVE:

Nearly a dozen reduction methods for the treatment of anterior shoulder dislocation have been reported, but the majority are painful and require patients to be in the supine or prone position.

METHODS:

This retrospective cohort study was conducted in a university-affiliated emergency department (ED). Sool's method and traditional shoulder reduction methods (TSRMs) were performed for the patient with anterior shoulder dislocation. Fifty-nine eligible patients were recruited; 35 were treated with TSRMs, wherease 24 were treated with Sool's method.

RESULTS:

The rate of successful reduction was 80% (26/35) in the TSRM group and 75% (18/24) in the Sool's method group (P=.75). The length of stay in the ED was 72.3 minutes in the Sool's method group and 98.4minutes in the TSRM group (P=.037). No significant difference was observed between the neurovascular deficit before and after reduction in either group. The procedural time of successfully reduced cases in patients treated by Sool's method was shorter than that of the failed cases (P=.015).

CONCLUSIONS:

Sool's method was as successful as other methods at reducing shoulder dislocation and has demonstrated encouraging results, including significant reduction in length of stay in the ED and unnecessary use of sedation. Sool's method is technically easy and requires only a place to sit and a single operator.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 27117465 [PubMed - as supplied by publisher]


Annals of Emergency Medicine

  1. If patients are sick enough and catecholamine depleted, even ketamine will cause a drop in blood pressure.
  2. Single dose oral dexamethasone 12mg was slightly non-inferior than 5 days of prednisone for adult asthma patients. Relapse rates were slightly higher in the dexamethasone group.
  3. Parent estimate of child weight was best, followed by the length-based Pediatric Advanced Weight-Prediction in the Emergency Room, Mercy method.  Age-based formulas and the Broselow tape predict ideal body weight.
  4. PCC reversed warfarin in patients needing LP and appeared to make the procedure safe.  It took ten years to recruit the 37 patients for the study.
  5. Coronary CTA was associated with low incidence of bad cardiac outcome and did not result in increased downstream testing, contrary to prior study of CCTA.

1.

Ann Emerg Med. 2016 Apr 26. pii: S0196-0644(16)30002-6. doi: 10.1016/j.annemergmed.2016.03.041. [Epub ahead of print]

Hemodynamic Response After Rapid Sequence Induction With Ketamine in Out-of-Hospital Patients at Risk of Shock as Defined by the Shock Index.

Miller M1, Kruit N2, Heldreich C3, Ware S4, Habig K5, Reid C5, Burns B5.

Author information:

1Aeromedical and Retrieval Service, Ambulance Service, New South Wales, Sydney, Australia; Kent Surry Sussex Air Ambulance, Marden, Kent, United Kingdom. Electronic address: mattdotmiller@gmail.com.

2Department of Anaesthesia, Westmead Hospital, Sydney, Australia.

3Department of Anaesthesia, Austin Hospital, Melbourne, Australia.

4Aeromedical and Retrieval Service, Ambulance Service, New South Wales, Sydney, Australia; School of Molecular Bioscience, University of Sydney, New South Wales, Australia.

5the Sydney Medical School, Sydney University, New South Wales, Australia.

 

Abstract

STUDY OBJECTIVE:

Ketamine is considered a stable induction agent for rapid sequence induction; however, hypotension rates up to 24% are reported. The shock index (shock index=pulse rate/systolic blood pressure [SBP]) may identify patients at risk of adverse hemodynamic change. We investigate whether SBP and pulse rate response to ketamine induction differ when patients are classified as being at risk of shock by their shock index.

METHODS:

We conducted a prospective observational study of electronically collected vital sign data from patients undergoing rapid sequence induction with ketamine. Patients were grouped into low shock index (shock index <0.9) or high shock index (shock index ≥0.9) preinduction. Pulse rate and SBP were compared between 3 minutes preinduction and for 3 measurements postinduction (3-minute intervals) by repeated-measures ANOVA. Proportions of patients developing hypotension or hypertension are also reported.

RESULTS:

One hundred twelve patients were enrolled (81 low shock index, 31 high shock index). Low shock index patients had increased SBP after induction (16 mm Hg; 95% confidence interval [CI] 11 to 21 mm Hg), whereas high shock index patients did not (2 mm Hg; 95% CI -4 to 7 mm Hg). Pulse rate in low shock index patients increased after induction (20 beats/min; 95% CI 16 to 25 beats/min) and remained elevated, whereas in high shock index patients a difference occurred at the second postinduction measurement only (15 beats/min; 95% CI 11 to 18 beats/min). More high shock index patients became hypotensive (26%; 95% CI 12% to 45%) than low shock index ones (2%; 95% CI 0% to 9%), whereas more low shock index patients became hypertensive (40%; 95% CI 29% to 51%) than high shock index ones (13%; 95% CI 4% to 30%).

CONCLUSION:

After ketamine induction, high shock index patients exhibited little change in SBP but were more likely to become hypotensive, whereas low shock index patients had sustained increases in pulse rate and SBP.

Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 27130803 [PubMed - as supplied by publisher]

 

2.

Ann Emerg Med. 2016 Apr 14. pii: S0196-0644(16)00215-8. doi: 10.1016/j.annemergmed.2016.03.017. [Epub ahead of print]

A Randomized Controlled Noninferiority Trial of Single Dose of Oral Dexamethasone Versus 5 Days of Oral Prednisone in Acute Adult Asthma.

Rehrer MW1, Liu B2, Rodriguez M2, Lam J2, Alter HJ2.

Author information:

1Department of Emergency Medicine, Kaiser Permanente, Oakland, CA. Electronic address: Matthew.W.Rehrer@kp.org.

2Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA.

 

Abstract

STUDY OBJECTIVE:

Oral dexamethasone demonstrates bioavailability similar to that of oral prednisone but has a longer half-life. We evaluate whether a single dose of oral dexamethasone plus 4 days of placebo is not inferior to 5 days of oral prednisone in treatment of adults with mild to moderate asthma exacerbations to prevent relapse defined as an unscheduled return visit for additional treatment for persistent or worsening asthma within 14 days.

METHODS:

Adult emergency department patients (aged 18 to 55 years) were randomized to receive either a single dose of 12 mg of oral dexamethasone with 4 days of placebo or a 5-day course of oral prednisone 60 mg a day. Outcomes including relapse were assessed by a follow-up telephone interview at 2 weeks.

RESULTS:

One hundred seventy-three dexamethasone and 203 prednisone subjects completed the study regimen and telephone follow-up. The dexamethasone group by a small margin surpassed the preset 8% difference between groups for noninferiority in relapse rates within 14 days (12.1% versus 9.8%; difference 2.3%; 95% confidence interval -4.1% to 8.6%). Subjects in the 2 groups had similar rates of hospitalization for their relapse visit (dexamethasone 3.4% versus prednisone 2.9%; difference 0.5%; 95% confidence interval -4.1% to 3.1%). Adverse effect rates were generally the same in the 2 groups.

CONCLUSION:

A single dose of oral dexamethasone did not demonstrate noninferiority to prednisone for 5 days by a very small margin for treatment of adults with mild to moderate asthma exacerbations. Enhanced compliance and convenience may support the use of dexamethasone regardless.

Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 27117874 [PubMed - as supplied by publisher]

 

3.

Ann Emerg Med. 2016 Apr 14. pii: S0196-0644(16)00147-5. doi: 10.1016/j.annemergmed.2016.02.043. [Epub ahead of print]

Weight Estimation Methods in Children: A Systematic Review.

Young KD1, Korotzer NC2.

Author information:

1David Geffen School of Medicine at UCLA, University of California, Los Angeles, and the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA. Electronic address: kyoung@emedharbor.edu.

2Palos Verdes Peninsula High School, Rolling Hills Estates, CA.

 

Abstract

STUDY OBJECTIVE:

We seek to collect, review, evaluate, and synthesize the current literature focusing on all published methods of pediatric weight estimation.

METHODS:

We conducted a literature review using PubMed and Web of Science databases, and the Google Scholar search engine, with the "similar articles" feature, as well as review of the bibliographies of identified studies. We excluded studies estimating weight of neonates, predominantly adults without separate information for children, child self-reported weight, and studies estimating outcomes other than weight. Quantitative outcomes of accuracy (proportion within 10% of actual weight), mean percentage error, and mean bias were preferred.

RESULTS:

Eighty studies met inclusion criteria with predominant methods: parent or health care worker weight estimation, age-based formulae, and length-based estimation without (eg, Broselow) or with adjustment for body habitus (eg, Pediatric Advanced Weight-Prediction in the Emergency Room, Mercy). Parent estimation was the most accurate at predicting total (actual) body weight, with length-based methods with habitus adjustment next. Length-based methods outperformed age-based formulae, and both tended to underestimate the weight of children from populations with high obesity rates and overestimate the weight of children from populations with high malnourishment rates. Health care worker estimation was not accurate.

CONCLUSION:

Parent estimation and length-based methods with adjustment for body habitus are the most accurate methods to predict children's total (actual) body weight. Age-based formulae and length-based methods without habitus adjustment likely tend to predict ideal body weight.

Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 27105839 [PubMed - as supplied by publisher]

 

4.

Ann Emerg Med. 2016 Apr 14. pii: S0196-0644(16)00158-X. doi: 10.1016/j.annemergmed.2016.03.003. [Epub ahead of print]

Treatment With Prothrombin Complex Concentrate to Enable Emergency Lumbar Puncture in Patients Receiving Vitamin K Antagonists.

Laible M1, Beynon C2, Sander P3, Purrucker J1, Müller OJ4, Möhlenbruch M5, Ringleb PA1, Rizos T6.

Author information:

1Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.

2Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.

3Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany; Department of Cerebrovascular diseases, Hetzelstift, Neustadt an der Weinstrasse, Germany.

4Department of Internal Medicine III, Heidelberg University Hospital, Heidelberg, Germany; German Center for Cardiovascular Research, partner site Heidelberg/Mannheim, Heidelberg, Germany.

5Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany.

6Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany. Electronic address: timolaos.rizos@med.uni-heidelberg.de.

 

Abstract

STUDY OBJECTIVE:

Lumbar punctures are frequently necessary in neurologic emergencies, but effective oral anticoagulation with vitamin K antagonists represents a contraindication. We report the effectiveness of prothrombin complex concentrates to reverse vitamin K antagonist to enable emergency lumbar punctures, as well as evaluate lumbar puncture- and prothrombin complex concentrates-related complications.

METHODS:

Consecutive patients treated with prothrombin complex concentrates between December 2004 and June 2014 to enable emergency lumbar puncture were included. International normalized ratio (INR) before and after prothrombin complex concentrates treatment and the time between start of reversal treatment and lumbar puncture were recorded. A target INR of less than or equal to 1.5 was defined as effective prothrombin complex concentrates treatment. Bleeding events, thromboembolic events, and allergic reactions after prothrombin complex concentrates treatment were identified and classified as "related," "probably," "possibly," "unlikely related," or "not related" to the lumbar puncture and prothrombin complex concentrates infusion.

RESULTS:

Thirty-seven patients were included (64.9% men; median age 76.0 years; interquartile range [IQR] 71.0 to 84.0 years). The intervention with prothrombin complex concentrates was effective in 33 of 37 patients (89.2%; 95% confidence interval [CI], 78.4% to 97.3%). The median INR was 2.2 (IQR 1.8 to 2.9; 95% CI, 1.9 to 2.5) before and 1.3 (IQR 1.2 to 1.4; 95% CI, 1.2 to 1.3) after prothrombin complex concentrates treatment. The median time between start of prothrombin complex concentrates treatment and lumbar puncture was 135 minutes (IQR 76 to 266 minutes; 95% CI, 84 to 198 minutes). One clinically irrelevant intracranial subdural hematoma "related" to the lumbar puncture developed. No allergic reaction was observed, but 2 of 37 patients (5.4%; 95% CI, 0% to 13.5%) experienced a thromboembolic event (1 ischemic stroke, classified "unlikely related," and 1 myocardial infarction, "possibly related" to prothrombin complex concentrates treatment).

CONCLUSION:

Reversing the effect of vitamin K antagonist with prothrombin complex concentrates to enable emergency lumbar puncture appears effective and safe, particularly in regard to bleeding events.

Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 27085368 [PubMed - as supplied by publisher]

 

5.

Ann Emerg Med. 2016 Apr;67(4):460-468.e1. doi: 10.1016/j.annemergmed.2015.09.014. Epub 2015 Oct 23.

Coronary Computed Tomography Angiography Versus Traditional Care: Comparison of One-Year Outcomes and Resource Use.

Hollander JE1, Gatsonis C2, Greco EM3, Snyder BS3, Chang AM4, Miller CD5, Singh H6, Litt HI7.

Author information:

1Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA. Electronic address: judd.hollander@jefferson.edu.

2Center for Statistical Sciences, Brown University School of Public Health, Providence, RI; Department of Biostatistics, Brown University School of Public Health, Providence, RI.

3Center for Statistical Sciences, Brown University School of Public Health, Providence, RI.

4Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA.

5Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.

6Department of Radiology, Penn State Hershey Medical Center, Hershey, PA.

7Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA.

 

Abstract

STUDY OBJECTIVE:

Three large, multicenter, randomized, clinical trials have shown that coronary computed tomography (CT) angiography allows efficient evaluation and safe discharge of patients with low- to intermediate-risk chest pain who present to the emergency department (ED). We report 1-year event rates and resource use from the American College of Radiology Imaging Network-Pennsylvania 4005 multicenter trial.

METHODS:

Patients with low- to intermediate-risk chest pain and presenting to the ED were randomized in a 2:1 ratio to a coronary CT angiography care pathway or traditional care. Subjects were contacted by telephone at least 1 year after ED presentation. Medical record review was performed for all cardiac hospitalizations, procedures and diagnostic tests, and adverse cardiac events. Our main outcome was the composite of cardiac death and myocardial infarction within 1 year. The secondary outcome was resource use.

RESULTS:

One thousand three hundred sixty-eight patients enrolled and 1,285 (94%) had direct participant or proxy contact at 1 year. All others had record review or death index search. From index presentation through 1 year, there was no difference between patients in the coronary CT angiography arm versus traditional care with respect to major adverse cardiac event (1.4% versus 1.1%; difference 0.3%; 95% CI -5.5% to 6.0%). From hospital discharge through 1 year, there was also no difference in ED revisits (36% versus 38%; difference -2.1%; 95% CI -7.9% to 3.7%), hospital admissions (16% versus 17%; difference -0.9%; 95% CI -6.7% to 4.9%), or subsequent cardiac testing (13% versus 13%; difference -0.4%; 95% CI -6.2% to 5.5%). One of 640 subjects with a negative coronary CT angiography result had a major adverse cardiac event within 1 year of presentation (0.16%; 95% CI 0.004% to 0.87%).

CONCLUSION:

A coronary CT angiography-based strategy for evaluation of patients with low- to intermediate-risk chest pain who present to the ED does not result in increased resource use during 1 year. A negative coronary CT angiography result is associated with a less than 1% major adverse cardiac event rate during the first year after testing.

Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 26507904 [PubMed - in process]


BMJ

  1. Epinephrine given within 2 minutes of defibrillation of a shockable rhythm is not recommended by American Heart Association, and in this study of in-hospital arrest was associated with decreased ROSC, overall survival, and survival with good functional outcome.
  2. In earlier ACLS days, the mantra was shock-shock-shock. Now it is shock, and do CPR a couple minutes before shocking again.  In arrest patients with initial defibrillation, delayed defibrillation (over a minute later) was associated with worse ROSC and survival to discharge, although the practice of deferred defibrillation has doubled since 2004.

1.

BMJ. 2016 Apr 6;353:i1577. doi: 10.1136/bmj.i1577.

Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis.

Andersen LW1, Kurth T2, Chase M3, Berg KM4, Cocchi MN5, Callaway C6, Donnino MW7; American Heart Association’s Get With The Guidelines-Resuscitation Investigators.

Author information:

1Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Rosenberg Building, One Deaconess Road, Boston, MA 02215, USA Department of Anesthesiology, Aarhus University Hospital, Nørrebrogade 44, Bygn. 21, 1 Aarhus 8000, Denmark Research Center for Emergency Medicine, Aarhus University Hospital, Trøjborgvej 72-74, Bygn. 30, Aarhus 8200, Denmark.

2Institute of Public Health, Charité - Universitätsmedizin Berlin, Seestrasse 73, Berlin D-13347, Germany.

3Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Rosenberg Building, One Deaconess Road, Boston, MA 02215, USA.

4Department of Medicine, Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.

5Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Rosenberg Building, One Deaconess Road, Boston, MA 02215, USA Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.

6Department of Emergency Medicine, 400A Iroquois, 3600 Forbes Avenue, Pittsburgh, PA 15260, USA.

7Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Rosenberg Building, One Deaconess Road, Boston, MA 02215, USA Department of Medicine, Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA mdonnino@bidmc.harvard.edu.

 

Abstract

OBJECTIVES:

 To evaluate whether patients who experience cardiac arrest in hospital receive epinephrine (adrenaline) within the two minutes after the first defibrillation (contrary to American Heart Association guidelines) and to evaluate the association between early administration of epinephrine and outcomes in this population.

DESIGN:

 Prospective observational cohort study.

SETTING:

 Analysis of data from the Get With The Guidelines-Resuscitation registry, which includes data from more than 300 hospitals in the United States.

PARTICIPANTS:

 Adults in hospital who experienced cardiac arrest with an initial shockable rhythm, including patients who had a first defibrillation within two minutes of the cardiac arrest and who remained in a shockable rhythm after defibrillation.

INTERVENTION:

 Epinephrine given within two minutes after the first defibrillation.

MAIN OUTCOME MEASURES:

 Survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and survival to hospital discharge with a good functional outcome. A propensity score was calculated for the receipt of epinephrine within two minutes after the first defibrillation, based on multiple characteristics of patients, events, and hospitals. Patients who received epinephrine at either zero, one, or two minutes after the first defibrillation were then matched on the propensity score with patients who were "at risk" of receiving epinephrine within the same minute but who did not receive it.

RESULTS:

 2978  patients were matched on the propensity score, and the groups were well balanced. 1510 (51%) patients received epinephrine within two minutes after the first defibrillation, which is contrary to current American Heart Association guidelines. Epinephrine given within the first two minutes after the first defibrillation was associated with decreased odds of survival in the propensity score matched analysis (odds ratio 0.70, 95% confidence interval 0.59 to 0.82; P<0.001). Early epinephrine administration was also associated with a decreased odds of return of spontaneous circulation (0.71, 0.60 to 0.83; P<0.001) and good functional outcome (0.69, 0.58 to 0.83; P<0.001).

CONCLUSION:

 Half of patients with a persistent shockable rhythm received epinephrine within two minutes after the first defibrillation, contrary to current American Heart Association guidelines. The receipt of epinephrine within two minutes after the first defibrillation was associated with decreased odds of survival to hospital discharge as well as decreased odds of return of spontaneous circulation and survival to hospital discharge with a good functional outcome.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

PMCID: PMC4823528 Free PMC Article

PMID: 27053638 [PubMed - in process]

 

2.

BMJ. 2016 Apr 6;353:i1653. doi: 10.1136/bmj.i1653.

Defibrillation time intervals and outcomes of cardiac arrest in hospital: retrospective cohort study from Get With The Guidelines-Resuscitation registry.

Bradley SM1, Liu W2, Chan PS3, Nallamothu BK4, Grunwald GK2, Self A5, Sasson C6, Varosy PD7, Anderson ML8, Schneider PM9, Ho PM7; American Heart Association’s Get With The Guidelines-Resuscitation Investigators.

Author information:

1VA Eastern Colorado Health Care System, Denver, CO, USA University of Colorado School of Medicine, Aurora, CO, USA Colorado Cardiovascular Outcomes Research Consortium, Denver, CO, USA Steven.Bradley@va.gov.

2VA Eastern Colorado Health Care System, Denver, CO, USA University of Colorado School of Public Health, Aurora, CO, USA.

3Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, MO, USA.

4University of Michigan Medical School, Ann Arbor, MI, USA.

5University of Colorado School of Medicine, Aurora, CO, USA.

6American Heart Association, Dallas, TX, USA.

7VA Eastern Colorado Health Care System, Denver, CO, USA University of Colorado School of Medicine, Aurora, CO, USA Colorado Cardiovascular Outcomes Research Consortium, Denver, CO, USA.

8Duke Clinical Research Institute, Durham, NC, USA.

9University of Colorado School of Medicine, Aurora, CO, USA Colorado Cardiovascular Outcomes Research Consortium, Denver, CO, USA.

 

Abstract

OBJECTIVE:

 To describe temporal trends in the time interval between first and second attempts at defibrillation and the association between this time interval and outcomes in patients with persistent ventricular tachycardia or ventricular fibrillation (VT/VF) arrest in hospital.

DESIGN:

 Retrospective cohort study

SETTING:

 172 hospitals in the United States participating in the Get With The Guidelines-Resuscitation registry, 2004-12.

PARTICIPANTS:

 Adults who received a second defibrillation attempt for persistent VT/VF arrest within three minutes of a first attempt.

INTERVENTIONS:

 Second defibrillation attempts categorized as early (time interval of up to and including one minute between first and second defibrillation attempts) or deferred (time interval of more than one minute between first and second defibrillation attempts).

MAIN OUTCOME MEASURE:

 Survival to hospital discharge.

RESULTS:

 Among 2733 patients with persistent VT/VF after the first defibrillation attempt, 1121 (41%) received a deferred second attempt. Deferred second defibrillation for persistent VT/VF increased from 26% in 2004 to 57% in 2012 (P<0.001 for trend). Compared with early second defibrillation, unadjusted patient outcomes were significantly worse with deferred second defibrillation (57.4%v62.5% for return of spontaneous circulation, 38.4%v43.6% for survival to 24 hours, and 24.7%v30.8% for survival to hospital discharge; P<0.01 for all comparisons). After risk adjustment, deferred second defibrillation was not associated with survival to hospital discharge (propensity weighting adjusted risk ratio 0.89, 95% confidence interval 0.78 to 1.01; P=0.08; hierarchical regression adjusted 0.92, 0.83 to 1.02; P=0.1).

CONCLUSIONS:

 Since 2004, the use of deferred second defibrillation for persistent VT/VF in hospital has doubled. Deferred second defibrillation was not associated with improved survival.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

PMCID: PMC4823520 Free PMC Article

PMID: 27052620 [PubMed - in process]


Chest

Procalcitonin predicted need for invasive respiratory or vasopressor support (IRVS).  Need for IRVS rose linearly 1-2% for every 1 ng/mL, with baseline of 4% at 0.05 ng/mL and 22% when > 10 ng/mL. When used with other clinical predictors, this biomarker may help determine which patients need the ICU vs. general floor.

Chest. 2016 Apr 20. pii: S0012-3692(16)48560-0. doi: 10.1016/j.chest.2016.04.010. [Epub ahead of print]

Procalcitonin as an Early Marker of the Need for Invasive Respiratory or Vasopressor Support in Adults with Community-Acquired Pneumonia.

Self WH1, Grijalva CG2, Williams DJ2, Woodworth A2, Balk RA3, Fakhran S4, Zhu Y2, Courtney DM5, Chappell J2, Anderson EJ6, Qi C5, Waterer GW7, Trabue C8, Bramley AM9, Jain S9, Edwards KM2, Wunderink RG5.

Author information:

1Vanderbilt University Medical Center, Nashville, TN. Electronic address: wesley.self@vanderbilt.edu.

2Vanderbilt University Medical Center, Nashville, TN.

3Rush University Medical Center, Chicago, IL.

4John H. Stroger, Jr Hospital of Cook County, Chicago, IL.

5Northwestern University Feinberg School of Medicine, Chicago, IL.

6Emory University School of Medicine, Atlanta, GA.

7Northwestern University Feinberg School of Medicine, Chicago, IL; University of Western Australia, Perth, Australia.

8University of Tennessee Health Science Center/Saint Thomas Health, Nashville, TN.

9Centers for Disease Control and Prevention, Atlanta, GA.

 

Abstract

BACKGROUND:

Predicting intensive care need among adults with community-acquired pneumonia (CAP) remains challenging.

METHODS:

Using a multicenter prospective cohort study of adults hospitalized with CAP, we evaluated the association of serum procalcitonin concentration at hospital presentation with the need for invasive respiratory and/or vasopressor support (IRVS) within 72 hours. Logistic regression was used to model this association, with results reported as the estimated risk of IRVS for a given procalcitonin concentration. We also assessed whether the addition of procalcitonin changed the performance of established pneumonia severity scores, including the pneumonia severity index and American Thoracic Society minor criteria, for prediction of IRVS.

RESULTS:

Of 1770 enrolled patients, 115 (6.5%) required IRVS. Using the logistic regression model, procalcitonin concentration had a strong association with IRVS risk. Undetectable procalcitonin (<0.05 ng/ml) was associated with a 4.0% (95% CI: 3.1%, 5.1%) risk of IRVS. For concentrations <10 ng/ml, procalcitonin had an approximate linear association with IRVS risk; for each 1 ng/ml increase in procalcitonin, there was a 1-2% absolute increase in the risk of IRVS. With a procalcitonin concentration of 10 ng/ml, the risk of IRVS was 22.4% (95% CI: 16.3%, 30.1%) and remained relatively constant for all concentrations > 10 ng/ml. When added to each pneumonia severity score, procalcitonin contributed significant additional risk information for prediction of IRVS.

CONCLUSIONS:

Serum procalcitonin concentration was strongly associated with the risk of requiring IRVS among adults hospitalized with CAP and is potentially useful for guiding decisions about intensive care unit admission.

Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 27107491 [PubMed - as supplied by publisher]


Circulation

This suggests prehospital resuscitation efforts in adults should be continued for at least 40 minutes to have a >99% sensitivity for 30-day neurologically intact survival.  Survival rates declined with longer resuscitation times.  Forty minutes of prehospital CPR is a long time.  I have always considered a down-time of more than 10-15 minutes to be the time to stop efforts.  I may need to rethink this.

Circulation. 2016 Apr 5;133(14):1386-96. doi: 10.1161/CIRCULATIONAHA.115.018788. Epub 2016 Feb 26.

Duration of Prehospital Resuscitation Efforts After Out-of-Hospital Cardiac Arrest.

Nagao K1, Nonogi H2, Yonemoto N2, Gaieski DF2, Ito N2, Takayama M2, Shirai S2, Furuya S2, Tani S2, Kimura T2, Saku K2; Japanese Circulation Society With Resuscitation Science Study (JCS-ReSS) Group*.

Author information:

1From Cardiovascular Center (K.N., S.F., S.T.), Nihon University Hospital, Tokyo, Japan; Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan (H.N.); Department of Epidemiology and Biostatistics, National Center of Neurology and Psychiatry, Tokyo, Japan (N.Y.); Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA (D.F.G.); Department of Cardiology, Kawasaki Saiwai Hospital, Japan (N.I.); Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan (M.T.); Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan (S.S.); Department of Cardiology, Kyoto University, Japan (T.K.); and Department of Cardiology, Fukuoka University of School of Medicine, Japan (K.S.). nagao.ken@nihon-c.ac.jp.

2From Cardiovascular Center (K.N., S.F., S.T.), Nihon University Hospital, Tokyo, Japan; Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan (H.N.); Department of Epidemiology and Biostatistics, National Center of Neurology and Psychiatry, Tokyo, Japan (N.Y.); Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA (D.F.G.); Department of Cardiology, Kawasaki Saiwai Hospital, Japan (N.I.); Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan (M.T.); Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan (S.S.); Department of Cardiology, Kyoto University, Japan (T.K.); and Department of Cardiology, Fukuoka University of School of Medicine, Japan (K.S.).

 

Abstract

BACKGROUND:

During out-of-hospital cardiac arrest, it is unclear how long prehospital resuscitation efforts should be continued to maximize lives saved.

METHODS AND RESULTS:

Between 2005 and 2012, we enrolled 282 183 adult patients with bystander-witnessed out-of-hospital cardiac arrest from the All-Japan Utstein Registry. Prehospital resuscitation duration was calculated as the time interval from call receipt to return of spontaneous circulation in cases achieving prehospital return of spontaneous circulation or from call receipt to hospital arrival in cases not achieving prehospital return of spontaneous circulation. In each of 4 groups stratified by initial cardiac arrest rhythm (shockable versus nonshockable) and bystander resuscitation (presence versus absence), we calculated minimum prehospital resuscitation duration, defined as the length of resuscitation efforts in minutes required to achieve ≥99% sensitivity for the primary end point, favorable 30-day neurological outcome after out-of-hospital cardiac arrest. Prehospital resuscitation duration to achieve prehospital return of spontaneous circulation ranged from 1 to 60 minutes. Longer prehospital resuscitation duration reduced the likelihood of favorable neurological outcome (adjusted odds ratio, 0.84; 95% confidence interval, 0.838-0.844). Although the frequency of favorable neurological outcome was significantly different among the 4 groups, ranging from 20.0% (shockable/bystander resuscitation group) to 0.9% (nonshockable/bystander resuscitation group; P<0.001), minimum prehospital resuscitation duration did not differ widely among the 4 groups (40 minutes in the shockable/bystander resuscitation group and the shockable/no bystander resuscitation group, 44 minutes in the nonshockable/bystander resuscitation group, and 45 minutes in the nonshockable/no bystander resuscitation group).

CONCLUSIONS:

On the basis of time intervals from the shockable arrest groups, prehospital resuscitation efforts should be continued for at least 40 minutes in all adults with bystander-witnessed out-of-hospital cardiac arrest.

CLINICAL TRIAL REGISTRATION:

URL: http://www.umin.ac.jp/ctr/. Unique identifier: 000009918.


Journal of Emergency Medicine

Early administration of more IV fluid in pediatric DKA improved the lab numbers more quickly but did not decreased length of stay.

J Emerg Med. 2016 Apr;50(4):551-9. doi: 10.1016/j.jemermed.2015.12.003. Epub 2016 Jan 25.

Effect of Volume of Fluid Resuscitation on Metabolic Normalization in Children Presenting in Diabetic Ketoacidosis: A Randomized Controlled Trial.

Bakes K1, Haukoos JS2, Deakyne SJ3, Hopkins E1, Easter J1, McFann K4, Brent A5, Rewers A5.

Author information:

1Department of Emergency Medicine, Denver Health Medical Center, University of Colorado, School of Medicine, Denver, Colorado.

2Department of Emergency Medicine, Denver Health Medical Center, University of Colorado, School of Medicine, Denver, Colorado; Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colorado.

3Department of Research Informatics, Children's Hospital Colorado, Research Institute, Aurora, Colorado.

4Colorado School of Public Health, University of Colorado, Aurora, Colorado.

5Section Emergency Medicine, Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado.

 

Abstract

BACKGROUND:

The optimal rate of fluid administration in pediatric diabetic ketoacidosis (DKA) is unknown.

OBJECTIVE:

Our aim was to determine whether the volume of fluid administration in children with DKA influences the rate of metabolic normalization.

METHODS:

We performed a randomized controlled trial conducted in a tertiary pediatric emergency department from December 2007 until June 2010. The primary outcome was time to metabolic normalization; secondary outcomes were time to bicarbonate normalization, pH normalization, overall length of hospital treatment, and adverse outcomes. Children between 0 and 18 years of age were eligible if they had type 1 diabetes mellitus and DKA. Patients were randomized to receive intravenous (IV) fluid at low volume (10 mL/kg bolus + 1.25 × maintenance rate) or high volume (20 mL/kg bolus + 1.5 × maintenance rate) (n = 25 in each).

RESULTS:

After adjusting for initial differences in bicarbonate levels, time to metabolic normalization was significantly faster in the higher-volume infusion group compared to the low-volume infusion group (hazard ratio [HR] = 2.0; 95% confidence interval [CI] 1.0-3.9; p = 0.04). Higher-volume IV fluid infusion appeared to hasten, to a greater extent, normalization of pH (HR = 2.5; 95% CI 1.2-5.0; p = 0.01) than normalization of serum bicarbonate (HR = 1.2; 95% CI 0.6-2.3; p = 0.6). The length of hospital treatment HR (0.8; 95% CI 0.4-1.5; p = 0.5) and time to discharge HR (0.8; 95% CI 0.4-1.5; p = 0.5) did not differ between treatment groups.

CONCLUSIONS:

Higher-volume fluid infusion in the treatment of pediatric DKA patients significantly shortened metabolic normalization time, but did not change overall length of hospital treatment. ClinicalTrials.gov ID NCT01701557.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 26823137 [PubMed - in process]


Journal of Pediatrics

In kids over age 4, URI lasts 10 days in 72%, with rhinovirus the most common cause. Kids 48-96 months got only 1.3 URIs per year, which was less than expected.  The rate of sinusitis (based on published clinical criteria) in these kids was 8.8%.

J Pediatr. 2016 Apr;171:133-139.e1. doi: 10.1016/j.jpeds.2015.12.034. Epub 2016 Jan 16.

Clinical Features, Virus Identification, and Sinusitis as a Complication of Upper Respiratory Tract Illness in Children Ages 4-7 Years.

DeMuri GP1, Gern JE1, Moyer SC1, Lindstrom MJ2, Lynch SV3, Wald ER1.

Author information:

1Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI.

2Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI.

3Department of Medicine, University of California, San Francisco, San Francisco, CA.

 

Abstract

OBJECTIVE:

To determine the rate of sinusitis complicating upper respiratory tract illnesses (URIs) in children. We prospectively identified the clinical, virologic, and epidemiologic characteristics of URIs in a population of 4- to 7-year-old children followed for 1 year.

STUDY DESIGN:

This was an observational cohort study in 2 primary care pediatric practices in Madison, Wisconsin. Nasal samples were obtained during 4 asymptomatic surveillance visits and during symptomatic URIs. A polymerase chain reaction-based assay for 9 respiratory viruses was performed on nasal samples. A diagnosis of sinusitis was based on published criteria.

RESULTS:

Two hundred thirty-six children ages 48-96 months were enrolled. A total of 327 URIs were characterized. The mean number of URIs per child was 1.3 (range 0-9) per year. Viruses were detected in 81% of URIs; rhinovirus (RV) was most common. Seventy-two percent of URIs were resolved clinically by the 10th day. RV-A and RV-C were detected more frequently at URI visits; RV-B was detected at the same rate for both asymptomatic surveillance visits and URI visits. Sinusitis was diagnosed in 8.8% of symptomatic URIs. Viruses were detected frequently (33%) in samples from asymptomatic children.

CONCLUSIONS:

Sinusitis occurred in 8.8% of symptomatic URIs in our study. The virus most frequently detected with URIs in children was RV; RV-A and RV-C detection but not RV-B detection were associated with illness. Viruses, especially RV, are detected frequently in asymptomatic children. Most URIs have improved or resolved by the 10th day after onset. Children experienced a mean of 1.3 URIs per year, which was lower than expected.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMCID: PMC4808614 [Available on 2017-04-01]

PMID: 26787374 [PubMed - in process]


Journal of Trauma

  1. Survival from blunt or penetrating traumatic arrest was 6.3% in this registry study, higher than expected.  Patients receiving bag-valve mask did better than those intubated or having supraglottic airway placed.  And no ALS procedures were associated with increased odds of survival.
  2. Using a trauma registry, REBOA was comparable (trending toward more favorable) to open aortic occlusion.

1.

J Trauma Acute Care Surg. 2016 Apr 8. [Epub ahead of print]

Prehospital traumatic cardiac arrest: management and outcomes from the Resuscitation Outcomes Consortium Epistry-Trauma and PROPHET registries.

Evans CC1, Petersen A, Meier EN, Buick JE, Schreiber M, Kannas D, Austin MA; Resuscitation Outcomes Consortium Investigators..

Author information:

11Department of Emergency Medicine, Queen's University, Kingston, ON 2Department of Biostatistics, University of Washington, Seattle, WA 3Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON 4Department of Surgery, Oregan Health and Science University, Portland OR 5Clinical Trials Center, University of Washington, Seattle, WA 6Department of Emergency Medicine, University of Ottawa, Ottawa, ON.

 

Abstract

BACKGROUND:

Traumatic arrests have historically had poor survival rates. Identifying salvageable patients and ideal management is challenging. We aimed to: 1) Describe the management and outcomes of prehospital traumatic arrests; 2) Determine regional variation in survival; and 3) Identify Advanced Life Support (ALS) procedures associated with survival.

METHODS:

This was a secondary analysis of cases from the Resuscitation Outcomes Consortium Epistry-Trauma and Prospective Observational Prehospital and Hospital Registry for Trauma registries. Patients were included if they suffered a blunt or penetrating injury and received CPR. Logistic regression analyses were used to determine the association between ALS procedures and survival.

RESULTS:

We included 2300 patients who were predominately young (Epistry mean: 39 years, SD: 20 years; PROPHET mean: 40 years, SD: 19 years), males (79%), injured by blunt trauma (Epistry: 68%, PROPHET: 67%), and treated by ALS paramedics (Epistry: 93%, PROPHET: 98%). A total of 145 patients (6.3%) survived to hospital discharge. More patients with blunt (Epistry 8.3%, PROPHET: 6.5%) vs. penetrating injuries (Epistry 4.6%, PROPHET: 2.7%) survived. Most survivors (81%) had vitals on EMS arrival. Rates of survival varied significantly between the 12 study sites (p=0.048) in the Epistry but not PROPHET (p=0.14) registries.PROPHET patients who received a supraglottic airway insertion or intubation experienced decreased odds of survival (Adjusted ORs: 0.27, 95% CI: 0.08-0.93, and 0.37, 95% CI: 0.17-0.78, respectively) compared to those receiving bag-mask ventilation. No other procedures were associated with survival.

CONCLUSIONS:

Survival from traumatic arrest may be higher than expected, particularly in blunt trauma and patients with vitals on EMS arrival. Although limited by confounding and statistical power, no ALS procedures were associated with an increased odds of survival.

LEVEL OF EVIDENCE:

Level IV, prognostic study.

PMID: 27070438 [PubMed - as supplied by publisher]

 

2.

J Trauma Acute Care Surg. 2016 Apr 5. [Epub ahead of print]

The AAST Prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA).

DuBose JJ1, Scalea TM, Brenner M, Skiada D, Inaba K, Cannon J, Moore L, Holcomb J, Turay D, Arbabi CN, Kirkpatrick A, Xiao J, Skarupa D, Poulin N; AAST AORTA Study Group.

Author information:

1From the David Grant Medical Center (J.J.D.), University of California-Davis, Davis, California; Department of Surgery (T.M.S., M.B.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland; Los Angeles County + University of Southern California Hospital (D.S., K.I.), Los Angeles, California; San Antonio Military Medical Center (J.C.), United States Army Institute of Surgical Research, San Antonio, Texas; University of Texas Health Sciences Center- Houston (L.M., J.H.), Houston, Texas; Loma Linda University Medical Center (D.T., C.N.A.), Loma Linda, California; University of Calgary (A.K., J.X.), Calgary, Alberta, Canada; University of Florida - Jacksonville (D.S.), Jacksonville, Florida; and East Carolina Medical Center (N.P.), New Bern, North Carolina.

 

Abstract

INTRODUCTION:

Aortic occlusion (AO) for resuscitation in traumatic shock remains controversial. Resuscitative Endovascular Balloon Occlusion of the aorta (REBOA) offers an emerging alternative.

METHODS:

The AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry prospectively identified trauma patients requiring AO from 8 ACS level I centers. Presentation, intervention and outcome variables were collected and analyzed to compare REBOA and open AO.

RESULTS:

From Nov 2013-Feb2015, 114 AO patients were captured (46 REBOA; 68 Open); 80.7% male; 62.3% blunt injured. AO occurred in the Emergency Department (ED) (73.7%) or Operating Room (OR) (26.3%). Hemodynamic improvement after AO was observed in 62.3% [REBOA 29/67.4%; Open 42/61.8%); 36.0% achieving stability (SBP consistently > 90 mm Hg, > 5 minutes) [REBOA 22/46; 47.8%; Open 19/68; 27.9%, p =0.014]. REBOA access was femoral cut-down (50%); US guided (10.9%) and percutaneous without imaging (28.3%). Deployment was achieved in zones I (78.6%), II (2.4%) and III (19.0%). A second AO attempt was required in 9.6% [REBOA 2/46, 4.3%; Open 9/68, 13.2%]. REBOA complications were uncommon (pseudoaneursym 2.1%; embolism 4.3%, 0% limb ischemia). There was no difference in time to successful AO between REBOA and open procedures [REBOA 6.6 ± 5.6 mins; Open 7.2 ± 15.1, p = 0.842]. Overall survival was 21.1% (24/114), with no significant difference between REBOA and open AO with regards to mortality [REBOA 28.2% (13/46); Open 16.1% (11/68); p = 0.120].

CONCLUSION:

REBOA has emerged as a viable alternative to open AO in centers that have developed this capability. Further maturation of the AAST AORTA database is required to better elucidate optimal indications and outcomes.

LEVEL OF EVIDENCE:

Therapeutic / Care management, level IV.

PMID: 27050883 [PubMed - as supplied by publisher]


JAMA

  1. Contrary to what I have been telling parents for years, dilute apple juice was actually better for oral rehydration than electrolyte solution in children 6-60 months with acute gastroenteritis.  This is a major dogma-busting article.
  2. In the massive nurse's health study, those who worked more night shifts had increased risk of coronary heart disease.  Beware to night owls like us!  Better keep jogging...
  3. Is this adolescent/young adult's sore throat mono?  This rational clinical exam feature found that, "posterior cervical, inguinal or axillary adenopathy, palatine petechiae, splenomegaly, or atypical lymphocytosis is associated with an increased likelihood of mononucleosis."

1.

JAMA. 2016 Apr 30. doi: 10.1001/jama.2016.5352. [Epub ahead of print]

Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial.

Freedman SB1, Willan AR2, Boutis K3, Schuh S3.

Author information:

1Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada.

2Ontario Child Health Support Unit, Hospital for Sick Children Research Institute, Dalla Lana School of Public Health, University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada.

3Division of Pediatric Emergency Medicine, The Hospital for Sick Children and Child Health Evaluative Sciences, Toronto, Ontario, Canada4Hospital for Sick Children Research Institute, Department of Pediatrics, University of Toronto, Faculty of Medicine, To.

 

Abstract

Importance:

Gastroenteritis is a common pediatric illness. Electrolyte maintenance solution is recommended to treat and prevent dehydration. Its advantage in minimally dehydrated children is unproven.

Objective:

To determine if oral hydration with dilute apple juice/preferred fluids is noninferior to electrolyte maintenance solution in children with mild gastroenteritis.

Design, Setting, and Participants:

Randomized, single-blind noninferiority trial conducted between the months of October and April during the years 2010 to 2015 in a tertiary care pediatric emergency department in Toronto, Ontario, Canada. Study participants were children aged 6 to 60 months with gastroenteritis and minimal dehydration.

Interventions:

Participants were randomly assigned to receive color-matched half-strength apple juice/preferred fluids (n=323) or apple-flavored electrolyte maintenance solution (n=324). Oral rehydration therapy followed institutional protocols. After discharge, the half-strength apple juice/preferred fluids group was administered fluids as desired; the electrolyte maintenance solution group replaced losses with electrolyte maintenance solution.

Main Outcomes and Measures:

The primary outcome was a composite of treatment failure defined by any of the following occurring within 7 days of enrollment: intravenous rehydration, hospitalization, subsequent unscheduled physician encounter, protracted symptoms, crossover, and 3% or more weight loss or significant dehydration at in-person follow-up. Secondary outcomes included intravenous rehydration, hospitalization, and frequency of diarrhea and vomiting. The noninferiority margin was defined as a difference between groups of 7.5% for the primary outcome and was assessed with a 1-sided α=.025. If noninferiority was established, a 1-sided test for superiority was conducted.

Results:

Among 647 randomized children (mean age, 28.3 months; 331 boys [51.1%]; 441 (68.2%) without evidence of dehydration), 644 (99.5%) completed follow-up. Children who were administered dilute apple juice experienced treatment failure less often than those given electrolyte maintenance solution (16.7% vs 25.0%; difference, -8.3%; 97.5% CI, -∞ to -2.0%; P < .001 for inferiority and P = .006 for superiority). Fewer children administered apple juice/preferred fluids received intravenous rehydration (2.5% vs 9.0%; difference, -6.5%; 99% CI, -11.6% to -1.8%). Hospitalization rates and diarrhea and vomiting frequency were not significantly different between groups.

Conclusions and Relevance:

Among children with mild gastroenteritis and minimal dehydration, initial oral hydration with dilute apple juice followed by their preferred fluids, compared with electrolyte maintenance solution, resulted in fewer treatment failures. In many high-income countries, the use of dilute apple juice and preferred fluids as desired may be an appropriate alternative to electrolyte maintenance fluids in children with mild gastroenteritis and minimal dehydration.

Trial Registration:

clinicaltrials.gov Identifier: NCT01185054.

PMID: 27131100 [PubMed - as supplied by publisher]

 

2.

JAMA. 2016 Apr 26;315(16):1726-34. doi: 10.1001/jama.2016.4454.

Association Between Rotating Night Shift Work and Risk of Coronary Heart Disease Among Women.

Vetter C1, Devore EE1, Wegrzyn LR2, Massa J3, Speizer FE4, Kawachi I5, Rosner B6, Stampfer MJ7, Schernhammer ES8.

Author information:

1Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

2Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

3Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

4Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts4Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

5Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

6Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts6Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

7Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts2Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts3Department of Nutri.

8Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts2Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts7Department of Epide.

 

Abstract

IMPORTANCE:

Prospective studies linking shift work to coronary heart disease (CHD) have been inconsistent and limited by short follow-up.

OBJECTIVE:

To determine whether rotating night shift work is associated with CHD risk.

DESIGN, SETTING, AND PARTICIPANTS:

Prospective cohort study of 189,158 initially healthy women followed up over 24 years in the Nurses' Health Studies (NHS [1988-2012]: N = 73,623 and NHS2 [1989-2013]: N = 115,535).

EXPOSURES:

Lifetime history of rotating night shift work (≥3 night shifts per month in addition to day and evening shifts) at baseline (updated every 2 to 4 years in the NHS2).

MAIN OUTCOMES AND MEASURES:

Incident CHD; ie, nonfatal myocardial infarction, CHD death, angiogram-confirmed angina pectoris, coronary artery bypass graft surgery, stents, and angioplasty.

RESULTS:

During follow-up, 7303 incident CHD cases occurred in the NHS (mean age at baseline, 54.5 years) and 3519 in the NHS2 (mean age, 34.8 years). In multivariable-adjusted Cox proportional hazards models, increasing years of baseline rotating night shift work was associated with significantly higher CHD risk in both cohorts. In the NHS, the association between duration of shift work and CHD was stronger in the first half of follow-up than in the second half (P=.02 for interaction), suggesting waning risk after cessation of shift work. Longer time since quitting shift work was associated with decreased CHD risk among ever shift workers in the NHS2 (P<.001 for trend). [table: see text]

CONCLUSIONS AND RELEVANCE:

Among women who worked as registered nurses, longer duration of rotating night shift work was associated with a statistically significant but small absolute increase in CHD risk. Further research is needed to explore whether the association is related to specific work hours and individual characteristics.

PMID: 27115377 [PubMed - in process]

 

3.

JAMA. 2016 Apr 12;315(14):1502-9. doi: 10.1001/jama.2016.2111.

Does This Patient Have Infectious Mononucleosis?: The Rational Clinical Examination Systematic Review.

Ebell MH1, Call M2, Shinholser J1, Gardner J1.

Author information:

1Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Atlanta.

2Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Atlanta2Now a PhD candidate at Georgia Health Sciences University, Augusta.

 

Abstract

IMPORTANCE:

Early, accurate diagnosis of infectious mononucleosis can help clinicians target treatment, avoid antibiotics, and provide an accurate prognosis.

OBJECTIVE:

To systematically review the literature regarding the value of the clinical examination and white blood cell count for the diagnosis of mononucleosis.

DATA SOURCES:

The databases of PubMed (from 1966-2016) and EMBASE (from 1947-2015) were searched and a total of 670 articles and abstracts were reviewed for eligibility.

STUDY SELECTION:

Eleven studies were included that reported data sufficient to calculate sensitivity, specificity, or both for clinical examination findings and white blood cell count parameters compared with a valid reference standard.

DATA EXTRACTION AND SYNTHESIS:

Data were abstracted from each article by at least 2 reviewers, with discrepancies reconciled by consensus. Clinical findings evaluated in only 1 study are reported with sensitivity, specificity, likelihood ratio (LR), and 95% confidence interval, which were calculated from the available data. Findings evaluated in only 2 studies were summarized with their range, findings evaluated in 3 studies were summarized with a univariate random-effects summary, and findings evaluated in 4 or more studies were summarized with a bivariate random-effects meta-analysis.

MAIN OUTCOMES AND MEASURES:

Sensitivity, specificity, and LRs for the diagnosis of mononucleosis.

RESULTS:

Mononucleosis is most commonly present among patients aged 5 to 25 years (especially those aged 16-20 years, among whom approximately 1 in 13 patients presenting with sore throat has mononucleosis). The likelihood of mononucleosis is reduced with the absence of any lymphadenopathy (summary sensitivity, 0.91; positive LR range, 0.23-0.44), whereas the likelihood increases with the presence of posterior cervical adenopathy (summary specificity, 0.87; positive LR, 3.1 [95% CI, 1.6-5.9]), inguinal or axillary adenopathy (specificity range, 0.82-0.91; positive LR range, 3.0-3.1), palatine petechiae (specificity, 0.95; positive LR, 5.3 [95% CI, 2.1-13]), and splenomegaly (specificity range, 0.71-0.99; positive LR range, 1.9-6.6). Symptoms are of limited value for the diagnosis of mononucleosis; sore throat and fatigue are sensitive (range, 0.81-0.83) but nonspecific. The presence of atypical lymphocytosis significantly increases the likelihood of mononucleosis (summary LR, 11.4 [95% CI, 2.7-35] for atypical lymphocytes ≥10%, 26 [95% CI, 9.6-68] for those with 20%, and 50 [95% CI, 38-64] for those with 40%). The combination of a patient having greater than 50% lymphocytes and greater than 10% atypical lymphocytes also is useful (specificity, 0.99; positive LR, 54 [95% CI, 8.4-189]).

CONCLUSIONS AND RELEVANCE:

In adolescent and adult patients presenting with sore throat, the presence of posterior cervical, inguinal or axillary adenopathy, palatine petechiae, splenomegaly, or atypical lymphocytosis is associated with an increased likelihood of mononucleosis.

PMID: 27115266 [PubMed - in process]


JAMA Pediatrics

A recent meta-analysis showed that hypertonic saline (HTS) is of benefit in bronchiolitis.  This study took another look at 2 prior meta-analyses and concluded that, in fact, HTS was of no benefit.  It appears prior supposed benefit was based on one outlier population with a markedly different primary outcome measure.  Once this was accounted for, the positive effect was not seen.

JAMA Pediatr. 2016 Apr 18. doi: 10.1001/jamapediatrics.2016.0079. [Epub ahead of print]

Association Between Hypertonic Saline and Hospital Length of Stay in Acute Viral Bronchiolitis: A Reanalysis of 2 Meta-analyses.

Brooks CG1, Harrison WN2, Ralston SL3.

Author information:

1Leadership in Preventive Medicine and Pediatrics Residencies, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.

2Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.

3Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire.

 

Abstract

Importance:

Two previous meta-analyses of nebulized hypertonic saline (HS) on hospital length of stay (LOS) in acute viral bronchiolitis have suggested benefit. Neither study fully addressed the issue of excessive heterogeneity in the cohort of studies, indicating that it may be inappropriate to combine such dissimilar studies to estimate a common treatment effect.

Objective:

To reanalyze the existing data set for sources of heterogeneity to delineate the population most likely to benefit from HS.

Data Sources:

We used the previously analyzed cohort of randomized trials from 2 published meta-analyses comparing HS with normal saline (or, in 1 case, with standard of care) in infants hospitalized for bronchiolitis. We also repeated the search strategy used by the most recent Cochrane Review in the Medline database through September 2015.

Study Selection:

Eighteen randomized clinical trials of HS in infants with bronchiolitis reporting LOS as an outcome measure were included.

Data Extraction and Synthesis:

The guidelines used for abstracting data included LOS, study year, setting, sample size, type of control, admission/discharge criteria, adjunct medications, treatment frequency, mean day of illness at study enrollment, mean severity of illness scores, and mean age.

Main Outcomes and Measures:

Weighted mean difference in LOS and study heterogeneity as measured by the I2 statistic.

Results:

There were 18 studies included of 2063 infants (63% male), with a mean age of 4.2 months. The mean LOS was 3.6 days. Two main sources of heterogeneity were identified. First, the effect of HS on LOS was entirely sensitive to the removal of one study population, noted to have a widely divergent definition of the primary outcome. Second, there was a baseline imbalance in mean day of illness at presentation between treatment groups. Controlling for either of these factors resolved the heterogeneity (I2 = reduced from 78% to 45% and 0%, respectively) and produced summary estimates in support of the null hypothesis (that HS does not affect LOS). There was a weighted mean difference in LOS of -0.21 days (95% CI, -0.43 to +0.02) for the sensitivity analysis and +0.02 days (95% CI, -0.14 to +0.17) for studies without unbalanced treatment groups on presentation.

Conclusions and Relevance:

Prior analyses were driven by an outlier population and unbalanced treatment groups in positive trials. Once heterogeneity was accounted for, the data did not support the use of HS to decrease LOS in infants hospitalized with bronchiolitis.

PMID: 27088767 [PubMed - as supplied by publisher]


New England Journal of Medicine

  1. Neither amiodarone nor lidocaine made an impact on survival or neurological outcome for out-of-hospital arrest due to v-fib or pulseless v-tach.  This is muy importante!
  2. Previous rate of CVA or ACS after TIA were reportedly 12-20% in the first 3 months.  This TIA registry found that CVA/ACS rates were actually much lower at 2.8%, which is quite a difference!  They also found that, "In multivariable analyses, multiple infarctions on brain imaging, large-artery atherosclerosis, and an ABCD(2) score of 6 or 7 were each associated with more than a doubling of the risk of stroke."

1.

N Engl J Med. 2016 May 5;374(18):1711-22. doi: 10.1056/NEJMoa1514204. Epub 2016 Apr 4.

Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest.

Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, Christenson J, Egan D, Ornato JP, Weisfeldt ML, Stiell IG, Idris AH, Aufderheide TP, Dunford JV, Colella MR, Vilke GM, Brienza AM, Desvigne-Nickens P, Gray PC, Gray R, Seals N, Straight R, Dorian P; Resuscitation Outcomes Consortium Investigators.

 

Comment in

Abstract

BACKGROUND:

Antiarrhythmic drugs are used commonly in out-of-hospital cardiac arrest for shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, but without proven survival benefit.

METHODS:

In this randomized, double-blind trial, we compared parenteral amiodarone, lidocaine, and saline placebo, along with standard care, in adults who had nontraumatic out-of-hospital cardiac arrest, shock-refractory ventricular fibrillation or pulseless ventricular tachycardia after at least one shock, and vascular access. Paramedics enrolled patients at 10 North American sites. The primary outcome was survival to hospital discharge; the secondary outcome was favorable neurologic function at discharge. The per-protocol (primary analysis) population included all randomly assigned participants who met eligibility criteria and received any dose of a trial drug and whose initial cardiac-arrest rhythm of ventricular fibrillation or pulseless ventricular tachycardia was refractory to shock.

RESULTS:

In the per-protocol population, 3026 patients were randomly assigned to amiodarone (974), lidocaine (993), or placebo (1059); of those, 24.4%, 23.7%, and 21.0%, respectively, survived to hospital discharge. The difference in survival rate for amiodarone versus placebo was 3.2 percentage points (95% confidence interval [CI], -0.4 to 7.0; P=0.08); for lidocaine versus placebo, 2.6 percentage points (95% CI, -1.0 to 6.3; P=0.16); and for amiodarone versus lidocaine, 0.7 percentage points (95% CI, -3.2 to 4.7; P=0.70). Neurologic outcome at discharge was similar in the three groups. There was heterogeneity of treatment effect with respect to whether the arrest was witnessed (P=0.05); active drugs were associated with a survival rate that was significantly higher than the rate with placebo among patients with bystander-witnessed arrest but not among those with unwitnessed arrest. More amiodarone recipients required temporary cardiac pacing than did recipients of lidocaine or placebo.

CONCLUSIONS:

Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT01401647.).

PMID: 27043165 [PubMed - in process]

 

2.

N Engl J Med. 2016 Apr 21;374(16):1533-42. doi: 10.1056/NEJMoa1412981.

One-Year Risk of Stroke after Transient Ischemic Attack or Minor Stroke.

Amarenco P, Lavallée PC, Labreuche J, Albers GW, Bornstein NM, Canhão P, Caplan LR, Donnan GA, Ferro JM, Hennerici MG, Molina C, Rothwell PM, Sissani L, Školoudík D, Steg PG, Touboul PJ, Uchiyama S, Vicaut É, Wong LK; TIAregistry.org Investigators.

 

 

Comment in

Abstract

BACKGROUND:

Previous studies conducted between 1997 and 2003 estimated that the risk of stroke or an acute coronary syndrome was 12 to 20% during the first 3 months after a transient ischemic attack (TIA) or minor stroke. The TIAregistry.org project was designed to describe the contemporary profile, etiologic factors, and outcomes in patients with a TIA or minor ischemic stroke who receive care in health systems that now offer urgent evaluation by stroke specialists.

METHODS:

We recruited patients who had had a TIA or minor stroke within the previous 7 days. Sites were selected if they had systems dedicated to urgent evaluation of patients with TIA. We estimated the 1-year risk of stroke and of the composite outcome of stroke, an acute coronary syndrome, or death from cardiovascular causes. We also examined the association of the ABCD(2) score for the risk of stroke (range, 0 [lowest risk] to 7 [highest risk]), findings on brain imaging, and cause of TIA or minor stroke with the risk of recurrent stroke over a period of 1 year.

RESULTS:

From 2009 through 2011, we enrolled 4789 patients at 61 sites in 21 countries. A total of 78.4% of the patients were evaluated by stroke specialists within 24 hours after symptom onset. A total of 33.4% of the patients had an acute brain infarction, 23.2% had at least one extracranial or intracranial stenosis of 50% or more, and 10.4% had atrial fibrillation. The Kaplan-Meier estimate of the 1-year event rate of the composite cardiovascular outcome was 6.2% (95% confidence interval, 5.5 to 7.0). Kaplan-Meier estimates of the stroke rate at days 2, 7, 30, 90, and 365 were 1.5%, 2.1%, 2.8%, 3.7%, and 5.1%, respectively. In multivariable analyses, multiple infarctions on brain imaging, large-artery atherosclerosis, and an ABCD(2) score of 6 or 7 were each associated with more than a doubling of the risk of stroke.

CONCLUSIONS:

We observed a lower risk of cardiovascular events after TIA than previously reported. The ABCD(2) score, findings on brain imaging, and status with respect to large-artery atherosclerosis helped stratify the risk of recurrent stroke within 1 year after a TIA or minor stroke. (Funded by Sanofi and Bristol-Myers Squibb.).

TRIAL REGISTRATION:

ClinicalTrials.gov .

PMID: 27096581 [PubMed - indexed for MEDLINE]


Pediatric Emergency Care

  1. An online PEM curriculum improved learning but was severely underutilized.
  2. The next article was not good but the title is amazing - "If you twinkle when you tinkle, stones are found on ultrasound."  Yes, that really is the title of the article!

1.

Pediatr Emerg Care. 2016 Apr 13. [Epub ahead of print]

Pediatric Emergency Medicine Online Curriculum Improves Resident Knowledge Scores, But Will They Use It?

Little-Wienert K1, Hsu D, Torrey S, Lemke D, Patel B, Turner T, Doughty C.

Author information:

1From the *Baylor College of Medicine, Texas Children's Hospital, Houston, TX; and †New York University School of Medicine, New York, NY.

 

Abstract

OBJECTIVE:

Shift work on a pediatric emergency medicine (PEM) rotation makes didactic scheduling difficult, thereby limiting teaching opportunities. These constraints make this rotation an ideal setting to supplement resident education with an online curriculum. We aimed to determine if implementation of an online curriculum during a resident PEM rotation improves posttest performance and increases satisfaction with resident educational experience.

METHODS:

This was a prospective before/after study of pediatric and emergency medicine residents on a 1-month rotation in a tertiary care pediatric emergency department. A curriculum was developed consisting of 17 online modules. In the first 5 months of the study, 42 control residents received traditional bedside teaching. In the last 12 months, 80 intervention residents completed at least 8 modules during their rotation. Both groups completed a pretest at rotation start and a posttest and end-of-rotation survey at rotation end.

RESULTS:

Control group pretest and posttest scores were not significantly different. In the intervention group, posttest scores were significantly increased compared with pretest scores (68 vs 59, P < 0.01). A low percentage of residents completed the study. Only 42% of the 189 residents enrolled in the intervention group completed the posttest and 28% completed the survey.

CONCLUSIONS:

Implementing an online PEM curriculum significantly improved knowledge. As residency programs face new duty hour requirements, online curricula may provide an effective way to supplement teaching. However, to capitalize on this self-directed curriculum, the low participation rates in this study suggest we must first determine and establish ways to overcome barriers to online learning.

TRIAL REGISTRATION:

ClinicalTrials.gov .

PMID: 27077995 [PubMed - as supplied by publisher]

 

2.

Pediatr Emerg Care. 2016 Apr;32(4):246-9. doi: 10.1097/PEC.0000000000000542.

If You Twinkle When You Tinkle, Stones Are Found on Ultrasound.

Riera A1, Bokhari SA, Bechtel K.

Author information:

1From the Departments of *Pediatric Emergency Medicine and †Diagnostic Radiology, Yale University School of Medicine, New Haven, CT.

 

Abstract

Urolithiasis in children is an underrecognized cause of pediatric abdominal pain. Our case describes a child who presented to the emergency department with right lower quadrant pain, in whom a point-of-care ultrasound detected an ureterovesicular stone, which obviated the need for any further radiographic studies. We review the current literature on pediatric urolithiasis with a focus on sonographic diagnosis.

TRIAL REGISTRATION:

ClinicalTrials.gov .

PMID: 26359827 [PubMed - in process]


Prehospital Emergency Care

Orotracheal intubation rates went down slightly after the introduction of the King LT.

 

Prehosp Emerg Care. 2016 Apr 8:1-8. [Epub ahead of print]

Impact of System-Wide King LT Airway Implementation on Orotracheal Intubation.

Hilton MT, Wayne M, Martin-Gill C.

Abstract

OBJECTIVES:

Orotracheal intubation is a key component of prehospital airway management and success rates are dependent on procedural experience. Supraglottic airway devices are increasingly being used in the prehospital setting. As a result, paramedics may have fewer opportunities for performing intubation, limiting their proficiency in the procedure. We aimed to determine the trends in intubation versus supraglottic airway use over an 8 year period. We also aimed to determine the association between system-wide introduction of King LT guidelines and ETI success rates.

METHODS:

We performed a retrospective observational study of 37 Emergency Medical Services (EMS) agencies in a 10 county region of Southwestern Pennsylvania. Cases between January 1, 2005 and December 31, 2012 were included if an advanced airway procedure was performed. We determined trends in advanced airway placement and compared the proportion of cases with first pass intubation success before and after the King LT was introduced and promoted by statewide protocol starting in 2007. Use of airway devices before and after King LT implementation were presented using descriptive statistics and compared using Pearson's Chi-square or Fishers Exact test as appropriate. We compared first pass success rate of orotracheal intubation between study periods using multivariable logistic regression, controlling for other factors that may impact success of orotracheal intubation (year, EMS agency, age category, traumatic injury, and cardiac arrest).

RESULTS:

There were 712 cases of orotracheal intubation before and 2,835 cases after introduction of the King LT. The proportion of cases ultimately managed with orotracheal intubation before and after 2007 decreased from 72.3% (95% CI 68.9-75.6%) to 67.1% (95% CI 65.3-68.8%) (p = 0.007). In the multivariable analysis, success of orotracheal intubation was not associated with implementation of the King LT airway (OR 1.02, 95% CI 0.74-1.41).

CONCLUSION:

Fewer patients with advanced airway management received orotracheal intubation since introduction of the King LT. In spite of this modest change in airway management, there has not been a change in orotracheal intubation success rate since introduction of this supraglottic device as a primary or rescue airway in this regional EMS setting.

TRIAL REGISTRATION:

ClinicalTrials.gov .

PMID: 27058646 [PubMed - as supplied by publisher]

 


Resuscitation

For experienced intubators, DL and VL (Glidescope) success was the same during CPR.  But chest compressions were interrupted less often with use of VL.

 

Resuscitation. 2016 Apr 16. pii: S0300-9572(16)30014-4. doi: 10.1016/j.resuscitation.2016.04.003. [Epub ahead of print]

Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators.

Kim JW1, Park SO2, Lee KR1, Hong DY1, Baek KJ1, Lee YH3, Lee JH4, Choi PC5.

Author information:

1Department of Emergency Medicine, School of Medicine, Konkuk University, Konkuk University Medical Center, Seoul, Republic of Korea.

2Department of Emergency Medicine, School of Medicine, Konkuk University, Konkuk University Medical Center, Seoul, Republic of Korea. Electronic address: empso@kuh.ac.kr.

3Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University, Anyang-si, Gyeonggi-do, Republic of Korea.

4Department of Emergency Medicine, College of Medicine, Dongguk University, Goyang-si, Gyeonggi-do, Republic of Korea.

5Department of Emergency Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

 

Abstract

AIM:

This study compared endotracheal intubation (ETI) performance during cardiopulmonary resuscitation (CPR) between direct laryngoscopy (DL) and video laryngoscopy (VL) (GlideScope®) by experienced intubators (>50 successful ETIs).

METHODS:

This was a prospective randomized controlled study conducted in an emergency department between 2011 and 2013. Intubators who used DL or VL were randomly allocated to ETI during CPR. Data were collected from recorded video clips and rhythm sheets. The success, speed, complications, and chest compressions interruption were compared between the two devices.

RESULTS:

Total 140 ETIs by experienced intubators using DL (n=69) and VL (n=71) were analysed. There were no significant differences between DL and VL in the ETI success rate (92.8% vs. 95.8%; p=0.490), first-attempt success rate (87.0% vs. 94.4%; p=0.204), and median time to complete ETI (51 [36-67] vs. 42 [34-62]s; p=0.143). In both groups, oesophageal intubation and dental injuries seldom occurred. However, longer chest compressions interruption occurred using DL (4.0 [1.0-11.0]s) compared with VL (0.0 [0.0-1.0]s) and frequent serious no-flow (interruption>10s) occurred with DL (18/69 [26.1%]) compared with VL (0/71) (p<0.001). For highly experienced intubators (>80 successful ETIs), frequent serious no-flow occurred in DL (14/55 [25.5%] vs. 0/57 in VL).

CONCLUSIONS:

The ETI success, speed and complications during CPR did not differ significantly between the two devices for experienced intubators. However, the VL was superior in terms of completion of ETI without chest compression interruptions.

TRIAL REGISTRATION:

Clinical Research Information Service (CRIS) in South Korea KCT0000849.

TRIAL REGISTRATION:

ClinicalTrials.gov .

Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

PMID: 27095126 [PubMed - as supplied by publisher]