Comparison of the diagnostic characteristics of two B-type natriuretic peptide point-of-care devices.

BACKGROUND: B-type natriuretic peptide (BNP) is used to diagnose heart failure (HF). OBJECTIVE: To compare the accuracy of two commercially available point-of-care (POC) devices for measuring B-type natriuretic peptide (BNP) in emergency department (ED) patients with suspected heart failure using the central laboratory testing results as the criterion standard. METHODS: Venous blood samples were collected from adults with suspected heart failure and split into three samples for BNP analysis: central laboratory (Siemens ADIVA Centaur; Siemens, Deerfield, IL), Triage BNP POC device (Biosite, San Diego, CA), and i-STAT BNP POC device (Abbott, East Windsor, NJ). The criterion standard for BNP levels was the central laboratory. RESULTS: Two hundred fifty patients were enrolled. Mean (SD) age was 70.7 (13.8) years; 200 (80%) were over age 55 years; 146 (58.4%) were male. A final hospital discharge diagnosis of heart failure was made in 108 (42%) patients. The i-STAT system yielded a result within a median of 9 min (interquartile range [IQR] 9-10 min). The Triage device yielded a result within a median of 19 min (IQR 15-22 min); p < 0.001. The device failure rate for the central laboratory (8 failures, 3.2%) was significantly higher than that of the i-STAT device (1 failure, 0.4%, p = 0.04), but not statistically different than the Triage device (3 failures, 1.2%). Neither the Triage nor the i-STAT were statistically different than the central laboratory result in terms of sensitivity; the i-STAT was less specific than the Triage result (p = 0.003). The area under the curve for the Triage device was 0.95 (95% confidence interval [CI] 0.91-0.98), whereas the area under the curve for the i-STAT device was 0.98 (95% CI 0.96-0.99; p < 0.01). CONCLUSIONS: Both POC devices tested were accurate and rarely failed; however, the i-STAT was faster with single use.

Single-layer versus double-layer closure of facial lacerations: a randomized controlled trial.

BACKGROUND: The objective of this study was to compare the cosmetic outcome of facial lacerations closed with a single or double layer of sutures. METHODS: Patients aged 1 year or older presenting to a university-based emergency department with nongaping (width, < 10 mm), simple, nonbite, facial lacerations were randomized to closure with a single layer of simple interrupted 6-0 polypropylene sutures or a double layer of simple interrupted 6-0 polypropylene plus inverted deep dermal 5-0 polyglactin sutures. At 90 days, the scar width and cosmetic appearance were determined using a validated 100-mm visual analogue scale ranging from 0 (worst) to 100 (best) and a validated wound evaluation score ranging from 0 (worst) to 6 (best). RESULTS: Sixty-five patients were randomized to single-layer (n = 32) or double-layer (n = 33) closure. Mean age (SD) was 18.5 years (20.0), and 14 percent were female. Groups were similar in baseline patient and wound characteristics. Length of single-layer closure was 7 minutes shorter (95 percent CI, 2 to 11 minutes) than double-layer closure. There were no infections or dehiscences in either group. There were no between-group differences in patient (mean difference, 0.5 mm; 95 percent CI, -5.7 to 6.6 mm) or practitioner (mean difference, 1.0 mm; 95 percent CI, -4.8 to 6.7 mm) visual analogue scale scores. All but one patient had an optimal wound evaluation score of 6 (p = not significant). Scar width was similar at 90 days (mean difference, 0.2 mm; 95 percent CI, -0.05 to 0.5). CONCLUSIONS: Single-layer closure of nongaping, minor (< 3 cm) facial lacerations is faster than double-layer closure. Cosmetic outcome and scar width are similar in sutured wounds whether or not deep dermal sutures are used.

Point-of-care testing reduces length of stay in emergency department chest pain patients.

STUDY OBJECTIVE: We determine the effect of cardiac troponin I point-of-care testing on emergency department (ED) length of stay in chest pain patients. METHODS: This was a before-and-after trial in a university-based ED with 75,000 annual visits. Participants were consecutive patients with a chief complaint of chest pain who were admitted to the hospital. During the first 2-week period (before), only central laboratory testing of troponin was performed. During the second 2-week period (after), treating nurses performed bedside point-of-care testing for troponin I, as well as central laboratory testing. Test turnaround times, time from triage until calling in admissions, and time from triage until patients left the ED to be transferred to a floor (ED length of stay) were determined and compared between the 2 study periods. Comparisons between study periods are expressed as mean differences with 95% confidence intervals (CIs). A sample of 100 patients in each group had 90% power to detect a 1-hour difference in length of stay (2-tailed alpha=0.05). RESULTS: There were 232 patients before and 134 after introduction of point-of-care testing. Mean age (SD) was 63 years (16 years), and 44% were female patients. Baseline characteristics were similar in both groups. The rate of positive troponins was also similar (9.5% versus 6.1%). ED length of stay was significantly reduced after introduction of point-of-care testing (5.2 hours [95% CI 4.6 to 5.8 hours] versus 7.1 hours [95% CI 6.6 to 7.7 hours]; mean difference 1.9 hours [95% CI 1.1 to 2.7 hours]). The time until the admission was called in to bed control was also significantly reduced by introducing point-of-care testing (2.7 hours [95% CI 2.4 to 3.1 hours] versus 4.7 hours [95% CI 4.3 to 5.0 hours]; mean difference 1.9 hours [95% CI 1.4 to 2.5 hours]). Point-of-care testing turnaround (14.8 minutes [95% CI 14.1 to 15.5 minutes]) was significantly shorter than for central laboratory testing (83 minutes [95% CI 77 to 89 minutes]; mean difference 68 minutes [95% CI 62 minutes to 74 minutes]). With central testing as the criterion standard, point-of-care testing had a sensitivity of 100% (95% CI 63% to 100%) and a specificity of 96% (95% CI 92% to 99%). CONCLUSION: Bedside performance of troponin I point-of-care testing by treating nurses significantly reduces ED length of stay.

Reaction toward a new treatment paradigm for acute otitis media.

OBJECTIVE: Recent evidence suggests that oral antibiotics may not be required in all children with acute otitis media (AOM). We determined whether parents and pediatricians were aware of and comfortable with a policy of selective use of antibiotics for AOM. DESIGN: Descriptive survey. SETTINGS: Suburban academic emergency department, urgent care center, and private pediatric practices. PARTICIPANTS: Parents of children presenting to an emergency department and urgent care center and pediatricians in faculty and private practice. INTERVENTIONS AND OUTCOMES: Parents were asked whether they were aware of any side effects associated with antibiotic use or of research that supports selective use of antibiotics for AOM. Physicians were queried regarding the methods used to diagnose AOM and their patterns of prescribing antibiotics for AOM. Parents and physicians were questioned regarding their comfort with withholding antibiotics for AOM using a 6-point Likert scale ranging from very uncomfortable to very comfortable. RESULTS: Six hundred fifty-four parents and 84 physicians were surveyed. Sixty-one percent of parents were unaware of the potential side effects of antibiotics, and 72% were unaware of research supporting selective use of antibiotics. Fifty-three percent of parents and 73% of physicians were somewhat comfortable to very comfortable with an observation option for AOM. Half of all pediatricians stated that they always prescribe antibiotic for AOM. CONCLUSIONS: Although most parents are unaware of selective use of antibiotics and half of all surveyed pediatricians stated that they always prescribed antibiotics for AOM, many parents and pediatricians felt comfortable with selective use of antibiotics.

Comparison of nasal tampons for the treatment of epistaxis in the emergency department: a randomized controlled trial.

STUDY OBJECTIVE: Nasal tampons are commonly used to stop bleeding, yet their insertion is painful. We compare the pain of insertion and removal of 2 commonly used nasal tampons. METHODS: This was a prospective randomized controlled trial in 1 urban and 1 suburban emergency department (ED). Subjects were a convenience sample of adult ED patients with active epistaxis requiring insertion of a nasal tampon, regardless of coagulation status. Pretreatment of the nasal mucosa was performed using an aerosolized lidocaine-Neo-Synephrine combination. Patients were randomized to tamponade with a single Rapid Rhino or Rhino Rocket nasal tampon. The pain and ease of insertion and success of tamponade were recorded. Tampon removal was performed after 1 to 3 days, and the pain and ease of removal, as well as the presence of any bleeding, were noted. Patients rated pain of insertion and removal on a previously validated 100-mm visual analogue pain scale (100=worst pain). Physician ease of insertion and removal was recorded on a 5-point Likert scale. Continuous data are presented as means and 95% confidence intervals (CIs). RESULTS: We evaluated 40 patients evenly distributed between study groups and sites. Median patient age was 61 years (interquartile range 48 to 79 years), and 33% were female patients. Coagulopathy was present in 10 (25%) patients. Baseline characteristics were similar in both treatment groups. The mean pain of insertion of the Rapid Rhino (30 mm, 95% CI 18 to 41 mm) was significantly less than with the Rhino Rocket (48 mm, 95% CI 34 to 61 mm; mean difference 18 mm, 95% CI 1 to 35 mm). The mean pain of removal of the Rapid Rhino (11 mm, 95% CI 1 to 21 mm) was also lower than with the Rhino Rocket (23 mm, 95% CI 13 to 33 mm; mean difference 12 mm, 95% CI -1 to 25 mm). The Rapid Rhino was also easier to insert and remove and had a lower incidence of recurrent bleeding after removal than the Rhino Rocket. Rates of successful tamponade were similar in the 2 groups. CONCLUSION: The Rapid Rhino nasal tampon is less painful to insert and easier to remove than the Rhino Rocket, whereas both are similarly effective at stopping nosebleeds.

Pediatric first aid knowledge among parents.

OBJECTIVE: The American Academy of Pediatrics (AAP) has published simple guidelines for the first aid management of ill or injured children. We determined knowledge of these first aid practices in parents. METHODS: Design-Descriptive survey. PARTICIPANTS: A convenience sample of adult parents presenting to the emergency department. SURVEY INSTRUMENT: Standardized collection of demographics was performed and adults were given a multiple-choice questionnaire concerning the proper management of stings and bites, burns and scalds, eye injuries, fractures and sprains, fever, head injuries, fainting, poisoning, dental emergencies, nosebleeds, seizures, and skin wounds. OUTCOMES: Percentage of adults responding to questions appropriately based on AAP guidelines. DATA ANALYSIS: Descriptive statistics and chi2 tests. RESULTS: Six hundred fifty-four adults were surveyed. Mean age (SD) was 38.5 (13.8), 56% were female, 69% were white, 56% had at least a high school education. None of those surveyed answered all questions correctly with roughly half being familiar with 60% of the questions. Knowledge of specific guidelines ranged from 21% to 92%. Subjects especially lacked knowledge regarding the need to rapidly remove all bee stingers (only 36% aware); keep wounds moist and covered (79% felt that drying wounds was beneficial); the need to cover victims of large burns (only 43% aware); and the need to seek medical attention after tick bites (only 47% aware). Knowledge was unaffected by age, gender, and education. CONCLUSIONS: Many adults are unfamiliar with AAP first aid measures according to the AAP guidelines and most believe that wounds should be allowed to dry. Further education is required to improve knowledge of first aid practices.

Comparison of valdecoxib and an oxycodone-acetaminophen combination for acute musculoskeletal pain in the emergency department: a randomized controlled trial.

UNLABELLED: Oral opioids are potent analgesics that are used to treat acute pain in the emergency department (ED). However, they are associated with adverse events such as sedation that may delay safe patient discharge. OBJECTIVE: To compare the safety and efficacy of a new cyclooxygenase-2 inhibitor, valdecoxib, with those of an oxycodone-acetaminophen combination in patients with acute musculoskeletal pain. METHODS: This was a double-blind, randomized controlled trial at an immediate care section of a suburban university-based ED with an annual census of 75,000. Adults with acute musculoskeletal pain without contraindications to the study medications were included. After recording their initial pain scores, patients were randomized to either oral valdecoxib 40 mg or oxycodone 10 mg with acetaminophen 650 mg. Pain scores were recorded at 30 and 60 minutes, and patients who requested additional pain relief were given an oral analgesic at the physician's discretion. Twenty-four-hour telephone follow-up was performed. The pain severity was recorded at 0, 30, and 60 minutes using a validated 100-mm visual analog scale marked "most" at the high end. The need for rescue medications and the occurrence of adverse events were determined. Study outcomes were compared with Student's t-test, repeated-measures analysis of variance (ANOVA), and chi(2) tests as appropriate. RESULTS: Fifty-one patients were randomized to valdecoxib (26) or oxycodone (25). Mean (+/- SD) age was 36 (+/- 14.7) years; 49% were women. Pain locations included extremities (49%), neck (29%), and back (22%). Baseline patient characteristics and pain severities were similar. There was no between-group difference in pain scores at 30 and 60 minutes. The changes in pain scores over time were also similar in the two study groups (repeated-measures ANOVA, p = 0.32). Patients treated with valdecoxib were less likely to experience sedation/dizziness (15% vs. 44%, p = 0.03) and to require rescue medications within the next 24 hours (44% vs. 74%, p = 0.04). CONCLUSIONS: Valdecoxib is as effective as an oxycodone-acetaminophen combination in treating ED patients with acute musculoskeletal pain at 30 minutes and less likely to cause sedation or the need for rescue analgesia over the next day.

Evaluation of a new high-viscosity octylcyanoacrylate tissue adhesive for laceration repair: a randomized, clinical trial.

OBJECTIVE: Tissue adhesives have recently been approved for skin closure. Their low viscosity may result in inadvertent migration. The authors compared the tendency of the adhesive to migrate after laceration closure with a high- or low-viscosity octylcyanoacrylate (OCA). METHODS: This was a randomized, clinical trial set in university and community-based emergency departments. Participants included patients with simple traumatic lacerations. Patients were randomized to laceration closure with low- or high-viscosity OCA tissue adhesive. The outcome measured was immediate adhesive migration (interobserver agreement, kappa = 0.90). Data analysis was performed with proportions compared with chi-square and Fisher's exact tests. RESULTS: Eighty-four patients were randomized to low- (n = 42) or high- (n = 42) viscosity OCA tissue adhesive. Groups were similar in baseline patient and wound characteristics. The high-viscosity OCA was less likely to migrate than the lower-viscosity agent (21% vs. 78%, p < 0.001; odds ratio = 0.3, 95% confidence interval = 0.1 to 0.5). The proportion of patients who noted a sensation of heat during OCA application was higher in the high-viscosity groups (44% vs. 26% respectively, p = 0.11); however, all such patients in both groups would use the device again. At 14 days, there were no wound infections in either group. There was one dehiscence in the high-viscosity group. CONCLUSIONS: The high-viscosity OCA tissue adhesive was less likely to migrate than the lower-viscosity device. Wound dehiscence and infection rates were acceptably low in both treatment groups.

Parents and practitioners are poor judges of young children's pain severity.

OBJECTIVE: Visual analog pain scales are reliable measures in older children and adults; however, pain studies that include young children often rely on parental or practitioner assessments for measuring pain severity. The authors correlated patient, parental, and practitioner pain assessments for young children with acute pain. METHODS: This was a prospective, descriptive study of a convenience sample of 63 emergency department patients aged 4-7 years, with acute pain resulting from acute illness or painful invasive procedures. A trained research assistant administered a structured pain survey containing demographic and historical features to all parents/guardians. Children assessed their pain severity using a validated ordinal scale that uses five different faces with varying degrees of frowning (severe pain) or smiling (no pain). Each face was converted to a numeric value from 0 (no pain) to 4 (severe pain). Parents and practitioners independently assessed their child's pain using a validated 100-mm visual analog scale (VAS) marked "most pain" at the high end. Pairwise correlations between child, parent, and practitioner pain assessments were performed using Spearman's or Pearson's test as appropriate. The association between categorical data was assessed using chi(2) tests. RESULTS: Sixty-three children ranging in age from 4 to 7 were included. Mean age (+/-SD) was 5.7 (+/-1.1); 42% were female. Fifty-seven successfully completed the face scale. The distribution of the children's scores was 0-17%, 1-9%, 2-30%, 3-14%, and 4-30%. Mean parental and practitioner scores (+/-SD) on the VAS were 61 (+/-26) mm and 37 (+/-26) mm, respectively (maximal = 100 mm). Correlation between child and parent scores was 0.47 (p < 0.001). Correlation between child and practitioner scores was 0.08 (p = 0.54). Correlation between parent and practitioner scores was 0.04 (p = 0.001). CONCLUSIONS: There is poor agreement between pain ratings by children, parents, and practitioners. It is unclear which assessment best approximates the true degree of pain the child is experiencing.