Monday, July 27, 2015

A Little Intubation Checklist Magic

In the interests of patient safety, many have turned to peri-procedural checklists.  Rather than,
essentially, “winging it”, a standardized protocol is followed each time, reducing the chance of an important omission.

These authors describe a checklist intervention for, as they describe, the high-risk procedure of endotracheal intubation in the setting of trauma.  The checklist involves, generally, assignment of roles, explicit back-up airway planning, and adequate patient positioning.  The authors used a before-and-after design using video review of all intubation events to compare steps performed.

In the six-month pre-checklist period, 7 of 76 intubation events resulted in complications – 6 desaturations, 2 emesis, and 2 hypotension.  In the post-intervention period, using the checklist, events were reduced to a single episode of desaturation in 65 events.  So, success?

As with every before-and-after study, it is hard to separate the use of the checklist to the educational diffusion associated with checklist exposure.  Would another, less intrusive, intervention been just successful?  Will the checklist lose effectiveness over time as it is superseded by newer safety initiatives?  And, most importantly, what did operators actually do differently after checklist implementation?

Only 4 of 15 checklist elements differed from the pre-checklist period: verbalization of backup intubation technique (61.8% vs. 90.8%), pre-oxygenation (47.3% vs. 75.4%), team member roles verbalized (76.4% vs. 98.5%), and optimal patient positioning (80.3% vs. 100%).  If only four behaviors were substantially changed, are they responsible for the outcomes difference – which, technically, is solely episodes of hypoxia?

Their intervention seems reasonable, and the procedure is likely high-risk enough to warrant a checklist.  However, I probably would not implement their specific checklist, as some refinement to the highest-yield items would probably be of benefit.

“A Preprocedural Checklist Improves the Safety of Emergency Department Intubation of Trauma Patients”

Friday, July 24, 2015

Patients Packin’ Heat

Does your Emergency Department have a metal detector?  No?  Then, read on.

These authors describe the installation of a typical arch-style metal detector at a single, Midwest, urban teaching hospital.  Between 2011 and 2013, security personnel screened all walk-in guests during hours of operation, ranging from 8h per day at initiation to 16h by the end of the study period.  In just two years of limited operation, they collected:
  • 268 firearms
  • 4,842 knives
  • 512 chemical sprays
  • 275 other weapons (brass knuckles, stun guns, box cutters)
Hospital maintenance also reported finding additional discarded weapons in the landscaping just outside the Emergency Department after the implementation of screening, while triage personnel also anecdotally noted some potential visitors turned away whence they came upon the security station.

Thus, the authors reasonably speculate their findings are representative – or even under-representative – of the weapons present, and concealed, inside their Emergency Department when security screening was absent.  The authors do not simultaneously evaluate any change in reduction in violent events in the Emergency Department, but it's a fair conclusion their department is now a much safer workplace.

“Weapons retrieved after the implementation of emergency department metal detection.”

Wednesday, July 22, 2015

And The Stoning Continues

A couple months ago, the world of ureterolithiasis was upended by The Lancet and its publication of a trial examining medical expulsive therapy.  In direct contrast to the prior (worthless) Cochrane Review, this large, reasonably-designed trial, does away with the notion of universal benefit of alpha- and calcium channel-blockers for MET.

Following on its heels comes the publication of another trial of moderate size, but with even more rigorous follow-up.  Rather than previously mentioned trial’s “urologic intervention” as the patient-oriented outcome, this trial used a disease-oriented outcome.  This trial, enrolling patients with distal ureteral stones, required patients to under go CT at 28 days to definitively assess for stone passage.

The trial randomized 403 patients to either tamsulosin 0.4mg daily for 28 days or identical placebo, but, unfortunately, 87 did not ultimately undergo second CT.  Of the patients that did undergo CT, there was no statistically significant difference in stone passage: 87.0% tamsulosin vs. 81.9% placebo, an absolute difference of 5.0% (95% CI -3.0 to 13.0).  Of the 87, 77 were available for follow-up regarding urologic intervention.  If a combined endpoint of CT passage and lack of urologic intervention is used, the results remain unchanged.

However, the trial was designed specifically to enroll adequate numbers of patients with stones of 5-10mm in size – targeting adequate sample size with which to include at least 49 patients to detect a difference in stone passage of 5 to 25%.  They ultimately randomized 103 large stones and completed imaging or clinical follow-up on 77.  The difference in stone passage rate in the large stones was 83.3% in the tamsulosin group, compared with 61.0% with placebo, for an absolute difference of 22.4% (95% CI 3.1 to 41.6).

So, what’s the takeaway – from decades of poor-quality studies, the recent Lancet publication, and now this?  There’s probably some signal in the noise – and that signal, all along, has probably been these large, distal stones.  Unless there’s a truly diminished risk of stone passage, there’s never been any reasonableness to the use of MET – but if passage rates are ~60%, the likelihood of a clinically meaningful benefit is finally possible.

If I’ve obtained a CT in a patient and diagnosed a large, distal stone – I am offering tamsulosin.  Otherwise, no.

Rory Spiegel also shares his typically excellent similar evaluation of the evidence: EM Nerd

“Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial”

Monday, July 20, 2015

Doctor Internet Will Misdiagnose You Now

Technology has insidiously infiltrated all manner of industry.  Many tasks, originally accomplished by humans, have been replaced by computers and robots.  All manner of industrialization is now automated, Deep Blue wins at chess, and Watson wins at Jeopardy!

But, don’t rely on Internet symptom checkers to replace your regular physician.

These authors evaluated 23 different online symptom checkers, ranging from the British National Health Service Symptom Checker to privately owned reference sites such as WebMD, with a variety of underlying methodologies.  The authors fed each symptom checker 45 different standardized patient vignettes, ranging in illness severity from pulmonary embolism to otitis media.  The study evaluated twin goals: are the diagnoses generated accurate?  And, do the tools triage patients to the correct venue for medical care?


For symptom checkers providing a diagnosis, the correct diagnosis was provided 34% of the time.  This seems pretty decent – until you go further into the data and note these tools left the correct diagnosis completely off the list another 42% of the time.  Most tools providing triage information performed well at referring emergent cases to high levels of care, with 80% sensitivity.  However, this performance was earned by simply referring the bulk of all cases for emergency evaluation, with 45% of non-emergent and 67% of self-care cases being referred to inappropriate levels of medical care.

Of course, this does not evaluate the performance of these online checkers versus telephone advice lines, or even against primary care physicians given the same limited information.  Before being too quick to tout these results as particularly damning, they should be evaluated in the context of their intended purpose.  Unfortunately, due to their general accessibility and typical over-triage, they are likely driving patients to seek higher levels of care than necessary.

“Evaluation of symptom checkers for self diagnosis and triage: audit study”

Friday, July 17, 2015

Let's Poison Our Kids With E-Cigarettes

The hazards of the natural world are not an issue for those of us born into “civilization”.  Without lions, tigers, bears, and dingoes to endanger our babies, we’ve had to become more creative.  Firearms in the home, detergent packets, and, now:  highly concentrated nicotine from e-cigarettes.  This short review provides a brief look at an increasingly prevalent health hazard.

The lethal dose of nicotine is approximately 1 mg/kg.  Concentrations of liquid nicotine cartridges may be as high as 35 mg/mL.  A typical 10 mL refill bottle, then, has easily a lethal dose for children, while a 50 mL bottle could have more than enough to bring down a horse.  For comparison, a conventional cigarette contains 10 to 1 5mg of nicotine – certainly a danger, but on a different scale entirely.

The expected clinical effects are consistent with the classical nicotinic and muscarinic toxodromes – vomiting, diarrhea, salivation, bronchorrhea, seizures, rhabdomyolysis, and respiratory failure.  Therapeutic management remains supportive – intravenous fluids, atropine, and mechanical ventilation as needed.  Inadvertent exposures are typical, but liquid nicotine may also be used for intentional overdose in suicide attempts.

Another proud cultural innovation for the 21st century.

“Liquid Nicotine Toxicity”

Wednesday, July 15, 2015

Expunging “Zero-Miss” from Chest Pain Evaluation

The admit rate for chest pain from the Emergency Department varies widely.  In some instances, the rule “chest pain = admit” is the norm – or, at the least, observation and provocative or anatomic radiology from the Emergency Department.  Indeed, such studies exhorting the advantages of CCTA in the ED included those aged as low as 30 years – patients in whom the false positives from testing far outweigh the true.

The typical motivating factor for such aggressive admission rates has been a culture of “zero miss”, motivated by huge settlements for missed MI.  Accordingly, this brief study followed Emergency Physicians and asked – what if there were no legal liability?  What if there was an acceptable miss rate of 1 or 2% in chest pain?  How many of these people would be discharged instead of admitted?

Based on 259 surveys completed regarding a convenience sample of admitted chest pain patients, the answer from this single-center study is: 30%.

With over 5 million ED visits for chest pain annually, cutting the current 35% admission rate by 30% turns into a massive reduction in resource utilization.  And, frankly, it’s not as daunting to implement such thresholds as one might imagine: ED physicians set the standard of care, not lawyers.  As Jeff Kline has alluded to the possibility, it’s time for domain experts to set reasonable practice variation and resource utilization, rather than leave it up to lawyers and their hired guns:

This definitely should be done.

“The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates”

Monday, July 13, 2015

Narcotic Overdoses Are Just Who We Expect

Deaths from narcotic overdose have jumped tremendously in the past years – to the point where naloxone distribution has become a life-saving public health initiative.  But, far more effective than treatment of overdose is prevention – and this small retrospective evaluation of Medicaid enrollees provides an insight into those at risk.

Based on an analysis of 90,010 Medicaid beneficiaries prescribed long-term opiate therapy, these authors made the following observations:
  • Patients without overlapping narcotic prescriptions, and who did not fill prescriptions at more than 3 pharmacies: 0.63% overdose incidence
  • Patients with overlapping narcotic prescriptions, and who filled prescriptions at more than 3 pharmacies: 6.09% overdose incidence
Other strongly predictive features for overdose were:
  • Morphine equivalent opioid doses >50mg per day
  • Concurrent sedative use
  • History of alcohol abuse
  • Depression diagnosis
Considering the increasing morbidity and mortality associated with opioid use and abuse, studies such as these help proactively identify those at greatest risk for early intervention.

“Defining Risk of Prescription Opioid Overdose: Pharmacy Shopping and Overlapping Prescriptions Among Long-Term Opioid Users in Medicaid”

Friday, July 10, 2015

The Utility of Urinalysis in Young Infants

When faced with the diagnostic evaluation of the young, febrile infant fewer than three months of age, the definitive tool for sepsis from urinary tract infection has traditionally been urine culture.  This stems from uncertainty over the adequacy of urinalysis sensitivity for serious bacterial infection, i.e., those truly bacteremic from a urinary source.

This is an analysis of a multicenter database of infants with bacteremia and urinary tract infection, as measured by isolation of the same pathologic organism from both blood and urine.  The key numbers:
  • Trace or greater leukocyte esterase: 97.6% (94.5-99.2) sensitive and 93.9% (87.9-97.5) specific.
  • Pyuria, >3 WBC/HPF: 96% (92.5-98.1) sensitive and 91.3% (84.6-95.6) specific.
  • Pyuria or any LE: 99.5% (98.5-100) sensitive and 87.8% (80.4-93.2) specific.
These are pretty impressive statistics, and differ significantly from the prior supposed sensitivity of the UA in young infants.  These authors postulate the problem with prior study has been its over-reliance on urine culture, and the resulting false positives.  If this seems a reasonable interpretation of the evidence, it has substantial ramifications for the diagnostic evaluation of young infants.  Importantly, it has the potential for obviating invasive procedures and unnecessary over-treatment.

I would like to see independent confirmation of these authors' findings, but, considering this study required 15 years to produce the 276 patients analyzed in this paper, this may be the best evidence we see for awhile.

“Diagnostic Accuracy of the Urinalysis for Urinary Tract Infection in Infants, 3 Months of Age”

Wednesday, July 8, 2015

High-Dose Oral Steroids for Multiple Sclerosis Flare

I am always a fan of evidence supporting treatments that are safe, efficacious, and massively less expensive than conventional care.  Even if multiple sclerosis flares are infrequently seen in the Emergency Department setting compared with, say, sepsis or chest pain, their care is part of the spectrum of our purview.

We’ve known all along oral steroids are just as useful as intravenous steroids for asthma.  However, multiple sclerosis flares are typically treated with 1000mg of intravenous methylprednisolone.  When’s the last time you gave that dose – or equivalent with another steroid – orally?

So, this is the COPOUSEP trial, and it is a non-inferiority investigation comparing three days of high-dose oral administration of methylprednisolone with intravenous.  Enrolling 199, and reporting outcomes on 90 and 93 patients in the oral and IV groups, respectively, the authors find functional improvement in the most disabling aspect persisting at 28 days in 81% for oral and 80% of IV.  Adverse effects tended to favor the intravenous cohort, with agitation and insomnia troubling the oral cohort in greater fashion than IV.  Despite these adverse effects, given the costs and inconvenience of inpatient or infusion center treatment, it is certainly reasonable to encourage patients to pursue the oral option.

Oddly, the authors omit their intention-to-treat results from the paper, and provide only the per-protocol.  The ITT results, supposedly, are available in a supplementary appendix – not yet available, apparently –  and are similar to the per-protocol outcomes.  Thus, I see no particular reason to omit the ITT, as such better reflects the efficacy and safety profile of pragmatic use; the authors should either present both together, or defer the per-protocol analysis to the appendix.

Nearly all individuals involved in the study declared conflicts of interest with multiple pharmaceutical companies, although I do not see how any would have untoward effect on the work in question.

“Oral versus intravenous high-dose methylprednisolone for treatment of relapses in patients with multiple sclerosis (COPOUSEP): a randomised, controlled, double-blind, non-inferiority trial”

Monday, July 6, 2015

Get on the Haloperidol Wagon

For many years, droperidol has been a valuable tool for nausea, vomiting, headache, and termination of psychosomatic contributors to patient distress.  Alas, droperidol availability has been markedly diminished in the U.S. in recent years, depriving us of one of our most efficacious management tools.

But, we still have plenty of haloperidol.  So, let’s use it for the same purposes.

What’s the difference between droperidol and haloperidol?  From a pharmacologic standpoint, the metabolism of haloperidol to active and toxic metabolites is far more complex than droperidol.  But, from a clinical standpoint, there is very little difference – they are both butyrophenones with similar receptor antagonism.

This paper is not terribly robust, but compares the use of haloperidol against metoclopramide for acute headache in the Emergency Department.  After pre-treatment with 25mg of IV diphenhydramine, either 10mg of IV metoclopromide or 5mg IV haloperidol was administered in double-blinded fashion.  Owing to the small sample size of 64 patients, all measures of pain reduction, nausea, restlessness, and sedation were statistically equivalent between groups, although 8 of 33 of the metoclopromide cohort required rescue medications, compared with just 1 of 31 in the haloperidol cohort.  However, telephone follow-up of patients following discharge also found the sedation and restlessness symptoms were more persistent in the haloperidol group compared with metoclopramide.

But, regardless, most of these differences – or lack thereof – is all small sample-size theatre.  However, in addition to anachronistic anesthesia research into post-operative nausea and vomiting, this reasonably reinforces what we already know: if you’ve been suffering the loss of droperidol, you ought now be using haloperidol.

“A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department.”