ED Push - August 2016 Second Issue

EDs Need to Prepare for More Zika Virus Evaluation

IRVINE, CA – With the Olympic Games ongoing in Zika virus hotspot Brazil and travel advisories recently issued for a small section of Miami, emergency departments are likely to evaluate patients concerned about the illness, especially pregnant women, even if the diagnosis ends up being something else.

An article published in the Emergency Medicine Clinics of North America publication reviewed what emergency physicians need to know about Zika, its diagnosis, and treatment.

“Associations between Zika virus with congenital anomalies and Guillain Barre syndrome (GBS) underscore the importance of understanding strategies for management and control of the virus,” write the authors, led by University of California, Irvine researchers. “There is significant concern for risk to pregnant women/women of reproductive age and the risks associated with the spreading disease and with travel to endemic areas. Preparations for the 2016 Olympic Games in Brazil cast an increased sense of urgency on the need for improved assessment/identification, management, and containment of Zika virus.”

Study authors add, “Given the potential for increased numbers of infected individuals, it is essential that emergency providers equip themselves with the knowledge and background necessary to effectively assess, manage, and counsel patients.”

Key points of the article include:

• Zika virus is a mosquito-borne arbovirus.
• Most individuals infected with Zika virus have minimal or no symptoms.
• If present, typical symptoms include rash, conjunctivitis, and fever.
• Pregnant women infected with Zika, particularly during the first trimester, appear to be at increased risk of having infants with congenital abnormalities such as microcephaly.
• There is currently no vaccine or treatment for Zika virus. Prevention through minimizing mosquito bites is the best means of decreasing risk of infection.

The review notes that the virus has an incubation period of three to 12 days, usually followed by a subclinical or mild illness. The usually mild symptoms, if present, typically last for two to seven days, according to the article, and could include fever, conjunctivitis, arthralgia/myalgia, diffuse rash, headache, retro-orbital pain, peripheral edema, and/or gastrointestinal upset.

While severe acute infections with Zika virus are rare, research has detected an association, and likely a causal relationship, with the serious sequelae of Guillain–Barre syndrome (GBS). In addition, subsequent studies established a possible link between Zika virus infection and congenital complications, including microcephaly in infants.

Differential diagnoses for Zika include dengue fever, chikungunya virus, initial human immunodeficiency virus (HIV) seroconversion, measles, scarlet fever, rickettsial infection, leptospirosis, parvovirus, enterovirus, rubella, and secondary syphilis.

“Given the nonspecific nature of the signs/symptoms and the broad differential diagnosis, clinical presentation alone is insufficient to make the diagnosis without confirmatory laboratory testing,” according to the report, which recommends RT-PCR testing of blood and saliva. That can be accomplished only with assistance from public health authorities, however, and is not yet available at individual hospitals. As a result, according to review authors, results generally are not accessible in a timely fashion and false-positive results are common.

The article advises that initial evaluation involve a thorough travel history and that a history of sexual contact with at-risk travelers be obtained. Because Zika is a nationally reportable condition, it adds, public health officials must be informed if a case is suspected.

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Toddlers, Not Adult Workers, Most Likely to Suffer Chemical Eye Burns

BALTIMORE – While even emergency clinicians might assume that most chemical eye burns usually occur in adults working in industry or other businesses where dangerous chemicals are in use, that actually isn’t the case.

At the highest risk of severe eye injury from chemicals are 1- and 2-year-old children, according to a report in JAMA Ophthalmology.

The Johns Hopkins Bloomberg School of Public Health-led research suggests more education is needed so that the avoidable but potentially permanent injuries occur less often. The study notes that factories and other businesses where dangerous chemicals are in use usually provide precautions such as safety goggles and treatments such as eye-wash stations.

"These are terrible injuries; they occur most frequently in the smallest of children and they are entirely preventable," explained study leader R. Sterling Haring, DO, MPH, a DrPH candidate in the Department of Health Policy and Management at the Bloomberg School of Public Health. "These children do not deal with chemicals on the job. They are injured largely because they get into chemicals such as household cleaners that are improperly stored."

Because chemicals continue to burn into the eye after contact, internal structures can be damaged irreparably, according to the study, touted as the first to use a national sample across all age groups. Researchers found that the most common type of injuries for young children came from alkaline agents — commonly found in cleansers — rather than from battery and sulfuric acids. Damage from alkaline agents continues unless the chemical is flushed out of the eye by running tap water over it for many minutes, Haring pointed out.

For the research, the study team analyzed four years of data from the Nationwide Emergency Department Sample, which includes information from roughly 30 million annual emergency department visits from more than 900 hospitals across the United States.

Results indicate that more than 144,000 emergency department visits related to chemical eye burns occurred nationwide between 2010 and 2013, most commonly occurring at home, in children in the bottom half of the income scale, and in the South.

With injuries most common among 1- and 2-year-olds, 1-year-olds were found to be twice as likely to suffer eye burns as 24-year-olds, who had the highest rate among adults. Injuries dropped off significantly once children were old enough to understand the dangers; 1-year-olds were 13 times more likely than 7-year-olds to burn their eyes.

Haring suggested that keeping household cleaners and other chemicals — most notably products in spray bottles — out of reach of young children could prevent the issue and called for a redesign so that the bottles were locked in place after each use.

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Number of Patients Dying in EDs Declines Dramatically

SAN FRANCISCO – You and your emergency department team must be doing something right.

A study recently published in the journal Health Affairs found that, between 1997 and 2011, mortality rates for adults plummeted nearly 50% in U.S. EDs.

The study, led by researchers from the University of San Francisco, is believed to be the first national study of this type. It involved analysis of ED visit data from the National Hospital Ambulatory Medical Care Survey from 1997 to 2011.

ED mortality rates were found to have decreased from 1.48 per thousand in 1997 to 0.77 per thousand U.S. adults in 2011, a 48% reduction. Study authors posit a range of potential explanations for the mortality rate drop, including:

• improvements in emergency medicine and prehospital care;
• the increasing role of palliative care, which results in patients dying outside EDs in hospice settings; and
• an overall decline in mortality trends in the U.S. population during the study period due to continued public health achievements.

More than 136 million emergency department visits took place in the United States in 2011, the latest year for which data are available, according to the U.S. Centers for Disease Control and Prevention. About 40 million of those visits were injury-related, and almost 12% resulted in hospital admission.

Compared to patients who survived, those who died tended to be older, more likely to be male and white, and were more severely ill or injured when brought to the ED. In nearly 63% of the mortality cases, patients were in cardiac arrest, unconscious, or dead on arrival, according to the study.

Overall, shortness of breath, injury, or chest pain were the most common presentations resulting in death, according to the report.

The national Centers for Disease Control and Prevention data set, which was used for the study, represents more than 1.3 billion patient visits, making it one of the largest nationally representative data sets for information on emergency conditions in the United States.

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Vasopressin or Norepinephrine to Avoid Kidney Failure After Septic Shock?

LONDON, UK – Early vasopressin use has been proposed as an alternative to norepinephrine in treating septic shock to avoid kidney failure. A new study, however, didn’t find an increase in the number of kidney failure-free days with that approach.

The research, published recently in JAMA, sought to compare the effect of early vasopressin vs. norepinephrine on kidney failure in patients with septic shock.

To do that, a study team led by Imperial College London researchers conducted a double-blind, randomized clinical trial in 18 general adult intensive care units in the United Kingdom between February 2013 and May 2015. Enrolled were 409 adult patients, median age 66 years and 58.2% male, who had septic shock requiring vasopressors, despite fluid resuscitation within a maximum of six hours after the onset of shock. The median time to study drug administration after diagnosis of shock was 3.5 hours.

For the study, patients were randomly allocated to vasopressin (titrated up to 0.06 U/min) and hydrocortisone; vasopressin and placebo; norepinephrine and hydrocortisone; or norepinephrine and placebo.

Researchers looked to quantify the number of kidney failure–free days during the 28-day period after randomization. That was measured as the proportion of patients who never developed kidney failure as well as the median number of days alive and free of kidney failure for patients who did not survive, who experienced kidney failure, or both. Secondary outcomes included rates of renal replacement therapy, mortality, and serious adverse events.

Results indicate that 57% of survivors in the vasopressin group and 59.2% in the norepinephrine group never developed kidney failure.

Meanwhile, the median number of kidney failure–free days for patients who did not survive, who experienced kidney failure, or both was nine in the vasopressin group and 13 in the norepinephrine group.

Researchers note less use of renal replacement therapy in the vasopressin group than in the norepinephrine group — 25.4% for vasopressin vs. 35.3% for norepinephrine — and no significant difference in mortality rates between groups was detected.

Overall, 10.7% of patients had a serious adverse event in the vasopressin group compared to 8.3% in the norepinephrine group, the study points out.

“Among adults with septic shock, the early use of vasopressin compared with norepinephrine did not improve the number of kidney failure–free days,” study authors conclude. “Although these findings do not support the use of vasopressin to replace norepinephrine as initial treatment in this situation, the confidence interval included a potential clinically important benefit for vasopressin, and larger trials may be warranted to assess this further.”

Background information in the article notes that, in 2015, an estimated 230,000 cases of septic shock occurred in the United States, leading to more than 40,000 deaths.

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