June 2016 EM Articles

Monthly Bolus - #FOAMed

Do you really want to read 41 articles?  Of course not!

Want to get one article at a time?

NNR* THIS MONTH = 73

You'd have to read 2982 articles to find these 41 (43 are listed, but 2 are for fun).

*NNR = Number Needed to Read


Academic Emergency Medicine

  1. The diagnostic performance of WBC and ANC in pediatric patients with appendicitis varied based on age.  As age increased, overall diagnostic performance of WBC and ANC increased.  What this means is that clinical decision instruments for pediatric appendicitis, such as the Alvarado score or Pediatric Appendicitis Score would benefit from age-specific cutoffs for WBC and ANC.
  2. Do residents "cherry pick" simpler patients?  In this study, residents signed up for patients more quickly who had simpler chief complaints like "ankle injury," "allergic reaction," or "wrist pain" and were slower to sign up for complaints like "abdominal pain," numbness/tingling," or "vaginal bleeding."  Whether this reflects a preference for simpler problems or aversion to perceived complaints with greater complexity (or for performing a pelvic exam) could not be determined on the basis of this study.  For a well rounded education, it's important to sign up for all kinds of patients and to beware of potential bias toward simpler patient problems.
  3. Apneic oxygenation is the use of high flow NC oxygen during RSI to provide passive oxygenation during the apneic phase.  The recent FELLOW trial called this into question. However, in this ED-based study, apneic oxygenation resulted in a marked improvement in first-pass success with no hypoxia, 82% with AP OX vs 69% without.  There seems to me to be no reason not to use such a simple intervention during ED RSI to prevent hypoxia.
  4. Could we finally be nearing a definitive answer as to whether LP is needed if CT is negative when working up possible SAH?  This meta-analysis found the prevalence of SAH in the 22 included studies was 7.5%.  CT without contrast within 6 hours was excellent at ruling in SAH (positive likelihood ratio [+LR] 230!) and in ruling it out (negative LR 0.01).  This is outstanding and about as good as it gets for a diagnostic test.  For those with CT > 6 hours from headache onset, LP would only benefit if the post-CT probability of SAH was still 5% or more.  Although no history, physical exam finding, or clinical decision rule alone could rule out SAH, they could be helpful in stratifying which patients may have high enough risk to warrant LP with negative CT.
  5. An important case series from California found fentanyl-adulterated tablets sold on the street this year in March as hydrocodone/acetaminophen.  Tablets had from 600-6900 micrograms of fentanyl per tablet but looked just like regular hydrocodone/acetaminophen tablets.  18 people were included in this series and had serious effects.  At the time of writing, 56 cases had already been reported to the county and there were 15 deaths.  Be on the lookout for opiate toxicity.  These patients required higher than normal doses of naloxone and prolonged infusion of naloxone.
  6. What is the significance of an elevated troponin?  In this retrospective look, about 25% were type 1 MI (plaque rupture + thrombus), 35% type 2 MI (supply-demand mismatch), 36% multifactorial, and 2.5% non-ischemic cardiac injury.  Does it matter that a patient has an elevated troponin?  Yes, those with non-type 1 MI had the same mortality as those with type 1 MI, around 10-11%.  An elevated troponin is a marker for badness and for increased mortality, whether due to classic MI from plaque rupture or for another reason.

1.

Acad Emerg Med. 2016 Jun 2. doi: 10.1111/acem.13018. [Epub ahead of print]

The Influence of Age on the Diagnostic Performance of White Blood Cell Count and Absolute Neutrophil Count in Suspected Pediatric Appendicitis.

Bachur RG1, Dayan PS2, Dudley NC3, Bajaj L4, Stevenson MD5, Macias CG6, Mittal MK7, Bennett J8, Sinclair K9, Monuteaux MC1, Kharbanda AB10.

Author information:

1Division of Emergency Medicine, Children's Hospital Boston and Harvard Medical School, Boston, MA.

2Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY.

3Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT.

4Department of Pediatrics, University of Colorado School of Medicine, Denver, CO.

5Department of Pediatrics, University of Louisville, Louisville, KY.

6Department of Pediatrics, Baylor College of Medicine, Houston, TX.

7Department of Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

8Department of Pediatrics, Alfred I. DuPont Hospital for Children, Wilmington, DE.

9Division of Emergency Medicine, Children's Mercy Hospitals and Clinics, Kansas City, MO.

10Department of Pediatric Emergency Medicine, Children's Hospital and Clinics of Minnesota, Minneapolis, MN.

Abstract

OBJECTIVE:

White blood cell (WBC) count and absolute neutrophil count (ANC) are a standard part of the evaluation of suspected appendicitis. Specific threshold values are utilized in clinical pathways, but the discriminatory value of WBC and ANC may vary by age. The objective of this study was to investigate whether the diagnostic value of WBC and ANC varies across age groups and whether diagnostic thresholds should be age-adjusted.

METHODS:

This is a multicenter prospective observational study of patients aged 3-18 years who were evaluated for appendicitis. Receiver operator characteristic curves were developed to assess overall discriminative power of WBC and ANC across 3 age groups: < 5 years, 5-11 years, 12-18 years of age. Diagnostic performance of WBC and ANC was then assessed at specific cut-points.

RESULTS:

2,133 patients with a median age of 10.9 years (IQR, 8-13.9) were studied. 41% had appendicitis. The area under-the-curve (AUC) for WBC was 0.69 [95% CI, 0.61-0.77] for patients < 5 years of age, 0.76 [95% CI, 0.73-0.79] for 5-11 years of age, and 0.83 [95% CI, 0.81, 0.86] for 12-18 years of age. The AUC's for ANC across age groups mirrored WBC performance. At a commonly-utilized WBC cut-point of 10,000/mm3 , the sensitivity decreased with increasing age: 95% (<5 years), 91% (5-11 years), and 89% (12-18 years) whereas specificity increased by age: 36% (<5 years), 49% (5-12 years), 64% (12-18 years).

CONCLUSION:

WBC and ANC had better diagnostic performance with increasing age. Age-adjusted values of WBC or ANC should be considered in diagnostic strategies for suspected pediatric appendicitis. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 27251399 [PubMed - as supplied by publisher]

 

2.

Acad Emerg Med. 2016 Jun;23(6):679-84. doi: 10.1111/acem.12895. Epub 2016 Feb 13.

Cherry Picking Patients: Examining the Interval Between Patient Rooming and Resident Self-assignment.

Patterson BW1, Batt RJ1,2, Wilbanks MD1, Otles E1, Westergaard MC1, Shah MN1.

Author information:

1BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI.

2Wisconsin School of Business, the University of Wisconsin-Madison, Madison, WI.

Abstract

OBJECTIVE:

We aimed to evaluate the association between patient chief complaint and the time interval between patient rooming and resident physician self-assignment ("pickup time"). We hypothesized that significant variation in pickup time would exist based on chief complaint, thereby uncovering resident preferences in patient presentations.

METHODS:

A retrospective medical record review was performed on consecutive patients at a single, academic, university-based emergency department with over 50,000 visits per year. All patients who presented from August 1, 2012, to July 31, 2013, and were initially seen by a resident were included in the analysis. Patients were excluded if not seen primarily by a resident or if registered with a chief complaint associated with trauma team activation. Data were abstracted from the electronic health record (EHR). The outcome measured was "pickup time," defined as the time interval between room assignment and resident self-assignment. We examined all complaints with >100 visits, with the remaining complaints included in the model in an "other" category. A proportional hazards model was created to control for the following prespecified demographic and clinical factors: age, race, sex, arrival mode, admission vital signs, Emergency Severity Index code, waiting room time before rooming, and waiting room census at time of rooming.

RESULTS:

Of the 30,382 patients eligible for the study, the median time to pickup was 6 minutes (interquartile range = 2-15 minutes). After controlling for the above factors, we found systematic and significant variation in the pickup time by chief complaint, with the longest times for patients with complaints of abdominal problems, numbness/tingling, and vaginal bleeding and shortest times for patients with ankle injury, allergic reaction, and wrist injury.

CONCLUSIONS:

A consistent variation in resident pickup time exists for common chief complaints. We suspect that this reflects residents preferentially choosing patients with simpler workups and less perceived diagnostic ambiguity. This work introduces pickup time as a metric that may be useful in the future to uncover and address potential physician bias. Further work is necessary to establish whether practice patterns in this study are carried beyond residency and persist among attendings in the community and how these patterns are shaped by the information presented via the EHR.

© 2016 by the Society for Academic Emergency Medicine.

PMID: 26874338 [PubMed - in process]

 

3.

Acad Emerg Med. 2016 Jun;23(6):703-10. doi: 10.1111/acem.12931. Epub 2016 May 13.

First Pass Success Without Hypoxemia Is Increased With the Use of Apneic Oxygenation During Rapid Sequence Intubation in the Emergency Department.

Sakles JC1, Mosier JM1, Patanwala AE2, Arcaris B3, Dicken JM3.

Author information:

1Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ.

2Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ.

3University of Arizona College of Medicine, Tucson, AZ.

Abstract

OBJECTIVES:

The objective was to determine the effect of apneic oxygenation (AP OX) on first pass success without hypoxemia (FPS-H) in adult patients undergoing rapid sequence intubation (RSI) in the emergency department (ED).

METHODS:

Continuous quality improvement data were prospectively collected on all patients intubated in an academic ED from July 1, 2013, to June 30, 2015. During this period the use of AP OX was introduced and encouraged for all patients undergoing RSI in the ED. Following each intubation, the operator completed a standardized data form that included information on patient, operator, and intubation characteristics. Adult patients 18 years of age or greater who underwent RSI in the ED by emergency medicine residents were included in the analysis. The primary outcome was FPS-H, which was defined as successful tracheal intubation on a single laryngoscope insertion without oxygen saturation falling below 90%. A multivariate logistic regression analysis was performed to determine the effect of AP OX on FPS-H.

RESULTS:

During the 2-year study period, 635 patients met inclusion criteria. Of these, 380 (59.8%) had AP OX utilized and 255 (40.2%) had no AP OX utilized. In the AP OX cohort the FPS-H was 312/380 (82.1%) and in the no AP OX cohort the FPS-H was 176/255 (69.0%) (difference = 13.1%, 95% confidence interval [CI] = 6.2% to 19.9%). In the multivariate logistic regression analysis, the use of AP OX was associated with an increased odds of FPS-H (adjusted odds ratio = 2.2, 95% CI = 1.5 to 3.3).

CONCLUSIONS:

The use of AP OX during the RSI of adult patients in the ED was associated with a significant increase in FPS-H. These results suggest that the use of AP OX has the potential to increase the safety of RSI in the ED by reducing the number of intubation attempts and the incidence of hypoxemia.

© 2016 by the Society for Academic Emergency Medicine.

PMID: 26836712 [PubMed - in process]

 

4.

Acad Emerg Med. 2016 Jun 16. doi: 10.1111/acem.12984. [Epub ahead of print]

Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis Describing the Diagnostic Accuracy of History, Physical Exam, Imaging, and Lumbar Puncture with an Exploration of Test Thresholds.

Carpenter CR1, Hussain AM2, Ward MJ3, Zipfel GJ4, Fowler S5, Pines JM6, Sivilotti ML7.

Author information:

1Emergency Medicine, Washington University in St. Louis School of Medicine.

2Department of Emergency Medicine, Northwestern University Feinberg School of Medicine.

3Emergency Medicine, Vanderbilt University.

4Neurosurgery, Washington University in St. Louis.

5Becker Medical Library, Washington University School of Medicine in St. Louis.

6Emergency Medicine, Center for Practice Innovation, George Washington University.

7Emergency Medicine and of Biomedical & Molecular Sciences, Queen's University.

Abstract

BACKGROUND:

Spontaneous subarachnoid hemorrhage (SAH) is a rare, but serious etiology of headache. The diagnosis of SAH is especially challenging in alert, neurologically intact patients, as missed or delayed diagnosis can be catastrophic.

OBJECTIVES:

The objective was to perform a diagnostic accuracy systematic review and meta-analysis of history, physical examination, cerebrospinal fluid (CSF) tests, computed tomography (CT), and clinical decision rules for spontaneous SAH. A secondary objective was to delineate probability of disease thresholds for imaging and lumbar puncture (LP).

METHODS:

PubMed, Embase, Scopus, and research meeting abstracts were searched up to June 2015 for studies of emergency department patients with acute headache clinically concerning for spontaneous SAH. QUADAS-2 was used to assess study quality and, when appropriate, meta-analysis was conducted using random effects models. Outcomes were sensitivity, specificity, and positive (LR+) and negative (LR-) likelihood ratios. To identify test and treatment thresholds, we employed the Pauker-Kassirer method with Bernstein test indication curves using the summary estimates of diagnostic accuracy.

RESULTS:

A total of 5,022 publications were identified, of which 122 underwent full-text review; 22 studies were included (average SAH prevalence = 7.5%). Diagnostic studies differed in assessment of history and physical examination findings, CT technology, analytical techniques used to identify xanthochromia, and criterion standards for SAH. Study quality by QUADAS-2 was variable; however, most had a relatively low risk of biases. A history of neck pain (LR+ = 4.1; 95% confidence interval [CI] = 2.2 to 7.6) and neck stiffness on physical examination (LR+ = 6.6; 95% CI = 4.0 to 11.0) were the individual findings most strongly associated with SAH. Combinations of findings may rule out SAH, yet promising clinical decision rules await external validation. Noncontrast cranial CT within 6 hours of headache onset accurately ruled in (LR+ = 230; 95% CI = 6 to 8,700) and ruled out SAH (LR- = 0.01; 95% CI = 0 to 0.04); CT beyond 6 hours had a LR- of 0.07 (95% CI = 0.01 to 0.61). CSF analyses had lower diagnostic accuracy, whether using red blood cell (RBC) count or xanthochromia. At a threshold RBC count of 1,000 × 106 /L, the LR+ was 5.7 (95% CI = 1.4 to 23) and LR- was 0.21 (95% CI = 0.03 to 1.7). Using the pooled estimates of diagnostic accuracy and testing risks and benefits, we estimate that LP only benefits CT-negative patients when the pre-LP probability of SAH is on the order of 5%, which corresponds to a pre-CT probability greater than 20%.

CONCLUSIONS:

Less than one in 10 headache patients concerning for SAH are ultimately diagnosed with SAH in recent studies. While certain symptoms and signs increase or decrease the likelihood of SAH, no single characteristic is sufficient to rule in or rule out SAH. Within 6 hours of symptom onset, noncontrast cranial CT is highly accurate, while a negative CT beyond 6 hours substantially reduces the likelihood of SAH. LP appears to benefit relatively few patients within a narrow pretest probability range. With improvements in CT technology and an expanding body of evidence, test thresholds for LP may become more precise, obviating the need for a post-CT LP in more acute headache patients. Existing SAH clinical decision rules await external validation, but offer the potential to identify subsets most likely to benefit from post-CT LP, angiography, or no further testing. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 27306497 [PubMed - as supplied by publisher]

 

5.

Acad Emerg Med. 2016 Jun 20. doi: 10.1111/acem.13034. [Epub ahead of print]

Fatal Fentanyl: One Pill Can Kill.

Sutter ME1,2, Gerona R3, Davis MT1,2, Roche BM1,2, Colby DK1,2, Chenoweth JA1,2, Adams AJ4, Owen KP1,2, Ford JB1,2, Black H2,5, Albertson TE2,5, Heard KJ.

Author information:

1University of California, Davis, Division of Medical Toxicology, Department of Emergency Medicine, PSSB 2100, Sacramento, CA 95817.

2Veterans Affairs Norther California, Mather, Mather, CA, 95655.

3University of California San Francisco, Division of Laboratory Medicine, 1001 Potrero Avenue, NH 2M16, San Francisco, CA, 94110.

4University of California, San Francisco School of Medicine, San Francisco, CA, 94143.

5University of California, Davis, Division of Pulmonary and Critical Care, Patient Services Support Building, 3400, Sacramento, CA, 95817.

 

Abstract

OBJECTIVE:

The current national opioid epidemic is a public health emergency. We have identified an outbreak of exaggerated opioid toxicity caused by fentanyl adulterated tablets purchased on the street as hydrocodone/acetaminophen.

METHODS:

Over an 8-day period in late March 2016, 18 patients presented to our institution with exaggerated opioid toxicity. The patients provided a similar history: ingesting their "normal dose" of hydrocodone/acetaminophen tablets but with more pronounced symptoms. Toxicology testing and analysis was performed on serum, urine, and surrendered pills.

RESULTS:

One of the 18 patients died in hospital. Five patients underwent cardiopulmonary resuscitation; 1 required extracorporeal life support; 3 required intubation; and 2 received bag-valve mask ventilation. One patient had recurrence of toxicity after 8 hours after naloxone discontinuation. Seventeen of 18 patients required boluses of naloxone, and 4 required prolonged naloxone infusions (26-39 hours). All 18 patients tested positive for fentanyl in the serum. Quantitative assays conducted in 13 of the sera revealed fentanyl concentrations of 7.9 to 162 ng/mL (mean, 52.9 ng/mL). Pill analysis revealed fentanyl amounts of 600-6900 μg/pill. The pills are virtually indistinguishable from authentic hydrocodone/acetaminophen tablets and are similar in weight. To date, our county has reported 56 cases of fentanyl opioid toxicity, with 15 fatalities. In our institution, the outbreak has stressed the capabilities and resources of the emergency department and intensive care units.

CONCLUSIONS:

A serious outbreak of exaggerated opioid toxicity caused by fentanyl adulterated tablets purchased on the street as hydrocodone/acetaminophen is underway in California. These patients required higher dosing and prolonged infusions of naloxone. Additionally, observation periods off naloxone were extended due to delayed, recurrent toxicity. The outbreak has serious ramifications for public health and safety, law enforcement, and health-care facilities and resources. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 27322591 [PubMed - as supplied by publisher]

 

6.

Acad Emerg Med. 2016 Jun 20. doi: 10.1111/acem.13033. [Epub ahead of print]

Causes of elevated cardiac troponins in the emergency department and their associated mortality.

Meigher S1, Thode HC1, Peacock WF2, Bock JL3, Gruberg L4, Singer AJ1.

Author information:

1Departments of Emergency Medicine, Stony Brook University, Stony Brook, NY.

2Department of Emergency Medicine, Baylor College of Medicine, Houston, TX.

3Department of Clinical Pathology, Stony Brook University, Stony Brook, NY.

4Department of Cardiology, Stony Brook University, Stony Brook, NY.

 

Abstract

STUDY OBJECTIVE:

Cardiac troponins (cTn) are structural components of myocardial cells and are expressed almost exclusively in the heart. Elevated cTn levels indicate myocardial cell damage/death but not reflect the underlying etiology. The 3rd Universal Definition of myocardial infarction (MI) differentiates MI into various types. Type 1 (T1MI) is due to plaque rupture with thrombus, while type 2 (T2MI) is a result of a supply: demand mismatch. Non-MI cTn elevations are also common. We determined the causes of elevated cTn in a tertiary care ED and the associated in-hospital mortality.

METHODS:

We performed a structured, retrospective review of all consecutive adult ED patients with elevated troponin I (defined as >99th %ile of the normal population, as run on the ADVIA Centaur® platform; Siemens USA, Malvern, PA) during 1 year. Causes of elevated cTn were classified based on the 3rd Universal Definitions. Comparisons between groups were performed using Χ2 and Mann-Whitney U tests.

RESULTS:

Of 96,612 ED patients presenting from 5/12-4/13, 13,502 (14%) had cTn measured, of which 1,310 (9.7%) were elevated. Of these, 340 (26.5%, 95% CI, 24.2-29.0) were T1MI, 452 (35.2%, 95% CI, 32.7-37.9) T2MI, 458 (35.7%, 95% CI, 33.1-38.4) multifactorial and 33 (2.5%, 95% CI, 1.8-3.5) due to non-ischemic injury. Non-T1MI patients were slightly older, more likely female, and had higher BUN and creatinine. Comorbidities were more common in non-T1MI while cardiac risk factors were more common in T1MI. Non-T1MI patients were less likely to have diagnostic ECGs and had lower initial and subsequent cTn levels. In hospital mortality rates were similarly high for T1MI and non-T1MI (11% [95% CI 8-15%] vs. 10% [95% CI 8-12%], P=0.48).

CONCLUSIONS:

Of all ED patients with elevated cTn, ~75% have a non-T1MI. The mortality of patients with non-T1MI is similar to the mortality in patients with T1MI. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 27320126 [PubMed - as supplied by publisher]


American Journal of Emergency Medicine

  1. Glucagon doesn't work for esophageal foreign body impaction (14% resolution vs 10% with no glucagon) and it made 13% of patients vomit. Skip glucagon and just call GI for endoscopy.  This was first released electronically in April.

  2. This single center retrospective study found that the mortality and risk of bleeding was similar in patients with massive or submassive PE whether systemic or catheter-based thrombolysis was given.  I assumed catheter-based treatment was superior and possibly safer, but this study does not support that.

  3. Does post-cardiac arrest neurological exam predict long-term outcome?  No, neurological exam in the ED was a poor predictor of ultimate outcome in arrest survivors and should not be the basis for determining use of targeted temperature management or other aggressive treatment options.  We also should be careful to tell family we are not able to accurately predict who will do well or who will do poorly in the early hours after arrest.

1.

Am J Emerg Med. 2016 Jun;34(6):1049-52. doi: 10.1016/j.ajem.2016.03.016. Epub 2016 Mar 9.

Effectiveness of glucagon in relieving esophageal foreign body impaction: a multicenter study.

Bodkin RP1, Weant KA2, Baker Justice S3, Spencer MT1, Acquisto NM4.

Author information:

1Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Box 655, Rochester, NY 14642.

2Medical University of South Carolina, 150 Ashley Ave, PO Box 25084, Charleston, SC 29425.

3Clinical Pharmacy Services, St Claire Regional Medical Center, 222 Medical Cir, Morehead, KY 40351.

4Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Box 655, Rochester, NY 14642; Department of Pharmacy, University of Rochester Medical Center, 601 Elmwood Ave, Box 638, Rochester, NY 14642. Electronic address: nicole_acquisto@urmc.rochester.edu.

Abstract

PURPOSE:

Glucagon is thought to decrease lower esophageal sphincter tone and is used as an alternative to invasive endoscopy for esophageal foreign body impaction (EFBI). The purpose of this study was to evaluate efficacy and safety of glucagon and identify characteristics associated with success.

METHODS:

A multicenter, retrospective study of patients receiving glucagon for EFBI at 2 academic emergency departments was conducted between 2006 and 2010. A control group of patients that did not receive glucagon was evaluated. Data collection included demographics, type of foreign body, glucagon dose, resolution of impaction, incidence of vomiting, additional medication, and endoscopy required. Descriptive and univariate analysis was performed as appropriate.

RESULTS:

A total of 133 doses of glucagon were administered in 127 patients. Glucagon-related resolution of EFBI occurred in 18 patients (14.2%) and vomiting in 16 patients (12.6%). No statistical differences between successful and unsuccessful groups were seen with the exception of concomitant medication administration (benzodiazepine or nitroglycerin) being associated with less glucagon success, 33.3% vs 59.6%, respectively (P = .04). Eighty-four percent of patients in the unsuccessful group underwent endoscopy. Comparing those that received glucagon (n = 127) and the control group (n = 29), there was no significant difference in resolution of EFBI, 14.2% vs 10.3%, respectively (P = .586).

CONCLUSIONS:

Glucagon-related resolution occurred in 14.2% of patients and was not significantly different compared with those that did not receive glucagon (10.3%). Concomitant medication administration was associated with lower success. Overall, glucagon had a low success rate, was related to adverse effects, and does not offer advantages for treatment.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 27038694 [PubMed - in process]

 

2.

Am J Emerg Med. 2016 Jun;34(6):985-8. doi: 10.1016/j.ajem.2016.02.037. Epub 2016 Feb 15.

Comparison between systemic and catheter thrombolysis in patients with pulmonary embolism.

Yoo JW1, Choi HC2, Lee SJ1, Cho YJ1, Lee JD1, Kim HC3.

Author information:

1Department of Internal Medicine, College of Medicine, Gyeongsang National University Hospital, Jinju, Gyeonsangnam-do, Republic of Korea.

2Department of Radiology, College of Medicine, Gyeongsang National University Hospital, Jinju, Gyeongsangnam-do, Republic of Korea.

3Department of Internal Medicine, College of Medicine, Gyeongsang National University Hospital, Jinju, Gyeonsangnam-do, Republic of Korea. Electronic address: hochkim@gnu.ac.kr.

Abstract

BACKGROUND:

Although systemic thrombolysis (ST) or catheter-directed therapy (CDT) is performed in patients with acute massive or submassive pulmonary embolism (PE), clinical data comparing between both therapies remain limited. We compared clinical outcomes between ST and CDT in patients with acute massive and submassive PE.

METHODS:

From January 2005 to June 2015, clinical outcomes of patients with acute massive or submassive PE receiving ST or CDT were evaluated and compared retrospectively.

RESULTS:

Of 72 patients, 44 were treated with ST; and 28, with CDT. The mean age was 63.9 ± 17 years old. The proportion of male sex was higher in patients receiving CDT compared to that with ST (46.4% vs 20.5%; P = .02). Half of patients presented with massive PE, and cardiac arrest occurred in 11 patients (15.3%). No difference was observed between the 2 groups with respect to 7-day mortality (13.6% in ST vs 10.7% in CDT), inhospital mortality (13.6% in ST vs 14.3% in CDT), and major bleeding complication (16.7% in ST vs 16.7% in CDT). Cardiac arrest (odds ratio, 6.286; 95% confidence interval, 1.081-36.555; P = .041) was associated with 14-day mortality.

CONCLUSIONS:

Similar clinical outcomes were shown between ST and CDT in patients with acute massive or submassive PE.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 27033736 [PubMed - in process]

 

3.

Am J Emerg Med. 2016 Jun;34(6):975-9. doi: 10.1016/j.ajem.2016.02.002. Epub 2016 Feb 21.

Early neurologic examination is not reliable for prognostication in post-cardiac arrest patients who undergo therapeutic hypothermia.

Merrill MS1, Wares CM2, Heffner AC3, Shauger KL4, Norton HJ5, Runyon MS2, Pearson DA2.

Author information:

1Carolinas Medical Center, Department of Emergency Medicine. Electronic address: mmerrill2011@gmail.com.

2Carolinas Medical Center, Department of Emergency Medicine.

3Carolinas Medical Center, Department of Emergency Medicine; Carolinas Medical Center, Department of Internal Medicine, Division of Critical Care Medicine.

4Carolinas Medical Center, Department of Neurology.

5Dickson Advanced Analytics, Charlotte, NC.

Abstract

BACKGROUND:

Recent advances in post-cardiac arrest (CA) care including therapeutic hypothermia (TH) have improved survival and favorable neurologic outcomes for survivors of CA. Survivors often present with deep coma and lack of brainstem reflexes, which are generally associated with adverse outcomes in many disease processes. Little is known regarding the role of initial emergency department (ED) neurological examination and its potential for prognostication.

OBJECTIVES:

The purpose of this study is to determine if components of a standardized neurologic examination are reliable prognosticators in patients recently resuscitated from CA. We hypothesize that lack of neurologic function does not reliably predict an adverse outcome and, therefore, should not be used to determine eligibility for TH.

METHODS:

A standardized neurologic examination was performed in the ED on a prospective, convenience cohort of post-CA patients presenting to a CA resuscitation center who would undergo a comprehensive postarrest care pathway that included TH. Data such as prior sedation or active neuromuscular blockade were documented to evaluate for the presence of possible confounders. Examination findings were then compared with hospital survival and neurologic outcome at discharge as defined by the cerebral performance category (CPC) score as documented in the institutional TH registry.

RESULTS:

Forty-nine subjects were enrolled, most of whom presented comatose with a Glasgow Coma Scale of 3 (n=41, 83.7%). Nineteen subjects (38.8%) had absence of all examination findings, of which 4 of 19 (21.1%) survived to hospital discharge. Of those with at least 1 positive examination finding, 13 of 30 subjects (43.3%) survived to hospital discharge. Subgroup analysis showed that 9 of the 19 patients with absence of brainstem reflexes did not have evidence of active neuromuscular blockade at the time of the examination; 2 of 9 (22.1%) survived to hospital discharge. Eight of these subjects in this group had not received any prior sedation; 1 of 8 (12.5%) survived to hospital discharge. Only 1 of the 17 subjects who survived was discharged with poor neurologic function with a CPC score=3, whereas all others who survived had good neurologic function, CPC score=1.

CONCLUSION:

In this cohort of patients treated in a comprehensive postarrest care pathway that included TH, absence of neurologic function on initial ED presentation was not reliable for prognostication. Given these findings, clinicians should refrain from using the initial ED neurological examination to guide the aggressiveness of care or in counseling of family members regarding anticipated outcome.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 26994681 [PubMed - in process]


Annals of Emergency Medicine

In patients with a glucose >400, does the discharge glucose level correlate with 7-day rate of return to the ED?  There was no correlation with discharge glucose level and rate of ED return.  I have always tried to make markedly elevated glucose numbers look better before discharge.  This may be less beneficial than I thought.  That said, pronounced hyperglycemia shouldn't be ignored on the basis of this study.  The point is that achieving a specific target glucose number prior to discharge is probably not that important.

Ann Emerg Med. 2016 Jun 25. pii: S0196-0644(16)30162-7. doi: 10.1016/j.annemergmed.2016.04.057. [Epub ahead of print]

Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia.

Driver BE1, Olives TD2, Bischof JE2, Salmen MR2, Miner JR2.

Author information:

1Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN. Electronic address: briandriver@gmail.com.

2Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.

 

Abstract

STUDY OBJECTIVE:

Hyperglycemia is frequently encountered in the emergency department (ED), and there is no consensus on optimal care before discharge. The importance of glucose reduction in the ED is unknown. We seek to determine whether an association exists between discharge glucose and 7-day adverse outcomes.

METHODS:

A cohort design with retrospective chart review was conducted at a high-volume urban ED. Patients were included if any glucose level was greater than or equal to 400 mg/dL and they were discharged from the ED. Generalized estimating equation models were created for the 7-day outcomes with a primary predictor of discharge glucose.

RESULTS:

The cohort consisted of 422 patients with 566 ED encounters. Mean arrival and discharge glucose were 491 mg/dL (SD 82 mg/dL) and 334 mg/dL (SD 101 mg/dL), respectively. In the 7-day follow-up period, 62 (13%) and 36 (7%) patients had a repeat ED visit for hyperglycemia and were hospitalized, respectively. Two patients had diabetic ketoacidosis. After adjustment for arrival glucose, whether a chemistry panel was obtained, amount of intravenous fluids administered, and amount of subcutaneous insulin administered, discharge glucose was not associated with repeat ED visit for hyperglycemia (adjusted odds ratio 0.997; 95% confidence interval 0.993 to 1.001) or hospitalization for any reason (adjusted odds ratio 0.998; 95% confidence interval 0.995 to 1.002).

CONCLUSION:

ED discharge glucose in patients with moderate to severe hyperglycemia was not associated with 7-day outcomes of repeat ED visit for hyperglycemia or hospitalization. Attaining a specific glucose goal before discharge in patients with hyperglycemia may be less important than traditionally thought.

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

PMID: 27353284 [PubMed - as supplied by publisher]


Annals of Surgery

  1. The pendulum has swung from giving large amounts of crystalloid for trauma and burn patients to using more restrictive fluid strategies.  When I was a resident, we used to say, "You have to swell to get well."  Recently, a more restrictive fluid strategy than Parkland formula has been used for burn patients.  But this study suggests perhaps the pendulum has swung too far.  This retrospective analysis found that about one third of burn patients received a restrictive fluid strategy, a third were very near Parkland (4-6mL/kg), and roughly a third got more than Parkland.  After adjustment for severity of illness, they found the restrictive strategy was associated with increased risk for acute kidney injury.  The larger volume strategy was not associated with increased pneumonia or burn wound infection.
  2. Are busier trauma centers better?  For each 1% increase in patient volume over time, mortality rate dropped in level 1 and level 2 trauma centers.  As volume decreased over time, mortality increased.  Why does this matter?  Prehospital transport of patients to a busy level 1 or 2 trauma center gives them the best chance for survival. Practice makes perfect.

1.

Ann Surg. 2016 Jun 17. [Epub ahead of print]

Hold the Pendulum: Rates of Acute Kidney Injury are Increased in Patients Who Receive Resuscitation Volumes Less than Predicted by the Parkland Equation.

Mason SA1, Nathens AB, Finnerty CC, Gamelli RL, Gibran NS, Arnoldo BD, Tompkins RG, Herndon DN, Jeschke MG; Inflammation and the Host Response to Injury Collaborative Research Program.

Author information:

1*Department of Surgery, Sunnybrook Health Sciences Centre and Division of General Surgery, University of Toronto, Toronto, Canada †Shriners Hospitals for Children - Galveston and Department of Surgery, University of Texas Medical Branch, Galveston, TX ‡Sealy Center for Molecular Medicine and the Institute for Translational Science, University of Texas Medical Branch, Galveston, TX §Department of Surgery, Loyola University Stritch School of Medicine, Maywood, IL ¶Department of Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, WA ||Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX **Department of Surgery, Massachusetts General Hospital, Shriners Hospital for Children, Harvard Medical School, Boston, MA ††Ross Tilley Burn Centre Sunnybrook Health Sciences Centre and Division of Plastic Surgery University of Toronto, Toronto, ON, Canada.

 

Abstract

OBJECTIVE:

To determine whether restrictive fluid resuscitation results in increased rates of acute kidney injury (AKI) or infectious complications.

BACKGROUND:

Studies demonstrate that patients often receive volumes in excess of those predicted by the Parkland equation, with potentially detrimental sequelae. However, the consequences of under-resuscitation are not well-studied.

METHODS:

Data were collected from a multicenter prospective cohort study. Adults with greater than 20% total burned surface area injury were divided into 3 groups on the basis of the pattern of resuscitation in the first 24 hours: volumes less than (restrictive), equal to, or greater than (excessive) standard resuscitation (4 to 6 cc/kg/% total burned surface area). Multivariable regression analysis was employed to determine the effect of fluid group on AKI, burn wound infections (BWIs), and pneumonia.

RESULTS:

Among 330 patients, 33% received restrictive volumes, 39% received standard resuscitation volumes, and 28% received excessive volumes. The standard and excessive groups had higher mean baseline APACHE scores (24.2 vs 16, P < 0.05 and 22.3 vs 16, P < 0.05) than the restrictive group, but were similar in other characteristics. After adjustment for confounders, restrictive resuscitation was associated with greater probability of AKI [odds ratio (OR) 3.25, 95% confidence interval (95% CI) 1.18-8.94]. No difference in the probability of BWI or pneumonia among groups was found (BWI: restrictive vs standard OR 0.74, 95% CI 0.39-1.40, excessive vs standard OR 1.40, 95% CI 0.75-2.60, pneumonia: restrictive vs standard, OR 0.52, 95% CI 0.26-1.05; excessive vs standard, OR 1.12, 95% CI 0.58-2.14).

CONCLUSIONS:

Restrictive resuscitation is associated with increased AKI, without changes in infectious complications.

PMID: 26764868 [PubMed - as supplied by publisher]

 

2.

Ann Surg. 2016 Jun 15. [Epub ahead of print]

Impact of Volume Change Over Time on Trauma Mortality in the United States.

Brown JB1, Rosengart MR, Kahn JM, Mohan D, Zuckerbraun BS, Billiar TR, Peitzman AB, Angus DC, Sperry JL.

Author information:

1*Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA †Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.

 

Abstract

OBJECTIVE:

To evaluate the association of trauma center volume change over time with mortality.

BACKGROUND:

Regionalization of trauma systems assumes a volume-outcome relationship for severe injury. Whereas this has been shown for cross-sectional volume, it is unclear whether volume changes over time translate into predictable outcome changes.

METHODS:

Retrospective cohort study of severely injured (injury severity score >15) patients from the National Trauma Databank 2000 to 2012. A center-level standardized mortality ratio (SMR) was constructed (ratio of observed to expected deaths). Expected mortality was obtained from multilevel logistic regression model, adjusting for demographics, mechanism, vital signs, and injury severity. Center-level percent volume change was assessed across early (2000-2006) and late (2007-2012) periods. Longitudinal panel modeling evaluated association between annual SMR change and volume change over preceding years.

RESULTS:

There were 839,809 patients included from 287 centers. Each 1% increase in volume was associated with 73% increased odds of improving SMR over time [odds ratio (OR) 1.73; 95% confidence interval (CI) 1.03-2.91; P = 0.03]. Each 1% decrease in volume was associated with 2-fold increase in odds of worsening SMR over time (OR 2.14; 95% CI 1.07-4.26, P = 0.03). Significant improvement in the SMR emerged after 3 or more preceding years of increasing volume (SMR change -0.008; 95% CI -0.015, -0.002; P = 0.01). This benefit occurred only in centers that were level I or II verified.

CONCLUSIONS:

Increasing volume was associated with improving outcomes, whereas decreasing volume was associated with worsening outcomes. High-level trauma center infrastructure seems to facilitate the volume-outcome relationship. The trauma center designation process should consider volume changes in the overall system.

PMID: 27308736 [PubMed - as supplied by publisher]


  British Medical Journal

Direct oral anticoagulants are increasingly used over warfarin. Many are still difficult to reverse or have no reversal agent.  Despite this, some studies suggest they may still be safer than warfarin and more effective.  This was a national observational cohort study from Denmark comparing warfarin and either rivaroxaban, apixaban, or dabigatran.  Risk of ischemic stroke or systemic embolism was less with rivaroxaban compared with warfarin.  Risk of death was less with apixaban and dabigatran compared to warfarin but not rivaroxaban.  Risk of any bleeding was lower with apixaban and dabigatran compared with warfarin but the same with rivaroxaban.  It is hard to pick a clear winner among the four agents.  The direct agents have the advantage of no routine INR monitoring and fewer drug interactions compared with warfarin.  And despite being more difficult to reverse, they appear to be just as safe as warfarin.

BMJ. 2016 Jun 16;353:i3189. doi: 10.1136/bmj.i3189.

Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study.

Larsen TB1, Skjøth F2, Nielsen PB3, Kjældgaard JN3, Lip GY4.

Author information:

1Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark tobl@rn.dk.

2Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark Unit for Clinical Biostatistics and Bioinformatics, Aalborg University Hospital, Aalborg, Denmark.

3Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.

4Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK.

 

Abstract

OBJECTIVE:

 To study the effectiveness and safety of the non-vitamin K antagonist oral anticoagulants (novel oral anticoagulants, NOACs) dabigatran, rivaroxaban, and apixaban compared with warfarin in anticoagulant naïve patients with atrial fibrillation.

DESIGN:

 Observational nationwide cohort study.

SETTING:

 Three Danish nationwide databases, August 2011 to October 2015.

PARTICIPANTS:

 61 678 patients with non-valvular atrial fibrillation who were naïve to oral anticoagulants and had no previous indication for valvular atrial fibrillation or venous thromboembolism. The study population was distributed according to treatment type: warfarin (n=35 436, 57%), dabigatran 150 mg (n=12 701, 21%), rivaroxaban 20 mg (n=7192, 12%), and apixaban 5 mg (n=6349, 10%).

MAIN OUTCOME MEASURES:

 Effectiveness outcomes defined a priori were ischaemic stroke; a composite of ischaemic stroke or systemic embolism; death; and a composite of ischaemic stroke, systemic embolism, or death. Safety outcomes were any bleeding, intracranial bleeding, and major bleeding.

RESULTS:

 When the analysis was restricted to ischaemic stroke, NOACs were not significantly different from warfarin. During one year follow-up, rivaroxaban was associated with lower annual rates of ischaemic stroke or systemic embolism (3.0% v 3.3%, respectively) compared with warfarin: hazard ratio 0.83 (95% confidence interval 0.69 to 0.99). The hazard ratios for dabigatran and apixaban (2.8% and 4.9% annually, respectively) were non-significant compared with warfarin. The annual risk of death was significantly lower with apixaban (5.2%) and dabigatran (2.7%) (0.65, 0.56 to 0.75 and 0.63, 0.48 to 0.82, respectively) compared with warfarin (8.5%), but not with rivaroxaban (7.7%). For the combined endpoint of any bleeding, annual rates for apixaban (3.3%) and dabigatran (2.4%) were significantly lower than for warfarin (5.0%) (0.62, 0.51 to 0.74). Warfarin and rivaroxaban had comparable annual bleeding rates (5.3%).

CONCLUSION:

 All NOACs seem to be safe and effective alternatives to warfarin in a routine care setting. No significant difference was found between NOACs and warfarin for ischaemic stroke. The risks of death, any bleeding, or major bleeding were significantly lower for apixaban and dabigatran compared with warfarin.

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: PMC4910696 Free PMC Article

PMID: 27312796 [PubMed - in process]


Chest

  1. For patients with smoke inhalation, mortality was higher in patients who required early vasopressor use, had higher DRG-assigned mortality risk assignment, and in smaller hospitals (<500 beds).  Similar to the recent study in Annals of Surgery this month showing busier trauma centers have better outcomes, larger burn centers have lower risk of mortality for smoke inhalation injury.  Why does this matter?  Many of you work in rural emergency departments and have a choice where to transfer patients.  For patients with smoke inhalation, you give them the best chance of survival when you transfer to a larger burn center.  If you have a choice, bigger is better for burn care.
  2. We know pregnancy and the postpartum period is a hypercoagulable state, but how does a vaginal delivery compare with c-section for venous thromboembolism (VTE) risk?  This was a meta-analysis of primarily retrospective studies that found the risk of VTE was about 4 times greater after a c-section than a vaginal delivery.  Overall VTE risk was 3/1000 after c-section.
  3. Parapneumonic effusion was associated with increased risk of death, hospitalization, and length of stay in this retrospective study.  The clinical prediction instrument, CURB-65, underestimated mortality risk, 7% predicted vs. 14% actual, in patients with parapneumonic effusion.  Why does this matter?  Standard clinical prediction rules to determine inpatient vs. outpatient treatment do not take this into account.  If an ED patient has a parapneumonic effusion, be extra cautious and err on the side of admission.

1.

Chest. 2016 Jun 14. pii: S0012-3692(16)50256-6. doi: 10.1016/j.chest.2016.06.008. [Epub ahead of print]

Risk factors for in-hospital mortality in smoke inhalation-associated acute lung injury: Data from 68 United States hospitals.

Kadri SS1, Miller AC2, Hohmann S3, Bonne S4, Nielsen C5, Wells C6, Gruver C6, Quraishi SA7, Sun J8, Cai R8, Morris PE9, Freeman BD4, Holmes JH6, Cairns BA5, Suffredini AF8; US Critical Illness and Injury Trials Group: Smoke Inhalation-associated Acute Lung Injury (SI-ALI) Investigators (USCIIT–SI-ALI).

Author information:

1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD; Department of Medicine, Massachusetts General Hospital, Boston, MA. Electronic address: sameer.kadri@nih.gov.

2Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD; Department of Emergency Medicine, West Virginia University, Morgantown, WV.

3University HealthSystem Consortium, Chicago, IL; Department of Health Systems Management, Rush University, Chicago, IL.

4Department of Surgery, Washington University School of Medicine, St. Louis, MO.

5North Carolina Jaycee Burn Center, University of North Carolina Hospital, Chapel Hill, NC.

6Department of General Surgery, Wake Forest Medical Center, Wake Forest School of Medicine, Winston-Salem, NC.

7Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Anesthesia, Harvard Medical School, Boston, MA.

8Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD.

9Division of Pulmonary and Critical Care Medicine, Wake Forest Medical Center, Wake Forest School of Medicine, Winston-Salem, NC.

Abstract

BACKGROUND:

Mortality after smoke inhalation-associated acute lung injury (SI-ALI) remains substantial. Age and burn surface area are risk factors of mortality, while the impact of patient and center-level variables and treatments on survival are unknown.

METHODS:

We performed a retrospective cohort study of burn and non-burn centers at 68 United States academic medical centers from 2011-2014. Adult SI-ALI inpatients were identified using an algorithm based on a billing code for respiratory conditions from smoke inhalation who were mechanically ventilated by hospital day 4, with either a length-of-stay ≥ 5-days or death within 4 days of hospitalization. Predictors of in-hospital mortality were identified using logistic regression. The primary outcome was the odds ratio for in-hospital mortality.

RESULTS:

769 patients (52.9 ± 18.1 years) with SI-ALI were analyzed. In-hospital mortality was 26% in the SI-ALI cohort and 50% in patients with ≥20% surface burns. In addition to age > 60 years (OR 5.1, 95%CI 2.53-10.26) and ≥20% burns (OR 8.7, 95%CI 4.55-16.75), additional risk factors of in-hospital mortality included initial vasopressor use (OR 5.0, 95%CI 3.16-7.91), higher DRG-based risk-of-mortality assignment and lower hospital bed capacity (OR 2.3, 95%CI 1.23-4.15). Initial empiric antibiotics (OR 0.93, 95%CI 0.58-1.49) did not impact survival. These new risk factors improved mortality prediction (ΔAUC) by 9.9%(p<0.001).

CONCLUSIONS:

In addition to older age and major surface burns, mortality in SI-ALI is predicted by initial vasopressor use, higher DRG-based risk-of-mortality assignment and care at centers with <500 beds, but not by initial antibiotic therapy.

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

PMID: 27316558 [PubMed - as supplied by publisher]

 

2.

Chest. 2016 Jun 1. pii: S0012-3692(16)49108-7. doi: 10.1016/j.chest.2016.05.021. [Epub ahead of print]

Risks of venous thromboembolism after cesarean sections: A meta-analysis.

Blondon M1, Casini A2, Hoppe KK3, Boehlen F2, Righini M2, Smith NL4.

Author information:

1Division of Angiology and Hemostasis, Department of Specialties of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, USA. Electronic address: marc.blondon@hcuge.ch.

2Division of Angiology and Hemostasis, Department of Specialties of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.

3Department of Obstetrics and Gynecology and of Maternal Fetal Medicine, University of Wisconsin, Madison, USA; Department of Obstetrics and Gynecology, University of Washington, Seattle, USA.

4Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, USA; Department of Epidemiology, University of Washington, Seattle, USA.

Abstract

BACKGROUND:

Cesarean sections (CS) are believed to be associated with greater risks of postpartum venous thromboembolism (VTE). Our objective was to systematically review the evidence on this association and on the absolute risk of VTE after CS.

METHODS:

We searched Pubmed, Embase and conference proceedings from 1980 to 11/2015 for reports on the associations of delivery methods with postpartum VTE and on the incidence of VTE after CS. We excluded studies on thrombophilia or recurrent VTE and restricted to prospective studies when assessing the incidence of VTE. Pooled relative and absolute risks were estimated with random-effects models.

RESULTS:

Our search retrieved 28 mostly retrospective observational studies comparing risks of VTE after CS and after vaginal deliveries (VD) (n>53000 VTE events), and 32 prospective studies reporting risks of VTE after CS (n=218 VTE events). Compared with VD, the relative risk of VTE after CS ranged from 1-22, with a meta-analytic odds ratio (OR) of 3.7 (95%CI 3.0-4.6). Adjustment for age and BMI had a marginal influence on the estimated pooled OR. Associations were observed for both elective and emergency CS, with stronger estimates of associations for emergency CS. The pooled incidence was 2.6VTE/1000 CS (95%CI 1.7-3.5), and was greater in studies with a longer and better follow-up in the postpartum (4.3/1000 CS).

CONCLUSION:

The risk of VTE is 4-fold greater after CS than VD, appears independent of other VTE risk factors, and is greater after emergency than elective CS. On average, 3 in 1000 women will develop a VTE after CS.

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

PMID: 27262227 [PubMed - as supplied by publisher]

 

3.

Chest. 2016 Jun;149(6):1509-15. doi: 10.1016/j.chest.2015.12.027. Epub 2016 Jan 16.

Pleural Effusions at First ED Encounter Predict Worse Clinical Outcomes in Patients With Pneumonia.

Dean NC1, Griffith PP2, Sorensen JS3, McCauley L4, Jones BE5, Lee YC6.

Author information:

1Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT. Electronic address: nathan.dean@imail.org.

2Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT.

3Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT.

4Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT.

5Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT; Division of Pulmonary and Critical Care Medicine, Salt Lake City VA Health System, Salt Lake City, UT.

6Pleural Diseases Unit, Sir Charles Gairdner Hospital, University of Western Australia-Perth, Western Australia.

Abstract

BACKGROUND:

Pleural effusions are present in 15% to 44% of hospitalized patients with pneumonia. It is unknown whether effusions at first presentation to the ED influence outcomes or should be managed differently.

METHODS:

We studied patients in seven hospital EDs with International Statistical Classification of Disease and Health Related Problems-Version 9 codes for pneumonia, or empyema, sepsis, or respiratory failure with secondary pneumonia. Patients with no confirmatory findings on chest imaging were excluded. Pleural effusions were identified with the use of radiographic imaging.

RESULTS:

Over 24 months, 4,771 of 458,837 adult ED patients fulfilled entry criteria. Among the 690 (14.5%) patients with pleural effusions, their median age was 68 years, and 46% were male. Patients with higher Elixhauser comorbidity scores (OR, 1.13 [95% CI, 1.09-1.18]; P < .001), brain natriuretic peptide levels (OR, 1.20 [95% CI, 1.12-1.28]; P < .001), bilirubin levels (OR, 1.07 [95% CI, 1.00-1.15]; P = .04), and age (OR, 1.15 [95% CI, 1.09-1.21]; P < .001) were more likely to have parapneumonic effusions. In patients without effusion, electronic version of CURB-65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years accurately predicted mortality (4.7% predicted vs 5.0% actual). However, eCURB underestimated mortality in those with effusions (predicted 7.0% vs actual 14.0%; P < .001). Patients with effusions were more likely to be admitted (77% vs 57%; P < .001) and had a longer hospital stay (median, 2.8 vs 1.3 days; P < .001). After severity adjustment, the likelihood of 30-day mortality was greater among patients with effusions (OR, 2.6 [CI, 2.0-3.5]; P < .001), and hospital stay was disproportionately longer (coefficient, 0.22 [CI, 0.14-0.29]; P < .001).

CONCLUSIONS:

Patients with pneumonia and pleural effusions at ED presentation in this study were more likely to die, be admitted, and had longer hospital stays. Why parapneumonic effusions are associated with adverse outcomes, and whether different management of these patients might improve outcome, needs urgent investigation.

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

PMID: 26836918 [PubMed - in process]


Critical Care

This is a great review and refresher article on LVADs for ED and critical care doctors who encounter them.  Key points, don't cut the drive line and have a backup battery.

Crit Care. 2016 Jun 25;20(1):153. doi: 10.1186/s13054-016-1328-z.

Mechanical circulatory assist devices: a primer for critical care and emergency physicians.

Sen A1, Larson JS2, Kashani KB3,4, Libricz SL2, Patel BM2, Guru PK5, Alwardt CM6, Pajaro O6, Farmer JC2.

Author information:

1Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA. sen.ayan@mayo.edu.

2Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA.

3Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.

4Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA.

5Department of Critical Care Medicine, Mayo Clinic Jacksonville, Florida, USA.

6Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA.

 

Abstract

Mechanical circulatory assist devices are now commonly used in the treatment of severe heart failure as bridges to cardiac transplant, as destination therapy for patients who are not transplant candidates, and as bridges to recovery and "decision-making". These devices, which can be used to support the left or right ventricles or both, restore circulation to the tissues, thereby improving organ function. Left ventricular assist devices (LVADs) are the most common support devices. To care for patients with these devices, health care providers in emergency departments (EDs) and intensive care units (ICUs) need to understand the physiology of the devices, the vocabulary of mechanical support, the types of complications patients may have, diagnostic techniques, and decision-making regarding treatment. Patients with LVADs who come to the ED or are admitted to the ICU usually have nonspecific clinical symptoms, most commonly shortness of breath, hypotension, anemia, chest pain, syncope, hemoptysis, gastrointestinal bleeding, jaundice, fever, oliguria and hematuria, altered mental status, headache, seizure, and back pain. Other patients are seen for cardiac arrest, psychiatric issues, sequelae of noncardiac surgery, and trauma. Although most patients have LVADs, some may have biventricular support devices or total artificial hearts. Involving a team of cardiac surgeons, perfusion experts, and heart-failure physicians, as well as ED and ICU physicians and nurses, is critical for managing treatment for these patients and for successful outcomes. This review is designed for critical care providers who may be the first to see these patients in the ED or ICU.

PMCID: PMC4921031 Free Article

PMID: 27342573 [PubMed - in process]


Critical Care Medicine

  1. How long does it take for a patient to die after palliative extubation?  In this retrospective ICU study, the median time to death was 8.9 hours, with a range of 4 minutes to 7 days. Over half died in the first 24 hours.  Why does this matter for us in the ED?  Occasionally we are asked to "just extubate" palliative care patients in the ED.  This study suggests that it is very difficult to predict how long it will take for a person to die post-extubation.  I would argue that this level of care and median time to death would better take place in a palliative care unit or ICU, not the ED.
  2. This is another study by the FELLOW investigators.  You may recall the recent FELLOW trial regarding apneic oxygenation.  This study looked at video (VL) vs. direct laryngoscopy (DL) and first-pass success in the ICU.  This was a randomized controlled trial of adult ICU patients.  VL provided better glottic visualization than DL but the same first-pass success rate, around 66-69%.  Other secondary outcomes were also not different.  Anecdotally, my sense is that this first-pass success rate is poor and is far less than the success rate I see in the ED.  This is, in fact, correct.  Success was lower than in this RCT than the ED first-pass success rate of 83-86%.  See this article by Ron Walls and colleagues about a year ago.  It does not make sense to me that if you can see the glottic opening better, you can't intubate better.  Granted, use of a hyperacute angle blade, like the GlideScope forces the operator to curve the stylet more.  And the tube will not pass, even when through the cords, unless the stylet is withdrawn slightly.  Maybe that was the issue.  In this study, intubators could choose between the McGrath, GlideScope, or Olympus Video Bronchoscope.  Why they didn't use a Storz C-MAC is baffling to me.  The future is VL and many studies have shown far superior intubating conditions using VL.  This study doesn't shake me from that conclusion.

1.

Crit Care Med. 2016 Jun;44(6):1138-44. doi: 10.1097/CCM.0000000000001642.

How Long Does (S)He Have? Retrospective Analysis of Outcomes After Palliative Extubation in Elderly, Chronically Critically Ill Patients.

Pan CX1, Platis D, Maw MM, Morris J, Pollack S, Kawai F.

Author information:

11Division of Geriatrics and Palliative Care Medicine, New York Presbyterian Queens, Flushing, NY. 2Department of Medicine, Weill Cornell Medical College, New York, NY. 3Hospice Care Network. Department of Medicine, Northwell Health, Woodbury, NY. 4Department of Internal Medicine, Wyckoff Heights Medical Center, Brooklyn, NY. 5Department of Decision Sciences, St. John's University, Flushing, NY.

Abstract

OBJECTIVE:

For chronically critically ill elderly patients on mechanical ventilation, prognosis for significant recovery may be minimal. These individuals, or their surrogates, may decide for "palliative extubation." A common prognostic question arises: "How long does she/he have?" This study describes demographics, mortality, time to death, and factors associated with death after palliative extubation.

DESIGN, SETTING, AND PATIENTS:

Retrospective 3-year study in community hospital with ethnically diverse elderly population. Chronically critically ill patients followed from palliative extubation to death or survival to discharge.

MEASURES:

Mortality/survival following palliative extubation, time to death or discharge, factors associated with death.

RESULTS:

Hundred and forty-eight subjects underwent palliative extubation. Mean age: 78 years, 60% female, ethnically diverse with 46% white, and 54% others. Top diagnostic categories: sepsis (47%) and respiratory failure (22%). After extubation, 114 patients (77%) died in hospital and 34 (23%) were discharged. Of those who died, median time to death 8.9 hours (range, 4 min to 7 d). Mortality proportion was 56% at 24 hours and increased with time. Factors associated with early death: Systolic blood pressure less than 90 (p = 0.002) and Charlson Comorbidity Index that is above 6 or 0 (p = 0.002).

CONCLUSIONS:

Palliative extubation at end of life was an option selected by an ethnically diverse elderly population. Approximately three-fourths of subjects died in hospital, and one-fourth was discharged alive. Over 50% who died did so within 24 hours, making this useful information for counseling and anticipatory planning. Subjects with systolic blood pressure less than 90 and Charlson Comorbidity Index that is very low or very high had higher mortality.

PMID: 26958748 [PubMed - in process]

 

2.

Crit Care Med. 2016 Jun 28. [Epub ahead of print]

Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults.

Janz DR1, Semler MWLentz RJMatthews DTAssad TRNorman BCKeriwala RDFerrell BANoto MJShaver CMRichmond BWZinggeler Berg JRice TWFacilitating EndotracheaL intubation by Laryngoscopy technique and apneic Oxygenation Within the ICU Investigators and the Pragmatic Critical Care Research Group.

Author information:

11Department of Medicine, Section of Pulmonary and Critical Care Medicine Louisiana State University School of Medicine, New Orleans, LA. 2Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.

 

Abstract

OBJECTIVE:

To evaluate the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt among critically ill adults.

DESIGN:

A randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy for 150 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows.

SETTING:

Medical ICU in a tertiary, academic medical center.

PATIENTS:

Critically ill patients 18 years old or older.

INTERVENTIONS:

Patients were randomized 1:1 to video or direct laryngoscopy for the first attempt at endotracheal intubation.

MEASUREMENTS AND MAIN RESULTS:

Patients assigned to video (n = 74) and direct (n = 76) laryngoscopy were similar at baseline. Despite better glottic visualization with video laryngoscopy, there was no difference in the primary outcome of intubation on the first laryngoscopy attempt (video 68.9% vs direct 65.8%; p = 0.68) in unadjusted analyses or after adjustment for the operator's previous experience with the assigned device (odds ratio for video laryngoscopy on intubation on first attempt 2.02; 95% CI, 0.82-5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct laryngoscopy.

CONCLUSIONS:

In critically ill adults undergoing endotracheal intubation, video laryngoscopy improves glottic visualization but does not appear to increase procedural success or decrease complications.

PMID: 27355526 [PubMed - as supplied by publisher]


Emergency Medicine Journal

  1. This articles asks, "What is the purpose of the log roll in unconscious trauma patients?"  The authors conclude that the sensitivity for detecting thoracolumbar spine injury is low and that the exam, "could be limited to visual inspection only to allow identification of penetrating wounds and other soft tissue injuries (including of the posterior scalp) and removal of foreign bodies, in patients planned for CT scans."  I agree with the authors.  We must look at the back in unconscious trauma patients (...all trauma patients), but we need to understand the limitations of spine palpation to detect injury and not be reassured by a "normal" exam.
  2. The PERC Rule for PE is only to be used when physician gestalt is low.  Some advocate using an objective score, such as Wells score, to determine if the PERC Rule may be applied rather than gestalt.  In this retrospective study of 377 patients, 2 subsegmental PEs would have been missed in patients with Wells score <2 and negative PERC.  Sensitivity for PERC was only 89% in this study.  It is hard to know what to do with this.  All data were collected retrospectively.  It would be challenging to calculate Wells and PERC scores by chart review, which is a major limitation.  Until this is confirmed in a larger, prospective study, I plan to continue using PERC rather than a low Wells + negative D-dimer method.  Too many patients will get unnecessary CTPA with that approach.
  3. How good are non-invasive measures of temperature - oral (PO), temporal (TA) and tympanic (TM) - compared to rectal?  36% of PO, TM, and TA measurements were >0.5 degrees C off from the rectal temperature and 50% of the oral temps.  I was surprised by how often oral temperature measurement was off target.  If you really need to know the temperature, rectal is the best way to measure.

.

Emerg Med J. 2016 Jun 9. pii: emermed-2015-205450. doi: 10.1136/emermed-2015-205450. [Epub ahead of print]

What is the purpose of log roll examination in the unconscious adult trauma patient during trauma reception?

Singh Tveit M1, Singh E2, Olaussen A3, Liew S4, Fitzgerald MC5, Mitra B6.

Author information:

1Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.

2Monash University, Melbourne, Victoria, Australia.

3Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia Monash University, Melbourne, Victoria, Australia Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia National Trauma Research Institute, Melbourne, Victoria, Australia Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia.

4Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia Department of Surgery, Monash University, Melbourne, Victoria, Australia.

5Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia National Trauma Research Institute, Melbourne, Victoria, Australia.

6Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia National Trauma Research Institute, Melbourne, Victoria, Australia Department of Epidemiology & Preventative Medicine, Monash University, Melbourne, Victoria, Australia.

 

Abstract

BACKGROUND:

During assessment after injury, the log roll examination, in particular palpation of the thoracolumbar spine, has low sensitivity for detecting spinal injury. The manoeuvre itself requires a pause during trauma resuscitation. The aim of this study was to assess the utility of the log roll examination in unconscious trauma patients for the diagnosis of soft tissue and thoracolumbar spine injuries.

METHODS:

A retrospective cohort study was undertaken, reviewing the cases of unconscious (Glasgow Coma Scale (GCS) <9) and/or intubated major trauma (Injury Severity Scale (ISS) >12, abbreviated injury scale 2008) patients from the Alfred Trauma Registry, over a 2-year period from January 2011 to December 2012. Log roll examination findings, as documented in the medical record, were compared with CT reports. Out of the 624 screened records, 222 (35.6%) were excluded as the log roll or CT/MRI had not been performed.

RESULTS:

There were a total of 2028 major trauma presentations to the Alfred Hospital Emergency and Trauma Centre during the study period. Excluded cases comprised 147 patients who did not have a documented log roll, and 75 patients who did not have a CT or MRI. Of the 402 cases that met inclusion criteria, 35.3% had a thoracolumbar fracture, and the sensitivity of log roll examination was found to be 27.5%, with a specificity of 91%. The negative likelihood ratio for abnormalities on log roll was low (0.8).

CONCLUSIONS:

Examination of the back in unconscious trauma patients could be limited to visual inspection only to allow identification of penetrating wounds and other soft tissue injuries (including of the posterior scalp) and removal of foreign bodies, in patients planned for CT scans. The low sensitivity and poor negative likelihood ratio suggest that a normal log roll examination does not accurately predict the absence of bony injury to the thoracolumbar spine.

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

PMID: 27287002 [PubMed - as supplied by publisher]

 

2.

Emerg Med J. 2016 Jun 10. pii: emermed-2016-205687. doi: 10.1136/emermed-2016-205687. [Epub ahead of print]

A retrospective analysis of the combined use of PERC rule and Wells score to exclude pulmonary embolism in the Emergency Department.

Theunissen J1, Scholing C1, van Hasselt WE1, van der Maten J2, Ter Avest E1.

Author information:

1Department of Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.

2Department of Pulmonology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.

Abstract

BACKGROUND:

The pulmonary embolism rule-out criteria (PERC) rule is an eight-factor decision rule to support the decision not to order a diagnostic test when the gestalt-based clinical suspicion on pulmonary embolism (PE) is low.

METHODS:

In a retrospective cohort study, we determined the accuracy of a negative PERC (0) in patients with a low Wells score (<2) to rule-out PE, and compared this to the accuracy of the default algorithm used in our hospital (a low Wells score in combination with a negative D-dimer).

RESULTS:

During the study period, 377 patients with a Wells score <2 were included. CT pulmonary angiography (CTPA) was performed in 86 patients, and V/Q scintigraphy in one patient. PE was diagnosed in 18 patients. 78 patients (21%) had a negative PERC score. When further diagnostic studies would have been omitted in these patients, two (subsegmental) PEs would have been missed, resulting in a sensitivity of 89% (64%-98%) and a negative likelihood ratio (LR-) of 0.52 (0.14-1.97). The default algorithm missed one (subsegmental) PE, resulting in a sensitivity of 95% (71%-99%) and an LR- of 0.25 (0.04-1.73).

CONCLUSIONS:

The combination of a Wells score <2 and a PERC rule of 0 had a suboptimal sensitivity for excluding PE in our sample of patients presenting in the ED. Further studies are warranted to test this algorithm in larger populations.

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

PMID: 27287004 [PubMed - as supplied by publisher]

 

3.

Emerg Med J. 2016 Jun 22. pii: emermed-2015-205122. doi: 10.1136/emermed-2015-205122. [Epub ahead of print]

Temperature measurement in the adult emergency department: oral, tympanic membrane and temporal artery temperatures versus rectal temperature.

Bijur PE1, Shah PD1, Esses D1.

Author information:

1Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, New York, USA.

 

Abstract

OBJECTIVE:

The objective was to compare agreement between three non-invasive measures of temperature and rectal temperatures and to estimate the sensitivity and specificity of these measures to detect a rectal temperature of 38°C or higher.

METHODS:

We conducted a study of the diagnostic accuracy of oral, tympanic membrane (TM) and temporal artery (TA) thermometry to measure fever in an urban emergency department (ED). Data were collected from adult patients who received rectal temperature measurement. Bland-Altman analysis was performed; sensitivity, specificity and 95% CIs were calculated.

RESULTS:

987 patients were enrolled. 36% of the TM and TA readings differed by 0.5°C or more from rectal temperatures, 50% of oral temperatures. TM measures were most precise-the SD of the difference from rectal was 0.4°C TM, and 0.6°C for oral and TA (p<0.001). The sensitivities of a 38°C cutpoint on oral, TM and TA measures to detect a rectal temperature of 38°C or higher were: 37.0%, 68.3% and 71.1%, respectively (oral vs TM and TA p<0.001). The corresponding specificities were 99.4%, 98.2% and 92.3% (oral, TM and TA) with oral specificity significantly higher than the other two methods (p<0.01). TM and TA cutpoints of 37.5°C provided greater than 90% sensitivity to detect fever with specificity of 90% and 72%, respectively.

CONCLUSIONS:

None of the non-invasive methods met benchmarks for diagnostic accuracy using the criterion of 38°C to detect rectal temperature of 38°C. A TM cutpoint of 37.5°C provides maximum diagnostic accuracy of the three non-invasive measures.

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

PMID: 27334759 [PubMed - as supplied by publisher]


Intensive Care Medicine

A NEJM study found surgical site infection was decreased by using chlorhexidine/alcohol (CA) over povidone iodine (PI) for skin prep.  This study focused on which was better for decreasing central line infection.  The CA prep was superior to PI for catheter related infection.  After the study mentioned above, I switched to CA for skin prep for all my ED procedures.  PI must be allowed to dry to be bactericidal.  CA kills on contact.  The only caveat is that for LP, CA must be allowed to dry.  It can cause arachnoiditis if introduced into the CSF.  The upshot is that CA beats PI for central line infection reduction.

Intensive Care Med. 2016 Jun 16. [Epub ahead of print]

Comparison of alcoholic chlorhexidine and povidone-iodine cutaneous antiseptics for the prevention of central venous catheter-related infection: a cohort and quasi-experimental multicenter study.

Pages J1, Hazera P2, Mégarbane B3, du Cheyron D4,5, Thuong M6, Dutheil JJ1, Valette X4, Fournel F1, Mermel LA7, Mira JP8, Daubin C4, Parienti JJ9,10,11; 3SITES Study Group.

Author information:

1Department of Biostatistics and Clinical Research, Caen University Hospital, Caen, France.

2Department of Intensive Care Medicine, General Hospital, Saint Lô, France.

3Department of Medial and Toxicologic Intensive Care, Lariboisière University Hospital, Paris, France.

4Department of Intensive Care Medicine, Caen University Hospital, Caen, France.

5EA4655 Risque Microbiens, Caen Normandie Université, Caen, France.

6Department of Intensive Care Medicine, General Hospital, Pontoise, France.

7Warren Alpert Medical School of Brown University, Providence, RI, USA.

8Department of Medial Intensive Care, Cochin University Hospital, Paris, France.

9Department of Biostatistics and Clinical Research, Caen University Hospital, Caen, France. parienti-jj@chu-caen.fr.

10EA4655 Risque Microbiens, Caen Normandie Université, Caen, France. parienti-jj@chu-caen.fr.

11Department of Infectious Diseases, Caen University Hospital, Caen, France. parienti-jj@chu-caen.fr.

 

Abstract

PURPOSE:

Compare the effectiveness of different cutaneous antiseptics in reducing risk of catheter-related infection in intensive care unit (ICU) patients.

METHODS:

We compared the risk of central venous catheter-related infection according to four-step (scrub, rinse, dry, and disinfect) alcoholic 5 % povidone-iodine (PVI-a, n = 1521), one-step (disinfect) alcoholic 2 % chlorhexidine (2 % CHX-a, n = 1116), four-step alcoholic <1 % chlorhexidine (<1 % CHX-a, n = 357), and four-step aqueous 10 % povidone-iodine (PVI, n = 368) antiseptics used for cutaneous disinfection and catheter care during the 3SITES multicenter randomized controlled trial. Within this cohort, we performed a quasi-experimental study (i.e., before-after) involving the four ICUs which switched from PVI-a to 2 % CHX-a. We used propensity score matching (PSM, n = 776) and inverse probability weighting treatment (IPWT, n = 1592). The end point was the incidence of catheter-related infection (CRI) defined as catheter-related bloodstream infection (CRBSI) or a positive catheter tip culture plus clinical sepsis on catheter removal.

RESULTS:

In the cohort analysis and compared with PVI-a, the incidence of CRI was lower with 2 % CHX-a [adjusted hazard ratio (aHR), 0.51; 95 % confidence interval (CI) (0.28-0.96), p = 0.037] and similar with <1 % CHX-a [aHR, 0.73; (0.36-1.48), p = 0.37] and PVI [aHR, 1.50; 95 % CI (0.85-2.64), p = 0.16] after controlling for potential confounders. In the quasi-experimental study and compared with PVI-a, the incidence of catheter-related infection was again lower with 2 % CHX-a after PSM [HR, 0.35; 95 % CI (0.15, 0.84), p = 0.02] and in the IPWT analysis [HR, 0.31; 95 % CI (0.14, 0.70), p = 0.005]. The incidence of CRBSI or adverse event was not significantly different between antiseptics in all analyses.

CONCLUSIONS:

In comparison with PVI-a, the use of 2 % CHX-a for cutaneous disinfection of the central venous catheter insertion site and maintenance catheter care was associated with a reduced risk of catheter infection, while the benefit of <1 % CHX-a was uncertain.

CLINICAL TRIALS IDENTIFIER:

NCT01479153.

PMID: 27311311 [PubMed - as supplied by publisher]


Journal of the American College of Cardiology

This was a negative trial.  IV metoprolol 5mg x 2 doses to STEMI patients prior to PCI did not affect infarct size, as measured by cardiac MRI.  Only about half of patients had the follow up MRI, however.  Malignant arrhythmia was less in the metoprolol group.  Mortality was not a listed outcome measure, which seems kind of important to me.  It was listed in one of the tables in the article and was not different, around 2% with or without metoprolol.  Giving beta blockers to STEMI patients pre-cath probably does not help them.

J Am Coll Cardiol. 2016 Jun 14;67(23):2705-15. doi: 10.1016/j.jacc.2016.03.522. Epub 2016 Apr 3.

Early Intravenous Beta-Blockers in Patients With ST-Segment Elevation Myocardial Infarction Before Primary Percutaneous Coronary Intervention.

Roolvink V1, Ibáñez B2, Ottervanger JP1, Pizarro G3, van Royen N4, Mateos A5, Dambrink JH1, Escalera N6, Lipsic E7, Albarran A8, Fernández-Ortiz A9, Fernández-Avilés F10, Goicolea J11, Botas J12, Remkes W1, Hernandez-Jaras V5, Kedhi E1, Zamorano JL13, Navarro F14, Alfonso F15, García-Lledó A16, Alonso J17, van Leeuwen M4, Nijveldt R4, Postma S18, Kolkman E18, Gosselink M1, de Smet B19, Rasoul S20, Piek JJ21, Fuster V22, van 't Hof AW23; EARLY-BAMI Investigators.

Author information:

1Department of Cardiology, Isala Hospital, Zwolle, the Netherlands.

2Department of Cardiology, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Department of Cardiology, IIS-Fundacion Jimenez Díaz Hospital, Madrid, Spain.

3Department of Cardiology, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Department of Cardiology, Hospital Universitario Quirón, Universidad Europea de Madrid & Hospital Ruber-Quirónsalud, Madrid, Spain.

4Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands.

5Department of Cardiology, Servicio de Urgencia Medica de Madrid (SUMMA 112), Madrid, Spain.

6Department of Cardiology, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.

7Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands.

8Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital 12 de Octubre, Madrid, Spain.

9Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital Clínico San Carlos, Madrid, Spain.

10Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital Gregorio Marañón, Madrid, Spain.

11Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital Puerta de Hierro, Madrid, Spain.

12Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital Fundación Alcorcón, Madrid, Spain.

13Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital Ramón y Cajal, Madrid, Spain.

14Department of Cardiology, IIS-Fundacion Jimenez Díaz Hospital, Madrid, Spain; Department of Cardiology, Codigo Infarto, Madrid, Spain.

15Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital de La Princesa, Madrid, Spain.

16Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain.

17Department of Cardiology, Codigo Infarto, Madrid, Spain; Department of Cardiology, Hospital de Getafe, Madrid, Spain.

18Diagram, Diagnostic Research and Management, Zwolle, the Netherlands.

19Department of Cardiology, Meander Medisch Centrum, Amersfoort, the Netherlands.

20Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands.

21Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands.

22Department of Cardiology, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.

23Department of Cardiology, Isala Hospital, Zwolle, the Netherlands. Electronic address: v.r.c.derks@isala.nl.

Abstract

BACKGROUND:

The impact of intravenous (IV) beta-blockers before primary percutaneous coronary intervention (PPCI) on infarct size and clinical outcomes is not well established.

OBJECTIVES:

This study sought to conduct the first double-blind, placebo-controlled international multicenter study testing the effect of early IV beta-blockers before PPCI in a general ST-segment elevation myocardial infarction (STEMI) population.

METHODS:

STEMI patients presenting <12 h from symptom onset in Killip class I to II without atrioventricular block were randomized 1:1 to IV metoprolol (2 × 5-mg bolus) or matched placebo before PPCI. Primary endpoint was myocardial infarct size as assessed by cardiac magnetic resonance imaging (CMR) at 30 days. Secondary endpoints were enzymatic infarct size and incidence of ventricular arrhythmias. Safety endpoints included symptomatic bradycardia, symptomatic hypotension, and cardiogenic shock.

RESULTS:

A total of 683 patients (mean age 62 ± 12 years; 75% male) were randomized to metoprolol (n = 336) or placebo (n = 346). CMR was performed in 342 patients (54.8%). Infarct size (percent of left ventricle [LV]) by CMR did not differ between the metoprolol (15.3 ± 11.0%) and placebo groups (14.9 ± 11.5%; p = 0.616). Peak and area under the creatine kinase curve did not differ between both groups. LV ejection fraction by CMR was 51.0 ± 10.9% in the metoprolol group and 51.6 ± 10.8% in the placebo group (p = 0.68). The incidence of malignant arrhythmias was 3.6% in the metoprolol group versus 6.9% in placebo (p = 0.050). The incidence of adverse events was not different between groups.

CONCLUSIONS:

In a nonrestricted STEMI population, early intravenous metoprolol before PPCI was not associated with a reduction in infarct size. Metoprolol reduced the incidence of malignant arrhythmias in the acute phase and was not associated with an increase in adverse events. (Early-Beta blocker Administration before reperfusion primary PCI in patients with ST-elevation Myocardial Infarction [EARLY-BAMI]; EudraCT no: 2010-023394-19).

Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

PMID: 27050189 [PubMed - in process]


JAMA

Well, gun-toting friends, this study makes us think.  In 1996, Australia banned all semi-automatic weapons as well as pump action shotguns and rifles.  Mortality from firearms was already on the decline before the ban, but declined more rapidly after the ban; mass shootings, defined as >/=5 people, completely stopped after that period.  Prior to the ban, there were 13.  This is a complex issue.  Many Americans feel passionately that the second amendment would not allow such a ban in the US; and they are right, based on how the Supreme Court has interpreted it in the past.  But this information from Australia is compelling.  Maybe a reasonable step would be to ensure universal enforcement of background checks in the US prior to gun purchase.  I don't have an answer in this "short-attention-span summary" that takes into account the tragedy of gun violence yet holds in balance individual liberty and responsibility.  At the end of the day, it's just sad.  I would value your thoughts and discussion on this.  It seems to me that rational people, like us, with a close up view of gun violence and a wide range of opinions should be able to openly talk about this in a helpful, productive (preferably non-cranky) way.  Please leave comments on Facebook.

JAMA. 2016 Jun 22. doi: 10.1001/jama.2016.8752. [Epub ahead of print]

Association Between Gun Law Reforms and Intentional Firearm Deaths in Australia, 1979-2013.

Chapman S1, Alpers P1, Jones M2.

Author information:

1School of Public Health, University of Sydney, Sydney, Australia.

2Department of Psychology, Macquarie University, Sydney, Australia.

 

Abstract

Importance:

Rapid-fire weapons are often used by perpetrators in mass shooting incidents. In 1996 Australia introduced major gun law reforms that included a ban on semiautomatic rifles and pump-action shotguns and rifles and also initiated a program for buyback of firearms.

Objective:

To determine whether enactment of the 1996 gun laws and buyback program were followed by changes in the incidence of mass firearm homicides and total firearm deaths.

Design:

Observational study using Australian government statistics on deaths caused by firearms (1979-2013) and news reports of mass shootings in Australia (1979-May 2016). Changes in intentional firearm death rates were analyzed with negative binomial regression, and data on firearm-related mass killings were compared.

Exposures:

Implementation of major national gun law reforms.

Main Outcomes and Measures:

Changes in mass fatal shooting incidents (defined as ≥5 victims, not including the perpetrator) and in trends of rates of total firearm deaths, firearm homicides and suicides, and total homicides and suicides per 100 000 population.

Results:

From 1979-1996 (before gun law reforms), 13 fatal mass shootings occurred in Australia, whereas from 1997 through May 2016 (after gun law reforms), no fatal mass shootings occurred. There was also significant change in the preexisting downward trends for rates of total firearm deaths prior to vs after gun law reform. From 1979-1996, the mean rate of total firearm deaths was 3.6 (95% CI, 3.3-3.9) per 100 000 population (average decline of 3% per year; annual trend, 0.970; 95% CI, 0.963-0.976), whereas from 1997-2013 (after gun law reforms), the mean rate of total firearm deaths was 1.2 (95% CI, 1.0-1.4) per 100 000 population (average decline of 4.9% per year; annual trend, 0.951; 95% CI, 0.940-0.962), with a ratio of trends in annual death rates of 0.981 (95% CI, 0.968-0.993). There was a statistically significant acceleration in the preexisting downward trend for firearm suicide (ratio of trends, 0.981; 95% CI, 0.970-0.993), but this was not statistically significant for firearm homicide (ratio of trends, 0.975; 95% CI, 0.949-1.001). From 1979-1996, the mean annual rate of total nonfirearm suicide and homicide deaths was 10.6 (95% CI, 10.0-11.2) per 100 000 population (average increase of 2.1% per year; annual trend, 1.021; 95% CI, 1.016-1.026), whereas from 1997-2013, the mean annual rate was 11.8 (95% CI, 11.3-12.3) per 100 000 (average decline of 1.4% per year; annual trend, 0.986; 95% CI, 0.980-0.993), with a ratio of trends of 0.966 (95% CI, 0.958-0.973). There was no evidence of substitution of other lethal methods for suicides or homicides.

Conclusions and Relevance:

Following enactment of gun law reforms in Australia in 1996, there were no mass firearm killings through May 2016. There was a more rapid decline in firearm deaths between 1997 and 2013 compared with before 1997 but also a decline in total nonfirearm suicide and homicide deaths of a greater magnitude. Because of this, it is not possible to determine whether the change in firearm deaths can be attributed to the gun law reforms.

PMID: 27332876 [PubMed - as supplied by publisher]


JAMA Pediatrics

This is one of the most important review articles you will read this year if you take care of febrile kids.  Just stop what you're doing and read this.  You can get full text access if you're part of an educational institution.  Click the Open in Read by QxMD icon in the email.  The gist: serious bacterial infection (SBI) is 9-14% in kids under 90 days.  Febrile neonates still need full sepsis evaluation, including CSF.  29-60 days is less clear.  Our institution recommends full sepsis evaluation with option for discharge if all low-risk criteria are met +/- empiric antibiotics.  This paper seems to advocate for a more limited workup.  "For infants aged 30 to 90 days, the risk of SBI declines, except for UTIs. Prioritizing viral testing and urinalysis or urine culture may preempt the rest of the evaluation."  Keep in mind, a positive RSV does not obviate the need for full sepsis evaluation in neonates.  In vaccinated children 3 months to 36 months, UTI is the most common SBI if no localizing signs of infection.  E. coli antibiotic resistance is increasing. 

JAMA Pediatr. 2016 Jun 20. doi: 10.1001/jamapediatrics.2016.0596. [Epub ahead of print]

Evaluation and Management of Febrile Children: A Review.

Cioffredi LA1, Jhaveri R2.

Author information:

1Division of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill.

2Division of Infectious Diseases, Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill.

 

Abstract

Importance:

Management of febrile children is an intrinsic aspect of pediatric practice. Febrile children account for 15% of emergency department visits and outcomes range from the presence of serious bacterial infection to benign self-limited illness.

Observations:

Studies from 1979 to 2015 examining febrile infants and children were included in this review. Management of febrile infants younger than 90 days has evolved considerably in the last 30 years. Increased rates of Escherichia coli urinary tract infections, increasing resistance to ampicillin, and advances in viral diagnostics have had an effect on the approach to caring for these patients. Widespread vaccination with conjugate vaccines against Haemophilus influenzae and Streptococcus pneumoniae has virtually eliminated the concern for bacterial infections in children aged 3 to 36 months. Urinary tract infections still remain a concern in febrile infants of all ages.

Conclusions and Relevance:

Advances over the last 30 years allow for more precise risk stratification for infants at high risk of serious bacterial infection. With appropriate testing at the initial visit, much of the diagnostic testing and empirical treatment can be avoided for infants younger than 90 days. In the vaccinated child aged 3 to 36 months, the only bacterial infection of concern is urinary tract infection.

PMID: 27322346 [PubMed - as supplied by publisher]


JAMA Surgery

In the era of modern CT scanners, do we need to keep the rigid c-collar on after CT c-spine is negative in intoxicated patients?  This study suggests the answer to that is no.  C-spine CT had a "negative predictive value of 99.8% for ruling out CSIs that required immobilization or stabilization."  Only 1 patient in 632 "had a symptomatic unstable ligament injury that was misread as normal on CT scan but was abnormal on magnetic resonance imaging."  My thoughts are that in patients with no gross motor deficits and normal c-spine CT, it is safe to remove the collar, even if intoxicated.  This is a major paradigm change.  This is a topic that needs to be discussed and debated.  Would you comment on the EM Topics Facebook Page or participate in this poll?  Honestly, this makes me nervous but I think the data backs me up?  Am I alone?

JAMA Surg. 2016 Jun 15. doi: 10.1001/jamasurg.2016.1248. [Epub ahead of print]

Evaluation of Cervical Spine Clearance by Computed Tomographic Scan Alone in Intoxicated Patients With Blunt Trauma.

Bush L1, Brookshire R1, Roche B1, Johnson A1, Cole F1, Karmy-Jones R1, Long W1, Martin MJ2.

Author information:

1Trauma and Acute Care Surgery Service, Legacy Emanuel Medical Center, Portland, Oregon.

2Trauma and Acute Care Surgery Service, Legacy Emanuel Medical Center, Portland, Oregon2Department of Surgery, Madigan Army Medical Center, Tacoma, Washington.

Abstract

Importance:

Current trauma guidelines dictate that the cervical spine should not be cleared in intoxicated patients, resulting in prolonged immobilization or additional imaging. Modern computed tomography (CT) technology may obviate this and allow for immediate clearance.

Objective:

To analyze cervical spine clearance practices and the utility of CT scans of the cervical spine in intoxicated patients with blunt trauma.

Design, Setting, and Participants:

We performed a prospective observational study of 1668 patients with blunt trauma aged 18 years and older who underwent cervical spine CT scans from March 2014 to March 2015 at an American College of Surgeons-verified Level I trauma center. Intoxication was determined by serum alcohol levels and urine drug screens. Physical examination and CT scan findings were evaluated for cervical spine injuries (CSI) and the incidence of missed injuries.

Main Outcomes and Measures:

Clinically relevant CSIs requiring cervical stabilization. The hypotheses formed prior to data collection were that cervical CT scans are sensitive and specific enough to diagnose CSIs that require stabilization and that normal CT scans are sufficient to clear CSIs in intoxicated patients.

Results:

Of 1668 patients, 1103 (66.1%) were male, with a mean (SD) age of 49 (20) years and a mean (SD) Injury Severity Score of 10 (9). Vehicular (734 [44.0%]) and falls (579 [34.7%]) were the most common mechanisms for hospitalization. Intoxication was identified in 632 of 1429 of patients tested (44.2%; 425 [29.7%] by serum alcohol levels and 350 [24.5%] by urine drug screens). Half (316 [50.0%]) were admitted with cervical spine immobilization, and 38 (12%) of these were solely owing to the presence of intoxication. There were 65 abnormal CT scans (10.3%) in the intoxicated group. Among 567 normal CT scans, 4 (0.7%) had central cord syndrome found on initial physical examination, and 1 (0.2%) had a symptomatic unstable ligament injury that was misread as normal on CT scan but was abnormal on magnetic resonance imaging. The 316 patients kept in a cervical collar for intoxication had no missed CSIs but were kept immobilized for a mean (SD) of 12 (19) hours. Computed tomographic scans had an overall negative predictive value of 99.2% for patients with CSIs and a negative predictive value of 99.8% for ruling out CSIs that required immobilization or stabilization.

Conclusions and Relevance:

In this study, alcohol or drug intoxication was common and resulted in significant delays to cervical spine clearance. Computed tomographic scans were highly reliable for identifying all clinically significant CSIs. Spine clearance based on a normal CT scan among intoxicated patients with no gross motor deficits appears to be safe and avoids prolonged and unnecessary immobilization.

PMID: 27305663 [PubMed - as supplied by publisher]


Journal of Emergency Medicine

Some trauma surgeons prefer skipping the AP pelvis in the initial trauma assessment, since they will get a CT immediately following.  This paper is the view from orthopedic surgery.  In this case series of patients with pelvic fractures, there were delays in care as a result of not obtaining initial AP pelvis, especially in those with hip dislocation.  The authors state, "Selective PXR was associated with a significant delay in recognition of (major) pelvic fractures, including those with associated hip dislocations and (potential) pelvic bleeding."  At our institution, we went through a phase of not obtaining an AP pelvis and now have resumed plain x-ray imaging as part of the initial trauma encounter.  What's your opinion?  Please comment on the EM Topics Facebook Page.

J Emerg Med. 2016 Jun;50(6):852-8. doi: 10.1016/j.jemermed.2015.03.048. Epub 2016 Apr 25.

Importance of Pelvic Radiography for Initial Trauma Assessment: An Orthopedic Perspective.

Verbeek DO1, Burgess AR1.

Author information:

1Department of Orthopedic Surgery, Memorial Hermann Hospital, University of Texas, Houston, Texas.

Abstract

BACKGROUND:

Many institutions have abandoned the routine for selective pelvic x-ray (PXR) for initial imaging in blunt trauma patients undergoing computed tomography (CT) scanning.

OBJECTIVE:

Our aim was to examine the association between selective use of PXR and time to diagnosis of (major) pelvic fractures, as well as prioritization of key immediate interventions (including hip reduction and pelvic arterial embolization).

METHODS:

We conducted a 1-year review of early management of pelvic fracture patients undergoing pelvic CT scanning. Time interval and sequence of initial imaging and key immediate interventions were recorded.

RESULTS:

Of 218 pelvic fracture patients, 79 (36%) had no initial PXR, and instead had an initial CT scan. Time to first pelvic imaging in those patients was 48 min (standard deviation [SD] = 47 min vs. 2 min [SD = 6 min] with PXR; p < 0.001). Of 40 hip dislocations, 15 (38%) were detected first on CT scan. Overall, 22 (55%) required a second CT scan after reduction in the emergency department. No initial PXR was performed in 42 of 120 (35%) pelvic ring fracture patients and in 16 of 61 (26%) unstable pelvic ring fractures. Time to pelvic arterial embolization was longer in 4 patients without initial PXR than in 14 patients with PXR (296 min [SD = 206 min] vs. 170 min [SD = 76 min], respectively, p = 0.038).

CONCLUSIONS:

Selective PXR was associated with a significant delay in recognition of (major) pelvic fractures, including those with associated hip dislocations and (potential) pelvic bleeding. PXR remains a useful screening tool to rapidly determine the need for immediate interventions and to allow early planning before CT scanning.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 27133737 [PubMed - in process]


Journal of Pediatrics

I chose this article as winner of the Captain Obvious Award.  Parents who used the public library were more likely to read aloud to their kids.  Wow...

J Pediatr. 2016 Jun;173:221-227.e1. doi: 10.1016/j.jpeds.2016.03.016. Epub 2016 Apr 4.

Associations between Public Library Use and Reading Aloud among Families with Young Children.

Chen P1, Rea C2, Shaw R3, Bottino CJ4.

Author information:

1Division of General Pediatrics, Boston Children's Hospital, Boston, MA; Harvard College, Faculty of Arts and Sciences, Harvard University, Cambridge, MA.

2Division of General Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.

3Division of General Pediatrics, Boston Children's Hospital, Boston, MA.

4Division of General Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA. Electronic address: clement.bottino@childrens.harvard.edu.

Abstract

OBJECTIVE:

To measure public library use in a sample of families with young children and examine associations with reading aloud.

STUDY DESIGN:

We interviewed 200 parents of 6- to 18-month-old children visiting a hospital-based pediatric clinic. We assessed public library card ownership, public library visitation, and awareness of public library programming. We assessed reading aloud using the StimQ READ questionnaire. We used multivariable logistic and linear regression to examine associations while adjusting for sociodemographic characteristics.

RESULTS:

In multivariable analysis, parents who owned a public library card had greater odds of reading aloud daily to their 6- to 18-month-old child (aOR, 2.0; 95% CI, 1.0-3.8) and higher StimQ READ scores (β = 0.9; 95% CI, 0.2-1.6). Parents who visited a public library once a month or more often had greater odds of reading aloud daily (aOR, 3.4; 95% CI, 1.8-6.7) and higher StimQ READ scores (β = 1.3; 95% CI, 0.6-2.0). Parents whose 6- to 18-month-old child had ever visited a public library did not have greater odds of reading aloud daily (aOR, 1.4; 95% CI, 0.7-2.9), but did have higher StimQ read scores (β = 1.2; 95% CI, 0.4-2.0). Parents who felt informed about available public library programs for children had greater odds of reading aloud daily (aOR, 2.5; 95% CI, 1.3-5.1) and higher StimQ READ scores (β = 1.1; 95% CI, 0.4-1.9).

CONCLUSION:

In this sample of families with young children, we found positive associations between public library use and reading aloud.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 27056451 [PubMed - in process]


Journal of Trauma

Lactate level in the ED was associated with mortality in trauma patients, according to this meta-analysis.  Trauma patients with elevated lactate, even in the absence of other clear injury need special consideration and warrant a period of observation, preferably in the hospital.

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

Do lactate levels in the Emergency Department predict outcome in adult trauma patients? A Systematic Review.

Baxter J1, Cranfield KR, Clark GE, Harris T, Bloom B, Gray AJ.

Author information:

11 College of Medicine and Veterinary Medicine, University of Edinburgh, The Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK 2 Department of Emergency Medicine, St John's Hospital, Howden South Road, Livingston, West Lothian EH54 6PP 3 Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK 4 Department of Emergency Medicine, Barts Health NHS Trust and QMUL, Whitechapel Road, London, E1 1BB, UK 5 Emergency Medicine Research Group Edinburgh (EMeRGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.

Abstract

BACKGROUND:

Serum lactate may be associated with clinical outcomes in trauma, even in the absence of physiological abnormality. Sensitive markers of injury and outcomes are needed to guide triage and management of trauma patients within the Emergency Department. We completed a systematic review to determine if lactate levels in adult trauma patients presenting to the Emergency Department were associated with clinical outcomes including mortality.

METHODS:

A systematic literature search was conducted in August 2014, updated in March 2016, using MEDLINE, Embase and CINAHL. Abstracts and full texts were screened for inclusion by two independent reviewers using predetermined inclusion and exclusion criteria. Data extraction and quality assessment was performed by each reviewer using a standardised form. 998 studies were screened; 28 studies were included and reviewed.

RESULTS:

The 28 studies recruited 44,154 adults in eight countries between 1997 and 2016. Twenty-one studies found a significant association between elevated Emergency Department lactate and risk of mortality. Three studies looked at lactate clearance; two showed poor clearance was an additional determinant of mortality but the other found no association. Ten studies also found an association between elevated lactate and other clinical outcomes. These included injury severity, Intensive Care Unit admission, length of hospital stay, organ failure, respiratory complications, blood loss, blood product requirement, catecholamine support or emergency operation. Two studies concluded that lactate levels do not affect management.

CONCLUSIONS:

This review shows that elevated Emergency Department lactate levels are associated with mortality and may be associated with other clinical outcomes in adult trauma patients. We conclude that lactate is a useful marker of outcome in trauma, in addition to current markers of severity. The potential roles of serial lactate measurement and lactate clearance require further research.

LEVEL OF EVIDENCE:

2b - Prognostic cohort studies.

PMID: 27280943 [PubMed - as supplied by publisher]


Lancet

Is the trauma pan-scan helping our patients?  This non-blinded, multicenter RCT found that immediate pan-scan vs. conventional x-ray and selective CT scan did not improve in-hospital mortality.  In reality, we have to work with our trauma team, who wants a pan-scan on trauma patients at our institution.  It will take papers with this level of quality to start persuading them that we can use clinical judgment, bedside exam, and selective use of CT to make rational imaging choices and not perform knee-jerk pan-scan on all trauma patients.  The risks of radiation are small but real, and limiting unnecessary scans is an area we can advocate for our patients in the ED.  Fight the good fight, ED friends!

 

Lancet. 2016 Jun 28. pii: S0140-6736(16)30932-1. doi: 10.1016/S0140-6736(16)30932-1. [Epub ahead of print]

Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial.

Sierink JC1, Treskes K1, Edwards MJ2, Beuker BJ3, den Hartog D4, Hohmann J5, Dijkgraaf MG6, Luitse JS1, Beenen LF7, Hollmann MW8, Goslings JC9; REACT-2 study group.

Author information:

1Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, Netherlands.

2Trauma Unit, Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands.

3Trauma Unit, Department of Surgery, University Medical Center Groningen, Groningen, Netherlands.

4Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.

5Department of Radiology and Nuclear Medicine, University of Basel Hospital, Basel, Switzerland.

6Clinical Research Unit, Academic Medical Center, Amsterdam, Netherlands.

7Department of Radiology, Academic Medical Center, Amsterdam, Netherlands.

8Department of Anaesthesiology, Academic Medical Center, Amsterdam, Netherlands.

9Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, Netherlands. Electronic address: j.c.goslings@amc.nl.

 

Abstract

BACKGROUND:

Published work suggests a survival benefit for patients with trauma who undergo total-body CT scanning during the initial trauma assessment; however, level 1 evidence is absent. We aimed to assess the effect of total-body CT scanning compared with the standard work-up on in-hospital mortality in patients with trauma.

METHODS:

We undertook an international, multicentre, randomised controlled trial at four hospitals in the Netherlands and one in Switzerland. Patients aged 18 years or older with trauma with compromised vital parameters, clinical suspicion of life-threatening injuries, or severe injury were randomly assigned (1:1) by ALEA randomisation to immediate total-body CT scanning or to a standard work-up with conventional imaging supplemented with selective CT scanning. Neither doctors nor patients were masked to treatment allocation. The primary endpoint was in-hospital mortality, analysed in the intention-to-treat population and in subgroups of patients with polytrauma and those with traumatic brain injury. The χ2 test was used to assess differences in mortality. This trial is registered with ClinicalTrials.gov, number NCT01523626.

FINDINGS:

Between April 22, 2011, and Jan 1, 2014, 5475 patients were assessed for eligibility, 1403 of whom were randomly assigned: 702 to immediate total-body CT scanning and 701 to the standard work-up. 541 patients in the immediate total-body CT scanning group and 542 in the standard work-up group were included in the primary analysis. In-hospital mortality did not differ between groups (total-body CT 86 [16%] of 541 vs standard work-up 85 [16%] of 542; p=0·92). In-hospital mortality also did not differ between groups in subgroup analyses in patients with polytrauma (total-body CT 81 [22%] of 362 vs standard work-up 82 [25%] of 331; p=0·46) and traumatic brain injury (68 [38%] of 178 vs 66 [44%] of 151; p=0·31). Three serious adverse events were reported in patients in the total-body CT group (1%), one in the standard work-up group (<1%), and one in a patient who was excluded after random allocation. All five patients died.

INTERPRETATION:

Diagnosing patients with an immediate total-body CT scan does not reduce in-hospital mortality compared with the standard radiological work-up. Because of the increased radiation dose, future research should focus on the selection of patients who will benefit from immediate total-body CT.

FUNDING:

ZonMw, the Netherlands Organisation for Health Research and Development.

Copyright © 2016 Elsevier Ltd. All rights reserved.

PMID: 27371185 [PubMed - as supplied by publisher]


Lancet Neurology

Risk of intracerebral hemorrhage (ICH) was found to be greatest in patients with higher NIH stroke scale.  The upshot of this meta-analysis is that early treatment of more severe stroke is of paramount importance.  I know passions run high when we discuss tPA for ischemic stroke.  Discuss!

Lancet Neurol. 2016 Jun 8. pii: S1474-4422(16)30076-X. doi: 10.1016/S1474-4422(16)30076-X. [Epub ahead of print]

Risk of intracerebral haemorrhage with alteplase after acute ischaemic stroke: a secondary analysis of an individual patient data meta-analysis.

Whiteley WN1, Emberson J2, Lees KR3, Blackwell L2, Albers G4, Bluhmki E5, Brott T6, Cohen G1, Davis S7, Donnan G8, Grotta J9, Howard G10, Kaste M11, Koga M12, von Kummer R13, Lansberg MG4, Lindley RI14, Lyden P15, Olivot JM16, Parsons M17, Toni D18, Toyoda K12, Wahlgren N19, Wardlaw J1, Del Zoppo GJ20, Sandercock P1, Hacke W21, Baigent C22; Stroke Thrombolysis Trialists' Collaboration.

Author information:

1University of Edinburgh, Edinburgh, UK.

2Clinical Trial Service Unit & Epidemiological Studies Unit, University of Oxford, Oxford, UK.

3University of Glasgow, Glasgow, UK.

4Stanford University, Stanford, CA, USA.

5Boehringer Ingelheim, Ingelheim, Germany.

6Mayo Clinic, Jacksonville, FL, USA.

7University of Melbourne, Melbourne, VIC, Australia.

8Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.

9Memorial Hermann Hospital, Houston, TX, USA.

10University of Alabama, Birmingham, AL, USA.

11Clinical Neurosciences, Neurology, University of Helsinki, Helsinki, Finland; Department of Neurology, Helsinki University Hospital, Helsinki, Finland.

12National Cerebral and Cardiovascular Centre, Suita, Japan.

13Technische Universität, Dresden, Germany.

14The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia.

15Department of Neurology, Cedars-Sinai, Los Angeles, CA, USA.

16Centre Hospitalier Universitaire de Toulouse, France.

17University of Newcastle, Newcastle, NSW, Australia.

18Sapienza University, Rome, Italy.

19Karolinska Institutet, Clinical Neuroscience, Stockholm, Sweden.

20University of Washington, Seattle, WA, USA.

21University of Heidelberg, Heidelberg, Germany.

22Clinical Trial Service Unit & Epidemiological Studies Unit, University of Oxford, Oxford, UK. Electronic address: STT@ctsu.ox.ac.uk.

Abstract

BACKGROUND:

Randomised trials have shown that alteplase improves the odds of a good outcome when delivered within 4·5 h of acute ischaemic stroke. However, alteplase also increases the risk of intracerebral haemorrhage; we aimed to determine the proportional and absolute effects of alteplase on the risks of intracerebral haemorrhage, mortality, and functional impairment in different types of patients.

METHODS:

We used individual patient data from the Stroke Thrombolysis Trialists' (STT) meta-analysis of randomised trials of alteplase versus placebo (or untreated control) in patients with acute ischaemic stroke. We prespecified assessment of three classifications of intracerebral haemorrhage: type 2 parenchymal haemorrhage within 7 days; Safe Implementation of Thrombolysis in Stroke Monitoring Study's (SITS-MOST) haemorrhage within 24-36 h (type 2 parenchymal haemorrhage with a deterioration of at least 4 points on National Institutes of Health Stroke Scale [NIHSS]); and fatal intracerebral haemorrhage within 7 days. We used logistic regression, stratified by trial, to model the log odds of intracerebral haemorrhage on allocation to alteplase, treatment delay, age, and stroke severity. We did exploratory analyses to assess mortality after intracerebral haemorrhage and examine the absolute risks of intracerebral haemorrhage in the context of functional outcome at 90-180 days.

FINDINGS:

Data were available from 6756 participants in the nine trials of intravenous alteplase versus control. Alteplase increased the odds of type 2 parenchymal haemorrhage (occurring in 231 [6·8%] of 3391 patients allocated alteplase vs 44 [1·3%] of 3365 patients allocated control; odds ratio [OR] 5·55 [95% CI 4·01-7·70]; absolute excess 5·5% [4·6-6·4]); of SITS-MOST haemorrhage (124 [3·7%] of 3391 vs 19 [0·6%] of 3365; OR 6·67 [4·11-10·84]; absolute excess 3·1% [2·4-3·8]); and of fatal intracerebral haemorrhage (91 [2·7%] of 3391 vs 13 [0·4%] of 3365; OR 7·14 [3·98-12·79]; absolute excess 2·3% [1·7-2·9]). However defined, the proportional increase in intracerebral haemorrhage was similar irrespective of treatment delay, age, or baseline stroke severity, but the absolute excess risk of intracerebral haemorrhage increased with increasing stroke severity: for SITS-MOST intracerebral haemorrhage the absolute excess risk ranged from 1·5% (0·8-2·6%) for strokes with NIHSS 0-4 to 3·7% (2·1-6·3%) for NIHSS 22 or more (p=0·0101). For patients treated within 4·5 h, the absolute increase in the proportion (6·8% [4·0% to 9·5%]) achieving a modified Rankin Scale of 0 or 1 (excellent outcome) exceeded the absolute increase in risk of fatal intracerebral haemorrhage (2·2% [1·5% to 3·0%]) and the increased risk of any death within 90 days (0·9% [-1·4% to 3·2%]).

INTERPRETATION:

Among patients given alteplase, the net outcome is predicted both by time to treatment (with faster time increasing the proportion achieving an excellent outcome) and stroke severity (with a more severe stroke increasing the absolute risk of intracerebral haemorrhage). Although, within 4·5 h of stroke, the probability of achieving an excellent outcome with alteplase treatment exceeds the risk of death, early treatment is especially important for patients with severe stroke.

FUNDING:

UK Medical Research Council, British Heart Foundation, University of Glasgow, University of Edinburgh.

Copyright © 2016 Elsevier Ltd. All rights reserved.

PMID: 27289487 [PubMed - as supplied by publisher]


New England Journal of Medicine

Does intensive BP lowering (to 110-139 systolic) vs. standard (140-179) using nicardipine in ICH patients help?  In this RCT called ATACH-2, the trial was stopped early due to futility.  There was no difference in intensive BP lowering, and this group had increased adverse renal outcomes.  What this means for us in the ED is that our goal should be modest BP reduction in ICH patients.

N Engl J Med. 2016 Jun 8. [Epub ahead of print]

Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage.

Qureshi AI1, Palesch YY1, Barsan WG1, Hanley DF1, Hsu CY1, Martin RL1, Moy CS1, Silbergleit R1, Steiner T1, Suarez JI1, Toyoda K1, Wang Y1, Yamamoto H1, Yoon BW1; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network.

Author information:

1From the Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis (A.I.Q.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (Y.Y.P., R.L.M.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.G.B., R.S.); the Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore (D.F.H.), and the Neurological Institute, National Institute of Neurological Disorders and Stroke, Bethesda (C.S.M.) - both in Maryland; China Medical University, Taichung, Taiwan (C.Y.H.); the Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, and the Department of Neurology, Heidelberg University Hospital, Heidelberg - both in Germany (T.S.); the Department of Neurology, Baylor College of Medicine, Houston (J.I.S.); the Departments of Cerebrovascular Medicine (K.T.) and Data Sciences (H.Y.), National Cerebral and Cardiovascular Center, Suita, Japan; Beijing Tiantan Hospital, Beijing (Y.W.); and the Department of Neurology, Seoul National University Hospital, Seoul, South Korea (B.-W.Y.).

Abstract

Background

Limited data are available to guide the choice of a target for the systolic blood-pressure level when treating acute hypertensive response in patients with intracerebral hemorrhage.

Methods

We randomly assigned eligible participants with intracerebral hemorrhage (volume, <60 cm3) and a Glasgow Coma Scale (GCS) score of 5 or more (on a scale from 3 to 15, with lower scores indicating worse condition) to a systolic blood-pressure target of 110 to 139 mm Hg (intensive treatment) or a target of 140 to 179 mm Hg (standard treatment) in order to test the superiority of intensive reduction of systolic blood pressure to standard reduction; intravenous nicardipine to lower blood pressure was administered within 4.5 hours after symptom onset. The primary outcome was death or disability (modified Rankin scale score of 4 to 6, on a scale ranging from 0 [no symptoms] to 6 [death]) at 3 months after randomization, as ascertained by an investigator who was unaware of the treatment assignments.

Results

Among 1000 participants with a mean (±SD) systolic blood pressure of 200.6±27.0 mm Hg at baseline, 500 were assigned to intensive treatment and 500 to standard treatment. The mean age of the patients was 61.9 years, and 56.2% were Asian. Enrollment was stopped because of futility after a prespecified interim analysis. The primary outcome of death or disability was observed in 38.7% of the participants (186 of 481) in the intensive-treatment group and in 37.7% (181 of 480) in the standard-treatment group (relative risk, 1.04; 95% confidence interval, 0.85 to 1.27; analysis was adjusted for age, initial GCS score, and presence or absence of intraventricular hemorrhage). Serious adverse events occurring within 72 hours after randomization that were considered by the site investigator to be related to treatment were reported in 1.6% of the patients in the intensive-treatment group and in 1.2% of those in the standard-treatment group. The rate of renal adverse events within 7 days after randomization was significantly higher in the intensive-treatment group than in the standard-treatment group (9.0% vs. 4.0%, P=0.002).

Conclusions

The treatment of participants with intracerebral hemorrhage to achieve a target systolic blood pressure of 110 to 139 mm Hg did not result in a lower rate of death or disability than standard reduction to a target of 140 to 179 mm Hg. (Funded by the National Institute of Neurological Disorders and Stroke and the National Cerebral and Cardiovascular Center; ATACH-2 ClinicalTrials.gov number, NCT01176565 .).

PMID: 27276234 [PubMed - as supplied by publisher]


Neurology

Would the Cincinnati Prehospital Stroke Scale (CPSS) and Recognition of Stroke in the Emergency Room (ROSIER) stroke assessment tools help determine which children in the ED were having true ischemic stroke vs. a stroke mimic?  Both instruments were retrospectively applied and were not able to tell stroke from stroke mimic, such as migraine, seizure, Bell palsy, or conversion.  Quick stroke screening tools like CPSS and ROSIER don't discriminate true from false in kids.

Neurology. 2016 Jun 7;86(23):2154-61. doi: 10.1212/WNL.0000000000002736. Epub 2016 May 13.

Performance of bedside stroke recognition tools in discriminating childhood stroke from mimics.

Mackay MT1, Churilov L2, Donnan GA2, Babl FE2, Monagle P2.

Author information:

1From the Department of Neurology (M.T.M.), Emergency Department (F.E.B.), and Department of Haematology (P.M.), Royal Children's Hospital; Florey Institute of Neurosciences and Mental Health (L.C., G.A.D.); Murdoch Childrens Research Institute (M.T.M., F.E.B., P.M.); and University of Melbourne (M.T.M., L.C., G.A.D., F.E.B., P.M.), Parkville, Australia. mark.mackay@rch.org.au.

2From the Department of Neurology (M.T.M.), Emergency Department (F.E.B.), and Department of Haematology (P.M.), Royal Children's Hospital; Florey Institute of Neurosciences and Mental Health (L.C., G.A.D.); Murdoch Childrens Research Institute (M.T.M., F.E.B., P.M.); and University of Melbourne (M.T.M., L.C., G.A.D., F.E.B., P.M.), Parkville, Australia.

Abstract

OBJECTIVE:

To assess the utility of the Cincinnati Prehospital Stroke Scale (CPSS) and Recognition of Stroke in the Emergency Room (ROSIER) tools in children presenting to the emergency department (ED) with brain attack symptoms.

METHODS:

The ROSIER and CPSS tools were retrospectively applied to 101 children with stroke, presenting from 2003 to 2010, and prospectively to 279 children with mimics, presenting from 2009 to 2010. Positive CPSS was defined as ≥1 positive sign (face/asymmetrical arm weakness, speech disturbance). Positive ROSIER was defined as a score of ≥1. Accuracy and interrater agreement between the tools and patients' true status were assessed for combined stroke types and arterial stroke (AIS) and hemorrhagic stroke (HS) subtypes vs mimics.

RESULTS:

Stroke subtypes included AIS (55), HS (34), TIA (10), and sinovenous thrombosis (2). Mimic diagnoses included migraine (84), first seizure (45), Bell palsy (29), and conversion disorders (18). Both tools had poor reliability and accuracy for combined strokes vs mimics (CPSS κ 0.36, receiver operator characteristic curve [ROC] 0.66; ROSIER κ 0.32, ROC 0.60) and for AIS vs mimics (CPSS κ 0.37, ROC 0.79; ROSIER κ 0.30, ROC 0.77). Both tools performed inadequately for HS vs mimics (CPSS κ -0.03, ROC 0.51; ROSIER κ -0.02, ROC 0.52).

CONCLUSIONS:

Adult stroke recognition tools perform poorly in children and require modification to be useful for pediatric stroke identification.

CLASSIFICATION OF EVIDENCE:

This study provides Class II evidence that, for children presenting to the ED with brain attack symptoms, the CPSS and ROSIER tools do not accurately distinguish strokes from mimics.

© 2016 American Academy of Neurology.

PMID: 27178704 [PubMed - in process]


Pediatric Critical Care Medicine

  1. Pediatric patients in EDs using telemedicine arrived with lower severity of illness than those who did not have telemedicine access, but did not have significantly lower mortality.  This was a retrospective study and could have significant confounders.  What if the 15 referring EDs with telemedicine were just better and more technologically advanced, and that is why their patients arrived less sick?  However, this study is an encouraging view of the potential benefit of telemedicine in improving healthcare delivery and patient outcomes.
  2. This was a post-hoc analysis of pediatric patients in a therapeutic hypothermia trial.  Those with a drowning mechanism did not show improvement with therapeutic hypothermia compared with normothermia.

1.

Pediatr Crit Care Med. 2016 Jun;17(6):516-21. doi: 10.1097/PCC.0000000000000761.

Impact of Telemedicine on Severity of Illness and Outcomes Among Children Transferred From Referring Emergency Departments to a Children's Hospital PICU.

Dayal P1, Hojman NM, Kissee JL, Evans J, Natale JE, Huang Y, Litman RL, Nesbitt TS, Marcin JP.

Author information:

1All authors: Department of Pediatrics, University of California, Davis, Sacramento, CA.

Abstract

OBJECTIVES:

To compare the severity of illness and outcomes among children admitted to a children's hospital PICU from referring emergency departments with and without access to a pediatric critical care telemedicine program.

DESIGN:

Retrospective cohort study.

SETTING:

Tertiary academic children's hospital PICU.

PATIENTS:

Pediatric patients admitted directly to the PICU from referring emergency departments between 2010 and 2014.

INTERVENTIONS:

None.

MEASUREMENTS:

Demographic factors, severity of illness, and clinical outcomes among children receiving care in emergency departments with and without access to pediatric telemedicine, as well as a subcohort of children admitted from emergency departments before and after the implementation of telemedicine.

MAIN RESULTS:

Five hundred eighty-two patients from 15 emergency departments with telemedicine and 524 patients from 60 emergency departments without telemedicine were transferred and admitted to the PICU. Children admitted from emergency departments using telemedicine were younger (5.6 vs 6.9 yr; p< 0.001) and less sick (Pediatric Risk of Mortality III score, 3.2 vs 4.0; p < 0.05) at admission to the PICU compared with children admitted from emergency departments without telemedicine. Among transfers from emergency departments that established telemedicine programs during the study period, children arrived significantly less sick (mean Pediatric Risk of Mortality III scores, 1.2 units lower; p = 0.03) after the implementation of telemedicine (n = 43) than before the implementation of telemedicine (n = 95). The observed-to-expected mortality ratios of posttelemedicine, pretelemedicine, and no-telemedicine cohorts were 0.81 (95% CI, 0.53-1.09), 1.07 (95% CI, 0.53-1.60), and 1.02 (95% CI, 0.71-1.33), respectively.

CONCLUSIONS:

The implementation of a telemedicine program designed to assist in the care of seriously ill children receiving care in referring emergency departments was associated with lower illness severity at admission to the PICU. This study contributes to the body of evidence that pediatric critical care telemedicine programs assist referring emergency departments in the care of critically ill children and could result in improved clinical outcomes.

PMID: 27099972 [PubMed - in process]

 

2.

Pediatr Crit Care Med. 2016 Jun 29. [Epub ahead of print]

Targeted Temperature Management After Pediatric Cardiac Arrest Due To Drowning: Outcomes and Complications.

Moler FW1, Hutchison JSNadkarni VMSilverstein FSMeert KLHolubkov RPage KSlomine BSChristensen JRDean JMTherapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital Trial Investigators.

Author information:

11Department of Pediatrics, University of Michigan, Ann Arbor, MI. 2Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada. 3Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA. 4Department of Pediatrics, Wayne State University, Detroit, MI. 5Department of Pediatrics, University of Utah, Salt Lake City, UT. 6Department of Physical Medicine and Rehabilitation and Neuropsychology, Kennedy Krieger Institute and Johns Hopkins University, Baltimore, MD.

 

Abstract

OBJECTIVE:

To describe outcomes and complications in the drowning subgroup from the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital trial.

DESIGN:

Exploratory post hoc cohort analysis.

SETTING:

Twenty-four PICUs.

PATIENTS:

Pediatric drowning cases.

INTERVENTIONS:

Therapeutic hypothermia versus therapeutic normothermia.

MEASUREMENTS AND MAIN RESULTS:

An exploratory study of pediatric drowning from the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital trial was conducted. Comatose patients aged more than 2 days and less than 18 years were randomized up to 6 hours following return-of-circulation to hypothermia (n = 46) or normothermia (n = 28). Outcomes assessed included 12-month survival with a Vineland Adaptive Behavior Scale score of greater than or equal to 70, 1-year survival rate, change in Vineland Adaptive Behavior Scale-II score from prearrest to 12 months, and select safety measures. Seventy-four drowning cases were randomized. In patients with prearrest Vineland Adaptive Behavior Scale-II greater than or equal to 70 (n = 65), there was no difference in 12-month survival with Vineland Adaptive Behavior Scale-II score of greater than or equal to 70 between hypothermia and normothermia groups (29% vs 17%; relative risk, 1.74; 95% CI, 0.61-4.95; p = 0.27). Among all evaluable patients (n = 68), the Vineland Adaptive Behavior Scale-II score change from baseline to 12 months did not differ (p = 0.46), and 1-year survival was similar (49% hypothermia vs 42%, normothermia; relative risk, 1.16; 95% CI, 0.68-1.99; p = 0.58). Hypothermia was associated with a higher prevalence of positive bacterial culture (any blood, urine, or respiratory sample; 67% vs 43%; p = 0.04); however, the rate per 100 days at risk did not differ (11.1 vs 8.4; p = 0.46). Cumulative incidence of blood product use, serious arrhythmias, and 28-day mortality were not different. Among patients with cardiopulmonary resuscitation durations more than 30 minutes or epinephrine doses greater than 4, none had favorable Pediatric Cerebral Performance Category outcomes (≤ 3).

CONCLUSIONS:

In comatose survivors of out-of-hospital pediatric cardiac arrest due to drowning, hypothermia did not result in a statistically significant benefit in survival with good functional outcome or mortality at 1 year, as compared with normothermia. High risk of culture-proven bacterial infection was observed in both groups.

PMID: 27362855 [PubMed - as supplied by publisher]


Pediatric Emergency Care

  1. This was an elegant study of pediatric patients receiving IV ondansetron.  Pre-med ECG QTc compared with peak effect (3 minutes post-ondansetron) and one hour post-med QTc showed the QTc increased by 3 milliseconds after ondansetron, not statistically significant.  The upshot is you can give ondansetron to kids without worrying about significant QT prolongation.
  2. It takes a lot for our pediatric surgeons to operate on a pediatric foreign body ingestion.  I have seen them allow sharp objects to pass under close observation many times, as the chance of causing harm in surgery is greater than the benefit for the patient.  Press-through package sheets may be a more dangerous problem though.  Press-through package sheets (PTPS) are plastic pill blister packs with paper or foil sealing in the pill.  This is a case report of a 12 year old with ingestion of one with it becoming lodged in the lower esophagus.  The diagnosis was made on CT.  This is just a FYI article.  I wasn't aware of the danger of PTPS.

1.

Pediatr Emerg Care. 2016 Jun 2. [Epub ahead of print]

Effect of Intravenous Ondansetron on the QT Interval of Patients' Electrocardiograms.

Krammes SK1, Jacobs T, Clark JM, Lutes RE.

Author information:

1From the Departments of *Emergency Medicine and †Cardiology, Akron Children's Hospital, Akron, OH.

Abstract

OBJECTIVE:

Ondansetron improves the success of oral rehydration in children with gastroenteritis. In postoperative adults, ondansetron has been shown to prolong the corrected QT (QTc). The aim of the study was to evaluate the effect of ondansetron on the QT at peak effect and at 1-hour postpeak effect in pediatric patients.

METHODS:

This was an observational study looking at patients aged 6 months to 18 years receiving intravenous ondansetron for nausea, vomiting, or the inability to take fluids in the emergency department. Patients had electrocardiogram performed at baseline, at ondansetron's peak effect, and 1 hour postpeak effect. A paired samples Student t test compared QTc change at peak effect to zero. Peak effect of intravenous ondansetron is 3 minutes.

RESULTS:

One hundred patients were included. Fifty-five percent of patients were female with a mean age of 8.3 years. The mean (range) baseline QTc was 435 (388 to 501) milliseconds. The mean (range) change in QTc at peak effect of ondansetron was 3 (-40 to 65) milliseconds (P = 0.072). The change in QTc 1-hour postpeak effect of ondansetron was 3 (-43 to 45) milliseconds (P = 0.082). No change at peak effect or 1-hour postpeak effect was clinically significant.

CONCLUSIONS:

Ondansetron does not affect the QTc of pediatric patients receiving the medication for nausea, vomiting, or inability to take fluids in the emergency department. No changes in the QTc are clinically significant. To date, there have been no studies evaluating the effect of ondansetron in this acutely ill population; therefore, a larger study should be completed to confirm these data.

PMID: 27261956 [PubMed - as supplied by publisher]

 

2.

Pediatr Emerg Care. 2016 Jun 21. [Epub ahead of print]

Effective Use of Computed Tomography for Detection of Press-Through-Package Sheet Ingestion in a Pediatric Patient.

Takeuchi I1, Ito TIto YUematsu SMisato MOono MTsuji SSakai H.

Author information:

1From the *Department of General Pediatrics and Interdisciplinary Medicine, †Division of Emergency Service and Transport Medicine, and ‡Division of Surgery, Department of Surgical Subspecialties, National Center for Child Health and Development, Tokyo, Japan.

 

Abstract

Press-through-package sheet (PTPS) ingestion can cause perforation of gastrointestinal tract. Such incidents, which require immediate medical attention, are often observed in elderly people. In this report, we describe the case of a 12-year-old patient who ingested PTPS. The patient, who has attention-deficit/hyperactivity disorder, presented with abdominal pain at our hospital. While it was not revealed by a chest x-ray, computed tomography scan showed a PTPS lodged in his lower esophagus. The ingested PTPS was removed by endoscopy without complications. Press-through-package sheets ingestion can occur in pediatric patients, and computed tomography scan is useful in the diagnosis.

PMID: 27331579 [PubMed - as supplied by publisher]


Pediatrics

Interestingly, our hospital epidemiologists just concluded that unless the pediatric UA had a high enough number of WBCs, then a culture would not be done.  There has been significant pushback from our PEM faculty, and this paper is timely.  This retrospective review of children at CHoP in the PED found that kids with paired UA and culture who grew a urinary pathogen had pyuria, defined as ≥5 white blood cells per high-powered field or ≥10 white blood cells per cubic millimeter, 87% of the time.  That leaves 13% with a documented urinary tract infection in the absence of pyuria.  The sensitivity for UA in children is less than in adults, and this is more evidence that children should have the gold standard, culture, to definitively exclude UTI.

Pediatrics. 2016 Jun 21. pii: e20160087. [Epub ahead of print]

Association Between Uropathogen and Pyuria.

Shaikh N1, Shope TR2, Hoberman A2, Vigliotti A2, Kurs-Lasky M2, Martin JM2.

Author information:

1Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania nader.shaikh@chp.edu.

2Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Abstract

OBJECTIVE:

We sought to determine factors associated with the absence of pyuria in symptomatic children whose urine culture was positive for a known uropathogen.

METHODS:

We obtained data on children evaluated at the Children's Hospital of Pittsburgh emergency department between 2007 and 2013 with symptoms of urinary tract infection (UTI) who had paired urinalysis and urine cultures. We excluded children with an unknown or bag urine collection method, major genitourinary anomalies, immunocompromising conditions, or with multiple organisms on culture. We chose a single, randomly-selected urine specimen per child and limited the analysis to those with positive cultures.

RESULTS:

There were 46 158 visits during the study period; 1181 children diagnosed with UTI met all inclusion criteria and had a microscopic urinalysis for pyuria. Pyuria (≥5 white blood cells per high-powered field or ≥10 white blood cells per cubic millimeter) was present in 1031 (87%) children and absent in 150 (13%). Children with Enterococcus species, Klebsiella species, and Pseudomonas aeruginosa were significantly less likely to exhibit pyuria than children with Escherichia coli (odds ratio of 0.14, 0.34, and 0.19, respectively). Children with these organisms were also less likely to have a positive leukocyte esterase on dipstick urinalysis. Results were similar when we restricted the analysis to children whose urine samples were collected by bladder catheterization.

CONCLUSIONS:

We found that certain uropathogens are less likely to be associated with pyuria in symptomatic children. Identification of biomarkers more accurate than pyuria or leukocyte esterase may help reduce over- and undertreatment of UTIs.

Copyright © 2016 by the American Academy of Pediatrics.

PMID: 27328921 [PubMed - as supplied by publisher]


Resuscitation

  1. The title of this article is "Automated external defibrillation skills by naive schoolchildren."  Does this sound like a bad idea to anyone else?  "Here you are little girl! Now you be careful with that fibby-fib.  Don't shock yourself!"
  2. This was a real-world application of strict therapeutic normothermia (STN) as opposed to therapeutic hypothermia (TH) in one hospital.  It was a before-after study.  They found STN was feasible in practice and associated with fewer complications than TH.
  3. I had not heard of dual defibrillation until recently.  This retrospective prehospital study found that dual defibrillation vs. standard defibrillation in recurrent or refractory v-fib did not improve neurologically intact survival.

1.

Resuscitation. 2016 Jun 25. pii: S0300-9572(16)30102-2. doi: 10.1016/j.resuscitation.2016.06.007. [Epub ahead of print]

Automated external defibrillation skills by naive schoolchildren.

Jorge-Soto C1, Abelairas-Gómez C2, Barcala-Furelos R3, Garrido-Viñas A4, Navarro-Patón R5, Muiño-Piñeiro M6, Díaz-Pereira MP7, Rodríguez-Núñez A8.

Author information:

1School of Nursing, University of Santiago de Compostela, Santiago de Compostela, Spain; CLINURSID Research Group. University of Santiago de Compostela, Spain.

2CLINURSID Research Group. University of Santiago de Compostela, Spain; University School of Health Sciences, European Atlantic University, Santander, Spain.

3CLINURSID Research Group. University of Santiago de Compostela, Spain; University School of Education and Sport Sciences, University of Vigo, Pontevedra, Spain.

4School of Nursing, University of Santiago de Compostela, Santiago de Compostela, Spain.

5Univerity School of Teacher Training, University of Santiago de Compostela, Lugo, Spain.

6University School of Sport Sciences and Physical Education, University of A Coruña, A Coruña, Spain.

7University School of Educational Sciences, University of Vigo, Ourense, Spain.

8School of Nursing, University of Santiago de Compostela, Santiago de Compostela, Spain; CLINURSID Research Group. University of Santiago de Compostela, Spain; Paediatric Emergency and Critical Care Division, Hospital Clínico Universitario de Santiago de Compostela, SERGAS, Santiago de Compostela, Spain. Institute of Research of Santiago (IDIS) and SAMID-II Network. Electronic address: Antonio.Rodriguez.Nunez@sergas.es.

 

Abstract

AIM:

Early defibrillation should achieve the highest survival rates when applied within the first minutes after the collapse. Public access defibrillation programs have increased the population awareness of the importance of defibrillation. Schoolchildren should be trained in basic life support (BLS) skills and some countries have included BLS in their school syllabus. However, little is known of the current knowledge and ability of schoolchildren to use an automated external defibrillator (AED).

METHODS:

A multicentric descriptive study, 1295 children from 6 to 16 years of age without previous BLS or AED training. Subjects performed a simulation with an AED and a manikin with no training or feedback and were evaluated by means of a checklist.

RESULTS:

A total of 258 participants (19.9%) were able to simulate an effective and safe defibrillation in less than three minutes and 25 (26.3% of this group) performed it successfully. A significant correlation between objective and age group was observed (G= 0,172) (p< 0.001). The average time to deliver a shock was 83.3±26.4seconds; that time decreased significantly with age [6 YO (108.3±40.4) vs. 16 YO (64.7±18.6)seconds] (p<0.001).

CONCLUSIONS:

Around 20% of schoolchildren without prior training are able to use an AED correctly in less than three minutes following the device's acoustic and visual instructions. However, only one quarter of those who showed success managed to complete the procedure satisfactorily. These facts should be considered in order to provide a more accurate definition and effective implementation of BLS/AED teaching and training at schools.

Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

PMID: 27353288 [PubMed - as supplied by publisher]

 

2.

Resuscitation. 2016 Jun 24. pii: S0300-9572(16)30117-4. doi: 10.1016/j.resuscitation.2016.06.019. [Epub ahead of print]

A Comparison of Therapeutic Hypothermia and Strict Therapeutic Normothermia after Cardiac Arrest.

Casamento A1, Minson A2, Radford S3, Mårtensson J4, Ridgeon E5, Young P6, Bellomo R3.

Author information:

1Intensive Care Unit, Austin Hospital, Melbourne, Victoria, Australia; Intensive Care Unit, The Northern Hospital, Melbourne, Victoria, Australia. Electronic address: andrew.casamento@austin.org.au.

2Intensive Care Unit, Austin Hospital, Melbourne, Victoria, Australia.

3Intensive Care Unit, Austin Hospital, Melbourne, Victoria, Australia; School of Medicine, The University of Melbourne, Victoria, Australia.

4Intensive Care Unit, Austin Hospital, Melbourne, Victoria, Australia; Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.

5Medical Research Institute of New Zealand, Wellington, New Zealand.

6Medical Research Institute of New Zealand, Wellington, New Zealand; Intensive Care Unit, Wellington Hospital, Wellington, New Zealand.

 

Abstract

BACKGROUND AND AIMS:

In a recent high-quality randomised controlled trial (RCT), strict therapeutic normothermia (STN) following cardiac arrest with coma resulted in similar outcomes to therapeutic hypothermia (TH). We aimed to test the feasibility, reproducibility, and safety of the STN protocol outside of its RCT context.

METHODS:

In two teaching hospital ICUs, we performed a before-and-after study comparing the previously International Liaison Committee on Resuscitation (ILCOR)-endorsed TH protocol to the recently studied STN protocol. The primary feasibility end point was the percentage of temperature recordings in the prescribed range in the first 24hours of treatment. Secondary end points included pharmacological management and complications.

RESULTS:

We studied 69 similar patients in each group. We found no difference in feasibility as shown by the proportion of within range temperatures. However, the median doses of midazolam (37mg vs. 9mg, p=0.02), fentanyl (883mcg vs. 310mcg, p=0.01) and the use of muscle relaxants (84.1% vs. 59.4%, p=0.001) was greater with the TH protocol. Furthermore, shivering (52.2% vs. 18.8%, p<0.001), a composite of other pre-defined complications (66.7% vs. 47.8%, p<0.03) and fever in the first 96hours (55.1% vs. 33.3%, p=0.01) were also more common with the TH protocol.

CONCLUSIONS:

The STN protocol was successfully reproduced outside of an RCT and appeared associated with fewer complications than the TH protocol. Our findings imply that the STN protocol may offer clinical advantages over the TH protocol.

Copyright © 2016. Published by Elsevier Ireland Ltd.

PMID: 27350372 [PubMed - as supplied by publisher]

 

3.

Resuscitation. 2016 Jun 21;106:14-17. doi: 10.1016/j.resuscitation.2016.06.011. [Epub ahead of print]

Dual defibrillation in out-of-hospital cardiac arrest: A retrospective cohort analysis.

Ross EM1, Redman TT2, Harper SA2, Mapp JG2, Wampler DA3, Miramontes DA3.

Author information:

1Department of Emergency Health Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA; San Antonio Fire Department, San Antonio, TX 78205, USA; San Antonio Uniformed Services Health Education Consortium, JBSA Fort Sam, Houston, TX 78234, USA. Electronic address: s5eross@yahoo.com.

2Department of Emergency Health Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA; San Antonio Fire Department, San Antonio, TX 78205, USA; San Antonio Uniformed Services Health Education Consortium, JBSA Fort Sam, Houston, TX 78234, USA.

3Department of Emergency Health Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA; San Antonio Fire Department, San Antonio, TX 78205, USA.

 

Abstract

STUDY OBJECTIVES:

The goal of our study is to determine if prehospital dual defibrillation (DD) is associated with better neurologically intact survival in out-of-hospital cardiac arrest.

METHODS:

This study is a retrospective cohort analysis of prospectively collected Quality Assurance/Quality Improvement data from a large urban fire based EMS system out-of-hospital cardiac arrest (OHCA) database between Jan 2013 and Dec 2015. Our inclusion criteria were administration of DD or at least four conventional 200J defibrillations for cases of recurrent and refractory ventricular fibrillation (VF). We excluded any case with incomplete data. The primary outcome for our study was neurologically intact survival (defined as Cerebral Performance Category 1 and 2).

RESULTS:

A total of 3470 cases of OHCA were treated during the time period of Jan 2013 to Dec 2015. There were 302 cases of recurrent and refractory VF identified. Twenty-three cases had incomplete data. Of the remaining 279 cases, 50 were treated with DD and 229 received standard single shock 200J defibrillations. There was no statistically significant difference in the primary outcome of neurologically intact survival between the DD group (6%) and the standard defibrillation group (11.4%) (p=0.317) (OR 0.50, 95% CI 0.15-1.72).

CONCLUSION:

Our retrospective cohort analysis on the prehospital use of DD in OHCA found no association with neurologically intact survival. Case-control studies are needed to further evaluate the efficacy of DD in the prehospital setting.

Published by Elsevier Ireland Ltd.

PMID: 27344928 [PubMed - as supplied by publisher]


Western Journal of Emergency Medicine

This is a disturbing article about social media (SM) use by healthcare professionals.  It was a survey study of residency leaders and residents at 14 programs in the US.  Posting of inappropriate content on SM was shockingly common.  This included: identifiable patient information, radiographs, clinical picture or other image, posting of images of intoxicated colleagues, inappropriate photographs, and inappropriate posts.  We all know this, but anything posted online is forever.  This is a serious issue for individuals and institutions.  The worst thing is it could violate a patient's privacy.  But it could also cost us our job.  ED directors, "reported that they were aware of or issued reprimands or terminations at least once a year (30% [faculty/nursing] and 22% residents)."  Be extremely careful what you post on SM!

West J Emerg Med. 2016 May;17(3):344-9. doi: 10.5811/westjem.2016.2.28451. Epub 2016 May 5.

Survey of Individual and Institutional Risk Associated with the Use of Social Media.

Garg M1, Pearson DA2, Bond MC3, Runyon M2, Pillow MT4, Hopson L5, Cooney RR6, Khadpe J7, Nomura JT8, Inboriboon PC9.

Author information:

1Temple University Hospital, Department of Emergency Medicine, Philadelphia, Pennsylvania.

2Carolinas Medical Center, Department of Emergency Medicine, Charlotte, North Carolina.

3University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland.

4Baylor College of Medicine, Department of Emergency Medicine, Houston, Texas.

5University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan.

6Conemaugh Memorial Medical Center, Department of Emergency Medicine, Johnstown, Pennsylvania.

7SUNY Downstate Medical Center, Department of Emergency Medicine, Brooklyn, New York.

8Christiana Care Health System, Department of Emergency Medicine, Newark, Delaware.

9University of Missouri-Kansas City, Department of Emergency Medicine, Kansas City, Missouri.

 

Abstract

INTRODUCTION:

Residents and faculty in emergency medicine (EM) residency programs might be unaware of the professional and legal risks associated with the use of social media (SM). The objective of this study was to identify and characterize the types and reported incidence of unprofessional SM behavior by EM residents, faculty, and nurses and the concomitant personal and institutional risks.

METHODS:

This multi-site study used an 18-question survey tool that was distributed electronically to the leaders of multiple EM residency programs, members of the Council of Emergency Medicine Residency Directors (CORD), and the residents of 14 EM programs during the study period May to June 2013.

RESULTS:

We received 1,314 responses: 772 from residents and 542 from faculty. Both groups reported encountering high-risk-to-professionalism events (HRTPE) related to SM use by residents and non-resident providers (NRPs), i.e., faculty members and nurses. Residents reported posting of one of the following by a resident peer or nursing colleague: identifiable patient information (26%); or a radiograph, clinical picture or other image (52%). Residents reported posting of images of intoxicated colleagues (84%), inappropriate photographs (66%), and inappropriate posts (73%). Program directors (PDs) reported posting one of the following by NRPs and residents respectively: identifiable patient information (46% and 45%); a radiograph, clinical picture or other image (63% and 58%). PDs reported that NRPs and residents posted images of intoxicated colleagues (64% and 57%), inappropriate photographs (63% and 57%), or inappropriate posts (76% and 67%). The directors also reported that they were aware of or issued reprimands or terminations at least once a year (30% NRPs and 22% residents). Residents were more likely to post photos of their resident peers or nursing colleagues in an intoxicated state than were NRPs (p=0.0004). NRPs were more likely to post inappropriate content (p=0.04) and identifiable patient information (p=0.0004) than were residents.

CONCLUSION:

EM residents and faculty members cause and encounter HRTPE frequently while using SM; these events present significant risks to the individuals responsible and their associated institution. Awareness of these risks should prompt responsible SM use and consideration of CORD's Social Media Task Force recommendations.

PMCID: PMC4899068 Free PMC Article

PMID: 27330669 [PubMed - in process]