EMS panelists at AAA say embracing new technology to manage supplies helped them reduce waste, cut costs and improve patient care
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Πέμπτη 30 Νοεμβρίου 2017
What is the Preferred Resuscitation Fluid for Patients with Severe Sepsis and Septic Shock?
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Michael E. Winters, Robert Sherwin, Gary M. Vilke, Gabriel Wardi
BackgroundCurrent guidelines for the management of patients with severe sepsis and septic shock recommend crystalloids as the initial fluid solution of choice in the resuscitation of these patients. In recent years, there have been numerous studies published on the type of fluid used in the resuscitation of patients with sepsis. The primary goal of this article is to determine the preferred intravenous fluid for the resuscitation of patients with severe sepsis and septic shock.MethodsA MEDLINE literature review was completed to identify studies that investigated the type of resuscitation fluid in the management of patients with severe sepsis and septic shock. Articles included were those published in English between 2011 and 2016, enrolled human subjects, and limited to the following types: randomized controlled trial, prospective observational trial, retrospective cohort trial, and meta-analyses. All selected articles then underwent a structured review by the authors.ResultsNine thousand sixty-two articles were identified in the search. After use of predetermined criteria, 17 articles were selected for review. Eleven of these were original investigations and six were meta-analyses and systemic reviews.ConclusionCrystalloids are the preferred solution for the resuscitation of emergency department patients with severe sepsis and septic shock. Balanced crystalloids may improve patient-centered outcomes and should be considered as an alternative to normal saline, if available. There is strong evidence that suggests semi-synthetic colloids decrease survival and should be avoided. The role of albumin in the resuscitation of patients with severe sepsis and sepsis is uncertain.
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Issue Highlights
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
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Warmer Weather as a Risk Factor for Cellulitis: A Population-based Investigation
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Jamal Taha
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Contents
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
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Response to Letter to the Editor
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Jan Van Keer, Karel Van Keer, Joachim Van Calster, Inge Derdelinckx
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Partial Contents of Volume 54, Number 1
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
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Blood Biomarkers for the Early Diagnosis of Stroke
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Heather Roesly
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Management of Pediatric Perforated Appendicitis
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Forrest Andersen
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Physician, Interrupted: Workflow Interruptions and Patient Care in the Emergency Department
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Renaldo C. Blocker, Heather A. Heaton, Katherine L. Forsyth, Hunter J. Hawthorne, Nibras El-Sherif, M. Fernanda Bellolio, David M. Nestler, Thomas R. Hellmich, Kalyan S. Pasupathy, M. Susan Hallbeck
BackgroundIt is unclear how workflow interruptions impact emergency physicians at the point of care.ObjectivesOur study aimed to evaluate interruption characteristics experienced by academic emergency physicians.MethodsThis prospective, observational study collected interruptions during attending physician shifts. An interruption is defined as any break in performance of a human activity that briefly requires attention. One observer captured interruptions using a validated tablet PC-based tool that time stamped and categorized the data. Data collected included: 1) type, 2) priority of interruption to original task, and 3) physical location of the interruption. A Kruskal-Wallis H test compared interruption priority and duration. A chi-squared analysis examined the priority of interruptions in and outside of the patient rooms.ResultsA total of 2355 interruptions were identified across 210 clinical hours and 28 shifts (means = 84.1 interruptions per shift, standard deviation = 14.5; means = 11.21 interruptions per hour, standard deviation = 4.45). Physicians experienced face-to-face physician interruptions most frequently (26.0%), followed by face-to-face nurse communication (21.7%), and environment (20.8%). There was a statistically significant difference in interruption duration based on the interruption priority, χ2(2) = 643.98, p < 0.001, where durations increased as priority increased. Whereas medium/normal interruptions accounted for 53.6% of the total interruptions, 53% of the interruptions that occurred in the patient room (n = 162/308) were considered low priority (χ2 [2, n = 2355] = 78.43, p < 0.001).ConclusionsOur study examined interruptions over entire provider shifts and identified patient rooms as high risk for low-priority interruptions. Targeting provider-centered interventions to patient rooms may aid in mitigating the impacts of interruptions on patient safety and enhancing clinical care.
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Editorial Board
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
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Comparison of Lactic Acid Levels in Children with Suspected and Confirmed Intussusception
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Vanessa Tamas, Paul Ishimine
BackgroundCurrently, no laboratory test can identify children with intussusception. Lactic acid is a marker of ischemia in gastrointestinal emergencies.ObjectivesWe present a case series comparing lactic acid levels in children with suspected and confirmed intussusception.MethodsThis is a prospective single case series of 39 patients who had suspected intussusception. Patients were eligible if they underwent abdominal ultrasound screening for suspected intussusception. Blood collected at the time of peripheral intravenous line placement was analyzed for lactic acid levels before ultrasound.ResultsThirty-nine patients were enrolled; 16 were diagnosed with intussusception. Mean (± standard deviation) lactic acid levels were not significantly different between children with suspected (1.7 ± 0.69 mmol/L) and confirmed intussusception (1.93 ± 1.13 mmol/L).ConclusionsLactic acid levels cannot identify children with intussusception.
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Emergency Coagulation Assessment During Treatment with Direct Oral Anticoagulants
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Krysia Crabtree
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Emergency Medicine Myths: Ectopic Pregnancy Evaluation, Risk Factors, and Presentation
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Jennifer J. Robertson, Brit Long, Alex Koyfman
BackgroundEctopic pregnancy (EP) is an important cause of morbidity and mortality in females of reproductive age. Proper diagnosis and treatment are critical, as complications such as rupture, hemorrhagic shock, and even death can occur.ObjectiveEP is a condition emergency physicians are trained to detect, yet there are multiple myths concerning its evaluation and diagnosis. This article reviews several of these myths in order to improve emergency department (ED) evaluation and diagnosis.DiscussionEP is a difficult diagnosis and may be missed on initial ED visit. While the diagnosis is often delayed simply due to very early presentations, it can also be missed because patients may not have all the same risk factors or demonstrate the same symptoms. They may also not demonstrate the same serum B-human chorionic gonadotropin levels and trends or have the same ultrasound findings at equivalent gestational ages. Some patients with early EP may have positive ultrasound findings with serum β-hCG levels under a defined discriminatory zone (DZ). On the other hand, some patients with an early viable intrauterine pregnancy may have no visible findings on initial ultrasound, but have serum β-hCG (quantitative) levels well above the DZ. Although rare, EP has even been demonstrated in women with negative urine β-hCG tests or low serum β-hCG levels.ConclusionsWhile EP may be a challenging diagnosis, understanding the myths surrounding EP may help emergency physicians consider it, even when patient risk factors, symptoms, or ED laboratory or imaging studies do not initially or easily define the diagnosis.
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Rotational Thromboelastometry Significantly Optimizes Transfusion Practices for Damage Control Resuscitation in Combat Casualties
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Heather Roesly
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Patterns and Outcomes Associated with Timeliness of Initial Crystalloid Resuscitation in Prospective Sepsis and Septic Shock Cohort
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Forrest Andersen
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Unintentional Marijuana Exposure Presenting as Altered Mental Status in the Pediatric Emergency Department: A Case Series
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Anita A. Thomas, Suzan Mazor
BackgroundUnintentional tetrahydrocannabinol (THC) exposure in pediatric patients can present as altered mental status. Altered mental status in a pediatric patient often leads to invasive diagnostic testing.Case ReportThe following cases describe 3 pediatric patients in Washington state who presented to a tertiary care children's hospital emergency department (ED) with altered mental status, later found to have urine toxicology screening positive for inactive THC metabolite (positive THC toxicology screen). Case 1 is a 6-year-old boy who presented with vomiting, lethargy, and hallucinations. Case 2 is a 5-year-old girl who presented with nausea, slurred speech, ataxia, and lethargy in the setting of a minor head injury. Case 3 is a 7-month-old boy who presented with vomiting and lethargy in the setting of a minor fall the day prior to ED evaluation. All children had extensive work-ups before the diagnosis was made; 2 were discharged home and 1 was admitted to the pediatric intensive care unit.Why Should an Emergency Physician Be Aware of This?As access to marijuana increases with growing legalization, it is important to be familiar with state marijuana legislation, to consider and ask families about access to marijuana products as a potential contributor to altered mental status, and to be aware of potential caretaker reluctance regarding disclosure of marijuana use secondary to perceived stigma. Maintaining awareness of the clinical effects of THC exposure in children may limit invasive testing in a hemodynamically stable child with altered mental status.
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Klebsiella pneumoniae Invasive Liver Abscess Syndrome and Endophthalmitis
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Beuy Joob, Viroj Wiwanitkit
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Low Yield of Clinically Significant Injury With Head-To-Pelvis Computed Tomography in Blunt Trauma Evaluation
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Shelby P. Murphy, Noah Hawthorne, David Haase, Chika Chiku, Jason Wen, Robert M. Rodriguez
BackgroundMany trauma centers have adopted routine head-to-pelvis computed tomography (CT) imaging for the evaluation of adults with blunt trauma.ObjectiveWe sought to determine the yields of detecting clinically significant injuries (CSIs) with CT in >1 anatomic region.MethodsWe conducted this observational cohort study of all trauma activation patients >14 years of age who received CT imaging during blunt trauma evaluation at a Level 1 trauma center from April to October 2014. Expert panels determined the clinical significance of head, neck, chest, abdomen, and pelvis injuries seen on CT. We calculated yields of CSI, defined as the number of patients with CSI divided by the total number of patients who underwent CT imaging. The 3 specified anatomic regions considered were head/neck, chest, and abdomen/pelvis.ResultsThe median age of 1236 patients who had CT was 48 years; 69% were male; 51.2% were admitted; and hospital mortality was 4.4%. Yields of CSI with 95% confidence intervals (CIs) were: head/neck region injury 11.3% (9.6–13.3%); chest region injury only 7.9% (6.0–10.4%); abdomen/pelvis region injury only 5.1% (3.7–7.0%); both head/neck and chest CSI 2.8% (1.7–4.5%); both head/neck and abdomen/pelvis CSI 1.6% (0.9–2.9%); and both chest and abdomen/pelvis CSI 1.1% (0.5–2.4%). The yield of CSI in all 3 anatomic regions with head-to-pelvis CT was 0.6% (0.2–1.7%), and 76.7% (68.8–83.1%) of CSIs occurred in isolation.ConclusionsDuring multiple anatomic region CT imagng for adult blunt trauma evaluation, the yield for CSI in >1 region is low. In low-risk populations, selective CT imaging of anatomic regions (instead of reflexive head-to-pelvis CT imaging) may be more appropriate.
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Expedited Discharge from an Academic Emergency Department: A Pilot Program
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Andrew Goldsmith, Luis Ticona, Ryan Thompson, Benjamin A. White, Joan Strauss, Robert Seger, David F.M. Brown, Ali S. Raja, Brian J. Yun
BackgroundAs the numbers of emergency department (ED) visits and inpatient admissions continue to increase, there is growing interest in alternatives to inpatient hospitalization.ObjectiveOur aim was to investigate a novel approach to expediting discharges from the ED with multidisciplinary discharge services to prevent an avoidable admission into the hospital.MethodsThis pilot study was conducted at a large urban tertiary-care ED in 2016. All patients presenting to the ED with planned inpatient or observation admission were considered for discharge with enhanced discharge planning services. The patients selected, discharge diagnoses, and outcomes were analyzed by descriptive statistics. This study was approved by the study site's Institutional Review Board, including waiver of patient consent.ResultsDuring the pilot period, 57 out of 143 (40%) selected patients with planned admission were discharged with enhanced discharge planning services. Median ED length of stay was 17.2 h and mean patient age was 73 years old. Of these patients, 7 (12%) returned within 72 h and 4 (0.07%) were subsequently admitted to the hospital.ConclusionsIn this pilot study, a novel approach to expediting discharges from the ED with multidisciplinary discharge services was feasible and resulted in fewer admissions to the hospital.
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Health Care Usage and Suicide Risk Screening within 1 Year of Suicide Death
Source:The Journal of Emergency Medicine, Volume 53, Issue 6
Author(s): Amy R. Stuck, Michael P. Wilson, Christen E. Chalmers, Jonathan Lucas, Andrew Sarkin, Kyle Choi, Kimberly Center
BackgroundResearch indicates patients often seek medical care within 1 year of suicide. Health care encounters are a crucial opportunity for health professionals to identify patients at highest risk and provide preventative services.ObjectiveStudy aims were to determine the characteristics of persons seeking health care within 12 months of suicide death and evaluate suicide risk screening (SRS) frequency in the emergency department (ED) vs. clinic settings.MethodsMedical examiner and hospital data of patients who died by suicide from 2007 to 2013 were evaluated. Descriptive analyses included demographics and frequency of ED vs. clinic visits. We also compared SRS before and after implementation of The Joint Commission's recommendation to assess suicide risk.ResultsThe 224 deceased patients were primarily single white males (mean age 67 years). Mental health issues, substance abuse, and prior suicide attempts were present alone or in combination in 74%. Visits were primarily behavioral health or substance abuse problems in the ED, and medical issues in the clinic. After implementation of universal SRS in the ED, screening increased from 39% to 92%. Among patients screened in the ED, 73% (37 of 51) screened negative for suicide risk.ConclusionsUniversal SRS increased the number of people screened in the ED. However, negative SRS may not equate to reduced risk for future suicide within 1 year. Future studies might investigate targeted screening of individuals with known suicide risk factors, as well as alternatives to patient self-report of intent to self-harm for patients with mental health or substance abuse problems.
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ZICO streamlines electrical accessory organization and transport
YARDLEY, Pa. — Ziamatic Corp. (ZICO) has developed a better, faster, easier way to keep your electrical accessories organized and transportable—the new Cord & Adapter Holder, Model QM-CADH. The innovative Cord & Adapter Holder secures electrical cord, adapters, and pigtails inside the compartment and keeps them organized and easy to locate on the scene. A sturdy, hook & loop ...
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Moped crash victim who lost her leg thanks responders who saved her
By EMS1 Staff OAK BLUFFS, Mass. — A college student who lost her leg in a moped crash thanked the first responders who saved her. Vineyard Gazette reported that Noelle Lambert rented a moped with her friend in July 2016 to take a tour of Martha’s Vineyard. Lambert lost control and crashed into a dump truck, resulting in the loss of her left leg. The University of Massachusetts lacrosse player ...
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Inside EMS Podcast: How to develop into an EMS role model and mentor
Download this podcast on iTunes, SoundCloud or via RSS feed In this Inside EMS Podcast episode, co-hosts Chris Cebollero and Kelly Grayson reflect on the life of Lou Jordan. Chris and Kelly ask: who will be the next EMS role model and mentor of the future" They give some practical advice in getting to the next level and securing the influence needed to inspire a career field. Learn more about the EMS1 ...
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Ford F-150 vs. ambulance: Who wins?
Braun Ambulances put the two vehicles head to head to see how safe an ambulance actually is
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Norwegian Army train Afghan medics how to save lives. Sigh...
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Thriller challenge for kids with eosinophilic diseases
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Norwegian Army train Afghan medics how to save lives. Sigh...
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Thriller challenge for kids with eosinophilic diseases
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Norwegian Army train Afghan medics how to save lives. Sigh...
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Thriller challenge for kids with eosinophilic diseases
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Father-daughter duo debut ‘AmbuPod’ microambulance
The solar-powered microambulance can be connected to any vehicle and its high-tech software allows patient information to be sent to doctors
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Masimo announces distribution of Rad-57® Pulse CO-Oximeters® by the Jeffrey Lee Williams Foundation to First Responders
Foundation awards devices to York County EMS departments to assist in monitoring for presence of carbon monoxide ROCK HILL, S.C. — Masimo (NASDAQ: MASI) announced today that The Jeffrey Lee Williams Foundation has distributed 20 Masimo Rad-57® Pulse CO-Oximeters® to EMS departments in York County, South Carolina, with the majority going to Piedmont Medical Center EMS. The Foundation purchases ...
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Spotlight: CATI Armor provides a lighter line of body armor
CATI Armor is protecting first responders with lighter, more secure body armor
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Wheezing, stridor ominous signs of impending airway loss in smoke inhalation
Treat aggressively with high-flow oxygen, rapid sequence intubation and Cyanokit in a patient with evidence of airway burns and CO2 poisoning
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Baltimore officials concerned about long wait times on 911 calls
Baltimore Fire Chief Niles Ford testified that the average wait time for the city's 911 is only six seconds
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How EMS is changing
In its second year, the EMS Trend Report describes revealing changes in clinical care, finance and the use of technology in EMS
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Norwegian Army train Afghan medics how to save lives. Sigh...
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Thriller challenge for kids with eosinophilic diseases
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EMS loses friend and mentor, Lou Jordan
He wore a T-shirt emblazoned with the caption, “EMS Artifact: Start conversation at your own risk,” and walking an EMS conference exhibit hall with him was simultaneously a study in professional networking and an exercise in frustration. It didn’t matter if you desperately wanted to see the new Tracheoblaster 5000 video laryngoscope or get pricing info on the latest generation of high-fidelity ...
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Cancer survivor becomes volunteer EMT while waiting for kidney donor
By EMS1 Staff EASTON, Conn. — A cancer survivor who is currently waiting for a kidney donor became an EMT after an EMS crew helped him while he fought for his life. WTNH reported that volunteer EMT Adam Goldstein, 37, was diagnosed with stage 4 testicular cancer when he was 21. “When I got to the hospital they did a CAT scan and they had told me that they had found cancer throughout my body,” ...
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How EMS is changing
To an outsider, EMS probably looks pretty similar today to how it did decades ago. Call 911, and an ambulance arrives and takes you to the hospital – simple. Yet we know that while progress can sometimes feel slow, in other ways the profession might be going through its most transformative era. Whether it’s a call to change "EMS" to "paramedicine," a push to reform reimbursement ...
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Lung ultrasound in diagnosing pneumonia in the emergency department: a systematic review and meta-analysis
Community-acquired pneumonia (CAP) is one of the most widespread and severe infectious diseases worldwide. In the emergency department (ED), there is still a need for a rapid and accurate tool that can diagnose CAP. Lung ultrasound (LUS) is a recent tool that is increasingly being for this purpose. So far, the LUS has been evaluated on a wide range of patients, but not yet on the specific population in the ED through a meta-analysis. Our aim was to assess the accuracy of the LUS in diagnosing CAP in this setting through a systematic review and a meta-analysis. A systematic research of literature was carried out for all published studies comparing the diagnostic accuracy of the LUS against chest radiography or computerized tomography scan in patients older than 18 years of age with clinical criteria for CAP assessed in the ED. We extracted the descriptive and quantitative data from eligible studies, and calculated the pooled sensitivity, specificity, and diagnostic odds ratio. We defined the summary receiver operating characteristic curve. Our initial search strategy yielded 10 377 studies, of which 17 (0.2%) were eligible. These studies provided a combined sample size of 5108 participants. The general risk of bias of the considered studies was quite low, but some concerns were highlighted. The diagnostic odds ratio was around 181 (I2: 27%). The pooled area under the curve, sensitivity, and specificity were, respectively, 97, 92, and 93%. The LUS was found to be an accurate tool in diagnosing CAP in adult patients in the ED. More methodologically rigorous trials are needed. Correspondence to Daniele Orso, MD, Department of Emergency Medicine, Ospedale Civile di Latisana (UD), A.A.S 2 ‘Bassa Friulana – Isontina’, via Sabbionera 45, Latisana, Udine 33053, Italy Tel: +39 329 016 2763; fax: +39 043 152 9461; e-mail: sd7782.do@gmail.com Received March 28, 2017 Accepted October 28, 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
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Are on-scene blood transfusions by a helicopter emergency medical service useful and safe? a multicentre case–control study
Introduction In the prehospital setting, crystalloid fluids are frequently used, but only erythrocytes are capable of transporting oxygen to tissues. The aim of this study was to establish the efficacy and safety of the prehospital use of uncross matched type O rhesus-negative packed red blood cells (URBC) by the Dutch physician-staffed helicopter emergency medical service. We hypothesized that prehospital URBC transfusions are safe and more effective with respect to survival than resuscitations with crystalloids. Methods The effects of prehospital URBC transfusions were studied by comparing a cohort of patients (>18 years) who were treated with a combination of URBC and crystalloid fluids with a matched control group of patients who received crystalloid fluids alone. Results Among 73 adults who received prehospital URBC transfusions, 50 (68%) patients were included. No transfusion reactions were observed. No effect of prehospital transfusion on 24-h or 30-day survival was found. Haemoglobin levels at presentation to the emergency department were higher in the URBC cohort. The two groups had similar cumulative erythrocyte requirements within the first 24 h. Conclusion Neither survival benefits nor a decreased incidence of shock on admission were observed after prehospital helicopter emergency medical service URBC transfusions. There were no prehospital transfusion reactions in this study; therefore, URBC transfusions were deemed to be safe. A prospective randomized study is warranted to evaluate the effect of early URBC transfusions and transfusions with preheated URBC on the survival of patients with severe prehospital haemorrhagic shock. Correspondence to Joost H. Peters, MD, Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands Tel: +31 243 613 996; fax: +31 243 540 501; e-mail: joost.peters@radboudumc.nl Received May 19, 2017 Accepted October 28, 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
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Appropriate use of laboratory test requests in the emergency department: a multilevel intervention
Objective Laboratory test requests in the emergency department (ED) are increasing worldwide. We evaluated whether a multilevel intervention on the basis of the optimization of test profiles and educational meetings with physicians could reduce the number of tests ordered. Patients and methods In a single-center before and after study design, the 8-month intervention period was compared with the 8-month preintervention period. Laboratory test profiles were reduced from 6 to 2 and the number of tests in each profile was reduced by 50%. All physicians received education about the costs and appropriate use of the tests. Primary outcomes were the number of laboratory blood tests and their costs, with a focus on high-cost tests. Secondary outcomes were ED and laboratory performances (patients’ waiting time, number of deaths in ED, re-entry, laboratory turn-around time, and add-on tests). Results Overall, 61 976 and 61 154 patients were evaluated, respectively, during the intervention and the preintervention period. Laboratory blood test requests were decreased by 207 637 (−36.3%) in the intervention period (P
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Definition of hemodynamic stability in blunt trauma patients: a systematic review and assessment amongst Dutch trauma team members
Abstract
Introduction
Trauma is a great contributor to mortality worldwide. One of the challenges in trauma care is early identification and management of bleeding. The circulatory status of blunt trauma patients in the emergency room is evaluated using hemodynamic (HD) parameters. However, there is no consensus on which parameters to use. In this study, we evaluate the used terms and definitions in the literature for HD stability and compare those to the opinion of Dutch trauma team members.
Method
A systematic review was performed to collect the definitions used for HD stability. Studies describing the assessment and/or treatment of blunt trauma patients in the emergency room were included. In addition, an online survey was conducted amongst Dutch trauma team members.
Results
Out of a total of 222, 67 articles were found to be eligible for inclusion. HD stability was defined in 70% of these articles. The most used parameters were systolic blood pressure and heart rate. Besides the variety of parameters, a broad range of corresponding cut-off points is noted. Despite some common ground, high inter- and intra-variability is seen for the physicians that are part of the Dutch trauma teams.
Conclusion
All authors acknowledge HD stability as the most important factor in the assessment and management of blunt trauma patients. There is, however, no consensus in the literature as well as none-to-fair consensus amongst Dutch trauma team members in the definition of HD stability. A trauma team ready to co-operate with consensus-based opinions together with a valid scoring system is in our opinion the best method to assess and treat seriously injured trauma patients.
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Focus on traumatic brain injury
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Τετάρτη 29 Νοεμβρίου 2017
Frequency of Desaturation and Association With Hemodynamic Adverse Events During Tracheal Intubations in PICUs
Objectives: Oxygen desaturation during tracheal intubation is known to be associated with adverse ICU outcomes in critically ill children. We aimed to determine the occurrence and severity of desaturation during tracheal intubations and the association with adverse hemodynamic tracheal intubation–associated events. Design: Retrospective cohort study as a part of the National Emergency Airway Registry for Children Network’s quality improvement project from January 2012 to December 2014. Setting: International PICUs. Patients: Critically ill children younger than 18 years undergoing primary tracheal intubations in the ICUs. Interventions: tracheal intubation processes of care and outcomes were prospectively collected using standardized operational definitions. We defined moderate desaturation as oxygen saturation less than 80% and severe desaturation as oxygen saturation less than 70% during tracheal intubation procedures in children with initial oxygen saturation greater than 90% after preoxygenation. Adverse hemodynamic tracheal intubation–associated event was defined as cardiac arrests, hypo or hypertension requiring intervention, and dysrhythmia. Measurements and Main Results: A total of 5,498 primary tracheal intubations from 31 ICUs were reported. Moderate desaturation was observed in 19.3% associated with adverse hemodynamic tracheal intubation–associated events (9.8% among children with moderate desaturation vs 4.4% without desaturation; p
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Hospital Readmissions After Pediatric Trauma
Objectives: To determine the rate, etiology, and timing of unplanned and planned hospital readmissions and to identify risk factors for unplanned readmission in children who survive a hospitalization for trauma. Design: Multicenter retrospective cohort study of a probabilistically linked dataset from the National Trauma Data Bank and the Pediatric Health Information System database, 2007–2012. Setting: Twenty-nine U.S. children’s hospitals. Patients: 51,591 children (
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Pediatric Critical Care Medicine Training: 2004–2016
Objectives: To describe growth trends in the number of programs, positions, and applicants in pediatric critical care medicine fellowship training as part of the Pediatric Critical Care Medicine Training Study. Design: Descriptive study. Settings: Available archived Match data through the National Resident Matching Program and training data from the Accreditation Council for Graduate Medical Education. Patients: None. Interventions: None. Measurements and Main Results: We analyzed all data on programs, positions, and applicants through the National Resident Matching Program Specialties Matching Service during the study period of 2004 to 2016. We also analyzed available training data available through the Accreditation Council for Graduate Medical Education for the corresponding study period. During the 12-year study period, there was a statistically significant expansion in programs (38%), positions (82%), and applicants (151%). Correspondingly, the percentage of pediatric critical care medicine programs participating in the Match as a percentage of all Accreditation Council for Graduate Medical Education–accredited programs for that academic year increased 24%. As of 2015, 94% of total first year positions offered for pediatric critical care medicine were through the Match. Conclusions: For the period 2004 to 2016, there was a substantial increase in positions and applicants applying for training in pediatric critical care medicine. We document an increase in demand (i.e., applicants) that has been matched by an increase in supply (i.e., positions) for pediatric critical care medicine fellowship training. The nearly complete use of the National Resident Matching Program for placing applicants in training positions in pediatric critical care medicine suggests that these data can be used to inform workforce analysis in pediatric critical care medicine. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/2gIrZ5Y). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: meredith.vandervelden@childrens.harvard.edu ©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
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Intraventricular Hemorrhage in Moderate to Severe Congenital Heart Disease
Objectives: Determine the prevalence of intraventricular hemorrhage in infants with moderate to severe congenital heart disease, investigate the impact of gestational age, cardiac diagnosis, and cardiac intervention on intraventricular hemorrhage, and compare intraventricular hemorrhage rates in preterm infants with and without congenital heart disease. Design: A single-center retrospective review. Setting: A tertiary care children's hospital. Patients: All infants admitted to St. Louis Children's Hospital from 2007 to 2012 with moderate to severe congenital heart disease requiring cardiac intervention in the first 90 days of life and all preterm infants without congenital heart disease or congenital anomalies/known genetic diagnoses admitted during the same time period. Interventions: None. Measurements and Main Results: Cranial ultrasound data were reviewed for presence/severity of intraventricular hemorrhage. Head CT and brain MRI data were also reviewed in the congenital heart disease infants. Univariate analyses were undertaken to determine associations with intraventricular hemorrhage, and a final multivariate logistic regression model was performed. There were 339 infants with congenital heart disease who met inclusion criteria and 25.4% were born preterm. Intraventricular hemorrhage was identified on cranial ultrasound in 13.3% of infants, with the majority of intraventricular hemorrhage being low-grade (grade I/II). The incidence increased as gestational age decreased such that intraventricular hemorrhage was present in 8.7% of term infants, 19.2% of late preterm infants, 26.3% of moderately preterm infants, and 53.3% of very preterm infants. There was no difference in intraventricular hemorrhage rates between cardiac diagnoses. Additionally, the rate of intraventricular hemorrhage did not increase after cardiac intervention, with only three infants demonstrating new/worsening high-grade (grade III/IV) intraventricular hemorrhage after surgery. In a multivariate model, only gestational age at birth and African-American race were predictors of intraventricular hemorrhage. In the subset of infants with CT/MRI data, there was good sensitivity and specificity of cranial ultrasound for presence of intraventricular hemorrhage. Conclusions: Infants with congenital heart disease commonly develop intraventricular hemorrhage, particularly when born preterm. However, the vast majority of intraventricular hemorrhage is low-grade and is associated with gestational age and African-American race This work was performed at Washington University in St. Louis, St. Louis, MO. Supported, in part, by the Washington University Institute of Clinical and Translational Sciences (UL1 TR000448 and KL2 TR000450) from the National Center for Advancing Translational Sciences, the Children’s Discovery Institute of Washington University and St. Louis Children’s Hospital, and the National Institutes of Health/National Institutes of Neurological Disorders and Stroke (K02 NS089852). Dr. Ortinau’s institution received funding from the National Institutes of Health (NIH)/Institute of Clinical and Translational Sciences (UL1 TR000448 and KL2 TR 000450) and the Children’s Discovery Institute, and she received support for article research from the NIH and Children’s Discovery Institute. Dr. Smyser’s institution received funding from the NIH/National Institutes of Neurological Disorders and Stroke (K02 NS089852), and he received support for article research from the NIH and Children’s Discovery Institute. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: ortinau_c@kids.wustl.edu ©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
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EM Nerd-The Case of Corporeal Clock
How exactly do trialists proceed when deciding upon the appropriate acronyms for their soon-to-be blockbuster trial? Is the proper etiquette to follow a traditional prospective process, utilizing the first letter of each word in a trial’s longer title? Or is the selection of an acronym based on its ability to inspire and only then, retrospectively […]
EMCrit by Rory Spiegel.
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EM Nerd-The Case of Corporeal Clock
How exactly do trialists proceed when deciding upon the appropriate acronyms for their soon-to-be blockbuster trial? Is the proper etiquette to follow a traditional prospective process, utilizing the first letter of each word in a trial’s longer title? Or is the selection of an acronym based on its ability to inspire and only then, retrospectively […]
EMCrit by Rory Spiegel.
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Τρίτη 28 Νοεμβρίου 2017
Prognosticating Clinical Prediction Scores Without Clinical Gestalt for Patients With Chest Pain in the Emergency Department
Source:The Journal of Emergency Medicine
Author(s): Chin Pang Wong, Chun Tat Lui, Jonathan Gabriel Sung, Ho Lam, Hin Tat Fung, Ping Wa Yam
BackgroundAssessment of patients with chest pain is a regular challenge in the emergency department (ED). Recent guidelines recommended quantitative assessment of ischemic risk by means of risk scores.ObjectiveOur aim was to assess the performance of Thrombosis in Myocardial Infarction (TIMI); Global Registry of Acute Coronary Events (GRACE); history, electrocardiogram, age, risk factors, and troponin (HEART) scores; and the North America Chest Pain Rule (NACPR) without components of clinical gestalt in predicting 30-day major adverse cardiac events (MACE).MethodsWe performed a prospective cohort study in adult patients who attended the ED with undifferentiated chest pain. Clinical prediction rules were applied and calculated. The clinical prediction rules were modified from the original ones, excluding components requiring judgment by clinical gestalt. The primary outcome was MACE. Performance of the tests were evaluated by receive operating characteristic curves and the area under curves (AUC).ResultsThere were 1081 patients included in the study. Thirty-day MACE occurred in 164 (15.2%) patients. The AUC of the GRACE score was 0.756, which was inferior to the TIMI score (AUC 0.809) and the HEART score (AUC 0.845). A TIMI score ≥ 1 had a sensitivity of 97% and a specificity of 45.7%. A GRACE score ≥ 50 had a sensitivity of 99.4% and a specificity of 7.5%. A HEART score ≥ 1 had a sensitivity of 98.8% and a specificity of 11.7%. The NACPR had a sensitivity of 93.3% and a specificity of 51.5%.ConclusionsWithout clinical gestalt, the modified HEART score had the best discriminative capacity in predicting 30-day MACE.
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Acute Management of Tension Pneumocephalus in a Pediatric Patient: A Case Report
Source:The Journal of Emergency Medicine
Author(s): Lauren M. L'Hommedieu, Michael W. Dingeldein, Krystal L. Tomei, Brendan J. Kilbane
BackgroundTension pneumocephalus is a rare but life-threatening condition in which air gains entry into the cranium and exerts mass effect on the brain, resulting in increased intracranial pressure. It occurs most frequently secondary to head trauma, particularly to the orbits or sinuses.Case ReportA 13-year-old male sustained facial trauma from a motor vehicle collision and was found to have tension pneumocephalus on computer tomography. The patient underwent immediate rapid sequence intubation without preceding positive pressure ventilation in the emergency department. At the time of his craniotomy, the tension pneumocephalus was found to have resolved and he went on to have a complete recovery.Why Should an Emergency Physician Be Aware of This?Any patient with facial or head trauma and pneumocephalus is at risk for the potential development of tension pneumocephalus. When present, we advocate that aggressive definitive airway management by rapid sequence intubation without preceding positive pressure ventilation and early surgical management should be prioritized.
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EMCrit – Critical Hyperkalemia by H. Pendell Meyers, EMCrit Intern
Critical Hyperkalemia ?s based on a recent publication
EMCrit by Guest Author.
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EMCrit – Critical Hyperkalemia by H. Pendell Meyers, EMCrit Intern
Critical Hyperkalemia ?s based on a recent publication
EMCrit by Guest Author.
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Δευτέρα 27 Νοεμβρίου 2017
Deflate to Extricate: A Technique for Rectal Foreign Body Removal of Inflatable Ball
Source:The Journal of Emergency Medicine
Author(s): Elizabeth C. Robinson, David Roy, Brian E. Driver
BackgroundRectal foreign bodies are commonly encountered in the emergency department (ED). Three techniques are well described in literature, including using a Foley catheter, “scooping” the object out, or grasping the object directly with ring forceps. We present a novel extraction method for an inflatable foreign body.Case ReportA 27-year-old man presented to the ED 13 h after inserting a rubber inflatable child's ball into his rectum. After well-described extraction techniques failed to remove the ball, an 18-gauge needle at the end of a syringe was inserted into the rectum to puncture the ball and partially deflate it. The ball was then able to be removed easily.Why Should an Emergency Physician Be Aware of This?Although recent published literature has pushed for early consultation of surgical specialties in lieu of emergency physician bedside extraction, this case report highlights the ability of emergency physicians to modify known extraction techniques to safely remove rectal foreign bodies in well-appearing patients at the bedside using appropriate analgesia, positioning, and readily available equipment.
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Bronchiolitis: What's All the Fuss About?
Source:The Journal of Emergency Medicine
Author(s): Nisa S. Atigapramoj
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The Tourniquet Gap: A Pilot Study of the Intuitive Placement of Three Tourniquet Types by Laypersons
Source:The Journal of Emergency Medicine
Author(s): Elliot M. Ross, Julian G. Mapp, Theodore T. Redman, Derek J. Brown, Chetan U. Kharod, David A. Wampler
BackgroundThe “Stop the Bleed” campaign in the United States advocates for nonmedical personnel to be trained in basic hemorrhage control and that “bleeding control kits” be available in high-risk areas. However, it is not clear which tourniquets are most effective in the hands of laypersons.ObjectivesThe objective of this pilot study was to determine which tourniquet type was the most intuitive for a layperson to apply correctly.MethodsThis project is a randomized study derived from a “Stop the Bleed” education initiative conducted between September 2016 and March 2017. Novice tourniquet users were randomized to apply one of three commercially available tourniquets (Combat Action Tourniquet [CAT; North American Rescue, LLC, Greer, SC], Ratcheting Medical Tourniquet [RMT; m2 Inc., Winooski, VT], or Stretch Wrap and Tuck Tourniquet [SWAT-T; TEMS Solutions, LLC, Salida, CO]) in a controlled setting. Individuals with formal medical certification, prior military service, or prior training with tourniquets were excluded. The primary outcome of this study was successful tourniquet placement.ResultsOf 236 possible participants, 198 met the eligibility criteria. Demographics were similar across groups. The rates of successful tourniquet application for the CAT, RMT, and SWAT-T were 16.9%, 23.4%, and 10.6%, respectively (p = 0.149). The most common causes of application failure were: inadequate tightness (74.1%), improper placement technique (44.4%), and incorrect positioning (16.7%).ConclusionOur pilot study on the intuitive nature of applying commercially available tourniquets found unacceptably high rates of failure. Large-scale community education efforts and manufacturer improvements of tourniquet usability by the lay public must be made before the widespread dissemination of tourniquets will have a significant public health effect.
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Male with Severe Hypertension and Dyspnea
Publication date: Available online 24 November 2017
Source:The Journal of Emergency Medicine
Author(s): Nubia Seyoum, Semhar Z. Tewelde, Zachary D.W. Dezman
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Source:The Journal of Emergency Medicine
Author(s): Nubia Seyoum, Semhar Z. Tewelde, Zachary D.W. Dezman
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Acute Coronary Syndrome in Octogenarians: Expect the Unexpected
Source:The Journal of Emergency Medicine
Author(s): Samuel T. Parnell, Austin T. Smith
BackgroundIschemic heart disease is the leading cause of death in the United States and the world. Advanced age is the strongest risk factor for ischemic heart disease and the best independent predictor for poor outcomes after acute coronary syndrome (ACS). Elderly patients are at high risk for ACS, and numerous studies have shown that octogenarians in particular experience increased morbidity and mortality compared to younger patients.Case ReportWe describe a case of an 83-year-old woman who presented to the emergency department with a chief complaint of sore throat and was found to have a non-ST elevation myocardial infarction (NSTEMI) and was treated successfully with primary coronary intervention (PCI).Why Should an Emergency Physician Be Aware of This?Chest pain is a common presenting symptom for ACS, but elderly patients with MI are more likely to present with other chief complaints. Only 40% of patients in the National Registry of Myocardial Infarction database ≥ 85 years of age had chest pain on initial presentation. Recent studies comparing invasive therapy (PCI or coronary artery bypass graft) with optimal medical therapy for patients > 75 years of age diagnosed with NSTEMI have reported a reduced risk of death and major cardiac events with invasive therapy. Emergency physicians should have a high level of suspicion for ACS in octogenarians, even in those presenting without chest pain. Timely diagnosis and management can improve morbidity and mortality in these patients.
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Alternative Treatment Options for Atrioventricular-Nodal-Reentry Tachycardia: an Emergency Medicine Review
Source:The Journal of Emergency Medicine
Author(s): Sarah Brubaker, Brit Long, Alex Koyfman
BackgroundAtrioventricular-nodal-reentry tachycardia (AVNRT) is a form of supraventricular tachycardia (SVT) that is relatively common in the emergency department (ED). It is rarely indicative of underlying electrical or structural pathology.ObjectiveThis review evaluates the literature and controversies concerning treatment of AVNRT in the ED.DiscussionFor treatment of narrow-complex tachycardia, Advanced Cardiovascular Life Support guidelines recommend the use of vagal maneuvers, followed by adenosine. Recent literature suggests that nondihydropyridine calcium channel blockers, such as verapamil and diltiazem, may be as effective as adenosine, without the negative short-term side effects. Multiple studies have demonstrated that although adenosine is rapid acting, there is no statistically significant difference in conversion rate between adenosine and calcium channel blockers. Both medications result in a conversion rate above 90%, but there are significantly more minor adverse effects, such as flushing or chest discomfort, with adenosine. Calcium channel blockers are a viable option for treatment for AVNRT, especially in refractory states. Beta-blockers have been evaluated but should not be used routinely due to lower efficacy. AVNRT is the most common tachydysrhythmia in pregnancy, and vagal maneuvers and adenosine are first line. Electrical cardioversion should be utilized for hemodynamically unstable patients. Most patients with AVNRT may be discharged with appropriate follow-up.ConclusionSeveral studies demonstrate that nondihydropyridine calcium channels (verapamil and diltiazem) are equally as efficacious as adenosine in converting AVNRT to sinus rhythm, without the negative (albeit short-lived) side effects. If given over 20 min, the risk for hypotension is low.
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A Randomized Controlled Trial of a Single Dose Furosemide to Improve Respiratory Distress in Moderate to Severe Bronchiolitis
Source:The Journal of Emergency Medicine
Author(s): Kristy Williamson, Gabriel Bredin, Jahn Avarello, Sandeep Gangadharan
BackgroundBronchiolitis is one of the most common disorders of the lower respiratory tract in infants. While historically diuretics have been used in severe bronchiolitis, no studies have looked directly at their early use in children in the emergency department.ObjectiveThe primary objective of this study was to determine whether a single early dose of a diuretic in infants with moderate to severe bronchiolitis would improve respiratory distress. Secondary objectives examined whether it reduced the use of noninvasive ventilation and hospital length of stay.MethodsPatients diagnosed with clinical bronchiolitis were enrolled at a tertiary care, academic children's hospital over a 3-year period. This was a double-blind, randomized controlled trial in which subjects were randomly assigned to either furosemide or placebo. Respiratory rate and oxygen saturation at the time of medication delivery and at 2 and 4 h post-intervention were recorded, as well as other data. Exact logistic regression was used to examine associations.ResultsThere were 46 subjects enrolled and randomized. There was no difference in respiratory rates, measured as a decrease of ≥ 25%, at both 2 and 4 h after intervention between furosemide and placebo groups (odds ratios 1.13 and 1.13, respectively). There was also no difference in oxygen saturation, intensive care unit admission rate, or hospital length of stay between groups.ConclusionsWhile theoretically a single dose of a diuretic to reduce lung fluid would improve respiratory distress in children with bronchiolitis, our randomized controlled medication trial showed no difference in outcomes. ClinicalTrials.gov ID: NCT02469597.
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Pellagra
Source:The Journal of Emergency Medicine
Author(s): Andreia de Oliveira Alves, Thaissa Bortolato, Fred Bernardes Filho
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An Unusual Case of Acute Retroperitoneal Hemorrhage: Dissecting Aneurysm of the Inferior Pancreaticoduodenal Artery
Source:The Journal of Emergency Medicine
Author(s): Ruei-Je Tsai, Ching-Huei Kung, Gong-Yau Lan, Kevin Li-Chun Hsieh, Chun-Yu Lin
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Primary Cutaneous Blastomycosis After Inoculation From A Woodworking Blade
Publication date: Available online 21 November 2017
Source:The Journal of Emergency Medicine
Author(s): Barry Ladizinski, Nicole Joy, David C. Reid
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Source:The Journal of Emergency Medicine
Author(s): Barry Ladizinski, Nicole Joy, David C. Reid
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The Use of Body Habitus Reference Images Improves the Ability of Novices to Accurately Estimate Children's Weight Using the PAWPER XL Tape System
Source:The Journal of Emergency Medicine
Author(s): Mike Wells, Lara Nicole Goldstein, Alison Bentley
BackgroundThe original methodology of the PAWPER (Pediatric Advanced Weight Prediction in the Emergency Room) tape relies on a gestalt visual assessment of a child's body habitus to adjust a length-based weight estimation. This assessment is dependent on the user's subjective opinion, which may result in aberrations in accuracy between users and populations. With the development of the second-generation PAWPER XL tape, a more objective method of habitus evaluation was desired.ObjectiveThe aim of this study was to evaluate a new, more objective figural reference image system and a new checklist system for quantifying body habitus.MethodsVolunteers were asked to assess the body habitus score of 90 children from a sequence of photographic images using the standard gestalt visual assessment system, a new checklist system, and a system using figural reference images. PAWPER XL tape weight estimations were generated from these scores, which were compared between the three test groups. Participants were also surveyed on their preferences for the different methodologies.ResultsThere were 11,505 habitus score assessments from 138 doctor, nurse, and paramedic participants. The figural reference image system significantly outperformed the checklist system and the gestalt visual assessment system in terms of weight estimation accuracy, achieving 70.9%, 61.1%, and 60.9% of estimations within 10% of measured weight, respectively. The participants expressed a strong subjective preference for the image system because of speed of use, ease of use, perceived accuracy, objectivity, and low cognitive load.ConclusionsThe figural reference image system was objectively much more accurate than, and subjectively preferable to, the original gestalt visual estimation methodology.
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Male with Toothache
Source:The Journal of Emergency Medicine
Author(s): Ming-Chen Tsai, Chun-Yuan Chiu, Shih-Hung Tsai
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Euglycemic Diabetic Ketoacidosis Secondary to Dapagliflozin Use: a Case Report
Source:The Journal of Emergency Medicine
Author(s): Felicity Brown, Tamara McColl
BackgroundSodium-glucose co-transporter-2 (SGLT2) inhibitors are a novel class of oral antihyperglycemic agents. They are associated with rare cases of euglycemic diabetic ketoacidosis (DKA), which presents a diagnostic challenge in the emergency department (ED) and potentially severe consequences if missed.Case ReportA 53-year-old man with type 2 diabetes mellitus and a recent Roux-en-Y gastric bypass surgery presented to the ED with nausea, vomiting, and generalized abdominal pain. His medications included dapagliflozin. Work-up revealed anion-gap acidosis, which prompted us to send serum ketone levels despite a blood glucose level of 9.8 mmol/L (162 mg/dL). The patient was ultimately diagnosed with euglycemic DKA.Why Should an Emergency Physician Be Aware of This?Patients on SGLT2 inhibitors may present in DKA despite having normal blood glucose levels. It is important for emergency physicians to be aware of this phenomenon in all SGLT2-inhibitor users, as a delay in the diagnosis of DKA can be life threatening.
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EMCrit Podcast 213 – Controlled Burn for Hypercapneic Encephalopathy in COPD
Intubation is failure!
EMCrit by Scott Weingart.
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EMCrit Podcast 213 – Controlled Burn for Hypercapneic Encephalopathy in COPD
Intubation is failure!
EMCrit by Scott Weingart.
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The decline of basic science publications in major emergency medicine journals and research conferences
Abstract
A recent publication reported on the decline of basic science publications in major medical journals in the last 20 years, making reference to the growing disconnect between basic science and clinical medicine1. Story Landis, former director of the National Institute of Neurological Disorders and Stroke also noted a striking decrease in grant applications for basic science projects in the same time period2.In the 1980s and 90s, a number of emergency physicians commented on the importance of basic science research to the future of emergency medicine3,4,5.
This article is protected by copyright. All rights reserved.
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Κυριακή 26 Νοεμβρίου 2017
iSepsis – A 30ml/kg bolus: Yes or No -The Results
The Results of the 30ml/kg Bolus Survey.
EMCrit by Paul Marik.
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iSepsis – A 30ml/kg bolus: Yes or No -The Results
The Results of the 30ml/kg Bolus Survey.
EMCrit by Paul Marik.
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Σάββατο 25 Νοεμβρίου 2017
S100A8/A9 and sRAGE kinetic after polytrauma; an explorative observational study
Following tissue injury after trauma, the activation of innate immune pathways results in systemic inflammation, organ failure and an increased risk of infections. The objective of this study was to characteri...
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Letter to the Editor regarding the article: "identifying pre-hospital factors associated with outcome for major trauma patients in a regional trauma network: an exploratory study"
The aim of this Letter to the Editor was to report some methodological shortcomings in a recently published article. Issues regarding missing values and overfitting are mentioned. First, Complete Case (CC) ana...
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Πέμπτη 23 Νοεμβρίου 2017
Treatment of splenic trauma in Norway: a retrospective cohort study
Non-operative management of splenic injuries has become the treatment of choice in hemodynamically stable patients over the last decades. The aim of the study is to describe the incidence, initial treatment an...
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Τετάρτη 22 Νοεμβρίου 2017
Procalcitonin-guided antibiotic therapy in intensive care unit patients: a systematic review and meta-analysis
Serum procalcitonin (PCT) concentration is used to guide antibiotic decisions in choice, timing, and duration of anti-infection therapy to avoid antibiotic overuse. Thus, we performed a systematic review and m...
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Anaphylaxis in an emergency care setting: a one year prospective study in children and adults
Current data on anaphylaxis is based on retrospective and register based studies. The objective of this study was to describe the epidemiology of anaphylaxis in a 1 year prospective study at the emergency care...
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A case of blunt thoracic aortic injury requiring ECMO for acute malperfusion before TEVAR
Blunt thoracic aortic injury (BTAI) is associated with a high mortality rate and the paradigm of treating patients with BTAI currently favours thoracic endovascular aneurysm repair (TEVAR) if possible. In BTAI...
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Past-year Prescription Drug Monitoring Program Opioid Prescriptions and Self-reported Opioid Use in an Emergency Department Population with Opioid Use Disorder
Abstract
Background
Despite increasing reliance on Prescription Drug Monitoring Programs (PDMPs) as a response to the opioid epidemic, the relationship between aberrant drug-related behaviors captured by the PDMP and opioid use disorder is incompletely understood. How PDMP data should guide Emergency Department (ED) assessment has not been studied.
Study Objective
To evaluate a relationship between PDMP opioid prescription records and self-reported non-medical opioid use of prescription opioids in a cohort of opioid dependent ED patients enrolled in a treatment trial.
Methods
PDMP opioid prescription records during one year prior to study enrollment on 329 adults meeting Diagnostic and Statistical Manual IV criteria for opioid dependence entering a randomized clinical trial (RCT) in a large, urban ED were cross tabulated with data on 30-day non-medical prescription opioid use self-report. The association among these two types of data was assessed by the Goodman and Kruskal's Gamma; a logistic regression was used to explore characteristics of participants who had PDMP record of opioid prescriptions.
Results
During one year prior to study enrollment,118/329 (36%) patients had ≥ 1 opioid prescriptions (range 1-51) in our states’ PDMP. Patients who reported ≥15 out of 30 days of non-medical prescription opioid use were more likely to have ≥4 PDMP opioid prescriptions (20/38; 53%) than patients reporting 1-14 days (14/38, 37%) or zero days of non-medical prescription opioid use (4/38,11%); p=0.002. Female gender and having health insurance were significantly more represented in the PDMP (p<0.05 for both).
Conclusion
PDMPs may be helpful in identifying patients with certain aberrant drug-related behavior, but are unable to detect many patients with OUD. The majority of ED patients with OUD were not captured by the PDMP, highlighting the importance of using additional methods such as screening and clinical history to identify OUDs in ED patients and the limitations of PDMPs to detect OUDs.
This article is protected by copyright. All rights reserved.
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Measurement of Dead Space Fraction Upon ICU Admission Predicts Length of Stay and Clinical Outcomes Following Bidirectional Cavopulmonary Anastomosis
Objectives: Increased alveolar dead space fraction has been associated with prolonged mechanical ventilation and increased mortality in pediatric patients with respiratory failure. The association of alveolar dead space fraction with clinical outcomes in patients undergoing bidirectional cavopulmonary anastomosis for single ventricle congenital heart disease has not been reported. We describe an association of alveolar dead space fraction with postoperative outcomes in patients undergoing bidirectional cavopulmonary anastomosis. Design: In a retrospective case-control study, we examined for associations between alveolar dead space fraction ([PaCO2 – end-tidal CO2]/PaCO2), arterial oxyhemoglobin saturation, and transpulmonary gradient upon postoperative ICU admission with a composite primary outcome (requirement for surgical or catheter-based intervention, death, or transplant prior to hospital discharge, defining cases) and several secondary endpoints in infants following bidirectional cavopulmonary anastomosis. Settings: Cardiac ICU in a tertiary care pediatric hospital. Patients: Patients undergoing bidirectional cavopulmonary anastomosis at our institution between 2011 and 2016. Interventions: None. Measurements and Main Results: Of 191 patients undergoing bidirectional cavopulmonary anastomosis, 28 patients were cases and 163 were controls. Alveolar dead space fraction was significantly higher in the case (0.26 ± 0.09) versus control group (0.17 ± 0.09; p
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Psychological and Psychiatric Outcomes Following PICU Admission: A Systematic Review of Cohort Studies
Objective: Admissions to PICU places pediatric patients at increased risk of persistent psychological and psychiatric morbidity. This systematic review aimed to summarize and critically examine literature regarding psychological and psychiatric outcomes of pediatric patients following PICU admission. Data Sources: MEDLINE, Web of Science, Cochrane Library, Science Direct, PsycInfo, CINAHL, LILACS, and SciELO were searched up to May 2016. Study Selection: Cohort studies about psychological and psychiatric outcomes of pediatric patients following PICU admission; full-text records published in English, Spanish, or Portuguese in peer-reviewed journals from 2000 to 2015 were included. Neonatal patient population (age,
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Neural Breathing Pattern and Patient-Ventilator Interaction During Neurally Adjusted Ventilatory Assist and Conventional Ventilation in Newborns
Objective: To compare neurally adjusted ventilatory assist and conventional ventilation on patient-ventilator interaction and neural breathing patterns, with a focus on central apnea in preterm infants. Design: Prospective, observational cross-over study of intubated and ventilated newborns. Data were collected while infants were successively ventilated with three different ventilator conditions (30 min each period): 1) synchronized intermittent mandatory ventilation (SIMV) combined with pressure support at the clinically prescribed, SIMV with baseline settings (SIMVBL), 2) neurally adjusted ventilatory assist, 3) same as SIMVBL, but with an adjustment of the inspiratory time of the mandatory breaths (SIMV with adjusted settings [SIMVADJ]) using feedback from the electrical activity of the diaphragm). Setting: Regional perinatal center neonatal ICU. Patients: Neonates admitted in the neonatal ICU requiring invasive mechanical ventilation. Measurements and Main Results: Twenty-three infants were studied, with median (range) gestational age at birth 27 weeks (24–41 wk), birth weight 780 g (490–3,610 g), and 7 days old (1–87 d old). Patient ventilator asynchrony, as quantified by the NeuroSync index, was lower during neurally adjusted ventilatory assist (18.3% ± 6.3%) compared with SIMVBL (46.5% ±11.7%; p
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Τρίτη 21 Νοεμβρίου 2017
Accuracy of Invasive and Noninvasive Parameters for Diagnosing Ventilatory Overassistance During Pressure Support Ventilation
Objective: Evaluate the accuracy of criteria for diagnosing pressure overassistance during pressure support ventilation. Design: Prospective clinical study. Setting: Medical-surgical ICU. Patients: Adults under mechanical ventilation for 48 hours or more using pressure support ventilation and without any sedative for 6 hours or more. Overassistance was defined as the occurrence of work of breathing less than 0.3 J/L or 10% or more of ineffective inspiratory effort. Two alternative overassistance definitions were based on the occurrence of inspiratory esophageal pressure-time product of less than 50 cm H2O s/min or esophageal occlusion pressure of less than 1.5 cm H2O. Interventions: The pressure support was set to 20 cm H2O and decreased in 3-cm H2O steps down to 2 cm H2O. Measurements and Main results: The following parameters were evaluated to diagnose overassistance: respiratory rate, tidal volume, minute ventilation, peripheral arterial oxygen saturation, rapid shallow breathing index, heart rate, mean arterial pressure, change in esophageal pressure during inspiration, and esophageal and airway occlusion pressure. In all definitions, the respiratory rate had the greatest accuracy for diagnosing overassistance (receiver operating characteristic area = 0.92; 0.91 and 0.76 for work of breathing, pressure-time product and esophageal occlusion pressure in definition, respectively) and always with a cutoff of 17 incursions per minute. In all definitions, a respiratory rate of less than or equal to 12 confirmed overassistance (100% specificity), whereas a respiratory rate of greater than or equal to 30 excluded overassistance (100% sensitivity). Conclusion: A respiratory rate of 17 breaths/min is the parameter with the greatest accuracy for diagnosing overassistance. Respiratory rates of less than or equal to 12 or greater than or equal to 30 are useful clinical references to confirm or exclude pressure support overassistance. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/29S62lw). Work was performed at the Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. Supported and funded by Fundação de Amparo a Pesquisa do Estado de São Paulo (Fapesp) (2012/09170-3 and 2010/08947-9), a governmental nonprofit agency. No restrictions were placed on authors regarding the statements made in the manuscript. Dr. de Albuquerque received support for article research from FAPESP - Fundação de Amparo à Pesquisa do Estado de São Paulo, and he disclosed government work. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: pedro.caruso@hc.fm.usp.br Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
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Initial Antifungal Strategy Reduces Mortality in Critically Ill Patients With Candidemia: A Propensity Score–Adjusted Analysis of a Multicenter Study
Objective: The objective of this study was to evaluate the impact of the empirical therapy with fluconazole or an echinocandin on 30- and 90-day mortality in critically ill patients with candidemia. The outcome of patients in whom the empirical echinocandin was deescalated to fluconazole was also assessed. Design: Retrospective, observational multicenter study. Setting: Medical and surgical ICUs in nine Spanish hospitals. Patients: Adult patients (≥ 18 yr) with an episode of Candida bloodstream infection during ICU admission from January 2011 to April 2016. Interventions: Patient characteristics, infection-related variables, therapeutic interventions, and metastatic complications were reviewed. A propensity score–adjusted multivariable analysis was performed to identify the risk factors significantly associated with 30-day and 90-day mortality. Measurements and Main Results: A total of 294 patients were diagnosed of candidemia in the participant ICUs. Sixty patients were excluded (other antifungals in the primary therapy or the patient died without empirical antifungal therapy). The study group comprised 115 patients who received fluconazole (30-day mortality, 37.4%) and 119 patients treated empirically with an echinocandin (30-day mortality, 31.9%). The use of an echinocandin in the empirical therapy was a protective factor for 30-day (odds ratio, 0.32; 95% CI, 0.16–0.66; p = 0.002) and 90-day mortality (odds ratio, 0.50; 95% CI, 0.27–0.93; p = 0.014) in the propensity score– adjusted multivariable analysis. Deescalation of the empirical echinocandin to fluconazole was not associated with a higher mortality or the occurrence of long-term complications. Conclusions: Empirical use of an echinocandin in critically ill patients with documented candidemia reduces mortality at 30 and 90 days significantly. Deescalation of the empirical echinocandin to fluconazole is safe and effective in fluconazole-susceptible infections. Dr. Garnacho-Montero has served as speaker for Merck, Sharp & Dohme (MSD) and Astellas; and received an educational grant from Astellas. Dr. Ramirez has served as speaker for Pfizer, MSD, and Astellas. Dr. Rodriguez-Delgado has served as speaker for Merck, Sharp, and Dohme de España S.A. Dr. Garcia-Garmendia received an educational grant from MSD in 2015. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: jgarnachom@gmail.com Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
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Impact of Quality Bundle Enforcement by a Critical Care Pharmacist on Patient Outcome and Costs
Objectives: Surgical and medical ICU patients are at high risk of mortality and provide a significant cost to the healthcare system. The aim of this study is to describe the effect of pharmacist-led interventions on drug therapy and clinical strategies on ICU patient outcome and hospital costs. Design: Before and after study in two French ICUs (16 and 10 beds). Patients: ICU patients. Intervention: From January 1, 2013, to June 30, 2015, a pharmacist observation period was compared with an intervention period in which a critical care pharmacist provided recommendations to clinicians regarding sedative drugs and doses, choice of mechanical ventilation mode and related settings, antimicrobial de-escalation, and central venous and urinary catheters removal. Differences in ICU and hospital length of stay, duration of mechanical ventilation, mortality rate, and hospital costs per patient were quantified between groups with patients matched for severity of illness (Simplified Acute Physiology Score II) at admission. Measurements and Main Results: From the 1,519 and 1,268 admitted patients during the observation and intervention periods, respectively, 1,164 patients were evaluable in both groups after matching for Simplified Acute Physiology Score II score. The intervention period was associated with mean (95% CI) reductions in patient hospital length of stay (3.7 d [5.2–2.3 d]; p
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The Glucagon-Like Peptide-1 Analog Exenatide Increases Blood Glucose Clearance, Lactate Clearance, and Heart Rate in Comatose Patients After Out-of-Hospital Cardiac Arrest
Objectives: To investigate the effects of the glucagon-like peptide-1 analog exenatide on blood glucose, lactate clearance, and hemodynamic variables in comatose, resuscitated out-of-hospital cardiac arrest patients. Design: Predefined post hoc analyzes from a double-blind, randomized clinical trial. Setting: The ICU of a tertiary heart center. Patients: Consecutive sample of adult, comatose patients undergoing targeted temperature management after out-of-hospital cardiac arrest from a presumed cardiac cause, irrespective of the initial cardiac rhythm. Interventions: Patients were randomized 1:1 to receive 6 hours and 15 minutes of infusion of either 17.4 μg of the glucagon-like peptide-1 analog exenatide (Byetta; Lilly) or placebo within 4 hours from sustained return of spontaneous circulation. The effects of exenatide were examined on the following prespecified covariates within the first 6 hours from study drug initiation: lactate level, blood glucose level, heart rate, mean arterial pressure, and combined dosage of norepinephrine and dopamine. Measurements and Main Results: The population consisted of 106 patients receiving either exenatide or placebo. During the first 6 hours from study drug initiation, the levels of blood glucose and lactate decreased 17% (95% CI, 8.9–25%; p = 0.0004) and 21% (95% CI, 6.0–33%; p = 0.02) faster in patients receiving exenatide versus placebo, respectively. Exenatide increased heart rate by approximately 10 beats per minute compared to placebo (p
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Should Transfusion Trigger Thresholds Differ for Critical Care Versus Perioperative Patients? A Meta-Analysis of Randomized Trials
Objective: To address the significant uncertainty as to whether transfusion thresholds for critical care versus surgical patients should differ. Design: Meta-analysis of randomized controlled trials. Setting: Medline, EMBASE, and Cochrane Library searches were performed up to 15 June 2016. Patients: Trials had to enroll adult surgical or critically ill patients for inclusion. Interventions: Studies had to compare a liberal versus restrictive threshold for the transfusion of allogeneic packed RBCs. Measurements and Main Results: The primary outcome was 30-day all-cause mortality, sub-grouped by surgical and critical care patients. Secondary outcomes included myocardial infarction, stroke, renal failure, allogeneic blood exposure, and length of stay. Odds ratios and weighted mean differences were calculated using random effects meta-analysis. To assess whether subgroups were significantly different, tests for subgroup interaction were used. Subgroup analysis by trials enrolling critically ill versus surgical patients was performed. Twenty-seven randomized controlled trials (10,797 patients) were included. In critical care patients, restrictive transfusion resulted in significantly reduced 30-day mortality compared with liberal transfusion (odds ratio, 0.82; 95% CI, 0.70–0.97). In surgical patients, a restrictive transfusion strategy led to the opposite direction of effect for mortality (odds ratio, 1.31; 95% CI, 0.94–1.82). The subgroup interaction test was significant (p = 0.04), suggesting that the effect of restrictive transfusion on mortality is statistically different for critical care (decreased risk) versus surgical patients (potentially increased risk or no difference). Regarding secondary outcomes, for critically ill patients, a restrictive strategy resulted in reduced risk of stroke/transient ischemic attack, packed RBC exposure, transfusion reactions, and hospital length of stay. In surgical patients, restrictive transfusion resulted in reduced packed RBC exposure. Conclusions: The safety of restrictive transfusion strategies likely differs for critically ill patients versus perioperative patients. Further trials investigating transfusion strategies in the perioperative setting are necessary. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Dr. Chong extracted the data, performed the data analysis, created the figures/tables, and prepared the article. Contribution: Dr. Krishnan extracted the data, performed the data analysis, created the figures/tables, and revised the article. Dr. Cheng provided resource support in this study, guidance with article preparation, and revised the final article. Dr. Martin conceived the idea of performing a meta-analysis of transfusion triggers, provided guidance with article preparation and data analysis, and revised the final article. All authors attest to the integrity of the original data and analysis, as well as approved the final article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/29S62lw). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: janet.martin@lhsc.on.ca Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
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Kinetics of Urinary Cell Cycle Arrest Markers for Acute Kidney Injury Following Exposure to Potential Renal Insults
Objectives: Urinary tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 predict the development of acute kidney injury following renal insults of varied aetiology. To aid clinical interpretation, we describe the kinetics of biomarker elevations around an exposure. Design: In an ancillary analysis of the multicenter SAPPHIRE study, we examined the kinetics of the urinary [tissue inhibitor of metalloproteinase-2]•[insulin-like growth factor binding protein 7] in association with exposure to common renal insults (major surgery, IV radiocontrast, vancomycin, nonsteroidal anti-inflammatory drugs, and piperacillin/tazobactam). Setting: Thirty-five sites in North America and Europe between September 2010 and June 2012. Patients: Seven hundred twenty-three critically ill adult patients admitted to the ICU. Interventions: None. Measurements and Main Results: We compared the urinary [tissue metalloproteinase-2]•[insulin growth factor binding protein 7] kinetics from the day prior to exposure up to 5 days after exposure in patients developing acute kidney injury stage 2–3, stage 1, or no acute kidney injury by Kidney Disease Improving Global Outcome criteria. Among the 723 patients, 679 (94%) had at least one, 70% had more than one, and 35% had three or more exposures to a known renal insult. There was a significant association between cumulative number of exposures up to study day 3 and risk of acute kidney injury (p = 0.02) but no association between the specific type of exposure and acute kidney injury (p = 0.22). With the exception of radiocontrast, patients who developed acute kidney injury stage 2–3 after one of the five exposures, had a clear rise and fall of urinary [tissue inhibitor of metalloproteinase-2]•[insulin-like growth factor binding protein 7] from the day of exposure to 24–48 hours later. In patients without acute kidney injury, there was no significant elevation in urinary [tissue inhibitor of metalloproteinase-2]•[insulin-like growth factor binding protein 7]. Conclusions: Exposure to potential renal insults is common. In patients developing acute kidney injury stage 2–3, the kinetics of urinary [tissue inhibitor of metalloproteinase-2]•[insulin-like growth factor binding protein 7] matched the exposure except in the case of radiocontrast. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. For a full list of the SAPPHIRE Investigators, see the supplemental data (Supplemental Digital Content 1, http://ift.tt/2zWVtrS). Supported by Astute Medical, San Diego, CA. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/29S62lw). Dr. Ostermann disclosed that the original Sapphire study was funded by Astute Medical. She received grant support from Fresenius Medical Care. Dr. Forni received funding from Astute Medical and Orthodox Clinical Diagnostic (lecture fees). Dr. Bagshaw received funding from Baxter Healthcare. He was also supported by a Canada Research Chair in Critical Care Nephrology. Dr. Joannidis received speaker´s fees from Astute Medical. Dr. Shi received funding from Astute Medical and disclosed that her husband also consults for Astute Medical. Dr. Kashani’s institution received funding from Astute Medical. Dr. Honore’s institution received funding from Baxter. Dr. Chawla disclosed that he is an employee of La Jolla Pharmaceutical. He also disclosed that he and his institution received funding from Astute Medical. Dr. Kellum and his institution received funding from Astute Medical. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Marlies.Ostermann@gstt.nhs.uk Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
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Δευτέρα 20 Νοεμβρίου 2017
Evaluation of a Low Risk Mild Traumatic Brain Injury and Intracranial Hemorrhage Emergency Department Observation Protocol
Abstract
Objectives
Among emergency physicians, there is wide variation in admitting practices for patients who suffered a mild traumatic brain injury (TBI) with an intracranial hemorrhage (ICH). The purpose of this study was to evaluate the effects of implementing a protocol in the emergency department (ED) observation unit for patients with mild TBI and ICH.
Methods
This retrospective cohort study was approved by the Institutional Review Board. Study subjects were patients ≥18 years of age with an International Classification of Diseases (ICD) code corresponding to a traumatic IC, and admitted to an ED observation unit (EDOU) of an urban, academic level 1 trauma center between February 1, 2015 and January 31, 2017. Patient data and discharge disposition were abstracted from the electronic health record; imaging data from the final neuroradiologist report. To measure kappa, two abstractors independently collected data for presence of neuro deficit from a 10% random sample of the medical charts. Using a multivariable logistic regression model with a propensity score of the probability of placement in the EDOU pre-post protocol implementation as a covariate, we sought to determine the pre-post effects of implementing a protocol on the composite outcome of admission to the floor, intensive care unit (ICU), or operating room (OR) from the EDOU, and the proportion of patients with worsening findings on repeat CT head scan in the EDOU.
Results
A total of 379 patients were identified during the study period; 83 were excluded as they were found to have no ICH on chart review. Interrater reliability kappa statistic was 0.63 for 30 charts. Among the 296 patients who remained eligible and comprised the study population, 143 were in the pre-protocol period; 153 post-protocol. The EDOU protocol was associated with an independently statistically significant decreased odds ratio (OR) for admission or worsening ICH on repeat CT scan (OR 0.45, 95% confidence interval [CI] 0.25, 0.82, p=0.009) in the observation unit. After a stay in the EDOU, 26% (37/143) of patients required an inpatient admission pre-implementation of the protocol and 13% (20/153) of patients required an inpatient admission post-protocol implementation. There was no statistically significant difference in log transformed EDOU length of stay (LOS) between the groups after adjusting for propensity score (p=0.34).
Conclusions
While there was no difference in EDOU LOS, implementing a low risk mild traumatic brain injury and intracranial hemorrhage protocol in the EDOU may decrease the rate of inpatient admissions from the EDOU. A protocol driven observation unit may help physicians by standardizing eligibility criteria and by providing guidance on management. As the propensity score method limits our ability to create a straightforward predictive model, a future larger study should validate the results.
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A Randomized Double Blind Trial of Needle-free Injected Lidocaine Versus Topical Anesthesia for Infant Lumbar Puncture
Abstract
Objectives
Lumbar punctures (LPs) are commonly performed in febrile infants to evaluate for meningitis, and local anesthesia increases the likelihood of LP success. Traditional methods of local anesthesia require injection which may be painful or topical application which is not effective immediately. Recent advances in needle-free jet injection may offer a rapid alternative to these modalities. We compared a needle-free jet-injection system (J-Tip™) with 1% buffered lidocaine to topical anesthetic (TA) cream for local anesthesia in infant LPs.
Methods
Single center randomized double-blind trial of J-Tip versus TA for infant LPs in an urban tertiary care Children's Hospital Emergency Department. A computer randomization model was used to allocate patients to either intervention. Patients aged 0-4 months were randomized to J-Tip syringe containing 1% lidocaine and a placebo topical anesthetic cream, or J-Tip syringe containing saline and TA. The primary outcome was the difference between the neonatal faces coding scale (NFCS) pre-procedure and during LP needle insertion. Secondary outcomes included changes in heart rate (HR) and NFCS throughout the procedure, difficulty with LP, number of LP attempts, provider impression of pain control, additional use of lidocaine, skin changes at LP site, and LP success.
Results
We enrolled 66 subjects, 32 were randomized to J-Tip with lidocaine and 34 to EMLA. 6 participants were excluded from the final analysis due to age greater than 4 months, and the remaining 58 were analyzed in their respective groups (32 J-Tip, 34 TA). There was no difference detected in NFCS between the two treatment groups pre-procedure and during needle insertion for the LP (p=0.58, p=0.37). Neither HR nor NCFS differed among the groups throughout the procedure. Median perception of pain control by the provider and the need for additional lidocaine were comparable across groups. LPs performed with a J-Tip were twice as likely to be successful as compared to those performed using TA (RR 2.0; 95% CI 1.01, 3.93; p=0.04) with no difference in level of training or number of prior LPs performed by providers.
Conclusions
In a randomized controlled trial of two modalities for local anesthesia in infant lumbar punctures, J-Tip is not superior to topical anesthetic cream as measured by pain control or physiologic changes. Infant LPs performed with J-Tip were twice as likely to be successful.
This article is protected by copyright. All rights reserved.
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