As the authors in this retrospective review state, “Vertigo/dizziness is a common and challenging problem faced by the ER physician.” And, this is obviously true. Is it dysequilibrium? Is it true vertigo? Is it central or peripheral? And, finally, “now what”?
This is a clearly pro-MRI and con-CT study which, unfortunately, leads to a massive disconnect with reality. For most institutions, CT might be feasible, but MRI comes to town once a week for scheduled studies only. But, in this review of 448 head CTs for dizziness, the CT picked up essentially 10 interesting findings – but 16% of the subset of follow-up MRIs performed changed the initial diagnosis. Mostly, the missed diagnoses on CT were posterior circulation strokes and intracranial masses.
So, essentially what they observed was more false negatives than true positives for CT. This implies – at least in a retrospective fashion – that if your pretest probability is high enough for an intracranial process causing dizziness, the intention ought to be to conclude your investigations only with a negative MRI. I think most folks – given infinite resources – would agree. Otherwise, you’ll need to base imaging (if any) on clinical findings and risk factors for cerebrovascular disease in an attempt to develop an estimate for their true probability.
“Utility of head CT in the evaluation of vertigo/dizziness in the emergency department”
www.ncbi.nlm.nih.gov/pubmed/22940762
Unsurprisingly, NHAMCS Data is Flawed
The National Hospital Ambulatory Medical Care Survey is a massive database of abstracted patient records, systematically generated to produce a representative sample of the nation’s Emergency Department visits.
It should come as no surprise that retrospectively abstracted data from the electronic medical record sometimes fails to accurately reflect patient care. The important question, however, is “how often?” This review of NHAMCS by one of the Annals editors looked at a measurement that ought to be pretty obvious – intubation. If you can’t figure out whether a patient has been intubated via chart review, there’s some serious issues with your data sourcing. However, in this review of NHAMCS, the author interprets up to one in four charts as being potentially inaccurate due to inconsistencies between documented intubation and the final disposition of the patient (e.g., non-ICU settings, home, observation status, etc.)
Now, there are some instances in which patients are intubated in the Emergency Department – yet not subsequently dispositioned to a critical care or morgue – but these “temporary” intubations certainly do not constitute 25% of intubations. The author goes on to note that Annals publishes a NHAMCS study at least twice a year – relatively influential towards practice given the Impact Factor – and the flaws in this data should limit the relative weighting of its importance.
“Congruence of Disposition After Emergency Department Intubation in the National Hospital Ambulatory Medical Care Survey”
Sometimes, the Dead (by Ultrasound) Rise
This article received a little bit of dissemination, with the assertion that some apparently futile resuscitations may yet be salvaged despite the lack of cardiac activity on ultrasound.
But, this article doesn’t necessarily tell the entire story. It’s a systematic review of several small, poor-quality cardiac arrest cohorts for whom bedside cardiac ultrasonography was performed. In aggregate, there were 378 patients with no cardiac activity visualized during resuscitation – and 9 went on to have return of spontaneous circulation. They calculate this out as an LR of 0.18 for ROSC after finding no cardiac activity.
The problem is, this is the only information we have regarding the context of the ultrasound findings or the performance characteristics of the ultrasonographers at work. The authors also appropriately note that ROSC is not necessarily the ultimate patient-oriented outcome of interest – since we know that most ROSC after cardiac arrest admitted to the hospital still goes on to have a dismal outcome.
I’m not entirely sure what my takeaway should be from this study, and it’s not going to significantly modify my practice. In the appropriate clinical context, a lack of cardiac activity will still lead me to cease resuscitative efforts. It would be extraordinarily helpful to have a larger body of data specifically regarding the patient characteristics of those who did have ROSC despite lack of cardiac activity, to see if there is a usable pattern to this small population of exceptions.
“Bedside Focused Echocardiography as Predictor of Survival in Cardiac Arrest Patients: A Systematic Review”
PCA in the ED is Brilliant and Horrible
Management of acute pain in the Emergency Department is frequently inadequate. Considering the practice environment, the ebb and flow of workload, and the heterogenous presentations, this is not surprising. On the inpatient side of things, many patients with acute, severe pain receive patient-controlled analgesia. So, this is a randomized, controlled trial of PCA vs. conventional, untitrated boluses in the ED.
And, they were successful in demonstrating significant trends towards better, faster pain control and increased patient satisfaction with the PCA. Both groups received the same total amount of morphine, but the dynamics by which patients were able to self-titrate their pain control resulted in improved pain relief.
Unfortunately, there are some flaws with this study. This multi-center study only managed to enroll 96 patients in a one-year timeframe – probably the number we could aggressively enroll at my institution in a week. There is no mention of adverse events – which is significant, because PCA medication variances are renowned on the inpatient side as significant sources of morbidity. And, finally, they don’t measure any of the other operational variables that are important – cost, time to set up, etc.
Patient-controlled analgesia may yet have a role in the ED – and studies like this help keep the flame alive – but significant hurdles remain.
“A Randomized Controlled Trial of Patient-Controlled Analgesia Compared with Boluses of Analgesia for the Control of Acute Traumatic Pain in the Emergency Department”
www.ncbi.nlm.nih.gov/pubmed/23068783
Arrhythmogenic Right Ventricular Dysplasia
In young Emergency Department patients with syncope, most of the time, testing is minimal. Generally, the only universal testing is a pregnancy test and/or an electrocardiogram.
We’ve gotten pretty good at understanding the “life-threatening” causes of syncope in young adults diagnosed by electrocardiography, including:
– Wolff-Parkinson-White Syndrome
– Hypertrophic Obstructive Cardiomyopathy
– Brugada Syndrome
– Congenital Long QT
But there’s always more, and Arrhythmogenic Right Ventricular Dysplasia is one of those “more” that seems not to be on everyone’s lists. ARVD is a genetically-inherited abnormality in cardiac desmosomes that leads to fibrofatty deposition in the right ventricle. It is currently estimated to result in ~5% of the sudden cardiac deaths in adults under age 65, secondary to sustained monomorphic ventricular tachycardia. The characteristic EKG finding to look out for is, unfortunately, quite subtle – the “epsilon wave”. These waves are most prominent in V1-V3, and manifest as sharp upward deflections from baseline at the conclusion of the QRS complex.
Very few Emergency Department presentations mix the high-risk needle-in-the-haystack with the low-risk like young adults with syncope, so it’s important to stay alert for these rare ECG findings.
“Impact of new electrocardiographic criteria in arrhythmogenic cardiomyopathy”
www.ncbi.nlm.nih.gov/pubmed/23015790
Still Overpromising Benefit of PCI After Cardiac Arrest
The folks in France have been promoting PCI universally after cardiac arrest for quite some time. It’s an appealing concept – when you look at subgroups of out-of-hospital cardiac arrest, there’s a significant portion of folks who clearly have a primary cardiac cause, and clearly will benefit from emergency or early PCI.
However, this study inappropriately tries to make the case for all patients to receive PCI and therapeutic hypothermia after out-of-hospital cardiac arrest. This is a retrospective, cohort study spanning eight years of resuscitation, coordinated between Paris, France and Seattle, Washington. They used vital records follow-up to determine patient status for each OHCA patient surviving to hospital discharge, and then looked for associations between survival and whether they received PCI or hypothermia in-house. The most absurd statement is as follows:
“A beneficial survival association was evident among those with and without ST-elevation MI. This finding is provocative given the current debate about whether patients without evidence of ST elevation following resuscitation can benefit from PCI and should undergo early and routine coronary catheterization.”
Retrospective studies such as this suffer from substantial selection bias, in which the patients who are selected for particular therapies have interactions and confounders that simply cannot be controlled or adjusted. Patients benefit from PCI when they have a disease process amenable to intervention – and this is clearly not every cardiac arrest patient. The patients in this study who received PCI – and hypothermia – likely had specific features that identified them to treating physicians as candidates to benefit from these therapies.
The reasonable conclusion from the data presented is exactly that – cardiac arrest patients that have specific features that make them candidate for these therapies will benefit. PCI following cardiac arrest should not be considered to be “routine”.
“Long-Term Prognosis Following Resuscitation From Out of Hospital Cardiac Arrest – Role of Percutaneous Coronary Intervention and Therapeutic Hypothermia”
ALTEs That Need Admission Need Admission
Coming from the west-coast PEM powerhouses of Harbor-UCLA, CHLA, and USC, this prospective observational study attempts to distill the clinical characteristics of “apparent life threatening events” requiring hospitalization. Traditional teaching has always errs on the side of admission for ALTEs, despite the typical low-yield nature of the admission.
They collected data on 832 ALTEs, 191 (23%) of which they felt truly necessitated admission for a set of predefined criteria. Based on this data, they came up with a simple decision rule to identify ALTEs for admission:
– They obviously need to be admitted.
– Concerning medical history/prematurity/congenital comorbidities.
– >1 ALTE in 24 hours.
This captured 89% of necessary hospitalizations with a specificity of 61%, with an AUC of 0.71.
It’s a bit of an odd rule that includes “obvious need for admission”, but, I suppose it’s rather pragmatic. However, the adoption of a rule such as this – after prospective validation – would depend on the “acceptable miss rate” in an infant with a possible life-threatening condition. A sensitivity of 89% probably isn’t going to cut it, so, in the end, what this study is only good for is perusing the interesting data they’ve collected along the way.
“Apparent Life-Threatening Event: Multicenter Prospective Cohort Study to Develop a Clinical Decision Rule for Admission to the Hospital”
November Annals of EM Journal Club
Our EM Journal Club group down here at UT-Houston collaborated to write the Annals of Emergency Medicine monthly Journal Club installment, published in the November issue.
You get the questions now – at least, they’re available online starting today – but you’ll have to wait in suspense for months to hear our “answers”.
I don’t know if it was an editorial decision to put our thinly veiled IST-3 critique on page 666 of this year’s volume, but I can’t imagine it’s just a coincidence….
“rt-PA and Stroke: Does IST-3 Make It All Clear or Muddy the Waters?”
http://www.ncbi.nlm.nih.gov/pubmed/23089093
More Probably Unnecessary Head CTs/Admissions
I work at one of only two trauma centers in a city of four million potential patients, and I have firsthand experience with this issue. The issue is to determine the best management strategy for patients with mild traumatic brain injury and bleeding. We already know what to do with major bleeding – but patients with minor bleeding are a little more of a dilemma. They almost universally do well, but we observe them and repeat tests on nearly all of them.
This is a retrospective review of 36 months of trauma admissions to a level one trauma center in New Jersey, trying to describe the natural progression of mild traumatic intracranial bleeding. Historically, 1/3rd of these patients have bleeding that progresses, but only 1-3% will require neurosurgical intervention. This review found 341 patients with mild injuries and bleeding, and noted that 69% of these patients had no interval change in head CT results when repeated at 24 hours. Of the remaining patients, either no CT was performed (25 patients) because the injury was too insignificant or there was interval progression – including 11 patients who received neurosurgical intervention. But, the point of the article is generally supposed to be shown in Figure 2 – estimating the number of ongoing hemorrhages at each time point in the first 24 hours. Essentially, >80% of the bleeding ceases to expand within the first few hours from injury.
This is a useful jumping off point to perform the sort of work that isn’t featured in this article – characterizing the characteristics of patients and bleeding that progresses. If patients with bleeding unlikely to progress can be safely discharged rather than being observed for interval CT, this is a useful reduction in ED length of stay, observation admissions, or CT use.
“The temporal course of intracranial haemorrhage progression: How long is observation necessary?”
www.ncbi.nlm.nih.gov/pubmed/22658418
The Emergency Medicine Literature is Tragic
This is a survey of the top twelve Emergency Medicine journals, as ranked by impact factor, providing a descriptive analysis of the features of the studies contained within. The authors manually reviewed 330 articles and found a mere 8.8% were randomized studies. Most (65.5%) were cross-sectional studies and 23.6% were cohort studies. 57.3% were prospective, 47.9% were from the U.S., and the minority of studies (31.2%) used informed consent or mentioned waivers of informed consent.
Compared with other fields, the surveyed EM literature was less likely to mention IRB approval, less likely to be prospective, less likely to be blinded and controlled, and enrolled fewer patients per study.
There are many barriers to research in the Emergency Deparment – particularly prospective, randomized, controlled research. However, the establishment of an office for emergency services research at the National Institutes of Health may improve the ability of U.S. researchers to obtain grant funding.
Of course, this will then only exacerbate the bias inherent in the already U.S.-centric published literature.
“Quality of publications in emergency medicine”