Journal of Emergency Medicine 2015

Treatment


1. J Emerg Med. 2015 Sep;49(3):318-25. doi: 10.1016/j.jemermed.2015.04.008. Epub
2015 Jun 22.

Predictive Role of Admission Lactate Level in Critically Ill Patients with Acute
Upper Gastrointestinal Bleeding.

El-Kersh K(1), Chaddha U(2), Sinha RS(2), Saad M(1), Guardiola J(1), Cavallazzi
R(1).

Author information: 
(1)Department of Pulmonary, Critical Care and Sleep Disorders Medicine,
University of Louisville, Louisville, Kentucky. (2)Department of Internal
Medicine, University of Louisville, Louisville, Kentucky.

BACKGROUND: The predictive role of lactate in critically ill patients with acute
upper gastrointestinal bleeding (UGIB) remains to be elucidated.
OBJECTIVE: The primary objective of this study was to assess the value of lactate
level on admission to predict in-hospital death in patients with UGIB admitted to
the intensive care unit (ICU). The secondary objective was to assess whether
lactate level adds predictive value to the clinical Rockall score in these
patients.
METHODS: This was a retrospective cohort study that included 133 patients with
acute UGIB admitted to the ICU. Inclusion criteria were age > 18 years and
presence of UGIB on admission to the ICU.
RESULTS: Mean age was 55.4 years old and 64.7% were male. The most common cause
of gastrointestinal bleeding was peptic ulcer disease, followed by erosive
esophagitis/gastritis. The in-hospital mortality was 22.6%. Median lactate level
in survivors and nonsurvivors was 2.0 (interquartile range [IQR] 1.2-4.2 mmol/L) 
and 8.8 (IQR 3.4-13.3 mmol/L; p < 0.01), respectively. The receiver operating
characteristic (ROC) area to predict in-hospital death for clinical Rockall score
and lactate level (0.82) was significantly higher than the ROC area for the
clinical Rockall score alone (0.69) (p < 0.01).
CONCLUSIONS: In patients admitted to the ICU with acute UGIB, lactate level on
admission has a high sensitivity but low specificity for predicting in-hospital
death. Lactate level adds to the predictive value of the clinical Rockall score. 
Given its high sensitivity, lactate level can be used in addition to other
prediction tools to predict outcomes in patients with UGIB.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 26113379  [PubMed - in process]


2. J Emerg Med. 2015 Sep;49(3):326-34. doi: 10.1016/j.jemermed.2015.03.023. Epub
2015 Jun 2.

A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous
Metoclopramide for Acute Migraine Therapy in the Emergency Department.

Gaffigan ME(1), Bruner DI(2), Wason C(1), Pritchard A(3), Frumkin K(1).

Author information: 
(1)Naval Medical Center Portsmouth, Portsmouth, Virginia. (2)Naval Medical Center
San Diego, San Diego, California. (3)Naval Hospital Camp Pendleton, Camp
Pendleton, California.

BACKGROUND: Emergency Department (ED) headache patients are commonly treated with
neuroleptic antiemetics like metoclopramide. Haloperidol has been shown to be
effective for migraine treatment.
STUDY OBJECTIVE: Our study compared the use of metoclopramide vs. haloperidol to
treat ED migraine patients.
METHODS: A prospective, double-blinded, randomized control trial of 64 adults
aged 18-50 years with migraine headache and no recognized risks for
QT-prolongation. Haloperidol 5 mg or metoclopramide 10 mg was given intravenously
after 25 mg diphenhydramine. Pain, nausea, restlessness (akathisia), and sedation
were assessed with 100-mm visual analog scales (VAS) at baseline and every 20
min, to a maximum of 80 min. The need for rescue medications, side effects, and
subject satisfaction were recorded. QTc intervals were measured prior to and
after treatment. Follow-up calls after 48 h assessed satisfaction and recurrent
or persistent symptoms.
RESULTS: Thirty-one subjects received haloperidol, 33 metoclopramide. The groups
were similar on all VAS measurements, side effects, and in their satisfaction
with therapy. Pain relief averaged 53 mm VAS over both groups, with equal times
to maximum improvement. Subjects receiving haloperidol required rescue medication
significantly less often (3% vs. 24%, p < 0.02). Mean QTcs were equal and normal
in the two groups and did not change after treatment. In telephone follow-up, 90%
of subjects contacted were "happy with the medication" they had received, with
haloperidol-treated subjects experiencing more restlessness (43% vs. 10%).
CONCLUSIONS: Intravenous haloperidol is as safe and effective as metoclopramide
for the ED treatment of migraine headaches, with less frequent need for rescue
medications.

Published by Elsevier Inc.

PMID: 26048068  [PubMed - in process]


3. J Emerg Med. 2015 Sep;49(3):294-300. doi: 10.1016/j.jemermed.2015.03.005. Epub
2015 May 26.

Falls and Implementation of NEXUS in the Elderly (The FINE Study).

Denver D(1), Shetty A(2), Unwin D(2).

Author information: 
(1)Memorial University of Newfoundland, St. John's, Newfoundland, Canada.
(2)Westmead Hospital Emergency Department, Westmead, Sydney, New South Wales,
Australia.

BACKGROUND: The incidence of cervical spine injuries (CSI) in people over 65
years of age from low-energy mechanisms is far greater than in younger
populations. Algorithms and decision rules exist for selection of trauma patients
requiring cervical spine imaging.
OBJECTIVES: To determine the validity of the NEXUS criteria in the elderly
population with low-mechanism injuries.
METHODS: We prospectively conducted computed tomography (CT) imaging in patients
> 65 years of age presenting with fall from standing height or less to rule out
predefined clinically significant CSI. Eligible patients were prospectively
categorized into NEXUS positive or negative.
RESULTS: There were 169 patients included in the final analyses. One hundred
twenty (71%) patients in the cohort were classified as "NEXUS positive." Eleven
patients (6.5% of the cohort) had CSI detected on CT imaging of the cervical
spine. Nine patients had clinically significant CSI. The NEXUS decision
instrument demonstrated 88.9% sensitivity (50.7-99.4%) and 98% negative
predictive value (NPV) (87.8-99.9%) in detecting clinically significant CSI. The
NEXUS decision instrument demonstrated 81.8% sensitivity (47.8-96.8%) and 95.9%
NPV (84.9-99.3%) in detecting any CSI.
CONCLUSION: In our study, the NEXUS decision instrument was not a valid tool to
rule out imaging for patients > 65 years of age presenting after a fall from
standing height or less. We advocate the liberal use of CT imaging of the
cervical spine in this cohort of patients to rule out cervical spine injury.

Crown Copyright © 2015. Published by Elsevier Inc. All rights reserved.

PMID: 26022935  [PubMed - in process]


4. J Emerg Med. 2015 Oct;49(4):505-12. doi: 10.1016/j.jemermed.2015.05.035. Epub
2015 Aug 1.

Predictors of a Top Performer During Emergency Medicine Residency.

Bhat R(1), Takenaka K(2), Levine B(3), Goyal N(4), Garg M(5), Visconti A(6),
Oyama L(7), Castillo E(7), Broder J(8), Omron R(9), Hayden S(7).

Author information: 
(1)Department of Emergency Medicine, MedStar Georgetown University,
Hospital/MedStar Washington Hospital Center, Washington, DC. (2)Department of
Emergency Medicine, University of Texas, Houston, Texas. (3)Department of
Emergency Medicine, Christiana Care Health System, Newark, Delaware.
(4)Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan.
(5)Department of Emergency Medicine, Temple University Hospital, Philadelphia,
Pennsylvania. (6)Department of Emergency Medicine, New York Methodist Hospital,
Brooklyn, New York. (7)Department of Emergency Medicine, University of California
at San Diego, La Jolla, California. (8)Division of Emergency Medicine, Department
of Surgery, Duke University Hospital, Durham, North Carolina. (9)Department of
Emergency Medicine, Johns Hopkins University Hospital, Baltimore, Maryland.

BACKGROUND: Emergency Medicine (EM) residency program directors and faculty spend
significant time and effort creating a residency rank list. To date, however,
there have been few studies to assist program directors in determining which
pre-residency variables best predict performance during EM residency.
OBJECTIVE: To evaluate which pre-residency variables best correlated with an
applicant's performance during residency.
METHODS: This was a retrospective multicenter sample of all residents in the
three most recent graduating classes from nine participating EM residency
programs. The outcome measure of top residency performance was defined as
placement in the top third of a resident's graduating class based on performance
on the final semi-annual evaluation.
RESULTS: A total of 277 residents from nine institutions were evaluated. Eight of
the predictors analyzed had a significant correlation with the outcome of
resident performance. Applicants' grade during home and away EM rotations,
designation as Alpha Omega Alpha (AOA), U.S. Medical Licensing Examination
(USMLE) Step 1 score, interview scores, "global rating" and "competitiveness" on
nonprogram leadership standardized letter of recommendation (SLOR), and having
five or more publications or presentations showed a significant association with
residency performance.
CONCLUSION: We identified several predictors of top performers in EM residency:
an honors grade for an EM rotation, USMLE Step 1 score, AOA designation,
interview score, high SLOR rankings from nonprogram leadership, and completion of
five or more presentations and publications. EM program directors may consider
utilizing these variables during the match process to choose applicants who have
the highest chance of top performance during residency.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 26242925  [PubMed - in process]


5. J Emerg Med. 2015 Oct;49(4):530-8. doi: 10.1016/j.jemermed.2015.05.016. Epub 2015
Jul 31.

Does Management of Diabetic Ketoacidosis with Subcutaneous Rapid-acting Insulin
Reduce the Need for Intensive Care Unit Admission?

Cohn BG(1), Keim SM(2), Watkins JW(1), Camargo CA(3).

Author information: 
(1)Division of Emergency Medicine, Washington University School of Medicine, St. 
Louis, Missouri. (2)Department of Emergency Medicine, The University of Arizona
College of Medicine, Tucson, Arizona. (3)Departments of Emergency Medicine and
Medicine, Harvard Medical School and Massachusetts General Hospital, Boston,
Massachusetts.

BACKGROUND: In the last 20 years, rapid-acting insulin analogs have emerged on
the market, including aspart and lispro, which may be efficacious in the
management of diabetic ketoacidosis (DKA) when administered by non-intravenous
(i.v.) routes.
CLINICAL QUESTION: In patients with mild-to-moderate DKA without another reason
for intensive care unit (ICU) admission, is the administration of a subcutaneous
(s.c.) rapid-acting insulin analog a safe and effective alternative to a
continuous infusion of i.v. regular insulin, and would such a strategy eliminate
the need for ICU admission?
EVIDENCE REVIEW: Five randomized controlled trials were identified and critically
appraised.
RESULTS: The outcomes suggest that there is no difference in the duration of
therapy required to resolve DKA with either strategy.
CONCLUSION: Current evidence supports DKA management with s.c. rapid-acting
insulin analogs in a non-ICU setting in carefully selected patients.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 26238182  [PubMed - in process]


6. J Emerg Med. 2015 Oct;49(4):561-72. doi: 10.1016/j.jemermed.2015.02.023. Epub
2015 Apr 3.

Is Platelet Transfusion Effective in Patients Taking Antiplatelet Agents Who
Suffer an Intracranial Hemorrhage?

Leong LB(1), David TK(2).

Author information: 
(1)Emergency Department, Jurong Health Services, Singapore. (2)Emergency
Department, Tan Tock Seng Hospital, Singapore.

BACKGROUND: Patients taking antiplatelet agents (APAs) with intracranial
hemorrhage (ICH) may be treated with platelet transfusion.
OBJECTIVES: We conducted a systematic review of the use of platelet transfusion
in the management of APA-related ICH.
METHODS: We searched the Cochrane, Medline, Embase, and CINAHL databases.
Included studies were randomized, case-controlled, or cohort studies comparing
outcomes in adult patients with APA-related ICH who received or did not receive
platelet transfusion. Study quality was measured using appropriate scores. The
primary outcome of interest was in-hospital mortality rate. Secondary outcomes
included rates of craniotomy, neurological, medical, or radiological
deterioration; mean length of hospital stay, delayed mortality, and functional
status at discharge. We reported proportions, medians with interquartile ranges, 
and pooled odds ratios with their 95% confidence intervals. p values < 0.05 were
considered statistically significant.
RESULTS: There were no randomized controlled trials. Seven retrospective cohort
studies (four traumatic, three primary ICH) were included. For APA-related
traumatic ICH, the pooled odds ratio (OR) for in-hospital mortality with platelet
transfusion was 1.77 (95% confidence interval [CI] 1.00-3.13). There were no
statistically significant differences for secondary outcomes except for
proportion with medical decline (6/44 vs. 2/64; p = 0.006). For APA-related
primary ICH, the pooled OR for in-hospital mortality with platelet transfusion
was 0.49 (95% CI 0.24-0.98). There were no statistically significant differences
for most secondary outcomes between the two groups. These studies had important
methodological limitations.
CONCLUSIONS: The evidence for platelet transfusion in APA-related ICH was
inconclusive due to methodological limitations.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 25843922  [PubMed - in process]


7. J Emerg Med. 2015 Nov;49(5):816-24. doi: 10.1016/j.jemermed.2015.02.051. Epub
2015 Oct 23.

Safety and Effectiveness of Topical Anesthetics in Corneal Abrasions: Systematic
Review and Meta-Analysis.

Puls HA(1), Cabrera D(1), Murad MH(2), Erwin PJ(3), Bellolio MF(4).

Author information: 
(1)Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota.
(2)Division of Preventive Medicine, Health Sciences Research, Mayo Clinic,
Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of
Health Care Delivery, Mayo Clinic, Rochester, Minnesota. (3)Medical Library, Mayo
Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the
Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota. (4)Department
of Emergency Medicine, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia
E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester,
Minnesota.

BACKGROUND: Topical anesthetics are used in the emergency department (ED) to
relieve eye pain and allow eye examinations in patients with corneal abrasions.
There is concern for delayed corneal healing, which is associated with the
long-term use of topical anesthetics, so outpatient use is not recommended.
OBJECTIVES: We sought to systematically study the effectiveness and complications
associated with the short-term use of topical anesthetics (≤72 hours) in the
management of patients presenting to EDs with corneal abrasions.
METHODS: Four electronic databases were searched from inception of the database
until April 2014. We included studies of patients >16 years of age who were using
topical anesthetics for <72 hours. Postoperative cases were not included.
RESULTS: A total of 140 patients (68 in the intervention group and 72 in the
control group) from 2 randomized trials were included in the analysis. Comparing
control patients who did not use topical anesthetics to study patients who did
use topical anesthetics, this meta-analysis found no significant difference in
pain scores (standardized mean difference -1.01 [95% confidence interval {CI}
-2.39 to 0.38), corneal healing (OR 1.31 [95% CI 0.53-3.27), or persistent
symptoms (OR 0.98 [95% CI 0.06-16.69). The 2 trials reported no adverse effects.
CONCLUSION: There were no differences regarding pain, persistent symptoms, or
corneal healing when comparing short-term use of topical anesthetics to placebo
in the treatment of corneal abrasion. Data on safety are sparse, and the use
of this treatment is currently not supported by evidence.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 26472608  [PubMed - in process]


8. J Emerg Med. 2015 Nov;49(5):810-5. doi: 10.1016/j.jemermed.2015.06.069. Epub 2015
Aug 15.

The Safety of Topical Anesthetics in the Treatment of Corneal Abrasions: A
Review.

Swaminathan A(1), Otterness K(1), Milne K(2), Rezaie S(3).

Author information: 
(1)Department of Emergency Medicine, New York University School of
Medicine/Bellevue Hospital, New York, New York. (2)Schulich School of Medicine
and Dentistry, Western University, London, Ontario, Canada. (3)University of
Texas Health Science Center, San Antonio, Texas.

BACKGROUND: Despite the fact that topical anesthetics provide superb analgesia to
the painful eye, they are not prescribed routinely to patients when they are
discharged from the emergency department because of concerns for delayed healing
and corneal erosion.
OBJECTIVE: To summarize the evidence for the safety of topical proparacaine and
tetracaine for pain relief in patients with corneal abrasions.
METHODS: This is a systematic review looking at the use of topical anesthetic
agents in the treatment of corneal abrasions in the emergency department.
RESULTS: Our literature search produced two emergency department-based,
randomized, double blind, placebo-controlled studies on human patients with
corneal abrasions. Additionally, we found four studies that investigated the
application of topical anesthetics in patients who underwent photorefractive
keratectomy. All six studies demonstrated that a short course of dilute topical
anesthetic provided efficacious analgesia without adverse effects or delayed
epithelial healing.
CONCLUSION: Limited available data suggests that the use of dilute topical
ophthalmologic proparacaine or tetracaine for a short duration of time is
effective, though their safety for outpatient use is inconclusive.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 26281814  [PubMed - in process]


9. J Emerg Med. 2015 Nov;49(5):799-809. doi: 10.1016/j.jemermed.2015.05.038. Epub
2015 Aug 4.

Safety of Epinephrine in Digital Nerve Blocks: A Literature Review.

Ilicki J(1).

Author information: 
(1)Department of Emergency Medicine, Karolinska University Hospital, Solna,
Stockholm, Sweden.

BACKGROUND: Digital nerve blocks are commonly performed in emergency departments.
Health care practitioners are often taught to avoid performing blocks with
epinephrine due to a risk of digital necrosis.
OBJECTIVE: To review the literature on the safety of epinephrine
1:100,000-200,000 (5-10 μg/mL) with local anesthetics in digital nerve blocks in
healthy patients and in patients with risk for poor peripheral circulation.
METHODS: PubMed, Web of Science, and the Cochrane Library were searched in June
2014 using the query "digital block AND epinephrine OR digital block AND
adrenaline". The searches were performed without any limits.
RESULTS: Sixty-three articles were identified, and 39 of these were found to be
relevant. These include nine reviews, 12 randomized control trials, and 18 other
articles. Most studies excluded patients with risk for poor peripheral
circulation. Two studies described using epinephrine on patients with vascular
comorbidities. No study reported digital necrosis or gangrene attributable to
epinephrine, either in healthy patients or in patients with risk for poor
peripheral circulation. In total, at least 2797 digital nerve blocks with
epinephrine have been performed without any complications.
CONCLUSIONS: Epinephrine 1:100,000-200,000 (5-10 μg/mL) is safe to use in digital
nerve blocks in healthy patients. Physiological studies show epinephrine-induced
vasoconstriction to be transient. There are no reported cases of
epinephrine-induced harm to patients with risk for poor peripheral circulation
despite a theoretical risk of harmful epinephrine-induced vasoconstriction. A
lack of reported complications suggests that the risk of epinephrine-induced
vasoconstriction to digits may be overstated.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 26254284  [PubMed - in process]


10. J Emerg Med. 2015 Mar;48(3):387-97. doi: 10.1016/j.jemermed.2014.10.009. Epub
2014 Dec 19.

Intravenous lipid emulsion in the emergency department: a systematic review of
recent literature.

Cao D(1), Heard K(2), Foran M(3), Koyfman A(4).

Author information: 
(1)Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority,
Denver, Colorado; Department of Emergency Medicine, University of Colorado School
of Medicine, Aurora, Colorado. (2)Department of Emergency Medicine, University of
Colorado School of Medicine, Aurora, Colorado. (3)Department of Emergency
Medicine, New York University School of Medicine, Bellevue Hospital Center, New
York, New York. (4)Department of Emergency Medicine, University of Texas at
Southwestern Medical Center and Parkland Memorial Hospital, Dallas, Texas.

BACKGROUND: Intravenous lipid emulsion (ILE) has been broadly attempted in the
resuscitation of neurologic and cardiac toxic drug overdoses, however, the role
of ILE in the emergency department is poorly defined.
OBJECTIVE: This review aims to identify recent literature on the use of ILE in
humans as an antidote and to familiarize emergency providers with the
indications, availability, dosing recommendations, and adverse reactions
associated with ILE use.
METHODS: A systemic literature search of MEDLINE, EMBASE, and major toxicology
conference abstracts was performed for human cases using ILE as an antidote with
documented clinical outcomes through January 2014.
RESULTS: Ninety-four published articles and 40 conference abstracts were
identified, 85% of which had positive outcomes. The most common indication for
ILE was for local anesthetic systemic toxicity (LAST). The most common nonlocal
anesthetic xenobiotics were tricyclic-antidepressants and verapamil.
DISCUSSION: No standard of care is defined for the use of ILE, although the
American Heart Association recommends use in LAST, and the American College of
Medical Toxicology recommends consideration for circumstances of hemodynamic
instability resultant from lipid-soluble xenobiotics. ILE should be administered
per American Society of Regional Anesthesia and Pain Medicine dosing
recommendations. Laboratory interference, pancreatitis, respiratory distress
syndrome, and interference with vasopressors should be considered as risks but
are uncommon.
CONCLUSIONS: In the setting of severe hemodynamic compromise by lipid-soluble
xenobiotics, ILE may be considered for resuscitation by emergency physicians. As
such, ILE may be stocked in emergency departments in close proximity to
resuscitation rooms and areas where local nerve blocks are performed.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 25534900  [PubMed - in process]


11. J Emerg Med. 2015 Jul;49(1):91-7. doi: 10.1016/j.jemermed.2014.12.024. Epub 2015
Mar 30.

American Academy of Emergency Medicine Position Statement: Safety of Droperidol
Use in the Emergency Department.

Perkins J(1), Ho JD(2), Vilke GM(3), DeMers G(4).

Author information: 
(1)Department of Emergency Medicine, University of Minnesota Medical School,
Minneapolis, Minnesota; Department of Emergency Medicine, Hennepin County Medical
Center, Minneapolis, Minnesota. (2)Department of Emergency Medicine, Virginia
Tech Carilion School of Medicine, Roanoke, Virginia. (3)Department of Emergency
Medicine, University of California at San Diego Medical Center, San Diego,
California. (4)Department of Emergency Medicine, Naval Medical Center San Diego, 
San Diego, California.

BACKGROUND: Droperidol (Inapsine®, Glaxosmithkline, Brent, UK) is a butyrophenone
used in emergency medicine practice for a variety of uses. QT prolongation is a
well-known adverse effect of this class of medications. Of importance to note, QT
prolongation is noted with multiple medication classes, and droperidol increases
QT interval in a dose-dependent fashion among susceptible individuals. The
primary goal of this literature search was to determine the reported safety
issues of droperidol in emergency department management of patients.
METHODS: A MEDLINE literature search was conducted from January 1995 to January
2014 and limited to human studies written in English for articles with keywords
of droperidol/Inapsine. Guideline statements and nonsystematic reviews were
excluded. Studies identified then underwent a structured review from which
results could be evaluated.
RESULTS: There were 542 papers on droperidol screened, and 35 appropriate
articles were rigorously reviewed in detail and recommendations given.
CONCLUSION: Droperidol is an effective and safe medication in the treatment of
nausea, headache, and agitation. The literature search did not support mandating
an electrocardiogram or telemetry monitoring for doses < 2.5 mg given either
intramuscularly or intravenously. Intramuscular doses of up to 10 mg of
droperidol seem to be as safe and as effective as other medications used for
sedation of agitated patients.

Published by Elsevier Inc.

PMID: 25837231  [PubMed - in process]


12. J Emerg Med. 2015 Aug;49(2):175-82. doi: 10.1016/j.jemermed.2015.01.014. Epub
2015 Apr 22.

Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with
Rapid Ventricular Rate in the Emergency Department.

Fromm C(1), Suau SJ(1), Cohen V(2), Likourezos A(1), Jellinek-Cohen S(1), Rose
J(1), Marshall J(1).

Author information: 
(1)Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New
York. (2)Department of Emergency Medicine, Maimonides Medical Center, Brooklyn,
New York; Arnold & Marie College of Pharmacy and Allied Health Sciences,
Brooklyn, New York.

BACKGROUND: Diltiazem (calcium channel blocker) and metoprolol (beta-blocker) are
both commonly used to treat atrial fibrillation/flutter (AFF) in the emergency
department (ED). However, there is considerable regional variability in emergency
physician practice patterns and debate among physicians as to which agent is more
effective. To date, only one small prospective, randomized trial has compared the
effectiveness of diltiazem and metoprolol for rate control of AFF in the ED and
concluded no difference in effectiveness between the two agents.
OBJECTIVE: Our aim was to compare the effectiveness of diltiazem with metoprolol
for rate control of AFF in the ED.
METHODS: A convenience sample of adult patients presenting with rapid atrial
fibrillation or flutter was randomly assigned to receive either diltiazem or
metoprolol. The study team monitored each subject's systolic and diastolic blood
pressures and heart rates for 30 min.
RESULTS: In the first 5 min, 50.0% of the diltiazem group and 10.7% of the
metoprolol group reached the target heart rate (HR) of <100 beats per minute
(bpm) (p < 0.005). By 30 min, 95.8% of the diltiazem group and 46.4% of the
metoprolol group reached the target HR < 100 bpm (p < 0.0001). Mean decrease in
HR for the diltiazem group was more rapid and substantial than that of the
metoprolol group. From a safety perspective, there was no difference between the
groups with respect to hypotension (systolic blood pressure < 90 mm Hg) and
bradycardia (HR < 60 bpm).
CONCLUSIONS: Diltiazem was more effective in achieving rate control in ED
patients with AFF and did so with no increased incidence of adverse effects.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 25913166  [PubMed - in process]


13. J Emerg Med. 2014 Dec;47(6):638-45. doi: 10.1016/j.jemermed.2014.07.056. Epub
2014 Oct 1.

Prospective evaluation of prehospital trauma ultrasound during aeromedical
transport.

Press GM(1), Miller SK(1), Hassan IA(2), Alade KH(1), Camp E(3), Junco DD(3),
Holcomb JB(3).

Author information: 
(1)Department of Emergency Medicine, University of Texas Medical School at
Houston, Houston, Texas. (2)Department of Internal Medicine, University of Texas
Medical School at Houston, Houston, Texas. (3)Department of Surgery and The
Center for Translational Injury Research, University of Texas Medical School at
Houston, Houston, Texas.

BACKGROUND: Ultrasound is widely considered the initial diagnostic imaging
modality for trauma. Preliminary studies have explored the use of trauma
ultrasound in the prehospital setting, but the accuracy and potential utility is
not well understood.
OBJECTIVE: We sought to determine the accuracy of trauma ultrasound performed by
helicopter emergency medical service (HEMS) providers.
METHODS: Trauma ultrasound was performed in flight on adult patients during a
7-month period. Accuracy of the abdominal, cardiac, and lung components was
determined by comparison to the presence of injury, primarily determined by
computed tomography, and to required interventions.
RESULTS: HEMS providers performed ultrasound on 293 patients during a 7-month
period, completing 211 full extended Focused Assessment with Sonography for
Trauma (EFAST) studies. HEMS providers interpreted 11% of studies as
indeterminate. Sensitivity and specificity for hemoperitoneum was 46% (95%
confidence interval [CI] 27.1%-94.1%) and 94.1% (95% CI 89.2%-97%), and for
laparotomy 64.7% (95% CI 38.6%-84.7%) and 94% (95% CI 89.2%-96.8%), respectively.
Sensitivity and specificity for pneumothorax were 18.7% (95% CI 8.9%-33.9%) and
99.5% (95% CI 98.2%-99.9%), and for thoracostomy were 50% (95% CI 22.3%-58.7%)
and 99.8% (98.6%-100%), respectively. The positive likelihood ratio for
laparotomy was 10.7 (95% CI 5.5-21) and for thoracostomy 235 (95% CI 31-1758),
and the negative likelihood ratios were 0.4 (95% CI 0.2-0.7) and 0.5 (95% CI
0.3-0.8), respectively. Of 240 cardiac studies, there was one false-positive and
three false-negative interpretations (none requiring intervention).
CONCLUSIONS: HEMS providers performed EFAST with moderate accuracy. Specificity
was high and positive interpretations raised the probability of injury requiring
intervention. Negative interpretations were predictive, but sensitivity was not
sufficient for ruling out injury.

Copyright © 2014 Elsevier Inc. All rights reserved.

PMID: 25281177  [PubMed - indexed for MEDLINE]

Diagnostic

None

Review

None

Clinical Prediction Rules

None