Von Willebrand disease in the emergency department.

BACKGROUND: The emergency department (ED) is often the first medical contact point for von Willebrand disease (VWD) patients experiencing acute conditions, notably bleeding. However, knowledge of VWD disease types and management options by ED providers is uncertain. AIM: To determine the scope of VWD bleeding and treatment in the ED. METHODS: We evaluated medical record data in an IRB-approved study from 922 notes accounting for 385 ER visits by 183 VWD patients from a single large institution's emergency department. RESULTS: Over half the ED visits were for an active or suspected bleed, the majority of which were associated with trauma, surgery, epistaxis, gastrointestinal bleeding or gynaecologic bleeding. By treatment, only 25% of all bleeds, including 77.8% of those with menorrhagia and 50.0% of those with epistaxis, received DDAVP or von Willebrand factor concentrate (VWF). The likelihood of receiving treatment was related to referral source, with the highest rates of treatment in patients referred by a haematologist. CONCLUSIONS: These data suggest more patient and physician education are needed in managing patients with VWD, preferably at the time of diagnosis, including confirmation of the diagnosis, response to DDAVP testing, indication for DDAVP testing and formulation of a plan for suspected or actual bleeding.

A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators.

PURPOSE: To determine whether early goal-directed therapy (EGDT) reduces mortality compared with other resuscitation strategies for patients presenting to the emergency department (ED) with septic shock. METHODS: Using a search strategy of PubMed, EmBase and CENTRAL, we selected all relevant randomised clinical trials published from January 2000 to January 2015. We translated non-English papers and contacted authors as necessary. Our primary analysis generated a pooled odds ratio (OR) from a fixed-effect model. Sensitivity analyses explored the effect of including non-ED studies, adjusting for study quality, and conducting a random-effects model. Secondary outcomes included organ support and hospital and ICU length of stay. RESULTS: From 2395 initially eligible abstracts, five randomised clinical trials (n = 4735 patients) met all criteria and generally scored high for quality except for lack of blinding. There was no effect on the primary mortality outcome (EGDT: 23.2% [495/2134] versus control: 22.4% [582/2601]; pooled OR 1.01 [95% CI 0.88-1.16], P = 0.9, with heterogeneity [I(2) = 57%; P = 0.055]). The pooled estimate of 90-day mortality from the three recent multicentre studies (n = 4063) also showed no difference [pooled OR 0.99 (95% CI 0.86-1.15), P = 0.93] with no heterogeneity (I(2) = 0.0%; P = 0.97). EGDT increased vasopressor use (OR 1.25 [95% CI 1.10-1.41]; P < 0.001) and ICU admission [OR 2.19 (95% CI 1.82-2.65); P < 0.001]. Including six non-ED randomised trials increased heterogeneity (I(2) = 71%; P < 0.001) but did not change overall results [pooled OR 0.94 (95% CI 0.82 to 1.07); P = 0.33]. CONCLUSION: EGDT is not superior to usual care for ED patients with septic shock but is associated with increased utilisation of ICU resources.

Use of a cardiocerebral-protective drug cocktail prior to countershock in a porcine model of prolonged ventricular fibrillation.

OBJECTIVES: This was the third study in a series exploring whether the use of combination pharmacotherapy with delayed countershock would produce higher rates of return of spontaneous circulation (ROSC) and one-hour survival when compared with standard advanced cardiac life support (ACLS) therapy in prolonged ventricular fibrillation (VF). METHODS: Twenty-four female, mixed-breed, domestic swine (ranging in mass from 22 to 25 kg) were used in this prospective, blinded, randomized, experimental trial. Animals were sedated (ketamine/xylazine), anesthetized (alpha-chloralose), paralyzed (pancuronium), mechanically ventilated with room air, and monitored with electrocardiography, arterial pressure, and Swan-Ganz catheters. VF was induced with a 3 s, 60 Hz, 100 mA transthoracic shock, and remained untreated for 8 min. One minute of basic life support followed (standardized by use of a mechanical device). At 9 min, animals were treated with one of three regimes: Group 1, cardiocerebral-protective cocktail (antioxidant U-74389G (3.0 mg/kg), epinephrine (0.2 mg/kg), lidocaine (1.0 mg/kg), bretylium (5.0 mg/kg), magnesium (2.0 g), and propranolol (1.0 mg)); Group 2, magnesium (2.0 g); and Group 3, standard ACLS. Groups 1 and 2 received drugs at minute nine (first countershock at minute 11), while Group 3 received first countershock at minute nine. Data were analyzed with two-tailed Fisher's exact tests. RESULTS: ROSC was achieved in Group 1, 7/7 (100%); Group 2, 3/9 (33%, P versus Group 1=0.01); and Group 3, 3/8 (38%; P versus Group 1=0.02). One-hour survival was attained in Group 1, 7/7 (100%); Group 2, 3/9 (33%; P versus Group 1=0.01), and Group 3, 1/8 (13%; P versus Group 1=0.001). CONCLUSIONS: Combination pharmacotherapy with a cardiocerebral-protective drug cocktail prior to countershock produced superior rates of ROSC and one-hour survival when compared with singular drug therapy (Group 2) and standard ACLS (Group 3) in this porcine model of prolonged VF.

Changing physician prescribing behavior: the community-acquired pneumonia intervention trial.

The Notes section welcomes the following types of contributions: (1) practical innovations or solutions to everyday practice problems, (2) substantial updates or elaborations on work previously published by the same authors, (3) important confirmations of research findings previously published by others, and (4) short research reports, including practice surveys, of modest scope or interest. Notes should be submitted with AJHP's manuscript checklist. The text should be concise, and the number of references, tables, and figures should be limited.

Systemic analgesia and sedation in managing orthopedic emergencies.

Many potent agents have become available in the emergency department for providing systemic analgesia and sedation for painful orthopedic procedures. This article details the pharmacology and principles of systemic analgesia and sedation, which will help the emergency physician provide maximal patient comfort with minimal complications during painful procedures. The use of an appropriate agent in these situations will optimize the outcome of the procedure itself and result in greater patient satisfaction.

Combination pharmacotherapy with delayed countershock vs standard advanced cardiac life support after prolonged ventricular fibrillation.

OBJECTIVE: To test the hypothesis that combination pharmacotherapy with delayed countershock would produce higher rates of return of spontaneous circulation (ROSC) and one-hour survival when compared with standard Advanced Cardiac Life Support (ACLS) therapy. METHODS: A prospective, block-randomized, blinded, laboratory experiment was conducted in an established swine model of prolonged ventricular fibrillation (VF). Fifty-six female domestic swine were anesthetized, instrumented, and shocked into VF with a bipolar pacing catheter. The VF was untreated for 8 minutes, then basic CPR was done mechanically for 1 minute. At 9 minutes of VF, the animals were randomized to treatment with one of seven therapies: group 1, combination pharmacotherapy with epinephrine (0.20 mg/kg), lidocaine (1.0 mg/kg), bretylium (5.0 mg/kg), propranolol (1.0 mg), and U-74389G (3.0 mg/kg); group 2, epinephrine (0.20 mg/kg); group 3, lidocaine (1.0 mg/kg) and bretylium (5.0 mg/kg); group 4, propranolol (1.0 mg); group 5, U-74389G (3.0 mg/kg); group 6, normal saline solution (volume equal to that for group 1); and group 7, standard ACLS (first countershock at 9 minutes of VF). Initial countershocks for groups 1-6 were given after 11 minutes of VF. Data were analyzed with two-tailed Fisher's exact test, with alpha set at 0.05. RESULTS: Return of spontaneous circulation occurred in group 1 = 8/8 (100%); group 2 = 7/8 (88%); group 3 = 3/8 (38%); group 4 = 3/8 (38%); group 5 = 5/8 (63%); group 6 = 4/8 (50%); and group 7 = 3/8 (38%). One-hour survival occurred in group 1 = 8/8 (100%); group 2 = 5/8 (63%); group 3 = 2/8 (25%); group 4 = 2/8 (25%); group 5 = 3/8 (38%); group 6 = 2/8 (25%); and group 7 = 1/8 (13%). CONCLUSIONS: Combination pharmacotherapy with delayed countershock (group 1) produced significantly higher rates of ROSC (p = 0.03) and one-hour survival (p = 0.001) when compared with standard ACLS in this porcine model of prolonged VF.

Assessing prognosis and selecting an initial site of care for adults with community-acquired pneumonia.

Over the last 20 years, more than 15 medical practice guidelines and clinical prediction rules have emerged to assist physicians in assessing the prognosis of adult patients with community-acquired pneumonia (CAP) and selecting an appropriately matched initial site of care. Most of these guidelines and rules suffer from major methodological flaws. One, the Pneumonia Patient Outcomes Research Team (PORT) clinical prediction rule, has satisfied rigorous methodological standards for the derivation and validation of high-quality prediction rules. This rule was incorporated into the Infectious Disease Society of America medical practice guideline for the management of adults with CAP. Strengths of the rule include its derivation and validation in over 50,000 inpatients and outpatients; stratification of all immunocompetent adult patients into one of five risk strata for short-term mortality and other unambiguous adverse medical outcomes; initial site of care recommendations for all patients, particularly those at low risk; and reliance on predictor variables readily available to clinicians at the time of initial patient presentation. A recent small-scale intervention trial demonstrates that the pneumonia PORT rule can reduce admissions for adult patients with CAP without compromising patient outcomes.

Use of automated external defibrillators by police officers for treatment of out-of-hospital cardiac arrest.

OBJECTIVE: To determine the feasibility of police officers providing defibrillation with automated external defibrillators (AEDs) and to assess the effectiveness of this strategy in reducing time to defibrillation of victims of out-of-hospital sudden cardiac arrest. METHODS: This was a prospective, interventional cohort study with historical controls conducted in 7 suburban communities in which police usually arrived at the scene of medical emergencies before EMS personnel. All adult patients who suffered cardiac arrest before EMS arrival and on whom EMS personnel attempted resuscitation were enrolled. Police officers who were trained to use and equipped with AEDs during the intervention phase were dispatched simultaneously with EMS to medical emergencies. Police were instructed to use the AED immediately on determination of pulselessness. Outcome measures were the difference between control and intervention phases in interval from the time the call was received at dispatch to the time of first defibrillation and in rate of survival to hospital discharge for patients initially in ventricular fibrillation. RESULTS: EMS personnel attempted 183 resuscitations in the control phase and 283 during the intervention; of these, 80 (44%) and 127 (45%), respectively, involved patients with initial ventricular fibrillation rhythms. Mean time to defibrillation decreased from 11.8+/-4.7 minutes in the control phase to 8.7+/-3.7 minutes in the intervention phase (P<.0001). Survival to hospital discharge of patients in ventricular fibrillation did not differ between phases (6% control versus 14% intervention, P=.1). When police arrived before EMS personnel, shock administered by police compared with shock administered by EMS was associated with improved survival (26% [12/46] versus 3% [1/29], P=.01). Logistic regression analysis revealed AED use was an independent predictor of survival to hospital discharge. CONCLUSION: In 7 suburban communities, police use of AEDs decreased time to defibrillation and was an independent predictor of survival to hospital discharge.

Multicenter comparison of two clinical decision rules for the use of radiography in acute, high-risk knee injuries.

STUDY OBJECTIVE: Two separate clinical decision rules, one developed in Ottawa and the other in Pittsburgh, for the use of radiography in acute knee injuries have been previously validated and published. In this study, the rules were prospectively validated and compared in a new set of patients. METHODS: A prospective, blinded, multicenter trial was conducted in the emergency departments of three urban teaching hospitals. A convenience sample of 934 patients with knee pain requiring radiographs was enrolled. A standardized data form was completed for each patient, comprising the 10 clinical variables included in the two rules. Standard knee radiographs were then taken in each patient. The rules were interpreted by the primary investigator on the basis of the data sheet and the final radiologist radiograph reading. RESULTS: In the 745 patients in whom the Pittsburgh rules could be applied there were 91 fractures (12.2%). The use of the Pittsburgh rule missed one fracture, yielding a sensitivity of 99% (95% confidence interval [CI], 94% to 100%); the specificity was 60% (95% CI, 56% to 64%). The Ottawa inclusion criteria were met by 750 patients, with 87 fractures (11.6%). The Ottawa rule missed three fractures, for a sensitivity of 97% (95% CI, 90% to 99%); specificity was 27% (95% CI, 23% to 30%). CONCLUSION: Prospective validation and comparison found the Pittsburgh rule for knee radiographs to be more specific without loss of sensitivity compared with the Ottawa rule.

End-tidal carbon dioxide monitoring in emergency medicine, Part 1: Basic principles.

End-tidal carbon dioxide (PetCO2) monitoring is becoming more common in both the ED and the out-of-hospital setting. Its main use has been as an aid when confirming endotracheal intubation. However, since CO2 is intrinsically coupled with states of metabolism, circulation, and ventilation, PetCO2 monitoring along with analysis of its capnographic component is becoming increasingly valuable for other uses in the ED. This article reviews the physiology of CO2, the means by which end-tidal CO2 may be monitored, and the components and analysis of the capnogram.

End-tidal carbon dioxide monitoring in emergency medicine, Part 2: Clinical applications.

End-tidal carbon dioxide (PetCO2) monitoring is becoming more common in both the ED and the out-of-hospital setting. Its main use has been as an aid when confirming endotracheal intubation. Other uses in the ED include monitoring CPR efforts and monitoring the ventilatory and hemodynamic status of intubated and nonintubated patients. In addition, future uses may include using PetCO2 as an adjunct when monitoring the status of asthma treatment, when making the diagnosis of pulmonary embolism, and when measuring cardiac output noninvasively. This article reviews these specific uses of PetCO2 monitoring in emergency medicine.

Underrecognition of cervical Neisseria gonorrhoeae and Chlamydia trachomatis infections in the emergency department.

OBJECTIVES: 1) To quantify the frequency of underrecognized Neisseria gonorrhoeae and Chlamydia trachomatis cervical infections in women tested in the ED, 2) to describe and compare the characteristics of those treated and not treated during the initial visit, and 3) to quantify the delay interval until treatment was provided. METHODS: A 2-year, retrospective consecutive case series was performed from June 1, 1992, to May 31, 1994. There were 148 women with > or = 1 discrete occurrence of culture-proven cervical N. gonorrhoeae or C. trachomatis infection studied. All the patients were evaluated in a university-affiliated, tertiary care hospital-based ED with a large rural referral area. The main outcome measures were the proportions of patients with positive cultures both treated and not treated in the ED, the clinical characteristics of each group, and the proportion remaining untreated or experiencing treatment delays of > 2 weeks after attempted phone, mail, and public health follow-up. RESULTS: Of 157 occurrences of positive cultures for N. gonorrhoeae or C. trachomatis, 86 (53%) were treated with a regimen suggested by the CDC prior to ED release. The proportion of women with isolated C. trachomatis infections that were underrecognized and untreated initially was larger than the proportions with isolated N. gonorrhoeae or combined infections (79% vs 27% and 53%, respectively, p < 0.0001). Women with findings suggestive of advanced disease (history of fever or chills, or examination evidence of temperature > 38 degrees C, purulent vaginal discharge, or any uterine/salpinx/ovarian tenderness) were more often recognized and treated with appropriate antibiotics initially (p = 0.02 to < 0.00001 for all). After phone, mail, and public health follow-up, treatment could not be documented for 25% of the occurrences, in all cases due to an inability to locate the patient. An additional 20% of the women did not receive treatment for 14-60 days. CONCLUSIONS: In this population, both N. gonorrhoeae and C. trachomatis cervical infections are frequently underrecognized in the ED, with isolated C. trachomatis infections associated with significantly higher proportions of underrecognition. Many affected women remain untreated for extended intervals, creating public and individual health risks. Improved point of contact detection, follow-up, and treatment policies are needed to limit these risks.