Daniel C. McGillicuddy

Morbidity and Mortality conference in Emergency Medicine.

BACKGROUND Morbidity and Mortality conferences (M&M) are used to meet many of the Core Competencies required by the Accreditation Council of Graduate Medical Education for residency training programs. This study seeks to describe and quantify different types of M&M conferences among Emergency Medicine (EM) training programs. METHODS A confidential survey was e-mailed to the Program Directors (PD) or Assistant PD of all United States (US) Emergency Medicine residency training programs with functional e-mail addresses listed in the Society for Academic Emergency Medicine residency catalog. Descriptive statistics and 95% confidence (CI) intervals are reported. RESULTS Of 124 surveys sent out, 89 (72%) completed surveys were returned. There were 88 programs (99%, CI 93-100%) that reported having an M&M. Conferences are held monthly at 67% (CI 57-76%) of programs. Cases for discussion are identified by an EM attending, quality assurance committee, or resident (70%, 57%, and 48%, respectively). Half of programs reported that > 40% of the cases involve systems errors. Twenty percent of programs report that > 40% of the cases involve deaths. Consultants are invited at 44% of programs, and 20% of programs specifically invite radiologists. If a medical error is identified in the M&M, 79% (70-86%) of programs have a protocol for addressing the error. CONCLUSION EM training programs almost uniformly have an M&M, but these conferences vary in frequency, content, and attendance. Future studies are needed to investigate resident and faculty perceptions of M&M, its educational impact, and ways to improve the conference.

Klebsiella Pneumoniae Liver Abscess: An Emerging Problem in North America

BACKGROUND Before the 1980s, Escherichia coli was the most common cause of pyogenic liver abscess, but more recently, Klebsiella pneumoniae has emerged as the most common organism in the United States and Taiwan. OBJECTIVE Our goal is to present a case of K. pneumoniae liver abscess (KLA) and review the risk factors, presenting symptoms, complications, and treatment of this disease that is emerging in North America. CASE REPORT We present a patient who was found to have KLA complicated by bacteremia and sepsis. CONCLUSIONS Initially described in the Asian literature, KLA is an emerging problem in North America. We present this case to increase awareness among emergency physicians of the diagnosis, risk factors, potential complications-including bacteremia and disseminated infection-and treatment.

Creatine kinase-MB does not add additional benefit to a negative troponin in the evaluation of chest pain☆

OBJECTIVE The aim of this study was to determine whether current troponin assay alone can be used for initial screening for acute myocardial infarction (AMI) and whether creatine kinase-MB (CK-MB) can safely be eliminated from this evaluation in the emergency department (ED). METHODS A retrospective cohort study of patients who had cardiac troponin T (Roche, Basel, Switzerland) and CK-MB ordered at an urban academic level 1 trauma center with more than 55,000 annual visits. Patients with troponin testing in the ED were identified over a period of 12 months, and corresponding CK-MB indexes were examined identifying patients with negative troponins (<0.01) and positive CK-MB indexes (>6.0). In these patients, further cardiac markers, hospital course, and 30-day mortality were then evaluated. A 99% confidence interval around point estimate was used in data analysis. RESULTS During the study period, there were 11,092 separate ED patient encounters where a patient had at least one troponin resulted. Most (97.9%) of the samples had an associated CK-MB ordered. There were 7545 initial negative troponins representing 68% of all initial samples. Seven of these had an associated positive MB index. When subsequent troponins were evaluated, an additional 4910 negative troponins were identified, with 4 patients having a positive MB. None of these 11 patients were judged to have ruled in for AMI by the treating physicians. The rate of true-positive CK-MB index with negative troponin was 0% (99% confidence interval, 0-0.04%). CONCLUSION Our results suggest that CK-MB is not necessary in the initial screening for AMI and may safely be omitted in patients with negative troponins.

Should creatine kinase-MB index be eliminated in patients with indeterminate troponins in the ED?

OBJECTIVES The objective of this study is to determine whether creatine kinase-MB (CK-MB) index (CK-MBi) is useful in the evaluation of acute myocardial infarction (AMI) in patients with indeterminate troponin (Tn) in the emergency department (ED). METHODS A retrospective cohort study was conducted of patients at an urban academic ED with over 55 000 annual visits who underwent Tn T (Roche, Indianapolis, IN) and CK-MB testing. One year of ED patients who had Tn testing were identified, and their corresponding CK-MBi was examined to find patients with indeterminate Tn (0.01-0.09) and positive CK-MBi (>6.0). Subsequent cardiac enzymes and hospital course were reviewed to identify patients diagnosed with AMI. A 95% confidence interval around point estimates were used in data analysis. RESULTS Over 1 year, 11 718 initial Tn were identified. Indeterminate Tn was seen in 2512 cases. Of these, 28 had positive CK-MBi. Of the 28, 5 were judged by treating physicians to be having AMI and underwent cardiac catheterization. Of the 5 patients, 4 had subsequent positive Tns on serial enzyme testing. One of the patients thought to be having AMI had no coronary artery disease on catheterization. The rate of true positive CK-MBi with indeterminate Tn was 0.16% (95% confidence interval, 0.04%-0.41%). CONCLUSION Initial results identify rare cases of AMI where CK-MBi is positive in the setting of indeterminate Tn. However, most patients with indeterminate Tn and positive CK-MBi were not judged to be having AMI. In most cases, CK-MBi is not positive with indeterminate Tn and when positive more commonly confuses the picture. This suggests CK-MBi could be eliminated in patients with indeterminate Tns.

Effect of Two Different FDA-approved D-dimer Assays on Resource Utilization in the Emergency Department

BACKGROUND The D-dimer assay has been shown to be an appropriate test to rule out pulmonary embolism (PE) in low-risk patients in the emergency department (ED). Multiple assays now are approved to measure D-dimer levels. Studies have shown a newer assay, Tina-quant, to have similar diagnostic accuracy to the VIDAS assay. OBJECTIVES The objective was to determine effects of transitioning from the VIDAS assay to the Tina-quant D-dimer assay on the need for computed tomography angiogram (CTA) and ED length of stay (LOS) in patients being evaluated for PE in the ED. METHODS A retrospective cohort study was conducted of patients who had D-dimer levels ordered at an urban, academic, Level I trauma center with over 55,000 annual ED visits. The results of D-dimer levels in the ED were recorded over a period of 6 months prior to and 6 months after the transition to the new D-dimer assay. The numbers of positive and negative D-dimers and need for subsequent CTAs were recorded for comparison. LOS was also recorded to determine time saved. Medians were calculated and compared using Wilcoxon rank sum. RESULTS During the initial period, 875 D-dimers were ordered, with a positive rate of 41.5%. During the period after the introduction of the Tina-quant assay, 859 tests were ordered, with 25.5% having positive results. An absolute decrease of 16% in the number of necessary CTAs (p < 0.003) was seen after the transition to the Tina-quant assay. LOS data showed a mean LOS of 481 minutes in the ED for patients who underwent testing with the Tina-quant assay compared to 526 minutes with the VIDAS assay, saving an average of 45 minutes per patient (p < 0.003). The positive rate on performed imaging studies for D-dimer of > 500 rose from 13 of 308 (4.2%) to 17 of 187 (9.1%). CONCLUSIONS Switching D-dimer assays reduced both LOS and number of imaging studies in our patient population.

Is a postintubation chest radiograph necessary in the emergency department

BackgroundPostintubation chest X-rays (CXR) are standard practice in emergency department (ED) intubations. In the operating room, it is not usually a standard practice to confirm endotracheal tube placement with a CXR.AimsWe seek to study the utility of postintubation CXR in ED patients.MethodsThis was a retrospective case series of 157 adult patients intubated in the ED of an urban academic hospital with an emergency medicine training program. Standardized chart review was performed by two emergency physicians (EP) using a structured data abstraction tool and final radiology attending reads of postintubation CXR to assess placement. Endotracheal tube placement was graded as satisfactory, too high, too low, or malpositioned in the esophagus. Descriptive statistics were used, and 95% confidence intervals (CI) were reported. Hospital Institutional Review Board approval was obtained.ResultsA total of 157 patients were intubated in the ED during the study period: 127 (81%, 95% CI: 74–86) had adequate tube placement by CXR confirmation, 9 (6%, 95% CI: 3–11) endotracheal tubes were judged to be too high, and 20 (13%, 95% CI: 8–19) were judged to be too low with 10 (6.5%, 95% CI: 3–11) of these being right mainstem bronchus intubations. One patient (<1%, 95% CI:<0.0001–4) had a CXR confirming esophageal intubation.ConclusionED intubations were judged to have “satisfactory” placement by CXR in 81% of patients. CXR is able to identify a small subset of patients that likely need immediate intervention based on their CXR. Until further studies refute the utility of postintubation CXR in ED intubations, they should remain a part of routine practice.

Enoxaparin-associated atraumatic compartment syndrome of the calf

Acute compartment syndrome (ACS) is a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space. ACS is an uncommon disease, most commonly associated with long bone fractures. In this report, we present a rare and limb-threatening complication of low molecular weight heparin (LMWH) use: atraumatic compartment syndrome of the calf.

A 50-year-old woman presenting after a motor vehicle collision

Dr. Daniel McGillicuddy: The patient is a 50-year-oldwoman who was involved in a single car, high-speed motorvehicle collision. The patient was an unrestrained driver ina car without air bags who sustained severe blunt forcefacial trauma secondary to the steering wheel, and wasbrought in as a non-trauma to this community hospital. Shewas also intoxicated and agitated. The patient was unableto provide a past medical history, social history or anyinformation with respect to the accident. The pre-hospitalfingerstick glucose level was normal. The patient’s vitalsigns were a heart rate of 88 beats/min, a blood pressure of160/palpation mmHg, a respiratory rate of 24 breaths/minand an oxygen saturation of 96% on room air. The patientdid not have a temperature recorded. The physical exami-nation revealed a patient who was awake, but agitated. Shewas in cervical spine immobilization as well as immobi-lized on a spine board. The head examination revealedblunt trauma to the left orbit and mid face. She had peri-orbital edema on the left, bilateral massive epistaxis, andshe was actively vomiting blood. The midface was stable,the trachea was midline, and she had normal bilateralbreath sounds. The heart sounds were regular, there was nojugular venous distention, and the pulses were fullthroughout. The abdomen was obese, soft and non-tender.The FAST examination was without free fluid. The pelviswas stable. The Glasgow Coma Score was 12 due toaltered speech. The back and extremity examinations werenormal.Dr. Peter Rosen: Dr. Ban, what is your assessment ofthis patient?Dr. Kevin Ban: The intoxicated, combative traumapatient presents unique challenges for the EmergencyPhysician (EP). The combative behavior may be secondaryto any number of underlying causes, including intoxication(drug or alcohol), head injury, hypoxemia, hypovolemicshock or underlying medical conditions (diabetes withhypoglycemia). The most important priority for the EP is toobtain immediate and definitive control of the patient’sairway to facilitate treatment and diagnosis of the severelyinjured patient. There is controversy as to whether or not toparalyze these patients or to sedate them without additionalneuromuscular blockade as is usually done in a rapidsequence intubation (RSI).Dr. Rosen: Dr. Davis, what is your opinion regardingintubation with sedation alone versus a RSI with neuro-muscular blockade?Dr. Daniel Davis: This is going to be a tough airway,and I’m a bit reluctant to paralyze someone like this. Shehas multiple features that raise concerns about being able tointubate her successfully: obesity, c-collar, facial trauma,blood in the airway. It is reasonable to consider ketamine inthis patient, which might allow an attempt to inspect the