ED Push - March 2016 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Effects of Time Change: Fall Back, Leap Forward, Stroke Out?
TURKU, FINLAND – If you’ve noticed an uptick in stroke cases at your emergency department during mid-March, here’s a possible reason why: daylight saving time.
A new study to be presented at the American Academy of Neurology’s 68th Annual Meeting in Vancouver, Canada, next month finds that turning the clock ahead or back one hour appears to be linked to an increased risk of ischemic stroke, although the effect is only temporary.
“Previous studies have shown that disruptions in a person’s circadian rhythm, also called an internal body clock, increase the risk of ischemic stroke, so we wanted to find out if daylight saving time was putting people at risk,” explained study author Jori Ruuskanen, MD, PhD, of the University of Turku in Turku, Finland.
For the study, researchers reviewed a decade of data for stroke in Finland, comparing the rate of stroke in 3,033 patients hospitalized during the week following a daylight saving time transition to the rate of stroke in a group of 11,801 patients hospitalized either two weeks before or two weeks after that week.
Results indicate that the overall rate of ischemic stroke was 8% higher during the first two days after a daylight saving time transition. No difference was identified after two days, however.
The stroke risk increase was more pronounced in some groups, according to study authors. For example, cancer patients were 25% more likely to have a stroke after daylight saving time than during another period. The risk was also higher for older people: the over-65 cohort was 20% more likely to have a stroke right after the change in time.
On the other hand, the study found that hospital deaths from stroke did not increase in the week after a daylight saving time transition, even if stroke rates went up.
“Further studies must now be done to better understand the relationship between these transitions and stroke risk and to find out if there are ways to reduce that risk,” said Ruuskanen in an American Academy of Neurology press release.
Failing to Appropriately Admit Elderly Patients Can Have Dire Repercussions
LOS ANGELES – Deciding whether to admit or discharge an older patient can be a difficult decision for emergency physicians. A new study provides some information to help make the choice.
A matched case-control study of patients age 65 or older who died or were admitted to the intensive care unit (ICU) within seven days of being evaluated in the emergency department, published recently in Annals of Emergency Medicine, finds that older adults at the ED with cognitive impairment, a change in disposition plan from admit to discharge, low blood pressure, and elevated heart rate were more likely to be admitted to the ICU or to die within seven days.
"Emergency physicians must exercise extra caution when making the decision to admit or discharge a geriatric patient," warned Gelareh Gabayan, MD, MSHS, of the Department of Medicine at the University of California at Los Angeles. "These patients tend to be more delicate than their younger counterparts. Even abnormal vital signs, like blood pressure and heart rate, are associated with potentially catastrophic events for patients who are discharged from the ER rather than admitted."
Here are the factors identified by the study in patients 65 or older:
- A change in disposition plan from admit to discharge;
- Acute or chronic cognitive impairment or mental status changes, and
- Abnormal vital signs -- a systolic blood pressure below 120 and heart rate above 90.
Study authors explain that a change in disposition could be directed by a physician or by the patient leaving the hospital against medical advice.
"Both patient families and hospital administrators can pressure emergency physicians to discharge seniors from the emergency department, but our study supports caution in these decisions," Gabayan added in an American College of Emergency Physicians press release. "Our study identifies the patients at risk and the findings show that even seemingly small indicators can add up to something dangerous in these vulnerable patients. It is important to note, however, that this study does not encourage that all older adults be admitted. The findings should act as a tool for emergency department providers."
For the study, researchers reviewed charts of 600 ED visit records among adults older than 65 years that resulted in discharge from any of 13 hospitals within Kaiser Permanente Southern California’s integrated health system in 2009 to 2010. Randomly choosing 300 patients who experienced the combined outcome -- either death or an ICU admission shortly after ED discharge – from 1.4 million visits, the study team matched them to controls who did not experience those outcomes. Two emergency physicians blinded to the outcome reviewed the records and identified whether a number of characteristics were present.
Results indicate that characteristics associated with the combined poor outcome included cognitive impairment with an adjusted odds ratio (AOR) of 2.10; disposition plan change with an AOR of 2.71; systolic blood pressure less than 120 mm Hg with an AOR of 1.48; and pulse rate greater than 90 beats/min with an AOR of 1.66.
“Increased awareness of these high-risk characteristics may improve ED disposition decision-making,” study authors conclude.
New Study Could Alter the Way EDs Treat Abscesses in Age of MRSA
LOS ANGELES – If you think surgical drainage alone is sufficient for treating abscesses, a new study might change your view.
A study published recently in the New England Journal of Medicine finds that using trimethoprim-sulfamethoxazole in addition to drainage improves recovery.
UCLA researchers point out that their discovery is especially important now that community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has been the most common cause of skin infections in the United States since 2000.
“We found that adding in a specific antibiotic to the medical treatment also resulted in fewer recurring infections, fewer infections in other places on the body and fewer people passing on the infection to other members of the household,” explained lead author David Talan, MD. “This translates into fewer medical visits and reduced healthcare costs.”
Background information in the article notes that U.S. emergency department visits for skin infections nearly tripled from 1.2 million to 3.4 million between 1993 and 2005, with most of the increase due to a greater incidence of skin abscesses.
“Traditional teaching has been that the only treatment needed for most skin abscesses is surgical drainage — and that antibiotics don’t provide an extra benefit,” added co-author Gregory Moran, MD, in a UCLA press release. “Our findings will likely result in patients more often being recommended to take antibiotics in addition to having surgical drainage when they get a skin abscess.”
For the study, researchers examined treatment for more than 1,200 patients at five hospital EDs in Los Angeles, Baltimore, Kansas City, Philadelphia, and Phoenix to determine whether trimethoprim–sulfamethoxazole (at doses of 320 mg and 1600 mg, respectively, twice daily, for seven days) would be superior to placebo in outpatients older than 12 years of age with uncomplicated abscess treated with drainage. The median age of the participants was 35, and 45.3% had wound cultures that were positive for MRSA.
The primary outcome was defined as clinical cure of the abscess, assessed 7 to 14 days after the end of the treatment period.
Results for the modified intention-to-treat population indicate that clinical cure of the abscess occurred in 80.5% of participants in the trimethoprim–sulfamethoxazole group vs. 73.6% in the placebo group. In the per-protocol population, meanwhile, clinical cure occurred in 92.9% in the trimethoprim–sulfamethoxazole group vs. 85.7% in the placebo group.
“Trimethoprim–sulfamethoxazole was superior to placebo with respect to most secondary outcomes in the per-protocol population, resulting in lower rates of subsequent surgical drainage procedures (3.4% vs. 8.6%; difference, −5.2 percentage points; 95% CI, −8.2 to −2.2), skin infections at new sites (3.1% vs. 10.3%; difference, −7.2 percentage points; 95% CI, −10.4 to −4.1), and infections in household members (1.7% vs. 4.1%; difference, −2.4 percentage points; 95% CI, −4.6 to −0.2) 7 to 14 days after the treatment period,” study authors point out.
Progress Made in Developing Pediatric Post-Concussion Symptoms Risk Score
OTTAWA, CANADA – Even though about a third of children suffering an acute concussion go on to experience somatic, cognitive, and psychological or behavioral symptoms, emergency physicians have had little way to predict who would develop persistent post-concussion symptoms (PPCS).
A study published recently in JAMA, however, describes the results of the effort to create and validate a clinical risk score for PPCS among children presenting to the emergency department.
For the prospective, multicenter cohort study, Predicting and Preventing Postconcussive Problems in Pediatrics (5P), Children’s Hospital of Eastern Ontario-led researchers enrolled 1,205 patients aged 5 to younger than 18 who presented within 48 hours of an acute head injury at one of nine pediatric EDs within the Pediatric Emergency Research Canada (PERC) network. The derivation cohort study was conducted from August 2013 through September 2014, followed by the validation cohort from October 2014 through June 2015.
The primary outcome was defined as PPCS risk score at 28 days, which was defined as three or more new or worsening symptoms using the patient-reported Post-concussion Symptom Inventory compared with recalled state of being prior to the injury.
Results indicate that persistent post-concussion symptoms were present in 31% of patients. The 12-point PPCS risk score model for the derivation cohort included the following variables:
- female sex,
- age 13 or older,
- physician-diagnosed migraine history,
- prior concussion with symptoms lasting longer than one week,
- headache,
- sensitivity to noise,
- fatigue,
- answering questions slowly, and
- four or more errors on the Balance Error Scoring System tandem stance.
“The area under the curve was 0.71 (95% CI, 0.69-0.74) for the derivation cohort and 0.68 (95% CI, 0.65-0.72) for the validation cohort,” study authors report.
“A clinical risk score developed among children presenting to the emergency department with concussion and head injury within the previous 48 hours had modest discrimination to stratify PPCS risk at 28 days,” the researchers conclude. “Before this score is adopted in clinical practice, further research is needed for external validation, assessment of accuracy in an office setting, and determination of clinical utility."
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