Emergency Medicine Journal 2015

Treatment


1. Emerg Med J. 2015 Nov 26. pii: emermed-2015-204908. doi:
10.1136/emermed-2015-204908. [Epub ahead of print]

The test characteristics of physician clinical gestalt for determining the
presence and severity of anaemia in patients seen at the emergency department of
a tertiary referral hospital in Tanzania.

Sawe HR(1), Mfinanga JA(1), Mwafongo V(1), Reynolds TA(2), Runyon MS(3).

Author information: 
(1)Emergency Medicine Department, Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania Emergency Medicine Department, Muhimbili
National Hospital, Dar es Salaam, Tanzania. (2)Emergency Medicine Department,
Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
Department of Emergency Medicine and Global Health Sciences, University of
California San Francisco, San Francisco, California, USA. (3)Emergency Medicine
Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam,
Tanzania Department of Emergency Medicine, Carolinas Medical Center, Charlotte,
North Carolina, USA.

OBJECTIVES: To evaluate the test characteristics of clinical gestalt for
detecting the presence and severity of anaemia in emergency department patients
at a tertiary referral hospital in Tanzania.
METHODS: This prospective study enrolled a convenience sample of emergency
department patients who had a complete blood count ordered by the treating
physician in the course of their clinical care. Physicians recorded their
impression of the presence and severity of anaemia before viewing the laboratory
results. To assess interobserver agreement, a second physician provided their
blinded gestalt impression of the patient's haemoglobin level.
RESULTS: We enrolled 216 patients and complete data were available for 210
patients (97%), 59% male, median age 30 years. The range of measured haemoglobin
values was 1.5-15.4 g/dL. The physicians rated anaemia mild or absent in 74
(35%), moderate in 72 (34%) and severe in 64 patients (30%). These estimates were
significantly concordant with the laboratory haemoglobin measurements (Kendall's
τ b=0.63, 95% CI 0.57 to 0.69, p<0.0001). The test characteristics of physician
gestalt estimates for severe anaemia were: sensitivity 64% (95% CI 53% to 74%),
specificity 91% (95% CI 85% to 96%), positive likelihood ratio of 7.4 (95% CI 4.2
to 13.3) and negative likelihood ratio of 0.40 (0.3 to 0.5). The weighted Cohen's
κ for interobserver agreement between physicians on the gestalt estimate of the
degree of anaemia was 0.87 (95% CI 0.76 to 0.98).
CONCLUSION: Physicians' estimates of the severity of anaemia were significantly
concordant with laboratory haemoglobin measurements. Sensitivity of the gestalt
estimate for severe anaemia was moderate. Interobserver agreement was 'almost
perfect'.

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PMID: 26612857  [PubMed - as supplied by publisher]


2. Emerg Med J. 2015 Nov;32(11):860-3. doi: 10.1136/emermed-2014-204378. Epub 2015
Jan 29.

Predictors of infection from dog bite wounds: which patients may benefit from
prophylactic antibiotics?

Tabaka ME(1), Quinn JV(2), Kohn MA(3), Polevoi SK(4).

Author information: 
(1)Stanford Emergency Department, Stanford School of Medicine, Stanford,
California, USA. (2)Department of Surgery/Emergency Medicine, Stanford
University, Stanford, California, USA. (3)Department of Epidemiology and
Biostatistics, University of California, San Francisco, California, USA.
(4)Department of Emergency Medicine, University of California, San Francisco,
California, USA.

OBJECTIVES: To determine a current infection rate of dog bite wounds and
predictors of wounds at risk for infection that may benefit from prophylactic
antibiotics.
METHODS: A prospective multicentre observational study was conducted over
4.5 years. At the time of treatment Emergency Physicians completed a structured
data form evaluating patient, wound and treatment characteristics of patients
with dog bite wounds. Patients were followed up at 30 days to assess for
infection. Predictor variables were analysed with univariate analysis, using
either χ(2), parametric or nonparametric methods where appropriate. Significant
variables and those with important interactions on univariate analysis were
considered in a logistic regression (LR) analysis.
RESULTS: 495 patients with dog bites were enrolled and 345 had complete
follow-up. Eighteen patients (5.2%, 95% CI 3.1% to 8.1%) had bites that became
infected. On univariate analysis, only puncture wounds were found to be
significantly associated with infection RR 2.8 (95% CI 1.2 to 6.9). However,
location and wound closure met criteria for entry into the model having important
interactions; facial wounds had a higher risk of infection than anticipated but
were also more likely to be closed (p < 0.0001). A LR model considering puncture
wounds, wound closure and wound location found that puncture wounds (OR 4.1 [95% 
CI 1.4 to 11.7]) and wound closure (OR 3.1 [95% CI 1.03 to 9.0]) were independent
predictors of infection. The incidence of infection in wounds that were not
punctured or closed during treatment was only 2.6% (95% CI 0.7% to 6.5%).
CONCLUSIONS: Puncture wounds or wounds closed during treatment are dog bite
wounds at a high risk of infection and should be considered for treatment with
prophylactic antibiotics.

Published by the BMJ Publishing Group Limited. For permission to use (where not
already granted under a licence) please go to
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PMID: 25634096  [PubMed - in process]


3. Emerg Med J. 2015 Mar;32(3):174-9. doi: 10.1136/emermed-2013-203200. Epub 2014
Jan 13.

A simple tool to predict admission at the time of triage.

Cameron A(1), Rodgers K(2), Ireland A(3), Jamdar R(1), McKay GA(1).

Author information: 
(1)Acute Medicine Unit, Glasgow Royal Infirmary, Glasgow, UK. (2)Medical School, 
University of Glasgow, Glasgow, UK. (3)Emergency Department, Glasgow Royal
Infirmary, Glasgow, UK.

AIM: To create and validate a simple clinical score to estimate the probability
of admission at the time of triage.
METHODS: This was a multicentre, retrospective, cross-sectional study of triage
records for all unscheduled adult attendances in North Glasgow over 2 years.
Clinical variables that had significant associations with admission on logistic
regression were entered into a mixed-effects multiple logistic model. This
provided weightings for the score, which was then simplified and tested on a
separate validation group by receiving operator characteristic (ROC) analysis and
goodness-of-fit tests.
RESULTS: 215 231 presentations were used for model derivation and 107 615 for
validation. Variables in the final model showing clinically and statistically
significant associations with admission were: triage category, age, National
Early Warning Score (NEWS), arrival by ambulance, referral source and admission
within the last year. The resulting 6-variable score showed excellent
admission/discharge discrimination (area under ROC curve 0.8774, 95% CI 0.8752 to
0.8796). Higher scores also predicted early returns for those who were
discharged: the odds of subsequent admission within 28 days doubled for every
7-point increase (log odds=+0.0933 per point, p<0.0001).
CONCLUSIONS: This simple, 6-variable score accurately estimates the probability
of admission purely from triage information. Most patients could accurately be
assigned to 'admission likely', 'admission unlikely', 'admission very unlikely'
etc., by setting appropriate cut-offs. This could have uses in patient streaming,
bed management and decision support. It also has the potential to control for
demographics when comparing performance over time or between departments.

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already granted under a licence) please go to
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PMCID: PMC4345772
PMID: 24421344  [PubMed - in process]


4. Emerg Med J. 2015 Jun 22. pii: emermed-2014-204230. doi:
10.1136/emermed-2014-204230. [Epub ahead of print]

Should we be looking for and treating isolated calf vein thrombosis?

Horner D(1), Hogg K(2), Body R(3).

Author information: 
(1)Emergency Department, Manchester Royal Infirmary, Central Manchester
University Hospitals NHS Foundation Trust, Manchester, UK. (2)Department of
Medicine, Thrombosis and Emergency Medicine, McMaster University, West Hamilton, 
Ontario, Canada. (3)Emergency Department, Manchester Royal Infirmary, Central
Manchester University Hospitals NHS Foundation Trust, Manchester, UK The
University of Manchester, Manchester, UK.

Management of isolated calf deep vein thrombosis is an area of significant
international debate and variable clinical practice. Both therapeutic
anticoagulation and conservative management carry risk. As clinical care of
suspected and confirmed venous thromboembolic disease increasingly becomes the
remit of emergency medicine, complex decisions are left to practising clinicians
at the front door. We aim to provide a contemporary overview of recent evidence
on this topic and associated challenges facing clinicians. Given the lack of
high-level evidence, we present this work as a narrative review, based on
structured literature review and expert opinion. A decision to manage calf
thrombosis is principally dependent on the risk of complications without
treatment balanced against the risks of therapeutic anticoagulation. Estimates of
the former risks taken from systematic review, meta-analysis, observational
cohort and recent pilot trial evidence include proximal propagation 7%-10%,
pulmonary embolism 2%-3% and death <1%. Fatal bleeding with therapeutic
anticoagulation stands at <0.5%, and major bleeding at approximately 2%.
Estimates of haemorrhagic risk are based on robust data from large prospective
management studies of venous thromboembolic disease; the risks of untreated calf
deep vein thrombosis are based on small cohorts and therefore less exact. Pending
further trial evidence, these risks should be discussed with patients openly, in
the context of personal preference and shared decision-making. Anticoagulation
may maximally benefit those patients with extensive and/or symptomatic disease or
those with higher risk for complication (unprovoked, cancer-associated or
pregnancy).

Published by the BMJ Publishing Group Limited. For permission to use (where not
already granted under a licence) please go to
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PMID: 26101406  [PubMed - as supplied by publisher]


5. Emerg Med J. 2015 Jan;32(1):32-5. doi: 10.1136/emermed-2013-203352. Epub 2014 Feb
19.

CORKSCREW 2013 CORK study of children's realistic estimation of weight.

Skrobo D(1), Kelleher G(1).

Author information: 
(1)Emergency Department, Cork University Hospital, Cork, Ireland.

BACKGROUND: In a resuscitation situation involving a child (age 1-15 years) it is
crucial to obtain a weight as most interventions and management depend on it. The
APLS formula, '2×(age+4)', is taught via the APLS course and is widely used in
Irish hospitals. As the prevalence of obesity is increasing the accuracy of the
formula has been questioned and a newer formula has been suggested, the Luscombe
and Owens (LO) formula, '(3×age)+7'.
AIMS AND OBJECTIVES: To gather data on the weights and ages of the Cork
paediatric population (ages 1-15 years) attending services at the Cork University
Hospital (CUH), and to identify which of the two age-based weight estimation
formulae has best diagnostic accuracy.
SETTING: CUH, Ireland's only level one trauma centre.
METHODS: Retrospective data collection from charts in the Emergency Department,
Paediatric Assessment Unit and the Paediatric wards of CUH.
RESULTS: 3155 children aged 1-15 years were included in the study. There were
1344 girls and 1811 boys. The formula weight='2×(age+4)' underestimated
children's weights by a mean of 20.3% (95% CI 19.7% to 20.9%) for the ages of
1-15 years. The LO formula weight='(3×age)+7' showed a mean underestimation of
4.0% (95% CI 3.3% to 4.6%) for the same age range.
CONCLUSIONS: The LO formula has been validated in several studies and proven to
be a superior age-based weight estimation formula in many western emergency
departments. This study shows that the LO formula leads to less underestimation
of weights in Irish children than the APLS formula. It is a simple, safe and more
accurate age-based estimation formula that can be used over a large age range
(1-15 years).

Published by the BMJ Publishing Group Limited. For permission to use (where not
already granted under a licence) please go to
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PMID: 24554448  [PubMed - indexed for MEDLINE]


6. Emerg Med J. 2015 Dec;32(12):916-20. doi: 10.1136/emermed-2014-203959. Epub 2015
Feb 5.

The effect of preinjury warfarin use on mortality rates in trauma patients: a
European multicentre study.

Lecky FE(1), Omar M(2), Bouamra O(1), Jenks T(1), Edwards A(1), Battle CE(3),
Evans PA(1).

Author information: 
(1)The Trauma Audit and Research Network, University of Manchester, Salford, UK. 
(2)NISCHR Haemostasis Biomedical Research Unit, Morriston Hospital, Swansea,
Wales. (3)NISCHR Haemostasis Biomedical Research Unit, Epidemiology Division,
Morriston Hospital, Swansea, Wales.

OBJECTIVE: To define the relationship between preinjury warfarin use and
mortality in a large European sample of trauma patients.
METHODS: A multicentred study was conducted using data collated from European
(predominately English and Welsh) trauma receiving hospitals. Patient data from
the Trauma Audit and Research Network database from 2009 to 2013 were analysed.
Univariate and multivariate logistic regression was used to estimate OR for
mortality associated with preinjury warfarin use in the whole adult trauma cohort
and a matched sample of patients comparable in terms of age, gender, GCS,
pre-existing medical conditions and injury severity.
RESULTS: A total of 136 617 adult trauma patients (2009-2013) were included, with
499 patients reported to be using warfarin therapy at the time of trauma.
Preinjury warfarin use was associated with a significantly higher mortality rate
at 30 days postinjury compared with the non-users. Following adjustment of age,
injury severity and GCS, preinjury warfarin use was associated with increased
mortality in trauma patients (adjusted OR 2.14; 95% CI 1.66 to 2.76; p<0.001). In
the matched subset, 22% of warfarinised trauma patients died compared with 16.3% 
of non-warfarinised trauma patients with comparable age, injury severity and GCS
(adjusted OR 1.94; 95% CI 1.25 to 3.01; p=0.003).
CONCLUSIONS: Preinjury warfarin use has been demonstrated to be an independent
predictor of mortality in trauma patients. Clinicians managing major trauma
patients on warfarin need to be aware of the vulnerability of this group.

Published by the BMJ Publishing Group Limited. For permission to use (where not
already granted under a licence) please go to
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PMID: 25656561  [PubMed - in process]


7. Emerg Med J. 2014 Dec;31(12):980-5. doi: 10.1136/emermed-2013-202479. Epub 2013
Aug 23.

Assessment of the impact on time to complete medical record using an electronic
medical record versus a paper record on emergency department patients: a study.

Perry JJ(1), Sutherland J(2), Symington C(2), Dorland K(2), Mansour M(2), Stiell
IG(1).

Author information: 
(1)Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario,
Canada. (2)Clinical Epidemiology Program, Ottawa Hospital Research Institute,
Ottawa, Ontario, Canada.

BACKGROUND: Electronic medical records are becoming an integral part of
healthcare delivery.
OBJECTIVE: The goal of this study was to compare paper documentation versus
electronic medical record for non-traumatic chest pain to determine differences
in time for physicians to complete medical records using paper versus electronic
mediums. We also assessed physician satisfaction with the electronic format.
METHODS: We conducted this before-after study in a single large tertiary care
academic emergency department. In the 'Before Period', stopwatches determined the
time for paper medical recording. In the 'After Period', a template-based
electronic medical record was introduced and the time for electronic recording
was measured. The time to record in the before and after periods were compared
using a two-sided t test. We surveyed physicians to assess satisfaction.
RESULTS: We enrolled 100 non-traumatic patients with chest pain in the before
period and 73 in the after period. The documentation time was longer using
electronic charting, (9.6±5.9 min vs 6.1±2.5 min; p<0.001). 18 of 20 physicians
participating in the after period completed surveys. Physicians were not
satisfied with the electronic patient recording for non-traumatic chest pain.
CONCLUSIONS: This is the first study that we are aware of which compared paper
versus electronic medical records in the emergency department. Electronic
recording took longer than paper records. Physicians were not satisfied using
this electronic record. Given the time pressures on emergency physicians, a
solution to minimise the charting time using electronic medical records must be
found before widespread uptake of electronic charting will be possible.

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.

PMID: 23975593  [PubMed - indexed for MEDLINE

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