ED Push - May 2016 First Issue
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Lung Ultrasound Is Safe Substitute for Chest X-Ray in Pediatric Pneumonia
NEW YORK -- Substituting lung ultrasound for chest X-ray to diagnose pneumonia in children is both safe and feasible, according to a new study.
The article was published in the journal Chest. It notes that pneumonia is the top cause of death in children around the world, yet chest X-ray, generally the preferred test, is not available to three-quarters of the world’s population.
For the study, Icahn School of Medicine researchers conducted a randomized controlled trial in the pediatric emergency department at The Mount Sinai Hospital, comparing lung ultrasound to chest X-ray in 191 children from birth to age 21.
Patients were randomly assigned into an investigational arm — in which participants received a lung ultrasound and, if the physician needed additional verification, a chest X-ray — and a control arm — in which participants received a chest X-ray followed by a lung ultrasound.
Results indicate a 38.8% reduction in chest X-rays in the investigational arm compared to no reduction in the control arm. No pneumonia cases were missed, and the investigators identified no increase in any other adverse events.
"Ultrasound is portable, cost-saving, and safer for children than an X-ray because it does not expose them to radiation," said lead investigator James Tsung, MD, MPH. "Our study could have a profound impact in the developing world where access to radiography is limited."
The reduction in chest X-rays in the investigational arm resulted in an overall cost savings of $9,200, while decreasing ED length of stay by an average of 26 minutes.
"In the era of precision medicine, lung ultrasound may also be an ideal imaging option in children who are at higher risk for radiation-induced cancers or have received multiple radiographic or CT imaging studies," Tsung said in a Mount Sinai Health System press release.
The authors call for more research on how antibiotic use and stewardship are affected by lung ultrasound use.
Minor Head Trauma Often Sends Older Adults Back to ED After Discharge
COLUMBUS, OH – U.S. emergency departments treat more than 2 million non-fatal falls among older adults each year. A new study looks at how the high rate of return to EDs among those patients could be lowered.
The report published recently in the Journal of the American Geriatrics Society discussed how chart review was used to determine factors associated with and increasing the risk for a return visit to the ED after discharge.
Ohio State University Wexner Medical Center researchers reviewed electronic medical records of 263 adults ages 65 and older who were evaluated and treated in the institution’s Level 1 Trauma Center for a fall within an 18-month study period and discharged.
“We found that more than one-third of older adults with minor head trauma caused by a fall will need to come back to the emergency room within 90 days after discharge,” said lead author Lauren Southerland, MD.
According to the study, 45% of the injuries were fractures and 34% were abrasions, lacerations, or contusions, with no serious injuries identified in 22% of cases. About 5% returned to the ED within 72 hours, 13% returned within 30 days, and 22% returned within three months.
The odds of returning to the ED within 90 days was more than twice as high for patients with head trauma as for those without that type of injury, with an odds ratio of 2.66.
About half of older adults are discharged after the ED evaluation but remain at risk for functional decline and difficulty accessing resources at home, according to study authors, who proposed that ED staff might be the only healthcare contact for those discharged patients. Emergency clinicians might not have the time or training, however, to ensure that all of the patient’s home healthcare needs are met, they added.
“Older adults with falls are a higher risk population that could benefit from early interventions to reduce their need for recurrent emergency care,” Southerland said in an Ohio State press release. “An emergency department visit for a fall should be seen as an opportunity to address unmet patient care needs.”
Study authors conclude, “These individuals should receive close attention from primary care providers. The link between minor head trauma and ED recidivism is a new finding.”
Need to Know Kids’ Weight in the ED? Parents Often Know Best
LOS ANGELES – When emergency physicians need to estimate the weight of a pediatric patient, asking Mom or Dad works about as well as or better than more sophisticated measurement systems.
That’s according to the results of a systematic review of the literature on pediatric weight estimation published online in Annals of Emergency Medicine.
"When emergency department staff needs to know the weight of children for purposes of emergency resuscitation, parents generally offer the most accurate estimates," said lead author Kelly D. Young, MD, MS, of the Harbor-UCLA Medical Center in Los Angeles. "Length-based methods of measurement came in second. We still have trouble getting accurate estimates for children from populations with high obesity rates and high malnourishment rates, regardless of which method is used."
How accurate were the parents’ estimations? The study found that 70% to 80% of parents and legal guardians estimated children's weight within a 10% margin higher or lower than the child's actual weight.
For the review, 80 studies met inclusion criteria with predominant methods: parent or healthcare worker weight estimation, age-based formulas, and length-based estimation without – for example Broselow Tape — or with adjustment for body habitus — for example, Pediatric Advanced Weight-Prediction in the Emergency Room (PAWPER) tape or the Mercy method.
“Length-based methods outperformed age-based formulae, and both tended to underestimate the weight of children from populations with high obesity rates and overestimate the weight of children from populations with high malnourishment rates,” according to study authors. “Healthcare worker estimation was not accurate.”
The study points out that age-based formulas and length-based methods without body-type adjustment tended to predict ideal, not actual, body weight.
"No reported method is truly ideal," Young added in an American College of Emergency Physicians press release. "Parental estimation, while pretty accurate, may not be available at the time of resuscitation or parents may be distraught. Parent estimation and length-based methods with adjustment for a child's body type are the most accurate methods for predicting children's total actual body weight. But then it gets complicated because some resuscitation drugs are best dosed based on ideal body weight."
Even Minor Blood Transfusion Delays Increase Trauma Death Rates
CINCINNATI — Even minor delays as little as 10 minutes in administering packed red blood cells (pRBC) can increase the risk of death from trauma, according to a recent study that suggests expedient prehospital and emergency department transfusion capabilities could improve outcomes.
The research, published recently in the Journal of Trauma and Acute Care Surgery, notes that hemorrhage is a leading cause of death in traumatically injured patients but that evidence about the effectiveness of earlier administration of pRBC to improve outcomes is limited.
"More than 180,000 people die from trauma every year," explained lead author Elizabeth Powell, MD, assistant professor of emergency medicine in the University of Cincinnati Department of Medicine. "Bleeding is the major cause of preventable death after trauma."
For the study, researchers tracked trauma patients transported from the injury location via Air Care to the University of Cincinnati Medical Center (UCMC) and who received at least one unit of blood within 24 hours of arriving at the hospital. Participants included 94 patients, average age of 43, mostly male Caucasians who had sustained blunt force injuries between March 11, 2010 and Oct. 30, 2013. Median injury severity score was 29, and about a third of the patients died within 30 days after injury.
The helicopter service carries two units of pRBCs for protocol-driven prehospital transfusion, according to the report, and 87% of the patients received their first pRBC transfusion during transport or within one hour of ED arrival.
For those trauma victims, results controlling for trauma score-injury severity score (TRISS) indicate that each 10-minute increase in time to transfusion increased mortality risk, with an odds ratio of 1.27.
“Air Care is the only helicopter in the area to carry blood (and plasma), so we had the research platform to study how early blood transfusions impact outcomes," Powell pointed out in a University of Cincinnati press release, adding that most patients received their first blood transfusion from Air Care or within one hour of getting to UCMC.
Noting that each 10-minute delay in receiving blood increased the chance of death for these patients, Powell suggested that “shortening the time to transfusion, including having blood available in the prehospital setting, may improve outcomes.”
While she said she does not anticipate a change in ED guidelines, Powell noted that “other critical care transport services may need to examine their protocols and consider the use of blood products in their practice." Few critical care transport services currently carry blood products, she said.
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