>In Case You Missed It – Fall 2013

ED Handover

A model for Emergency Department (ED) multiprofessional morning handover is described in the Clinical Teacher (2013;10:219–23). The authors describe how prior to the introduction of multiprofessional handover, the ED used to adopt the traditional approach of separate handovers for medical and nursing staff. Their multiprofessional handover has an emphasis on enabling all staff to enhance their learning and was generally well received.

STICH II

The second randomized trial comparing early surgery with initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral hematomas (STICH II) has been published in the Lancet (2013;382:397–408). The study recruited patients from 78 centres in 27 countries, excluding those who had any intraventricular hemorrhage. It found little benefit of surgery for conscious patients with a superficial intracerebral hemorrhage with a volume of 10–100 mL. However, early surgery might yet have a role to play in a small subgroup of patients with a poor prognostic score or whose neurological status progressively deteriorates.

Sigmoid Diverticulitis

The natural history of a first episode of sigmoid diverticulitis was investigated in a prospective study from Switzerland and published in the British Journal of Surgery (2013;100:976–9). Patients were included if they presented with a first episode of uncomplicated sigmoid diverticulitis which was confirmed on CT scanning and required admission to hospital. Interestingly, the diverticulitis in most patients followed a relatively benign course without recurrence. When it did recur, the diverticulitis was very rarely complicated. In contrast to previous beliefs, there was no evidence that it followed a more aggressive course in younger patients.

SERIAL MULTIPLE BIOMARKERS IN THE ASSESSMENT OF SUSPECTED ACUTE CORONARY SYNDROME: MULTIPLE INFARCT MARKERS IN CHEST PAIN (MIMIC) STUDY

Macdonald, S.P.J., et al, Emerg Med J 30(2):149, February 2013

METHODS: This prospective observational Australian study evaluated the utility of a biomarker panel consisting of myoglobin, CK-MB, cTnI and B-type natriuretic peptide (BNP) (Biosite Triage) in facilitating early identification of suitability for discharge in 1,758 adults presenting to two tertiary and three general hospital EDs with acute chest pain without definitive EKG findings. Patients were tested on presentation and after two hours, and any abnormal result was considered to represent a positive test. Final diagnoses were based on standard cTnI testing, EKGs and 30-day follow-up.

RESULTS: AMI was diagnosed in 11% of patients with sufficient data, and the secondary outcome of all-cause mortality, MI or unplanned coronary revascularization at 30 days occurred in 14%. When considered in isolation, the biomarker panel had a sensitivity of 90% for AMI on presentation and 84% for the 30-day combined outcome. Sensitivity improved to 99% for each outcome if biomarker panel results were combined with a TIMI clinical risk score of 0, but this combination would have identified only 9.4% of patients as suitable for discharge from the ED. Sensitivities were 98% for MI and 95% for the 30-day outcome if biomarker panel results were combined with a National Heart Foundation of Australia score of low-to-intermediate clinical risk, which would have identified 28% of patients as being suitable for discharge from the ED.

CONCLUSIONS: The two-hour biomarker panel in isolation does not appear to be suitable for identifying chest pain patients who would be suitable for early discharge from the ED. Combining panel results with clinical risk stratification might prove to be more useful.

 

ULTRASOUND-GUIDED PERIPHERAL INTRAVENOUS ACCESS PROGRAM IS ASSOCIATED WITH A MARKED REDUCTION IN CENTRAL VENOUS CATHETER USE IN NONCRITICALLY ILL EMERGENCY DEPARTMENT PATIENTS

Shokoohi, H., et al, Ann Emerg Med 61(2):198, February 2013

 

BACKGROUND: Central venous catheter-associated bloodstream infections are more common when these devices are placed in the ED rather than in other settings (24 vs. 1.7 per 1000 catheter-days). Difficult peripheral IV access in noncritical patients sometimes prompts central venous catheter placement in the ED.

METHODS: This retrospective study, from George Washington University, evaluated central venous catheter use in ED patients after implementation of a program of instruction in ultrasound-guided peripheral IV catheter placement in patients with difficult peripheral access. Instruction was provided for all emergency medicine residents beginning in 2005 and for all ED technicians beginning in 2008.

RESULTS: During a six-year period (2006-2011), central venous catheters were placed in 0.39% of patients treated in this urban academic ED. Despite a 24% increase in the ED census, central venous catheter placement decreased by 80%, from 0.81% in 2006 to 0.16% in 2011. The average monthly decrease was much greater in noncritical patients than in those admitted to the ICU (4.4% in patients admitted to telemetry, 4.8% in those admitted to a medical/surgical ward and 7.6% in patients discharged from the ED vs. 0.9% in critical patients). By 2011, no patient who was discharged from the ED had a central venous catheter placed while in the department.

CONCLUSIONS: The authors acknowledge the methodologic limitations of their study, but suggest that implementation of training in ultrasound-guided peripheral IV access can be associated with a dramatic decrease in central venous catheter placement in the ED.

 

Post-Concussion Symptoms

A study of children and young adults who had sustained a head injury with post-concussion symptoms investigated the risk factors for prolonged symptoms. 280 patients aged between 11 and 22 years who presented to a tertiary care children’s hospital in Boston were enrolled. Most of the head injuries were sustained during a sporting activity. Those individuals who had a previous history of minor head injury were at increased risk of developing prolonged symptoms—this effect was particularly pronounced for patients with very recent or multiple head injuries (Pediatrics 2013;132:8–17).

 

RISK OF TRAUMATIC INTRACRANIAL HEMORRHAGE IN PATIENTS WITH HEAD INJURY AND PREINJURY WARFARIN OR CLOPIDOGREL USE

Nishijima, D.K., et al, Acad Emerg Med 20(2):140, February 2013

 

BACKGROUND: There is uncertainty about the need for head CT scanning after mild blunt head trauma in older patients taking anticoagulant or antiplatelet drugs.

METHODS: This prospective observational study, coordinated at the University of California, Davis, attempted to identify variables associated with a low risk for intracranial hemorrhage (ICH) in adults presenting to six Northern California EDs with mild blunt head trauma during treatment with warfarin or clopidogrel (Plavix). The study included 982 patients (mean age 75.4) presenting after blunt head trauma with an initial GCS score of 13-15, regardless of loss of consciousness or amnesia. Head CT scanning was performed in all of the patients.

RESULTS: Preinjury warfarin use was documented for 72.7% of the patients and clopidogrel use for 28.4%; just under 5% were also taking aspirin. The most common mechanism of injury was a ground-level fall (83.6%). The initial head CT demonstrated ICH in 6.1% of the patients (30 on warfarin and 30 on clopidogrel), 20% of whom (12/60) required neurosurgical intervention and 17% of whom (10/60) died during the hospital course. Of eleven variables that were evaluated, there was substantial overlap between patients with and without ICH. Only two independent predictors of ICH were identified (vomiting – relative risk [RR] 3.53, and abnormal mental status – RR 2.85). A model that included these two predictors had a sensitivity for ICH of only 37%, a specificity of 87%, and positive and negative predictive values of 16% and 95%, respectively.

CONCLUSIONS: The authors were unable to develop a reliable prediction rule for ICH after mild blunt head trauma in patients taking preinjury warfarin or clopidogrel, and they therefore recommend a liberal policy for head CT scanning in this population.

 

CANADIANS’ WILLINGNESS TO RECEIVE CARE FROM PHYSICIAN ASSISTANTS

Doan, Q., et al, Can Fam Phys 58(8):e459, August 2012

 

BACKGROUND: Physician assistants (PAs) have been utilized for the provision of healthcare in the United States since the 1960s, but their incorporation into the Canadian healthcare system has only recently been considered. Primary care capacity shortages in Canada have resulted in decreased resources and longer wait times to be seen by a physician. The use of PAs could improve patient flow and decrease the costs of care.

METHODS: In this study, mothers accompanying children to be seen at the British Columbia Children’s Hospital were surveyed about their willingness to be treated by a PA for minor injuries. The scenarios that were presented included a sprained ankle and a forearm laceration in the respondent, and a forehead laceration in a child. Wait times that were presented were four hours to be treated by a physician vs. 30 minutes, one hour or two hours to be treated by a PA.

RESULTS: Responses were received from 229 of 270 potential participants (mothers who were familiar with PA services were excluded from participation). Nearly all of the respondents (99%) opted for treatment by a PA for at least one of the time trade-off scenarios for an ankle sprain or forearm laceration in themselves. Choice of a PA over a physician increased from about 85% if the wait to see the PA was two hours to 99% if the wait to see the PA was 30 minutes. For a forehead laceration in a child, 96% of the respondents opted for treatment by a PA for at least one of the time trade-off scenarios, increasing from 67% if the wait for a PA was two hours to 96% if the wait was 30 minutes.

CONCLUSIONS: The results of this survey suggest that Canadian patients would be willing to be treated by PAs for lower acuity complaints if this option would reduce the time to treatment.

Stroke Thrombolysis Over-rated?

A controversial article highlighting the continuing problem of conflicts of interest among authors and sponsors of clinical guidelines will resonate with many emergency practitioners. Using the now discredited practice of giving high-dose steroids for acute spinal cord injury as a historical example, the article focusses upon the evidence (or lack of it) that underpins the current practice of stroke thrombolysis (BMJ 2013;346:20–2).

Satisfaction of Trauma Patients

Does Sophia really know who our most satisfied trauma patients are? According to a recent epidemiological study, it is those elderly patients who require surgery that are essentially happy with all aspects of their care. In contrast, least satisfied are the younger, non-operatively treated patients, who experience complications in their care ( J Trauma 2013;75:110–15).

Diaphragmatic Rupture

Interrogation of a large US trauma registry revealed that 773 patients had sustained traumatic diaphragmatic injury. The reputation of this injury as being elusive and associated with a high mortality continues. Unsurprisingly, concomitant cardiac injury carried a particularly poor prognosis ( J Trauma 2013;74:1392–8).

Thoracolumbar Spine Injuries

There are two validated clinical guidelines that are widely used around the world to help guide the investigation and ‘clearance’ of patients who present with possible cervical spine injuries. In contrast, there are no such guidelines to help clinicians assess patients with injuries of the thoracolumbar spine. Writing in an editorial in Injury (2013;44:881–2), a group of trauma experts call for the development of clear, evidence-based decision rules to help redress this. They share their concerns about the relatively large amount of radiation exposure involved in computerised tomography of the thoracic and lumbar spine.

Backboard Time

Questions have arisen over the evidence behind routine use of backboards in trauma care, as well as the possible harm associated with their use. Early removal of the backboard is generally considered to be best practice. A study undertaken in a US level 1 academic trauma centre observed that patients with a lower perceived need for emergency care may have to wait longer for backboard removal, thereby putting them at increased risk of potential harm. Factors increasing the total backboard time need to be recognised and addressed within individual units (Int J Emerg Med 2013;20:17).

MANAGEMENT OF OESOPHAGEAL COINS IN CHILDREN

Nafousi, O., et al, Emerg Med J 30(2):157, February 2013

 

BACKGROUND: There are conflicting recommendations for the management of children with an asymptomatic esophageal coin.

METHODS: These British authors did an implicit chart review of 63 children aged 8 months to 13 years (median, 4 years) presenting from 2004 through 2010 with a radiologically confirmed esophageal coin. They excluded children with prior tracheal or esophageal surgery or coin ingestion more than 24 hours prior to presentation.

RESULTS: Most of the children (42/63) were asymptomatic. Among these asymptomatic children, the coin was located in the upper esophagus in 13, the middle esophagus in 10 and the lower esophagus in 19. Thirty-seven of the 42 children were managed conservatively with observation and repeat x-rays after 18 hours. Spontaneous passage was confirmed on repeat imaging in all but four of these 37 children. No asymptomatic child observed for a coin in the middle or lower esophagus subsequently underwent a procedure requiring general anesthesia, and no child who was managed conservatively developed complications.

CONCLUSIONS: The authors suggest that a period of observation for 18 hours (perhaps at home) followed by repeat x-rays may be an effective strategy for the management of asymptomatic children with an esophageal coin ingested within 24 hours prior to presentation in the absence of prior tracheal or esophageal surgery. Retained coins can be managed according to local practice. They do note that the British penny, the coin most commonly ingested in this study, is larger and heavier than the US penny, and caution that what they found may perhaps not be generalizable to other countries.

 

LONG-TERM FOLLOW-UP OF PATIENTS AFTER CHILDHOOD URINARY TRACT INFECTION

Hannula, A., et al, Arch Ped Adol Med 166(12):1117, December 2012

 

BACKGROUND: Guideline updates from several professional organizations, including the American Academy of Pediatrics, no longer recommend routine voiding cystourethrography (VCUG) after a first urinary tract infection (UTI) in children in the absence of risk factors for renal abnormalities.

METHODS: This observational study from Finland reports on the follow-up of a random sample of 193 patients undergoing ultrasonography (US) and VCUG after a childhood UTI in whom major renal dysplasia or obstructive uropathy had been excluded on an initial US exam. The patients entered the study from 1993 through 2003 at an age of 0-14, and underwent final follow-up exams in 2009 and 2010 after a mean follow-up of 11.1 years.

RESULTS: Just over half of the patients (53%) were managed with antibiotic prophylaxis and 22% underwent urinary tract surgery during childhood. In the 150 patients who underwent ultrasonography during follow-up, 15% (22/150) had unilateral renal parenchymal defects and 3% (5/150) had unilateral retardation of kidney growth. It was estimated that the potential frequency of new renal defects was about 3% overall. Twenty-one of the 22 patients with parenchymal defects had grade 3 to 5 vesicoureteral reflux on VCUG. When compared with patients without parenchymal defects on US, those with defects more frequently experienced recurrent UTIs (82% vs. 40%), more often received antibiotic prophylaxis (95% vs. 60%), and more frequently underwent urinary tract surgery (68% vs. 21%). All of the patients in the series had serum cystatin C concentrations, estimated GFRs, blood pressure values and height that were within the normal range.

CONCLUSIONS: The authors acknowledge the limitations of an observational study design, but suggest that the risk of long-term adverse sequelae of childhood urinary tract infection appears to be low.

 

 

Knee Meniscal Injuries

Osteoarthritis is a common cause of pain and reduced mobility, yet relatively little is known about the risk factors contributing to its pathogenesis. A prospective study from the University of Pittsburgh concluded that certain medial meniscal tears can predispose to osteoarthritis, a finding that may help guide future surgical management (Am J Sports Med 2013;41:1238–44).

 

Minor Ailment Schemes

If you want to avoid Emergency Department waiting times or need to get that appointment slot with your general practitioner, then a pharmacy-based scheme may be helpful. That is what a new systematic review published in the British Journal of General Practice (2013;63:e472–81) suggests. Evidence points to high patient satisfaction with such services, which from an economic standpoint, are cheaper to provide. How this fits in with the numerous other minor ailment service providers in both primary and secondary care has yet to be determined.

 

META-ANALYSIS: SERUM CREATININE CHANGES FOLLOWING CONTRAST ENHANCED CT IMAGING

Kooiman, J., et al, Eur J Rad 81(10):2554, October 2012

 

METHODS: These Dutch authors performed a meta-analysis of 40 studies (19,563 patients) of the incidence of contrast-induced nephropathy (CIN) after contrast-enhanced CT scanning. All of the studies were published after the year 2000, after which the use of high osmolar contrast markedly decreased. In all of the studies, CIN was defined as an increase in serum creatinine in excess of 25% or a level above 44mmol/L after contrast-enhanced CT.

RESULTS: The mean patient age in the 40 studies ranged from 44 to 74, and the mean amount of contrast administered ranged from 10ml to 230ml. Most of the studies (33/40) included patients with chronic kidney disease and in three-fourths of these studies, prophylactic hydration was advised. The incidence of CIN in the individual studies varied from 0% to 25%, but the weighted pooled incidence was 6.4%. In 20 studies that followed the course of renal function after a diagnosis of CIN, a decline in renal function persisted in 1.1% of all patients undergoing contrast-enhanced CT. The weighted pooled incidence of a need for renal replacement therapy was only 0.06%. The risk of CIN after contrast-enhanced CT was increased in patients with chronic kidney disease (8.8%, odds ratio [OR] 2.3) and in those with diabetes (9.3%, OR 3.1).

CONCLUSIONS: The overall risk of CIN after contrast-enhanced CT scanning in published studies is about 6%, but this decline in renal function persists as long as a week in only about 1%, and the need for renal replacement therapy is extremely rare. The risk of such an (almost always transient) increase in creatinine is slightly higher in patients with chronic kidney disease or diabetes.

 

 

VITAL SIGNS ARE UNRELIABLE

Yeh, D.D., et al, ANZ J Surg 82(9):574, September 2012

 

Unrecognized hemorrhagic shock can result in failure to transport trauma victims to designated trauma centers as well as a failure to appropriately triage in the ED setting. The authors, from Harvard Medical School, comment on the weaknesses of relying on stepwise vital sign abnormalities for assessing a patient’s status. They note that, in contrast to conventional models, 20-45% of hypotensive patients are bradycardic rather than tachycardic, and that hypotension is “usually a late (stage) finding.” Interpretation of blood pressure and heart rate is further confounded by alcohol, illicit drugs, and stress-response emotions (pain, fear, and anger). Elderly trauma patients present further challenges due to higher ‘normal’ blood pressures required for vital organ perfusion, and an absence of tachycardia due to medications such as beta-blockers or age-related decreased capacities for tachycardia. The authors suggest that alternate strategies might be superior to vital signs for assessing trauma victims. Elevated lactic acid levels are robust prognosticators of outcomes from shock, and are associated with the need for blood transfusion and other interventions. The potential value of a shock index (heart rate/systolic blood pressure) above a reference range of 0.5-0.7 is currently being evaluated. The authors conclude that the reliability of trauma triage criteria recommended by ATLS and most prehospital systems should be reevaluated, and that the best tool for assessment of the condition of a trauma patient is the clinical acumen of an experienced physician who considers all related variables including injury patterns and mechanism, lab abnormalities and the response to volume. They note that reliance on vital signs can result in under-triage of patients in early shock.

 

 

Best regards,

 

Paul Atkinson

Site Director for Research

 

Sources:

  1. Emergency Medicine Journal 2013
  2. Emergency Medicine Abstracts2013

 

 

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