Emergency Medicine News
Inappropriate Prehospital Ventilation in Severe Traumatic Brain Injury Increases In-Hospital Mortality
In the setting of acute brainstem herniation in traumatic brain injury (TBI), the use of hyperventilation to reduce intracranial pressure may be life-saving. However, undue use of hyperventilation is thought to increase the incidence of secondary brain injury through direct reduction of cerebral blood flow. This retrospective review determined the effect of prehospital hyperventilation on in-hospital mortality following severe TBI. Patients with normocarbia on presenting arterial blood gas testing had in-hospital mortality of 15%, significantly improved over patients presenting with hypocarbia (in-hospital mortality 77%) or hypercarbia (in-hospital mortality 61%). Although there are many reports of the negative impact of prophylactic hyperventilation following severe TBI, this modality is frequently utilized in the prehospital setting. These results suggest that abnormal Pco2 on presentation after severe head trauma is correlated with increased in-hospital mortality and the advocatation of normoventilation in the prehospital setting.
Comparing the efficacy and safety of two regimens of sequential systemic corticosteroids in the treatment of acute exacerbation of bronchial asthma
Corticosteroids are commonly used in the management of acute asthma. However, studies comparing various steroids in the management of acute asthma are lacking.This article compared the efficacy and safety of two treatment regimens - intravenous (IV) methylprednisolone (MP) followed by oral MP and IV hydrocortisone (HC) followed by oral prednisolone in acute bronchial asthma patients. This study found that in acute asthma patients, IV MP followed by oral MP is a more efficacious and safer treatment regimen than IV HC followed by oral prednisolone.
Therapeutic Efficacy of Icatibant in Angioedema Induced by Angiotensin-Converting Enzyme Inhibitors: A Case Series
The pathophysiology of angiotensin-converting enzyme inhibitor (ACEi)–induced angioedema most likely resembles that of hereditary angioedema, ie, it is mainly mediated by bradykinin-induced activation of vascular bradykinin B2 receptors. THis article hypothesized that the bradykinin B2 receptor antagonist icatibant might be an effective therapy for ACEi-induced angioedema.Overall, first symptom improvement after icatibant injection occurred at a mean time of 50.6 minutes (standard deviation [SD] 21 minutes) and complete relief of symptoms at 4.4 hours (SD 0.8 hours). No patient received tracheal intubation, other drug treatment, tracheotomy, or a second icatibant injection. Although sample size limits the external validity of our results, the substantial decrease of time to complete symptom relief suggests that this new treatment is likely effective as a pharmacotherapeutic approach to treat ACEi-induced angioedema.
Are 2 smaller intravenous catheters as good as 1 larger intravenous catheter?
Using Poiseuille's law and standardized gauge sizes, an 18-gauge (g) intravenous catheter (IV) should be 2.5 times faster than a 20-g IV, but this is not borne out by observation, in vitro testing, and manufacturer's data. This article sought to determine if the infusion rate of a single 18-g IV was equivalent to the infusion rate of two 20-g IVs.
The mean infusion rate for a single 18-g 500-mL IV administration was 35.6 mL/min (95% confidence interval [CI], 30.3-40.8), with manufacturer's rating being 105 mL/min. The mean infusion rate for two 20-g IVs was 41.3 mL/min (95% CI, 36.1-46.4), with manufacturer's rating being 120 mL/min. The rate of infusion via two 20-g IVs were statistically significantly faster than the single 18-g IV, with a mean difference in flow rate of 5.7 mL/min.
Circadian, day-of-week, and age patterns of the occurrence of acute coronary syndrome
Previous in-hospital studies suggest that there are significant circadian rhythms associated with the incidence of acute coronary syndromes (ACSs). No study to date has examined the presentation of ACS in the prehospital setting. This article sought to examine circadian, day-of-week, and age patterns of occurrence ACS. It was found that the presentation of ACS has significant circadian rhythm characterized by 2 peaks within 24 hours, the morning peak is 0800 to 1000, and the late evening peak is 2200 to 2400 and no significant weekly rhythm observed in the present study.
Femoral-Based Central Venous Oxygen Saturation Is Not a Reliable Substitute for Subclavian/Internal Jugular-Based Central Venous Oxygen Saturation
Central venous oxygen saturation (Scvo2) has been used as a surrogate marker for mixed venous oxygen saturation (Svo2). Femoral venous oxygen saturation (Sfvo2) is sometimes used as a substitute for Scvo2. The purpose of this study is to test the hypothesis that these values can be used interchangeably in a population of patients who are critically ill. This study revealed a significant difference between paired samples of Scvo2 and Sfvo2. More than 50% of Scvo2 and Sfvo2 values diverged by > 5%. Sfvo2 is not always a reliable substitute for Scvo2 and should not routinely be used in protocols to help guide resuscitation.
Outcomes of patients with severe traumatic brain injury who have Glasgow Coma Scale scores of 3 or 4 and are over 65years old
The objective of the study was to investigate the outcomes of patients with traumatic brain injury (TBI) who had Glasgow Coma Scale (GCS) scores of 3 or 4, and were aged 66 years or older. The Factors having significant effect on outcomes were ISS, TRISS and AIS head. Closed or partially closed basal cisterns and/or midline shift > 15mm were associated with unfavorable outcome. SAH was associated with favorable outcome. Patients with GCS 3 or 4 and older than 65 years have a poor, but not hopeless prognosis. Confirmed factors of poor prognosis for this group of patients are closed basal cisterns and midline shift >15 mm on the first CT. Factors possibly related to favorable outcomes were female gender, lower trauma severity, open or partially open basal cisterns and no midline shift on first CT scan.
Treating Headache Recurrence After Emergency Department Discharge: A Randomized Controlled Trial of Naproxen Versus Sumatriptan
Multiple parenteral medications are used to treat migraine and other acute primary headaches in the emergency department (ED). Regardless of specific headache diagnosis, no medication eliminates the frequent recurrence of primary headache after ED discharge. It is uncertain which medication primary headache patients should be given on discharge from an ED. The aim of this study is to compare the efficacy of oral sumatriptan with naproxen for treatment of post-ED recurrent primary headache. In this trial, nearly three quarters of patients reported headache recurrence within 48 hours of ED discharge. Naproxen 500 mg and sumatriptan 100 mg taken orally relieve post-ED recurrent primary headache and migraine comparably. Clinicians should be guided by medication costs, contraindications, and a patient's previous experience with the medication.
Tranexamic Acid Reduces Mortality in Trauma Patients
Tranexamic acid may be an effective option for reducing bleeding and mortality among trauma patients, without increasing the risk of serious complications such as myocardial infarction, stroke, or pulmonary embolism, according to a study published online June 15 in The Lancet.
Clinical Findings Distinguishing Hemorrhagic Stroke From Ischemic Stroke
The 2 fundamental subtypes of stroke are hemorrhagic stroke and ischemic stroke. Although neuroimaging is required to distinguish these subtypes, the diagnostic accuracy of bedside findings has not been systematically reviewed. This article out of this weeks JAMA sought to determine the accuracy of clinical examination in distinguishing hemorrhagic stroke from ischemic stroke. Several findings significantly increase the probability of hemorrhagic stroke: coma, neck stiffness, seizures accompanying the neurologic deficit, diastolic blood pressure greater than 110 mm Hg, vomiting, and headache. While other findings decrease the probability of hemorrhage such as cervical bruit and prior transient ischemic attack. In patients with acute stroke, certain findings accurately increase or decrease the probability of intracranial hemorrhage, but no finding or combination of findings is definitively diagnostic in all patients, and diagnostic certainty requires neuroimaging.
The accuracy of pulse oximetry in emergency department patients with severe sepsis and septic shock
Pulse oximetry is routinely used to continuously and noninvasively monitor arterial oxygen saturation (SaO2) in critically ill patients. Although pulse oximeter oxygen saturation (SpO2) has been studied in several patient populations, including the critically ill, its accuracy has never been studied in emergency department (ED) patients with severe sepsis and septic shock. The cohort consisted of 88 subjects, with a mean age of 57 years (19 - 89). The mean difference (SpO2 - SaO2) was 2.75% and the standard deviation of the differences was 3.1%. Subgroup analysis demonstrated that hypoxemia (SaO2 < 90) significantly affected pulse oximeter accuracy. The mean difference was 4.9% in hypoxemic patients and 1.89% in non-hypoxemic patients (p < 0.004). In 50% (11/22) of cases in which SpO2 was in the 90-93% range the SaO2 was <90%. Though pulse oximeter accuracy was not affected by acidoisis, hyperlactatementa, anemia or vasoactive drugs, these factors worsened precision.
Procainamide Doesn't Help Survival in Ventricular Fibrillation Out-of-hospital Cardiac Arrest
Procainamide is an antiarrhythmic drug of unproven efficacy in cardiac arrest. The association between procainamide and survival from out-of-hospital cardiac arrest was investigated to better determine the drug's potential role in resuscitation. Procainamide is an antiarrhythmic drug of unproven efficacy in cardiac arrest. The association between procainamide and survival from out-of-hospital cardiac arrest was investigated to better determine the drug's potential role in resuscitation. Of the 665 eligible patients, 176 received procainamide, and 489 did not. On average, procainamide recipients received more shocks and pharmacologic interventions and had lengthier resuscitations. Adjusted for their clinical and resuscitation characteristics, procainamide recipients had a lower likelihood of survival to hospital discharge.
Association Between Arterial Hyperoxia Following Resuscitation From Cardiac Arrest and In-Hospital Mortality
Laboratory investigations suggest that exposure to hyperoxia after resuscitation from cardiac arrest may worsen anoxic brain injury; however, clinical data are lacking. This study was a multicenter cohort study using the Project IMPACT critical care database of intensive care units (ICUs) at 120 US hospitals between 2001 and 2005. Patients were divided into 3 groups defined a priori based on PaO2 on the first arterial blood gas values obtained in the ICU. Hyperoxia was defined as PaO2 of 300 mm Hg or greater; hypoxia, PaO2 of less than 60 mm Hg (or ratio of PaO2 to fraction of inspired oxygen <300); and normoxia, not classified as hyperoxia or hypoxia. Of 6326 patients, 1156 had hyperoxia (18%), 3999 had hypoxia (63%), and 1171 had normoxia (19%). The hyperoxia group had significantly higher in-hospital mortality, 63%, compared with the normoxia group, 45%, and the hypoxia group 57%. Among patients admitted to the ICU following resuscitation from cardiac arrest, arterial hyperoxia was independently associated with increased in-hospital mortality compared with either hypoxia or normoxia.
Inferior Vena Cava Diameter Correlates with Invasive Hemodynamic Measures in Mechanically Ventilated Intensive Care Unit Patients with Sepsis
Early optimization of fluid status is of central importance in the treatment of critically ill patients. This study out of the Journal of Emergency Medicine investigated whether inferior vena cava (IVC) diameters correlate with invasively assessed hemodynamic parameters and whether this approach may thus contribute to an early, non-invasive evaluation of fluid status. The investigators found a statistically significant correlation of both inspiratory and expiratory IVC diameter with central venous pressure, extravascular lung water index , intrathoracic blood volume index, the intrathoracic thermal volume, and the PaO2/FiO2 oxygenation index. In this study, IVC diameters were found to correlate with central venous pressure, extravascular lung water index, intrathoracic blood volume index, the intrathoracic thermal volume, and the PaO2/FiO2 oxygenation index. Therefore, sonographic determination of IVC diameter seems useful in the early assessment of fluid status in mechanically ventilated septic patients.
Platelet hyperfunction is decreased by additional aspirin loading in patients presenting with myocardial infarction on daily aspirin therapy
Currently 162-325 mg aspirin is recommended for the treatment of acute coronary syndrome. This article out of the journal Critical Care Medicine tested the effect of an additional loading dose of 250 mg aspirin at the onset of acute coronary syndrome in patients who were already on chronic therapy with 100 mg aspirin. It found that aspirin loading in the emergency room further reduced thromboxane B2 levels and further inhibited platelet function in many patients with acute coronary syndrome already on 100 mg aspirin.
β-Blockers for Chest Pain Associated With Recent Cocaine Use
Although β-blockers prevent adverse events after myocardial infarction, they are contraindicated when chest pain is associated with recent cocaine use. Recommendations against this use of β-blockers are based on animal studies, small human experiments, and anecdote. This article in the Archives of Internal Medicine tested the hypothesis that β-blockers are safe in this setting and found of 331 patients with chest pain in the setting of recent cocaine use, 151 (46%) received a β-blocker in the emergency department. There were no meaningful differences in electrocardiographic changes, troponin levels, length of stay, use of vasopressor agents, intubation, ventricular tachycardia or ventricular fibrillation, or death between those who did and did not receive a β-blocker. It also found that over a median follow-up of 972 days , after adjusting for potential confounders, patients discharged on a β-blocker regimen exhibited a significant reduction in cardiovascular death.
Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses in Patients at Risk for Community-Associated Methicillin-Resistant Staphylococcus aureus Infection Decreases Number of Lesions but Not Treatment Failures
Community-associated methicillin-resistant Staphylococcus aureus is now the leading cause of uncomplicated skin abscesses in the United States, and the role of antibiotics is controversial. We evaluate whether trimethoprim-sulfamethoxazole reduces the rate of treatment failures during the 7 days after incision and drainage and whether it reduces new lesion formation within 30 days. A multicenter, double-blind, randomized, placebo-controlled trial, randomized adults to oral trimethoprim-sulfamethoxazole or placebo after uncomplicated abscess incision and drainage and followed with in 7 days. Overall a statistically similar incidence of treatment failure in patients receiving trimethoprim-sulfamethoxazole (15/88; 17%) versus placebo (27/102; 26%), difference 9%, 95% confidence interval –2% to 21%; P=.12. On 30-day follow-up (successful in 69% of patients), we observed fewer new lesions in the antibiotic (4/46; 9%) versus placebo (14/50; 28%) groups, difference 19%, 95% confidence interval 4% to 34%, P=.02.
Etomidate Decreases Cortisol Levels in Patients After Use in Intubation
An article out the Annals of Emergency Medicine the evidence on the effect of a bolus dose of etomidate on adrenal function, mortality, and health services utilization compared with other induction agents used for rapid sequence intubation. Overall it found that the mean cortisol levels were lower in elective surgical patients induced with etomidate compared with those induced with other agents between 1 and 4 hours postinduction. The differences varied from 6.1 μg/dL (95% confidence interval [CI] 2.4 to 9.9 μg/dL; P=.001) to 16.4 μg/dL (95% CI 9.7 to 23.1 μg/dL; P<.001). Two studies in critically ill patients reported significantly different cortisol levels up to 7 hours postinduction. None of the studies reviewed, nor our pooled estimate (odds ratio 1.14; 95% CI 0.81 to 1.60), showed a statistically significant effect on mortality. Only one study reported longer ventilator, ICU, and hospital lengths of stay in patients intubated with etomidate.
Predicting bacteremic pneumonia in HIV-1–infected patients consulting the ED
HIV-1–infected patients have higher incidence of community-acquired pneumonia (CAP) and risk of complications. Bacteremia has been associated with a higher risk of complications in such patients. An article out of the American Journal of Emergency Medicine investigated factors associated with bacteremia in HIV-1–infected patients with CAP presenting at the emergency department. Overall the study found that bacteremia was present in 24%. Independent predictors of bacteremia were the detection of S pneumoniae antigen in urine and the absence of current antiretroviral treatment. It was also found that the in-hospital mortality was higher in patients with bacteremia (15% vs 0%) showing that bacteremic patients have a poor outcome.
Do Either Corticosteroids or Antiviral Agents Reduce the Risk of Long-Term Facial Paresis in Patients with New-Onset Bell's Palsy?
The cause of Bell's palsy remains uncertain, although accumulating evidence suggests a viral etiology. To date, treatment to minimize long-term deficits from this disorder typically includes anti-inflammatory or antiviral medication. Three multicenter, randomized, controlled trials enrolled over 1500 adult patients with paroxysmal, unilateral paresis of cranial nerve VII and treated them with varying regimens and combinations of prednisolone, antiviral agents, and placebo, and evaluated complete recovery up to 12 months later. Current evidence suggests that prednisolone, an inexpensive and readily available medication, is effective for this common condition, but there was no statistically significant difference observed with acyclovir. Valacyclovir provides minimal added benefit to prednisolone alone.
Initial Bolus Insulin in the Treatment of Diabetic Ketoacidosis
Current guidelines for treatment of diabetic ketoacidosis (DKA) recommend administration of an intravenous bolus dose of insulin followed by a continuous infusion. A study in this months Journal of Emergency Medicine investigated whether the initial bolus dose is of significant benefit to adult patients with DKA and if it is associated with increased complications. Overall there were no statistically significant differences in the incidence of hypoglycemia (6% vs. 1%, respectively, p = 0.12), rate of change of glucose (60 vs. 56 mg/dL/h, respectively, p = 0.54) or AG (1.9 vs. 1.9 mEq/L/h, respectively, p = 0.66), LOS in the Emergency Department (8 vs. 7 h, respectively, p = 0.37) or hospital (5.6 vs. 5.9 days, p = 0.81). Equivalence testing revealed no clinically relevant differences in IVF change, rate of change of glucose, or AG. Administration of an initial bolus dose of insulin was not associated with significant benefit to patients with DKA and demonstrated equivalent changes in clinically relevant endpoints when compared to patients not administered the bolus.
Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia
Patients with acute neurologic symptoms may have other causes simulating ischemic stroke, called stroke mimics (SM), but they may also have averted strokes that do not appear as infarcts on neuroimaging, which we call neuroimaging-negative cerebral ischemia (NNCI). A study out of the Journal Neurology determined the safety and outcome of IV thrombolysis within 3 hours of symptom onset in patients with SM and NNCI. The data support the safety of administering IV tissue plasminogen activator to patients with suspected acute cerebral ischemia within 3 hours of symptom onset, even when the diagnosis ultimately is found not to be stroke or imaging does not show an infarct.
Significance of a prominent Q wave in lead negative aVR (−aVR) in acute anterior myocardial infarction
The aim of this study was to clarify the significance of a Q wave in lead negative aVR (−aVR) in anterior wall acute myocardial infarction (AMI). Eighty-seven patients with a first anterior wall AMI were classified into 2 groups according to the presence (n = 17, group A) or absence (n = 70, group B) of a prominent Q wave (duration ≥20 milliseconds) in lead −aVR at predischarge. Group A had a higher prevalence of a long left anterior descending coronary artery (LAD), a lower left ventricular ejection fraction, and more reduced regional wall motion in the apical and inferior regions than group B concluding that a prominent Q wave in lead −aVR in anterior wall AMI is related to severe regional wall motion abnormality in the apical and inferior regions, with an LAD wrapping around the apex.
12-Lead ECG Findings of Pulmonary Hypertension Occur More Frequently in Emergency Department Patients With Pulmonary Embolism Than in Patients Without Pulmonary Embolism
Acute pulmonary embolism can produce abnormalities on ECG that reflect severity of pulmonary hypertension. Early recognition of these findings may alter the estimated pretest probability of pulmonary embolism and prompt more aggressive treatment before hemodynamic instability ensues, but it is first important to test whether these findings are specific to patients with pulmonary embolism. An article in this months Annals of Emergency Medicine compared hypothesized that ECG findings consistent with pulmonary hypertension would be observed more frequently in patients with pulmonary embolism. Overall the findings of acute pulmonary hypertension were infrequent overall but were observed more frequently in patients with the final diagnosis of pulmonary embolism compared with patients who do not have pulmonary embolism.
Hydroxocobalamin and Sodium Thiosulfate Versus Sodium Nitrite and Sodium Thiosulfate in the Treatment of Acute Cyanide Toxicity
Cyanide can cause severe hypotension with acute toxicity. To our knowledge, no study has directly compared hydroxocobalamin and sodium nitrite with sodium thiosulfate in an acute cyanide toxicity model. A study published in this months Annals of Emergency Medicine compared the return to baseline of mean arterial blood pressure between 2 groups of swine with acute cyanide toxicity and treated with hydroxocobalamin with sodium thiosulfate or sodium nitrite with sodium thiosulfate. Overall it showed that hydroxocobalamin with sodium thiosulfate led to a faster return to baseline mean arterial pressure compared with sodium nitrite with sodium thiosulfate; however, there was no difference between the antidote combinations in mortality, serum acidosis, or serum lactate.
Elevated serum S100B levels in acute spinal fracture without head injury
S100B is a biomarker that reflects injury to the central nervous system. As the spine is an integral part of the spinal cord, a study publised in this months Emergency Medicine Journal was undertaken to investigate whether serum S100B levels are associated with acute spinal fracture without head injury. Serum S100B levels were higher in the spinal fracture group than in the non-spinal fracture group, and 19 of the 20 patients in the spinal fracture group (95%) had an S100B level >0.12 μg/l, whereas all 12 of the non-spinal fracture group had an S100B level ≤0.12 μg/l. Overall the Serum S100B levels are raised in all patients with acute spinal fracture without head injury. Spinal fracture may therefore be one of the extracerebral sources of S100B. Serum S100B levels may be an effective tool for excluding subtle spinal fractures with no clear radiographic findings.
Bicarbonate therapy in the treatment of septic shock: a second look
The use of supplemental sodium bicarbonate for the treatment of patients with septic shock and elevated blood lactate levels remains a controversial therapy. An article in Internal and Emergency Medicine conducted a retrospective study between March 2004 and February 2009 of 36 consecutive patients diagnosed with septic shock who received continuous infusion of bicarbonate therapy. Although there was no difference in 28-day mortality between the two study groups, infusion of sodium bicarbonate in septic patients with arterial hyperlactatemia the median time to liberation of mechanical ventilation was significantly reduced in the bicarbonate group (10 days [95% CI 5.0–13.0] compared to the control group (14 days [95% CI 9.0–19.0], p = 0.02) and the length of intensive care unit (ICU) stay was also shorter in the surviving patients who received bicarbonate compared to controls
No Difference in Mortality Seen with Factor VIIa in Emergency Department Patients With Warfarin Use and Traumatic Intracranial Hemorrhage
A study out Academic Emergency Medicine compared outcomes in emergency department (ED) patients with preinjury warfarin use and traumatic intracranial hemorrhage (tICH) who did and did not receive recombinant activated factor VIIa (rFVIIa) for international normalized ratio (INR) reversal. Overall in patients with preinjury warfarin and tICH, use of rFVIIa was associated with a decreased time to normal INR. However, no difference in mortality was identified. Use of rFVIIa in patients on warfarin and tICH requires further study to demonstrate important patient-oriented outcomes.
No Significant Difference in the Rate of Death Between Patients with Shock Treated with Dopamine or Norepinephrine
Both dopamine and norepinephrine are recommended as first-line vasopressor agents in the treatment of shock. There is a continuing controversy about whether one agent is superior to the other. A multicenter, randomized trial was conducted and assigned 1679 patients with shock to receive either dopamine or norepinephrine as first-line vasopressor therapy to restore and maintain blood pressure. There was no significant between-group difference in the rate of death at 28 days (52.5% in the dopamine group and 48.5% in the norepinephrine group; odds ratio with dopamine, 1.17; 95% confidence interval, 0.97 to 1.42; P=0.10). However, there were more arrhythmic events among the patients treated with dopamine than among those treated with norepinephrine (207 events [24.1%] vs. 102 events [12.4%], P<0.001). A subgroup analysis showed that dopamine, as compared with norepinephrine, was associated with an increased rate of death at 28 days among the 280 patients with cardiogenic shock but not among the 1044 patients with septic shock or the 263 with hypovolemic shock.
End Tidal CO2 Monitoring Predicts Hypoxia by 60 Seconds During Emergency Department Procedural Sedation and Analgesia With Propofol
An article from the Annals of Emergency Medicine sought to determine whether the use of capnography is associated with a decreased incidence of hypoxic events than standard monitoring alone during emergency department (ED) sedation with propofol. One hundred thirty-two subjects were evaluated and included in the final analysis. We observed hypoxia in 17 of 68 (25%) subjects with capnography and 27 of 64 (42%) with blinded capnography. Capnography identified all cases of hypoxia before onset (sensitivity 100%; specificity 64%), with the median time from capnographic evidence of respiratory depression to hypoxia 60 seconds concluding the addition of capnography to standard monitoring reduced hypoxia and provided advance warning for all hypoxic events.
Routine testing in patients with asymptomatic elevated blood pressure in the ED
There are no clear recommendations for the diagnostic evaluation of patients who present to the emergency department (ED) with asymptomatic elevated blood pressure. In patients presenting with asymptomatic elevated blood pressure in the ED, we measured the prevalence of abnormalities on a basic metabolic profile (BMP) that led to hospital admission as well as the prevalence of diminished renal function. One hundred sixty-seven patients with asymptomatic elevated BP were studied and Twelve patients were admitted due to abnormal results on the BMP. Twenty-seven patients met the secondary outcome measure of diminished renal function. In a homogenous African American population presenting to the ED with asymptomatic elevated BP, there is a relatively high prevalence of abnormalities on the BMP that led to hospital admission. We suggest routine testing of a serum creatinine should be strongly considered in a largely African American patient population with asymptomatic elevated BP in the ED.
Optimization of initial energy for cardioversion of atrial tachyarrhythmias with biphasic shocks
Optimization of initial energy for cardioversion of atrial tachyarrhythmias with biphasic shocks. Recommendations for optimal first-shock energies with biphasic waveforms are conflicting. We evaluated prospectively the relation between type and duration of atrial tachyarrhythmias and the probability of successful cardioversion with a specific biphasic shock waveform to develop recommendations for the initial energy setting aiming at the lowest total cumulative energy with 2 or less consecutive shocks.
Cardioversion was successful in 448 patients (cumulative efficacy, 99 %). In patients with AFL/AT, the lowest total cumulative energy was attained with an initial energy setting of 50 J. In patients with AF, lowest values were achieved with an initial energy of 100 J for arrhythmia durations of 2 days or less and an initial energy of 150 J for arrhythmia durations of more than 2 days.
We recommend an initial energy setting of 50 J in patients with AFL/AT, of 100 J in patients with AF 2 days or less, and of 150 J with AF more than 2 days.
ST-segment depression in aVR as a predictor of culprit artery and infarct size in acute inferior wall ST-segment elevation myocardial infarction
ST-segment depression in lead aVR in acute inferior wall ST-segment elevation myocardial infarction (STEMI) has recently been suggested as a predictor of left circumflex (LCx) artery involvement. The purpose of this study is to evaluate the clinical significance of aVR depression during inferior wall STEMI. The sensitivity and specificity of aVR depression as a predictor of LCx infarction were 53% and 86%, respectively. In patients with right coronary artery infarction, aVR depression was associated with increased cardiac enzymes and the involvement of a large posterolateral branch, which may explain the larger infarction. ST-segment depression in lead aVR in inferior wall STEMI predicts LCx infarction or larger RCA infarction involving a large posterolateral branch.
Nasogastric Aspiration and Lavage in Emergency Department Patients with Hematochezia or Melena Without Hematemesis
The utility of nasogastric aspiration and lavage in the emergency management of patients with melena or hematochezia without hematemesis is controversial. This evidence-based emergency medicine review evaluates the following question: does nasogastric aspiration and lavage in patients with melena or hematochezia and no hematemesis differentiate an upper from lower source of gastrointestinal (GI) bleeding? A literature review out of the Journal of Academic Emergency Medicine was done showing that nasogastric aspiration, with or without lavage, has a low sensitivity and poor negative likelihood ratio, which limits its utility in ruling out an upper GI source of bleeding in patients with melena or hematochezia without hematemesis.
Anticholinergics and Ketamine Sedation in Children: Atropine Bests Glycopyrrolate
Adjunctive anticholinergics are commonly administered during emergency department (ED) ketamine sedation in children under the presumption that drying oral secretions should decrease the likelihood of airway and respiratory adverse events. Pharmacologic considerations suggest that glycopyrrolate might exhibit a superior adverse effect profile to atropine. A study out the Journal of Academic Emergency Medicine contrasted the adverse events noted with use of each of these anticholinergics in a large multicenter observational database of ketamine sedations. This secondary analysis unexpectedly found that the coadministered anticholinergic atropine exhibited a superior adverse event profile to glycopyrrolate during ketamine sedation.
Imaging Recomendations for new-onset afebrile seizures in infants
To investigate the presenting characteristics of new-onset afebrile seizures in infants (age 1–24 months) a prospective trial was conducted. It was found half of the infants had partial features to their seizures, yet evidence for primary generalized seizures was rare. The majority had more than 1 seizure upon presentation. Seizures in this age group tended to be brief, with 44% lasting less than 1 minute. EEG abnormalities were found in half. One-third of CTs were abnormal, with 9% of all CTs requiring acute medical management. Over half of MRIs were abnormal, with cerebral dysgenesis being the most common abnormality (p < 0.05). One-third of normal CTs had a subsequent abnormal MRI—only 1 resulted in altered medical management. Infantile seizures are usually brief, but commonly recurrent, and strong consideration should be made for inpatient observation. Acute imaging with CT can alter management in a small but important number of infants. Due to the superior yield, strong consideration for MRI should be given for all infants, as primary generalized seizures are rare, and there is a high rate of cerebral dysgenesis.
