(ann emerg med [ta] OR am j emerg med [ta]) AND ("clinical trials"[MeSH Terms] OR "clinical trial"[Text Word] OR "meta analysis"[MeSH Terms] OR "meta analysis"[Text Word] OR "guideline"[All Fields] OR "consensus development conference"[All Fields] OR systematic [sb]) (only with abstract)

982 articles - 08.09.10

1: Ann Emerg Med. 2010 Jun 18; [Epub ahead of print]

Evidence-Based Emergency Medicine Clinical Synopsis.

Latulippe M, Lang ES.

University of Calgary, Faculty of Medicine, Division of Emergency Medicine Foothills Medical Centre, Calgary, Alberta, Canada.

Methods DATA SOURCES: Searches were conducted of MEDLINE (1966 to 2006), EMBASE (1980 to April 2006), and the Cochrane's CENTRAL register (Issue 2, 2006), and hand-searched information from cardiology conferences, principal investigators of identified trials, pharmaceutical manufacturers, and other experts in the field were used. There were no language restrictions. STUDY SELECTION: Randomized controlled trials enrolling patients with non-ST-segment elevation acute coronary syndromes who initially received GPIIb/IIa inhibitors as part of the early medical management were eligible. DATA EXTRACTION AND SYNTHESIS: Primary outcomes were 30-day and 6-month mortality and the subsequent development of myocardial infarction; the secondary endpoint was major hemorrhage, defined as intracranial bleeding or any bleeding with a decrease in hemoglobin of greater than 5 g/dL or a greater than 15% reduction in hematocrit level. Data were reported as odds ratios (ORs) with a fixed-effect model if minimal heterogeneity was identified; otherwise, a random-effects model was used. All analyses were presented as intention to treat. Copyright (c) 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Publication Types: EDITORIAL

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20646787&dopt=ExternalLink

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2: Ann Emerg Med. 2010 Jun 18; [Epub ahead of print]

Evidence-Based Emergency Medicine Clinical Synopsis.

Worster A.

McMaster Clinic, Hamilton General Hospital, Hamilton, Ontario, Canada.

Methods DATA SOURCES: The investigators searched the Cochrane Stroke Group Trials and Central Register of Controlled Trials, MEDLINE (from1966), EMBASE (from 1980), bibliographies of relevant articles, and clinical trial registries. Authors and pharmaceutical companies were contacted for clarification and to identify any additional studies. STUDY SELECTION: Randomized controlled trials with clinical outcome measures evaluating all doses and administration routes of single or multiple hemostatic agents, including anti fi brinolytics, blood coagulation factors, and platelet activators. DATA EXTRACTION AND SYNTHESIS: All trials were assessed for randomization and concealment of treatment allocation and blinded assessment of outcome. Heterogeneity was measured with the Inconsistency Index (I(2)) statistic. Results including 95% confidence intervals are presented as relative risk for dichotomous outcomes and as mean difference for continuous data; estimates were based on a fixed-effect or random-effects model. Copyright (c) 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Publication Types: EDITORIAL

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20646786&dopt=ExternalLink

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3: Am J Emerg Med. 2010 Jul;28(6):748.e5-748.e10. Epub 2010 Mar 26.

Is threshold for treatment of methemoglobinemia the same for all? A case report and literature review.

El-Husseini A, Azarov N.

Texas Tech University Health Sciences Center-Permian Basin, Odessa, TX 79763, USA.

Acquired methemoglobinemia (MetHb) is a rare complication of exposure to toxic chemicals or drugs, most commonly topical anesthetic agents. This condition occurs when the rate of methemoglobin production exceeds the rate of methemoglobin reduction. Topical anesthetics have been reported to cause MetHb, but this adverse event is extremely rare and is not usually listed as one of the possible complications of transesophageal echocardiography (TEE). However, the number of published case reports of TEE-associated MetHb has recently increased. Benzocaine (ethyl aminobenzoate) is a topical anesthetic widely used for oropharyngeal anesthesia before TEE. Health care providers who are not familiar with the association of TEE and benzocaine-induced MetHb may not recognize the idiosyncratic and often nonspecific characteristics of this condition. Recognition is critical, as clinically important symptoms may occur at relatively low MetHb levels. If left untreated, MetHb can lead to cardiopulmonary compromise, severe neurologic impairment, and even death. The current report documents a case of TEE-associated MetHb from a high-volume (3000 cases per year including 300-350 TEEs per year) echo laboratory. Our patient was symptomatic and severely distressed, despite a MetHb level of only 10.8%. This case report emphasizes the importance of early recognition and treatment of MetHb, as it represents a medical emergency and can be severely symptomatic, especially in young children and the elderly, even with low MetHb levels.

Publication Types: Case Reports Review

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20637402&dopt=ExternalLink

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4: Am J Emerg Med. 2010 Jul;28(6):724-7. Epub 2010 Mar 25.

Are 2 smaller intravenous catheters as good as 1 larger intravenous catheter?

Li SF, Cole M, Forest R, Chilstrom M, Reinersman E, Jones MP, Zinzuwadia S, King S, Yadav K.

Department of Emergency Medicine, Jacobi Medical Center, Bronx, NY 10461, USA. siuf@verizon.net

OBJECTIVE: 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. Our objective was to determine if the infusion rate of a single 18-g IV was equivalent to the infusion rate of two 20-g IVs. METHODS: This was a prospective study in healthy adult volunteers. Subjects simultaneously received 500 mL of normal saline via an 18-g IV in one arm and 500 mL of normal saline via two 20-g IVs in the other arm. We measured the rates of fluid administration. Paired Student's t test was used for comparison of the 2 arms of the study. We estimated that 18 trials were needed in sample size analysis. RESULTS: Eighteen trials were completed. 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 (95% CI, 1.3-10; P = .026). CONCLUSION: In healthy volunteers, administration of intravenous fluids through two 20-g IVs is faster than a single 18-g IV, although both approaches are markedly slower than the manufacturer's estimates. Copyright 2010 Elsevier Inc. All rights reserved.

Publication Types: Clinical Trial Comparative Study

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20637391&dopt=ExternalLink

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5: Am J Emerg Med. 2010 Jul;28(6):711-4. Epub 2010 Mar 25.

Concordance between capnography and capnia in adults admitted for acute dyspnea in an ED.

Delerme S, Freund Y, Renault R, Devilliers C, Castro S, Chopin S, Juillien G, Riou B, Ray P.

Department of Emergency Medicine and Surgery, Centre Hospitalo-Universitaire Pitie-Salpetriere, Assistance-Publique Hopitaux de Paris, 75013 Paris, UPMC- Univ Paris 6, France.

BACKGROUND: End-tidal carbon dioxide pressure (etCO(2)) is widely used in anaesthesia and critical care in intubated patients. The aim of our preliminary study was to evaluate the feasibility of a simple device to predict capnia in spontaneously breathing patients in an emergency department (ED). PATIENTS AND METHODS: This study was a prospective, nonblind study performed in our teaching hospital ED. We included nonintubated patients with dyspnea (> or =18 years) requiring measurement of arterial blood gases, as ordered by the emergency physician in charge. There were no exclusion criteria. End-tidal CO(2) was measured by an easy-to-use device connected to a microstream capnometer, which gave a continuous measurement and graphical display of the etCO(2) level of a patient's exhaled breath. RESULTS: A total of 43 patients (48 measurements) were included, and the majority had pneumonia (n = 12), acute cardiac failure (n = 8), asthma (n = 7), or chronic obstructive pulmonary disease exacerbation (n = 6). Using simple linear regression, the correlation between etCO(2) and Paco(2) was good (R = 0.82). However, 18 measurements (38%) had a difference between etCO(2) and Paco(2) of 10 mm Hg or more. The mean difference between the Paco(2) and etCO(2) levels was 8 mm Hg. Using the Bland and Altman matrix, the limits of agreement were -10 to +26 mm Hg. CONCLUSION: In our preliminary study, etCO(2) using a microstream method does not seem to accurately predict Paco(2) in patients presenting to an ED for acute dyspnea. Copyright 2010 Elsevier Inc. All rights reserved.

Publication Types: Controlled Clinical Trial

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20637388&dopt=ExternalLink

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6: Am J Emerg Med. 2010 Jul;28(6):689-93.

Evaluation of a modified early goal-directed therapy protocol.

Crowe CA, Mistry CD, Rzechula K, Kulstad CE.

Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, IL 60453, USA.

OBJECTIVES: The study aimed to determine mortality in septic patients 2 years after introduction of a modified early goal-directed therapy (EGDT) protocol and to measure compliance with the protocol. DESIGN: This was an observational study of prospectively identified patients treated with EGDT in our emergency department (ED) from May 2007 through May 2008 and compared with retrospectively obtained data on patients treated before protocol implementation, from May 2004 to May 2005. SETTING: This study was conducted at a large tertiary-care suburban community hospital with more than 85 000 ED visits annually and 700 inpatient beds. PATIENTS: Patients with severe sepsis or septic shock were included in the study. INTERVENTIONS: A modified EGDT protocol was implemented. MEASUREMENTS AND MAIN RESULTS: A total of 216 patients were treated with our EGDT protocol, with 32.9% mortality (95% confidence interval [CI], 26.6%-39.2%); 183 patients (84.7%) had septic shock, with a mortality of 34.4% (95% CI, 28%-41%). Our control group of 205 patients had a 27.3% mortality (95% CI, 21.2%-33.5%), of which 123 had septic shock with a mortality of 43.1% (95% CI, 34%-52%). Early goal-directed therapy protocol compliance was as follows: 99% received adequate intravenous fluids, 99% had a central line, 98% had antibiotics in the first 6 hours, 28% had central oxygen saturation measured, 3.7% received dobutamine, and 19% were transfused blood. CONCLUSIONS: Although we found a trend toward decreased mortality in patients with septic shock treated with EGDT, with an absolute difference of 8.7%, this difference was not statistically significant. Compliance with individual elements of the protocol was variable. Copyright 2010 Elsevier Inc. All rights reserved.

Publication Types: Evaluation Studies

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20637384&dopt=ExternalLink

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7: Ann Emerg Med. 2010 Jul;56(1):77-9.

Optimizing the treatment of pain in patients with acute presentations. Policy statement.

American Society for Pain Management Nursing (ASPMN); Emergency Nurses Association (ENA); American College of Emergency Physicians (ACEP); American Pain Society (APS).

Management of pain is an essential nursing and physician responsibility. This joint position statement describes recommendations for improving pain management in health care settings.

Publication Types: Practice Guideline

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20620657&dopt=ExternalLink

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8: Ann Emerg Med. 2010 Jul 7; [Epub ahead of print]

Evidence-Based Emergency Medicine Clinical Synopsis.

Vadera R.

Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

Methods DATA SOURCES: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and references in review articles were searched. The authors also attempted to identify the grey literature by contacting trialists. STUDY SELECTION: Randomized controlled trials that enrolled patients with hypertensive emergencies in which a selected antihypertensive agent was compared with placebo, no treatment, or another drug in a different class. Fifteen randomized controlled trials with 869 patients met the inclusion criteria. DATA EXTRACTION: Two reviewers extracted data from the included studies and selected studies independently. Discrepancies were resolved by discussion or a third reviewer. Primary outcome measures were total serious adverse events, all-cause mortality, and composite of nonfatal cardiovascular events (ie, unstable angina, aortic dissection, acute renal failure, stroke, respiratory failure). Secondary outcome measures were weighted mean difference in systolic pressure, diastolic blood pressure, pulse rate, and withdrawal because of adverse events. The adequacy of concealment and blinding was assessed. MAIN RESULTS: Almost all of the trials (14/15) were open label. Because of insufficient data, no meta-analysis could be performed on clinical outcomes. Pooling the effect of 3 antihypertensives (calcium-channel blockers, angiotensin-converting enzyme inhibitors, and alpha-1 adrenergic antagonists) from a single placebo controlled study showed a statistically significant reduction in both systolic (weighted mean difference -13; 95% confidence interval -19 to -7 mm Hg) and diastolic (weighted mean difference -8; 95% confidence interval -12 to -3 mm Hg) blood pressure. CONCLUSIONS: In patients presenting with a hypertensive emergency, randomized controlled trial evidence that antihypertensive drug therapy reduces morbidity or mortality is lacking. Some drug classes were more effective at decreasing blood pressure, but the clinical significance of this physiologic outcome measure is not known. Copyright (c) 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Publication Types: EDITORIAL

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20619499&dopt=ExternalLink

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9: Am J Emerg Med. 2010 Jun;28(5):596-602.

Topical antacid therapy for capsaicin-induced dermal pain: a poison center telephone-directed study.

Kim-Katz SY, Anderson IB, Kearney TE, MacDougall C, Hudmon KS, Blanc PD.

Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, CA 94143-1369, USA. susank@calpoison.org

PURPOSE: The study aimed to assess the effects of topical antacids for treatment of capsaicin-induced dermal pain after exposure to capsaicin containing hot peppers, personal protection sprays, or topical creams. PROCEDURES: Participants of the study were California Poison Control System (CPCS) hotline callers 12 years or older with dermal pain from exposure to capsaicin-containing products or plants. Participants were instructed to apply a topical antacid and assessed for perceived pain (using a 0-10 scale) pre- and posttreatment. A positive response was defined as a sustained reduction of pain 33% or more within 30 minutes or achieving a pain score of 0 to 1. MAIN FINDINGS: Of 93 eligible patients, 64 applied antacids and had outcome data available. Patients contacted the CPCS a median of 1 hour postexposure with a median initial pain score of 7.5/10. Thirty-six (56%) were exposed to unrefined (natural) peppers and 28 (44%) to refined capsaicin (eg, capsaicin-containing cream). Before calling the CPCS, 57 (89%) attempted at least one treatment. Forty-five (70%) reported positive response to antacid treatment as a 33% reduction in pain in 30 minutes (n = 17), a reduction in pain to a score of 0 to 1 (n = 3), or both (n = 25). A 33% reduction in pain within 30 minutes was associated with exposure to refined capsaicin (odds ratio, 3.37; 95% confidence interval, 0.98-11.66). Concomitant refined capsaicin exposure and early treatment (<1 hour of symptoms) was associated with even greater odds of response (odds ratio, 5.4; 95% confidence interval, 1.4-21.2). CONCLUSION: Topical application of antacids for capsaicin-induced pain is effective, particularly in early treatment of exposure to refined capsaicin. Copyright (c) 2010 Elsevier Inc. All rights reserved.

Publication Types: Clinical Trial

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20579556&dopt=ExternalLink

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10: Am J Emerg Med. 2010 Jun;28(5):582-7.

Physiologic effects of prolonged conducted electrical weapon discharge in ethanol-intoxicated adults.

Moscati R, Ho JD, Dawes DM, Miner JR.

Department of Emergency Medicine, State University of New York at Buffalo, Erie County Medical Center, Buffalo, NY 14215, USA. moscati@buffalo.edu

OBJECTIVES: This study examines the physiologic effects of prolonged conducted electrical weapon (CEW) exposure on alcohol-intoxicated adult subjects. METHODS: Adult volunteers were recruited at a TASER International training conference. All subjects ingested mixed drinks until clinical intoxication or until a minimum breath alcohol level of 0.08 mg/dL was achieved. Blood samples for venous pH, Pco(2), bicarbonate, and lactate were measured in all subjects at baseline, immediately after alcohol ingestion, immediately after exposure to a 15-second TASER X26 discharge (Taser International Inc, Scottsdale, AZ), and 24 hours post-alcohol ingestion. Laboratory values were compared at sampling times using repeated-measure analysis of variance. A focused analysis comparing time points within groups was then performed using paired t tests. RESULTS: Twenty-two subjects were enrolled into the study. There was a decrease in pH and bicarbonate and an increase in lactate after alcohol ingestion. There was a further increase in lactate and drop in pH after CEW exposure. No subject experienced a significant adverse event. All values had returned to baseline levels at 24 hours except lactate, which demonstrated a small but clinically insignificant increase. CONCLUSIONS: Prolonged continuous CEW exposure in the setting of acute alcohol intoxication has no clinically significant effect on subjects in terms of markers of metabolic acidosis. The acidosis seen is consistent with what occurs with ethanol intoxication or moderate exertion. Copyright (c) 2010 Elsevier Inc. All rights reserved.

Publication Types: Clinical Trial Research Support, Non-U.S. Gov't

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20579553&dopt=ExternalLink

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11: Ann Emerg Med. 2010 May 19; [Epub ahead of print]

Immediate beta-Blockade in Patients With Myocardial Infarctions: Is There Evidence of Benefit?

Sinert R, Newman DH, Brandler E, Paladino L.

Department of Emergency Medicine, SUNY-Downstate Medical Center, Brooklyn, NY.

STUDY OBJECTIVE: The American Heart Association recommends the initiation of beta-blockade to all patients with an ST-segment elevation myocardial infarction (STEMI) without contraindications to beta-blocking agents. The present study seeks to systematically review the medical literature to determine the efficacy of treating STEMI patients with a beta-blocker within the first 24 hours. METHODS: We searched databases for articles through MEDLINE with the PubMed interface and from 1966 through May 2009 and EMBASE from 1980 to August 2009 with the Ovid Technologies interface, using a search strategy derived from the following PICO (Patient-Intervention-Comparator-Outcome) clinical question: In patients presenting with STEMI (P), does immediate treatment with beta-blockers (I) followed by standardized care beginning on day 2 or 3 compared with placebo or no treatment followed by standardized care on day 2 or 3 (C) reduce the risk of death, reinfarction, or cardiogenic shock (O)? The methodological quality of the studies was assessed. RESULTS: From more than 2,000 references identified in the search, only a single randomized trial met the inclusion criteria. There were no statistically significant differences in mortality; the relative risk for the combined endpoint (mortality and reinfarction) was 0.67 (95% confidence interval 0.44 to 1.03) at 6 days and 0.74 (95% confidence interval 0.53 to 1.06) at 6 weeks. Outcomes for cardiogenic shock were not reported. CONCLUSION: Evidence from a single randomized trial failed to demonstrate a reduction in mortality or reinfarction with administration of beta-blocker within the first 24 hours after STEMI. Copyright (c) 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20493586&dopt=ExternalLink

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12: Am J Emerg Med. 2010 May;28(4):499-504.

Verification of airway management during cardiac arrest: a manikin-based observational study.

Kobayashi M, Fujiwara A, Morita H, Nishimoto Y, Mishima T, Nitta M, Hotta T, Hayashi T, Hayashi Y, Sato K.

Department of Emergency Medicine, Osaka Medical College Hospital, Takatsuki-city, Osaka 569-8686, Japan. emm003@poh.osaka-med.ac.jp

INTRODUCTION: The study aimed to clarify the difficulties concerning insertion of advanced airway devices during cardiac arrest. METHOD: In an observational study using manikins, we examined the airway management techniques of 19 teams at the Osaka Senri medical rally. For ex-post verification, we recorded chest compression and ventilation using the Resusci Anne Advanced Skill Trainer (Laerdal, Norway) and recorded actions of the teams using a video camera. RESULTS: Only a small proportion of teams did not adopt advanced airway management (4 teams, 21.1%). Thirteen teams selected tracheal intubation. None showed chest compression interruptions during intubation manipulation, and the median duration of chest compression interruption during confirmation of postintubation was 6.4 seconds. The median duration of ventilation interruption during intubation was 45.5 seconds. When teams were evaluated for the duration of direct laryngoscopy, that is, so-called duration of intubation, the median duration was 19 seconds, which constituted a large underestimate compared with the duration of ventilation interruption. This represents an underestimation of about 27 seconds. We considered the issues to be identified for shortening the duration of ventilation interruption. CONCLUSION: From this study, it is clear that the strategy of Guideline 2005 that was designed to minimize chest compression interruption has permeated deeply. The recommendation that the duration of intubation manipulation should not exceed 30 seconds has had various interpretations, but it is important to focus on the duration of ventilation interruption. (c) 2010 Elsevier Inc. All rights reserved.

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20466233&dopt=ExternalLink

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13: Am J Emerg Med. 2010 May;28(4):485-91. Epub 2010 Jan 28.

Quality of emergency care provided by physician assistants and nurse practitioners in acute asthma.

Tsai CL, Sullivan AF, Ginde AA, Camargo CA Jr.

Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA. cltsai@post.harvard.edu

OBJECTIVE: The aim of this study was to evaluate the quality of care provided by physician assistants or nurse practitioners (ie, midlevel providers [MLPs]) in acute asthma, as compared with that provided by physicians. METHODS: We performed a secondary analysis of the asthma component of the National Emergency Department Safety Study. We identified emergency department (ED) visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Quality of care was evaluated based on 12 guideline-recommended process-of-care measures, a composite guideline concordance score, and 2 outcome-of-care measures (admission and ED length of stay). RESULTS: Of the 4029 patients included in this analysis, 3622 (90%) were seen by physicians only, 319 (8%) by MLPs supervised by physicians, and 88 (2%) by MLPs not supervised by physicians. After adjustment for patient mix, unsupervised MLPs were less likely to administer inhaled beta-agonists within 15 minutes of ED arrival (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.7), less likely to prescribe systemic corticosteroids in the ED (OR, 0.4; 95% CI, 0.2-0.9), and were more likely to prescribe inappropriate antibiotics at discharge (OR, 2.1; 95% CI, 1.1-4.1), as compared with physicians. Overall, their composite guideline concordance score was lower than that of physicians (-6 points; 95% CI, -9 to -3 points). Supervised MLPs provided similar quality of care to that of physicians. CONCLUSIONS: The MLPs were involved in 10% of ED patients with acute asthma and provided independent care for 2% of these patients. Compared with care provided by physicians or by supervised MLPs, there are opportunities for improvement in unsupervised MLP care. (c) 2010 Elsevier Inc. All rights reserved.

Publication Types: Comparative Study Research Support, N.I.H., Extramural Research Support, U.S. Gov't, P.H.S.

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20466230&dopt=ExternalLink

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14: Am J Emerg Med. 2010 May;28(4):391-8.

Inhomogeneity and temporal effects in AutoPulse Assisted Prehospital International Resuscitation--an exception from consent trial terminated early.

Paradis NA, Young G, Lemeshow S, Brewer JE, Halperin HR.

Department of Emergency Medicine, University of Southern California and ZOLL Circulation, Sunnyvale, CA, USA.

BACKGROUND: The ASPIRE trial (AutoPulse Assisted Prehospital International Resuscitation) was multicenter exception from consent clinical trial that compared mechanical cardiopulmonary resuscitation (CPR) with a device (AutoPulse-CPR) to traditional manual CPR (manual-CPR) in out-of-hospital cardiac arrest. Enrollment was suspended early due to safety concerns. One site (site C) made a potentially important protocol change midtrial, and enrollment at that site was noted to be independently associated with outcome. METHODS: The study used a post hoc reanalysis of source data and documentation using standard statistical approaches evaluating for possible secular, temporal, and trial design, factors that may have related to the trial's outcome. RESULTS: The protocol change at site C also appears to have resulted in a delay in application of AutoPulse-CPR. Before and after the protocol change survival in patients receiving AutoPulse-CPR decreased from 19.6% to 4% (P = .024). Logistic regression analysis showed site C was significantly different (P = .008) from the remaining sites with respect to survival. Unlike site C, the other sites actually showed an increase over time in the primary end point of 4-hour survival (P = .008) favorable to AutoPulse-CPR. There did not appear to be significant safety (P = .42) nor efficacy concerns (P = .17) at these sites. CONCLUSIONS: The difference in survival that caused early suspension of ASPIRE appears to have been limited to one site after its protocols change. At the time the trial was suspended, the outcomes of patients at the other sites appear to have been trending in favor of the intervention. (c) 2010 Elsevier Inc. All rights reserved.

Publication Types: Multicenter Study Randomized Controlled Trial

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20466215&dopt=ExternalLink

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15: Ann Emerg Med. 2010 Apr 9; [Epub ahead of print]

Sufentanil Is Not Superior to Morphine for the Treatment of Acute Traumatic Pain in an Emergency Setting: A Randomized, Double-Blind, Out-of-Hospital Trial.

Bounes V, Barthelemy R, Diez O, Charpentier S, Montastruc JL, Ducasse JL.

the Pole de Medecine d'Urgences, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Faculte de Medecine, Laboratoire de Pharmacologie Medicale et Clinique, Unite de Pharmacoepidemiologie, EA 3969, Universite de Toulouse, Toulouse, France.

STUDY OBJECTIVE: We determine the best intravenous opioid titration protocol by comparing morphine and sufentanil for adult patients with severe traumatic acute pain in an out-of-hospital setting, with a physician providing care. METHODS: In this double-blind randomized clinical trial, patients were eligible for inclusion if aged 18 years or older, with acute severe pain (defined as a numeric rating scale score >/=6/10) caused by trauma. They were assigned to receive either intravenous 0.15 mug/kg sufentanil, followed by 0.075 mug/kg every 3 minutes or intravenous 0.15 mg/kg morphine and then 0.075 mg/kg. The primary endpoint of the study was pain relief at 15 minutes, defined as a numeric rating scale less than or equal to 3 of 10. Secondary endpoints were time to analgesia, adverse events, and duration of analgesia during the first 6 hours. RESULTS: A total of 108 patients were included, 54 in each group. At 15 minutes, 74% of the patients in the sufentanil group had a numeric rating scale score of 3 or lower versus 70% of those in the morphine group (Delta4%; 95% confidence interval -13% to 21%). At 9 minutes, 65% of the patients in the sufentanil group experienced pain relief versus 46% of those in the morphine group (Delta18%; 95% confidence interval 0.1% to 35%). The duration of analgesia was in favor of the morphine group. Nineteen percent of patients experienced an adverse event in both groups, all mild to moderate. CONCLUSION: Intravenous morphine titration using a loading dose of morphine followed by strictly administered lower doses at regular intervals remains the criterion standard. Moreover, this study supports the idea that the doses studied should be considered for routine administration in severe pain protocols. Copyright (c) 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20382445&dopt=ExternalLink

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16: Ann Emerg Med. 2010 Apr 8; [Epub ahead of print]

Pediatric Suicide-Related Presentations: A Systematic Review of Mental Health Care in the Emergency Department.

Newton AS, Hamm MP, Bethell J, Rhodes AE, Bryan CJ, Tjosvold L, Ali S, Logue E, Manion IG.

Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Department of Psychiatry, Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Women and Children's Health Research Institute, Edmonton, Alberta, Canada.

STUDY OBJECTIVE: We evaluate the effectiveness of interventions for pediatric patients with suicide-related emergency department (ED) visits. METHODS: We searched of MEDLINE, EMBASE, the Cochrane Library, other electronic databases, references, and key journals/conference proceedings. We included experimental or quasiexperimental studies that evaluated psychosocial interventions for pediatric suicide-related ED visits. Inclusion screening, study selection, and methodological quality were assessed by 2 independent reviewers. One reviewer extracted the data and a second checked for completeness and accuracy. Consensus was reached by conference; disagreements were adjudicated by a third reviewer. We calculated odds ratios, relative risks (RRs), or mean differences for each study's primary outcome, with 95% confidence intervals (CIs). Meta-analysis was deferred because of clinical heterogeneity in intervention, patient population, and outcome. RESULTS: We included 7 randomized controlled trials and 3 quasiexperimental studies, grouping and reviewing them according to intervention delivery: ED-based delivery (n=1), postdischarge delivery (n=6), and ED transition interventions (n=3). An ED-based discharge planning intervention increased the number of attended post-ED treatment sessions (mean difference=2.6 sessions; 95% CI 0.05 to 5.15 sessions). Of the 6 studies of postdischarge delivery interventions, 1 found increased adherence with service referral in patients who received community nurse home visits compared with simple placement referral at discharge (RR=1.28; 95% CI 1.06 to 1.56). The 3 ED transition intervention studies reported (1) reduced risk of subsequent suicide after brief ED intervention and postdischarge contact (RR=0.10; 95% CI 0.03 to 0.41); (2) reduced suicide-related hospitalizations when ED visits were followed up with interim, psychiatric care (RR=0.41; 95% CI 0.28 to 0.60); and (3) increased likelihood of treatment completion when psychiatric evaluation in the ED was followed by attendance of outpatient sessions with a parent (odds ratio=2.78; 95% CI 1.20 to 6.67). CONCLUSION: Transition interventions appear most promising for reducing suicide-related outcomes and improving post-ED treatment adherence. Use of similar interventions and outcome measures in future studies would enhance the ability to derive strong recommendations from the clinical evidence in this area. Copyright (c) 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20381916&dopt=ExternalLink

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17: Ann Emerg Med. 2010 Apr 2; [Epub ahead of print]

Delphi Consensus on the Feasibility of Translating the ACEP Clinical Policies Into Computerized Clinical Decision Support.

Melnick ER, Nielson JA, Finnell JT, Bullard MJ, Cantrill SV, Cochrane DG, Halamka JD, Handler JA, Holroyd BR, Kamens D, Kho A, McClay J, Shapiro JS, Teich J, Wears RL, Patel SJ, Ward MF, Richardson LD.

Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY.

Clinical practice guidelines are developed to reduce variations in clinical practice, with the goal of improving health care quality and cost. However, evidence-based practice guidelines face barriers to dissemination, implementation, usability, integration into practice, and use. The American College of Emergency Physicians (ACEP) clinical policies have been shown to be safe and effective and are even cited by other specialties. In spite of the benefits of the ACEP clinical policies, implementation of these clinical practice guidelines into physician practice continues to be a challenge. Translation of the ACEP clinical policies into real-time computerized clinical decision support systems could help address these barriers and improve clinician decisionmaking at the point of care. The investigators convened an emergency medicine informatics expert panel and used a Delphi consensus process to assess the feasibility of translating the current ACEP clinical policies into clinical decision support content. This resulting consensus document will serve to identify limitations to implementation of the existing ACEP Clinical Policies so that future clinical practice guideline development will consider implementation into clinical decision support at all stages of guideline development. Copyright (c) 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20363531&dopt=ExternalLink

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18: Ann Emerg Med. 2010 Aug;56(2):105-13.e5. Epub 2010 Mar 25.

The effect of a bolus dose of etomidate on cortisol levels, mortality, and health services utilization: a systematic review.

Hohl CM, Kelly-Smith CH, Yeung TC, Sweet DD, Doyle-Waters MM, Schulzer M.

Department of Emergency Medicine, University of British Columbia, Vancouver, Canada. chohl@interchange.ubc.ca

STUDY OBJECTIVE: To synthesize 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. METHODS: We developed a systematic search strategy and applied it to 10 electronic bibliographic databases. We hand searched journals; reviewed conference proceedings, gray literature, and bibliographies of relevant literature; and contacted content experts for studies comparing a bolus dose of etomidate with other induction agents. Retrieved articles were reviewed and data were abstracted with standardized forms. Data were pooled with the random-effects model if at least 4 clinically homogenous studies of the same design reported the same outcome measure. All other data were reported qualitatively. RESULTS: From 3,083 titles reviewed, 20 met our inclusion criteria. Pooled 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 microg/dL (95% confidence interval [CI] 2.4 to 9.9 microg/dL; P=.001) to 16.4 microg/dL (95% CI 9.7 to 23.1 microg/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. CONCLUSION: The available evidence suggests that etomidate suppresses adrenal function transiently without demonstrating a significant effect on mortality. However, no studies to date have been powered to detect a difference in hospital, ventilator, or ICU length of stay or in mortality. 2009 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Publication Types: Research Support, Non-U.S. Gov't Review

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20346542&dopt=ExternalLink

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19: Ann Emerg Med. 2010 Jul;56(1):42-8. Epub 2010 Mar 26.

Frequent users of emergency departments: the myths, the data, and the policy implications.

LaCalle E, Rabin E.

Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA. eduardo.lacalle@mssm.edu

STUDY OBJECTIVE: Frequent emergency department (ED) users have been the targets of health care reform proposals and hospital crowding interventions, but it is not clear that common assumptions about this group are supported by data. We review the literature pertaining to frequent ED users, their demographics, acuity of illness, and patterns of health care utilization. We seek to inform development of policies directed at frequent ED use and to highlight potential related challenges. METHODS: A systematic review of the literature on frequent ED users was performed. RESULTS: Frequent users comprise 4.5% to 8% of all ED patients but account for 21% to 28% of all visits. Most frequent ED users are white and insured; public insurance is overrepresented. Age is bimodal, with peaks in the group aged 25 to 44 years and older than 65 years. On average, these patients have higher acuity complaints and are at greater risk for hospitalization than occasional ED users. However, the opposite may be true of the highest-frequency ED users. Frequent users are also heavy users of other parts of the health care system. Only a minority of frequent ED users remain in this group long term. Complaints vary with age, location, and usage patterns. CONCLUSION: Frequent ED users are a heterogeneous group along many dimensions and defy popular assumptions. The subgroups have not yet been sufficiently defined to allow clearly directed policy design, and many frequent users present with true medical needs, which may explain why existing attempts to address the phenomena have had mixed success at best. Copyright 2009 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Publication Types: Review

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20346540&dopt=ExternalLink

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20: Am J Emerg Med. 2010 Mar;28(3):275-83.

Practice variation in the management for nontraumatic pediatric patients in the ED.

Chang YC, Ng CJ, Chen YC, Chen JC, Yen DH.

Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Tao-Yuan, Taiwan.

STUDY OBJECTIVE: To improve the management quality and monitoring for common pediatric illnesses in the general emergency department (ED), we examined the effect of physician specialty training on medical resource use and patient outcomes. METHODS: This was a retrospective cohort review of visits by children less than 18 years to the ED of 2 university-affiliated teaching hospitals. Clinical management by 2 groups (emergency physicians [EPs] and pediatricians each working 168 h/wk) was compared with respect to demographics, ED resource use, short-term outcome, disposition, direct ED costs for each visit, and frequency of radiographic and laboratory test use. The effects of medical decision making on resource use was assessed by comparing costs of radiographic studies, laboratory studies, and medication. RESULTS: Between-group differences in mean patient age, sex, and triage category were insignificant. Compared to pediatricians, EPs used radiographic and laboratory studies more frequently (respectively, 10.1% and 3.8% higher frequency and 90.5% and 7.6% higher cost) and less medication (12.5% lower cost). Patients managed by EPs had longer ED length of stay (LOS), higher admission rates to general wards, and shorter LOS per hospitalization but similar 72-hour revisit rates, needed more frequent referral for medical reasons, and left more frequently against medical advice. CONCLUSION: Emergency physicians spent more time and medical resources and admitted patients at a higher rate. Emergency physicians and pediatricians managed critical patients similarly. 2010 Elsevier Inc. All rights reserved.

Publication Types: Multicenter Study

Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20223383&dopt=ExternalLink

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MedASq (the Medline Abstract Squeezer) is © Ernesto de Bernardis 2002. Thanks to Eric Mueller for his on-the-fly ZIP creation code, to Google for automatic translations, to the NCBI people who wrote the new Entrez Utilities, and to the USA Government and NLM who allowed free access to the PubMed database [Disclaimer]. The URL of this site is http://www.debernardis.it/medasq.php; my home page is in http://www.debernardis.it