Early Recognition of Massive Transfusion

From trauma resuscitation, a Chinese study trying to predict who will need massive transfusion after trauma.  They have a 7-item scoring system retrospectively derived…and it’s probably not terribly helpful.

It’s a nice idea, considering there’s only so much blood readily available in the bank, and a lot of massive transfusion protocols are 1:1 with FFP and sometimes platelets, so advance warning based on the initial clinical evaluation would definitely be helpful.  There are some interesting pieces of information in the paper, although, I wish they had all their OR listed for massive transfusion, as opposed to just the ones that shook out from their stepwise regression.  Their highest predictor for massive transfusion – a hemoglobin < 7 g/dL with an OR 45.7.  SBP < 90 and positive CT or FAST were also predictors with useful OR.  Their rule is a little unusual for a theoretically beneficial intervention (massive transfusion), as they focus on specificity rather than sensitivity – probably due to a need to conserve blood component products.

In the end, though, I think most folks with a hypotensive trauma patient whose FAST is positive and a Hgb < 7 could clinically predict massive transfusion as well as this rule does.

http://www.ncbi.nlm.nih.gov/pubmed/21458905

Pediatric Sedation with Propofol

Lovely descriptive statistics of 25,000 occurrences of propofol sedation in children.

Interestingly – 75% of their sedations occurred in radiology.  My experience has primarily been to sedate children for uncomfortable procedures – but I am aware that our pediatric critical care intensivists staff the MRI machine specifically to run sedations for children for imaging.

2.3% had “serious adverse events” – although their “other adverse events” includes 1.3% who had “unexpected need for PPV”, which, to me, seems rather serious.  1% had airway obstruction, another 1% had desaturation and 0.5% had apnea.  They also did some chart mining to see if anything showed up as associated with a serious adverse event.  The highest OR was only 4.6, and that was when an “upper respiratory” diagnosis was documented in the chart.  Other associations included prematurity, and then the addition of benzo, ketamine, anticholinergics, or opioids to the sedation.

I would say there are a couple emerging trends that might help further increase sedation safety – addition of end-tidal CO2 monitoring might give better warning of apnea and desaturation, and increased use of nitrous oxide may reduce the number of propofol sedations needed.  Otherwise – be ready for too much excitement in one out of fifty pediatric sedations.

http://www.ncbi.nlm.nih.gov/pubmed/21513827

MRSA is Everywhere and You Can’t Stop It

No doubt your hospital has an infection control committee, signs for handwashing, sterile showers, plasma arc denudes, etc. and your e-mail box is filled with Journey to Zero or Destination: Excellence spam.

Unfortunately, it didn’t seem to work up at Mayo.  They had ICUs where they put signs up trying to inspire more barrier precautions and hand hygiene, they did more surveillance and topical intranasal antibiotics – and the intervention group valiantly tried to obey.  They were somewhat poor in their compliance with suggested barrier precautions, but they were used far more often than in the control clusters – and they found no differences in any of their measures of MRSA or VRE colonization or infection following their intervention.

I will certainly not argue against cleanliness and godliness, but I am impressed they published this lovely negative study to confound us and make us think about how we should go about focusing our resources effectively.

http://www.ncbi.nlm.nih.gov/pubmed/21488763

News Flash: Dilaudid Treats Pain

Albert Einstein in Montefiore is singlehandedly, repeatedly pushing literature regarding appropriate titration of pain control in the Emergency Department.  They have several previously published papers describing their hydromorphone 1 + 1 protocol, describing its safety and efficacy.  This paper is their prospective, randomized version demonstrating its safety and superiority to “usual practice”.  You could implement their protocol tomorrow and have better narcotic pain control in your ED.  It clearly works.

But the real issue this line of research uncovers is not that they’ve discovered a magic protocol.  What we’re missing by taking the simple interpretation is more that our pain control in the ED is flawed.  If you look at the morphine equivalents their patients received in this article, they’re preposterous.  I am a huge proponent of 0.1mg/kg for morphine – even in adults – and their mean dose in the “usual care” arm was 6mg morphine equivalents, and their mean additional dose was 3mg.  0.1mg/kg is a starting dose for morphine that gives less than 50% of patients adequate pain relief – which is where the second part of their protocol comes in.  Scheduled reassessment for pain and a standing order for additional medication is another area where “usual care” will obviously fall behind, simply because of the uncontrollable chaos of the ED.

So, my take home from this article is that protocolized, standing orders for narcotic analgesia in appropriately selected patients is safe and effective, and, you can use their protocol or develop your own.

http://www.ncbi.nlm.nih.gov/pubmed/21507527

Badgering Your Consultants to Death

This article describes a fascinating and absolutely untenable situation with numbers that just defy comprehension.

At an academic teaching hospital in Korea, 75% required consultation towards their admission rate of 36% – and their ED LOS median was seven hours.  Then, they implemented this brutal system in which an automated computer protocol paged out a consultation – and then, at the three hour mark – if there was still no disposition, they autopaged every resident in the consulted department.  Then, at the six hour mark, a page went out to every resident and faculty member in the consulted department regarding the disposition delay.  And their median ED LOS and time to disposition basically each improved by an hour and a half with this intervention.

So, this situation is insane.  Their admission rate is pretty high, but I still cannot fathom consulting on 75% of my patients.  And, these time to disposition numbers are equally alien, especially to a community emergency physician.  At my hospital, if a consultation goes over one hour in our EDIS, the badgering begins – but it’s more likely friendly, desperate begging as opposed to this hospital’s automated irritant spam.

So, shed a tear for Korea and their dysfunctional ED.

http://www.ncbi.nlm.nih.gov/pubmed/21496143

Intracranial Extension of Sinusitis in Children

Interesting descriptive study of a decade’s worth of children transferred/admitted to Texas Children’s in Houston with intra-orbital or intra-cranial extension of their sinusitis.  It’s really just a summary of the clinical and hospital courses of 118 patients identified through retrospective chart review.

Interesting tidbits:
– Of these patients, 40% had been prescribed outpatient courses of antibiotics prior to the time of diagnosis of intra-cranial or intra-orbital extension.
– All patients with intra-orbital involvement presented with eye swelling.
– Intra-cranial extension had substantially (and significantly) more headache and vomiting, and only 67% received antibiotics prior to transfer.
– Identical numbers in each group – 16% – of patients were afebrile upon presentation.
– 33% of patients with intracranial extension of sinusitis did not complain of a URI-like syndrome at presentation.
– Frontal sinus involvement was associated with 84% of their intra-cranial extension.
– All organisms recovered were sensitive to clindamycin or vancomycin plus cefotaxime except for a single pseudomonal infection.
– There were no deaths, and four patients had persistent neurologic or visual sequelae.

Short summary – orbital cellulitis was a little more straightforward in diagnosis than intracranial extension of sinusitis, and a significant minority of both groups would definitely diagnostic challenges.  CT imaging, anathema as it may be, is the diagnostic modality of choice.

http://www.ncbi.nlm.nih.gov/pubmed/20970813

Psychiatry & ED Agreement

Not as helpful an article as I hoped when I pulled it to peruse.  Part of the issue is the surveys are administered to psychiatry and emergency department residents regarding their evaluation of the patient, so you’re almost certain to have a lot more variability – not just in assessment, but in level of understanding of language and the process of acute psychiatric assessment.

Where I’m not surprised we have a low kappa with our psych colleagues are areas like mood disorders – as emergency physicians are looking more at threat to themselves, threat to others, acute psychosis, and other factors affecting their global level of function to determine whether they are safe for discharge.  What’s interesting are the 2×2 tables regarding things like suicidality, where psychiatry is eliciting suicidality in a significant number of individuals where that was not reported by the emergency physician.  Out in community practice where psychiatry is not always readily available, the discharge of psychiatry patients is a high-risk endeavor – and I would have expected the emergency physician to be more attuned to suicide risk and document a lot more concern for suicidality that was deemed not an issue for the consulting team.
Mostly just an article to read out of passing curiosity that won’t impact your practice.

More Conflicts of Interest

I don’t know if I’m the only one who gets depressed by these sorts of articles.  You have the progression through medical school and residency, you finally start feeling up-to-date on current treatment, your Grand Rounds invited speakers present results from some trials, and you think you’re fully armed to provide the best care modern medicine can provide.

And, then you discover that it’s all a stack of cards predicated on results influenced by pharmaceutical funding.

This article is from JAMA, again, very important topic given studies performed with pharmaceutical funding have a fourfold greater chance of reporting positive results.  They looked at meta-analysis, one of the techniques we try to use to increase statistical power in our reading of the literature.  They discovered that nearly no meta-analyses included comment on whether the included studies were funded by pharmaceutical literature – even though 60% of the studies reported funding sources, and 70% of those studies reported receiving funding from the pharmaceutical industry – and the same sort of dismal reporting for author conflicts of interest.  What it means – it’s another cautionary tale regarding how pervasive the masking of conflicts of interest really is, and how easily it creeps into the medical literature without our knowledge.

http://www.ncbi.nlm.nih.gov/pubmed/21386079

Adrenal Insufficiency in Pediatric Shock

This falls into the “don’t use etomidate” pile of literature.  Well-demonstrated, primarily in the pediatric literature, that etomidate and its association with adrenal insufficiency results in poorer outcomes in shock.  This article doesn’t look at etomidate, but rather it describes relative or absolute adrenal insufficiency in pediatric shock, and finds it relatively pervasive.  It then finds an association between their two definitions of adrenal insufficiency and length of stay, length of ventilator days, and required doses of vasopressors.  They only 5% mortality in their study, so they can’t comment on any mortality association.

So, this is another study that helps describe why etomidate may be contributing to poorer outcomes.  The days of ketamine + rocuronium RSI are coming (we’ll save the succinylcholine vs rocuronium debate for another day).

http://www.ncbi.nlm.nih.gov/pubmed/21336126

Out of Hospital Arrest Score Validation

There are nice studies in the U.S. defining and validating a rule that determines which patients are unlikely to have ROSC or survival to hospital discharge, e.g. BLS-TOR.  This is a study from France that looks at people who do have ROSC to see, not just if they’ll survive, but survival where the patient is not severely disabled or vegetative.  One of the nice things about Europe is that their cultural perception of “life” really has to do more with living, and not just simply “being alive”.  So, whether we can actually implement something like this in the U.S. may be difficult.

It’s a chart review, which limits its quality to some extent.  The other real issue I have with this OHCA score is its complexity – it incorporates initial rhythm, no-flow and low-flow intervals, and admission levels of creatinine and lactate.  The U.S. validation cohort had 34% therapeutic hypothermia, which is pretty good – the derivation cohort was only at 11%.  Predictors of good neurologic outcome, consistent with other articles: ventricular fibrillation, bystander CPR, lower creatinine and lactate.

Unfortunately, for this rule to get up to 100% specificity, the sensitivity drops to 19%.  Alternatively, you could say that’s 20% of out-of-hospital arrest ROSC that shouldn’t have further intervention, which would be an important cost and medical resource utilization savings.

So, this is something that your colleagues in critical care are going to use to discuss prognosis, although I’d like to see something along these lines that helps attenuate the number of people we resuscitate until our post-resuscitation care demonstrates much, much improved outcomes.

http://www.ncbi.nlm.nih.gov/pubmed/21494106