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The Written Summary of the EM:RAP Monthly Audio Program
July 2015: Volume 15, Issue 7
Editor-in-Chief: Mel Herbert, MD
Executive Editor: Paul Jhun, MD
Associate Editor: Marlowe Majoewsky, MD
www.emrap.org
Cardiology Corner: Pericarditis
What are the classic chest pain symptoms? Sharp chest
pain that tends to be pleuritic. It tends to be positional. Classically, it radiates to the trapezius ridge as the left phrenic nerve
lies across the pericardium.
The ECG is not always a classic presentation. You may have
pericarditis with non-specific ECG findings.
There are probably many patients with pericardial inflammation that we send home with a diagnosis of musculoskeletal or non-specific chest pain, and the majority do
fine. We should probably be concerned about the patients
with pronounced symptoms and ECGs.
Rob Orman MD and Amal Mattu MD
Highlights
The diagnosis of acute pericarditis requires at least two
of the following symptoms or signs: chest pain consistent with pericarditis, pericardial friction rub, typical
ECG changes, or a pericardial effusion of more than a
trivial size.
Misinterpretation of the ECG is a potential pitfall; look
for any ECG changes that rule-in STEMI.
Treatment with nonsteroidal anti-inflammatory drugs
and colchicine is well-studied and effective.
Troponin elevation may indicate concurrent myocarditis;
these patients are at higher risk for complications of
CHF or arrhythmia.
LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J
Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707.
What are the biggest pitfalls in the diagnosis and treatment
of pericarditis? Misinterpretation of the ECG. Overdiagnosis of
acute pericarditis rather than true STEMI based on age of the
patient or characterizations of pain. STEMI may produce sharp
and positional pain and may occur in younger patients.
How common are the ECG changes? There isn’t good literature
available, possibly due to the vague diagnostic criteria of pericarditis. The majority of patients with a final diagnosis of pericarditis
have ECG changes, but there is diagnostic bias involved.
What are typical ECG changes?
ST elevation in multiple leads. It does not have to involve all
12 leads. There will often be PR segment depression in the involved leads. There are some caveats: the ST elevation may be
very subtle and sometimes only PR depression is apparent.
PR depression is not pathognomonic for acute pericarditis; acute coronary syndromes may produce PR depression.
Any atrial abnormality can produce PR segment changes. It is
helpful, but it is not pathognomonic for pericarditis.
Look for any ECG changes that rule-in STEMI: ST elevations
which are horizontal or convex, ST segment or reciprocal
depression. ST depression may be present in leads V1 or aVR
in many conditions. However, if you see ST depression in any
of the other ten leads, it virtually rules out pericarditis and you
are looking at a STEMI.
Spodick’s sign is downsloping of the TP segment. This is
fairly predictive of pericarditis. A study examining this association is currently underway.
The classic diffuse ST elevation and PR depression is often
present only with viral pericarditis. There has to be inflammation in the pericardial region to produce the classic ECG
changes, and conditions such as uremia may not manifest
with classic ECG findings.
How do you diagnose pericarditis?
If you hear a pericardial friction rub, you are lucky. The rub
is very specific but less sensitive for pericarditis. It occurs
at some point during the disease process in most patients
but is transient. The rub is usually a high-pitched, scratching
sound that is heard best at the left sternal border. It may be
heard in any or all of the phases of cardiac activity. You can
listen to the heart sounds with the patient supine, sitting up,
and leaning forward.
The diagnosis of acute pericarditis requires at least two
of the following symptoms or signs: chest pain consistent with pericarditis, pericardial friction rub, typical ECG
changes, or a pericardial effusion of more than a trivial size.
There aren’t any good studies that have determined clear
diagnostic criteria; most of this appears to be based upon
consensus and experience.
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Four stages of ECG findings in pericarditis are often taught,
however it is very rare that we see this in the Emergency
Department. This is more useful for board examination preparation. Stage 1 is the classic ST elevation with PR depression.
Stage 2 has normalization of the ST and PR segments. Stage
3 has inversion of the T waves. Stage 4 has normalization of
all segments. This process may take a week or more.
has been found to decrease the duration and intensity of symptoms, as well as decrease the likelihood of recurrence. It needs
to be given for about 3 months. The most common side effects
are gastrointestinal, but most patients tolerate it well. There are
several different dosing regimens. The review article recommends a dose of 0.5 mg twice a day in patients with a body
weight >70 kg and 0.5 mg daily with a body weight <70 kg.
The review article recommends a work-up including a complete blood count with a differential, high-sensitivity C-reactive protein (CRP), measurements of troponin I or T, serum
creatinine, and liver function tests. Is this really necessary?
These are designed to identify unusual causes of pericarditis
and complications. Troponin may be elevated in about 15-25%
of patients with pericarditis. The pericardium does not release
troponin. Elevation in troponin suggests that there may be concurrent myocarditis. These patients are at higher risk for complications such as congestive heart failure or arrhythmias. This
might be an indication to admit or monitor the patient.
Most patients’ symptoms resolve within the first week. Some
suggest following the CRP to determine duration of therapy.
Not all patients with pericarditis need to be admitted. If the patient has reasonable follow-up, the patient might be discharged.
Patients that are afebrile, not immunosuppressed, have no history of trauma, have no evidence of myopericarditis, have no large
pericardial effusion, and are not on anticoagulants tend to do
well when managed as outpatients. If they have any of the above
conditions, they should probably be observed or admitted to rule
out complications such as congestive heart failure or arrhythmias.
Patients may have a low grade fever with pericarditis, especially with suspected viral etiology. However, fevers greater
than 38.5ºC (101.3ºF) might indicate another etiology such
as a bacterial infection or tuberculosis.
It is a good idea to get an echocardiogram. This does not necessarily need to be done prior to discharge if the patient has
good follow-up. This is to make sure they don’t have a large effusion, as this is a predictor of complications. However, if you have
bedside ultrasound available, it is very simple to rapidly identify
a large pericardial effusion.
Treatment
The nonsteroidal anti-inflammatory drug (NSAID) and colchicine combination has been well-studied and found to
be effective.
NSAIDs used are often ibuprofen (600-800mg every 6-8
hours) or indomethacin. However, indomethacin tends to have
more side effects. In Europe, aspirin is frequently used (2-4
grams per day in divided doses). A proton pump inhibitor (PPI)
is also recommended.
Colchicine is recommended and recent literature has been
supportive. The anti-inflammatory effect is thought to be due
to blockage of microtubule assembly in white cells. Colchicine
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Steroids are not recommended. There is some evidence that
they may increase the rate of recurrence and blunt the effect
of colchicine. They may be an option in patients with renal insufficiency who are not candidates for treatment with NSAIDs
or colchicine, but this has not been discussed much in the
literature. Aspirin in combination with a PPI may be another
option in patients with renal insufficiency.
Should recurrences be treated differently? No. Give NSAIDs
and colchicine.
Drowning Resuscitation
Sean Nordt MD, PharmD, Mizuho Spangler DO, Andrew
Schmidt DO and Sam Borghei MD
Highlights
Drowning is defined as the process of experiencing respiratory impairment from submersion/immersion in liquid.
Your primary focus in the drowning patient should be
reversing hypoxemia.
Although therapeutic hypothermia was recommended for
drowning victims, the literature does not show good outcomes.
Case
It was a busy day in the Emergency Department (ED) with
ambulance runs lined up in the hallway awaiting gurneys.
There was a commotion and a burly police officer ran into
the ED holding a lifeless child who looked to be about 3
or 4 years old. The child was blue. Borghei directed the officer to the nearest room, which already contained a patient
hooked up to the monitors. The patient was removed from
the gurney and the child was placed on it. The police officer reported that he was the first responder on a drowning
case. He scooped the patient up and ran to the ED. CPR
and bag-valve-mask ventilation was started. The patient
was intubated quickly and a nurse was able to place an
external jugular line while another physician placed an IO
line. The patient had return of pulses with ventilation but no
return of neurologic response.
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What happened next? A work-up was initiated. The family arrived and was informed that the child had a very poor prognosis. The patient was transferred to a children’s hospital. Over
the next several days, the patient had worsening function of the
lungs and required pressor support. However, she later began
developing some purposeful movements.
Two weeks later, Borghei arrived for his shift and noticed a
little girl running around who looked somewhat familiar. It
was his patient, who had completely recovered with no neurologic deficits. The only apparent sequela was a subconjunctival
hemorrhage.
Drowning resuscitation has evolved over time. The ancient
Egyptians would hold drowning patients upside to try to drain
their lungs.
There are about 1.2 per 100,000 deaths (about 500,000 total) due to drowning in the United States per year. Patients
between the ages of 0 to 4 years are at particular risk from accidental drowning. Teenagers and young adults are more likely
to be involved in boating accidents or alcohol-related incidents.
Education efforts attempt to decrease non-fatal drowning injuries.
What is the definition of drowning? In 2002, the World Congress on Drowning developed a standard definition: “the process
of experiencing respiratory impairment from submersion/immersion in liquid.” There are three possible outcomes: mortality,
morbidity, or no morbidity.
They recommend against using confusing terms such as “near
drowning,” “wet versus dry drowning,” “passive drowning,” or
“secondary drowning.” These terms may not exist and they
don’t change your treatment.
What is the pathophysiology of drowning? When the airway
goes below the level of the water, patients may initially struggle and hold their breath. At some point, they will take a deep
breath, due to the need for oxygen, and water enters the airway.
This can result in atelectasis, washout of surfactant, and VQ mismatch leading to hypoxemia.
The best treatment starts in the prehospital setting. The first
5-10 minutes are the most important in reversing the hypoxemia.
The patient needs to be ventilated whether via mouth-to-mouth,
mouth-to-mask, bag-valve-mask, etc. By the time the patient arrives at the ED or the ICU, the damage has been done.
There is no indication for the Heimlich maneuver; it just delays initial resuscitation and administration of oxygen.
What should you focus on when the patient arrives in the
ED? Focus on reversing the hypoxemia. IV fluids can help; studies show that patients with persistent hypotension have higher
mortality. There are no great prospective studies, and most of the
available literature is based on case studies.
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Non-rebreather masks or nasal cannulas can be used if the
patient is protecting his/her airway. There are case studies that
support the use of non-invasive positive pressure ventilation. If
the patient is not improving within 10 to 30 minutes, the patient
should be intubated. However, intubation may be very difficult in
these patients. Suctioning may be useful in clearing the upper
airways. The lungs are fairly resilient and most patients can be
extubated within 1-2 days. Most follow an ARDSNet protocol, although there is no specific literature regarding drowning patients.
Steroids and prophylactic antibiotics are no longer recommended. Although some will give empiric antibiotics if patients
were removed from grossly contaminated water, it is better to
allow bronchial or tracheal aspirates to guide treatment. Pneumonias secondary to drowning are often multi-drug resistant.
CT imaging of the head and cervical spine. The prevalence of
cervical spinal injury is between 0.5 and 5%. There is no indication for routine backboards or C-spine imaging on every case.
Most of the drowning patients with cervical spinal injuries will
be altered, be intoxicated, have obvious signs of facial trauma,
or have a story consistent with injury. If the patient is evaluable
with a good story and without facial trauma, you can use NEXUS
criteria or other criteria to clear them.
In 2002, the World Congress on Drowning recommended the
use of the therapeutic hypothermia when patients demonstrated return of spontaneous circulation (ROSC) without
neurologic improvement. Unfortunately, there is no supporting literature. There have been some recent studies but they
have shown poor outcome with therapeutic hypothermia. These
studies are biased because these are very sick patients who
have had cardiac arrest. Patients with cardiac arrest in the field
usually experience PEA or asystole.
A recent study on pediatric patients with cardiac arrest
and hypothermia showed less than 10% with survival
and good neurologic return. Kieboom JK, et al. Outcome
after resuscitation beyond 30 minutes in drowned children
with cardiac arrest and hypothermia: Dutch nationwide
retrospective cohort study. BMJ. 2015 Feb 10;350:h418.
[Free open access article]
In general, patients who are hypothermic when they are
pulled out of the water tend to have a poor outcome. Do we
warm them or cool them? You can warm them to achieve ROSC
and then make a treatment decision based on the clinical picture. There is no evidence supporting therapeutic hypothermia.
Extracorporeal membrane oxygenation (ECMO) has shown
promise in patients with irreversible hypoxemia or hypothermia after the initial resuscitation. However, it is very early in
the investigation of its utility.
Should you get a chest x-ray? Most will obtain a chest x-ray in
any drowning patient with respiratory symptoms. However, the
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initial chest x-rays do not provide any prognostic value. It does
not tell you who will get intubated. Some patients will initially
have infiltrates that do not result in clinical significance. Pneumonias will develop in several days.
Disposition. What should you do with patients that are successfully resuscitated and appear to be at their neurologic baseline
without respiratory distress? There is some evidence that patients with a GCS greater than 13, who are oxygenating well, with
continued improvement during their ED stay, are usually ok to go
home. If the patient is going to decompensate, it usually occurs
within the first four hours. Current recommendations are to observe the patient for four to eight hours, and if there is no clinical
decompensation with normal oxygenation and mentation, the
patient can be discharged.
There is no clinical difference between outcomes of saltwater
versus fresh water drowning.
Drowning continues to be a leading cause of death in pediatric
patients between the ages of zero to four years. There are no
clinical guidelines for pediatricians to guide prevention recommendations and no evidence supporting infant survival skills classes.
Keep children within arm’s reach. Educate patients on pool fencing.
Community Medicine Rants: EDAP
Al Sacchetti MD
Highlights
The Emergency Medical Services (EMS) for Children
designates certain hospital Emergency Departments
(ED) as an Emergency Department Approved for Pediatrics (EDAP).
Many pediatric patients are brought to the ED by family
members and not EMS.
This concentration of pediatric expertise is not a good
model. All EDs should be able to care for children.
There has been an increasing trend towards specialized receiving centers such as STEMI or stroke receiving centers.
There are Emergency Departments that are not equipped to treat
pediatric patients. Most pediatric patients arrive via private vehicle and not ambulance.
The Emergency Medical Services for Children goes into a
state and designates certain hospital EDs as approved for
children. These are the EDAPs (Emergency Departments Approved for Pediatrics). These hospitals will have an ED that is
well-stocked and well-qualified to care for children. The rest of
the hospitals do whatever they want. EMS personnel are instructed to take sick children to an EDAP. The EDAPs may be located in
children’s hospitals, university hospitals, or community hospitals
with particularly good EDs.
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If you have an EMS transport system that takes all sick pediatric patients to EDAPs, it makes sense. But if you have a
family member taking the child to the hospital, they will take
the patient to whatever ED they encounter first. If they arrive
at a hospital that has not elected to be an EDAP, that child is
screwed. The EDAP system has encouraged this. They have allowed hospitals in the community to self-select to be EDAPs. If
there are a lot of EDAPs in your community, statistically the child
will probably wind up at one. If not, you are going to have a problem. Unless you have provided all parents and caregivers of
pediatric patients with a map identifying EDAPs, they aren’t
going to know. Also, the EDAPs may change status, which while
EMS personnel may be able to keep abreast of the changes,
most laypeople won’t.
All pediatric expertise is now concentrated in these facilities.
Now you have some facilities providing excellent pediatric care,
while others provide terrible care. This requires the community to
come to the areas where pediatric emergency care is available.
This is not a great model. It is a good model for tertiary care
because not every hospital needs to be able to do pediatric
cardiothoracic surgery. Emergency care should be available at
every hospital and not just EDAPs.
EDAPs arose in response to the EDs of the past, which were
often staffed with moonlighters of other specialties and
there were few emergency physicians and even fewer with
experience with pediatrics. In 2015, emergency physicians are
trained in the care of children. Nurses are often certified and
trained in the care of children. There are pediatric emergency
physicians who are developing an entire science around the care
of children. They are designing care that can be provided anywhere. This is where the system falls apart.
Specialists, such as pulmonologists or endocrinologists, do
not take care of all patients with asthma or diabetes; they
take care of the difficult cases. A lot of pediatric emergency physicians developed the mindset that they needed to take care of
every pediatric patient rather than serve as a resource for the
general emergency physician. There is an increase in pediatric
EDs staffed by only pediatric emergency physicians, with regulations saying that certain treatments should be reserved for pediatric emergency physicians and that medical directors should be
pediatric emergency physicians. This concentrates knowledge.
What is the alternative? The goal should be to have every ED
be able to take care of children. Every board certified Emergency
Medicine physician should be able to take care of children. They
need to be able to provide stabilizing care and not definitive care.
Sacchetti A, et al. Should pediatric emergency care be decentralized?: an out-of-hospital destination model for critically ill children. Acad Emerg Med. 2000 Jul;7(7):787-91.
PMID: 10917329.
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This study looked at what happened if EDAPs were dissolved
and all EDs in the state became capable of taking care of sick
children.
The model showed that the time to stabilization for a critically ill child anywhere in the state was shortest with a system
where any ED could stabilize and transport the patient, compared to an EDAP model.
Sacchetti A, et al. Should pediatric emergency physicians be
decentralized in the medical community? Pediatr Emerg Care.
2014 Aug;30(8):521-4. PMID: 25062291.
This study was similar to the previous but focused on pediatric
emergency physicians. What happens if you take a fixed number of pediatric emergency physicians and distribute them
between two hospitals in the community or all the hospitals
in the community? While they might not practice in the community hospital, they could provide input in the care, ensure
the general emergency physicians were providing appropriate
care with appropriate equipment, and provide a resource for
difficult cases.
They found that distribution of pediatric emergency physicians
throughout the community had the greatest impact. With a restrictive EDAP model, the additions of 10 pediatric emergency
physicians to the community would impact only 27% of the
pediatric ED care in the community. A distributive model could
impact up to 69% of pediatric emergency care.
This has been done before. They wrote regulations that every
ED in the state had to meet the standards of an EDAP. They had
to have the appropriate equipment, training, and nurses/physicians who were champions of pediatric care. They found that
New Jersey performed better than states with EDAPs, in terms of
outcomes.
Sacchetti A, et al. Emergency medical services for children: the New Jersey model. Pediatr Emerg Care. 2012
Apr;28(4):310-2. PMID: 22453722.
It is not that hard to become an ED prepared to take care
of a child. Marianne Gausche-Hill and Steven Krug have published widely on recommendations on the care of children in the
ED, including what equipment is needed, what medications are
needed, and references for staff training. You need a commitment from the staff. You need legislators who are willing to evaluate this critically and realize that creating islands of expertise in
an access system is not the way to go.
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Mini Journal Club: Endovascular Clot Therapy
Stuart Swadron MD and David Newman MD
Highlights
Three major randomized controlled trials on endovascular therapies published in 2013 did not find benefit.
There are now three new randomized controlled trials
(MR CLEAN, ESCAPE, and EXTEND-IA) that show betterthan-expected benefit to endovascular therapy.
Two of the studies used imaging to identify patients with a
definite ischemic penumbra around a small infarcted core.
There was a significant benefit to the endovascular
therapies, but this will be relevant to a small number of
carefully selected patients.
There have been three major randomized controlled trials on
endovascular therapies published in 2013: MR RESCUE, IMS
3, and SYNTHESIS. These three trials did not find a benefit.
There are now three new randomized controlled trials: MR
CLEAN, ESCAPE, and EXTEND-IA.
There are some similarities between these trials.
The majority of the patients admitted to these trials had received tPA already. The studies ranged from 75-100% of subjects with tPA administration prior to endovascular therapy.
This is extremely important for selection.
The patients had large vessel occlusions: major MCA stroke,
internal carotid occlusion or anterior cerebral artery stroke.
Two of the trials used newer techniques to determine who had
ischemic penumbra and a small infarcted core.
The MR CLEAN trial
Berkhemer OA, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015 Jan
1;372(1):11-20. [Free open access article]
This was performed at 16 stroke centers in the Netherlands.
This was an industry-supported, non-blinded treatment trial
comparing usual care versus usual care with endovascular
therapy. Clinical strokes with a large, proximal occlusion proven on imaging were enrolled. Patients had to present within
the first zero to six hours. Primary outcome was neurologic
status at 90 days.
The average age of patients was in the mid to late 60s. NIH
stroke scale was on average 17. The average time from stroke
onset to groin puncture was 4 hours and 20 minutes. 500
patients were randomized.
Patients with a modified Rankin score of 0-2 (independent at
90 days) were 33% in the group that received endovascular
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therapy, compared to 19% in the usual care group. This is a
14% difference, with a number needed to treat of 7.
They placed a large emphasis on what had gone wrong in the
previous negative studies.
6% of patients had complications.
They had a median age of 70 years with an NIH stroke scale of
17. The time from symptom onset to puncture was about 4 hours.
They enrolled 315 patients and the trial was terminated early.
There were terrible outcomes in this study: 66% of patients
were dependent or dead at 90 days.
The EXTEND-IA trial
Campbell BC, et al. Endovascular therapy for ischemic stroke
with perfusion-imaging selection. N Engl J Med. 2015 Mar
12;372(11):1009-18. PMID: 25671797.
This trial involved 14 different centers in Australia and New
Zealand. Patients were enrolled over 24 months. This was
an industry-supported, non-blinded trial with treatment of
usual care versus usual care with endovascular therapy. They
included clinical strokes with a proximal occlusion. There were
only 70 patients enrolled and it was stopped early.
They performed CT perfusion scans to try to identify patients with a definite ischemic penumbra around a small
infarcted core. This was not used as inclusion criteria in the
MR CLEAN trial.
The median age was 69 years. The NIH stroke scale was 15.
Stroke to puncture time was about 3.5 hours (this was faster
than the MR CLEAN trial).
The percentage of patients with a modified Rankin Scale of
0-2 (i.e. independent at 90 days) was 72% versus 39%. This
is a 33% difference. This is very different from the MR CLEAN
trial; these patients had lower stroke scores, fewer internal
carotid artery occlusions and did better overall. This trial had
a number needed to treat of 3.
There were 6% complications similar to the MR CLEAN trial.
This was a small trial that was stopped early and was not
blinded, so there are variety of reasons that it may seem too
good to be true.
The ESCAPE trial
Goyal M, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015 Mar
12;372(11):1019-30. PMID: 25671798.
This was performed at 22 centers in Canada, the United
States, South Korea, Ireland, and the UK over 20 months. This
was also industry-funded and non-blinded, and it compared
usual care versus usual care with endovascular treatment.
Only about 75% received tPA prior to endovascular treatment.
They included clinical strokes with large, proximal occlusions.
These were proven by imaging; they only enrolled patients with
collateral flow to an ischemic penumbra with an infarcted
core with CT angiography. They included patients with symptoms onset within zero to twelve hours. The primary outcome
was neurologic status at 90 days.
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The percentage of patients with a modified Rankin Scale
of 0-2 was 53% versus 29%. This was a 24% difference with
a number needed to treat of 4 for good neurologic outcome.
Complications were 6%.
They reduced mortality from 13% to 6%. This is the first time
any randomized controlled trial has shown a mortality benefit
to reperfusion for ischemic stroke. This was a number needed
to treat of 15 to save a life.
All of the trials had a complication rate of 6%. There are patients that will be harmed by this therapy but the benefits appear
to outweigh the harm.
Three randomized control trials including 500, 70 and 315
patients showed a 14%, 33% and 24% absolute benefit. The
MR CLEAN had really bad outcomes but the ESCAPE trial had
29% and the EXTEND-IA control group had 39% that were independent at 90 days. MR CLEAN was the only study that did
not definitively prove an ischemic penumbra with small infarcted
core prior to enrollment.
These studies are promising.
These studies showed greater benefits than expected. These are
non-blinded trials and the effect may be exaggerated secondary to
this. Much of the data was reporting of recovery by the patient and
they were not blinded. Two of the trials were also stopped early.
We have been trying to identify the patients who will benefit from
reperfusion therapy and who will have harm. There is a strong suggestion that we may have identified patients who will benefit; those
with a large, at-risk penumbra and small infarcted core.
Selection is important. The MR CLEAN study was able to enroll
1.3 patients per center per month. The EXTEND-IA trial enrolled
0.2 patients per center per month. The ESCAPE trial enrolled 1.4
patients per center per month. This was about a maximum of one
patient per center per month.
There are probably very few patients who will benefit from
this therapy. These stroke centers likely saw many patients that
they passed up. Only one of the trials documented who was
excluded; the MR CLEAN and ESCAPE trials did not document
exclusions. The EXTEND-IA trial showed approximately 8,000 patients with ischemic strokes. Only 1,000 received tPA and only
70 were randomized to receive endovascular treatment.
There was a significant benefit to the endovascular therapies,
but it is clear that this will be relevant to few patients. There
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is a fear that they will start extending the indication to patients
who were not included in the original trial.
It would be nice to see a study using these selection criteria to determine who receives thrombolytics in general. This
might identify who benefits from thrombolytics. We have one
randomized study on thrombolytics that shows benefit that no
one has been able to replicate. Now we need to use imaging to
identify patients who might benefit. This will be a struggle.
There have been two additional studies published. These were
similar to the three previous studies and only included a select population of patients with proven large vessel stroke that were eligible
for tPA. They used specific imaging criteria that prove the amount
of infarction is minimal to the tissue at risk. Both were industrysponsored and non-blinded. Both studies had dramatic results.
The REVASCAT study
Jovin TG, et al. Thrombectomy within 8 Hours after Symptom Onset in Ischemic Stroke. N Engl J Med. 2015 Apr 17.
[Free open access article]
This study was performed in Spain and randomized 206 patients.
Saver JL, et al. Stent-Retriever Thrombectomy after intravenous t-PA vs. t-PA Alone in Stroke. N Engl J Med. 2015 Apr 17.
[Free open access article]
This study included 196 patients.
This treatment is very resource intensive.
Human Trafficking – Part 2
Paul Jhun MD, Mike Weinstock MD and Theresa Flores
Highlights
Human trafficking is not limited to foreign nationals
brought into the country but may affect victims of all
backgrounds.
The National Human Trafficking Hotline is 1-888-3737888 and is staffed 24 hours a day, 7 days a week, in
114 different languages.
Theresa Flores is a survivor of human trafficking from the
United States. She is not the classic victim of human trafficking.
She is from a white, Irish Catholic and upper middle class background. She was the oldest child of four children and her father
was an executive for General Electric. She moved to new towns
frequently as a child. She went to a new school as a sophomore
in high school and developed a crush on a boy. She was not allowed to date by her parents. One day, the boy asked her if she
wanted a ride home from school. Instead of taking her home,
he went in a different direction. She went to his house and he
convinced her to come inside. After giving her a tour of the home,
he drugged and raped her.
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She did not tell her family because she was afraid she would
get in trouble. Several days later, he showed her pictures and
told her that she had to earn them back or else he would kill her
family. For two years, he would take her from her home at night.
She was taken to upscale homes in Detroit and forced to have
sex with multiple men. She would return home around 3 am. No
one had any idea that this was occurring. Her grades dropped.
She was exhausted. She didn’t know how to get out. She was
abused and physically restrained.
Flores now operates an organization called SOAP (Save Our
Adolescents from Prostitution). They do outreach with volunteers. They label bars of soap with a hotline number and hand
them out for free to hotels. Flores developed this strategy as a
response to one of her worst experiences. After she was taken
to a motel and abused by multiple men, she was helped by a
hotel waitress who called the police. She was returned to her
family but did not tell them about the abuse. Frequently, trafficking victims are supervised but often will be able to use the
bathroom in motel independently; the bars of soap are a way to
communicate.
The bars of soap have questions on them. Are you being threatened to do something that you do not want to do? Are you able
to leave? Are you witnessing the prostitution of young girls?
People started calling the hotline and they have been able to
rescue young girls.
The National Human Trafficking Hotline is 1-888-373-7888.
This goes to an organization called the Polaris Project in Washington DC and is staffed 24 hours a day, 7 days a week, in 114 different languages. When they are contacted by a victim, they determine if she wants to get out immediately or just needs resources.
What steps can medical providers take to identify potential
trafficking victims?
Have the family members or companions step out.
What questions should you ask? Age. Ask in different ways.
In what year were you born? What year did you graduate from
high school?
Who are you here with? Do you want to be with them?
Try to establish trust. Treat the patient as a person first. Believe them.
These are difficult patients. Often they aren’t cooperative and
they are time-consuming.
To learn more, go to www.traffickfree.com. Her TED talk may be
viewed at https://www.youtube.com/watch?v=5QW_nsAjweE.
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Human Trafficking – Part 1
Stuart Swadron MD, Mike Weinstock MD, Ruth Downing
CNP and Laura Kaiser RN
Highlights
There are two places in the community able to identify
trafficking victims while they are being trafficked: law
enforcement and health care.
If you don’t include human trafficking in your differential, you won’t spot it.
Let the patient know that you are there to help them and
not judge them.
There are approximately 17,000 people who are brought into
the United States every year and sold into slavery. There are
victims of human trafficking in every state and it is a worldwide
problem. How many times have we missed this?
Patel RB, et al. Human trafficking in the emergency department. West
J Emerg Med. 2010 Dec;11(5):402-4. [Free open access article]
A 36-year-old Spanish-speaking female was transported
by the police to the Emergency Department for “intimate
partner violence.” The initial history was vague on details.
She reported that she had been living with her boyfriend for
the previous two months. Recently she was told that she “constantly made mistakes” and was punished for them. Her vital
signs were normal. Examination revealed multiple ecchymosis
in various stages of healing about her eyes and ears, her left
shoulder, and her upper left thigh. No evidence of fractures.
An interpreter provided a more detailed history. She had
been living in Colombia until several months previously and
had been befriended by a woman, who claimed she was visiting the country temporarily. She was put in contact with a
man in Massachusetts. The patient traveled to Massachusetts
to meet the man and initially was swept off her feet. The romance was quickly replaced by endless work and physical
and sexual abuse. On the day the patient presented to the
Emergency Department, she escaped from the home and ran
to a neighbor for help.
Ruth Downing is a nurse practitioner and Laura Kaiser is a
nurse and runs the forensic nurse program at the Mount Carmel Health Systems.
29% of emergency providers felt human trafficking could be a
problem in the Emergency Department but only 13% felt confident that they could identify a victim.
There are two places in the community able to identify trafficking victims while they are being trafficked: law enforcement and health care. Awareness had led to the identification
of more victims.
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Human trafficking does not affect just foreign nationals
brought into the United States; there is a larger problem
with domestic sex and labor trafficking within the US. Young
women between the ages of 12-14 years are at risk. Children
who have experienced childhood abuse are at increased risk.
Some of the women rescued have been victims for ten or more
years, and many first experienced trafficking as adolescents.
At least 27 million people worldwide are estimated to be involved in human trafficking, with annual revenues of almost
$10 billion.
The United Nations defines trafficking as: “The recruitment,
transportation, transfer, harboring and receipt of persons, by
means of threat or use of force or other forms of coercion.” Exploitation may involve prostitution or other forced labor, including
removal of organs. It is thought that 20% of kidney transplants
come from the black market.
They have been identifying close to 5 victims of human trafficking per month in central Ohio. Patients may appear disheveled and malnourished. The use of drugs such as heroin is very
common in central Ohio and may be used to lure girls into trafficking. Victims may have been sexually assaulted by their traffickers. Patients may have drug dependency and be pregnant. If
you don’t include it in your differential, you won’t spot it.
Patients may have defense mechanisms and be argumentative and defensive.
What questions can we ask?
Where do you sleep? What type of environment are you
living in? Typically, these women are in an environment with
more than 10 people living in a small space.
What type food have you eaten? They may appear malnourished. Traffickers may provide a large pizza for multiple women
to last several days. They may ask for multiple trays of food.
Let the patient know that you are there to help them and
not judge them. “Is it possible that you are being forced to do
things against your will to receive drugs?”
It may be helpful to involve a forensic nurse or SANE nurse
(Sexual Assault Nurse Examiner). Forensic nurses tend to have
specialized training in caring for this population of caring, but
SANE nurses may also have this education.
The majority of women on the streets are victims of human
trafficking and it is rare that they are doing this without exploitation. It is important to be able to identify red flags in the
emergency room. Traffickers do not give up victims easily. One
woman can generate $100,000-$200,000 per year for their
trafficker. Victims may provide canned answers.
Isolate the patient from her companions. That may involve security personnel. Opportunities to question the patient may arise
when they provide urine samples or receive x-ray imaging.
EM:RAP Written Summary | www.emrap.org
The Written Summary of the
If you do not have local resources, you may contact the national hotline. If it is urgent, you can call 911. More law enforcement personnel are familiar with human trafficking and can
respond appropriately.
Case
A young woman presented for a sexual assault exam.
She exhibited red flags for trafficking. After Kaiser expressed
concern that she was in an unsafe environment, she became very serious and asked, “Can you help me? Can you
protect me?” The patient said she was too scared at the
time and was provided with resources.
These victims may be marginalized. They may have Stockholm
syndrome, as the perpetrator is providing them with food and
shelter. It may take weeks for a victim to realize that she has
been abused by a trafficker.
Are we able to keep these patients against their will if we feel
they are in danger? You need to follow your state requirements
for mandated reporting. If they are under the age of 18 years,
then yes. Over the age of 18 years, it depends on your state requirements. It is important to provide resources. Give the hotline
number on a card she can put in her shoe to use when she is
ready. It may not be safe for her to disclose at that time.
Let her know that the Emergency Department is a safe place.
STD clinics and Emergency Departments are common sites of
access. 88% of survivors have had contact with healthcare
and this is a great opportunity for us to intervene.
Case
A young patient with multiple psychological issues presented to the Emergency Department. She was a runaway
and had been involved in trafficking since a young age. She
had a large family that was unable to provide a stable environment for her. Her parents were drug users. She had
no support system and ended up on the streets. She had
frequent presentations for sexual assault and suicidal ideation. Kaiser sat down with her and the patient said, “So
what are you going to do?” The patient was provided with
resources but was unwilling to receive help at that time.
Human trafficking victims have rates of post-traumatic stress
disorder equivalent to combat veterans.
How do you know the patient’s companions are who they say
they are? Traffickers may bring children and women into the
Emergency Department and we have no idea.
18 women were recently rescued from a massage parlor in Ohio
and are now beginning their recovery.
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The LIN Sessions:
Finance
Michelle Lin MD and Sam Shen MD
Highlights
Invest with a long timeframe.
Start early and use the power of compounding to your
advantage. Every little bit helps.
Expect market corrections.
Finance is an important topic and we do not have much exposure to it during medical school and residency. A 2014 American Medical Association survey examining physician work-life
balance identified concerns with retirement planning and saving
for children’s college.
In 2015, we are in a historic bull market that has lasted
nearly 7 years. Many remember the crashes of 2008 and 2001.
These volatile events can lead to fear and anxiety about investing, so it is important to have a disciplined approach to guide
your strategy. There are different types of investment.
Principle #1. “If it sounds too good to be true…” The idea of
risk versus reward. The more risk you take, the higher the rewards.
Imagine a spectrum with cash under your mattress (minimal risk
and minimal rewards) to CDs (Certificate of Deposit), options,
bonds, mutual funds, stocks (greater returns). In the stock market, you can expect returns of about 8-9% per year historically.
If someone is offering high return with little risk, this violates the
principle and is likely too good to be true.
Principle #2. You can’t handle the truth. This is the idea that
you can’t beat the stock market. Not everybody can be Warren
Buffett. A study compared twenty years of returns for the average
investor to international funds, the S&P 500, and different industries, versus doing nothing and investing money in the generic
stock market. By doing nothing, there was a much higher return
of about 9%. The average active investor only generated a 2.5%
return. It is tempting to pick your stocks but doing more doesn’t
necessarily generate results.
Principle #3. The sprint versus the marathon. Invest with a long
timeframe. You should invest and not trade. Trading is a short
term mindset: you take on higher risk, you assume that you can
time the market, and it requires a lot more energy. Investing has
a longer timeframe: you take on less risk, reduce the chance
variable in timing the market, and it requires less energy. A study
looking at the returns of a $10,000 investment over a twenty
year period found returns of 9.2% for people who kept their
money invested. If you missed the 10 best days of the market,
the return was only 5.5%. If you missed the twenty best days, the
return was only 3%.
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Principle #4. Diversification and asset allocation. This is the
principle of not putting all your eggs in one basket. Different asset classes include stocks (such as international stocks, health
care sectors, etc.), bonds and cash. You don’t want to put all your
money in one particular sector or class. One sector may increase
while another decreases; over time, you can benefit from that
rise without unnecessarily exposing yourself to the volatility of
any one particular class.
There are different asset allocation models to assist you.
Depending on your goals, time frame and age, you want to pick
an allocation that fits your needs. If you are young and just
coming out of residency, it is okay to have a higher percentage
of your investment in stocks (such as 60% in stocks and 40%
in non-stocks). Closer to retirement, you want less in stocks and
more in safer, less volatile instruments such as bonds or cash.
In one model over a thirty-year period, if you have 60% of your
money in stocks and 40% in fixed income and cash, there
was a 9.6% average return. If you had 20% in stocks and 80%
in non-stocks, the return was around 8% but there was much
less volatility.
You can research allocation models online or talk to your
financial advisor to fit your needs.
A mutual fund is just a collection basket of stocks. The S&P
500 is an index representing 500 companies of the stock market. You can invest in an individual stock or a collection of companies bundled together into a mutual fund. The S&P 500 index
happens to be one type of mutual fund. Managers may create
mutual funds with a variety of companies, such as healthcare
stocks, internet stocks, etc. If you have a particular interest and
believe that collection of stocks will do well, you can invest in it.
Stocks have a similar risk profile to mutual funds.
Principle #5. There is no crying in investing. Remove emotions
from investing and understand some of the behavioral biases.
In 2008, when the stock market crashed, there was panic. It is
important to have a disciplined approach and stick to the principles. It is nerve-wracking to take a loss but the market has more
than recovered since the crash in 2008. An article by Fidelity
reported investors who had forgotten they had active accounts
for twenty years and found that they had good returns.
Principle #6. The marshmallow test. This is based on the experiments performed at Stanford University where children were
given a choice of a marshmallow now or two marshmallows later
to evaluate delayed gratification. Would you rather receive your
tax refund or pay your balance on April 15? It is better to pay a
tax balance on April 15 because it was money that was yours
until you pay the balance. If you receive a thousand dollars back
as a tax refund, it represents money that you could have invested
and received a return. There is a time value of money due to
inflation and potential returns.
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Principle #7. Time is on your side. Start early and use the power
of compounding to your advantage. If you are a recent graduate
from residency, you may not feel you have much to contribute
right away but every little bit helps. If you start investing at age 25
and invest $200 every month into a tax deferred account earning 9% compared to a 45-year-old investing $400 into the same
account, by age 65, both of you have put in $96,000. However,
the first individual has accumulated $884,000 and the second
has accumulated only $268,000. This is almost three times difference for contributing the same principle.
Principle #8. Avoid unnecessary fees. Trades through a brokerage might charge $8 a trade and mutual funds may charge
1-2% of your investment. Exchange trader funds are mutual
funds that have lesser fees, often less than 1%. Hedge funds
will often charge 20% of the profit on top of 1-2% of the investment. Financial advisers may charge up to 1% of the assets to
manage. These add up over the course of your investment. It is
important to understand your investment and associated fees. In
general, most mutual funds and exchange trader funds should
not require much more than 1%.
Principle #9. Expect market corrections. Every 1-2 years, the
market will drop 10 percent or more. It may drop 20% and 30%
or more in a decade and 50% over your lifetime. This allows you
to prepare your asset allocation strategy to account for this. These
are small blips in the big scheme of things but they can be very
anxiety-provoking. Knowing this can allow you to maintain a disciplined approach. There was a study that looked at the predictions
of market leaders and investing managers and correlated that with
what the market actually did: it was an inverse relationship. When
the crash index went up, the returns went up. It is very difficult to
predict the market, even for the people who do it every day.
Principle #10. Pay attention to the tax impact. You have the
ability to invest through your tax-deferred account, like a 401K
account, similar to how you invest in your brokerage account.
If you are trading a lot, there are capital gains tax that may be
short-term or long-term and taxes on dividends. If you are expecting a lot of taxes, it may be better to invest through a tax-deferred account. Your income tax bracket will also help determine
how you invest and manage your tax strategy.
Is it worth it to pay for professional advice? In the late 1990s,
the Wall Street Journal had a dartboard contest where they had
professionals manage a portfolio compared to stocks selected
by throwing darts. 40% of the time, the pros lost to the darts.
When it comes to investing, it is difficult to beat the market and
it is a very small segment of the population able to do so. For
the vast majority of investors, it is better to just stay in the market
and invest in index funds. There is nothing wrong with paying the
1% for professional advice, as long as you know what you are
paying for (e.g. if you want an objective opinion; however, don’t
pay someone because you think they will beat the market.)
EM:RAP Written Summary | www.emrap.org
The Written Summary of the
Dollar cost averaging is an investing strategy. If you were to
invest in the same stock and mutual fund and put in the same
dollar amount every month, the fund will fluctuate; but, over time
the fluctuation will go up. You may miss the high point and midpoint, but it will average out to result in a good return.
Paper Chase 1:
Corticosteroids for Severe CAP?
Sanjay Arora MD and Michael Menchine MD
Highlights
A study evaluating the use of corticosteroids for patients
with severe community acquired pneumonia found benefit, but this was mostly due to the finding of reduced
progression of disease on chest x-ray.
Patients were randomized to receive placebo vs 0.5mg/
kg bolus of methylprednisolone every 12 hours for 5 days.
There was no difference in mortality with the use of corticosteroids.
Torres A, et al. Effect of corticosteroids on treatment failure
among hospitalized patients with severe community-acquired
pneumonia and high inflammatory response: a randomized clinical trial. JAMA. 2015 Feb 17;313(7):677-86. PMID: 25688779.
This was a multicenter, randomized, double-blind, placebocontrolled trial evaluating the use of corticosteroids for patients with severe community acquired pneumonia. The authors found a strong benefit, but this was largely driven by a late
finding of reduced progression of disease on chest radiography.
Community acquired pneumonia is the leading infectious
cause of death in developed countries. Mortality can be up
to 10-20% in cases that are severe and in the ICU. Some data
suggests that patients with evidence of higher inflammatory response are at greater risk of treatment failure.
Results of trials looking at corticosteroid replacement therapy in pneumonia to inhibit cytokine inflammatory response
are mixed. These authors suggest that these prior trials are too
small and did not include the appropriate patients: the sickest
patients with a high inflammatory response.
This trial was a multicenter, randomized, double-blind, placebo-controlled trial in patients with severe community pneumonia and a high inflammatory response. This was performed
at 3 Spanish teaching hospitals.
Patients were eligible if they were age greater than 18 years, had
symptoms of pneumonia and an infiltrate on chest x-ray, were
severe as defined by criteria from the American Thoracic Society (such as high respiratory rate), and had a CRP greater than
150mg/L (this was a marker for a high inflammatory response).
They were excluded if they were already on steroids, had hospital
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acquired pneumonia, HIV, history of diabetes, or history of GI bleed.
Patients were randomized to receive placebo vs 0.5mg/kg
bolus of methylprednisolone every 12 hours for 5 days. Their
primary efficacy outcome was rate of early and late treatment
failure. Early treatment failure was defined as a composite endpoint of shock, need for ventilation, and death within 72 hours.
Late treatment failure was defined as an increase in the size of
the infiltrate by 50%, persistence of severe respiratory failure or
distress as measured by PaO2 and respiratory rate, development
of shock, the need for ventilation, or death between 72 hours
and 120 hours after treatment initiation. They assumed a treatment failure rate of 35% and determined 60 patients in each
arm via power calculation.
120 patients were randomized and 93% completed the study.
The baseline characteristics (age, comorbid conditions, lab values, time to antibiotics, etc.) were generally the same, except
that the patients in the placebo group were much sicker to start
with. 17% of these patients were on ventilators versus 8%, and
31% were in shock compared to 17% in the intervention group.
What did they find? They presented both the intent-to-treat
group (some patients didn’t receive steroids or stopped them)
and the per-protocol analysis (patients were put in the groups
according to what they received as opposed to what they were
randomized to receive). For the primary outcome of overall treatment failure, the intent-to-treat group had 31% in the placebo
group versus 13% in the steroid group, and the per-protocol
group had 28% versus 9%. There was clearly a big difference.
There was no difference in the early treatment failure group.
There was a big difference in the late treatment failure group,
but only in terms of radiographic progression.
The authors provided references indicating that this finding
is associated with a higher mortality rate, but this finding was
not observed in their own data.
They did some regression models controlling for illness severity,
among other factors, and stated that the difference in late progression persists, but this was a fairly small sample size to do this.
This study took place over 8 years and a lot has changed in
the general management of septic shock patients from 2004
to 2012.
The authors should be applauded for conducting a highly ambitious trial for a group of very sick patients with pneumonia (even
intubated patients), but we need to be careful of the interpretation of these results and not let this creep into treatment of nonsevere pneumonia patients. The only real impact was on late
progression as seen on radiograph; there were no lives saved.
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Paper Chase 2:
Negative CT C-spine in Obtunded Patients
Sanjay Arora MD and Michael Menchine MD
Highlights
A systematic review with approximately 1,800 blunt trauma patients with obtundation and negative CT C-spine
imaging found no unstable cervical spinal injuries.
MRI is very sensitive for unstable cervical spinal injuries
but it is not very specific. It identifies ligamentous injuries of unclear clinical significance.
The authors concluded that the negative predictive value of a CT cervical spine, if done with axial images less
than 3mm, is 100%.
Whether or not to obtain MRI in these patients may be
influenced by your institutional practices.
Patel MB, et al. Cervical spine collar clearance in the obtunded
adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery
of Trauma. J Trauma Acute Care Surg. 2015 Feb;78(2):430-41.
[Free open access article]
This is a systematic review of the literature on how you can
clear the C-spine in the comatose blunt trauma patient. They
conclude that the way to clear them is to get a good CT and take
the collar off.
Procedures to clear the cervical spinal precautions are pretty
well-established for the alert patient. There is still some debate as to whether the Canadian C-spine rule or the NEXUS Cspine rule is better. Most agree that CT C-spine imaging is the
modality of choice if you fail one of the rules.
What do you do with someone who fails the rule due to obtundation but has a normal CT C-spine? Traditional teaching has
been to leave the patient in the collar until they wake up.
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cautions for an unspecified amount of time, or the occasional
neck operation. The optimal strategy is unclear.
Prolonged neck immobility is bad for the multiply-injured
trauma patient. They have increased risk of pressure sores, decreased venous return, elevated intracranial pressure, problems
with intubation and central lines, and aspiration.
In this systematic review, they asked the question, “What
happens with a negative modern CT C-spine. Are these patients at risk for significant injury?” A good modern CT C-spine
was defined as less than 3mm axial cuts.
This paper utilized good methods. They found 52 relevant articles, of which 40 were excluded, leaving 12 articles. There were
no randomized controlled trials and most were retrospective.
Overall this leads to a low grade for the quality of evidence. The
studies utilized very heterogeneous definitions of obtundation.
For the most part, obtundation was a GCS less than 13, but they
had different criteria for inclusion and the presence or absence
of alcohol was not addressed.
They identified approximately 1,800 patients in these 12 studies. All of these patients had a high grade CT of the cervical
spine, which was negative and all were obtunded. All of these patients had mobility of all four extremities. 176 of these patients
had a positive MRI. 3 of the patients who had a positive neck
MRI received surgery but the indications were not described.
What did they find with MRIs? Ligamentous and muscular injuries, but there were no cases of unstable cervical spine injury.
The authors concluded that the negative predictive value
of a CT cervical spine, if done with axial images less than
3mm, is 100%. They offered a conditional recommendation
to just clear the C-spine with negative high-grade imaging.
They identified the high cost, difficulties with transport, and low
yield as reasons to not obtain a MRI. More research needs to be
performed. Whether or not to obtain an MRI in these patients
may be influenced by the culture at your institution.
The Eastern Association for the Surgery of Trauma group offers the following guideline, which is not very helpful:
Flexion/extension radiography should not be performed. Only
4% of these films are adequate.
The risk/benefit ratio of MRI in addition to CT is not clear.
Options include continuation of cervical collar immobilization,
removal of the C-collar on the basis of the CT alone, or obtain
an MRI and remove the collar if the MRI has no abnormalities.
MRI is very sensitive for unstable cervical spinal injuries but
it is not very specific. They find a lot of ligamentous injuries
of unclear clinical significance. These injuries lead to all sorts
of treatments including C-collar removal, continued c-collar pre-
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The Written Summary of the
Paper Chase 3:
The LOOP Technique
Sanjay Arora MD and Michael Menchine MD
Highlights
A retrospective study in pediatric patients with skin abscesses comparing LOOP incision and drainage versus
standard technique found a failure rate of 16.5% in the
standard incision and drainage group compared to 3.9%
in the LOOP group.
The study was not randomized and limited by a follow-up
rate of only 60%.
The effect on pain, satisfaction of physicians and patients, and procedure length is unclear but there is sufficient literature to vouch for its utility and safety.
Ladde JG, et al. The LOOP technique: a novel incision and drainage technique in the treatment of skin abscesses in a pediatric
ED. Am J Emerg Med. 2015 Feb;33(2):271-6. PMID: 25435407.
This was a retrospective study looking at the use of a LOOP drainage technique for the drainage of abscesses in pediatric patients.
The study has some significant limitations but reports improved
success rates compared with standard incision and drainage.
Abscesses are a common presenting complaint. They are
painful despite anesthesia. Some providers pack the abscess,
which is even more painful. There has been a lot of previous
discussion about the lack of utility in packing. There has also
been some recent literature that suggests that we can just close
it after drainage. However, this is from the surgery literature and
most don’t feel comfortable closing the abscess in the Emergency Department.
The LOOP incision and drainage. The first step is to numb the
area as best you can. Make a small incision at the juiciest part.
Make a second small incision no more than 4cm away from the
first incision. Break up the loculations. All of the studies recommend irrigation at this time. Take a hemostat and put it through
both holes, take a Penrose drain and pull it back through both
holes. Use a 30 cc syringe laid flat just over the skin between
the holes to give yourself some distance when tying 5 or 6 knots.
This is supposed to be loose, in order to minimize irritation and
necrosis. Trim the ends. Send the patient home and they can cut
it off themselves in 5-7 days.
This was a retrospective study. Cases were identified by using
ICD-9 codes. This was not a randomized controlled trial. 79 patients received the LOOP technique and 154 received standard
incision and drainage during the 12-month study period.
The primary outcome was treatment failure, defined as need
for: repeat incision, IV antibiotics, admission, or other surgi-
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cal intervention in 10 days. They did their best to follow-up but
they were only able to obtain follow-up information for 60% of
their cohort, which is a big limitation.
What did they find?
Patients in the LOOP group were about twice as likely to get sedation for an unknown reason. There is some selection bias here.
Most of the LOOP patients had buttock abscesses, while most
of the standard incision and drainage patients had extremity
abscesses. This is not too surprising, as most of the literature
on primary closure is in buttock abscesses.
They report a failure rate of 16.5% in the standard incision
and drainage group compared to 3.9% in the LOOP group.
Is this too good to be true? Yes. The authors stated that the
retrospective design introduces so many confounders, such
as sedation and biases (for example, physicians might have
just chosen the LOOP for small abscesses to become familiar
with the technique).
It would be nice to see data on pain, satisfaction of physicians and patients, length of procedure, etc. However, there
is sufficient literature to vouch for its utility and safety, and it
may be worth trying out.
Paper Chase 4:
Ketamine the Analgesic
Sanjay Arora MD and Michael Menchine MD
Highlights
Low-dose ketamine appears to be safe in the management of a variety of painful conditions in the Emergency
Department (ED).
The suggested dose is 0.1-0.3 mg/kg of ketamine IV or
about ¼ to ½ of the dissociative dose.
Documented adverse events were rare, occurring in 6%,
and none changed disposition or caused permanent harm.
Ahern TL, et al. The first 500: initial experience with widespread
use of low-dose ketamine for acute pain management in the ED.
Am J Emerg Med. 2015 Feb;33(2):197-201. PMID: 25488336.
Low-dose ketamine appears to be safe in the management of
a variety of painful conditions in the ED.
Ketamine is amazing. An Institute of Medicine report in 2011
noted that poor management of pain in the ED is a major public
health concern. Typically, we rely on NSAIDs or opioids for pain
management. These can lead to complications such as respiratory depression, hypotension, altered mental status, tolerance,
etc. There is also increased concern about prescription drug
abuse and there has been a movement to reduce use.
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Ketamine, which is used frequently for procedural sedation,
has much lower risks of bradypnea or hypoxemia, with less
concern for tolerance or abuse. Low-dose ketamine (LDK) has
been adopted by anesthesia, surgery, and palliative care for the
treatment of pain cases that are difficult to manage.
More recently, a few small ED and pre-hospital studies have
looked at LDK use (with a dose of 0.1-0.3 mg/kg of ketamine
IV or about 1/4 to 1/2 of the dissociative dose). In general,
these studies have been favorable.
Highland Hospital developed a LDK protocol for use in the
ED and report on their 2-year experience with the drug. This
was a retrospective review of all patients given ketamine for analgesia rather than procedural sedation. The authors performed
fairly good chart abstraction of 530 consecutive cases looking
for safety endpoints of cardiac arrest, apnea, hypoxemia, laryngospasm, emesis, psychomotor agitation, or frank psychosis.
They also looked at patients and conditions given ketamine.
530 cases were reviewed. Ketamine was given for a broad range
of complaints: about 33% received it for abdominal pain, 12% for
back pain, and 5% for chest pain. The patients were diverse with
comorbidities, such as COPD and schizophrenia (about 12%).
Ketamine was given intravenously 93% of the time.
Documented adverse events were rare and only occurred in
30 patients, or about 6%. 7 patients had transient hypoxemia
and all but one patient responded to nasal cannula. The patient
that required more aggressive respiratory support for hypoxemia
had been hypoxic at triage, was on a non-rebreather prior to LDK,
and was experiencing a COPD exacerbation.
About 3.5% of patients had a bad trip. These were mostly
mild: “I feel like a zombie,” or “You all look like aliens.” Only
one patient had a major freak-out; this was an elderly patient with metastatic cancer who needed lorazepam but then
calmed down.
About 1% of patients had emesis.
None of the adverse events changed disposition or caused
permanent harm.
The authors concluded that this was the largest reported
series of patients getting LDK in the ED. There are some limitations with a retrospective chart review. For example, it is possible that there were some adverse events that were simply not
recorded or there may have been some over-reporting, as this
was a new protocol. However, the method is sufficient to confirm
that nothing terrible happened to any patients.
They did not address efficacy in pain relief. Other studies have
claimed good results but this was not addressed in this study.
This study was done in conjunction with pharmacy, nursing,
and emergency physicians to generate a LDK protocol. The
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use of ketamine at your facility may be synonymous with procedural sedation, so you could get into trouble for using it off-label
for pain relief. If you want to try it for a trauma patient who can’t
tolerate hypotension or a respiratory patient who can’t tolerate
hypoventilation, be sure to document why you are choosing this
agent for pain. Consider starting a discussion at your faculty or
staff meeting before going rogue.
Paper Chase 5:
What Just Happened to Me?
Sanjay Arora MD and Michael Menchine MD
Highlights
Communicating with patients is a critical part of what
we do.
A study using physician observers during real patient
interactions showed that patients’ general understanding of their encounters was good, but 30% did not understand their diagnosis.
Musso MW, et al. Patient’s comprehension of their emergency
department encounter: a pilot study using physician observers.
Ann Emerg Med. 2015 Feb;65(2):151-5. PMID: 25233813.
This pilot study, using physician observers during real patient
interactions, showed that the patient’s general understanding
of his/her encounter was good, but 30% did not understand
his/her diagnosis. Lab results and medication instructions were
other areas that we need to focus on before discharge.
Communicating with patients is a critical part of what we do,
from building rapport to getting an accurate history and explaining follow-up and return precautions. This is not easy due
to rushed conditions, loud noises, overwhelming information for
patients, and language and cultural barriers. Some physicians
may have their own personal barriers. Satisfaction and understanding go down with major discordance.
Several small studies have reported that patients often don’t
know the actual processes of care that occurred during their
stay, but these studies utilized charts to see what happened.
This study used physician observation throughout the whole encounter and then asked the patients about what happened to
them immediately afterwards.
They included a convenience sample of low acuity adult patients who were discharged from the Emergency Department
(ED). The physician observers were residents who explained to
the patient that they were just observers and would ask questions after the encounter. The observers recorded whether or not
the physician introduced themselves, asked about the chief complaint, examined the area of the chief complaint, and obtained
tests or medications. They then recorded verbatim what the doc-
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tor said regarding test results, diagnosis, treatment, and plans for
follow-up. The observers rated their impression of the patient’s
comprehension on a 5-point Likert scale. They interviewed the patient using a standard form. A panel with three physicians looked
at the patient responses and physician’s verbatim statements
and rated the patient’s understanding as poor, fair, or good.
They observed a total of 89 encounters. The population was primarily African American (over 70%) and 33% had less than a high
school education. The results were presented in large table, with
the percentage of time the observer recorded the physician doing
a specific action, the percentage of time the patient felt the physician did a specific action, and the agreement between the two.
What did they find? The observer and patient reported that the
physician introduced themselves, asked about the chief complaint, and examined the patient nearly 100% of the time. The
diagnosis was provided only about 75% of the time, per the
observers and patient. Patients were informed about abnormal
blood tests only about 50% of the time.
Agreement about specific actions was worst regarding
whether or not the physician talked to the patient prior to
discharge, whether or not patients were informed about
blood tests in the ED, and the indication for medications
given. The disagreement stemmed from the observer recording the action but the patient not reporting it.
When the physician panel reviewed the forms, they felt that
patients generally had a good understanding, but almost 70%
of patients did not have good understanding in at least one
pre-defined domain, such as medication instructions, test results, discharge plan, and diagnosis.
These findings did not vary based on gender, race, or age, but
they did not look at language.
This is a good reminder to tell patients what is happening to
them, what are their test results, what we are putting in their
IVs, and what is their diagnosis. Generally, we do well in our
patient interactions, but we don’t relay specific information such
as tests, medications, and diagnosis as well as we should. Even
if we do relay the information, the patients still might not get it.
Although not studied, this is likely worse in patients who have a
language barrier or are very ill.
Monthly Audio Program
Mysteries of the Tetanus Shot
Sean Nordt MD, PharmD, Stuart Swadron MD, Rob Orman MD
and Ran Ran MD
Highlights
In a review of all tetanus cases in the United States,
70% of wounds were considered prone to tetanus, such
as contaminated or puncture wounds, and 30% were
clean wounds.
Increased age leads to decreased immunity, and the elderly are at increased risk of clinical tetanus.
A study measuring antibody titers at day 0 and day 4
after tetanus vaccination found no statistically or clinically significant change in titer levels.
Patients who have not received the complete primary
series of vaccinations and have a wound that is not
clean should receive the tetanus immunoglobulin.
Tetanus is seen infrequently in the western world but it still
accounts for much morbidity and mortality, including in neonates, in the developing world.
Tetanus is caused by Clostridium tetani. Tetanus inhibits the
release of glycine and GABA. These are inhibitory neurotransmitters. This causes the classic opisthotonus and leads to respiratory arrest. Another Clostridium bacterium, botulism, inhibits the
release of acetylcholine.
Opisthotonus is severe arching of the back. This occurs because the extensor muscles of the back are much stronger than
the flexor muscles in the front. All of these muscles are firing and
the back wins. This is not subtle. If you see this, also consider
strychnine poisoning. Strychnine poisoning inhibits the binding
of glycine in the spinal cord and presents similarly.
Do tetanus vaccinations work? Yes. The vaccination was first
introduced during World War I. Prior to its introduction, about 1
out of every 300 soldiers contracted tetanus. There was a thirtyfold decrease in the incidence of tetanus in the subsequent two
months. In the 1940s, it was introduced as a routine vaccination
in children. Since then, the rate of tetanus has dropped thirtyfold in the civilian population.
The primary series of three vaccines during childhood educates your immune system to recognize the pathogen, and
this is followed by a booster shot every 10 years for the rest
of your life. Although this has not been well studied, the Centers
for Disease Control (CDC) found that 100% who adhere to this
regimen will have antibodies at a protective level.
Can people who have had the vaccine still get tetanus? Yes.
Titer level is only one component: the pathogen burden and immune system function also contribute.
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In a review of all tetanus cases between 2001-2008 released
by the CDC, 70% of wounds were considered prone to tetanus, such as contaminated wounds or puncture wounds. 30%
were clean wounds and there have been case reports of surgical
wounds, using autoclaved instruments, resulting in tetanus.
CDC. Tetanus surveillance – United States. 2001-2008.
MMWR 2011,60(No. 12) [Free open access article]
When does immunity start to wane? Increased age leads to
decreased immunity. In the United States, there have not been
any neonatal cases of tetanus and only 1-2 cases in patients
under 20 years old. The booster is very important in older individuals. Tetanus is a unique pathogen, and recovering from clinical tetanus doesn’t convey immunity. The tetanus toxoid is one of
the most potent toxins known to man. The lethal dose is 2.5 ng/
kg. It is important to keep a supratherapeutic level of antibody
titers, as it is important for protection. Diabetes, HIV, and prednisone can also weaken the immune response.
Case
You are working at your Emergency Department on Saturday
night. A 30-year-old male stepped on a rusty nail. He had
all of his immunizations and boosters for college. Does he
need to get a tetanus shot immediately or can he wait until
Monday?
Irrigation and debridement of necrotic tissue are the most important intervention. Tetanus vaccine is terrific as primary prevention before an exposure, but it doesn’t do much as secondary prevention.
Porter JD, et al. Lack of early antitoxin response to tetanus
booster. Vaccine. 1992;10(5):334-6. PMID: 1574917.
31 adults had antibody titers measured at day 0 and day 4
after tetanus vaccination. There was no statistically or clinically significant change in titer levels. Clinical tetanus can develop within 3 days but it may take longer to develop.
Should the person get a dose of tetanus immunoglobulin? In the United States, there are two indications for tetanus immunoglobulin. Immunoglobulin should be given if: 1)
the wound is anything other than clean and simple; and 2)
the patient must have an incomplete primary series with less
than 3 doses of tetanus vaccine. In the rest of the world, for
example in the United Kingdom, they try to estimate the risk
of tetanus based on the wound characteristics such as puncture wounds, foreign bodies, significant devitalized tissue,
heavy contamination, burns, or sepsis.
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What if the patient has never received tetanus vaccination
or does not remember? About half of patients do not remember when their last tetanus booster was received. About 25%
of patients who think they are up-to-date are not. If tetanus
booster is provided based on patient recall, treatment will
be incorrect about 40% of the time. Given that the tetanus
booster is of questionable utility for secondary prevention, a
better question is whether the patient has received their primary series. Were you born in North America? Did you receive
vaccinations as a child? You can look to see if tetanus is included in the childhood vaccinations in his/her home country.
If the patient has never received the primary tetanus series, they need tetanus immunoglobulin. They also need the
tetanus vaccination series. The tetanus immunoglobulin is
given in one arm and the vaccination is given in the other arm.
The tetanus booster is available as Tdap (tetanus diphtheria
and pertussis) and Td (tetanus diphtheria). The CDC recommends that everyone receive a tetanus booster every ten years,
and one of those doses should be Tdap after the age of 18 years.
Pregnant women should receive Tdap with every pregnancy. Giving elderly patients Tdap is not cost effective but would reduce
the likelihood of the patient developing pertussis by 25%. Tdap
is twice as expensive as Td ($50 versus $25).
Who is likely to develop tetanus despite vaccination? Immunity wanes with age. Most of the cases of clinical tetanus happen
in the elderly.
Talan DA, et al. Tetanus immunity and physician compliance
with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med.
2004 Mar;43(3):305-14. PMID: 14985655.
Immunoglobulin levels were measured in nearly 2,000 patients. 5% of patients who reported that they were up-to-date
on vaccination did not have protective levels of antibodies.
This increases to 15% in patients who are not up-to-date. The
CDC case series found that 12% of tetanus cases had completed their primary series but most of them were not up-todate on their boosters. 3% of cases had received their primary
series and were up-to-date on their boosters.
There is no herd immunity; tetanus is infectious but not contagious.
Don’t forget about tetanus in open fractures and ocular injuries. If you are worried about tetanus, metronidazole or penicillin
are the recommended antibiotics.
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It is important to look at the integrity of the device on chest x-ray.
Annals of Emergency Medicine:
Twiddler’s Syndrome
Paul Jhun MD and Jan Shoenberger MD
Case
A 53-year-old-female who was three days status post
placement of a defibrillator/pacemaker presented to the
Emergency Department after a syncopal episode. The pacemaker was placed for intermittent complete heart block
leading to recurrent syncope. Since her discharge, she had
complained of incisional pain but denied fever, erythema or
exudates from her incision. On arrival, an electrocardiogram
showed an intermittently paced regular rhythm. The patient
became symptomatic with lightheadedness when her heart
rate dropped to the 40s. Physical examination was unremarkable but the patient was noted by nursing staff to be
frequently touching her incision.
Follow the leads from the pulse generator to make sure they
are in the right place. There are many different pacemakers.
A single-lead pacemaker has a single lead that usually goes
to the right atrium or ventricle. A dual lead pacemaker usually
has a lead going to the right atrium and a lead going to the
right ventricle. An AICD has two defibrillator coils on the lead.
Look for fractures in the leads.
What do you do when you diagnose Twiddler’s syndrome? The
electrophysiologist or interventionalist will need to fix the device.
If there is a fractured lead, it will probably need to be replaced.
Otherwise, it will have to be repositioned and the pulse generator
will have to be secured.
Case Continued
A chest x-ray showed lead migration and coiling around the
pulse generator. The patient then underwent lead revision
and was discharged without complication.
Twiddler’s syndrome. This is a problem with pacemakers or other implantable medical devices (such as vagal nerve stimulators,
deep brain stimulators, chemotherapy ports, intrathecal devices,
etc.) due to intentional or unintentional manipulation or “twiddling” by the patient. With pacemakers, the pulse generator can
move around in the subcutaneous pocket and the leads can curl
around the pulse generator like a fishing reel.
This has been reported in the literature multiple times. The
first implantable pacemaker was placed in 1960. The first reported case of Twiddler’s syndrome was in 1968.
What are the symptoms? If the lead is displaced, the patient
may not have the electrical pulse generated and may present
with symptoms such as syncope. Sometimes, however, depending on where the lead is displaced, the electrical impulse may
cause the patient to exhibit other symptoms/signs such as diaphragmatic spasms, hiccups, abdominal muscular spasms, arm
twitching (if it touches the brachial plexus) and chest pain.
Who is higher risk? Elderly and obese patients are higher risk
due to a looser subcutaneous pocket. In addition, elderly patients may have dementia and may be more prone to touching
the pacemaker. Also, patients with obsessive compulsive disorder and children with developmental delay.
It is important to obtain an EKG to look for appropriate sensing
and pacing and a chest x-ray to look for hardware malfunction.
Figure. Anterior-posterior upright chest radiograph.
This article was published in Annals of Emergency Medicine, Volume 65, Frizell AW et al, A Peculiar Pacemaker Problem, Copyright
Elsevier 2015. Image reproduced with permission.
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