ED Push - December 2014 First Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Epinephrine Can Help Restart Heart, But At What Cost
PARIS – Administering epinephrine to restart the heart may not be the best way to save lives when patients are in cardiac arrest, according to a new French study.
The report, published recently in the Journal of the American College of Cardiology, notes that administering epinephrine can increase the overall likelihood of death or debilitating brain damage.
The research from the Parisian Cardiovascular Research Center provides new data in the ongoing debate about the risks and benefits of using epinephrine to treat cardiac arrest. International guidelines currently recommend administering 1 milligram of epinephrine every 3-5 minutes during resuscitation.
"The role of epinephrine is more and more questionable in cardiac arrest," said lead author Florence Dumas, MD, PhD. "We need to constantly assess our procedures and protocols to make sure that the use of epinephrine is effective and done at the correct time."
While administering epinephrine to patients in cardiac arrest improves the return of spontaneous circulation (ROSC), it also harms patients' chances of surviving past the post-resuscitation period with brain function intact, according to the report.
The researchers analyzed hospital records for more than 1,500 patients – all of whom had suffered out-of-hospital cardiac arrest, been resuscitated and achieved ROSC – admitted to a large Parisian hospital over a 12-year period. Almost three-quarters of the patients had received at least one dose of epinephrine.
Results indicate that 63% of patients who did not receive epinephrine achieved the primary outcome, defined as discharge from the hospital with normal or only moderately compromised brain functioning. On the other hand, only 19% of patients who received epinephrine met that goal.
In addition, patients receiving higher doses of epinephrine fared worse than those with lower doses. Compared to patients resuscitated without epinephrine, those receiving 1-milligram doses were 52% more likely to have a bad outcome while those receiving 5-milligram or larger doses were 77% more likely to have a bad outcome, according to the study.
Patients who had not received epinephrine were generally younger and more likely to have been near a witness when they collapsed, but statistical methods were used to account for the differences.
Another factor was found to be timing, with patients receiving epinephrine in the later stages of resuscitation faring worse than those who got their first epinephrine dose shortly after collapsing.
Post-resuscitation medical treatments, such as techniques to cool the body to reduce tissue damage or interventions to restore the flow of blood through blocked arteries, had little effect on epinephrine’s adverse outcomes, study authors report.
"It's very difficult, because epinephrine at a low dose seems to have a good impact in the first few minutes, but appears more harmful if used later," said Dumas, who did not suggest an immediate change in guidelines. "It would be dangerous to completely incriminate this drug, because it may well be helpful for certain patients under certain circumstances. This is one more study that points strongly to the need to study epinephrine further in animals and in randomized trials."
The authors called for studies on other drugs and drug combinations that could offer safer alternatives to epinephrine during cardiac arrest.
Riding Toys Blamed for Injuries Sending More Children to EDs
COLUMBUS, OH – As Christmas approaches, children may be dreaming of toys under the tree, but emergency physicians face a different kind of nightmare: the spate of injuries caused by those playthings.
Researchers from the Center for Injury Research and Policy at Nationwide Children's Hospital report that more than 3.2 million children were treated in U.S. emergency departments from 1990 through 2011 for a toy-related injury.
In 2011, for example, a child was treated every three minutes for that type of injury, most of which occurred in children younger than 5.
The study, published online in Clinical Pediatrics and will appear in print in the February issue, found that the rate of injury rose almost 40% during the 22-year period analyzed. Accounting for much of the increase were foot-powered scooters.
"The frequency and increasing rate of injuries to children associated with toys, especially those associated with foot-powered scooters, is concerning," said senior author Gary Smith, MD, DrPH, director of the Center for Injury Research and Policy at Nationwide Children's Hospital. "This underscores the need for increased efforts to prevent these injuries to children. Important opportunities exist for improvements in toy safety standards, product design, recall effectiveness, and consumer education."
Smith noted that likely injuries vary based on children’s age. Those younger than 3 years are at particular risk of choking on small toys and small toy parts. The study reports more than 109,000 cases of children younger than 5 swallowing or inhaling "foreign bodies," which works out to about 14 cases per day.
Injuries involving riding toys increase as children get older. Those types of toys, including foot-powered scooters, wagons, and tricycles, were associated with 42% of injuries to children 5 to 17 years of age and 28% of injuries to children younger than 5, according to the study. Furthermore, injuries with ride-on toys were three times more likely to involve a broken bone or a dislocation than other toys.
The most common way children were injured with toys of all categories include falls (46%) and collisions (22%), the authors report.
The worst offenders in recent years have been foot-powered scooters, according to the article. From 2000, when the scooters first became popular, through 2011, an estimated 580,037 injuries occurred -- about one every 11 minutes. In fact, much of the increase in the overall toy injury rate after 1999 is due to foot-powered scooters, the authors emphasize.
The study suggests children have a reduced chance of having to visit their local ED if parents and caregivers:
- Follow age restrictions and other manufacturer guidelines for all toys.
- Examine toys for small parts that could be choking hazards for young children.
- Use riding toys on dry, flat surfaces away from vehicle traffic.
- Closely supervise any child who is younger than 8 years of age on a riding toy.
- Wear helmets, knee pads, and elbow pads on scooters and other riding toys with wheels.
- Check Recalls.gov to see if toys have been recalled.
ACEP Resolution Gives Boost to Trend of Pharmacists in EDs
PISCATAWAY, NJ – A quiet trend going on for decades received a boost this fall with the passage of a resolution by the American College of Emergency Physicians (ACEP) recognizing and supporting the use of pharmacists in emergency departments.
Noting that EDs have “been identified as a hospital department with high rates of preventable adverse drug events,” ACEP resolved to “create a policy statement that supports clinical pharmacy services in emergency departments and collaboration among emergency medicine providers to promote safe, effective, and evidence-based medication practices, to conduct emergency-medicine-related clinical research, and to foster an environment supporting pharmacy residency training in emergency medicine.”
The news was characterized as “historic” on the “Emergency Medicine PharmD” blog launched by Craig Cocchio, PharmD, BCPS, a professor in the Emergency Medicine Pharmacy program at Rutgers, The State University of New Jersey, in Piscataway.
“For the first time, ACEP is now recognizing and supporting the presence and various roles EM pharmacists as members of the multidisciplinary team in the emergency department,” writes Nadia Awad, PharmD, BCPS, a Rutgers pharmacy professor who also serves as the blog’s associate editor.
Awad notes, however, that the reaction was “a ‘Duh!’ moment for many folks. For a service that has been around for 40-some years, this is quite a feat and has actually made some folks wonder why ACEP never officially recognized us EM pharmacists up until this moment. I think if you speak to any provider who has a dedicated EM pharmacist, he or she will sing praises related to the value of their EM pharmacist[s] within their department. But to have an official non-pharmacy body recognize us as valued clinicians in the emergency department – and our own EM physician colleagues at that – well, it is pretty amazing, to say the least.”
The ACEP resolution, introduced by the group’s New York chapter, points out that the acute nature of the patient population in the ED can make it difficult to use traditional medication use system safety mechanisms such as pharmacist prospective review, medication cabinet, patient profiling, medication preparation and labeling by the pharmacy department and bar code medication administration.
It also cites “a substantial body of literature” for more than 40 years indicating a reduction in the number of medication errors when a clinical pharmacist is present in the emergency department compared to staff pharmacist oversight delivered from a remote area of the hospital or elsewhere.
Other advantages to having dedicated pharmacists in the ED include lower costs, greater ED staff satisfaction and leadership initiatives, research and scholarly activities, according to the resolution.
Resolution supporters pointed out that, a decade ago, The Joint Commission proposed a standard that called for a prospective review by a pharmacist prior to medications being administered to hospital patients, including those in the ED. After ACEP expressed significant concern about the impact of the proposed prospective review by a pharmacist and the medication reconciliation standards on timely care in the ED, The Joint Commission allowed an exception, reading, in part, “Before dispensing or removing medications from floor stock or from an automated storage and distribution device, a pharmacist reviews all medication orders or prescriptions unless …a delay would harm the patient in an urgent situation (including sudden changes in a patient’s clinical status), in accordance with law and regulation.”
The American Society of Health-System Pharmacists, on the other hand, maintains that “… every hospital pharmacy department should provide its emergency department [ED] with the pharmacy services that are necessary for safe and effective patient care.”
Supporters of the resolution argue that “providing pharmacy services in the ED to meet identified institutional needs rather than mandating pharmacist review prior to administration of medications in the ED” would be most desirable.
ACEP budgeted funds to encourage pharmacy residency training in emergency medicine.
Brief ED Interventions with Drug Abusers Show Little Effect
ALBUQUERQUE, NM – Could emergency departments do more than just acute medical stabilization for patients who present with substance abuse?
It may sound good on paper, but a new study published in JAMA Internal Medicine suggests that might be very difficult with current tools.
Noting that medical treatment settings such as EDs offer important opportunities to address problematic substance use beyond acute treatment, the study led by researchers from the University of New Mexico Health Sciences Center in Albuquerque sought to contrast the effects of a brief intervention with telephone boosters (BI-B) with those of screening, assessment, and referral to treatment (SAR) and minimal screening only (MSO) among drug-using ED patients.
The study, conducted between October 2010 and February 2012, focused on 1,285 adult ED patients from six academic hospitals in the United States. All scored 3 or greater on the 10-item Drug Abuse Screening Test, indicating moderate to severe problems related to drug use, and were currently using drugs.
With 431 study subjects randomized to MSO, 427 to SAR and 427 to BI-B, follow-up assessments were conducted at 3, 6, and 12 months by blinded interviewers.
Following screening, MSO participants received only an informational pamphlet. The SAR participants received assessment plus referral to addiction treatment if indicated. The BI-B participants, however, received assessment and referral as in SAR, plus a manual-guided counseling session based on motivational interviewing principles and up to two “booster” sessions by telephone during the month following the ED visit.
At follow-up visits, researchers evaluated effects based on self-reported days using the patient-defined primary problem drug, days using any drug, days of heavy drinking, and drug use based on analysis of hair samples.
Results indicate that estimated differences in number of days of use were:
- MSO vs BI-B, 0.72 (−0.80 to 2.24);
- SAR vs BI-B, 0.70 (−0.83 to 2.23),
- SAR vs MSO, −0.02 (−1.53 to 1.50).
“There were no significant differences between groups in self-reported days using the primary drug, days using any drug, or heavy drinking days at 3, 6, or 12 months,” the authors report. “At the 3-month follow-up, participants in the SAR group had a higher rate of hair samples positive for their primary drug of abuse (265 of 280 [95%]) than did participants in the MSO group (253 of 287 [88%]) or the BI-B group (244 of 275 [89%]). Hair analysis differences between groups at other time points were not significant.”
The study laments that, in this sample of drug users seeking emergency medical treatment, “a relatively robust brief intervention did not improve substance use outcomes. More work is needed to determine how drug use disorders may be addressed effectively in the ED.