Vote which Annals of EM articles to be open-access in July

Here’s your chance to help choose two articles to be open access in July’s Annals of Emergency Medicine . Take a look at the article abstracts accepted for publication in July’s issue. Vote on your top two choices over the next 4 days, and the top two will be made open after the July issue of Annals of EM goes online.

This may be the last month we are doing this, so if you like this opportunity, please vote! Your participation will help us decide whether or not to continue this feature.

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Absorbing Citywide Patient Surge During Hurricane Sandy: A Case Study in Accommodating Multiple Hospital Evacuations

Amesh A. Adalja, Matthew Watson, Nidhi Bouri, Kathleen Minton,et al.

Study objective

Hospital evacuations have myriad effects on all elements of the health care system. We seek to (1) examine the effect of patient surge on hospitals that received patients from evacuating hospitals in New York City during Hurricane Sandy; (2) describe operational challenges those hospitals faced pre- and poststorm; and (3) examine the coordination efforts to distribute patients to receiving hospitals.

Methods

We used a qualitative, interview-based method to identify medical surge strategies used at hospitals receiving patients from evacuated health care facilities during and after Hurricane Sandy. We identified 4 hospital systems that received the majority of evacuated patients and those departments most involved in managing patient surge. We invited key staff at those hospitals to participate in on-site group interviews.

Results

We interviewed 71 key individuals. Although all hospitals had emergency preparedness plans in place before Hurricane Sandy, we identified gaps. Insights gleaned included improvement opportunities in these areas: prolonged increased patient volume, an increase in the number of methadone and dialysis patients, ability to absorb displaced staff, the challenges associated with nursing homes that have evacuated and shelters that have already reached capacity, and reimbursements for transferred patients.

Conclusion

Our qualitative, event-based research identified key opportunities to improve disaster preparedness. The specific opportunities and this structured postevent approach can serve to guide future disaster planning and analyses.

 

Association Between Survival and Early Versus Later Rhythm Analysis in Out-of-Hospital Cardiac Arrest: Do Agency-Level Factors Influence Outcomes?

Thomas Rea, David Prince, Laurie Morrison, Clifton Callaway, et al.

Study objective

Effectiveness of a resuscitation strategy may vary across communities. We hypothesize that a strategy that prioritizes initial emergency medical services (EMS) rhythm analysis (analyze early) will be associated with survival advantage among EMS systems with lower baseline (pretrial) ventricular fibrillation survival, whereas a strategy that prioritizes initial EMS cardiopulmonary resuscitation (analyze late) will be associated with survival advantage among systems with higher ventricular fibrillation baseline survival.

Methods

We conducted a secondary, post hoc study of a randomized trial of out-of-hospital cardiac arrest. Subjects were stratified according to randomization status (analyze early versus analyze late) and EMS agency baseline ventricular fibrillation survival. We used a mixed-effects model to determine whether the association between favorable functional survival to hospital discharge and trial intervention (analyze late versus analyze early) differed according to EMS agency baseline ventricular fibrillation survival (<20% or >20%).

Results

Characteristics were similar among patients randomized to analyze early (n=4,964) versus analyze late (n=4,426). For EMS agencies with baseline ventricular fibrillation survival less than 20%, analyze late compared with analyze early was associated with a lower likelihood of favorable functional survival (3.8% versus 5.5%; odds ratio [OR]=0.67 [95% CI 0.50, 0.90]). Conversely, among agencies with a ventricular fibrillation survival greater than 20%, analyze late compared with analyze early was associated with higher likelihood of favorable functional survival (7.5% versus 6.1%; OR=1.22 [95% CI 0.98, 1.52]). In the multivariable-adjusted model, for every 10% increase in baseline ventricular fibrillation survival, analyze late versus analyze early was associated with a 34% increase in odds of favorable functional survival (OR=1.34 [95% CI 1.07 to 1.66]).

Conclusion

The findings suggest that system-level characteristics may influence resuscitation outcomes.

 

Clinical, Laboratory, Diagnostic, and Histopathologic Features of Diethylene Glycol Poisoning—Panama, 2006

Nestor R. Sosa, Giselle M. Rodriguez, Joshua G. Schier, James J. Sejvar

Study objective

Diethylene glycol is a toxic industrial solvent responsible for more than 13 mass poisonings since 1937. Little is known about the clinical spectrum, progression, and neurotoxic potential of diethylene glycol–associated disease because of its high mortality and the absence of detailed information in published mass poisoning reports. This incident includes the largest proportion of cases with neurotoxic signs and symptoms. We characterize the features of a diethylene glycol mass poisoning resulting from a contaminated cough syrup distributed in Panama during 2006.

Methods

This was a retrospective chart review and descriptive analysis in a tertiary level, urban health care facility. A case was a person admitted to the Social Security Metropolitan Hospital in Panama City between June 1 and October 22, 2006, with unexplained acute kidney injury and a serum creatinine level of greater than or equal to 2 mg/dL, or unexplained chronic renal failure exacerbation (>2-fold increase in baseline serum creatinine level) and history of implicated cough syrup exposure. Main outcomes and measures were demographic, clinical, laboratory, diagnostic, histopathologic, and mortality data with descriptive statistics.

Results

Forty-six patients met inclusion criteria. Twenty-four (52%) were female patients; median age was 67 years (range 25 to 91 years). Patients were admitted with acute kidney injury or a chronic renal failure exacerbation (median serum creatinine level 10.0 mg/dL) a median of 5 days after symptom onset. Forty patients (87%; 95% confidence interval [CI] 74% to 95%) had neurologic signs, including limb (n=31; 77%; 95% CI 62% to 89%) or facial motor weakness (n=27; 68%; 95% CI 51% to 81%). Electrodiagnostics in 21 patients with objective weakness demonstrated a severe sensorimotor peripheral neuropathy (n=19; 90%; 95% CI 70% to 99%). In 14 patients without initial neurologic findings, elevated cerebrospinal fluid protein concentrations without pleocytosis were observed: almost all developed overt neurologic illness (n=13; 93%; 95% CI 66% to 100%). Despite use of intensive care and hemodialysis therapies, 27 (59%) died a median of 19 days (range 2 to 50 days) after presentation.

Conclusion

A high proportion of patients with diethylene glycol poisoning developed progressive neurologic signs and symptoms in addition to acute kidney injury. Facial or limb weakness with unexplained acute kidney injury should prompt clinicians to consider diethylene glycol poisoning. Elevated cerebrospinal fluid protein concentrations without pleocytosis among diethylene glycol–exposed persons with acute kidney injury may be a predictor for progressive neurologic illness.

 

Critical Care Paramedics – a Missing Component for Safe Interfacility Transport in the United States (Editorial)

Douglas F Kupas, MD, Henry E Wang, MD, MS

 

Critical Events During Land-Based Interfacility Transport

Jeffrey M. Singh, Russell D. MacDonald, Mahvareh Ahghari

Study objective

The risks associated with urgent land-based transport of critically ill patients are not well known and have important implications for patient safety, care delivery, and policy development. We seek to determine the incidence of in-transit critical events and associated patient- and transport-level factors.

Methods

We conducted a retrospective cohort study using clinical and administrative data. We included adults undergoing urgent land-based critical care transport by a dedicated transport provider between January 1, 2005, and December 31, 2010. The primary outcome was in-transit critical event, defined by adverse events or resuscitative procedures.

Results

In-transit critical events were observed in 333 (6.5%) of 5,144 urgent land transports. New hypotension (4.4%) or new vasopressors (1.6%) were the most common critical events, with fewer respiratory events (1.3%). Advanced care paramedics had a higher rate compared with critical care paramedics (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.1 to 2.2), especially for patients with baseline hemodynamic instability. In multivariate analysis, mechanical ventilation (adjusted OR 1.7; 95% CI 1.3 to 2.2), baseline hemodynamic instability (adjusted OR 3.7; 95% CI 2.8 to 4.9), out-of-hospital duration (adjusted OR 3.6; 95% CI 2.9 to 4.5 per log-fold increase in time), and neurologic diagnosis (adjusted OR 0.5; 95% CI 0.3 to 0.7 compared with that of medical patients) were associated with critical events.

Conclusion

Critical events occurred in approximately 1 in 15 transports and were associated with mechanical ventilation, hemodynamic instability, and transport duration, and were less frequent in neurologic patients. The finding that hypotension is common and predicted by pretransport hemodynamic instability has implications for the preparation and management of this patient group.

 

Does Noninvasive Ventilation Have a Role in Chest Trauma Patients? (Editorial)

Angela Hua, Kaushal H. Shah

 

Emergency Department Identification and Critical Care Management of a Utah Prison Botulism Outbreak

Benjamin T. Williams, Sarah M. Schlein, E.Martin Caravati, Holly Ledyard, et al.

Study objective

We report botulism poisoning at a state prison after ingestion of homemade wine (pruno).

Methods

This is an observational case series with data collected retrospectively by chart review. All suspected exposures were referred to a single hospital in October 2011.

Results

Twelve prisoners consumed pruno, a homemade alcoholic beverage made from a mixture of ingredients in prison environments. Four drank pruno made without potato and did not develop botulism. Eight drank pruno made with potato, became symptomatic, and were hospitalized. Presenting symptoms included dysphagia, diplopia, dysarthria, and weakness. The median time to symptom onset was 54.5 hours (interquartile range [IQR] 49-88 hours) postingestion. All 8 patients received botulinum antitoxin a median of 12 hours post–emergency department admission (IQR 8.9-18.8 hours). Seven of 8 patients had positive stool samples for type A botulinum toxin. The 3 most severely affected patients had respiratory failure and were intubated 43, 64, and 68 hours postingestion. Their maximal inspiratory force values were −5, −15, and −30 cm H2O. Their forced vital capacity values were 0.91, 2.1, and 2.2 L, whereas the 5 nonintubated patients had median maximal inspiratory force of −60 cm H2O (IQR −60 to −55) and forced vital capacity of 4.5 L (IQR 3.7-4.9). Electromyography abnormalities were observed in 1 of the nonintubated and 2 of the intubated patients.

Conclusion

A pruno-associated botulism outbreak resulted in respiratory failure and abnormal pulmonary parameters in the most affected patients. Electromyography abnormalities were observed in the majority of intubated patients. Potato in the pruno recipe was associated with botulism.

 

Extension Test and Ossal Point Tenderness Cannot Accurately Exclude Significant Injury in Acute Elbow Trauma

Kim E. Jie, Lisette F. van Dam, Thijs F. Verhagen, Eric R. Hammacher

Study objective

Elbow injury is a common presentation at the emergency department (ED). There are no guidelines indicating which of these patients require radiography, whereas clinical decision rules for other limb injuries are widely accepted and resulted in less radiography and reduced waiting times. We aim to identify clinical signs that can be used to predict the need for radiography in elbow injury.

Methods

A prospective observational study at 2 ED locations in the Netherlands was performed. For every eligible patient with acute elbow injury, elbow extension and addition of point tenderness at the olecranon, epicondyles, and radial head were evaluated for predicting the need for radiography (primary endpoint). A subgroup of patients was assessed by a blinded second investigator to analyze interobserver variability (secondary endpoint). All patients received anterior-posterior and lateral elbow radiographs. Fractures were treated according to current guidelines and patients were followed at outpatient clinics.

Results

In total, 587 patients were included. Normal extension was observed in 174 patients (30%). Normal extension predicted absence of a fracture or isolated fat pad with 88% sensitivity and 55% specificity. Five patients with normal extension had a fracture that required surgery. Absence of point tenderness in patients with normal extension was observed in only 24 patients, of whom 3 showed a fracture and 1 required surgery. Addition of point tenderness to the extension test to predict absence of a fracture or isolated fat pad resulted in 98% sensitivity and 11% specificity. Interobserver analysis for extension and palpation of olecranon, epicondyles, and radial head resulted in κ values between 0.6 and 0.7.

Conclusion

In contrast with previous studies, ours shows that in acute elbow injury, the extension test alone or in combination with point tenderness assessment does not safely rule out clinically significant injury. Interobserver variability was substantial. We would not recommend the use of the extension test (+/– point tenderness assessment) as a clinical decision rule to guide radiologic diagnostics in acute elbow trauma.

 

Many Emergency Department Patients With Severe Sepsis and Septic Shock Do Not Meet Diagnostic Criteria Within Three Hours of Arrival

Julian Villar, MD, MPH, Joseph P Clement, RN MS, Jim Stotts, RN MS, Daniel Linnen, RN MS, David J Rubin, RN BSN, David Thompson, MD, Antonio Gomez, MD, Christopher Fee, MD

Objective
Proposed national performance measures for severe sepsis/septic shock include interventions within 3 hours of emergency department (ED) arrival rather than from time of first meeting diagnostic criteria. We aimed to determine the percentage of ED patients who first meet criteria >3 hours after arrival.

Methods
We conducted a retrospective analysis of adult patients with severe sepsis/septic shock in 2 EDs (university hospital (September 2012 – June 2013) and public trauma center (December 2012 – May 2013)). Times of ED arrival and first meeting clinical criteria
were collected for quality assurance programs which differed between institutions. At the university hospital, patients with admission diagnoses consistent with infection were included. Clinical presentation was defined as time meeting 2 or more systemic
inflammatory response syndrome criteria and evidence of end-organ dysfunction. At the trauma center, only patients with hospital discharge diagnoses consistent with infection were included. Clinical presentation was defined by time of end-organ dysfunction.

Results
372 patients met inclusion criteria at the university hospital and 133 at the trauma center. Median times from ED arrival to first meeting criteria were 68 min (IQR 34–130 min) and 31 min (IQR 8 – 73 min), respectively. 15.3% (95% CI 11.9 – 19.3%) and 9.8%  (95% CI 5.5-15.7%) first met criteria >3 hours from ED arrival, respectively.

Conclusions
Compliance with a performance metric for severe sepsis and septic shock within 3 hours of ED arrival would require application of this measure to patients who do not meet diagnostic criteria, potentially resulting in unnecessary interventions. Measure developers should consider these findings.

 

Ondansetron and the Risk of Cardiac Arrhythmias: A Systematic Review and Postmarketing Analysis

Stephen B. Freedman, Elizabeth Uleryk, Maggie Rumantir, Yaron Finkelstein

Study objective

To explore the risk of cardiac arrhythmias associated with ondansetron administration in the context of recent recommendations for identification of high-risk individuals.

Methods

We conducted a postmarketing analysis and systematically reviewed the published literature, grey literature, manufacturer’s database, Food and Drug Administration Adverse Events Reporting System, and the World Health Organization Individual Safety Case Reports Database (VigiBase). Eligible cases described a documented (or perceived) arrhythmia within 24 hours of ondansetron administration. The primary outcome was arrhythmia occurrence temporally associated with the administration of a single, oral ondansetron dose. Secondary objectives included identifying all cases associating ondansetron administration (any dose, frequency, or route) to an arrhythmia.

Results

Primary: No reports describing an arrhythmia associated with single oral ondansetron dose administration were identified.Secondary: Sixty unique reports were identified. Route of administration was predominantly intravenous (80%). A significant medical history (67%) or concomitant use of a QT-prolonging medication (67%) was identified in 83% of reports. Approximately one third occurred in patients receiving chemotherapeutic agents, many of which are known to prolong the QT interval. An additional third involved administration to prevent postoperative vomiting.

Conclusion

Current evidence does not support routine ECG and electrolyte screening before single oral ondansetron dose administration to individuals without known risk factors. Screening should be targeted to high-risk patients and those receiving ondansetron intravenously.

Pretreatment With Intravenous Lipid Emulsion Reduces Mortality From Cocaine Toxicity in a Rat Model

Stephanie Carreiro, Jared Blum, Jason B. Hack

Study objective

We compare the effects of intravenous lipid emulsion and normal saline solution pretreatment on mortality and hemodynamic changes in a rat model of cocaine toxicity. We hypothesize that intravenous lipid emulsion will decrease mortality and hemodynamic changes caused by cocaine administration compared with saline solution.

Methods

Twenty male Sprague-Dawley rats were sedated and randomized to receive intravenous lipid emulsion or normal saline solution, followed by a 10 mg/kg bolus of intravenous cocaine. Continuous monitoring included intra-arterial blood pressure, pulse rate and ECG tracing. Endpoints included a sustained undetectable mean arterial pressure (MAP) or return to baseline MAP for 5 minutes. The log-rank test was used to compare mortality. A mixed-effect repeated-measures ANOVA was used to estimate the effects of group (intravenous lipid emulsion versus saline solution), time, and survival on change in MAP, pulse rate, or pulse pressure.

Results

In the normal saline solution group, 7 of 10 animals died compared with 2 of 10 in the intravenous lipid emulsion group. The survival rate of 80% (95% confidence interval 55% to 100%) for the intravenous lipid emulsion rats and 30% (95% confidence interval 0.2% to 58%) for the normal saline solution group was statistically significant (P=.045).

Conclusion

Intravenous lipid emulsion pretreatment decreased cocaine-induced cardiovascular collapse and blunted hypotensive effects compared with normal saline solution in this rat model of acute lethal cocaine intoxication. Intravenous lipid emulsion should be investigated further as a potential adjunct in the treatment of severe cocaine toxicity.

 

Snapshot From Superstorm Sandy: American Red Cross Mental Health Risk Surveillance in Lower New York State

Merritt D. Schreiber, Rob Yin, Mostafa Omaish, Joan E. Broderick

Study objective

Disasters often cause psychological injury, as well as dramatic physical damage. Epidemiologic research has identified a set of disaster experiences and predisposing characteristics that place survivors at risk for post traumatic stress disorder (PTSD), depression, and anxiety. Rapid triage of at-risk survivors could have benefits for individual and population-level outcomes. We examine American Red Cross mental health risk surveillance data collected from October 29 to November 20, 2012, immediately after Hurricane Sandy in 8 lower New York State counties to evaluate the feasibility and utility of collecting these data.

Methods

PsySTART, an evidence-based disaster mental health triage tool, was used to record survivor-reported risk factors after each survivor contact. Red Cross disaster mental health volunteers interfaced with survivors at disaster operation sites, including shelters, emergency aid stations, and mobile feeding and community outreach centers. Risk data were called into the operations center each day and reported by county.

Results

PsySTART risk surveillance data for 18,823 disaster mental health contacts are presented for adults and children. A total of 17,979 risk factors were reported. Overall levels of risk per contact were statistically different (χ2(1, N=6,045)=248.1; P<.001) across the 8 counties. Survivors with high levels of risk were found in locations apart from the areas with the greatest physical damage.

Conclusion

Aggregated PsySTART data in Superstorm Sandy indicate substantial population-level impact suggestive of risk for disorders that may persist chronically without treatment. Mental health triage has the potential to improve care of individual disaster survivors, as well as inform disaster management, local health providers, and public health officials.

 

Temporization of Penetrating Abdominal-Pelvic Trauma With Manual External Aortic Compression: A Novel Case Report

Matthew Douma, Katherine E. Smith, Peter G. Brindley

A young civilian man experienced multiple gunshots to the lower abdomen, pelvis, and thigh. These were not amenable to direct compression by a single rescuer. This report outlines the first case in the peer-reviewed literature of manual external aortic compression after severe trauma. This technique successfully temporized external bleeding for more than 10 minutes and restored consciousness to the moribund victim. Subsequently, external bleeding could not be temporized by a second smaller rescuer, or during ambulance transfer. Therefore, we also gained insights about the possible limits of bimanual compression and when alternates, such as pneumatic devices, may be required. Research is needed to test our presumption that successful bimanual compression requires larger-weight rescuers, smaller-weight victims, and a hard surface. It is therefore unclear whether manual external aortic compression is achievable by most rescuers or for most victims. However, it offers an immediate and equipment-free life-sustaining strategy when there are limited alternatives.

 

 

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