Use of Topical Anesthetics in the Management of Patients With Simple Corneal Abrasions: Consensus Guidelines From the American College of Emergency Physicians.

The management of corneal abrasions has largely excluded dispensing topical local anesthetics for home use due to concern for corneal toxicity. We have reviewed and critically appraised the available literature evidence regarding the use of topical anesthetics in patients with simple corneal abrasions. Using sequential Delphi review, we have developed these clinical guidelines. Herein are evidentiary summaries and consensus recommendations for 8 specific relevant questions. Our key observation is that for only simple corneal abrasions, as diagnosed and treated in accordance with the full protocol described herein, it appears safe to prescribe or otherwise provide a commercial topical anesthetic (ie, proparacaine, tetracaine, oxybuprocaine) for use up to every 30 minutes as needed during the first 24 hours after presentation, as long as no more than 1.5 to 2 mL total (an expected 24-hour supply) is dispensed and any remainder is discarded after 24 hours. Importantly, although published findings suggest absent harm for short courses, more rigorous studies with a greater cumulative sample size and ophthalmologic follow-up are needed.

ACR Appropriateness Criteria® Acute Onset Flank Pain-Suspicion of Stone Disease (Urolithiasis).

Noncontrast CT (NCCT) is the imaging study of choice for initial evaluation of patients with acute onset of flank pain and suspicion of stone disease without known prior stone disease. NCCT can reliably characterize the location and size of an offending ureteral calculus, identify complications, and diagnose alternative etiologies of abdominal pain. Although less sensitive in the detection of stones, ultrasound may have a role in evaluating for signs of obstruction. Radiography potentially has a role, although has been shown to be less sensitive than NCCT. For patients with known disease and recurrent symptoms of urolithiasis, NCCT remains the test of choice for evaluation. In pregnancy, given radiation concerns, ultrasound is recommended as the initial modality of choice with potential role for noncontrast MRI. In scenarios where stone disease suspected and initial NCCT is inconclusive, contrast-enhanced imaging, either with MRI or CT/CT urogram may be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Remote Dispensing of Emergency Release Red Blood Cells.

OBJECTIVES: Patients with acute bleeding are frequently transfused with emergency release (ER) group O RBCs. This practice has been reported to be safe with a low rate of acute hemolytic transfusion reactions (AHRs). METHODS: Records of patients who received ER RBCs over a 30-month period were examined at our hospitals. During this period, satellite refrigerators were on site in the emergency department (ED), which were electronically connected to the blood bank (electronically connected satellite refrigerator [ECSR]). Nurses accessing the refrigerator were required to give patient identification information, when known, prior to removal of the ER RBCs, allowing technologists the opportunity to check for previous serologic records and communicate directly with the ED if a serologic incompatibility was potentially present. RESULTS: In total, 935 patients were transfused with 1,847 units of ER RBCs. Thirty of these patients had a current (22/30) or historic (8/30) antibody. In 15 cases, incompatible RBCs were interdicted. In six cases, the transfusion was considered urgent, and an AHR occurred in four of these six (overall 0.4%), including one fatal AHR due to anti-KEL1. CONCLUSIONS: Use of KEL1-negative RBCs and ECSR merits consideration as approaches to mitigate the occurrence of ER RBC-associated AHRs.

A Pilot Study Testing the Novel Use of a Snake Bite Compression Device for Field Hemostasis and Wound Repair in an Animal Model.

INTRODUCTION: A commercially available snake bite device was pilot tested for novel use as a method of hemostasis and wound repair at a noncompressible site in a live swine model. The device is light, is plastic, uses a hook-and-loop strap attachment, and is easily deployed. The device could offer a method for the field repair of an actively bleeding laceration at a noncompressible site in an austere environment. MATERIALS AND METHODS: This was an interventional, prospective, controlled study in a large animal model. The study was approved by the Rhode Island Hospital Institutional Review Board (IRB) and the Animal Welfare Committee/Institutional Animal Care and Use Committee and the Lifespan Research Conflict of Interest Committee. Each animal acted as its own control. Blood loss was measured and compared between repairs of standardized incisions with and without the device's application. The lacerations were sutured closed. Two proceduralists alternated tasks of wound repair versus blood collection. Blood loss was measured by using gauze sponges to capture the blood during a 30-second free-bleeding period and during the repair itself. Using a one sample t-test (the expected difference in blood loss between the two incision repair methods = 0 if the null hypothesis were true), we calculated the mean difference in the deltas between the repair methods. RESULTS: The mean delta difference was 3.1 g (SE ± 0.97). The t-test demonstrated that there was a significantly greater blood loss during the standard repair method, t(9) = 3.11, P < 0.01 than during the repair with the device in place (see Fig. 2). A statistical power analysis conducted showed that with a sample size of 10 animals, there was sufficient statistical power to detect this significant effect (ß = 0.82, α < 0.05, one-tailed). CONCLUSIONS: There was statistically significantly less blood loss during the repairs with the device's application. This feasibility experiment demonstrates that a commercially available snakebite device may be useful for hemostasis during laceration repair at anatomic sites not amenable to application of tourniquets or compressive dressings. Strengths of the study include the prospective controlled design, including the use of each animal as its own control; alternating proceduralists to account for any variability in suturing efficiency; and the statistical significance of the results despite the small number of subjects. One weakness is that the time required for each repair was not measured. The device's portability and reusability suggest applicability in austere medical environments. Future studies could include timing the repairs, using a skin stapler or wound adhesive instead of sutures, applying a hemostatic agent before the repair, and sequentially applying the device to wounds longer than the device.

Local and Topical Anesthetics for Pediatric Patients in the Emergency Department.

Painful diagnostic and therapeutic procedures are common in the emergency department. Adequately treating pain, including the pain of procedures is an essential component of the practice of emergency medicine. Pain management is also part of the core competency for emergency medicine residencies and pediatric emergency medicine fellowships. There are many benefits to providing local and/or topical anesthesia before performing a medical procedure, including better patient and family satisfaction and increased procedural success rates. Local and topical anesthetics when used appropriately, generally, have few, if any, systemic side effects, such as hypotension or respiratory depression, which is an advantage over procedural sedation. Use of local and topical anesthetics can do much toward alleviating the pain and anxiety of pediatric patients undergoing procedures in the emergency department.

ACR Appropriateness Criteria® Pneumonia in the Immunocompetent Child.

Pneumonia is one of the most common acute infections and the single greatest infectious cause of death in children worldwide. In uncomplicated, community-acquired pneumonia in immunocompetent patients, the diagnosis is clinical and imaging has no role. The first role of imaging is to identify complications associated with pneumonia such as pleural effusion, pulmonary abscess, and bronchopleural fistula. Radiographs are recommended for screening for these complications and ultrasound and CT are recommended for confirmation. The second role of imaging is to identify underlying anatomic conditions that may predispose patients to recurrent pneumonia. CT with intravenously administered contrast is recommended for this evaluation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Correction: Correction to 'Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection' [Annals of Emergency Medicine 65 (2015) 32-42.e12].

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Correction: Correction to 'Clinical Policy for Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever' [Annals of Emergency Medicine 67 (2016) 625-639.e13].

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

False-negative chest radiographs in emergency department diagnosis of pneumonia.

BACKGROUND: Emergency department (ED) patients frequently undergo chest x-ray (CXR) to evaluate for pneumonia. The rate of false-negative CXR in patients with pneumonia is unclear. OBJECTIVES: Identify patients admitted with pneumonia who were diagnosed by CT despite nondiagnostic CXR. METHODS: Retrospective analysis of quality improvement data on adult ED patients admitted with pneumonia over 21 months. Primary outcome was percent of patients diagnosed by CT despite normal CXR. Patients were classified as CXR-diagnosed if they had CXR and no CT, or if antibiotics were ordered after CXR and before CT. CT-based diagnosis was indicated by administration of antibiotics only after CT was completed. RESULTS: 49 patients (11.4%) were diagnosed by CT (p<0.001). These patients were younger (p<0.001) and more often complained of chest pain (p<0.001). CONCLUSIONS: Patients with pneumonia may present with normal or nondiagnostic CXR, although false negatives may be less common than previously reported.

'Not just little adults' - a pediatric trauma primer.

This article describes pediatric trauma care and specifically how a pediatric trauma center, like Hasbro Children's Hospital, provides specialized care to this patient population. The authors review unique aspects of pediatric trauma patients broken down into anatomy and physiology, including Airway and Respiratory, Cardiovascular Response to Hemorrhage, Spine Injuries, Traumatic Brain Injuries, Thoracic Injuries and Blunt Abdominal Trauma. They review certain current recommendations for evaluation and management of these pediatric patients. The authors also briefly review the topic of Child Abuse/Non-accidental Trauma in pediatric patients. Although Pediatric Trauma is a very broad topic, the goal of this article is to act as a primer and describe certain characteristics and management recommendations unique to the pediatric trauma patient.

Activated chlorine dioxide solution can be used as a biocompatible antiseptic wound irrigant.

OBJECTIVE: The purpose of this study was to compare cosmesis at 3 to 4 months and infection in simple lacerations irrigated with normal saline (NS) versus activated chlorine dioxide (CD). DESIGN: This was a prospective, randomized trial of a convenience sample of patients. This study was approved by the institutional review board and Food and Drug Administration as a physician-sponsored trial (FDA investigational new drug no. 68762). SETTING: The study was conducted in a large urban, academic emergency department. PATIENTS: Patients aged 18 to 100 with simple, uncomplicated lacerations requiring repair that were less than 8 hours old were enrolled. INTERVENTIONS: Patients were randomized to receive either NS or CD wound irrigation. MAIN OUTCOME MEASURES: Demographics, infection, and cosmesis were analyzed and assessed. Cosmetic outcome was assessed at 3 to 4 months using a visual analog scale (VAS), wound evaluation score (WES), patient VAS (VASPt), and digital imaging VAS by 2 plastic surgeons (VASPlast). MAIN RESULTS: One hundred ninety-three patients were enrolled. Data analysis was available for 175 cases (86 NS and 89 CD). Wound infection follow-up was obtained in 74.9% of the patients. The 3- to 4-month cosmesis follow-up was 37.7% for VAS/WES, 40.0% for VASPt, and 37.7% for VASPlast. There were no significant differences in demographics, key wound characteristics, infection, adverse reactions, and cosmesis. CONCLUSION: The authors report the use of a novel antimicrobial irrigation solution. Chlorine dioxide appears to be a safe biologically acceptable antiseptic wound irrigant that does not appear to interfere with cosmetic outcomes.

Time to first antibiotics for pneumonia is not associated with in-hospital mortality.

BACKGROUND: Time to first antibiotic (TTFA) is postulated to impact pneumonia mortality. The Joint Commission/Centers for Medicare and Medicaid Services national quality standards previously indicated that TTFA should be <6 h (modified from <4 h when the study was initiated, now eliminated as a time measure entirely). OBJECTIVE: The purpose of this article was to determine whether TTFA is associated with inpatient mortality. METHODS: The records of 444 consecutive patients admitted with pneumonia at a single institution were retrospectively reviewed for a correlation between TTFA and inpatient complications, including death. Statistical significance was set at p < 0.01 due to multiple comparisons. RESULTS: Patients whose TTFA was <4 h had more complications (27% vs. 3%; p < 0.01) including death, intensive care unit admission, and intubation. These patients were judged sicker on arrival (median Emergency Severity Index 2 vs. 3; p < 0.001) and were more likely to be triaged to a critical care bed (36% vs. 5%; p < 0.001). Shortness of breath was the only presenting factor that was more frequent in the TTFA <4-h group (61% vs. 16%; p < 0.01). CONCLUSIONS: Shorter TTFA is not associated with improved inpatient mortality. TTFA should not be considered to be a marker of quality of care but rather a reflection of patient disease severity.

Digital imaging analysis of scar aesthetics.

OBJECTIVE: Aesthetic outcome is an important end point of wound care. The purpose of this study was to compare a wound aesthetic scoring system by emergency physicians, patients, and digital imaging by blinded plastic surgeons. The goal was to see if digital photography could accurately analyze the aesthetics of closed lacerations for future research. METHODS: This was a subanalysis of a prospective, randomized trial conducted in an urban, academic emergency department. Patients aged 18 to 100 years were included if they had simple, uncomplicated lacerations 8 hours old or less located on the trunk, head or neck (not scalp), or extremities that required repair by sutures. Exclusion criteria included immunocompromised state of health, a complicated laceration, specialty consultant intervention in management of the wound, or current use of or need for antibiotics for wound prophylaxis. Complicated lacerations were defined in the article. Infection outcomes, demographics, and aesthetic outcomes were assessed. Scar appearance was assessed at 3 to 4 months after closure using a previously validated 0-to 100-mm visual analog scale (VAS) score and 6-point wound evaluation score (WES) done by 2 trained emergency physicians (MD1 and MD2). Patients also performed self-VAS (VAS(Pt)), whereas VAS was done using digital imaging by 2 trained plastic surgeons (VAS(Plast1) and VAS(Plast2)). Data were evaluated when both plastic surgeons independently believed that the digital images were able to be adequately scored. Pearson correlation coefficients were performed using mean values. RESULTS: Three- to 4-month VAS(MD) and WES(MD) follow-up was obtained in 66 of 175 (37.7%), 3- to 4-month VAS(Pt) follow-up was obtained in 70 of 175 (40.0%), and 3- to 4-month digital imaging assessment was obtained in 66 of 175 (37.7%). Digital images were evaluated for VAS(Plast) in 34 of 66 (51.5%). Mean scores for VAS(MD1) and VAS(MD2) were 84.2 (SD, 12.4) mm and 87.8 (SD, 10.5) mm. Mean scores for WES(MD1) and WES(MD2) were 5.5 (SD, 1.0) and 5.4 (SD, 1.0). Mean scores for VAS(Pt) were 86.6 (SD, 16.6) mm. Mean scores for VAS(Plast1) and VAS(Plast2) were 78.7 (SD, 26.6) mm and 66.2 (SD, 30.2) mm. Moderate correlation was noted for VAS(MD1) and VAS(MD2) (r = 0.63; n = 34; P < .001), WES(MD1) and WES(MD2) (r = 0.70; n = 34; P < .001), and VAS(Plast1) and VAS(Plast2) (r = 0.74; n = 34; P < .001). Correlations were also moderate for VAS(MD) and VAS(Plast) (r = 0.56; n = 34; P < .001), VAS(Pt) and WES(MD) (r =0.60; n = 34; P < .001), and VAS(MD) and WES(MD) (r = 0.64; n = 34; P < .001). However, correlations were weak for VAS(Pt) and VAS(Plast) at r = 0.25 (n = 34; P = .16), VAS(Pt) and VAS(MD) at r = 0.37 (n = 34; P =.03), and WES(MD) and VAS(Plast) at r = 0.13 (n = 34; P =.45). Three- to 4-month VAS(MD) and WES(MD) follow-up was obtained in 66 of 175 (37.7%), 3- to 4-month VAS(Pt) follow-up was obtained in 70 of 175 (40.0%), and 3- to 4-month digital imaging assessment was obtained in 66 of 175 (37.7%). Digital images were evaluated for VAS(Plast) in 34 of 66 (51.5%). Mean scores for VAS(MD1) and VAS(MD2) were 84.2 (SD, 12.4) mm and 87.8 (SD, 10.5) mm. Mean scores for WES(MD1) and WES(MD2) were 5.5 (SD, 1.0) and 5.4 (SD, 1.0). Mean scores for VAS(Pt) were 86.6 (SD, 16.6) mm. Mean scores for VAS(Plast1) and VAS(Plast2) were 78.7 (SD, 26.6) mm and 66.2 (SD, 30.2) mm. Moderate correlation was noted for VAS(MD1) and VAS(MD2) (r = 0.63; n = 34; P < .001), WES(MD1) and WES(MD2) (r = 0.70; n = 34; P < .001), and VAS(Plast1) and VAS(Plast2) (r = 0.74; n = 34; P < .001). Correlations were also moderate for VAS(MD) and VAS(Plast) (r = 0.56; n = 34; P < .001), VAS(Pt) and WES(MD) (r = 0.60; n = 34; P < .001), and VAS(MD) and WES(MD) (r = 0.64; n = 34; P < .001). However, correlations were weak for VAS(Pt) and VAS(Plast) at r = 0.25 (n = 34; P = .16), VAS(Pt) and VAS(MD) at r = 0.37 (n = 34; P =.03), and WES(MD) and VAS(Plast) at r = 0.13 (n = 34; P =.45).Three-to 4-month VAS(MD) and WES(MD) follow-up was obtained in 66 of 175 (37.7%), 3- to 4-month VAS(Pt) follow-up was obtained in 70 of 175 (40.0%), and 3- to 4-month digital imaging assessment was obtained in 66 of 175 (37.7%). Digital images were evaluated for VAS(Plast) in 34 of 66 (51.5%). Mean scores for VAS(MD1) and VAS(MD2) were 84.2 (SD, 12.4) mm and 87.8 (SD, 10.5) mm. Mean scores for WES(MD1) and WES(MD2) were 5.5 (SD, 1.0) and 5.4 (SD, 1.0). Mean scores for VAS(Pt) were 86.6 (SD, 16.6) mm. Mean scores for VAS(Plast1) and VAS(Plast2) were 78.7 (SD, 26.6) mm and 66.2 (SD, 30.2) mm. Moderate correlation was noted for VAS(MD1) and VAS(MD2) (r = 0.63; n = 34; P < .001), WES(MD1) and WES(MD2) (r = 0.70; n = 34; P < .001), and VAS(Plast1) and VAS(Plast2) (r = 0.74; n = 34; P < .001). Correlations were also moderate for VAS(MD) and VAS(Plast) (r = 0.56; n = 34; P < .001), VAS(Pt) and WES(MD) (r = 0.60; n = 34; P < .001), and VAS(MD) and WES(MD) (r = 0.64; n = 34; P < .001). However, correlations were weak for VAS(Pt) and VAS(Plast) at r = 0.25 (n = 34; P = .16), VAS(Pt) and VAS(MD) at r = 0.37 (n = 34; P =.03), and WES(MD) and VAS(Plast) at r = 0.13 (n = 34; P =.45). CONCLUSIONS: Correlations were moderate for VAS(MD) and VAS(Plast); however, correlations were weak for VAS(Pt) and VAS(Plast), VAS(Pt) and VAS(MD), and WES(MD) and VAS(Plast). This small study assessing digital imaging as a tool for evaluating scar aesthetics demonstrated limitations in its use. Future studies with larger populations and improved imaging modalities, such as 3-dimensional cameras and high-dynamic-range imaging, may provide potential for better assessment.