ED Push - December 2014 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Guidelines: Be Quick on the Trigger with Epinephrine to Treat Anaphylaxis
ROCHESTER, MN – Emergency physicians need to be quick on the trigger when administering epinephrine to patients presenting with symptoms of a severe allergic reaction, according to new guidelines.
In fact, according to the guidelines published recently in the Annals of Allergy, Asthma and Immunology, there is little reason to delay epinephrine when anaphylaxis is suspected.
"Since emergency department physicians are often the first to see patients who are suffering from anaphylaxis, it's especially important that they not only correctly diagnose the problem, but understand that epinephrine should be administered as soon as possible," said lead author Ronna L. Campbell, MD, PhD, an emergency physician at the Mayo Clinic in Rochester, MN.
The recommendations, which emphasize there is no substitute for epinephrine in treatment of anaphylaxis, also include:
• Immediately triaging and monitoring patients with signs and symptoms of anaphylaxis in preparation of epinephrine administration.
• Administering epinephrine intramuscularly in the anterolateral thigh immediately after the diagnosis is made. The drug can be administered every 5 to 15 minutes as needed to control symptoms.
• Administering antihistamines and corticosteroids in conjunction with epinephrine, not instead of it.
• Determining whether the patient has risk factors for severe and potentially fatal anaphylaxis, such as delayed administration of epinephrine, asthma, a history of biphasic reactions, or cardiovascular disease.
• Administering β-agonist for anaphylaxis patients with bronchospasms.
• Observing patients 4 to 8 hours or even longer for those with a history of risk factors for severe anaphylaxis.
• Referring patients to see an allergist-immunologist upon discharge.
Stanley Fineman, MD, past president of the American College of Allergy, Asthma and Immunology, noted that “the collaboration between emergency department personnel and allergists is vital," and said that ED physicians and allergists participated in a roundtable discussion on the topic at the group’s recent Annual Scientific Meeting.
“We discussed how, together, we can get the word out about the importance of rapid epinephrine administration for those suffering from anaphylaxis,” Fineman recounted. “It's a message we want to get out to everyone dealing with severe allergies."
Poison Control Reports Help ED Physicians Keep Up with Latest Dangers
DENVER – Most emergency physicians know that bath salts aren’t only something to pour into a tub for a relaxing soak or that plant food isn’t just a way to provide nutrients to begonias.
ED care providers have to keep up with illicit street drugs such as “bath salts,” “plant food,” and synthetic marijuana – as well as seemingly harmless grocery store products like laundry detergent pods – to know what agents are likely to poison patients, according to the author of a report from the National Poison Control Center. The study, “Poisoning in the United States: 2012 Emergency Medicine Report of the National Poison Data System,” was published online recently in Annals of Emergency Medicine.
"The poison center system can provide real-time advice and collect data regarding a variety of poisonings, including those that may be new or unfamiliar to emergency physicians," said lead study author Richard Dart, MD, PhD, of the Rocky Mountain Poison and Drug Center in Denver. "Emergency physicians are continually challenged by the emergence of new types of poisonings, which lately include illicit street drugs as well as laundry detergent pods.”
Dart noted that the National Poison Data System (NPDS) plays an integral role in helping EMS and emergency departments respond to the dangerous substances.
In 2012, poison centers across the country recorded 2.2 million human poison exposures, although the vast majority are managed without patients having to show up at EDs. The need to go to a medical facility for poisonings increases with patient age, however: In 2012, 11.6% of children under 5, 14% of children age 6 to 12, 51.2% of teenagers and 37.9% of adults were treated in a health care facility for poisonings.
By far, the most common cause of poisoning, 83%, were from pharmaceutical products, especially opioid painkillers although the report also included cardiovascular and antidepressant medications. Prescription opioid exposures by children more than doubled between 2002 and 2012 from 2,591 to 5,541. Carbon monoxide was the leading non-pharmaceutical agent leading to poisoning deaths, according to the review.
While generally not life-threatening, laundry detergent pods emerged in 2012 as a new source of pediatric poisoning, according to the report. In 2013, poison centers received reports of 10,395 exposures to highly concentrated packets of laundry detergent by children 5 and younger, according to the American Association of Poison Control Centers.
Also increasingly dangerous are designer drugs such as bath salts, plant food and synthetic marijuana, which can poison users severely enough to require emergency medical treatment. Everything from seizures to psychotic episodes has been reported. While bath salts exposures peaked in 2011, new illicit drugs sold to consumers are constantly monitored by poison control centers, according to the report.
"Poisoning continues to be a significant cause of injury and death in the United States," Dart said. "The near real-time responsiveness of NPDS helps emergency physicians respond to new poisoning threats, while also assisting patients who call for help to know when they need the ER and when they can manage things safely at home."
New Algorithm Helps Diagnose Pulmonary Embolism in Older Patients
SALT LAKE CITY – A new sliding scale model is more accurate than current diagnostic methods in helping emergency physicians rule out pulmonary embolisms in older patients, according to a recent study.
The new model factors in patient age and more accurately identifies a patient's risk of potentially fatal blood clots, according to the research published recently in the journal CHEST. That can avert the need for additional, more invasive tests and help reduce unnecessary costs, according to the study led by researchers from Intermountain Medical Center in Salt Lake City.
Background in the article notes that pulmonary embolism is associated with more deaths annually than breast cancer, HIV/AIDS, prostate cancer, and motor vehicle accidents combined.
"When patients come to the ER with the symptoms of a pulmonary embolism, we begin by doing a physical exam and identifying their previous medical history," explained lead author Scott Woller, MD, co-director of Intermountain Medical Center's Thrombosis Program. "Once we get that initial information, we often conduct a simple blood test called a d-dimer, which tests for proteins found in the blood when a clot is present. If the protein levels are above a certain threshold, we most often order a CT scan to confirm or rule out a pulmonary embolism. However, as we age, D-dimer levels naturally increase, which means when we test D-dimer in elderly patients, we often find an elevated result – even when a clot is absent. This is referred to as a false-positive test."
Looking at more than 900 patients who presented to the ED with symptoms of a pulmonary embolism (PE) and had D-dimer tests ordered, researchers determined that adjusting the threshold of D-dimer levels in correlation to a patient's age accurately excluded a pulmonary embolism diagnosis without requiring additional testing.
While the conventional cutoff used to identify a normal D-dimer value is 500, researchers suggest that patients older than 50 should have the cutoff adjusted upward to a value equal to the patient's age multiplied by 10. For example, a 72-year-old patient would have a normal D-dimer value of less than 720.
No PEs were found within 90 days among 104 patients with a negative conventional D-dimer test result and a Revised Geneva Score equal to or less than 10, according to the results. Among 273 patients with a negative age-adjusted D-dimer result and an RGS equal to or less than 10, four PEs were observed within 90 days.
"A CT scan is most often used to ultimately rule out a pulmonary embolism, however it delivers radiation to the patient and contrast dye," Woller pointed out. "Elderly patients are at greater risk for inadvertent harm related to the CT scan, and the contrast dye may also impact kidneys function, plus the scan adds to the cost of the patient's care. If we can safely and accurately diagnose the patient's risk of a pulmonary embolism using this sliding D-dimer scale, we can eliminate the need for additional imaging tests."
The study notes that adoption of the age-adjusted cutoff would decrease the number of CT scans that would need to be performed by nearly 20%. More studies are being conducted to verify the accuracy of the sliding scale.
“Use of an age-adjusted D-dimer threshold reduces imaging among patients aged > 50 years with an RGS ≤ 10,” study authors conclude. “Although the adoption of an age-adjusted D-dimer threshold is probably safe, the CIs surrounding the additional 1.5% of PEs missed necessitate prospective study before this practice can be adopted into routine clinical care."
Ebola Assessment Centers Will Make Speedy Diagnoses, Transfers
ATLANTA – With 44 hospitals designated as Ebola treatment centers by public health officials as of mid December, more than 80% of returning travelers from Ebola-stricken countries now live within 200 miles of such a facility in the United States.
The CDC notes that an increasing number of U.S. hospitals are now equipped to treat patients with Ebola, giving nationwide health system Ebola readiness efforts a boost. The CDC reported that state health officials had identified and designated the first group of hospitals with Ebola treatment centers and that facilities would be added to the list weekly.
“As long as Ebola is spreading in West Africa, we must prepare for the possibility of additional cases in the United States,” said CDC Director Tom Frieden, MD, MPH. “We are implementing and constantly strengthening multiple levels of protection, including increasing the number of hospitals that have the training and capabilities to manage the complex care of an Ebola patient. These hospitals have worked hard to rigorously assess their capabilities and train their staff.”
Now, CDC is turning its attention to working with state and local public health officials to identify Ebola assessment hospitals. Assessment hospitals or, more specifically, their emergency departments, would have the capability to:
- evaluate and care for someone who is having the first symptoms of Ebola virus disease (EVD) for up to 96 hours;
- initiate and coordinate testing for Ebola and for other diseases alternative diagnoses; and
- either rule out Ebola or transfer the individual to an Ebola treatment center, as needed.
CDC recently released guidance for states and hospitals to use as they identify Ebola assessment hospitals.
Patients who had traveled to an Ebola-affected area or had potential exposure to someone with EVD within the past 21 days and developed signs and symptoms of EVD would be referred to the assessment hospitals. The designated centers also might receive patients transferred from frontline healthcare facilities that are not prepared to provide evaluation, arrange for testing, and care for patients with possible EVD.
“Ebola assessment hospitals should ensure there is no delay in the care for these patients by being prepared to test, manage, and treat alternative etiologies of febrile illness (e.g., malaria, influenza) as clinically indicated,” the CDC emphasizes.
Public health officials note that EVD is likely to be detected early in the clinical course among patients already involved in active monitoring. Those patients probably would present for evaluation with mild symptoms such as isolated fever and could be managed using standard Ebola infection control practices and personal protective equipment. On the other hand, some patients might present with more severe symptoms or may exhibit vomiting, copious diarrhea, or obvious bleeding, and Ebola assessment hospitals must be equipped and ready to handle those situations, public health officials point out.
Because confirming an EVD may take up to 72 hours or longer, and potentially require an additional 12-24 hours for specimen transport, testing, and identification of another facility for transfer, Ebola assessment hospitals would need to be able to provide care for a potential Ebola case for up to 96 hours.
Once diagnosis is confirmed, the patient would be transferred to an Ebola treatment center.
Already, the additional Ebola treatment centers supplement the three national bio containment facilities at Emory University Hospital in Atlanta, Nebraska Medical Center in Omaha, and the National Institutes of Health in Bethesda, MD, which the CDC said would continue to play a major role in the overall national treatment strategy, especially for patients medically evacuated from overseas.
The priority areas for Ebola treatment and assessment centers are jurisdictions served by the five international airports screening returning travelers for Ebola, cities with high proportions of returning travelers from West Africa, and cities with large populations of individuals from West Africa. Federal health officials explained that, because of the active monitoring program of returning travelers from countries where Ebola is present, they have a good idea of where travelers from affected countries in West Africa are going and where Ebola care is most likely to be needed.