Anna Domingo

Diagnostic characteristics of a clinical screening tool in combination with measuring bedside lactate level in emergency department patients with suspected sepsis.

BACKGROUND Early identification of sepsis and initiation of aggressive treatment saves lives. However, the diagnosis of sepsis may be delayed in patients without overt deterioration. Clinical screening tools and lactate levels may help identify sepsis patients at risk for adverse outcomes. OBJECTIVES The objective was to determine the diagnostic characteristics of a clinical screening tool in combination with measuring early bedside point-of-care (POC) lactate levels in emergency department (ED) patients with suspected sepsis. METHODS This was a prospective, observational study set at a suburban academic ED with an annual census of 90,000. A convenience sample of adult ED patients with suspected infection were screened with a sepsis screening tool for the presence of at least one of the following: temperature greater than 38°C or less than 36°C, heart rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min, or altered mental status. Patients meeting criteria had bedside POC lactate testing following triage, which was immediately reported to the treating physician if ≥2.0 mmol/L. Demographic and clinical information, including lactate levels, ED interventions, and final diagnosis, were recorded. Outcomes included presence or absence of sepsis using the American College of Chest Physicians/Society of Critical Care Medicine consensus conference definitions and intensive care unit (ICU) admissions, use of vasopressors, and mortality. Diagnostic test characteristics were calculated using 2-by-2 tables with their 95% confidence intervals (CIs). The association between bedside lactate and ICU admissions, use of vasopressors, and mortality was determined using logistic regression. RESULTS A total of 258 patients were screened for sepsis. Their mean (± standard deviation [SD]) age was 64 (±19) years; 46% were female, and 82% were white. Lactate levels were 2.0 mmol/L or greater in 80 (31%) patients. Patients were confirmed to meet sepsis criteria in 208 patients (81%). The diagnostic characteristics for sepsis of the combined clinical screening tool and bedside lactates were sensitivity 34% (95% CI = 28% to 41%), specificity 82% (95% CI = 69% to 90%), positive predictive value 89% (95% CI = 80% to 94%), and negative predictive value 23% (95% CI = 17% to 30%). Bedside lactate levels were associated with sepsis severity (p < 0.001), ICU admission (odds ratio [OR] = 2.01; 95% CI = 1.53 to 2.63), and need for vasopressors (OR = 1.54; 95% CI = 1.13 to 2.12). CONCLUSIONS Use of a clinical screening tool in combination with early bedside POC lactates has moderate to good specificity but low sensitivity in adult ED patients with suspected sepsis. Elevated bedside lactate levels are associated with poor outcomes.

The Wong-Baker pain FACES scale measures pain, not fear.

Objective The Wong-Baker FACES Pain Rating Scale (WBS) is preferred by parents and patients for reporting pain severity. However, it is speculated that the “no hurt” and “hurts worst” anchors confound pain measurement with nonnociceptive states. The objective of our study was to determine if fear confounds reporting of pain severity on the WBS. We hypothesized that the WBS would correlate with a psychometrically different pain severity scale (the visual analog scale [VAS]) and not correlate with a fear measure, the Child Medical Fear Scale (CMFS). Methods This was a prospective observational study of children 7 to 12 years presenting to a university-based suburban pediatric ED with acute pain. Patients rated pain severity on the WBS ordinal scale and a 100-mm unhatched VAS with marked end points of “no pain” and “worse pain ever.” Patients also completed a 26-item CMFS. Correlations between the WBS and VAS with the CMFS total score were assessed with Spearman correlation and exploratory factor analysis. Results All 3 scales were completed in 197 children. Correlation between the severity scales (WBS-VAS) was moderate: 0.63 (95% confidence interval [CI], 0.54–0.71). However, correlations between the WBS-CMFS and VAS-CMFS were poor: −0.02 (95% CI, −0.16 to −0.12) and 0.01 (95% CI, −0.13 to 0.15), respectively. Correlations did not differ by sex, grade, pain location, or cause of pain (traumatic vs atraumatic). Exploratory factor analysis demonstrated excellent loadings within 2 factors: pain and fear. Conclusions The WBS demonstrates moderate correlation with another measure of pain (VAS) and is not mistaken for fear among school-aged patients presenting to the ED with pain.

Ibuprofen vs acetaminophen vs their combination in the relief of musculoskeletal pain in the ED: a randomized, controlled trial

Non-opioid analgesics are often administered to emergency department (ED) patients with musculoskeletal pain but if inadequate, opioids are given with associated potential adverse events. We tested the hypothesis that the reduction in pain scores with the combination of ibuprofen and acetaminophen would be at least 15 mm greater than with either of the agents alone. We conducted a double-blind, randomized, controlled trial of adult ED patients with acute musculoskeletal pain. Patients were randomized to oral ibuprofen 800 mg, acetaminophen 1 g, or their combination. Pain scores across the groups were compared with repeated measures analysis of variance at 20, 40, and 60 minutes. A sample of 30 patients in each group had 80% power to detect a 15 mm difference in pain scores across the groups (α = .05). Thirty patients were randomized to each study group. Mean (SD) age was 36 (15), 54% were male, 73% were white, and 13% were Hispanic. Groups were well balanced in baseline characteristics including initial pain scores (59, 61, and 62 for ibuprofen, acetaminophen, and their combination). Pain decreased over the one hour study period for all groups (P < .001) with mean (SD) scores about 20 mm lower on the Visual Analogue Scale than the mean initial score. However, there was no significant difference among treatments (P = .59). The need for rescue analgesics was similar across groups. We conclude that the combination of ibuprofen and acetaminophen did not reduce pain scores or the need for rescue analgesics compared with either agent alone in ED patients with pain secondary to acute musculoskeletal injuries.

Utilization of coronary computed tomography angiography for exclusion of coronary artery disease in ED patients with low- to intermediate-risk chest pain: a 1-year experience ☆

OBJECTIVE We describe our preliminary experience with coronary computed tomography angiography (CCTA) in emergency department (ED) patients with low- to intermediate-risk chest pain. METHODS A convenience cohort of patients with low- to intermediate-risk acute chest pain presenting to a suburban ED in 2009 were prospectively enrolled if the attending physician ordered a CCTA for possible coronary artery disease. Demographic and clinician data were entered into structured data collection sheets required before any imaging. The results of CCTA were classified as normal, nonobstructive (1%-50% stenosis), and obstructive (>50% stenosis). Outcomes included hospital admission and death within a 6-month follow-up period. RESULTS In 2009, 507 patients with ED chest pain had a CCTA while in the ED. The median (interquartile range) age was 54 (47-62) years; 51.5% were female. Thrombolysis in myocardial infarction risk scores were 0 (42.6%), 1 (42.2%), 2 (11.8%), 3 (2.4%), and 4 (1.0%). The results of CCTA were normal (n = 363), nonobstructive (n = 123), and obstructive (n = 21). Admission rates by CCTA results were obstructive (90.5%), nonobstructive (4.9%), and normal (3.0%). None of the patients with normal or nonobstructive CCTA died within the 6-month follow-up period (0%; 95% confidence interval, 0-0.9%). CONCLUSIONS Many ED patients with low- to intermediate-risk chest pain have a normal or nonobstructive CCTA and may be safely discharged from the ED without any associated mortality within the following 6 months.

Evaluation of a Liquid Dressing for Minor Nonbleeding Abrasions and Class I and II Skin Tears in the Emergency Department

BACKGROUND Minor abrasions and skin tears are usually treated with gauze dressings and topical antibiotics requiring frequent and messy dressing changes. OBJECTIVE We describe our experience with a low-cost, cyanoacrylate-based liquid dressing applied only once for minor abrasions and skin tears. METHODS We conducted a single-center, prospective, noncomparative study in adult emergency department (ED) patients with minor nonbleeding skin abrasions and class I and II skin tears. After cleaning the wound and achieving hemostasis, the wounds were covered with a single layer of a cyanoacrylate liquid dressing. Patients were followed every 1-2 days until healing. RESULTS We enrolled 40 patients with 50 wounds including 39 abrasions and 11 skin tears. Mean (standard deviation) age was 54.5 (21.9) years and 57.5% were male. Wounds were located on the face (n = 16), hands (n = 14), legs (n = 11), and arms (n = 9). Pain scores (0 to 10 from none to worst) after application of the liquid dressing were 0 in 62% and 1-3 in the remaining patients. Follow-up was available on 36 patients and 46 wounds. No wounds re-bled and there were no wound infections. Only one wound required an additional dressing. Median (interquartile range [IQR]) time to complete sloughing of the adhesive was 7 (5.5-8) days. Median (IQR) time to complete healing and sloughing of the overlying scab was 10 (7.4-14) days. CONCLUSIONS Our study suggests that a single application of a low-cost cyanoacrylate-based liquid adhesive is a safe and effective treatment for superficial nonbleeding abrasions and class I and II skin tears that eliminates the need for topical antibiotics and dressings.