June 2011 – Emergency Medicine Literature of Note

Time To Let ABCD2 Die

The problem – the most difficult clinical situations are the ones where we need a handy decision tool – and the hardest to come up with an effective one. Syncope rules, PE prediction rules, ACS prediction rules, and now TIA evaluation.

The most important number to come out of this paper is probably 1.8% – the number of patients with a TIA who went on to have a stroke in the next seven days. That’s 38 out of their 2056 patients enrolled. The next number is 2.7%, which is the 56 patients who had another TIA within 7 days. So somehow a rule has to magically pick out that tiny proportion of patients who are going to have bad outcomes without excessively testing the remaining supermajority.

Nearly everyone had a CT of the head, nearly everyone had an EKG, very few (15% with an ABCD2 score ≤ 5 and 22.% with a score > 5) had consultation with a neurologist, and even fewer were admitted. The specificity for stroke within 7 days with a score >2 – the AHA definition of “high risk” – is only 12.5%. Not only that, but there was significant disagreement between enrolling physicians and the study center regarding the correct ABCD2 score for a patient.

So, in the end, ABCD2 is difficult to apply and only minimally useful. You’re going to miss half the strokes at 7 days if you apply it in a situation where the specificity is >50% – so, sure, a sky-high score tells you they’re in trouble, but that still doesn’t help you discharge the majority of your TIAs safely for outpatient follow-up.

“Prospective validation of the ABCD2 score for patients in the emergency department with transient ischemic attack.”
www.ncbi.nlm.nih.gov/pubmed/21646462

Surfactant for Hydrocarbon Aspiration

I’ve seen surfactant administered for alveolar collapse following near-drowning, but this is a case report regarding surfactant use in severe pneumonitis after low viscosity/low volatility lamp oil. Less than 1mL of similar aspirated hydrocarbons may result in significant lung injury. In their specific case they administered 80 mL/m2 of surfactant intratracheally as rescue therapy when their patient continued to become hypoxemic despite recruitment maneuvers on mechanical ventilation.

Definitely something to keep in mind depending on the pathophysiology of the lung injury.

“Early administration of intratracheal surfactant (Calfactant) after hydrocarbon aspiration.”
http://www.ncbi.nlm.nih.gov/pubmed/21624880

Kids Are Too Fat For The Broselow Tape Now

Now that increasing numbers of children are overweight and obese (up to 36% of 10 to 17 year olds now), 53% of this pediatric sample from West Virginia fell out of the Broselow tape estimate based on height. Of these, 77.1% of the incorrect weights were greater than that predicted by the Broselow.

It is West Virginia – not the healthiest state in the U.S. – but any hospital that serves a predominantly disadvantaged population may have similar results, and should realize that they may be under dosing their medications. The authors suggest only a couple alternative strategies, but I think we’re probably just best off using clinical judgement as to whether the tape is accurate in each individual clinical situation.

“Is the Broselow tape a reliable indicator for use in all pediatric trauma patients?”
http://www.ncbi.nlm.nih.gov/pubmed/21629149

The Mortality Burden of Homelessness

Anyone working in the Emergency Department knows that homelessness and psychiatric disorders go hand-in-hand – and that also goes psychiatric disorders and substance abuse. This study confirms what we already know about the prevalence of these issues in the homeless population.

The most interesting number I read out of it was that the life expectancy of a homeless male aged 15-24 years was 38.7, and 47.4 for similarly aged homeless females – compared to life expectancies of 60.3 and 64.8 in their general population. It makes me wonder how much of that life expectancy difference is just the homelessness, or whether it’s the psychiatric and substance abuse disorders – I would probably say most of that difference is made up with the substance abuse.

“Psychiatric disorders and mortality among people in homeless shelters in Denmark: a nationwide register-based cohort study.”
http://www.ncbi.nlm.nih.gov/pubmed/21676456

Pediatric Sexual History Should Not Be Neglected

I am torn regarding whether 82% represents appropriate performance on history taking in pediatric adolescent (ages 14 – 19) lower abdominal pain/dysuria/vaginal complaint, or whether that remaining 18% represents potentially uncaptured pathology. Considering that 76% of patients asked regarding sexual history reported sexual activity, and 83% of their subgroup completing anonymous questionnaires reported sexual activity, I think >90% enquiry regarding sexual activity would be a better target.

So, we’re doing a pretty good job – but it could be better.

“Sexual history documentation in adolescent emergency department patients.”
http://www.ncbi.nlm.nih.gov/pubmed/21646260

Ceftaroline – The New Wonder Drug

Don’t use it.

If you’re like me, every journal you pick up nowadays has a three page glossy fold-out of some confident-looking fake doctor showing off the new broad-spectrum magic medicine, ceftaroline fosamil (Teflaro). 600mg IV q12, ask your doctor if you should be receiving Teflaro.

So, finally, when I got a booklet mailed to my house, I gave in and looked at the literature. And, I was almost legitimately defeated by the literature because most of the recent, relevant published literature regarding outcomes in the phase III trials…is written by employees of Forest Laboratories and published in a special “clinical supplement” to an infectious disease journal. There isn’t much data out there that isn’t just advertising.

However, my survey of the animal studies, and presuming the human studies aren’t blatantly made up, seems to indicate this is a great antibiotic. It doesn’t work against VRE, pseudomonas, ESBL e. coli, ESBL klebsiella, or acinetobacter, but it’s active against many strains of MRSA, DNS MRSA, and VISA, along with the other strep and staph we worry about.

Which is exactly why we shouldn’t use this antibiotic – it’s so good it should be on every hospital’s formulary, but locked in a vault with the same key system a nuclear launch requires. Keep it as third- or fourth-line to prevent additional resistances. But, don’t use it.

Sadly, the article I have for you is just a review of all the manufacturer-supported data – but at least it’s not written by them.

“Ceftaroline: a comprehensive update.”
http://www.ncbi.nlm.nih.gov/pubmed/21420284

Patients Bleed When On Aspirin and Plavix

And they bleed a heck of a lot more on Plavix than Aspirin. This is probably the first article I’ve ever read out of Academic Dermatology, and it’s mildly relevant to EM in the sense that we perform a lot of minor cutaneous procedures – suturing, I&D, etc.

This is a retrospective review of bleeding associated with minor surgical dermatology, and, the good news, it was rare – at 0.3% of cases on clopidogrel, and even rarer on aspirin alone, and then zero when on neither. Bleeding doesn’t stress us out as much, probably, so this isn’t practice changing. They do importantly mention in their discussion that holding/changing these medications prior to the procedure can be associated with thrombotic complications – I wouldn’t be rushing off to give DDAVP to wake any platelets up if I ran into procedural troubles.

“Complications of cutaneous surgery in patients taking clopidogrel-containing anticoagulation.”
http://www.ncbi.nlm.nih.gov/pubmed/21514003

Public Insurance Places Children At Risk

Determining proper payment for healthcare services is a fascinating problem of substantial complexity, and, with the “Affordable Care Act” and various past and future movements towards public insurance, there is a great deal of uncertainty regarding physician payment – both in the amount (public vs. private insurance) or whether (uncompensated care in hospitals, emergency departments).

This is a very interesting study out of NEJM that is applicable to the 70 to 80% of emergency departments we send home with instructions to “follow-up with X”. They nicely demonstrate that, in Chicago, at least, “follow-up with X” is nearly trivially easy with private insurance, and much more difficult if funded by one of their Medicaid providers for children. Excepting child psychiatry – which is in shortage – when calling a specialist for follow-up claiming to have private insurance, their research assistants could schedule an appointment well over 90% of the time. Alternatively, when stating they had public insurance for their child, ability to follow-up ranged from 20 to 57%, depending on the specialty.

Not only that, public insurance patients waited a mean of 42 days for their appointment versus 22 days for private insurance, when they looked at clinics that would even accept that insurance option.

And, the clinical scenarios they presented for follow-up were not just routine new patient appointments – they were pediatric patients with legitimate uncontrolled morbid disease with the potential to significantly worsen and impact their overall health.

I don’t have a solution to a complex social, financial, and political problem with complex social, financial, and political obstacles – but the more good articles like this are published, the more likely smart folks will start working on solutions.

“Auditing access to specialty care for children with public insurance.”
http://www.ncbi.nlm.nih.gov/pubmed/21675891

Do Not Use Etomidate/Fentanyl For Orthopedic Reduction In Children

Sometimes, when I read a study, I think to myself – great study! If only they had sufficient enrollment to have power and validity! When I read this study, I thought, Heavens to Betsy – I am so glad they only subjected 12 patients to etomidate/fentanyl for sedation.

This is comparing ketamine/midazolam to etomidate/fentanyl for procedural sedation and the authors hoped that, perhaps, the shorter duration of action of etomidate would make it a viable alternative. But, it isn’t. Objective measures of procedural distress favored ketamine, parents favored ketamine, and the practitioners favored ketamine. Sedation time and recovery time favored etomidate – but at what cost? 18% of the ketamine group had an adverse event (vomiting, emergency reaction), while 50% of the etomidate group did (hypoxemia, etc.)

Propofol/fentanyl may be considered, but not etomidate/fentanyl.

“Ketamine/midazolam versus etomidate/fentanyl procedural sedation for pediatric orthopedic reductions.”
http://www.ncbi.nlm.nih.gov/pubmed/20502386

Sensitivity of CT Angiography for Aneurysms

Not exactly the article I was expecting when I pulled it, but mildly interesting nonetheless. The real applicability of this article is towards those folks who say the LP for SAH is outdated, and we should just proceed with CTA to identify the culprit aneurysm.

As opponents say, many aneurysms identified by CTA are asymptomatic and unrelated to the acute headache in the Emergency Department, and, without the LP, you don’t know their clinical relevance. This study lets them also say that CTA doesn’t even necessarily perform well enough at this task to warrant use – it will miss 5% of aneurysms and overcall 3.8%.

However, it must be said, this meta-analysis uses data from a number of old studies that have older CT scanners that were very poor at detecting <4mm aneurysms. Once you get to 16 and 64 row CT, your sensitivity is closer to 98-99% – and then you have to fall back to the asymptomatic/clinical relevance argument.

“Diagnosing cerebral aneurysms by computed tomographic angiography: meta-analysis”
http://www.ncbi.nlm.nih.gov/pubmed/21391230