Annals of Emergency Medicine - Articles in Press

Older Patients in the Emergency Department: A Review - Corrected Proof

Nikolaos Samaras, Thierry Chevalley, Dimitrios Samaras, Gabriel Gold — 2010-07-12

Older patients account for up to a quarter of all emergency department (ED) visits. Atypical clinical presentation of illness, a high prevalence of cognitive disorders, and the presence of multiple comorbidities complicate their evaluation and management. Increased frailty, delayed diagnosis, and greater illness severity contribute to a higher risk of adverse outcomes. This article will review the most common conditions encountered in older patients, including delirium, dementia, falls, and polypharmacy, and suggest simple and efficient strategies for their evaluation and management. It will discuss age-related changes in the signs and symptoms of acute coronary events, abdominal pain, and infection, examine the yield of different diagnostic approaches in this population, and list the underlying medical problems present in half of all “social” admission cases. Complete geriatric assessments are time consuming and beyond the scope of most EDs. We propose a strategy based on the targeting of high-risk patients and provide examples of simple and efficient tools that are appropriate for ED use.

Evidence-Based Emergency Medicine: Clinical Synopsis - Corrected Proof

Raj Vadera — 2010-07-12

MethodsData Sources: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and references in review articles were searched. The authors also attempted to identify the grey literature by contacting trialists.Study Selection: Randomized controlled trials that enrolled patients with hypertensive emergencies in which a selected antihypertensive agent was compared with placebo, no treatment, or another drug in a different class. Fifteen randomized controlled trials with 869 patients met the inclusion criteria.Data Extraction: Two reviewers extracted data from the included studies and selected studies independently. Discrepancies were resolved by discussion or a third reviewer. Primary outcome measures were total serious adverse events, all-cause mortality, and composite of nonfatal cardiovascular events (ie, unstable angina, aortic dissection, acute renal failure, stroke, respiratory failure). Secondary outcome measures were weighted mean difference in systolic pressure, diastolic blood pressure, pulse rate, and withdrawal because of adverse events. The adequacy of concealment and blinding was assessed.Main Results: Almost all of the trials (14/15) were open label. Because of insufficient data, no meta-analysis could be performed on clinical outcomes. Pooling the effect of 3 antihypertensives (calcium-channel blockers, angiotensin-converting enzyme inhibitors, and α-1 adrenergic antagonists) from a single placebo controlled study showed a statistically significant reduction in both systolic (weighted mean difference –13; 95% confidence interval –19 to –7 mm Hg) and diastolic (weighted mean difference –8; 95% confidence interval –12 to –3 mm Hg) blood pressure.Conclusions: In patients presenting with a hypertensive emergency, randomized controlled trial evidence that antihypertensive drug therapy reduces morbidity or mortality is lacking. Some drug classes were more effective at decreasing blood pressure, but the clinical significance of this physiologic outcome measure is not known.

Consilience - Corrected Proof

Arthur L. Kellermann — 2010-07-12

SEE RELATED ARTICLES, P. ■■■. [Ann Emerg Med. 2010;■■:■■■.]

Computed Tomography Use in the Adult Emergency Department of an Academic Urban Hospital From 2001 to 2007 - Corrected Proof

2010-07-12

Study objective: There is both increasing recognition and growing scrutiny of the increased utilization of computed tomography (CT) in medicine. For our primary objective, we determine and quantify the CT utilization rate in our emergency department (ED) during the last 7 years. As a secondary objective, we compare trends in utilization for various types of CT scans.Methods: We performed an electronic chart review at our inner-city, academic ED with an annual census of 110,000 patients. We identified all patients older than 21 years who had a CT scan performed during ED management from January 2001 to December 2007. Specific, predetermined data elements (eg, subject demographics, type of CT scan) were extracted on standardized data forms by trained abstractors. We analyzed our data with standard descriptive statistics and linear regression.Results: The rate of CT utilization increased steadily at approximately 10 CTs per 1,000 (95% confidence interval 7.5 to 13.6 CTs) patients annually during our study period, from 51 per 1,000 patient visits in 2001 to 106 per 1,000 in 2007. Among these CTs, chest CTs increased most, with a 6-fold increase from 10 per 1,000 patient visits to 60 per 1,000. Neck CTs increased by 5-fold, from 20 per 1,000 patient visits to 100 per 1,000 patients. Similarly, the utilization of abdomen-pelvis CTs, facial bone CTs, and head CTs increased from 13 per 1,000 to 33 per 1,000 patient visits (150%), 1 per 1,000 to 2 per 1,000 patient visits (100%), and 33 per 1,000 to 53 per 1,000 patient visits (60%), respectively.Conclusion: Recent CT utilization in our ED increased in all anatomic categories assessed, with chest CTs and neck CTs increasing the most, followed by abdomen-pelvis CTs, facial bone CTs, and head CTs.

Spontaneous Tension Pneumocephalus Resulting From a Scalp Fistula in a Patient With a Remotely Placed Ventriculoperitoneal Shunt - Corrected Proof

Jessica Monas, David A. Peak — 2010-07-12

Tension pneumocephalus is a life-threatening condition that requires rapid recognition and intervention. It usually occurs as an early postoperative complication after neurosurgery or after trauma. Delayed tension pneumocephalus after ventriculoperitoneal shunt placement is unusual, with fewer than 50 published case reports, and is rarely caused by a scalp defect. We present a patient with nontraumatic tension pneumocephalus caused by a scalp fistula from a remote ventriculoperitoneal shunt placed 5 years earlier. This case is unique in that the patient underwent percutaneous aspiration of the tension pneumocephalus as a lifesaving procedure in the emergency department, with complete resolution of her symptoms at 30-day follow-up.

Evidence-Based Emergency Medicine: Clinical Synopsis - Corrected Proof

Maude Latulippe, Eddy S. Lang — 2010-06-21

MethodsData Sources: Searches were conducted of MEDLINE (1966 to 2006), EMBASE (1980 to April 2006), and the Cochrane's CENTRAL register (Issue 2, 2006), and hand-searched information from cardiology conferences, principal investigators of identified trials, pharmaceutical manufacturers, and other experts in the field were used. There were no language restrictions.Study Selection: Randomized controlled trials enrolling patients with non-ST-segment elevation acute coronary syndromes who initially received GPIIb/IIa inhibitors as part of the early medical management were eligible.Data Extraction and Synthesis: Primary outcomes were 30-day and 6-month mortality and the subsequent development of myocardial infarction; the secondary endpoint was major hemorrhage, defined as intracranial bleeding or any bleeding with a decrease in hemoglobin of greater than 5 g/dL or a greater than 15% reduction in hematocrit level. Data were reported as odds ratios (ORs) with a fixed-effect model if minimal heterogeneity was identified; otherwise, a random-effects model was used. All analyses were presented as intention to treat.

Evidence-Based Emergency Medicine: Clinical Synopsis - Corrected Proof

Andrew Worster — 2010-06-21

MethodsData Sources: The investigators searched the Cochrane Stroke Group Trials and Central Register of Controlled Trials, MEDLINE (from1966), EMBASE (from 1980), bibliographies of relevant articles, and clinical trial registries. Authors and pharmaceutical companies were contacted for clarification and to identify any additional studies.Study Selection: Randomized controlled trials with clinical outcome measures evaluating all doses and administration routes of single or multiple hemostatic agents, including antiﬁbrinolytics, blood coagulation factors, and platelet activators.Data Extraction and Synthesis: All trials were assessed for randomization and concealment of treatment allocation and blinded assessment of outcome. Heterogeneity was measured with the Inconsistency Index (I2) statistic. Results including 95% confidence intervals are presented as relative risk for dichotomous outcomes and as mean difference for continuous data; estimates were based on a fixed-effect or random-effects model.

Noninvasive Measurement of Carboxyhemoglobin: How Accurate Is Accurate Enough? - Corrected Proof

William H. Maisel, Roger J. Lewis — 2010-06-21

SEE RELATED ARTICLE, P. ■■■. [Ann Emerg Med. 2010;■■■■■.]

At-Risk Populations and the Critically Ill Rely Disproportionately on Ambulance Transport to Emergency Departments - Corrected Proof

Benjamin T. Squire, Aracely Tamayo, Joshua H. Tamayo-Sarver — 2010-06-16

Study objective: Emergency department (ED) crowding increases ambulance diversion. Ambulance diversion disproportionately affects individuals who rely on ambulance transport. The purpose of this study is to determine which populations rely most on ambulance transport.Methods: We queried the National Hospital Ambulatory Medical Care Survey database for 1997 to 2000 and 2003 to 2005 for patients who arrived by ambulance or personal transport. We performed bivariate analysis to assess the extent to which all patients and a subset of critically ill patients use ambulance transport relative to self-transport.Results: In our sample, 30,455 (15%; 95% confidence interval [CI] 15% to 16%) patients arrived by ambulance and 162,091 (85%; 95% CI 84% to 85%) arrived by walk-in/self-transport. Overall, patients with Medicare insurance were more likely to rely on ambulance transport, at 34% (95% CI 33% to 35%), than the privately insured, at 11% (95% CI 10% to 11%). Among the critically ill, privately insured patients were less likely to rely on ambulance transport, at 47% (95% CI 42% to 52%), than those with Medicare insurance (61%; 95% CI 58% to 65%), the publicly insured (60%; 95% CI 52% to 67%), or the uninsured (57%; 95% CI 49% to 64%). Among the critically ill, patients aged 15 to 24 years and those older than 74 years were most likely to rely on ambulance transport, at 63% (95% CI 53% to 72%) and 67% (95% CI 62% to 71%), respectively. Fifty-seven percent (95% CI 54% to 59%) of the critically ill used ambulance versus 15% (95% CI 14% to 15%) of noncritical patients.Conclusion: Patients with Medicare insurance or public insurance, the uninsured, the elderly, and the critically ill disproportionately rely on ambulance transport to the ED. Ambulance diversion may disproportionately affect these populations.

A Primer on the Complicated Subject of Cost-Effectiveness Analyses for Pulmonary Embolism - Corrected Proof

Jeffrey A. Kline — 2010-06-11

SEE RELATED ARTICLE, P.■■■. [Ann Emerg Med. 2010;■■:■■■.]

Comparison of Web-Versus Classroom-Based Basic Ultrasonographic and EFAST Training in 2 European Hospitals - Corrected Proof

2010-06-11

Study objective: Training physicians in new skills through classroom-based teaching has inherent cost and time constraints. We seek to evaluate whether Web-based didactics result in similar knowledge improvement and retention of basic ultrasonographic principles and the Extended Focused Assessment with Sonography for Trauma (EFAST) compared with the traditional method.Methods: Physicians from 2 German emergency departments were randomized into a classroom group with traditional lectures and a Web group who watched narrated lectures online. All participants completed a pre- and posttest and a second posttest 8 weeks later. Both groups underwent hands-on training after the first posttest. A control group completed the 2 initial tests without didactic intervention.Results: Fifty-five subjects participated in the study. Both the classroom and Web group showed significant improvement in pre- and posttest 1 scores (75.9% versus 93.9% and 77.8% versus 92.5%; P<.001 for both), with similar knowledge retention after 8 weeks (88.6% and 88.9%; P=.87). No statistically significant difference in mean test scores could be found between the 2 groups at each point: –1.9% (95% confidence interval [CI] –5.2% to 1.4%) for the pretest, 1.4% (95% CI –0.6% to 3.4%) for posttest 1, and –0.3% (95% CI –3.9% to 3.3%) for posttest 2. The control group showed no learning effect without intervention (83.3% versus 82.8%, ; P=.88).Conclusion: Web-based learning provides the potential to teach physicians with greater flexibility than classroom instruction. Our data suggest that Web-based ultrasonography and EFAST didactics are comparable to traditional classroom lectures and result in similar knowledge retention.

A Randomized Controlled Trial Comparing Patient-Controlled and Physician-Controlled Sedation in the Emergency Department - Corrected Proof

2010-06-11

Study objective: We compare patient-controlled sedation (PCS) and emergency physician–controlled sedation (EPCS) with respect to propofol requirements, depth of sedation, adverse events, recovery time, physician satisfaction, and patient satisfaction in emergency department (ED) patients requiring brief but painful procedures.Methods: One hundred sixty-six patients in this randomized controlled trial received propofol sedation according to one of 2 regimens: infusion of propofol at doses determined by the treating physician (EPCS group) or infusion of propofol with a patient-controlled infusion pump (PCS group). The PCS group received an initial physician-controlled bolus following by self-administered doses. Depth of sedation was assessed at 3-minute intervals. Adverse events were recorded as they occurred. Physician and patient satisfaction were recorded with 100-mm visual analog scales.Results: There was a nonsignificant trend toward lower total propofol doses with PCS relative to EPCS (medians 1.36 versus 1.60 mg/kg, respectively; median difference –0.15 mg/kg; 95% confidence interval of the difference –0.33 to 0.05 mg/kg; P=.14). Adverse events, requirement for treatment of adverse events, and recovery time did not differ in the 2 groups. Depth of sedation was lower in the PCS group. Procedural success, ease of procedure, and patient satisfaction were similar in both groups despite nearly twice as many patients recalling the procedure in the PCS group and 15% of patients requiring additional physician-administered doses in the PCS group.Conclusion: Compared with EPCS, PCS demonstrated similar propofol dosing, safety, recovery, and satisfaction but resulted in lighter sedation. Propofol PCS appears safe and effective for ED procedures requiring moderate rather than deep sedation.

A Randomized Controlled Trial of a Brief Emergency Department Intimate Partner Violence Screening Intervention - Corrected Proof

2010-06-11

Study objective: We evaluate the efficacy of emergency department (ED) brief intimate partner violence screening intervention in reducing short-term revictimization.Methods: A randomized controlled trial with blinded 3-month follow-up was conducted in an urban New Zealand ED. Participants included 399 nonacute, English-speaking women aged 16 years and older, 199 randomly assigned to the treatment group and 200 to the control group. Participants in both groups received usual emergency health care. Women assigned to the treatment group received a standardized 3-item intimate partner violence screen, statements about the unacceptability of violence, risk assessment, and referral by a health professional research assistant. The main outcome measure was self-reported intimate partner violence exposure. Secondary outcomes included self-care strategies (use of safety behaviors and community resources).Results: Forty-four of 344 (12.8%) women reported intimate partner violence during the 3-month follow-up period: 24 of 177 (13.6.%) among women in the usual care group and 20 of 167 (12.0%) among women in the treatment group. The adjusted odds ratio, controlling for design effects and covariates, was 0.86 (95% confidence interval 0.39 to 1.92).Conclusion: This brief intimate partner violence screening intervention did not significantly reduce short-term violence exposure. Continuing work is needed to maximize intervention effectiveness and monitor medium- and long-term outcomes.

The Effect of Triage Diagnostic Standing Orders on Emergency Department Treatment Time - Corrected Proof

Rodica Retezar, Edward Bessman, Ru Ding, Scott L. Zeger, Melissa L. McCarthy — 2010-06-11

Study objective: Triage standing orders are used in emergency departments (EDs) to initiate evaluation when there is no bed available. This study evaluates the effect of diagnostic triage standing orders on ED treatment time of adult patients who presented with a chief complaint for which triage standing orders had been developed.Methods: We conducted a retrospective nested cohort study of patients treated in one academic ED between January 2007 and August 2009. In this ED, triage nurses can initiate full or partial triage standing orders for patients with chest pain, shortness of breath, abdominal pain, or genitourinary complaints. We matched patients who received triage standing orders to those who received room orders with respect to clinical and temporal factors, using a propensity score. We compared the median treatment time of patients with triage standing orders (partial or full) to those with room orders, using multivariate linear regression.Results: Of the 15,188 eligible patients, 25% received full triage standing orders, 56% partial triage standing orders, and 19% room orders. The unadjusted median ED treatment time for patients who did not receive triage standing orders was 282 minutes versus 230 minutes for those who received a partial triage standing order or full triage standing orders (18% decrease). Controlling for other factors, triage standing orders were associated with a 16% reduction (95% confidence interval −18% to −13%) in the median treatment time, regardless of chief complaint.Conclusion: Diagnostic testing at triage was associated with a substantial reduction in ED treatment time for 4 common chief complaints. This intervention warrants further evaluation in other EDs and with different clinical conditions and tests.

Cost-Effectiveness of Strategies for Diagnosing Pulmonary Embolism Among Emergency Department Patients Presenting With Undifferentiated Symptoms - Corrected Proof

Ram S. Duriseti, Margaret L. Brandeau — 2010-06-04

Study objective: Symptoms associated with pulmonary embolism can be nonspecific and similar to many competing diagnoses, leading to excessive costly testing and treatment, as well as missed diagnoses. Objective studies are essential for diagnosis. This study evaluates the cost-effectiveness of different diagnostic strategies in an emergency department (ED) for patients presenting with undifferentiated symptoms suggestive of pulmonary embolism.Methods: Using a probabilistic decision model, we evaluated the incremental costs and effectiveness (quality-adjusted life-years gained) of 60 testing strategies for 5 patient pretest categories (distinguished by Wells score [high, moderate, or low] and whether deep venous thrombosis is clinically suspected). We performed deterministic and probabilistic sensitivity analyses.Results: In the base case, for all patient pretest categories, the most cost-effective diagnostic strategy is to use an initial enzyme-linked immunosorbent assay D-dimer test, followed by compression ultrasonography of the lower extremities if the D-dimer is above a specified cutoff. The level of the preferred cutoff varies with the Wells pretest category and whether a deep venous thrombosis is clinically suspected. D-dimer cutoffs higher than the current recommended cutoff were often preferred for patients with even moderate and high Wells categories. Compression ultrasonography accuracy had to decrease below commonly cited levels in the literature before it was not part of a preferred strategy.Conclusion: When pulmonary embolism is suspected in the ED, use of an enzyme-linked immunosorbent assay D-dimer assay, often at cutoffs higher than those currently in use (for patients in whom deep venous thrombosis is not clinically suspected), followed by compression ultrasonography as appropriate, can reduce costs and improve outcomes.

Performance of the RAD-57 Pulse Co-Oximeter Compared With Standard Laboratory Carboxyhemoglobin Measurement - Corrected Proof

2010-06-04

Study objective: We assess agreement between carboxyhemoglobin levels measured by the Rad-57 signal extraction pulse CO-oximeter (RAD), a Food and Drug Administration–approved device for noninvasive bedside measurement, and standard laboratory arterial or venous measurement in a sample of emergency department (ED) patients with suspected carbon monoxide poisoning.Methods: The study was a cross-sectional cohort design using a convenience sample of adult and pediatric ED patients in a Level I trauma, burn, and hyperbaric oxygen referral center. Measurement of RAD carboxyhemoglobin was performed simultaneously with blood sampling for laboratory determination of carboxyhemoglobin level. The difference between the measures for each patient was calculated as laboratory carboxyhemoglobin minus carboxyhemoglobin from the carbon monoxide oximeter. The limits of agreement from a Bland-Altman analysis are calculated as the mean of the differences between methods ±1.96 SDs above and below the mean.Results: Median laboratory percentage carboxyhemoglobin level was 2.3% (interquartile range 1 to 8.5; range 0% to 38%). The mean difference between laboratory carboxyhemoglobin values and RAD values was 1.4% carboxyhemoglobin (95% confidence interval [CI] 0.2% to 2.6%). The limits of agreement of differences of measurement made with the 2 devices were −11.6% and 14.4% carboxyhemoglobin. This range exceeded the value of ±5% carboxyhemoglobin defined a priori as clinically acceptable. RAD correctly identified 11 of 23 patients with laboratory values greater than 15% carboxyhemoglobin (sensitivity 48%; 95% CI 27% to 69%). There was one case of a laboratory carboxyhemoglobin level less than 15%, in which the RAD device gave a result greater than 15% (specificity of RAD 96/97=99%; 95% CI 94% to 100%).Conclusion: In the range of carboxyhemoglobin values measured in this sample, the level of agreement observed suggests RAD measurement may not be used interchangeably with standard laboratory measurement.

Web-Based Self-Triage of Influenza-Like Illness During the 2009 H1N1 Influenza Pandemic - Corrected Proof

2010-06-04

The sudden emergence of 2009 H1N1 influenza in the spring of that year sparked a surge in visits to emergency departments in New York City and other communities. A larger, second wave of cases was anticipated the following autumn. To reduce a potential surge of health system utilization without denying needed care, we enlisted the input of experts from medicine, public health, nursing, information technology, and other disciplines to design, test, and deploy clinical algorithms to help minimally trained health care workers and laypeople make informed decisions about care-seeking for influenza-like illness. The product of this collaboration, named Strategy for Off-Site Rapid Triage (SORT) was disseminated in 2 forms. Static algorithms, posted on the Centers for Disease Control and Prevention's Web site, offered guidance to clinicians and telephone call centers on how to manage adults and children with influenza-like illness. In addition, 2 interactive Web sites, http://www.Flu.gov and http://www.H1N1ResponseCenter.com, were created to help adults self-assess their condition and make an informed decision about their need for treatment. Although SORT was anchored in a previously validated clinical decision rule, incorporated the input of expert clinicians, and was subject to small-scale formative evaluations during rapid standup, prospective evaluation is lacking. If its utility and safety are confirmed, SORT may prove to be a useful tool to blunt health system surge and rapidly collect epidemiologic data on future disease outbreaks.

Stress Cardiac Magnetic Resonance Imaging With Observation Unit Care Reduces Cost for Patients With Emergent Chest Pain: A Randomized Trial - Corrected Proof

2010-05-31

Study objective: We determine whether imaging with cardiac magnetic resonance imaging (MRI) in an observation unit would reduce medical costs among patients with emergent non-low-risk chest pain who otherwise would be managed with an inpatient care strategy.Methods: Emergency department patients (n=110) at intermediate or high probability for acute coronary syndrome without electrocardiographic or biomarker evidence of a myocardial infarction provided consent and were randomized to stress cardiac MRI in an observation unit versus standard inpatient care. The primary outcome was direct hospital cost calculated as the sum of hospital and provider costs. Estimated median cost differences (Hodges-Lehmann) and distribution-free 95% confidence intervals (Moses) were used to compare groups.Results: There were 110 participants with 53 randomized to cardiac MRI and 57 to inpatient care; 8 of 110 (7%) experienced acute coronary syndrome. In the MRI pathway, 49 of 53 underwent stress cardiac MRI, 11 of 53 were admitted, 1 left against medical advice, 41 were discharged, and 2 had acute coronary syndrome. In the inpatient care pathway, 39 of 57 patients initially received stress testing, 54 of 57 were admitted, 3 left against medical advice, and 6 had acute coronary syndrome. At 30 days, no subjects in either group experienced acute coronary syndrome after discharge. The cardiac MRI group had a reduced median hospitalization cost (Hodges-Lehmann estimate $588; 95% confidence interval $336 to $811); 79% were managed without hospital admission.Conclusion: Compared with inpatient care, an observation unit strategy involving stress cardiac MRI reduced incident cost without any cases of missed acute coronary syndrome in patients with emergent chest pain.

Safety of Assessment of Patients With Potential Ischemic Chest Pain in an Emergency Department Waiting Room: A Prospective Comparative Cohort Study - Corrected Proof

2010-05-26

Study objective: Emergency department (ED) crowding has been associated with a variety of adverse outcomes. Current guidelines suggest that patients with potentially ischemic chest pain should undergo rapid assessment and treatment in a monitored setting to optimize the diagnosis of acute coronary syndrome. These patients may be at high risk of incorrect diagnosis and adverse events when their evaluation is delayed because of crowding. To mitigate crowding-related delays, we developed processes that enabled emergency physicians to evaluate potentially sick patients in the waiting room when all nurse-staffed stretchers are occupied. The objective of this study was to investigate the safety of waiting room chest pain evaluation.Methods: This prospective comparative cohort study was conducted in a busy urban, tertiary care ED. Explicit triage and waiting room evaluation processes were introduced. One thousand one hundred seven patients with chest pain of potential cardiac origin were triaged either to a monitored bed or a waiting room chair, depending on bed availability and triage judgment. After diagnostic evaluation, patients were followed for 30 days to identify the proportion of missed cases of acute coronary syndrome (primary outcome) and other prespecified adverse events. Analysis was based on intention to treat.Results: Eight hundred four patients were triaged to monitored bed and 303 to waiting room evaluation. Initial vital signs were similar, but the waiting room group was younger and had lower rates of some cardiovascular risk factors. The rate of acute coronary syndrome, defined as acute myocardial infarction or objective unstable angina, was 11.7% in the monitored bed group and 7.6% in waiting room patients. There were no missed acute coronary syndrome cases in either the monitored bed group (0%; 95% confidence interval [CI] 0% to 0.4%) or the waiting room group (0%; 95% CI 0% to 1.0%). There were 32 adverse events in the monitored bed group (4.0%; 95% CI 2.6% to 5.3%) and 2 in the waiting room group (0.7%; 95% CI 0% to 1.6%).Conclusion: Our organized approach to triage and waiting room evaluation for stable chest pain patients was safe and efficient. Although waiting room evaluation is not ideal, it may be a feasible contingency strategy for periods when ED crowding compromises access to monitored, nurse-staffed ED beds.

Immediate β-Blockade in Patients With Myocardial Infarctions: Is There Evidence of Benefit? - Corrected Proof

Richard Sinert, David H. Newman, Ethan Brandler, Lorenzo Paladino — 2010-05-21

Study objective: The American Heart Association recommends the initiation of β-blockade to all patients with an ST-segment elevation myocardial infarction (STEMI) without contraindications to β-blocking agents. The present study seeks to systematically review the medical literature to determine the efficacy of treating STEMI patients with a β-blocker within the first 24 hours.Methods: We searched databases for articles through MEDLINE with the PubMed interface and from 1966 through May 2009 and EMBASE from 1980 to August 2009 with the Ovid Technologies interface, using a search strategy derived from the following PICO (Patient-Intervention-Comparator-Outcome) clinical question: In patients presenting with STEMI (P), does immediate treatment with β-blockers (I) followed by standardized care beginning on day 2 or 3 compared with placebo or no treatment followed by standardized care on day 2 or 3 (C) reduce the risk of death, reinfarction, or cardiogenic shock (O)? The methodological quality of the studies was assessed.Results: From more than 2,000 references identified in the search, only a single randomized trial met the inclusion criteria. There were no statistically significant differences in mortality; the relative risk for the combined endpoint (mortality and reinfarction) was 0.67 (95% confidence interval 0.44 to 1.03) at 6 days and 0.74 (95% confidence interval 0.53 to 1.06) at 6 weeks. Outcomes for cardiogenic shock were not reported.Conclusion: Evidence from a single randomized trial failed to demonstrate a reduction in mortality or reinfarction with administration of β-blocker within the first 24 hours after STEMI.

Evidence-Based Emergency Medicine: Clinical Synopsis - Corrected Proof

Rawle A. Seupaul — 2010-05-17

MethodsData Sources: The authors searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE from 1966 to 2005, and EMBASE from 1988 to 2005, without language restriction.Study Selection: Randomized and quasirandomized controlled trials comparing short-term (2 to 4 days) with standard (7 to 14 days) oral antibiotic therapy in children aged 3 months to 18 years, with culture-proven urinary tract infections.Data Extraction and Synthesis: Two authors independently assessed study quality and extracted data from included trials. A random-effects model was used to analyze data. Only randomized controlled trials were included; only 2 clearly described allocation concealment, whereas none of the trials defined appropriate blinding or used an intention-to-treat analysis.

Computerized Decision Support for Medication Dosing in Renal Insufficiency: A Randomized, Controlled Trial - Corrected Proof

2010-05-11

Study objective: Emergency physicians prescribe several discharge medications that require dosage adjustment for patients with renal disease. The hypothesis for this research was that decision support in a computerized physician order entry system would reduce the rate of excessive medication dosing for patients with renal impairment.Methods: This was a randomized, controlled trial in an academic emergency department (ED), in which computerized physician order entry was used to write all prescriptions for patients being discharged from the ED. The sample included 42 physicians who were randomized to the intervention (21 physicians) or control (21 physicians) group. The intervention was decision support that provided dosing recommendations for targeted medications for patients aged 18 years and older when the patient's estimated creatinine clearance level was below the threshold for dosage adjustment. The primary outcome was the proportion of targeted medications that were excessively dosed.Results: For 2,783 (46%) of the 6,015 patient visits, the decision support had sufficient information to estimate the patient's creatinine clearance level. The average age of these patients was 46 years, 1,768 (64%) were women, and 1,523 (55%) were black. Decision support was provided 73 times to physicians in the intervention group, who excessively dosed 31 (43%) prescriptions. In comparison, control physicians excessively dosed a significantly larger proportion of medications: 34 of 46, 74% (effect size=31%; 95% confidence interval 14% to 49%; P=.001).Conclusion: Emergency physicians often prescribed excessive doses of medications that require dosage adjustment for renal impairment. Computerized physician order entry with decision support significantly reduced excessive dosing of targeted medications.

Evidence-Based Emergency Medicine: Clinical Synopsis - Corrected Proof

J. Adam Oostema, Dale J. Ray — 2010-05-11

MethodsData Sources: The authors searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Wounds Group Specialized Register (May 29, 2008), MEDLINE (1950 to May 2008), EMBASE (1980 to May 2008), and CINAHL (1982 to May 2008).Study Selection: The review included randomized controlled trials examining various burn dressings, frequently using silver sulfadiazine as a control. Dressing types included the following:Hydrocolloids (eg, DuoDerm; ConvaTec Ltd, Skillman, NJ): 5 studies; 314 patientsPolyurethane films (eg, Tegaderm; 3M, St. Paul, MN): 2 studies; 106 patientsHydrogels (eg, Curagel; Kendall, Mansfield, MA): 2 studies; 115 patientsSilicon-coated nylon (eg, Mepitel; Molnlycke Health Care, Norcross, GA): 2 studies; 142 patientsBiosynthetic skin substitutes (eg, Biobrane; Smith & Nephew, Largo, FL): 10 studies; 441 patientsSilver impregnated (eg, Acticoat; Smith & Nephew, Largo, FL): 3 studies; 162 patientsHydrofiber (eg, Aquacel; ConvaTec Ltd): 2 studies; 152 patientsStudies addressing topical skin agents, full-thickness burns, hand burns, and biological skin replacements were excluded.The primary outcomes included time to complete wound healing and change in wound surface area over time. Secondary outcomes included number of dressing changes, pain, patient satisfaction, infection rate, need for surgery, cost, and hospital length of stay.Data Extraction and Synthesis: Studies were reviewed by 2 authors independently and data were abstracted using standardized forms. The authors abstracted and pooled data from eligible studies by using appropriate analytical methods according to the Cochrane Handbook, version 5.0.0.Studies were assessed for the adequacy of randomization and allocation concealment, blinding of providers and participants, potential selection bias after allocation, and completeness of follow-up.

Therapeutic Efficacy of Icatibant in Angioedema Induced by Angiotensin-Converting Enzyme Inhibitors: A Case Series - Corrected Proof

2010-05-06

Study objective: The pathophysiology of angiotensin-converting enzyme inhibitor (ACEi)–induced angioedema most likely resembles that of hereditary angioedema, ie, it is mainly mediated by bradykinin-induced activation of vascular bradykinin B2 receptors. We hypothesize that the bradykinin B2 receptor antagonist icatibant might be an effective therapy for ACEi-induced angioedema.Methods: Eight patients with acute ACEi-induced angioedema were treated with a single subcutaneous injection of icatibant. The outcome was assessed by the time to first improvement of symptoms, complete symptom relief, and drug safety. In addition, we retrospectively assessed the clinical course of 47 consecutive patients of our clinic with ACEi-induced angioedema.Results: First symptom improvement after icatibant injection occurred at a mean time of 50.6 minutes (standard deviation [SD] 21 minutes) and complete relief of symptoms at 4.4 hours (SD 0.8 hours). No patient received tracheal intubation, other drug treatment, tracheotomy, or a second icatibant injection. There were no adverse effects except erythema occurring at the injection site. In the historical comparison group treated with methylprednisolone and clemastine, the mean time to complete relief of symptoms was 33 hours (SD 19.4 hours). Some of these patients received a tracheotomy (3/47), were intubated (2/47), or received a second dose of methylprednisolone (12/47).Conclusion: Although sample size limits the external validity of our results, the substantial decrease of time to complete symptom relief suggests that this new treatment is likely effective as a pharmacotherapeutic approach to treat ACEi-induced angioedema.

Eccentrically Located Intrauterine Pregnancy Misdiagnosed as Interstitial Ectopic Pregnancy - Corrected Proof

Adam Ash, Patrick Ko, Christopher Dewar, Christopher Raio — 2010-05-06

This is a case report of an eccentrically located intrauterine pregnancy initially diagnosed as an interstitial ectopic pregnancy. Although interstitial ectopic pregnancy represents a well-known pitfall in first-trimester sonography, the common error is to misidentify the ectopic pregnancy as intrauterine, not the reverse. Such an error is potentially catastrophic because it may lead to the inadvertent termination of a viable pregnancy. Although the role of ultrasonography for evaluation of ectopic pregnancy is well established, its diagnostic accuracy for interstitial ectopic pregnancy remains uncertain. Because of this, sonographic findings should be considered suggestive, but not diagnostic, in this setting.

Pediatric Suicide-Related Presentations: A Systematic Review of Mental Health Care in the Emergency Department - Corrected Proof

2010-04-12

Study objective: We evaluate the effectiveness of interventions for pediatric patients with suicide-related emergency department (ED) visits.Methods: We searched of MEDLINE, EMBASE, the Cochrane Library, other electronic databases, references, and key journals/conference proceedings. We included experimental or quasiexperimental studies that evaluated psychosocial interventions for pediatric suicide-related ED visits. Inclusion screening, study selection, and methodological quality were assessed by 2 independent reviewers. One reviewer extracted the data and a second checked for completeness and accuracy. Consensus was reached by conference; disagreements were adjudicated by a third reviewer. We calculated odds ratios, relative risks (RRs), or mean differences for each study's primary outcome, with 95% confidence intervals (CIs). Meta-analysis was deferred because of clinical heterogeneity in intervention, patient population, and outcome.Results: We included 7 randomized controlled trials and 3 quasiexperimental studies, grouping and reviewing them according to intervention delivery: ED-based delivery (n=1), postdischarge delivery (n=6), and ED transition interventions (n=3). An ED-based discharge planning intervention increased the number of attended post-ED treatment sessions (mean difference=2.6 sessions; 95% CI 0.05 to 5.15 sessions). Of the 6 studies of postdischarge delivery interventions, 1 found increased adherence with service referral in patients who received community nurse home visits compared with simple placement referral at discharge (RR=1.28; 95% CI 1.06 to 1.56). The 3 ED transition intervention studies reported (1) reduced risk of subsequent suicide after brief ED intervention and postdischarge contact (RR=0.10; 95% CI 0.03 to 0.41); (2) reduced suicide-related hospitalizations when ED visits were followed up with interim, psychiatric care (RR=0.41; 95% CI 0.28 to 0.60); and (3) increased likelihood of treatment completion when psychiatric evaluation in the ED was followed by attendance of outpatient sessions with a parent (odds ratio=2.78; 95% CI 1.20 to 6.67).Conclusion: Transition interventions appear most promising for reducing suicide-related outcomes and improving post-ED treatment adherence. Use of similar interventions and outcome measures in future studies would enhance the ability to derive strong recommendations from the clinical evidence in this area.

Examining Emergency Department Communication Through a Staff-Based Participatory Research Method: Identifying Barriers and Solutions to Meaningful Change - Corrected Proof

2010-04-12

Study objective: We test an initiative with the staff-based participatory research (SBPR) method to elicit communication barriers and engage staff in identifying strategies to improve communication within our emergency department (ED).Methods: ED staff at an urban hospital with 85,000 ED visits per year participated in a 3.5-hour multidisciplinary workshop. The workshop was offered 6 times and involved: (1) large group discussion to review the importance of communication within the ED and discuss findings from a recent survey of patient perceptions of ED-team communication; (2) small group discussions eliciting staff perceptions of communication barriers and best practices/strategies to address these challenges; and (3) large group discussions sharing and refining emergent themes and suggested strategies. Three coders analyzed summaries from group discussions by using latent content and constant comparative analysis to identify focal themes.Results: A total of 127 staff members, including attending physicians, residents, nurses, ED assistants, and secretaries, participated in the workshop (overall participation rate 59.6%; range 46.7% to 73.3% by staff type). Coders identified a framework of 4 themes describing barriers and proposed interventions: (1) greeting and initial interaction, (2) setting realistic expectations, (3) team communication and respect, and (4) information provision and delivery. The majority of participants (81.4%) reported that their participation would cause them to make changes in their clinical practice.Conclusion: Involving staff in discussing barriers and facilitators to communication within the ED can result in a meaningful process of empowerment, as well as the identification of feasible strategies and solutions at both the individual and system levels.

Sufentanil Is Not Superior to Morphine for the Treatment of Acute Traumatic Pain in an Emergency Setting: A Randomized, Double-Blind, Out-of-Hospital Trial - Corrected Proof

2010-04-12

Study objective: We determine the best intravenous opioid titration protocol by comparing morphine and sufentanil for adult patients with severe traumatic acute pain in an out-of-hospital setting, with a physician providing care.Methods: In this double-blind randomized clinical trial, patients were eligible for inclusion if aged 18 years or older, with acute severe pain (defined as a numeric rating scale score ≥6/10) caused by trauma. They were assigned to receive either intravenous 0.15 μg/kg sufentanil, followed by 0.075 μg/kg every 3 minutes or intravenous 0.15 mg/kg morphine and then 0.075 mg/kg. The primary endpoint of the study was pain relief at 15 minutes, defined as a numeric rating scale less than or equal to 3 of 10. Secondary endpoints were time to analgesia, adverse events, and duration of analgesia during the first 6 hours.Results: A total of 108 patients were included, 54 in each group. At 15 minutes, 74% of the patients in the sufentanil group had a numeric rating scale score of 3 or lower versus 70% of those in the morphine group (Δ4%; 95% confidence interval –13% to 21%). At 9 minutes, 65% of the patients in the sufentanil group experienced pain relief versus 46% of those in the morphine group (Δ18%; 95% confidence interval 0.1% to 35%). The duration of analgesia was in favor of the morphine group. Nineteen percent of patients experienced an adverse event in both groups, all mild to moderate.Conclusion: Intravenous morphine titration using a loading dose of morphine followed by strictly administered lower doses at regular intervals remains the criterion standard. Moreover, this study supports the idea that the doses studied should be considered for routine administration in severe pain protocols.

Pandemic H1N1 Influenza in the Pediatric Emergency Department: A Comparison With Previous Seasonal Influenza Outbreaks - Corrected Proof

Brian E. Costello, Harold K. Simon, Robert Massey, Daniel A. Hirsh — 2010-04-05

Study objective: We compare the acuity of pediatric emergency department (ED) patients between the ongoing H1N1 influenza pandemic and previous seasonal influenza outbreaks.Methods: An observational, cross-sectional analysis of patient visits at 2 pediatric tertiary care EDs was made for the following periods: (1) regional fall 2009 H1N1 influenza surge (August 17 to September 20, 2009), and (2) combined regional 2007 to 2009 early peak influenza seasons (January 28 to March 2, 2008, and February 2 to March 8, 2009). Proportions of admissions, return visits, and return visits resulting in admission were compared between the 2 periods. Subset analysis of patients with influenza-like illness was performed.Results: Of total visits, no difference was found in the proportions of hospital admissions between the 2009 H1N1 surge (18,503 visits) and the previous influenza seasons (29,002 visits): non-ICU 9.9% versus 10.4%, 95% confidence interval of the difference −0.07% to 1.0%; ICU 0.9% versus 0.9%, 95% CI of the difference −0.1% to 0.2%. Of patients with influenza-like illness, no difference was found in the proportions of non-ICU admissions between the 2009 H1N1 surge (7,064 visits) and the previous influenza seasons (8,489 visits): 4.8% versus 5.2%, 95% CI of the difference −0.3% to 1.1%, whereas the proportion of ICU admissions increased during the 2009 H1N1 surge: 0.3% versus 0.1%, 95% CI of the difference 0.05% to 0.4%. The proportions of return visits within 7 days, including those resulting in admission, were similar between the 2 periods for both the total ED population and the influenza-like illness subset.Conclusion: The severity of illness during the 2009 H1N1 surge appeared similar to that of previous influenza seasons for the total population of the 2 pediatric tertiary care EDs, whereas an increase in the proportion of ICU admissions was observed for patients with influenza-like illness.

Delirium in the Emergency Department: An Independent Predictor of Death Within 6 Months - Corrected Proof

2010-04-05

Study objective: Delirium's adverse effect on long-term mortality in older hospitalized patients is well documented, whereas its effect in older emergency department (ED) patients remains unclear. Similarly, the consequences of delirium on nursing home patients treated in the ED are also unknown. As a result, we seek to determine whether delirium in the ED is independently associated with 6-month mortality in older patients and whether this relationship is modified by nursing home status.Methods: Our prospective cohort study was conducted at a tertiary care, academic ED, using convenience sampling, and included English-speaking patients who were aged 65 years and older and were in the ED for less than 12 hours at enrollment. Patients were excluded if they refused consent, were previously enrolled, were unable to follow simple commands at baseline, were comatose, or had incomplete data. The Confusion Assessment Method for the Intensive Care Unit was used to determine delirium and was administered by trained research assistants. Cox proportional hazard regression was performed to determine whether delirium in the ED was independently associated with 6-month mortality after adjusting for age, comorbidity burden, severity of illness, dementia, functional dependence, and nursing home residence. To test whether the effect of delirium in the ED on 6-month mortality was modified by nursing home residence, an interaction term (delirium*nursing home) was incorporated into the multivariable model. Hazard ratios with their 95% confidence intervals were reported.Results: Of the 628 patients enrolled, 108 (17.2%) were delirious in the ED and 58 (9.2%) were from the nursing home. For the entire cohort, the 6-month mortality rate was higher in the delirious group compared with the nondelirious group (37.0% versus 14.3%). Delirium was an independent predictor of increased 6-month mortality (hazard ratio=1.72; 95% confidence interval 1.04 to 2.86) after adjusting for age, comorbidity burden, severity of illness, dementia, functional dependence, and nursing home residence. The “delirium*nursing home” interaction was nonsignificant (P=.86), indicating that place of residence had no effect on the relationship between delirium in the ED and 6-month mortality.Conclusion: Delirium in older ED patients is an independent predictor of increased 6-month mortality, and this relationship appears to be present regardless of nursing home status.

The Inability of B-type Natriuretic Protein to Predict Short-Term Risk of Death or Myocardial Infarction in Non-Heart-Failure Patients With Marginally Increased Troponin Levels - Corrected Proof

2010-04-05

Study objective: We want to know whether a low B-type natriuretic peptide (BNP) level, obtained shortly after presentation and independent of information provided by other clinical findings and laboratory tests, would affect management decisions for emergency department (ED) patients with nondiagnostic troponin levels. Previous studies have generally been retrospective or inclusive of patients with heart failure.Methods: We prospectively studied patients evaluated for possible acute coronary syndromes who had nondiagnostic levels of serum troponin, nondiagnostic ECGs, and no clinical heart failure within 4 hours of presentation. BNP levels were obtained but results not provided to clinical staff. The primary outcome was the composite of acute myocardial infarction or death within 30 days. The secondary outcome was the composite of the primary outcome, percutaneous coronary intervention, or coronary artery bypass grafting.Results: Almost half of the patients screened for but excluded from the study had known heart failure or a history of heart failure. The resulting cohort was composed of 348 patients, with a median age of 64 years and 51% women. The primary outcome occurred in 16.1% of patients; the secondary outcome, in 27.6%. At a standard cutoff of BNP greater than or equal to 80 pg/mL, the negative predictive value for the primary outcome was 80% (95% confidence interval 73% to 86%). The negative predictive value for the secondary outcome was 69% (95% confidence interval 61% to 75%). Multivariable analyses supported these findings.Conclusion: A single, low BNP level obtained shortly after presentation to the ED could not identify patients at low risk for 30-day acute myocardial infarction or death.

Delphi Consensus on the Feasibility of Translating the ACEP Clinical Policies Into Computerized Clinical Decision Support - Corrected Proof

2010-04-05

Clinical practice guidelines are developed to reduce variations in clinical practice, with the goal of improving health care quality and cost. However, evidence-based practice guidelines face barriers to dissemination, implementation, usability, integration into practice, and use. The American College of Emergency Physicians (ACEP) clinical policies have been shown to be safe and effective and are even cited by other specialties. In spite of the benefits of the ACEP clinical policies, implementation of these clinical practice guidelines into physician practice continues to be a challenge. Translation of the ACEP clinical policies into real-time computerized clinical decision support systems could help address these barriers and improve clinician decisionmaking at the point of care. The investigators convened an emergency medicine informatics expert panel and used a Delphi consensus process to assess the feasibility of translating the current ACEP clinical policies into clinical decision support content. This resulting consensus document will serve to identify limitations to implementation of the existing ACEP Clinical Policies so that future clinical practice guideline development will consider implementation into clinical decision support at all stages of guideline development.

Coronary Artery Calcium Scoring: Are the Data Rock Solid? - Corrected Proof

Judd E. Hollander — 2010-04-05

SEE RELATED ARTICLE, P. ■■■. [Ann Emerg Med. 2010;■■:■■■.]

Improved Out-of-Hospital Cardiac Arrest Survival After the Sequential Implementation of 2005 AHA Guidelines for Compressions, Ventilations, and Induced Hypothermia: The Wake County Experience - Corrected Proof

2010-04-01

Study objective: We assess survival from out-of-hospital cardiac arrest after community-wide implementation of 2005 American Heart Association guidelines.Methods: This was an observational multiphase before-after cohort in an urban/suburban community (population 840,000) with existing advanced life support. Included were all adults treated for cardiac arrest by emergency responders. Excluded were patients younger than 16 years and trauma patients. Intervention phases in months were baseline 16; phase 1, new cardiopulmonary resuscitation 12; phase 2, impedance threshold device 6; and phase 3, full implementation including out-of-hospital-induced hypothermia 12. Primary outcome was survival to discharge. Other survival and neurologic outcomes were compared between study phases, and adjusted odds ratios with 95% confidence intervals (CIs) for survival by phase were determined by multivariate regression.Results: One thousand three hundred sixty-five cardiac arrest patients were eligible for inclusion: baseline n=425, phase 1 n=369, phase 2 n=161, phase 3 n=410. Across phases, patients had similar demographic, clinical, and emergency medical services characteristics. Overall and witnessed ventricular fibrillation and ventricular tachycardia survival improved throughout the study phases: respectively, baseline 4.2% and 13.8%, phase 1 7.3% and 23.9%, phase 2 8.1% and 34.6%, and phase 3 11.5% and 40.8%. The absolute increase for overall survival from baseline to full implementation was 7.3% (95% CI 3.7% to 10.9%); witnessed ventricular fibrillation/ventricular tachycardia survival was 27.0% (95% CI 13.6% to 40.4%), representing an additional 25 lives saved annually in this community.Conclusion: In the context of a community-wide focus on resuscitation, the sequential implementation of 2005 American Heart Association guidelines for compressions, ventilations, and induced hypothermia significantly improved survival after cardiac arrest. Further study is required to clarify the relative contribution of each intervention to improved survival outcomes.

The Application of Mechanical Devices for CPR: Make the First 5 Minutes the Best 5 Minutes! - Corrected Proof

Robert E. O'Connor — 2010-04-01

SEE RELATED ARTICLE, P.■■■. [Ann Emerg Med. 2010;■■:■■■.]

Six Years of Epinephrine Digital Injections: Absence of Significant Local or Systemic Effects - Corrected Proof

Andrew E. Muck, Vikhyat S. Bebarta, Doug J. Borys, David L. Morgan — 2010-03-29

Study objective: Epinephrine autoinjectors are known to result in accidental digital injections. Treatment recommendations and adverse outcomes are based on case reports. The objective of our study is to determine the frequency of digit ischemia after epinephrine autoinjector digital injections. In addition, we describe the frequency of epinephrine digital injections, treatments used, adverse local effects, and systemic effects.Methods: We performed a retrospective cohort study on cases reported to 6 poison centers during 6 years, using a search of the Texas Poison Center Network database. Patients who had an epinephrine injection of the hand were reviewed, and digital injections were included. Variables collected included demographics, local and systemic effects, symptom duration, treatments used, comorbidities, and whether admission, surgery, or hand surgery consultation was used. One trained abstractor used a standard electronic data collection form.Results: There were 365 epinephrine injections to the hand identified for the 6-year period. Of these, 213 were digital injections, and 127 had follow-up. All patients had complete resolution of symptoms. None of the patients were hospitalized or received hand surgery consultation or surgical care. Significant systemic effects were not reported. Pharmacologic vasodilatory treatment was used in 23% (29/127) of patients. Ischemic effects were documented for 4 patients, and 2 of these had symptom resolution within 2 hours. All 4 patients received vasodilatory therapy and were discharged home, with complete resolution of symptoms.Conclusion: In our series of patients using poison center calls about digital epinephrine autoinjections, there were no cases in which clinically apparent systemic effects were recorded and few patients had ischemia. No patient was admitted or had surgery. Most clinicians did not use vasodilation medications or techniques.

Randomized Controlled Trial of Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses in Patients at Risk for Community-Associated Methicillin-Resistant Staphylococcus aureus Infection - Corrected Proof

2010-03-29

Study objective: Community-associated methicillin-resistant Staphylococcus aureus is now the leading cause of uncomplicated skin abscesses in the United States, and the role of antibiotics is controversial. We evaluate whether trimethoprim-sulfamethoxazole reduces the rate of treatment failures during the 7 days after incision and drainage and whether it reduces new lesion formation within 30 days.Methods: In this multicenter, double-blind, randomized, placebo-controlled trial, we randomized adults to oral trimethoprim-sulfamethoxazole or placebo after uncomplicated abscess incision and drainage. Using emergency department rechecks at 2 and 7 days and telephone follow-up, we assessed treatment failure within 7 days, and using clinical follow-up, telephone follow-up, and medical record review, we recorded the development of new lesions within 30 days.Results: We randomized 212 patients, and 190 (90%) were available for 7-day follow-up. We observed a statistically similar incidence of treatment failure in patients receiving trimethoprim-sulfamethoxazole (15/88; 17%) versus placebo (27/102; 26%), difference 9%, 95% confidence interval –2% to 21%; P=.12. On 30-day follow-up (successful in 69% of patients), we observed fewer new lesions in the antibiotic (4/46; 9%) versus placebo (14/50; 28%) groups, difference 19%, 95% confidence interval 4% to 34%, P=.02.Conclusion: After the incision and drainage of uncomplicated abscesses in adults, treatment with trimethoprim-sulfamethoxazole does not reduce treatment failure but may decrease the formation of subsequent lesions.

Accidental Digital Self-Injection of Epinephrine: Debunking the Myth - Corrected Proof

Adam J. Singer — 2010-03-29

SEE RELATED ARTICLE, P.■■■. [Ann Emerg Med. 2010;■■:■■■.]

Reducing Error in the Emergency Department: A Call for Standardization of the Sign-out Process - Corrected Proof

Kapil R. Dhingra, Andrew Elms, Cherri Hobgood — 2010-03-22

[Ann Emerg Med. 2010;■■:■■■.] Since the increased recognition of medical error in the late 1990s, the medical profession has made significant efforts to eliminate both systemic and human error. As a result, many strategies have been implemented to reduce and eliminate error. These include national recommendations to limit resident work hours and encourage clear communication between providers, especially concerning the handoff of care. The transition of care has become a focus of error reduction because The Joint Commission (TJC) has found that 70% of all sentinel medical error events arise from communication breakdowns and 50% of these errors occur during the handoff of care. The emergency department (ED) is no exception. The simultaneous management of multiple ill patients, practitioner shift work, limited knowledge of patients' preexisting medical conditions, high levels of diagnostic uncertainty, and high decision density make ED transfer of care especially vulnerable to error. Initial research and intervention efforts have focused on the transfer of care to the inpatient setting, with 29% of respondents in one study reporting adverse events occurring after transfer of patients from the ED to inpatient units.

Olfactory and Gustatory Hallucinations Presenting as Partial Status Epilepticus Because of Glioblastoma Multiforme - Corrected Proof

2010-03-22

Olfactory and gustatory hallucinations are not often encountered in the acute care setting but may represent the subtle presenting features of a significant underlying disease process. We describe a patient whose most striking presenting symptoms were of olfactory and gustatory hallucinations and in whom the diagnosis and treatment of a new brain tumor and partial status epilepticus occurred entirely in the emergency department. The lesion was subsequently identified as glioblastoma multiforme involving the hippocampus and amygdala.

Identifying the Minimum Clinically Significant Difference in Acute Pain in the Elderly - Corrected Proof

Polly E. Bijur, Andrew K. Chang, David Esses, E. John Gallagher — 2010-03-19

Study objective: To identify the minimum clinically significant difference in pain in elderly emergency department (ED) patients.Methods: This was an observational, prospective study of a convenience sample of patients aged 65 years or older with acute pain. Patients rated their pain on an 11-point numeric rating scale (NRS) on entering the study and every 30 minutes for 2 hours. The arithmetic minimum clinically significant difference was defined as the mean difference between current and preceding NRS scores when the subject described his or her pain as “a little less pain” or “a little more pain.” The proportional minimum clinically significant difference was change in NRS in a 30-minute interval divided by the NRS at the beginning of the interval. We used generalized estimating equations to adjust for nonindependence of pain scores and to test trend over time.Results: One hundred ninety-five patients were enrolled (mean age 74 years; 73% women; 51% Hispanic; 33% black). The arithmetic minimum clinically significant difference averaged over all periods was 1.5 (95% confidence interval 1.3 to 1.6), the proportional minimum clinically significant difference was 25% (95% confidence interval 20% to 29%). The arithmetic minimum clinically significant difference unexpectedly decreased over time: 2.1 from baseline to 30 minutes, 1.4 from 30 to 60 minutes, 1.3 from 60 to 90 minutes, and 1.0 from 90 to 120 minutes (P<.001). In contrast, the proportional differences were more stable: 27% from baseline to 30 minutes, 22% from 30 to 60 minutes, 22% from 60 to 90 minutes, and 28% from 90 to 120 minutes (P=.89).Conclusion: The arithmetic minimum clinically significant difference in older ED patients was 1.5 NRS units and decreased over time, whereas the proportional change was 25% and more stable.

Improving Cardiac Resuscitation: Evolution or Revolution? - Corrected Proof

Arthur L. Kellermann — 2010-03-08

[Ann Emerg Med. 2010;■■:■■■.] In November 2009, the National Institutes of Health (NIH) prematurely terminated a large, multicenter study by the Resuscitation Outcomes Consortium. It was designed to assess 2 therapies intended to improve blood flow during out-of-hospital cardiac arrest. One arm assessed whether a 3-minute interval of conventional cardiopulmonary resuscitation (CPR) before the first defibrillation attempt improves survival. The other arm examined the efficacy of an impedance threshold device, a valve designed to increase negative chest pressure during the relaxation phase of CPR. When data from the first 11,500 subjects showed that neither intervention increased survival, the NIH ended the trial.

Postdischarge Adverse Events for 1-Day Hospital Admissions in Older Adults Admitted From the Emergency Department - Corrected Proof

2010-03-02

Study objective: We assess hospital readmission and death within 60 days in older adults admitted from the emergency department (ED) and discharged by an inpatient service within 24 hours.Methods: This was a retrospective review of ED patients aged 64 years or older, admitted from 2 hospitals (2004 to 2006), who were discharged home within 24 hours. Excluded were inhospital deaths, observation admissions, transfers to other facilities, patients who left against medical advice, and hospice patients. Outcomes were 72-hour and 30-day readmissions and postdischarge deaths that occurred within 60 days of ED admission. Logistic regression was used to assess for predictors of readmission. A chart review of deaths after discharge was performed to assess for potential contributors to adverse outcomes.Results: A total of 1,470 admissions met inclusion criteria as 1-day admissions. Of those, 22 (1.5%) patients returned for hospital readmission within 72 hours and 156 (10.6%) within 30 days of discharge. In the multivariable analysis, previous admissions (odds ratio [OR] 1.3; 95% confidence interval [CI] 1.1 to 1.4) and an admission diagnosis of heart failure (OR 2.2; 95% CI 1.0 to 5.0) were associated with 30-day readmission. In 841 individual patients with greater than or equal to one 1-day admission, there were 15 deaths (1.8%) within 60 days. Of those, 11 (73%) patients had abnormal ED ECG results, 6 (40%) were ruled out for acute myocardial infarction while hospitalized, and 3 (20%) had definitive follow-up arranged at discharge.Conclusion: One-day admissions in hospitalized older adults through the ED do not represent a group at low risk for postdischarge adverse outcomes.

Extracorporeal Life Support in a Case of Fatal Flecainide and Betaxolol Poisoning Allowing Successful Cardiac Allograft - Corrected Proof

2010-02-22

Use of cardiac allograft for transplantation from donors after acute poisoning is a matter of debate because of potential toxic organ injuries, especially if death results from massive ingestion of cardiotoxic drugs. We report successful allograft cardiac transplantation from a brain-dead patient after severe flecainide and betaxolol self-poisoning requiring extracorporeal life support. Extracorporeal life support was initiated in the emergency department because of a refractory cardiac arrest caused by the cardiotoxicants' ingestion and continued after the onset of brain death to facilitate organ donation of the heart, liver, and kidneys. Forty-five months later, each organ recipient was alive, with normal graft function.

Cardiopulmonary Resuscitation Interruptions With Use of a Load-Distributing Band Device During Emergency Department Cardiac Arrest - Corrected Proof

2010-02-08

Study objective: Our primary aim is to measure no-flow time and no-flow ratio before and after an emergency department (ED) switched from manual to a load-distributing band mechanical cardiopulmonary resuscitation (CPR) device.Methods: This was a phased, before-after cohort evaluation at an urban tertiary hospital ED. We collected continuous video and chest compression data with the Physiocontrol CodeStat Suite 7.0 for resuscitations during the period just before and after adoption of load-distributing band CPR. All out-of-hospital, nontraumatic cardiac arrest, adult patients were eligible. From February 2007 to July 2008, there were 26 manual and 41 load-distributing band cases.Results: Patients in both phases were comparable in terms of demographics, medical history, witnessed arrest, arrest location, bystander CPR rates, out-of-hospital defibrillation, initial rhythm, and ED defibrillation. The median no-flow time, defined as the sum of all pauses between compressions longer than 1.5 seconds, during the first 5 minutes of resuscitation, was manual CPR 85 seconds (interquartile range [IQR] 45 to 112 seconds) versus load-distributing band 104 seconds (IQR 69 to 151 seconds). The mean no-flow ratio, defined as no-flow time divided by segment length, was manual 0.28 versus load-distributing band 0.40 (difference=−0.12; 95% confidence interval −0.22 to −0.02). However, from 5 to 10 minutes into the resuscitation, median no-flow time was manual 85 seconds (IQR 59 to 151 seconds) versus load-distributing band 52 seconds (IQR 34 to 82 seconds) and mean no-flow ratio manual 0.34 versus load-distributing band 0.21 (difference=0.13; 95% confidence interval 0.02 to 0.24). The average time to apply load-distributing band CPR during this period was 152 seconds.Conclusion: Application of a load-distributing band in the ED is associated with a higher no-flow ratio than manual CPR in the first 5 minutes of resuscitation. We suggest that attention to team training, rapid application of the device to minimize interruption, and feedback from defibrillator and video recordings may be useful to improve resuscitation team performance.

Coronary Artery Calcium Scoring in the Emergency Department: Identifying Which Patients With Chest Pain Can Be Safely Discharged Home - Corrected Proof

2010-02-08

Study objective: Coronary artery calcium scoring (CACS) is a simple and readily available test for identifying coronary artery disease. Our objective is to evaluate whether a CACS of zero will identify chest pain patients who can be safely discharged home, without need for further cardiac testing.Methods: This was a prospective observational cohort study conducted at an urban tertiary care hospital of stable patients presenting to the emergency department (ED) with chest pain of uncertain cardiac cause. Patients with a normal initial troponin level, nonischemic ECG, and no history of coronary artery disease had stress myocardial perfusion imaging (SPECT) and CACS within 24 hours of ED admission. Cardiac events were defined as an acute coronary syndrome during the index hospitalization or in follow-up. CACS results were assessed in relation to SPECT findings and cardiac events.Results: The 1,031 patients enrolled (mean [SD] age 54 [13] years) had a median CACS of 0 (61% with CACS of 0). The frequency of an abnormal SPECT ranged from 0.8% (CACS of 0) to17% (CACS>400). Cardiac events occurred in 32 patients (3.1%) during the index hospitalization (N=28) or after hospital discharge (N=4) (mean 7.4 [3.3] months). Only 2 events occurred in 625 patients with a CACS of 0 (0.3%; 95% confidence interval 0.04% to 1.1%). Thus, 2 of 32 patients with a cardiac event had a CACS of 0 (6%; 95% confidence interval 0.8% to 21%). Both of these patients developed increased troponin levels during their index visit but had normal serial ECG and SPECT study results and no cardiac events at 6-month follow-up.Conclusion: A majority of patients (61% in our sample) evaluated for chest pain of uncertain cardiac cause have a CACS of 0, which predicts both a normal SPECT result and an excellent short-term outcome. Our results suggest that patients with a CACS of 0 can be discharged home, without further cardiac testing.