ED Push - May 2015 First Issue
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Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Asthma “Oversharing” Helps EDs Predict Daily Traffic
TUCSON, AZ – Believe it or not, some people suffering an acute asthma attack take the time to tweet about their experiences.
As bizarre as that level of oversharing might seem, it actually benefits emergency departments, according to a new study in the IEEE Journal of Biomedical and Health Informatics' special issue on big data. University of Arizona researchers found that Twitter data coupled with air quality sensors can help predict ED traffic.
The researchers, led by Sudha Ram, PhD, a UA professor of management information systems and computer science, created a model that was able to use asthma-related tweets along with electronic medical record information and data from air quality sensors to successfully predict approximately how many asthma sufferers would visit the ED at a large hospital in Dallas on a given day.
"We realized that asthma is one of the biggest traffic generators in the emergency department," Ram said. "Often what happens is that there are not the right people in the ED to treat these patients, or not the right equipment, and that causes a lot of unforeseen problems."
The study team, including researchers from the Parkland Center for Clinical Innovation in Dallas, collected air quality data from environmental sensors in the vicinity of the hospital while simultaneously gathering and analyzing tweets containing certain keywords such as "asthma," "inhaler" or "wheezing." Text-mining techniques then were used to drill down to relevant tweets in the ZIP codes detailing where most of the hospital's patients live, as determined by electronic medical records.
As certain air quality measures worsened, asthma visits to the ED went up, the researchers determined. Asthma visits also increased as the number of asthma-related tweets went up. While researchers also looked at asthma-related Google searches in the area, they found those were not a good predictor for ED visits.
The researchers employed machine learning algorithms to predict with 75% accuracy whether the emergency room could expect a low, medium or high number of asthma-related visits on a specific day.
"You can get a lot of interesting insights from social media that you can't from electronic health records," Ram said. "You only go to the doctor once in a while, and you don't always tell your doctor how much you've been exercising or what you've been eating. But people share that information all the time on social media. We think that prediction models like this can be very useful, if we can combine various types of data, to address chronic diseases."
Determining Risk of Second Occurrence Affects First Seizure Treatment
WASHINGTON, DC – Adults who have a first seizure have the greatest risk of another within two years. How much risk, however, has been hard to determine. In fact, the risk could range from about 21% to more than twice that at 45%.
A new guideline from the American Academy of Neurology and the American Epilepsy Society, appearing recently in the journal Neurology, offers valuable information on gauging the risk, which can help determine appropriate treatment.
The guideline cites strong evidence that the risk of a second seizure is greatest in patients with a previous brain problem, such as head injury, stroke, or brain tumor and in those with an EEG test result that indicate the possibility of epilepsy.
The risk also appears to be greater when a significant abnormality shows up in brain imaging and when the seizure occurred during sleep, although the evidence for that is only moderate, according to the report.
"This is a valuable new guideline that could change the approach many doctors take to treating a first seizure and could improve patients' lives," said guideline author Allan Krumholz, MD, of the University of Maryland School of Medicine. "About 150,000 adults have an unprovoked first seizure in the United States each year. Even one seizure is traumatic and affects a person's life in many social ways, such as driving a car, employment options, falling risks and the fear of having another seizure in public. This guideline clarifies when risk factors put individuals at greater risk."
Determining the risk is crucial because the article emphasizes that having patients take epilepsy drugs immediately after a first seizure may reduce the risk of having another one. When to treat, however, can be a difficult decision for emergency physicians and other clinicians, because the risks and benefits for each patient must be weighed.
The evidence of effectiveness also isn’t irrefutable. After more than three years, immediate treatment with an epilepsy drug, rather than waiting for another seizure before treating, rarely increases or decreases the likelihood of long-term improvement, according to moderate evidence cited by the guideline.
At the same time, epilepsy drugs carry risks of side effects that complicate treatment in 7% to 31% of patients, the report points out.
"This guideline does not give a simple, black-and-white recommendation whether an adult should immediately be started on an epilepsy drug," explained Jacqueline French, MD, of the New York University Langone Comprehensive Epilepsy Center. "What is most important is that the decision whether to immediately treat a first seizure requires meaningful conversation between patient and doctor so that the patient's individual circumstances, balance of risks and benefits, and personal preferences are understood and accounted for."
Background in the article notes that one in 10 people worldwide have a first seizure in their lifetime, although many of those could be non-recurring and caused by situations such as low blood sugar, not epilepsy.
Is Droperidol Safe for ED Sedation Despite Black Box Warning?
NEWCASTLE, AUSTRALIA – Emergency physicians practicing before 2001 will recall that droperidol often was used to help manage patients who were violent or aggressive because of issues such as mental illness, intoxication or attempts to harm themselves.
That changed after the FDA added a black box warning to droperidol’s label, reporting an unknown number of case reports of ventricular arrhythmias (including Torsades des pointes) and associated patient deaths.
A new Australian study suggests, however, that droperidol is safe and effective for calming out-of-control ED patients. The report published online recently in Annals of Emergency Medicine maintains the negative effects leading to the black box warning are actually quite rare.
"In our study, the two side effects that led to the black box warning – QT prolongation and Torsades des pointes, both heart rhythm disorders – turned out to be rare and non-existent, respectively," said lead study author Geoff Isbister, MD, of Calvary Mater Newcastle Emergency Department in Newcastle, Australia. "In addition, almost all patients were sedated within two hours, which of course is the goal with an agitated patient. We did find some adverse effects in patients who were sedated with droperidol in combination with benzodiazepines."
Background information in the article notes that droperidol is a sedating anti-psychotic agent used for many years to treat acute behavior disturbance. It was commonly administered to emergency patients who were violent and/or aggressive because of mental illness, intoxication and/or deliberate self-harm.
"The goal in the management of patients with acute behavioral disturbance is to ensure safety for the patient, staff and other patients in the emergency department,” Isbister added. "Although our study supports concerns about using benzodiazepines in conjunction with droperidol, high-dose droperidol on its own seems to be both safe and effective for patients who are potentially dangerous to themselves and others."
For the prospective observational study in six EDs from August 2009 to April 2013, adult patients requiring parenteral sedation for acute behavioral disturbance – a total of 1,009 – were administered 10 mg of droperidol. If that did not sedate the patient within 15 minutes, further sedation was allowed, but droperidol 10 mg was recommended as part of the sedation protocol.
The proportion of patients with an abnormal QT interval, defined by the at-risk line on the QT nomogram, was the primary outcome. Secondary outcomes were defined as effectiveness determined by the time to sedation measured on the Sedation Assessment Tool, use of additional sedation, adverse events, and injury to staff or patients, according to the report.
Of the patients sedated with droperidol, six had an abnormal QT not attributed to other factors, such as pharmaceutical intoxication, while none developed Torsades des pointes.
Study authors note that adverse effects occurred in 5% and that over sedation without complications occurred in 8% of patients, most of them administered benzodiazepines in addition to droperidol.
Sensitive Cardiac Troponin Assays Accelerate MI Rule-outs, Rule-Ins
BASEL, SWITZERLAND – Can a new algorithm speed the process by which emergency physicians rule-out or rule-in myocardial infarction (MI)?
A recently published study by Swiss and Spanish researchers suggests it can. Led by investigators from the Universitätsspital Basel in Switzerland, the trial’s results appeared online recently in CMAJ, the Canadian Medical Association Journal.
"Introducing the high-sensitivity cardiac troponin T 1-hour algorithm into clinical practice would represent a profound change and it is therefore important to determine if it works in a large patient group," noted lead author Tobias Reichlin, MD, of the Division of Cardiology at University Hospital Basel.
The algorithm previously was tested in a small pilot study, also led by Reichlin, which was published in JAMA Internal Medicine in 2012. Noting that MIs account for about 10% of all ED consultations, the authors suggested that the newly developed sensitive and high-sensitivity cardiac troponin (hs-cTn) assays enabled measurement of cTn concentrations not reliably detected with prior generations of tests. They also raised the possibility that the new tests, which have been shown to improve the diagnostic accuracy in the early diagnosis of MI, would make it possible to rule-in or rule-out heart attacks more rapidly.
For the more recent clinical trial of the algorithm, the researchers enrolled 1,320 patients who visited EDs with suspected acute MI and applied the algorithm to blood samples.
As a result, the authors report, they were able to determine that 786 (60%) of patients did not have an acute MI, 216 (16%) were "rule-in" and 318 (24%) were to be observed because of inconclusive results.
The final diagnoses were then reviewed by two independent cardiologists using all available information, including coronary angiography, echocardiography, follow-up data and serial measurements of high-sensitivity cardiac troponin T levels. After that process, acute MI was the final diagnosis in 17.3% of patients.
Cumulative 30-day mortality was 0.0%, 1.6% and 1.9% in patients classified in the rule-out, observational and rule-in groups, respectively.
“This rapid strategy incorporating high-sensitivity cardiac troponin T baseline values and absolute changes within the first hour substantially accelerated the management of suspected acute MI by allowing safe rule-out as well as accurate rule-in of acute MI in 3 out of 4 patients,” the study concludes.
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