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Academic Emergency Medicine
- Any scalp hematoma increased the odds of intracranial injury (ICI). Large, boggy, non-frontal hematomas in infants 0-6 months increased odds even more. And scalp hematoma alone, even in the absence of linear skull fracture, increased odds of ICI.
- Almost 40% of pediatric transfers to children's hospitals were potentially avoidable, defined as stay <1 day and no additional procedures performed. This increased medical and family costs by nearly $1000. The most common conditions that were potentially avoidable were: seizure, fracture, isolated traumatic brain injury without extra-axial bleeding, respiratory infection, and wheezing.
Acad Emerg Med. 2016 Mar 7. doi: 10.1111/acem.12957. [Epub ahead of print]
Burns EC1, Grool AM2, Klassen TP3, Correll R4, Jarvis A5, Joubert G6, Bailey B7, Chauvin-Kimoff L8, Pusic M9, McConnell D10, Nijssen-Jordan C11, Silver N11, Taylor B12, Osmond MH2,13; Pediatric Emergency Research Canada (PERC) Head Injury Study Group.
1Department of Emergency Medicine, Dalhousie University, Halifax, Canada.
2Pediatric Emergency Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.
3Department of Pediatrics, University of Alberta, Edmonton, Canada.
4Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.
5Department of Pediatrics, University of Toronto, Toronto, Canada.
6Department of Pediatrics, University of Western Ontario, London, Canada.
7Department of Pediatrics, CHU Sainte-Justine, Montreal, Canada.
8Department of Pediatrics, McGill University, Montreal, Canada.
9Pediatric Emergency Medicine, Columbia University Medical Centre, New York, NY, United States.
10Department of Pediatrics, University of Calgary, Calgary, Canada.
11Department of Pediatrics, University of Manitoba, Winnipeg, Canada.
12Department of Pediatrics, Dalhousie University, Halifax, Canada.
13Department of Pediatrics, University of Ottawa, Ottawa, Canada.
Minor head trauma accounts for a significant proportion of pediatric emergency department (ED) visits. In children younger than 24 months, scalp hematomas are thought to be associated with the presence of intracranial injury (ICI). We investigated which scalp hematoma characteristics were associated with increased odds of ICI in children less than 17 years who presented to the ED following minor head injury, and whether an underlying linear skull fracture may explain this relationship.
This was a secondary analysis of 3866 patients enrolled in the Canadian Assessment of Tomography of Childhood Head Injury (CATCH) study. Information about scalp hematoma presence (yes/no), location (frontal, temporal/parietal, occipital), and size (small and localized, large and boggy) was collected by emergency physicians using a structured data collection form. ICI was defined as the presence of an acute brain lesion on CT. Logistic regression analyses were adjusted for age, sex, dangerous injury mechanism, irritability on examination, suspected open or depressed skull fracture, and clinical signs of basal skull fracture.
ICI was present in 159 (4.1%) patients. The presence of a scalp hematoma (n=1189) in any location was associated with significantly greater odds of ICI (OR=4.4, 95% CI 3.06-6.02), particularly for those located in temporal/parietal (OR=6.0, 95% CI 3.9-9.3) and occipital regions (OR=5.6, 95% CI 3.5-8.9). Both small and localized and large and boggy hematomas were significantly associated with ICI, although larger hematomas conferred larger odds (OR=9.9, 95% CI 6.3-15.5). Although the presence of a scalp hematoma was associated with greater odds of ICI in all age groups, odds were greatest in children aged 0 to 6 months (OR=13.5, 95% CI 1.5-119.3). Linear skull fractures were present in 156 (4.0%) patients. Of the 111 patients with scalp hematoma and ICI, 57 (51%) patients had a linear skull fracture and 54 (49%) did not. The association between scalp hematoma and ICI attenuated but remained significant after excluding patients with linear skull fracture (OR=3.3, 95% CI 2.1-5.1).
Large and boggy, and non-frontal scalp hematomas had the strongest association with the presence of ICI in this large pediatric cohort. Although children 0 to 6 months of age were at highest odds, the presence of a scalp hematoma also independently increased the odds ICI in older children and adolescents. The presence of a linear skull fracture only partially explained this relation, indicating that ruling out a skull fracture beneath a hematoma does not obviate the risk of intracranial pathology. This article is protected by copyright. All rights reserved.
PMID: 26947778 [PubMed - as supplied by publisher]
Acad Emerg Med. 2016 Mar 28. doi: 10.1111/acem.12972. [Epub ahead of print]
1University of Iowa Carver College of Medicine, Iowa City, Iowa.
2University of Iowa College of Public Health, Iowa City, Iowa.
Inter-hospital transfer is a common strategy to provide high-quality regionalized care in rural emergency departments (EDs), but several reports have highlighted problems with selection of children for transfer. The purpose of this study is to characterize the burden of potentially avoidable transfer (PAT) and to estimate the medical and family-oriented costs associated with PAT.
This study was a cohort study of all children treated in Iowa EDs between 2004 and 2013. PAT was defined as a child who was transferred, then either discharged from the receiving ED or admitted for ≤ 1 day, without having any separately billed procedures performed. Costs of care were estimated from (1) medical costs, (2) ambulance transfer, and (3) family costs (travel and lodging).
Over 10 years, 2,117,317 children were included (1% transferred to another hospital). Only 63% were transferred to a designated children's hospital, and PATs were identified in 39% of all transfers. PAT was associated with $909 in additional cost. The conditions most strongly associated with PAT were seizure (additional cost $1,138), fracture ($814), isolated traumatic brain injury without extra-axial bleeding ($1,455), respiratory infection ($556), and wheezing ($804). Few of these charges are attributable to non-medical family costs ($21).
Potentially avoidable pediatric inter-hospital transfer is common and is responsible for significant healthcare-related costs. Future work should focus on improving selection of children who benefit from inter-hospital transfer for high-yield conditions, to reduce the costly and distressing burden that PAT places on rural patients and their families. This article is protected by copyright. All rights reserved.
PMID: 27018337 [PubMed - as supplied by publisher]
American Journal of Emergency Medicine
- 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.
- How much does ED care cost in the US? The authors sum it up best with a plain-language conclusion: "More than 1 in 10 health care dollars is spent on ED episodes of care. Of this, less than 1 in 5 dollars is potentially avoidable; therefore, efforts to reduce ED visits through improved primary care may have little impact on overall costs."
Am J Emerg Med. 2016 Mar 9. pii: S0735-6757(16)00198-4. doi: 10.1016/j.ajem.2016.03.016. [Epub ahead of print]
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: email@example.com.
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.
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.
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).
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.
PMID: 27038694 [PubMed - as supplied by publisher]
Am J Emerg Med. 2016 Mar;34(3):357-65. doi: 10.1016/j.ajem.2015.06.001. Epub 2015 Jun 6.
1Department of Emergency Medicine, George Washington University, Washington, DC. Electronic address: firstname.lastname@example.org.
2Department of Emergency Medicine, George Washington University, Washington, DC; Department of Health Policy, George Washington University, Washington, DC.
Emergency department (ED) care is a focus of cost reduction efforts. Costs for acute care originating in the ED, including outpatient and inpatient encounters (i.e. ED episodes), have not been estimated.
We estimate total US costs of ED episodes, potentially avoidable costs, and proportional costs of national health expenditures (NHEs).
We conducted a secondary analysis of 2010 data from the Medical Expenditure Panel Survey, National Hospital Ambulatory Medical Care Survey, and the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. Outpatient ED encounters were categorized based on the New York University algorithm and admissions by ambulatory care-sensitive condition (ACSC) vs non-ACSC. Potentially avoidable encounters were nonemergent ED visits and ACSC hospital admissions. Using the Medical Expenditure Panel Survey, we determined mean per-visit payments for each visit type. Using the National Hospital Ambulatory Medical Care Survey and Nationwide Inpatient Sample, we estimated aggregate expenditures and proportional costs of NHE by visit category.
Emergency department episodes of care accounted for $328.1 billion in payments in 2010. This represented 12.5% of NHE; ED admissions were 8.3% and outpatient ED care was 4.2%. Nonemergent outpatient visits were the most common, comprising 30.4% of ED episodes, and non-ACSC admissions were the most costly at $188.3 billion. Potentially avoidable encounters accounted for $64.4 billion, 19.6% of ED episodes, and 2.4% of NHE.
More than 1 in 10 health care dollars is spent on ED episodes of care. Of this, less than 1 in 5 dollars is potentially avoidable; therefore, efforts to reduce ED visits through improved primary care may have little impact on overall costs.
PMID: 26763823 [PubMed - in process]
Anesthesia and Analgesia
- A 20mL saline flush after 0.6mg/kg rocuronium reduced time to effect by about 15 seconds but, surprisingly, prolonged the clinical recovery by about 4 minutes (35 vs 31 minutes) and complete recovery (90% train-of-four) by 11 minutes (61 vs 50 minutes). For me, in patients who require rocuronium vs succinylcholine (i.e. hyperkalemia), optimal intubating conditions 15 seconds earlier is worth it.
- The Storz C-MAC D-Blade had slightly lower first pass success than the GlideScope.
Anesth Analg. 2016 Mar;122(3):706-11. doi: 10.1213/ANE.0000000000001094.
1From the Department of Anesthesiology, National Defense Medical College, Tokorozawa, Saitama, Japan.
Circulatory factors modify the onset time of neuromuscular-blocking drugs. Therefore, we hypothesized that infusion of a saline flush immediately after rocuronium administration would shorten the onset time without influencing the duration of the rocuronium effect.
Forty-eight patients were randomly allocated to the control or saline flush group. Anesthesia was induced and maintained with propofol and remifentanil, and all patients received 0.6 mg/kg rocuronium in 10 mL of normal saline. In the saline flush group, 20 mL normal saline was immediately infused after rocuronium administration. Neuromuscular blockade was assessed using acceleromyography at the adductor pollicis muscle with train-of-four (TOF) stimulation. The neuromuscular indices for rocuronium were calculated as follows: the latent onset time, defined as the time from the start of rocuronium infusion until first occurrence of depression of the first twitch of the TOF (T1) ≥5%; onset time, defined as the time from the start of rocuronium infusion until first occurrence of depression of the T1 ≥95%; clinical duration, defined as the time from the start of rocuronium administration until T1 recovered to 25% of the final T1 value; recovery index, defined as the time for recovery of T1 from 25% to 75% of the final T1 value; and the total recovery time, defined as the time from the start of rocuronium administration until reaching a TOF ratio of 0.9. Significance was designated at P <0.05.
The measured latent onset time and onset time were significantly shorter in the saline flush group than the control group by 15 seconds (95.2% confidence interval, 0-15, P = 0.007) and 15 seconds (0-30, P = 0.018), respectively. Saline flush significantly depressed the T1 height at 30, 45, and 60 seconds after the rocuronium bolus by 17%, 24%, and 14%, respectively. In addition, the recovery phase was significantly prolonged in the saline flush group. The mean clinical duration (5th-95th percentile range) in the saline flush group and control group was 35 minutes (27-63 minutes) and 31 minutes (19-48 minutes; P = 0.032), respectively; the recovery index was 13 minutes (8-25 minutes) and 10 minutes (7-19 minutes; P = 0.019), respectively; and the total recovery time was 61 minutes (44-108 minutes) and 50 minutes (35-93 minutes; P = 0.048), respectively.
Administering a 20-mL saline flush immediately after infusion of 0.6 mg/kg rocuronium in 10 mL normal saline shortened the onset time and prolonged the recovery phase of neuromuscular blockade.
PMID: 26599796 [PubMed - in process]
Anesth Analg. 2016 Mar;122(3):740-50. doi: 10.1213/ANE.0000000000001084.
First-Attempt Intubation Success of Video Laryngoscopy in Patients with Anticipated Difficult Direct Laryngoscopy: A Multicenter Randomized Controlled Trial Comparing the C-MAC D-Blade Versus the GlideScope in a Mixed Provider and Diverse Patient Population.
1From the *Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon; †Department of Anesthesia, University of Iowa, Iowa City, Iowa; and ‡Department of Anesthesiology, University of Texas at Houston, Houston, Texas.
Intubation success in patients with predicted difficult airways is improved by video laryngoscopy. In particular, acute-angle video laryngoscopes are now frequently chosen for endotracheal intubation in these patients. However, there is no evidence concerning whether different acute-angle video laryngoscopes can be used interchangeably in this scenario and would allow endotracheal intubation with the same success rate. We therefore tested whether first-attempt intubation success is similar when using a newly introduced acute-angle blade, that is an element of an extended airway management system (C-MAC D-Blade) compared with a well-established acute-angle video laryngoscope (GlideScope).
In this large multicentered prospective randomized controlled noninferiority trial, patients requiring general anesthesia for elective surgery and presenting with clinical predictors of difficult laryngoscopy were randomly assigned to intubation using either the C-MAC D-Blade or the GlideScope video laryngoscope. The hypothesis was that first-attempt intubation success using the new device (D-Blade) is no >4% less than the established device (GlideScope), which would determine noninferiority of the new instrument versus the established instrument. The secondary outcomes we observed included intubation success with multiple attempts and airway-related complications within 7 days of enrollment.
Eleven hundred patients were randomly assigned to either video laryngoscope. Intubation success rate on first attempt was 96.2% in the GlideScope group and 93.4% in the C-MAC D-Blade group. Although the absolute difference between the 2 groups was only 2.8%, the 90.35% upper confidence limit of the difference exceeded the predefined margin (4.98%), indicating a rejection of the noninferiority hypothesis for first-attempt intubation success. For attending anesthesiologists, and upon multiple attempts, intubation success did not differ between systems. Pharyngeal injury was noted in 1% of the patients, and the incidence did not differ between interventional groups.
Head-to-head comparison in this large multicenter trial revealed that the newly introduced C-MAC D-Blade does not yield the same first-attempt intubation success as the GlideScope in patients with predicted difficult laryngoscopy except in the hands of attending anesthesiologists. Additional research would be necessary to identify potential causes for this difference. Intubation success rates were very high with both systems, indicating that acute-angle video laryngoscopy is an exceptionally successful strategy for the initial approach to endotracheal intubation in patients with predicted difficult laryngoscopy.
PMID: 26579847 [PubMed - in process]
Auscultation of right mainstem, left mainstem, or tracheal ETT position had poor sensitivity (66%) and specificity (59%) compared to bedside ultrasound (93 and 96%) to confirm tube position. U/S looked at tracheal dilation by the ETT cuff and pleural sliding.
Anesthesiology. 2016 Mar 7. [Epub ahead of print]
1From the Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, California (D.R., E.F., R.H., J.S., K.M.G., E.B., J.R.); and Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Irvine, Los Angeles, California (M.C.).
Unrecognized malposition of the endotracheal tube (ETT) can lead to severe complications in patients under general anesthesia. The focus of this double-blinded randomized study was to assess the accuracy of point-of-care ultrasound in verifying the correct position of the ETT and to compare it with the accuracy of auscultation.
Forty-two adult patients requiring general anesthesia with ETT were consented. Patients were randomized to right main bronchus, left main bronchus, or tracheal intubation. After randomization, the ETT was placed via fiber-optic visualization. Next, the location of the ETT was assessed using auscultation by a separate blinded anesthesiologist, followed by an ultrasound performed by a third blinded anesthesiologist. Ultrasound examination included assessment of tracheal dilation via cuff inflation with air and evaluation of pleural lung sliding. Statistical analysis included sensitivity, specificity, positive predictive value, negative predictive value, and interobserver agreement for the ultrasound examination (95% CI).
In differentiating tracheal versus bronchial intubations, auscultation showed a sensitivity of 66% (0.39 to 0.87) and a specificity of 59% (0.39 to 0.77), whereas ultrasound showed a sensitivity of 93% (0.66 to 0.99) and specificity of 96% (0.79 to 1). Identification of tracheal versus bronchial intubation was 62% (26 of 42) in the auscultation group and 95% (40 of 42) in the ultrasound group (P = 0.0005) (CI for difference, 0.15 to 0.52), and the McNemar comparison showed statistically significant improvement with ultrasound (P < 0.0001). Interobserver agreement of ultrasound findings was 100%.
Assessment of trachea and pleura via point-of-care ultrasound is superior to auscultation in determining the location of ETT.
PMID: 26950708 [PubMed - as supplied by publisher]
Annals of Emergency Medicine
- Irrigation of cutaneous abscesses did not improve outcome, namely need for further intervention in the following month.
- How good is your FOAM, free open-access medical education? Can it be reliably rated? The ALiEM AIR score had good inter-rater reliability, better than educational expert gestalt. Because FOAM on a PBR is just not the same as FOAM on a Turtle Anarchy Portly Stout. FOAM well, my friends. See Academic Life in EM for more information.
- How does "goal-directed" echo compare with comprehensive echo in detecting RV dysfunction in PE? Sensitivity/specificity was 100 and 99%. Test characteristics were much lower for BNP and troponin and moderate for CTPA.
Ann Emerg Med. 2016 Mar;67(3):379-83. doi: 10.1016/j.annemergmed.2015.08.007. Epub 2015 Sep 23.
1Department of Emergency Medicine, UCSF-Fresno Medical Education Program, Fresno, CA. Electronic address: email@example.com.
2Department of Emergency Medicine, UCSF-Fresno Medical Education Program, Fresno, CA.
Irrigation of the cutaneous abscess cavity is often described as a standard part of incision and drainage despite no randomized, controlled studies showing benefit. Our goal is to determine whether irrigation of a cutaneous abscess during incision and drainage in the emergency department (ED) decreases the need for further intervention within 30 days compared with no irrigation.
We performed a single-center, prospective, randomized, nonblinded study of ED patients receiving an incision and drainage for cutaneous abscess, randomized to irrigation or no irrigation. Patient characteristics and postprocedure pain visual analog scale score were obtained. Thirty-day telephone follow-up was conducted with a standardized data form examining need for further intervention, which was defined as repeated incision and drainage, antibiotic change, or abscess-related hospital admission.
Of 209 enrolled patients, 187 completed follow-up. The irrigation and no-irrigation groups were similar with respect to diabetes, immunocompromise, fever, abscess size, cellulitis, and abscess location, but the irrigation group was younger (mean age 36 versus 40 years) and more often treated with packing (89% versus 75%) and outpatient antibiotics (91% versus 73%). The need for further intervention was not different in the irrigation (15%) and no-irrigation (13%) groups (difference 2%; 95% confidence interval -8% to 12%). There was no difference in pain visual analog scale scores (5.6 versus 5.7; difference 0.1; 95% confidence interval -0.7 to 0.9).
Although there were baseline differences between groups, irrigation of the abscess cavity during incision and drainage did not decrease the need for further intervention.
Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID: 26416494 [PubMed - in process]
Ann Emerg Med. 2016 Mar 29. pii: S0196-0644(16)00122-0. doi: 10.1016/j.annemergmed.2016.02.018. [Epub ahead of print]
1Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Academic Life in Emergency Medicine and the MedEdLIFE Research Collaborative. Electronic address: firstname.lastname@example.org.
2Department of Emergency Medicine, University of California, Olive View, CA, and Academic Life in Emergency Medicine.
3Regions Hospital and the Department of Emergency Medicine, University of Minnesota.
4Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, and the Wilson Centre for Health Professions Education, University Health Network, Toronto, ON, Canada.
5Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.
6Academic Life in Emergency Medicine and the MedEdLIFE Research Collaborative; Department of Emergency Medicine, University of California, San Francisco, CA.
Since 2014, Academic Life in Emergency Medicine (ALiEM) has used the Approved Instructional Resources (AIR) score to critically appraise online content. The primary goals of this study are to determine the interrater reliability (IRR) of the ALiEM AIR rating score and determine its correlation with expert educator gestalt. We also determine the minimum number of educator-raters needed to achieve acceptable reliability.
Eight educators each rated 83 online educational posts with the ALiEM AIR scale. Items include accuracy, usage of evidence-based medicine, referencing, utility, and the Best Evidence in Emergency Medicine rating score. A generalizability study was conducted to determine IRR and rating variance contributions of facets such as rater, blogs, posts, and topic. A randomized selection of 40 blog posts previously rated through ALiEM AIR was then rated again by a blinded group of expert medical educators according to their gestalt. Their gestalt impression was subsequently correlated with the ALiEM AIR score.
The IRR for the ALiEM AIR rating scale was 0.81 during the 6-month pilot period. Decision studies showed that at least 9 raters were required to achieve this reliability. Spearman correlations between mean AIR score and the mean expert gestalt ratings were 0.40 for recommendation for learners and 0.35 for their colleagues.
The ALiEM AIR scale is a moderately to highly reliable, 5-question tool when used by medical educators for rating online resources. The score displays a fair correlation with expert educator gestalt in regard to the quality of the resources. The score displays a fair correlation with educator gestalt.
PMID: 27033141 [PubMed - as supplied by publisher]
Ann Emerg Med. 2016 Mar 11. pii: S0196-0644(16)00037-8. doi: 10.1016/j.annemergmed.2016.01.027. [Epub ahead of print]
1Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC. Electronic address: email@example.com.
2Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC.
We determine the diagnostic accuracy of goal-directed echocardiography, cardiac biomarkers, and computed tomography (CT) in early identification of severe right ventricular dysfunction in normotensive emergency department patients with pulmonary embolism compared with comprehensive echocardiography.
This was a prospective observational study of consecutive normotensive patients with confirmed pulmonary embolism. Investigators, blinded to clot burden and biomarkers, performed qualitative goal-directed echocardiography for right ventricular dysfunction: right ventricular enlargement (diameter greater than or equal to that of the left ventricle), severe right ventricular systolic dysfunction, and septal bowing. Brain natriuretic peptide and troponin cutoffs of greater than or equal to 90 pg/mL and greater than or equal to 0.07 ng/mL and CT right ventricular:left ventricular diameter ratio greater than or equal to 1.0 were also compared with comprehensive echocardiography.
One hundred sixteen normotensive pulmonary embolism patients (111 confirmed by CT, 5 by ventilation-perfusion scan) were enrolled. Twenty-six of 116 patients (22%) had right ventricular dysfunction on comprehensive echocardiography. Goal-directed echocardiography had a sensitivity of 100% (95% confidence interval [CI] 87% to 100%), specificity of 99% (95% CI 94% to 100%), positive likelihood ratio (+LR) of 90.0 (95% CI 16.3 to 499.8), and negative likelihood ratio (-LR) of 0 (95% CI 0 to 0.13). Brain natriuretic peptide had a sensitivity of 88% (95% CI 70% to 98%), specificity of 68% (95% CI 57% to 78%), +LR of 2.8 (95% CI 2.0 to 3.9), and -LR of 0.17 (95% CI 0.06 to 0.43). Troponin had a sensitivity of 62% (95% CI 41% to 80%), specificity of 93% (95% CI 86% to 98%), +LR of 9.2 (95% CI 4.1 to 20.9), and -LR of 0.41 (95% CI 0.24 to 0.62). CT had a sensitivity of 91% (95% CI 72% to 99%), specificity of 79% (95% CI 69% to 87%), +LR of 4.3 (95% CI 2.8 to 6.7), and -LR of 0.11 (95% CI 0.03 to 0.34).
Goal-directed echocardiography was highly accurate for early severe right ventricular dysfunction identification and pulmonary embolism risk-stratification. Brain natriuretic peptide was sensitive but less specific, whereas troponin had lower sensitivity but higher specificity. CT had good sensitivity and moderate specificity.
PMID: 26973178 [PubMed - as supplied by publisher]
Annals of Internal Medicine
- I thought IV saline was just as good as IV NAC for preventing contrast nephropathy. But this meta-analysis found the most effective strategy to prevent contrast nephropathy was combined IV NAC+IV saline+low osmolar constrast. Or IV NAC+statin+IV saline was also very effective.
- Advice on antibiotics for respiratory illness: no antibiotics for bronchitis; antibiotics if strep + pharyngitis; antibiotics if rhinosinusitis >10 days, fever, severe symptoms, facial pain, or worsening after initial URI improvement; no antibiotics for colds.
Ann Intern Med. 2016 Mar 15;164(6):406-16. doi: 10.7326/M15-1456. Epub 2016 Feb 2.
N-acetylcysteine, sodium bicarbonate, statins, and ascorbic acid have been studied for reducing contrast-induced nephropathy (CIN).
To evaluate the comparative effectiveness of interventions to reduce CIN in adults receiving contrast media.
MEDLINE, EMBASE, Cochrane Library, ClinicalTrials.gov, and Scopus databases through June 2015. Risk of bias and overall strength of evidence (SOE) of studies were assessed.
Randomized, controlled trials of N-acetylcysteine, sodium bicarbonate, statins, or ascorbic acid that used intravenous (IV) or intra-arterial contrast media and defined CIN with enough data for meta-analysis.
Two reviewers independently extracted data and assessed study quality.
Low-dose N-acetylcysteine plus IV saline compared with IV saline (risk ratio [RR], 0.75 [95% CI, 0.63 to 0.89]; low SOE), N-acetylcysteine plus IV saline compared with IV saline in patients receiving low-osmolar contrast media (RR, 0.69 [CI, 0.58 to 0.84]; moderate SOE), and statins plus N-acetylcysteine plus IV saline versus N-acetylcysteine plus IV saline (RR, 0.52 [CI, 0.29 to 0.93]; low SOE) had clinically important and statistically significant benefits. The following 3 comparisons suggested a clinically important difference that was not statistically significant: sodium bicarbonate versus IV saline in patients receiving low-osmolar contrast media (RR, 0.65 [CI, 0.33 to 1.25]; low SOE), statins plus IV saline versus IV saline (RR, 0.68 [CI, 0.39 to 1.20]; low SOE), and ascorbic acid versus IV saline (RR, 0.72 [CI, 0.48 to 1.01]; low SOE). Strength of evidence was generally insufficient for comparisons of the need for renal replacement, cardiac events, and mortality.
Too few studies were done in patients receiving IV contrast media.
The greatest reduction in CIN was seen with N-acetylcysteine plus IV saline in patients receiving LOCM and with statins plus N-acetylcysteine plus IV saline.
PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.
PMID: 26830221 [PubMed - in process]
Ann Intern Med. 2016 Mar 15;164(6):425-34. doi: 10.7326/M15-1840. Epub 2016 Jan 19.
Acute respiratory tract infection (ARTI) is the most common reason for antibiotic prescription in adults. Antibiotics are often inappropriately prescribed for patients with ARTI. This article presents best practices for antibiotic use in healthy adults (those without chronic lung disease or immunocompromising conditions) presenting with ARTI.
A narrative literature review of evidence about appropriate antibiotic use for ARTI in adults was conducted. The most recent clinical guidelines from professional societies were complemented by meta-analyses, systematic reviews, and randomized clinical trials. To identify evidence-based articles, the Cochrane Library, PubMed, MEDLINE, and EMBASE were searched through September 2015 using the following Medical Subject Headings terms: "acute bronchitis," "respiratory tract infection," "pharyngitis," "rhinosinusitis," and "the common cold."
HIGH-VALUE CARE ADVICE 1:
Clinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected.
HIGH-VALUE CARE ADVICE 2:
Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis (for example, persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates or other appropriate combination of symptoms) by rapid antigen detection test and/or culture for group A Streptococcus. Clinicians should treat patients with antibiotics only if they have confirmed streptococcal pharyngitis.
HIGH-VALUE CARE ADVICE 3:
Clinicians should reserve antibiotic treatment for acute rhinosinusitis for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening).
HIGH-VALUE CARE ADVICE 4:
Clinicians should not prescribe antibiotics for patients with the common cold.
PMID: 26785402 [PubMed - in process]
RV:LV ratio >/= 0.9 is a marker of RV strain on CTPA. These authors found a small LA on CTPA correlated with increased PE mortality. This takes clever software to calculate LA volume on CT, but a LA volume <62mL had a hazard ratio for mortality of 2.44. Plus this is one of the first chambers to change in hemodynamically significant PE, so it is a potential early marker for mortality in these patients.
Chest. 2016 Mar;149(3):667-75. doi: 10.1378/chest.15-0666. Epub 2016 Jan 12.
1Department of Radiology, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address: firstname.lastname@example.org.
2Department of Radiology, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
3Department of Internal Medicine 'D' and 'E', Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
4Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University.
5Clinical Performances Research Unit, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
6Department of Cardiology, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Preliminary reports suggest that a small left atrium (LA) is associated with severe acute pulmonary embolism (PE). This study used data derived from volumetric analyses of computed tomographic pulmonary angiography (CTPA) to investigate whether a reduced LA volume can predict adverse outcome in a large series of patients with acute PE.
We retrospectively analyzed 756 consecutive patients who received a diagnosis of acute PE by nongated CTPA between January 2007 and December 2010. Each CTPA was investigated with volumetric analysis software that automatically provides the volumes of the LA, right atrium, right ventricle, and left ventricle. A classification tree divided the cardiac chamber volumes and ratios into categories according to mortality. Cox regression assessed the association between these categories and 30-day mortality after adjustment for age, sex, and clinical background.
The final study group consisted of 636 patients who had successful volumetric segmentation and complete outcome data. Eighty-four patients (13.2%) died within 30 days of PE diagnosis. There was a higher mortality rate among patients with an LA volume ≤62 mL compared with those with an LA volume >62 mL (19.6% vs 8.9%, respectively; HR, 2.44; P < .001), a left ventricle volume ≤67 mL (16.4% vs 8.3%; HR, 1.8; P = .024) and a right atrium/LA volume ratio >1.2 (17% vs 9.4%; HR, 2.1; P = .002). A reduced LA volume was the best predictor of adverse outcome.
Decreased LA volume is associated with higher mortality and is the first among the various cardiac compartments to predict mortality in patients with acute PE.
PMID: 26356029 [PubMed - in process]
Critical Care Medicine
In one of my favorite article titles in long time, Unpeeling the Evidence for the Banana Bag, authors use pharmacokinetic rationale for abandoning "the banana bag and utilizing the following formula for routine supplementation during the first day of admission: 200-500 mg IV thiamine every 8 hours, 64 mg/kg magnesium sulfate (approximately 4-5 g for most adult patients), and 400-1,000 μg IV folate. If alcoholic ketoacidosis is suspected, dextrose-containing fluids are recommended over normal saline."
Crit Care Med. 2016 Mar 21. [Epub ahead of print]
11Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY. 2Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY. 3Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky College of Medicine, Lexington, KY.
Patients with a chronic alcohol use disorder presenting to the ICU may be deficient in important vitamins and electrolytes and are often prescribed a "banana bag" as a reflexive standard of therapy. The difficulty of diagnosing Wernicke's encephalopathy in the critical care setting is reviewed. Furthermore, whether the contents and doses of micronutrients and electrolytes in standard banana bags meet the needs of critically ill patients with an alcohol use disorder is assessed based on available evidence.
MEDLINE/PubMed (1966 to June 2015) database search, the Cochrane Database of Systematic Reviews, and manual selection of bibliographies from selected articles.
STUDY SELECTION AND DATA EXTRACTION:
Articles relevant to Wernicke's encephalopathy, vitamin and electrolyte deficiencies in patients with alcohol use disorders, and alcoholic ketoacidosis were selected. Articles were narratively synthesized for this review.
Of these deficiencies, thiamine is the most important for the practicing clinician to assess and prescribe replacement in a timely manner. Based on a pharmacokinetic assessment of thiamine, the banana bag approach likely fails to optimize delivery of thiamine to the central nervous system. Folic acid and magnesium may also merit supplementation although the available data do not allow for as strong a recommendation as for prescribing thiamine in this setting. There is no available evidence supporting the prescription of a multivitamin.
Based on the published literature, for patients with a chronic alcohol use disorder admitted to the ICU with symptoms that may mimic or mask Wernicke's encephalopathy, we suggest abandoning the banana bag and utilizing the following formula for routine supplementation during the first day of admission: 200-500 mg IV thiamine every 8 hours, 64 mg/kg magnesium sulfate (approximately 4-5 g for most adult patients), and 400-1,000 μg IV folate. If alcoholic ketoacidosis is suspected, dextrose-containing fluids are recommended over normal saline.
PMID: 27002274 [PubMed - as supplied by publisher]
Emergency Medicine Journal
Ultrasound was able to detect proper central venous catheter placement and to detect absence of PTX as well as CXR, and it was 19 minutes faster to do.
Emerg Med J. 2016 Mar;33(3):176-80. doi: 10.1136/emermed-2015-205000. Epub 2015 Oct 7.
1Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA.
2Department of Emergency Medicine, Good Shepherd Medical Center, Longview, Texas, USA.
3Department of Emergency Medicine, Chandler Medical Center, Lexington, Kentucky, USA.
To prospectively compare ultrasound (US) versus CXR for confirmation of central vascular catheter (CVC) placement. Secondary objective was to determine the incidence of pneumothorax (PTX) and compare US with CXR completion times.
Investigators performed the US saline flush echo test, and evaluated each anterior hemithorax for pleural sliding with US after subclavian or internal jugular CVC placement.
MEASUREMENTS AND MAIN RESULTS:
151 total (135 in the emergency department, 16 in the intensive care unit) patients after CVC placement, mean age 62.1±15.6 years and 83 (55%) female patients. The rapid atrial swirl sign ( RASS) was ultrasound finding of an immediate appearance of turbulence entering the right atrium via superior vena cava after a rapid saline flush of the distal CVC port. RASS was considered 'negative' for CVC malposition. US identified all correct CVC placements. Four suboptimal CVC tip placements were detected by CXR. US identified three of these misplacements (McNemar exact p value >0.99). There were no cases of PTX or abnormal pleural sliding by either CXR or US. Median times for US and CXR completion were 1.1 (IQR 0.7) minutes and 20 (IQR: 30) minutes, respectively, median difference 23.8 (95% CI 19.6 to 29.3) minutes, p<0.0001.
PTX and CVC tip malposition were rare after US-guided CVC placement. There was no significant difference between saline flush echo and CXR for the identification of catheter tip malposition. Benefits of US assessment for complications include reduced radiation exposure and time delays associated with CXR.
PMID: 26446313 [PubMed - in process]
Intensive Care Medicine
ICU attending physicians and residents had reduced cognitive abilities in the domains of memory, processing speed, reasoning, and flexibility after a night shift. Obviously, someone has to do the night shift, so what do we do with findings that prove we are stupid when we don't sleep? I think it means that responsibilities in the morning should be limited for those who have been awake all night.
Intensive Care Med. 2016 Mar;42(3):393-400. doi: 10.1007/s00134-015-4115-4. Epub 2015 Nov 10.
1Assistance Publique, Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses Respiratoires et des Infections Sévères, Chemin des Bourrely, 13015, Marseille, France. email@example.com.
2Assistance Publique, Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses Respiratoires et des Infections Sévères, Chemin des Bourrely, 13015, Marseille, France.
3Faculté de médecine, Aix-Marseille Université, URMITE UMR CNRS 7278, 13005, Marseille, France.
4Assistance Publique, Hôpitaux de Marseille, Hôpital de la Conception, Service d'Anesthésie-Réanimation, 13005, Marseille, France.
5Assistance Publique, Hôpitaux de Marseille, Hôpital Nord, Service d'Anesthésie-Réanimation, 13015, Marseille, France.
6Assistance Publique, Hôpitaux de Marseille, Hôpital Sainte-Marguerite, Service de Santé Publique et de l'Information Médicale, 13009, Marseille, France.
7Assistance Publique, Hôpitaux de Marseille, Hôpital Nord, Service d'accueil des Urgences, 13015, Marseille, France.
8Assistance Publique, Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses Respiratoires et des Infections Sévères, Chemin des Bourrely, 13015, Marseille, France. firstname.lastname@example.org.
9Faculté de médecine, Aix-Marseille Université, URMITE UMR CNRS 7278, 13005, Marseille, France. email@example.com.
The relationship between tiredness and the risk of medical errors is now commonly accepted. The main objective of this study was to assess the impact of an intensive care unit (ICU) night shift on the cognitive performance of a group of intensivists. The influence of professional experience and the amount of sleep on cognitive performance was also investigated.
A total of 51 intensivists from three ICUs (24 seniors and 27 residents) were included. The study participants were evaluated after a night of rest and after a night shift according to a randomized order. Four cognitive skills were tested according to the Wechsler Adult Intelligence Scale and the Wisconsin Card Sorting Test.
All cognitive abilities worsened after a night shift: working memory capacity (11.3 ± 0.3 vs. 9.4 ± 0.3; p < 0.001), speed of processing information (13.5 ± 0.4 vs. 10.9 ± 0.3; p < 0.001), perceptual reasoning (10.6 ± 0.3 vs. 9.3 ± 0.3; p < 0.002), and cognitive flexibility (41.2 ± 1.2 vs. 44.2 ± 1.3; p = 0.063). There was no significant difference in terms of level of cognitive impairment between the residents and ICU physicians. Only cognitive flexibility appeared to be restored after 2 h of sleep. The other three cognitive skills were altered, regardless of the amount of sleep during the night shift.
The cognitive abilities of intensivists were significantly altered following a night shift in the ICU, regardless of either the amount of professional experience or the duration of sleep during the shift. The consequences for patients' safety and physicians' health should be further evaluated.
PMID: 26556616 [PubMed - in process]
Journal of the American College of Cardiology
A large or wide S-wave in lead I (>/= 1mV or 40ms) in patients with Brugada syndrome conferred a hazard ratio of 39.1 for V-fib/sudden cardiac death. Next time you see a Brugada pattern, look at lead I closely.
J Am Coll Cardiol. 2016 Mar 29;67(12):1427-40. doi: 10.1016/j.jacc.2016.01.024.
Calò L1, Giustetto C2, Martino A3, Sciarra L3, Cerrato N2, Marziali M3, Rauzino J4, Carlino G5, de Ruvo E3, Guerra F6, Rebecchi M3, Lanzillo C3, Anselmino M2, Castro A7, Turreni F7, Penco M5, Volpe M4, Capucci A6, Gaita F2.
1Division of Cardiology, Policlinico Casilino, ASL Rome B, Rome, Italy. Electronic address: firstname.lastname@example.org.
2Division of Cardiology, University of Torino, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Torino, Italy.
3Division of Cardiology, Policlinico Casilino, ASL Rome B, Rome, Italy.
4Department of Clinical and Molecular Medicine, School of Medicine and Psychology, Sapienza University of Rome, Ospedale S. Andrea and IRCCS Neuromed, Pozzilli (Isernia), Italy.
5Department of Cardiology, University of L'Aquila, L'Aquila, Italy.
6Cardiology Clinic, Ospedali Riuniti Umberto I-Lancisi-Salesi, Ancona, Italy.
7Division of Cardiology, Policlinic Sandro Pertini, ASL Rome B, Rome, Italy.
Risk stratification in asymptomatic patients remains by far the most important yet unresolved clinical problem in the Brugada syndrome (BrS).
This study sought to analyze the usefulness of electrocardiographic parameters as markers of sudden cardiac death (SCD) in BrS.
This study analyzed data from 347 consecutive patients (78.4% male; mean age 45 ± 13.1 years) with spontaneous type 1 BrS by ECG parameters but with no history of cardiac arrest (including 91.1% asymptomatic at presentation, 5.2% with a history of atrial fibrillation [AF], and 4% with a history of arrhythmic syncope). Electrocardiographic characteristics at the first clinic visit were analyzed to predict ventricular fibrillation (VF)/SCD during follow-up.
During the follow-up (48 ± 38 months), 276 (79.5%) patients remained asymptomatic, 39 (11.2%) developed syncope, and 32 (9.2%) developed VF/SCD. Patients who developed VF/SCD had a lower prevalence of SCN5A gene mutations (p = 0.009) and a higher prevalence of positive electrophysiological study results (p < 0.0001), a family history of SCD (p = 0.03), and AF (p < 0.0001). The most powerful marker for VF/SCD was a significant S-wave (≥0.1 mV and/or ≥40 ms) in lead I. In the multivariate analysis, the duration of S-wave in lead I ≥40 ms (hazard ratio: 39.1) and AF (hazard ratio: 3.7) were independent predictors of VF/SCD during follow-up. Electroanatomic mapping in 12 patients showed an endocardial activation time significantly longer in patients with an S-wave in lead I, mostly because of a significant delay in the anterolateral right ventricular outflow tract.
The presence of a wide and/or large S-wave in lead I was a powerful predictor of life-threatening ventricular arrhythmias in patients with BrS and no history of cardiac arrest at presentation. However, the prognostic value of a significant S-wave in lead I should be confirmed by larger studies and by an independent confirmation cohort of healthy subjects.
PMID: 27012403 [PubMed - in process]
Journal of Pediatrics
- Children with neurologic disorders (defined as cerebral palsy, developmental delay, Down syndrome, epilepsy, non-Down syndrome chromosomal abnormalities, and spinal cord abnormalities) hospitalized with community acquired pneumonia, were less likely to have a specific pathogen identified and more likely to need ICU care.
- In pediatric patients with sepsis, lactate clearance (>10%) within 4 hours did not predict decreased risk of persistent organ dysfunction at 48 hours, but lactate normalization (to <2mmol/L) did.
J Pediatr. 2016 Mar 17. pii: S0022-3476(16)00271-7. doi: 10.1016/j.jpeds.2016.02.049. [Epub ahead of print]
1Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA; Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA. Electronic address: email@example.com.
2Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA.
3National Center on Birth Defects and Developmental Disabilities, Atlanta, GA.
4Vanderbilt University School of Medicine, Nashville, TN.
5Le Bonheur Children's Hospital, Memphis, TN; University of Tennessee Health Science Center, Memphis, TN.
6Emory University School of Medicine, Atlanta, GA.
7Le Bonheur Children's Hospital, Memphis, TN; University of Tennessee Health Science Center, Memphis, TN; St. Jude Children's Research Hospital, Memphis, TN.
8University of Utah Health Sciences Center, Salt Lake City, UT.
To describe and compare the clinical characteristics, outcomes, and etiology of pneumonia among children hospitalized with community-acquired pneumonia (CAP) with neurologic disorders, non-neurologic underlying conditions, and no underlying conditions.
Children <18 years old hospitalized with clinical and radiographic CAP were enrolled at 3 US children's hospitals. Neurologic disorders included cerebral palsy, developmental delay, Down syndrome, epilepsy, non-Down syndrome chromosomal abnormalities, and spinal cord abnormalities. We compared the epidemiology, etiology, and clinical outcomes of CAP in children with neurologic disorders with those with non-neurologic underlying conditions, and those with no underlying conditions using bivariate, age-stratified, and multivariate logistic regression analyses.
From January 2010-June 2012, 2358 children with radiographically confirmed CAP were enrolled; 280 (11.9%) had a neurologic disorder (52.1% of these individuals also had non-neurologic underlying conditions), 934 (39.6%) had non-neurologic underlying conditions only, and 1144 (48.5%) had no underlying conditions. Children with neurologic disorders were older and more likely to require intensive care unit (ICU) admission than children with non-neurologic underlying conditions and children with no underlying conditions; similar proportions were mechanically ventilated. In age-stratified analysis, children with neurologic disorders were less likely to have a pathogen detected than children with non-neurologic underlying conditions. In multivariate analysis, having a neurologic disorder was associated with ICU admission for children ≥2 years of age.
Children with neurologic disorders hospitalized with CAP were less likely to have a pathogen detected and more likely to be admitted to the ICU than children without neurologic disorders.
PMID: 27017483 [PubMed - as supplied by publisher]
J Pediatr. 2016 Mar;170:149-155.e4. doi: 10.1016/j.jpeds.2015.11.071. Epub 2015 Dec 19.
1Children's Hospital Colorado, Aurora, CO; Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO. Electronic address: firstname.lastname@example.org.
2Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
3Children's Hospital Colorado, Aurora, CO.
4Colorado School of Public Health, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado and Children's Hospital Colorado, Aurora, CO.
5Children's Hospital Colorado, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
6Children's Hospital Colorado, Aurora, CO; Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
To evaluate whether lactate clearance and normalization during emergency care of pediatric sepsis is associated with lower rates of persistent organ dysfunction.
This was a prospective cohort study of 77 children <18 years of age in the emergency department with infection and acute organ dysfunction per consensus definitions. In consented patients, lactate was measured 2 and/or 4 hours after an initial lactate; persistent organ dysfunction was assessed through laboratory and physician evaluation at 48 hours. A decrease of ≥10% from initial to final level was considered lactate clearance; a final level <2 mmol/L was considered lactate normalization. Relative risk (RR) with 95% CIs, adjusted in a log-binomial model, was used to evaluate associations between lactate clearance/normalization and organ dysfunction.
Lactate normalized in 62 (81%) patients and cleared in 70 (91%). The primary outcome, persistent 48-hour organ dysfunction, was present in 32 (42%). Lactate normalization was associated with decreased risk of persistent organ dysfunction (RR 0.46, 0.29-0.73; adjusted RR 0.47, 0.29-0.78); lactate clearance was not (RR 0.70, 0.35-1.41; adjusted RR 0.75, 0.38-1.50). The association between lactate normalization and decreased risk of persistent organ dysfunction was retained in the subgroups with initial lactate ≥2 mmol/L and hypotension.
In children with sepsis and organ dysfunction, lactate normalization within 4 hours was associated with decreased persistent organ dysfunction. Serial lactate level measurement may provide a useful prognostic tool during the first hours of resuscitation in pediatric sepsis.
PMID: 26711848 [PubMed - in process]
Click the button for the abbreviated version of the new CDC guidelines on opioid prescribing. This is important.
JAMA. 2016 Mar 15. doi: 10.1001/jama.2016.1464. [Epub ahead of print]
1Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
Primary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose.
To provide recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care.
The Centers for Disease Control and Prevention (CDC) updated a 2014 systematic review on effectiveness and risks of opioids and conducted a supplemental review on benefits and harms, values and preferences, and costs. CDC used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to assess evidence type and determine the recommendation category.
Evidence consisted of observational studies or randomized clinical trials with notable limitations, characterized as low quality using GRADE methodology. Meta-analysis was not attempted due to the limited number of studies, variability in study designs and clinical heterogeneity, and methodological shortcomings of studies. No study evaluated long-term (≥1 year) benefit of opioids for chronic pain. Opioids were associated with increased risks, including opioid use disorder, overdose, and death, with dose-dependent effects.
There are 12 recommendations. Of primary importance, nonopioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks. Before starting opioids, clinicians should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks. When opioids are used, clinicians should prescribe the lowest effective dosage, carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day, and avoid concurrent opioids and benzodiazepines whenever possible. Clinicians should evaluate benefits and harms of continued opioid therapy with patients every 3 months or more frequently and review prescription drug monitoring program data, when available, for high-risk combinations or dosages. For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone.
Conclusions and Relevance:
The guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.
PMID: 26977696 [PubMed - as supplied by publisher]
Does dehydration make an infant LP less likely to be successful and would a saline bolus improve this? Nope. The size of the subarachnoid space did not increase after a saline bolus in infants. My advice is to inform parents during consent that sometimes the CSF cannot be obtained. My practice is to infiltrate the L4-5 space with lidocaine and with the same stick to also infiltrate the L3-4 space. If I am not successful on the first stick, I can move up an interspace and cause the patient no pain.
JAMA Pediatr. 2016 Mar 7;170(3):e154636. doi: 10.1001/jamapediatrics.2015.4636. Epub 2016 Mar 7.
1Department of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California3Keck School of Medicine, University of Southern California, Los Angeles.
2Department of Radiology, Children's Hospital Los Angeles, Los Angeles, California3Keck School of Medicine, University of Southern California, Los Angeles.
Neonatal and infant lumbar puncture is a commonly performed procedure in emergency departments, yet traumatic and unsuccessful lumbar punctures occur 30% to 50% of the time. Dehydration may be a risk factor for unsuccessful lumbar punctures, but to our knowledge, no studies have investigated the use of intravenous (IV) fluid bolus prior to lumbar puncture.
To investigate the association of IV fluid bolus administration with the sonographic measure of the neonatal and infant lumbar subarachnoid space. We hypothesized that IV fluids would increase subarachnoid space size.
DESIGN, SETTING, AND PARTICIPANTS:
Prospective observational study conducted from August 2012 to April 2015.The study took place at the emegency department of the Children's Hospital Los Angeles, an urban pediatric emergency department with an annual census of 76 000 visits.A convenience sample of patients aged 0 to 3 months were enrolled if they had a clinical presentation consistent with pyloric stenosis. This population was used as a proxy because they are similar in age to patients undergoing lumbar puncture for evaluation of neonatal fever and are routinely given IV fluids for dehydration.
Patients with a sonographic diagnosis of pyloric stenosis underwent additional ultrasonography evaluation to determine the size of the subarachnoid space before and after IV fluids.
MAIN OUTCOMES AND MEASURES:
Primary outcomes included the difference in the size of the subarachnoid space in millimeters squared before and 1 hour after administration of an IV fluid bolus in the emergency department. Interobserver consistency for the subarachnoid space measurement between attending radiologists was measured using intraclass correlation coefficient. The Wilcoxon signed-rank test was used to examine changes in subarachnoid space measurements (millimeters squared).
The study sample consisted of 40 patients with a mean (SD) age of 37 (11.3) days (range, 15-71 days). The mean (SD) size of the subarachnoid space before and 1 hour after IV fluid bolus was 37.8 (11.1) mm2 and 36.9 (11.2) mm2 respectively (P = .42). The intraclass correlation coefficient ranged from 0.96 to 0.99 (95% CI, 0.90-0.99).
CONCLUSIONS AND RELEVANCE:
Intravenous fluid boluses were not associated with a significant increase in the sonographic measure of the neonatal and infant subarachnoid space.
PMID: 26954534 [PubMed - in process]
- Former premature infants are almost twice as likely to have adverse respiratory events during procedural sedation than term infants, and the risk persists past age 20.
- Videolaryngoscopy (VL) increased overall success rate in neonatal intubation (75.2% vs 63.4%) and slightly improved skill when the same residents later performed conventional laryngoscopy (CL). The authors conclude that VL is a good teaching tool. I conclude that, as in the ED, VL should replace CL.
- Using a massive lit search, tooth eruption was associated with gingival irritation, fussiness, and drooling but was not associated with fever. Stop the myth.
Pediatrics. 2016 Mar;137(3):1-9. doi: 10.1542/peds.2015-0463. Epub 2016 Feb 25.
1The Dartmouth Institute, Lebanon, New Hampshire; email@example.com.
2The Dartmouth Institute, Lebanon, New Hampshire;
3Riley Children's Hospital Indianapolis, Indiana; and.
4Boston Children's Hospital, Boston, Massachusetts.
BACKGROUND AND OBJECTIVES:
Preterm and former preterm children frequently require sedation/anesthesia for diagnostic and therapeutic procedures. Our objective was to determine the age at which children who are born <37 weeks gestational age are no longer at increased risk for sedation/anesthesia adverse events. Our secondary objective was to describe the nature and incidence of adverse events.
This is a prospective observational study of children receiving sedation/anesthesia for diagnostic and/or therapeutic procedures outside of the operating room by the Pediatric Sedation Research Consortium. A total of 57 227 patients 0 to 22 years of age were eligible for this study. All adverse events and descriptive terms were predefined. Logistic regression and locally weighted scatterplot regression were used for analysis.
Preterm and former preterm children had higher adverse event rates (14.7% vs 8.5%) compared with children born at term. Our analysis revealed a biphasic pattern for the development of adverse sedation/anesthesia events. Airway and respiratory adverse events were most commonly reported. MRI scans were the most commonly performed procedures in both categories of patients.
Patients born preterm are nearly twice as likely to develop sedation/anesthesia adverse events, and this risk continues up to 23 years of age. We recommend obtaining birth history during the formulation of an anesthetic/sedation plan, with heightened awareness that preterm and former preterm children may be at increased risk. Further prospective studies focusing on the etiology and prevention of adverse events in former preterm patients are warranted.
PMID: 26917674 [PubMed - in process]
Pediatrics. 2016 Mar;137(3):1-8. doi: 10.1542/peds.2015-2156. Epub 2016 Feb 12.
1Division of Neonatology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada; and firstname.lastname@example.org.
2Division of Neonatology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada; and.
3Division of Neonatology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada; and Centre for Molecular Medicine and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.
To assess whether the videolaryngoscope (VL) is superior to the classic laryngoscope (CL) in acquiring skill in neonatal endotracheal intubation (ETI) and, once acquired with the VL, whether the skill is transferable to the CL.
This randomized controlled trial, in a level 3 Canadian hospital, recruited junior pediatric residents who performed ETI in the NICU. The primary outcome was success rate of ETI. Secondary outcomes were time to successful intubation, number of bradycardia episodes and lowest oxygen saturation during procedure, occurrence of mucosal trauma, reason for ETI failure, and recognition of problems related to ETI by supervisor and resident.
In phase 1, 34 pediatric residents performed 213 ETIs by using either VL or CL. Intervention groups were comparable at baseline. The success rate was higher (75.2% vs 63.4%, P = .03), and time to successful intubation was longer, inVL group (57 vs 47 seconds, P = .008). In phase 2, 23 residents performed 55 ETIs using CL. The success rate of residents in VL group performing ETI by using the CL was 63% (compared with 75% in phase 1, P = .16).
When learning ETI, the success rate is improved with the VL. Time to successful intubation is longer, but the difference is not clinically significant. When switched to the CL, residents' success rate slightly decreased, but not significantly. This suggests that residents retain a certain level of ETI skill when switched to the CL. The VL is a promising tool for teaching neonatal ETI.
PMID: 26908701 [PubMed - in process]
Pediatrics. 2016 Mar;137(3):1-19. doi: 10.1542/peds.2015-3501. Epub 2016 Feb 18.
1Department of Dentistry, and.
2Bauru School of Dentistry, Bauru, São Paulo, Brazil;
3Gulhane Military Medical Academy, Istanbul, Turkey; and.
4Department of Dentistry, and Brazilian Centre for Evidence-based Research, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil; Department of Dentistry, University of Alberta, Edmonton, Canada.
5Department of Dentistry, and Brazilian Centre for Evidence-based Research, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil;
6Department of Dentistry, and email@example.com.
Symptoms associated with the primary tooth eruption have been extensively studied but it is still controversial.
To assess the occurrence of local and systemic signs and symptoms during primary tooth eruption.
Latin American and Caribbean Health Sciences, PubMed, ProQuest, Scopus, and Web of Science were searched. A partial gray literature search was taken by using Google Scholar and the reference lists of the included studies were scanned.
Observational studies assessing the association of eruption of primary teeth with local and systemic signs and symptoms in children aged 0 to 36 months were included.
Two authors independently collected the information from the selected articles. Information was crosschecked and confirmed for its accuracy.
A total of 1179 articles were identified, and after a 2-phase selection, 16 studies were included. Overall prevalence of signs and symptoms occurring during primary tooth eruption in children between 0 and 36 months was 70.5% (total sample = 3506). Gingival irritation (86.81%), irritability (68.19%), and drooling (55.72%) were the most frequent ones.
Different general symptoms were considered among studies. Some studies presented lack of confounding factors, no clear definition of the diagnostics methods, use of subjective measures and long intervals between examinations.
There is evidence of the occurrence of signs and symptoms during primary tooth eruption. For body temperature analyses, eruption could lead to a rise in temperature, but it was not characterized as fever.
PMID: 26908659 [PubMed - in process]
Prehospital Emergency Care
EMS pros were good at discerning which trauma patients did NOT need lights and sirens (LS) transport but less so those who did. Only 23% of patients transported LS needed a time critical hospital intervention, usually an airway or respiratory intervention. If LS transports can be further reduced, this will decrease the risk of injury or death for EMS pros without increasing risk of harm for patients.
Prehosp Emerg Care. 2016 Mar-Apr;20(2):260-5. doi: 10.3109/10903127.2015.1076094. Epub 2015 Sep 18.
Emergent ambulance transportation is associated with increased risk of collision, injury, and death for EMS professionals, patients, and the general public. Time saved using lights and siren (L&S) is typically small, and often provides minimal clinical benefit. Our objective was to investigate the frequency of L&S transports, describe the precision of the decision to employ L&S to predict the need for a time critical hospital intervention (TCHI) within 15 minutes of hospital arrival, identify clinical predictors of a TCHI, and compare clinical outcomes in patients transported by Emergency Medical Services (EMS) with and without L&S in a trauma-specific population. EMS patient care reports and trauma registry data were retrospectively reviewed for trauma patients consecutively transported from the field by three EMS agencies to three trauma centers within urban and suburban settings over a two-year period. TCHIs were collaboratively developed by the study team. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were utilized to report the precision of the decision to employ L&S to predict the need of a TCHI. Univariate and multivariate analyses determined predictors of a TCHI and compared clinical outcomes. 2,091 patients were included in the study. Of the 19.8% of patients transported with L&S, 22.9% received a TCHI. The most common TCHI was airway or respiratory procedures (87.2% of all TCHI's). The sensitivity and specificity of L&S to predict the need for a TCHI was 87.2% (95% CI 79.4-92.8) and 84.0% (95% CI 82.2-85.5), respectively. PPV was 23.0% (95% CI 23.53-38.01); NPV was 99.2% (95% CI 98.6-99.6). L&S was predictive for the need for a TCHI (p < 0.001), as was abnormal Glasgow Coma Score (p < 0.001), abnormal systolic blood pressure and age (p < 0.05 for all). Among patients that received a TCHI, over a third that were transported with L&S (36.8%) expired, compared with two of 14 patients (14.3%) not transported L&S. EMS professionals in this study demonstrated a high ability to discern which trauma patients did not require L&S. Nevertheless, L&S transport resulted in a TCHI less than one quarter of the time, suggesting an opportunity for further reduction of L&S transports in trauma patients.
PMID: 26382707 [PubMed - in process]
Only 1% of shocks were detected while wearing neoprene gloves or a neoprene shield and none were detected with fire gloves or when using a manual compression/decompression device. Use your discretion on this. I clear the patient and instruct my team to do so during the shock while performing CPR. If compressions are continued during charging, the pause is miniscule. I just don't think the benefit outweighs the risk, but you may come to a different conclusion.
Resuscitation. 2016 Mar 29;103:37-40. doi: 10.1016/j.resuscitation.2016.03.019. [Epub ahead of print]
1University of Texas Health Science Center at San Antonio, Department of Emergency Health Sciences, 4201 Medical Dr. Suite 120, San Antonio, TX, 78229, United States. Electronic address: firstname.lastname@example.org.
2United States Air Force, Military EMS & Disaster Medicine Fellowship, Joint Base San Antonio, San Antonio, TX, United States.
3Bulverde Spring Branch Emergency Services, Centre for Emergency Health Sciences, Spring Branch, TX, United States.
4University of Texas Health Science Center at San Antonio, Department of Emergency Health Sciences, 4201 Medical Dr. Suite 120, San Antonio, TX, 78229, United States.
Chest compressions and defibrillation are the only therapies proven to increase survival in cardiac arrest. Historically, rescuers must remove hands to shock, thereby interrupting chest compressions. This hands-off time results in a zero blood flow state. Pauses have been associated with poorer neurological recovery.
This was a blinded randomized control cadaver study evaluating the detection of defibrillation during manual chest compressions. An active defibrillator was connected to the cadaver in the sternum-apex configuration. The sham defibrillator was not connected to the cadaver. Subjects performed chest compressions using 6 barrier types: barehand, single and double layer nitrile gloves, firefighter gloves, neoprene pad, and a manual chest compression/decompression device. Randomized defibrillations (10 per barrier type) were delivered at 30 joules (J) for bare hand and 360J for all other barriers. After each shock, the subject indicated degree of sensation on a VAS scale.
Ten subjects participated. All subjects detected 30j shocks during barehand compressions, with only 1 undetected real shock. All barriers combined totaled 500 shocks delivered. Five (1%) active shocks were detected, 1(0.2%) single layer of Nitrile, 3(0.6%) with double layer nitrile, and 1(0.2%) with the neoprene barrier. One sham shock was reported with the single layer nitrile glove. No shocks were detected with fire gloves or compression decompression device. All shocks detected barely perceptible (0.25(±0.05)cm on 10cm VAS scale).
Nitrile gloves and neoprene pad prevent (99%) responder's detection of defibrillation of a cadaver. Fire gloves and compression decompression device prevented detection.
PMID: 27036661 [PubMed - as supplied by publisher]